Can`t Get No Satisfaction

     Recruiting enthusiastic EMS providers and retaining experienced personnel can be challenging. Some estimates purport that as many as 40% of those entering the field will leave within 2-5 years.¹ Those who leave for other agencies or who leave the field altogether often cite reasons such as a lack of leadership, an overtly political environment, poor pay, a lack of promotional opportunities and feeling unappreciated.

     Examining which aspects of the job EMS providers enjoy, as well as the parts that frustrate them, can help agencies retain dedicated employees. Further, employees who are satisfied with their jobs are more likely to be a positive force in recruitment efforts.

     One way to gauge employee satisfaction is through conducting a survey. Surveys are not always the most popular tool of business managers, as some managers are not prepared or are unable to implement the changes suggested by such surveys. Furthermore, gauging how satisfied employees are is not an easy task. Some fear retribution for their comments, while others simply feel that nothing will change regardless of sharing their thoughts. The purpose of collecting data for the job satisfaction survey I conducted was to see how administrators might increase employees' job satisfaction. In addition to examining paramedic job satisfaction, the survey was also designed to determine, to the extent possible, the satisfaction levels of paramedics in fire-based EMS departments versus paramedics in non-fire-based departments.

METHODOLOGY AND LIMITATIONS
     Over three months, paramedics in both fire-based and non-fire-based departments were notified of an online survey. Out of 300 responses, non-fire department paramedics submitted 209, while 91 came from paramedics working in fire-based EMS departments.

     Please note that this is not a scientific survey. For example, just because 34% of non-fire-based paramedics responded that they do not have job security does not mean readers should infer that 34% of all paramedics feel that way. It simply means that 34% of the people who chose to participate in the survey felt that way. Furthermore, people who are generally satisfied with their jobs may not bother to reply to such surveys. However, even with such limitations, it is still possible to examine overall job satisfaction of the paramedics who did respond to the survey and discuss the issues that were deemed important to unhappy employees. What follows is the author's interpretation of the data. Names used in follow-up interviews have been changed.

OVERVIEW OF RESULTS
     Employees need to feel part of the organization and that they are treated fairly and with respect. They need to understand an organization's policies and be able to communicate with those in charge. Finally, employees need to feel they have financial security in their job. Financial security may include an adequate salary and a retirement plan.

     Participants in this survey responded to a series of questions designed to give some insight into these areas. Survey questions came from several human resource management websites concerning employee job satisfaction.

Pension systems and union representation
     Fire-based organizations scored better than non-fire organizations when it came to pension systems and union representation. Slightly more than 90% of fire-based EMS medics have pensions, while just over 50% of medics in non-fire-based EMS employment have pensions. Few would argue against the value of a pension system. Employees with a pension system are more likely to see their job as a career rather than a steppingstone to the next job opportunity.

     Nearly 80% of fire-based EMS medics have union representation, but less than 25% of non-fire-based EMS medics have union representation. While it is not the intent of this survey to endorse the benefits of union representation, it is worth asking whether the lack of union representation in non-fire-based EMS services is related to low employee satisfaction scores.

Retirement plans
     Perhaps the most important finding in terms of the issue of retention is the discrepancy between the percentages of medics in non-fire-based EMS and fire-based EMS who plan on retiring from their current job. Only 40% of medics in non-fire-based EMS plan to retire from the job. That number is almost double for medics in fire-based EMS, where nearly 80% of respondents indicated a desire to retire from their current job. EMS managers should ask why fire-based EMS medics are more likely to stick with the job. Retaining trained and experienced personnel benefits not only the employer and employee, but also the public.

Feeling integral to the organization
     Both fire-based and non-fire-based EMS organizations scored low when it came to feeling like an integral part of their organization. Both types of agencies scored below the 50th percentile in questions asking whether employees felt they had a "voice" in their jobs, if they were treated fairly and whether they felt management listened to their concerns. Employees who feel that their opinions and experience are not valued by the organization are likely to seek out jobs with agencies where they feel respected.

     Most fire departments are designed around a paramilitary hierarchy called a scalar structure in which power is distributed from the top in a series of steps. Paramilitary organizations don't always lend themselves to friendly relationships between administration and employees because the purpose of such systems is to maintain a rigid authority structure. Participative management—the practice of giving employees the opportunity for input or a "voice"—could help bridge the gap between management and workers.

Harassment
     It is difficult to imagine feeling high levels of job satisfaction if you perceive the work environment as hostile. Half of the fire department paramedics in this study reported that they had witnessed sexual, racial or age discrimination and harassment. Non-fire-based agencies scored slightly better.

     Some fire department respondents stated in follow-up interviews that their administrations simply turned a blind eye to harassment complaints. Part of the problem may be the so-called tradition of hazing in the fire service. Probationary members are often made to do menial tasks, subjected to teasing and practical jokes, and are sometimes excluded from activities that permanent employees enjoy.

     Phil, a paramedic with a large urban fire department in Georgia, stated that when paramedics in his fire department complained of harassment they were told that it "came with the territory" and they needed to look for jobs elsewhere if they didn't like it. John, a longtime fire department paramedic in Ohio, noted that his administration made it clear that EMS was in the fire department primarily as a revenue generator. He went on to describe how he and others were singled out for harassment simply because they were enthusiastic about EMS. John noted there was a period of time where he actually felt "unsafe" at the fire station, but his administration refused to address complaints.

     While these are extreme cases, incidents like these shouldn't occur. Administrators should keep in mind that they don't have to have direct knowledge of harassment taking place to be held liable. In some cases, all that is necessary for a judgment against the agency is the finding that the administrator should have known about the harassment taking place.³

Is your agency progressive?
     Both provider types scored near the 40th percentile when respondents were asked whether their employer was progressive. EMS is a continually changing landscape of new medications, procedures and equipment. Paramedics who feel that their employer is striving to stay on the cutting edge of EMS will feel challenged and are more likely to have job satisfaction. Successful EMS agencies should always be willing to support reform when it improves organizational safety, operational efficiency and community service.

Overall job satisfaction
     Interestingly, while medics with both system types gave low marks to various aspects of their employment, a majority still expressed overall satisfaction with their jobs. Despite some frustration with job satisfaction issues, apparently a majority still feel they have good jobs.

RECOMMENDATIONS
     Employee recruitment and retention is a top priority for EMS agencies. Poorly motivated employees make the job of keeping people in the system that much more difficult. It would be disingenuous to state based on the information collected in this survey that one EMS service provider is better or more efficient than another. In the results of this survey, however, details have emerged that highlight some of the challenges facing each type of service provider.

The fire service model
     If properly utilized, the fire service can be an efficient way to provide EMS. The problem is that some fire departments that provide EMS don't use their paramedics in an efficient and integrated manner. Some seek to use the revenue-generating power of EMS to prop up sagging fire budgets. If you work in a fire department that provides EMS, ask yourself these questions:

1. Are your paramedics cross-trained? While controversial, I believe that fire departments that don't utilize cross-trained EMS personnel are defeating the purpose of combined services. Cross-training is a useful tool to increase efficiency and save money. If your paramedics don't want to be firefighters, and your firefighters don't want to perform EMS, why combine services?
2. Do your paramedics enjoy the same amount of respect, peer recognition and advancement opportunities as firefighters? Several fire service paramedics reported in follow-up interviews that they are treated as "necessary evils" and are given the impression that the only reason they are in the fire department is because of the revenue they generate. Many also reported resentment at being subjected to performance review/discipline by non-paramedic supervisors.
3. Finally, what is the overall focus of your fire department? If your focus is still fire suppression when 80% or more of your runs are medical, your department is not well integrated with EMS. Effective combined agencies should have their focus split at least evenly between fire service and EMS.

     Fire departments providing EMS that aren't at least attempting to meet these standards are doing a disservice to their employees, their agencies and the citizens they protect. Forcing together two services in the absence of mutual respect is a recipe for poor morale and high turnover.

Private ambulance EMS
     Third-service, private ambulance and hospital-based EMS services have their own set of difficulties. In follow-up interviews, pay and benefits remain the No. 1 complaint of non-fire-based providers. Private ambulance agencies, from the one-office family business to the multimillion-dollar conglomerate, must offer competitive wages and benefit packages to attract and retain employees.

     Bill, a 15-year veteran paramedic, reported that his former employer in West Virginia pays paramedics under $10 per hour. An unacceptable wage, Bill says, considering their training and what they're expected to do. It is not surprising that Bill is planning to leave EMS for a career in nursing. EMS agencies will continue to suffer high turnover if they don't do more to advance employee pension systems, increase pay and add benefits.

CONCLUSION
     EMS managers who assess their departments and strive to improve the work environment may increase employee levels of job satisfaction and avoid high turnover. Establishing a blueprint for employee retention is of paramount importance for all administrators in EMS.

References

1. Lowe BL, Bolton B. 21st century EMS retention strategies. EMS 31:11, 75-77.
2. Hawks SR, Hammond RL. Tackling stress management from all sides. In Fitch JJ. Prehospital Care Administration (pp. 143-151). San Diego, CA: JEMS Communications, 2004.
3. Wirth SR. The new workplace ABCs: avoiding the courthouse scene. In Fitch JJ. Prehospital Care Administration (pp. 101-107). San Diego, CA: JEMS Communications, 2004.

Dominick J. Swinhart, EMT-P, is a paramedic/firefighter for the Aberdeen (WA) Fire Department.