FACTORS ASSOCIATED WITH WORKFORCE RETENTION AMONG EMERGENCY

MEDICAL TECHNICIANS IN MONTANA

Bobbi Jo Perkins, Jim DeTienne, EMT-B, Kevin Fitzgerald, EMT-P, Mary Hill, EMT-B,Todd S. Harwell, MPH

ABSTRACT

Objective. To assess potential factors associated withworkforce retention among emergency medical technicians(EMTs). Methods. In 2008, the Montana Department of Pub-lic Health and Human Services conducted a telephone sur-vey of a representative sample of licensed EMTs to assess fac-tors associated with workforce retention. Respondents wereasked whether they were considering leaving the professionin the next 12 months and the next five years. Respondentsconsidering leaving the profession in the next five years werealso asked to indicate why. Results. One thousand eight li-censed and practicing EMTs completed the survey (responserate = 53%). Nine percent of the EMTs were considering leav-ing the profession in the next year, and approximately onein four (24%) were considering leaving the profession in thenext five years. EMTs who were 50 years of age or older (oddsratio [OR] 1.78; 95% confidence interval [CI] 1.58–2.01), thosewho had worked as an EMT ≥10 years (OR 1.71; 95% CI 1.12–2.63), and those who were dissatisfied with the profession(OR 2.94; 95% CI 1.84–4.72) were more likely to be consid-ering leaving the profession in the next five years. Amongthose EMTs who were considering leaving the profession,most indicated that retirement (47%) was the primary reason,while fewer indicated that a career change (16%), personal orfamily issues (16%), organizational issues (13%), work hours(12%), job stress (11%), or pay/benefits (9%) were a reason forconsidering leaving the profession. Conclusions. Approxi-mately one in four EMTs in Montana is considering leav-ing the leaving the profession in the next five years. Effec-tive strategies to address EMT recruitment and retention areneeded. Key words: emergency medical services; emergencymedical technician; workforce; retention; rural; Montana

PREHOSPITAL EMERGENCY CARE 2009;13:456–461

Received December 1, 2008, from the Emergency Medical Services(EMS) and Trauma Systems Section, Montana Department of Pub-lic Health and Human Services (BJP, JDeT, KF, MH, TSH), Helena,Montana. Revision received February 18, 2009; accepted for publica-tion February 26, 2009.

Supported by the Emergency Medical Services for Children Programfrom the Health Resources and Services Administration, Rockville,Maryland (CFDA # 93.127).

The contents of this report are solely the responsibility of the authorsand do not necessarily represent the official views of the Health Re-sources and Services Administration.

Address correspondence and reprint requests to: Todd S. Har-well, MPH, Montana Department of Public Health and HumanServices, PO Box 202951, Room C-314, Helena, MT 59620. e-mail:tharwell@mt.gov

doi: 10.1080/10903120902935330

INTRODUCTION

Maintaining the viability of the emergency medicaltechnician (EMT) workforce is a significant concernfor local communities, states, and the federal govern-ment, and recruitment and retention of this workforcehave been identified as one of the key challenges need-ing to be addressed.1 Multiple issues have been iden-tified as potential factors associated with the recruit-ment and retention of EMTs, including the lack of com-petitive pay and benefits, the lack of recruitment pro-grams, the lack of career ladders within the profession,the lack of accessible education and training programs,licensure/ certification requirements, time commit-ment, occupational stress and burnout, the quality ofservice management and leadership, and the changinglevels of volunteerism.2–7 Rural communities face ad-ditional challenges to maintaining an EMT workforcein that many emergency medical services (EMS) sys-tems are staffed by volunteers.2,8–10 A survey of NorthDakota EMTs found that 32% overall thought that re-tention was a significant problem, and a larger percent-age of rural EMTs compared with urban EMTs thoughtit was a serious problem (36% vs. 29%).6 A recent na-tional assessment of the EMT workforce indicated thatdata necessary for conducting EMT workforce plan-ning are incomplete and that more research is neededto assess factors related to workforce retention.2

In 2008, the Emergency Medical Services (EMS) andTrauma Systems Section, part of the Montana Depart-ment of Public Health and Human Services (DPHHS),conducted a survey of EMTs in Montana. The objec-tives of this study were to assess factors and reasonsEMTs are considering leaving profession in the nextfive years.

METHODS

Study Population and Data Collection

Between January and March 2008, the MontanaDPHHS conducted a telephone survey of EMTs to as-sess workforce retention issues and training needs. Alisting of all licensed EMTs, which included first re-sponders (21%), basics and intermediates (70%), andparamedics (9%), was obtained through the Busi-ness and Occupational Licensing Bureau of the Mon-tana Department of Labor and Industry. A repre-sentative systematic sample of EMTs was selected

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Perkins et al. WORKFORCE RETENTION AMONG EMTS 457

FIGURE 1. Emergency medical technicians (EMTs) sampled and completing the survey, Montana, 2008.

from the population of licensed EMTs in the state(Fig. 1). Trained interviewers conducted the surveyusing computer-assisted telephone interviewing soft-ware (Survey System v9.0, Petaluma, CA). The ques-tionnaire was tested by DPHHS staff and EMTs in thefield prior to use to identify problems with the ques-tionnaire. Prior to administering the survey, a postcardwas mailed to all potential participants to notify themof the upcoming survey to assure them that the surveywas legitimate. Up to 10 attempts were made on tele-phone numbers not resulting in completed interviews(e.g., ring/no answer, answering machines). If poten-tial participants no longer lived at the listed house-hold or had a nonworking number, efforts were madeto determine the respondent’s residential telephonenumber using the telephone directory and Internetsearches.

Survey Content

The survey instrument included 74 questions andwas adapted in part from the National Registry ofEmergency Medical Technicians Longitudinal Emer-gency Medical Technician Attributes and Demograph-ics Study (LEADS).11 The survey included questionsregarding the respondent’s demographic characteris-tics, the characteristics of the respondent’s current jobas an EMT, questions regarding the last certificationtraining and refresher course, and recent EMT contin-uing education and training. Respondents were asked“How likely is it that you would choose to leave theEMS profession in the next 12 months?” The responsecategories included definitely would leave, probablywould leave, probably would not leave, and definitelywould not leave. Respondents who indicated that they

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458 PREHOSPITAL EMERGENCY CARE OCTOBER/DECEMBER 2009 VOLUME 13 / NUMBER 4

would not be likely to leave the EMS profession inthe next 12 months were then asked “How likely isit that you would choose to leave the EMS profes-sion in the next five years?” The same response cat-egories described above were used for this question.Respondents who indicated that they would be def-initely or probably likely to leave the profession inthe next five years were asked to identify reasonsthey were considering leaving the profession. Respon-dents could indicate multiple reasons for consideringleaving the profession. The responses to this ques-tion were grouped into the following categories: retire-ment, career (career change, lack of challenges on thejob), organizational (dissatisfaction with management,job training requirements, negative work relationshipswith other EMTs, organizational changes at work),personal/family (family issues, health-related condi-tions, moving to a new location), work hours (lackof flexible schedule, number of hours worked, timecommitments for job), job stress, and pay/benefits. Re-spondents were also asked “How satisfied are youwith the EMS profession?” The response categories in-cluded very satisfied, satisfied, neither satisfied nordissatisfied, dissatisfied, and very dissatisfied.

Respondents were also asked to identify the countyin which their main EMS job was located. The countyof practice was categorized as either an urban or afrontier county based on the five urbanization lev-els defined by Eberhardt et al.12 We combined smallmetropolitan counties (n = 2) and nonmetropolitancounties (n = 6) into the category defined as urban.The remaining 48 counties, defined as nonmetropoli-tan counties without a city of 10,000 or more popula-tion, were defined as frontier.

Human Subjects

Institutional review board approval for this workforceassessment project was not required by the MontanaDPHHS. Survey participation was voluntary and con-fidential, and there were no risks associated with par-ticipating in the survey.

Data Analyses

Data analyses were conducted using SPSS softwarev.14.0 (Chicago, IL). Pearson chi-square tests were usedto identify demographic and service-related variablesassociated with EMTs definitely/probably consider-ing leaving the EMS profession in the next five years(Table 1). Multiple logistic regression analyses wereused to identify factors independently associated withdefinitely/probably considering leaving the EMS pro-fession in the next five years. Each of the variablesassessed in Table 1 was block-entered into the logis-tic regression model. The final model –2 log likeli-hood, Nagelkerke R square, and Hosmer-Lemeshow

TABLE 1. Characteristics of the Emergency MedicalTechnicians Responding to the Survey, Montana, 2008

% (n)

EMT typeFirst responder 26 (270)Basic/intermediate 65 (667)Paramedic 8 (86)

GenderMale 63 (648)Female 37 (375)

Age18–34 years 24 (241)35–49 years 39 (388)50+ years 36 (363)

Education12 years or less 25 (250)Some college/college graduate 75 (756)

County of practiceUrban 41 (415)Frontier 58 (594)

EMS roleProvider 82 (839)Supervisor/manager 9 (96)Other 7 (74)

Position’s level of compensationNoncompensated 50 (510)Partially compensated 21 (210)Fully compensated 28 (287)

EMS agency typeHospital 11 (114)Fire 26 (264)Community/municipal 26 (266)Volunteer rescue 17 (175)

Other 19 (190)Time working as an EMT

<5 years 34 (349)5–9 years 21 (219)≥10 years 43 (444)

Satisfaction with the EMS professionVery satisfied/satisfied 91 (915)Neither satisfied nor dissatisfied/dissatisfied/very 9 (92)

dissatisfied

EMS = emergency medical services; EMT = emergency medical technician.

test statistics were 986.0, 0.14, and 12.55 (degrees offreedom = 8, p = 0.13), respectively.

RESULTS

One thousand one hundred one EMTs completed thesurvey, and the survey response rate was 53% (Fig. 1).Of these EMTs, 78 (7%) were not currently licensedand were excluded from the analyses. Of the remain-ing 1,023 EMTs, 15 did not respond to the questions re-garding whether they would be leaving the professionin the next one to five years and were also excludedfrom the analyses. The final sample size was 1,008.

The majority of respondents were EMT basic/intermediates (65%) or first responders (26%) (Table 1).Approximately two-thirds of the respondents weremen, and 60% worked in an urban county. Eightypercent of the respondents provided EMT fieldcare, and 50% were volunteers (noncompensated

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Perkins et al. WORKFORCE RETENTION AMONG EMTS 459

TABLE 2. Characteristics of Emergency Medical TechniciansConsidering Leaving the Profession in the Next Five Years,

Montana, 2008

% (n/N ) p-Value

Total 24 (245/1,008) —EMT type

First responder 24 (65/270) 0.72Basic/intermediate 24 (156/652)Paramedic 28 (24/86)

GenderMale 22 (143/638) 0.07Female 28 (102/370)

Age18–34 years 19 (46/241) <0.00135–49 years 17 (64/388)50+ years 35 (127/363)

Education12 years or less 24 (59/250) 0.75Some college/college graduate 25 (186/756)

County of practiceUrban 25 (103/415) 0.75Frontier 24 (142/593)

EMS roleProvider 22 (185/839) 0.01Supervisor/manager 37 (35/95)Other 34 (25/74)

Position’s level of compensationNoncompensated 23 (117/509) 0.23Partially compensated 24 (51/210)Fully compensated 27 (77/287)

EMS agency typeHospital 33 (28/114) 0.42Fire 21 (56/264)Community/municipal 20 (53/266)Volunteer rescue 25 (44/175)Other 29 (54/189)

Time working as an EMT<5 years 18 (61/344) <0.0015–9 years 19 (42/218)≥10 years 32 (141/439)

Satisfaction with the EMS professionVery satisfied/satisfied 22 (205/915) <0.001Neither satisfied nor dissatisfied/ 44 (40/92)

dissatisfied/very dissatisfied

EMS = emergency medical services; EMT = emergency medical technician.

position). Fire- and community/municipal-based ser-vices were the most frequently identified agencytypes (26%), followed by other (19%) and volun-teer rescue (17%). More than 40% of the respon-dents reported working as an EMT for 10 years ormore. Ninety-one percent of the respondents indicatedthey were very satisfied or satisfied with the EMSprofession.

Overall, 9% (n = 87) of the respondents indicatedthat they were definitely/probably considering leav-ing the profession in the next year, and 24% (n = 245)indicated they were definitely/probably consideringleaving the profession in the next five years (Table 2).Women, respondents aged 50 years and older, super-visors/managers, respondents working as an EMT for10 years or more, and respondents who were dissat-isfied with the EMS profession were more likely to

TABLE 3. Factors Independently Associated with EmergencyMedical Technicians’ Considering Leaving the Profession in

the Next Five Years, Montana, 2008

Odds Ratio (95% CI) p-Value*

EMT typeFirst responder 1.16 (0.57–2.58) 0.68Basic/intermediate 1.17 (0.63–2.20) 0.62

Gender—female 1.41 (1.00–1.98) 0.05Age 35–49 years 0.64 (0.40–1.03) 0.02Age 50+ years 1.78 (1.58–2.01) <0.001Education 12 years or less 0.99 (0.68–1.43) 0.94Small urban county of practice 1.14 (0.79–1.65) 0.49EMS role

Provider 0.71 (0.41–1.23) 0.22Supervisor/manager 1.49 (0.73–3.03) 0.27

Position’s level of compensationNoncompensated 0.86 (0.55–1.35) 0.52Partially compensated 0.99 (0.59–1.67) 0.98

EMS agency typeHospital 1.30 (0.75–1.74) 0.35Fire 0.62 (0.29–1.32) 0.06Community/municipal 0.63 (0.39–1.03) 0.06Volunteer rescue 1.00 (0.59–1.70) 0.99

Time working as an EMT5–9 years 0.99 (0.62–1.59) 0.98≥10 years 1.71 (1.12–2.63) 0.01Not satisfied with the EMS 2.94 (1.84–4.72) <0.001

profession

*Referent groups: EMT type (paramedic), gender (male), age (18 to 34 years),education (some college/college graduate), EMS role (other), position compen-sation (fully compensated), EMS facility type (other), years worked as an EMT(0–4), and satisfaction with EMS profession (very satisfied/satisfied).CI = confidence interval; EMS = emergency medical services; EMT = emer-gency medical technician.

indicate that they were definitely/probably consider-ing leaving the profession in the next five years com-pared with respondents who did not have these char-acteristics (Table 2). After adjusting for multiple factorsusing multiple regression, only dissatisfaction withthe EMS profession, respondent age (≥50 years), andlength of service as an EMT (≥10 years) were indepen-dently associated with definitely/probably consider-ing leaving the EMS profession in the next five years(Table 3).

Among the respondents indicating they woulddefinitely/probably consider leaving the EMS pro-fession in the next five years, approximately halfindicated that retirement was a major reason (47%).Fewer respondents indicated that a career change(16%), personal or family issues (16%), organizationalissues (13%), work hours (12%), job stress (11%),or pay/benefits (9%) were a reason for consideringleaving the profession. Compensated EMTs weresignificantly more likely than noncompensated EMTsto indicate that a career change (25% vs. 6%, p ≤ 0.05)and pay and benefits (13% vs. 4%, p ≤ 0.05) were areason they were considering leaving the profession inthe next five years (Fig. 2).

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460 PREHOSPITAL EMERGENCY CARE OCTOBER/DECEMBER 2009 VOLUME 13 / NUMBER 4

FIGURE 2. Reasons for considering leaving the emergency medical technician profession in the next five years, Montana, 2008.

DISCUSSION

Our findings suggest that approximately one in fourEMTs in Montana was considering leaving the pro-fession in the next five years. Those EMTs who wereolder, who had longer tenure in the profession, andwho were dissatisfied with the profession were morelikely to be considering leaving the profession in thenext five years. We did not find an association be-tween the geographic location of practice (urban vs.frontier) or the position’s level of compensation withEMTs’ intentions to leave the profession. Among theEMTs who were considering leaving the profession,approximately half indicated that retirement was theprimary reason. EMTs receiving compensation weresignificantly more likely than noncompensated EMTsto indicate that a career change and pay and benefitswere a reason they were considering leaving the pro-fession in the next five years.

Relatively few studies are available for comparisonregarding individual-level issues of EMT retention.Patterson and colleagues, utilizing data from the 2003LEADS project,13 found that a range of 6% of EMT-basics and EMT-paramedics across very small com-munities (<2,500 persons) to 4% of EMTs in largermetropolitan areas (≥75,000 persons) were consideringleaving the EMS profession in the next 12 months.13

We found a slightly higher percentage of EMTs consid-ering leaving the profession in the next year (9%). Thisdifference may be due in part to methodologic differ-ences between our assessment and the LEADS project(e.g., mailed survey, lower response rates), sociode-mographic differences between EMTs in Montana andEMTs in the entire United States, and other potentialfactors. The Journal of Emergency Medical Services(JEMS) 2008 salary and workplace survey found an at-trition rate of 11% among full time EMTs nationally.14A2004 survey of volunteer EMTs in Nebraska found that78% of EMTs less than 40 years of age and 64% of

EMTs greater than 40 years of age intended to remainin the profession for five years or more.10 We foundthat 84% of EMTs less than 40 years of age and 64% ofEMTs greater than or equal to 40 years of age in Mon-tana indicated that they were not intending to leavethe profession in the next five years. We were unableto identify other similar studies of nurses and other al-lied health professionals in Montana or in the UnitedStates for comparison.

Limitations

There are a number of limitations to this study. First,our findings are based on a telephone survey, whichhas several limitations. However, our overall surveyresponse rate was relatively high. Second, we did notmeasure all potential factors that may be associatedwith intentions to leave the EMT profession such as li-censure and certification requirements or the qualityof service management. These and other factors maybe associated with EMT retention. Third, this assess-ment was conducted among EMTs in Montana andmay not be generalizable to other geographic regionsof the United States.

Conducting assessments such as this is one strategyfor states to more clearly define the problem of EMT re-tention in their jurisdictions. The findings can be usedto establish a baseline measure for improvement. Theinformation can also be used by state and local pro-grams, advocates, and policy makers to identify po-tential solutions. A number of potential strategies arebeing considered to address this problem in Montanasuch as providing state income tax breaks and fundingfor a retirement program for volunteer EMTs, and pro-viding funding to support ongoing EMT and servicemanager training. Strategies are also needed for non-volunteer EMTs to create a career ladder that allowsthem to progress to higher levels of responsibility andcompensation within their agencies.

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Perkins et al. WORKFORCE RETENTION AMONG EMTS 461

CONCLUSIONS

Our findings suggest that a considerable proportionof EMTs in Montana are considering leaving the pro-fession in the next five years. The EMTs who wereolder, those who had longer tenure in the profession,and those who were dissatisfied with the professionwere more likely to be considering leaving the profes-sion in the next five years. Overall, the primary reasonEMTs were considering leaving the profession was re-tirement. Paid EMTs were more likely than noncom-pensated EMTs to indicate that a career change andpay and benefits were a reason they were consideringleaving the profession in the next five years.

We thank Linda Priest and the staff members from Northwest Re-source Consultants for their work conducting the telephone survey.

References

1. National Highway Traffic Safety Administration. EMS Agendafor the Future. Washington, DC: National Highway Traffic SafetyAdministration, 1996. Available at: http://www.nhtsa.gov/people/injury/ems/agenda/emsman.html. Accessed October17, 2008.

2. National Highway Traffic Safety Administration. EMS Work-force for the 21st Century: A National Assessment. Wash-ington, DC: National Highway Traffic Safety Administration,2008.

3. Freeman VA, Patterson D, Slifkin RT. Issues in staffing emer-gency medical services: results from a national survey of lo-cal rural and urban EMS directors. Final report number 93.Chapel Hill, NC: North Carolina Rural Health Research and Pol-icy Analysis Center, University of North Carolina at Chapel Hill,2008.

4. Patterson PD, Probst JC, Leith KH, Corwin SJ, Powell MP. Re-cruitment and retention of emergency medical technicians: aqualitative study. J Allied Health. 2005;34(3):153–62.

5. Brown WE Jr, Dawson D, Levine R. Compensation, benefits,and satisfaction: the Longitudinal Emergency Medical Techni-cian Demographic Study (LEADS) project. Prehosp Emerg Care.2003;7:357–62.

6. University of North Dakota. Recruitment and retention issuesamong North Dakota EMS personnel. Grand Forks, ND: Univer-sity of North Dakota, March 2000.

7. Virginia Department of Health. Keeping the best—how to lever-age retention of Virginia’s EMS professionals. Richmond, VA:Virginia Department of Health, April 2005.

8. McGinnis KK. State EMS Rural Needs Survey 2004. Availableat: http://www.nasemsd.org/Projects/RuralEMS/documents/RuralNeedsSurvey2004.pdf. Accessed February 17, 2009.

9. Office of Rural Health and Primary Care. A quiet crisis: Min-nesota’s rural ambulance services at risk. Minnesota Departmentof Health, December 2002. Available at: http://www.health.state.mn.us/divs/orhpc/flex/rasstudy.html. Accessed Febru-ary 17, 2009.

10. Ullrich F, Mueller KJ, Shambaugh-Miller M. Emergency med-ical service volunteer personnel in Nebraska: workforce ofthe present, hope for the future? Nebraska Center for RuralHealth Research. December 2004. Available at: http://www.unmc.edu/rural/documents/ne-ems-report-final.pdf. AccessedFebruary 17, 2009.

11. Brown WE Jr, Dickison PD, Misselbeck WJ, Levine R. Longi-tudinal Emergency Medical Technician Attribute and Demo-graphic Study (LEADS): an interim report. Prehosp Emerg Care.2002;6:433–9.

12. Eberhardt MS, Ingram DD, Makuc DM, et al. Urban and Ru-ral Health Chartbook: Health, United States, 2001. PublicationN. (PHS) 01-1232. Hyattsville, MD: National Center for HealthStatistics, Centers for Disease Control and Prevention, Depart-ment of Health and Human Services, 2001.

13. Patterson PD, Freeman VA, Moore CG, Slifkin RT. North Car-olina Rural Health Research and Policy Center. Becoming anEmergency Medical Technician: Urban–Rural Differences in Mo-tivation and Job Satisfaction. No. 89. Chapel Hill, NC: Universityof North Carolina, March 2007.

14. Williams DM. JEMS 2008 salary & workplace survey: so, re-mind me again why EMS is a good job? J Emerg Med Serv.2008;33(10):48–64.

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