Where care meets crisis: Rethinking our approach to occupational violence in paramedicine

Where care meets crisis: Rethinking our approach to occupational violence in paramedicine Justin Mausz 1,2 Keywords paramedic, occupational violence, violence, emergency medical sciences, paramedicine Date received: 25 July 2024; accepted 19 August 2024 Occupational violence is a complex and growing problem that threatens the integrity of our healthcare systems, including paramedicine. In a 10-year review of the United States (US) Bureau of Labor Statistics, Maguire and colleagues found an average of 426 violence-related nonfatal injuries per year for Emergency Medical Services (EMS) personnel as recently as 2020, with EMS personnel experiencing a risk of injury from violence five and a half times higher than the general population, nearly seven times higher than firefighters, and 60% higher than nurses. 1 Maguire’s work paralleled what is now a robust and compelling body of evidence characterizing violence against paramedics as a “serious public health issue” 2 with the potential for significant physical 3,4 and psychological harm. 5–7 Tragically, violent encounters can sometimes turn deadly, with recent cases in the US 8 and Australia 9 of paramedics being killed in the course of their work. Amid high rates of Post-Traumatic Stress Disorder (PTSD), 10,11 violence has the potential to compound what was already widely recognized as a mental health crisis among paramedics before the COVID-19 pandemic. 12 The pandemic, meanwhile, brought with it enormous societal disruption and unprecedented strain on healthcare systems around the world. One unfortunate result has been the proliferation of violence against healthcare workers. Although research among paramedics is still emerging, there are abundant studies pointing to accelerated rates of violence against physicians, nurses, and allied health professionals, 13,14 which, in turn, is fueling burnout, suicide, and what has been described as an “exodus”from health care. 14–19 Taken together, occupational violence is an issue that transcends professional and geographic boundaries, the impacts of which threaten the health and well-being of providers and— ultimately—the safety of our communities. In this issue, Drew and colleagues present the results of a qualitative study of paramedics in Australia that sheds light on the social processes underpinning—and perhaps contributing—to violent encounters with patients. 20 Through interviews with 25 (mostly) senior paramedics, Drew describes violence as the product of a dynamic interaction between the paramedic and the patient, underpinned by the context of care. Within this framework, the risk of violence hinges on the degree to which the paramedic and patient are able to co-construct a trusting and therapeutic relationship wherein the patient’s concerns are heard and their engagement in the care process is valued. “Failure”can occur on either side (or both), as may be the case, for example, with a patient whose cognition is impaired by pain, stress, intoxication, or psychosis, limiting trust and degrading the relationship between the two. Alternatively, fatigue, stress, or preconceptions held by the paramedic can undermine the relationship and escalate the encounter. In both cases, the context of care— the physical space, time of day, nature of the patient’s 1 Peel Regional Paramedic Services, Operations, Brampton, ON, Canada 2 Department of Family and Community Medicine, The University of Toronto, Toronto, ON, Canada Corresponding author: Justin Mausz, Department of Family and Community Medicine, The University of Toronto, 500 University Avenue, Toronto, ON M5G 1V7, Canada. Email: [email protected] Creative Commons Non Commercial CC BY-NC: This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 License (https://creativecommons.org/licenses/by-nc/4.0/) which permits non-commercial use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access page (https://us.sagepub.com/en-us/nam/open-access-at-sage). Correction (October 2025): In this article, “Declaration of conflicting interests”section has been updated. Commentary Paramedicine 2024, Vol. 21(6) 260–262 © The Author(s) 2024 Article reuse guidelines: sagepub.com/journals-permissions DOI: 10.1177/27536386241280408 journals.sagepub.com/home/pam illness or injury, or regulatory or resource constraints— can impact the relationship and raise the risk of violence. The ability of the paramedic to engage with the patient and the patient’s reaction to this engagement can profoundly alter not only the behavior associated with the interaction but also the associated progression of scene management objectives. (p. 8) With the prevailing literature focusing on the epidemiology of occupational violence and often framing the issue as primarily patient-initiated, Drew’sworkisa welcome contribution in this space, not least because it raises an uncomfortable truth: paramedic behavior can precipitate or escalate violent patient encounters. Within this construction, the focus in risk mitigation shifts from modifying patient behavior toward a more holistic understanding of the lifespan of the clinical encounter and, critically, the paramedic’s role within it. In practical terms, Drew explains that this means emphasizing the development of professional competencies to proactively mitigate the risk of violence through improved situational awareness, communication, and interpersonal skills, among other things. And yet, the unpredictability of paramedic work—to use Drew’s words—“may all but preclude the complete prevention of violent and aggressive behavior”(p. 10). It is worth lingering on this point. While it may be intuitively appealing to adopt frameworks from other health disciplines in developing violence risk mitigation policy, the paramedic context is indeed unique, and we must take care in extrapolating what works in other settings to our own. Unlike many clinical settings, paramedics enter into the patient’s environment, 21 with all its resource limitations and potential dangers, and very often, we do so at a moment when the underlying problem has reached a crisis point, the de-escalation from which can be nearly impossible. This is not to say that we should abdicate our responsibility in contributing to violence or view all patients as potentially dangerous. But nor can we rely entirely (or perhaps even primarily) on empathic interpersonal connection. Equitable, patient-centered care can only occur when both the paramedic and the patient are safe from harm. This means, as much as possible, creating the conditions for safe patient care wherever it occurs. Complex problems require complex, multimodal solutions, and in this respect, the uniqueness of the paramedic context may well be a strength. For all the limitations in space, time, resources, and control of the out-of-hospital context, perhaps our greatest advantage as paramedics is our capacity to optimize “bad”spaces for good outcomes. Solving for violence while leveraging our professional strengths means developing strategies to proactively identify emergency calls with the potential for violence and implement response plans tailored to the degree of risk. In practical terms, this could include (for example) dispatching clinicians with specialized training in mental health, addictions, or homelessness, and working collaboratively with police or crisis response teams to ensure a robust security presence. Patients with a history of violence— whatever the reason—could be flagged 22 to trigger a modified response plan that emphasizes both provider and patient safety. Finally, working further upstream, we must seek to address the unmet health and social needs that lay the foundation for conflict to escalate into violence, as may happen, for example, when a patient’s expectations for care are misaligned with what the paramedic service can provide. 23 As a useful case-in-point, data from my own service has pointed strongly to calls involving substance use, mental health problems, or homelessness as creating an increased risk of violence. 24 Canadian researcher Polly Ford-Jones has explored this tension between patient and paramedic safety during mental health calls 25 and has used her findings to develop alternate treatment and disposition pathways for patients experiencing mental health concerns, 26 not only improving patient care, but paramedic safety as well. Similarly, Jennifer Bolster—now Director of Clinical Services at Ambulance Tasmania—has advanced a program of research on strengthening the relationship between people who use drugs and paramedics 27 through education, harm reduction strategies, and empathic communication. These scholars, and others like them, are working proactively to develop policy that places paramedic and patient safety on equal footing in providing equitable, patient-centered care. There are cases where violence rises to the level of criminality, and in these instances, we should indeed have zero tolerance for volitional behavior that seeks to harm paramedics or other healthcare professionals. In that respect, both Australia and the United Kingdom have legislation on the books intended to deter and respond to criminal assaults against paramedics or other emergency workers. Similar legislation is being considered in Canada. 28 Securing a criminal conviction, however, requires paramedics to document and report violent encounters, a historically challenging undertaking, 29 but scholarship on the topic raises the importance of the issue among providers and policymakers alike. In sharing their work on the social processes underpinning occupational violence in paramedicine, Drew has offered another piece of a large and complex puzzle that can lead to meaningful improvements in both patient and provider safety. Declaration of conflicting interests Author Justin Mausz is a member of the Editorial Board of Paramedicine. The author did not take part in the peer review or decision-making process for this submission and has no further conflicts to declare. Funding The author received no financial support for the research, authorship, and/or publication of this article. Mausz 261 ORCID iD Justin Mausz https://orcid.org/0000-0001-6955-5387 References 1. Maguire BJ, Al Amiry A and O’Neill BJ. Occupational injuries and illnesses among paramedicine clinicians: analyses of US department of labor data (2010–2020). Prehosp Disaster Med 2023; 38: 581–588. 2. Maguire BJ and O’Neill BJ. Emergency medical service personnel’s risk from violence while serving the community. Am J Public Health 2017; 107: 1770–1775. 3. Maguire BJ. Violence against ambulance personnel: a retrospective cohort study of national data from Safe Work Australia. Public Health Res Pract 2018; 28: 1–8. 4. Maguire BJ, Browne M, O’Neill BJ, et al. International survey of violence against EMS personnel: physical violence report. Prehosp Disaster Med 2018; 33: 526–531. 5. Braun D, Reifferscheid F, Kerner T, et al. Association between the experience of violence and burnout among paramedics. Int Arch Occup Environ Health 2021; 94: 1559–1565. 6. Kim JH, Lee N, Kim JY, et al. Organizational response to workplace violence, and its association with depressive symptoms: a nationwide survey of 1966 Korean EMS providers. J Occup Health 2019; 61: 101–109. 7. Setlack J, Brais N, Keough M, et al. Workplace violence and psychopathology in paramedics and firefighters: mediated by posttraumatic cognitions. Can J Behav Sci/Revue canadienne des sciences du comportement 2021; 53: 211–220. 8. Kilgannon C. Slain paramedic, ‘mother of the station, was near retirement. The New York Times, 2022. 9. Drewitt-Smith A and Fuller K. NSW paramedic Steven Tougher farewelled at emotional service in Wollongong. ABC News, 2023. 10. Berger W, Coutinho ES, Figueira I, et al. Rescuers at risk: a systematic review and meta-regression analysis of the worldwide current prevalence and correlates of PTSD in rescue workers. Soc Psychiatry Psychiatr Epidemiol 2012; 47: 1001–1011. 11. Hoell A, Kourmpeli E and Dressing H. Work-related posttraumatic stress disorder in paramedics in comparison to data from the general population of working age. A systematic review and meta-analysis. Front Public Health 2023; 11: 1151248. 12. Koopmans E, Wagner SL, Schmidt G, et al. Emergency response services suicide: a crisis in Canada? J Loss Trauma 2017; 22: 527–539. 13. Devi S. COVID-19 exacerbates violence against health workers. Lancet 2020; 396: 658. 14. Canpolat EK and Gulacti U. Changes in violence against healthcare professionals with the COVID-19 pandemic. Disaster Emerg Med J 2022; 7: 75–82. 15. Harry EM, Carlasare LE, Sinsky CA, et al. Childcare stress, burnout, and intent to reduce hours or leave the job during the COVID-19 pandemic among US health care workers. JAMA Netw Open 2022; 5: e2221776. 16. Poon YR, Lin YP, Griffiths P, et al. A global overview of healthcare workers’turnover intention amid COVID-19 pandemic: a systematic review with future directions. Hum Resour Health 2022; 20: 70. 17. Shen K, Eddelbuettel JCP and Eisenberg MD. Job flows into and out of health care before and after the COVID-19 pandemic. JAMA Health Forum 2024; 5: e234964. 18. Chirico F, Afolabi AA, Ilesanmi OS, et al. Workplace violence against healthcare workers during the COVID-19 pandemic: a systematic review. J Health Soc Sci 2022; 7: 14–35. 19. Ramzi ZS, Fatah PW and Dalvandi A. Prevalence of workplace violence against healthcare workers during the COVID-19 pandemic: a systematic review and meta-analysis. Front Psychol 2022; 13: 896156. 20. Drew P, Devilish S, Tippett, V. Paramedic occupational violence: a qualitative examination of aggressive behaviour during out-of-hospital care. Paramedicine (Online First); 2024: 1–12. DOI: 10.1177/27536386241264293. 21. Garner DG Jr, DeLuca MB, Crowe RP, et al. Emergency medical services professional behaviors with violent encounters: a prospective study using standardized simulated scenarios. J Am Coll Emerg Physicians Open 2022; 3: e12727. 22. Mausz J, Piquette D, Bradford R, et al. Hazard flagging as a risk mitigation strategy for violence against paramedics. Healthcare; 2024; 12: 909. 23. Evans BA, Khanom A, Edwards A, et al. Experiences and views of people who frequently call emergency ambulance services: a qualitative study of UK service users. Health Expect 2023; 27: 1–13. 24. Mausz J, Johnston M, Arseneau-Bruneau D, et al. Prevalence and characteristics of violence against paramedics in a single Canadian site. Int J Environ Res Public Health 2023; 20: 6644. 25. Ford-Jones PC. Enhancing safety and mitigating violence on prehospital mental health calls: for the care providers and care recipients. CanJCommunMentalHealth2023; 42: 17–31. 26. Meijer P, Ford-Jones P, Carter D, et al. Examining an alternate care pathway for mental health and addiction prehospital emergencies in Ontario, Canada: a critical analysis. Int J Environ Res Public Health 2024; 21: 146. 27. Bolster J, Armour R, O’Toole M, et al. The paramedic role in caring for people who use illicit and controlled drugs: a scoping review. Paramedicine 2023; 20: 117–127. 28. Mausz J. The role of legislation in response to violence against healthcare professionals and first responders: considering Bill C-321, 2023. 29. Murray RM, Davis AL, Shepler LJ, et al. A systematic review of workplace violence against emergency medical services responders. New Solut 2020; 29: 487–503. 262 Paramedicine 21(6)