Sowing the Seeds

     Although EMS recruitment and retention issues have been frequently discussed, little scientific research has been conducted to determine why people are entering and leaving the EMS field. To date no research has been done to analyze the demographics of people enrolling in EMT classes and determine what their attitudes and expectations are for employment.

     Our group of authors from the Loyola University Medical Center EMS office in Chicago wanted to investigate the demographics, perceptions and expectations of those who enroll in EMT classes, regardless of their completion, anticipated employment or long-term success. Therefore, we undertook the SEEDS Project—the Study of Employment Expectations and Demographics of EMT Students. The objectives we outlined are shown in Table 1.

     By better understanding these EMT students, we hope EMS managers will be better equipped to address recruitment and retention problems.

METHODS
     A survey instrument consisting of 15 questions was distributed to instructors of EMT classes throughout the Chicagoland area. Survey responses were collected from March–September 2006. Prior to distribution of the study, paramedics and EMTs employed by the Loyola EMS office evaluated survey questions for format and content and concluded that all selections were exhaustive and exclusive. Approval with waiver of consent from the Loyola University Medical Center's Institutional Review Board was obtained. Consent was also obtained from the lead instructor at each surveyed location. A cover letter was included with the survey explaining the goals of the project, informing the students that participation was voluntary, and assuring that responses would remain anonymous. The survey was administered to students within the first two weeks of classes beginning.

RESULTS AND DISCUSSION
     A total of 203 of a possible 232 surveys (82%) were returned from seven different locations. The demographics of EMT students are shown in Table 2.

     Students taking EMT classes were mainly young adults, 80% of them being 30 and younger. Almost 70% had at least some college education, and over one third had prior healthcare experience (mostly as Certified Nursing Assistants). A prior study showed that EMTs in 2003 were most likely to have high school educations (45.7%), but large numbers held associate's (25.1%) or bachelor's degrees (22.2%), and very few (0.35%) had less than a high school education.³ This is important for EMS educators to know. The range of students' educational backgrounds can be quite broad, and may affect how they are taught and tested. We were surprised with the numbers of college-educated students. Only 74 of the 203 respondents (36%) reported family histories of EMS employment; 75 (37%) had prior healthcare experience; and 16 (8%) had military experience. This leads us to wonder what factors are attracting students to our classes.

EMPLOYMENT CHARACTERISTICS
     Most students (95%) planned to utilize their EMT licenses upon completion of the class (see Table 3). A surprising finding was the number of students who had plans to complete further education. Forty-four (22%) planned to get EMT-Intermediate licenses, 127 (63%) paramedic licenses, 37 (18%) wanted to become Registered Nurses, 11 (5%) wanted to go to medical school, and 13 (6%) planned to obtain dispatcher certifications. The most interesting of these findings lies with the EMT-I and paramedic licenses. Intermediate EMT licenses are not recognized in northern Illinois and northwestern Indiana, the location of all the classes surveyed. Therefore, these 44 students either plan to relocate after completing their classes or have a gross misunderstanding of the levels of prehospital care workers in their areas. Because of this, we strongly advocate that educators take time early in an EMT class to explain the EMS profession, possible opportunities for advancement, and the scope of practice for each level of EMS.

     Educating students about the field of EMS is especially important, given that 63% of students plan to eventually obtain paramedic licenses. This is an important finding for several reasons. First, we need EMTs. EMTs are frequently required for transportation companies and used as ambulance drivers, and many departments only have BLS providers. The largest group of EMTs nationwide by far is EMT-Basics, who constituted 62.2% of all EMTs in 2003.1 Paramedics comprised another 31.3%, while only 6.5% were registered at a level higher than Basic but below paramedic.¹ Second, in Illinois, obtaining a paramedic license requires a significant commitment. It is a full-time year-long class that demands students have a strong mastery of physiology, pharmacology, ACLS and many other skills. Many of these students may not have an understanding of the differences between an EMT and a paramedic.

     Finally, it is worth mentioning students who have plans to get RN or MD licenses. These students often have the greatest educational backgrounds. Many told us they are taking EMT classes because it is a part-time commitment that will boost their resumes. They may frustrate other students with their ability to rapidly understand lecture material and their familiarity with preparing for written exams. An instructor must develop strategies to intellectually inspire these students without overwhelming other students in the class.

EMPLOYMENT EXPECTATIONS
     Given that 95% of all EMT students planned to utilize their licenses, they will be in need of jobs. However, only 65% said they had already looked into EMS employment. In the Chicagoland area, finding employment is location-dependent. Some areas have many job opportunities, while in other places it is difficult to find employment. Educators should explain to students the current job outlook in the geographic areas of their classes. This is especially critical given that 132 of the 203 students (65%) said they wanted to work for fire departments. The Chicago Fire Department currently has a waiting list of thousands of candidates, and many suburban fire departments only hire paramedics and individuals with firefighter certifications. A trend we've noticed at Loyola is the number of firefighters required to take EMT classes. Many of these individuals have little interest in working with the medical side of a fire department, preferring to focus on the firefighting aspects.

     Many job opportunities for EMTs lie with private transport companies. Although 30% of students planned on this setting for employment, it is likely that a much higher percentage will ultimately work for one of these companies. These companies may not provide the action of fire departments, but they do provide employment, and frequently pay better than municipal agencies.

     A growing trend in EMS is having personnel with prehospital licenses working in hospitals. These EMTs are able to perform basic emergency care in the ED setting, allowing nurses and physicians more time to treat complex cases. With a little additional training, the scope of practice for such personnel can be expanded so that they can start IVs, draw blood or give vaccinations. Although becoming more popular, hospital jobs are still difficult to come by. Almost 40% of students said they'd consider working in this setting. These jobs may be desirable to students looking to obtain future RN or MD licenses, those looking for more standard shift work and those hesitant to work on ambulances.

     Given that our survey was distributed within the Chicagoland area, it is not surprising that only 16% of students wanted to work in rural settings. This is an important point to consider. EMT curricula aren't standardized, either across Chicago or across the country. Demand for EMTs and paramedics will continue to be strong in rural areas, but is difficult to estimate, as rural areas rely much more heavily on volunteers than do urban areas. In 2003, 75% of EMTs in rural areas were volunteer, compared to 7.5% in large cities.¹

     Another important topic to students is the financial implications of prehospital work. Our survey showed that 82% of students had expectations of receiving benefits from prehospital employment. According to a 2006 study, 51% of EMS organizations share medically related benefits with employees, 60% with employees' families, 49% have dental coverage, 61% offer life insurance, 41% short-term and 39% long-term disability, 58% have tuition reimbursement, and 84% have uniform reimbursement.² In recent years there has been an increased focus on non-monetary benefits (e.g., paid time off).3 With retention of EMTs being difficult for many departments, these percentages may need to increase in order to continue to attract and maintain people.

     Very few students (2%) were planning to work as volunteers. Certainly this varies from location to location across the country. According to data gathered from a sample of National Registry members in 2003, 36.5% of registered EMTs were volunteers.¹

     In regard to salary, we asked two questions: first, the student's expected salary as an EMT, and second, the lowest range of money they would accept as a full-time EMT-B. The question about expected salary received a wide range of answers (see Table 4). Why so wide? We suspect that since so few students actually researched EMS employment, they did not know how much money to expect. Unfortunately, some students appeared to have high expectations. According to a 2006 study, EMT-Basics in the Chicago region started employment making $27,929 a year, with a maximum of $39,677.² During a November 13, 2003, episode of CBS MarketWatch, EMS was listed as one of the 10 most underpaid jobs in the U.S., with an average annual salary of $25,450 (per the Bureau of Labor Statistics).

     When students were asked about the minimum salaries they would accept, 17% were willing to accept $15,000 or lower, 37% between $15,001–$25,000, 22% between $25,001–$35,000, 10% between $35,001–$45,000, and 6% expected $45,000 or greater. We felt these numbers were more in line with the reality a full-time EMT in the Chicagoland area could expect. Still, many students may have to settle for lower salaries than they'd anticipated. We wonder if high salary expectations are one of the factors pushing EMT students to consider becoming paramedics or entering other, more highly trained professions.

CONCLUSION
     Given that this was the first survey of its kind, there were some important findings for EMS educators and managers. With recruitment and retention increasing challenges for departments nationwide, we need to further examine exactly whom we're educating and why they're in our classrooms. While our results are limited to only students in the Chicagoland area, and our system may not be like yours, there are some important lessons to take from our research. Our EMT students are generally young, with some college education, but without healthcare or military experience. Many plan to obtain higher licensure and work in fire departments. Despite most students expecting benefits, expectations for salary vary greatly.

     It is up to us to utilize these insights as a basis for further investigation and to help improve our systems and the care we deliver to our communities.

References

1. National Registry of Emergency Medical Technicians. Longitudinal Emergency Medical Technician Attributes and Demographics Survey (LEADS) data, 2003.

2. Williams D. 2006 JEMS Salary and Workplace Survey. J Emerg Med Serv 31(10): 38–49, Oct 2006.

3. Monosky, KA. 2002 JEMS Salary Survey. J Emerg Med Serv 27(10): 30–46, 2003.

The authors would like to thank David Blitz for his statistical assistance, Myrna Romero for her graphical support, all members of the LUMC EMS office, and the students who took the time to complete the survey.

Matthew R. Deluhery, BS, EMT-B, is a fourth-year medical student at the Loyola University Chicago Stritch School of Medicine. He plans on a career in emergency medicine. Contact him at mdeluhery@lumc.edu.

Ginger M. Worlds, CCEMT-P, NREMT-P, has had a long career as an NREMT-P and an EMS instructor at Loyola University Medical Center.

Christine E. Stake, MA, is research program coordinator for the EMS Department at Loyola University Medical Center.

Mark E. Cichon, DO, FACEP, FACOEP, is an emergency physician and medical director for Loyola University Medical Center's prehospital system.