Violent and aggressive behaviour is reported to be widely experienced across health care and welfare disciplines in Australia.1^–3 Where it has been examined, it is so pervasive in these occupations that it is often seen as “part of the job” and therefore “acceptable” rather than a harmful activity needing assessment and management in the work environment.4 5 Recent studies in Australia reported occupational homicides as 2–3% of all traumatic workplace deaths; 24% occurred in the community service sector which includes medical services.3 5 6 Studies from Australia, the UK and the USA report that occupations with substantial face to face contact are particularly at risk of client initiated violence.3 Women experience higher levels of verbal aggression and sexual abuse, while men experience more overt threats and physical assaults.7

Studies of emergency service workers in the USA reported that 61% had been assaulted in the field and 25% had sustained an injury from violence.8 9 A Swedish study found 80.3% of emergency paramedics had been threatened or subject to violence, 67% subjected to physical violence, and over one third had experienced threats of violence every 3 months, usually from a patient, a relative or a friend of the patient.10 Suserund found that 98.1% of ambulance paramedics felt that threats of violence or violence from the patient altered the relationship with the patient.10 Eighty per cent felt the care provided to patients was altered by threats or violence from relatives.10

We reviewed the literature, which included searching the Medline, EMBASE, CINAHL electronic databases and reference lists of retrieved articles, and were unable to locate any published Australian literature that described Australian ambulance paramedics’ experience of workplace violence. The objective of this study was to identify the types of violence paramedics experienced within the workplace in Australia.

METHODS

This pilot study utilised a cross sectional study methodology using a convenience sample to elicit paramedics’ responses of experience to workplace violence.

The setting for the study was the paramedics from the rural ambulance service in Victoria, Rural Ambulance Victoria (RAV), and the metropolitan staff from the South Australian Ambulance Service (SAAS).

Victoria is a south eastern state of Australia covering approximately 227 590 square kilometres with an approximate population of some 4.9 million people.11 South Australia is a southern state of Australia covering approximately 984 377 square kilometres with an approximate population of some 1.5 million people.11

RAV has some 113 ambulance stations with approximately 310 ambulances and a staff of approximately 1100, including volunteer staff located in the more isolated and low workload areas of the state.12 The SAAS has some 104 ambulance stations with approximately 200 ambulances and a staff of approximately 1900, including volunteer staff located in the more isolated and low workload areas of the state. In the metropolitan area, SAAS has 19 ambulance stations and an on road staff of approximately 430.13

We defined workplace violence as violence that was associated with work. As such it included violence that occurred in the ambulance station or offices where management was housed, the ambulance itself, a health care facility, and the incident location.

Workplace violence perpetrators included, but were not limited to, other paramedic staff (including all management levels), the patient, the patient’s relative or friend, incident bystanders, other emergency service staff (fire and police), and health care facility staff.

A questionnaire was developed to explore paramedics’ experience of violence (see supplementary file available at http://emj.bmj.com/supplemental). The questionnaire consisted of five specific sections. The first section covered the experience of the paramedic to six forms of workplace violence as defined by Tolhurst et al14—verbal abuse, property damage or theft, intimidation, physical abuse, sexual harassment, and sexual assault. The definitions of violence types were included in the questionnaire and are listed in table 1. The second section of the questionnaire covered the paramedic’s description, using three qualitative questions, of how they felt personally after experiencing an episode of violence in the workplace, as defined in the first section. The third section covered the paramedic’s response to the violent incident(s). The fourth section covered the Impact of Event Scale which measured the paramedic’s response to a violent workplace event in the following 7 days.15 The fifth section covered general demographic information like age, gender, qualification, and work location.

The questionnaire was piloted on a group of rural paramedics. Following the return of the questionnaires and comments, changes were made to the questionnaire.

The questionnaire was then distributed by the respective ambulance service (RAV and SAAS) to their staff. RAV randomly distributed 500 questionnaires to their paramedics with SAAS distributing 430 questionnaires to all their metropolitan paramedics. Paramedics completed the questionnaire and returned it using a reply paid envelope to the research assistant. There was no follow up letter sent to the paramedics to encourage them to complete the questionnaire.

Descriptive data analysis was undertaken using SPSS (Statistical Package for the Social Sciences Version 14.0, SPSS Inc, Chicago, Illinois, USA). Additional statistics, including proportional differences, mean confidence intervals and p values, were undertaken using EpiCalc 2000 (Version 1.02, Brixton Books, 1998).

Descriptive statistics were used to summarise the data, gender differences were analysed using χ² test for independence or Fisher’s exact test, comparisons between groups were undertaken using a two-tailed t test, and differences in proportions were used to compare metropolitan and rural cohorts. The results are considered significant if the p value was <0.05; all confidence intervals (CI) were 95%.

Ethics approval for this study was granted by the Monash University Standing Committee for Ethics in Research on Humans.

RESULTS

The questionnaire was distributed to 500 rural paramedics via RAV. There were 152 questionnaires returned, four of which were returned to the researchers due to a change of address and hence excluded. The response for RAV paramedics was therefore 29.6%. There were 430 questionnaires distributed to metropolitan paramedics via the SAAS. Of these, 108 were returned with one excluded due to a change of address. The response rate was therefore 25.1%. A total of 930 questionnaires were distributed with an overall response rate of 28%.

The study of paramedics consisted of 74.5% males, 24.3% females, and 1.2% not defined. Information about paramedics’ ethnicity was not collected as it is particularly difficult to define. The median age of respondents was 41 years, range 21–62 years. The median number of years that paramedics had worked as paramedic was 14 years, range 6 months to 39 years. The median number of hours worked per week was 42 h, range 19–90 h. The median hours of direct patient contact was 24.5 h, range no contact time to 66 h.

The highest qualification obtained by the majority of paramedics was qualified ambulance paramedic/officer, with a small number of students identified as outlined in table 2.

Table 3 presents the number and percentage of paramedics who had experienced workplace violence in the last 12 months, according to place of practice (metropolitan versus rural, and then overall).

Of the paramedics surveyed, 87.5% had experienced at least one form of violence associated with the workplace in the last 12 months.

Table 3 demonstrates that the most common form of violence experienced by paramedics overall was verbal abuse followed by intimidation and physical abuse. The least common form of violence was sexual assault. The only statistically significant results were the comparison between metropolitan and rural paramedics for those who experienced sexual harassment and sexual assault; all other comparisons between metropolitan and rural paramedics were not statistically significant. These results indicate that more metropolitan paramedics experienced sexual harassment and sexual assault than rural paramedics.

The results from this point onwards represent aggregate data—that is, rural and metropolitan paramedic responses combined, classified according to gender.

Table 4 demonstrates that more female than male paramedics experienced sexual harassment and sexual assault. All other comparisons between male and female paramedics were not statistically significant.

Paramedics were asked to indicate how frequently, in the last 12 months, they experienced each form of violence. These results are presented in table 5. It is clear that almost half the paramedics experienced verbal abuse a few times in the last 12 months, and one third experienced intimidation a few times in the last 12 months. Just over 3% of paramedics reported experiencing verbal abuse on a daily basis and approximately 12% about once a week.

DISCUSSION

This pilot study is the first of its kind in Australia to investigate paramedics’ experience of workplace violence. This study has revealed that paramedics commonly experience workplace violence, predominantly in the forms of verbal abuse and intimidation.

The reporting of workplace violence against paramedics has only occurred in relatively recent times. The first scientific report of violence against paramedics occurred in the early 1990s by Tintinalli and McCoy in the USA, and demonstrated that there were indeed violent acts committed against paramedics in the course of their duty.16

The rate of verbal abuse in the international studies varied from 21–78%, and we found that 82% of paramedics had been verbally abused.17^–19 Even though this is normally the most common type of workplace violence, it probably has the least long lasting effect on a paramedic; however, racial verbal abuse is a different matter and will effect different people in a variety of ways. There was no specific question about racial abuse in the current study.

The rate of physical violence previously reported is predominantly much higher, 2.9–79.5%, compared to what we found. Several of the US studies specifically reported physical assault with a weapon; we did not specifically ask about assault with a weapon which may account for why our prevalence was much lower than that reported by others. Indeed, assault with weapons on paramedics appears to be a rare occurrence in Australia compared to other countries such as the USA.9 16^–21

There were two international studies that just reported paramedic exposure to violent acts; one study did not elaborate any further about the specific types of “violent acts”.17 19 21 It is difficult to compare the violence exposure results in this study and the one by Grange and Corbett17 as it is hard to determine if they included violent acts as part of the total “ambulance runs” or just as part of the total violent acts.

This study is unique in that, unlike international studies, we reported specifically on paramedics’ experience of sexual assault, sexual harassment, and intimidation in the workplace. International studies have not reported on these forms specifically, but it may be that they have been included in another form of violence such as physical assault or intimidation. Intimidation may be a precursor to sexual assault/harassment; however, we are unable to determine this fact from the questionnaire data, and it would require a prospective study to help confirm this.

In this study the percentage of males was approximately 75%, similar to a study in Sweden by Suserud et al,19 but less than two studies in the USA by Grange et al17 and Mock et al.18 There were two other US based studies that had male staff numbers between 55–60%9 20; this could become the norm in the future as the intake of undergraduate paramedics in Victoria is predominantly females. The gender distribution of operational paramedics in South Australia is 60% males and 40% females.13

The median age of our respondents was 1–5 years higher than those studies in the USA and Sweden9 17^–20; likewise, the median years of experience is higher in our study by 3–5 years compared to the international studies.17^–19 21 Outside of formal education in handling workplace violence, the additional work experience identified in Australia may assist the paramedics in dealing with actual or potentially violent episodes. Australia fortunately does not have the level of violence highlighted in several of the US studies—for example, paramedics being threatened with dangerous weapons.16 21

This study is limited by the ability of the paramedics to recall incidents of workplace violence. Some components of the questionnaire asked the paramedic to recall what had transpired in the preceding 12 months. Furthermore, using a single method of measurement (that is, self reports over a 12 month period) without corroboration from other external sources of information, such as observer ratings, may have limited the validity of our findings. The retrospective nature of the study and the return rate may mean that the results are not a true representation of the total paramedic population in both state areas.

CONCLUSION

This study demonstrates that paramedics do experience workplace violence and that there is a need for additional prospective studies to determine the actual prevalence of workplace violence. This study also highlights that there is a significant number of paramedics who experience sexual harassment/assault in the workplace by work colleagues. These results also highlight a need for education, especially for new paramedics fresh from a university education, about how to deal with workplace violence.