Changing the stagnant culture of rural EMS

3 steps to obtaining leadership buy-in to establish a training department or program


By Brent Crawford, MPA, NRP

Fewer things can be more detrimental to an EMS organization than becoming stagnant. Stagnation usually begins with just a few individuals, but can quickly spread throughout an entire organization.

There are a number of causes than can contribute to an agency becoming stagnant. Simple laziness, poor leadership, lack of training and resources, and insufficient funding can all play a role. While some agencies may have one or two of these issues, what about the agencies that have them all?

Trying to convert a stagnant organization into a proactive one is no easy task, but it can be done. (Photo/Getty Images)
Trying to convert a stagnant organization into a proactive one is no easy task, but it can be done. (Photo/Getty Images)

Rural EMS agencies are often tasked with trying to recruit good employees, while competing with the larger city fire and EMS departments. Often, the rural agencies are losing this battle. Many major cities have fire and EMS departments combined into one. These departments can offer better pay, better benefits, more vacation, civil service protection, state or hazard pay, and so on.

Many rural EMS agencies are just happy to be able to staff their ambulances week to week, let alone carve out time each month for training. Therein lies the problem; has this lack of training and education become acceptable practice? Smaller EMS agencies cannot be so content to be able to fill their schedules that they ignore their lack of training and education. While larger metropolitan departments have more resources, money, and established training departments, some rural EMS agencies are doing little to nothing to improve the skill sets and knowledge of their employees.

In the absence of leadership and quality assurance

Often, stagnation can be attributed to poor leadership at the top. Leadership issues are present in departments all across the country, regardless of the size, but may be more obvious in smaller organizations. The criteria for being the chief of a Class 1 Fire/EMS department is, undoubtedly, more complex than the criteria for being the chief of a rural EMS department that runs 1,800 calls a year and has a $700,000 dollar budget.

Typically, chiefs at large departments have not only been with their organizations for a number of years, but they also have college degrees, leadership training, and have spent time as a fire driver and captain. Some rural EMS agencies simply grab the paramedic who has the most years of service and put them in the boss’s chair. Smaller, more rural departments have fewer opportunities for advancement into those all-important leadership positions.

If the organization’s leadership doesn’t value training and education, the stagnant culture will take over. All of us in EMS have seen or heard of this happening, not just in rural EMS, but with larger organizations also. Protocols go years before being updated, ACLS, PALS and CPR courses are pencil whipped, and there is no quality assurance system in place to review run reports; so treatments – right or wrong – go unchecked. If the only education and training an organization is holding each year is its annual EMT refresher, then the EMS professionals are not going to function as effectively as they should.

3 steps to starting an EMS training program

So what can you do if you are at an organization that does not prioritize training and education? This can be a difficult field to navigate. The mere mention that your organization’s employees need to be receiving more training may cause some of those employees to resent you. Start by talking to your fellow employees and see if you can get a feel for how the majority of them view training. This is simple to do and can be easily brought up during back porch conversation, or at the dinner table.

Chances are, many of your colleagues will agree that the department could benefit from some more training and education. Once you have made the decision to take your concerns to administration, be prepared to face resistance. Nothing about beginning a training department, or even something as simple as monthly training sessions is easy. There are a few keys to success.

1. Get buy-in from the chief

The leader of the organization must fully support what you are trying to accomplish, and understand why it is needed. Make sure the chief understands this is not an attempt to further yourself personally, but something that benefits the organization as a whole.

2. Earn the medical director’s confidence and trust

This may actually be more important than winning over the chief. The medical director must have complete confidence and trust in you, and believe you are taking the responsibility of what you are proposing seriously.

3. Establish a QA program

This is a must. If you are not reading reports and seeing what medical errors are being made, how can you train and educate providers to fix them? Some mistakes may be localized to one employee, others may be systemic and require further intervention. If you are able to QA every report, do it! If you do not have the time or resources to view every report, develop a plan as to which reports you will review. This can be at random, or specific runs, such as trauma, CHF and diabetic patients, just as an example.

While there are certainly more factors that contribute to the success of a training program, these three are the most important to establish early. Be prepared for resistance in the beginning. This is change and stagnant departments do not like change; they want things to remain as they are. Remember, you are going to be asking more from your colleagues, and some will view additional training as nothing more than busy work, instead of an attempt to improve at their profession.

Protect your providers from paramedic malpractice

Change does not always equal stress; it can actually bring on the exact opposite. While the initial reaction for more training and education may not be a positive one from the employees, they will start having more confidence in themselves and in their treatments.

I tell my paramedics all the time, “If you are not studying your guidelines, not paying attention in monthly staff meetings, and rolling your eyes in our monthly simulation lab, then you are playing the odds, and hoping you don’t ever have a critical patient that you don’t know how to treat.”

Unlike city-based EMS agencies, rural EMS agencies often do not have the luxury of being within a 5-10 minute drive of the nearest emergency room. Those 30-40 minute transports with a critical CHF patient can feel like an eternity. What’s worse, it can feel even longer if you are trying to read the CHF protocol going down the road because you haven’t looked at your protocols in the last 6 months.

While I understand the headache monthly training can bring to an organization, it can also bring a sense of relief. Knowing your crew members have been given proper education and training, and given it often, brings a sense of confidence to the leadership of an organization.

In today’s lawsuit-friendly world, paramedic malpractice lawsuits are becoming more prevalent. Ask anyone in EMS who has ever been involved in a lawsuit for malpractice, one of the first records requested by the plaintiff’s legal team will be your training records. The plaintiff’s lawyers want to be able to show you’re not competent, and if the only records your agency has for you are a CPR, ACLS, PALS and refresher certificate (the bare minimum) this may help them make their case.

Trying to convert a stagnant organization into a proactive one is no easy task, but it can be done. Once you have buy-in from administration and the medical director, and you have set the standard for what the agency’s expectations are for their employees, the employees themselves will buy into the system you and your team have created.

Read next: 3 factors to change a stubborn EMS culture

About the author

Brent Crawford, MPA, NRP, is a national registry paramedic and the training officer for DeSoto Parish EMS in Louisiana. He is a NAEMSE certified EMS instructor and possesses a Master of Public Administration degree from the University of Louisiana at Monroe and a Bachelor of Science degree in Unified Public Safety Administration from Northwestern State University.

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