The Emergency Medical Services (EMS) profession was described as one with a profound sense of collegiality, team spirit and a culture of experts and colleagues (Brink et al, 2012). Within this environment and profession are EMS leaders tasked with organisational responsibilities and ensuring the response capabilities of a system. The roles of EMS leaders are known, but so are EMS leadership failures (Leggio, 2013). The EMS profession has been criticised as resistant to change due to tradition (Foster et al, 2011; Powers, 2006). Leadership and personality characteristics such as defensiveness, emotional instability, poor interpersonal skills and weak technical and cognitive skills have been attributed to the failures of EMS leadership (Cotter, 2005). The lack of formal leadership education in EMS has resulted in EMS leadership being learned by less than ideal on-the-job training, informal mentoring and experience (Leggio, 2013).
Background
The EMS profession has typically relied on a rigid and hierarchical structure that tightly controls employees through rewards and punishment, and this has resulted in high turnover rates and dissatisfied employees who are over-managed and under-lead (Powers, 2006). Leaders in EMS must allow vision and values guide their actions and transform employees from feeling powerless into self-actualised and empowered team members (Powers, 2006; Evans and Dyar, 2010). Transformational leadership is power with others and not to others, which requires trust, empowerment and a genuine concern for fair actions and treatment of all employees (Powers, 2006). The leaders in EMS need to see the big picture beyond processes and take responsibility for developing their followers (Foster et al, 2011).
Actions are the single most measurable conduct of an EMS leader and is a connection between transformational and military leadership (Porter, 2004). Military leadership is focused on actions and has been examined from an EMS perspective (Gienapp, 2005). Military leadership is guided by seven core values of loyalty, duty, respect, selfless service, honour, integrity and perseverance (Gienapp, 2005). The guiding principle of military leadership and decision-making is taking care of those you lead, or for EMS those you take care of. Leaders who failed to understand these values misunderstand military leadership (Gienapp, 2005). Military leadership is often mistaken for militant leadership, which demands absolute subservience, obedience and harsh leadership with no room for error (Gienapp, 2005; Powers, 2006). Lester and Krejci (2007) supported the military model of leadership in EMS because leadership training is stressed at all levels. This allows for lower ranks of soldiers to act in accordance of the mission when cut off from leadership. Catlett et al (2011) applied the importance of military leadership to EMS since initial responders may find themselves in the initial roles of a unified command.
Simply, leadership styles vary across the EMS profession (Hagen, 2012). The objective of this article is to discuss the profile of leadership characteristics and abilities that emerged from a larger study on how leadership is learned in EMS from a multi-national perspective of EMS providers working in Riyadh, Kingdom of Saudi Arabia (Leggio, 2013). Who is a leader in EMS, and leadership skills, qualities and characteristics of leadership that emerged within the data is the topic of this article. The other themes within the larger study will not be discussed.
Methods
Study design
A phenomenological qualitative methodology was applied in interviewing EMS providers from multiple nations working in Riyadh, Kingdom of Saudi Arabia. Creswell (2012) described how phenomenological studies research common meanings for individuals and their lived experience. The providers interviewed had a shared phenomenon of international EMS experience. For this study international EMS experience was defined as studying, training and/or providing EMS in more than one country (Leggio, 2013: 41–2).
Population and setting
The population of this study were EMS providers working in Riyadh, Kingdom of Saudi Arabia. Participants met specific criteria of:
In the Kingdom of Saudi Arabia approximately one fifth of the population are foreign national workers and can be found in all fields of employment (Central Intelligence Agency, 2013). The Kingdom of Saudi Arabia has promoted peace and cultural understanding as well as opportunity by sponsoring 120 000 Saudi students to study abroad (Royal Embassy of Saudi Arabia in Washington, DC, 2011). Therefore, given the international crossroads of education and experience this setting provided insights to the international community in terms of EMS leadership (Leggio, 2013: 42–3).
Instrument
The investigator sent his autobiographical statement and interview protocol to three individuals with international EMS and previous research experience to review for bias, ethical concerns and leading questions. Ten open-ended interview questions were developed to learn how those interviewed learned EMS leadership as a student and throughout their career. Interviews consisted of the following questions:
Procedure
The Institutional Review Board at Creighton University in Omaha, Nebraska, USA granted approval for the study. In May 2013 the investigator contacted EMS organisations in Riyadh, Saudi Arabia with a brief overview of the study, selection criteria and a request for assistance in identifying EMS providers to be part of this study. The investigator contacted the selected EMS providers by phone or e-mail and confirmed their willingness to be part of this study. Those who responded favourably were sent the written consent by email and scheduled an interview time with the investigator.
Data collection was scheduled to start on Saturday 1 June 2013 and end on Monday 1 July 2013. Prior to each interview the participant signed a written consent form. Recorded audio confirmation of the written consent being reviewed and signed by the participant was obtained.
Analysis of findings
Audio files from each interview were sent for transcription. Data was first manually analysed to identify themes. The data was then uploaded to NVivo 10 software (QRS International, Doncaster, Victoria, Australia) for digital analysis. All responses in each interview question were reviewed. Themes, patterns and meaningful segments were identified and coded. Artifacts within the data were identified and coded for further analysis. A final analysis of the data and original transcripts was performed. A final review of all transcripts was completed and found the identified themes and patterns were consistent with the original transcripts. Four super-oriented themes of 1) How Leadership was Learned; 2) Who is a Leader in EMS? 3) Leadership Skills, Qualities and Characteristics of leadership; and 4) Recommendations for the Future, with sub-themes were developed from the data set. Final themes and patterns that were supported by the literature were identified.
Validating the findings
Prior to collecting data the investigator preformed a bracketing session to discuss his autobiographical statement and biases with his dissertation chair. Each transcription was reviewed by the investigator and then sent to the participant for their review as a form of member checking. The investigator used two different transcription services. Each transcription service received an interview that the other had done. The investigator cross-examined the transcripts that both services transcribed and found insignificant differences. Coded artifacts within the data were triangulated and further evaluated by the investigator. Participants received the final study for review and were asked to provide comments. The dissertation chair served as the study auditor and reviewed all data, findings and conclusions.
Results
A total of 21 interviews were scheduled. A South African male paramedic and female paramedic from the United Kingdom cancelled their interviews for reasons unrelated to this study. They were asked to reschedule before 1 July 2013 and did not. A total of 19 interviews were conducted between 1 June 2013 and 9 June 2013 in person and included in this study.
A total of 13 paramedics, one EMT-Intermediate and five EMTs participated in the study. Participants collectively represented the nationalities of United States of America, Kingdom of Saudi Arabia, Germany, Philippines and Jordan. The participants had studied EMS or trained in the United States, Saudi Arabia, Germany, Canada, Philippines, Australia and Qatar. Participants reported being employed as an EMS provider in the United States, Saudi Arabia, Germany, Philippines and Qatar.
Participants entered into the profession between the years of 1975 to 1979 and 2000 to 2009. Ten participants reported completing a bachelor's degree, one completed an associate degree and two completed a master's degree. Following the interviews participants were contacted and asked to respond to an age group. Participants who did not respond were assigned an age group by the investigator based on dates within his or her interview. Ten participants were between the ages of 25 and 34 years. Six participants were between the ages of 35 and 44 years. Three participants were between the ages of 45 and 54 years.
Leadership roles
Participants reported that EMS leaders are not always found in formal leadership positions. As a participant stated, ‘I have experienced some good leaders within my organisation, but they are not necessarily in management’ (Leggio, 2013: 63). Participants described EMS leaders being both basic level and advance level providers, as well as instructors, dispatchers and medical directors. Participants described how EMTs are often not in leadership roles because they provide basic care, but are still capable of being viewed as a leader. Similar to EMTs, dispatchers can be leaders as they are responsible for knowing crew strengths, weaknesses and schedules when assigning EMS calls. Instructors were viewed as possible EMS leaders since they can role model leadership and professional behaviour in the classroom. Participants reported medical directors as possible leaders because they can directly impact patient care and EMS service capabilities. However, participants mostly focused on shift supervisors and EMS managers as being leaders. Participants considered these roles as mid-level management and not executive since these positions are focused on day-to-day operations and short-term planning (Leggio, 2013: 63–5).
Visible, confident communicators, listeners and problem solvers
Participants described how EMS leaders cannot be someone who sits behind a desk and is never seen or heard from. It was described as essential for EMS leaders to be visible within the organisation (Leggio, 2013: 81–2). Participants described how EMS leaders need strong communication skills and how with communication skills comes confidence. Participants summarised EMS leaders needing to be confident communicators (Leggio, 2013: 66). Participants emphasised this since EMS Leaders need to communicate with hospitals, colleagues, employees, patients and families. Included with communication skills was listening. Participants described listening as having the willingness to listen to the concerns and problems of others, which was described as an important component of being a confident communicator (Leggio, 2013: 65–7).
It was discussed how EMS leaders need to be able to solve problems and follow through on their decision. Participants described EMS leaders needing to negotiate or solve a problem in a way that addresses the concerns of everyone who wants to be right (Leggio, 2013: 67–9). This will require EMS leaders to make hard decisions and solve difficult problems as one participant stated, ‘this is why you are the leader’ (Leggio, 2013: 68).
Empowering and open to feedback
Participants emphasised how EMS leaders should not see themselves as centre of attention but as the organisation and employees (Leggio, 2013: 69). The importance of EMS leaders needing to empower employees to succeed by knowing the strengths and weaknesses of individual employees was described by participants. The importance of EMS leaders remembering to welcome and be responsive to feedback instead of talking down to their employees was discussed (Leggio, 2013: 69–70, 72). Participants described the need for EMS leaders to recognise when they need help and delegate authority to others when appropriate. Delegating authority was seen as another way for EMS leaders to empower employees (Leggio, 2013: 74).
Lead by example with integrity and taking responsibility
A participant described the measurement of EMS leadership as who is following you, and how this could either be a good or bad thing (Leggio, 2013: 75). Participants simply described the importance of EMS leaders leading by example with integrity and being accountable. Integrity was described as doing the right thing at the right time even when no one else is looking. Integrity included having the willingness to stand up for what is right by speaking up even if it meant sacrificing a leadership position for the right decision (Leggio, 2013: 94).
It was expected that EMS leaders stand up for what is right and have the ability to take responsibility for their own actions (Leggio, 2013: 73). The importance of actions as an EMS leader was emphasised; as a participant described, ‘you don't need the crown to be king, even though if they take your crown or leave it for you, you will be the king’ (Leggio, 2013: 82).
Be fair, separate personal from professional, team builders and focused on quality
Participants stressed the importance of EMS leaders being fair to others, which was described by a participant as the golden rule, ‘treat others the way you want to be treated’ (Leggio, 2013: 76). The EMS environment was described as one where many individuals closely work together and friendships quickly develop. The ability to recognise this and be able to be fair by separating professional from personal when making decisions was expected of EMS leaders (Leggio, 2013: 76–7). The EMS profession was described as a team-oriented environment, which is required to provide quality patient care. Participants emphasised the importance of EMS leaders being focused on quality patient outcomes in their decision-making.
Participants stressed the importance of EMS leaders being able to build teams in a way that took into account the dynamics of teamwork and relationships within EMS. Being able to identify available resources including the strengths of individual employees was described as a required step for developing teams and quality outcomes in EMS (Leggio, 2013: 81). A participant stressed the importance of EMS leaders understanding, ‘quality of the job is what it should be versus just getting the job done’ (Leggio, 2013: 81).
An experienced EMS provider and avoid tunnel vision by being proactive
Participants discussed the importance of EMS leaders first being good EMS providers to establish credibility and eliminate employee doubts of the EMS leader's abilities as a practitioner. Having EMS field experience would develop a real genuine concern for patient care, which was described as a requirement for EMS leaders (Leggio, 2013: 74).
Being able to avoid tunnel vision and remain open-minded were described as required abilities of EMS leaders. Tunnel vision was defined as, ‘when you only see what is in front of you, you don't see anything else that is behind those blinds on either side and you can't fully get a global view’ (Leggio, 2013: 79). Avoiding tunnel vision was deemed a requirement since EMS leaders are expected to take control of, or de-escalate, a situation or scene and function under stress (Leggio, 2013: 79–80).
Being a proactive EMS leader instead of reactive was described as a way to avoid tunnel vision. Being proactive was explained as avoiding the mindset of, ‘this is the way it has always been done and will continue to be done’ (Leggio, 2013: 79). Participants described how EMS can have a resistant nature to change, but stressed the importance of EMS leaders serving as change agents within their organisations (Leggio, 2013: 79).
Discussion
Within the data of a larger multinational study emerged the profile of an EMS leader. It is important to remember EMS leadership styles vary across the profession and one style may be better suited for a particular time or instance than another (Hagen, 2012). The findings supported the need of EMS leaders to empower and develop individual employees (Powers, 2006; Evans and Dyar, 2010; Leggio, 2013). The findings described an EMS leader who placed the EMS organisation first, employees as the centre of attention and took time to know individual employees by their strengths and weaknesses. Further, findings supported EMS leaders empowering employees with opportunities to contribute to the organisation by delegating authority and creating opportunities to assist in developing their fullest potential (Powers, 2006; Foster et al, 2011; Leggio, 2013).
The importance of actions emerged from the findings. EMS leaders need to take responsibility for their actions and act with integrity (Leggio, 2013). Connections were present in the findings between the importance of taking responsibility and integrity to the military values discussed by Gienapp (2005). When making decisions, EMS leaders need to focus on providing quality patient care and taking care of employees and this was similar to the guiding military value of decision-making based on taking care of those you lead (Gienapp, 2005; Leggio, 2013).
In their actions and decision-making or solving problems EMS leaders need to be fair (Powers, 2006; Leggio, 2013). Being fair included understanding how relationships are formed in EMS and having the ability to separate personal from professional (Leggio, 2013). It is essential for EMS leaders to have strong communication skills. EMS leaders must be able to inform others of decisions and serve as a liaison between an EMS organisation and other departments or institutes.
Being proactive instead of reactive is required of EMS leaders. They must avoid and be able to overcome the mindset of accepting the way it has always been as the only way. Adding to this challenge, EMS leaders must do so in a profession with a resistant nature against change (Leggio, 2013).
Developing an appreciation to the value of being seen within the organisation and understanding the importance of actions would be beneficial to EMS leaders. Being seen within the organisation as a proactive change agent open and responsive to feedback that empowers and develops employees is expected of EMS leaders. Regardless of being in a formal leadership role or not, EMS leaders need to remember that we lead and develop individuals, not manage them. (Leggio, 2013).
The call for further research on the topic of EMS leadership at all levels should not go unheard. The need to research the effectiveness of the abilities and characteristics in the findings is recommended. Additionally, there is a need to research and identify how these abilities or characteristics are learned or influence to further develop an understanding of how EMS leadership is developed (Leggio, 2013: 106–7).
Limitations
The data of this study was collected from 19 EMS providers from multiple nations working in Riyadh, Kingdom of Saudi Arabia in June 2013. Interviews conducted were only in English and the participants had completed EMS training or worked in at-least one country other than Saudi Arabia (Leggio, 2013: 4).
Conclusions
This study discovered connections between literature and data from a multinational study but could not fully support one leadership style over another in EMS. EMS agencies and educational institutes that develop EMS leadership courses need to understand how relationships are formed in EMS and the resulting challenges found within the profession. This study identified the importance of actions, the way EMS leaders interact with others and their ability to communicate and make decisions. These characteristics and skills are imperative across situations encountered by EMS leaders. This understanding of an EMS leader holds practical implications for continuing the development of the EMS profession and education standards and should not go unnoticed. The discussion specifically on EMS leadership is limited in research and literature. Further discussions on the topic of EMS leadership should continue through scholarly research, academic and professional settings (Leggio, 2013).