Explorative thematic qualitative analysis of a UK emergency medical systems staff’s experiences, perceptions and interpretations of violence and aggression directed towards them

Abstract

Background

Emergency medical services (EMS) staff worldwide have long been at risk of encountering violence and aggression (V&A) at work, including threats, verbal, physical and sexual assault, and on rare occasions, fatalities occur. Exposure to V&A can result in stress, fear and burnout. This is an international problem and EMS employers, trade unions and others are working towards tackling it. The aim of this research was to conduct an exploratory qualitative interview study of EMS staff focusing on experiences, perceptions and interpretations of V&A directed towards them.

Methods

This study took place in 2022 in one UK ambulance service covering a population of three million people. Individual, one-to-one semi-structured interviews were conducted with EMS staff via a Voice over Internet Protocol. Data were thematically analysed drawing on evolved grounded theory methodology concepts.

Results

10 EMS staff were interviewed, and the following categories emerged: Rusted, busted and inevitability of V&A in EMS environment, Tolerable or intolerable V&A in EMS, Gendered V&A and genderisation in EMS, Modifiable factors and harm reduction of V&A in EMS, Professional, ethical and clinical judgments of V&A in EMS and Sociocultural and system frustrations of V&A in EMS. The basic social process that emerged was one of Systemic frustration and gender-based V&A in EMS.

Conclusion

Protecting EMS staff from V&A is complex and multifaceted, and we have conducted a thematic analysis drawing on evolved grounded theory concepts that proposes V&A in EMS may be borne out of, and sustained, by systemic frustration and gender-based issues. We draw on Dollard’s et al (1939) frustration–aggression hypothesis and Kelly’s ‘Continuum of Violence’ (1988). Experiences of sexual V&A revealed in our study, supported by a wider body of knowledge, lay bare a caring context of rampant gender-based V&A directed towards EMS staff by members of society, colleagues and within the context of a patriarchal EMS. Our study revealed how EMS has not effectively tackled V&A and the many sociocultural constructs within EMS. We advocate for purposeful efforts, further research and systemic interventions beyond punitive measures to tackle this issue.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• Thematic analysis drawing on a constructivist and evolved grounded theory concepts harnessed the research team backgrounds as experienced paramedic researchers and insiders, adding a richness of insight, and ability to bring meaning to the data.

• The Voice over Internet Protocol allowed for broader engagement and flexibility in terms of geography, paramedic work patterns and accessibility.

• Limitations include recall bias of participants, along with recognising the need for some caution of the framing due to the small and context specific sample size and emergency medical services site, the insider-ness of the research team and potential for preconceived ideas to influence the construction of theory.

• Transparency and trustworthiness were observed by a second researcher independently reviewing coding, reflective notes and member-checking’ techniques.

Introduction

Emergency medical services (EMS) staff internationally experience violence and aggression (V&A) in their workplace.^1–3 This can involve verbal, physical and sexual V&A and fatal injury.^4–7 Experiencing such V&A can result in stress, fear, anxiety, emotional exhaustion and burnout syndrome.^{5 8 9} Up to 90% of EMS personnel report V&A in their workplace^{2 10–12} and this is increasing.² EMS systems internationally have attempted to tackle this problem through training, community education, policies and legislation, yet little is known of their effectiveness.^{2 13–15} In Wales (UK) this has involved initiatives, such as the obligatory responses to violence in healthcare (2018),¹⁶ changes in legislation including the Assaults on Emergency Workers (Offences) Act (2018)¹⁷ and media campaigns Joint Emergency Services Group (JESG) #WithUsNotAgainst Us.¹⁴ We have described this multiagency approach, the associated complex clinical, societal and legislative issues, and developed a programme of research and innovation exploring potential strategies for protecting EMS staff from V&A in conflict encounters.¹⁴ Efforts to tackle this problem often lack underpinning with empirical research, may be working from an incomplete evidence base, and often therefore fail to address the complexity of issues at play.

The body of knowledge on V&A on EMS staff is growing, and qualitative studies have been conducted in Iran, Czech Republic, Australia, USA and Sweden employing a range of methodologies including inductive methods, content analysis and grounded theory (GT).^18–24 These studies highlight opportunities to prevent V&A.¹⁹ Studies also recognise the role of dynamic scene management, the situational context and social interactions that occur which both promote, suppress and exert significant influence on the evolution of V&A.²⁰

Qualitative research has described the barriers related to culture in society, attitudes of staff, human factors, mental health issues and frustrations over legal processes, organisational factors and lack of capacity for EMS to take action following violent events or support for clinicians to cope with the aftermath of V&A.^21–23 Few however have explored violence directed towards ambulance staff, from the patient’s perspective. Viking et al²⁴ recently conducted a qualitative study using inductive thematic analysis of trial transcripts of V&A directed to EMS staff which revealed the need for such healthcare professionals to recognise how their behaviour may influence the risk of workplace violence.

The aim of this research was to conduct an exploratory qualitative interview study of EMS staff focusing on experiences, perceptions and interpretations of V&A directed towards them. This paper reports the results of an explorative thematic qualitative analysis of the interviews with EMS staff drawing on evolved GT (EGT) concepts.

Methods

Data were analysed thematically, drawing on EGT methodology (EGTM) concepts,^{25 26} which is an inductive, theory-discovery methodology which sits within the constructivist paradigm of inquiry, where our research team were passionate participants, facilitating a multivoice construction of protecting EMS staff from V&A in conflict encounters.²⁷ This team included experienced academic research paramedics; their background and insider positions are important, as theoretical constructions are interpretations made by the researchers and researched from respective given perspectives.²⁸ We argue this perspective adds a richness of insight, awareness and ability to bring meaning to the data.²⁹ We do however recognise the potential for preconceived ideas and previous encounters to influence the construction of theory and have included techniques to assure trustworthiness.

Sample selection

An electronic poster calling for participants was disseminated throughout one UK ambulance service, covering a population of 3 million people. Data collection was conducted between September 2022 and February 2023. Responses were collated and participants selected using theoretical sampling based on characteristics identified by a review of the literature. Following the poster call, study participants were contacted by email, consented and invited for interview.

Patient and public involvement

Patients and members of the public are involved in the overarching research group, and while they were not directly involved at the time of data collection, they are actively involved in further analysis and research development,

Ethics

Participants were provided with a pack by email including an information sheet and consent form which they completed and returned and were also consented verbally during the interview. All data were collected and stored in accordance with GDPR regulations.³⁰ Due to the sensitive subject matter, a range of support was available to participants.

Data collection

Interviews

Individual, one-to-one semi-structured interviews were conducted by Microsoft Teams which may be considered a Voice over Internet Protocol (VoIP) and has been successfully used previously by our team.³¹ Interviews were of 1-hour duration using a semi-structured interview guide (online supplemental information 1), video recorded with notes taken and transcribed verbatim.

Data analysis

Analysis drew on Strauss and Corbin’s²⁵ three levels of open, axial and selective coding which involved ‘explication of the story line’ (Strauss and Corbin 1998, p. 148) and identifying the basic social process (BSP) around which all other categories revolve and development of an EGT. We have successfully used this methodology previously with paramedics (Rees et al 2018, 2021).

Analysis involved the following levels of coding:

• Open coding: Raw transcripts from interviews were read line-by-line to ‘fracture’ the data into discrete parts. Data were compared for similarities, differences and questions regarding emergent phenomena, in line with EGTM.²⁵ The concept-indicator model³² was used in this process. An indicator refers to a word, phrase or sentence, and a concept is a label associated with that indicator. Indicators were grouped together under concept headings, when another indicator did not generate new insights to a concept, it was deemed theoretically saturated and thus well grounded.

• Axial coding: A second stage of coding involved categorisation which involved taking concepts and thinking how they could be subsumed under a higher-level heading.

• Selective coding: Defined as ‘explication of the story line’.²⁵ This entails intense analysis around categories,³² seeking to answer questions about when, where, why, who, how and with what consequence? Selective coding also involves identifying the BSP, which relies on higher level abstraction to identify one overarching emergent social process which can explain variation in all lower level categories, concepts and processes.

• The BSP is central to the GT explaining the social phenomenon under investigation, the nature of which is the subject of the derived theory.^{33 34} The BSP helps conceptualise and explain the social processes influencing V&A directed towards EMS Staff. This was done across all the categories using reflective memos and returning to the literature to describe the underlying social processes.

• Finally, theoretical constructions conceptualised the relationship among the three levels of coding, by weaving the fractured data back together again.

Figure 1 provides illustration of the generation and relationship between coding:

Figure 1. An illustration of the generation and relationship between coding. EMS, emergency medical services.

Transparency and trustworthiness was observed by a second researcher independently reviewing the coding framework and then discussing this framework with the primary researcher. Reflective notes were made, and member-checking’ techniques were used where the primary researcher returned to study participants to check their response and the construction the EGTM.

Researcher characteristics and reflexivity

Positionality and insider status: The lead researcher (NR) and co-researchers (JW and PO’M) identify as ‘insiders’ within the international ambulance sector, and paramedic profession, each possessing over three decades of experience, spanning emergency medical technician to professorial levels. This shared professional background facilitated rapid rapport and ‘insider’ trust, allowing participants to use technical shorthand without extensive explanation. However, we remained vigilant to the potential of this shared understanding to be taken for granted, where for instance participants might withhold information they deemed obvious.

We acknowledged that data and analysis were co-constructed through our interactions. We used memo-writing throughout the research cycle to document our evolving perspectives. We recognise the potential power imbalance inherent in the lead researcher’s (NR) senior role within the ambulance service sector where participants worked, and to mitigate this, interviews were conducted outside of working hours and using a remote VoIP online approach provided a neutral medium to conduct these interviews. Reflexivity was treated as a continuous process rather than a one-time disclosure. We held biweekly team meetings to validate findings and explore how our unique perspectives influenced the emerging theoretical framework.

Results

Ten EMS staff were interviewed. Figure 2 presents demographic data of EMS staff included in the study.

Figure 2. Demographic data of EMS staff included in the study. EMS, emergency medical services.

Four participants engaged in member checking, the coding book with emerging categories was forwarded to all participants during their construction and an audit trail was documented through researcher notes. Minor clarifications were sought in areas, and responses were integrated into the emerging theory.

The following six categories emerged: Rusted, busted and inevitability of V&A in EMS environment, Tolerable or intolerable V&A in EMS, Gendered V&A and genderisation in EMS, Modifiable factors and harm reduction of V&A in EMS, Professional, ethical and clinical judgments of V&A in EMS and Sociocultural and system frustrations of V&A in EMS. The BSP which emerged was one of Systemic frustration and gender-based V&A in EMS. The BSP and EGT is presented in figure 3.

Figure 3. Evolved grounded theory of emergency medical systemic frustration of aggression and violence in conflict encounters. EMS, emergency medical services.

Rusted, busted and inevitability of V&A in EMS environment

Our participants reported how most people they encounter do not present a threat of V&A to them and talked about the trusted context of care they provide, involving intimate contact and invasive procedures. They told how this context inevitably made them vulnerable to V&A and its physical and emotional consequences and they all reported times of being scared and that V&A was increasing. Powerful experiences were shared of a wide range of V&A including verbal abuse, threats, sexual and physical assault with body fluids such as vomit and spitting, and weapons such as pens, screwdrivers and knives. Participant 9 shared a terrifying assault on him by a housebound elderly man:

his right arm came around, grabbed the carving knife, he brought it right around, just underneath my chin there, and his words to me was listen don’t fucking start (P9)

V&A was seen as just part of their job, but that it would not be accepted in other workplaces:

Although we are frontline workers, you wouldn’t expect it in an office job, you wouldn’t expect it in a college, you wouldn’t expect it as a teacher, so it’s unacceptable. Is it understandable? Very much so, and you can understand the processes (P2)

Our participants talked about the inevitability of V&A within the EMS environment due to the context of dealing with people who may be intoxicated with drugs and alcohol, those with impaired mental capacity such as the elderly and medically ill or responding to people who are frightened, in pain and frustrated. Participant 2 said:

I think there is an acceptance at some point you will be assaulted (P2)

While participant 3 said:

sometimes it comes with the job that we’re doing. If you look at that drunk, we’re picking up, if you look at that family, that sort of whatever the road accident of nobody intoxicated but the adrenaline is so high that they’re abusive and verbally abusive, we have to de-escalate them scenarios (P3)

They also reported being tired and stressed and talked about their exasperation with hospital hand-over delays.

with waiting times, and hospitals, you know the way things are. That is stressful. You know the common thing you hear is we didn’t train for this, we didn’t train for waiting for hours on end but it’s become part of the job that we do…. it is frustrating when you’re sitting there but you cant allow that frustration to overspill into the way that you speak to and treat patients, you’ve got to be able to sort of deal with that frustration and some people just don’t seem to be able to (P8)

And

The crews that we’re sending out potentially are more burnt out, stressed? Fed up, or what’s the other one I’ve learned recently? rusted out…. So instead of doing the job you’re sat outside hospital for 12 hours babysitting a patient, so you’re sort of rusting like (P2)

All our participants recognised the potential for EMS staff to contribute to the V&A and how a minority of staff seemed to receive more V&A than other colleagues:

I think sometimes, some crews through their own frustration sometimes don’t help themselves. I’m not saying everyone deserves what happens, not at all. However, I have been with people and you’re thinking, if you speak to them like that, you’re just going to wind them up (P7)

Despite recognition of the influence of EMS staff own behaviour in V&A and a sense of its inevitability in EMS, some V&A appeared to be more tolerable than others.

Tolerable or intolerable V&A in EMS

Participants talked about V&A directed towards them by patients, bystanders, relatives, friends and coworkers. While they felt it was never acceptable, they acknowledged it could be understandable in some situations. They reported how a wide range of medical conditions could present with V&A, such as dementia, mental problems, head injury or diabetes. They were understanding and tolerant towards such patients and talked of the importance of not missing such conditions requiring prompt treatment. They did however acknowledge that it should never be acceptable to face such V&A within the workplace, as articulated by participant 9:

Understandable, to a certain extent, so like you know, we have staff you know, getting assaulted by patients with dementia or you know, the elderly patient has got various infections which affect them sort of mentally, I understand it a little bit more, is it acceptable? No not to me, it isn’t acceptable because it shouldn’t be acceptable for anybody to go out, do their job, and get abused and assaulted in the process of doing your work. So, I can understand it, but as far as being accepted? (P9)

Participants were less accepting of V&A from those intoxicated with drugs and alcohol which they appeared to find intolerable. This intolerance seemed to emanate from the deliberate nature of V&A by those who choose to become intoxicated from alcohol or drug taking as opposed to medical conditions deemed to be less within their control. Participant 2 said:

it’s not the patient wanting to hurt me, it’s the patient or the illness. Whereas…the sort of under the influence Friday night drunk—It could be the alcohol talking, not him or her, but they’ve chosen to potentially get into that state… there’s a choice that there’s a series of choices that have led them to their presentation, whereas things like dementia, delirium, UTIs, that kind of thing. I wouldn’t say there’s a conscious “I’m going to get a UTI so I can scrap”. (P2)

Paramedic participants reflected how they needed to assimilate a lot of information, which was often incomplete, in a short space of time, and in the absence of diagnostics such as X-ray or blood tests to inform their decision-making and clinical judgements. This decision-making is also made in an unstructured pre-hospital environment where their own safety is at risk where tolerance and intolerance can have significant consequences for themselves and patients as articulated by participant 4:

Maybe I’m a little bit too tolerant of that, maybe we should be a little bit quicker and say no actually we’ve turned up, you’re being a bit aggressive towards us, we can’t see any obvious reason for that other than, you know drug or alcohol sort of thing, you know it’s not an obvious head injury or hypo or something like that (P4).

Intolerable V&A following intoxication with drugs and alcohol was referred to in a masculine form whereas tolerable V&A such as those in nursing home with fracture was referred to in a feminine form. This raised potential gender issues which extended tolerance of V&A.

Gendered V&A and genderisation in EMS

All participants reported awareness of sexual and gender-related V&A in EMS. This ranged from sexism and inappropriate language to sexual assaults by patients and coworkers resulting in dismissal. Four of the participants had experienced V&A and sexual assault by coworkers; all victims were women and all perpetrators’ were men. They reported experiences including inappropriate and sexual comments, groping of breasts and buttocks and men revealing themselves. Participant 6 talked about her experiences with a patient:

we were, trying to turn him onto the bed umm, and he groped me and then again, we were lifting that patient from a chair and he was in a position to grope me again (P6)

And

one wasn’t a patient, one was a crew mate who sexually assaulted me and then consequently in the two months after, was two elderly patients who didn’t have any neurodegenerative diseases, so yeah that was fun, they were both sexual assaults as well (P6)

Participants talked about a perceived acceptance of this behaviour within EMS. Participant 9 shared her experiences of how this behaviour in patients had long been tolerated, telling how:

it just used to be the oh they’re drunk or things like that, or you know, they don’t really know what they’re doing, which is questionable (P9)

While participant 8 shared her experiences of tackling such behaviour in patients:

I’ve had to talk to the patient and say, that’s completely unacceptable and its not appropriate to be talking to my colleague in that kind of way or to be making that kind of suggestion (P8)

Such acceptance of sexual and gender-related V&A was also shared by participants in relation to EMS colleagues. Those who had been sexually assaulted by coworkers told of their discomfort in working with their assailants prior to the assault and how their behaviour was known to other colleagues and tolerated. Participant 7 powerfully shared her experiences and escalation of this behaviour:

I never used to like working with him it’s just my little spider senses, I wasn’t comfortable, and he used to say things and people just took it, that, that was just him. That was just him being perverted and—so therefore I didn’t like to speak up…. he probably felt he got away with it until this one night, thought he could, reveal himself, umm, on a night shift, which totally threw me. Umm, and was totally unwarranted, totally unacceptable, umm, but put me in a—I didn’t know what to do (P7)

And

So yeah, but I think if that wasn’t accepted, I could have spoken up earlier and said I don’t like this and unfortunately because of my background I didn’t have the confidence to say you know, what do you think you’re doing? I was like oh go away, go away and inside panicking thinking, this is not right, I don’t feel comfortable, but because that’s the way of the ambulance service that those things were oh it’s fine, it’s banter, it’s not quite clear as what’s banter, and I wasn’t comfortable but (P7)

And

I think it’s just like the line isn’t it? Between banter and being sexually abusive, sort of unacceptable. It’s just that line that we seem to, as I said for me, it was—everybody saw him as, oh he’s a pervert (P7)

Participants exhibited an element of genderisation; for instance when referring to older people presenting with illness such as dementia the perpetrator was referred to in the feminine form, whereas younger assailants intoxicated with drugs and alcohol were referred to in a male form as evident in comments by participant 2:

I think there is an acceptance at some point you will be assaulted, and I’d hope from my point of view, if I am assaulted again, I hope it’s by little 86-year-old Doris in a nursing home as opposed to coked up Dave in the street. Because, although they are the same one paper, they’re really not. (P2).

Gender issues spanned all the categories and may relate to EMS culture, but many modifiable factors were also suggested to reduce V&A and reduce its harm in EMS.

Modifiable factors and harm reduction of V&A in EMS

Modifiable factors and opportunities for harm reduction were presented by our participants which included the need for training, opportunities to intervene early in the call cycle, communication, media, meal breaks and efforts to address tiredness and reduce hospital handover delays. They gave examples of technologies being used to protect staff and address V&A, including flagging addresses of perpetrators, panic buttons on radios, stab vests, spit masks and spit tests to protect and gather evidence for prosecutions, body-worn cameras (BWCs) and vehicle cameras to prevent V&A and record encounters for evidence and training. Participant 4 said:

[control] put a red flag on the address so that any crews that were called there, would know that a patient has branded a weapon at us, umm, and that they wouldn’t send solo’s as well (P4)

They did however report disappointment in having to introduce such things into EMS, and the potential consequences. BWCs for instance were seen as an invasion of privacy which may escalate V&A. Participants also talked of their experiences with simple improvements such as their frustrations at reporting incidents of V&A, how it could be a waste of time and that they rarely had feedback. Participant 3 said:

for everyone that’s reported there’s probably 10 that haven’t been reported (P3)

And

the amount of statements I’ve done with police is ridiculous and nothing has happened (P6)

Participants provided sensitive accounts of the emotional burden of reporting, and their attachment to this process which extended into their personal lives and influenced their recovery. Participant 6 told of her ongoing distress and unresolved issues following an attack and how she received a call while shopping with her infant child:

I was walking around a supermarket with him [infant child], and I had a call saying “oh the person you reported has died, so we’re not going to take it any further” so I was like ok fair enough (P6)

For some there was a wish to see justice being served, to punish perpetrators and prevent future encounters, but many were doubtful this was happening, as told by participant 2:

the legal system itself is struggling with these cases because you know what’s the deterrent? Probably—I probably get paid £50 in 10 pence instalments, as a victim surcharge, they do some community service. Where you know, where’s the deterrent in that? There isn’t any (P2)

Others reported the loss of control by their perpetrators at the time of the incidents and the remorse they would feel when not in that state. This presented a dilemma for some staff where perpetrators of V&A were also viewed as patients with complex needs and vulnerabilities. Participant 7 said:

I had the choice of taking it further to possibly prosecute or mediate with the patient, and I chose mediation, because she had a child who was sort of, palliative care, and I felt it wouldn’t have been in her benefit or mine really…. she took that substance, rightly or wrongly just to cope and just to have that moment of escapism and I felt that if I could chat to her and just let her know the consequences of her actions, (P7)

Participant 7 also reported the following powerful and empathetic exchange between her and her perpetrator:

we had a chat because we couldn’t meet up due to COVID and she was just crying and crying and so apologetic and to me, I felt that, I could sort of put myself in her position and not sympathise but just sort of maybe understand a bit (P7)

EMS staff in our study told of the importance of being listened to, and the role of policies and groups such as the National Health and Safety Group, colleagues, managers and their trade unions. Participant 7 shared how:

its just frustrating to me to see that they, that management could have such a better, more supportive workforce if only they would just sort of—just try, looking into how crews are supported. And this is it, they keep saying why are so many crews off, I could tell them why lots of crews are off, they’ve just had enough (P7)

While it was recognised that there was still a lot of work to do, many staff reported the importance of supporting them through this process and its role in their recovery. Participant 6 told of the support he had received:

For PTSD, which I still do struggle with now, but umm, it was brilliant, really good and it really helped, hence why I can talk about it, because I wouldn’t have been able to previously, so really good stuff (P6)

Many spoke of the lasting emotional and psychological effect the V&A encounter had on them along with the subsequent investigations. Participant 7 told of the lengthy processes she endured following sexual assault by a co-worker and how:

the [The Trust] has been amazing. [NAME], do you know [NAME]? She’s in [DEPARTMENT] oh my god, she saved my life. She was amazing, amazing. Umm, and they sent me for EMDR counselling. Because obviously what he did then opened a can of worms, so, you know, I had my days but, on the whole, I was totally supported by work. Work were absolutely amazing, amazing, so I was lucky (P7)

Addressing modifiable factors and limiting harm from V&A raised many ethical issues which relate to professional responsibilities and judgements of EMS staff.

Professional, ethical and clinical judgements of V&A in EMS

Participants talked about the professional, ethical and clinical judgements of V&A in EMS. They gave examples of the challenges faced and judgements they had to make around the assessment and management of patients presenting with conditions such as head injuries and diabetes where V&A could occur.

there’s so many different conditions out there now where violence can be a symptom…. hypos, head injuries, or any other metabolic disorder, so it’s something that we’ve always got to be very mindful of (P4)

They presented many difficult scenarios, navigating such risks and duty to care. Paramedic 8 said:

if they said anything like, well you know, I’m going to kill myself if you kick me off the ambulance or whatever, well, are they? Don’t know. Can you take that risk? Not really. (P8)

They shared their vulnerability to V&A when weighing up risks to patients of not receiving their care as discussed by paramedic 9:

we could request that we stand off until somebody is there to help us, but you know, at the end of the day you’re being told somebody is dead and you know that’s what we’re all trained to do is for those situations so I suppose, you know, we do sort of put ourselves in vulnerable positions at certain times (P9)

Navigating these professional and clinical judgements raised the complex interplay of social, cultural and organisational factors within EMS.

Sociocultural and system frustrations of V&A in EMS

Our participants gave examples of system related sources of frustration influencing V&A which spanned the following sociocultural, organisational and technological areas:

Sociocultural

Sociocultural issues related to the role of alcohol and drugs, responding to disturbances, patients and their relatives being scared and in pain. They talked about communication challenges, and all told how the attitudes of EMS colleagues could incite V&A where they felt the same EMS staff got assaulted due to their own poor attitudes and communication:

The public are not always at fault… staff are not wholly innocent (P1)

And

I’m not innocent, I’m not, but if we go in there a bit bolshy, you know, when they’re fragile anyway they, you know… but people are—staff are overtired. They haven’t been fed, they haven’t been watered, whatever is going on or they’re burnt out, or they’re stressed out, if they’re going to go to somebody’s house who’s been waiting over the—over the time and the relatives are a little bit narky only a tiny bit that could be enough to—to give them attitude, you know? (P1)

And

because they’ve got their own frustrations, their own, they’re upset with work, they don’t feel supported, they don’t feel valued and all this, they then hold onto that frustration and it can, not always, but it can come across with their patients then (P7)

Organisational

Many organisational related issues were raised, including delays in ambulance responses as a source of frustration to patients and their family members which could result in V&A. They described how they were often the first person a caller encounters and their efforts to de-escalate the situation:

something that we’re seeing more and more of is patients saying we’ve waited so long for you, I can understand why the public would be upset if they’ve had to wait 6,8 maybe even longer hours, for what they see as their emergency, when we walk through the door, I can see why people would be potentially upset at that, that it has taken so long umm (P.4)

And

when they sat waiting and waiting [for an ambulance] and they’re getting more and more worked up, for whatever reason, they might have taken drugs, they might, you know, they’re desperate aren’t they? So, when we knock the door then, they’re like—they just erupt and we’re gonna get it both barrels (P1)

They described efforts of tackling V&A such as calling for help from colleagues and the police to detain and prosecute perpetrators. Participants were mostly aware of recent legislative changes, and while many could not name the Assaults on Emergency Workers Act (2018), they supported raising awareness of this issue and this legislation with the public. They also shared personal experiences which resulted in prosecutions:

that is what that lady was prosecuted under when she spat at me and the police officer. I understand that it allows for harsher sentencing than potentially if it had been a member of the public towards another member of the public so I really, think its an excellent element of law (P4)

Some participants did however report doubts over the effectiveness of the legislation within the context and that it may not be effective in deterring or preventing V&A as:

No amount of Acts is going to change peoples attitude, if they have that inclination to act violently and aggressively towards somebody, either because they feel threatened or they’re being asked to do something they don’t want to do, they are just going to act like that (P8)

These doubts were also accompanied by a degree of cynicism that such legislation and efforts would be effective and were politically motivated to appear to be doing something about this issue as shared by participant 2:

I fail to see how, that—that might be my warped opinion because I have seen some political commentators and legal commentators talking about it… then their core message is that it’s a political statement as opposed to a real one… It’s like trying to stick a plaster over the whole of the Titanic, it’s a bit of a holding point as opposed to a meaningful change (P2)

The role of such legislation and communication in preventing V&A was questioned by participants:

if you’re in a state of mind where you can remember the law, you’re probably not going to assault somebody in the first place or act in a manner that is violent or aggressive, so I suppose, it’s probably not going to act as a deterrent, however what it will do is get those potentially dangerous people off the streets, isn’t it (P4)

Technological

The introduction of technology has previously been discussed and includes placing flags on addresses, body-worn video (BWV), stab vests and panic buttons. Participants provided sophisticated accounts of the intention of such technology within their system to protect them from V&A as solo responders, but this raised many sociocultural and system issues within their unique care context. Unlike other emergency services, paramedics are primarily caregivers with privileged access to personal information and environments, and they talked about maintaining a balance of privacy and trust while protecting themselves. Comments by Paramedic 6 highlight the important differences between the police and EMS staff.

he did react to us when we got him on the ambulance, when he came around and thought that we were the police, umm, and we were able to sort of deescalate that and persuade him and help him to understand that we were actually ambulance and there were no police on the ambulance, we were ambulance service and we were there to help him and take him to a safe place (p6)

But also:

as soon as we got him into triage the police sergeant who was on duty looked at him and said, I know him, and she got onto her PDA and said, well, he’s red flagged for violence and aggression and drugs and all manner of things and she arrested him on the spot (p6)

Paramedics reflected longstanding debate around equipment such as stab vests in EMS where they could be criticised if assaulted and not wearing them, yet the inability to predict V&A may lead to requiring their routine use in all calls. Paramedics reflected the cost in terms of altering the dynamics of care interactions, where public perceptions of them may change, threatening their privileged access to information and settings which ultimately may increase risk for them and patients.

I know there are very few services that are sort of routinely providing body armour or anything like that, but again. I—those measures that may seem safer would probably put us at an increased risk of violence and aggression by taking away our neutrality. (P7)

And:

It could be seen as an invasion of a patients you know, privacy. Umm, it’s like, you know, in America, oh I’ve got a gun to protect myself but just the fact you’ve got a gun does that then make you a target? Yeah. That’s how I feel about it. Umm, you know if it came down to it, yes, I would wear one if it was required of us, yes. Umm, but I don’t think we should be, I will always try to talk a patient down first, always. (P3)

Participant 4 summed the situation by recognising the need for their provision in specialist teams, but cautioned against a blanket deployment:

if you dress everybody up like the police, everybody’s a culprit until proven otherwise, so therefore—have a pop, whereas having us unarmoured, I think is potentially safer. Outside of hazardous area team because you know they can do what they like [laughs]. That’s what they’re paid to do (P4)

Few technologies were recognised to prevent V&A, but the potential of BWV to capture footage of V&A was mentioned, which also has systemic and socio-cultural benefits in terms of what could be learnt from them. This included learning for EMS staff:

we’ve got the video footage of the vehicles, a body cam as well would show us that, you know, sometimes our staff escalate stuff as well as deescalate it. And it would be interesting to see the ones that have been assaulted—How many of them have been assaulted more than once? And then let’s give them the cameras first and see what’s going on (P2)

And for people who perpetrate V&A on EMS staff:

some of these people under the influence, best thing we could possibly do to just show them would be our video footage next day…here is the video evidence of how you’ve behaved towards this emergency medical crew. They were there to help you at your time of need, and this is what you’ve done, I think that would have more impact on the public if we were able to share them videos. (P2)

EGT: systemic frustration and gender-based V&A in EMS

The BSP was derived by the lead researcher (NR) through intense analysis, constant comparison and reflective memoing across all the categories while returning to the literature to describe and conceptualise the underlying social processes influencing V&A directed towards EMS staff. The following theoretical construction serves as a weaving of the fractured data together to conceptualise the relationship among the three levels of coding. Two theoretical positions were drawn on in this process, including the frustration–aggression hypothesis first proposed by Dollard et al³⁵ and Kelly’s ‘Continuum of Violence’.³⁶

Dollard et al states: ‘the occurrence of aggressive behaviour always presupposes the existence of frustration’ (³⁵ p.1) which reflects many frustrations revealed within our study, including EMS staff, patients, bystanders and others which spanned all the categories. Dollard et al³⁵ define frustration not as an emotional experience, but as ‘an interference with the occurrence of an instigated goal-response’” (³⁵ p.7). Frustration in this sense is therefore viewed as an event or action that complicates the accomplishment of a task, or as Berkowitz³⁷ proposed in his reformulation of this hypothesis, that: ‘frustrations are aversive events and generate aggressive inclinations only to the extent that they produce negative affect’ (p.71). While there may be other sources of aggression, it is widely acknowledged that frustrations generate negative affect, which, in turn, can lead to or increase aggression.^{37 38}

The range of V&A reported in our study is also commonly encountered by other EMS staff internationally, who experience verbal abuse (67–99%), intimidation (41–80%), physical assault (26–69%), sexual harassment (14–61%) and sexual assault (3–4%).^{4 12 39–42} Our study also reflects previous research where EMS staff appear to accept V&A is just part of the job, which was also found in our study and evident in statements such as just ‘poo pooing’ aggressive behaviour. This is an example of the complex interplay of contextual and systemic issues within EMS staff working culture and environment reported in the literature.^{12 42}

We found some forms of V&A were tolerable; in older people for instance, presenting with disease such as dementia which has also been reported by others.⁴³ Conversely, our participants conveyed a sense of frustration and intolerance to V&A involving drugs and alcohol due to its deliberate nature, which may be subject to choice, rather than in injury or illnesses which may be less under less control. Despite this, drugs and alcohol presentations have high mortality and EMS staff have long played a crucial role in their care, often being the first and only point of medical contact.^44–46

All participants in our study highlighted how behaviour of EMS staff may contribute to V&A, which may have many influences, such as individual personality, presupposition to V&A, limited communication skills, training and more systemic factors, such as long hospital delays, busyness, tiredness and stress in themselves and colleagues. The Rusted and Busted metaphor presents these issues and reflects assertions of Bolster et al⁴⁶ that the role of EMS staff in drugs and alcohol crisis may be complicated by increasing burnout, helplessness and moral distress, and this once rewarding patient encounter has evolved into one which may leave patients and paramedics feeling dissatisfied. Bolster et al⁴⁶ forwards the notion of such cumulative stress as potential contributory factors of such dissatisfaction, revealing that paramedic students have the lowest levels of empathy for people who use drugs than any other patient population, and some view them as unworthy of medical treatment, and a burden on the medical system, which is also found by others.^47–54

We have also previously reported how V&A may be influenced by compassion fatigue, which can occur when practitioners become emotionally exhausted and lose the ability to respond empathically to their patients.^{54 55} We have also reported systemic issues in EMS, to include training, tiredness, lack of appropriate care options and safe alternatives to emergency department (ED) for people with mental health problems and alcohol intoxication.¹⁴ Decision-making of EMS staff in a context of risk has also been reported to be usual in this context; especially when faced with patients who present with V&A, lack mental capacity or appear intoxicated with underlying medical problems or injuries.¹⁴

This frustrated environment where V&A is so prevalent may be creating conditions for, and reinforcing, the potential of further V&A. Work frustration is the negative emotion resulting from unsatisfied needs and motivation due to the obstacles and interference experienced by an individual in a workplace.⁵⁵ The psychological explanation of frustration aggression is not without criticism, as frustration does not always lead to aggression. People can indeed decide to be aggressive without being frustrated. The theory excessively focuses on the individual’s internal mechanism, but such individual action occurs within a wider social context, and hence we argue this frustration is not solely observed in the individual, but rather, the frustrated wider EMS system. Such system frustrations and reports by EMS staff reflect the challenging factors related to this issue, and previous research reports between 52% and 81.6% of cases of V&A on EMS staff is associated with mental behavioural disorders (MBD) or significant mental illness, 47% of which requiring psychiatric admission (79%, involuntarily), 11% have a history of violence, 24% are repeat perpetrator (93.5% associated with an MBD), 17–42.4% involve alcohol, psychoactive substance or illicit drugs.^{56 57}

The frustration–aggression theory suggests that V&A can occur because of the disparity between what is sought or desired and what is obtainable.³⁵ Our participants all cited delays in ambulance response as a major factor in V&A, and such delay has previously been reported as a predisposing factor for V&A in other emergency settings.^{5 10 58–60} Indeed, delays and other complicating contributors negatively influence a strained relationship between people who use drugs, EMS systems and its staff.^{46 61} Patients may be in pain or injured, where themselves, relatives or bystanders may become frustrated when the desired goal of receiving care is not attainable, provoking an emotional response towards perceived authorities standing in the way of his achieving or attaining his desire. Waiting times may be seen as a source of frustration and irritation;^62–64 indeed, Morken et al reported how ED nurse participants perceived episodes of V&A to be the result of a mismatch between patient expectations and the actual service.⁶⁵

EMS staff encounter V&A in their everyday work, which we argue above, is both systemic and often borne out of frustration. Participants also reflected the normalisation of V&A with some acceptance of it being part of the job, but also recognised the significant volume of sexual related V&A, which is also reflected in the literature, with 14−61% of EMS staff reporting assault and harassment and 3–4% sexual assault.^{4 12 39–41} None of our male participants reported personal experiences of this but acknowledged its presence.

Kelly’s ‘Continuum of Violence’ (1988)³⁶ describes how normalisation of daily violence can lead to sexual violence, and posits that sexual violence exists on a continuum, ranging from ‘everyday’ incidents such as catcalling to extreme acts of rape. This theory suggests that all forms of gendered violence are linked by the common thread of male social control and are normalised within patriarchal structures. Such a position follows that sexual violence is both a cause and a consequence of inequality based on gender, and the rich, yet disturbing, experiences reported by female EMS staff in our study may reflect elements of feminist sociologists’ assertions of gender inequality being central to sexual violence and therefore may be at the intersection of gender with other structural forms of oppression in EMS.^66–68

Female participants in our study revealed powerful and disturbing experiences of sexual assault by patients and coworkers; they wanted to speak up and have their stories heard. While both males and females are victims of sexual harassment and assault in EMS, it is experienced significantly more in females than males, with around 34.2% females staff experiencing, versus 9.2% male counterparts.^{12 39 69} This picture is also reported in other professions.^70–74 Within our study, however, many of these were perpetrated by EMS coworkers, which has also been reported elsewhere.¹²

Our participants raised a range of one-off violent acts, to repeated, routinised instances of sexual violence, assault and harassment, which included groping, touching breasts, physical and sexual assaults. Kelly³⁶ suggests a continuum of sexual violence exists both within any individual woman’s lifetime and connects different women’s experiences under patriarchy, even as these experiences are differentiated in relation to overarching socio-political structures as well as through the such as race, dis/ability, age or sexuality.

EMS may be characterised as a patriarchal social system, where historically men held primary power, controlled resources and dominated authority in political, economic and social structures, which Kelly³⁶ suggests can lead to systemic gender inequality, where feminine traits are devalued and women are excluded from full participation. While the gender balance of the UK paramedic workforce has recently become equal, this is not reflected internationally, and such a male dominated culture may be partly due to the quasi-militaristic historical roots of EMS, as highlighted by a participant in our study:

it’s the culture and I think because it’s quite traditionally quite a military based culture, male dominated culture, I think now obviously there’s a proportion of females, and I’m not saying males don’t get assaulted at all

Boulding⁷⁵ outlined the structural relationship between patriarchy and all forms of oppression, including sexual oppression. Boulding further outlined how such militarisation, male-dominated social institutions and violence are interconnected.⁷⁵ Collins (1998 p.919)^{76 77} extends this further, arguing that violence may serve as the conceptual glue that binds systems of domination together, that sexual violence—of different forms, against different bodies and across locations and time—maintains and creates power asymmetries, and those deploying sexual violence need not be consciously aware of its power for it to achieve these effects.

Hanna-Osborne⁷⁸ explored the sex-based harassment experiences of women working in a large Australian ambulance service, focusing on harassment from coworkers and managers. Of the 30 participants, 25 had experienced sex-based harassment from male colleagues. Most commonly this took the form of gender harassment such as comments and jokes designed to belittle and demean women based on their gender. Hanna-Osborne⁷⁸ also found that most sex-based harassment went unreported, and participants articulated a range of barriers to speaking out about harassment including: difficulty in gathering adequate evidence, women being perceived as overly sensitive or a ‘troublemaker’, and belief that the complaint would not be properly investigated and acted on, particularly if the perpetrator was a manager. Many participants in this study believed there were informal ‘boys’ clubs’ in the organisation which insulated certain men from the consequences of their actions finally, a fear that making a report could expose the woman to further harm was another reason women were hesitant to do so.

McFarlane et al^79–82 also reported how female paramedics experience everyday sexism, gender discrimination and sexual harassment in the workplace which influenced how they practised, and negatively impacted on career progression and well-being. The Victorian Equal Opportunity and Human Rights Commission (2022)⁸³ conducted an inquiry into the culture at Ambulance Victoria (AV) where 83% of staff reported sexually suggestive comments or jokes and 10% indicated they had experienced requests or pressure for sex or other sexual acts, 3.6% had been subjected to actual or attempted rape or sexual assault. AV is a jurisdictional ambulance service in Australia servicing a population of almost 7 million people across urban and rural settings that is comparable to Wales. AV was recognised in this report to be an increasingly tired and frustrated community, but this may reflect EMS staff experiences internationally as Mausz and Johnston also found 61.5% of EMS staff report sexual harassment and 13.8% sexual assault.⁴²

A sexualised and sexist culture within UK Ambulance services is not new and has been reported over many decades, including accounts of serious incidents, exposure to pornographic material, physical propositioning and sexual assault.^{42 84–88} Female EMS staff have talked about ‘sexual predators’ among male colleagues who ‘groomed students’ for sexualised ends⁸⁸ which also reflects Sheen et al who found that 16% of paramedic students were exposed to unwanted sexual behaviour.⁸⁹

Our study also revealed elements of genderisation when referring to older people presenting with illness such as dementia, where the perpetrator was referred to in the feminine form, whereas younger assailants intoxicated with drugs and alcohol presented as males. While further work is needed to establish the accuracy of such perceptions, this may relate to wider societal gender norms and stereotypes which restrict individuals to gender identities and expressions that conform to the male–female binary. Such genderisation is evident across wider society.^90–93 Early work of Broverman et al⁹⁴ suggests agency and communion as core dimensions of gender stereotypes. Agency incorporates traits such as competence, instrumentality and independence; communion encompasses expressivity, warmth and concern with the welfare of others. Such attitudes may however reflect the cultural problems above and machismo, which is a sociocultural construction where men are characterised as aggressive, independent and dominant, and women are characterised as weak, dependent and submissive.⁸²

Discussion

Our study aimed to conduct an exploratory qualitative interview study of EMS staff focusing on experiences, perceptions and interpretations of V&A directed towards them and has revealed rich, yet disturbing insights which rarely surface in professional and public discourses on this issue. The BSP of systemic frustration and gender-based V&A in EMS presents complex societal and organisational challenges which many working within EMS may be aware of, but effective solutions to protect staff remain elusive.

We did not set out to explore gender-based V&A, but the dominance of this issue in the accounts resulted in our acknowledgement of this within the BSP. This reflects a wider body of knowledge reporting how female ambulance personnel are more likely to experience more episodes of sexual assault and sexual harassment than males.^{4 12 41 95 96} Such experiences of sexual assault and harassment by ambulance personnel in the workplace impact victims’ work and private lives, with reports of minimal support or resources from their organisations to help them manage this trauma, aid them in reporting assault or harassment or to educate others.^{78 97}

The Victorian Equal Opportunity and Human Rights Commission⁸³ reflected an unawareness in senior leaders of this culture of sexism in EMS. The National Guardian’s Office (UK)⁹⁸ also recently conducted a ‘Speak Up’ review of National Health Service ambulance trusts in England and found reports of sexism and a culture that did not support workers to speak up. A ‘macho’ culture has also been suggested to exist within UK ambulance trusts leading to widespread abuse of female staff.⁸⁷ While such sexism and sexual abuse is reflected in the research literature,^{78–81 99} few studies have explored coworker sexual violence. Hanna-Osborne however, found in her study that 25 out of 30 participants had experienced sex-based harassment from male colleagues. Most commonly this took the form of gender harassment such as comments and jokes designed to belittle and demean women based on their gender.⁷⁸ Boyle et al¹² also reported that a significant number of paramedics experience sexual harassment/assault in the workplace by work colleagues, and participants in Hanna-Osborne⁷⁸ experienced sexualised forms of harassment, including unwelcome sexual attention and propositions. They expressed reluctance to report the behaviour through organisational channels because of the perceived futility of doing so and the potential for reprisals and career repercussions. The preferred responses to harassment were informal and included avoidance, humour, direct appeals and work withdrawal.

Mixed opinions were shared in our study of the potential impact of legislation, ranging from support to doubts of its effectiveness within the context, and that it may not prevent V&A as perpetrators are often incapacitated or intoxicated during the V&A. This notion is also supported by Eburn and Townsend¹⁰⁰ who propose that in most people who commit V&A on EMS staff, such legislation will unlikely be at the forefront of their minds, and punishment after the event shows that the desire for protection has not worked. As in our study, Eburn and Townsend¹⁰⁰ highlight how the very people who need EMS assistance are those suffering mental health crises, intoxication and injury, and such people are unlikely to make rational decisions at that time. Eburn and Townsend¹⁰⁰ argue that punitive sentences such as jail will not decrease the risk of or actual events of V&A, nor will it address the causes or reduce the risk of future offending.

Viking et al²⁴ recently explored workplace violence directed toward ambulance services from the offender’s perspective through an explorative qualitative study using inductive thematic analysis of trial transcripts from cases tried in court between 2013 and 2023 and found: (1) the offender was misunderstood, which included communication problems and other misunderstandings; (2) the offender was disrespected, which described perceived unprofessional behaviour and unpleasant or painful treatment by ambulance personnel; (3) the offender was vulnerable, which described the state of the offender (ie, being under the influence of alcohol or drugs); and (4) the offender had unmet expectations, which included perceived unreasonable waiting time and conflicting expectations of ambulance care.

Our participants reflected on the trusted context of their care, involving intimate contact and invasive procedures also highlighted by Eburn and Townsend¹⁰⁰ who argue this trust may be eroded if people contact EMS for unconscious friends or family members to be prosecuted or jailed if they become agitated or violent. Communications and media reports in Wales highlight doubling of maximum prison sentences under the Assault on Emergency Workers (Offences) Act¹⁰¹ which may be seen as a deterrent towards such V&A, but as was suggested in our study, Eburn and Townsend¹⁰⁰ argue that such legislation may be more politically motivated, for governments to appear to be doing something about this issue. Some of our participants reported disappointment at low sentences, which again may reflect Eburn and Townsend's¹⁰⁰ assertions that despite government rhetoric around mandatory sentences, all cases are different, judged on their own facts, by magistrates and judges not governments or legislators. Eburn and Townsend¹⁰⁰ highlight how reports focus on maximum sentences, which allow for lesser sentences in special circumstances which often include offenders affected by drugs or alcohol at the time.

People who use drugs or alcohol often feature in media reports, but not as special circumstances, rather, in pejorative and demeaning language such as ‘drug addict’, ‘drug-addled stupor’ and aligned with ‘thugs, perverts, drug dealers and other criminals’.¹⁴ This is not consistent with the professional and considered manner of our respondents when talking about these patient groups. Such pluralistic media rhetoric of villains being locked up for assaulting heroic EMS staff belies the complexity of this issue, may ultimately be unhelpful in tackling it, and rather, have the opposite effect of marginalising these patient groups further, eroding their trust in EMS staff and increasing the vulnerability of them and EMS staff rather than making things safer.^{14 46 100 102–104}

The moral judgements, stigma and language used to describe the drugs and alcohol taking population therefore matter and the complex interplay of tolerable and intolerable V&A can have significant implications for patients and EMS staff. We therefore concur with calls for EMS and their leaders to receive education in this area which has been shown to result in significantly less stigmatisation of this population.⁵¹ Such education should start at the point of entry such as university and induction, then continue to be reinforced throughout their career through case-based discussion, reflection and clinical supervision.

EMS leaders and staff therefore have a difficult balance to strike in protecting EMS staff when considering barriers of harm reduction, such as the willingness to activate EMS drugs and alcohol and decreasing police presence to reduce on-scene tension bred from longstanding negative from intergenerational trauma, criminalisation and stigma⁴⁶ as well as the opportunities for post-drug poisoning therapeutics can be viewed as life-saving.¹⁰⁴

Many modifiable factors were suggested, some of which involved technological innovations such as stab vests, spit tests and flagging addresses. Many have been introduced despite sparse evidence for their effectiveness. Participants for instance spoke of BWC technology which EMS systems are increasingly adopting at considerable financial cost, yet Bruton et al¹⁰⁴ found no evidence that implementation of BWCs, alone or as part of a broader suite of initiatives, reduces the incidence of V&A towards paramedics and calls for further research.

Some modifiable factors however were cultural and systemic; for instance, some reported negative experiences and futility in reporting V&A, which reflects research which found only 40% of EMS staff report the incidents to service management and 21.3% to police.⁴⁰ Support from colleagues, unions, managers and opportunities for face-to-face meetings with the perpetrator seemed to be valued. One of our participants told of a formal meeting with her attacker as a form of restorative justice. Non-punitive intervention such as this aims to increase accountability for perpetrators at a societal level and have been trialled elsewhere which presents an opportunity to tackle V&A, but further prospective trials are needed in EMS.²¹ Our study revealed the potential BWC’s within a restorative justice context, whereby showing footage to perpetrators of V&A may modify future behaviour which should be the focus of such future research.

In delayed EMS responses participants highlighted the role of the dispatchers keeping callers informed which may help resolve a mismatch between patient expectations and the service offered. Alerting EMS staff and involving the police where there is risk of V&A such as in cases involving severe mental health problems or intoxication with drugs flagging addresses validated risk.

Our participants suggested that efforts to tackle V&A such as legislation is like trying to stick a plaster over the whole of the Titanic… a bit of a holding point as opposed to a meaningful change. This reflects Eburn and Townsend’s¹⁰⁰ assessment of the problem, that this sort of work is expensive, slow and unpopular in today’s rhetoric and being ‘tough on crime’. To protect paramedics the community needs to address offending before it happens, fund education, mental health services and drug rehabilitation.¹⁰⁰

In 2022, while we were conducting this research, studies exploring V&A directed towards EMS staff in Western Iran were ongoing that report remarkably similar findings to ours which add to the credibility of our novel theoretical contribution and demonstrate methodological convergence of the complex interplay of our theory across EMS settings.^{105 106} The categories reported in Torabi et al¹⁰⁵ and Afshari et al^{107 106} reveal a similar range of complex issues, which include: organisational culture and workforce dynamics, professional satisfaction, society and judicial laws, cultural and societal barriers, shortcomings in organisational safety and support, interpersonal and operational pressures, barriers to effective prehospital care, resource and infrastructure limitations and challenges in interagency coordination, interprofessional problems, challenges inside individuals and training in de-escalation techniques. These studies demonstrate that our findings are not isolated, but resonate with established research, and crucially reflect the need to address the many cultural, organisational and societal root causes of V&A to create a safer and more supportive environment for patients and staff.

Strengths and limitations

Our study is limited in being conducted in one UK country and single EMS. Our small sample also may reflect non-response bias, where those interested in telling their stories may have been more likely to engage in the research. This may have resulted in our sample being more representative of individuals who have suffered severe V&A or who feel passionately about change. We also recognise the need for some caution of the framing due to the small and context specific sample size. The research team included paramedics which again may be considered a potential bias, but we believe this adds to the richness and ability to bring meaning to the constructed GT. We found consistency and agreement throughout analysis, member checking and previous studies which adds to the trustworthiness and transferability of our findings.

This study raised areas which deserve significant further research, in particular tolerable and intolerable V&A and the interplay between moral judgements, stigma and decision-making. We also recognise the significant limitation of this study and other V&A research in EMS, which does not include the voice of patients and perpetrators of V&A. We therefore recommend that future research explore perpetrator and patient perspectives.

Conclusion

Protecting EMS staff from V&A is complex and multifaceted. Through interviews with EMS staff we have explored and constructed an EGT which proposes that V&A in EMS may be borne out of, and sustained, by systemic frustration and gender-based issues. We draw on the theoretical position of the frustration–aggression hypothesis first proposed by Dollard et al which views frustration as an event or action that complicates the accomplishment of a task. EMS staff reported that V&A is inevitable within their working context and many issues emerged that complicate the accomplishment of the task of EMS staff providing care.³⁵ We also draw on Kelly’s ‘Continuum of Violence’ which can exist both within any individual woman’s lifetime, throughout society and overarching sociopolitical structures.³⁶ The experiences of sexual V&A revealed in our study are supported by a wider body of knowledge that lays bare a caring context of rampant gender-based V&A directed towards EMS staff by members of society and colleagues, and within a historically patriarchal EMS.

EMS staff provide care for people with medical problems which impair their mental capacity and may involve V&A yet is tolerated. This contrasts with V&A in those intoxicated with alcohol or drugs which they find intolerable, which can present significant professional, ethical and clinical judgements and challenges including balancing risk to EMS staff against potential stigmatisation barriers to care for these high risk groups. Systemic frustrations within EMS revealed may be modifiable in tackling V&A include delays in ambulance response, lack of referral options, tiredness, stress, lengthy hospital handover times, communication skills and training shortfalls. Technological solutions such as BWV and other opportunities, such as validated risk decision tools for minimising frustration in delayed EMS response and dispatchers keeping callers informed. These opportunities are costly and require research to evaluate their effectiveness. The impact of V&A may also be minimised through policies that support the victim, and positive examples were provided of support from colleagues, managers and unions, along with restorative initiatives all of which require more research.

Our study revealed how EMS has not effectively tackled V&A and many sociocultural constructs accepted within EMS and we advocate for purposeful efforts, and systemic interventions, beyond punitive measures to be introduced to tackle this issue.

Data availability statement

Data are available upon reasonable request.