Why the EMS Workforce Is Shrinking

The EMS workforce is shrinking at a time when calls are up in most jurisdictions. Many states are seeing the same number of people entering the workforce and getting licenses as usual while the number of active practitioners drops. EMTs and paramedics are keeping their licenses active but in many cases not working on the streets. The net effect is fewer EMS providers dealing with more calls than ever.

The larger health care workforce is also in dire straits, with nursing shortages leaving many hospital beds unavailable because they aren’t staffed. This shortage increases EMS wait times to offload in facilities around the country, leaving fewer of its resources free. Patients can’t be discharged because ambulances aren’t available. They may be tied up with other patients in the emergency department, waiting to offload and with more calls holding. The stresses on both field personnel and hospital staff are among the reasons many are rethinking their chosen careers.

Job satisfaction is near an all-time low in health care and emergency medical services. Like their brethren in the food service industry, our workers are often underappreciated, overworked, and underpaid. Providers who make a living wage aren’t necessarily thriving either. Experienced providers with the credentials should make a decent living, not just enough to pay the bills and buy groceries. I believe this is part of why we’re deep into a recruitment and retention crisis. We were already there before the pandemic; then COVID-19 put a match on our industry, making more people rethink their profession sooner.

The Role of Pay

Several studies have been conducted of people who left the EMS workforce. Their reasons for leaving included several recurring themes:

• Insufficient pay for the work performed
• Lack of appreciation from the public
• Working hours and forced overtime
• Poor management
• Lack of benefits

There are many reasons agencies can’t pay employees more. These generally include low reimbursement rates for EMS services, the tax burden on the local community, or an unwillingness to raise salaries above what officials believe is a fair wage. Most public officials aren’t aware of the training required to become an EMT or paramedic and the hazardous conditions in which providers operate daily. Police deal with armed criminals, firefighters deal with fire and hazardous materials, and EMS providers are often present during all these calls and more, providing emergency care and dealing with biohazards while helping with 
the aftermath.

Reported Fortune in late 2021:

“Today, with tools like MIT’s Living Wage Calculator, we can put a dollar amount on what it takes for individuals to earn a ‘decent living’ in every county in the country. But this information is typically not leveraged by corporate America when establishing pay practices. By benchmarking against market competitors and median pay rates, corporate HR departments wind up setting pay too low, and executives don’t realize their workers are struggling financially. They aren’t talking to their workers and assessing whether they can make ends meet after each paycheck. This disconnect is hurting their business and undervaluing workers’ skills.”¹ 

The job listings on a popular EMS site’s careers page have a paramedic pay range from $15–$40 an hour. This may be a solid living wage for entry-level personnel based on their location. But are we taking location into account? We need more than an entry-level living wage to recruit new providers to our services and a wage where employees can thrive if we’re going to retain personnel and recruit experienced providers. A competitive wage allows employees to thrive—make car payments, go on vacations, make house payments, and save for retirements and emergencies.

Leadership Issues

Working hours for EMS providers have begun to change from the traditional 24-hour shifts used by many 9-1-1 services over the years. As call loads have increased, so has the downtime necessary to perform our jobs safely. I am aware of many services that have forced overtime on personnel because their relief called in sick. This is dangerous! The Federal Motor Carrier Safety Administration sets rules for commercial drivers who conduct interstate commerce; maybe EMS should consider similar regulations for the safety of our people and customers.

We see many employees disgruntled when passed over for promotions. Even more problems arise when younger and newer employees find themselves managed by people who aren’t good managers. Many systems simply promote people based upon being good field providers. But a good field provider isn’t necessarily a good manager or supervisor. Leadership roles require different skill sets. These are often skill sets that can be learned, but agencies need to put the time and effort into training personnel to be good managers and supervisors. Leadership is not intuitive to many people, yet it’s often a desired trait that is lacking. 

Following the rule of 3-deep leadership can provide depth and security to organizations’ structure. The person above you should know your job, and at least 2 people below you should be trained to do it. None of us are going to live forever, and should we be fired, suffer an accident that puts us out of commission for a few weeks, or something else, our agency and people will suffer if we don’t prepare them.

Many employers offer benefits like health insurance, sick time, personal days, and vacation days. How many also offer tuition assistance, family leave, and financial coaching? The more benefits an agency can offer its employees, the more valuable the agency becomes. 

Other Options

Many providers have chosen to move beyond the streets. EMS providers can often find jobs in hospitals, medical and dental offices, amusement parks, and industrial settings. Those who transition to these alternative careers do so for several reasons. 

Dustin Housewright, an EMS captain at Eastman Chemical Company in Kingsport, Tennessee says, “I’d probably narrow it down to these reasons: The pay is often better; they want to get away from 24-hour shifts; and they are burned out or heading there.”

Housewright says an industrial setting lets him work without having to run nonstop for an entire shift. Those making this change will require expanded training that could include fire suppression, hazmat response, technical rescue, and more. Many industries have multifunction departments where they issue permits (hot work, confined-space entry, etc.). The industrial provider may be the sole on-site medical provider and have to deal with drug screens and Occupational Safety and Health Administration regulations as well. Housewright says he’d encourage anyone considering such a transition to look at the job requirements and see if a ride-along is available, as this type of job isn’t for everyone.

Al Jenkins, safety manager at Dollywood theme park Pigeon Forge, Tennessee, says many of their new hires are tired of the stress of running emergency calls and working 24-hour shifts. Most of their EMS personnel are former 9-1-1 service providers who were on the verge of burnout. Jenkins says it makes a big difference in their outlook on life and job satisfaction to come to work and see smiling faces and people who seem appreciative.

Those thinking about transitioning to work at a theme park or other nontraditional environment should be prepared and keep their credentials up, according to Jenkins. They’ll still need to maintain their EMS license, CPR, ACLS, BTLS, etc. They’ll also have to learn about safety inspections and park-related duties. Everyone I met at Dollywood was happy to be working there, and all had 9-1-1 or aeromedical backgrounds.

Conclusion

The predominant theme found in most informal surveys is providers on the street feel they are increasingly burned out and underappreciated by the public and their agencies. They also report supervisors being seriously underprepared for advancement and a lack of job training for managers.

Companies with established employee development programs retain employees longer than agencies that don’t invest time and effort in developing their workforce for advancement. Are we afraid the employees we train to lead will leave after we build them into better people? We should be afraid they will stay if we don’t make them better.  

Sidebar: Self-Promotion

Appreciation from the public is hard to get without providing exemplary customer service. It also doesn’t hurt to toot your own horn with a designated public relations officer. Depending upon the size of the department, this could be a full-time position or a supervisor who also does PR as part of his duties. It doesn’t hurt to spread the work around, as long as one person coordinates and oversees the efforts. 

Every agency normally has a website and social media accounts and issues press releases. The PR coordinator should write and disseminate the news releases but can recruit other employees to work on the website and manage feeds. Being part of the team and helping with these tasks increases employees’ value—just don’t overburden them. They need time to do the job, direction, and oversight to keep everything within company guidelines.

Sidebar: What's the Solution?

Replacing people is expensive. The American Ambulance Association’s 2021 Ambulance Industry Employee Turnover Study found the average cost to recruit and attract, screen and select, and onboard and train a new EMT was more than $6780. For a paramedic that increased to $9112. 

The problem, the report notes, “is in identifying solutions to the problems underlying turnover. Based on the reasons listed for turnover, two possibilities are increasing career and promotional opportunities and increasing pay.” One possibility, the authors concluded, was to implement organizational interventions associated with psychologically healthy workplaces. These can include increased attention to employee health and safety; introducing programs to allow for career growth and development outside traditional career ladders; and scheduling to allow for increased work-life balance.

Reference

1. Glasmeier A, Omens A. $15 an hour isn’t enough: U.S. workers need a living wage. Fortune. Published September 6, 2021 . Accessed March 30, 2022. https://fortune.com/2021/09/06/minimum-wage-15-an-hour-living-wage-labor-day/

John M. Dabbs is a consultant and investigator for the Northeast Tennessee Regional Health Office.