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

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 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’s work is a 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.