By Justin Mausz,2,3, ACP, PhD(c); Mandy Johnston1, ACP; and Elizabeth Donnelly3, NREMT, LICSW, PhD
 Peel Regional Paramedic Services, Brampton, Ontario; 2 McMaster University, Department of Health Research Methods, Evidence, and Impact, Hamilton, Ontario; 3 The University of Windsor, School of Social Work, Windsor, Ontario, Canada
Violence against paramedics is increasingly recognized as an important threat to workplace health and safety (1, 2). Cross-sectional research from around the world indicates that a concerning majority of paramedics have experienced some form of workplace violence – ranging from verbal abuse to physical or sexual assault – within the past year (3-14). Exposure to workplace violence creates the possibility of potentially significant physical (4, 9, 11, 15) and emotional harm (16), particularly within the context of already high rates of mental illness among paramedics (17). Perhaps most concerning, however, is that the vast majority of incidents of workplace violence against paramedics go unreported. For example, in a large, multi-site study in Canada, Bigham and colleagues identified that more than 80% of survey participants had not reported incidents of violence to either paramedic service administration or the police (12). This significantly limits the ability of paramedic service organizations to both support individual paramedics who are victimized by violence and develop risk mitigation strategies on a policy level. The reasons for underreporting are multifactorial, with our own research (18) suggesting a complex interaction of workplace cultural features that conspire to normalize exposure to violence as an expected part of paramedic work. However, one potential – and readily modifiable – barrier to reporting is in the accessibility of avenues to document incidents of workplace violence. Indeed, in their report, Bigham and colleagues highlighted the need for meaningful, accessible reporting mechanisms, and further suggested that frontline paramedics should be involved in the development of such reporting processes (12). We describe the development of the External Violence Incident Report (EVIR) in our paramedic service in Ontario, Canada.
Development of the EVIR
Setting and context
Peel Regional Paramedic Services (PRPS) provides land ambulance paramedic services to the municipalities of Brampton, Mississauga, and Caledon in Ontario, Canada. PRPS employs more than 700 Primary and Advanced Care Paramedics (P/ACPs), responding to over 130,000 emergency calls per year. In 2019, PRPS established the External Violence Against Paramedics (EVAP) working group with the mandate of developing organizational strategies to mitigate the risks posed by workplace violence. This included the development of a comprehensive reporting process.
The work of the EVAP group began with distributing a web-based survey to the service’s paramedic workforce in the spring of 2019, with the goals of exploring our paramedics’ experiences with workplace violence and the reasons for underreporting. The results from the survey are being reported elsewhere (18), but in brief, the survey participants identified a complex interplay of features of organizational culture that conspire to normalize exposure to violence as an expected part of paramedic work. Within that construction, the significance of violent incidents are often downplayed and – hence – positioned as not worth reporting. These sentiments speak to a broader and more complex need for culture change.
Within the context of the existing reporting process specifically, our participants identified a number of accessibility issues. Lack of knowledge around process (i.e., which form to fill out), the length of time required, and the administrative burden for both paramedics and supervisors were often cited as barriers to reporting. We used the findings from the survey to inform the next steps in our mandate of developing a coherent organizational response to workplace violence.
Gap & need analysis
Our next task was to examine the existing reporting mechanisms and related workflow processes to identify what gaps exist and what an improved reporting mechanism would need to achieve in order to be effective. To streamline workflow processes, our new reporting mechanism would need to simultaneously:
- Collect the necessary information to comply with provincial documentation standards;
- Gather the information required for occupational health and safety documentation, particularly where compensation claims are required; and
- Facilitate address hazard flagging where the risk of repeat occurrences is likely
The reporting mechanism would also need to collect data about the incidents themselves that functionally allows for ongoing analysis in support of risk mitigation strategies. Finally – and most importantly – the reporting mechanism needs to be accessible and user-friendly, minimizing the administrative burden on both paramedics and supervisors. With these requirements in mind, we began our development process.
We assembled a team of stakeholders to develop the reporting process, including practicing paramedics, and representation from service leadership, administration, and occupational health and safety. Our goal was to identify and define the features of violent incidents that are important for tracking – our ‘construct’ of interest – and the ‘back end’ processes for what should occur when a report is submitted. We determined our reporting process would need to gather information about:
- The type of violence using definitions adapted from scholarly and government sources
- The circumstances surrounding the incident, such as where the incident occurred and whether alcohol, drugs, or other forms of cognitive impairment were involved
- The specifics of the incident itself, through a detailed free-text narrative description
- What existing risk mitigation strategies had been used, such as whether police or a paramedic supervisor were present, or an existing hazard flag had been communicated as part of the dispatch information
- Whether the paramedic experienced any physical or psychological harm as a result of the incident, and whether the paramedic wanted a supervisor to follow up with them
Based on comments from our survey, we wanted to limit the amount of free-text and instead make use of drop-down menu selections, tick boxes, and fields that would auto-populate from the corresponding electronic Patient Care Report (ePCR). Over the course of several months, our team engaged in successive rounds of brainstorming to develop and then refine a prototype incident report (Figure 1).
Our goals for pilot testing were to evaluate the accessibility, usability, and ‘construct coverage’ of the prototype incident report. Over the course of two days, we recruited a convenience sample of 45 paramedics to evaluate the prototype incident report. We gave each a brief explanation of the goals of the incident report and then asked them to think back to an incident that they had previously encountered (provided they felt comfortable recalling the event). We asked the paramedics to complete the form with this incident in mind and provide us with feedback about the form’s layout, accessibility, technical features, and whether or not the fields in the form adequately captured their experience. The participants provided us with positive feedback, identifying no issues related to construct coverage and only a handful of (mostly technical) edits to improve functionality.
Next steps: Implementation of the EVIR
Full-scale rollout of the External Violence Incident Report is scheduled for January 2021. As part of the implementation, we are providing training on the incident report and associated reporting process to all service leadership and paramedics. When a paramedic completes an EVIR, our reporting process will (optimally) ensure that:
- Each EVIR is flagged for review by a paramedic supervisor who will follow up with the paramedic, complete occupational health and safety documentation, and create or modify a hazard flag for the call location as required
- The EVIRs are entered into an ongoing prospective database from which we can mine quantitative and qualitative data to identify features of emergency calls that are associated with an increased risk of violence to inform both risk mitigation strategies and scholarly research.
Once implemented, we additionally plan on conducting various forms of program evaluation to assess the efficacy and acceptability of the new reporting process, including a follow-up survey. All of this allows the paramedic service to support individual paramedics who experience workplace violence and develop broader, policy-level risk mitigation strategies to enhance paramedic safety and wellbeing.
We would like to express our gratitude and appreciation to Kavita Chauhan Marieiro, Kris Dubuque, Ethel Gonzales, Kyle Johansen, and Alexis Silverman for their invaluable contributions to the development of the External Violence Incident Report. We would also like to acknowledge and thank the Paramedic Leadership Team (PLT) for their support of this important work.
Declaration of Interest
The development and implementation of the External Violence Incident Report is funded by Peel Regional Paramedic Services as part of a broader, ongoing initiative to ensure the psychological health and safety of service members. Authors JM and MJ are currently employed by Peel Regional Paramedic Services. None of the authors have any financial or other relationship with Interdev Technologies and, aside from technical processes, Interdev Technologies had no involvement in the planning or development of the content development of the EVIR.
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