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What paramedics need to persevere

EMS1’s EMS trends state-of-the-industry survey provides targets for reducing stress, staffing challenges and leadership shortfalls


Issues that continue to impact EMS include the post-pandemic labor environment, financial factors that appear to be causing EMS to careen toward financial ruin, as well as an increase in violent interactions.

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Editor’s note: This article originally appeared in the EMS1 state-of-the-industry report. Download the full report, “What Paramedics Want in 2023".

By Jay Fitch, PhD

For the past 8 years, the EMS Trend Survey has chronicled what our profession feels are key concerns. Several overarching issues that continue to impact EMS include the post-pandemic labor environment, financial factors that appear to be causing EMS to careen toward financial ruin, as well as an increase in violent interactions. While these issues are not directly addressed by the survey, they certainly provide a context against which we can interpret the survey results.

Labor shortages across all business sectors (including EMS) have continued since the pandemic. Retention has remained the No. 1 critical issue facing EMS for 4 straight years. In EMS, recruitment and retention efforts have been exacerbated by the inability of agencies to provide competitive compensation packages as compared to other healthcare and public safety positions. For the past 2 years, pay and benefits have been consistently identified by nearly 9 out of 10 respondents as an issue impacting retention. Interestingly, career development and advancement were rated as a higher critical factor than in past years which is also likely impacting retention.


It’s clear that violence throughout American society has increased. A review of recent EMS1 articles includes several incidents in which medics and EMTs have been assaulted. Equally disturbing is the number of articles indicating EMS workers have been the perpetrators of assaults against patients. The EMS community was shocked when two Illinois providers were charged with first-degree murder over the death of Earl Moore, Jr., a patient restrained prone on an ambulance stretcher who then died of compressional and positional asphyxia. Other incidents have also been the subject of national media stories in recent months. This is one trend we don’t want to see expand in future years.

Staffing is the single-most identified issue that has increased provider stress, followed closely by concerns about leadership competency. Over 86% of respondents indicated their agency has experienced staffing challenges in the past 3 years. Being short staffed has also had direct operational impacts. Over 60% of respondents indicated their department had to respond to an increased number of calls outside their primary jurisdiction due to staffing issues at neighboring departments.

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Inflation and changes in payor mix have also impacted organizations’ ability to absorb the cost of increased wages. For years, it’s been well known that EMS costs are higher than Medicare reimbursement. To verify this, EMS agencies are now required to participate in the Medicare Ground Ambulance Data Collection System and report information on costs, revenues, utilization and other information. With many private insurance companies tying ambulance reimbursement to Medicare rates, it has also darkened the EMS economic outlook, requiring a number of agencies to request increased tax subsidies, reduce services or change delivery models.

While there is complexity in our profession, there is also an upside. If you are reading this report or were one of the more than 3,000 respondents, you are already on the positive side of the future equation.

Workforce trends and strategies

Turnover can be expected to continue. Based upon survey responses from 2022 to 2023 there is a significant (124%) increase in those planning to leave their employer in the next 3-5 years. Nearly half of respondents (48%) indicated they have considered leaving or retiring early due to staffing challenges. Compensation, poor leadership and stress were frequently cited as key reasons for turnover in the open-ended comments.


When asked what strategies have been used to attract more candidates in the past 3 years, the top responses were lowered educational requirements, reducing the minimum age and eliminating certification before hiring (e.g. paid time for initial training). The top recruitment strategies identified by respondents this year included employing a social media coordinator, participating in career fairs, using an on-line recruitment portal, stipends for equipment and cadet programs.

There are more Millennials and Gen Xer’s represented in today’s EMS workforce than ever before. Gen Z (those born between 1997 and 2012) will be an increasing segment of caregivers. Continued creativity will be required to both attract and retain younger generations of caregivers.

The impact of leadership

When it comes to retention, poor leadership was cited by 7 in 10 respondents this year (72%) as having an impact on retaining quality people. This is up from 64% last year. The open-ended comments clearly outline why caregivers are concerned about leadership. Here’s a sampling:


  • “The lack of leadership contributes to the lack of retention, recruitment and further short staffing ambulances to a busy 911 system.”
  • “Leadership is out of touch with personnel wants. They do not realize they are no longer innovative and believe there is no need for change in current department culture.”
  • “Poor leadership causes a lot of friction within an organization. Specifically, when there is not a lot of accountability for anything. Some do their jobs, some don’t. The ones that do have to do more and there’s no repercussions for the ones not doing what is required.”
  • “Our leadership feels threatened by anyone with more experience that offer solid ideas to assist them with their duties. Most of our leadership do not have the qualifications to hold their positions and lack the personality to be positive influences on the system.”
  • “More training is needed for EMS leaders at all levels.”

Yet only 14% or respondents noted their organizations frequently use internal leadership training (with another 28% using occasionally and 11% planning to adopt).


Directors responding to the survey were also concerned about their effectiveness leaders. One agency chief outlined the struggles they have trying to be a good leader, lamenting:

“The multiple issues related to lack of personnel have completely consumed my workday. Employees being mandated to work overtime which creates home-life issues, which causes unhappy employees. Retaining employees when other agencies are actively trying to steal them away by offering higher wages and sign-on bonuses creates a constant pressure to increase wages. AND while trying to do this, everyone from the Medicaid managed care folks to CMS/Medicare, to the commercial insurance providers are doing everything they can to reduce the amount they pay for our services. It’s gone beyond ridiculous what EMS has to do to be reimbursed for the service we provide...and to add insult to injury we’re only being reimbursed pennies on the dollar of our cost to provide the service.”

Leadership and career development is clearly an area that EMS needs to continue to focus on and invest resources in. Those efforts will pay dividends in terms of being able to retain valued caregivers.


Operational challenges, advancements

Staffing shortages have had a variety of negative impacts on EMS operations. In addition to the number of out-of-district responses previously outlined, 47% of respondents indicated that response times to time-critical calls have increased. Fifty-two percent indicated that non-emergent response times have increased. Nearly half of respondents (45%) indicated that safety education efforts including school visits and CPR training have been reduced.

On a more positive note, alternative treatment and transport modalities appear to be increasing.

Workplace stress

EMS is a stressful environment. This year’s survey included a number of questions about stress and its impact to help determine future workforce trends. In 2023, 63% of respondents indicated that staffing shortages have increased their stress levels. The downstream consequences are severe – 51% noted their stress level is negatively impacting their health, 41% noted their stress level is negatively impacting their relationships with their family and 30% noted their stress level is negatively impacting the quality of service they provide.

Next steps

If the question remains: is the future for EMS a half-full or half-empty glass, the answer is; it’s complicated. It will take a clear effort on the part of EMS leadership, perseverance on the part of caregivers, and investment on the part of politicians to move EMS trends in a positive direction. In this What paramedics want Digital Edition, find resources and strategies for taking the first steps towards filling the glass at your agency.

2023 survey demographics

Survey questions for the EMS Trend Survey were developed through a collaboration between EMS1, Fitch & Associates and the EMS Survey Team – which was instrumental in collection and interpretation of data. The EMS Trend Survey was conducted online in early 2023. The survey was widely promoted and open to any member of the EMS community.

A total of 3,141 responses were received from EMS professionals representing a wide range of service models across the U.S., U.S. Territories, Canada and overseas military. Respondents were primarily from suburban (36%) service areas, with 29% from rural and urban areas respectively, and fairly evenly split between service models.

The majority of respondents were Millennials (39%) or Generation X (34%); 65% were male; 74% were White; and 29% reported 4-10 years of EMS experience.

Forty-one percent of respondents were ground field providers (8% of those certified community paramedics), while another 41% described their role as supervisor or senior leadership. Seventy-six percent of respondents worked in paid roles (12% volunteer and 12% both). Sixty-five percent of respondents obtained a degree (25% associates, 27% bachelor’s, 11% master’s and 2% doctorate).

About the author

Jay Fitch, PhD, is a founding partner at the emergency services consulting firm, Fitch & Associates. He has nearly five decades of EMS/public safety experience and now serves as the executive director of the non-profit Fitch EMS Education Foundation.

For more than three decades, the Fitch & Associates team of consultants has provided customized solutions to the complex challenges faced by public safety organizations of all types and sizes. From system design and competitive procurements to technology upgrades and comprehensive consulting services, Fitch & Associates helps communities ensure their emergency services are both effective and sustainable. For ideas to help your agency improve performance in the face of rising costs, call 888-431-2600 or visit