Workplace Violence Poses a ‘Wicked’ Problem for EMS Responders

Workplace violence – by patients, their friends, or bystanders – is a major problem around the globe, described as an epidemic, persistent and costly. It can take many forms, from physical assaults to verbal abuse, sexual harassment, spitting, and bullying. Researchers have described it as a “wicked” problem – one that can only be solved with complex, multifaceted solutions.[i]

For emergency first responders, violence is a source of injury, lost work days, Worker’s Compensation claims, mental health issues, job dissatisfaction, turnover, and a reason to consider leaving the field altogether. Nathan White RN, CEN, TCRN, NRP, who works both as an emergency nurse in Huntsville, Ala., and as a paramedic in southwest Virginia, says the field has seen a marked increase in both assaults and injuries from workplace violence.

In his own career, White has experienced a lot of violent encounters. These include having knives pulled on him multiple times, being witness to two hospital shootings and even having a gun fired at him. “That’s just the patients I remember offhand. A number of times patients have put their hands around my throat, sometimes just because they were under the influence of an illicit medication. An hour later, they didn’t remember that they had done it.”

And then there are the people who have attacked him out of malice, “because they had something against me that I cannot fathom. This violence is a very real thing—it hits home for me because I’ve seen it so often.”

Paramedic Donnie Fisi, a quality assurance specialist and educator for the Alameda County, Calif., Fire Department’s EMS program, who has also been assaulted on the job by patients, says violence against EMS personnel has exploded over the last few years. “It used to be we were viewed as the good guys. We’re not taking you to jail, we’re not here to judge, we just want to help you. These days, people don’t care about that. You represent ‘The Man,’ who is trying to keep them down.”

Poor Communication?

White, who represents nursing and paramedicine as chair of the Emergency Nurses Association’s Emergency Medical Services Advisory Council, says many violent incidents originate with poor communication.

“A lot of people have a lot of polarizing opinions about what should or shouldn’t be happening and they express that,” White says. “For example, a patient was in cardiac arrest and the family didn’t understand what power of attorney and do-not-resuscitate orders are or why, according to our state’s legislation, these have to be physically in hand in order for us to honor them. So when our crew starts doing chest compression on the patient, I’m getting a family member trying to punch me, another pulling a gun on me. I have to call the police department."

“We come from a paradigm of ‘scoop ‘em up and go,’ so we may tend to forget that like most service industries we’re dealing with people and we need to be able to communicate effectively with them,” White says. “Have we thought about how we communicate, how we train our staff, how we deal with psycho-social demands? Am I coming at this situation with a perspective of the best interests of my patient, versus trying to close out this call so I can move on to the next one.”

EMS responders need to be 100 percent present and engaged with the situation in front of them.

“How do I recognize moments of high intensity? White asks. "Can I recognize that this is about to become a problem, and do I have the appropriate resources to handle that? Where does verbal versus non-verbal communication fit? Can I talk this situation down? Once you get hands-on, all bets are off."

Structural Barriers to Solutions   

Research has shown that workplace violence in EMS is a problem not just in the United States. It has been studied in Australia, Canada, the United Kingdom, and elsewhere, including with focus group surveys of professionals and assessments of the different kinds of responses to violence. Focus groups conducted by Evelien Spelten and colleagues identified the need to move away from a one-size-fits-all approach and to develop interventions at the organizational level to reduce the impact of violence.[ii]

One of the structural barriers to managing workplace violence, White says, is the tendency to dismiss violent incidents as just “part of the job” for paramedics and EMTs. At the agency level, those victimized by acts of violence may not get the support they need. When advocates try to get legislation or policies in place to address workplace violence in emergency rooms or other health care settings, too often the pre-hospital world is forgotten, or just left out, he says.

In the hospital, increasingly, there is security personnel on hand to back up the professionals, but in the community, the EMS crew often is the first responder on the scene—the one to size it up and assess the hazard. A relationship with local police departments is essential, but there can be wide variation in how quickly police are able to show up for a difficult situation.

There’s also a stigma against EMS workers – that they are a stepchild of the health care system – and that because violence is inherent in the job, they just have to deal with it.

“Well, maybe that’s what occurs, but it’s not part of my job," White says. "This job is for us to take care of people with emergency medical needs, to be always available, not fearful, when it comes to taking care of people’s emergency needs.”

What Can EMS Personnel Do About Violence?

Paramedicine training curricula from Day One emphasize personal safety and what to do when a patient gets violent. “But it’s difficult to anticipate, let alone, predict, when someone will choose to be violent,” says Dia Gainor, executive director of the National Association of State Emergency Medical Services Officials. 

EMS policymakers need better information on what’s happening out there, according to Gainor. There are mechanisms to report violent incidents, and every state submits data to the National Highway Traffic Safety Administration’s National EMS information system. But the data available from these sources varies widely.

“It’s clear that there’s growing concern about the increased severity of these incidents," Gainor says.

A number of tools and strategies have been proposed for EMS professionals to deal with potentially violent encounters on the job, including learning de-escalation techniques used by mental health professionals, police, and other first responders in order to defuse potentially volatile situations before they ignite into violent incidents. White teaches a class in basic de-escalation techniques for EMS personnel developed by MOAB Training International.

“It’s not just advocacy for protecting yourself but knowing what are your legal rights,” he says.

Jason Brooks, BAS, EMT-P, I/C, is a paramedic and Chief Executive Officer of the company DT4EMS, which has taught violence management classes for 27 years. It's Escaping Violent Encounters (EVE) course is disseminated through a “train the trainer” format to thousands of EMS personnel nationwide.

“We don’t just teach you techniques for getting out of a violent situation, we focus on tactics to avoid having to use those techniques," says Brooks. Participating agencies typically see a 50 percent decrease in Worker’s Compensation claims after the training, Brooks reports.

“One of the things we talk about in our classes is how to understand the differences between a patient, an uncooperative patient, and an attacker. Take what the person says and their actions seriously,” he explains. Someone who has expressed in words and deeds their intent to harm you should no longer be considered a patient. At that point, EMS personnel can disengage and withdraw the offer to care for that individual until the person wants their care.

DT4EMS also teaches the appropriate use of force in self-defense and reasonable measures for escaping a situation. “Our job is not to detain or restrain these people. That’s when we’re more likely to get hurt. EMS works on the assumption of providing care to people based on their consent. Trying to force medical intervention on people who have said they don’t want it creates desperation.”

The EVE train-the-trainer course is normally taught in person over 40 hours to future trainers, with the first two days demonstrating to participants the course they will eventually be asked to teach how to escape, mitigate and survive violent encounters. “We turn these trainers into subject matter experts in the use of force in health care,” Brooks says. “We teach things you should do on every call you make, starting with how to be more aware of your surroundings and when the situation starts to change. You need to recognize and honor that change.”

Other Interventions

Other approaches to violence mitigation include learning self-defense techniques, such as from martial arts training, the increased use of body cams on EMS personnel, and even carrying a handgun while on the job as a self-defensive measure. Several states have passed laws making it legal for EMS personnel to carry guns in certain circumstances, although it has generated controversy.

“You can create legislation, but are you providing enough education to where everyone is at least baseline competent (with the handgun)?” White asks. The escalation of force potentially could make the problem worse, although “if I have a patient getting combative with me, I want to be able to defend myself.”

Joseph Coley, a paramedic and shift supervisor with Tazewell, Va., EMS, and advocacy coordinator for the state of Virginia for the National Association of Emergency Medical Technicians, says his agency had two violent incidents of assaults on providers just in the previous week. “Every practitioner has the right to feel safe in the performance of their jobs.” But as the EMS field has become more defensive, Coley has a bulletproof vest that he dons in certain prescribed situations like responding to shootings, stabbings, and domestic violence.

“We’re in an inherently dangerous profession, and sometimes things happen," he says. "But I’d like to know that if I get stabbed on the job, that person is going to get charged with the stabbing, in line with the same law that protects police, judges, and other public servants.”

An important piece of legislation, The Workplace Violence Prevention for Health Care and Social Service Workers Act (S 1176 and HR 2663), was reintroduced into Congress in April by Sen. Tammy Duckworth (D-WI) and Rep. Joe Courtney (D-CT). It proposes standard data collection tools and a definitive data system for compiling data on occupational violence against health care workers—specifically including “emergency services and transport services.” That way, policymakers would have better information about the actual scope of the problem when drafting solutions.

The bill also directs the Secretary of Labor to issue OSHA standards requiring employers in health care and social services to develop and implement a corporate workplace violence prevention plan. A recent article in JEMS[iii] urges those who work in the field to contact their Congressional representatives to urge its passage.