Category Archives: Emergency Medical Services

101 Things We Should Teach Every New EMT

Originally posted at TheEMTSpot

I do not usually steal content or original writings, but this post is too important not to share (and keep for reference).  This was originally posted, with all credit due to the author of origin, at:

Though this list is focused towards emergency medical technicians, it has inferred and inherent application in many clinical and non-clinical professions.

1) You aren’t required to know everything.

2) You are required to know the foundational knowledge and skills of your job. No excuses.

3) Always be nice. It’s a force multiplier.

4) There is no greater act of trust than being handed a sick child.

5) Earn that trust.

6) Don’t ever lie to your patient. If something is awkward to say, learn to say it without lying.

7) Read Thom Dick’s, People Care. Then read it again.

8) You can fake competence with the public, but not with your coworkers.

9) Own your mistakes. We all make them, but only the best of us own them.

10) Only when you’ve learned to own your mistakes will you be able to learn from them.

11) Experience is relative.

12) Proper use of a BVM is hard and takes practice.

13) OPAs and NPAs make using a BVM less hard.

14) Master the physical assessment. Nobody in the field of medicine should be able to hold a candlestick to your physical assessment skills.

15) Keep your head about you. If you fail at that, you’ll likely fail at everything else.

16) There is a huge difference between not knowing and not caring. Care about the things you don’t yet know.

17) Train like someone’s life depends on it.

18) Drive like nobody’s life depends on it.

19) Pet the dog (even when you’re wearing gloves).

20) Have someone to talk to when the world crashes down.

21) Let human tragedy enhance your appreciation for all that you have.

22) Check the oil.

23) Protect your back. It will quite possibly be the sole determining factor in the length of your career.

24) Say please and thank you even when it’s a matter of life or death.

25) Wipe your feet at the door.

26) When you see someone who is really good at a particular skill say, “Teach me how you do that.”

27) Nobody can give you your happiness or job satisfaction; it is yours and yours alone, and you have to choose it.

28) We can’t be prepared for everything.

29) We can be prepared for almost everything.

30) Check out your rig. It’s more meaningful that just confirming that everything is still there.

31) Tell your patients that it was a pleasure to meet them and an honor to be of service.

32) Mean it.

33) Keep a journal.

34) Make it HIPAA compliant.

35) Thank the police officer that hangs out on your scene for no good reason.

36) Recognize that he or she probably wasn’t hanging out for no good reason.

37) Interview for a job at least once every year, even if you don’t want the job.

38) Iron your uniform.

39) Maintain the illusion of control. Nobody needs to know that you weren’t prepared for what just happened.

40) Apologize when you make a mistake. Do it immediately.

41) Your patient is not named honey, babe, sweetie, darling, bud, pal, man or hey. Use your patient’s name when speaking to them. Sir and Ma’am are acceptable alternatives.

42) Forgive yourself for your mistakes.

43) Forgive your coworkers for their quirks.

44) Exercise. Even when it isn’t convenient.

45) Sometimes it’s OK to eat the junk at the QuickyMart.

46) It’s not OK to always eat the junk at the QuickyMart.

47) Don’t take anything that a patient says in anger personally.

48) Don’t take anything that a patient says when they are drunk personally.

49) Don’t ever convince yourself that you can always tell the difference between a fake seizure and a real seizure.

50) Think about what you would do if this was your last shift working in EMS. Do that stuff.

51) Carry your weight.

52) Carry your patient.

53) If firefighters ever do #51 or # 52 for you, say thank you (and mean it).

54) Being punched, kicked, choked or spit on while on duty is no different than being punched, kicked, choked or spit on while you’re sitting in church or in a restaurant. Insist that law enforcement and your employer follow up with appropriate action.

55) Wave at little kids. Treat them like gold. They will remember you for a long time.

56) Hold the radio mike away from your mouth.

57) There is never any reason to yell on the radio….ever.

58) When a patient says, “I feel like I’m going to die,” believe them.

59) Very sick people rarely care which hospital you’re driving toward.

60) Very sick people rarely pack a bag before you arrive.

61) Sometimes, very sick people pack a bag and demand a specific hospital. Don’t be caught off guard.

62) Bring yourself to work. There is something that you were meant to contribute to this profession. You’ll never be able to do that if you behave like a cog.

63) Clean the pram.

64) Clean your stethoscope.

65) Your patient’s are going to lie to you. Assume they are telling you the truth until you have strong evidence of the contrary.

66) Disregard #65 if it has anything to do with your personal safety. Trust nobody in this regard.

67) If it feels like a stupid thing to do, it probably is.

68) You are always on camera.

69) If you need save-the-baby type “hero moments” to sustain you emotionally as a caregiver you will likely become frustrated and eventually leave.

70) Emergency services was never about you.

71) The sooner you figure out #69 and #70, the sooner the rest of us can get on with our jobs.

72) People always remember how you made them feel.

73) People rarely sue individuals who made them feel safe, well cared for and respected.

74) You represent our profession and the internet has a long, long memory.

75) Don’t worry too much about whether or not people respect you.

76) Worry about being really good at what you do.

77) When you first meet a patient, come to their level, look them in the eyes and smile. Make it your habit.

78) Never lie about the vital signs. If the patients vital signs change dramatically from the back of the rig to the E.R. bed, you want everyone to believe you.

79) Calm down. It’s not your emergency.

80) Stand still. There is an enormous difference between dramatic but senseless action and correct action. Stop, think and then move with a purpose.

81) Knowing when to leave a scene is a vital skill that you must constantly hone.

82) The fastest way to leave a scene should always be in your field of awareness.

83) Scene safety is not a five second consideration as you enter the scene. It takes constant vigilance.

84) Punitive medicine is never acceptable. Choose the right needle size based on the patients clinical needs.

85) Know what’s happening in your partner’s life. Ask them about it after you return from your days off.

86) If your partner has a wife and kids, know their names.

87) No matter how hard you think you worked for them, your knowledge and skills are not yours. They were gifted to you. The best way to say thank you is to give them away.

88) Learn from the bad calls. Then let them go.

89) When you’re lifting a patient and they try to reach out and grab something, say, “We’ve got you.”

90) Request the right of way.

91) Let your days off be your days off. Fight for balance.

92) Have a hobby that has nothing to do with emergency services.

93) Have a mentor who knows nothing about emergency services.

94) Wait until the call is over. Once the patient is safe at the hospital and you’re back on the road, there will be plenty of time to laugh until you can’t breathe.

95) Tell the good stories.

96) You never know when you might be running your last call. Cherish the small things.

97) You can never truly know the full extent of your influence.

98) If you’re going to tell your friends and acquaintances what you do for a living, you’ll need to embrace the idea that you’re always on duty.

99) Be willing to bend the rules to take good care of people. Don’t be afraid to defend the decisions you make on the patients behalf.

100) Service is at the heart of everything we do. The farther away from that concept you drift, the more you are likely to become lost.

101) There is no shame in wanting to make the world a better place.

See more at:

Changing the Paradigm of the Emergency Medical Services


Can the Emergency Medical Services Evolve to Meet the Needs of Today?

Click here to view the PowerPoint PDF

The emergency medical services (EMS) provide a means of rapid treatment and transportation to definitive care for those people who suffer immediate life-threatening injuries or illnesses (Department of Transportation, National Highway Traffic Safety Administration, n.d.; Mayer, 1980). There are a number of models across the country and the world that are seeking to redefine EMS in a way that is more meaningful in both of its missions, public safety and public health (Washko, 2012). However, financial constraints and overzealous regulations serve only to pigeon-hole EMS into the decade of its birth and refinement, the 1970s, by restricting incentive and growth and limiting the efficacy of directed research and its application towards the much needed restructuring of EMS.

In this brief literature review, I will examine the roots and context of EMS, its mission and current application, as well as possibilities for research, growth, and development. It is important to recognize that EMS is a grand resource for both public safety and public health, especially in light of the growing body of legislation that officials are using to redefine the current health care system within the United States. As we continue to develop EMS, other nations will look to us as they have in the past to adopt and adapt our system for use throughout the world.

A Brief History of Contemporary EMS

There were many forms of organized out-of-hospital medical aid provided throughout history from the biblical good Samaritan to the triage and extrication from the battlefields of the Roman conquests and the Napoleonic wars through the U.S. Civil War and every major war and conflict in U.S. history; however, it was not until the advent of combined mouth-to-mouth resuscitation and closed chest massage (what we know today as cardiopulmonary resuscitation, or CPR), enhanced 9-1-1 for use by the public in summoning emergency services, and the release of a 1966 white paper prepared by the Committee on Trauma and Committee on Shock of the National Academy of Sciences, National Research Council, that we have the EMS system that we are familiar with today (Department of Transportation, National Highway Traffic Safety Administration, 1996). It was about this time that the Department of Transportation (DOT) was given purview over EMS at the national level with the passage of the National Highway Safety Act of 1966.

During the 1970s, EMS had transitioned from mostly untrained funeral home drivers to providers trained by emergency physicians to treat many of the life-threatening scenarios that prevent people from seeking medical attention at hospitals, such as traumatic injuries, cardiac arrest, and many breathing problems. Since this time, there have been a number of concerted efforts and official recommendations by the DOT to augment and improve the delivery model of EMS throughout the country (Department of Transportation, National Highway Traffic Safety Administration, n.d., 1996, 2008). As early as 1996, the DOT published the vision of the future of EMS:

Emergency medical services (EMS) of the future will be community-based health management that is fully integrated with the overall health care system. It will have the ability to identify and modify illness and injury risks, provide acute illness and injury care and follow-up, and contribute to treatment of chronic conditions and community health monitoring. This new entity will be developed from redistribution of existing health care resources and will be integrated with other health care providers and public health and public safety agencies. It will improve community health and result in more appropriate use of acute health care resources. EMS will remain the public’s emergency medical safety net. (Department of Transportation, National Highway Traffic Safety Administration, 1996, p. iii)

Even as today’s emergency rooms, operating suites, and trauma centers throughout the world are overflowing capacity with an increasingly deficient workforce, EMS is expected to answer the call for help as the front-line of a fractured and inefficient health care system (Kellermann, 2006; Mason, Wardrope, & Perrin, 2003; O’Meara et al., 2006; Washko, 2012).

Hampered Efforts

EMS is known throughout the United States as rapid responders in times of medical and traumatic emergencies; however, ever-increasingly, EMS is being used as the front-line alternative to primary care for the non-emergent uninsured and under-insured patient population (Heightman & McCallion, 2011; Washko, 2012). There is a limited number of ambulances, EMTs, and paramedics available at any given moment, which is subject to financial constraints, and non-emergent use of these resources prevents their availability for when a true emergency arises. Secondary to the mission of providing care to the public, EMS is also needed to provide services for fire department and police department operations, such as firefighter rehabilitation at fire scenes and tactical medicine in concert with bomb squads, S.W.A.T. teams, and hazardous materials teams.

EMS resources are costly, and overburdened systems are negatively affected when these resources are misused, especially by those who are unwilling or unable to pay for the services.

Financial Impact

According to the DOT (2008) EMS workforce report, employers reported difficulties in retaining EMTs and paramedics partly due to the inability to raise wages or provide better fringe benefits. The report goes on to show that EMTs and paramedics suffer a wage disparity when compared to other similar public safety ($12.54/hr vs. firefighters: $26.82/hr; police officers: $22.25/hr) and health care workers (licensed vocational nurses and licensed practical nurses: $16.94/hr; respiratory therapists: $21.70/hr; registered nurses: $26.28/hr). In the five years leading up to 2005, the average wage for EMTs and paramedics grew only by $0.29/hr. It is important to note that these numbers do not take cross-trained firefighters and police officers into consideration.

Furthering the concern of wages, as the DOT (2008) report shows, is the lack of growth potential within EMS as most systems lack the ability to provide a meaningful career ladder to the EMTs and paramedics in their employ. These circumstances together create the scenario that EMS is an underpaid dead-end job causing high attrition as most EMTs and paramedics either suffer from burnout, culminated psychological stress from the job, or use the profession as a stepping stone into other health care fields, such as nursing, respiratory therapy, or physician-level medicine.

The DOT (2008) report provides evidence that transport-based reimbursement policies are likely to blame for the unusually low profit margin in EMS (Heightman & McCallion, 2011). The Medicare and Medicaid programs, as well as many private insurers, require documentation that the transport of a patient be medically necessary before they will pay; however, the Medicare and Medicaid reimbursement rates are very low and do not cover the cost of EMS operations. To complicate the matter, EMS providers are mandated by law to provide care to the public regardless of their insurance status or ability to pay (Heightman & McCallion, 2011). EMS is subsidized by either taxes or insurance reimbursement or some combination of the two.

Broad Mission

In addition to providing for the mundane care and transportation of the ill and injured and performing ancillary duties for the police and fire departments as noted above, EMS is tasked with disaster preparedness – preparing for the major incident that is highly unlikely to occur but would be devastating to lives and infrastructure if it does. That is if the EMT or paramedic is employed for an emergency service. Many of the EMTs and paramedics, today, are employed by private ambulance services who transport non-emergent patients to and from skilled nursing facilities and doctors’ offices. The multitude of these EMTs and paramedics are not considered when planning for emergency response schemes.

I consider EMS to be the caulking used to fill many of the fractures and gaps in today’s health care system. If it occurs outside of the hospital, then EMS will take responsibility, yet, they seldom get paid for their actions.

Proposed Solutions

There has been much talk over the past few years regarding the efficacy and efficiency of EMS, and all agree that the current definitive model is inefficient with, at best, questionable efficacy. Washko (2012) describes in detail the number of EMS schemes and their shortfalls. In his article, Washko is correct in stating that transport-based reimbursement policies fail to reward the greater EMS community for their willingness to take on further responsibility within the two scopes of operation: public health and public safety.

Wingrove and Laine (2008) explore the opportunity for training and equipping the most experienced paramedics for a public health centered role delivering community-based care. These community-based paramedics are described as augmenting the traditional emergency responder role with opportunities to direct patients to more appropriate care, such as doctor’s offices and urgent care centers instead of hospital emergency departments when appropriate to their condition. This model was researched recently in Australia with good results, and is now a recommended career path both there and in the United Kingdom (Mason, Wardrope, and Perrin, 2006; O’Meara et al., 2012). In the U.S., EMS professionals feel a responsibility to participate in disease and injury prevention efforts, and research on models that utilize specially-trained paramedics to perform home safety inspections, hazard mitigation, and reduce the risks of injuries to children have proven effective (Hawkins, Brice, & Overby, 2007; Lerner, Fernandez, & Shah, 2009). Hennepin Technical College, in Minnesota, now offers certification in Community Paramedic training when the recommended curriculum is provided by an accredited college, according to Wingrove and Laine.

Other, more immediate (but, arguably, less meaningful) solutions, as Washko (2012) describes, are incorporating operational tactics that better utilize ambulances by attempting to predict call volumes and locations based on historical data, the high-performance model. This, however, creates high-call volume, less resource driven scenarios with ambulances idling on street corners awaiting the next call. As mentioned earlier, attrition is a significant concern in EMS and these tactics are demanding on providers physically and psychologically leading to high incidences of burnout and injury (Department of Transportation, National Highway Traffic Safety Administration, n.d., 2008).


The standard operational benchmarks of EMS – response times and mortality and morbidity of cardiac arrest – are antiquated measures and typically distract policymakers when they are considering financial incentives for EMS (Heightman & McCallion, 2011; Washko, 2012). EMS needs to evolve with the changing health care system, and I feel that it is poised, specifically, to help address disparities in health and health care. Using the community-based paramedic model of health care delivery, we can address many public health concerns, provide for public safety, and still maintain the traditional role of emergency responder. The community-based paramedic model will provide an acceptable alternative to the options that lie ahead.

The economics of health care is a reality that must be considered by every EMS operation when approaching growth and change. As long as EMS can fill the gaps in the current health care system, it will be worth the money required to subsidize a robust, well-trained, and well-equipped contingent of emergency medical professionals. In the meantime, though, EMS agencies will have to seek more efficient models that maximize reimbursement while minimizing costs.


Committee on Trauma & Committee on Shock, Division of Medical Sciences, National Academy of Sciences, National Research Council. (1966). Accidental Death and Disability: The Neglected Disease of Modern Society. Washington, D.C.: Author.

Department of Transportation, National Highway Traffic Safety Administration. (n.d.). A leadership guide to quality improvement for emergency medical services (EMS) systems (Contract DTNH 22-95-C-05107). Retrieved from

Department of Transportation, National Highway Traffic Safety Administration. (1996). Emergency medical services: agenda for the future (DOT HS 808441 – NTS-42). Retrieved from

Department of Transportation, National Highway Traffic Safety Administration. (2008). EMS workforce for the 21st century: a national assessment. Retrieved from

Hawkins, E. R., Brice, J. H., & Overby, B. A. (2007). Welcome to the World: Findings from an emergency medical services pediatric injury prevention program. Pediatric Emergency Care, 23(11), 790-795. doi:10.1097/PEC.0b013e318159ffd9

Heightman, A. J. & McCallion, T. (2011). Management lessons from Pinnacle: Key messages given to EMS leaders at the 2011 conference. Journal of EMS, 36(10), 50-54.

Kellermann, A. L. (2006). Crisis in the emergency department. New England Journal of Medicine, 355(13), 1300-1303. doi:10.1056/NEJMp068194

Lerner, E. B., Fernandez, A. R., & Shah, M. N. (2009). Do emergency medical services professionals think they should participate in disease prevention? Prehospital Emergency Care, 13(1), 64-70. doi:10.1080/10903120802471915

Mason, S., Wardrope, J., & Perrin, J. (2003). Developing a community paramedic practitioner intermediate care support scheme for older people with minor conditions. Emergency Medicine Journal, 20(2), 196-198. doi:10.1136/emj.20.2.196

Mayer, J. D. (1980). Response time and its significance in in medical emergencies. Geographical Review, 70(1), 79-87. Retrieved from

National Traffic and Motor Vehicle Safety Act of 1966, Pub. L. No. 89-563, 80 Stat. 718 (1966).

O’Meara, P., Walker, J., Stirling, C., Pedler, D., Tourle, V., Davis, K., … Wray, D. (2006, March). The rural and regional paramedic: moving beyond emergency response (Report to The Council of Ambulance Authorities, Inc.). Retrieved from

Washko, J. D. (2012). Rethinking delivery models: EMS industry may shift deployment methods. Journal of EMS, 37(7), 32-36.

Wingrove, G. & Laine, D. (2008). Community paramedic: A new expanded EMS model. Domain3, 32-37. Retrieved from

EMS Research: Using t Tests

When considering the emergency medical services, there has been much discussion regarding the utility of advanced life support and its effectiveness within the emergency medical services (Stiell et al., 2005; Stiell et al., 2003; Stiell et al., 2002; Stiell et al., 1999). One of the most basic skills that paramedics use exclusively is intravenous cannulation and the subsequent delivery of isotonic intravenous fluid. Intravenous cannulation is one of the first advanced skills that paramedics utilize within the course of treatment as it allows to correct for shock, provides a means for administering parenteral medications, and provides a means for drawing blood for testing either in the field or upon arrival at the receiving emergency department. As the body’s stress increases when dehydration is present, it is imperative to correct dehydration during the course of treating most ailments; otherwise, the body’s own compensatory mechanisms can fail despite otherwise adequate treatment (Wakefield, Mentes, Holman, & Culp, 2008). Additionally, dehydration can mask some critical tests, such as other blood values and radiological findings (Hash, Stephens, Laurens, & Vogel, 2000).

Though the research is limited, it is also important to note that judicious use, or overuse, of intravenous fluids can be detrimental in some cases (Rotstein et al., 2008). In order to test the effectiveness of paramedic treatment of co-morbid dehydration, we can observe for fluid status before and after treatment as well as between those patients transported by paramedic ambulance as compared to patients who present to the emergency department by other means (e.g. basic life support ambulance, walk-in); however, it is first important to understand if those patients who present to the emergency department are, indeed, dehydrated.

In order to study if paramedics have an impact in treating co-morbid dehydration, there has to be an assumption that a) most people are not dehydrated and b) people who present to the emergency department (the dependent variable) are more dehydrated (independent variable) than most of the population. As we can never be sure of the hydration status of the entire population at any given time or the standard deviation of the entire population, we can use the normal mean blood urea nitrogen value of 10 mmol/L and assume a normal distribution (Hash et al., 2000).

H0:μ=10: Patients who present to the emergency department are not dehydrated (BUN = 10 mmol/L)
Ha:μ>10: Patients who present to the emergency department are dehydrated (BUN > 10 mmol/L)

Once the random sample of BUN values have been obtained, I can use the t-distribution to find the value of the t-test statistic:

t = (x̄ - μ) / (s / √n)

Next, I would compute the degrees of freedom (it is important to note that the sample size [n] must be greater than 30 as the standard deviation of the population is not known):

DOF = n - 1

As this test is one-tailed (specifically, right-tailed), and I am concerned with a 95% CI, I would compare the t-value with the t-table row indicated by the DOF. If the t-value is greater than the t-value corresponding with the DOF, then I will be able to reject the null hypothesis; otherwise, if the computed t-value is less than the table value, I will not be able to reject the null hypothesis.


Hash, R. B., Stephens, J. L., Laurens, M. B., & Vogel, R. L. (2000). The relationship between volume status, hydration, and radiographic findings in the diagnosis of community-acquired pneumonia. Journal of Family Practice, 49(9), 833-837.

Rotstein, C., Evans, G., Born, A., Grossman, R., Light, R. B., Magder, S., … & Zhanel, G. G. (2008). Clinical practice guidelines for hospital-acquired pneumonia and ventilator-associated pneumonia in adults. Canadian Journal of Infectious Diseases & Medical Microbiology, 19(1), 19–53.

Stiell, I. G., Nesbitt, L., Pickett, W., Brisson, D., Banek, J., Field, B, … & Wells, G., for the OPALS Study Group. (2005). OPALS Major Trauma Study: impact of advanced life support on survival and morbidity. Academy of Emergency Medicine, 12(5), 7.

Stiell, I. G., Nesbitt, L., Wells, G. A., Beaudoin, T., Spaite, D. W., Brisson, D., … & Cousineau, D., for the OPALS Study Group. (2003). Multicenter controlled trial to evaluate the impact of ALS on out-of-hospital chest pain patients. Academy of Emergency Medicine, 10(5), 501.

Stiell, I. G., Wells, G. A., Spaite, D. W., Nichol, G., Nesbitt, L., De Maio, V. J., … & Cousineau, D., for the OPALS Study Group. (2002). Multicenter controlled clinical trial to evaluate the impact of advanced life support on out-of-hospital respiratory distress patients. Academy of Emergency Medicine, 9(5), 357.

Stiell, I. G., Wells, G. A., Spaite, D. W., Nichol, G., O’Brien, B., Munkley, D. P., … & Anderson, S., for the OPALS Study Group. (1999). The Ontario Prehospital Advanced Life Support (OPALS) Study Part II: Rationale and methodology for trauma and respiratory distress patients. Annals of Emergency Medicine, 34, 256-262.

Wakefield, B. J., Mentes, J., Holman, J. E., & Culp, K. (2008). Risk factors and outcomes associated with hospital admission for dehydration. Rehabilitation Nursing, 33(6), 233-241. doi:10.1002/j.2048-7940.2008.tb00234.x

Discussing Cost-Effective Analysis

This week I was directed to provide insight to the cost-effective analysis (CEA) provided by Penner (2004) in A Cost-Effective Analysis for Proposed Alternative Interventions to Post-Procedure Surgical Pain Reduction. Within the CEA, three alternative treatments (guided imagery, hypnosis, and biofeedback) are proposed to reduce post-operative pain. The CEA is used to determine the efficiency that each intervention offers comparably to each of the other two alternatives.

I developed a PowerPoint™ presentation [click here] to provide a summation of the CEA and visually present the information for a quick rationalization of the chosen intervention. I will explain each slide of the PowerPoint™ as it pertains to the CEA.

The Cost-Effective Analysis

The CEA provided by Penner (2004) describes the various costs and benefits of using guided imagery, hypnosis, and biofeedback therapies to reduce post-operative pain (as defined on slide #3), which improves the overall healing process. The objective, as noted on slide #2, is the importance of effective pain control. The author of the CEA concedes that all three interventions similarly meet the therapeutic objective of limiting post-operative pain in a safe and low-risk manner; however, the cost differences are significant.


As provided in the CEA, the most significant tangible benefits, as mentioned above, are providing effective pain management in a safe, low-risk manner. Additionally, and as a result of reducing pain effectively, increased patient satisfaction, better patient compliance, and overall better healing leads to reduced costs associated with post-operative recovery, such as reduced length of stay and reduced need for post-surgical care (e.g. nursing care, physician care, rehospitalization, medications). Slide #4 of the presentation outlines these similar benefits.


The costs of each intervention are significant factors in deciding which intervention to promote. Once the annual cost for each intervention if figured, each of the identified costs are distributed across the expected patient volume of 197 and further distributed over the likelihood of each of three surgical procedures (spinal fusion, total hip replacement, and auto hema stem cell transplant) being performed. Though this is largely unnecessary, it does provide perspective for how the costs will be distributed and raise the overall cost for each surgical procedure performed, as shown on slide #8. The total annual cost for each intervention, as well as the per-patient cost, is outlined on slide #5 and graphed on slides #6 and #7.

The fixed costs for guided imagery include a psychology consultant, a surgery PA coordinator, wages for clerical staff, and training for the surgery PA.

The fixed costs for hypnosis includes a psychologist skilled in hypnotherapy and wages for clerical staff. The amount of resources for hypnosis are significantly less than for guided imagery; however, the intervention is more substantial requiring significantly more hours per week paid (12 for hypnosis vs. 2 for guided imagery).

The fixed costs for biofeedback are more equivalent to, though slightly more than, those of guided imagery. Biofeedback requires a psychology consultant, a surgery PA coordinator, wages for clerical staff, and training for the surgery PA, but the fixed costs for biofeedback also include specific equipment, including skin sensors, two video monitors, VCRs, and carts.

The total identified costs for guided imagery is 32.18% less than biofeedback and 64.56% less than hypnosis.


Based on the CEA, the most cost-effective intervention for impacting and controlling post-operative pain on patients undergoing one of the three surgical procedures outlined is guided imagery. This result is stated on slide #10.


The appropriate management of pain is crucial to patient care. Assuming that the three interventions investigated are equally effective towards the objective of reducing and controlling pain, the cost of each intervention is the deciding factor when considering which of the three interventions to employ. In this case, guided imagery is the most cost-effective intervention and is the recommended intervention, per the CEA.

It is important to understand that these costs will be borne by not one but three different departments – the pain clinic, the orthopedic surgery department, and the patient education department. This cost-sharing removes the burden of providing the intervention from a single department and disperses the burden over the budgets of three different departments.


Penner, S. J. (2004). Introduction to health care economics & financial management: fundamental concepts with practical applications. Philadelphia, PA: Lippincott Williams & Wilkins.

Financial Statements:

What to Use, When to Use It

Accounting in health care is very important in order to understand the economic health of the organization. Without understanding the financial status of the organization, directionality of growth and prosperity is certainly in question; however, with financial statements as a guide, one can make informed and logical decisions to develop a strategic plan to direct organizational growth in a fiscally responsible nature.

Ittelson (2009) and Penner (2004) outline the various financial statements and how they are used. I will review three financial statements (the balance sheet, the income statement, and the cash flow statement) and the means to use the values on these statements to provide meaning, through the use of ratio analysis, of the fiscal health of the organization.

Financial Statements

Balance Sheet

The balance sheet is one of two main organizational financial statements. Ittelson (2009) outlines the balance sheet as showing assets = liabilities + worth, in that the value of an organization’s assets (or, what an organization has) is the sum of the organization’s liabilities (or, what is owed) and worth (or, the value of the organization to the owners).

Assets are usually listed on the balance sheet in order of liquidity and include everything valuable within an organization, including cash, accounts receivable, any inventory (included at depreciated value, if applicable), expenses that were prepaid, and any other intangibles that offer intrinsic value to the organization (Ittelson, 2009; Penner, 2004).

Liabilities, according to Ittelson (2009), are listed on the balance sheet as groupings of term (short- and long-term) and include current liabilities (accounts payable, expenses, portions of contracted debt currently payable, and taxes), long-term debt (or, contracted debt payable outside of the bounds of the current statement), and shareholder equity (or, the sum of capital stock value and the amount of retained earnings). The shareholder equity is also the worth of the organization.

By definition, the balance sheet must be balanced in the end with the value of the assets being the total liabilities and equities offset by the shareholder equity. The balance sheet, with this comparison, provides the fixed financial picture of the organization at any particular date.

Income Statement

The income statement, which describes an organization’s profitability, is the other main financial statement of an organization (Ittelson, 2009). The income statement details the value of inputs and expenses required to develop a specific income for a defined period of time; however, according to Ittelson (2009), it does not provide timing on payments or an assessment of how much cash the organization has on hand.

The income statement accounts for the gross margin (net sales vs. cost of goods sold), operating expenses (e.g. sales and marketing, research and development, and general and administrative expenses), interest income, and income taxes to derive net income (Ittelson, 2009; Penner, 2004).

As the organization’s net income increases, reflections of increased assets or decreased liabilities will be seen on the balance sheet. Likewise, this link will also show the reverse to be true as decreased assets or increased liabilities (Ittelson, 2009).

Cash Flow Statement

The cash flow statement, as noted by Ittelson (2009) and Penner (2004), simply describes the movement, or flow, of cash within the organization. Starting with the amount of cash on hand at the beginning of the reporting period, the cash flow statement tracks how cash is paid and received, such as cash receipts and disbursements, purchases of fixed assets, money borrowed, stock sales, and taxes paid, ending with the amount of cash on hand at the end of the reporting period. However, this statement does not account for receiving inventory or delivering finished products to customers as these would account for non-cash transactions. Only when the organization pays for the inventory or the customer pays for the product would it affect the cash flow statement.

According to Ittelson (2009), the cash flow statement describes the velocity of cash, exclusively, within an organization, and accounts for a portion of the organization’s assets as well as some new liabilities (such as a new mortgage or loan) and old liabilities (debt being paid).

Ratio Analysis

Although the financial statements described above describe the general financial health of an organization, the relationships of particular items within those reports can provide more specific indicators of financial condition (Ittelson, 2009; Penner, 2004). The use of these relationships is called ratio analysis.

Ratio analysis can help to determine factors, such as profitability, liquidity, asset management, and leverage. Ratio analysis can also help to compare various organizations among various industries by using a statement conversion to “common size” (Ittelson, 2009, p. 194), which represents items as percentages of the largest item on each statement.

Profitability, according to Ittelson (2009), is the ability of an organization to generate a return of profit on equity, sales, and assets. The gross margin, as a percentage, is also a profitability ratio analysis.

Liquidity, as opposed to the measure of returning a profit, is a measure of an organization’s ability to maintain a financial cushion and show financial strength.

Asset management ratios are measures of the efficient or inefficient use of assets and the time generally taken from using inputs to receiving payment. According to Ittelson (2009), “asset management ratios provide a tool to investigate how effective in generating profits the [organization’s] investment in accounts receivables, inventory [sic] and fixed assets is” (p. 198).

Leverage, much like liquidity, is a safety measure that describes the organization’s ability to absorb loss and meet obligations. The leverage safety cushion is also referred by Ittleson (2009) as the “equity cushion” (p. 202). Too much leverage is risky, but too little leverage decreases the ability to maximize profit and growth. Leverage is the use of other people’s money to augment the owner’s investment in order to maximize profits.


By using strict accounting guidelines and keeping accurate records, financial statements can be prepared that will provide insight into the financial health of an organization. These statements can help to compare the financial status of the organization at different times or to compare the organization with other organizations. Also, accurate financial statements will help to draw investors, secure lending opportunities, and comply with legal requirements.


Ittelson, T. R. (2009). Financial statements: A step-by-step guide to understanding and creating financial reports (Revised and expanded ed.). Pompton Plains, NJ: Career Press.

Penner, S. J. (2004). Introduction to health care economics & financial management: fundamental concepts with practical applications. Philadelphia, PA: Lippincott Williams & Wilkins.

Political and Technical Budget Strategies

When preparing an agency or department budget, two strategies may be employed, usually in combination: political budgeting and technical budgeting (Menifield, 2009). While most budgets are defended politically, the technical budgeting stategy is most useful when defending mandatory and base expenditures of a legally mandated service, such as a police or fire department (Menifield, 2009). New programs, especially those viewed largely as ancillary, or “nice to have,” would be largely defended using a more polital than technical strategy.

Menifield (2009) explains the technical budgeting strategy as “[concentrating] on the numbers or budgetary facts [and] split into two categories: mandatory, [sic] and discretionary spending” (p. 43) with base expenditures “to maintain the same level of service” (p. 44) identified for each. Efficiency and productivity are foci of the technical budgeting strategy. The political budgeting strategy, according to Menifield (2009), is used to “sell” a program based more on its merits or public demand than on mandate or efficiency and productivity.

In the emergency medical services, since its provision is usually not a legal requirement of the government, it would make sense to defend the budget politically if the service was started within the last few years; however, a more technical budget in continuing years might help to buttress the perceptions of the public that it is actually a needed service. Continuing to defend an emergency medical services budget with a more political strategy could make it actually appear less important and subject to tighter budget controls. Additionally, as the emergency medical service is the only public safety entity that routinely charges user fees, the structure of a technical budget would plainly show revenue offsetting expenditures, making it less likely to suffer cuts. Again, both strategies would be used proportionally to their need.


Menifield, C. E. (2009). The basics of public budgeting and financial management: A handbook for academics and practitioners. Lanham, MD: University Press of America.

Human Resource Challenges

Human resource management is a comprehensive support paradigm for both the employer (and his or her agents) and the employee. Most of the discussion regarding human resources revolves around problem employees and how human resources management can be used to deal with them. This week, however, we get to appreciate how human resources management can be effective at mediating employee concerns. Presented with two scenarios involving employee concerns, we will choose one and explore the fundamentals of human resources management as it relates to the challenges presented.

Throughout the past two weeks, Paul, a physical therapist, has been receiving in his work e-mail inbox some disturbing messages from an unknown sender. Many of the messages are sexual in nature and some even refer to Paul’s coworkers. Paul has reluctantly confided in the head of the organization’s HR department to help him with the issue. He is very embarrassed about the situation and is concerned that an investigation might jeopardize his relationships with coworkers and even his position with the organization.

As internet technology and systems management is a forte or mine, it is difficult for me not to take the easy path by selecting scenario 1. For this scenario, Paul would only have to enlist his manager in engaging the IT department to track the emails, which is a very simple process (most people do not understand how much information is generated in server logs and attached to email messages). The sender of the offensive emails would be found out and dealt with, and/or future messages of this type would be blocked by the email server, and Paul would no longer be distracted by these offensive emails.

However, as I stated previously, I prefer a challenge and will review the problems and some potential solutions regarding scenario 2.

For the past year, the nurses’ union at Good Health Hospital has been meeting to discuss grievances against Good Health’s management. In particular, the nurses are concerned with the way managers treat them; many feel overworked, undercompensated, and underappreciated. They have recently submitted a proposal to Good Health’s executives asking for better management practices, an increase in nurse staffing, and better compensation and benefits for nurses. The executives have enlisted the help of Good Health’s HR department in addressing the concerns in the proposal; they are concerned about budget constraints as well as the possibility of a nurses’ union strike.

Scenario 2 involves organized employees threatening a work stoppage if, at least, some of their concerns are not mitigated. Work stoppages, or strikes, are detrimental to any organization. The nurses’ union at Good Health Hospital have presented grievances that are typical in health care (Fallon & McConnell, 2007). It is a wonder why these concerns were not identified early. As Fallon and McConnell (2007) point out, “the best time to address a problem is before it becomes a problem” (p. 281). In this case, effective management would have identified these concerns early and developed a plan, perhaps integrating potential solutions through the organizations strategic plan, and prevented the growing acrimonious and bitter discontent amongst the rank and file employees. Though Fallon and McConnell discuss various types of organizational leadership, I prefer to lead with libertarian values in mind; ergo, both respect and responsibility must be virtues of both employee and employer, and both must work hard for the other. Fallon and McConnell discuss how trust and mutual respect lends to an effective, efficient, and rewarding work environment. Unfortunately, in scenario 2, it seems that we are beyond mitigation and prevention and, legally and contractually, they must be addressed.

Good Health Hospital administrators should take heed to the complaints noted in the nurses’ grievances. Although many managers and adminstrators dislike unions, ignoring them is not the answer. In this case, the concerns are probably real. Fallon and McConnell (2007) tell how information pertinent to employer-employee relations does not typically transcend the ranks, and this set of grievances may be the first indication to upper management that there is an issue. Still, the hospital adminstration, depending on the organizational schema (for-profit, not-for-profit, public, private, et al.), has a responsibility to its stakeholders and must ensure both operational feasibility and cost containment. Answering to these grievances could jeopardize one or both of these. A work stoppage would be detrimental to the operation and prove costly while meeting the demands in full would unrealistically obliterate the profit margin (note: the demands are not listed within the scenario; however, we can infer that they are significant).

If I were in the position of dealing with these grievances, I would, first, separate the demands by genre: safety and ethics, emotion, and economics. First and foremost, any ethical or safety concerns should be dealt with immediately, anyway. By identifying and dealing with these issues first, the perception of a receptive and action-oriented administration is gained. The solutions for these issues can also be highly visible and can be made to work for the organization by way of press releases outlining improvements in safety if not mere visible changes in the work environment and culture. Second, addressing emotional issues, such as poor treatment by managers and the perception of a lack of appreciation, can be solved by the employees, themselves. For instance, a “grade your manager” program might be cost neutral and provide some insight for future coaching. This would also give a sense of the prevailing attitude of the employees in the way comment cards give businesses a sense of the clientele. Another way of addressing emotion is to direct each manager to inquire of their staff periodically about any minor concerns they might have. This would give a sense of open communications, something that appears to be lacking. Finally, it is time to address the economical concerns.

Many times, the pay and benefits that are offered to unionized workers are stipulated in the collective bargaining agreement. These, fortunately (or, unfortunately) cannot be changed until the contract is renegotiated. Ethically and respectfully, the compensation package should hover near market levels. Fortunately for Good Health Hospital, we have already addressed a few concerns, so we have latitude in addressing the economic issues. As Fallon and McConnell (2007) state, working conditions are just as important as financial incentives, and employees may sacrifice pay and benefits for a decent working environment.

Regardless of the hospital’s ability to meet the nurses’ demands, I would insist on meeting with them, out of respect, to hear their concerns; however, the meeting would be official and the labor relations attorneys would be present to ensure compliance to the National Labor Relations Board regulations.


Fallon, L. F. & McConnell, C. R. (2007). Human resources management in health care: principles and practice. Sudbury, MA: Jones and Bartlett.

Establishing S.M.A.R.T. Goals

“Employees learn better when they actually become involved in the process” (Fallon & MCConnell, 2007, p. 192), so what better way to grow than to define the process?!

Meyer (2006) outlines a methodology, referred to as S.M.A.R.T., of developing goals and a plan to attain them. The S.M.A.R.T. goal methodology that Meyer describes is reflected in the acronym of the name: specific, measurable, attainable, realistic, and time-bound. However, as Rubin (2002) points out, the acronym is dynamic and variable to include any number of variations: simple, specific, sensible, significant; meaningful, motivating; acceptable, achievable, action-oriented, accountable, agreed, actionable, assignable; realistic, reviewable, relative, rewarding, reasonable, results-oriented, relevant; timelines, time-frame, time-stamped, tangible, timely, time-based, time-specific, time-sensitive, timed, time-scaled, time-constrained, time-phased, time-limited, time-driven, time-related, time-line, toward what you want, and truthful. Even more dynamic, as Rubin points out, some add “efficacy” and “rewarding” making S.M.A.R.T. goals S.M.A.R.T.E.R. goals!

Regardless, however, of the actual mnemonic, the methodology represents the continuum of goal-analysis, goal-setting, and goal-attainment in a systematic manner that is tangible and results-oriented. The philosophy remains true and valid.

Setting a Goal

In the past, one of my goals was to obtain a college degree. I knew that I was intelligent and should have no problem, otherwise, attaining this goal, but life always seemed to place obstacles in my path. One day, not so long ago and with chiding from my father, I decided to put a date to this goal: December, 2012. I was lacking this one important motivational step for so long, but because I finally made my goal time-sensitive, I was finally able to measure my progress in a specific manner. I feel that because I developed a realistic time-line to attain this goal, I will obtain my bachelors degree this year.

Now that I am close to completing one goal, it makes sense to reflect and determine my next set of goals, but how can I apply the S.M.A.R.T. methodology of setting one? Reviewing Meyer (2006) and Rubin (2002), I find that, first, I need to conceptually understand that goals should be simple and realistic. Next, my goal needs to somehow be constrained by time so that it is measurable and my progress is quantifiable. Further, my goal, itself, needs to be motivating and rewarding.

My goal cannot be something as simple as make more money or be a better person. These goals are broader, I feel, than the methodology is designed for. However, breaking one of these goals down to measurable steps seems to be preferred. Instead of make more money, a more specific goal might be to earn a six-figure income by a set date.


According to Meyer (2006), the first question is if this goal is specific. Yes. If I continue to earn any less than $100,000 in a single year, I have not met my goal.


The next question: Is it measurable? For the same reasons that it is specific, it is measurable. Additionally, my progress is measurable by the year-to-date column of my paycheck, which should increase towards my ultimate goal amount.


Is this goal attainable? As I take stock of my current income and skill set with the addition of my bachelors degree and other certifications and licenses, I do feel that a six-figure income is attainable.


In order to be a realistic goal, others in my profession must have attained this goal, or I must be willing to change professions. I am hard-pressed to leave the emergency medical services, and there are a number of positions available within the emergency medical services that earn six-figures. These positions are mostly administrative in nature, but I feel that I have the experience to start considering these positions as realistic.


Setting a time-frame for completion of my last major goal underscores the importance of this step, but it is my weakness, and I acknowledge that. However, as I expect to obtain my bachelors degree later this year, realistically, I would have to give myself another year or two to find a position for which I could apply. I would, then, need another year in order to actually earn the income. The 2015 tax year seems appropriate, though unrealistic, perhaps. Still, I will set this time-line and reconsider each objective of my goal as 2015 draws closer.


Setting a goal is a difficult task. It is sometimes difficult to look to the future, and often times, we are haunted by our failings in the past. Using a methodology, such as S.M.A.R.T., can help us to reflect on realistic and meaningful goals that can ultimately help us work toward the more obscure long-term goals, like being affluent or saving the world.


Fallon, L. F. & McConnell, C. R. (2007). Human resource management in health care: principles and practice. Sudbury, MA: Jones & Bartlett.

Meyer, P. J. (2006). Attitude is everything. Retrieved from smartgoals.pdf

Rubin, R. S. (2002). Will the real SMART goals please stand up? The Industrial-Organizational Psychologist, 39(4), 26-27.

Burnout: “What a Star—What a Jerk”

The character, Andy Zimmerman, in Cliffe’s (2001) fictitious hypothetical is obviously intelligent and hard-working; however, he appears to be suffering from “burnout”. Korczak, Huber, and Kister (2010) describe the contemporary definition of burnout as essentially equated to work-related syndrome, which is characterized by “emotional exhaustion, depersonalisation [sic] or cynicism and reduced professional efficacy” (p. 3); however, the authors acknowledge a plethora of symptoms, definitions, and theories in the literature and call for standardization for improved diagnosis and research. Maslach and Leiter (2010) describe burnout as “[reflecting] an uneasy relationship between people

and their work” (p. 44). In the case of Andy Zimmerman, it appears that he has depersonalized his work, evidenced by his egoism and rage towards his co-workers. Also, from reading the fictitious account, assumptions can be made: 1) Andy Zimmerman did not start his job by acting in such manner; therefore, this is a change that Jane Epstein would not be privy, and 2) Andy Zimmerman may feel that his work is falling from his own personal standard and finds blame in others, which goes towards his egoism. In all, these might account for some level of reduced professional efficacy. However, as Korczak et al. discuss, there is no valid diagnostic criteria of burnout and application is difficult as burnout has strong correlation with depression and alexithymia (see footnote 1), each of which could contribute to Andy Zimmerman’s attitudes and outbursts.

Employees who are suffering burnout or other psychosocial maladies have a negative and detrimental effect on other co-workers (Maslach and Leiter, 2010; Korczak, Huber, & Kister, 2010). In the case of Andy Zimmerman, his relationship with his work environment is certainly reducing the efficacy of others. Is it possible that Andy Zimmerman’s tirades are the only reason that he is the top performer? Could it be that culling inappropriate behavior would more than make up for the loss of one man’s productivity?

According to Fallon and McConnell (2007), many employees that are suffering personal problems to the degree that they interfere with work are able to benefit from managers pointing out how their work has been suffering, but employees that are identified as possibly suffering from burnout syndrome (or, any major personal problem that adversely effects work) should be referred to the employee assistance program, if at all possible. Fallon and McConnell go further to state, and rightly so, that managers should not give advice on personal matters but only provide a means of rectifying professional performance. Managers are poorly equipped to handle counseling of a personal nature. Instead, Fallon and McConnell demonstrate the utility of the progressive discipline model to both educate an employee about his or her responsibilities and allow him or her to rectify the situation. Unfortunately, however, behavior problems sometime end with termination, though “experts note that when an employee is released for a serious infraction, the problem has been corrected by removing its cause” (Fallon & McConnell, 2007, p. 260).

In regards to Jane Epstein’s troubles with Andy Zimmerman, double standards of employee conduct cannot exist (Fallon & McConnell, 2007). Jane must do something to quell the growing rift within her department. First, Jane must document everything in regards to Andy (Fallon & McConnell, 2007). This, most of all, will support the premise that Jane used all possible solutions before considering termination. Next, Jane should ensure that Andy understands that the behavior will not be tolerated any longer. This could, perhaps, be coupled with a statement referencing the employee assistance program or other route of anger management counseling. Finally, Jane might consider that the work being performed is not well matched for Andy. Mismatched work is a significant cause of burnout, and if this is suspected, Jane could discuss the potential for professional growth with Andy, which might alleviate the outbursts (“Don’t take your people for granted,” 2010; Maslach & Leiter, 2010). Finally, if Andy continues to fail to conform to the department policies, he must be terminated. Jane needs to view her responsibilities to the department over any she might feel towards a single employee (Fallon & McConnell, 2007).


Cliffe, S. (2001). What a star — what a jerk. Harvard Business Review, 79(8), 37–48.

Don’t take your people for granted. (2010). Healthcare Executive, 25(4), 40.

Fallon, L. F. & McConnell, C. R. (2007). Human resource management in health care: principles and practice. Sudbury, MA: Jones and Bartlett.

Hosoi, M., Molton, I. R., Jensen, M. P., Ehde, D. M., Amtmann, S., O’Brien, S., … Kubo, C. (2010). Relationships among alexithymia and pain intensity, pain interference, and vitality in persons with neuromuscular disease: Considering the effect of negative affectivity. Pain, 149(2): 273–277. doi:10.1016/j.pain.2010.02.012

Korczak, D., Huber, B., & Kister, C. (2010). Differential diagnostic of the burnout syndrome. GMS Health Technology Assessment, 6, 1-9. doi:10.3205/hta000087

Maslach, C. & Leiter, M. P. (2010). Reversing burnout: How to rekindle your passion for work. IEEE Engineering Management Review, 38(4), 91-96. doi:10.1109/EMR.2010.5645760


1. Alexithymia is defined as a lack of emotional awareness and the inability to identify or label emotions, which is demonstrated by difficulty identifying and describing feelings and difficulty with externally-oriented thinking (Hosoi et al., 2010).

2. In response to Cliffe’s (2001) “What a Star—What a Jerk”:

  • Mary Rowe calls on Jane to show laissez-faire leadership in which she does nothing directly but tries to “work with Andy” to come to a workable solution, relying on upper management to provide discipline. In the writing, Jane has already approached Andy and discussed his attitudes towards his co-workers; however, the positive result of this conversation was short-lived, and Andy reverted to his tactics of ill-temperment and hostility. In my opinion, these attitudes have no place in the workplace, and Jane should be adamant about this point before Andy directs his rage towards her, further undermining her authority.
  • Chuck McKenzie, however, makes some good points on how to work with Andy (so long as there is actual value in Andy remaining employed with TechiCo). Mr. McKenzie calls for some innovative changes in the organizational structure to separate Andy from the rest of the team, capitalizing on increased productivity all around. Additionally, creating a specialized team of high performers might alleviate burnout (if, in fact, that is what Andy is suffering) and demonstrate to Jane’s superiors that there are ways to isolate and reward top performers while tolerating average performers. Before doing anything, as Mr. McKenzie points out, Jane needs to become a leader and stop acting like a manager.
  • While Kathy Jordan elucidates more of the same philosophy as Chuck McKenzie in regards to leadership, she advocates trust and positivity between Jane and Andy. I feel that trust and positivity are a product of a viable working relationship and are more goals than standards. Ms. Jordan is right, however, that Jane must prove her mettle in a very short time.
  • Finally, James Waldroop provides some real insight into how Jane might best lead and mold Andy into a star employee. Either that, or Jane has started the time table for Andy’s departure. All in all, leaders need followers, and leaders cultivate followers; however, if a subordinate does not wish to follow, then the leader cannot lead or cultivate. In this case, the relationship has failed.

Employee Retention

I am familiar with a local EMS organization where the perception of the employee-base is that middle management sacrifices requisite supplies in order to regain budget losses, losses that were incurred due to their overall mismanagement. Sacrificing supplies in the emergency medical service arena equates to negligence and could, indeed, prove harmful to patients. This, coupled with the notion of incompetence, has a negative effect on morale, especially as this is one of the only divisions within the larger company that experiences these types of problems. Many have considered leaving (in fact, I have been told that most consider it quite often); however, the compensation package that they receive cannot be met by any other provider in the area. This leaves the employee in an ethical quandary. This issue is not isolated to this particular company, though. Although many private ambulance companies in the region face the same mismanagement, they do not offer comparable compensation packages and are much easier to leave.

Fallon and McConnell (2007) discuss how pay and benefits are vitally linked to overall job satisfaction, and I agree with their determination. However, there are other components, such as conscience. Duffy (2010) explains, in the light of pharmacists refusing to dispense abortion pills as a right of conscience, how “medical professions are among those where ethics and morality are of paramount concern” (p. 509). Consider Duffy’s explanation in reverse as this particular company is forcing their employees not to care for patients who they would otherwise be able to treat. The result is a significant emotional and psychological toll, I can imagine, but the employees cannot just walk away from their paycheck. This company, I feel, has learned to balance some of the positive working conditions with some of the negative working conditions, and the company relies heavily on wages and benefits to do so. According to Fallon and McConnell (2007), this tactic helps to relieve employee turnover rates; however, if the company would mitigate the negative aspects of the job, the wages and benefits offered could be used to attract employees with higher skill levels. Instead of leveraging ambition and affecting positive psychology within the workforce, as Amabile and Kramer (2011) recommend, the typical leverage is financial at a cost of ambition and morale.

In contrast, I have worked for agencies that paid far less in compensation than their competition, but the appreciation on the part of management was evident and allowed me to overlook the compensation gap with the other companies where the employees were always complaining and just seemed unhappy. Unfortunately, the gap grew to a point that was unbearable and I had to ultimately leave, but it was quite a while before I found another agency that commended professional evolution and progress, such as described by Amabile and Kramer (2011) — the company discussed above, however, is not.

Amabile and Kramer (2011) describe the withholding of resources to be a “toxin” that negatively effects morale. By improving supply requisition, a “catalyst” to improve morale, and improving recognition and supporting a free exchange of ideas, this company could improve morale significantly and focus on hiring skilled and experienced providers rather than those that will merely acquiesce to their ambiguous demands.


Amabile, T. M. & Kramer, S. J. (2011). The power of small wins. Harvard Business Review, 89(5), 70-80.

Duffy, M. E. (2010). Good medicine: Why pharmacists should be prescribed a right of conscience. Valparaiso University Law Review, 44(2), 509-564.

Fallon, L. F. & McConnell, C. R. (2007). Compensation and benefits. In Human resource management in health care: principles and practice (pp. 201-218). Sudbury, MA: Jones & Bartlett.