Workplace Violence: How can paramedics prioritise their own safety?

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Kristin Häikiö This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9233243/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 5 You are reading this latest preprint version Abstract Background: Despite growing awareness, workplace violence (WPV) against paramedics is a persistent and complex problem that threatens staff safety and quality of patient care. There is a lack of implemented, efficient, and effective mitigation strategies. To identify such strategies that can inform training and education, we use paramedics' experiences to explore their reasoning before, during and after a violent episode. This study aims to explore paramedics’ lived experiences and to examine how they perceive individual and contextual factors that influence risk assessments and management. Method: An episodic narrative interview approach was employed to elicit paramedics’ narratives of WPV and their broader reflections, in a Norwegian context. Data were analysed inductively using thematic and interpretive narrative analysis. Peer-debriefing was used to increase the credibility and trustworthiness of interpretations of results. Results: Six main themes were identified: internal motivation to provide care, becoming “speed blind”, challenges in conveying risk assessments, the importance of documenting risk assessments, paramedics' perceived role in the hierarchy, and the handling of reported incidents. From these insights, I propose the Paramedic Risk Matrix for WPV to visualise and raise awareness on how paramedics often balance risks and gains and make discretionary decisions. I discuss how the Paramedic Risk Matrix for WPV may be used for training and education to increase students' awareness of how they conduct risk assessments. Further studies are needed to assess the practical use of the Paramedic Risk Matrix for WPV, to determine whether it helps paramedics be more aware of their risk assessments and thus enables them to better argue, communicate and document their reasoning. Conclusion: Paramedics’ responses to WPV are grounded in complex, context-dependent reasoning that balances ethical, legal, emotional, and professional factors. Although paramedics discretionarily balance their own safety with the patient’s needs, there are large variations in paramedics' and other stakeholders’ perceptions of what constitutes acceptable and unacceptable risks. This has informed the Paramedic Risk Matrix for WPV, which may enhance awareness and reflection, and spark discussions on how acceptable or unacceptable risks are assessed and managed, but its practical use needs to be tested. The insights from this study may, however, inform future studies and inform more realistic prevention strategies, organisational support systems, and policy development. Paramedicine Ambulance Violence Safety Risk assessment Risk management Workplace violence occupational violence prehospital Figures Figure 1 Introduction Workplace violence (WPV) against healthcare workers is an increasing, worldwide phenomenon ( 1 – 4 ). Emergency medical service (EMS) workers, especially paramedics, operating in uncontrolled settings and isolated from the security and support systems that often exist in other workplaces, are exposed to risks rarely seen in other professions. ( 2 , 3 , 5 – 10 ) WPV against paramedics occurs primarily from patients and bystanders during emergency responses and is associated with attending unconscious patients, intoxicated patients, homeless patients and patients with mental health problems ( 2 , 5 , 11 ). WPV harms safety, well-being, professional performance and service quality. ( 12 – 15 ) It can lead to physical injuries and profound psychological effects, such as post-traumatic stress disorder (PTSD), anxiety, and depression. In addition, it negatively impacts service delivery and organisational culture, resulting in increased time lost from work and associated costs. ( 13 , 14 , 16 , 17 ) This paper focuses on violence inflicted on ambulance clinicians (AC) by patients while providing care. International studies report that WPV occurs in 0.4–0.8% of ambulance runs, whereas 18–38% involve physical assaults. ( 2 , 11 , 18 , 19 ). Due to the high number of ambulance runs during a career, most paramedics will encounter WPV. Career-long exposure to WPV is reported in a Swedish study to be 66% for paramedics, and a systematic review examining EMS workers found rates between 57–93% for verbal and/or physical violence. ( 12 , 13 ) Verbal threats and non-physical violence are more frequently reported than physical violence. ( 12 , 13 ) However, there is no consensus on the definitions of WPV. Multiple definitions exist, but the European Agency for Safety and Health at Work (EU-OSHA) define violence as “intentional use of power, threatened or actual, against another person or against a group, in work-related circumstances that either results in or has a high degree of likelihood of resulting in injury, death, psychological harm, bad development or deprivation”. ( 20 ) Although the rates of violence are reported in several studies, there is a gap in the literature regarding why WPV occurs and how to effectively mitigate such situations. ( 21 ) Spelten et al.( 10 ), exploring paramedic WPV, conclude that we need to move away from focusing on the individual worker to a system-based approach. Other recent studies highlight the lack of literature providing qualitative insights into how paramedics perceive and navigate risks and risk assessments in their daily practices ( 11 ) and that the social interactions that occur during healthcare exert a significant influence on the evolution of aggressive behaviour. ( 22 ) Our study aims to build on these results and address the gaps in the literature by providing an in-depth exploration of paramedics’' lived experiences, in the prehospital social context, and their perceptions of individual and contextual factors influencing WPV risk assessments and management. There is a lack of effective prevention and mitigation strategies in practice, prompting this study to explore paramedics’ experiences and identify solutions applicable to ambulance service managers and paramedics. Thus, I used the results to propose and discuss the implications for training and education. Consequently, this paper presents the results from the interviews, and in the discussion section, I present a visualisation of paramedics' risk assessments, which can be used to spark discussions, reflections, and increased awareness for risk assessments, risk prevention strategies, and safety management for individuals, service managers and ambulance services stakeholders, sparking further discussions regarding acceptable or unacceptable risks. Method Study design and philosophical underpinning The research question “What are paramedics’ experiences with WPV and what are their perceptions of individual and contextual factors influencing risk assessments and management?” was chosen following discussions between me (the researcher) and ambulance service managers to mitigate the increasing reports of WPV. The researcher reviewed the literature and identified knowledge gaps regarding effective, pragmatic mitigation strategies. I designed a hermeneutic-phenomenological and narrative study, to explore the phenomenon “workplace violence” (WPV) through the interpretation of paramedics' narratives and lived experience. Episodic narrative interviews were conducted to elicit focused, firsthand and context-rich experiences of WPV, enhancing culturally derived interpretations of their social life world – the Norwegian prehospital context. By inviting participants to reflect on these experiences, I created situations that yielded rich, meaningful data generated through their narrative and the subsequent interview process. To support reflection, to understand their worldview, and to interpret meaning across respondents, I honoured the listening process in a dialogic interview format, using a semi-structured interview guide to deepen my understanding of the phenomenon. ( 23 ) In all phases of the study, I drew on feedback from paramedic clinicians and engaged in deep reflexivity to uncover new perspectives and broaden my horizon of preunderstanding and interpretation. This aligned with recommendations for reflexivity in qualitative analysis and for combining interpretative phenomenology and narrative methodology. ( 24 , 25 ) Consequently, I took the role of an active listener to respondents’ narratives of workplace violence and sought to understand the situations and interpret the context of each unique experience. I took a naïve, curious approach and used follow-up questions to develop a more in-depth understanding of participants’ lived experiences. Through respondents’ narratives, subsequent reflections and reflexive thematic analysis, I sought to understand their individual experiences within the social environment and organisational culture, which contextually influenced their experiences and sought a more universal meaning. ( 23 – 25 ) This is consistent with an interpretivist epistemology capturing participants' subjective realities and interpretations. ( 26 ) Combining narrative methodology and hermeneutic phenomenology, this study is underpinned by the hermeneutical-phenomenological research paradigm, which aligns with the interpretivist epistemology. ( 26 ) Researcher’s reflexivity and positionality I hold a PhD in health sciences, have several prior experiences with qualitative research interviews and work with paramedic education in Norway. I have solid experience in health services research, particularly ambulance research. I have extensive clinical experience as an emergency nurse, but no clinical experience working within ambulance services. Consequently, I am familiar with paramedic culture through collaboration with paramedic academics, researchers, clinicians, and students. I therefore take an informed outsider perspective. Unlike a naïve outsider, I am informed enough to avoid superficial or purely speculative interpretations and compared to an insider, I am less constrained by internal assumptions, loyalties, or institutional blind spots. To better understand the context-sensitive challenges, we planned an interview study in which paramedics could speak with the researcher about their workplace experiences without being identified by their managers. Being an informed outsider, I let respondents be the experts, allowing me to be seen as less of a threat to their professional integrity. To enhance the credibility and trustworthiness of the results and their interpretation, peer debriefing was utilised across all phases of the project. Feedback from ambulance clinicians, paramedic academics, and ambulance service managers was sought during the design phase, data collection phases, analysis, interpretation, and discussion of results. Peer feedback was also received from paramedics and researchers attending conferences and seminars where preliminary results were presented. As a supplement to the initial analytic phase, when searching for preliminary themes, a naïve outsider perspective was also sought from a researcher outside of the paramedic community. The input from both insiders and outsiders broadened my understanding and contributed to the analysis. Recruitment and description of the sample Service quality coordinators, in a large ambulance service in Norway, distributed information about the study to all paramedics in their service, encouraging them to volunteer for individual research interviews. Participants volunteered by contacting the researcher directly or through the service quality coordinators. The snowball sampling method was used to strategically invite new participants from the respondents' network, who would otherwise not respond to an open invitation, ensuring maximum variation in age, gender, and experience. Recruitment continued until I had sufficient information power, assessed by the quality and richness of the interviews, the aim of the study, the sample specificity and the analysis strategy. ( 27 ) The population of paramedics in Norway, and particularly when respondents are invited from only one district, is small. Thus, there is a risk of identification if respondents' exact characteristics are presented and there is a risk of identification through details in quotes. Consequently, I present a few variables from each individual, and the gender of some respondents is changed to reduce the risk of identification. The proportions for each gender remain unchanged. To further avoid identification, I present education dichotomised in lower education (occupational training and/or education without a completed bachelor's degree) or higher education (completed bachelor's degree or higher degree in a related profession). See Table 1 . Table 1 Overview of the sample Alias (gender) Age group Education Ambulance Experience Interview time Interview no. Thomas (M) 18–34 Higher 1–5 years 95 min 1 Eric (M) 35–59 Higher 1–5 years 84 min 2 Magnus (M) 18–34 Lower > 10 years 58 min 3 Elisabeth (F) 35–59 Higher > 10 years 68 min 4 Mary (F) 35–59 Higher 6–10 years 58 min 5 Mark (M) 35–59 Lower > 10 years 61 min 6 Silvia (F) 18–34 Higher 1–5 years 69 min 7 Ursula (F) 18–34 Lower 6–10 years 74 min 8 Katryn (F) 18–34 Lower 6–10 years 77 min 10 Morten (M) 18–34 lower > 10 years 65 min 11 Interviews and analysis Interviews were conducted between January and April 2024. The interviews followed a flexibly used topic guide based on the existing literature in the field, the knowledge needs identified by ambulance service managers, and the aim of the study. Inspired by the Episodic Narrative Interview method, I used respondents’ narratives as the starting point of the interview and followed up with open-ended questions. The first version of the topic guide contained the following topics: 1) introduction to the study, 2) the respondent's experience with violence, including their self-experienced narrative 3) Participants' reflections regarding risk factors or signs of escalation of the situation before the incidence 4) Participant’s reflections regarding their and others responsibilities and expectations before, during and after the incidence, 5) Rounding off the interview. Following a flexible, explorative design, each interview yielded a broader understanding of the phenomenon, and the researcher’s broadened understanding of the phenomenon was embedded in the future interviews. Consequently, data were generated and shaped by the respondents' responses in relation to the researcher and the questions asked. ( 23 ) I expected research participants to have a heterogeneous understanding of and definitions of “workplace violence” and “violence”. In our interviews, I did not ask participants to define the phenomenon. Instead, encouraged research participants to share bounded stories about their experiences of workplace violence and used their narratives to understand their interpretation of the terms. Consequently, it was possible to collect small, focused narratives about individual experiences of workplace violence, use latent analysis to interpret how they understand the phenomenon and thus explore their experiences. ( 23 ) The first six interviews were conducted face-to-face at a facility chosen by participants, usually their home or a public place such as the library or the university. Four interviews were conducted digitally. All interviews were conducted individually by the first author, lasting between 60 and 90 minutes. The analysis was inductive and data-driven, following reflexive thematic analysis ( 28 ), which is considered suitable for analysing narratives and well-suited to a hermeneutic-phenomenological approach. ( 24 , 28 , 29 ) Reflexive thematic analysis was iteratively moving through familiarisation, coding, theme development/review, and write‑up, with regular peer discussion. For details about the analysis, see the supplementary file. Ethics Participants provided voluntary, written, informed consent to participate in the study and to the publication of results in which they cannot be identified. Interviews were audio recorded, and encrypted data was transferred and stored on TSD (Tjeneste for Sensitive Data), a secure storage server approved for storing sensitive data. ( 30 ) The computer software Whisper was used for auto-transcription. ( 31 ) Data access was restricted to two researchers outside of the ambulance service. One who withdrew from the project in the early phases of analysis and did not contribute to the writing of the manuscript or to the development of the final themes. The data storage plan was supported by the Norwegian Agency for Shared Services in Education and Research (SIKT) (ref. no. 170712) and the local data protection officer at the Hospital Trust (ref. no. 23/05574-4). Interviews avoided the use of identifiable information about the patients, and the project complies with local regulations for research, data storage, and privacy protection. All contributors to this study who do not meet the criteria for authorship according to the Vancouver convention ( 32 ) and the CRediT Framework are mentioned in the acknowledgement section upon acceptance. The context In Norway, ambulances are typically staffed with two healthcare personnel who hold a relevant education. Relevant education ranges from vocational training with or without additional training to higher university education, primarily in nursing or paramedicine. Ambulances are dispatched by the Emergency Medical Call Center (EMCC) where medically trained staff (usually a nurse) receive and assess medical emergency calls and dispatch ambulances accordingly. The term “paramedic” is used interchangeably with the term “ambulance clinician” in this paper, and the terms do not distinguish between their educational backgrounds. Results The respondents’ narratives include incidents ranging from minor assaults to life-threatening episodes with weapons. They include episodes such as inappropriate sexual remarks, slaps from confused older persons, anger or verbal threats, aggressive behaviour and physical violence. Most respondents describe being worried about their safety from time to time. Participants’ risk willingness and risk assessments varied between individuals and depended on the situations. Common for all participants was that they all assessed and balanced risks and safety. They said they typically based their assessments on the patient’s body language, whether the patient had a history of being violent, their gut feeling, the risk of weapons being used, the patient having a background with psychiatry and substance use, or if the ambulance run involved involuntary admissions. Wen describing, interpreting and analysing paramedics’' lived experiences in the prehospital social context and their perceptions of individual and contextual factors influencing WPV risk assessments and management, I developed the following main themes: 1) Internal willingness to help; 2) Becoming “speed blind”; 3) Challenges in conveying risk assessment; 4) Challenges with documenting risk assessments; 5) Paramedics’ perceived role in the hierarchy; 6) The handling of reported incidents mirroring role expectations. The findings demonstrated that risk perception was shaped by individual and contextual factors intertwined, influencing paramedics’’ risk-taking, risk assessments and risk management related to WPV The internal motivation to provide care Despite differences in how the situations were assessed and solved, one important driver for risk willingness seemed to be paramedics’’ experienced inner moral responsibility to help. Despite saying that safety was their first priority, most respondents, when discussing their assessments in relation to their experiences, expressed an inner moral obligation to help first, followed by self-risk assessments second. Ursula said it like this: Ursula: Well, my expectations then, which I experienced, were a bit that we have to help this patient. Because obviously, no matter what it is, whether it's psychiatry or if it's somatics that does it, he's not doing well. We must try to help in the best possible way and ensure his safety in the midst of it, but also my own. Although participants mentioned expectations from bystanders, managers, local authorities, and legal duties as factors affecting them in their work, several explicitly said that their inner moral duty to help was the strongest motivation to intervene. Consequently, paramedics’' inner willingness to help is a driver of risk-taking and represents an important factor influencing how respondents balance risks and safety for themselves and their patients. Several participants talked about the challenges of wanting to help patients who do not cooperate with them. The short window of opportunity to help a patient who will otherwise run off, the difficulties of making rapid decisions based on insufficient information, and the potential consequences for the patient and themselves were mentioned by several. Morten’s quote illustrates how he tries to balance all this: Morten: It's a bit, it's a dilemma, a difficult dilemma, in relation to what you should do. Are you going to use force to hold [the patient] back? Or should you let it go? And it's one of those decisions, you get a millisecond to decide. Kristin: yes, right? One involves risks for you, the other involves risks for the patient. How do you weigh them up against each other? Morten: Yes, good question. It's very difficult. Kristin: But you've probably done it many times? Morten: Yes, and that's the way it is, maybe the assessments I make the most are in relation to "Can I hold you back?” Kristin: yes, size and physique? Morten: There is a difference between small skinny people and big strong people. It is also in relation to the seriousness of what we are called out on. What's your gut feeling? Is this something like.., will we find you again just across the street here? Or are you actually the one who jumps the river, then, or does something? So it's a bit like that…how will I feel after the mission is finished? If you choose to run away or if something happens. It's often that you can get a feeling of guilt for it. That I should indeed stop you. The quote above illustrates Morten’s assessment of being able to manage the situation on scene (safety on scene). However, he also mentions the potential later consequences which may influence his decision. When encouraging Morten to elaborate on his risk willingness, risk assessments and risk management, he explicitly mentioned the perceived acuity of the patient’s condition, the types of risks involved, and the availability of support from others. Many participants mentioned these same factors. Some were more willing to handle situations that could escalate than others, and respondents' narratives described that some were willing to use physical restraints on the patient if de-escalation failed, while others were not. Physical restraints were typically used if they assessed the situation to be manageable, considering the patient's size, the surroundings, and other available persons. The possibility of avoiding harm seemed to underpin this decision and was illustrated by Silvia: «I think many men lack the understanding of how it is to be physically smaller than someone. Most men could manage to kill me if they wanted to. That is just how it is». It was more common among some participants to describe a higher threshold for requesting police support, and this seemed to be related to their assessment of the potential consequences the situation posed for their own safety. The relative risk of injury, however, may be the same because all respondents were unwilling to suffer a serious injury or risk of death. Becoming “speed blind” All respondents acknowledged the need for self-safety assessments, and many mentioned “safety first” as an important principle, but the level of risk that respondents seemingly accepted varied among individuals. Several participants talked about how their perceptions of violence and risk assessments developed along their career path. While most respondents claimed to be more aware of potential risks later in their careers and thus more considerate of safety measures, many also seemed to have developed a tolerance for behaviour that, for most people, would be considered violent. This impression was confirmed by Silvia: Silvia: I think the reason for what you consider threats, it moves a lot when you are used to it. Because if my mom, who is [administrative employee], experienced that somebody had told her that I am going to kill you, then she would have remembered it. But I would have forgotten about it at the end of my shift. I forget to write a report on an adverse event from it, because I wasn’t scared. If there are a lot of people around me, and someone says they're going to kill me, and they seem a little lost, then... I don't get scared. So I think that it is hugely underreported because it is not taken seriously. But that's not okay, sort of. The perception of threatening and potentially violent situations appears to change over time and with exposure. When it changes in the direction of greater acceptability, this can be interpreted as “speed-blindness,” meaning that paramedics become accustomed to incidents that others, who are less exposed, would never accept. Challenges in conveying risk assessments Some respondents specifically discussed how they evaluated the patient’s body language and verbal language to assess the risk of violence, while others mentioned their “gut feeling” as the primary reason for being alert. Several mentioned drugs and psychiatry as risk factors, including alcohol. Still, many expressed challenges in conveying risk assessments to the police and other healthcare professionals. Being understood by the police Most respondents expressed difficulties communicating their risk assessments in a way that was sufficiently understood and acknowledged by the Police. Simultaneously, respondents emphasised the importance of police assistance in situations they felt were unsafe, and many explicitly discussed Elizabeth's point: “the police are indeed our health, safety, and environment”. Elizabeth, among others, said that the police-ambulance debate in Norway (discussions about when the police should or should not assist healthcare personnel in handling people with mental illnesses) affects paramedics and leads to them trying to deal with things alone for a longer time. “It is difficult to get support [by the police] until you push the safety alarm button, but it usually has to go to hell first, before you get support” (Elizabeth). Elizabeth, among others, emphasised the police’s lack of understanding of paramedics’ role and their unawareness of the limited training paramedics have in handling escalated situations as an underlying reason for the lack of police support. Elizabeth: I think [those working in the Police control room], may not have the same updated opinion then, about how much risk it actually is we are in, and how unbelievably little we have to defend ourselves with. And that, I don't know, maybe forgets that we don't have an exam on violence. We don't have an exam in folding people up and taking control of people. They [the police] have. […] So it's probably a bit of that kind of communication, a kind of knowledge about each other, that is lacking, I think. It is certainly part of the package. The paramedics’ lack of training in describing risks and communicating them effectively to the Police was noted by some respondents. Some talked about their “gut feeling” but also about their inability to describe what this meant in professional language when seeking police support. Magnus: we often find ourselves in that battle regarding mentally ill patients, where we have a bad gut feeling. I also think we are bad at putting into words to describe in a professional way why I experience that situation. Right? […] My gut feeling, based on 11 years of experience from ambulance work, indicates that this is a ticking time bomb, but I still haven't learned how to put it into words and formulate it. Because I think we are too bad at that. Being understood by other healthcare professionals Many respondents highlighted that other healthcare professionals' lack of understanding of the prehospital environment and its impact on the risks and consequences of WPV. Several emphasised that the situation inside a hospital or doctor's office differs significantly from the prehospital context. The quote below illustrates some differences that the respondent did not think the physician was aware of. Magnus: Yes. Then there's a doctor there who says, like, “no, this is fine” [regarding the feasibility of ambulance transport for the patient]. Yes, and then I think there is an understanding that, like, yes, it is okay to have that patient in a closed room, in a doctor's office. That's fine, but it's a little worse in 2x1.50 meters, driving at 90 km an hour, in a place far away from everything. A few respondents emphasised that conveying risk assessments was challenging when doctors, who outrank them and usually have access to more information about the patient, lack understanding of prehospital risks and make decisions on behalf of paramedics. Several pointed out that if paramedics at least had access to the patient’s former ambulance reports, they could use this information to better argue for their perspectives in cases where the patient had a history of becoming agitated and violent. Magnus explained that his lack of trust in others stemmed from their lack of understanding of his role and work context. Magnus: [In] most health services [staff] are used to working within white walls, dry and comfortable, with patients who come with a referral note [saying] why they are there, or what. It says something about what is wrong with the patient, or what the problem is. So, this is not the case for us. […] if I do something wrong, it's an anesthesiologist who will scrutinise my work. Which just easily trumps the credits I have, right? And who has access to all possible medical records and looks at the event in retrospect. Kristin: So that hierarchy of power, then, can be a contributing factor to why it's very difficult to set any boundaries and say, like, we think that this patient can act out, therefore our assessment is that we need police, for example. Magnus: Yes. Then there's a doctor there who says, like, “no, this is fine”. Importance of documenting risk assessments The difficulties in communicating risks and the lack of background information also had other implications, such as challenges in documenting risks. Difficulties documenting made it difficult to argue for prioritising their own safety over the patients’ needs. Katryn talked about how important it is to document thoroughly if she chooses to prioritise her own safety at the cost of the patient’s needs. In the quote below, she talked about a situation in which the EMCC and the paramedics assessed the situation to involve a high risk of violence if they approached the patient, but they still chose to approach the scene carefully: Kristin: If you hadn’t [approached the patient], would you have had to document anything particular? Argue for why you don't go in [into the house] and help this person? Kathryn: Then I will have documented it very well in the journal. Kristin: What do you imagine you could have written then? Kathryn: Then I write the information we receive from the EMCC. That the caller is very intense on the phone. That we should be careful. It's been a while now, it may be that we learned more about the threats, but then it is documented what we got from the EMCC and that the police could not come. Several mentioned feeling uneasy about a potential National Board-initiated investigation. They were concerned that an investigation into the delayed medical help would not be well-received, as key stakeholders lacked understanding of the risks involved in the prehospital context. In addition to documenting their prioritisation of safety in risky situations, several participants said they prioritised documenting the risks they experience in everyday work, hoping to gather evidence to argue for improved work safety. Altogether, this illustrates the importance of documenting risk assessments and risk management. Paramedics’ perceived role in the hierarchy Many mentioned feeling inferior to other professionals, such as physicians, EMCC operators, and hospital nurses. In situations where other professions made decisions about ambulance transport, many expressed that they had no choice or influence over patient transport decisions. Magnus: No, I feel that we are at the bottom of the rank in the health service, so we just do what we are told. No matter how prudent it is, [...] So we are always put in a squeeze then. […] There's nothing to do, it's decided, sort of. It's decided, you're going to do this and that. This feeling of inferiority affected their risk management, as they often perceived themselves as lacking a choice. Silvia also felt little autonomy in deciding her actions on assigned ambulance runs and expressed a feeling of having to do what you are told to do: Kristin: So you feel obligated to at least investigate? Silvia: Yes, investigate and take him with us. Kristin: Both? Silvia: But I could actually have gone out to the ambulance and said we're standing there waiting until the police arrive. But I thought that we had to solve this ourselves. Kristin: Why did you think that? Do you have any ideas about why? Silvia: I think people are afraid to [go] against what the EMCC says. Yes, I don't think you really know the consequences of that. The handling of reported incidents mirrors role expectations Many mentioned that they were encouraged by their managers to report violent episodes. Still, some respondents reported that after submitting their internal report, the legal experts assessed it and chose not to press charges or report the incident to the police on their behalf. Mary is one of those who shared this experience: Mary: Well, you might write an internal report on violence and threats, but it's somehow not serious enough for the health trust to get..., it's the lawyers who assess whether it should be reported to the Police or not. […] And I'm pretty sure it [a recent experience] wouldn't have been serious enough for that. […] it’s the lawyers who sit and decide it, then. The perception that the incident had to be considered “serious enough” by legal experts contrasted with the efforts of managers and paramedics to highlight the importance of reporting all kinds of threats and violent behaviour. Ursula and Mark both emphasised the irony of this, and Ursula points out that the signal she picks up from this is that you should tolerate this type of violence as part of the job. Kristin: But what's crucial there [whether it's reported or not], you know? About what they [the health trust] choose to do? Ursula: No, that's what I don't know. There have been some situations where we have discussed afterwards that there should clearly have been a Police report, but then we get an answer that the lawyers believe that there is reason to do so, because based on the patient's medical condition or such types of things, then, that the report will just lapse. […] So I think a bit like that, yes, how long should..., where is the limit on... Or what is it like, what should you tolerate from mentally ill patients that you can't tolerate from mentally healthy patients, then? Similar to Ursula’s experience, Mark expressed being discouraged from reporting incidents despite the manager's encouragement. Mark: I'm thinking, what's the point of reporting? It was taken down from there [lawyers/managers] anyway, and then there are many... We are exposed to violence every single day, our colleagues all over the country, including here in [place name], and are strictly told that "yes must report" and things like that, then it is not dealt with anyway because it is stopped by the lawyer. That's how I've understood it, then. Discussion Based on paramedics’' narratives and reflections, this study has identified several intertwined internal and external factors that influence their risk-taking, risk assessment, and risk management related to WPV. The factors identified were 1) the internal willingness to help; 2) becoming “speed blind”; 3) challenges in conveying risk assessments; 4) the importance of documenting risk assessments; 5) paramedics’ perceived role in the hierarchy; and 6) the handling of reported incidents mirrors role expectations. Understanding risk assessments and risk management of workplace violence in the prehospital context Unlike many healthcare professionals, paramedics cannot control the types of cases they encounter. They respond to all calls for service and must be constantly prepared to provide a range of emergency services. ( 32 ) The management of an out-of-hospital scene involves many physical and technical practices, but the paramedic workspace is also influenced by the paramedic social processes. This social process is described by Campeau's as the Space Control Theory of Paramedic Scene Management (SCTPSM), and supported by, among others, Drew and colleagues ( 32 , 33 ). Campeau’s SCTPSM described five categories of social processes, with the first category being “establishing a safety zone”. ( 32 ) Subsequently, as our respondents constantly sought to ensure safety, the SCTPSM provides a useful conceptual lens for interpreting the results of this study. In the following discussion, I will start by utilising Campeau’s first category, “establishing a safety zone,” and its three subcategories. The three Sub-categories are a) the what-if strategy, b) the rationalised self-interest, and c) trading off patient care and scene safety. The what-if strategy The what-if strategy, as described by Campeau, describes that paramedics assess the scene and make risk assessments based on their assessments of what could occur, taking a “what-if” perspective and subsequent precautions. As Campeau mentions, paramedics “define the situation in high-risk terms and subsequently take actions to make the risks manageable” (32 p. 292). Similarly, the results of my study show that paramedics do what-if risk assessments with a suspicious and cautious orientation toward potential hazards, and seek to make the risks manageable. However, despite differences in experience, background, skills, and role expectations, participants also made risk assessments based on a strong inner willingness to help. Our study indicates that making risks manageable was perceived as difficult for many, and the factors we identified were their inner motivation to provide care, becoming speed-blind, and having challenges in conveying risk assessments. Combined with their perceived inferior role and external role expectations from managers, the police, and other healthcare professionals, these factors seemed to affect risk assessment and risk management. Consequently, paramedics’ what-if strategy seems strongly influenced by factors outside their control, emphasising the need for collaboration across professions and sectors to mitigate the risks of WPV for paramedics. As the paramedic research literature has concluded earlier, it is unlikely that paramedics can work without any risks ( 34 ). Still, in Norway and beyond, the discussion on what constitutes acceptable or unacceptable risks for paramedics is lacking. Different stakeholders have different perceptions of what risks paramedics are expected to take. For example, we have identified perceived disparities between and hospital managers, as well as between paramedics and the Police. The acceptance of paramedics to participate in a high-risk situation is reinforced by the Norwegian Government’s PLIVO procedure (not publicly available). After a traumatic terror attack, killing 69 people, most of them children attending a political camp in Norway, in 2011, the Norwegian Government developed a national procedure (PLIVO) to manage collaboration across the Police, Ambulance services and Fire Brigades more effectively in situations involving ongoing life-threatening violence. Following this national procedure, when the Police declare a PLIVO situation, the procedure explicitly states that paramedics are expected to take increased risks to protect the public. ( 35 ) The PLIVO procedure represents an example of governmental role expectations and other stakeholders for paramedics’ risk assessments, which affects their role, their what-if strategy, and makes it explicit that their role is not risk-free. In summary, the broader society and important stakeholders seem to hold the view that some risks of violence for paramedics are acceptable. In this study and in previous research, paramedics have reported incidents that are clearly dangerous and have the potential to hurt them physically and mentally. It is well known that WPV can lead to physical injuries and profound psychological effects, such as post-traumatic stress disorder (PTSD), anxiety, and depression, thereby affecting safety, well-being and professional performance. ( 12 – 15 ) In addition, it negatively impacts service delivery and organisational culture, resulting in increased time lost from work and associated costs. ( 14 , 16 , 17 ) Simultaneously, paramedic education and ambulance services in Norway and beyond offer little or no training in managing violent situations beyond de-escalating communication techniques. ( 36 , 37 ) There are ongoing discussions about protective gear and the use of body cameras ( 34 ). Nevertheless, a gap remains in the paramedic research literature concerning effective protective gear and safety measures against WPV. Trading off patient care and scene safety - Prioritising one's own safety Respondents in this study discussed stakeholders' limited understanding of the specific types of risks that occur in the prehospital context. Based on the author’s experience working with paramedic education for several years, the public’s understanding of paramedic education and the role of paramedics is limited. The lack of knowledge of paramedics’ competences and limitations is relevant when discussing our findings in the light of Campeau’s third subcategory: trading off patient care and scene safety. As respondents in this study emphasised, their decisions were often assessed and judged by people who lacked an understanding of the paramedics’ role and context. In previous research, discussions have highlighted the role ambiguity among paramedics ( 33 ) and the lack of clarity regarding the interpretation of regulations and legislation in the prehospital context. ( 38 – 40 ) The paramedic role has developed rapidly in many countries, including Norway, and the number of paramedics working in ambulance services is small compared to the number of nurses and doctors working in hospitals and community services. ( 41 ) Consequently, it is no surprise that there is limited knowledge among policymakers, other healthcare personnel, and stakeholders of the paramedic role and the nature of their work. It is, however, problematic when legal assessments are made by individuals who lack understanding of their work and education, who outrank paramedics in education, and who are used to having access to information that paramedics usually lacks. This poses a risk for paramedics of being misunderstood in National Board-initiated investigations, being misjudged by authorities, stakeholders and the public, and thus not being supported when prioritising one’s own safety. As Campeau points out, decisions are not made in a vacuum, and an paramedics’ perception of what is an acceptable risk is influenced by the broader societal responses. As mentioned, the PLIVO procedure has influenced the perception of “acceptable risk” for paramedics, and public discussions between the health sector and legal sector in Norway indicate that the Police expect paramedics to rely less on the police support in situations that can be perceived as risky for paramedics but have not yet escalated. This is due to limited resources combined with an increase in the number of police involvement in situations where people experiencing mental illness and substance use ned medical attention. ( 42 ) These discussions go in favour of paramedics accepting more risks. Although the paramedic literature has raised concerns about the risks of WPV ( 7 , 19 , 23 , 30 – 33 ), and co-response teams have been explored in many places ( 43 , 44 ), there is little discussion of the risks that paramedics are supposed to accept. There is also a void of documented, implemented, and effective mitigation strategies for WPV. I argue that to find effective and efficient mitigation strategies, a broader societal discussion is needed to clarify role expectations, clarify what should be considered acceptable and unacceptable risks for paramedics, and clarify who gets to decide when a risk is acceptable or not. In such discussions, a solid understanding of the prehospital context is essential. Hospital managers, legal experts and policy makers need to include paramedics’ perspectives, and, as pointed out by Morrison ( 45 ), paramedics’ role should expand to include public advocacy, ethical leadership, and systems stewardship beyond the paramedic domain to start shaping the healthcare system and bring their unique and important perspectives in when policy documents are developed, interpreted and employed. The rationalised self-interest The rationalised self-interest, described by Campeau as a strategy to guide decision-making, allows paramedics to believe that their own safety is a prerequisite to assisting the patient. This allows for a “paramedic's first” approach, meaning that the paramedic's safety is a priority. The results presented in this paper suggest that when the risk was considered elevated, paramedics exercised discretion to determine whether the risk was acceptable. If it was unacceptable, they would delay their approach and treatment of the patient until an acceptable level of risk could be ensured. The difficult part, however, is to decide whether it is an unacceptable risk. Campeau highlights that paramedics see themselves as rescuers, and when they are unable to help, this undermines their role and may lead to a sense of “losing face”. The willingness to help patients was evident in this study, but it was rarely explained by their fear of “losing face”. However, to discuss the balance between risks and safety, I utilised the results from this study and constructed a visualisation that I have called the Paramedic Risk Matrix for Workplace Violence (hereby referred to as “The Paramedic Risk Matrix) (see Fig. 1 ). The Paramedic Risk Matrix, explained in more detail below, can spark discussions and raise awareness about the rationalised self-interest and help argue for the rationale behind prioritising one’s own safety. The Paramedic Risk Matrix was developed based on the results from this study, but it is not scientifically tested. This remains for future studies. However, by discussing situations in light of the Paramedic Risk Matrix, it is possible that the matrix can help paramedics argue more precisely for their safety assessment and thus management. It can help clarify, through discussions and reflections, when risks are perceived as unacceptable and could be helpful for clarifying role expectations and the rationale for prioritising one’s own safety. The Paramedic Risk Matrix for Workplace Violence Based on the results, we interpreted that risk assessments and decisions to engage or prioritise own safety were often made mainly based on two aspects that were weighed against each other: 1) the potential gain for the patient (the acuity, vulnerability, and risk of deterioration of the patient’s condition) and 2) the possible consequences for paramedics. Consequences for paramedics were, as shown in the results section, usually discussed as physical or psychological injury, but also as the risk of being investigated for adverse outcomes and not being understood or supported by managers, legal experts, other allied health professionals, or stakeholders. In the Paramedic Risk Matrix, I seek to illustrate the consequences for health outcomes only and to increase awareness of how these assessments have implications for risk management. In contrast to many other assessment matrices used in healthcare and beyond ( 46 ), the Paramedic Risk Matrix does not rely on probability estimates and likelihood for WPV. Rather, it focuses on how the patient's health gains and the health consequences for paramedics together can inform whether the risk of WPV is perceived as acceptable or unacceptable from a paramedic perspective. The model comprises the two axes “expected health gains for the patient” and “possible health consequences for paramedics”. We suggest that “health” can be understood as physical or mental health, or a combination of these. The verbal indicators on the x-axis in Fig. 1 must be interpreted as a discretionary assessment to the question: based on your best judgment in the situation, what can be the consequences to your health if you enter this scene now? The answer can be somewhere on the continuum between “no consequences” and “death”. The categories “no consequences”, “minor consequences”, “moderate consequences” and “serious consequences” are included for reference and clarity and are not meant to be precise cut-off levels. Similarly, the Y-axis must be interpreted as a discretionary assessment to the question: based on your best judgment in the situation, what can be the health gain for the patient if you enter this scene now? (no health gain, negligible health gain, small health gain, moderate gain, crucial health gain, preventing death). As our results indicate, personal differences such as training, size, gender, the proximity of further support and contextual factors are likely to influence the potential consequences in different situations. These assessments will be part of the discretionary decision on where on the x-axis one would put oneself. The colours in the model indicate how risk is perceived on a spectrum, from acceptable (green) to unacceptable (black). Again, the colours do not indicate an absolute scientific answer to how the risk is assessed. Rather, the model should be used as a visualisation of how paramedics usually balance their own safety and the patient's care. This can be tested and perhaps used to discuss, reflect and increase awareness and understanding of what constitutes acceptable and unacceptable risks from a paramedic perspective. It is likely and reasonable that there will be differences in opinions about which colour is the correct one in each cell. Still, we propose the Paramedic Risk Matrix as a helpful tool for discussions among clinicians, managers, and stakeholders. In the future, the model could be developed and tested further to support or falsify its practical use, and its ability to increase awareness about risks and safety, and help justify paramedics’ decisions to prioritise safety when the gain for the patient is low, and the potential consequences for paramedics are high. We do not suggest a clear-cut-off between different colours in the Paramedic Risk Matrix. Instead, we want to illustrate that the acceptable and unacceptable risks are considered relative to the expected gains and potential consequences, as determined by the paramedics at the site, using their best discretion. Thus it can help support paramedics decisions. To assess which point on the x and y axes best represents the situation on the scene, paramedics needs to use their best professional discretion, and by using this illustration risk assessments are based on the potential health benefit for the patient and the potential health risk for the AC. This is in coherence with how several respondents argued when making difficult discretionary risk assessments on the scene. The Paramedic Risk Matrix is useful in discussing, visualising and communicating risks and the need for safety measures. Among safety scientists, the focus has earlier been on unsafe activities or system operations, such as failures, accidents and losses, rather than on safe activities or operations. This is referred to as the Safety I perspective. ( 47 ) From a Safety I perspective, it presumes that things go wrong because of identifiable errors or failures in procedures, human workers, technology and the organisation in which they are embedded. ( 47 ) Following the safety I approach, a response is needed when something happens, or the risk is judged unacceptable, typically involving the elimination of the cause, improved barriers, or both. ( 47 ) This thinking is in contrast to the Safety II perspective, in which safety is seen as the ability to succeed under varying conditions. From a Safety II perspective, humans are viewed as resources necessary to achieve safety, focusing on a proactive approach that continuously seeks to anticipate developments and events. A Safety II perspective requires an ability to manage performance variability. Subsequently, a Safety III perspective focuses on freedom from unacceptable losses. Rather than a simple linear system and cause-and-effect relationship between errors and risks, the Safety III perspective focuses on hierarchical socio-technical systems, emphasising system theory for handling complexity. ( 47 ) The Paramedic Risk Matrix can be used systematically to facilitate a broader discussion on safety for paramedics in a prehospital context and function as a system theory for discussing risky situations. Awareness and new insights gained through discussions around the Paramedic Risk Matrix may mitigate unacceptable losses, prevent hazards, and facilitate safety measures in situations where paramedics would otherwise take risks. This is because they can find support in the model for their decisions to prioritise their own safety when the risk is unacceptable. Consequently, the Paramedic Risk Matrix may assist risk assessments in hierarchical, complex social environments where paramedics lack tools to communicate risks to stakeholders who have less insight and understanding of their work environment. In this study, we have identified and presented multiple factors that influence paramedics’’ risk-taking, risk assessment, and risk management. The results indicate that similar situations are perceived differently. Moderating these factors has the potential to influence where on the x and y axes paramedics places the situation in the scene. Consequently, these factors influence where on the continuum between acceptable and unacceptable the risk is perceived to be. The identified influencing factors indicate to paramedics, ambulance service managers and stakeholders where they can focus their efforts to mitigate risky behaviour among paramedics and instead contribute to building a paramedic safety culture. The prehospital medical emergency work can never be free from risks, and not all WPV incidents are avoidable. Still, from a Safety III perspective, it makes sense to avoid unacceptable losses, thus reflecting on unacceptable risks rather than a simple “safety-first” perspective. What constitutes “unacceptable losses” is, according to the Safety III perspective, determined by the system stakeholders and as we have discussed above, the discussion on unacceptable risks, and thus potential losses, is missing for the social context where paramedics work in the prehospital environment ( 47 ) Strengths and limitations The credibility and trustworthiness of this study are strengthened by the researcher's familiarity with the prehospital culture and context, and the discussions of the results with ambulance service managers and paramedics served as a peer debriefing, supporting the researcher's reflexivity and facilitating a broader understanding and interpretation of the results. Credibility is also strengthened by the study's aim, grounded in an experienced clinical problem, supported by a research gap in the literature, and informed by the information-rich interviews. The findings are based on a small sample from one regional ambulance service in Norway, which limits transferability but strengthens the credibility of the results being relevant in similar social cultures. The sample consisted of paramedics with a broad variation of experiences, education, gender, and age, which strengthens the transferability to similar social and cultural contexts. The researcher's informed outsider perspective may contrast with that of an insider, but may also add new perspectives. Input from insiders and naïve outsiders strengthens the credibility of the results. Conclusion Paramedics’ willingness to help patients, combined with their perceived role expectations and stakeholders’ lack of understanding of their work context, influences how risks for violence are assessed and managed by paramedics. Despite their gut feeling and clinical experience, many struggle to describe, convey and document risks for violence sufficiently to the police, General Practitioners (GPs), hospital staff and managers. This leads to difficulties getting support for their decisions to prioritise safety. The lack of understanding among stakeholders of prehospital risks within the paramedic social context is problematic, and the lack of consensus among stakeholders and paramedics regarding which risks are acceptable and which are not complicates risk assessments and management. The Paramedic Risk Matrix for WPV should be tested for education and training, as it may help raise awareness and spark discussions regarding when risks are perceived as unacceptable. It may be helpful for clarifying role expectations. Further research is needed to explore the use of the Paramedic Risk Matrix for WPV in training and education, and to further explore how WPV for paramedics can be mitigated. Abbreviations EMC Emergency Medical Service EMCC Emergency Medical Call Center GP General Practitioners SCTPSM Space Control Theory of Paramedic Scene Management WPV Work place violence Declarations Ethical approval and consent to participate The study was approved by the Norwegian Agency for Shared Services in Education and Research (SIKT) (ref. no. 170712) and the local data protection officer at Vestre Viken Hospital Trust (ref. no. 23/05574-4). All participants voluntarily gave their written consent to participate in the study and to communicate and comprehend the information they provided. According to the Norwegian Health Research Act, the scope of this study falls outside the scope of the act, and ethical approval is not required. In compliance with the Norwegian Health Personnel Act, participants avoided disclosing identifiable patient information or that of any third person. The project complies with local regulations for research, data storage and privacy protection. Consent for publication Participants provided their oral and written consent to the use of anonymised data in publications. Availability of data and materials The datasets generated and/or analysed during the current study are not publicly available due to a significant amount of indirectly identifiable data, but are available from the corresponding author on reasonable request. Competing interest The authors declare that they have no competing interests Funding Not applicable Author’s contribution The author (KH) is responsible for the design, data collection, analysis and writing of the paper. Contributions from researchers who do not meet the authorship requirements are acknowledged in the acknowledgement section. Acknowledgement First of all, I want to thank all respondents who shared their valuable experiences and contributed to this study. This would not be possible without you. I also give thanks to the ambulance service and prehospital clinic that supported this study, helping us disseminate information and encourage participation. A special thank you goes to Jon Richard Figenschou, Head of Quality and Health Safety and Environment at Vestre Viken Ambulance Service, and Birgitte Larsen, Paramedic and Head of Section for Competence development at Vestre Viken Ambulance Department, for their support in discussing the results and providing valuable feedback on the manuscripts. I also want to give my sincere thanks to Professor Ole Martin Moen at Oslo Metropolitan University for contributing to correcting transcriptions and for discussing initial themes during the familiarisation phase, and for discussing initial codes in the third analytic phase. No substantial contribution to the final analysis was made. Thank you for your time and effort. 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Paramedicine. 2025;22(4):202–4. Kaya GK, Ward J, Clarkson J. A Review of Risk Matrices Used in Acute Hospitals in England. Risk Anal. 2019;39(5):1060–70. Aven T. A risk science perspective on the discussion concerning Safety I, Safety II and Safety III. Reliab Eng Syst Saf. 2022;217:108077. Additional Declarations No competing interests reported. Supplementary Files SRQRChecklist.pdf Suplementaryfile.pdf Cite Share Download PDF Status: Under Review Version 1 posted Reviewers invited by journal 24 Apr, 2026 Editor invited by journal 31 Mar, 2026 Editor assigned by journal 29 Mar, 2026 Submission checks completed at journal 29 Mar, 2026 First submitted to journal 26 Mar, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9233243","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":634393620,"identity":"b4ff86fc-ddce-49f0-88d3-7b9bf2a6610f","order_by":0,"name":"Kristin Häikiö","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAwElEQVRIiWNgGAWjYBACAwbGZoYEBhsGBnYStaQxMDCDuAlEaQGrPUyCFnP2w80GDyrOy8k3Mx/d8PEHQx4/IS2WPYnNCQlnbhsbHGZLuzkjgaFYsoGQww4kNh9IbLuduIGZx+w2TwJD4oYDhLScfwjSci5xfjNQyx+itNwAOiyx7UBiw2GgFgbitDxsNkg4kwzxS0+aROJMgn45n/5Y8keFnZx8e/OxGz9sbBL7CejAABKkahgFo2AUjIJRgA0AAAGORFu0hGw5AAAAAElFTkSuQmCC","orcid":"","institution":"Oslo Metropolitan University (OsoMet)","correspondingAuthor":true,"prefix":"","firstName":"Kristin","middleName":"","lastName":"Häikiö","suffix":""}],"badges":[],"createdAt":"2026-03-26 11:08:20","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9233243/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9233243/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":108837336,"identity":"37fd95b1-04be-410f-83ed-474b5b73a29f","added_by":"auto","created_at":"2026-05-09 00:09:43","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":84530,"visible":true,"origin":"","legend":"\u003cp\u003eThe Paramedic Risk Matrix for WPV\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-9233243/v1/176920b62197ba5faa3d5554.png"},{"id":108837339,"identity":"35cdd870-352f-4240-96bf-9c579e5fa670","added_by":"auto","created_at":"2026-05-09 00:09:57","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":429613,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9233243/v1/0b1d2493-d405-4d6f-bff1-c435847f8498.pdf"},{"id":108837335,"identity":"2331d51c-45be-4c82-8649-e11abfb8cc01","added_by":"auto","created_at":"2026-05-09 00:09:43","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":155865,"visible":true,"origin":"","legend":"","description":"","filename":"SRQRChecklist.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9233243/v1/c2de8d1dcb72b25348832def.pdf"},{"id":108837334,"identity":"3e6928b9-31bb-438c-9d0e-c078ccf73a40","added_by":"auto","created_at":"2026-05-09 00:09:43","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":97879,"visible":true,"origin":"","legend":"","description":"","filename":"Suplementaryfile.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9233243/v1/73997252df4adf9117073d16.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Workplace Violence: How can paramedics prioritise their own safety?","fulltext":[{"header":"Introduction","content":"\u003cp\u003eWorkplace violence (WPV) against healthcare workers is an increasing, worldwide phenomenon (\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e–\u003cspan class=\"CitationRef\"\u003e4\u003c/span\u003e). Emergency medical service (EMS) workers, especially paramedics, operating in uncontrolled settings and isolated from the security and support systems that often exist in other workplaces, are exposed to risks rarely seen in other professions. (\u003cspan class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e5\u003c/span\u003e–\u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e) WPV against paramedics occurs primarily from patients and bystanders during emergency responses and is associated with attending unconscious patients, intoxicated patients, homeless patients and patients with mental health problems (\u003cspan class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e11\u003c/span\u003e). WPV harms safety, well-being, professional performance and service quality. (\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e–\u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e) It can lead to physical injuries and profound psychological effects, such as post-traumatic stress disorder (PTSD), anxiety, and depression. In addition, it negatively impacts service delivery and organisational culture, resulting in increased time lost from work and associated costs. (\u003cspan class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eThis paper focuses on violence inflicted on ambulance clinicians (AC) by patients while providing care. International studies report that WPV occurs in 0.4–0.8% of ambulance runs, whereas 18–38% involve physical assaults. (\u003cspan class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e). Due to the high number of ambulance runs during a career, most paramedics will encounter WPV. Career-long exposure to WPV is reported in a Swedish study to be 66% for paramedics, and a systematic review examining EMS workers found rates between 57–93% for verbal and/or physical violence. (\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e13\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eVerbal threats and non-physical violence are more frequently reported than physical violence. (\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e13\u003c/span\u003e) However, there is no consensus on the definitions of WPV. Multiple definitions exist, but the European Agency for Safety and Health at Work (EU-OSHA) define violence as “intentional use of power, threatened or actual, against another person or against a group, in work-related circumstances that either results in or has a high degree of likelihood of resulting in injury, death, psychological harm, bad development or deprivation”. (\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eAlthough the rates of violence are reported in several studies, there is a gap in the literature regarding why WPV occurs and how to effectively mitigate such situations. (\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e) Spelten et al.(\u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e), exploring paramedic WPV, conclude that we need to move away from focusing on the individual worker to a system-based approach. Other recent studies highlight the lack of literature providing qualitative insights into how paramedics perceive and navigate risks and risk assessments in their daily practices (\u003cspan class=\"CitationRef\"\u003e11\u003c/span\u003e) and that the social interactions that occur during healthcare exert a significant influence on the evolution of aggressive behaviour. (\u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e) Our study aims to build on these results and address the gaps in the literature by providing an in-depth exploration of paramedics’' lived experiences, in the prehospital social context, and their perceptions of individual and contextual factors influencing WPV risk assessments and management. There is a lack of effective prevention and mitigation strategies in practice, prompting this study to explore paramedics’ experiences and identify solutions applicable to ambulance service managers and paramedics. Thus, I used the results to propose and discuss the implications for training and education. Consequently, this paper presents the results from the interviews, and in the discussion section, I present a visualisation of paramedics' risk assessments, which can be used to spark discussions, reflections, and increased awareness for risk assessments, risk prevention strategies, and safety management for individuals, service managers and ambulance services stakeholders, sparking further discussions regarding acceptable or unacceptable risks.\u003c/p\u003e"},{"header":"Method","content":"\u003cp\u003eStudy design and philosophical underpinning\u003c/p\u003e\u003cp\u003eThe research question “What are paramedics’ experiences with WPV and what are their perceptions of individual and contextual factors influencing risk assessments and management?” was chosen following discussions between me (the researcher) and ambulance service managers to mitigate the increasing reports of WPV. The researcher reviewed the literature and identified knowledge gaps regarding effective, pragmatic mitigation strategies.\u003c/p\u003e\u003cp\u003eI designed a hermeneutic-phenomenological and narrative study, to explore the phenomenon “workplace violence” (WPV) through the interpretation of paramedics' narratives and lived experience. Episodic narrative interviews were conducted to elicit focused, firsthand and context-rich experiences of WPV, enhancing culturally derived interpretations of their social life world – the Norwegian prehospital context. By inviting participants to reflect on these experiences, I created situations that yielded rich, meaningful data generated through their narrative and the subsequent interview process.\u003c/p\u003e\u003cp\u003e To support reflection, to understand their worldview, and to interpret meaning across respondents, I honoured the listening process in a dialogic interview format, using a semi-structured interview guide to deepen my understanding of the phenomenon. (\u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e) In all phases of the study, I drew on feedback from paramedic clinicians and engaged in deep reflexivity to uncover new perspectives and broaden my horizon of preunderstanding and interpretation. This aligned with recommendations for reflexivity in qualitative analysis and for combining interpretative phenomenology and narrative methodology. (\u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e) Consequently, I took the role of an active listener to respondents’ narratives of workplace violence and sought to understand the situations and interpret the context of each unique experience. I took a naïve, curious approach and used follow-up questions to develop a more in-depth understanding of participants’ lived experiences.\u003c/p\u003e\u003cp\u003eThrough respondents’ narratives, subsequent reflections and reflexive thematic analysis, I sought to understand their individual experiences within the social environment and organisational culture, which contextually influenced their experiences and sought a more universal meaning. (\u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e–\u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e) This is consistent with an interpretivist epistemology capturing participants' subjective realities and interpretations. (\u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e) Combining narrative methodology and hermeneutic phenomenology, this study is underpinned by the hermeneutical-phenomenological research paradigm, which aligns with the interpretivist epistemology. (\u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e)\u003c/p\u003e\u003cp\u003eResearcher’s reflexivity and positionality\u003c/p\u003e\u003cp\u003eI hold a PhD in health sciences, have several prior experiences with qualitative research interviews and work with paramedic education in Norway. I have solid experience in health services research, particularly ambulance research. I have extensive clinical experience as an emergency nurse, but no clinical experience working within ambulance services. Consequently, I am familiar with paramedic culture through collaboration with paramedic academics, researchers, clinicians, and students. I therefore take an informed outsider perspective. Unlike a naïve outsider, I am informed enough to avoid superficial or purely speculative interpretations and compared to an insider, I am less constrained by internal assumptions, loyalties, or institutional blind spots.\u003c/p\u003e\u003cp\u003eTo better understand the context-sensitive challenges, we planned an interview study in which paramedics could speak with the researcher about their workplace experiences without being identified by their managers. Being an informed outsider, I let respondents be the experts, allowing me to be seen as less of a threat to their professional integrity.\u003c/p\u003e\u003cp\u003eTo enhance the credibility and trustworthiness of the results and their interpretation, peer debriefing was utilised across all phases of the project. Feedback from ambulance clinicians, paramedic academics, and ambulance service managers was sought during the design phase, data collection phases, analysis, interpretation, and discussion of results. Peer feedback was also received from paramedics and researchers attending conferences and seminars where preliminary results were presented. As a supplement to the initial analytic phase, when searching for preliminary themes, a naïve outsider perspective was also sought from a researcher outside of the paramedic community. The input from both insiders and outsiders broadened my understanding and contributed to the analysis.\u003c/p\u003e\u003cp\u003eRecruitment and description of the sample\u003c/p\u003e\u003cp\u003eService quality coordinators, in a large ambulance service in Norway, distributed information about the study to all paramedics in their service, encouraging them to volunteer for individual research interviews. Participants volunteered by contacting the researcher directly or through the service quality coordinators. The snowball sampling method was used to strategically invite new participants from the respondents' network, who would otherwise not respond to an open invitation, ensuring maximum variation in age, gender, and experience. Recruitment continued until I had sufficient information power, assessed by the quality and richness of the interviews, the aim of the study, the sample specificity and the analysis strategy. (\u003cspan class=\"CitationRef\"\u003e27\u003c/span\u003e)\u003c/p\u003e\u003cp\u003eThe population of paramedics in Norway, and particularly when respondents are invited from only one district, is small. Thus, there is a risk of identification if respondents' exact characteristics are presented and there is a risk of identification through details in quotes. Consequently, I present a few variables from each individual, and the gender of some respondents is changed to reduce the risk of identification. The proportions for each gender remain unchanged. To further avoid identification, I present education dichotomised in lower education (occupational training and/or education without a completed bachelor's degree) or higher education (completed bachelor's degree or higher degree in a related profession). See Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" class=\"colspec\"\u003e\u003c/div\u003e\u003ctable id=\"Tab1\" border=\"1\"\u003e \u003ccaption\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eOverview of the sample\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003c/colgroup\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\"\u003e \u003cp\u003eAlias (gender)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\"\u003e \u003cp\u003eAge group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\"\u003e \u003cp\u003eEducation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\"\u003e \u003cp\u003eAmbulance Experience\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\"\u003e \u003cp\u003eInterview time\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\"\u003e \u003cp\u003eInterview no.\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eThomas (M)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e18–34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eHigher\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e1–5 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e95 min\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eEric (M)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e35–59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eHigher\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e1–5 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e84 min\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eMagnus (M)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e18–34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eLower\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e\u0026gt; 10 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e58 min\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eElisabeth (F)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e35–59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eHigher\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e\u0026gt; 10 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e68 min\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eMary (F)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e35–59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eHigher\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e6–10 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e58 min\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eMark (M)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e35–59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eLower\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e\u0026gt; 10 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e61 min\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eSilvia (F)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e18–34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eHigher\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e1–5 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e69 min\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eUrsula (F)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e18–34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eLower\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e6–10 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e74 min\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eKatryn (F)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e18–34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eLower\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e6–10 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e77 min\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eMorten (M)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e18–34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003elower\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e\u0026gt; 10 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e65 min\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/table\u003e\u003c/div\u003e\u003cp\u003eInterviews and analysis\u003c/p\u003e\u003cp\u003eInterviews were conducted between January and April 2024. The interviews followed a flexibly used topic guide based on the existing literature in the field, the knowledge needs identified by ambulance service managers, and the aim of the study. Inspired by the Episodic Narrative Interview method, I used respondents’ narratives as the starting point of the interview and followed up with open-ended questions. The first version of the topic guide contained the following topics: 1) introduction to the study, 2) the respondent's experience with violence, including their self-experienced narrative 3) Participants' reflections regarding risk factors or signs of escalation of the situation before the incidence 4) Participant’s reflections regarding their and others responsibilities and expectations before, during and after the incidence, 5) Rounding off the interview.\u003c/p\u003e\u003cp\u003eFollowing a flexible, explorative design, each interview yielded a broader understanding of the phenomenon, and the researcher’s broadened understanding of the phenomenon was embedded in the future interviews. Consequently, data were generated and shaped by the respondents' responses in relation to the researcher and the questions asked. (\u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e)\u003c/p\u003e\u003cp\u003eI expected research participants to have a heterogeneous understanding of and definitions of “workplace violence” and “violence”. In our interviews, I did not ask participants to define the phenomenon. Instead, encouraged research participants to share bounded stories about their experiences of workplace violence and used their narratives to understand their interpretation of the terms. Consequently, it was possible to collect small, focused narratives about individual experiences of workplace violence, use latent analysis to interpret how they understand the phenomenon and thus explore their experiences. (\u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e)\u003c/p\u003e\u003cp\u003e The first six interviews were conducted face-to-face at a facility chosen by participants, usually their home or a public place such as the library or the university. Four interviews were conducted digitally. All interviews were conducted individually by the first author, lasting between 60 and 90 minutes.\u003c/p\u003e\u003cp\u003eThe analysis was inductive and data-driven, following reflexive thematic analysis (\u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e), which is considered suitable for analysing narratives and well-suited to a hermeneutic-phenomenological approach. (\u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e) Reflexive thematic analysis was iteratively moving through familiarisation, coding, theme development/review, and write‑up, with regular peer discussion. For details about the analysis, see the supplementary file.\u003c/p\u003e\u003cp\u003eEthics\u003c/p\u003e\u003cp\u003e Participants provided voluntary, written, informed consent to participate in the study and to the publication of results in which they cannot be identified. Interviews were audio recorded, and encrypted data was transferred and stored on TSD (Tjeneste for Sensitive Data), a secure storage server approved for storing sensitive data. (\u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e) The computer software Whisper was used for auto-transcription. (\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e) Data access was restricted to two researchers outside of the ambulance service. One who withdrew from the project in the early phases of analysis and did not contribute to the writing of the manuscript or to the development of the final themes. The data storage plan was supported by the Norwegian Agency for Shared Services in Education and Research (SIKT) (ref. no. 170712) and the local data protection officer at the Hospital Trust (ref. no. 23/05574-4). Interviews avoided the use of identifiable information about the patients, and the project complies with local regulations for research, data storage, and privacy protection. All contributors to this study who do not meet the criteria for authorship according to the Vancouver convention (\u003cspan class=\"CitationRef\"\u003e32\u003c/span\u003e) and the CRediT Framework are mentioned in the acknowledgement section upon acceptance.\u003c/p\u003e\u003cp\u003eThe context\u003c/p\u003e\u003cp\u003eIn Norway, ambulances are typically staffed with two healthcare personnel who hold a relevant education. Relevant education ranges from vocational training with or without additional training to higher university education, primarily in nursing or paramedicine. Ambulances are dispatched by the Emergency Medical Call Center (EMCC) where medically trained staff (usually a nurse) receive and assess medical emergency calls and dispatch ambulances accordingly.\u003c/p\u003e\u003cp\u003eThe term “paramedic” is used interchangeably with the term “ambulance clinician” in this paper, and the terms do not distinguish between their educational backgrounds.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe respondents\u0026rsquo; narratives include incidents ranging from minor assaults to life-threatening episodes with weapons. They include episodes such as inappropriate sexual remarks, slaps from confused older persons, anger or verbal threats, aggressive behaviour and physical violence. Most respondents describe being worried about their safety from time to time. Participants\u0026rsquo; risk willingness and risk assessments varied between individuals and depended on the situations. Common for all participants was that they all assessed and balanced risks and safety. They said they typically based their assessments on the patient\u0026rsquo;s body language, whether the patient had a history of being violent, their gut feeling, the risk of weapons being used, the patient having a background with psychiatry and substance use, or if the ambulance run involved involuntary admissions.\u003c/p\u003e \u003cp\u003eWen describing, interpreting and analysing paramedics\u0026rsquo;' lived experiences in the prehospital social context and their perceptions of individual and contextual factors influencing WPV risk assessments and management, I developed the following main themes: 1) Internal willingness to help; 2) Becoming \u0026ldquo;speed blind\u0026rdquo;; 3) Challenges in conveying risk assessment; 4) Challenges with documenting risk assessments; 5) Paramedics\u0026rsquo; perceived role in the hierarchy; 6) The handling of reported incidents mirroring role expectations. The findings demonstrated that risk perception was shaped by individual and contextual factors intertwined, influencing paramedics\u0026rsquo;\u0026rsquo; risk-taking, risk assessments and risk management related to WPV\u003c/p\u003e \u003cp\u003eThe internal motivation to provide care\u003c/p\u003e \u003cp\u003eDespite differences in how the situations were assessed and solved, one important driver for risk willingness seemed to be paramedics\u0026rsquo;\u0026rsquo; experienced inner moral responsibility to help. Despite saying that safety was their first priority, most respondents, when discussing their assessments in relation to their experiences, expressed an inner moral obligation to help first, followed by self-risk assessments second. Ursula said it like this:\u003c/p\u003e \u003cp\u003eUrsula: Well, my expectations then, which I experienced, were a bit that we have to help this patient. Because obviously, no matter what it is, whether it's psychiatry or if it's somatics that does it, he's not doing well. We must try to help in the best possible way and ensure his safety in the midst of it, but also my own.\u003c/p\u003e \u003cp\u003eAlthough participants mentioned expectations from bystanders, managers, local authorities, and legal duties as factors affecting them in their work, several explicitly said that their inner moral duty to help was the strongest motivation to intervene. Consequently, paramedics\u0026rsquo;' inner willingness to help is a driver of risk-taking and represents an important factor influencing how respondents balance risks and safety for themselves and their patients.\u003c/p\u003e \u003cp\u003e Several participants talked about the challenges of wanting to help patients who do not cooperate with them. The short window of opportunity to help a patient who will otherwise run off, the difficulties of making rapid decisions based on insufficient information, and the potential consequences for the patient and themselves were mentioned by several. Morten\u0026rsquo;s quote illustrates how he tries to balance all this:\u003c/p\u003e \u003cp\u003eMorten: It's a bit, it's a dilemma, a difficult dilemma, in relation to what you should do. Are you going to use force to hold [the patient] back? Or should you let it go? And it's one of those decisions, you get a millisecond to decide.\u003c/p\u003e \u003cp\u003eKristin: yes, right? One involves risks for you, the other involves risks for the patient. How do you weigh them up against each other?\u003c/p\u003e \u003cp\u003eMorten: Yes, good question. It's very difficult.\u003c/p\u003e \u003cp\u003eKristin: But you've probably done it many times?\u003c/p\u003e \u003cp\u003eMorten: Yes, and that's the way it is, maybe the assessments I make the most are in relation to \"Can I hold you back?\u0026rdquo;\u003c/p\u003e \u003cp\u003eKristin: yes, size and physique?\u003c/p\u003e \u003cp\u003eMorten: There is a difference between small skinny people and big strong people. It is also in relation to the seriousness of what we are called out on. What's your gut feeling? Is this something like.., will we find you again just across the street here? Or are you actually the one who jumps the river, then, or does something? So it's a bit like that\u0026hellip;how will I feel after the mission is finished? If you choose to run away or if something happens. It's often that you can get a feeling of guilt for it. That I should indeed stop you.\u003c/p\u003e \u003cp\u003eThe quote above illustrates Morten\u0026rsquo;s assessment of being able to manage the situation on scene (safety on scene). However, he also mentions the potential later consequences which may influence his decision. When encouraging Morten to elaborate on his risk willingness, risk assessments and risk management, he explicitly mentioned the perceived acuity of the patient\u0026rsquo;s condition, the types of risks involved, and the availability of support from others. Many participants mentioned these same factors.\u003c/p\u003e \u003cp\u003eSome were more willing to handle situations that could escalate than others, and respondents' narratives described that some were willing to use physical restraints on the patient if de-escalation failed, while others were not. Physical restraints were typically used if they assessed the situation to be manageable, considering the patient's size, the surroundings, and other available persons. The possibility of avoiding harm seemed to underpin this decision and was illustrated by Silvia: \u0026laquo;I think many men lack the understanding of how it is to be physically smaller than someone. Most men could manage to kill me if they wanted to. That is just how it is\u0026raquo;. It was more common among some participants to describe a higher threshold for requesting police support, and this seemed to be related to their assessment of the potential consequences the situation posed for their own safety. The relative risk of injury, however, may be the same because all respondents were unwilling to suffer a serious injury or risk of death.\u003c/p\u003e \u003cp\u003eBecoming \u0026ldquo;speed blind\u0026rdquo;\u003c/p\u003e \u003cp\u003eAll respondents acknowledged the need for self-safety assessments, and many mentioned \u0026ldquo;safety first\u0026rdquo; as an important principle, but the level of risk that respondents seemingly accepted varied among individuals. Several participants talked about how their perceptions of violence and risk assessments developed along their career path. While most respondents claimed to be more aware of potential risks later in their careers and thus more considerate of safety measures, many also seemed to have developed a tolerance for behaviour that, for most people, would be considered violent. This impression was confirmed by Silvia:\u003c/p\u003e \u003cp\u003eSilvia: I think the reason for what you consider threats, it moves a lot when you are used to it. Because if my mom, who is [administrative employee], experienced that somebody had told her that I am going to kill you, then she would have remembered it. But I would have forgotten about it at the end of my shift. I forget to write a report on an adverse event from it, because I wasn\u0026rsquo;t scared. If there are a lot of people around me, and someone says they're going to kill me, and they seem a little lost, then... I don't get scared. So I think that it is hugely underreported because it is not taken seriously. But that's not okay, sort of.\u003c/p\u003e \u003cp\u003eThe perception of threatening and potentially violent situations appears to change over time and with exposure. When it changes in the direction of greater acceptability, this can be interpreted as \u0026ldquo;speed-blindness,\u0026rdquo; meaning that paramedics become accustomed to incidents that others, who are less exposed, would never accept.\u003c/p\u003e \u003cp\u003eChallenges in conveying risk assessments\u003c/p\u003e \u003cp\u003e Some respondents specifically discussed how they evaluated the patient\u0026rsquo;s body language and verbal language to assess the risk of violence, while others mentioned their \u0026ldquo;gut feeling\u0026rdquo; as the primary reason for being alert. Several mentioned drugs and psychiatry as risk factors, including alcohol. Still, many expressed challenges in conveying risk assessments to the police and other healthcare professionals.\u003c/p\u003e \u003cp\u003eBeing understood by the police\u003c/p\u003e \u003cp\u003eMost respondents expressed difficulties communicating their risk assessments in a way that was sufficiently understood and acknowledged by the Police. Simultaneously, respondents emphasised the importance of police assistance in situations they felt were unsafe, and many explicitly discussed Elizabeth's point: \u0026ldquo;the police are indeed our health, safety, and environment\u0026rdquo;. Elizabeth, among others, said that the police-ambulance debate in Norway (discussions about when the police should or should not assist healthcare personnel in handling people with mental illnesses) affects paramedics and leads to them trying to deal with things alone for a longer time. \u0026ldquo;It is difficult to get support [by the police] until you push the safety alarm button, but it usually has to go to hell first, before you get support\u0026rdquo; (Elizabeth).\u003c/p\u003e \u003cp\u003eElizabeth, among others, emphasised the police\u0026rsquo;s lack of understanding of paramedics\u0026rsquo; role and their unawareness of the limited training paramedics have in handling escalated situations as an underlying reason for the lack of police support.\u003c/p\u003e \u003cp\u003eElizabeth: I think [those working in the Police control room], may not have the same updated opinion then, about how much risk it actually is we are in, and how unbelievably little we have to defend ourselves with. And that, I don't know, maybe forgets that we don't have an exam on violence. We don't have an exam in folding people up and taking control of people. They [the police] have. [\u0026hellip;] So it's probably a bit of that kind of communication, a kind of knowledge about each other, that is lacking, I think. It is certainly part of the package.\u003c/p\u003e \u003cp\u003eThe paramedics\u0026rsquo; lack of training in describing risks and communicating them effectively to the Police was noted by some respondents. Some talked about their \u0026ldquo;gut feeling\u0026rdquo; but also about their inability to describe what this meant in professional language when seeking police support.\u003c/p\u003e \u003cp\u003eMagnus: we often find ourselves in that battle regarding mentally ill patients, where we have a bad gut feeling. I also think we are bad at putting into words to describe in a professional way why I experience that situation. Right? [\u0026hellip;] My gut feeling, based on 11 years of experience from ambulance work, indicates that this is a ticking time bomb, but I still haven't learned how to put it into words and formulate it. Because I think we are too bad at that.\u003c/p\u003e \u003cp\u003eBeing understood by other healthcare professionals\u003c/p\u003e \u003cp\u003eMany respondents highlighted that other healthcare professionals' lack of understanding of the prehospital environment and its impact on the risks and consequences of WPV. Several emphasised that the situation inside a hospital or doctor's office differs significantly from the prehospital context. The quote below illustrates some differences that the respondent did not think the physician was aware of.\u003c/p\u003e \u003cp\u003eMagnus: Yes. Then there's a doctor there who says, like, \u0026ldquo;no, this is fine\u0026rdquo; [regarding the feasibility of ambulance transport for the patient]. Yes, and then I think there is an understanding that, like, yes, it is okay to have that patient in a closed room, in a doctor's office. That's fine, but it's a little worse in 2x1.50 meters, driving at 90 km an hour, in a place far away from everything.\u003c/p\u003e \u003cp\u003eA few respondents emphasised that conveying risk assessments was challenging when doctors, who outrank them and usually have access to more information about the patient, lack understanding of prehospital risks and make decisions on behalf of paramedics. Several pointed out that if paramedics at least had access to the patient\u0026rsquo;s former ambulance reports, they could use this information to better argue for their perspectives in cases where the patient had a history of becoming agitated and violent.\u003c/p\u003e \u003cp\u003eMagnus explained that his lack of trust in others stemmed from their lack of understanding of his role and work context.\u003c/p\u003e \u003cp\u003eMagnus: [In] most health services [staff] are used to working within white walls, dry and comfortable, with patients who come with a referral note [saying] why they are there, or what. It says something about what is wrong with the patient, or what the problem is. So, this is not the case for us. [\u0026hellip;] if I do something wrong, it's an anesthesiologist who will scrutinise my work. Which just easily trumps the credits I have, right? And who has access to all possible medical records and looks at the event in retrospect.\u003c/p\u003e \u003cp\u003eKristin: So that hierarchy of power, then, can be a contributing factor to why it's very difficult to set any boundaries and say, like, we think that this patient can act out, therefore our assessment is that we need police, for example.\u003c/p\u003e \u003cp\u003eMagnus: Yes. Then there's a doctor there who says, like, \u0026ldquo;no, this is fine\u0026rdquo;.\u003c/p\u003e \u003cp\u003eImportance of documenting risk assessments\u003c/p\u003e \u003cp\u003eThe difficulties in communicating risks and the lack of background information also had other implications, such as challenges in documenting risks. Difficulties documenting made it difficult to argue for prioritising their own safety over the patients\u0026rsquo; needs. Katryn talked about how important it is to document thoroughly if she chooses to prioritise her own safety at the cost of the patient\u0026rsquo;s needs. In the quote below, she talked about a situation in which the EMCC and the paramedics assessed the situation to involve a high risk of violence if they approached the patient, but they still chose to approach the scene carefully:\u003c/p\u003e \u003cp\u003eKristin: If you hadn\u0026rsquo;t [approached the patient], would you have had to document anything particular? Argue for why you don't go in [into the house] and help this person?\u003c/p\u003e \u003cp\u003eKathryn: Then I will have documented it very well in the journal.\u003c/p\u003e \u003cp\u003eKristin: What do you imagine you could have written then?\u003c/p\u003e \u003cp\u003eKathryn: Then I write the information we receive from the EMCC. That the caller is very intense on the phone. That we should be careful. It's been a while now, it may be that we learned more about the threats, but then it is documented what we got from the EMCC and that the police could not come.\u003c/p\u003e \u003cp\u003eSeveral mentioned feeling uneasy about a potential National Board-initiated investigation. They were concerned that an investigation into the delayed medical help would not be well-received, as key stakeholders lacked understanding of the risks involved in the prehospital context.\u003c/p\u003e \u003cp\u003eIn addition to documenting their prioritisation of safety in risky situations, several participants said they prioritised documenting the risks they experience in everyday work, hoping to gather evidence to argue for improved work safety. Altogether, this illustrates the importance of documenting risk assessments and risk management.\u003c/p\u003e \u003cp\u003eParamedics\u0026rsquo; perceived role in the hierarchy\u003c/p\u003e \u003cp\u003eMany mentioned feeling inferior to other professionals, such as physicians, EMCC operators, and hospital nurses. In situations where other professions made decisions about ambulance transport, many expressed that they had no choice or influence over patient transport decisions.\u003c/p\u003e \u003cp\u003eMagnus: No, I feel that we are at the bottom of the rank in the health service, so we just do what we are told. No matter how prudent it is, [...] So we are always put in a squeeze then. [\u0026hellip;] There's nothing to do, it's decided, sort of. It's decided, you're going to do this and that.\u003c/p\u003e \u003cp\u003eThis feeling of inferiority affected their risk management, as they often perceived themselves as lacking a choice. Silvia also felt little autonomy in deciding her actions on assigned ambulance runs and expressed a feeling of having to do what you are told to do:\u003c/p\u003e \u003cp\u003eKristin: So you feel obligated to at least investigate?\u003c/p\u003e \u003cp\u003eSilvia: Yes, investigate and take him with us.\u003c/p\u003e \u003cp\u003eKristin: Both?\u003c/p\u003e \u003cp\u003eSilvia: But I could actually have gone out to the ambulance and said we're standing there waiting until the police arrive. But I thought that we had to solve this ourselves.\u003c/p\u003e \u003cp\u003eKristin: Why did you think that? Do you have any ideas about why?\u003c/p\u003e \u003cp\u003eSilvia: I think people are afraid to [go] against what the EMCC says. Yes, I don't think you really know the consequences of that.\u003c/p\u003e \u003cp\u003eThe handling of reported incidents mirrors role expectations\u003c/p\u003e \u003cp\u003eMany mentioned that they were encouraged by their managers to report violent episodes. Still, some respondents reported that after submitting their internal report, the legal experts assessed it and chose not to press charges or report the incident to the police on their behalf. Mary is one of those who shared this experience:\u003c/p\u003e \u003cp\u003eMary: Well, you might write an internal report on violence and threats, but it's somehow not serious enough for the health trust to get..., it's the lawyers who assess whether it should be reported to the Police or not. [\u0026hellip;] And I'm pretty sure it [a recent experience] wouldn't have been serious enough for that. [\u0026hellip;] it\u0026rsquo;s the lawyers who sit and decide it, then.\u003c/p\u003e \u003cp\u003eThe perception that the incident had to be considered \u0026ldquo;serious enough\u0026rdquo; by legal experts contrasted with the efforts of managers and paramedics to highlight the importance of reporting all kinds of threats and violent behaviour. Ursula and Mark both emphasised the irony of this, and Ursula points out that the signal she picks up from this is that you should tolerate this type of violence as part of the job.\u003c/p\u003e \u003cp\u003eKristin: But what's crucial there [whether it's reported or not], you know? About what they [the health trust] choose to do?\u003c/p\u003e \u003cp\u003eUrsula: No, that's what I don't know. There have been some situations where we have discussed afterwards that there should clearly have been a Police report, but then we get an answer that the lawyers believe that there is reason to do so, because based on the patient's medical condition or such types of things, then, that the report will just lapse. [\u0026hellip;] So I think a bit like that, yes, how long should..., where is the limit on... Or what is it like, what should you tolerate from mentally ill patients that you can't tolerate from mentally healthy patients, then?\u003c/p\u003e \u003cp\u003eSimilar to Ursula\u0026rsquo;s experience, Mark expressed being discouraged from reporting incidents despite the manager's encouragement.\u003c/p\u003e \u003cp\u003eMark: I'm thinking, what's the point of reporting? It was taken down from there [lawyers/managers] anyway, and then there are many... We are exposed to violence every single day, our colleagues all over the country, including here in [place name], and are strictly told that \"yes must report\" and things like that, then it is not dealt with anyway because it is stopped by the lawyer. That's how I've understood it, then.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eBased on paramedics\u0026rsquo;' narratives and reflections, this study has identified several intertwined internal and external factors that influence their risk-taking, risk assessment, and risk management related to WPV. The factors identified were 1) the internal willingness to help; 2) becoming \u0026ldquo;speed blind\u0026rdquo;; 3) challenges in conveying risk assessments; 4) the importance of documenting risk assessments; 5) paramedics\u0026rsquo; perceived role in the hierarchy; and 6) the handling of reported incidents mirrors role expectations.\u003c/p\u003e \u003cp\u003eUnderstanding risk assessments and risk management of workplace violence in the prehospital context\u003c/p\u003e \u003cp\u003eUnlike many healthcare professionals, paramedics cannot control the types of cases they encounter. They respond to all calls for service and must be constantly prepared to provide a range of emergency services. (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e) The management of an out-of-hospital scene involves many physical and technical practices, but the paramedic workspace is also influenced by the paramedic social processes. This social process is described by Campeau's as the Space Control Theory of Paramedic Scene Management (SCTPSM), and supported by, among others, Drew and colleagues (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). Campeau\u0026rsquo;s SCTPSM described five categories of social processes, with the first category being \u0026ldquo;establishing a safety zone\u0026rdquo;. (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e) Subsequently, as our respondents constantly sought to ensure safety, the SCTPSM provides a useful conceptual lens for interpreting the results of this study. In the following discussion, I will start by utilising Campeau\u0026rsquo;s first category, \u0026ldquo;establishing a safety zone,\u0026rdquo; and its three subcategories. The three Sub-categories are a) the what-if strategy, b) the rationalised self-interest, and c) trading off patient care and scene safety.\u003c/p\u003e \u003cp\u003eThe what-if strategy\u003c/p\u003e \u003cp\u003eThe what-if strategy, as described by Campeau, describes that paramedics assess the scene and make risk assessments based on their assessments of what could occur, taking a \u0026ldquo;what-if\u0026rdquo; perspective and subsequent precautions. As Campeau mentions, paramedics \u0026ldquo;define the situation in high-risk terms and subsequently take actions to make the risks manageable\u0026rdquo; (32 p. 292). Similarly, the results of my study show that paramedics do what-if risk assessments with a suspicious and cautious orientation toward potential hazards, and seek to make the risks manageable. However, despite differences in experience, background, skills, and role expectations, participants also made risk assessments based on a strong inner willingness to help. Our study indicates that making risks manageable was perceived as difficult for many, and the factors we identified were their inner motivation to provide care, becoming speed-blind, and having challenges in conveying risk assessments. Combined with their perceived inferior role and external role expectations from managers, the police, and other healthcare professionals, these factors seemed to affect risk assessment and risk management. Consequently, paramedics\u0026rsquo; what-if strategy seems strongly influenced by factors outside their control, emphasising the need for collaboration across professions and sectors to mitigate the risks of WPV for paramedics.\u003c/p\u003e \u003cp\u003eAs the paramedic research literature has concluded earlier, it is unlikely that paramedics can work without any risks (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). Still, in Norway and beyond, the discussion on what constitutes acceptable or unacceptable risks for paramedics is lacking. Different stakeholders have different perceptions of what risks paramedics are expected to take. For example, we have identified perceived disparities between and hospital managers, as well as between paramedics and the Police.\u003c/p\u003e \u003cp\u003eThe acceptance of paramedics to participate in a high-risk situation is reinforced by the Norwegian Government\u0026rsquo;s PLIVO procedure (not publicly available). After a traumatic terror attack, killing 69 people, most of them children attending a political camp in Norway, in 2011, the Norwegian Government developed a national procedure (PLIVO) to manage collaboration across the Police, Ambulance services and Fire Brigades more effectively in situations involving ongoing life-threatening violence. Following this national procedure, when the Police declare a PLIVO situation, the procedure explicitly states that paramedics are expected to take increased risks to protect the public. (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e) The PLIVO procedure represents an example of governmental role expectations and other stakeholders for paramedics\u0026rsquo; risk assessments, which affects their role, their what-if strategy, and makes it explicit that their role is not risk-free.\u003c/p\u003e \u003cp\u003eIn summary, the broader society and important stakeholders seem to hold the view that some risks of violence for paramedics are acceptable. In this study and in previous research, paramedics have reported incidents that are clearly dangerous and have the potential to hurt them physically and mentally. It is well known that WPV can lead to physical injuries and profound psychological effects, such as post-traumatic stress disorder (PTSD), anxiety, and depression, thereby affecting safety, well-being and professional performance. (\u003cspan additionalcitationids=\"CR13 CR14\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e) In addition, it negatively impacts service delivery and organisational culture, resulting in increased time lost from work and associated costs. (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e) Simultaneously, paramedic education and ambulance services in Norway and beyond offer little or no training in managing violent situations beyond de-escalating communication techniques. (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e) There are ongoing discussions about protective gear and the use of body cameras (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). Nevertheless, a gap remains in the paramedic research literature concerning effective protective gear and safety measures against WPV.\u003c/p\u003e \u003cp\u003eTrading off patient care and scene safety - Prioritising one's own safety\u003c/p\u003e \u003cp\u003eRespondents in this study discussed stakeholders' limited understanding of the specific types of risks that occur in the prehospital context. Based on the author\u0026rsquo;s experience working with paramedic education for several years, the public\u0026rsquo;s understanding of paramedic education and the role of paramedics is limited. The lack of knowledge of paramedics\u0026rsquo; competences and limitations is relevant when discussing our findings in the light of Campeau\u0026rsquo;s third subcategory: trading off patient care and scene safety.\u003c/p\u003e \u003cp\u003eAs respondents in this study emphasised, their decisions were often assessed and judged by people who lacked an understanding of the paramedics\u0026rsquo; role and context. In previous research, discussions have highlighted the role ambiguity among paramedics (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e) and the lack of clarity regarding the interpretation of regulations and legislation in the prehospital context. (\u003cspan additionalcitationids=\"CR39\" citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eThe paramedic role has developed rapidly in many countries, including Norway, and the number of paramedics working in ambulance services is small compared to the number of nurses and doctors working in hospitals and community services. (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e) Consequently, it is no surprise that there is limited knowledge among policymakers, other healthcare personnel, and stakeholders of the paramedic role and the nature of their work. It is, however, problematic when legal assessments are made by individuals who lack understanding of their work and education, who outrank paramedics in education, and who are used to having access to information that paramedics usually lacks. This poses a risk for paramedics of being misunderstood in National Board-initiated investigations, being misjudged by authorities, stakeholders and the public, and thus not being supported when prioritising one\u0026rsquo;s own safety.\u003c/p\u003e \u003cp\u003eAs Campeau points out, decisions are not made in a vacuum, and an paramedics\u0026rsquo; perception of what is an acceptable risk is influenced by the broader societal responses. As mentioned, the PLIVO procedure has influenced the perception of \u0026ldquo;acceptable risk\u0026rdquo; for paramedics, and public discussions between the health sector and legal sector in Norway indicate that the Police expect paramedics to rely less on the police support in situations that can be perceived as risky for paramedics but have not yet escalated. This is due to limited resources combined with an increase in the number of police involvement in situations where people experiencing mental illness and substance use ned medical attention. (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e) These discussions go in favour of paramedics accepting more risks. Although the paramedic literature has raised concerns about the risks of WPV (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan additionalcitationids=\"CR31 CR32\" citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e), and co-response teams have been explored in many places (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e), there is little discussion of the risks that paramedics are supposed to accept. There is also a void of documented, implemented, and effective mitigation strategies for WPV.\u003c/p\u003e \u003cp\u003eI argue that to find effective and efficient mitigation strategies, a broader societal discussion is needed to clarify role expectations, clarify what should be considered acceptable and unacceptable risks for paramedics, and clarify who gets to decide when a risk is acceptable or not. In such discussions, a solid understanding of the prehospital context is essential. Hospital managers, legal experts and policy makers need to include paramedics\u0026rsquo; perspectives, and, as pointed out by Morrison (\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e), paramedics\u0026rsquo; role should expand to include public advocacy, ethical leadership, and systems stewardship beyond the paramedic domain to start shaping the healthcare system and bring their unique and important perspectives in when policy documents are developed, interpreted and employed.\u003c/p\u003e \u003cp\u003eThe rationalised self-interest\u003c/p\u003e \u003cp\u003eThe rationalised self-interest, described by Campeau as a strategy to guide decision-making, allows paramedics to believe that their own safety is a prerequisite to assisting the patient. This allows for a \u0026ldquo;paramedic's first\u0026rdquo; approach, meaning that the paramedic's safety is a priority. The results presented in this paper suggest that when the risk was considered elevated, paramedics exercised discretion to determine whether the risk was acceptable. If it was unacceptable, they would delay their approach and treatment of the patient until an acceptable level of risk could be ensured. The difficult part, however, is to decide whether it is an unacceptable risk. Campeau highlights that paramedics see themselves as rescuers, and when they are unable to help, this undermines their role and may lead to a sense of \u0026ldquo;losing face\u0026rdquo;. The willingness to help patients was evident in this study, but it was rarely explained by their fear of \u0026ldquo;losing face\u0026rdquo;.\u003c/p\u003e \u003cp\u003eHowever, to discuss the balance between risks and safety, I utilised the results from this study and constructed a visualisation that I have called the Paramedic Risk Matrix for Workplace Violence (hereby referred to as \u0026ldquo;The Paramedic Risk Matrix) (see Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The Paramedic Risk Matrix, explained in more detail below, can spark discussions and raise awareness about the rationalised self-interest and help argue for the rationale behind prioritising one\u0026rsquo;s own safety. The Paramedic Risk Matrix was developed based on the results from this study, but it is not scientifically tested. This remains for future studies. However, by discussing situations in light of the Paramedic Risk Matrix, it is possible that the matrix can help paramedics argue more precisely for their safety assessment and thus management. It can help clarify, through discussions and reflections, when risks are perceived as unacceptable and could be helpful for clarifying role expectations and the rationale for prioritising one\u0026rsquo;s own safety.\u003c/p\u003e \u003cp\u003eThe Paramedic Risk Matrix for Workplace Violence\u003c/p\u003e \u003cp\u003eBased on the results, we interpreted that risk assessments and decisions to engage or prioritise own safety were often made mainly based on two aspects that were weighed against each other: 1) the potential gain for the patient (the acuity, vulnerability, and risk of deterioration of the patient\u0026rsquo;s condition) and 2) the possible consequences for paramedics. Consequences for paramedics were, as shown in the results section, usually discussed as physical or psychological injury, but also as the risk of being investigated for adverse outcomes and not being understood or supported by managers, legal experts, other allied health professionals, or stakeholders. In the Paramedic Risk Matrix, I seek to illustrate the consequences for health outcomes only and to increase awareness of how these assessments have implications for risk management.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eIn contrast to many other assessment matrices used in healthcare and beyond (\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e), the Paramedic Risk Matrix does not rely on probability estimates and likelihood for WPV. Rather, it focuses on how the patient's health gains and the health consequences for paramedics together can inform whether the risk of WPV is perceived as acceptable or unacceptable from a paramedic perspective.\u003c/p\u003e \u003cp\u003eThe model comprises the two axes \u0026ldquo;expected health gains for the patient\u0026rdquo; and \u0026ldquo;possible health consequences for paramedics\u0026rdquo;. We suggest that \u0026ldquo;health\u0026rdquo; can be understood as physical or mental health, or a combination of these. The verbal indicators on the x-axis in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e must be interpreted as a discretionary assessment to the question: based on your best judgment in the situation, what can be the consequences to your health if you enter this scene now? The answer can be somewhere on the continuum between \u0026ldquo;no consequences\u0026rdquo; and \u0026ldquo;death\u0026rdquo;. The categories \u0026ldquo;no consequences\u0026rdquo;, \u0026ldquo;minor consequences\u0026rdquo;, \u0026ldquo;moderate consequences\u0026rdquo; and \u0026ldquo;serious consequences\u0026rdquo; are included for reference and clarity and are not meant to be precise cut-off levels. Similarly, the Y-axis must be interpreted as a discretionary assessment to the question: based on your best judgment in the situation, what can be the health gain for the patient if you enter this scene now? (no health gain, negligible health gain, small health gain, moderate gain, crucial health gain, preventing death). As our results indicate, personal differences such as training, size, gender, the proximity of further support and contextual factors are likely to influence the potential consequences in different situations. These assessments will be part of the discretionary decision on where on the x-axis one would put oneself.\u003c/p\u003e \u003cp\u003eThe colours in the model indicate how risk is perceived on a spectrum, from acceptable (green) to unacceptable (black). Again, the colours do not indicate an absolute scientific answer to how the risk is assessed. Rather, the model should be used as a visualisation of how paramedics usually balance their own safety and the patient's care. This can be tested and perhaps used to discuss, reflect and increase awareness and understanding of what constitutes acceptable and unacceptable risks from a paramedic perspective. It is likely and reasonable that there will be differences in opinions about which colour is the correct one in each cell. Still, we propose the Paramedic Risk Matrix as a helpful tool for discussions among clinicians, managers, and stakeholders. In the future, the model could be developed and tested further to support or falsify its practical use, and its ability to increase awareness about risks and safety, and help justify paramedics\u0026rsquo; decisions to prioritise safety when the gain for the patient is low, and the potential consequences for paramedics are high. We do not suggest a clear-cut-off between different colours in the Paramedic Risk Matrix. Instead, we want to illustrate that the acceptable and unacceptable risks are considered relative to the expected gains and potential consequences, as determined by the paramedics at the site, using their best discretion. Thus it can help support paramedics decisions.\u003c/p\u003e \u003cp\u003eTo assess which point on the x and y axes best represents the situation on the scene, paramedics needs to use their best professional discretion, and by using this illustration risk assessments are based on the potential health benefit for the patient and the potential health risk for the AC. This is in coherence with how several respondents argued when making difficult discretionary risk assessments on the scene. The Paramedic Risk Matrix is useful in discussing, visualising and communicating risks and the need for safety measures.\u003c/p\u003e \u003cp\u003eAmong safety scientists, the focus has earlier been on unsafe activities or system operations, such as failures, accidents and losses, rather than on safe activities or operations. This is referred to as the Safety I perspective. (\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e) From a Safety I perspective, it presumes that things go wrong because of identifiable errors or failures in procedures, human workers, technology and the organisation in which they are embedded. (\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e) Following the safety I approach, a response is needed when something happens, or the risk is judged unacceptable, typically involving the elimination of the cause, improved barriers, or both. (\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e) This thinking is in contrast to the Safety II perspective, in which safety is seen as the ability to succeed under varying conditions. From a Safety II perspective, humans are viewed as resources necessary to achieve safety, focusing on a proactive approach that continuously seeks to anticipate developments and events. A Safety II perspective requires an ability to manage performance variability. Subsequently, a Safety III perspective focuses on freedom from unacceptable losses. Rather than a simple linear system and cause-and-effect relationship between errors and risks, the Safety III perspective focuses on hierarchical socio-technical systems, emphasising system theory for handling complexity. (\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e) The Paramedic Risk Matrix can be used systematically to facilitate a broader discussion on safety for paramedics in a prehospital context and function as a system theory for discussing risky situations.\u003c/p\u003e \u003cp\u003eAwareness and new insights gained through discussions around the Paramedic Risk Matrix may mitigate unacceptable losses, prevent hazards, and facilitate safety measures in situations where paramedics would otherwise take risks. This is because they can find support in the model for their decisions to prioritise their own safety when the risk is unacceptable. Consequently, the Paramedic Risk Matrix may assist risk assessments in hierarchical, complex social environments where paramedics lack tools to communicate risks to stakeholders who have less insight and understanding of their work environment.\u003c/p\u003e \u003cp\u003eIn this study, we have identified and presented multiple factors that influence paramedics\u0026rsquo;\u0026rsquo; risk-taking, risk assessment, and risk management. The results indicate that similar situations are perceived differently. Moderating these factors has the potential to influence where on the x and y axes paramedics places the situation in the scene. Consequently, these factors influence where on the continuum between acceptable and unacceptable the risk is perceived to be. The identified influencing factors indicate to paramedics, ambulance service managers and stakeholders where they can focus their efforts to mitigate risky behaviour among paramedics and instead contribute to building a paramedic safety culture.\u003c/p\u003e \u003cp\u003eThe prehospital medical emergency work can never be free from risks, and not all WPV incidents are avoidable. Still, from a Safety III perspective, it makes sense to avoid unacceptable losses, thus reflecting on unacceptable risks rather than a simple \u0026ldquo;safety-first\u0026rdquo; perspective. What constitutes \u0026ldquo;unacceptable losses\u0026rdquo; is, according to the Safety III perspective, determined by the system stakeholders and as we have discussed above, the discussion on unacceptable risks, and thus potential losses, is missing for the social context where paramedics work in the prehospital environment (\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eStrengths and limitations\u003c/p\u003e \u003cp\u003eThe credibility and trustworthiness of this study are strengthened by the researcher's familiarity with the prehospital culture and context, and the discussions of the results with ambulance service managers and paramedics served as a peer debriefing, supporting the researcher's reflexivity and facilitating a broader understanding and interpretation of the results. Credibility is also strengthened by the study's aim, grounded in an experienced clinical problem, supported by a research gap in the literature, and informed by the information-rich interviews. The findings are based on a small sample from one regional ambulance service in Norway, which limits transferability but strengthens the credibility of the results being relevant in similar social cultures. The sample consisted of paramedics with a broad variation of experiences, education, gender, and age, which strengthens the transferability to similar social and cultural contexts. The researcher's informed outsider perspective may contrast with that of an insider, but may also add new perspectives. Input from insiders and na\u0026iuml;ve outsiders strengthens the credibility of the results.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eParamedics\u0026rsquo; willingness to help patients, combined with their perceived role expectations and stakeholders\u0026rsquo; lack of understanding of their work context, influences how risks for violence are assessed and managed by paramedics. Despite their gut feeling and clinical experience, many struggle to describe, convey and document risks for violence sufficiently to the police, General Practitioners (GPs), hospital staff and managers. This leads to difficulties getting support for their decisions to prioritise safety. The lack of understanding among stakeholders of prehospital risks within the paramedic social context is problematic, and the lack of consensus among stakeholders and paramedics regarding which risks are acceptable and which are not complicates risk assessments and management. The Paramedic Risk Matrix for WPV should be tested for education and training, as it may help raise awareness and spark discussions regarding when risks are perceived as unacceptable. It may be helpful for clarifying role expectations. Further research is needed to explore the use of the Paramedic Risk Matrix for WPV in training and education, and to further explore how WPV for paramedics can be mitigated.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eEMC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eEmergency Medical Service\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eEMCC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eEmergency Medical Call Center\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eGP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eGeneral Practitioners\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSCTPSM\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSpace Control Theory of Paramedic Scene Management\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\u003eWork place violence\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthical approval and consent to participate\u003c/p\u003e\n\u003cp\u003eThe study was approved by the Norwegian Agency for Shared Services in Education and Research (SIKT) (ref. no. 170712) and the local data protection officer at Vestre Viken Hospital Trust (ref. no. 23/05574-4). All participants voluntarily gave their written consent to participate in the study and to communicate and comprehend the information they provided. According to the Norwegian Health Research Act, the scope of this study falls outside the scope of the act, and ethical\u0026nbsp;approval is not required. In compliance with the Norwegian Health Personnel Act, participants avoided disclosing identifiable patient information or that of any third person. The project complies with local regulations for research, data storage and privacy protection.\u003c/p\u003e\n\u003cp\u003eConsent for publication\u003c/p\u003e\n\u003cp\u003eParticipants provided their oral and written consent to the use of anonymised data in publications.\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analysed during the current study are not publicly available due to a significant amount of indirectly identifiable data, but are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003eCompeting interest\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003eFunding\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003eAuthor\u0026rsquo;s contribution\u003c/p\u003e\n\u003cp\u003eThe author (KH) is responsible for the design, data collection, analysis and writing of the paper. Contributions from researchers who do not meet the authorship requirements are acknowledged in the acknowledgement section.\u003c/p\u003e\n\u003cp\u003eAcknowledgement\u003c/p\u003e\n\u003cp\u003eFirst of all, I want to thank all respondents who shared their valuable experiences and contributed to this study. This would not be possible without you. I also give thanks to the ambulance service and prehospital clinic that supported this study, helping us disseminate information and encourage participation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eA special thank you goes to Jon Richard Figenschou, Head of Quality and Health Safety and Environment at Vestre Viken Ambulance Service, and Birgitte Larsen, Paramedic and Head of Section for Competence development at Vestre Viken Ambulance Department, for their support in discussing the results and providing valuable feedback on the manuscripts. I also want to give my sincere thanks to Professor Ole Martin Moen at Oslo Metropolitan University for contributing to correcting transcriptions and for discussing initial themes during the familiarisation phase, and for discussing initial codes in the third analytic phase. No substantial contribution to the final analysis was made. Thank you for your time and effort.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFinally, I would like to express my gratitude to Oslo Metropolitan University for supporting the time spent on this research project and to all my colleagues who contributed with feedback and discussions on the findings.\u003c/p\u003e\n\u003cp\u003eAuthors\u0026rsquo; information\u003c/p\u003e\n\u003cp\u003eKH has many years of clinical experience as an Emergency nurse, but has never worked as a paramedic. She is an experienced researcher in health services research and qualitative methods, among others. She has worked on paramedic education since 2020 and is engaged in research on ambulance services and paramedic education.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eFricke J, Siddique SM, Douma C, Ladak A, Burchill CN, Greysen R, et al. Workplace Violence in Healthcare Settings: A Scoping Review of Guidelines and Systematic Reviews. Trauma, Violence. Abuse. 2023;24(5):3363\u0026ndash;83.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePaulin J, Lahti M, Riihim\u0026auml;ki H, H\u0026auml;nninen J, Vesanen T, Koivisto M, et al. The rate and predictors of violence against EMS personnel. BMC Emerg Med. 2024;24(1):200.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShabanikiya H, Kokabisaghi F, Mojtabaeian M, Sahebi T, Varmaghani M. Global prevalence of workplace violence against paramedics: a systematic review and meta-analysis. 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Reliab Eng Syst Saf. 2022;217:108077.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Paramedicine, Ambulance, Violence, Safety, Risk assessment, Risk management, Workplace violence, occupational violence, prehospital","lastPublishedDoi":"10.21203/rs.3.rs-9233243/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9233243/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Despite growing awareness, workplace violence (WPV) against paramedics is a persistent and complex problem that threatens staff safety and quality of patient care. There is a lack of implemented, efficient, and effective mitigation strategies. To identify such strategies that can inform training and education, we use paramedics' experiences to explore their reasoning before, during and after a violent episode. This study aims to explore paramedics’ lived experiences and to examine how they perceive individual and contextual factors that influence risk assessments and management.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethod:\u003c/strong\u003e An episodic narrative interview approach was employed to elicit paramedics’ narratives of WPV and their broader reflections, in a Norwegian context. Data were analysed inductively using thematic and interpretive narrative analysis. Peer-debriefing was used to increase the credibility and trustworthiness of interpretations of results.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e Six main themes were identified: internal motivation to provide care, becoming “speed blind”, challenges in conveying risk assessments, the importance of documenting risk assessments, paramedics' perceived role in the hierarchy, and the handling of reported incidents.\u003c/p\u003e\n\u003cp\u003eFrom these insights, I propose the \u003cem\u003eParamedic Risk Matrix for WPV\u003c/em\u003e to visualise and raise awareness on how paramedics often balance risks and gains and make discretionary decisions. I discuss how the Paramedic Risk Matrix for WPV may be used for training and education to increase students' awareness of how they conduct risk assessments. Further studies are needed to assess the practical use of the Paramedic Risk Matrix for WPV, to determine whether it helps paramedics be more aware of their risk assessments and thus enables them to better argue, communicate and document their reasoning.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e Paramedics’ responses to WPV are grounded in complex, context-dependent reasoning that balances ethical, legal, emotional, and professional factors. Although paramedics discretionarily balance their own safety with the patient’s needs, there are large variations in paramedics' and other stakeholders’ perceptions of what constitutes acceptable and unacceptable risks. This has informed the Paramedic Risk Matrix for WPV, which may enhance awareness and reflection, and spark discussions on how acceptable or unacceptable risks are assessed and managed, but its practical use needs to be tested. The insights from this study may, however, inform future studies and inform more realistic prevention strategies, organisational support systems, and policy development.\u003c/p\u003e","manuscriptTitle":"Workplace Violence: How can paramedics prioritise their own safety?","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-05-09 00:09:39","doi":"10.21203/rs.3.rs-9233243/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewersInvited","content":"","date":"2026-04-24T13:09:14+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-03-31T06:26:16+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-30T03:15:47+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-30T03:15:22+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Education","date":"2026-03-26T10:55:46+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"2ebdd818-1e65-493f-8e0a-bd0ef8291e92","owner":[],"postedDate":"May 9th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-09T00:09:39+00:00","versionOfRecord":[],"versionCreatedAt":"2026-05-09 00:09:39","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9233243","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9233243","identity":"rs-9233243","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}