Table 4 Emblematic quotes and provider-suggested solutions for EMS working environment

Reduce excessive workloads

Increase hiring but prioritize retention

Incorporate more off-service time for education

Increased financial incentives for rural practitioners

Better targeted recruitment of the next generation of paramedics

The status quo of managing immediate challenges only is counterproductive, longer term solutions are needed.

Increased hiring was stressed to be unlikely on its own to result in quick improvements to working conditions.

New hires would benefit from the implementation of structured mentorship programs (i.e. Formal roles where staff could exercise leadership and directly provide better support to providers) to help with retention and address perceived gaps in knowledge.

Current incentives may not be adequate. Increased incentives may provide benefit from compensating any expanded roles necessary in rural areas.

More active and earlier recruitment is needed including targeting high school students, particularly in rural communities. Participants advocated specifically that grant funding be allocated to rural communities to train high school students as medical first responders, which would provide a starting block to a career in EMS. This was also mentioned as a potentially useful strategy for enhancing care in Indigenous communities, especially coupled with increased supports and scope of practice changes to facilitate community-based care.

“We’re having a huge influx of very new practitioners and a huge exodus of the old, experienced practitioners” (P1).

“Consequentially, we lose a lot of our new staff because the environment that they’re coming into is… it’s so toxic, and it’s so broken”(P15).

“I think better benefits and things like health benefits and spending accounts and things. I mean, those always attract people. Obviously more money. If you pay them more than the cities, then chances you’re able to attract at least some people out there” (P4).

“Bring in some of these local Indigenous students, who would be just incredibly phenomenal in a paramedic role and especially in some kind of community paramedicine role really targeted into their communities and their homes.” (P11).

Workplace

Culture Improvements Require Broader Progress First

Paramedics expressed near universal burnout within the profession. Significant psychologic effects of an EMS system perceived to be crumbling, associated moral injury and feelings of powerlessness were described. Providers indicated direct progress on changing culture in the near-term is likely to be infeasible. They could not propose any interventions on culture directly that were thought to have any potential efficacy.

“I think we work our full-time employees really hard, and they either burn out, which results in absenteeism, or they burn out, and they just become kind of emotionally shut down at work” (P16).

Change shifting patterns

Eliminate the Core-Flex staffing model in rural settings (often scheduling paramedics for 96 h at a time)

Providers need more flexibility including part-time options and options for variable shift lengths.

Consider establishing more flexible roles within the ED in rural areas, which would have potential advantages of facilitating learning and development, improving job satisfaction and helping address broader profound staff shortages in rural Eds.

“People don’t want to work full-time. So, trucks can’t reliably be staffed, which is the issue I’ve seen the most. And it just leads to an already under-resourced system losing more resources, which feeds into a negative feedback loop”(P18).

“Getting rid of core-flex but still having available housing to stay there. Core-flex is a nightmare. Nobody should have to work it, ever. I think that going to a fire-style schedule that has 24 hours on, 24 hours off, 24 hours on and five days off, would lend to more staff being inclined to go and stay for a 24-hour shift and then have almost a week off every time”(P10).

Expand competencies and roles for the profession

Define and expand “blended emergency response and clinical-based” (P7) roles

Participants suggested converting the two-year ACP Diploma to a four-year baccalaureate degree – bringing further credibility and rigour. More training also expands possibilities for use of new competencies and capabilities.

Creating mentorship and leadership roles will allow paramedics greater direct capability to combat attrition and manage the destiny of their environment. The relative skills rural paramedics have are often underutilized – expanded clinical roles and responsibilities could bolster human resources in small communities, improve access to care and potentially reduce the transfers of patients to more specialized facilities.

Expansion of MIH and ATR protocols would expand appropriate utilization of paramedic skills (concurrently hopefully reducing morale-draining underutilization) and reduce ED visits.

“Having our PCPs and our ACPs working at their full scope, moving to two-year diplomas and four-year degrees as the default for those qualifications” (P7).

“There’s a huge, huge potential for us to, not only through community paramedicine, the MIH initiatives, but with our treat and refer programs, for us to leverage our scope more fully with telemetry, with virtual communications.” (P7)