Administration and Leadership, Columns

Shedding Light on Patient-Initiated Violence Against Paramedics

Issue 40 and Volume 41.


Taylor JA, Barnes B, Davis AL, et al. Expecting the unexpected: A mixed methods study of violence to EMS responders in an urban fire department. Am J Ind Med. 2016;59(2):150–163.

An estimated 2,100 EMS practitioners were treated in EDs for work-related violence in 2013.1 Studies of violence against EMS practitioners based in Canada and Iran found 75% of the participants in both studies reported they had experienced work-related violence within the past 12 months.2,3 The study featured this month intends to gain a better understanding of patient-initiated violence within a career urban fire department.

Method: The authors of this study used a convergent parallel mixed methods design to study patient-initiated violence. The data for the quantitative strand of the study was obtained from workers’ compensation, the fire department’s safety office first report of injury, and the city’s accident injury and illness report.

Results: The initial quantitative analysis discovered women within the department were more than six times more likely than men to suffer a patient-initiated violent injury (OR 6.25, 95% CI: 3.8–10.2). Fire department personnel serving as advisors to the research team noted women within the department were more likely to be paramedics than firefighters, which prompted the data to be analyzed again for both gender and occupational factors of patient-initiated violence. The analysis found paramedics were 14 times more likely to suffer from a patient-initiated violent injury than firefighters (OR 14.4, 95% CI: 9.2–22.2).

The qualitative strand of the study conducted five interviews, each of a single study participant, and a single focus group of five participants. All of the participants interviewed were members of the department who had suffered a patient-initiated violent injury. In this type of study, the interviews are structured, recorded, transcribed and then analyzed carefully for content.

The major themes to emerge from the participants were factors relating to underreporting, dispatch, community expectations, psychological impact, leadership/policy, the legal process, training and the work environment. All of these themes weave together to attempt to explain a complex culture in which EMS practitioners are at increased odds of suffering violent injury inflicted by the patients they serve.

Discussion: This study is interesting both in design and findings. The qualitative data of the study adds a practical and pragmatic element to evidence presented by the numeric data. The study not only confirms EMS is a dangerous profession, but also identifies EMS responders may be at an increased risk of physical violence than single-role fire service responders.

This study is also valuable because it takes gender into account, and results indicate that being a female EMS practitioner doesn’t increase the odds of suffering violence as compared to male colleagues.


Convergent parallel mixed methods design: A mixed methods research design combines both quantitative (i.e., numerical) and qualitative (i.e., non-numerical) components in order to achieve a more in-depth understanding of what’s being studied. In a convergent parallel mixed methods design, the data and analysis for the quantitative and qualitative components are performed separately and then brought together for comparison and analysis.


What we already know: EMS is a dangerous profession and the body of literature differentiating risk factors continues to grow.

What this study adds: Even though patient-initiated violent injury is higher for paramedics than firefighters, female paramedics aren’t at increased risk compared to male paramedics. This study also provides insight into the aspects of the profession that need to be targeted in order to reduce violence against EMS practitioners.


1. National Institute for Occupational Safety and Health. (Aug. 17, 2015.) EMS workers injury and illness data, 2013. Centers forDisease Control and Prevention. Retrieved Feb. 20, 2016, from

2. Bigham BL, Jensen JL, Tavares W, et al. Paramedic self-reported exposure to violence in the EMS workplace: A mixed-methods cross-sectional survey. Prehosp Emerg Care. 2014;18(4):489–494.

3. Rahmani A1, Hassankhani H, Mills J, et al. Exposure of Iranian EMTs to workplace violence: A cross-sectional analysis. Emerg Med Australas. 2012;24(1):105–110.