Scientific Solutions

NEW SOLUTIONS: A Journal of

Environmental and Occupational
A Systematic Review of Workplace Health Policy
2020, Vol. 29(4) 487–503
Violence Against Emergency ! The Author(s) 2019

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DOI: 10.1177/1048291119893388
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Regan M. Murray1 , Andrea L. Davis1, Lauren J. Shepler1,

Lori Moore-Merrell2, William J. Troup3, Joseph A. Allen4, and
Jennifer A. Taylor1

Abstract
Emergency Medical Service (EMS) responders deliver patient care in high-risk, high-stress, and highly variable scenarios.
This unpredictable work environment exposes EMS responders to many risks, one of which is violence. The primary goals of
this systematic literature review were to (1) define the issue of violence experienced by EMS responders and (2) identify the
risk factors of violence associated with the EMS profession. An innovative inclusion of industrial literature with traditional
peer-reviewed literature was performed. Of 387 articles retrieved, 104 articles were assessed and reviewed. Career expo-
sure for EMS responders to at least one instance of verbal and/or physical violence was between 57 and 93 percent. There is
a great need for rigorously designed, nationally representative examinations of occupational exposures in order to better
understand the temporal associations of violence, cumulative occupational stressors, and the outcomes of physical and
psychosocial injuries that are occurring as a result of exposures to violence.

Keywords
systematic literature review, workplace violence, emergency medical services, first responders

Introduction volume of twenty-two million.4 Due to the lack of

The Centers for Disease Control and Prevention and a centralized licensing body, capturing a true estimate
National Institute for Occupational Safety and Health of the total number of EMS agencies and providers on
(NIOSH) define workplace violence (WPV) as “violent a national level is difficult.5 Increasingly, 911 emergency
acts, including physical assaults and threats of assaults, response systems are experiencing a departure from fire-
directed toward persons at work or on duty.”1 The often related calls, toward a greater number of calls for EMS.6
unrecognized psychosocial component of violence is fur- Of the 34.7 million calls to 911 in 2017, the average
ther refined in the World Health Organization’s defini- majority (64%) were for medical assistance7 with some
tion of WPV as “incidents where staff are abused, fire departments experiencing upward of 80 to 90 percent
threatened or assaulted in circumstances related to of their call volume dedicated to the EMS side of their
their work, including commuting to and from work, work.8 In 2015, there were twenty-nine million calls for
involving an explicit or implicit challenge to their
safety, well-being or health.”2 Health-related industries, 1
Department of Environmental and Occupational Health, Dornsife School
particularly those involving patient care, experience the of Public Health, Drexel University, Philadelphia, PA, USA
highest rates of WPV compared to all other industries— 2
International Association of Fire Fighters, Washington, DC, USA
3
with patients described as the most significant contribu- United States Fire Administration, Emmitsburg, MD, USA
4
tor to provider injuries resultant from violence.3 University of Utah Health, Salt Lake City, UT, USA
In the United States, the Emergency Medical Services Corresponding Author:
Jennifer A. Taylor, Department of Environmental and Occupational Health,
(EMS) profession is comprised of approximately nine Dornsife School of Public Health, Drexel University, Nesbitt Hall, Room
hundred thousand paid and unpaid (volunteer) EMS 655, 3215 Market Street, Philadelphia, PA 19104, USA.
providers, responsible for an estimated annual patient Email: Jat65@drexel.edu
488 NEW SOLUTIONS: A Journal of Environmental and Occupational Health Policy 29(4)

EMS services, a 23 percent increase from 2014.9 This the workplace when the phenomenon “aggression begets
increase represents a continually growing trend in the aggression” was first noted.20 Similar sentiments contin-
United States. Subsequently, the 911 response system ue to be voiced by emergency medical providers four
is strained and increasingly calling upon EMS respond- decades later.11 By contrast, the first academic study
ers to deliver services6 contributing to their feelings of was published in 1993.21 Research on violence against
being “banged-up and burned out.”10 Feelings of burn- EMS responders categorized violence as verbal abuse,
out coupled with exposures to violent incidents can have physical abuse, property damage or theft, sexual harass-
lasting impacts upon EMS providers.11 ment, sexual assault, and intimidation.22–27 Acts of vio-
Increased community demand for services necessi- lence against EMS responders have been reported as
tates increased patient interactions, thereby increasing “struck by patient,” “punched in the face by a drunkard,”
the injury potential to EMS responders. In 2016, “tackled by a large man,” and “assaulted by a combative
approximately three thousand five hundred EMS res- patient.”11 Formal recognition of this issue is increasing;
ponders were treated in the emergency department however, compared to other healthcare settings, WPV in
(ED) due to injuries sustained from violence.12 A retro- the prehospital setting is inadequately described and
spective cohort study of nationally registered Emergency requires further consideration.21,24,27–31
Medical Technicians (EMTs) found that assault was the The primary objective of this literature review was to
cause for 8 percent of fatal injuries.4 While these num- describe what is known about the phenomena of vio-
bers may seem small in comparison to the nature and lence against EMS responders by patients and bystand-
cause of other leading occupational injuries and fatalities ers. An innovative approach was taken to include
in the fire and rescue service, there is evidence to believe academic and industrial publications. The second objec-
injuries related to violence are vastly underreported due tive of this literature review was to identify risk factors
to the nonexistence of policies, procedures, and practices and outcomes of violence in EMS.
to support reporting of such incidents.6,11 Yet, work-
related injuries among EMS responders were three
times higher than the national average for all other occu-
Methods
pations in 2013.4 The rate of occupational fatalities Literature Search Strategy
among paramedics is more than twice the national aver-
age for all occupations and comparable to the rates of This systematic review was conducted in accordance
police and firefighters at 12.7 per one hundred thousand with the preferred reporting items for systematic reviews
workers per year.13 The rate of nonfatal injuries among from the PRISMA-P checklist.32 Review of industrial
paramedics is more than five times higher than the literature has been excluded from prior academic
national average for all workers at 34.6 per 100 full- research on this topic. We chose to include the voices
time workers per year.14 Fatal assault (i.e., homicide) and perspectives of the industry to provide a more com-
was found to be the third leading cause of death for plete and comprehensive representation of the violence
EMS workers upon review of three fatality databases.13 experienced by EMS responders. Three academic data-
Serving as a crucial public health safety net, EMS is in bases (PubMed, CINHAL, and Web of Science) were
a constant state of response to the persistent and emerg- utilized systematically and iteratively to collect manu-
ing health needs of the community.15 As a result, EMS scripts from peer-reviewed and industrial trade journals,
responders are expected to provide patient care in unpre- using EMS-specific terminology (Table 1). Medical
dictable and ever-changing environments, and while Subject Headings (MeSH) operationalized the search
some occupational hazards are “clear and imposing,” by providing delineated sets of terms allowing various
others, like violence, can be “insidious and silent.”16 levels of specificity and contributing to the collection of
While legally, no EMS responder must unreasonably relevant literature. As such, the term “Emergency
place their own life in jeopardy as maintained in the Responder” when used with the MeSH subject heading
Occupational Safety and Health Act’s (OSHA) automatically included the terms Emergency Medical
General Duty Clause, Section 5(a)(1) of 1970,17 the Technician, Firefighter, and Police in the search results.
expectations of the community coupled with the inter- MeSH subject headings were only used if the MeSH
nalized belief among responders that they exist to serve hierarchical terms were relevant to the field of EMS
frequently place the safety of the responder as secondary (e.g., “emergency responder” was used with MeSH head-
to the safety and well-being of the patient.18 ings because it returned results pertaining to EMTs and
Less than a decade after the formal recognition of the firefighters). In each database, operands and operators
EMS system in 1973,19 industry publications mentioning (e.g., “AND,” “OR,” and “NOT”) increased the number
violent patient encounters began to surface.20 The year of relevant manuscripts as they permitted emphasis on
1978 marks the beginning of a decades-long conversa- desired search terms (e.g., assault OR violence) and
tion by the EMS industry about violence experienced in excluded any unwanted subjects or terms (e.g., police).
Murray et al. 489

Additionally, the asterisk indicated in Table 1 denotes All literature relating to the issue of violence in EMS
searching for a derivate of the search term. published prior to 31 December 2016 was considered.
Endnote, a referencing software tool, was used to
Selection of Articles for Review assist with deduplication, ease of access, and citation
The literature review was conducted in three phases: of manuscripts. Special effort was made to find evaluat-
Phase 1 involved evaluating each article based on its ed studies that would give rise to an evidence base of
title, abstract, and keywords; Phase 2 involved review- effective violence prevention interventions. While aca-
ing, assessing, and documenting titles and abstracts in demic literature allows for enumeration and quantifica-
chronological order; Phase 3 involved reviewing, assess- tion of violence, industry publications discuss specific
ing, and documenting the full articles of those deemed knowledge neglected by the scientific literature and pro-
relevant based on the first two phases. In Phase 3, liter- vide a rich contextual portal into the realities of EMS
ature was coded per an iterative process in which major work. Therefore, it was determined early in the literature
themes were recognized and cataloged. Phase 3 also search that industry-specific publications, such as trade
included manual searches of the retrieved articles for journals and magazines would be included in this review.
additional references. A total of 104 full-text articles
were reviewed for in-depth analysis based upon prioriti- Results
zation and relevance to our research question (Figure 1).
Of the 104 articles we retained for analysis, thirty-six were
from industrial trade journals and sixty-eight articles were
Criteria for Inclusion and Exclusion from academic journals (see online supplements Tables 2
The researchers decided the inclusion or exclusion of and 3). Of the sixty-eight peer-reviewed articles, twenty-
specific articles based on the process described here, seven articles provided some estimate of violence (see
which is consistent with current literature review conven- online supplement Table 4). Of the twenty-seven articles
tion.33 Articles were excluded if (1) they did not discuss measuring the prevalence of violence, fifteen articles
violence to EMS providers, (2) were published in a non- defined or described the types of violence being measured.
English language, (3) full-text versions were unavailable, The articles retained for analysis revealed eight key
and (4) were not in a prehospital environment or ED. themes: “evolution of the definition of workplace

Table 1. Literature search terms used to retrieve academic peer-reviewed literature and industry publications through PubMed, CINHAL
and Web of Science.

Literature Search Terms

Paramedic Assault* Staffing Models Occupational Risk

Emergency Medical Technician Patient Aggression Risk Assessment Occupational Injury
Medic* Healthcare Violence Intervention Occupational Hazard
First Responder Attack* Scene Safety Occupational Health
Healthcare Worker Combative Patient Violence Reduction Retention
Emergency Medical Services Patient Initiated Violence Conflict Resolution Burnout
Emergency Responder Fatality Defensive Tactics Personal Protection
Pre-Hospital Care Aggression Violence Prevention De-escalation
Fire Fighter Workplace Violence Situational Awareness
Note. Asterisk denotes searching for a derivative of the search term.

Phase 1: Phase 2: Phase 3:

Evaluation Thematic Arrangement Analysis
Full Text Articles Reviewed: 387
(each article placed into thematic and digestible categories described
Titles and Abstracts: below) 164 total articles reviewed
PubMed 1,119 articles reviewed
for relevance 1. Assault and Violence/Background Information (141 articles) 104 articles chosen for
2. Injuries and Fatalities (23 articles) inclusion
PubMed:
339 articles
CINHAL
CINHAL: 3. Preparedness and Interventions (144 articles)
95 articles 4. Psychosocial Stress and Strain (45 articles)
5. Resilience (9 articles)
Web of 6. Social and Community Perceptions (12 articles)
Web of Science:
Science 125 articles 7. Surveillance (13 articles)

Figure 1. Flow diagram of literature search and retrieved results.

490 NEW SOLUTIONS: A Journal of Environmental and Occupational Health Policy 29(4)

violence,” “estimates of violence,” “psychosocial impact work colleague(s) causing damage to, or stealing
(stress),” “EMS responder-level characteristics,” property belonging to you, your family, or your
“characteristics of perpetrators of violence,” “reporting/ workplace. It includes damage to or theft of a vehicle,
underreporting,” “industry best practices, policies, and personal effects, home contents, office equipment and
procedures,” and “intervention and policy oppor- supplies, or office furnishings. Attempted theft of the
tunities.” The tables include a descriptive statement, sum- above items is also included.
mary of major findings, and weight of evidence • Intimidation: a patient/client, their friend(s), family
assessment for each article. member(s), other professional(s), or work colleague(s)
purposely threatening, following you, or using ges-
Evolution of the Definition of WPV tures to purposely offend or frighten you.
• Physical abuse: a patient/client, their friend(s), family
Definitions of WPV in EMS have gradually evolved to
member(s), other professional(s), or work colleague(s)
encompass more comprehensive classifications as the
physically attacking you, or attempting to attack you.
EMS system has developed. For instance, one of the
It includes behaviors such as punching, slapping,
first industry definitions of WPV defined it as “violent
kicking, or using a weapon or other object with the
client behavior destructive to self, others or property.”34
intent of causing bodily harm.
As previously stated, evaluation of the definition became
• Sexual harassment: any form of sexual propositioning
inclusive of psychological impacts including cumulative
or unwelcome sexual attention from a patient/client,
stress and burnout.2
their friend(s), family member(s), other professional(s),
Often, the definitions used to measure violence in
or work colleague(s). It includes behaviors such as
research are purposefully selected and operationalized
humiliating or offensive jokes and remarks with
by the researcher, thereby resulting in varying violence
sexual overtones; suggestive looks or physical ges-
measures.35 In EMS-focused research on WPV, many
tures; inappropriate gifts or requests for inappropri-
survey studies do not define violence for the participants.
ate physical examinations; pressure for dates; and
When no definition of violence is predetermined or
brushing, touching, or grabbing excluding sexual
defined, it may be concluded that the interpretation of
touching (e.g., the genital or breast area).
violence may vary significantly from participant to par-
• Sexual assault: any forced sexual act, rape or indecent
ticipant.35 Across selected studies, no standardized defi-
assault perpetrated by a patient/client, their friend(s),
nition of violence was used. Of studies measuring
family member(s), other professional(s), or work col-
frequency of violence, 37 percent (ten out of twenty-
league(s). It includes brushing, touching, or grabbing
seven articles; see online supplement Table 3) did not
of the genitals or breast. It also includes attempted
define or differentiate between types of violence (i.e.,
sexual assault.29
verbal assault versus physical assault).4,21,26,27,36–41
In 15 percent of studies (four out of twenty-seven), vio-
Thus, where applicable, we describe the extant literature
lence was determined after using other proxy terms such
in the following terms: verbal abuse, property damage or
as “homicide” or injury-related terms.11,13,14,42
theft, intimidation, physical abuse, sexual harassment,
The lack of a standardized definition of WPV is prob-
and sexual assault.29
lematic when attempting to describe the prevalence of
violence, risks of exposure, and types of violence experi-
enced. The American College of Emergency Physicians
Estimates of Violence
has recognized this limitation and has emphasized the The key methods used to quantify the problem of vio-
importance of categorizing violence against EMS res- lence against EMS responders have been cross-sectional
ponders.43 In response, we found the work of Koritsas surveys, direct observations, and injury reports. These
et al. to be comprehensive and more highly utilized than methodological variations do not permit cross-
any other definitions in the EMS literature, defining comparisons between studies because they do not con-
types of WPV against EMS responders: tain the same population denominator, and the intervals
of violence measurement vary. While some studies assess
• Verbal abuse: a patient/client, their friend(s), family career exposure, others compare rates of violence occur-
member(s), other professional(s), or work colleague(s) ring over the last twelve months, three months, or one
using offensive language, yelling, or screaming with month. Thus, we can only describe the estimates and
the intent of offending or frightening you. It can ranges of violence that exist compared to the population
include threats of abuse over the phone but excludes from which they were collected, and the appropriate
sexual harassment and sexual assault. time frame measured (see online supplement Table 4).
• Property damage or theft: a patient/client, their To date, there have been four studies conducted in the
friend(s), family member(s), other professional(s), or United States that may be considered nationally
Murray et al. 491

representative. These four studies utilized survey data followed by “punching, slapping, or scratching,”
from nationally certified EMS responders participating “spitting,” and “biting.”22,26,39,44,53 The least frequent
in the Longitudinal EMT Attributes and Demographics types of physical violence experienced by EMS personnel
Study (LEADS) administered by the National Registry were “stabbing or stabbing attempts” and “shooting or
of EMTs.5,15,44,45 These data are the most comprehen- shooting attempts.”44 Minor injuries from these actions
sive information on demographic characteristics and of violence include minor bruises and abrasions, whereas
occupational injuries and exposures in EMS responders more serious injuries included contusions, hematomas,
at the present time. Gormley et al.44 note that while the sprains and strains, eye injuries, facial injuries, bites, lac-
National EMS Certification is required in forty-six erations, dislocations, and fractures.27,47,53
states, nationally certified EMS responders are found
in each state. Psychosocial Impact (Stress)
In studies measuring career prevalence, between
57 and 93 percent of EMS responders reported While we found robust evidence on the expected physical
having experienced at least one act of verbal and/or outcomes of violence against EMS responders, equally
physical violence during their career.21–24,26,27,46–48 concerning information was discovered about the psy-
A 2013 LEADS found that among the 1789 respondents chosocial impact of experiencing violence in this work.
of nationally registered EMTs in the United States, 69 Some research found violence to be the leading cause of
percent experienced at least one form of physical and/or stress,26 and stress found to be the most frequent injury
verbal violence in the last twelve months.44 Furthermore, reported by EMS survey respondents.38 Violence expo-
44 percent experienced one or more forms of physical sure also has been associated with increased levels of
violence over the same study period.44 Gormley et al.44 stress, fear, and anxiety in EMS responders.41
defined violence in seven categories: cursing or making Oftentimes, stress is a result of exposure to traumatic
threats; punching, slapping, or scratching; spitting; incidents in the field. A systematic review of occupation-
biting; being struck with an object; stabbing or stabbing al risk factors in EMS found that between 82 and 100
attempt; and shooting or shooting attempt. A New percent of responders reported experiencing a traumatic
England study with a convenience sample of EMTs event.54 Numerous studies place prevalence rates of
found the prevalence rate of violence to be 20.3/100 posttraumatic stress disorder in EMS responders to be
full-time employees/year. Thirty-eight percent of those greater than 20 percent.54–60
surveyed reported multiple assaults within the last six Stress has been categorized not only by exposure to
months, and one EMT reported being assaulted nine traumatic incidents but also by exposure to the monot-
times during that same six-month period.38 Conversely, onous operational characteristics in EMS such as paper-
crude estimates from a study conducted in Southern work, lack of administrative support, low wages, long
California found a much lower frequency of 0.4 assaults hours, irregular shifts, and cynical societal attitudes
per year per prehospital care provider.27 Non-U.S. stud- toward public safety officers.61,62 Attitudes about job
ies find comparable rates, with studies ranging from 67 performance, job stress, and lack of job satisfaction
to 88 percent of respondents whom reported some form have been found to impact employee retention
of verbal and/or physical violence in the last twelve rates.63,64 Cumulative stress associated with the monot-
months.22,23,46 In a mixed methods study of violence onous duties or low acuity calls and experiences with
on rural and urban EMS responders in Sweden, rates violence has led to EMS responders feeling decreased
of verbal and physical violence in the last twelve months empathy toward their patients and desensitized from
were 67 and 78 percent, respectively, showing similar their job as a whole.6,11,65 Chronic organizational stres-
rates to U.S. violence exposures.46 In this same study, sors in combination with cumulative exposure to critical
an additional 35 percent reported being victimized at incident stress, such as violence, can increase the risk for
least every three months.46 negative psychological outcomes like posttraumatic
Verbal abuse, physical assaults, and intimidation were stress disorder.54
the most frequently reported types of violence.22,23,25–27,49 Chronic organizational stress and cumulative critical
Verbal violence was repeatedly described as the most incident stress from repeated traumatic exposures can
prevalent form of occupational violence that EMS also lead to organizational outcomes such as burnout.
responders reported.22,23,25,26,44,46,48,50,51 The range of Burnout, defined as a “syndrome of emotional exhaus-
verbal violence ever experienced by EMS responders is tion and cynicism,”66 is one of many organizational out-
estimated to be between 21 and 88 percent.23,25,28,46 comes that may arise as a result of violence experienced
The range of physical violence ever experienced by EMS by EMS responders. The question of whether or not
responders is estimated between 23 and 90 percent.2,52 violence would eventually lead to burnout was first
Sources of physical violence varied. The most frequent raised by the industry in the early 1990s,62 yet there is
source of physical violence was “struck by” attempts, little known about the issue, and studies of burnout in
492 NEW SOLUTIONS: A Journal of Environmental and Occupational Health Policy 29(4)

EMS have been described as lacking.60,67,68 Despite this, more than double the median years of experience in a
burnout has been identified as a potential factor associat- longitudinal cohort study of nationally registered EMTs.
ed with decreased levels of quality patient care.65,69 Likewise, Oliver and Levine45 found that EMTs or their
Furthermore, mixed methods studies conducted in partners with more than ten years of work experience
Sweden and the United States found that violent encoun- were more likely to experience violence in the form of
ters alter the patient–provider relationship.11,46 Similar to being punched, slapped, or scratched compared to less
findings in EDs,69,70 a 1998 study found that 7 percent of experienced EMTs. These findings present inconclusive
survey respondents within one urban fire department con- evidence supporting years of experience as a risk factor
sidered leaving EMS as a direct result of the violence they for EMS responders.
experienced on the job, and 42 percent stated that vio-
lence had an overall effect on their attitudes about their Occupational role. In Philadelphia, one study analyzed all
job,26 suggesting that despite the lack of abundant evi- injuries reported between January 1996 and December
dence, there is a concerning relationship between burnout, 1998. Of 1,100 injury reports related to violent incidents,
violence, and quality of patient care. 93.2 percent of documented assaults occurred during
patient care activities, suggesting that EMS calls pose
EMS Responder-Level Characteristics more risk compared to fire calls.53 All other selected
research yielded results showing provider level to be
Age. Age was found to be a significant indicator for
significantly associated with increased risk of violent
increased risk of violence in three selected studies.22,44,53
interactions. Robust evidence points to paramedics
Conversely, one study of Canadian paramedics found
being at increased risk for violence compared to fire-
age to be a protective factor and described that with
fighters.11,44,53 Responders who spent more time provid-
each incremental increase in age, medics were less
ing direct patient care were at increased risk for
likely to be exposed to verbal violence.22 In a nationally
violence.29 In one fire department, the odds of paramed-
representative sample of EMTs in the United States,
ics being assaulted compared to their firefighter counter-
responders who experienced physical violence from a
parts were fourteen-fold higher.11 Thus, these findings
patient were 1.9 years younger than those who did not
present robust evidence of occupational role as a
experience violence in the last twelve months.44
strong characteristic associated with WPV.
In Mechem et al.’s53 study detailing intentional and
unintentional assault, the average age of victims was
37.0  8.2 years and 33.8  8.4 years, respectively, mark- Characteristics of Perpetrators of Violence
ing no difference in age. Therefore, we find the evidence The literature identifies several patient characteristics
supporting age to be inconclusive. associated with violent events including age, gender,
mental status, substance abuse, and underlying health
Gender. While some studies indicated with statistical sig- condition. No data exist describing which of these char-
nificance that men were more likely to experience vio- acteristics is the most frequent. We describe what is
lence,25,28,38,53 others found women were more at known from the extant literature included in this review.
risk.22,39 Not until Gormley et al.44 and Oliver and
Levine45 utilized longitudinal cohort designs was this Patient. A large body of evidence points to patients
risk factor studied under more rigorous conditions. as the most common perpetrator of
They found that among nationally registered EMTs, violence.5,13,22,25,26,28,34,38,42,44,46,47,50 It is worthwhile to
women had an increased risk for physical consider the environment associated with providing pre-
violence,44 while men had an increased risk for verbal hospital care, as violent behaviors may be exacerbated
violence.44,45 Other research found the female gender by the confined space of an ambulance. Another consid-
to be a predictor only for cases of sexual assault and eration to note is the limited translation and transferabil-
sexual harassment,23 while another study found women ity of policies, procedures, and practices that provide
at significant risk with regard to sexual assault, sexual important institutional mechanisms to protect the
harassment, and verbal violence.29 In a review of three safety and health of workers in the “bricks and mortar”
fatality databases, women were found to be the majority fixed environment to that of the mobile EMS environ-
of EMS assault-related fatalities.13 We found conflicting ment. These findings strongly suggest the patient as the
evidence of gender as a risk factor for EMS responders. primary contributor of violence against EMS providers.

Years of experience. Some research shows that work expe- Patient’s family, friend, or bystanders. Patients are not the
rience is not a significant risk factor for encountering only perpetrators of violence. Violence is also initiated
violence.22,47 Gormley et al.44 found that personnel by nonpatients such as family members of patients and
who had experienced violent patient encounters had bystanders.25,26,44,46,47,50,53,71 In a prospective,
Murray et al. 493

observational case-series study of 297 EMS runs con- reported having “ever seen or found” a weapon on a
ducted over 737 hours of observation, the violent patient.27 More years of experience and those trained
person was not the patient in as many as one third at the paramedic level were significantly associated
(five out of sixteen) of violent calls.25 A separate obser- with finding weapons on patients.49 Likewise, EMS res-
vational case-series found “others” to be the cause of ponders who had received weapons-specific training
violence in 10.3 percent (19 out of 184) of violent were more likely to report weapons found.49 These stud-
calls.28 Studies were uniform in their findings that in ies suggest the need for more robust research to under-
addition to patient-initiated violence, family, friends, stand the role of a patient’s possession of a weapons.
and bystanders also frequently engage in violence
against EMS. Violent call type. Violent call type, a call that comes into
dispatch as violence-related, is an understudied charac-
Mental status, substance abuse, and underlying health teristic of the occupation that may be predictive of expo-
conditions. In a study of violent patients in the ED, sures to violence. One study found that while only 5
those who demonstrated violent behaviors were more percent of calls (297 EMS runs over 737 hours of obser-
likely to be suffering from an altered mental capacity, vation) involved a violent situation directed at EMS res-
compared to violent patients committing violence against ponders, an additional 14 percent of calls were flagged as
EMS responders.49 In the prehospital setting, Bernaldo- locations where violence was mentioned to have
de-Quiros et al.49 found that a majority (55.2%) of violent occurred prior to the arrival of EMS responders (i.e.,
patients had no known altered mental capacity, and fewer “postviolent” runs).25 The 14 percent indicates a poten-
than half of violent perpetrators had a psychiatric disor- tially hostile environment for responders upon arrival.
der or were under the influence of drugs and alcohol. Consequently, Mock et al.25 suggest that 5 to 20 percent
Conversely, a prospective case-series study found that a of sampled EMS calls in the urban EMS system were
suspected psychiatric disorder was significantly associated related to either physical or verbal violence. However,
with violence against EMS responders.28 Further, indus- dispatch codes intended to alert responders to potential-
try perspectives were uniform that three of the major ly violent scenes were not used in almost 40 percent of
patient characteristics associated with violence are intox- violent calls.25 An analysis of responder narratives from
ication, drugs, and altered mental status.16,72 Several aca- the near-miss and injury events reported to the National
demic studies support this claim.22,25,39,46,47 Additional Fire Fighter Near-Miss Reporting System revealed that
research suggests that any medical condition that causes violence may not be anticipated by responders in many
an altered mental status or consciousness, such as trauma cases, as violence can often erupt instantaneously.42
and diabetes, may lead to patients committing violent Evidence supporting violent call type is inconclusive
acts.16,21,22,39,47,53,72–74 For instance, insulin-dependent and future studies should continue to evaluate this var-
diabetics experiencing hypoglycemic episodes were the iable in relation to WPV experienced in EMS.
cause of 9 percent of violent incidents in a retrospective
review of ambulance call reports over a six-month study Other factors. Other potential contributing factors for
period.21 In the larger healthcare context, altered mental violent patient behaviors include dissatisfaction with
status associated with dementia, delirium, and substance response time49; lack of understanding of treatment
intoxication were the most common characteristics of vio- and care needs49; feelings of helplessness, frustration,
lence perpetrators against healthcare workers. 75–80 These and anger in the face of an emergency47; wishes to
studies provide strong support that the patient’s medical refuse transport25; culture clash47; and communication
status is a potential indicator for violent behavior. or language inadequacies.47,49 Similar factors have been
indicated in the larger healthcare context.81 Unlike other
Weapon possession. In studies measuring weapon posses- fields which have found a history of violence to be a
sion, weapons were present on scene in less than 12 per- precursor to committing interpersonal violence,82,83 the
cent of violence-related patient cases.21,25,26 Although relationship between history of violence and resulting
these studies suggest a relatively low incidence of weap- violent acts against healthcare workers has not yet
ons possessed by violent or combative patients, other been found.84 Additional research on factors that con-
research shows that many EMS responders may not be
tribute to and presage violent patient behaviors in
equipped or prepared to deal with the issue. As many as
healthcare and EMS is needed.
42 percent of study participants comprised of EMS res-
ponders from the Boston and Los Angeles metropolitan
areas indicated that they did not regularly search their
Reporting/Underreporting
patient for weapons, yet 62 percent had found a weapon One of the limitations that is frequently mentioned in
on a patient in the course of their careers.48 Another both academic and industrial publications is the percep-
study showed that as many as 79 percent of respondents tion that violence is inherent to the profession and
494 NEW SOLUTIONS: A Journal of Environmental and Occupational Health Policy 29(4)

reporting violent incidents implies an inability to provide the need to build and maintain supportive relationships
patient care and perform job duties competently.27 between EMS and other organizational entities such as
Such attitudes might lead to significant underreporting police and dispatch86–89,91,97–100,102 and is supported in
of violence in the field.26 A study of 1,500 medical pro- academia as well.71,103,104
viders in New Mexico found that 56 percent of EMS The industrial literature also emphasized the need for
survey respondents stated that violence is “just a part significant improvements to the quantity and quality of
of the job.”85 And although a large percentage believe trainings provided to EMS responders, inclusive of de-
violence is a part of the job, 40 percent believed that if no escalation trainings to confer professional command and
one was injured during the incident then there was no control in the event of unexpectedly violent per-
need to report.85 Reasons for not reporting violent sons.97,105,106 The industrial literature is particularly
encounters include the fear of punitive actions such as helpful in identifying specific call types and situations
being fired.85 Other studies show higher frequencies, most likely to be associated with violence, such as alco-
with as many as 71 percent believing that violence is a hol or drug use, gang violence, homicides, domestic vio-
part of their job, and 84 percent believing that their per- lence, mental health and psychiatric calls, suspected
sonal safety was at risk as a direct result of violence.26 In suicides and suicidal ideation, active shootings, bomb-
a Canadian study, 62 percent of participants stated that ings, terrorist events, and other events that pose threats
no actions were taken by most paramedics in response to of mass casualties.16,102,107,108 It is a lack of training that
the violent events, 61 percent did not report the violence leads individuals to use excessive force or “pick the
to a superior or authority, and 81 percent did not for- wrong tool to solve the problem” in many of these
mally document the occurrence in the patient care report scenarios.97,109
narratives.22 Regarding proper documentation of violent Discussions regarding self-defense have become
encounters, one study found that only 31 percent of all highly controversial, due to some attempts or requests
violent encounters were properly mentioned in the para- by EMS organizations or EMS responders to arm per-
medic narrative.25 This indicates that while the rates of sonnel with weapons such as guns, tasers, mace, and
violence from the literature are concerning, there is pepper spray as additional forms of protection.11,91
reason to believe that violence is vastly underreported The industrial literature provides warning that protec-
and ill-documented in EMS. Therefore, any retrospec- tive measures designed to arm EMS responders should
tive reviews of ambulance calls or paramedic narratives be considered only as a last resort, and others argue
are likely to be missing the true prevalence of violence whether their implementation is needed at all.91,100,110
experienced by responders.25 These research studies pro- No standards or evaluations on effectiveness exist
vide strong evidence that the issue of WPV in EMS is for departments considering this protective measure.
vastly underreported. Furthermore, it has been posited in the academic litera-
ture that protocols to increase the safety of communities,
Industry Best Practices, Policies, and Procedures in addition to training to provide confidence and com-
petency in the face of violence, might supplant the need
To date, there exist no evidence-based interventions in
for EMS personnel to carry weapons for personal pro-
the academic literature that prepare EMS responders for
tection.27 While providing body armor is less controver-
violence. Therefore, EMS has relied heavily on industrial
sial than providing armament to EMS responders, it
publications to disseminate best practices, policies, and
remains heavily debated.87,100,111
procedures. Industrial literature primarily highlights the
use of prevention strategies to keep EMS providers from
entering a potentially violent situation, such as scene Intervention and Policy Opportunities
safety.86–96 If scene safety precautions indicate potential Currently, violence prevention training that exists con-
violence, or if there is a known history of violence for sists of generic programs that are not tailored to the
that patient or location, current recommendations large- prehospital patient care provider and unique EMS
ly suggest requesting police backup; however, it is also mobile environment.112 Available trainings also tend to
cautioned that police do not guarantee responder safety focus primarily on self-defense techniques rather than
and are not always available to respond to EMS requests prevention.112 Infantino34 suggests the following consid-
for backup.86–89,91,97–101 While dispatch is integral to erations for an EMS violence intervention program:
EMS operations, patient information received by EMS environmental considerations, self-assessment, preven-
from dispatch is often unclear, incorrect, or incomplete, tion, verbal intervention (calming/defusing techniques),
thus contributing to EMS responders feeling unsup- escape and release procedures, control and restraint pro-
ported and placed unnecessarily in dangerous situa- cedures, staff anxiety decompression, and postincident
tions.11 The industrial literature recognizes these follow-up. Additional considerations include increasing
fractures within the EMS system and heavily emphasizes (1) communication skills with patients and/or relatives
Murray et al. 495

and bystanders, (2) the ability to identify high-risk sit- kind of advocacy organization can have that kind of
uations, (3) the ability to effectively implement safety direct impact on individual workplaces.
measures, (4) support for mental health, and (5) the Other active initiatives to address WPV in EMS
availability of resources to professionals who have suf- include the Center for Leadership, Innovation, and
fered from WPV.51 Research in EMS (CLIR), which has launched the
In 1998, the United States Department of EMS Voluntary Event Notification Tool to assist in
Transportation developed a new paramedic-training cur- data collection of exposures to violence.117 In 2010,
riculum that included expanded topics of abuse, assault, CLIR partnered with the National EMS Management
and violence. The curriculum is noted to have included Association and the End Violence Against Paramedics
learning objectives concerning how to handle victims, initiative to include violence in their data collection pro-
diffuse violent situations, and ensure personal safety.113 cesses, which can be used to inform the development of
However, since authority over EMS initiatives is held by interventions.118 One such intervention that exists is
state jurisdictions, individual states can choose not to Defensive Tactics 4 Escaping Mitigating Surviving
adopt certain training interventions or curriculums.71,113 Violence.119 While this intervention has been developed
There have been calls for development of protocols at specifically for the EMS industry, it has not been evalu-
the national level in response to violent incidents ated to determine its reach and effectiveness. In response
through initiatives such as the National Fallen to the growing issue of violence, some departments have
Firefighters Foundation Firefighter Life Safety taken it upon themselves to investigate causes of violence
Initiative 12, which states the need for development and respond proactively.
and implementation of practices and policies to reduce While NIOSH has not developed an EMS-specific
the likelihood that EMS responders will encounter vio- intervention, they have recommended several best prac-
lence, to standardize response protocols, and to increase tices for fire departments as a way to prevent and miti-
survivability for fire and EMS personnel when violent gate violence at both the organizational and employee
situations are unavoidable.92,114 Other entities that level.120 In 2004, NIOSH released recommendations on
advocate for safety and health in EMS include labor methods to best mitigate violence following the investi-
organizations, such as the International Association gation into the death of a female firefighter who
of Fire Fighters, the International Association of responded to the scene of a civilian shooting.121 While
EMTs and Paramedics, EMS Workers United/ the recommendations have been disseminated, no formal
American Federation of State, County and Municipal intervention program has been developed nor has a
Employees, and many others. These labor organizations formal evaluation of the recommendations been con-
are dedicated and committed advocates that lobby for ducted. NIOSH has also recommended that employers
increased safety and health protections for the EMS establish a zero-tolerance policy for all incidents of vio-
work force. In fact, in 2016, the United States Fire lence, train workers on recognizing and preventing
Administration subcontracted a study on violence WPV, investigate all reports of violence, and work
against EMS responders to the International with police to identify dangerous neighborhoods where
Association of Fire Fighters because of their strong special precautions need to be taken and provide that
advocacy and commitment to improving responder information to employees. From the employee’s stand-
safety.115 Labor unions in healthcare and related indus- point, NIOSH recommends that employees should par-
tries have long called for increased research and protec- ticipate in violence prevention training and report all
tive regulations on the issue.84 Within fire departments, incidents of violence, no matter how minor.122
local labor unions are successful champions of safety Supplemental to NIOSH’s recommendations are the
and health and advocates of policy change, resource guidelines proffered by OSHA in their updated 2015
installation, and safe reporting environments.116 At indi- “Guidelines for Preventing Workplace Violence for
vidual workplaces, union advocacy can bring about Healthcare and Social Service Workers.”75 These guide-
changes in policies and in the availability of protective lines offer critical recommendations on effective
equipment even between contract negotiations. Unions approaches to eliminate violence in the workplace,
can have an impact on underreporting by advocating for including the essential components to an effective
the elimination of disincentives to reporting. All of these WPV prevention program. While the guidelines are not
can be strengthened further by getting them written into regulatory in nature, several states including New York
collective bargaining agreements. The ability to build and California have adopted these guidelines as
solutions from the bottom up workplace by workplace policy.123,124 In fact, in 1993, Cal OSHA (the
and demonstrate their feasibility produces immediate California state OSHA program) was the first entity to
gains for the represented workplaces and can ultimately establish WPV guidelines, which was a result of the per-
lead to the adoption of similar solutions as best practi- sistent pressuring done by a multiunion task force
ces, guidelines, and/or enforceable standards. No other on WPV.84 This union-led initiative ultimately informed
496 NEW SOLUTIONS: A Journal of Environmental and Occupational Health Policy 29(4)

the creation of the federal OSHA guidelines,84 further Moreover, our case inclusion criteria and review of
demonstrating the union’s fortified commitment to the literature led to the inclusion of thirty-six industrial
health and safety, especially as it relates to influencing publications. The industrial literature provided the
the local, state, and federal policy arena of WPV. unique perspective of how the industry perceives the
Components of OSHA’s guidelines that are relevant to issue of violence, its ideas for training opportunities,
EMS include their identified risk factors, of which eight and its attempts at interventions to best mitigate and
out of ten, apply to EMS.75 In addition, the components reduce violence exposures. It is our opinion that academ-
to an effective violence prevention program are highly ic researchers should source from these publications to
adaptable to the EMS work environment and include the same degree they do the peer-reviewed literature. In
management commitment and employee participation, particular, the industrial literature gives unique credence
worksite analysis, hazard prevention and control, to practices already utilized in the fire and rescue service
safety and health training, and record-keeping and pro- that could be further buttressed by the academic com-
gram evaluation.75 munity in terms of intervention development and evalu-
While the EMS literature notes that the guidelines ation. For example, the industrial literature expounds on
developed for violence reduction specific to ED settings a variety of best practices used during the multiple
do not generalize well to the EMS industry,27 there is phases of emergency response. Fields such as public
great utility in evaluating educational initiatives in the health and organizational science could bring their con-
hospital setting for goodness of fit in the prehospital siderable prevention acumen to this process. With an
setting. Interventions such as the “Workplace Violence approximately 20 percent increase in call volume each
year, it is imperative to begin thinking about interven-
Prevention for Nurses” online training program have
tions that focus not on the individual EMS responders
been designed and evaluated as a method to help health-
by making them do more with less11 but by shifting the
care workers recognize violence in the workplace and
onus of safety and health from the individual to the
may be useful to consider when developing EMS-
organization. By utilizing the counsel of the industrial
specific interventions and policy initiatives that focus
literature, multiple training, policy, and environmental
on primary prevention.125
interventions could be developed to better protect the
safety, health, and well-being of EMS responders from
Discussion stress and violence. Such interventions have the potential
to impact organizational and safety outcomes in this
WPV is a concerning and complex issue facing much of
profession.134
the healthcare industry, including EMS. Most of our
The academic literature focused on incidence and
knowledge on the issue of WPV in healthcare stems
prevalence estimates. Research conducted through
from EDs and psychiatric facilities. Indeed, many
2016 used cross-sectional designs with small convenience
research findings on WPV in EMS are not unique and
samples. As such, there are very few studies that
have been indicated in the larger healthcare con-
employed strong scientific design. Other limitations iden-
text.81,84,126–131 However, research on the issue of WPV
tified include (1) the lack of a standardized definition of
in EMS is still lacking, with little to offer in terms of violence, (2) variation in study design, (3) depth of data
prevention programs and policy. This literature review available, (4) insufficient studies using nationally repre-
sought to compile what is currently known so that effec- sentative data, and (5) wide-ranging estimates. There is a
tive interventions and policies aimed at increasing the great need for rigorously designed, nationally represen-
safety and health of emergency responders can develop. tative examinations of occupational exposures in order
To date, two systematic reviews have been conducted to better understand the temporal associations of vio-
regarding violence against EMS responders.132,133 Each lence, cumulative occupational stressors, and the out-
employed a systematic process: Pourshaikhian’s review comes of physical and psychosocial injuries that are
included eighteen articles in their analysis, and occurring as a result of exposures to violence. Based
Maguire’s included twenty-five articles. There are six on current studies, it is not possible to discuss causality
total articles between the two literature reviews absent among violence risk factors and reported outcomes.
from our analysis. This is likely due to their scope and Noticeably absent from both industry and academic lit-
case inclusion criteria, in which Maguire included liter- erature is intervention evaluation to assess the effective-
ature pertaining to military ambulance officers and air ness of best practices, training programs, and policies
ambulances, and Pourshaikhian included articles pub- mentioned in both literatures. Research in the larger
lished in English and Persian. We believe these differ- healthcare sector also shows that studies are typically
ences to be insignificant due to the immense return of designed to quantify the problem, with little mention or
our literature search which led to a total of sixty-eight focus on methods designed to prevent violence from
academic publications included in our analysis. occurring.81 Issues reminiscent of our findings—especially
Murray et al. 497

WPV being poorly defined and underreported—compli- the creation of standard operating procedures for sup-
cate the design of evidence-based policy.81,84,128,129 porting members assaulted on duty (Philadelphia)140,141
In the United States, there have been no widely appli- and the creation of resilience programs to reduce occu-
cable, efficacious interventions to address WPV in pational burnout (Dallas).142
healthcare.81 Due to the high prevalence of occupational We undertook this comprehensive literature review to
violence compared to other industries, healthcare is more deeply understand the incidence and prevalence of
often the subject of WPV research and initiatives, yet violence against EMS responders, but in so doing, we
EMS is often absent from these national efforts. While uncovered additional stressors that emanate from the
numerous states have enacted felony assault statutes that organizational culture. Such stressors may be duration
include first responders, these policies are tertiary in of shift for busy EMS responders, the skill mix of per-
nature and do not offer much in terms of prevention.135 sonnel on EMS runs, the ability to rest and recover after
In order to prevent WPV in EMS from happening, we traumatic or compelling events, and the busyness of res-
must focus our policy efforts on primary prevention ponders visiting the community. Also important to con-
strategies. The first step in doing so is to have national sider is the sometimes sensitive nature of this research
support advocating for the inclusion of EMS in forums topic. Sharing sensitive and traumatic details associated
and policy discussions on WPV. We can look to OSHA’s with violent exposures can impact an individual’s will-
Guidelines for Preventing Workplace Violence to devel- ingness to report. Academic and industry publications
op strong and effective prevention programs and poli- equally posit the notion that violence is an expectation
cies.75 In 2017, the Department of Labor and OSHA of the work, and the high frequency of violence occur-
issued a “Request For Information” on the prevention ring in the profession has caused it to be internalized as
of WPV in healthcare and social assistance (Docket No. “part of the job.”26,27,85,98 This perception is validated
OSHA-2016–0014).136 In response, coauthors of this by the almost nonexistent reporting by EMS responders
manuscript submitted an executive summary on WPV Thus, it is imperative for leadership in EMS to support
in EMS advocating for the inclusion of emergency med- and champion consistent and mandatory reporting and
ical responders in OSHA’s development of standards follow-up with responders who have experienced vio-
and policies to prevent violence in the workplace.137 lence during the course of their duty. The sharp rise in
This level of inclusion is important to ensure that EMS community demand is an increasing stressor for depart-
providers are not left out of crucial legislation and pre- ments and agencies providing EMS. For example, the
vention opportunities. However, policy at the national- top five busiest medic units in the United States run
level is not the only way to affect positive changes in the between seventeen and twenty-four calls per day.143 In
safety and health of EMS providers. By focusing policy a twenty-four-hour period, this gives little or no time to
efforts at the local-level, we may be able to affect more “eat, sleep, or pee.” These added occupational stressors
immediate change by creating EMS-specific solutions to can increase the level of job dissatisfaction that respond-
violence. The SAVER Systems-level Checklist, part of a ers experience.6 Exposures to WPV, especially cumula-
current research study exploring the efficacy of policy tive exposures, in concert with these added stressors,
and training to prevent WPV in fire-based EMS, holds may result in mental health outcomes such as anxiety,
promise for primary prevention.138,139 It was created as a depression, and posttraumatic stress disorder. Poor
checklist for the system (department and union leader- work environments and deficient social networks, in
ship teams), as opposed to an individual-level checklist combination with anxiety, depression, and posttrau-
that would put more burden on already overstretched matic stress disorder, have been known to lead to suicid-
EMS responders. The checklist contains training, al ideation and, in some cases, suicide completion.59
policy, and environmental modification interventions Future research should systematically measure and
organized by phases of EMS response. It has “pause understand the degree to which the stress of increasing
points” which are feedback mechanisms for the individ- community demand intersects with the stress of insuffi-
ual responder. The pause points redistribute traditional cient resources in fire and rescue organizations. Finally,
hierarchical power by giving the individual EMS the psychological impact of experiencing violence on the
responder the authority to pause an EMS encounter job can change the way EMS responders approach the
based on perceived risks to their safety. The checklist occupation and has implications for quality of patient
creates organizational support that can positively care and patient outcomes.11
impact burnout, morale, and work engagement while
decreasing the number of assaults and injuries experi-
enced by EMS personnel. While too early in its imple-
Conclusion
mentation to have evaluation results, the SAVER We found that from 1978 to 1992, the issue of WPV in
Systems-level Checklist is already inspiring policy and EMS is only discussed within industrial trade journals
program development within fire departments such as which addressed the risks of the job long before the first
498 NEW SOLUTIONS: A Journal of Environmental and Occupational Health Policy 29(4)

peer-reviewed research was published in 1993. While unions are uniquely positioned to advocate on the issue of
prevalence estimates fluctuate slightly from 1993 to workplace violence.
2016, authors are discussing the same issues forty years
later, highlighting the fact that little progress has been Declaration of Conflicting Interests
made to protect EMS responders against violence in the The author(s) declared no potential conflicts of interest with
field. Today, literature on the issue of violence has been respect to the research, authorship, and/or publication of this
bolstered by intensified efforts of EMS organizations article.
and officials to decrease the prevalence of violence in
the industry, yet violence remains poorly defined and Funding
assessed. This systematic review warrants further rigor-
The author(s) disclosed receipt of the following financial sup-
ous scientific inquiry to better identify risk factors for
port for the research, authorship, and/or publication of this
violence, circumstances surrounding violence, and meth-
article: This research was supported by a subcontract from
ods to best mitigate violence so that resources can be
the International Association of Fire Fighters under their con-
properly allocated to protect the health, safety, and
tract with the Department of Homeland Security/Federal
well-being of EMS responders. As public health
Emergency Management Agency/United States Fire
researchers, we are compelled to advocate for increased
research and development of interventions and policies Administration contract number: HSFE20-15-Q-0053 and the
to reduce and prevent the occurrence of WPV in EMS. Federal Emergency Management Agency (FEMA) FY 2016
In order to ensure that EMS remains a vital community Assistance to Firefighters Grant Program, Fire Prevention
resource, we must protect the safety and well-being of and Safety Grants (Research & Development) Grant number:
responders against all harm, starting with the harm EMW-2016-FP-00277.
caused by the very people they are seeking to help. We
have identified the following content areas for future ORCID iD
inquiry for EMS-focused research and practice related Regan M. Murray https://orcid.org/0000-0001-7396-6517
to OSHA’s Guidelines for Preventing Workplace
Violence. These content areas include (1) standardizing Supplemental Material
the definition of violence used in EMS research; (2) cre- Supplemental material for this article is available online.
ating reliable and consistent epidemiological surveillance
on violence against EMS responders through data References
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129. Brophy J, Keith M and Hurley M. Breaking point: vio- Regan M. Murray is a project manager and certified
lence against long-term care staff. New Solut 2019; 29: emergency medical technician at the Center for
10–35. Firefighter Injury Research and Safety Trends (FIRST)
130. Morgan DG, Crossley MF, Stewart NJ, et al. Taking the at the Drexel University Dornsife School of Public
hit: focusing on caregiver “error” masks organizational- Health. She provides oversight to the project funded
level risk factors for nursing aide assault. Qual Health Res by the Federal Emergency Management Agency:
2008; 18: 334–346.
“Stress and Violence in fire-based EMS Responders
131. Wolf LA, Delao AM and Perhats C. Nothing changes,
nobody cares: understanding the experience of emergency (SAVER).” Ms. Murray received her Bachelor of Arts
nurses physically or verbally assaulted while providing degree from St. Lawrence University and her Master of
care. J Emerg Nurse 2014; 40: 305–310. Public Health degree, concentrating in Community
132. Pourshaikhian M, Abolghasem Gorji H, Aryankhesal A, Health and Prevention, from Drexel University.
et al. A systematic literature review: workplace violence
against emergency medical services personnel. Arch Andrea L. Davis, MPH, CPH is the senior project man-
Trauma Res 2016; 5: e28734 . ager at the FIRST Center. She earned her Master of
133. Maguire BJ, O’Meara P, O’Neill BJ, et al. Violence Public Health degree from Drexel University in 2012
against emergency medical services personnel: a system-
and holds the designation of Certified in Public Health
atic review of the literature. Am J Ind Med 2017; 61:
167–180. doi:10.1002/ajim.22792
from the National Board of Public Health Examiners.
134. Christian MS, Bradley JC, Wallace JC, et al. Workplace Ms. Davis holds a Master of Liberal Arts degree from
safety: a meta-analysis of the roles of person and situation the Harvard University Extension School and Bachelor
factors. J Appl Psychol 2009; 94: 1103–1127. doi:10.1037/ of Art from the University of Delaware.
a0016172
135. Wright JY, Davis AL, Brandt-Rauf S, et al. Felony Lauren J. Shepler, MPH, is the outreach and communi-
assault should stick:” assaulted EMS responders’ frustra- cations manager at the FIRST Center. She received her
tion and dissatisfaction with the legal system. Am J Ind Bachelor of Science degree from North Carolina State
Med 2019; 62: 938–950. doi:10.1002/ajim.23036
University in 2012 and her Master in Public Health
136. Occupational Safety and Health Administration, U.S.
Department of Labor. Request for information: preven-
degree, concentrating in Environmental and
tion of workplace violence in healthcare and social assis- Occupational Health, from Drexel University in 2015.
tance. In: Occupational Safety and Health Administration
(ed) Federal register/Vol 81, No 235/Wednesday, December Lori Moore-Merrell, DrPH, is the president and CEO of
7, 2016/proposed rules. Washington, DC: OSHA, 2016. the International Public Safety Data Institute. She serves
137. Taylor JA and Murray RM. Executive summary: violence as a senior executive with the International Association of
against Emergency Medical Services (EMS) responders. Fire Fighters, responsible for frontline interaction with
Washington, DC: Occupational Safety and Health elected officers; executive board members; state, provin-
Administration, 2017.
cial, and local chapter leaders and individual members
138. Taylor JA, Murray RM, Davis AL, et al. Creation of a
throughout the United States and Canada. Dr. Moore-
systems-level checklist to address stress and violence in
fire-based EMS responders. Occup Health Sci 2019; 3: Merrell is an expert in emergency response system evalu-
265–295. ation, data collection and analysis, costs and benefits
139. Center for Firefighter Injury Research and Safety Trends. analysis, strategic planning, advocacy, consensus build-
Stress and violence in fire-based EMS responders ing, and policy development and implementation.
Murray et al. 503

William J. Troup has served at the United States Fire three major areas of inquiry including the study of work-
Administration for over twenty-nine years, as the Chief place meetings, nonprofit organizational effectiveness,
of the National Fire Data Center managing the National and emotional labor in various service-related contexts.
Fire Incident Reporting System, On-Duty Firefighter
Fatality Reporting Program, the National Fire Jennifer A. Taylor, PhD, MPH, CPPS, is an injury epi-
Department Registry, and other data reporting programs. demiologist and the Arthur L. and Joanne B. Frank
He oversees United States Fire Administration research Professor of Environmental and Occupational Health
programs in Firefighter and Emergency Responder at the Drexel University Dornsife School of Public
Health and Safety and serves on the DHS Science and Health in Philadelphia, PA. Dr. Taylor is the founding
Technology First Responders Resource Group. director of the FIRST Center at Drexel University. She
received her doctorate from Johns Hopkins Bloomberg
Joseph A. Allen, PhD, is a professor in Industrial and School of Public Health, specializing in Injury
Organizational Psychology and the Director for the Prevention and Control, where she received the
Center for Meeting Effectiveness at the University of Haddon Fellowship and the ERC-NIOSH Training
Utah. He completed his doctorate in Organizational Fellowship in Occupational Injury. Dr. Taylor’s research
Science at the University of North Carolina at investigates the impact of safety climate on occupational
Charlotte in 2010 and received his Master of Arts injury and related psychosocial outcomes among first
degree in Industrial and Organizational Psychology at responders.
the UNCC in 2008. Dr. Allen’s research focuses on