There's been a lot of chatter about the lack of quality candidates for new EMS positions. I think it's safe to say that a lot of the new hires and paramedics knocking on the door don't have the same work ethic or idea of service as the previous generation. This issue has been the topic of numerous presentations on the national lecture circuit.

Let me to get into this subject with a personal anecdote. More than six months ago, I arranged for a kitchen remodel from the Home Depot, but the project still isn't complete. One employee assigned to install a portion of the project failed to apply a work ethic that we apply to medicine often: Take care of the customer (the patient) like he or she is one of your family members.

This lack of what I consider an adequate work ethic resulted in my testing the Home Depot complaint system and ultimately involved the store manager, the district manager, the owner of the subcontracting company responsible for product installation and representatives from the product manufacturing company. It has turned out to be a very expensive proposition in terms of the time of all those dealing with the complaint for a project that could have been done right the first time with the proper work ethic.

Like Home Depot, a metro fire department has many divisions and must cover a large area with hundreds of employees, some of whom rarely interact with “upper management.” Leadership may assume that everything is going to plan from a customer service standpoint. But it takes just one person on the staff lacking the correct work ethic to trigger an expensive managerial intervention.

Most fire department — based EMS agencies test new hires fairly extensively for firefighting and mechanical knowledge, physical capabilities, and medical skills. But the attitude and the ethical perspective under which a new paramedic operates can be as much or more important yet may receive only a brief assessment via an oral board or a chief's interview.

We can teach medicine, firefighting skills and fitness, but changing attitudes and work ethics is a much greater challenge, especially with a generation that seems to ask only, “What's in it for me?” While there are some vocational screening tools that help assess ethical perspectives, they have had little application in fire service and EMS work.

The term “ethic” comes from the Greek word ethos meaning “character or custom.” While good customer service is expected by most agencies, few actually teach what conduct, beliefs and values are expected. Ethical conduct requires doing the right thing whether someone is watching or not. Ethical conduct involves beliefs, values, standards, and the principles of honor and morality. Ethics is concerned with how one should behave, and values determine how a person actually does behave. It's a guideline for human action and how we make decisions or what motivates our decision-making.

There are five commonly defined ethical models: utilitarian, rights, fairness or justice, common good, and virtue. All have influence on different applications in the fire service.

Utilitarian ethical approaches are actions that will produce the greatest good for the greatest number. This is the concept of most emergency triage and can depersonalize individual need. As most experienced providers know, not every patient fits in a protocol to make that decision.

The rights ethical approach embraces the concept that people have free will to choose their actions. An ethical decision within the rights model will first have considered, “Does the action respect the moral rights of everyone involved?” A decision that violates a person's rights — even if it's in the best interest of the patient — is considered wrong. It creates, however, a trap for the paramedic: Should he or she release a slightly intoxicated patient? It may be that individual's right, but what if the person falls, strikes his head and is later found with a subdural hematoma?

The fairness or justice ethical perspective evaluates decision-making on how fair the action is and questions whether it treats everyone the same way. This ethical perspective can be a huge challenge for EMS providers. Many experienced paramedics make biased decisions based on their years of experience on the street. An example might be the case of the 50-year-old female with shortness of breath who is given an anxiety workup rather than a cardiac exam, despite American Heart Association Statistics showing equal numbers for acute myocardial infarctions.

The common good model is based on the fact that society is made up of individuals whose ethical behavior is linked to the community and bound by a common interest and values. The common good decision will fit with the culture of the organization.

An ethical decision made from the perspective of the virtue model assumes there are certain ideals toward which we should strive that provide for the full development of our humanity. It holds that people who have developed virtues will be naturally disposed to act consistently with the moral conviction that they will do the best they can and give 100%.

A lack of ethical behavior focused on service and community ultimately will result in a bad interaction with the public. Behind many EMS medical malpractice suits is the fact a paramedic failed to show a person respect, angered the person or compromised that person's dignity. Such actions start the patient (or the patient's family) looking at every aspect of the care provided, and if an incident is examined closely enough, often something can be found. If such a situation arises, it's important that EMS leadership and the fire management team act quickly. It often may be a sentinel event that should signal a closer look at operations as a whole.

Complaints typically will come from one of two avenues: a citizen complaining directly to the fire department, or a patient, facility or provider complaining to a regulatory authority that then notifies the fire or EMS agency. When a complaint comes, it's not uncommon to ask for the person to put the complaint in writing. This provides a solid record and ensures the story of the events won't change as an investigation proceeds.

Once a complaint is verified, management should immediately ask for incident reports from any staff member involved. It's important to separate employees for this process, not so much out of concern for a collaborated story but to ensure the most objective report of events is obtained.

One thing many EMS managers fail to do is ensure that the employees involved with a complaint are properly notified that an investigation is being conducted that may result in disciplinary action. This notification should be made before information is collected from anyone other than the complainant. In addition, if the employee toward whom the complaint is directed is covered by a typical IAFF labor contract, union representation should be offered as part of due process.

If there are criminal implications, employees also must be advised of their Garrity rights. When invoking the Garrity rule, a public employee is invoking the right against self-incrimination. Any statements made after invoking Garrity may be used only for department investigation and not for criminal prosecution. The Garrity Rule stems from the court case Garrity v. New Jersey, 385 U.S. 493 (1967), which was decided in 1966 by the U.S. Supreme Court. The IAFF does not support poor medical decision-making, but it does support the protection of employee's rights and following the rules for discipline.

Of course, in advance of any complaint alleging medical malpractice, the medical director, EMS chief, fire chief, legal consultants and union officials should have met and mapped out how such complaints are to be dealt with in the union contract. The delineation of what becomes the fire chief's responsibility and what falls within the purview of the medical director needs to be discussed and put down in policy. In many cases the medical director holds the paramedic's right to practice medicine under a state-delegated practice act. The catch here is that often a union contract or condition of employment requires the employees to hold a paramedic license. Because an EMT level practice is often a certification and usually under supervision of another higher-trained EMT provider, the physician medical director's option may be for decertification and downgrading to an EMT certification versus forcing the discharge of an employee.

In any case, a failure with respect to work ethic can spread across a department. Sometimes a peer review process can have more impact on curbing poor behavior or attitudes than a formal disciplinary processes. Some agencies make it part of their culture to share mistakes as an awareness piece of the education program. Ideally, all parties should be looking for an education prescription before moving toward discipline. It also provides a character-building opportunity to take responsibility and learn from a mistake or moment of bad judgment.

Finding new EMS providers with the right attitude, ethics and moral prevalence to consider themselves a servant to the community requires fire department and EMS leadership to look harder. The good news is that psychologists say they are observing in individuals entering high school today that their grandparents have had a significant influence on their upbringing. The duty and sacrifices of the generation that endured World War II have been instilled in them. The challenge will be how to find these folks and convince them to join your team.

Two helpful sources of information on ethical perspective can be found online. The Web site of the Williams Institute at www.ethics-twi.org has a survey tool to help identify a person's ethical perspective. The Josephson Institute's site at www.josephsoninstitute.org offers resources for training and promoting ethics in the workplace, including education targeted for public safety personnel.

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Bruce Evans is the fire science program coordinator at the Community College of Southern Nevada as well as an adjunct faculty member for the National Fire Academy's EMS and injury prevention courses. A captain at the Henderson (Nev.) Fire Department, he has an associate's degree in fire management and a master's degree in public administration.