Workplace Violence in Asian Emergency Medical Services: A Pilot Study

Workplace violence among Asian emergency medical services (EMS) has rarely been examined. A cross-sectional, mainly descriptive study using a standardized, paper-based, self-reported questionnaire survey was conducted between August and October 2018 among emergency medical technicians (EMTs) in the Tainan City Fire Bureau, Taiwan. A total of 152 EMT-paramedics responded to the questionnaire survey, constituting an overall response rate of 96.2%. The participants were predominantly male (96.1%), college-educated (4-year bachelor’s degree) (49.3%), and middle-aged (35–44 years old) (63.8%). Among them, 113 (74.3%) and 75 (49.3%) participants had experienced verbal and physical assaults at work, respectively. Only 12 (7.9%) participants were familiar with relevant regulations or codes. The assaults predominantly occurred during evening shifts (16:00–24:00) and at the scene of the emergency. The most predominant violence perpetrators included patients, patients’ families, or patients’ friends. Nearly 10% of participants had experienced verbal assaults from hospital personnel. EMTs who encountered workplace violence rarely completed a paper report, filed for a lawsuit, or sought a psychiatric consultation. Fifty-eight (38.2%) and 16 (10.5%) participants were victims of frequent (at least once every 3 months) verbal and physical forms of violence, respectively; however, no statistically significant association was observed in terms of EMT gender, age, working years, education level, or the number of EMS deployments per month. The prevalence of workplace violence among Asian EMS is considerable and is comparable to that in Western countries. Strategies to prevent workplace violence should be tailored to local practice and effectively implemented.


Introduction
Workplace violence is a global issue. Workplace violence is defined as any act or threat of psychological or physical violence, harassment, intimidation, or other threatening disruptive behavior that occurs at work [1]. Compared to other occupations, emergency medical services (EMS) have a high risk of workplace violence [2][3][4]. Emergency medical technicians (EMTs) usually respond to medical emergencies and access unfamiliar patients in stressful environments. EMTs have an occupational fatality rate comparable to those of police and firefighters and a nonfatal injury rate that is much higher than the average for all workers [5,6].
A recent literature review found that the frequency of verbal violence toward EMS providers was about 21%-82%, while physical violence was reported to occur in about 13%-79% of cases [3].

Study Setting and Design
This pilot study was a cross-sectional, mainly descriptive survey study using a questionnaire survey. It was completed between August and October 2018 in Tainan City, Taiwan. The governmental EMS in Taiwan are all fire-based service. There are three levels of care providers (EMT-basic, EMT-intermediate, EMT-paramedic) and the services are generally free of charge. Tainan City has a population of 1.9 million and covers an area of 2192 km 2 . There are 55 fire stations in Tainan City. The annual EMS call volume in Tainan City was 95,310 in 2018, which is equivalent to 13.8 calls per 100,000 population per day. During the study period, there were 1024 EMTs (aged 27.0-55.0 years, mean 38.2 years; 946 (92.4%) of whom were male) affiliated with the Tainan City Government Fire Bureau. Among them, 58 (5.7%) were EMT-basic, 810 (79.1%) were EMT-intermediate, and 156 (15.2%) were EMT-paramedic.
The survey was conducted during a three-session, continuing education course for EMT-paramedics. All of the survey participants were EMT-paramedics who were affiliated with the Tainan City Government Fire Bureau. Participation in the survey was voluntary and confidential. A 30-min debriefing session to promote the awareness of occupational safety and workplace violence was delivered, following which an anonymous questionnaire was distributed, and it was collected 30 min later.

Survey Questionnaire
The survey took the form of a standardized, paper-based, self-reported questionnaire. The questionnaire was modified partially by reference to the Workplace Violence in the Health Sector Country Case Studies Research Instruments Survey Questionnaire [25] as well as to questionnaires that had been used in relevant studies [22,26].
In our questionnaire survey, verbal violence was defined as using offensive language, yelling or screaming with the intent to offend or frighten. Verbal violence could be delivered through the phone. Physical violence was defined as a physical assault or any attempt at a physical attack. Physical assaults include behaviors, such as punching, slapping, kicking, or using a weapon or other objects with intent to cause bodily harm. In this pilot study, we did not address sexual harassment or gender-related mistreatment, which could be a form of workplace violence.
The survey questionnaire had three parts: participants' information (Part I), experience of workplace violence (Part II), and strategies to prevent workplace violence (Part III). Part I included demographic information about the participants (such as gender, age, and education level), EMS career experience (such as length of EMS career, working hours per month, and the number of EMS deployments per month), and knowledge of relevant regulations or codes regarding workplace violence. Part I of the survey mainly used closed-ended, multiple-choice, and single-answer questions.
If a participant had experienced workplace violence, then completed Part II of the survey. Part II included questions regarding the experience of verbal or physical violence in the workplace. It allowed questions of the perpetrator types (such as patients, families or friends of patients, bystanders, or colleagues), and the time and location of workplace violence (for example, at the emergency scene, during transportation to the hospital, at the hospital, and/or at the fire station). It also included the response to workplace violence (for example, trying to comfort the perpetrators, discussion with colleagues, completing a paper report, applying for a job transfer, seeking psychiatric consultation, and/or reporting the incident to the news media) and asked about the personal impact of workplace violence (such as personal mood, professional performance, interpersonal relationships, and family relationships). Part II of the survey mainly used closed-ended, multiple-choice, and multiple answer questions.
All participants participated in Part III of the survey. Part III identified six domains of strategies to prevent workplace violence. These included knowledge and training (such as education, simulation training, and consultations for emotional control), equipment and resources (such as the use of chemical or physical restraints, video recording, self-defense techniques, and bullet-proof helmets) and systems (such as reporting system, police activation system, and patient records). In addition, it addressed policy considerations (such as EMS agency policy, advocation of antiviolence policy, and use of internet resources and social media), situation awareness (such as keeping a safe distance, improving situation awareness, self-protection strategies, and removing dangerous materials), and security (such as warning systems, continuing video recording during the time of duty, and police escorts). In Part III, a five-point Likert scale (strongly disagree, disagree, neutral, agree and strongly agree) was used. The items of "agree" and "strongly agree" were considered a positive response to the question, while the other items were not.
The English version of the questionnaire used in this study is provided in Appendix A.

Data Analysis
Data were entered into an Excel (Microsoft, OVS-ES, 2016) database, and statistical analyses were performed using SPSS 17.0 software (SPSS Inc., Chicago, IL, USA). Descriptive proportions were used for the categorical variables. The chi-squared and Fisher's exact tests were applied to analyze the differences for the nominal variables, as applicable.
We assumed that the frequency of workplace violence could reveal more insights. EMTs who experienced verbal or physical assaults at least once every 3 months were defined as victims of frequent workplace violence. Multivariate logistic regression analyses were performed to identify the risk factors for frequent workplace violence using odds ratios (ORs) and 95% confidence intervals (CIs). A two-tailed p-value of less than 0.05 indicated statistical significance.

Ethical Considerations
The data was de-identified, allowing participants to remain anonymous throughout the research. The study protocol was reviewed and approved by the Institutional Review Board of National Cheng Kung University Hospital (B-ER-107-338).

Characteristics of Participants
In this survey, of 156 EMT-paramedics (149 (95.5%) of whom were male) who completed the continuing education courses between August and October 2018, 152 responded to the questionnaire. The overall response rate was 96.2%. Table 1 describes the basic demographic information of the participants. The participants were predominantly male (96.1%), college-educated (4-year bachelor's degree) (49.3%), and middle-aged (35-44 years old) (63.8%). Totals of 113 (74.3%) and 75 (49.3%) respondents reported that they had ever experienced verbal and physical forms of workplace violence, respectively. In addition, more than 80% of participants reported that their colleagues had experienced workplace violence. Only 12 (7.9%) participants were familiar with the regulations regarding workplace violence, with more than half of the respondents did not know that such regulations even existed. Table 2 describes the frequency of verbal and physical assaults that the participants experienced during work. Participants generally experienced verbal assaults more frequently than physical assaults.  Table 3 summarizes the patterns of workplace violence. Violence perpetrators were predominately male. Either verbal assaults (47.8%) or physical assaults (48.0%) were more likely to occur during evening shifts (16:00-24:00). The assaults predominantly occurred at the emergency scene. The most predominant violence perpetrators included patients, patients' families, or patients' friends. Among patients who were treated by EMTs, patients with substance abuse or alcohol intoxication were most likely to assault, either verbally or physically.  Table 4 describes the response to and impact of encountering workplace violence for the EMTs in this study. Most of the participants' immediate reaction was taking a deep breath and trying to manage the patient while they encountered verbal (68.1%) or physical violence (58.7%). EMTs were more likely to file a lawsuit when they experienced physical violence compared to verbal violence (14.7% vs. 3.5%, p = 0.006). None of the 113 participants who experienced verbal assaults and only 1 (1.3%) of the 75 participants who experienced physical assaults had sought a psychiatric consultation. Workplace violence may affect personal mood in more than 80% of the participants and professional performance in nearly half of the EMTs.

Response to Workplace Violence
Few participants reported the occurrence of verbal violence (8.8%) or physical violence (22.7%) to their superiors at the fire bureau. The behavior of reporting workplace violence to the superiors is of interest; however, the bivariate analysis found no significant association with respect to EMT age, working years, education level, or the number of EMS deployments per month (Appendix B).

Risk Factors of Frequent Workplace Violence
A total of 58 (38.2%) and 16 (10.5%) participants were victims of frequent (that is, at least once every 3 months) verbal and physical forms of violence, respectively. Table 5 shows the bivariate and multivariate logistic regression analysis of the risks for frequent verbal or physical violence. Regarding frequent workplace violence, no statistically significant association was observed in terms of gender, age, working years, education level, or the number of EMS deployments per month.

Workplace Violence Prevention
Appendix C shows the participants' perceptions of strategies to prevent workplace violence. Regarding the domain of knowledge and training, more than 70% of participants believed that anti-violence law enforcement could be effective in preventing workplace violence. Video-recording devices were the most feasible equipment to prevent either verbal (83.6%) or physical violence (84.2%). Nearly 80% of participants indicated that a registry of patients with a known history of violent assaults or substance abuse could lessen workplace violence. Nearly 90% of participants said that maintaining a safe distance and improving situation sensitivity could be useful.

Discussion
People of Asian background are often described as having a tendency to avoid conflicts and confrontations [23]; however, our study shows that workplace violence toward EMTs is common in Asian communities. The prevalence of workplace violence in the Taiwan EMS was comparable to that in Western countries [2,3,[7][8][9][10]. The prevelance of verbal violence and physical violence among EMS could be at least 8 times and 40 times greater, respectively, than that of overall workers in Taiwan [24]. Very few EMTs were familiar with the regulations or codes regarding workplace violence. Workplace violence across Asian EMS deserves further research and in-depth discussion.
The association of EMT gender and workplace violence risks is controversial [2,13,[26][27][28]. In our study, 109 (74.7%) of 146 male participants and 4 (66.7%) of 6 female participants experienced verbal assaults at work (p = 0.646). In addition, 74 (50.7%) of 146 male participants and 1 (16.7%) of 6 female participants experienced physical assaults (p = 0.210). The percentage of male EMTs who had experienced workplace violence, either in the form of verbal or physical assaults, was higher than that of female EMTs. However, with respect to frequent workplace violence (at least once every 3 months), we did not find any significant association in terms of EMT gender, age, working years, education level, or the number of EMS deployments per month. Other factors, such as personality traits, coping styles, attitudes or participating in violence prevention training, could be associated with risks for work-related threats [29]. However, we were unable to explore the association of personality characteristics or communication skills with the risks of workplace violence in this study.
Patients, especially those who have cognitive dysfunction [30][31][32], are some of the most common perpetrators of violence [26]. EMTs should be extremely cautious when handling patients with substance abuse or alcohol intoxication. We also found that patients' families or friends were perpetrators more often. Patients' families or friends may request a rush transfer to a hospital, rather than proper and necessary medical care in the prehospital setting prior to transport [4]. Managing emotionally agitated patients or families can cause anxiety in even the most seasoned EMTs. Using verbal de-escalation and certain coping techniques when dealing with people with aggression or agitation appears to be accepted as good clinical practice [33]. EMTs should also monitor their own emotional and physiological response so as to remain calm and alert at an emergency scene.
Many Asian EMS are public sectors and the services are generally free of charge to users [34]. Public sector workers, compared with private sector employees, could have higher risks of workplace violence and higher levels of client-related burnout [24]. Public perception of EMT professionalism may be underrecognized and should be promoted in Asian communities. However, training on interpersonal skills and emotional intelligence in a professional context is often lacking within Asian EMS system. Simulation training and other education modules could enhance knowledge of workplace violence [35]. We strongly recommend that communication skills and clinical empathy should be integrated into EMT education programs [36,37].
Verbal assaults were the most common form of workplace violence [2,7]. Verbal violence, especially in the fields of emergency and intensive care medicine, is a known hazard for healthcare-related personnel [38]. Verbal assaults toward prehospital care personnel are not uncommon and occur mostly at the emergency scene [39][40][41]. However, our study revealed that verbal assaults toward EMTs could occur in hospitals and could be delivered by hospital personnel. Overcrowding in emergency departments has become a public health problem worldwide in the last decade. Heavy workload and emergency department overcrowding could render emergency physicians and nurses to frustration and feelings of burnout [42,43]. When EMTs transport patients to the emergency departments, the impression of increasing emergency department workload may generate conflicts between hospital personnel and EMS providers. Beyond the difficulties arising from ambulance diversion practices, many EMTs find themselves detained in emergency departments for prolonged periods, unable to transfer care of their transported patients to hospital staff [44,45]. Building a collaborative approach and developing a mutual understanding environment, especially among EMTs and emergency medicine personnel, should be emphasized in regional emergency care systems.
EMTs who encountered workplace violence rarely completed a paper report, verbally reported the incident to their superior, or filed for a lawsuit. The silence of Asian EMTs toward workplace violence is noteworthy. It is beyond the scope of this study to thoroughly explore the reasons of silence; however, potential causes of silence at the collective level and on the organization-level factors were identified [46,47]. Our study showed that most EMTs were unaware of regulations regarding workplace violence. Voice could be curtailed if EMTs do not feel that their reports will be taken fairly and acted upon [48]. EMTs may remain quiet when they think that they may suffer unwanted consequences [48]. The feeling of futility to speak up is a key determinant of acquiescence [49]. Another important judgment could be the extent to which it is safe or supported to engage in actions against workplace violence [50,51].
The hierarchical and "masculine" culture of EMS might impede the pursuit of legal or administrative justification or even professional assistance, such as psychiatric consultation [14,17,52]. Some EMTs may even have a perception that experiencing violence is necessarily part of the job [4,22]. In our study, more than 80% of EMTs reported that their moods were obviously affected by workplace violence. Either verbal or physical assaults could impair professional performance in nearly half of the EMTs. Therefore, regulations against workplace violence should be developed not only for the mental health of EMTs but also for the quality of patient care. Awareness of occupational safety should be promoted among Asian EMS as well. Certain tools could be utilized to evaluate workplace violence risks and prevention modules [53]. Reporting might be valuable and contribute to improvement of the situation. A proper reporting protocol with considerations of protecting personal information should also be provided when EMTs encounter assaults [16]. Strategies to prevent workplace violence in EMS systems should be tailored to local practice.

Limitations
Our study had several limitations. First, our study used a self-administered questionnaire survey; thus, the accuracy of the survey results could be biased due to cultural and personal factors. Nevertheless, the anonymity of the survey may accurately gauge the true experience of EMTs and reflect a certain reality. Second, we did not explore several potentially important factors. We did not evaluate the personality characteristics of the EMTs in this study, which could be valuable for the analysis of behavior patterns and risks of workplace violence. The work culture in each individual fire station and EMS team could vary and may deserve investigation as well. In this pilot study, we were unable to investigate sexual harassment or gender-related mistreatment, which is a form of workplace violence. Third, the obvious disproportion of EMT gender in our study, which was inherent in many Asian EMS as well, may hinder further analysis of workplace violence regarding the role of gender. Finally, since our study only assessed EMT-paramedics in one single EMS system, further research might be needed to validate the generalizability and applicability of our study results.

Conclusions
The prevalence of workplace violence in Asian EMS is considerable and is comparable to that in Western countries [2,3,[7][8][9][10]. Many EMTs are unaware of regulations regarding workplace violence. EMTs rarely report workplace violence to their superiors. EMT training on interpersonal skills and emotional intelligence needs to be strengthened. Public perception of EMT professionalism could be promoted in Asian communities. A mutual understanding environment between EMTs and emergency medicine personnel should be developed. The identification of risk factors for workplace violence could provide important guidance for policymaking and education programs. The silence of Asian EMTs toward workplace violence warrants further exploration. Workplace violence prevention should be tailored to local practice and effectively implemented.

Availability of Data and Material:
The datasets used or analyzed during the current study are available from the corresponding author on reasonable request. Verbal violence was defined as using offensive language, yelling or screaming with the intent to offend or frighten. Verbal assaults could be delivered through the phone.
B1. Have your colleagues ever experienced verbal assaults during work? Yes No B2. Have you ever experienced verbal assaults during work?