The purpose of this study was to identify the activities necessary to develop effective leaders within the emergency medical services (EMS) organisations. Leadership development is an important undertaking that influences staff retention, organisational performance and the long-term sustainability of any organisation.
Despite the differences that might exist between individual EMS agencies, there are commonalities between them—staffing shortages, budget constraints, supply chain disruptions and employee wage concerns are found in most of them. Both current and future prehospital leaders will have to confront these matters in a prehospital environment that is ever-increasing in complexity and chaos.
To meet this responsibility, EMS officers must have a firm grasp of their new role to lead and manage their staff effectively. While there are many ways to define both of these concepts, EMS leadership could be defined as the provision of strategic direction (e.g. cultural development and long-term organisational growth) and management as the delivery of short-term operational tactics (e.g. daily staffing and direct patient care). Each potentiates the other and, without at least some ability in both, those aiming to be leaders will not be effective (Kotter, 1990).
The author proposes that leadership development within EMS organisations is not widespread, and that this lack contributes to the ongoing staffing and morale issues affecting EMS organisations.
This article aims to add to the research on this subject by examining how current leaders overcame a lack of preparation to succeed in their leadership roles and proposes recommendations that future leaders within EMS professions can follow to be successful.
Literature review
A literature search using Medline, PubMed and Scopus with the keywords ‘Emergency Medical Services’, ‘Paramedic’, ‘Leadership’, ‘EMS’, and ‘Leadership Transition’ found few articles about the transition from paramedic clinician to leader that were not biased toward clinical topics.
Broadening the search to be more inclusive of other health professions revealed that nursing and physician leadership transitions were more widely studied. Article findings included the peer-to-boss phenomenon, overcoming a lack of management training, and the identification of specific traits or strategies to help a new leader succeed (Stoller, 2009; Wiggins, 2019; Perez, 2021; Sherman and Cohn, 2021). These topics were later confirmed to be relevant to this study by those interviewed.
In his multinational, qualitative study profiling emergency medical services leaders, Leggio (2014) determined that leadership could be both formal and informal in nature and identified traits his study participants felt those leaders should possess. In particular, strong communication skills, impartiality, professionalism and integrity were all felt to be essential. He concluded that further research was necessary to identify how these traits are learned and, by extension, taught, so that the field of EMS leadership could be developed further.
The article ‘The transition from clinician to manager: the paramedic experience’ not only met all search criteria but was also the inspiration for this study (Stewart et al, 2021). This study asked participants recruited from a large territorial ambulance service in Australia a series of questions designed to gain an understanding of their unique experience during their transition to leadership roles. Several common themes were found during the interviews, with some notable examples: the commonest themes were being underprepared for the new role by the organisation; and a feeling of being separated from clinical staff who used to be peers.
That study had two main limitations: a small sample size with a majority of men; and being restricted to a single ambulance service serving one geographic location. Despite those limitations, this study provides evidence that clinical staff looking for promotion to a leadership position should be actively prepared for the role to meet their full potential.
Survey methodology
Study participants were recruited using an email distribution list and social media. In total, 18 paramedic leaders chose to respond. The email distribution list was personally compiled and made up of ambulance service administrators throughout the state of Missouri in the United States.
Five participants were recruited by email and 12 by posting requests on the social media site Twitter between 2 June and 13 July 2021. One participant had an email forwarded to him and chose to participate because of that communication. These recruitment techniques may have introduced bias because of the selective nature of the email list and social media platform chosen.
Participants were chosen based on the following criteria: they had: to be a current or previously practising paramedic; work for a prehospital agency that provides ground or air transport EMS, first responder EMS, or search and rescue services with an EMS component; and have had responsibilities for either direct supervision of field staff or executive management of an organisation in the United States or Canada (Table 1). The one participant from Canada was removed from the study as they did not meet the criterion of direct supervision.
| Country | State | n |
|---|---|---|
| United States | Colorado | 1 |
| Georgia | 1 | |
| Illinois | 2 | |
| Missouri | 6 | |
| New Mexico | 1 | |
| North Carolina | 1 | |
| Ohio | 1 | |
| Tennessee | 1 | |
| Texas | 2 | |
| Virginia | 1 | |
| Total | 17 |
The study participants represented a wide range of both ground and flight EMS delivery models, such as hospital based (n=4), ambulance district based (n=3), fire department based (n=4), government based (n=1), air medical (n=3), training/regulatory (n=1) and non profit (n=1) from areas throughout the United States and Canada in urban, suburban and rural response areas.
Fifteen participants were male and two were female. All maintained a paramedic-level patient care licence, with two participants also maintaining concurrent nursing licences. The participants had a span of control that varied from 2–12 direct reports and a total staff of up to 300 employees who held a variety of roles (Table 2).
| Job Title | N |
|---|---|
| Flight program supervisor | 2 |
| District chief | 1 |
| Manager | 2 |
| Director | 4 |
| Emergency medical services chief | 1 |
| Regional manager | 1 |
| Chief medical officer | 1 |
| Training coordinator | 1 |
| Fire chief | 1 |
| Captain | 1 |
| Assistant division chief | 1 |
Video communication software platform Zoom was used to record interviews between 10 June and 27 July. The longest interview lasted 72 minutes and the shortest 21 minutes, with a mean of 40.5 minutes.
During the semi-structured interviews, the participants were asked seven standardised questions (Table 3). The seven main questions, some with associated sub-questions, were designed to obtain background information on each participant and their transition from frontline patient care provider to a leadership role. The last two questions were intended to gather information about how the participants were currently assisting in the leadership transitions of subordinates and to have each participant give what they considered to be their most important piece of advice for new leaders. All participants chose to answer all seven questions.
|
|
Results and analysis
Leadership development
All participants but one mentioned the lack of leadership development provided by employers before they assumed the new role, with the majority claiming never to have received any type of preparatory training.
‘Trial by fire’ or being ‘thrown into the deep end’ were used often to describe this period, and it was during this time that most participants first realised they needed to work on developing the skills they lacked.
‘I realized, if I don't figure out how to manage effectively, either I'm going to get fired because I can't do my job or, even if I don't get fired, we're not going to be effective.’
‘I quickly figured out, even though I had no idea what I was searching for, that if I didn't change how I was, I was going to be a bad leader. I was going to be detrimental.’
When asked how they prepared themselves, 13 respondents said they learned by working through the mistakes that either they or another leader had made:
‘Unfortunately, it was probably the school of hard knocks. I've had bosses, you know, over the years, or leaders over the years, and took things from each one of them that I felt they did well. And then I tried to avoid things that I thought they didn't do so well. Over the years, I combined the two into my own style.’
The one participant that received leadership training before assuming a formal leadership role within their agency was given mentoring sessions with current officers within the department, time within a ‘step-up’ leadership position and classes to understand departmental policies, procedures and guidelines. While this was far more than that received by the rest of the participants, it was still described by the participant as being inadequate for what was needed.
The most common reason given for a promotion was seniority, defined as either time as paramedic or total time at an organisation. This was acknowledged as being an archaic way to promote organisational leaders, and one that usually resulted in a poor manager:
‘EMS has always been the guy that's been there the longest generally gets the job. And we're trying to break that model.’
Two of those interviewed had experienced being promoted directly from a field-level position to the highest level of their organisation almost overnight:
‘The person who served as the chief before me was asked to resign—given the option to resign or the other option, which was to be terminated. As the board of directors was walking out, they asked me, they said “will you just keep the doors open until we can figure out what's going on?”’
In smaller departments where the leadership structure is typically flat, stepping into an executive-level position from the field and learning not just how to lead people but also the nuts and bolts of how to run an ambulance service with very little support proved to be difficult.
Participants 4 and 18 both had military backgrounds and gave a lot of credit for their current success to how they had been prepared to be leaders during their military careers. An emphasis on traits such as organisation, communication, task prioritisation and the acceptance of responsibility were all given as reasons for why a military background was valuable. Participant 18 also had a background in owning a business, which they said gave them a much broader base of skills and experience to draw from.
When asked how they could have prepared themselves differently given the opportunity, the most common suggestion given by the participants was that the transition process should be formalised within their organisation. This process should be started well before a position becomes vacant, rather than when a position becomes unexpectedly available.
‘I think if it had been a planned transition, it would have been a lot nicer. Having it be a middle of the night type transition, where it's the “you're going to be the deputy chief, that's your new job title” wasn't ideal, by any stretch of the imagination.’
Concentrating on the more transactional parts of the job, such as policy or protocol training, was acknowledged as important, but not at the price of neglecting the more transformational aspects such as how to communicate with, motivate and inspire staff.
Finally, since so many participants had been promoted at a young age, having a better understanding of what it meant to manage a team would have been another way they would have prepared themselves differently:
‘So on a personal level, I wish I knew… what actually is leadership? And I wish I would have taken the time to think about it more as a process of social influence rather than clinical competence. Just because I'm good at EMS, doesn't mean I have that skill set to lead people at an informal or formal level.’
Transition challenges
All study participants reported some common challenges during their transition from frontline patient caregiver to a new leadership role.
A common theme (mentioned by eight of the leaders) was being a peer one day then the boss the next. Field staff tend to distrust management, which can strain relationships once a person has moved into a leadership role:
‘In my mind, you know, these were my friends, these were my buddies, my pals, the ones we would go out on our days off and go floating and fishing… in my mind, I thought everything would go great because nothing would change. However, that did not occur. As soon as you go from working the truck to working the Tahoe [i.e. working as a supervisor] … you become the enemy.’
Two participants mentioned how isolated they felt in their new position. One said the experience of internal promotion from field staff to the EMS chief position was so terrible that if given a chance to relive the process, they would choose not to.
For seven participants, staff perceptions about both their age and total time as a paramedic were seen as being relevant to their management ability. Learning how to be comfortable making a decision despite opposition from senior staff and peers and not second-guessing themselves, was a skill learned over time.
‘If somebody who I'd previously viewed as more senior, who maybe was more experienced, in some cases significantly more experienced people who were working as paramedics when I was born. And when they didn't agree with what I thought was the right choice, being able to trust my judgement and the trust my leadership had placed in me in giving me this title and position.’
‘I was managing and supervising people who were more than twice my age in some cases. I was promoted at age 20… I was managing and supervising men who came out of World War II and Korea, that had 20, 30 years on. I never would have survived by saying, “I'm the boss, you listen to me”.’
Building strong relationships outside work was found to be a way to cope with both of these leadership transition challenges. Having a support structure outside the work environment made reliance on previous peer friendships less important and allowed new leaders to keep a healthy distance from subordinates.
Sexism was also cited as a challenge during the leadership transition for one participants. The two female participants reported that their organisations were still male-dominated, and that women often had a difficult time establishing their authority:
‘It is true. You often get attempts to be outspoken against. It's difficult. Oftentimes, when a man projects their voice or says something in a way, it's more militaristic, it's them getting their point across. If I do it, I'm the bitch. I'm just being a bitch that day.’
Mentoring
Mentor relationships, both informal and formal, were found to be invaluable by all the leaders. Two participants actively looked for mentors to gather focused feedback on their performance before deciding to apply for promotion; the rest all found mentors afterwards to help guide their development.
‘Mentoring usually takes the form of sitting on the ramp [e.g. apparatus bay] or sitting and talking to someone in their office and learning from them. You know, I learned a lot when I got brought down to fire headquarters and got put on the staff of a fire chief. I didn't realise he was mentoring me, and he didn't know he was mentoring me, but to be able to sit in his office and talk about different things was valuable.’
All participants used mentorship to develop their own frontline staff, understanding that they were the next generation of department leaders.
‘I try to keep them after calls, I try to discuss with them. Listen, this is why I did what I did. This is why I said what I said. This is what you need to think about. So they can understand why I made them do something they didn't want to do.’
Professional networking was also a way for new leaders to obtain support during transition. Six participants were members of professional organisations and used the connections they gathered to either obtain another leadership job elsewhere or to work through operational and interpersonal issues:
‘Early in my career, I didn't network and build relationships with people and that's one of the things that I find probably helps more than anything—having those relationships where you can call up someone, get advice or reach out to other people who have had a problem.’
‘You have to learn early on how important collaboration is. No one succeeds alone.’
One barrier to developing mentor/mentee relationships or networking was the interconnectedness of the prehospital professions, especially in niche specialties such as air medical transport. It is common for both field and administrative staff to have multiple jobs spanning different regions and agencies, some of which might compete directly with their primary job for 911 market share or interfacility transfer contracts.
One participant specifically mentioned feeling that sensitive information might be shared that would lead to either their clinical staff quitting or their own position being terminated.
Interpersonal dynamics
Developing interpersonal skills was another major topic of discussion among all of the study participants. Once in a leadership role, participants were faced with complex scenarios requiring the ability to effectively communicate, be receptive to feedback, delegate tasks, resolve conflict and collaborate, almost on a daily basis.
A key part of developing these skills is the concept of social intelligence. Described by Cantor and Kihlstrom (1985) as an individual's ability to solve social problems to achieve a goal, based on their beliefs and previous solutions to similar situations, social intelligence is developed through repetition. Participants said practice was key to developing interpersonal skills.
Before assuming a position of authority, clinical staff do not have management responsibilities to address difficult conversations between coworkers. Toxic behaviour can be ignored by staff in non-managerial roles. Shifts can be traded between staff members or bad behaviour dealt with for just that operational period.
‘As an employee, it's pretty easy to avoid difficult conversations—you can have somebody else above you in the chain of command handle those things. But, as a manager, you are kind of forced to do that.’
How to deal with problem employees was a critical skill to learn. It is necessary for leaders to address poor behaviour, for legal reasons or to preserve the organisational culture.
‘It's very challenging sometimes to deal with the same people over and over because, bad employees, they tend to stay. They leave a bad taste in your mouth, and they're frustrating sometimes. That's something you don't appreciate until you're doing it, how frustrating that can be.’
There was also an understanding that the farther up the management ladder you go, the less information you receive, either because of your job title or because of physical separation. For two of the participants, technology, such as smartphone apps used for communication (e.g. Slack and Zoom), was found to be a way to increase touchpoints with staff members who are geographically separated or who work outside management's typical working hours:
‘Communication is the biggest thing, just being so disconnected. I'm certainly not the only one facing that—COVID did that to everybody. You know, suddenly you were used to seeing people in the hallways and now they're miles apart and may never come back. There are a lot of people having to shift to this virtual leadership approach, which is certainly difficult in its own right.’
Patient care and staffing
All study participants believed that regularly providing direct patient care, participating in training opportunities or in some other way sharing in regular field operations gave them credibility and built up trust with line staff. This included working on holidays and weekends:
‘It helps me stay grounded as a leader. I'll still practise and pick up a shift if we're short. I like to work holidays—I've worked Christmas the last three years. It really helps with morale and shows that I'm willing to be in the trenches.’
There was an understanding that going out to the point where patient care is being performed was essential to understanding how decisions were affecting clinical staff:
‘The higher up I go in leadership, the less I hear about how things really are… it's not just the credibility piece—you get a deeper understanding of what's really going on. And I've noticed that I spot things nobody in the field would realise are an issue.’
‘It kinda gives us a pulse check for what the actual industry itself is doing. In the role that we're in, being regulatory, we can make a rule and not really think about the consequence of it or what it actually means for medics. It's definitely eye opening for those of us still on a truck, thinking this is how that's going to impact the actual people that are doing it, because it impacts us.’
One participant said that, as important as they felt demonstrating competence in patient care was, the credibility gained came at a greater cost for the overall organisation:
‘That's the justification everyone uses, but it's a double-edged sword. If you're providing direct care, you aren't doing your job.’
In addition to providing credibility, continued staffing issues throughout the profession have made it necessary for many leaders to provide frontline patient care.
All of the participants performed direct patient care on a regular basis. One regularly worked two 24-hour shifts a week and another averaged more than 100 hours a week for several months during the pandemic. Both of them did so to keep units in service and both were performing patient care in addition to their administrative duties.
The need to continue to be proficient at providing direct patient care could be compared to the United States Marine Corps' unofficial motto of ‘Every Marine a rifleman’. The cost of this ‘every medic a caregiver’ mentality was a level of underlying stress for many of the participants, with stressors related to keeping the same level of clinical competency as their field staff reported by all but two participants:
‘Yes, and I think a lot of that pressure is internal. When it's something you're not doing every day, and you want to stay relevant, there's some fear there… and as that interval gets longer and longer for me and it's been several weeks for me on the trucks, I start to feel it, I get a little jittery. Am I going to get that IV when I really need it, you know, am I going to get that tube if I really need it? Those skills are so perishable.’
Many of the study participants reported difficulty in striking a balance between building confidence in their new role and maintaining their old skillset. The cumulative stress of working to maintain both proficiencies undoubtedly contributes to leadership burnout throughout the profession.
Education and training
Formal education appeared to play a role in how prepared new leaders felt. Of the study participants, 72% have college degrees. Several reported having an associate or baccalaureate degree before taking a management position. Participants 18 and 5 had achieved advanced degrees at master's level or higher before their transition to leadership.
Degrees were seen as a way to hone communication skills and develop a broader base of knowledge outside emergency services. Common degrees were in business, healthcare administration, emergency management and public administration.
Several participants liked the idea of EMS moving from a technical programme to requiring a 2- or 4-year degree as a minimum requirement to enter the paramedic profession, but said they had no idea how to provide that for their staff with current financial constraints:
‘The way that we have grown clinically has gone from a technician to a clinician, and I think a formal education really helps bridge that gap… as we transition into that clinical role… in order to really be a competent clinician, we need a good amount of education for that.’
Boot camp-style manager or frontline supervisor classes were unknown, too expensive to attend or not an option because of staffing issues. Only one participant had attended such a courses to become credentialled before assuming a new management position.
Succession planning
Succession planning and leadership development were particular issues for the leaders interviewed. Four had hand selected members of their staff to follow them and had provided them with focused mentoring sessions to help them develop as leaders.
Those who were in executive management also supported the creation of informal pathways into leadership, such as field training officer or step-up/charge paramedic positions, to help build staff leadership experience early. Providing this type of early exposure to management has the added bonus of creating staff members who not only know the reason behind why decisions are made but can also support their leadership team by explaining decisions to their coworkers
‘I think it's also helped on a couple of fronts, because they've actually become advocates for leadership, because some of ours when their coworkers are complaining about a decision we've had to make about a transfer, they're like, “now hold on a second here—this is what these guys think about before they send you off. These are all the things they do to make sure it's the right thing to do and it's safe”.’
The most important thing was being active about looking for clinicians who might be interested in a future leadership position and providing focused feedback on how they could improve:
‘We have a lack of people, not a lack of opportunities, at this point. The way I think about it is, it's a pipeline to grow people into leadership roles and keep them in EMS and at our company. It's an ongoing challenge. You can't make a good field supervisor overnight.’
Advice for new leaders
As a final question, each participant was asked to suggest advice for clinicians looking to move into a leadership position. This learned wisdom ranged from how to manage yourself and manage others, communicate better and become more operationally efficient;
‘Find a system to keep track of details to help you recall information—notepads, organising your inbox or phone, whatever you need to do. Otherwise, you lose credibility.’
‘Manage your people like you're trying to help them, not punish them. Do not let staff see you as someone who is out to get them or hurt them in some way.’
‘Talk less, listen more.’
‘Pick your battles wisely—figure out what is important versus not worth fighting over.’
‘Don't be afraid to fail. On the clinical side, failure is not an option. Leadership does not work that way.’
‘It takes a village, so reach out to find mentors. Ask questions and don't try to do it all on your own.’
‘Educate yourself as much as you can on communication styles and techniques and learn when to apply them. One size doesn't fit all.’
‘Think outside the box. We are an innovative profession, remember that.’
‘Stay humble and check your ego.’
‘Get a mentor. Choosing a mentor is not easy—generally, you gravitate towards someone you like or who tells you what you want to hear, so choose them carefully.’
‘Your success is predicated on how you treat people—you will fail if you don't take care of your people or if you act like an arrogant boss.’
‘Leadership is risky. Even if you make what is the right decision, everyone might walk away not feeling super great about it. And that there are consequences to exercising leadership, even if you are doing it well and competently.’
‘Don't focus on the clinical aspects as much as you do on the people—everything comes from the relationships you build with people.’
‘Don't be scared of failure. You will fail and it's okay. If you fail and are willing to admit it, and work to change it, they'll stay by your side.’
‘You go from helping patients to helping your employees help patients. And if you understand that, then it becomes much easier.’
‘You're never truly prepared for this position. I don't think anybody is ever really, fully prepared to listen to what you're being told.’
‘Choose your battles wisely and leave your emotions out of it.’
Discussion
Despite differences in geographic area and workplace, all participants had similar experiences during the transition from frontline clinician to leader.
Only one participant was prepared before assuming a leadership role with their agency. That preparation consisted of informal mentoring sessions and courses to understand departmental policies, procedures and a period in a step-up leadership position. Even that degree of preparation was described by that individual as inadequate.
As modern EMS have existed in the United States only since the mid-1960s (Shah, 2006) the field of EMS leadership is still developing. Management degrees and leadership development courses specific to the profession have been available for decades but are costly and require a high time commitment on the part of participants; staffing levels and budgetary concerns prevent many agencies from supporting staff to enrol in them. Focus is placed instead on courses that improve clinical skills (e.g. airway or invasive skills labs) because of the relative ease with which the content can be delivered.
The skills required to be an effective clinical provider may overlap to a degree with those needed to be an effective leader, but they are not entirely the same. Success in one does not guarantee success in the other.
During a leadership transition, a person needs to learn their new role and any skills that accompany it, establish themselves as a credible manager and build momentum for any initiatives they may have, not to mention develop a different understanding of who they are and how they fit in their organisation. This can be a herculean task.
While opinions vary on how long it takes a new leader to complete the transition process, it has been suggested that it can take from 6 months to 3 years (Wiggins, 2019). Fewer than 50% of new leaders successfully manage their transition into a new leadership role, and leadership transitions have been rated as only less stressful than divorces (Wiggins, 2019).
The effects of poor leadership skills on an organisation can be substantial. Inefficient operations, reduced staff productivity, a lack of organisational focus and lower employee morale can all negatively affect customer satisfaction and increase employee turnover (Gonfa, 2019; Perez, 2021). It has also been estimated that the financial cost of replacing a leader after a failed transition can greatly exceed that person's yearly salary when both the direct and indirect costs are considered (Sherman and Cohn, 2021).
During their transition, the participants in this study found several methods of preparation helpful, with mentorship the most common. Both informal and formal mentorships were used to reduce stress, problem solve and sharpen leadership skills by enabling learning from someone with more experience or with a different point of view. In turn, the participants who found mentorship of value made a point of providing focused mentorship to their subordinates to prepare them for their own leadership transition.
The improvement required in interpersonal skills was the second most common theme found. Frontline clinicians are not often placed in situations where critical conversations are common outside patient interactions. To be successful, new leaders had to develop abilities to communicate, give and receive feedback, delegate tasks to subordinates, resolve conflict and collaborate with peers effectively. This was done primarily through repetition.
Participants had some issues in common, some of which proved to be substantial barriers to success. One was the continued provision of patient care. Clinicians who assume management positions are still expected to maintain their skill levels for a variety of reasons, such as credibility or to help during staffing deficits. However, continuing to stay current with equipment, protocols and skills was acknowledged to be a point of stress by all but two study participants.
Continuing to expect those in administration to maintain the same level of competence as when they were frontline providers undoubtably contributes to the high level of burnout at the leadership level.
Another issue was that of the peer-to-boss phenomenon, where an internal promotion to a management position occurs with little time for former peers or the new leader to adjust to the change in role. This experience was another large source of stress because of the loss of the previous social support structure and identity (Sherman and Cohn, 2021). Study participants found several ways to cope, including by finding a new support structure at their new peer level or outside the workplace, as well as by redefining their personal identity to include the leadership role.
Final issues during the transition period were of youth and gender. Participants who were younger than their staff reported it taking an appreciably long time to establish their credibility as a leader. Gender was also found to be a factor. One of the female study participants reported having issues during her transition establishing that her position was earned through merit and not because of her sex.
As EMS continues to become a more diverse profession, differences in race, gender and age at the leadership level need to be more widely supported by those in positions of influence.
Overall, study participants found moving to a managerial role from a patient-facing care role to be stressful and isolating, and caused considerable self-doubt. Previously, they had been able to depend on clinical acumen to work through difficult patient care scenarios but that clinical knowledge did not lend itself as well to difficult leadership situations.
Without adequate preparation, every leadership situation was found to be a novel one that had to be addressed with very little experience to draw upon. Because of this, paramedics looking to make the leap to management should look for opportunities to increase their experience level well before their promotion.
Despite the challenges they dealt with, most of the study participants would choose to repeat their leadership journey. Many spoke about how enriching their role was and acknowledged that they could affect organisational change and influence patient care beyond what they could do as field providers.
Recommendations
Regardless of what licence level a provider holds, preparing for a leadership position should be started as early as possible. This can be accomplished in several ways—by building leadership concepts into initial clinical education, by the creation of mid-level leadership positions at the agency level, and by individual clinicians seeking out educational opportunities on their own.
EMS education programme coordinators should emphasise leadership theory and practice in the classroom. The concepts that make up small unit leadership, such as the ability to plan in the short term, communicate effectively and delegate tasks are relevant in the clinical realm and should be introduced both early and often during initial education. Becoming proficient in these concepts will not only make students better clinicians when they graduate but also build habits that are necessary for a career in leadership.
Agency executives should provide staff with leadership potential experience early in their careers by creating mid-level, non-supervisory positions (Kotter, 1990). Positions such as field training officer or charge paramedic are excellent ways for prehospital agencies to develop their future leaders. These positions increase an organisation's capacity to onboard new staff and respond to incidents, while providing opportunities to gain real-world leadership experience.
Paramedics looking to make the transition from clinician to supervisor should actively look for opportunities to increase their knowledge base. Reading books about management and leadership, attending seminars and leadership courses, finding a mentor to emulate or deciding to pursue a degree are all ways in which field staff can gain leadership knowledge to improve their current and future practice.
Conclusion
In his book ‘Leadership without easy answers’, Heifetz (1994) offers an explanation for why leadership education is not routinely provided to those looking to assume leadership positions in EMS: ‘The myth of leadership is the myth of the lone warrior: the solitary individual whose heroism and brilliance enable him to lead the way.’
Paramedics continue to believe that promotions based on seniority or technical competence alone will succeed although the evidence does not confirm this as reality. Just as clinicians practise in an intentional way to administer medications or perform a medical procedure in the field, so should future leaders prepare to assume a leadership position. Competent leaders are created through meaningful practice, not born fully realised.
To effectively direct an EMS workforce, leaders must lead in an intentional way. Failing to prepare candidates for the challenge of management has led to technically proficient clinicians struggling to make the transition from patient care provider to supervisor. To successfully fulfil the requirements of their leadership position, participants had to work hard to educate themselves instead of being able to concentrate fully on their new role. This was found to be stressful and isolating, and was a considerable cause of self-doubt.
Because EMS are such a vital link in the health care continuum, if future prehospital leaders are not prepared for the responsibilities of leadership, that already precarious link will be in further danger of failing. More emphasis should be placed on how to prepare future prehospital leaders effectively for the realities of what it means to be both an administrator and people leader. Industry stakeholders (i.e. agency administrators, regulatory bodies and educators) must continue to emphasise how the paramedic profession can support the next generation of EMS leaders.
Limitations
Further research opportunities exist to study leadership development and the transition process more widely throughout the profession by interviewing clinicians from more varied backgrounds who are assuming new leadership roles in their organisations. Differences in gender identity, sex, sexual orientation, race, religion, age and geographic region may add to or amend themes found during this study and prove of great value to future paramedics transitioning to a leadership position.