Motivation of emergency medical services volunteers: a study of organized Good Samaritans

Volunteers form a significant part of the personnel of many EMS organizations [8‐10]. In the US, the urban EMS workforce is comprised of approximately 30% volunteers, with rural EMS workforces reaching up to 75% volunteer staffing [8, 10]. In Austria volunteers make up more than 80% of EMS personnel [11] and in Israel about 89% of the National EMS (Magen David Adom or MDA) personnel are time-donation volunteers.

The classic form of volunteering in EMS is by time donation, such as one shift per week [10, 12]. EMS organizations experience significant shortages of time-donation volunteers (TDV), especially in rural areas [8, 10]. Significant numbers of volunteer-based organizations seek to leverage information and communication technologies to enhance administrative and operational efficiency and effectiveness [13].

EMS organizations and health policy makers try to achieve faster response times through various approaches. These include Automatic External Defibrillator (AED) deployment in public places [14‐17]; the use of drones to deliver emergency equipment [18]; and the establishment of different networks of first responders [19‐28]. The density of first responders in a given geographic area is strongly correlated with faster first aid [29].

People help each other in emergency situations and the phenomenon of “bystander intervention” has been vigorously studied over the past five decades [30‐34]. Off-duty doctors and other medical professionals have the highest potential to help given their medical knowledge and training, and have been identified as an important source of volunteers in disaster recovery plans [35]. About 80% of physicians have had an opportunity to provide a Good Samaritan response and 93% agreed to provide help when asked [36‐38]. In 1959 California gave physicians immunity from civil liability resulting from provision of a Good Samaritan response and since then all other states have followed suit [39].

mHealth is defined as “healthcare to anyone, anytime and anywhere by removing temporal and locational constraints” [40]. Developments in mHealth have led to a sharp increase in the availability of applications (apps) supporting medically motivated physical interaction between app users, leading to potentially significant changes in healthcare delivery and the structure of emergency response organizations [41, 42]. Multiple apps exist in this area, such as Pulsepoint [43], AllergyHero [44], and UnityPhilly [45]. An extensive review of emergency response apps can be found in the study by Gaziel-Yablowitz and Schwartz [46].

Most such apps are unmediated by EMS call centers, enabling people in distress to directly ask other app users for help, and potential responders react based on the app information provided. The requester must have the same app as the responder. Mediation by an emergency organization eliminates the aforementioned limitation. EMS mediation also means that the requester does not need to rely on an app, but can resort to the tried and true emergency phone call to 911 (101 in Israel). With EMS mediation of app communications, the command and control center of the emergency service can dispatch OGS to any event, regardless of how it was reported.

Mobilization of off-duty police officers, military personnel, or medical professionals in emergency situations existed long before the smartphone revolution, by means of pagers, two-way radios, and telephones. However, an organization that wants to integrate OGS into its EMS processes needs a completely different technological approach in order to effectively locate OGS who are close to the scene, notify them, and process their feedback about their ability to respond. The “Life Guardians” system developed by MDA [47] includes an app and a server that tracks the location of OGS and dispatches them automatically or at the discretion of a dispatcher. This system has managed thousands of OGS since its introduction in 2016.

The willingness to volunteer has been studied from several perspectives. Individual characteristics, such as age, social background, resources, and health status, help predict an individual’s voluntary action participation [48‐50]. Motives such as altruism, self-actualization, need for power, need for mutual support, and self-esteem explain many aspects of volunteer behavior [51‐57]. Organizational factors affecting volunteers such as an organization’s values and attitudes have also been studied [58].

Understanding the different characteristics and volunteering functions of volunteers can help volunteer-dependent organizations focus their recruitment efforts on the most relevant people and develop programs that help satisfy the volunteers’ motives [59‐63].

Previous studies have identified several motives for volunteering as a first responder, including altruism, need for social interaction, improvement of skills and knowledge, getting experience for future careers, and self-esteem [64]. Having a flexible schedule and controlling the decision of when to be on duty were found to be important factors for many volunteers [9, 64].

Motivation and satisfaction can vary between organized volunteers such as TDV and occasional volunteers such as Good Samaritans [55].

Clary and Snyder identified six motivational functions served by volunteering [52]:

Clary and Snyder [52] developed a widely accepted and validated research tool, the Volunteer Functions Inventory (VFI), which enables assessment of these six volunteering functions.

Magen David Adom (MDA) is the Israeli national EMS, belongs to the International Red Cross and Red Crescent Movement, and serves as the Israeli Red Cross National Society. MDA has operated a nationwide volunteer first responder (VFR) network since 2000. In 2016 MDA began to integrate the OGS approach into its organizational processes. MDA launched a new program, Life Guardians, through which people with medical certification or training are invited to download a smartphone app, making them identifiable and reachable based on geographic proximity to an emergency event, and enabling them to provide a first response. The identity and medical certifications of Life Guardians are verified. Those approved are provided basic equipment and supplies by the EMS. Upon emergency event verification, the event’s characteristics, the volunteers’ capabilities, and the expected arrival time of the ambulance and VFR are taken into the account [47, 65]. MDA tries not to overload Life Guardians, which may lead to burnout, and dispatches them only to high-priority events such as resuscitation, unconsciousness, choking, and severe trauma, when the expected time of arrival of an ambulance or a VFR is longer than the expected response time of OGS. The Life Guardians project differs from the aforementioned networks of volunteers [19‐28] in that it is not condition-specific (other projects usually focus on a single condition, mostly OHCA). MDA requires and records existing medical background and doesn’t provide any training. Similar to the Life Guardians program, Australia’s Rural Emergency Responder Network (RERN) acts on a smaller scale by targeting the participation of general practitioners in rural areas [66].

The study provides a qualitative formalization of technology-enabled OGS. This enables the formal analysis of the phenomenon whereby organizations leverage technology to integrate occasional volunteers into the network of first responders to emergency situations. A brief outline of the required technology is also presented.

The qualitative analysis is followed by a quantitative comparison of the professional background, demographics, and volunteering functions of traditional time-donation EMS volunteers versus those of OGS.

The sample for this study consisted of volunteers from a national EMS organization in Israel, Magen David Adom. It has an employed professional workforce of 2200 medical personnel, augmented by 20,000 certified time-donation volunteers and 17,000 certified OGS volunteers.

For this research a random representative sample of 800 TDV and 1000 OGS within MDA were surveyed. 331 (41%) valid responses were received from the time-donation volunteers and 601 (60%) valid responses were received from the OGS.

Clary and Snyder’s VFI instrument [52] was used to assess the volunteering functions of the two types of volunteers. Data was collected using Google Docs between March and May 2017. The VFI instrument consists of 30 statements, ranked on a 7-point Likert scale with responses ranging from 1: not at all important/accurate to 7: extremely important/accurate. Each volunteering function was scored based on five distinct statements in the instrument. The complete questionnaire is presented in Appendix.

For each response, the six motivational functions were calculated.

To assess the questionnaire’s reliability, Cronbach’s alpha analysis was used, with results indicating that the questionnaire is reliable (Table 1).

Table 2 presents the gender and age statistics of the different types of volunteers.

Figure 1 compares the professional background of OGS and TDV.

The χ² test for independence showed the professional background of OGS and TDV to be significantly (p-value = 0.000) different. The proportion of physicians and nurses is much higher among OGS (12 and 13%, respectively) than among TDV (0.5 and 0.3%, respectively).

Figure 2 shows the differences in volunteering functions between TDV and OGS on a 7-point scale ranging from 1 (not at all important) to 7 (extremely important).

Table 3 presents a comparison of the motivational functions.

Table 4 presents the differences in the ranked importance of the volunteering functions.

A principal component analysis revealed two possible components with high correlations between the variables and the component, and thus no variables were omitted. A binary logistic regression with a dependent variable representing the type of volunteering (OGS vs. TDV) and independent variables, including age, gender, and the six volunteering functions resulted in a significant model (p-value = 0.000) where the Cox and Snell pseudo R² = 0.375 and the Nagelkerke pseudo R² = 0.519. Table 5 presents the results of the regression analyses.

The correlation matrix did not show any strong correlations between independent variables, and thus no multicollinearity is suspected.

In order to analyze the factors that influence one’s decision to become a TDV or an OGS, the J48 classification tree analysis [68] was performed. The tree correctly classified 78.9% of the cases, as shown in Fig. 3.

80% of OGS surveyed expressed willingness to become time-donation volunteers. Results also show that 28.3% of OGS were former TDV in MDA (MDA doesn’t allow active TDV to concurrently serve as OGS).

It is helpful to characterize OGS within a broader taxonomy of volunteers, as shown in Fig. 4. The time-donation volunteers are the most organized part of the pyramid. They are an integral part of the EMS personnel, wear a uniform, must successfully complete courses and certifications offered by EMS, and can be promoted within the EMS organization. The Good Samaritans at the base of the pyramid are occasional volunteers: any layperson who witnesses an emergency can, and in many countries is obligated to, provide help to a person in distress. Organized Good Samaritans are a hybrid of the aforementioned two types of volunteers. On the one hand, they do not have scheduled shifts to attend or a uniform to wear, but on the other hand, they are not fully occasional: by joining the program, they greatly increase their chances of involvement in the organization’s life-saving activities.

The upward arrow in Fig. 4 represents two potential transitions: occasional Good Samaritans with a medical background who become Organized Good Samaritans in order to increase their chances of involvement in the organization’s life-saving activities; and Organized Good Samaritans who become time-donation volunteers. As we already mentioned, in this survey, 80% of the OGS expressed willingness to become time-donation volunteers.

The downward arrow in Fig. 4 represents two potential transitions: Organized Good Samaritans who return to the status of occasional Good Samaritans because they are not interested in continuing with the program; and time-donation volunteers who transition to OGS because they are not able to continue to donate time on a regular daily, weekly, or monthly schedule, but still want to volunteer albeit in a less binding framework. As previously mentioned, our sample showed 28.3% of the OGS were former TDV in MDA.

Clearly, TDV and OGS may also serve as occasional Good Samaritans when they are off duty and spontaneously encounter an emergency situation in which they can help. Understanding movement between volunteer categories should be the focus of future research.

The gender distribution is significantly different between OGS and TDV. This finding is consistent with previous studies that found gender differences in bystander response behavior [69], emergency response [70], OGS response [71] and EMS providers [72]. This can be explained by the fact that while TDV act as a team, OGS have to act alone.

Our finding that TDV are significantly younger than OGS is not surprising because in the case of MDA many TDV are young people, even high school students. OGS are primarily mid-career medical professionals who do not have enough time to donate and are looking for a less binding form of volunteering. This finding differs from previous studies that have found that the average age of emergency services volunteers is increasing, due to sociological changes such as two-income families and longer working hours [10, 73].

We also find that the proportion of physicians and nurses is much higher in OGS than in TDV. Previous studies have found that physicians are half as likely to volunteer as the general public, that they cite lack of time as the primary barrier to volunteering [74], and that full-time employment reduces the probability of volunteering [75]. It seems that the OGS platform provides a volunteering opportunity to those who are not able to serve as TDV.

Significant differences between the volunteering functions of OGS and TDV can be explained by several complementary factors.

Most time-donation volunteers have non-medical careers. By contrast, most OGS are active medical professionals for whom professional achievement or clinical practice might be a more important priority, as noted in previous studies [76, 77]. Related findings were observed by Switzer et al. who compared motivational factors between medical students and the general population of volunteers and found that the importance of career was significantly higher among medical students [78].

Time-donation volunteers expect emergency events during their shifts. By contrast, OGS perform their daily activities until they are notified of an emergency, and hence their response is spontaneous. Kulik at al. found significant differences in motivational factors between spontaneous and organized volunteers [55].

The differences between OGS and TDV in all volunteering functions except values are significant. OGS were found to have higher motivation in all six factors. However, the magnitude of these differences varies among the volunteering functions. As can be seen in Table 3, the average difference is 1 point or 34%. The highest (above the average) differences are observed in the understanding, career, and protective functions while the lowest (below the average) differences are observed in the enhancement, social, and values functions (the difference in values is not statistically significant). We conclude that overall OGS are more highly motivated than TDV, but the most significant differences are in the understanding, career, and protective functions.

Values shows no significant difference between OGS and TDV. The relatively low importance of this function for both groups of volunteers does not match the results of previous studies [52, 57, 63, 78] and is surprising. Further research is needed to investigate this finding, which lies beyond the scope of the present study.

Understanding is significantly higher in OGS than in TDV. The difference has a high magnitude, 1.17 points or 56%, but its relative importance is low, fifth place for both groups of volunteers. Volunteer satisfaction is influenced by matching activities to motivations [79]. Opportunities to learn and develop new skills are an effective tool for volunteer retention [80]. Thus, the implication of this finding is that provision of nonmandatory training by the EMS to OGS may be useful in OGS recruitment and retention.

Social, surprisingly, was found to be significantly higher in OGS than in TDV in spite of the fact that OGS have no regular meetings or social activities like TDV. On the other hand, the relative importance of this function is as expected as social ranked highest in importance for TDV and only third in importance for OGS. The magnitude of the difference is low at 0.68 points or 18% (compared to an average magnitude of 1 point or 34%). Further research is needed in order to investigate the causes of this unexpected difference.

Most results of the binary logistic regression are consistent with the results of other techniques applied and complement them. Specifically, the probability of becoming a TDV was higher for individuals with higher enhancement and values volunteering functions. The lower importance of the enhancement volunteering function for OGS can be explained by the fact that OGS are older and many of them are certified medical professionals. While other techniques didn’t reveal a significant difference in the values volunteering function, the binary logistic regression suggests that the values volunteering function is more important for TDV than OGS.

The results of the J48 classification tree analysis are consistent with our previous findings and thus strengthen them.

This research examines one national EMS. Cultural differences can lead to different results in other countries, as observed by Anheier and Salamon [81]. Multinational research may be useful to explore how cultural differences influence the volunteering functions of different groups of volunteers.

This study is limited to factors related to volunteer motivation, but does not address the effectiveness of different types of volunteers in emergency situations. The effectiveness of OGS should be studied along two dimensions: response time, i.e., in what percentage of cases do OGS arrive significantly earlier than the ambulance, and medical outcome, i.e., how does intervention by OGS influence survival rates and prognosis.