Towards a Paramedic Risk Matrix: Exploring workplace violence through ambulance clinicians’ narratives

Towards a Paramedic Risk Matrix: Exploring workplace violence through ambulance clinicians’ narratives | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Towards a Paramedic Risk Matrix: Exploring workplace violence through ambulance clinicians’ narratives Häikiö, Kristin This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7887148/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Workplace violence (WPV) against ambulance clinicians (ACs) is a persistent and complex problem that threatens staff safety, health and quality of patient care. Despite growing awareness, limited attention has been given to how paramedics reason and manage risks of WPV. Aim: This study aimed to explore ACs' lived experiences of WPV in the prehospital context and how they perceive individual and contextual factors influencing risk assessments and management. Method: An episodic narrative interview approach was employed, involving 10 paramedics exposed to WPV, to elicit narratives of WPV and broader reflections. Data were analysed inductively, drawing on thematic and interpretive narrative analysis. Peer-debriefing was used to increase the credibility and trustworthiness of interpretations. Results: Participants’ narratives revealed individual differences and changes throughout their careers in how they assessed the risk for WPV. A combination of internal willingness to help, situational awareness, professional duty, moral reasoning, and intuitive judgment influenced their assessments. In addition, challenges in conveying and documenting risk assessments, perceptions of being misunderstood by stakeholders, feeling low-ranked, and not being supported by managers challenged their risk management. Perceptions among paramedics and their stakeholders on what constitutes acceptable and unacceptable risks challenged risk management. From these insights, a conceptual framework—the Paramedic Risk Matrix for Workplace Violence —was developed. The model, based on paramedics' experiences and reasoning, can be useful for sparking discussions among and beyond paramedics on what are considered acceptable and unacceptable levels of risk in paramedic practice. Conclusion: ACs’ responses to WPV are grounded in complex, context-dependent reasoning that balances ethical, emotional, and professional factors. Understanding how paramedics construct and manage risk can inform more realistic prevention strategies, organisational support systems, and policy development. The Paramedic Risk Matrix offers a practical tool to guide reflection, training, and decision-making in WPV management within paramedicine. Critical Care & Emergency Medicine Nursing Paramedicine Paramedic 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 ACs, and a systematic review examining EMS workers found rates between 57–93% for verbal and/or physical violence. (12, 13) There is a lack of consensus on the definitions of WPV. Still, it is defined by the European Agency for Safety and Health at Work (EU-OSHA) 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) There is a gap in the literature regarding why WPV occurs and how to 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 ACs' 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 implemented effective prevention and mitigation strategies, prompting this study to explore paramedics’ experiences and identify possible solutions applicable to ambulance service managers and ACs. We used the results to propose and discuss a theoretical model for risk assessment, the Paramedic Risk Matrix for Workplace Violence. Thus, this paper presents a theoretical model and contributes valuable knowledge that can inform more effective 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 inspired by Episodic narrative interview methodology In this hermeneutical-phenomenological case study, we explored “workplace violence” through the lens of paramedics' lived experiences. Identity, the social environment, and the organisational culture contextually influence experiences. (23) In this case, the participants’ narratives were interpreted within the social context of ACs working in an ambulance service in Norway. Episodic narrative interviews were conducted to elicit focused, firsthand and context-rich experiences of WPV and invited participants to reflect on these. To support reflections, we honoured the listening process in a dialogic interview format, using semi-structured interview guides to deepen our understanding of the phenomenon. (24) Recruitment and description of the sample Service quality coordinators, in a large ambulance service in Norway, distributed information about the study to all AC 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, who would otherwise not respond to an open invitation and ensure maximum variation of age, gender and experiences. Recruitment continued until we 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. (25) The population of AC is small. Thus, there is a risk of identification if respondents' exact characteristics are presented. Consequently, we present a few variables from each individual, and the gender of some respondents is changed to reduce the risk of identification. The proportion of each gender remains unchanged. To further avoid identification, we 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, we 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 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. (24) We expected research participants to have a heterogeneous understanding of and definitions of “workplace violence” and “violence”. In our interviews, we 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. (24) The first six interviews were conducted face-to-face in a facility chosen by participants, usually the participants’ home or a public place, such as the library or at of the local universities. Four interviews were conducted digitally. All interviews were conducted individually by the first author, lasting between 60 and 90 minutes. The first author holds a PhD in health sciences, has several prior experiences with qualitative research interviews and works with paramedic education in Norway. She has 15 years of clinical experience as an emergency nurse, but no clinical experience working within ambulance services. The analysis was inductive and data-driven and followed reflexive thematic analysis (26), iteratively moving through familiarisation, coding, theme development/review, and write‑up, with regular peer discussion. For details about the analysis and the author’s reflexivity, see the supplementary file. Ethics Participants gave their voluntary, written, informed consent to participate in the study and the publication of results where participants cannot be identified. Interviews were audio recorded, and encrypted data was transferred and stored on TSD, a secure storage server approved for storing sensitive data. (27) The computer software Whisper was used for auto-transcription. (28) Data access was restricted to two researchers. 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 Vestre Viken Hospital Trust (ref. no. 23/05574-4). Interviews avoided identifiable information about the patients, and the project complies with local regulations for research, data storage and privacy protection. The context Norwegian ambulances are typically staffed with two trained ACs and 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. 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. The term “paramedic” is used interchangeably with the term “ambulance clinician” in this paper. 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, episodes with weapons, verbal threats 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 ACs' lived experiences in the prehospital social context and their perceptions of individual and contextual factors influencing WPV risk assessments and management, we 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) Ambulance clinicians’ 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 ACs’ 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 ACs’ experienced inner moral responsibility to help. Despite saying that safety was their first priority, most respondents, when talking about their assessments in relation to their experiences, expressed an inner moral obligation to help first, followed by self-risk assessments secondly. Ursula said it like this: P8: 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. (Ursula) Although participants mentioned expectations from bystanders, managers, local authorities and legal duties as factors affecting them in their work, several said explicitly that their inner moral duty to help was the strongest motivation to enter the scene. Consequently, ACs' 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: P11: 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. K11: yes, right? One involves risk for you, the other is risk for the patient. How do you weigh it up against each other? P11: Yes, good question. It's very difficult. K11: But you've probably done it many times? P11: Yes, and that's the way it is, maybe the assessments I make the most are in relation to can I hold you back? K11: yes, size and physique? P11: 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, to think a little about 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. (Morten) 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 had a larger willingness to handle situation that had the potential to escalate, than others and respondents narratives described that some were willing to use physical restraints of the patient if de-escalation failed, while others were not. The use of physical restraints was typically if they assessed the situation to be manageable, considering the size of the patient, the surroundings and other persons available. 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» (Silvia) It was more common to describe a higher threshold for requesting police support among some of the participants and this seemed to be related to their assessment of the potential consequences the situation would pose 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 being more considerate of safety measures, many also seemed to have developed a tolerance for many types of behaviour that, for most people, would be considered violent. This impression was confirmed by Silvia: P7: 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. This can be understood as a “speed-blindness”, meaning that ACs 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 affects ACs 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 AC’s role and their unawareness of the limited training ACs have in handling escalated situations as an underlying reason for the lack of police support. P4: 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. (Elizabeth) The AC’s lack of training to describe risks and communicate them effectively to the Police was mentioned by some respondents. Some talked about their “gut feeling” but also how they were unable to describe what this meant in a professional language when asking for police support. P3: 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. (Magnus) Being understood by other healthcare professionals The lack of understanding among other healthcare professionals about the prehospital environment and its impact on the risks and consequences of WPV was highlighted by many respondents. Several emphasised that the situation inside a hospital or doctor's office differs significantly from prehospital context. The below quote illustrates some differences which the respondent did not think the physician was aware of. P3: Yes. Then there's a doctor there who says, like, “no, this is fine”. 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. (Magnus) 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 ACs. Several pointed out that if ACs 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. P3: [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. K3: 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. P3: 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 mad 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 that the EMCC and the ACs assessed to have a high risk of violence if they approached, but they chose to approach the scene carefully: K10: 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? P10: Then I will have documented it very well in the journal. K10: What do you imagine you could have written then? P10: 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. (Kathryn) Several mentioned that they felt unease regarding 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, several participants said they documented risks in everyday work, hoping to help facilitate improvements in work safety. Altogether, this illustrates the importance of documenting risk assessments and risk management. Ambulance clinicians' perceived role in the hierarchy Many mentioned that they felt inferior to other professionals, such as physicians, EMCC operators, and hospital nurses. Many felt they had no choice or influence over the decisions regarding patient transportation. P3: 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. (Magnus) This feeling of being inferior affected their risk management, as they often perceived themselves as not having 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: K7: So you feel obligated to at least investigate? P7: Yes, investigate and take him with us. K7: Both? P7: 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. K7: Why did you think that? Do you have any ideas about why? P7: I think people are afraid to [go] against what the EMCC says. Yes, I don't think you really know the consequences of that. (Silvia) 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: P5: 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 the legal experts contrasted with the effort made by managers and ACs to illuminate 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. K8: But what's crucial there [whether it's reported or not], you know? About what they [the health trust] choose to do? P8: 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? (Ursula) Similar to Ursula’s experience, Mark expressed being discouraged from reporting incidents despite the manager's encouragement. P6: 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. (Mark) Discussion Based on ACs' narratives and reflections, this study has identified several factors, a mix of internal and external factors intertwined, 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) the 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, ACs 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. (29) 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 (29, 30). Campeau’s SCTPSM described five categories of social processes, where the first category is “establishing a safety zone”. (29) Subsequently, as our respondents constantly sought to ensure safety, the SCTPSM provides a useful theoretical lens for interpreting the results of this study. In the following discussion, we will start with utilising Campeau’s first category, “establishing a safety zone”, with 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 As described as the what-if strategy, the results in this study show that, despite differences in experience, background, skills, and role expectations, participants assessed the scene and made risk assessments based on a willingness to help combined with a suspicious and cautious orientation to potential hazards. As Campeau mentions, ACs “define the situation in high-risk terms and subsequently take actions to make the risks manageable” (29 p. 292). Our study indicates that making risks manageable was perceived as difficult for many. Participants’ reasoning behind their help-willingness, and their weighting of the potential health gains, consequences and risks varied and affected how the what-if strategy was applied. This was moderated by the “speed-blindness” which occurred after concurrent exposure to crises. Combined with the perceived support from stakeholders, these factors seemed to affect the clinical risk assessment and management, and subsequently, the reasoning behind the what-if strategy. Complicating this further, the results indicate that ACs struggle to convey and document risks and find it challenging to ensure sufficient support for what they perceive to be unacceptable risks. Consequently, their what-if strategy is strongly influenced by factors outside of their control, thus emphasising the need for collaboration across professions and sectors to mitigate risks of violence for paramedics in clinical prehospital work. It is unlikely that AC can work without any risks, but in Norway and beyond, the discussion on what constitutes acceptable or unacceptable risks for ACs is lacking. Different stakeholders have different perceptions of what risks ACs are expected to take. For example, we have identified perceived disparities between AC and hospital managers, as well as between AC and the Police. The acceptance of AC 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 AC are expected to take increased risks to protect the public. (31) The PLIVO procedure represents an example of governmental role expectations and other stakeholders for AC 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 AC are acceptable. AC have reported incidents that are clearly dangerous and have the potential to hurt them physically and mentally. It is well described 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. (32, 33) 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. 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. By the author’s experience, who has worked with paramedic education for several years, the public’s understanding of the paramedic education and thus the role of AC is also lacking. The lack of knowledge of AC 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 AC’s 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. (34–36) The paramedic role has developed rapidly in many countries. (37) It is no surprise that there is a lack of updated knowledge among policy makers and stakeholders of the paramedic role and the nature of their work. It is problematic when legal assessments are decided by individuals who outrank AC in education and have access to information that AC did not possess. The various opinions and lack of consensus on what are acceptable or unacceptable risks, as well as a lack of understanding of the AC role and context among stakeholders, make AC decisions vulnerable. It is therefore risky for AC to trade off patient care and prioritise their own safety. The risk is being misunderstood and misjudged by authorities, stakeholders and the public. As Campeau points out, decisions are not made in a vacuum, and an AC’s 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 AC, and public discussions between the health sector and legal sector in Norway indicate that the Police expect AC to rely less on Police support 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. (38) These discussions go in favour of ACs accepting more risks. Although the paramedic literature has raised concerns about the risks of WPV (7, 19, 23, 30–33), there is a lack of discussion about the risks that AC are supposed to accept, as well as a lack of documented, implemented, and effective mitigation strategies for WPV. Consequently, a broader societal discussion is needed to clarify what should be considered acceptable and unacceptable risks for ACs and who gets to decide what. In such discussions, a solid understanding of the prehospital context is essential. Hospital managers, legal experts and policy makers need to include AC’s perspectives, and, as pointed out by Morrison (39), AC’s 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 used to guide decision-making, allows AC to think that their own safety is a prerequisite for being able to assist 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, AC used discretion to decide whether the risk was acceptable or not. 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 was an unacceptable risk or not. Campeau highlights that ACs see themselves as rescuers, and when they are incapacitated from helping, this undermines their role and may inflict a sense of “losing face”. The willingness to help patients was also evident in this study. With a significant desire to help and a willingness to take various risks, making discretionary risk assessments based on unclear support from stakeholders such as the police, physicians, managers, hospital staff, and legal advisors made prioritising one's own safety challenging. To discuss this balance between risks and safety, we let ourselves be inspired by the results in this study and developed a theoretical model, which we call the Paramedic Risk Matrix for WPV (hereby referred to as “The Paramedic Risk Matrix) (see Fig. 1 ). The Paramedic Risk Matrix, explained below, can help clarify when risks are perceived as unacceptable and is helpful for discussions and clarifying role expectations. Based on the analysis and 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 ACs. Consequences for ACs were usually talked about as serious injury or death, but also the risk of being investigated for adverse outcome and not being supported by the managers, legal experts, other allied health professions or stakeholders. The Paramedic Risk Matrix for Workplace Violence In contrast to many other assessment matrices used in healthcare and beyond (40), the Paramedic Risk Matrix does not rely on probability estimates and likelihood for WPV. Still, it focuses on how the health gain for the patient and the health consequences for AC together indicate if the risk for WPV is acceptable or unacceptable. The model comprises the two axes “expected health gains for the patient” and “possible health consequences for AC”. We suggest “health” can be understood as physical or mental health, or a combination of these. 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 “minor consequences”, “minor consequences”, “moderate consequences” and “serious consequences” are included for reference and clarity and are not meant to be a precise cut-off level. Similarly, the Y-axis must be interpreted as a discretionary assessment to the question: based on your best judgment of the patient, will your immediate help represent a significant health gain for the patient? (no health gain, negligible health gain, small health gain, moderate gain, crucial health gain, preventing death) The colours in the model indicate how risk is perceived on a spectrum, from perceived as acceptable (green) to perceived as unacceptable (black). Again, the colours do not indicate an absolute opinion on how the risk is assessed. Rather, the model should be used as a theoretical model to discuss and increase our understanding of what constitutes acceptable and unacceptable risks. Cultural differences, differences in training and contextual factors are likely to influence 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 into a support tool for AC to create awareness about their risks and safety, and help justify their decisions to prioritise safety when the gain for the patient is low and the potential consequences for AC 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 AC at the site, using their best discretion. To assess which point on the x and y axes best represents the situation on the scene, AC needs to use their best professional discretion. They will need to use their what-if strategy to assess the gain for the patient and the consequences for themselves. By using this theoretical model, 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. (41) 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. (41) 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. (41) 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. (41) The Paramedic Risk Matrix can be used systematically to facilitate a broader discussion on safety for ACs in a prehospital context and function as a system theory for handling and discussing risky situations. Awareness and new insights gained through discussions around the Paramedic Risk Matrix can mitigate unacceptable losses, prevent hazards, and facilitate safety measures in situations where AC 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 has the potential to assist risk assessments in hierarchical and complex social environments where ACs lack tools for communicating risks to stakeholders with less insight and understanding of their work environment. In this study, we have identified and presented multiple factors that influence ACs’ 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 AC 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 ACs, ambulance service managers and stakeholders where they can focus their efforts to mitigate risky behaviour among AC 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 AC work in the prehospital environment (41) 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 as the aim of the study is based on an experienced clinical problem, supported by the research gap in the literature, and the information-rich interviews. The findings are based on a small sample from a regional ambulance service in Norway, which limits transferability. However, the sample consisted of paramedics with a broad variation of experiences, education, gender and age, which strengthens the transferability, and the results can be a starting point for further investigations in a broader prehospital context. Conclusion AC’s willingness to help patients, combined with their perceived role expectation and stakeholders’ lack of understanding of their work context, influences how risks for violence are assessed and managed by ACs. Despite their gut feeling and clinical experience, they struggle to describe, convey and document risks for violence sufficiently to the police, GPs, hospital staff and managers. This leads to difficulties getting support for their decisions to prioritise safety. The lack of understanding among stakeholders of the prehospital risks within the paramedic social context is problematic, and the lack of consensus among stakeholders and ACs regarding what are acceptable and unacceptable risks complicates risk assessments and management. The theoretical model, The Paramedic Risk Matrix, can help clarify when risks are perceived as unacceptable and is helpful for discussions regarding risk assessment, risk willingness and clarifying role expectations. Further research is needed to explore the use of the Paramedic Risk Matrix and to further explore how WPV for paramedics can be mitigated. Declarations 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 HSE, Ambulance Service Vestre Viken HF and Birgitte Larsen, Paramedic, Head of Section for Competence development, Ambulance Department, Vestre Viken HF, for their support in discussing results and providing valuable feedback on the manuscripts. I also want to give my sincere thank you to Professor Ole Martin Moen for contributing to correcting transcriptions and discussing preliminary codes and themes. Thank you for your time and effort. Finally, 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. Declaration of conflicting interest The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Funding statement The author received no financial support for the research, authorship, and/or publication of this article. Ethical approval and informed consent statements 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 act, and ethical approval is not required. Complying with the Norwegian Health Personnel Act, participants avoided identifiable information of patients or any third persons. The project complies with local regulations for research, data storage and privacy protection. Data availability statement Verbatim interview transcripts contain a significant amount of indirectly identifiable data that we are not allowed to share. Consequently, the data is not available for sharing. Any other identifying information related to the authors and/or their institutions, funders, approval committees, etc, that might compromise anonymity. Only anonymised quotes have been shared with ambulance service managers and colleagues when providing input to this paper. Ambulance service managers and hospital managers have not influenced the findings presented in this paper og limited this research in any way. References Fricke J, Siddique SM, Douma C, Ladak A, Burchill CN, Greysen R, Mull NK. Workplace Violence in Healthcare Settings: A Scoping Review of Guidelines and Systematic Reviews. Trauma, Violence, & Abuse. 2023;24(5):3363-83. Paulin J, Lahti M, Riihimäki H, Hänninen J, Vesanen T, Koivisto M, Peltonen L-M. The rate and predictors of violence against EMS personnel. 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Brage: University of Stavanger; 2016. Corbett SW, Grange JT, Thomas TL. Exposure of prehospital care providers to violence. Prehosp Emerg Care. 1998;2(2):127-31. Gjelsten M, Nielsen NS, Øygard T. Vold og trusler mot ambulansepersonell - en del av jobben (violence and threaths against ambulance clinicians - a part of the job). Oda archive: Oslo Metropolitan University (OsloMet); 2019. Häikiö K, Bergem AK, Holst Ø, Thorvaldsen NØ. Ambulance personnel use of coercion and use of safety belts in Norway. BMC Health Services Research. 2023;23(1):1303. Thorvaldsen N, Bergem AK, Holst Ø, Häikiö K. Coercion in the ambulance setting. Tidsskr Nor Laegeforen. 2022;142(14). Feerick F, Coughlan E, Knox S, Murphy A, Grady IO, Deasy C. Barriers to paramedic professionalisation: a qualitative enquiry across the UK, Canada, Australia, USA and the republic of Ireland. BMC Health Services Research. 2025;25(1):993. Reed B, Cowin L, O'Meara P, Wilson I. Professionalism and Professionalisation in the Discipline of Paramedicine. Australasian Journal of Paramedicine. 2019;16:1-10. Cederkvist V. Antall psykiatriopdrag forstter å øke (The number of psychiatric related assignments are still on the increase): Politiforum (Forum for the Police); 2023 [Available from: https://www.politiforum.no/psykiatri-psykiatrioppdrag/antall-psykiatrioppdrag-fortsetter-a-oke/235037. Morrison A. Transcending identity politics in paramedicine: Start shaping the health system. Paramedicine. 2025;22(4):202-4. Kaya GK, Ward J, Clarkson J. A Review of Risk Matrices Used in Acute Hospitals in England. Risk Analysis. 2019;39(5):1060-70. Aven T. A risk science perspective on the discussion concerning Safety I, Safety II and Safety III. Reliability Engineering & System Safety. 2022;217:108077. Additional Declarations The authors declare no competing interests. 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narratives\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eWorkplace 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)\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. (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 ACs, and a systematic review examining EMS workers found rates between 57–93% for verbal and/or physical violence. (12, 13)\u003c/p\u003e\u003cp\u003eThere is a lack of consensus on the definitions of WPV. Still, it is defined by the European Agency for Safety and Health at Work (EU-OSHA) 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)\u003c/p\u003e\u003cp\u003eThere is a gap in the literature regarding why WPV occurs and how to 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 ACs' 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 implemented effective prevention and mitigation strategies, prompting this study to explore paramedics’ experiences and identify possible solutions applicable to ambulance service managers and ACs. We used the results to propose and discuss a theoretical model for risk assessment, the Paramedic Risk Matrix for Workplace Violence. Thus, this paper presents a theoretical model and contributes valuable knowledge that can inform more effective 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\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e"},{"header":"Method","content":"\u003cp\u003eStudy design inspired by Episodic narrative interview methodology\u003c/p\u003e\u003cp\u003eIn this hermeneutical-phenomenological case study, we explored “workplace violence” through the lens of paramedics' lived experiences. Identity, the social environment, and the organisational culture contextually influence experiences. (23) In this case, the participants’ narratives were interpreted within the social context of ACs working in an ambulance service in Norway. Episodic narrative interviews were conducted to elicit focused, firsthand and context-rich experiences of WPV and invited participants to reflect on these. To support reflections, we honoured the listening process in a dialogic interview format, using semi-structured interview guides to deepen our understanding of the phenomenon. (24)\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 AC 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, who would otherwise not respond to an open invitation and ensure maximum variation of age, gender and experiences. Recruitment continued until we 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. (25)\u003c/p\u003e\u003cp\u003eThe population of AC is small. Thus, there is a risk of identification if respondents' exact characteristics are presented. Consequently, we present a few variables from each individual, and the gender of some respondents is changed to reduce the risk of identification. The proportion of each gender remains unchanged. To further avoid identification, we 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 refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\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\" colname=\"c1\"\u003e\u003cp\u003eAlias (gender)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAge group\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eEducation\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eAmbulance Experience\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eInterview time\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eInterview no.\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eThomas (M)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e18–34\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eHigher\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1–5 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e95 min\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEric (M)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e35–59\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eHigher\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1–5 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e84 min\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMagnus (M)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e18–34\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eLower\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026gt; 10 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e58 min\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eElisabeth (F)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e35–59\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eHigher\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026gt; 10 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e68 min\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMary (F)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e35–59\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eHigher\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e6–10 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e58 min\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMark (M)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e35–59\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eLower\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026gt; 10 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e61 min\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSilvia (F)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e18–34\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eHigher\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1–5 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e69 min\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUrsula (F)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e18–34\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eLower\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e6–10 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e74 min\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eKatryn (F)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e18–34\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eLower\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e6–10 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e77 min\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMorten (M)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e18–34\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003elower\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026gt; 10 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e65 min\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\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, we 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 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. (24)\u003c/p\u003e\u003cp\u003eWe expected research participants to have a heterogeneous understanding of and definitions of “workplace violence” and “violence”. In our interviews, we 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. (24)\u003c/p\u003e\u003cp\u003e The first six interviews were conducted face-to-face in a facility chosen by participants, usually the participants’ home or a public place, such as the library or at of the local universities. Four interviews were conducted digitally. All interviews were conducted individually by the first author, lasting between 60 and 90 minutes. The first author holds a PhD in health sciences, has several prior experiences with qualitative research interviews and works with paramedic education in Norway. She has 15 years of clinical experience as an emergency nurse, but no clinical experience working within ambulance services. The analysis was inductive and data-driven and followed reflexive thematic analysis (26), iteratively moving through familiarisation, coding, theme development/review, and write‑up, with regular peer discussion. For details about the analysis and the author’s reflexivity, see the supplementary file.\u003c/p\u003e\u003cp\u003eEthics\u003c/p\u003e\u003cp\u003e Participants gave their voluntary, written, informed consent to participate in the study and the publication of results where participants cannot be identified. Interviews were audio recorded, and encrypted data was transferred and stored on TSD, a secure storage server approved for storing sensitive data. (27) The computer software Whisper was used for auto-transcription. (28) Data access was restricted to two researchers. 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 Vestre Viken Hospital Trust (ref. no. 23/05574-4). Interviews avoided identifiable information about the patients, and the project complies with local regulations for research, data storage and privacy protection.\u003c/p\u003e\u003cp\u003eThe context\u003c/p\u003e\u003cp\u003eNorwegian ambulances are typically staffed with two trained ACs and 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\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. The term “paramedic” is used interchangeably with the term “ambulance clinician” in this paper.\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, episodes with weapons, verbal threats 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 ACs' lived experiences in the prehospital social context and their perceptions of individual and contextual factors influencing WPV risk assessments and management, we 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) Ambulance clinicians\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 ACs\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 ACs\u0026rsquo; experienced inner moral responsibility to help. Despite saying that safety was their first priority, most respondents, when talking about their assessments in relation to their experiences, expressed an inner moral obligation to help first, followed by self-risk assessments secondly. Ursula said it like this:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eP8: 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. (Ursula)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eAlthough participants mentioned expectations from bystanders, managers, local authorities and legal duties as factors affecting them in their work, several said explicitly that their inner moral duty to help was the strongest motivation to enter the scene. Consequently, ACs' 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:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eP11: 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\u003eK11: yes, right? One involves risk for you, the other is risk for the patient. How do you weigh it up against each other?\u003c/p\u003e\u003cp\u003eP11: Yes, good question. It's very difficult.\u003c/p\u003e\u003cp\u003eK11: But you've probably done it many times?\u003c/p\u003e\u003cp\u003eP11: Yes, and that's the way it is, maybe the assessments I make the most are in relation to can I hold you back?\u003c/p\u003e\u003cp\u003eK11: yes, size and physique?\u003c/p\u003e\u003cp\u003eP11: 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, to think a little about 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. (Morten)\u003c/p\u003e\u003c/div\u003e\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 had a larger willingness to handle situation that had the potential to escalate, than others and respondents narratives described that some were willing to use physical restraints of the patient if de-escalation failed, while others were not. The use of physical restraints was typically if they assessed the situation to be manageable, considering the size of the patient, the surroundings and other persons available. 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; (Silvia) It was more common to describe a higher threshold for requesting police support among some of the participants and this seemed to be related to their assessment of the potential consequences the situation would pose 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 being more considerate of safety measures, many also seemed to have developed a tolerance for many types of behaviour that, for most people, would be considered violent. This impression was confirmed by Silvia:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eP7: 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\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThe perception of threatening and potentially violent situations appears to change over time and with exposure. This can be understood as a \u0026ldquo;speed-blindness\u0026rdquo;, meaning that ACs 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 affects ACs 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 AC\u0026rsquo;s role and their unawareness of the limited training ACs have in handling escalated situations as an underlying reason for the lack of police support.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eP4: 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. (Elizabeth)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThe AC\u0026rsquo;s lack of training to describe risks and communicate them effectively to the Police was mentioned by some respondents. Some talked about their \u0026ldquo;gut feeling\u0026rdquo; but also how they were unable to describe what this meant in a professional language when asking for police support.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eP3: 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. (Magnus)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eBeing understood by other healthcare professionals\u003c/p\u003e\u003cp\u003eThe lack of understanding among other healthcare professionals about the prehospital environment and its impact on the risks and consequences of WPV was highlighted by many respondents. Several emphasised that the situation inside a hospital or doctor's office differs significantly from prehospital context. The below quote illustrates some differences which the respondent did not think the physician was aware of.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eP3: Yes. Then there's a doctor there who says, like, \u0026ldquo;no, this is fine\u0026rdquo;. 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. (Magnus)\u003c/p\u003e\u003c/div\u003e\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 ACs. Several pointed out that if ACs 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.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eP3: [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\u003eK3: 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\u003eP3: Yes. Then there's a doctor there who says, like, \u0026ldquo;no, this is fine\u0026rdquo;.\u003c/p\u003e\u003c/div\u003e\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 mad 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 that the EMCC and the ACs assessed to have a high risk of violence if they approached, but they chose to approach the scene carefully:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eK10: 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\u003eP10: Then I will have documented it very well in the journal.\u003c/p\u003e\u003cp\u003eK10: What do you imagine you could have written then?\u003c/p\u003e\u003cp\u003eP10: 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. (Kathryn)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eSeveral mentioned that they felt unease regarding 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, several participants said they documented risks in everyday work, hoping to help facilitate improvements in work safety. Altogether, this illustrates the importance of documenting risk assessments and risk management.\u003c/p\u003e\u003cp\u003eAmbulance clinicians' perceived role in the hierarchy\u003c/p\u003e\u003cp\u003eMany mentioned that they felt inferior to other professionals, such as physicians, EMCC operators, and hospital nurses. Many felt they had no choice or influence over the decisions regarding patient transportation.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eP3: 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. (Magnus)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThis feeling of being inferior affected their risk management, as they often perceived themselves as not having 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:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eK7: So you feel obligated to at least investigate?\u003c/p\u003e\u003cp\u003eP7: Yes, investigate and take him with us.\u003c/p\u003e\u003cp\u003eK7: Both?\u003c/p\u003e\u003cp\u003eP7: 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\u003eK7: Why did you think that? Do you have any ideas about why?\u003c/p\u003e\u003cp\u003eP7: I think people are afraid to [go] against what the EMCC says. Yes, I don't think you really know the consequences of that. (Silvia)\u003c/p\u003e\u003c/div\u003e\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:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eP5: 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\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThe perception that the incident had to be considered \u0026ldquo;serious enough\u0026rdquo; by the legal experts contrasted with the effort made by managers and ACs to illuminate 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.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eK8: 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\u003eP8: 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? (Ursula)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eSimilar to Ursula\u0026rsquo;s experience, Mark expressed being discouraged from reporting incidents despite the manager's encouragement.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eP6: 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. (Mark)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eBased on ACs' narratives and reflections, this study has identified several factors, a mix of internal and external factors intertwined, 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) the 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, ACs 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. (29) 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 (29, 30). Campeau\u0026rsquo;s SCTPSM described five categories of social processes, where the first category is \u0026ldquo;establishing a safety zone\u0026rdquo;. (29) Subsequently, as our respondents constantly sought to ensure safety, the SCTPSM provides a useful theoretical lens for interpreting the results of this study. In the following discussion, we will start with utilising Campeau\u0026rsquo;s first category, \u0026ldquo;establishing a safety zone\u0026rdquo;, with 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\u003eAs described as the what-if strategy, the results in this study show that, despite differences in experience, background, skills, and role expectations, participants assessed the scene and made risk assessments based on a willingness to help combined with a suspicious and cautious orientation to potential hazards. As Campeau mentions, ACs \u0026ldquo;define the situation in high-risk terms and subsequently take actions to make the risks manageable\u0026rdquo; (29 p. 292). Our study indicates that making risks manageable was perceived as difficult for many. Participants\u0026rsquo; reasoning behind their help-willingness, and their weighting of the potential health gains, consequences and risks varied and affected how the what-if strategy was applied. This was moderated by the \u0026ldquo;speed-blindness\u0026rdquo; which occurred after concurrent exposure to crises. Combined with the perceived support from stakeholders, these factors seemed to affect the clinical risk assessment and management, and subsequently, the reasoning behind the what-if strategy. Complicating this further, the results indicate that ACs struggle to convey and document risks and find it challenging to ensure sufficient support for what they perceive to be unacceptable risks. Consequently, their what-if strategy is strongly influenced by factors outside of their control, thus emphasising the need for collaboration across professions and sectors to mitigate risks of violence for paramedics in clinical prehospital work.\u003c/p\u003e\u003cp\u003eIt is unlikely that AC can work without any risks, but in Norway and beyond, the discussion on what constitutes acceptable or unacceptable risks for ACs is lacking. Different stakeholders have different perceptions of what risks ACs are expected to take. For example, we have identified perceived disparities between AC and hospital managers, as well as between AC and the Police. The acceptance of AC 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 AC are expected to take increased risks to protect the public. (31) The PLIVO procedure represents an example of governmental role expectations and other stakeholders for AC 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 AC are acceptable. AC have reported incidents that are clearly dangerous and have the potential to hurt them physically and mentally. It is well described 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\u0026ndash;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. (32, 33) 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.\u003c/p\u003e\u003cp\u003ePrioritising 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. By the author\u0026rsquo;s experience, who has worked with paramedic education for several years, the public\u0026rsquo;s understanding of the paramedic education and thus the role of AC is also lacking. The lack of knowledge of AC 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 AC\u0026rsquo;s 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. (34\u0026ndash;36) The paramedic role has developed rapidly in many countries. (37) It is no surprise that there is a lack of updated knowledge among policy makers and stakeholders of the paramedic role and the nature of their work. It is problematic when legal assessments are decided by individuals who outrank AC in education and have access to information that AC did not possess. The various opinions and lack of consensus on what are acceptable or unacceptable risks, as well as a lack of understanding of the AC role and context among stakeholders, make AC decisions vulnerable. It is therefore risky for AC to trade off patient care and prioritise their own safety. The risk is being misunderstood and misjudged by authorities, stakeholders and the public.\u003c/p\u003e\u003cp\u003eAs Campeau points out, decisions are not made in a vacuum, and an AC\u0026rsquo;s 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 AC, and public discussions between the health sector and legal sector in Norway indicate that the Police expect AC to rely less on Police support 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. (38) These discussions go in favour of ACs accepting more risks. Although the paramedic literature has raised concerns about the risks of WPV (7, 19, 23, 30\u0026ndash;33), there is a lack of discussion about the risks that AC are supposed to accept, as well as a lack of documented, implemented, and effective mitigation strategies for WPV.\u003c/p\u003e\u003cp\u003eConsequently, a broader societal discussion is needed to clarify what should be considered acceptable and unacceptable risks for ACs and who gets to decide what. In such discussions, a solid understanding of the prehospital context is essential. Hospital managers, legal experts and policy makers need to include AC\u0026rsquo;s perspectives, and, as pointed out by Morrison (39), AC\u0026rsquo;s 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 used to guide decision-making, allows AC to think that their own safety is a prerequisite for being able to assist 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, AC used discretion to decide whether the risk was acceptable or not. 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 was an unacceptable risk or not. Campeau highlights that ACs see themselves as rescuers, and when they are incapacitated from helping, this undermines their role and may inflict a sense of \u0026ldquo;losing face\u0026rdquo;. The willingness to help patients was also evident in this study. With a significant desire to help and a willingness to take various risks, making discretionary risk assessments based on unclear support from stakeholders such as the police, physicians, managers, hospital staff, and legal advisors made prioritising one's own safety challenging.\u003c/p\u003e\u003cp\u003eTo discuss this balance between risks and safety, we let ourselves be inspired by the results in this study and developed a theoretical model, which we call the Paramedic Risk Matrix for WPV (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 below, can help clarify when risks are perceived as unacceptable and is helpful for discussions and clarifying role expectations. Based on the analysis and 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 ACs. Consequences for ACs were usually talked about as serious injury or death, but also the risk of being investigated for adverse outcome and not being supported by the managers, legal experts, other allied health professions or stakeholders.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eThe Paramedic Risk Matrix for Workplace Violence\u003c/p\u003e\u003cp\u003eIn contrast to many other assessment matrices used in healthcare and beyond (40), the Paramedic Risk Matrix does not rely on probability estimates and likelihood for WPV. Still, it focuses on how the health gain for the patient and the health consequences for AC together indicate if the risk for WPV is acceptable or unacceptable. The model comprises the two axes \u0026ldquo;expected health gains for the patient\u0026rdquo; and \u0026ldquo;possible health consequences for AC\u0026rdquo;. We suggest \u0026ldquo;health\u0026rdquo; can be understood as physical or mental health, or a combination of these.\u003c/p\u003e\u003cp\u003eThe 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;minor 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 a precise cut-off level. Similarly, the Y-axis must be interpreted as a discretionary assessment to the question: based on your best judgment of the patient, will your immediate help represent a significant health gain for the patient? (no health gain, negligible health gain, small health gain, moderate gain, crucial health gain, preventing death)\u003c/p\u003e\u003cp\u003eThe colours in the model indicate how risk is perceived on a spectrum, from perceived as acceptable (green) to perceived as unacceptable (black). Again, the colours do not indicate an absolute opinion on how the risk is assessed. Rather, the model should be used as a theoretical model to discuss and increase our understanding of what constitutes acceptable and unacceptable risks. Cultural differences, differences in training and contextual factors are likely to influence 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 into a support tool for AC to create awareness about their risks and safety, and help justify their decisions to prioritise safety when the gain for the patient is low and the potential consequences for AC 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 AC at the site, using their best discretion.\u003c/p\u003e\u003cp\u003eTo assess which point on the x and y axes best represents the situation on the scene, AC needs to use their best professional discretion. They will need to use their what-if strategy to assess the gain for the patient and the consequences for themselves.\u003c/p\u003e\u003cp\u003eBy using this theoretical model, 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. (41) 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. (41) 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. (41) 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. (41) The Paramedic Risk Matrix can be used systematically to facilitate a broader discussion on safety for ACs in a prehospital context and function as a system theory for handling and discussing risky situations.\u003c/p\u003e\u003cp\u003eAwareness and new insights gained through discussions around the Paramedic Risk Matrix can mitigate unacceptable losses, prevent hazards, and facilitate safety measures in situations where AC 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 has the potential to assist risk assessments in hierarchical and complex social environments where ACs lack tools for communicating risks to stakeholders with less insight and understanding of their work environment.\u003c/p\u003e\u003cp\u003eIn this study, we have identified and presented multiple factors that influence ACs\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 AC 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 ACs, ambulance service managers and stakeholders where they can focus their efforts to mitigate risky behaviour among AC 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 AC work in the prehospital environment (41)\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 as the aim of the study is based on an experienced clinical problem, supported by the research gap in the literature, and the information-rich interviews. The findings are based on a small sample from a regional ambulance service in Norway, which limits transferability. However, the sample consisted of paramedics with a broad variation of experiences, education, gender and age, which strengthens the transferability, and the results can be a starting point for further investigations in a broader prehospital context.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eAC\u0026rsquo;s willingness to help patients, combined with their perceived role expectation and stakeholders\u0026rsquo; lack of understanding of their work context, influences how risks for violence are assessed and managed by ACs. Despite their gut feeling and clinical experience, they struggle to describe, convey and document risks for violence sufficiently to the police, GPs, hospital staff and managers. This leads to difficulties getting support for their decisions to prioritise safety. The lack of understanding among stakeholders of the prehospital risks within the paramedic social context is problematic, and the lack of consensus among stakeholders and ACs regarding what are acceptable and unacceptable risks complicates risk assessments and management. The theoretical model, The Paramedic Risk Matrix, can help clarify when risks are perceived as unacceptable and is helpful for discussions regarding risk assessment, risk willingness and clarifying role expectations. Further research is needed to explore the use of the Paramedic Risk Matrix and to further explore how WPV for paramedics can be mitigated.\u003c/p\u003e"},{"header":"Declarations","content":"\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 HSE, Ambulance Service Vestre Viken HF and Birgitte Larsen, Paramedic, Head of Section for Competence development, Ambulance Department, Vestre Viken HF, for their support in discussing results and providing valuable feedback on the manuscripts. I also want to give my sincere thank you to Professor Ole Martin Moen for contributing to correcting transcriptions and discussing preliminary codes and themes. 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\u003eDeclaration of conflicting interest\u003c/p\u003e\n\u003cp\u003eThe author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.\u003c/p\u003e\n\u003cp\u003eFunding statement\u003c/p\u003e\n\u003cp\u003eThe author received no financial support for the research, authorship, and/or publication of this article.\u003c/p\u003e\n\u003cp\u003eEthical approval and informed consent statements\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 act, and ethical\u0026nbsp;approval is not required. Complying with the Norwegian Health Personnel Act, participants avoided identifiable information of patients or any third persons. The project complies with local regulations for research, data storage and privacy protection.\u003c/p\u003e\n\u003cp\u003eData availability statement\u003c/p\u003e\n\u003cp\u003eVerbatim interview transcripts contain a significant amount of indirectly identifiable data that we are not allowed to share. Consequently, the data is not available for sharing.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAny other identifying information related to the authors and/or their institutions, funders, approval committees, etc, that might compromise anonymity.\u003c/p\u003e\n\u003cp\u003eOnly anonymised quotes have been shared with ambulance service managers and colleagues when providing input to this paper. Ambulance service managers and hospital managers have not influenced the findings presented in this paper og limited this research in any way.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eFricke J, Siddique SM, Douma C, Ladak A, Burchill CN, Greysen R, Mull NK. Workplace Violence in Healthcare Settings: A Scoping Review of Guidelines and Systematic Reviews. Trauma, Violence, \u0026amp; Abuse. 2023;24(5):3363-83.\u003c/li\u003e\n\u003cli\u003ePaulin J, Lahti M, Riihim\u0026auml;ki H, H\u0026auml;nninen J, Vesanen T, Koivisto M, Peltonen L-M. 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Reliability Engineering \u0026amp; System Safety. 2022;217:108077.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"OsloMet – Oslo Metropolitan University","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":true,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Paramedicine, Paramedic, Ambulance, Violence, Safety, Risk assessment, Risk management, Workplace violence, occupational violence, prehospital","lastPublishedDoi":"10.21203/rs.3.rs-7887148/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7887148/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Workplace violence (WPV) against ambulance clinicians (ACs) is a persistent and complex problem that threatens staff safety, health and quality of patient care. Despite growing awareness, limited attention has been given to how paramedics reason and manage risks of WPV.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAim:\u003c/strong\u003e This study aimed to explore ACs' lived experiences of WPV in the prehospital context and how they perceive individual and contextual factors influencing risk assessments and management.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethod:\u003c/strong\u003e An episodic narrative interview approach was employed, involving 10 paramedics exposed to WPV, to elicit narratives of WPV and broader reflections. Data were analysed inductively, drawing on thematic and interpretive narrative analysis. Peer-debriefing was used to increase the credibility and trustworthiness of interpretations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e Participants’ narratives revealed individual differences and changes throughout their careers in how they assessed the risk for WPV. A combination of internal willingness to help, situational awareness, professional duty, moral reasoning, and intuitive judgment influenced their assessments. In addition, challenges in conveying and documenting risk assessments, perceptions of being misunderstood by stakeholders, feeling low-ranked, and not being supported by managers challenged their risk management. Perceptions among paramedics and their stakeholders on what constitutes acceptable and unacceptable risks challenged risk management.\u003c/p\u003e\n\u003cp\u003eFrom these insights, a conceptual framework—the \u003cem\u003eParamedic Risk Matrix for Workplace Violence\u003c/em\u003e—was developed. The model, based on paramedics' experiences and reasoning, can be useful for sparking discussions among and beyond paramedics on what are considered \u003cem\u003eacceptable\u003c/em\u003e and \u003cem\u003eunacceptable\u003c/em\u003e levels of risk in paramedic practice.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e ACs’ responses to WPV are grounded in complex, context-dependent reasoning that balances ethical, emotional, and professional factors. Understanding how paramedics construct and manage risk can inform more realistic prevention strategies, organisational support systems, and policy development. The \u003cem\u003eParamedic Risk Matrix\u003c/em\u003e offers a practical tool to guide reflection, training, and decision-making in WPV management within paramedicine.\u003c/p\u003e","manuscriptTitle":"Towards a Paramedic Risk Matrix: Exploring workplace violence through ambulance clinicians’ narratives","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-20 09:44:13","doi":"10.21203/rs.3.rs-7887148/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"2ebdd818-1e65-493f-8e0a-bd0ef8291e92","owner":[],"postedDate":"October 20th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":56478943,"name":"Critical Care \u0026 Emergency Medicine"},{"id":56478944,"name":"Nursing"}],"tags":[],"updatedAt":"2025-10-20T09:44:13+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-20 09:44:13","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7887148","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7887148","identity":"rs-7887148","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}