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Decoding the stress in EMS

More staff, better leaders needed

Puzzle pieces with word ‘Stress’

“Poor leadership and staffing issues are notable stress-inducers among EMS personnel,” Duffee writes.

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In the What paramedics want in 2023 report, EMS1, Fitch & Associates and the EMS Survey Team unveiled poor leadership and staffing as critical issues causing widespread stress among EMS personnel. The findings reveal most respondents regard inadequate leadership as one of the most stressful aspects of their job [1]. Fill out the form on this page to download 8 leadership tips to improve your management acumen.

To understand the underlying reasons behind these findings, I undertook a comprehensive qualitative analysis of the data, allowing us to delve deeper into why respondents ranked certain factors as the most stressful. This analysis is particularly significant given that only 41% of the respondents were field providers, indicating a large portion of the feedback came from those in administrative and management roles. As I sifted through responses, distinct themes began to emerge from both the management and field staff sides. The responses from the management side revealed stress relating to staffing and recruiting challenges, while field staff responses painted a picture of stress stemming from poor leadership.


Management and administrative staff describe their big stress as difficulty with finding adequate staff. One respondent reported, “The stress of the job right now is all about having the folks to run the calls. We run a lot of calls each day and relying on the new generation to show up and continue to show up is very stressful. We do not have enough people to work as it is and then the people we do have, call off. Also, poor work ethic, ‘when the going gets tough ... they quit’.” This sentiment showing staffing frustration is prevalent and an obvious stress to the system that can increase the workload for field staff.

Toxic leadership

When it comes to field staff, many respondents described frustrations with pay, however, the most descriptive comments from the survey reveal a disturbing picture of toxic behavior and bullying by those in leadership roles. Some respondents noted that individuals in leadership positions would resort to “passive-aggressive behaviors” when they did not get their way, and such behavior was often tolerated by others in upper management. The presence of such toxicity creates a hostile work environment, increasing the stress levels of field staff [2,3].

Lack of competency among leaders was another major concern raised by respondents. Several respondents pointed out the lack of qualifications of their leaders, with one stating bluntly, “The agency director is unqualified.” Incompetent leadership and training voids can lead to mismanagement, confusion and inconsistency, which can exacerbate the stress experienced by field staff [4, 5].

Many agree poor leadership has a direct impact on morale and employee turnover. As one respondent aptly put it, “Poor leadership leads to lower morale which leads to people leaving the company. Everyone seems to leave bad management, not bad companies.” High turnover disrupts service continuity and places additional burdens on remaining staff, thereby increasing their stress levels [6].

Unrealistic expectations

Respondents also highlighted a disconnect between the realities of field operations and agency leadership. One respondent lamented that their “agency leadership is devoid of reality when it comes to the aspects impacting daily operations of field personnel.” This gap can lead to unrealistic expectations and demands, contributing to increased stress among field staff [7].

A concerning trend of promoting poor leaders was mentioned by a respondent who stated, “Our agency has a long history of poor leadership which encourages cyclical promotion of poor leaders.” This recurring pattern of promoting unqualified leaders can lead to ongoing issues such as unjust punishment from management, low morale, and low trust in leadership, all of which can cause significant stress [8].

Lacking support

Lastly, a lack of appreciation and recognition from management was highlighted as an issue. One respondent stated, “No one wants to work where you are not appreciated and are not paid enough for the very hard work that you do and no recognition.” Such an environment can lead to feelings of resentment and burnout, both significant contributors to stress [9].

The Peter Principle

The comments about poor leadership deserve some consideration. Are most EMS supervisors ever taught the skills required to manage people? The absence of proper management training in EMS means supervisors are often unprepared for the challenges that come with leadership roles. They may have excelled in their previous position as an EMT or paramedic, but managing a team requires a different skill set. Leadership involves planning, coordinating resources, decision-making, conflict resolution and effective communication. Without formal training, these supervisors can struggle, leading to inefficient operations, low morale and stress for field staff.

The Peter Principle, coined by Dr. Laurence J. Peter in 1969, posits that employees are promoted based on their performance in their current role, not on their potential to perform in the next role [4]. In the context of EMS, this means that an excellent paramedic might be promoted to a managerial position without the necessary skills to effectively manage a team. This can result in a decrease in productivity and effectiveness, as the person is now operating outside of their area of expertise.

Listen for more: Transforming EMS leadership: Beyond buzzwords to real change

In addition, the Peter Principle explains how newly promoted managers could suffer a decrease in job satisfaction. They may feel overwhelmed by their new responsibilities, leading to stress and burnout. To mitigate these issues, it is crucial to implement robust management training programs within the EMS field. Such programs should not only focus on developing technical competencies, but also on soft skills, like leadership, communication, decision-making and conflict resolution. Additionally, promotions should be based not only on performance in the current role, but also on the potential to succeed in the new role.

In general, this survey has unveiled that poor leadership and staffing issues are notable stress-inducers among EMS personnel. As we move forward, it is imperative to address these issues head-on because a properly trained manager can help foster a positive relationship between employees and supervisors that can help with stress containment and reduce turnover [10]. Implementing robust management training programs that focus on both technical and soft skills, as well as reconsidering promotion policies, could be key steps in alleviating these stressors and fostering a more positive, productive environment for all EMS personnel.


  1. EMS1, Fitch & Associates. What paramedics want in 2023. July 21, 2023.
  2. Winn, G. L., & Dykes, A. C. (2019). Identifying toxic leadership and building worker resilience. Professional Safety, 64(03), 38-45.
  3. Luong, A. D., & Green, C. A. (2023). Mental health and harassment in the workplace. Journal of Emergency Nursing, 49(3), 341-344.
  4. Ghinea, V. M., Cantaragiu, R., & Ghinea, M. (2019). The Peter Principle and the limits of our current understanding of organizational incompetence. Calitatea, 20(172), 74-77.
  5. Waller, J. (2022). Identifying effective paramedic leadership skills. International Paramedic Practice, 12(3), 55-64.
  6. Kaplan, E. (2021). Job Turnover of EMTs and Paramedics in the US: The Impact of Emotional Intelligence, Stress, Occupational Burnout, and Health.
  7. Örtenblad Anders. (2021). Debating bad leadership : reasons and remedies. Palgrave Macmillan.
  8. Blank, W. (2021). What Explains the Quality of Today’s Leaders?. Debating bad leadership: Reasons and remedies, 163-179.
  9. Luthans, K. (2000). Recognition: A powerful, but often overlooked, leadership tool to improve employee performance. Journal of Leadership Studies, 7(1), 31-39.
  10. De Clercq, D., Azeem, M. U., Haq, I. U., & Bouckenooghe, D. (2020). The stress-reducing effect of coworker support on turnover intentions: Moderation by political ineptness and despotic leadership. Journal of Business Research, 111, 12-24.
Bram Duffee, PhD, EMT-P, is the host of the vlog and podcast “EMS Research with Professor Bram.” He is an Institutional for Social Innovation Research Fellow at Fielding Graduate University and an Assistant Professor of Communication at Kennesaw State University. He is co-author of the book “Hypnotic Communication in Emergency Medical Settings: For Life-saving and Therapeutic Outcomes.” To connect with him or participate in a research study on first responder stress, visit