Prehospital emergency medical care is a crucial element in the management of ill and injured patients in the United States. The volume of calls to emergency medical services (EMS) has increased dramatically in recent years in the US (Carr et al, 2019). In the period between 2010 to 2017, 911 emergency systems in the US experienced a 33% rise in emergency call volume (Carr et al, 2020). However, the capacity to match EMS resources to this increased demand seems to be problematic for the profession, in part because of continued problems in retaining experienced emergency medical technicians (EMTs) and paramedics (Rivard et al, 2020).
The purpose of the paper is to examine issues relating to the retention of EMS personnel in the United States and highlight the use of organisational behaviour theory, a sociological theory, as a pathway for addressing such issues in future research.
This theoretical concept paper attempts to apply as organisational behaviour theory to the issue of retention of EMS personnel. According to Borkowski and Meese (2020), this theory provides a pathway for understanding human behaviour, culture and practices within organisational structures and appears to offer potential for improvements when addressing organisational issues such as staff retention.
In the United States, retention of prehospital care personnel, specifically EMTs and paramedics, has declined within EMS-centric response agencies at a time where more healthcare workers are required to meet increased service demands (Rivard et al, 2020). For this article, retention refers to individuals leaving the profession and does not include retirement, termination, promotion or moving to another EMS or fire-rescue system.
The high degree of turnover and attrition of EMS professionals in the United States seem to have created a series of negative consequences for the emergency medical services career field. The high rate of EMS personnel exiting the field diminishes the ability to provide consistent care with guaranteed quality care, especially to poor, underserved and uninsured populations (Adio et al, 2020). A reduction in personnel results in an EMS system becoming unable to respond effectively and in a timely fashion to the growing number of emergency medical incidents (Carr et al, 2020). As Blau and Chapman (2016) note, EMS are reaching a point where EMS providers feel increasingly marginalised while they are being expected to take on expanded patient care requirements and face an increasing amount of accountability associated with emergency medical services.
Sociological theories provide possibilities for examining the issues of retention associated with a decline in EMS personnel, including the underlying reason why the decline is occurring and how this can be addressed to avoid further loss of qualified responders. Specifically, organisational behaviour theory could possibly help explain the root causes of retention problems, as well as identify pathways for improvement. Use of this theory, coupled with future research to examine an organisational situation or problem (in this case retention), can provide a framework for adjustments to organisational structures and policies and help achieve long-term solutions.
Pathways for theoretical discovery exist within the social sciences (Shoemaker et al, 2004). One of these paths involves working with existing theories within specific literature on a subject through a process known as secondary research (Stewart and Kamins, 1992; Shoemaker et al, 2004). Secondary research design opens up the possibilities for discovering new ideas through a convergence of existing empirical works and theories (Stewart and Kamins, 1992). Moreover, it opens up future lines of research enquiry.
The authors employed a secondary research design to conceptually theorise on the potential organisational behaviour theory has for improving the retention of EMS personnel (Stewart and Kamins, 1992; Shoemaker et al, 2004). They used an analytical process involving inductive logic as it applies to the topic of retention and organisational behaviour theory to form the study's theoretical concept (Coyne, 1984).
Organisational behaviour theory
Stemming from the works of Barnard (1938) and Follett (1941), organisational behaviour theory is characterised by its approach to the analysis of an organisation and its people on a macro scale. The theory relates to organisational structures and systems, resembling the workings of a skeletal arrangement in which the different components of individual systems aim to support the whole (Borkowski and Meese, 2020). The theory is used to identify the inner structural workings of individual organisations, their culture, interactions between organisations and the effect of collaboration on supervision and action (Schein, 2010; Borkowski and Meese, 2020).
Organisational behaviour theory creates a structure that allows researchers to analyse institutional frameworks, review the current efficacy of procedures and policy, and gain insight into the trajectory of an organisation (Byers et al, 2012).
The strength of the theory is that it focuses less on the individual and more on the structures and culture within an organisation (Borkowski and Meese, 2020). It provides a platform for managers, leaders, consultants and researchers to identify any failures that have occurred or may occur, anticipate future obstacles and draw up potential solutions.
The use of such a theory can help to identify any weaknesses within an organisation or grouping of organisations, revealing whether the problems stem from structure or policies, and provides a scaffold to uncover solutions that are likely to be successful (Byers et al, 2012). This can help reduce disputes, create a culture of more cohesive communication and improve employees' perceptions that their needs and complaints are being heard and addressed.
The authors focus on organisational behaviour theory because of its potential for uncovering solutions to organisational problems such as the retention of EMTs and paramedics in emergency medical services. However, before organisational behaviour theory can be discussed, organisational factors that seem to cause poor retention in the EMS professions need to be addressed.
Factors influencing staff retention
There is no one single factor that one can point to as the only cause of poor retention rates of EMS professionals (Rivard et al, 2020). It seems that multiple factors influence or at least compound an individual's decision to leave EMS.
The following section addresses organisational and personnel issues associated with EMS that the authors found repeatedly cited in the literature and which seemingly contribute to retention problems. These issues, which are not necessarily exhaustive, include: inequitable pay levels and job requirements; injury and illness; extended work hours with fatigue and sleeplessness; and burnout (Sweeney, 2015; Blau and Chapman, 2016).
Inequity in compensation and job requirements
Rivard et al (2020) and Studnek (2016) conducted studies to identify the central rationale for why EMS professionals are leaving the field, despite the amount of time, energy and resources they needed to spend to achieve their qualifications and position.
Rivard et al (2020) found EMS personnel wanted better pay and benefits and expected that leaving the field to pursue higher education would lead to in more fruitful endeavours.
Studnek (2016) found EMS professionals said inadequate pay and benefits were chief areas of concern and, specifically, that the risk and responsibility they took on were not balanced with the financial compensation. Because of pay and benefits issues, EMS agencies in the United States experience a loss of personnel to fire-rescue agencies for better pay, benefits and promotional opportunities (Studnek, 2016).
Chapman et al (2016) discussed that the issue of compensation was not limited to retention but also influenced the recruitment of new EMS personnel into the profession. They emphasised that EMS leadership needed to take an active role in addressing the grievances associated with compensation and benefits. This would also increase any likelihood that potential employees would regard the EMS field as one that could provide appropriate compensation and career advancement, and this would improve recruitment.
Incident of injury and illness
Emergency medical technicians (EMTs) and paramedics can find themselves leaving an EMS career because of an injury or illness. Because of the physical nature of EMS work, it can have injurious impacts (Taylor et al, 2015). Staff move and lift patients, which is are physically taxing. These can have an adverse effect to a both physical and mental health. In addition, as Taylor et al (2015) note, injuries that compound over time have the potential to force an EMS provider to choose between their health and their career.
Taylor et al (2015) identified that EMS professionals, because of the physical demands of the work, have a significant chance of near-injuries and injuries. Using a national reporting system that tracks workplace injuries, Taylor et al (2015) found that EMS employees frequently found themselves in high-risk scenarios.
Moreover, the nature of emergency calls means working environments and involved parties vary, so certain calls will involve violent patients. In this situation, patients can often be unpredictable in their response to treatment, and bodily harm from violence to the responder may be the result of an unexpected patient reaction or patients' relatives/companions becoming violent. Experience of physical trauma plays a significant role in the potential decline of a person's health.
A less discernible and quantifiable reason for leaving EMS is a lack of appropriate reporting of post-traumatic stress disorder (PTSD). Drewitz-Chesney (2012) identifies EMS personnel as having a significantly high vulnerability to symptoms of PTSD throughout the course of their career because of the situations they encounter.
The nature of emergency response places EMS responders in emergency situations that can challenge their mental and emotional capacity. While EMS professionals have been trained for and exposed to these types of settings more frequently than the general public, over time, the psychological consequences of these experiences can have a negative impact on their psyche (Jenkins, 2020).
Despite the likelihood that an EMT or paramedic will experience some degree of PTSD, the probability they will seek professional help is comparatively low (Drewitz-Chesney, 2012). Instead, employees turn to unconventional and often negative coping methods to attempt self-help and avoid acknowledging the disorder outright. It is concerning that the frequency of PTSD in EMS seems to have become normalised. This means that PTSD is expected as a typical side effect of the job, which prompts employees to downplay the severity and frequency of its occurrence and trivialise the harm it can cause (Jenkins, 2020).
Fatigue and sleeplessness
An element that contributes to the likelihood of injury, in addition to other detrimental impacts on a person's health, is a lack of sleep (Khan et al, 2020). The amount and quality of sleep can have a tremendous effect on how a person manages physical and mental stress and is able to perform functions accurately and without injury.
Sleeplessness and fatigue are key factors in work-related stress experienced by employees who work long shifts and extended hours (Peterson et al, 2019). The physical, mental and emotional fortitude of an EMS responder can be greatly diminished when they have experienced a prolonged loss of sleep (Kahn et al, 2020).
The responsibility of EMS personnel on the front lines is ensuring that the general public has access to the emergency medical care that is critical to their health and security. The ability of an EMS worker to react quickly, competently and correctly seems to correlate with the successful outcome of an emergency situation (Kahn et al, 2020).
Sleep deprivation and impairment can give rise to direct and negative effects on an EMT or paramedic's ability to operate at peak performance, in addition to increasing the likelihood of turnover and intention to leave the field (Blau, 2011).
Increased stress caused by a lack of sleep is a main contributor to the likelihood that an EMS practitioner would experience burnout (Peterson et al, 2019).
Burnout
Workplace conditions and daily circumstances experienced by EMS professionals play a key role in their high incidence of burnout and consequent decision to seek other professional pursuits (Russell, 2019). The collective definition of burnout has been identified as a disorder created by mental, physical and emotional exhaustion (Russell, 2019). A perceived detachment from one's behaviours and thoughts is also experienced, alongside a feeling of being overwhelmed and unable to meet the requirements of a position (Peterson et al, 2019).
The frequency of burnout within EMS is immense compared to other occupations in the general population (Williams et al, 2017). The combined potential for a person to experience destructive repercussions to their mental health, physical wellbeing and emotional capacity, leading to burnout, is very high among the EMS profession (Williams et al, 2017; Peterson et al, 2019; Russell, 2019).
Burnout is a complex concept, with multiple factors contributing to its likelihood, and symptoms of it vary (Peterson et al, 2019). Burnout increases employee absenteeism and has a high rate of negative health consequences including ‘an increased risk of mental and behavioural problems, cardiovascular diseases, respiratory diseases, musculoskeletal disorders and digestive diseases’ (Leszczyński et al, 2019: 114).
Crowe et al (2020) highlighted the importance of identifying the underlying causes of burnout in EMS individuals. Present efforts focus primarily on a reactive approach of identifying techniques for coping with symptoms rather than identifying a proactive method for reducing or ideally eliminating the circumstances that cause the condition to occur (Crowe et al, 2020).
Organisational behaviour theory and emergency medical services
From a review of the literature, it seems organisational behaviour theory holds promise in identifying issues related to EMS responder retention that need to be tackled. There seems to be potential for this theory to address issues related to retention such as injury and burnout experienced by EMS responders. Moreover, it seems it could be used to help identify the role the organisation plays in issues that affect responder retention and contribute to high turnover.
The literature seems to reveal the issue of an organisational culture or lack thereof that forms a community in EMS (Schein, 2010; Russell, 2019). Specifically, one problem is bureaucracy in the form of the people serving the policies and procedures rather than the policies and procedures serving the people (Russell, 2019). The health and post-traumatic growth of responders is associated with a positive organisational culture of community where individuals experience a sense of belonging (Russell, 2019). If the needs of the bureaucracy are more important than the needs of the people, this erodes the responder's sense of community (Russell, 2019). Organisational behaviour theory could be instrumental in discovering the actions that need to be taken to amend and update policies and procedures that are affecting employees and thus retention in an adverse way, and therefore perpetuating negative outcomes (Borkowski and Meese, 2020).
While a significant amount of research has been conducted on the topic of the EMS responders, as well as the negative impacts their job can have on health, there is still a need for more research to identify what seem to be multiple gaps in evidence relating to organisational behaviour and responder retention (Blau and Chapman, 2016; Carr et al, 2020).
For example, there is a gap in research on determining the method for resolving systemic burnout (Crowe et al, 2020). Many studies focus on the need to address problems, yet fall short of providing actionable solutions that can be widely employed, and this is where organisational behaviour theory holds promise (Borkowski and Meese, 2020). Organisational behaviour theory provides insight to help identify and address some of these issues. For example, studies such that by Rivard et al (2020) have identified various degrees of responder burnout, as well as the short and long-term impact of side-effects and symptoms of this.
This includes the potential role burnout plays in an increased frequency of suicide within a population of responders (Rivard, et al, 2020; Sweeny, 2012). While Hird et al (2019) emphasise the substantial higher rate of suicide among EMS professionals, there is a lack of literature on the relationship between burnout and the risk of suicide.
Because organisational behaviour theory encompasses individuals and groups through an organisational approach, it holds promise for discovering aspects of organisational deficiencies and cultural incompetence that foster responder burnout (Russell, 2019; Borkowski and Meese, 2020; Rivard, et al, 2020)
A continuation of the analysis on the retention of EMS practitioners and a strategy for how best to recruit and retain EMS practitioners is vital for the profession's ability to perform the its critical within emergency medical care. Since organisational behaviour theory can look at not only culture within an organisation but also the relationship an organisation has with broader society, it seems to have promise for addressing retention of responders within the EMS profession (Tsui et al, 2007).
Conclusion
The purpose of this theoretical concept paper was to spark a dialogue on some of the underlying issues affecting the retention of EMS personnel and the role organisational behaviour theory can have in addressing said issues.
While this paper is just a beginning, the systemic review and synthesis of the literature seem to show the benefits of using organisational behaviour theory and the application of its theoretical structures for future research.
Moreover, it appears organisational behaviour theory can play a substantial role in determining how comprehensive an investigation is, as well as the influence a study's recommended changes can have on future organisational policies and administration practices.
As noted in this paper, organisational behaviour theory can be used to advance the field of EMS research from the close-view perspective of EMS professionals as individuals within an EMS system, with each individual existing as a key player in the community of the emergency medical system culture (Schein, 2010; Russell, 2019). All past experiences each person has had shape their view of workplace encounters, and the collective sum of those encounters seems to have a connection to the responder's decision to leave the EMS field (Blau and Chapman, 2016).
Additionally, organisational behaviour theory can be used in a similar way on a broader scale (Follett, 1941). Examination of the provocation for a particular outcome or action within an individual organisation can be the starting point in identifying any patterns or potential chain reactions within an interconnected organisational system (Schein, 2010).