VIOLENCE AGAINST AMBULANCE WORKERS: COMPARATIVE STUDY OF THE STATIONS OF YEREVAN AND GYUMRI

Abstract

Introduction.

According to the World Health Organization (WHO), violence is widespread in the world, about 1 million people dying from various forms of violence each year. Currently, violence in the workplace is increasing, especially in emergency department against medical personal.

Purpose of the research:

to study the perception of violence by medical workers in ambulance stations in the cities of Yerevan and Gyumri, to identify the types, causes and qualitative characteristics of the prevalence of violence against medical ambulance workers. Give a comparative description of the violence situation in Yerevan and Gyumri stations.

Material and methods.

Qualitative research was carried out among the medical staff of emergency stations of Yerevan and Gyumri cities using the in-depth interview method in 2021. The tool was the guide, the total number of participants was 61.

Results.

The survey found that violence against emergency workers was common: 42 out of the 61 participants reported about lifetime experience of any type of violent behavior of patients or their relatives. Among the types of violence, physical and psychological were mentioned most often.

Conclusions.

Violence is a common, frequent occurrence in the emergency department. Emergency medical personnel primarily perceive violence in its psychological and physical manifestations. Among the reasons are, in particular, the apparent delays of the emergency personnel, the nervous and mental overstrain of the abusers, and the use of alcohol.

INTRODUCTION

Various manifestations of violence have always existed in human history. According to the WHO, about 1 million people die from violence each year and many are injured to varying degrees (1).

Violence is one of the leading causes of death among adults. It also overburdens the health care system, diverting financial resources to support and restore the lives of people who have been abused (2).

Wars, terrorism, riots, domestic and sexual violence are the most frequently spoken forms of violence in the mass media (3). And labor violence, especially against doctors, remains unnoticed by the public (4). Various manifestations of violence have been reinforced in the socio-cultural life of many countries. In the majority of cases the victims of violence are young, weak and unable to defend themselves (2).

Today, humanity must deny and exclude the manifestations of violence based on the ideas of humanism, the moral value systems of humanity. Religion, philosophy, human rights, communal-life systems prevent the use and spread of violence by complementing each other, but none of them completely solves the issue of violence (5).

Nowadays, incidents of violence are a frequent occurrence in the workplace, especially in the emergency service. Doctors, nurses, paramedics, and drivers are subjected to violence (6).

2018 In Italy, 70.6% of medical workers were subjected to verbal violence, 60.2% to psychological violence, 31.2% to physical violence (7).

A 2018 study by the Emergency Medicine Institute of America found that 47% of physicians surveyed had experienced physical abuse (8).

The Australian Emergency Medicine Science Direct reports that the incidence of violence among emergency medical workers is high, reaching up to 60–90% (9).

A 2015 survey of emergency workers at the Mayo Clinic in Rochester, Minnesota, USA and published in The Permanente Journal found that 55.8% of workers view violence as part of their job (6).

This phenomenon is a serious problem for health care, because as a result of violence, moral and psychological damage is caused, the daily work of the doctor is affected, the doctor-patient relationship is violated, as a result, both the doctor and the medical care can be affected. Provision of safe working conditions for the doctor is also violated, which requires the training of the medical staff and the formation of a critical attitude towards violence (6).

However, assessing the scale of the problem is difficult because information on incidents of violence against health workers is even more limited (10).

Among the growing expressions of violence, in contrast to domestic and sexual violence, which are more talked about because they are more visible, aggression and violence against doctors and health care workers still remain an unknown and unspoken issue for many people (11).

Data from the European Organization for Occupational Safety and Health document that health care is the most common area of workplace violence (12).

The most frequent manifestations of violence against emergency medical personnel are psychological and physical types of violence (10).

Violence not only disrupts the normal rhythm of work, as a result of which health care delivery and doctor-patient, nurse-paramedics-patient relationships are affected, it also carries great risks. Consequences of violence acts against emergency medical workers causes work and psychological stress mechanisms among emergency medical workers, which have a serious impact on the human body and nervous system and causes the pathological condition. In emergency medical personnel perceive violence an integral part of the job (10).

In Italy in 2019, it was found that psychological and emotional violence is more common during the provision of emergency medical care (10).

Violence at the workplace can be considered a single case or small episodes of regularly repeated expressions of violence, which can cause serious damage to the physical and mental health of the healthcare worker. All of these are important occupational risk factors for emergency medical personnel (13, 14).

However, the volumes of expression and display of violence are increasing, especially towards nurses, and the data for a summary assessment of the prevalence of this problem are not sufficient (15).

Doctors have an important role in the health care system to maintain and ensure public health. Violence against them is a serious problem not only for the individual doctor, but also for the organization and management of the work of the entire system and the creation of safe working conditions for doctors. Therefore, understanding the prevalence of violence and its causes is a critical health issue (16).

Violence is difficult to study also because different tools have been developed to characterize violence in the workplace, they are diverse and comparing with each other is problematic.

The instigator of violence is most often the patients, relatives and visitors of the patient.

Emotional abuse, physical violence, and sexual assault are common forms of violence. The term emotional abuse refers to psychological abuse, verbal rather than physical. Although physical violence has always been more visible, the prevalence of psychological violence has always been underestimated and only recently received due attention (10).

Research conducted in recent years confirms that violence by patients and their relatives is increasing. On the other hand, the lack of research and the incompleteness of information make it difficult to identify the true prevalence of violence. New scientific research directed at the given problem will create radical schemes of system solution (10).

The expression of violence is due to various reasons, both personal and situational factors (12).

Violence against emergency medical personnel by patients and their relatives and visitors is a common problem in both developed and developing countries (10). There are no clear statistics and statistical reliable data on this issue in Republic of Armenia (16).

Purpose of the research:

to study the perception of violence by medical workers in ambulance stations in the cities of Yerevan and Gyumri, to identify the types, causes and qualitative characteristics of the prevalence of violence against medical ambulance workers. Give a comparative description of the violence situation in Yerevan and Gyumri stations.

Hypothesis of the research:

violence against RA emergency medical workers is a widespread phenomenon. Psychological violence against emergency medical workers is the most common. There may be a difference between the manifestations of violence against emergency medical workers in Yerevan and Gyumri.

Objectives:

Disclosing perceptions of violence by medical personnel. Refinement of the qualitative assessment of the prevalence of violence against medical personnel. Revealing the motives of the used violence. Analysis of differences between cases of violence against ambulance staff in Yerevan and Gyumri.

MATERIAL AND METHODS

Qualitative research was carried out using the in-depth interview method among the medical staff of emergency stations in Yerevan and Gyumri in 2021. The cities of Yerevan and Gyumri were chosen for the research, because they are the two largest cities of RA in terms of population and size, and they are also the only ones where separate emergency stations operate. In all other regions and centers of regions there are no separate stations, they operate as a separate emergency department within other medical facilities.

The research was conducted in Yerevan city emergency number 1 central station and the only station in Gyumri city of Shirak region. Visits were made to the emergency stations of the mentioned cities over several days in order to include the medical staff working in shifts at the stations on different days.

The interview had a tendency to find out the attitude of emergency medical staff to violence, what kind of violence they were subjected to, for what reasons, and to understand the qualitative characteristics of its frequency. Thus, the study sought to cover two different cities of RA, to study the structure of violence, the qualitative characteristics of its prevalence in most cases, and also to highlight the reasons that may also differ by city, which may be due to the mentality, character and different habits of expression of the population.

The number of in-depth interview participants was formed according to the principle of information saturation characteristic of qualitative research, when the research stops receiving new information during new interviews. The survey was conducted in both cities according to the same principle, the total number of participants was 61 people. The interviews were conducted among the available medical personnel during the visits to the stations of Yerevan and Gyumri cities.

As a result, 33 participants, including 19 doctors, 11 paramedics, and 3 nurses, were included from the number 1 emergency central station of Yerevan city. From emergency station of Gyumri 28 in-depth interviews were conducted. 9 respondents were doctors, 10 nurses, 5 paramedics, and 4 drivers-paramedics. Interviews lasted 15–16 minutes on average.

The interview tool was the guide, which contained 8 open questions (tab. 1). The survey was audio-recorded and further processed through the transcripts. The in-depth interview was conducted by an interviewer, in a flexible, dynamic way, in case of misunderstanding by the participants on any issue, additional, clarifying questions were asked. Written consent to participate in the study was obtained from the medical staff prior to the interview.

Table 1.

Basic in-depth interview guide.

Violence against ambulance workers. Comparative study of the stations of Yerevan and Gyumri
1	What is violence in your work by your opinion and what are its manifestations?
2	What categories of workers do you believe are subjected to violence? What examples of violence against medical personnel can you provide us with?
3	What cases can you mention during your ambulance medical practice, what do you think were the reasons, in what situation did they was? Or/ Can you provide some violence examples from your ambulance medical practice? How did these incident happen?
4	And who were the main instigators of the accident?
5	Do you think there is a connection between the severity of the patient’s condition and the ‘violence exerted by the patient or his relatives’? Or/ What types of situations do you think increase the risk for violence? What types of situations related to the patient? The community/ environment?
6	What do you think is the cause of violence against doctors, distrust of the doctor, low level of education, lack of culture of managing emotions, etc.?
7	How is this phenomenon perceived by the population? It happened that the residents come to help? Can you provide some examples?
8	What are some of your ideas about how to reduce violence against ambulance medical staff?

The research was attended by senior, middle, and junior medical workers working in emergency stations: doctors, nurses, paramedics, drivers.

The audio-recorded interviews of the participants were entered verbatim into MS Word, then transferred to MS Excel, through which keyword searches and inductive narrative analysis were performed. Clarification of common patterns of opinions as well as divergent opinions was done.

RESULTS

Thus, the research produced the following results.

The majority of respondents perceived violence as an oppressive action directed against a person’s will, rights, and desires.

“Violence is any action against a person’s will and can be manifested in any situation and in any issue, in any field”.

A doctor at the central emergency station of Yerevan

“Violence is the phenomenon of taking hold of a person’s moral and psychological will, it is not only physical, psychological is also violence”.

Nurse at Gyumri emergency station

As a manifestation of violence, the majority of participants mentioned verbal, loud expression, pressure, beating, speak obscene words, violent acts especially against will, rights, desire, application of force, coercion using the appropriate words.

Fewer participants mentioned the words push, pull, tie, hit, disrespect, attitude, torture, accuse, torment, threaten. There have also been unique and divergent opinions.

“And the psychological, it can be from the state of mind, from the mood, from the behavior, from the look, it is expressed from getting into contact, it can also be from the aura”.

Driver of Gyumri emergency station

41 out of 61 survey participants mentioned physical violence as a type of violence. 33 of those who identified this form of violence as a type also mentioned psychological violence. Other participants mentioned different keywords related to violence, but did not use the words physical and psychological. (fig. 1).

Figure 1.

Perception of violence by the medical staff of Yerevan and Gyumri emergency stations, RA, 2021.

Among the different ideas voiced as a manifestation or type of violence was the idea of violence against doctor’s rights, one participant noted.

“Violence against doctor’s rights is when you go to call, they say you are a doctor, you have to…”

Doctor of the central emergency station of Yerevan

In the course of the question, such an opinion was encountered several times that an emergency doctor is more vulnerable than a doctor in a hospital.

“I don’t forget the incident when we went, he greeted the doctor with curses, grabbed his hair and lifted him up. The patient was hysterical, neurotic, during that time the doctor said, I’m very bad, I called and asked for a second car, but by the time it arrived, he (the doctor) was already died.

Nurse at Gyumri emergency station

DISCUSSION

Interpreting the answers, it follows that the medical staff mainly perceives violence and considers it as an unacceptable act by individuals or groups of people against other people. The perception of violence among the majority of participants is associated with actions of oppressing, grabbing, causing harm, and humiliating people. Medical workers understand violence as a negative phenomenon and criticize its use.

Medical workers consider physical and psychological types of violence. According to 67% of the participants (41 out of 61 participants) there is physical violence in the ambulance, and 54% (33 out of 61 participants) believe that there is both physical and psychological violence. This phenomenon probably stems from the fact that the medical staff mostly encounters these manifestations in their work practice. Physical violence is considered to be beating, pushing, hitting, pulling, and psychological violence is verbal insulting, humiliating, speaking loudly, shouting, cursing, etc.

A number of participants described acts of violence against themselves, but did not qualify as violence. This phenomenon may be related to the fact that they probably hide the violence against them, especially the psychological one, or that they do not really perceive these manifestations as violence, or that they witness these cases so often that it seems to be a common occurrence.

In response to the questions, sexual violence was never mentioned as a type of violence or a form of expression.

Summarizing the answers, 42 out of 61 participants consider violence against emergency medical personnel to be common, which is 68.8 percent of the respondents. Therefore, a qualitative assessment of the prevalence of violence can be given, that is. violence is a common phenomenon among emergency personnel of Yerevan and Gyumri stations.

Most of the cases of violence occurred due to emotional stress of the patients or their relatives.

Many of the participants believed that there was a connection between the severity of the patient’s condition and the violence that was displayed.

Physical violence against the medical workers of Gyumri emergency station is more common, and psychological violence is more common against the staff of Yerevan Emergency Medical Service. The reason for this phenomenon can be the bad socio-economic situation, mentality, behavioral habits, or the fact that Gyumri’s emergency medical staff does not perceive psychological violence as violence.

CONCLUSION

1. Thus, the research concludes. Violence against emergency medical personnel is common. The most common forms of violence are physical and psychological manifestations.

2. The causes of violence against emergency medical personnel are the apparent delays of emergency teams, alcohol intoxication of patients or relatives, unhealthy, unbalanced state of mind, nervous tension, mistrust of the doctor, poor socio-economic status of patients, low educational level, lack of emotion management culture.

3. The violence against the medical staff of emergency stations in Yerevan and Gyumri cities differs according to the types of manifestation.

4. Cases of physical violence against the medical staff of the emergency station in Gyumri prevail, and psychological violence against the emergency staff of Yerevan prevails.