Correlates of intent to leave joband profession for emergency

medical technicians andparamedics

Susan A. ChapmanSchool of Nursing, University of California, San Francisco (UCSF)

San Francisco, California, USA

Gary Blau, Robert Pred and Andrea B. LopezTemple University, Philadelphia, Pennsylvania, USA

Abstract

Purpose – A very limited number of studies have explored factors related to emergency medicalservices (EMS) workers leaving their jobs and the profession. This paper aims to investigate thecorrelates of intent to leave EMS jobs and the profession and compared two types of workers:emergency medical technicians (EMTs) and paramedics.

Design/methodology/approach – A national sample of 308 EMTs and 625 paramedics respondedto a cross-sectional survey. Independent variables were personal, job related, and work attitudes (jobsatisfaction). Outcomes were intent to leave job and profession. Analytic methods included factoranalysis, t-tests, correlation, and hierarchical regression.

Findings – Factor analysis identified a five-item intrinsic job satisfaction measure and a four-itemextrinsic job satisfaction measure across both samples. Contrary to what hypothesis one predicted,paramedics had lower extrinsic job satisfaction than EMTs. There was no difference between thesetwo groups on intrinsic job satisfaction. Consistent with the second hypothesis, after controlling forpersonal and job-related perceptions, extrinsic job satisfaction was negatively related to intent to leavejob and profession for both EMTs and paramedics. However, intrinsic job satisfaction was negativelyrelated only to intent to leave the profession for paramedics.

Research limitations/implications – Future research efforts might utilize stronger measures andincorporate longitudinal methodologies to further explore the career intention of EMS workers andsimilar occupational groups.

Originality/value – This paper examines job satisfaction and job and career intentions in a rarelystudied occupation that provides critical prehospital emergency care to the population.

Keywords Job satisfaction, Employee turnover, United States of America, Medical personnel

Paper type Research paper

IntroductionThere is growing awareness of problems with recruitment and high turnover in theemergency medical services (EMS) profession (Brown et al., 2003; Chng et al., 2001;National Highway Traffic Safety Administration, 2008; Patterson et al., 2005). In 2004,state EMS officials ranked recruitment and retention as the most important issuesfacing rural EMS agencies (McGinnis, 2004). In 2007, the National Conference of StateLegislators (NCSL) held special sessions on the state of the EMS workforce during itsannual meeting (Goodwin, 2007). The overall purpose of this study was to assist in

The current issue and full text archive of this journal is available at

www.emeraldinsight.com/1362-0436.htm

Correlates ofintent to leave job

and profession

487

Received 22 December 2008Revised 9 June 2009

Accepted 10 June 2009

Career Development InternationalVol. 14 No. 5, 2009

pp. 487-503q Emerald Group Publishing Limited

1362-0436DOI 10.1108/13620430910989861

filling a research gap and compare Emergency Medical Technicians (EMTs) toparamedics on intent to leave job and profession.

Need to study EMS job satisfaction, intent to leave the job, and intent to leave professionEMS is present in virtually every community in the USA in some capacity. Toillustrate the importance of EMS in the US, it should be noted that the federalgovernment spends approximately three billion dollars annually (Medicare andMedicaid) on EMS care that is provided by an estimated 18,000 EMS agencies andEMS personnel (Committee on the Future of Emergency Care in the US Health System,2007). As the US population continues to grow and the proportion of the elderlyincreases, EMS utilization is expected to increase as well (Committee on the Future ofEmergency Care in US Health Committee on the Future of Emergency Care in the USHealth System, 2007). The four most commonly recognized types (levels) of EMSprofessionals include the First Responder, EMT-Basic, EMT-Intermediate, andEMT-Paramedic (www.nremt.org). This study is focused primarily on EMT-basics(referred to as EMTs) and EMT-paramedics (referred to as paramedics) who comprisethe majority of personnel performing emergency (911) and interfacility transportfunctions. The Bureau of Labor Statistics (BLS) projects that over 62,000 additionalEMTs and paramedics will be needed over the next decade to fill new positions andreplace workers who leave the profession (US Bureau of Labor Statistics, 2006). Thisexpected demand for an increase in the number of EMTs and paramedics underscoresthe need to understand factors affecting job retention as well as occupational retention.

EMT and paramedics have differing usual job duties, also referred to as scope ofpractice. EMTs perform basic skills and non-invasive procedures focused on the acutemanagement and transport of critical and emergent patients (National HighwayTraffic Safety Administration, 2007). The paramedic scope of practice includes moreadvanced skills such as airway intubation and pharmacologic interventions (NationalHighway Traffic Safety Administration, 2007).

Most states require that EMS personnel undergo training using standardizedcurriculum provided by the US National Highway Traffic Safety Administration’sOffice of EMS (www.ems.gov). EMTs and paramedics differ in training requirementsand the number of hours invested in training. Requirements for the EMT range from110 to 140 hours (www.nremt.org). The paramedic represents the highest level ofcertification in the EMS profession. Paramedic training requirements varyconsiderably across states; however, the training often includes more than 1,000didactic and clinical training hours in addition to EMT certification. The wider scope ofpractice and greater training requirement for paramedics compared to EMTs suggeststhat the paramedic job may be more “enriched” in some ways (Hackman and Oldham,1975). More enriched jobs have greater skill variety, autonomy, task identity, tasksignificance, and feedback. There is a body of research over the past 25 years showingthat more enriched jobs generally result in greater job satisfaction (Hackman andOldham, 1976; Roberts and Glick, 1981).

There are few studies of EMT and paramedic job satisfaction and none that testhypotheses about differences in job satisfaction between EMTs and paramedics. Onestudy of EMS job satisfaction found that a majority of EMTs and paramedics wereconcerned about inadequate retirement incomes; more than one-third were dissatisfiedwith recognition from their employer, and about one-third were dissatisfied with their

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employee benefits (Brown et al., 2003). Another study of EMTs and paramedics foundthat quality of training and interaction with physicians was related to job satisfaction(Bowron and Todd, 1999). Based on the broader skill level and job enrichment factorsfor paramedics compared to EMTs, we hypothesize that:

H1. Paramedics will have greater job satisfaction then EMTs.

A model for studying changing professions (occupations) and review of empiricalresearchAlthough there are models focused on either job turnover (Mobley, 1977) or careerchange (Neapolitan, 1980), to the authors’ knowledge, there has only been one generalpsychological model of voluntary job and career change presented in the literature,(Rhodes and Doering, 1983). According to Rhodes and Doering, changing one’s career,“refers to movement to a new occupation that is not part of a typical careerprogression”. Rhodes and Doering based their model on prior voluntary job turnovermodels, particularly Mobley et al. (1979). As noted by Mobley et al. (1979), job(dis)satisfaction is the key work attitude that begins the process of leaving one’s job.More recent research highlights the impact of job satisfaction on job turnover (Griffethet al., 2000). Rhodes and Doering theorized that personal factors such as earnings andjob-related factors such as fit with work environment and growth opportunities,affected one’s job satisfaction. As noted by Rhodes and Doering, job dissatisfaction aswell as career or occupational dissatisfaction lead to thoughts of changing jobs andcareers. Lower levels of job satisfaction lead to greater job and career withdrawalcognitions, which when combined with a job search and the availability of alternatives,leads to actual change.

Prior research on leaving one’s job and occupation (profession)It is logistically very difficult for researchers to obtain actual job and occupationchange data. Obtaining this type of data would require that researchers have access toemployer-based employee tracking systems. Given these logistical difficulties, priorsurvey-based field studies, across a number of different samples have focused on the“intent to leave” as the outcome variable. This variable is conceptually presented as themost proximal representation of actual leaving behavior (Rhodes and Doering, 1983).The occupations/professions investigated in previous studies regarding the intent toleave one’s job and/or occupation have included a diverse range of samples, includingnurses (Meyer et al., 1993; Nogueras, 2006), football coaches (Cunningham and Sagas,2004), teachers (Rhodes and Doering, 1993), human resource professionals (Snape andRedman, 2003), cancer registrars (Chapman et al., 2009), medical technologists (Blauet al., 2003), and film and photo manufacturing (van Dam, 2008).

The general flow of variables in the Rhodes and Doering’s (1993) career changemodel suggests that there is a hierarchy of correlates, with certain variables expectedto show a weaker or more distal relationship to leaving intent, while other variablesshow a stronger or more proximal relationship. Personal variables are conceptualizedto be the most distal to the intent to leave variable, followed by perceived job-relatedvariables. Work attitude variables are expected to be the most proximal to intent toleave. In prior empirical work, the personal and job-related distal variables controlledfor have varied somewhat across samples (Blau et al., 2003; Chapman et al., 2009);

Correlates ofintent to leave job

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489

Cunningham and Sagas, 2004; Meyer et al., 1993; Nogueras, 2006; Rhodes and Doering,1993; Snape and Redman, 2003).

Based on the Rhodes and Doering model, job satisfaction is expected to be asignificant negative correlate of both intent to leave job and intent to leave profession.Job satisfaction is generally viewed as a transitory or dynamic work attitude, due to itsmeasuring aspects of a job that can change fairly quickly, e.g. supervisor, co-workers,or schedule (Harrison and Martocchio, 1998). However, if one is unhappy with his job,this can also lead to cognition about leaving the general occupation, especially if oneanticipates similar job issues with other jobs in the occupation (Blau, 2007). Thissuggests a second more complex study hypothesis:

H2. Beyond personal and job perception-related variable controls, job satisfactionwill be a significant negative correlate to intent to leave the job and EMSprofession for both EMTs and paramedics.

MethodsSample and procedureThe National Registry of Emergency Medical Technicians (NREMT) maintains themost comprehensive national database of EMS professionals (www.nremt.org). Inpartnership with the NREMT, the US national highway traffic safety administration(NHTSA) funded a workforce research initiative, the longitudinal emergency medicaltechnician attributes and demographic study (LEADS). The LEADS project includes acommittee of EMS, government, and research professionals who meet regularly todiscuss EMS workforce needs and manage a ten-year longitudinal study. The study’smain measurement tool is an annual cross-sectional survey of the nationally registeredEMS workforce. Our study is based on responses to the 2007 LEADS survey thatincluded core questions from the longitudinal survey and a supplement focused onoccupational commitment.

Surveys were mailed to 5,807 EMTs and paramedics; a total of 1,334 surveys werereturned for a response rate of 23 percent. The overall survey response rate of 23% wasless than expected. However, it is consistent with the response rates found in ameta-analysis of 231 surveys found in management journals (Cyota and Harrison,2006). Other researchers have argued that nonresponse bias does not bias therelationship between variables (Goldberg, 2003). The total usable sample size for thisanalysis is 933 (70 percent of 1,334), comprised of 308 EMTs and 625 paramedics.These sample sizes are more than adequate for conducting inferential analyses to testour second hypothesis (McNemar, 1969). For the smaller sample of 308 EMTs, thepower for testing the relationships of job satisfaction to intent to leave variables is over99 percent, assuming the literature supports medium effect size and alpha (probabilityof rejecting the null when it is true ¼ 0.01 two-tailed) probability. For the largerparamedic sample, the power is also over 99 percent. A total of 401 (30 percent of 1,334)were designated as “incomplete data respondents,” and were excluded from furtheranalyses. A comparison of the complete and incomplete data respondents was made ona number of important demographic variables and is presented in Table I. Table Ishows that there are few substantial differences between these two respondent groups.

There is a higher percentage of paramedics with complete data, while therespondents with incomplete data have a higher percentage not currently practicing.Given that active practice status is self-reported to the NREMT, it is not possible to

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490

Variable Complete data (n ¼ 933) Incomplete data (n ¼ 401)

Current EMT practice levelEMT basic 32.3 44.8EMT intermediate 2.1 1.3EMT paramedic 65.2 35.7Not practicing 0.2 17.5GenderMale 71 63RaceCaucasian 74 72Non-caucasian 26 28Education levelDid not complete high school 0 0High school/GED 8 8Some college 39 34Associate degree 24 23Baccalaureate 25 27Graduate degree 4 8Marital statusMarried 59 54Not-married 41 46Years worked as EMTNever worked as EMT 0 14Less than one year 9 181-2 years 10 133-4 years 19 115-7 years 22 148-10 years 11 1011-15 years 13 716-20 years 8 6Over 20 years 8 7Volunteer EMTYes 32 35No 68 65Currently serving in military/reservesYes 6 8No 94 92Type of community employed inRural (less than 2,500 people) 13 16Small town (2,500-24,999) 28 21Medium town (25,000-74,999) 17 14Large town (75,000-149,999) 10 7Mid-sized city (less than 500,000) 11 8Suburb/fringe of mid-sized city 3 1Large city (500,000 or more) 14 31Suburb/fringe of large city 4 3Type of employerFire-based 41 34Non-fire based 59 66Primary role at main EMT jobClinician (EMT or paramedic) 70 59Non-clinician 30 41

Note: All figures are percentages

Table I.Demographic variablecomparison of overall

sample versus completedata sample

Correlates ofintent to leave job

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491

delete this group prior to survey administration. The complete data group has slightlyhigher proportions of males and those who are married, longer job tenure, fewervolunteers, more fire-based employers, and those whose primary EMS role is clinical.Those who completed the survey were more likely to have five or more years on the jobas EMT professionals (62 percent) compared to the incomplete responders (44 percent).It would seem reasonable that those currently practicing in EMS, and those withgreater tenure might feel more motivated to complete the eight-page survey than thoseless active in their profession.

MeasuresPersonal control variables. Past year gross EMS earnings, perceived health, trained as afirefighter, and the number of days absent within last twelve months due to workillness or injury were measured. Past year gross EMS earnings were measured using11 incremental categories from 1 ¼ $0 to 11 ¼ $100,000 or more (see Table II for allcategories). A meta-analysis of correlates of job turnover suggests that higher earningslead to lower turnover (Griffeth et al., 2000). Health was measured by two-items, “Howwould you rate your overall health?”, and “How would you rate your overall physicalfitness?”, both items using a 1 ¼ poor, 2 ¼ fair, 3 ¼ good and 4 ¼ excellent responsescale. Becker and Spicer (2007) found that EMS workers have comparatively high ratesof injury and illness and that these are likely underreported. Being trained as afirefighter was measured as 1 ¼ yes and 2 ¼ no, and number of days absent withinlast 12 months due to work illness or injury was measured from 1 ¼ none to 5 ¼ ten ormore days. Respondents who have higher self-reported absences may be in the processof looking to change jobs and/or occupations (Griffeth et al., 2000).

Job-related control variables. Hours available per week for EMS response, theproportion of emergency to scheduled transports, the proportion of a fire-based jobdevoted to EMS, and evaluation of the EMS instructor were measured (see Table II forall categories). The hours available per week for an EMS response was measured usinga one-item scale from 1 ¼ 0 hours, to 6 ¼ more than 60 hours. The proportion ofemergency to scheduled transports was measured by one item, using a scale from1 ¼ all of my calls are emergency calls to 5 ¼ all of my calls are scheduled transports.The proportion of a fire-based job devoted to EMS was measured by one-item using ascale from 1 ¼ did not work for a fire-based service in the past 12 months to 6 ¼ all ornearly all of my work involved fire suppression and prevention activities. Pattersonet al. (2005) found that having a challenging, time-sensitive task outlet for thrill-seekingbehavior attracted some to the EMS profession. A higher proportion of emergencytransports and a higher proportion of fire suppression and prevention activities, as wellas being trained as a firefighter, would meet this challenging, time sensitive task outlet.

EMS instructor evaluation was measured using a six-item scale which asked EMTsto evaluate their classroom instructors over the past year on characteristics such astechnical knowledge, teaching ability, and enthusiasm, using a fourpoint scale where1 ¼ poor to 4 ¼ excellent. Patterson et al. (2005) found that EMTs and paramedics feelthat their educational process was underdeveloped, compared to other healthprofessionals such as nurses. This suggests that higher perceived instructor educationevaluation could be negatively related to intent to leave EMS profession.

Work attitude. Job satisfaction was measured using nine items. Respondents wereasked to “to indicate how satisfied you are with the following aspects of your EMS

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position” on a four-point response scale, where 1 ¼ very dissatisfied, 2 ¼ dissatisfied,3 ¼ satisfied, 4 ¼ very satisfied, The nine items were: “amount of pay and benefits”;“having a job that is exciting”; the technical challenges provided by the job”;“performing a variety of tasks in a variety of situations”; “my work schedule”;“opportunities for advancement at my job”; “being able to work without closesupervision”; “being able to help others” and “your direct supervisor”. Such items arecommonly measured by other job satisfaction scales (Spector, 1997). We performedfactor analysis to determine whether these job satisfaction items could be reduced tomulti-item scales, and so that scale reliabilities could be calculated. A principalcomponents analysis was conducted (Ford et al., 1986), and the results suggested atwo-factor model, based on the scree test and eigenvalues of at least 1.0 (Ford et al.,1986).

EMTs (n ¼ 308) Paramedic (n ¼ 625)Variable name (reliabilitya) M SD M SD

Past year gross-EMT earningsb (NA) 3.24 2.25 6.72 2.16Health (0.78)c 3.12 0.60 3.04 0.59Trained as a firefighter (1 ¼ yes, 2 ¼ no) (NA) 48 percent yes NA 65 percent yes NA

48 percent yes NA 65 percent yes NANumber of days absent within last 12 monthsdue to work illness or injury (NA)d 1.24 0.80 1.41 0.97Hours available per week for EMS response (NA)e 4.57 1.25 5.08 0.89Proportion of emergency to scheduled transports(NA)f

4.30 1.81 1.67 0.85

Proportion of fire-based job devoted to EMS (NA)g 2.19 1.47 2.15 1.21Instructor EMS education evaluation (0.92)c 3.45 0.52 3.29 0.58Intrinsic job satisfaction (0.83)h 3.44 0.40 3.46 0.41Extrinsic job satisfaction (0.71)h 3.04j 0.49 2.91j 0.57Intent to leave job in next 12 months (NA)i 1.38 0.63 1.42 0.67Intent to leave profession in next 12 months (NA)i 1.61 0.87 1.67 0.85

Notes: aReliability calculated if multi-item scale using coefficient alpha, otherwise NA ¼ notapplicable. bGross-earning categories, 1 ¼ $0; 2 ¼ $1 to $999; 3 ¼ $1,000 to $9,999; 4 ¼ 10,000 to$19,999; 5 ¼ $20,000 to $29,999; 6 ¼ $30,000 to $39,999; 7 ¼ $40,000 to $49,999; 8 ¼ $50,000 to$59,999; 9 ¼ $60,000 to $74,999; 10 ¼ $75,000 to $99,999; 11 ¼ $100,000 or more. c4-point responsescales used for Health and Instructor Evaluation (1 ¼ poor, 4 ¼ excellent). dself-reported absence,1 ¼ none, 2 ¼ 1 day, 3 ¼ two to four days, 4 ¼ five to nine days, 5 ¼ ten or more days. ehoursavailable/week, 1 ¼ 0, 2 ¼ 1 to 8, 3 ¼ 9 to 16, 4 ¼ 17 to 40, 5 ¼ 41 to 60, six more than 60.f1 ¼ all of my calls are emergency calls; 2 ¼ most of calls are emergency calls; 3 ¼ about equalnumber of emergency calls/scheduled transports; 4 ¼ most of my calls are scheduled transports;all of my calls are scheduled transports. g1 ¼ did not work for a fire-based service; 2 ¼ all ornearly all of my work involved EMS; 3 ¼ most of my work involved EMS; about one-half of mywork involved EMS; 5 ¼ most of my work involved fire suppression and prevention; 6 ¼ all ornearly all of my work involved fire suppression and prevention. h Four-point response scale usedfor intrinsic and extrinsic job satisfaction (1 ¼ very dissatisfied, 4 ¼ very satisfied). i Both intentto leave measures use five-point scale, 1 ¼ definitely stay, 2 ¼ probably stay, 3 ¼ probably leave,4 ¼ definitely leave, 5 ¼ I have already left. jsignificant difference in extrinsic job satisfactionmeans, t ¼ 4:01ðdf ¼ 931Þ; p , 0:01

Table II.Means, standard

deviations and scalereliabilities of studyvariables for EMTsversus paramedics

Correlates ofintent to leave job

and profession

493

Oblique (direct oblimin) rotation was used on the nine-item/two-factor model sinceconceptually, as well as empirically, these two factors called “intrinsic satisfaction”(Factor 1) and “extrinsic job satisfaction” (Factor 2) should be correlated (Spector,1997). A five-item, intrinsic job satisfaction scale was formed focusing on content of thework itself (e.g. exciting job, technical challenges, variety of tasks, working withoutclose supervision, helping others), and a four-item extrinsic job satisfaction scale,focusing on the context of the work and how well people are treated (e.g. pay andbenefits, work schedule, advancement opportunities, supervision). Thisintrinsic-extrinsic job satisfaction distinction fits with prior work by Herzberg (1966,1974). The correlation between these scales was r ¼ 0:55; p , 0:01 for EMTs andr ¼ 0:53; p , 0:01 for paramedics. Results of the factor analysis are included inTable III. Dominant loadings on either one factor or the other are evident (Ford et al.,1986).

Outcome variables. Intent to leave the job was measured by asking “How likely is itthat you will choose to leave your main EMT job in the next 12 months?” Intent toleave profession was measured by asking “How likely is it that you will choose to leavethe EMS profession in the next 12 months?” Both items were measured using afive-point response scale, 1 ¼ definitely stay, 2 ¼ probably stay, 3 ¼ probably leave,4 ¼ definitely leave, 5 ¼ I have already left. Prior research has measured intent toleave job versus intent to leave occupation (profession) as related but distinct outcomevariables (Lee et al., 2000). The one year time frame used for intent to leave job andprofession is consistent with prior research (van Dam, 2008) in which “urgent leavers”were those defined as intending to leave the organization within the next year.

Data analysesMeans, standard deviations, and reliabilities (for multi-item scales) are shown inTable II. Correlations between study variables for EMTs versus paramedics are shownin Table IV. An independent samples t-test was used to test H1. Hierarchicalregression analyses were used to test H2. SPSS-PC version 15 was used to analyze thedata. Regression models were also checked for outliers (33 were eliminated).

Pattern matrix loadingItem 1 2

Amount of pay and benefits 20.11 0.80 a

Having a job that is exciting 0.78 0.08Technical challenges of job 0.80 0.08Variety of tasks and situations 0.84 0.03Work schedule 0.22 0.58Opportunities for advancement 0.02 0.79Working without close supervision 0.58 0.10Being able to help others 0.78 20.16Direct supervision 0.04 0.66Eigenvalue 3.90 1.28Percentage of variance accounted for 43.33 14.27

Note: aPattern matrix loading larger than 0.40 in italics

Table III.Oblique rotation of ninejob satisfaction items

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orts

.f 1¼

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ra

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ved

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S;

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S;

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ton

e-h

alf

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ork

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;5¼

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kin

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fire

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pre

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nan

dp

rev

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on;6

¼al

lor

nea

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all

ofm

yw

ork

inv

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resu

pp

ress

ion

and

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ven

tion

.gF

our-

poi

nt

resp

onse

scal

eu

sed

for

intr

insi

can

dex

trin

sic

job

sati

sfac

tion

(1¼

ver

yd

issa

tisfi

ed,4

¼v

ery

sati

sfied

).h

Bot

hin

ten

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leav

em

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res

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,2¼

pro

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lyst

ay,

3¼

pro

bab

lyle

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4¼

defi

nit

ely

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e,5¼

Ih

ave

alre

ady

left

Table IV.Correlations between

study variables for EMTsversus paramedics

Correlates ofintent to leave job

and profession

495

It was determined that the assumptions of no multicollinearity, linearity, andhomoscedasticity were satisfactorily met (Myers, 1990). The assumption of nomulticollinearity for the four regression models was evaluated by tolerance andvariance inflation factor (VIF) collinearity statistics (Stevens, 1992). Across all fourregression models, none of the VIFs were substantially greater than 1.0 (overall meanVIF was 1.26). A VIF over 10 is cause for concern. The tolerance statistics were alsowithin the parameters to rule out multicollinearity since all were 0.57 or higher with anoverall average tolerance across all four models of 0.85. A tolerance of under 0.20indicates a potential problem. These results suggest that multicollinearity is not anissue.

ResultsGeneral descriptive and correlational findingsTable II shows study variable means, standard deviations, and reliabilities for studyvariables for EMTs and paramedics. All multi-item scales have reliabilities, whichexceed the recommended threshold of .70 (Nunnally, 1978).

For all multi-item measures, items were averaged to create a scale score based onthe response scale used. A review of the variable means indicates that paramedics arepaid more, more likely to be trained as a firefighter, have more hours available/weekfor an EMS response, and have a higher proportion of emergency calls compared toEMTs. Although there is no significant difference on intrinsic job satisfaction forEMTs compared to paramedics, there is a significant difference on extrinsic jobsatisfaction in that paramedics are less satisfied, t ¼ 4:01ðdf ¼ 931Þ; p , 0:01. This isopposite to what was expected, i.e. paramedics being more satisfied. Thus, we found nosupport for H1.

Table IV shows the correlations between study variables, with correlations forparamedics above the diagonal, and correlations for EMTs below the diagonal. Thereis a great deal of consistency when comparing correlations between these two groups(e.g. both types of job satisfaction are negatively related to both types of withdrawalintent). Compensation is one important difference in that only for paramedics are pastyear gross earnings positively related to extrinsic job satisfaction, and negativelyrelated to intent to leave job and profession. As would be expected, based on priorliterature, there is a fairly strong correlation between intrinsic and extrinsic jobsatisfaction for both EMTs (r ¼ 0:55; p , 0:01), and paramedics (r ¼ 0:53; p , 0:01);as well as between both types of withdrawal intent, job versus profession for EMTs(r ¼ 0:69; p , 0:01), and paramedics (r ¼ 0:66; p , 0:01). However, prior researchindicates that these types of job satisfaction and withdrawal intent are also distinctenough to be used as separate variables (Blau, 2000; Hackman and Oldham, 1976;Spector, 1997).

Regression analyses to test H2Based on the general ordering of variables in the occupation change model of Rhodesand Doering (1983), and prior research on turnover intent (Meyer et al., 1993; Snape andRedman, 2003) the order for entering variables in the forward stepwise hierarchicalregression procedures was as follows: step 1 – personal variable controls (past yeargross EMS earnings, health, trained as a firefighter, number of days absent within thelast 12 months); step 2 – job-related perceptions (hours available per week for EMS

CDI14,5

496

response, proportion of emergency to scheduled transports, proportion of fire-based jobdevoted to EMS, instructor EMS education evaluation); and step 3 – job satisfaction(intrinsic job satisfaction, extrinsic job satisfaction). The results for the stepwisehierarchical regression analyses are shown in Table V.

The results provide partial support for H2. Beyond the personal and workperception control steps, extrinsic job satisfaction is significantly negatively related tointent to leave job and intent to leave profession for both EMTs, (leave job,b ¼ 20:66; t ¼ 24:69; p , 0:01; leave profession, b ¼ 20:37; t ¼ 22:66; p , 0:01)and paramedics (leave job, b ¼ 20:74; t ¼ 211:15; p , 0:01; leave profession,b ¼ 20:35; t ¼ 26:60; p , 0:01), which is supportive of H2. However, intrinsic jobsatisfaction had a significant negative relationship only to paramedics’ intent to leavethe profession (b ¼ 20:33; t ¼ 5:09; p , 0:01). The job satisfaction variable stepaccounted for a significant increase in variance in both types of intent for EMTs andParamedics.

Looking at other results in Table V, for personal correlates, self-reported health wasnegatively related to intent to leave profession for both EMTs(b ¼ 20:14; t ¼ 22:00; p , 0:05) and paramedics (b ¼ 211; t ¼ 22:59; p , 0:01).Not being trained as a firefighter was positively related to intent to leave professionfor both groups, EMT (b ¼ 0:20; t ¼ 2:76; p , 0:01) and paramedics(b ¼ 0:13; t ¼ 2:26; p , 0:05). For work perception correlates, having feweremergency calls and more scheduled transports was positively related to intent toleave the job for both groups, EMT (b ¼ 0:16; t ¼ 3:48; p , 0:01), and paramedics(b ¼ 0:16; t ¼ 4:17; p , 0:01). There are also some results that differed between EMTsand paramedics. For example, earnings were negatively related to intent to leave jobonly for paramedics (b ¼ 20:03; t ¼ 21:97; p , 0:05). A higher number of missedabsences was positively related to intent to leave profession only for paramedics(b ¼ 0:05; t ¼ 2:08; p , 0:05). Having fewer hours available/week for an EMSresponse was negatively related to intent to leave job for paramedics(b ¼ 20:10; t ¼ 22:44; p , 0:05). Lower instructor evaluation was negativelyrelated to intent to leave profession only for EMTs (b ¼ 20:17; t ¼ 22:97; p , 0:01).

Overall 22 percent of the variance on intent to leave job and intent to leaveprofession was accounted for in EMTs. Among paramedics, a somewhat greaterproportion of explained variance was obtained for intent to leave job (36 percent) andfor intent to leave profession (29 percent).

DiscussionTo our knowledge this is the first empirical research comparing correlates of intent toleave job versus intent to leave the EMS profession for EMTs versus paramedics. Noneof the studies we reviewed of EMT and paramedic job satisfaction utilized multipleitem scales to measure job satisfaction in EMTs and paramedics.

This analysis found no support for H1, that job satisfaction would be higher forparamedics than EMTs. Paramedics reported lower mean extrinsic job satisfactiondespite the fact that they are paid more. Using a self-referent equity perspective ofgreater inputs leading to greater outputs (Adams, 1965), it may be that the more highlytrained and skilled paramedics expect financial remuneration as well as opportunitiesfor advancement and higher quality supervision than their EMT colleagues who haveless training and perhaps less experience in the EMS field. In the EMS field,

Correlates ofintent to leave job

and profession

497

EM

Ts

(n¼

308)

Par

amed

ics

(n¼

625)

Inte

nt

tole

ave

job

Inte

nt

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pro

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Inte

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Inte

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tion

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ased

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ctor

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0.17

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0.07

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**

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*0.

29*

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Notes

:R

egre

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are

un

stan

dar

diz

edre

gre

ssio

nw

eig

hts

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p,

0:05

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0:01

Table V.Summary of final modelstepwise multipleregression analyses forcontribution of personal,perceived work, and jobsatisfaction variables forexplaining intent to leavejob and intent to leaveprofession for EMTsversus paramedics

CDI14,5

498

supervisory responsibilities are often assigned based to seniority with little training inmanagement skills (National Highway Traffic Safety Administration, 2008).

Intrinsic job satisfaction was negatively related to intent to leave the profession forparamedics but not for EMTs. Intrinsic job motivators in the Herzberg model includerecognition, interesting work, and increased responsibility (Herzberg, 1966, 1974). Ourmeasure of intrinsic job satisfaction measured similar issues such as achievement,interesting work, autonomy, and helping others. Focus group findings indicated that astrong sense of camaraderie and making a difference in peoples lives is a keycomponent of EMS careers (Patterson et al., 2005). If paramedics have higherexpectations for enriched jobs yet perceive less intrinsic satisfaction with these issuesthey are more likely to think about leaving the EMS profession. EMTs may have lowerexpectations for intrinsic job satisfaction in that they have less time invested ineducation and have a more limited scope of work. They may find the work interestingyet not expect an increasing degree of autonomy or more advanced work.

This analysis found partial support for H2, that controlling for personal andjob-related variables, job satisfaction would be negatively related to EMTs andparamedics intent to leave their job and profession. Leaving one’s profession oroccupation is a more significant work transition for most than leaving one’s job, butstaying in the same occupation (Carson et al., 1995). According to Carson andcolleagues, career (occupational) entrenchment consists of three dimensions;occupational investment, emotional costs, and limitedness of occupationalalternatives. Occupational investment measures the accumulated investments orcosts (e.g. time, money, training) in one’s occupation which would be lost if onechanged occupations. Emotional costs measures the anticipated emotional priceassociated with pursuing a new occupation. For example, the loss of co-workerfriendships and severance of professional ties can exact an emotional toll whenchanging one’s occupation. EMTs and paramedics place a high value on camaraderiewithin the profession (Patterson et al., 2005) and thus could pay a high emotional pricein leaving the profession. Workers in any occupation willing to leave their occupationdue to intrinsic dissatisfaction would seem to place strong importance on receivingintrinsic rewards from their work.

In our study, extrinsic job satisfaction was negatively related to intent to leave thejob and profession, for both groups, which is consistent with the Rhodes and Doering(1983) model. The extrinsic job satisfaction scale included pay and benefits,opportunities for advancement, and supervision. Consistent with other studies (Brownet al., 2003; Federiuk et al., 1993), pay and benefits are key factors of job satisfaction.EMTs and paramedics receive lower wages compared to other allied health and publicsafely occupations such as respiratory therapists and nurses, firefighters, and policeofficers (National Highway Traffic Safety Administration, 2008). More attention toother extrinsic job satisfiers (opportunity for career progression and improvedsupervision) for EMTs and paramedics would be beneficial to addressing retention inthe EMS profession.

The importance of pay and benefits, opportunities for advancement, andsatisfaction with supervision to job retention suggests that separate standardizedscales should be used to improve measures for each of these factors in future research(Griffeth et al., 2000); Spector, 1997). Standardized measures of job satisfaction facetsshould also be used (Spector, 1997).

Correlates ofintent to leave job

and profession

499

The correlational findings related to perceived health status and intent to leave thejob and profession are important to the retention of experienced EMTs andparamedics. Good physical health is critical to EMS work. A work-related injury andillness may result in a permanent departure from the profession. Employers shouldfocus more attention on safety, health promotion, and wellness programs for EMTsand paramedics throughout their career in the EMS field.

There are various study limitations to acknowledge, most prominently thecross-sectional research design which prohibits assessing true causality. In additionthere are various measurement limitations, including uneven response categories forthe income and hours worked variables, the dichotomous training as a firefightervariable, and the one-item intent to leave job and profession measures. Weacknowledge that our sample may not be representative of EMTs and paramedics,however, it is not unreasonable to assume that it is a close approximation.

It can be argued that there is a fairly strong overlap between the two intentions toleave variables, job versus occupation. However, past empirical research has shownthat while these variables overlap, they also have distinct or unique relationships toother variables (Lee et al., 2000). The regression results in Table V show that except forthe consistent impact of extrinsic job satisfaction across EMT and paramedic intent toleave job and profession, there are unique relationships of correlates to one intentionbut not the other intention. Health status and trained as a firefighter are related tointent to leave profession but not job; the proportion of emergency to scheduledtransports are related to intent to leave job but not profession. Factors such as theproportion of emergency calls vary across EMS employment settings while goodhealth is important for employment in the profession, regardless of job setting.

Future research efforts should incorporate longitudinal methodologies with strongermeasures to continue the exploration of differences between EMTs and paramedicpopulations. Another direction for follow-up future research would be to incorporatemeasuring the protean career values of being self-directed and values-driven (Briscoeet al., 2006), to see how such values impact occupational retention decisions in the EMSprofession. In this study, we used the time frame “next year” to measure intent to leaveboth job and occupation. This is consistent with van Dam’s (2008) “urgent leaver”category. In future research of the EMS and related health professions it would be usefulto measure other categories of time in intent to leave such as “long-term leavers” as wellas “stayers” (van Dam, 2008). In addition, it would be useful to focus on organizationaland occupational commitment related to turnover intentions (Cohen and Golan, 2007).

ConclusionRetention of EMTs and paramedics has been considered the greatest human resourceschallenge for EMS services. The purpose of this study was to contribute to knowledgeabout job satisfaction and intent to leave one’s job and/or profession for this group ofworkers who provide critical health services.

Our findings may be useful to public and private EMS employers, educators, andprofessional organizations to address specific factors that lead to turnover of EMTsand paramedics. While pay and benefits are critical, factors such as the quality ofsupervision, work assignments, and job growth opportunities seem to be important aswell. In times of increasing demand for EMTs and paramedics, the EMS professioncannot afford to lose valuable human resources.

CDI14,5

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About the authorsSusan A. Chapman, PhD, RN is Associate Professor and Director of the Masters program inHealth Policy Nursing in the Department of Social and Behavioral Sciences, at the University ofCalifornia, San Francisco (UCSF) School of Nursing. Her areas of expertise are nursing and alliedhealth workforce research, health policy, and global health workforce development. She receivedher PhD from the University of California, Berkeley in Health Services and Policy Analysis.Susan A. Chapman is the corresponding author and can be contacted at: schapman@thecenter.ucsf.edu

Gary Blau is currently Chair of the Human Resource Management Department in the FoxSchool of Business & Management at Temple University. His research interests focus onunderstanding worker attitudes and perceptions for explaining different types of work-relatedbehavior. He received his PhD and MBA from the University of Cincinnati.

Robert Pred, PhD, is Assistant Professor in the Department of Statistics in the Fox School ofBusiness at Temple University. His areas of expertise include social and industrial psychology,with a focus on the relationships between personality traits, performance, and health.

Andrea B. Lopez teaches compensation management at Temple University. Her areas ofinterest include studying perceptions of procedural and distributive justice, and their impact onwork attitudes and behaviors. She earned her PhD from the department of Human ResourceManagement at Temple’s Fox School of Business in 1997.

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