The prevalence of violence directed at paramedic services personnel

Introduction: Providers of health care are frequently subject to violence. The purpose of this research is to identify the type of violence suffered by first responders and the frequency of violence, since there is a lack of research in this area. Methods: A non-experimental sampling research method was used for this research; the research instrument is a structured questionnaire. We invited 36 rescue stations in Slovenia to participate, and 29 responded to the request; 246 questionnaires (68.3 %) were returned out of a total of 360. Data were analysed by means of descriptive statistics, correlation, the Kolmogorov-Smirnov test, Pearson's χ2 test, Mann-Whitney U test and linear regression with a significance of p < 0.05. Results: Seventy-eight per cent of respondents reported they had been verbally abused by their patients in the reporting year, while 49.6 % respondents reported they had been physically abused and 26.8 % of all respondents suffered injuries inflicted by patients. In the reporting year, 24.4 % of respondents experienced sexual harassment. A correlation was established between facing and experiencing fear (p = 0.017), between physical violence and feelings of vulnerability (p = 0.005), and between experiencing physical violence by the patient and lack of knowledge of how to manage patients' aggression (p = 0.012). Discussion and conclusion: The research could serve as a basis for a comprehensive approach to aggression management for nursing care professionals in paramedic services.


Introduction
Healthcare professionals encounter many medical risks when providing services to individuals and the community (Ozturk & Babacan, 2014). Clements and colleagues (2005) found that hospital personnel, particularly nurses, most often encounter patient violence. Between 35 % and 80 % of hospital staff had been physically assaulted at least once while on duty, and nurses were the most exposed to violence (Clements, et al., 2005). In a Swedish study (Soares, 2000), the author found that the majority of participants (85 %) reported that they had been exposed to violence, with 57 % being victimised in the reporting year. According to a Swiss study (Hahn, et al., 2010) 72 % of nurses had been verbally abused by patients or visitors, and 42 % had suffered physical abuse in the reporting year. An extensive study in 2013  showed that 92.6 % of psychiatric nurses reported experiencing verbal abuse, as many as 84.2 % physical violence and 40.9 % reported verbal abuse by patients' relatives, while 63.5 % had been injured. Zeller and colleagues (2009) also found a high incidence of violence towards nursing employees in nursing homes. Likewise, Franz and colleagues (2010) found that 83.9 % of healthcare workers had been exposed to physical violence. In the United States of America, violence against employees is most frequent among nursing assistants providing long-term care (Gates, et al., 2005).
Although the reported incidence is high, the common non-reporting of incidents means that the frequency is actually higher (Gates, et al., 2011). Similarly, Stokowski (2010) argues that up to 70 % of incidents and abuse of nurses are not reported. The work place affects the organisational culture, ensuring safety by setting up systematic education models, taking preventive steps to ensure safety and procedures in the event of an outbreak of violence and its aftermath (Gabrovec & Lobnikar, 2015).
There are fewer studies on violence toward paramedics some of which are mentioned here. Boyle and colleagues (2007) report that 87.5 % of paramedics were exposed to at least one form of workplace violence. Verbal abuse was most common (82 %), followed by intimidation (55 %), physical abuse (38 %), sexual abuse (17 %) and sexual assault (4 %). A Canadian study (Bigham, et al., 2014) found that in a 12-month period, 75 % of paramedics experienced at least one form of violence. The most common form of violence reported was verbal assault (67 %), followed by intimidation (41 %), physical assault (26 %), sexual harassment (14 %), and sexual assault (3 %). A high incidence of verbal assault, particularly through intimidation (66 %), was also established by Petzäll and colleagues (2011).

Aim and objectives
The study sought to establish the type and prevalence of violence directed at nursing staff and paramedics.
The goal of the study was to develop guidelines for resolving violent incidents directed at healthcare personnel employed in paramedical services.
We formed the following research hypotheses: H1: There is a correlation between nursing professionals working in emergency services experience of fear and actual verbal abuse during an examination of an aggressive patient.
H2: There is a correlation between nursing professionals working in emergency services feeling of being threatened and actual physical abuse during the examination of an aggressive patient.
H3: Employees who have experienced physical violence inflicted by patients largely believe that their skills are not sufficient to control an aggressive patient.
H4: There is a correlation between the following variables: verbal abuse, sexual harassment, physical violence and injury.

Methods
A non-experimental sample research method was used. The study instrument was a structured questionnaire.

Description of the research instrument
The questionnaire was prepared after reviewing the literature on previous studies, different situations faced by employees in the event of outbursts of aggression, and the quality and safety of patient treatment (Kobal, 2009;Hahn, et al., 2010;Gabrovec & Lobnikar, 2015).
The questionnaire consisted of 55 questions, divided into five sections: 1. work and violence at the workplace (23 questions) 2. organisation of work (11 questions), 3. influence of different factors on employee safety and patient treatment (11 questions), 4. education (6 questions) and 5. demographic data (4 questions). The management of safety was the dependent variable, while the independent variables included: appropriate means, clear view of the issue, awareness of work-related errors, attention to conditions promoting safety, the significance of safety in an employment organisation, response to outbursts of violence, supervision, motivation and initiative, appropriate number of employees, security protocols, reporting undesired events, team management and support, and measures to improve the situation. A descriptive Likert scale was used (1 -strongly disagree; 2 -disagree; 3 -partly agree; 4 -agree; 5 -strongly agree). The content proved relevant, with a moderate to very good level of internal consistency reliability (Cencič, 2009)

Description of the sample
Thirty-six Slovenian rescue stations were invited to participate in the study, of which 29 responded. A total of 246 out of 360 questionnaires were returned (68.3 %) A simple randomised sample with random sampling was used. Questionnaires were randomly distributed among employees who were willing to participate in the study. Each person could respond only once.
The sample included 166 men (67.5 %) and 80 (32.5 %) women. The mean age of respondents was 37.5, s = 8.64 years. The oldest respondent was 58 years old, and the youngest 20. The mean value of work experience was 15.43, s = 9.80 years. Demographic details are presented in Table 1.

Description of the research procedure and data analysis
The survey was conducted in April 2015. Participation was voluntary and the participants' anonymity was ensured. When necessary, the administration of the relevant institutions gave their consent to participation in the study. The poll was conducted in accordance with the Code of Ethics for Nurses and Nurse Assistants and the Declaration of Helsinki: Ethical Principles for Medical Research Involving Human Subjects. The data were analysed with descriptive statistics, correlation, the Kolmogorov-Smirnov test, Mann-Whitney U test and linear regression. The data were processed with the statistics program IBM SPSS v. 21.0 and IBM AMOS v. 21 with a p < 0.05 level of significance.

Results
The study found a high level of verbal abuse, frequent occurrence of physical violence and sexual harassment. The type, incidence and percentage of violence directed toward employees are presented in Table 2.
As many as 78 % of all respondents experienced verbal abuse by patients in the reporting period, while 49.6 % experienced physical abuse; 26.8 % of respondents were injured by a patient. Sexual harassment was experienced by 24.4 % of respondents. One in five respondents was subject to verbal abuse from superiors or colleagues in the reporting period. The emotions and states experienced by respondents during patients' aggressive episodes are presented in Table 3.
The most important links between certain emotions and states include uncertainty and anxiety (r = 0.783, p = 0.01), lack of understanding from colleagues or superiors (r = 0.683, p < 0.01) powerlessness and insecurity (r = 0.612, p = 0.01). Lack of understanding from colleagues and feeling threatened correlated negatively with other variables (r = -0.387, p = 0.01).
Furthermore, we were interested in various measures taken by employers to ensure safety in the event of patient aggression and the impact of other factors. Respondents largely report that: "Sufficient staff is a prerequisite for 24-hour detection of changes and perception of threats" ( = 4.11); "Understanding among team members affects the quality of my work" ( = 4.03); "The personality traits of team members affect the quality of work" ( = 3.97); "Conflict among team members affects the safety and quality of work with patients" ( = 3.95). The following statements received poorer evaluations: "The employer arranged for the supervised management of aggression in the patient" ( = 2.68); "In the event of aggression or a security incident, we receive team treatment and support" ( = 2.64), while the lowest rating was for the statement: "We are rewarded and motivated enough to perform safe, high-quality work" ( = 2.28).
The participants' opinions of their knowledge of, and training in violence management are shown in Table 4.
On average, the respondents believe that they have adequate knowledge to manage aggressive patients ( = 2.81). They place the highest importance on multiple refresher workshops ( = 4.09), followed by written guidelines ( = 3.91) and practical workshops ( = 3.82).

Verification of hypotheses
The hypotheses were tested to identify statistically significant differences in the means. First, the normal distribution of variables was verified using skewness and kurtosis coefficients and a Kolmogorov-Smirnov test. None of the variables of hypotheses H1, H2 and H3 were found to be normally distributed. A Mann-Whitney non-parametric test was therefore used to identify differences in the means.
A Pearson's χ 2 test showed a significance of p = 0.017 for H1, meaning that there are statistically significant differences in the level of fear reported by respondents who had experienced verbal abuse by a patient in the workplace in the reporting year compared to those who had not. Participants who experienced verbal abuse reported a higher level of fear. Based on the above, H1, i.e. that there is a correlation between the level of fear experienced and verbal abuse in the management of violent patients, was confirmed, as respondents who experienced verbal abuse reported a statistically significantly higher level of fear.
A Pearson's χ 2 test showed a significance of p = 0.005 for H2, meaning that there are statistically significant differences in the level of fear reported by participants who experienced physical violence by a patient in the workplace in the reporting year compared to those who did not. Participants who experienced physical violence reported a higher level of fear. Based on the above, H2, i.e. that there is a correlation between the
As regards H3, it was found that employees who did not experience physical violence by a patient in the reporting year rated the adequacy of their knowledge on the management of violent patients above average.
H3 was found to have a significance of 0.012 (p = 0.05), meaning that there are statistically significant differences in the rated adequacy of knowledge on the management of violent patients between respondents who experienced physical violence by a patient in the workplace in the reporting year and those who had not. Participants who experienced physical violence reported a higher level of fear. Based on the above, H3, i.e. that individuals who have experienced physical violence by a patient are more likely to rate their level of knowledge on the management of aggressive patients inadequate, was confirmed, as respondents who did not face physical violence in the reporting year rated the adequacy of their knowledge on the management of violent patients above average.
The correlation between the variables of H4, i.e. the correlation between different types of violence, was analysed by means of a model. As shown in Figure  1, statistically significant correlations were found between sexual harassment and injury (r = 0.640, p = 0.01), sexual harassment and physical violence (r = 0.420, p = 0.01), physical violence and injury (r = 0.350, p = 0.01), and verbal abuse and physical violence (r = 0.290, p = 0.01).
H4 was confirmed, as correlations were found between verbal abuse, sexual harassment, physical violence and injury variables.
The verbal abuse, physical violence and injury variables were found to explain the 10 % variance in the fear variable. The sexual harassment and physical violence variables are the best predictors ( Figure 1).

Discussion
The purpose and goal of the study were achieved. We found that paramedics are subject to a high level of threat, with verbal abuse from patients being the most prevalent, followed by physical violence and sexual harassment. The prevalence of vertical and horizontal abuse in the professional group is worrisome. When faced with aggressive patients, respondents most often experience fear, insecurity and powerlessness, while lack of understanding from colleagues is the least prevalent.
We established a statistical correlation between sexual harassment and injury, sexual harassment and physical violence, physical violence and injury, and verbal abuse and physical violence. The results of the study are in alignment with previous researh . We found that types of violence are not isolated, but correlated.
The most important correlation between emotions and states include insecurity and fear, lack of understanding from colleagues and lack of understanding from superiors, and powerlessness and insecurity. The variables of lack of understanding from colleagues and feeling threatened correlate negatively, which means that respondents who felt that they were understood by colleagues felt less threatened in the work place. Violence against nursing professionals has not been well documented, with most studies focusing on one area of work and using different research methods. Comparable studies report different threat incidence figures for nursing professionals. In a period of one year, 35-80 % healthcare employees experienced physical violence (Clements, et al., 2005), 42 % (Hahn, et al., 2010) or 83 % (Franz, et al., 2010). The results of our survey are comparable to studies abroad. In 2013, an extensive study on violence toward psychiatric nurses was performed with the same methodology  and found that the incidence of verbal and physical abuse toward psychiatric nurses was higher than among paramedics by 20-40 percentage points. While the highest incidence is among psychiatric nurses, percentages are also high in other areas. We found a high incidence of horizontal and lateral violence towards paramedics.
Research results can provide a starting point for developing a comprehensive approach to managing aggression toward paramedical staff, as proposed and implemented in psychiatric nursing, where the preliminary results of applying a comprehensive model have been very successful .
We have confirmed all the hypotheses. We found that employees who faced verbal violence were more fearful, that there is a correlation between feeling threatened and physical violence during the treatment of an aggressive patient; and that respondents who have experienced physical violence from patients largely believe that they have insufficient skills to control them.
We recognise that the selected sampling technique limits the study, as it affects the degree to which the sample is representative; the percentage of women in the study is higher than the percentage of women working in paramedical services, which might indicate that women were more willing to cooperate in the study, or the credibility of questionnaires is unreliable. The questionnaire enquired about education levels, while the register of healthcare providers lists education levels for actual positions, which prevented a comparison between the education structure of respondents and the register. Approval to conduct the survey was required only in a few institutions, not all.

Conclusion
The article presents the results of a study on the prevalence of types and frequency of violence against employees in paramedical services. Epidemiological, empirical and research data are presented. The purpose of the study was achieved. The study shows that employees in paramedical services need to develop a comprehensive approach to managing aggression. In order to determine the range of problems, it would be useful to conduct a survey with the same methodology on other aspects of healthcare.