Perceptions of Workplace Violence and its Underreporting among Prehospital Emergency Care Personnel in Johannesburg, South Africa

Perceptions of Workplace Violence and its Underreporting among Prehospital Emergency Care Personnel in Johannesburg, South Africa | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Perceptions of Workplace Violence and its Underreporting among Prehospital Emergency Care Personnel in Johannesburg, South Africa Muhammad Yaaseen Hokee, Andrew William Makkink, Craig Vincent-Lambert This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8385902/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 8 You are reading this latest preprint version Abstract Background Prehospital emergency care personnel (PECP) are tasked with providing emergency care to injured and ill patients in environments that are unpredictable and carry several risks to both caregivers and patients. One of those inherent risks is workplace violence (WPV) against the caregiver. Workplace violence against the PECP is on the rise and has been shown to impact the PECP and the care that it provides. In our study, we investigated and described WPV against PECP within Johannesburg, South Africa. Methods This study followed a qualitative descriptive design in which face-to-face, semistructured interviews were employed to gather data. The participants involved were registered with the Health Professions’ Council of South Africa and were working in Johannesburg, South Africa, as PECP. The interviews were audio-recorded, transcribed verbatim, and analyzed thematically. The thematic analysis was used to identify themes, patterns, and insights. Data saturation was reached after nine interviews. Results A total of nine participants participated in the study. Among the nine participants, five (56%) were female, and four (44%) were male. Seven participants (78%) were from the private sector, and two (22%) were from the public sector. The participants identified substance abuse, the location of the scene, and the relationship between the PECP and managers as contributors to WPV. The reporting of WPV was generally poor and was attributed to victimization and incidents not being addressed correctly. A lack of preparedness and training on WPV incidents also emerged from the participants. Conclusion PECP in Johannesburg continues to experience and be affected by WPV. Drivers of WPV were heavily influenced by the broader social dynamics of South Africa. Despite experiencing high amounts of WPV, participants faced various challenges with the reporting of WPV, which hindered addressing WPV. Targeted interventions are urgently needed to improve reporting practices and training and foster a culture of accountability and safety within the prehospital environment. Prehospital Emergency Care Personnel Paramedic Prehospital Workplace Violence South Africa Background Prehospital emergency care personnel (PECP) provide emergency care and the transportation of ill and injured patients in the prehospital setting ( 1 ). The prehospital setting to which PECP are exposed is often unpredictable and can pose several risks for the caregiver as well as the patient ( 1 ). One of the inherent risks associated with working in the prehospital setting is exposure to workplace violence (WPV) ( 1 , 2 ). Workplace violence is defined as an incident or situation where a staff member is subject to verbal, physical, and/or sexual abuse in a situation that is related to their working environment ( 3 ). Workplace violence against PEPC is viewed as a global problem that is on the rise ( 1 , 3 – 7 ). The increasing exposure of PECP to WPV has added another layer of stress and concern to an already demanding emergency care profession. Two core factors have been identified as contributing to WPV: the unpredictable and uncontrolled nature of the prehospital environment itself and the people, including both patients and nonpatients, who they encounter within the environment ( 8 , 9 ). Violence, particularly in South Africa (SA), has become a norm within society, and SA has been particularly affected by increasing levels of violence such that it is viewed as one of the most violent countries in the world ( 10 , 11 ). The high levels of violence in SA are often attributed to inequality, poverty, politics, and criminal elements ( 10 , 11 ). High levels of violence are suggested to have an impact on PECP working in the prehospital environment. South African PECP continues to experience an increase in the number of attacks and violence while responding to scenes and treating patients, including verbal, physical and sexual violence as well as experiencing robbery, being shot at, and hijacking ( 12 – 14 ). The effects of WPV negatively impact PECP, causing significant physical and psychological damage ( 7 , 15 – 18 ). Some of the effects experienced by PECP include bruises, fractures, higher levels of stress, occupational burnout, a decrease in job satisfaction, anxiety, feelings of fear, anger, guilt and an unwillingness to continue working ( 4 , 7 , 15 , 17 ). The long-term effects of WPVs may not only affect the PECP but also hinder the operational growth and functioning of EMS systems and may encourage the PECP to seek alternate employment or leave the EMS profession together ( 4 ). Methods Aim The WPV is a phenomenon that is increasing and becoming a detrimental part of the general working conditions of the PECP. The indications are that WPV is increasing, especially within the prehospital environment, and that there is a paucity of literature regarding WPV against PECP and its reporting. The aim of this study, therefore, was to investigate and describe perceptions of WPV and its underreporting among the PECP within Johannesburg, South Africa. Study Design and Setting This study utilized a qualitative descriptive design in which face-to-face, semistructured interviews were used to gather data. The study used and reported the use of the consolidated criteria for reporting qualitative research (COREQ) guidelines ( 19 , 20 ). This study took place in Johannesburg, South Africa, which is inherently known for being a dangerous and violent city ( 8 , 21 ). Population and Recruitment The sample population consisted of PECP who were operating within the Johannesburg region. This population was chosen because Johannesburg is one of the busiest metropolitan areas in South Africa ( 22 , 23 ). The city is characterized by high levels of violence, societal unrest, and diverse patient populations ( 21 ). The participants were required to be registered with the Professional Board for Emergency Care, the Health Profession’s Council of South Africa (HPCSA), and to hold a prehospital qualification. The participants were contacted to schedule times convenient to them for conducting the interviews. The interviews commenced at appropriate venues that were agreed upon between the researcher and the participant. The researcher ensured that the venue chosen had adequate privacy, and all interviews were audio-recorded with two recording devices being used to mitigate any loss of data because one of the devices was faulty or had poor environmental audio acoustics. The interviews were conducted in a confidential environment, with no identifying data being collected, recorded, or transcribed. The interviews initially involved a set of generic questions at the beginning of the interviews, followed by more in-depth questions related to WPV against the PECP. (See annexure 1) Data analysis The audio recordings from the interviews were transcribed verbatim by the researcher. Transcribing the data personally facilitated deeper engagement and immersion in the dataset, which is a critical component of qualitative analysis ( 24 ). The research team used Atlas.ti [ATLAS.ti Scientific Software Development GmbH (2023) ATLAS.ti Mac (Version 23.2.1)], and the audio transcriptions were imported and transcribed. Two members of the research team (MYH, AWM) independently reviewed the transcripts and analyzed the data. The analysis followed Braun and Clarke’s six-phase approach to thematic analysis ( 25 ). First, both researchers familiarize themselves with the data through repeated horizontal and vertical readings of the transcripts to gain a comprehensive understanding of the content. Second, initial codes were generated independently within Atlas.ti, with semantic and latent coding used to capture both the statement and the underlying meanings. Third, these codes were examined and clustered into potential themes, with similar codes grouped to identify early thematic patterns. Fourth, the developing themes were reviewed against the coded extracts and the full dataset, with new codes incorporated and themes refined, merged, or separated as needed. Fifth, each theme was defined and named by identifying its central idea to ensure that it reflected a distinct and meaningful aspect of the data. Finally, the themes were organized into a coherent analytical narrative. This structured process ensured methodological rigor and consistency in the development of the study themes. Data saturation In this study, we draw on the principles of information power as described by Malterud, Siersma, & Guassora (2021) to guide decisions regarding sample adequacy rather than relying on the traditional notion of “data saturation”. The more relevant and rich the data obtained in relation to the study aim were, the fewer participants were required ( 26 ). Decisions regarding sample adequacy were based on the information richness and relevance of the data as opposed to a numerical threshold or an absence of new codes. In this study, decisions about sample adequacy were guided by the concept of information power rather than traditional saturation. The interview data were reviewed throughout the study, with ongoing assessment of the relevance, specificity, and contribution to the study aim. The focused aim of the research, the relative homogeneity of the participant group, and the strong quality of the interview dialog contributed to high information power. The research team determined that the sample held sufficient information power to address the study aim. Trustworthiness To ensure methodological rigor, the study followed the four fundamental criteria of trustworthiness in the form of credibility, transferability, dependability, and confirmability ( 27 – 29 ). Credibility This was strengthened through independent coding by two of the researchers, through repeated engagement with the transcripts and the use of Braun and Clarke’s structured thematic analysis ( 25 ). This approach ensured that the findings of the study accurately reflected the participants' experiences. Transferability Transferability was supported by providing clear descriptions of the study setting, the participants and the contextual factors. This allows readers to judge how these findings may apply to other EMS or prehospital environments. Dependability The clear structure of the methodology, coding processes and theme development ensured the dependability of the study. The use of Atlas.ti provided further systematic organization of the data and supported consistency throughout the analysis of the data. Confirmability The confirmability of the study was addressed through reflexive practices, independent coding, and preservation of the raw data. These strategies helped to demonstrate that the findings were grounded in the data and reduce researcher bias. Results Demographics A total of nine participants were interviewed. Five participants (56%) were female. Seven participants (78%) were employed in the private EMS sector, whereas two participants (22%) worked in the government sector. Among the nine participants, seven (78%) were advanced life support EMS providers. These demographic details provide insight into the perspectives represented in the study. Themes & Subthemes Four dominant themes were identified from the data: 1) factors perceived to increase the risk of WPV while delivering prehospital care; ( 2 ) factors perceived to increase the risk of WPV at the place of work (i.e., the station/base); ( 3 ) barriers related to the reporting of WPV; and ( 4 ) coping mechanisms and strategies for addressing WPV. Each theme had subthemes; this is presented in Table 1 . Table 1 Themes and Subthemes Theme Subtheme 1. Factors perceived to increase the risk of WPV while delivering prehospital care 1.1 Substance abuse 1.2 Socioeconomic status of the community & location of the scene 1.3 Unrealistic expectations of EMS by community members 1.4 Absence or delayed response from law enforcement 1.5 Patient’s mental state and/or presence of related psychiatric illnesses 2. Factors perceived to increase the risk of WPV at the place of work (i.e., the station/base) 2.1 The relationship between employees and management 2.2 Poor communication between peers 3. Challenges relating to the reporting of WPV 3.1 Fears of being seen as “weak” and/or being victimized 3.2 WPV is viewed as part of the job and is a normal occurrence to be expected. 3.3 Failure of management to properly manage reported cases of WPV 4. Insufficient training to deal with WPV Theme 1. Factors perceived to increase the risk of WPV while delivering prehospital care The participants identified six primary factors that contributed to the risk of WPV within the prehospital environment. These factors included 1) substance abuse, 2) the geographical location and linked socioeconomic status (SES) of the community, 3) the community having unrealistic expectations of the emergency services, 4) response from law enforcement, 5) the patient’s mental state and 6) the presence of stressed family members. Each of these factors is unpacked below. 1) Substance Abuse Our participants believed that alcohol and drugs were associated with their experiences with WPV. The participants indicated that while on scenes, patients, patient family members, and bystanders have been intoxicated and created a problematic and disruptive scene. “… Most of the time, it [WPV] is either because of alcohol intoxication or drug intoxication that they have [perpetrators of WPV] been pretty violent with us.” (Participant 5) “…. and particularly those (bystanders) who are under the influence of alcohol.” (Participant 7) “…there were several incidents [of WPV], usually alcohol was involved, where people would become verbally violent…” (Participant 9) 2) Geographical location and linked socioeconomic status of the community The participants perceived a strong link between the risk of WPV and the geographical location of the incident and further linked this to the SES of the community in which the incident was being responded to. Furthermore, participants felt that some of the poverty-stricken areas they were dispatched to were inherently dangerous and unsafe and therefore placed them at increased risk of experiencing WPV. “… I felt that it [WPV] most commonly came in your more poverty-stricken areas” (Participant 6) “…As EMSs in South Africa, we are bound to go into hostile environments and unsafe locations and unsafe buildings and unsafe areas. I mean, the Joburg CBD is one of the most dangerous places in the world, and it’s often where we end up spending a lot of our time treating the most vulnerable.” (Participant 7) “We sometimes get attacked because we work in rural settlements.” (Participant 9) 3) Unrealistic expectations of the EMS by community members Our participants indicated that community members had unrealistic expectations of what the EMS could provide. The lack of understanding caused difficulty in providing emergency care and potentially led to a violent scene. “Yes. There have been instances, yes, that I have experienced with the environment has become hostile because the public think that we should be able to fix the situation as per what is seen on TV.” (Participant 1) “They [the public] do not understand our limitations and capabilities of what we are able to do in the prehospital environment, and with that, if we cannot provide or meet their expectation, primarily owing to the naivety if we cannot meet their expectation, that is when they start to get hostile and start to question and start to become violent and hurl obscenities at us.” (Participant 1) 4) Absence or delayed response from law enforcement In our study, we found that the absence of law enforcement or the late arrival of law enforcement directly affected participants experiencing WPV. In certain cases, participants indicated that after requesting assistance from law enforcement, they often arrive at hostile scenes alone. “We arrive at scenes whereby when we ask for SAPS (South African Police Service), SAPS will not be there on time… We’ll be attacked by the community” (Participant 3) “There have been many cases where we have attempted to go and assist the patient, and we got first verbal threats, but it does not end there. We get rocks thrown at us or at our vehicles. We tend to them [SAPS] generally we need South African police services to be on scene, but they never truly there and we do not get the protection we need.” (Participant 6). “Therefore, whether that is private security or the SAPS, I think [we need] better support because there's been instances where there is a violent scene or something is happening and you ask for that assistance, that backup, that protection and it is not offered” (Participant 7) 5) Patient’s mental state and/or presence of related psychiatric illnesses The participants reported that patients who presented with mental health challenges and/or the presence of related psychiatric illnesses were linked to an increased risk of WPV. Interestingly, participants were cognizant that WPV perpetuated by psychiatric patients was not deliberately harmful but was a byproduct of their illness. “… We do situations where its psych patients are violent, but they obviously do not have control of that.” (Participant 5) “… However, we get our patients who are not truly mentally fit or mentally ok, and we receive violence from them as well” (Participant 6) “…I’ve had the few odd scenarios where patients have been violent toward me, but it was because of their [psychiatric] condition more than it was them just being violent…So basically a psychiatric patient busy going through a psychosis. They tend to be more violent than others [patients].” (Participant 8) Theme 2. Factors perceived to increase the risk of WPV at the workplace (i.e., the station/base) The participants indicated that not only did they experience WPV in the prehospital environment but that this also extended to the office space or base from which they worked. There were two primary sources of WPV at the office: from coworkers and from managers. 1) The relationship between employees and management The participants described feeling that EMS management did not fully understand the realities of WPV faced by frontline EMS personnel. The participants attributed this to managers being primarily office-based or burdened with administrative responsibilities. This results in limited engagement and exposure to operational challenges. The participants also expressed frustration that incidents of WPV were not taken seriously when reported and that reporting incidents of WPV rarely led to meaningful action or support. “I do not believe that a manager will understand to full capacity what you're going on specifically if it is a manager that is specifically office-based or desk-bound.” (Participant 1) “I do not know if it is because of, you know, management being overworked and having a hundred other things to do. However, I just do not think it is [WPV] always thought of it as seriously.” (Participant 7) “Y es, I have been exposed to violence. Yes, I'm going to report it to my manager, but she's not going to do anything about it in my mind.” (Participant 6) 2) Poor communication between peers The participants acknowledged that fellow healthcare staff were not only a source of WPV but also that this could be rooted in poor communication escalating to the point of conflict. “I think we also forget that abuse toward healthcare staff can also come from fellow healthcare members” (Participant 7) “…due to a lack of communication, it can lead to misunderstandings, which can then result in something going further and miscommunication, resulting in a hostile environment between two personnel or two people at work.” (Participant 1) Theme 3. Barriers related to WPV reporting The participants provided several reasons why WPV was underreported. Three dominant themes emerged: 1) participants were fearful of being victimized or seen as ‘weak’ when they reported WPV, 2) WPV was common and viewed merely as part of the job, and 3) there was a general failure of management structures to adequately manage cases of WPV that were reported. 1) Fears of being seen as “weak” and/or being victimized The participants were perceived to shy away from reporting incidents of WPV with fears that they would be viewed as “weak” or victimized for reporting WPV. The participants also indicated that if they had reported a case of WPV, they would become ostracized and victimized, typically from their work colleagues. “I feel it is [WPV] quite a common occurrence, and if you're constantly complaining about the same thing or reporting the same thing, you could be deemed weak.” (Participant 1) “…You will be reporting what has happened to you with the particular person instead of solving the issue; they blame you.” (Participant 3) “These people [PECP] get bullied and bullied and after a while when they finally report it and everything, they actually sometimes get ostracized…” (Participant 9) 2) WPV is viewed as part of a job and is a common occurrence Our participants indicated that WPV was a common occurrence for them. The participants felt that they had become complacent to the risks associated with WPV, as WPV had become part of their job, and this outlook affected their desire to report incidents of WPV. “So I think a lot of us [PECP] do take it [WPV] in our stride, we take it, and we see it [WPV] as a norm.” (Participant 8) “However, I think we have become complacent to those risks, complacent to the violence that we experienced.” (Participant 7) “… We just tend to overlook it [WPV] and underplay it [WPV]. In addition, that is why we do not report it.” (Participant 4) “I think we have become so used to it [WPV] that if it is a small issue and we can handle it [WPV].” (Participant 5) 3) Failure of management to manage reported cases of WPV properly The underreporting of WPV was further exacerbated by inadequate management of reported incidents of WPV. The participants expressed a lack of genuine concern from EMS management, as reported incidents were often handled ineffectively. This resulted in participants being discouraged from reporting incidents of WPV. “The leadership itself [management] is the perpetrator cause if you come with a complaint and say this is what is happening to me; they just do not care.” (Participant 3) “If you report a case that you have been mistreated or there was an abuse or something, it is not been taken into consideration” (Participant 3) “In my experience, it [reported WPV] has been dealt with quite poorly…” (Participant 7) “…Often it is a case, but what are they [management] going to do about it?” (Participant 7) Theme 4. Insufficient training to address WPV Given the high incidence of WPV and the negative impacts it has on the PECP, participants generally felt that their training was insufficient to address incidents of WPV. Some participants mentioned receiving a brief presentation on WPV, whereas other participants reported never receiving training on how to address WPV. “… I have not received formal training, and I do not believe the attached training that we have received throughout our training to become paramedics is adequate.” (Participant 1) “There was not any formal training on how to prevent these [WPV] situations from occurring.” (Participant 8) “… I’ve received no formal training. There's been no access to it; my workplace has never provided me access to this kind of training.” (Participant 7) Discussion WPV against PECP is a recognized global challenge, and the findings of this study confirm that South African PECP encounters patterns similar to those of WPV described in other studies ( 1 , 3 , 4 , 15 , 30 – 36 ). This study investigated and described WPV experienced by PECP, offering insight into context-specific factors that contribute to the prehospital environment and EMS workplace violence. A central finding was that several scene-related factors placed the PECP at a heightened risk of WPV. Consistent with international reports, alcohol and drug intoxication have emerged as prominent contributors to aggression and hostility toward PECP ( 33 , 37 – 40 ). The South African context amplifies this risk, given the high prevalence of substance use in many communities ( 41 – 43 ). The participants also highlighted the influence of broader socioeconomic and geographic conditions, which included increased exposure to violence in communities with high crime rates, chronic service delivery challenges, and limited social resources. Similar associations between socioeconomic deprivation and violence directed at the PECP have been reported globally, ( 44 – 47 ) but the combination of unpredictable scenes and entrenched structural inequality may intensify these risks in South Africa. Unrealistic expectations of the EMS further contributed to aggressive encounters. This finding aligns with the literature showing that a limited community understanding of EMS capabilities, combined with frustration regarding broader health system limitations, can escalate hostility toward PECP ( 36 , 40 , 48 , 49 ). In this study, the participants felt that community members occasionally projected systemic frustrations onto the PECP, placing them at risk of verbal and/or physical aggression. The participants also described how delayed or absent law enforcement support heightened their vulnerability. Although previous research has confirmed that police presence can de-escalate scenes ( 50 ), resource constraints and prolongers’ response times (a well-documented challenge in South Africa) often leave PECP to navigate and manage dangerous situations without protection ( 12 , 51 ). This highlights a significant operational barrier that may not be as pronounced in better-resourced EMS systems. The mental state of patients was another contributor to WPV. The participants described heightened risk when treating patients with altered mental status or psychiatric conditions. Prior studies have similarly linked hypoxia, hypoglycemia, and psychosis to violent behavior ( 17 , 52 – 55 ). Given South Africa’s large burden of psychiatric illness and longstanding gaps in mental healthcare access ( 56 – 59 ), PECP frequently encounters patients whose conditions have deteriorated without appropriate intervention, placing them at increased risk of experiencing WPV. In addition to these risks, workplace-based factors (i.e., at the EMS station or base) also contribute to the PECP experiencing WPV. The participants expressed concerns regarding insufficient managerial support, particularly when incidents of WPV were reported. The literature indicates that poor leadership practices, inadequate managerial training, and unclear organizational processes may contribute to tense or unsupportive workplace environments ( 60 , 61 ). The perception that reported incidents were not taken seriously reflects broader findings of organizational inaction in response to WPV in EMS systems worldwide. Another challenge within the workplace was communication. This included misunderstandings among colleagues and difficulties engaging with dispatchers. This further contributed to frustration and interpersonal conflict. These findings are linked to the literature, which highlights that ineffective communication pathways among PPCPs lead to an increased risk of WPV and diminished operational cohesion within EMS systems ( 36 , 40 , 50 ). A persistent theme across interviews was the underreporting of WPV. The participants described avoiding formal reporting due to fear of being judged as weak, being victimized, and the normalization of WPV as “part of the job”. These findings mirror the widespread evidence that PECP frequently internalize WPV as an occupational inevitability and that the stigma and perceptions of reporting futility contribute to substantial underreporting ( 3 , 4 , 32 , 34 , 39 , 62 – 65 ). The normalization of WPVs undermines organizational efforts to address safety concerns and limits the development of targeted support systems. Finally, participants felt inadequately prepared to manage WPV, reporting minimal or outdated training during their EMS education. Studies from multiple settings similarly describe WPV training for PECP as insufficient or inconsistently delivered ( 54 , 66 – 68 ). Traditional guidance focused primarily on “scene safety” and did not truly reflect the realities of the South African prehospital context; thus, withdrawing from unsafe scenes and/or environments may not be possible ( 66 ). The literature increasingly emphasizes the need for context specific, evidence-based training with a focus on risk recognition, de-escalation, and personal safety strategies ( 6 , 54 , 67 , 69 , 70 ). The findings of this study reinforce these recommendations and highlight a critical opportunity for educational and organizational improvement. Limitations This study has limitations that should be considered when the findings are interpreted. First, the study used a qualitative descriptive design with a sample of nine PECP from Johannesburg, which may limit the diversity of the perspectives captured. While the study drew on principles of information power to guide sample adequacy, the experiences described may not reflect those of the PECP in other regions of South Africa or in differently structured EMS systems. The findings rely on self-reported experiences, which are potentially subject to recall bias and personal interpretation. The participants may also have withheld or softened descriptions of sensitive incidents due to concerns about professional relationships or organizational repercussions. Only the perspectives of the frontline PECP were included; the views of EMS managers, dispatch personnel, law enforcement and/or community members were not explored and may have provided a more comprehensive understanding of the factors influencing WPVs. Finally, the context-specific nature of South Africa may limit the transferability of the findings to countries with different EMS structures or levels of resourcing. Conclusion This study highlights a range of factors that contribute to WPV against PECP in South Africa, including scene-related risks, community expectations, patient presentations, organizational dynamics and training gaps. While many of these challenges reflect global trends, the South African context includes high levels of substance abuse, socioeconomic disparities, limited law enforcement capacity, and a significant burden of untreated mental illnesses. Persistent underreporting and inadequate organizational responsiveness further reinforce the normalization of WPV and hinder efforts to improve safety. The findings underscore the need for strengthened organizational support systems, clearer reporting processes, improved interprofessional communication and context specific, evidence-based training that prepares providers for the realities of WPV in South Africa. Addressing these challenges is essential for improving safety and ensuring the sustainability of the PECP workforce. Future research should explore targeted interventions, evaluate training approaches and examine organizational strategies that may reduce WPV and improve support and safety for PECP. Abbreviations CBD Central Business District EMS Emergency Medical Services HPCSA Health Professions Council of South Africa PECP Prehospital Emergency Care Personnel SA South Africa SAPS South African Police Service WPV Workplace Violence Declarations Ethics approval and consent to participate The study was conducted in accordance with the ethical principles of the Declaration of Helsinki and the South African National Health Research Ethics Council (NHREC) guidelines. Ethical approval was obtained from the University of Johannesburg’s Faculty of Health Sciences Higher Degrees Committee and the Research Ethics Committee (REC-1294-2021). All data collection sites and relevant institutional committees granted gatekeeper permission prior to the commencement of the study. Informed consent was obtained from all participants by providing an information document and written consent form, which participants were required to review and sign before participation. Participants provided consent to be interviewed and for the interviews to be audio-recorded. Consent for publication The participants were asked for consent via deidentified code names and quotes for research and academic purposes, including publication. Competing Interests The authors declare that they have no competing interests. Authors’ Information Muhammad Yaaseen Hokee; Department of Emergency Medical Care, University of Johannesburg – Doornfontein Campus, Johannesburg, Gauteng, South Africa ( [email protected] ) Andrew William Makkink; 2 Discipline of Paramedicine, College of Medicine and Public Health, Flinders University, Adelaide, Australia ( [email protected] ) Craig Vincent-Lambert; Department of Emergency Medical Care, University of Johannesburg – Doornfontein Campus, Johannesburg, Gauteng, South Africa ( [email protected] ) Funding This study received no funding. Author Contribution All the authors contributed to the conception and design of the study and to the drafting of the manuscript. YH collected the data, and YH and AM independently coded, categorized and analyzed the data. All the authors read and approved the final manuscript. Acknowledgement The authors would like to acknowledge all the participants and any other prehospital emergency care personnel who were victims of workplace violence. 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Inquiry: J Health Care. 2024;61:1. https://doi.org/10.1177/00469580241233452 . Cheney PR, Gossett L, Fullerton-Gleason L, Weiss SJ, Ernst AA, Sklar D. Relationship of restraint use, patient injury, and assaults on EMS personnel. Prehospital Emerg Care. 2006;10:207–12. https://doi.org/10.1080/10903120500541050 . Gleby F. Ambulance in Red Zones in Cape Town, South Africa. 2018. Scheppke KA, Braghiroli J, Shalaby M, Chait R. Prehospital use of im ketamine for sedation of violent and agitated patients. Western J Emerg Med. 2014;15:736–41. https://doi.org/10.5811/westjem.2014.9.23229 . Kowalczuk K, Krajewska-Kułak E. Patient aggression toward different professional groups of healthcare workers. Ann Agric Environ Med. 2017;24:113–6. https://doi.org/10.5604/12321966.1228395 . Koritsas S, Boyle M, Coles J. Factors Associated with Workplace Violence in Paramedics. Prehospital Disaster Med. 2009;24:417–21. Mausz J, Braaksma MJ, Johnston M, Batt AM, Donnelly EA. Paramedic Willingness to Report Violence Following the Introduction of a Novel, Point-of-Event Reporting Process in a Single Canadian Paramedic Service. Int J Environ Res Public Health. 2024;21:1–12. https://doi.org/10.3390/ijerph21030363 . Shisana O, Stein DJ, Zungu NP, Wolvaardt G. The rationale for South Africa to prioritize mental health care as a critical aspect of overall health care. Compr Psychiatry 2024;130. https://doi.org/10.1016/j.comppsych.2024.152458 Petersen I, Fairall L, Bhana A, Kathree T, Selohilwe O, Brooke-Sumner C, et al. Integrating mental health into chronic care in South Africa: The development of a district mental healthcare plan. Br J Psychiatry. 2016;208:s29–39. https://doi.org/10.1192/bjp.bp.114.153726 . Meyer J, Matlala M, Chigome A. Mental Health Care - A Public Health Priority in South Africa. South Afr Family Pract. 2019;61:25–9. Pillay Y. State of mental health and illness in South Africa. South Afr J Psychol. 2019;49:463–6. https://doi.org/10.1177/0081246319857527 . Naidoo D, Lowies A, Pillay Y. Leadership styles and qualifications for emergency medical service managers. Arab J Bus Manage Rev (OMAN Chap. 2014;3:92–110. Ghorbanian A, Bahadori M, Nejati M. The relationship between managers’ leadership styles and emergency medical technicians’ job satisfaction. Australasian Med J. 2012;5:1–7. https://doi.org/10.4066/AMJ.2012.892 . Halpern J, Gurevich M, Schwartz B, Brazeau P. Intervention for critical incident stress in emergency medical services: A qualitative study. Stress Health. 2009;25:139–49. https://doi.org/10.1002/smi.1230 . Halpern J, Maunder RG, Schwartz B, Gurevich M. Downtime after critical incidents in emergency medical technicians/paramedics. Biomed Res Int 2014;2014. https://doi.org/10.1155/2014/483140 Shabanikiya H, Kokabisaghi F, Mojtabaeian M, Sahebi T, Varmaghani M. Global Prevalence of Workplace Violence Against Paramedics: A Systematic Review and Meta-analysis. Health Emergencies Disasters Q. 2021;6:205–16. https://doi.org/10.32598/hdq.6.4.259.3 . Mausz J, Johnston M, Donnelly E. The role of organizational culture in normalizing paramedic exposure to violence. J Aggress Confl Peace Res. 2021;1–11. https://doi.org/10.1108/JACPR-06-2021-0607 . Garner DG, DeLuca MB, Crowe RP, Cash RE, Rivard MK, Williams JG, et al. Emergency medical services professional behaviors with violent encounters: A prospective study using standardized simulated scenarios. JACEP Open. 2022;3:1–11. https://doi.org/10.1002/emp2.12727 . Touriel R, Dunne R, Swor R, Kowalenko T. A Pilot Study: Emergency Medical Services–Related Violence in the Out-of-Hospital Setting in Southeast Michigan. J Emerg Med. 2021;60:554–9. https://doi.org/10.1016/j.jemermed.2020.12.007 . Dadashzadeh A, Rahmani A, Hassankhani H, Boyle M, Mohammadi E, Campbell S. Iranian prehospital emergency care nurses’ strategies to manage workplace violence: A descriptive qualitative study. J Nurs Manag. 2019;27:1190–9. https://doi.org/10.1111/jonm.12791 . Rahmani A, Hassankhani H, Mills J, Dadashzadeh A. Exposure of Iranian emergency medical technicians to workplace violence: A cross-sectional analysis. Emerg Med Australasia. 2012;24:105–10. https://doi.org/10.1111/j.1742-6723.2011.01494.x . Sahebi A, Jahangiri K, Sohrabizadeh S, Golitaleb M. Prevalence of Workplace Violence Types against Personnel of Emergency Medical Services in Iran: A Systematic Review and Meta-Analysis Systematic Review. 14. 2019. Additional Declarations No competing interests reported. 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19:42:27","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":20208,"visible":true,"origin":"","legend":"","description":"","filename":"Annexure1.docx","url":"https://assets-eu.researchsquare.com/files/rs-8385902/v1/6910aa46e718aca5949fac14.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Perceptions of Workplace Violence and its Underreporting among Prehospital Emergency Care Personnel in Johannesburg, South Africa","fulltext":[{"header":"Background","content":"\u003cp\u003ePrehospital emergency care personnel (PECP) provide emergency care and the transportation of ill and injured patients in the prehospital setting (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). The prehospital setting to which PECP are exposed is often unpredictable and can pose several risks for the caregiver as well as the patient (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). One of the inherent risks associated with working in the prehospital setting is exposure to workplace violence (WPV) (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Workplace violence is defined as an incident or situation where a staff member is subject to verbal, physical, and/or sexual abuse in a situation that is related to their working environment (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Workplace violence against PEPC is viewed as a global problem that is on the rise (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan additionalcitationids=\"CR4 CR5 CR6\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). The increasing exposure of PECP to WPV has added another layer of stress and concern to an already demanding emergency care profession. Two core factors have been identified as contributing to WPV: the unpredictable and uncontrolled nature of the prehospital environment itself and the people, including both patients and nonpatients, who they encounter within the environment (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eViolence, particularly in South Africa (SA), has become a norm within society, and SA has been particularly affected by increasing levels of violence such that it is viewed as one of the most violent countries in the world (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). The high levels of violence in SA are often attributed to inequality, poverty, politics, and criminal elements (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). High levels of violence are suggested to have an impact on PECP working in the prehospital environment. South African PECP continues to experience an increase in the number of attacks and violence while responding to scenes and treating patients, including verbal, physical and sexual violence as well as experiencing robbery, being shot at, and hijacking (\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe effects of WPV negatively impact PECP, causing significant physical and psychological damage (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan additionalcitationids=\"CR16 CR17\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Some of the effects experienced by PECP include bruises, fractures, higher levels of stress, occupational burnout, a decrease in job satisfaction, anxiety, feelings of fear, anger, guilt and an unwillingness to continue working (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). The long-term effects of WPVs may not only affect the PECP but also hinder the operational growth and functioning of EMS systems and may encourage the PECP to seek alternate employment or leave the EMS profession together (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eAim\u003c/h2\u003e \u003cp\u003e \u003cem\u003eThe\u003c/em\u003e WPV is a phenomenon that is increasing and becoming a detrimental part of the general working conditions of the PECP. The indications are that WPV is increasing, especially within the prehospital environment, and that there is a paucity of literature regarding WPV against PECP and its reporting. The aim of this study, therefore, was to investigate and describe perceptions of WPV and its underreporting among the PECP within Johannesburg, South Africa.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy Design and Setting\u003c/h3\u003e\n\u003cp\u003eThis study utilized a qualitative descriptive design in which face-to-face, semistructured interviews were used to gather data. The study used and reported the use of the consolidated criteria for reporting qualitative research (COREQ) guidelines (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). This study took place in Johannesburg, South Africa, which is inherently known for being a dangerous and violent city (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e).\u003c/p\u003e\n\u003ch3\u003ePopulation and Recruitment\u003c/h3\u003e\n\u003cp\u003eThe sample population consisted of PECP who were operating within the Johannesburg region. This population was chosen because Johannesburg is one of the busiest metropolitan areas in South Africa (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). The city is characterized by high levels of violence, societal unrest, and diverse patient populations (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). The participants were required to be registered with the Professional Board for Emergency Care, the Health Profession\u0026rsquo;s Council of South Africa (HPCSA), and to hold a prehospital qualification.\u003c/p\u003e \u003cp\u003e The participants were contacted to schedule times convenient to them for conducting the interviews. The interviews commenced at appropriate venues that were agreed upon between the researcher and the participant. The researcher ensured that the venue chosen had adequate privacy, and all interviews were audio-recorded with two recording devices being used to mitigate any loss of data because one of the devices was faulty or had poor environmental audio acoustics. The interviews were conducted in a confidential environment, with no identifying data being collected, recorded, or transcribed. The interviews initially involved a set of generic questions at the beginning of the interviews, followed by more in-depth questions related to WPV against the PECP. (See annexure 1)\u003c/p\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eThe audio recordings from the interviews were transcribed verbatim by the researcher. Transcribing the data personally facilitated deeper engagement and immersion in the dataset, which is a critical component of qualitative analysis (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). The research team used Atlas.ti [ATLAS.ti Scientific Software Development GmbH (2023) ATLAS.ti Mac (Version 23.2.1)], and the audio transcriptions were imported and transcribed. Two members of the research team (MYH, AWM) independently reviewed the transcripts and analyzed the data.\u003c/p\u003e \u003cp\u003eThe analysis followed Braun and Clarke\u0026rsquo;s six-phase approach to thematic analysis (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). First, both researchers familiarize themselves with the data through repeated horizontal and vertical readings of the transcripts to gain a comprehensive understanding of the content. Second, initial codes were generated independently within Atlas.ti, with semantic and latent coding used to capture both the statement and the underlying meanings. Third, these codes were examined and clustered into potential themes, with similar codes grouped to identify early thematic patterns. Fourth, the developing themes were reviewed against the coded extracts and the full dataset, with new codes incorporated and themes refined, merged, or separated as needed. Fifth, each theme was defined and named by identifying its central idea to ensure that it reflected a distinct and meaningful aspect of the data. Finally, the themes were organized into a coherent analytical narrative. This structured process ensured methodological rigor and consistency in the development of the study themes.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eData saturation\u003c/h3\u003e\n\u003cp\u003eIn this study, we draw on the principles of information power as described by \u003cem\u003eMalterud, Siersma, \u0026amp; Guassora (2021)\u003c/em\u003e to guide decisions regarding sample adequacy rather than relying on the traditional notion of \u0026ldquo;data saturation\u0026rdquo;. The more relevant and rich the data obtained in relation to the study aim were, the fewer participants were required (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Decisions regarding sample adequacy were based on the information richness and relevance of the data as opposed to a numerical threshold or an absence of new codes.\u003c/p\u003e \u003cp\u003eIn this study, decisions about sample adequacy were guided by the concept of information power rather than traditional saturation. The interview data were reviewed throughout the study, with ongoing assessment of the relevance, specificity, and contribution to the study aim. The focused aim of the research, the relative homogeneity of the participant group, and the strong quality of the interview dialog contributed to high information power. The research team determined that the sample held sufficient information power to address the study aim.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eTrustworthiness\u003c/h2\u003e \u003cp\u003eTo ensure methodological rigor, the study followed the four fundamental criteria of trustworthiness in the form of credibility, transferability, dependability, and confirmability (\u003cspan additionalcitationids=\"CR28\" citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eCredibility\u003c/h3\u003e\n\u003cp\u003eThis was strengthened through independent coding by two of the researchers, through repeated engagement with the transcripts and the use of Braun and Clarke\u0026rsquo;s structured thematic analysis (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). This approach ensured that the findings of the study accurately reflected the participants' experiences.\u003c/p\u003e\n\u003ch3\u003eTransferability\u003c/h3\u003e\n\u003cp\u003eTransferability was supported by providing clear descriptions of the study setting, the participants and the contextual factors. This allows readers to judge how these findings may apply to other EMS or prehospital environments.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eDependability\u003c/h2\u003e \u003cp\u003eThe clear structure of the methodology, coding processes and theme development ensured the dependability of the study. The use of Atlas.ti provided further systematic organization of the data and supported consistency throughout the analysis of the data.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eConfirmability\u003c/h2\u003e \u003cp\u003eThe confirmability of the study was addressed through reflexive practices, independent coding, and preservation of the raw data. These strategies helped to demonstrate that the findings were grounded in the data and reduce researcher bias.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eDemographics\u003c/h2\u003e \u003cp\u003eA total of nine participants were interviewed. Five participants (56%) were female. Seven participants (78%) were employed in the private EMS sector, whereas two participants (22%) worked in the government sector. Among the nine participants, seven (78%) were advanced life support EMS providers. These demographic details provide insight into the perspectives represented in the study.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eThemes \u0026amp; Subthemes\u003c/h2\u003e \u003cp\u003eFour dominant themes were identified from the data: 1) factors perceived to increase the risk of WPV while delivering prehospital care; (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) factors perceived to increase the risk of WPV at the place of work (i.e., the station/base); (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) barriers related to the reporting of WPV; and (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) coping mechanisms and strategies for addressing WPV. Each theme had subthemes; this is presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThemes and Subthemes\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTheme\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSubtheme\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1. Factors perceived to increase the risk of WPV while delivering prehospital care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.1 Substance abuse\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.2 Socioeconomic status of the community \u0026amp; location of the scene\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.3 Unrealistic expectations of EMS by community members\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.4 Absence or delayed response from law enforcement\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.5 Patient\u0026rsquo;s mental state and/or presence of related psychiatric illnesses\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2. Factors perceived to increase the risk of WPV at the place of work (i.e., the station/base)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.1 The relationship between employees and management\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.2 Poor communication between peers\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3. Challenges relating to the reporting of WPV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.1 Fears of being seen as \u0026ldquo;weak\u0026rdquo; and/or being victimized\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.2 WPV is viewed as part of the job and is a normal occurrence to be expected.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.3 Failure of management to properly manage reported cases of WPV\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4. Insufficient training to deal with WPV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eTheme 1. Factors perceived to increase the risk of WPV while delivering prehospital care\u003c/h2\u003e \u003cp\u003eThe participants identified six primary factors that contributed to the risk of WPV within the prehospital environment. These factors included 1) substance abuse, 2) the geographical location and linked socioeconomic status (SES) of the community, 3) the community having unrealistic expectations of the emergency services, 4) response from law enforcement, 5) the patient\u0026rsquo;s mental state and 6) the presence of stressed family members. Each of these factors is unpacked below.\u003c/p\u003e \u003cp\u003e \u003cb\u003e1) Substance Abuse\u003c/b\u003e \u003c/p\u003e \u003cp\u003eOur participants believed that alcohol and drugs were associated with their experiences with WPV. The participants indicated that while on scenes, patients, patient family members, and bystanders have been intoxicated and created a problematic and disruptive scene.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;\u0026hellip; Most of the time, it [WPV] is either because of alcohol intoxication or drug intoxication that they have [perpetrators of WPV] been pretty violent with us.\u0026rdquo;\u003c/em\u003e (Participant 5)\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;\u0026hellip;. and particularly those (bystanders) who are under the influence of alcohol.\u0026rdquo; (Participant 7)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;\u0026hellip;there were several incidents [of WPV], usually alcohol was involved, where people would become verbally violent\u0026hellip;\u0026rdquo; (Participant 9)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003e2) Geographical location and linked socioeconomic status of the community\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe participants perceived a strong link between the risk of WPV and the geographical location of the incident and further linked this to the SES of the community in which the incident was being responded to. Furthermore, participants felt that some of the poverty-stricken areas they were dispatched to were inherently dangerous and unsafe and therefore placed them at increased risk of experiencing WPV.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;\u0026hellip; I felt that it [WPV] most commonly came in your more poverty-stricken areas\u0026rdquo;\u003c/em\u003e (Participant 6)\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;\u0026hellip;As EMSs in South Africa, we are bound to go into hostile environments and unsafe locations and unsafe buildings and unsafe areas. I mean, the Joburg CBD is one of the most dangerous places in the world, and it\u0026rsquo;s often where we end up spending a lot of our time treating the most vulnerable.\u0026rdquo;\u003c/em\u003e (Participant 7)\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;We sometimes get attacked because we work in rural settlements.\u0026rdquo; (Participant 9)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003e3) Unrealistic expectations of the EMS by community members\u003c/b\u003e \u003c/p\u003e \u003cp\u003eOur participants indicated that community members had unrealistic expectations of what the EMS could provide. The lack of understanding caused difficulty in providing emergency care and potentially led to a violent scene.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Yes. There have been instances, yes, that I have experienced with the environment has become hostile because the public think that we should be able to fix the situation as per what is seen on TV.\u0026rdquo; (Participant 1)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;They [the public] do not understand our limitations and capabilities of what we are able to do in the prehospital environment, and with that, if we cannot provide or meet their expectation, primarily owing to the naivety if we cannot meet their expectation, that is when they start to get hostile and start to question and start to become violent and hurl obscenities at us.\u0026rdquo; (Participant 1)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003e4) Absence or delayed response from law enforcement\u003c/b\u003e \u003c/p\u003e \u003cp\u003eIn our study, we found that the absence of law enforcement or the late arrival of law enforcement directly affected participants experiencing WPV. In certain cases, participants indicated that after requesting assistance from law enforcement, they often arrive at hostile scenes alone.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;We arrive at scenes whereby when we ask for SAPS (South African Police Service), SAPS will not be there on time\u0026hellip; We\u0026rsquo;ll be attacked by the community\u0026rdquo; (Participant 3)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e\u003cem\u003e \u0026ldquo;There have been many cases where we have attempted to go and assist the patient, and we got first verbal threats, but it does not end there. We get rocks thrown at us or at our vehicles. We tend to them [SAPS] generally we need South African police services to be on scene, but they never truly there and we do not get the protection we need.\u0026rdquo; (Participant 6).\u003c/em\u003e\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Therefore, whether that is private security or the SAPS, I think [we need] better support because there's been instances where there is a violent scene or something is happening and you ask for that assistance, that backup, that protection and it is not offered\u0026rdquo; (Participant 7)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003e5) Patient\u0026rsquo;s mental state and/or presence of related psychiatric illnesses\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe participants reported that patients who presented with mental health challenges and/or the presence of related psychiatric illnesses were linked to an increased risk of WPV. Interestingly, participants were cognizant that WPV perpetuated by psychiatric patients was not deliberately harmful but was a byproduct of their illness.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;\u0026hellip; We do situations where its psych patients are violent, but they obviously do not have control of that.\u0026rdquo;\u003c/em\u003e (Participant 5)\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;\u0026hellip; However, we get our patients who are not truly mentally fit or mentally ok, and we receive violence from them as well\u0026rdquo; (Participant 6)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;\u0026hellip;I\u0026rsquo;ve had the few odd scenarios where patients have been violent toward me, but it was because of their [psychiatric] condition more than it was them just being violent\u0026hellip;So basically a psychiatric patient busy going through a psychosis. They tend to be more violent than others [patients].\u0026rdquo; (Participant 8)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eTheme 2. Factors perceived to increase the risk of WPV at the workplace (i.e., the station/base)\u003c/b\u003e \u003c/p\u003e \u003cp\u003e The participants indicated that not only did they experience WPV in the prehospital environment but that this also extended to the office space or base from which they worked. There were two primary sources of WPV at the office: from coworkers and from managers.\u003c/p\u003e \u003cp\u003e \u003cb\u003e1) The relationship between employees and management\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe participants described feeling that EMS management did not fully understand the realities of WPV faced by frontline EMS personnel. The participants attributed this to managers being primarily office-based or burdened with administrative responsibilities. This results in limited engagement and exposure to operational challenges. The participants also expressed frustration that incidents of WPV were not taken seriously when reported and that reporting incidents of WPV rarely led to meaningful action or support.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I do not believe that a manager will understand to full capacity what you're going on specifically if it is a manager that is specifically office-based or desk-bound.\u0026rdquo; (Participant 1)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I do not know if it is because of, you know, management being overworked and having a hundred other things to do. However, I just do not think it is [WPV] always thought of it as seriously.\u0026rdquo; (Participant 7)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e\u0026ldquo;Y\u003cem\u003ees, I have been exposed to violence. Yes, I'm going to report it to my manager, but she's not going to do anything about it in my mind.\u0026rdquo; (Participant 6)\u003c/em\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003e2) Poor communication between peers\u003c/b\u003e \u003c/p\u003e \u003cp\u003e The participants acknowledged that fellow healthcare staff were not only a source of WPV but also that this could be rooted in poor communication escalating to the point of conflict.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I think we also forget that abuse toward healthcare staff can also come from fellow healthcare members\u0026rdquo;\u003c/em\u003e (Participant 7)\u003c/p\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip;due to a lack of communication, it can lead to misunderstandings, which can then result in something going further and miscommunication, resulting in a hostile environment between two personnel or two people at work.\u0026rdquo;\u003c/em\u003e (Participant 1)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eTheme 3. Barriers related to WPV reporting\u003c/h2\u003e \u003cp\u003eThe participants provided several reasons why WPV was underreported. Three dominant themes emerged: 1) participants were fearful of being victimized or seen as \u0026lsquo;weak\u0026rsquo; when they reported WPV, 2) WPV was common and viewed merely as part of the job, and 3) there was a general failure of management structures to adequately manage cases of WPV that were reported.\u003c/p\u003e \u003cp\u003e \u003cb\u003e1) Fears of being seen as \u0026ldquo;weak\u0026rdquo; and/or being victimized\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe participants were perceived to shy away from reporting incidents of WPV with fears that they would be viewed as \u0026ldquo;weak\u0026rdquo; or victimized for reporting WPV. The participants also indicated that if they had reported a case of WPV, they would become ostracized and victimized, typically from their work colleagues.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I feel it is [WPV] quite a common occurrence, and if you're constantly complaining about the same thing or reporting the same thing, you could be deemed weak.\u0026rdquo; (Participant 1)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;\u0026hellip;You will be reporting what has happened to you with the particular person instead of solving the issue; they blame you.\u0026rdquo;\u003c/em\u003e (Participant 3)\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;These people [PECP] get bullied and bullied and after a while when they finally report it and everything, they actually sometimes get ostracized\u0026hellip;\u0026rdquo;\u003c/em\u003e (Participant 9)\u003c/p\u003e \u003cp\u003e \u003cb\u003e2) WPV is viewed as part of a job and is a common occurrence\u003c/b\u003e \u003c/p\u003e \u003cp\u003eOur participants indicated that WPV was a common occurrence for them. The participants felt that they had become complacent to the risks associated with WPV, as WPV had become part of their job, and this outlook affected their desire to report incidents of WPV.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;So I think a lot of us [PECP] do take it [WPV] in our stride, we take it, and we see it [WPV] as a norm.\u0026rdquo; (Participant 8)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;However, I think we have become complacent to those risks, complacent to the violence that we experienced.\u0026rdquo;\u003c/em\u003e (Participant 7)\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;\u0026hellip; We just tend to overlook it [WPV] and underplay it [WPV]. In addition, that is why we do not report it.\u0026rdquo;\u003c/em\u003e (Participant 4)\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I think we have become so used to it [WPV] that if it is a small issue and we can handle it [WPV].\u0026rdquo; (Participant 5)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003e3) Failure of management to manage reported cases of WPV properly\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe underreporting of WPV was further exacerbated by inadequate management of reported incidents of WPV. The participants expressed a lack of genuine concern from EMS management, as reported incidents were often handled ineffectively. This resulted in participants being discouraged from reporting incidents of WPV.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;The leadership itself [management] is the perpetrator cause if you come with a complaint and say this is what is happening to me; they just do not care.\u0026rdquo; (Participant 3)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;If you report a case that you have been mistreated or there was an abuse or something, it is not been taken into consideration\u0026rdquo; (Participant 3)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;In my experience, it [reported WPV] has been dealt with quite poorly\u0026hellip;\u0026rdquo; (Participant 7)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;\u0026hellip;Often it is a case, but what are they [management] going to do about it?\u0026rdquo; (Participant 7)\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eTheme 4. Insufficient training to address WPV\u003c/h2\u003e \u003cp\u003eGiven the high incidence of WPV and the negative impacts it has on the PECP, participants generally felt that their training was insufficient to address incidents of WPV. Some participants mentioned receiving a brief presentation on WPV, whereas other participants reported never receiving training on how to address WPV.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;\u0026hellip; I have not received formal training, and I do not believe the attached training that we have received throughout our training to become paramedics is adequate.\u0026rdquo;\u003c/em\u003e (Participant 1)\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;There was not any formal training on how to prevent these [WPV] situations from occurring.\u0026rdquo;\u003c/em\u003e (Participant 8)\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;\u0026hellip; I\u0026rsquo;ve received no formal training. There's been no access to it; my workplace has never provided me access to this kind of training.\u0026rdquo;\u003c/em\u003e (Participant 7)\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eWPV against PECP is a recognized global challenge, and the findings of this study confirm that South African PECP encounters patterns similar to those of WPV described in other studies (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan additionalcitationids=\"CR31 CR32 CR33 CR34 CR35\" citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e). This study investigated and described WPV experienced by PECP, offering insight into context-specific factors that contribute to the prehospital environment and EMS workplace violence.\u003c/p\u003e \u003cp\u003eA central finding was that several scene-related factors placed the PECP at a heightened risk of WPV. Consistent with international reports, alcohol and drug intoxication have emerged as prominent contributors to aggression and hostility toward PECP (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan additionalcitationids=\"CR38 CR39\" citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e). The South African context amplifies this risk, given the high prevalence of substance use in many communities (\u003cspan additionalcitationids=\"CR42\" citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e). The participants also highlighted the influence of broader socioeconomic and geographic conditions, which included increased exposure to violence in communities with high crime rates, chronic service delivery challenges, and limited social resources. Similar associations between socioeconomic deprivation and violence directed at the PECP have been reported globally, (\u003cspan additionalcitationids=\"CR45 CR46\" citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e) but the combination of unpredictable scenes and entrenched structural inequality may intensify these risks in South Africa.\u003c/p\u003e \u003cp\u003eUnrealistic expectations of the EMS further contributed to aggressive encounters. This finding aligns with the literature showing that a limited community understanding of EMS capabilities, combined with frustration regarding broader health system limitations, can escalate hostility toward PECP (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e). In this study, the participants felt that community members occasionally projected systemic frustrations onto the PECP, placing them at risk of verbal and/or physical aggression.\u003c/p\u003e \u003cp\u003eThe participants also described how delayed or absent law enforcement support heightened their vulnerability. Although previous research has confirmed that police presence can de-escalate scenes (\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e), resource constraints and prolongers\u0026rsquo; response times (a well-documented challenge in South Africa) often leave PECP to navigate and manage dangerous situations without protection (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e). This highlights a significant operational barrier that may not be as pronounced in better-resourced EMS systems.\u003c/p\u003e \u003cp\u003eThe mental state of patients was another contributor to WPV. The participants described heightened risk when treating patients with altered mental status or psychiatric conditions. Prior studies have similarly linked hypoxia, hypoglycemia, and psychosis to violent behavior (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan additionalcitationids=\"CR53 CR54\" citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e). Given South Africa\u0026rsquo;s large burden of psychiatric illness and longstanding gaps in mental healthcare access (\u003cspan additionalcitationids=\"CR57 CR58\" citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e), PECP frequently encounters patients whose conditions have deteriorated without appropriate intervention, placing them at increased risk of experiencing WPV.\u003c/p\u003e \u003cp\u003eIn addition to these risks, workplace-based factors (i.e., at the EMS station or base) also contribute to the PECP experiencing WPV. The participants expressed concerns regarding insufficient managerial support, particularly when incidents of WPV were reported. The literature indicates that poor leadership practices, inadequate managerial training, and unclear organizational processes may contribute to tense or unsupportive workplace environments (\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e, \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e). The perception that reported incidents were not taken seriously reflects broader findings of organizational inaction in response to WPV in EMS systems worldwide.\u003c/p\u003e \u003cp\u003eAnother challenge within the workplace was communication. This included misunderstandings among colleagues and difficulties engaging with dispatchers. This further contributed to frustration and interpersonal conflict. These findings are linked to the literature, which highlights that ineffective communication pathways among PPCPs lead to an increased risk of WPV and diminished operational cohesion within EMS systems (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eA persistent theme across interviews was the underreporting of WPV. The participants described avoiding formal reporting due to fear of being judged as weak, being victimized, and the normalization of WPV as \u0026ldquo;part of the job\u0026rdquo;. These findings mirror the widespread evidence that PECP frequently internalize WPV as an occupational inevitability and that the stigma and perceptions of reporting futility contribute to substantial underreporting (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan additionalcitationids=\"CR63 CR64\" citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e). The normalization of WPVs undermines organizational efforts to address safety concerns and limits the development of targeted support systems.\u003c/p\u003e \u003cp\u003eFinally, participants felt inadequately prepared to manage WPV, reporting minimal or outdated training during their EMS education. Studies from multiple settings similarly describe WPV training for PECP as insufficient or inconsistently delivered (\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e, \u003cspan additionalcitationids=\"CR67\" citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e). Traditional guidance focused primarily on \u0026ldquo;scene safety\u0026rdquo; and did not truly reflect the realities of the South African prehospital context; thus, withdrawing from unsafe scenes and/or environments may not be possible (\u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e). The literature increasingly emphasizes the need for context specific, evidence-based training with a focus on risk recognition, de-escalation, and personal safety strategies (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e, \u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e, \u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e, \u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e). The findings of this study reinforce these recommendations and highlight a critical opportunity for educational and organizational improvement.\u003c/p\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThis study has limitations that should be considered when the findings are interpreted. First, the study used a qualitative descriptive design with a sample of nine PECP from Johannesburg, which may limit the diversity of the perspectives captured. While the study drew on principles of information power to guide sample adequacy, the experiences described may not reflect those of the PECP in other regions of South Africa or in differently structured EMS systems. The findings rely on self-reported experiences, which are potentially subject to recall bias and personal interpretation. The participants may also have withheld or softened descriptions of sensitive incidents due to concerns about professional relationships or organizational repercussions. Only the perspectives of the frontline PECP were included; the views of EMS managers, dispatch personnel, law enforcement and/or community members were not explored and may have provided a more comprehensive understanding of the factors influencing WPVs. Finally, the context-specific nature of South Africa may limit the transferability of the findings to countries with different EMS structures or levels of resourcing.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study highlights a range of factors that contribute to WPV against PECP in South Africa, including scene-related risks, community expectations, patient presentations, organizational dynamics and training gaps. While many of these challenges reflect global trends, the South African context includes high levels of substance abuse, socioeconomic disparities, limited law enforcement capacity, and a significant burden of untreated mental illnesses. Persistent underreporting and inadequate organizational responsiveness further reinforce the normalization of WPV and hinder efforts to improve safety.\u003c/p\u003e \u003cp\u003eThe findings underscore the need for strengthened organizational support systems, clearer reporting processes, improved interprofessional communication and context specific, evidence-based training that prepares providers for the realities of WPV in South Africa. Addressing these challenges is essential for improving safety and ensuring the sustainability of the PECP workforce. Future research should explore targeted interventions, evaluate training approaches and examine organizational strategies that may reduce WPV and improve support and safety for PECP.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCBD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCentral Business District\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eEMS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eEmergency Medical Services\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHPCSA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHealth Professions Council of South Africa\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePECP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePrehospital Emergency Care Personnel\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSouth Africa\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSAPS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSouth African Police Service\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eWPV\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eWorkplace Violence\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e \u003cp\u003e The study was conducted in accordance with the ethical principles of the Declaration of Helsinki and the South African National Health Research Ethics Council (NHREC) guidelines. Ethical approval was obtained from the University of Johannesburg\u0026rsquo;s Faculty of Health Sciences Higher Degrees Committee and the Research Ethics Committee (REC-1294-2021). All data collection sites and relevant institutional committees granted gatekeeper permission prior to the commencement of the study. Informed consent was obtained from all participants by providing an information document and written consent form, which participants were required to review and sign before participation. Participants provided consent to be interviewed and for the interviews to be audio-recorded.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication\u003c/strong\u003e \u003cp\u003e The participants were asked for consent via deidentified code names and quotes for research and academic purposes, including publication.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eCompeting Interests\u003c/h2\u003e \u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eAuthors\u0026rsquo; Information\u003c/h2\u003e \u003cp\u003eMuhammad Yaaseen Hokee; Department of Emergency Medical Care, University of Johannesburg \u0026ndash; Doornfontein Campus, Johannesburg, Gauteng, South Africa ([email protected])\u003c/p\u003e \u003cp\u003eAndrew William Makkink; \u003csup\u003e2\u003c/sup\u003eDiscipline of Paramedicine, College of Medicine and Public Health, Flinders University, Adelaide, Australia ([email protected])\u003c/p\u003e \u003cp\u003eCraig Vincent-Lambert; Department of Emergency Medical Care, University of Johannesburg \u0026ndash; Doornfontein Campus, Johannesburg, Gauteng, South Africa ([email protected])\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThis study received no funding.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAll the authors contributed to the conception and design of the study and to the drafting of the manuscript. YH collected the data, and YH and AM independently coded, categorized and analyzed the data. All the authors read and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eThe authors would like to acknowledge all the participants and any other prehospital emergency care personnel who were victims of workplace violence.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe data analyzed in our study are not publicly available. This was done to protect the confidentiality of the participants. The participants did not provide consent from their data to be made publicly available.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eGormley MA, Crowe RP, Bentley MA, Levine R. A National Description of Violence toward Emergency Medical Services Personnel. 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One of those inherent risks is workplace violence (WPV) against the caregiver. Workplace violence against the PECP is on the rise and has been shown to impact the PECP and the care that it provides. In our study, we investigated and described WPV against PECP within Johannesburg, South Africa.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis study followed a qualitative descriptive design in which face-to-face, semistructured interviews were employed to gather data. The participants involved were registered with the Health Professions\u0026rsquo; Council of South Africa and were working in Johannesburg, South Africa, as PECP. The interviews were audio-recorded, transcribed verbatim, and analyzed thematically. The thematic analysis was used to identify themes, patterns, and insights. Data saturation was reached after nine interviews.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA total of nine participants participated in the study. Among the nine participants, five (56%) were female, and four (44%) were male. Seven participants (78%) were from the private sector, and two (22%) were from the public sector. The participants identified substance abuse, the location of the scene, and the relationship between the PECP and managers as contributors to WPV. The reporting of WPV was generally poor and was attributed to victimization and incidents not being addressed correctly. A lack of preparedness and training on WPV incidents also emerged from the participants.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003ePECP in Johannesburg continues to experience and be affected by WPV. Drivers of WPV were heavily influenced by the broader social dynamics of South Africa. Despite experiencing high amounts of WPV, participants faced various challenges with the reporting of WPV, which hindered addressing WPV. Targeted interventions are urgently needed to improve reporting practices and training and foster a culture of accountability and safety within the prehospital environment.\u003c/p\u003e","manuscriptTitle":"Perceptions of Workplace Violence and its Underreporting among Prehospital Emergency Care Personnel in Johannesburg, South Africa","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-19 19:42:22","doi":"10.21203/rs.3.rs-8385902/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-01-30T18:46:09+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"255748151977800119725201244097947967164","date":"2026-01-19T07:10:32+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"59349378546839966729519606126539318458","date":"2026-01-14T17:13:45+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-14T06:27:21+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-12-22T07:33:37+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-12-18T10:53:45+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-12-18T10:51:11+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Emergency Medicine","date":"2025-12-17T12:43:33+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-emergency-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"emmd","sideBox":"Learn more about [BMC Emergency Medicine](http://bmcemergmed.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/emmd","title":"BMC Emergency Medicine","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a9e79d35-b3c0-461b-964a-35e8f0582a28","owner":[],"postedDate":"January 19th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-01-19T19:42:23+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-19 19:42:22","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8385902","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8385902","identity":"rs-8385902","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}