Fitting the pieces together for an overall picture of health

(7 min read) Over the past few years, the focus of EMS research, best practice, and policy/procedure has taken a more selfish turn towards provider health and safety – and for very good reason.  As our workforce ages and the “sliver tsunami” comes crashing down upon us, EMS finds itself in an all-too-common scenario affecting specialized workforces across the nation.  Simply put, our knowledge and experience is retiring or moving on faster than it can be effectively replaced.  As in other industries, this creates a very real, multi-pronged problem, and highlights the need for immediate allocation of financial resources to leadership development, succession planning, and openness to working with consultants classified as EMS subject matter experts. 

But future planning initiatives such as these take time to reach maturity and yield benefits.  The knowledge and experience shortages of today will not be solved by these long-term strategic planning efforts.  For these reasons, the short term goal needs to be safeguarding and preserving our current workforce; considering work-life balance, physical and mental resiliency, and optimal career longevity as our primary elements of focus and strategy.

Many progressive agencies are already working diligently to implement the pieces of the provider health puzzle described above.  At first glance, every piece may take the shape of its own initiative with its own inherent implementation challenges and its own project champions working towards individual goals.  But treating every health and well-being effort as its own initiative runs the risk of missing the big picture and leaving the entire puzzle unfinished.  Only by creating a comprehensive plan which incorporates all aspects of provider and leader health and safety can an organization truly take the elusive next step towards self-actualization, and ultimately achieve these lofty goals. 

This plan must be bilaterally supported from the top-down and the bottom-up, and must promote honesty about current state as fervently as it promotes idea sharing about potential future states.  Existing structures like safety committees, RCA investigatory teams, HR just culture representation, and other forms of advisory panels must be incorporated into the decision support scheme, and the leader or leaders charged with prioritization and implementation must be familiar with best practices across the industry as well as project management and process improvement methodologies.  Perhaps the next round of NEMSMA leadership specialty designations (Quality Manager and Safety Manager) can provide some structure and validation for leaders assuming these roles in the near future.

And although each of these contributory elements will undoubtedly play a pivotal role in the creation of such a comprehensive approach to provider health, well-being, and longevity, the sustainability of such a plan will be determined by a far more important factor.  Organizational Culture.  Ultimately, in order for improvement and mitigation strategies to become cemented into the “who we are” and the “how we work” fabric of the agency or department, the initiatives need to resonate throughout the entire team in the following three ways:

1. Does the idea make sense? Is it grounded in fact, reason, logic, or research if available?
2. Does the idea fit into existing workflows, policies, procedures? Will it create friction or incongruence in daily organizational operations?
3. Do the positives outweigh the negatives for the individual? (followed by) Do the positives outweigh the negatives for the organization?

Often reconciliation of the first two questions is easier than reconciliation of the third.  Getting front-line providers and administrators alike to consider long-term benefits on equal footing with short term concessions is the inherent leadership challenge in any burgeoning profession, and the makeup of the workforce often plays a key role in a team’s willingness to sacrifice individual perks for collective improvements.  For instance, factors like benefitted to non-benefitted team member ratios, desire for employment stability vs higher compensation, etc., can certainly make “greater good” initiatives a tougher sell, and may indeed run afoul of entrenched values and norms. 

“My belief is that we are at a turning point in EMS, and as we stand on the shoulders of the EMS giants that came before us, we see plainly that no one, no matter how great, can do this job forever.  For this reason, it is my assertion that the ground is more fertile than it has ever been for changes such as the ones outlined above.”

One such strategy that affects our entire team from the leader to the rank-and-file, and has been proven to directly affect many important aspects of EMS care from professional longevity, to individual health, to skill proficiency and error prevention, is fatigue management and acceptable length of shifts.  This topic is truly one that hits home at every level, and understandably so.  I have had the pleasure of hosting two debates on the subject at large conferences within the past year, and the scope of discussion has been nothing short of staggering.

Leaders struggle as they attempt to balance team satisfaction and the personal financial needs of the providers on whom they rely with organizational mandates, best practice guidelines, and personal opinion (most of us are still providers at heart as well).  Although arguments like “we have always been ok doing 24 hour shifts in the past” are hard to justify (are you sure? And what’s your definition of “ok”?), more pragmatic concerns like “I have no control over what the provider was doing or where he/she was working prior to or after punching in/out” do pose very real challenges to the enforcement of any policy.

Front line providers often fall into three distinct categories:

1. Those that need a certain number of hours and overtime every pay period to make ends meet.
2. Those that are helpers at heart (aren’t we all) and can’t stand to see an open shift go unfilled if they are free.
3. Those that often go overboard looking to fill designed days off with “bonus” income through overtime or a second/third job.

At the heart of all three types above are our core personality traits as pre-hospital providers: independence and autonomy.  “If I say I can handle it, who are you to tell me I can’t?”.

Through this chaotic mess of conflicting information and interests, a few things have become clear to me regarding the way forward as a profession.  First, we must do everything possible to avoid the pitfall we blindly stumble into again and again in EMS – One Size Does Not Fit All! 

“Fatigue mitigation strategies should be personal to an agency or organization, and should be based on size, volume, deployment model, pace, complexity of cases, environment, distances travelled, service line, modes of transport, and countless other factors that differ ever-so-slightly or exponentially from organization to organization across the nation.” 

Adopting someone else’s canned fatigue mitigation policy is like wearing someone else’s uniform.  It isn’t going to fit right and it’s going to lead to a crisis of identity.  Second, it MUST be a team effort.  This one doesn’t happen top-down, or from external stakeholders.  Providing EMS care is too nuanced and too personal to exclude those that stand to gain or lose the most from the policies in question.  If ever there was a moment for true employee engagement and open lines of communication, this is it.  Our teams are our most important resource, they should have a say in the care they provide and the way they provide it.

Thankfully, on this particular topic within the overall EMS health and well-being landscape, we are not left alone to wander without resources.  More information and recommendations are coming out every year, and reliable resources are available through a variety of organizations.  Visit NHTSA’s EMS.gov and peruse the Projects section to find links to “Fighting Fatigue in EMS”. Included in this resource are links to the current evidence based guidelines and other supporting reference materials designed to assist teams in creating their own mitigation strategies.  And just as importantly, start your own conversation.  After two conference debate sessions and multiple internal discussions at my own agency, I am grateful to all who broadened my opinions and perspective on this crucial issue.  It is clear that consensus will take work and compromise, but I personally am optimistic that once our puzzle is assembled it will provide a clearer picture of who we are than we have ever seen before.