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2023 EMS Trend Report: Are We Causing the Stress in EMS?

2023 EMS Trend Report: Are We Causing the Stress in EMS?

Editor's Note: On July 21st, 2023, EMS1, Fitch & Associates, and the National EMS Management Association released their annual EMS Trend Report, proudly sponsored by Pulsara. Because the articles and advice found within contain such critical subject matter, we've elected to publish each segment one at a time here on our blog. Read, enjoy, share, and take to heart the following information brought to you by the most prestigious thought leaders in EMS. Today's entry is written by Anthony Minge, EdD, senior partner at Fitch & Associates. 


A closer look at the causes and effects of pressure, strain, and anxiety on the EMS workforce

Stress is taking a monumental toll on EMS. This year’s EMS Trend Survey found more than 80% of respondents experience moderate job stress, with 11% categorizing it as extreme. Over 40% of those completing this year’s survey felt that stress is negatively impacting their professional development, 30% feel it is negatively impacting the quality of service they provide, and more than 50% feel it is having debilitating effects on their health.

Leading Causes of Stress

Given the environment most EMS professionals work in, this is probably not surprising to most. What should be of concern is those stress-causing factors topping the list. While a variety of elements were identified, respondents ranked the most stressful aspects of their job as:

1. Poor agency leadership

2. Their direct supervisor

3. Personnel management/staffing

4. Salary

The last two come as no surprise and are not jaw-dropping to anyone who has been in or associated with the field for any length of time. Leadership being the top two stressors should be a shocker, though! Based on this year’s responses, we may be our own worst enemy.

Let’s focus on these issues in reverse order, starting with pay and working our way up to those top stressors.


It is not surprising that compensation continues to be a top concern. Salaries will continue to be an area of concern and focus for EMS until it becomes clear to Medicare and Medicaid (the top two payor groups for most every EMS agency in the U.S.) that the rate of reimbursement for EMS is not keeping up with the rising cost of providing these services.

It is not uncommon for EMTs, paramedics, and dispatchers to pull additional shifts and work more than one job to make ends meet. This causes other stressors, such as fatigue, lack of interest or time to participate in activities outside work, and reduced quality interaction with family and friends. Maslow’s Hierarchy of Needs lists food, water, and shelter as the most basic needs. Just above these basic needs, the Hierarchy lists safety and security, employment, family, and health. In order to maintain each of these at even minimal levels, fair compensation is required.

The HHS has set the 2023 Federal Poverty Level for a family of four at $30,000, or roughly $14.42 per hour. National averages for childcare for 2021 (the most recent statistic identified) ranged from $269 for afterschool care up to over $420 per week for two children for full-time daycare. A family with two children could be expected to pay more than half of an individual salary of $30,000 per year just on daycare services. Even if combined salaries are $60,000, this is still one-third of the household income. And, this doesn’t begin to account for fulfilling those other basic needs identified by Maslow.


The bottom line is that money is a huge stressor, and the EMS industry has not been able to reasonably accommodate the monetary needs of staff who are struggling to keep up with inflation and rising costs of the most basic necessities.

*One respondent noted, “I make $30 less than my RN partner for doing the exact same job,” and another noted, “I’m making less money as a 21-year medic than a brand-new RN.”

I think the stress-causing factors associated with pay were best summed up, however, by this comment: “When you worry about providing for your family, you are distracted. When you are distracted, you do not focus on other items that you should focus on, like improving your skills and teaching newcomers.” Stressed workers cannot do their best work because their focus is divided. When this happens, mistakes are certain to follow, which causes more problems, increasing stress levels, thus becoming a vicious cycle which can lead to a downward spiral for the employee and the agency.


Eighty-six percent of respondents reported experiencing staffing shortages in the past three years. Open positions create a great deal of stressors, including holdovers, additional shifts, and unbudgeted overtime. While additional shifts and pay may be welcome to those who identified pay as a stressor, it comes at a cost, leading to other issues that, you guessed it, cause more stress.

When staffing shortages lead to increased work on an often-overworked workforce, fatigue is imminent. Fatigue is associated with health complaints, including musculoskeletal issues, obesity, cardiovascular disease, and cancer.

In addition, fatigue can cause mistakes, from miscalculating a medication dosage, to missing symptoms, to driving safety issues. Stress and fatigue can impact judgment and may lead to a loss of respect for coworkers and leadership, and can even cause someone to doubt their self-worth.

Close to half of the people responding to this year’s survey said that their stress level has caused them to consider leaving the industry. This should be extremely concerning given the fact that most every agency in the post-COVID environment is experiencing some form of staffing issues. Losing experienced personnel while not being able to effectively and efficiently bring staffing levels up to acceptable minimums, much less full capacity, should be a cause for alarm.


Poor leadership and direct supervisors are the top two issues causing stress amongst our caregivers. This is not a badge of honor; rather, it warrants a plaque on the industry wall-of-shame.

It is often said that attitudes are contagious. When not handled appropriately, stress can be as well. Leaders who are under pressure may not realize that they are not processing the situations well and are negatively affecting their peers and subordinates. Thirty-three percent of respondents identified that their supervisor does not handle stress well, with 45% feeling that the general wellbeing of other EMS providers is impacted by the stress level of their supervisor. Finally, 42% said that their supervisor’s stress level has a direct impact on their stress level.


It is critical that leadership understand how their words and actions are impacting those around them and the department at large. This is not to say that supervisors, managers and directors must be immune to stress. The truth is, highly effective leaders may actually have more stress, and they work to reduce, relieve and prevent those problematic situations crews face. In order to remain effective, they must be able to recognize when their own stress levels may become harmful, resulting in undesirable attitudes and behaviors. Finding healthier means to deal with stressful situations will help the leader be the “calm in the storm” and can actually diffuse problematic situations. In doing so, the leader role models the benefits of a positive attitude, which can actually reduce the stress of those around them.

Leadership Red Flags

The rankings for leadership are gravely concerning. However, the open-ended responses to the question: “What are the three most stressful aspects of your job?” should be eye-opening. A few of the responses included the following verbiage:

  • “Stagnant”
  • “Bumbling moron”
  • “Doesn’t understand EMS”
  • “Zero trust”
  • “Micro-managing”
  • “Not engaged”
  • “An absolute joke”
  • “Lack of communication”
  • “Manager has a bad attitude”
  • “Inconsistent”
  • “Horrible at managing problems”

Impact on Caregivers/Patients

Stress can take a toll in a variety of negative ways, many of which can cause a caregiver to act out inappropriately. This can include behavioral issues; substance abuse; and even violence toward family, friends, coworkers or patients.

A stressed-out individual may turn to destructive habits. While tobacco and alcohol are the most common, drug abuse is on the rise. The Addiction Center reports higher levels of drug abuse by paramedics and EMTs than any other area of emergency response professions, citing stress as a potential cause.

Stress negatively impacts the service and the community. Paramedics and EMTs who have felt destructive pressure for too long may call off, leaving the agency scrambling to fill open shifts, potentially missing calls as a result of not being able to keep units on the street. Providers may also begin to exhibit disorderly or disruptive behavior. Left unchecked, this can have a harmful effect on the culture of the organization as others are often impacted.

Stress is having an increasing negative impact on not only patient care, but also caregiver attitudes and actions towards patients. Respondents reported their stress levels negatively impact the quality of service they provide (30%) and their rapport with patients (21%).

While it is well known that patient violence towards caregivers has been on the rise for several years, a more recent trend has shown paramedics and EMTs are becoming the aggressors. Recent incidents include:

While stress may or may not have been the contributing factor in each of these incidents, what is known is that the actions taken, or failed to be taken, are positively atrocious and cannot be tolerated. Are the pressures of the job creating such high levels of compassion fatigue that caregivers simply don’t care? We must question how we’ve gotten so far off track and identify how we reverse this trend.

How Do We, As Leaders, Fix the Root Cause of EMS Stress? 

1. Pay attention: Only 13% of leadership responders identify poor leadership as a major issue impacting retention, vs. 32% of field providers.

2. Show that you care: 36% of respondents do not believe their supervisor is actively working to reduce the stress levels of staff.

3. Actively manage your own stress: 29% of respondents report their supervisor’s stress level impacts their own.

4. Provide wellness programs and the time to use them: 24% of respondents are not aware of any behavioral health resources at their agencies, and 42% have had less time to access health and wellness support due to staffing challenges.

5. Support families: 38% of respondents report having to work more mandatory overtime due to staffing challenges, and only 11% report their departments offer stress and behavioral health support to their families.

6. Advocate for increased salaries: Use outcomes and impact data to advocate with payors and local stakeholders; and provide career advancement opportunities. Respondents rated salary and benefits the fourth most stressful aspect of their jobs, behind poor agency leadership, their direct supervisor and staffing.

Download the full 2023 EMS Trend Report

About the Author

Anthony Minge, EdD, is a senior partner at Fitch & Associates. He has more than two decades of leadership, revenue cycle management, compliance and healthcare business operations experience. Prior to joining the firm, he was the business manager for Northwest MedStar in Spokane, Washington.

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