A concerted effort of emails, letters and calls would show representatives that the paramedicine clinician profession supports this important bill!
Executive Summary
This paper is written in support of the Workplace Violence Prevention for Health Care and Social Service Workers Act, (S.1176 and H.R. 2663), reintroduced in Congress on April 18, 2023. The current national data show that paramedicine clinicians have rates of occupational violence related injuries that are far higher than the rates for firefighters, healthcare workers and the national average for all workers. Yet even though paramedicine clinicians respond to over 40 million calls for assistance every year, the currently available data are inadequate to support any risk reduction programs. The bill proposes a standard data collection tool and a definitive data system that will greatly expand the available information on the circumstances and outcomes of these perilous events. The new information will be a critical component of the foundation needed for developing, testing, and implementing occupational violence and risk reduction initiatives. Ultimately, the bill can help reduce the risks of occupational violence for paramedicine clinicians and all health care personnel.
Abbreviations
DOL: U.S. Department of Labor
EMS: emergency medical services
EMT: emergency medical technicians
RN: registered nurses
PC: paramedicine clinicians
Introduction
On April 18, 2023, the Workplace Violence Prevention for Health Care and Social Service Workers Act, (S.1176 and H.R. 2663), introduced by Rep. Joe Courtney (D-CT-2) and Sen. Tammy Baldwin (D-WI) was referred to committees for further consideration.1,2
The bill aims to direct the Secretary of Labor to issue an Occupational Safety and Health Administration (OSHA) standard that requires employers within the health care and social service industries to develop and implement a comprehensive workplace violence prevention plan. A key component of the plan requires capturing data on the circumstances surrounding these violent events. This effort should be supported because there is currently a critical data gap regarding the circumstances associated with violent incidents, particularly when it comes to paramedicine clinicians (PCs), including emergency medical technicians (EMTs) and paramedics. The purpose of this paper is to report on what is currently known about violence against PCs, provide the most current U.S. Bureau of Labor Statistics data on workplace violence, to describe why more precise data on these incidents are needed, and to advocate for support of this bill.
The PCs work primarily in emergency medical services (EMS) agencies and have a rate of workplace violence that is six times higher than the rate for all workers in the U.S.3 There is on average a fatal assault against a PC every year.4 In one dual-profession department, PCs had a risk of occupational violence that was 40 times higher than for their firefighter colleagues.5 Approximately two thirds of surveyed PCs indicated that they had been victims of assault.6 Furthermore, female PCs are disproportionately affected by violence compared to their male colleagues.7,8 This sex disparity is also seen for all U.S. workers9 and warrants special attention in any effort to develop risk-reduction solutions.
Violence against PCs can take many forms, including physical assaults, verbal abuse, sexual harassment, and bullying. These incidents can not only cause harm to the clinicians but can also impact their ability to provide care to their patients. The incidents can cause injury and traumatic stress and may contribute to staff turnover. The most common perpetrators of violence against PCs are patients.7 However, perpetrators also include co-workers, personal acquaintances, and individuals with no association with the worker;10 several on-duty PCs have been severely injured or killed by individuals unrelated to an EMS call.11,12
Few people realize that the very essence of the EMS response places PCs in the heart of situations that are uncontrolled, and many times the PCs are operating on the scene without a law enforcement presence. For example, PCs often respond for an unknown injury or illness and once on the scene determine the patient is a domestic violence victim, and that the perpetrator is in the room. The PCs have no way to know if the perpetrator has a weapon and no way to know if the perpetrator will allow the PCs to treat or transport the patient; the PCs themselves are now also at risk of being assaulted.
At the same time the paramedicine profession struggles with the peril and impacts of violence, it faces unprecedented financing and employee retention problems. An inadequate fee-for-service funding model without the necessary support for expenses such as disaster support, and fixed and standard costs, means that EMS agencies are unable to properly equip or protect their employees.13 As healthcare rapidly advances in the areas of treatment, equipment and safety, EMS in the U.S. has been left behind due to this defective funding model. This is a critical defect which has broad implications across the EMS enterprise as well as its impacts on responder and patient safety. The funding deficits have also resulted in the U.S. system falling far behind the capabilities of EMS systems in many other countries that have continued to modernize and improve while the U.S. system has largely stagnated.13
Another critical aspect of systemic inadequate funding is that PCs earn about half of what nurses, police and firefighters earn.13 Prior to the pandemic, the EMS turnover rate was about 25% per year,14 a recent report indicated that 40% of the EMS workforce left in one year.15 The high turnover contributes to the difficulty of protecting these health care workers. Moreover, this attrition rate reduces professional institutional knowledge and concurrently contributes to a diminishment of sustained EMS clinical expertise within an agency and for the community.
One of the challenges of addressing the violence problem is poor data. Today, each of the over 20,000 EMS agencies in the U.S. have their own policies and procedures for documenting violent incidents. There is no central repository of comprehensive data and no reasonable way to compile the records from all the agencies. If approved, the bill would provide all agencies with a standard Violent Incident Log Description and the agencies will be required to submit that log on an annual basis, to contribute to an annual national report that will be submitted to Congress. Currently, the data on workplace violence among PCs comes from the U.S. Department of Labor (DOL), Bureau of Labor Statistics. The DOL data allows for comparisons but does not provide details of violent incidents. Those details are a necessary foundation for any efforts to reduce these risks.
The overall risk of violence targeting EMS and healthcare is alarming and requires immediate action. The unique nature of EMS work makes the risks of occupational violence vexing and particularly challenging to address. Although PCs respond to over 40 million calls for assistance a year,16 there remains no evidence base for efforts to reduce their risks of violence related injury.17-19 The proposed bill helps address the problem by supporting the development and implementation of a comprehensive workplace violence prevention plan and the collection of needed data. The bill helps address a critical gap requiring redress to protect PC’s.
Methods
To determine the current risks for PCs and how those risks compare to other occupations, data on workplace violence from the DOL20 were downloaded for the following occupations: emergency medical technicians and paramedics, registered nurses (RNs), healthcare practitioners and technical occupations, physicians and surgeons, firefighters, and all U.S. workers, for event type: “Violence and other injuries by persons or animal.” The relative risk is calculated by dividing the EMS rate by the rate for each of the other professions.
Results
Figure 1 shows the rates of injury and illness per 10,000 full-time workers for violence-related injuries for each profession. It shows that the rate of 37.8 per 10,000 workers for EMTs and paramedics is much higher than the rates for the other groups.
all occupations in the U.S., for 2020.
Figure 1 shows that PCs have a rate of violence related injury that is seven times higher than the rate for firefighters, 5.5 times higher than for all workers in the U.S., twice as high as for healthcare practitioners, and 60% higher than for RNs. There is no 2020 rate of violence related injuries for physicians, however their rate for 2018, the last year available, was 0.9; PCs have a rate of violence related injury that is 42 times higher than the last known rate for physicians.
Discussion
The rate of violence related injuries for PCs of 37.8 in 2020, is up from a rate of 5.2 in 2007;21 this is a seven-fold increase. Corresponding to previously published research, these findings reaffirm that PCs have high rates of violence-related injuries, and high relative risks of injuries compared to other similar professions. Further, although the focus of the bill, and of this paper, is on the scope of the problem in the U.S., violence against EMS and health care workers is recognized as an international problem.22-25
Although the DOL data have allowed us to document the problem, compare the rates to other professions, and to calculate changes over time, it is not sufficient for the next steps of reducing those risks. For example, the DOL data do not provide the circumstances surrounding the incidents. The CDC recommends that the “who,” “what,” “where,” “when,” and “how,” data are collected for every case.26 The proposed bill will help fill the data gap by requiring EMS agencies to log specific data including a description of the violent incident; the date, time, and location of the incident, and the names and job titles of involved employees; the nature and extent of injuries to covered employees; a classification of the perpetrator who committed the violence; the type of violent incident (such as Type 1, Type 2, Type 3, or Type 4 violence); how the incident was abated; and the total number of hours worked by the covered employees for the year. The collection of this information is an important step towards developing evidence-based interventions that will address the root causes of violent incidents.
Anecdotal reports indicate that EMS agencies may be employing dozens of different types of interventions to reduce the risks of violence for their personnel, but there are no interventions that have an evidence-base documenting their effectiveness.27,28 The data in this paper also demonstrate that despite the reported reduction efforts, the risks for PCs remains very high and has increased substantially since 2007. Additionally, due to the unique nature of the work, PC job duties and work environment, remediation interventions that may be effective for other health care workers may not be effective for EMS professionals.
Successful risk reduction interventions can only be developed and evaluated if there are reliable data. Today, an estimated 44% of assaults against PCs are unreported.29 Further, there are currently no reliable and comprehensive national data available for evaluation.30 The proposed bill will create a national reporting standard.
There are a variety of potential strategies for reducing violence related injuries among PCs.26,31 One option is to provide them with appropriate training. For example, a survey of over 600 PCs who had been assaulted found that many, after the incident, noted that they should have noticed the warning signs earlier;29 training in situational awareness may help protect PCs. Training for PCs could include self-defense, conflict resolution, communication, and de-escalation techniques. Other risk-reduction interventions that should be explored include the use of pepper-spray, chemical restraints, and physical restraints. Bullet-proof and stab-proof vests have been used by some EMS agencies, but they have not yet been proven to be effective for PCs.28
Any meaningful and effective interventions will require a team approach to ensure effective development, testing and policy implementation, along with on-going annual analyses. That project team should include PCs, EMS leadership, union representatives, epidemiologists, engineers, physicians, and local elected officials. Implementing effective strategies to reduce violence-related injuries among PCs requires multifaceted approaches that include coherent policies, appropriate training, engineering solutions, administrative support, and the development of a safety culture.
It may not be reasonable to expect an EMS agency with 40 PCs (or a small healthcare agency) to take on the responsibility for developing, implementing, and maintaining an effective written workplace violence prevention plan. Instead, agencies could be encouraged and supported to form collaborations that can work together to pool their resources and collectively create, implement and monitor risk reduction interventions.31
Clearly, based on the data available, the overall risk of violence targeting EMS and healthcare is alarming and requires immediate action. The proposed bill helps address the problem by supporting the collection of necessary data and the development and implementation of a comprehensive workplace violence prevention plan; this is a critical step in any efforts to protect PC’s. Not explicitly stated in the bill but equally important will be to make the violence logs available to researchers and to make funding available to support the needed research.
There are a number of resources that paramedicine clinicians can use to write to their Representatives in support of the bill:
The executive summary of this paper can be used in the body of a message and the link for this paper can be sent to the Representative(s) for further information.
Conclusion
Paramedicine clinicians have a rate of violence-related injury that is almost six times higher than the national average for all workers, seven times higher than the rate for firefighters, and twice the rate of healthcare practitioners. Their rate of violence-related injury in 2020 is seven times higher than their rate was in 2007. On average, a PC is killed every year in a violent attack.
It is imperative that concrete steps are taken to specifically protect PCs and ensure their safety while on the job. Evidence-based interventions must be developed, tested, and implemented across the country. These dedicated health care professionals respond to 40 million calls for assistance each year. Everything possible must be done to ensure their safety and well-being on the job.
The proposed bill is a critical step in the right direction and supports a process for Congress to work with the EMS profession to find effective solutions to these urgent problems.
A concerted effort of emails, letters and calls would show Representatives that the paramedicine clinician profession supports this important bill!
Acknowledgements
- Conflict of interest: The authors report no conflicts of interest.
- Funding: There was no funding for this project.
- This research has no human subjects and is exempt from IRB review.
- Disclaimer: The views expressed in this journal article reflect the results of research conducted by the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, nor the U.S. Government.
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