Mitigation of Occupational 

Violence to Firefighters and 

EMS Responders

June 2017

Mission Statement

We provide national leadership to foster a solid foundation for 

our fi re and emergency services stakeholders in prevention, 

preparedness and response.

Mitigation of Occupational Violence to 

Firefighters and EMS Responders

Final report

Contract: HSFE20-15-Q-0053

Project Period: January 2016 to March 2017

Affiliation/Award Institution:

International Association of Fire Fighters (IAFF)

1750 New York Avenue NW

Washington, DC 20006

202-824-1594

Research Team: 

Drexel University Dornsife School of Public Health 

Department of Environmental and Occupational Health 

Jennifer A. Taylor, PhD, MPH, CPPS: Principal Investigator — co-author

Regan Murray, MPHc: Graduate Research Assistant — co-author

Lauren Shepler, MPH: Communications and Outreach Manager

Andrea Davis, MPH, CPH: Project Manager

Project Oversight Consultant: Editor

Lori Moore-Merrell, DrPH, MPH, EMT-P

IAFF

Date of final report completion: June 2017

Cover photo courtesy of Aaron Dean, M.S., Apparatus Operator/City of Sacramento (CA) 

Fire Department.

Table of contents i

Table of contents

Abstract ................................................................................................................................ 1

Background .......................................................................................................................... 1

Objective............................................................................................................................... 2

Project relevance................................................................................................................. 2

Specific project aims ........................................................................................................... 5

AIM 1: To define the issue of violence experienced by EMS professionals................ 5

AIM 2: To identify the risk factors of violence associated with the EMS profession.... 5

AIM 3: To identify best practices and intervention opportunities.............................. 5

Project methods .................................................................................................................. 5

Phase 1: Literature search................................................................................................ 6

Phase 2: Appraisal and selection..................................................................................... 6

Phase 3: Analysis, documentation and writing manuscript ........................................ 7

Literature review key findings........................................................................................... 9

Historical and contextual grounding .............................................................................. 9

Evolution of the definition of violence............................................................................ 10

Characteristics of patients/perpetrators of violence ................................................... 12

Estimates of violence ........................................................................................................ 14

EMS responder risk factors .............................................................................................. 16

Psychosocial impact.......................................................................................................... 18

Reporting/Under-reporting.............................................................................................. 21

Conceptual diagram............................................................................................................ 21

Mind map............................................................................................................................ 22

Mind map key: Factors related to violence against fire and EMS responders .......... 25

Best practices....................................................................................................................... 28

Inventory of best practices and intervention opportunities....................................... 30

Summary .............................................................................................................................. 34

References............................................................................................................................ 35

Acronyms.............................................................................................................................. 45

Appendices........................................................................................................................... 47
ii Mitigation of Occupational Violence to Firefighters and EMS Responders
Abstract | Background 1

Abstract

Purpose and aims: Violence is a major occupational challenge confronting the field of 

Emergency Medical Services (EMS). Firefighters and EMS responders are increasingly called 

upon to meet community demands for service. As a result, firefighters and EMS responders 

are often expected to respond to incidents where they can be exposed to violence. Violence 

against EMS responders has been recognized as an occupational hazard since the early 

1970s, and recent incidents are evidence that the problem has not been abated. A review 

of the literature from academic and industry trade journals shows an increase in attention 

to the issue over the years. However, there is limited understanding of risk factors and 

preventive measures. The literature provides insight into the characteristics of violence 

perpetrators, EMS responder risk factors, and best practices. Much of the available 

information on these factors is contradictory, or not rooted in evidence-based assessment. 

The purpose of this report is to document the causes and risk factors of violence and 

mitigation opportunities to reduce and prevent violence to EMS responders.

Relevance: This literature review provides an assessment of existing literature and publicly 

available information on the issue of violence against firefighters and EMS responders.

Methods: This literature review was innovative, in that it included both peer-reviewed 

and industry publications. While special attention was paid to scientific and peer-reviewed 

literature that provided quantification of the issue, industry publications provided a more 

intimate glance into the realities facing EMS personnel who are experiencing violence in 

the line of duty. This method also revealed to us other findings on the topic of violence 

in EMS, such as the lapse in time between the first industry publication and the first 

academic publication regarding violence in the prehospital setting — a finding which 

would have gone undetected had industry publications not been included in this review. 

This novel approach created a deeper understanding of the issue.

Results: A critical analysis of the literature led to the identification of nine key themes: 

historical and contextual grounding, evolution of the definition of violence, characteristics 

of patients/perpetrators of violence, estimates of violence, EMS responder risk factors, 

psychosocial impact, under-reporting, best practices, and inventory of best practices and 

intervention opportunities.

Conclusions: Predicting risk factors associated with violence are difficult to confirm due to 

the contradictory nature of study findings. Variation in study design, lack of a standardized 

definition of violence, and under-reporting all contribute to the limited understanding of 

the issue of violence against EMS responders. However, alarming information regarding 

the psychological impact from experiencing violence was uncovered. The results of this 

review thus warrant the need for more rigorous scientific research focused on gathering 

nationally representative data to better describe the issue of violence to EMS providers. 

Once gaps in the literature have been addressed, targeted interventions can be developed 

and organizational, educational and policy reform can be implemented to better protect 

the safety and well-being of the EMS community.

Background

In January 2016, Drexel University was subcontracted by the International Association 

of Fire Fighters under their contract with the Department of Homeland Security/Federal 

Emergency Management Agency contract number: HSFE20-15-Q-0053 for the Mitigation 

of Occupational Violence to Firefighters and EMS Responders.
2 Mitigation of Occupational Violence to Firefighters and EMS Responders

Objective

The objective of this project was to study causes and mitigation of violence to firefighters 

and EMS responders. This study examined both technological and operational mitigation of 

workplace/on-duty incidents of violence and provided examples of current best practices.

Project relevance

The workplace is a known risk factor for violence-related incidents (Occupational Safety 

and Health Association (OSHA), 2015). Health care professionals experience the highest 

rate of workplace violence (WPV) compared to all other industries, with the majority of 

violent injuries committed by their patients (Bureau of Labor Statistics, 2007). Maguire 

and Smith demonstrated that work-related injuries among EMS responders were three 

times higher than the national average for all other occupations (Maguire & Smith, 2013). 

In regards to occupational fatalities, the rate among paramedics is more than twice the 

national average for all occupations and is comparable to those of police and firefighters 

at 12.7 per 100,000 workers per year (Maguire, Hunting, Smith, & Levick, 2002). The rate 

of nonfatal injuries among United States paramedics was 34.6 per 100 full-time workers 

per year — a rate more than five times higher than the national average for all workers 

(Maguire, Hunting, Guidotti, & Smith, 2005). In regard to fatal injuries, a retrospective 

cohort study of nationally registered emergency medical technicians (EMTs) in the U.S. 

found that 8 percent of fatalities were due to assaults (Maguire & Smith, 2013).

The Centers for Disease Control and Prevention (CDC) and the National Institute for 

Occupational Safety and Health (NIOSH) define WPV as “violent acts (including physical 

assaults and threats of assaults) directed toward persons at work or on duty” (Jenkins, 

1996). In violence-related research in the prehospital setting, WPV can be further 

categorized as verbal and physical abuse, property damage or theft, sexual harassment, 

sexual assault, and intimidation (Bigham et al., 2014; Boyle, Koritsas, Coles, & Stanley, 

2007; Corbett, Grange, & Thomas, 1998; Koritsas, Coles, Boyle, & Stanley, 2007; Mock, 

Wrenn, Wright, Eustis, & Slovis, 1998; Pozzi, 1998).

In the U.S., there are approximately 900,000 EMS responders treating a patient base of 

approximately 22 million on an annual basis (Maguire & Smith, 2013). The EMS system 

serves as a critical community-based interface for the population entering the health 

care system, placing responders at risk for experiencing interpersonal violence from their 

patients (Lucas, 1999). In 2014, approximately 2,600 EMS responders were treated in the 

Emergency Department (ED) for injuries resulting from WPV (CDC, 2014).

Acts of violence experienced by EMS responders have been described as “struck by 

patient,” “punched in the face by a drunkard,” “tackled by a large man,” and “assaulted by 

a combative patient” (Taylor et al., 2016). Formal recognition of the problem is increasing, 

however, compared to other health care settings, such as hospitals, WPV in the prehospital 

setting is inadequately described and requires further consideration (Koritsas, Boyle, & 

Coles, 2009; Koritsas et al., 2007; Kowalenko, Gates, Gillespie, Succop, & Mentzel, 2013; 

Kowalenko, Walters, Khare, & Compton, 2005).
Project relevance 3

Incidents of violence in which firefighters and EMS responders have been injured or 

killed have captured national attention. Since the beginning of this project, numerous 

acts of violence have been committed against firefighters and EMTs, some of which are 

outlined below: 

ĵ Jan. 5, 2016: EMT struck by ATV at crash scene, Youngstown, Ohio, https://www.ems1.

com/ems-assaults/articles/46383048-EMT-struck-by-ATV-at-crash-scene/.

ĵ Jan. 12, 2016: Ambulance hit in Texas rock-throwing incident, Austin, Texas, https://

www.ems1.com/ems-assaults/articles/48999048-Ambulance-hit-in-Texas-rock-throwingincident/.

ĵ Jan. 20, 2016: Denver fire chief stabbed near station, Denver, Colorado, https://www.

ems1.com/ems-assaults/articles/51807048-Denver-fire-chief-stabbed-near-station/.

ĵ Jan. 22, 2016: Ark. firefighter shot, killed on EMS call, Pulaski County, Arkansas, https://

www.ems1.com/ems-assaults/articles/52653048-Ark-firefighter-shot-killed-on-EMS-call/.

ĵ Feb. 5, 2016: Hepatitis C-infected patient spits blood into EMT’s eye, Arcade, Georgia, 

https://www.ems1.com/ems-assaults/articles/57355048-Hepatitis-C-infected-patientspits-blood-into-EMTs-eye/.

ĵ Feb. 9, 2016: Chicago medics attacked by couple, Chicago, Illinois, https://www.ems1.

com/ems-assaults/articles/58662048-Chicago-medics-attacked-by-couple/.

ĵ Feb. 15, 2016: Ky. EMS providers assaulted by burglar, McKinney, Kentucky, https://

www.ems1.com/ems-assaults/articles/60919048-Ky-EMS-providers-assaulted-by-burglar/.

ĵ Feb. 28, 2016: Drunk NJ woman attacked, spit on paramedics, Parsippany, New 

Jersey, https://www.ems1.com/ems-assaults/articles/65165048-Drunk-NJ-womanattacked-spit-on-paramedics/.

ĵ March 30, 2016: Woman drives car into creek, assaults paramedic, Sioux Falls, South 

Dakota, https://www.ems1.com/ems-assaults/articles/76595048-Woman-drives-carinto-creek-assaults-paramedic/.

ĵ April 8, 2016: Texas man bites, hits paramedic with guitar, Corpus Christi, Texas, 

https://www.ems1.com/ems-assaults/articles/79430048-Texas-man-bites-hitsparamedic-with-guitar/.

ĵ April 15, 2016: Firefighter fatally shot, second wounded in Prince George’s,

Baltimore, Maryland, https://www.washingtonpost.com/local/public-safety/threepeople-including-two-firefighters-shot-in-prince-georges/2016/04/15/a0f599bc-0369-

11e6-9203-7b8670959b88_story.html?utm_term=.ce4090d59c77.

ĵ April 18, 2016: Man revived with Narcan, grabs EMT’s testicles, Red Lion, Pennsylvania, 

https://www.ems1.com/ems-assaults/articles/82607048-Man-revived-with-Narcangrabs-EMTs-testicles/.

ĵ April 21, 2016: Disoriented man attacks paramedic after car crash, Seattle, 

Washington, https://www.ems1.com/ems-assaults/articles/83667048-Disorientedman-attacks-paramedic-after-car-crash/.

ĵ May 2, 2016: Intoxicated teen assaults Md. ambulance crew, Langley Park, Maryland, 

https://www.ems1.com/ems-assaults/articles/87395048-Intoxicated-teen-assaultsMd-ambulance-crew/.
4 Mitigation of Occupational Violence to Firefighters and EMS Responders

ĵ May 3, 2016: Two arrested for assaulting Cal Fire captain, damaging ambulance,

San Jacinto, California, https://www.ems1.com/ems-assaults/articles/87696048-2-

arrested-for-assaulting-Cal-Fire-captain-damaging-ambulance/.

ĵ May 9, 2016: Ohio paramedic assaulted by drunk woman, Youngstown, Ohio, 

https://www.ems1.com/ems-assaults/articles/89278048-Ohio-paramedic-assaultedby-drunk-woman/.

ĵ May 10, 2016: NY EMT attacked by man in ambulance, Elmont, New York, https://www.

ems1.com/ems-assaults/articles/89644048-NY-EMT-attacked-by-man-in-ambulance/.

ĵ May 17, 2016: NY police medic punched by patient, Freeport, New York, https://

www.ems1.com/ems-assaults/articles/91518048-NY-police-medic-punched-by-patient/.

ĵ May 26, 2016: First person: Sexually assaulted, harassed as an EMS explorer, https://

www.ems1.com/ems-assaults/articles/94359048-First-person-Sexually-assaultedharassed-as-an-EMS-explorer/.

ĵ Sept. 9, 2016: Paramedic stabbed in the neck while responding to call, Cleveland, 

Tennessee, https://www.ems1.com/ems-assaults/articles/124776048-Paramedicstabbed-in-the-neck-while-responding-to-call/.

ĵ Sept. 9, 2016: Patient accused of punching, tackling Dallas paramedic, Dallas, 

Texas, https://www.ems1.com/ems-assaults/articles/124837048-Patient-accused-ofpunching-tackling-Dallas-paramedic/.

ĵ Sept. 16, 2016: Ohio man convicted for assault on paramedic, Gallipolic, Ohio, 

https://www.ems1.com/ems-assaults/articles/126533048-Ohio-man-convicted-forassault-on-paramedic/.

ĵ Nov. 2, 2016: Woman restrained after fighting with EMTs, police, State College, 

Pennsylvania, https://www.ems1.com/ems-assaults/articles/140469048-Womanrestrained-after-fighting-with-EMTs-police/.

ĵ March 16, 2017: Man fractures paramedic’s rib after assault in ambulance, Phoenix, 

New York, https://www.ems1.com/ems-assaults/articles/221773048-Man-fracturesparamedics-rib-after-assault-in-ambulance/.

ĵ March 16, 2017: EMT run over, killed by man driving stolen ambulance, New York, 

New York, http://nypost.com/2017/03/16/1-medic-dead-another-injured-after-mansteals-ambulance-and-slams-into-them/.

Without effective policies and precautions in place to reduce and prevent the occurrence 

of violence against EMS responders, the issue will continue to persist. The findings 

presented in this literature review should serve as an indication that further research is 

needed in order to better identify risk factors for violence, circumstances surrounding 

violence, and methods to best mitigate violence so that resources can be properly 

allocated to protect the health, safety and well-being of EMS responders.
Specific project aims | Project methods 5

Specific project aims

The overarching goal of the project was to gather and analyze data on the incidence 

of WPV for fire and EMS responders. Special interest was dedicated to learning about 

violence that resulted in on-duty fatalities or serious injuries from operational incident 

response or internal WPV.

To accomplish this goal, our research project had the following three aims:

AIM 1: To define the issue of violence experienced by EMS professionals.

AIM 2: To identify the risk factors of violence associated with the EMS profession.

AIM 3: To identify best practices and intervention opportunities.

This literature review addressed a major gap in understanding violence against firefighters 

and EMS responders. Little is known about the issue of violence against fire and EMS 

responders. Our literature review contributes added value to the field by including both 

academic and industry publications, which is an innovative approach to the topic. By 

including industry publications, there is a more complete and comprehensive representation 

of the experiences and risk factors associated with exposures to violence in the line of 

duty. In addition to an analysis of the psychosocial implications that violent exposures have 

upon personal and organizational outcomes, the literature review incorporates relevant 

and available literature, as well as the various definitions of violence used in EMS research.

Project methods

This project was comprised of three phases. Phase 1 of the review involved examining each 

article based on title, abstract and keywords. Phase 2 involved reviewing, assessing and 

documenting titles and abstracts. Phase 3 involved reviewing, assessing and documenting 

the full articles of those deemed relevant based on the first two phases. Phase 3 also 

included manual searches for literature references. A total of 103 full-text articles were 

assessed and reviewed for in-depth analysis based upon prioritization. Articles retained 

for analysis are indicated in bold (Figure 1).

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

Pubmed

CINAHL

Web of

Science

Titles and Abstracts:

1,119 articles

reviewed for

relevance

Pubmed = 399

CINAHL = 595

Web of Science = 125

Full Text Articles Reviewed

354 Articles

(Each article placed into thematic and 

digestible categories described below)

1. Assault and Violence/Background 

Information (108 articles)

2. Injuries and Fatalities(23 articles)

3. Preparedness and Interventions 

(144 articles)

4. Psychosocial Stress and Strain 

(45 articles)

5. Resilience (9 articles)

6. Social and Community Perceptions 

(12 articles)

7. Surveillance (13 articles)

Secondary 

Literature Search

33 articles

164 total articles 

reviewed

103 articles 

chosen for 

inclusion

Phase 1 Phase 2 Phase 3
6 Mitigation of Occupational Violence to Firefighters and EMS Responders

Phase 1: Literature search

Phase 1 of the literature review process consisted of resource collection through three 

academic databases: PubMed, Cumulative Index to Nursing and Allied Health Literature 

(CINAHL) and Web of Science. The primary accomplishment completed during Phase 1 was 

the identification, collection and organization of the literature regarding the incidence of 

violence to firefighters and EMS responders. Three hundred and fifty-four articles were 

identified for review through a formal literature review.

The literature search strategy included developing a list of EMS specific terminology in 

regards to: EMS provider level (including firefighters), violence and related terms, and 

organizational outcomes (Table 1). The asterisk indicated in Table 1 denotes searching 

for a derivate of the search term. An asterisk can be employed in academic databases to 

search for a prefix, root or suffix of a key term (e.g., assault* returns literature containing 

the terms assaults, assaulted, assaulting, assaultive).

Table 1. Literature search terms used to retrieve academic peer-reviewed 

literature and industry publications through PubMed, CINAHL 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

Health Care 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

Fire Fighter Workplace Violence Situational 

Awareness

De-escalation

The articles identified in Phase 1 pertain to the incidence of on-duty violence (e.g., patientinitiated violence, patient-on-worker violence, assaults) and the work environment for fire 

and EMS responders. The articles chosen reflect the comprehensive array of occupational 

consequences experienced by the fire and EMS workforce, most particularly physical 

injuries and fatalities, and the psychosocial stress and strain experienced as a result of 

occupational duties, conditions and exposure to critical incidents.

Phase 2: Appraisal and selection

Phase 2 consisted of reviewing, documenting and synthesizing the information from 131 of 

the 354 articles. The 131 articles were prioritized by how closely they related to: violence, 

assault and aggression; the incidence and prevalence of on-duty violence (e.g., patientinitiated violence, patient-on-worker violence, assaults); and injuries and fatalities.
Project methods 7

Throughout the literature review process, each article was assessed and scored in order to 

provide documentation on the quality of the articles’ contents. The Evidence Pyramid used 

in this literature review is adapted from the Medical Research Library of Brooklyn-SUNY 

Downstate Medical Center and the Cochrane Review (Figure 2). The pyramid provides both 

a conceptual and visual representation of the quality and amount of evidence available. 

Systematic reviews hold the greatest academic rigor and are limited in number. In contrast, 

the bottom of the pyramid demonstrates a decrease in the quality of evidence, yet is more 

widely available. The levels of the pyramid can be distinguished by two groups: filtered 

information and unfiltered information. Filtered resources appraise the quality of studies 

and often make recommendations for practice. Unfiltered resources are comprised of 

primary resources, which must be checked and verified to ensure that the information is 

valid and reliable.

Figure 2. Evidence Pyramid used to assess and score literature. Adaptation of 

the Evidence Pyramid Diagram developed by the Medical Research Library of 

Brooklyn-SUNY Downstate Medical Center and the Cochrane Review.

Meta-Analysis

Randomized Control

Trial

Cohort Study

Case Control Study

Cross Sectional Study

Case Reports and Case Series

Background Information, Ideas, Opinions, Editorials

Systematic

Review Filtered 

information

Increasing evidence

strength

Unfiltered 

information

Phase 3: Analysis, documentation and writing manuscript

Phase 3 was dedicated to identifying key themes within the literature, documenting the 

findings, and drafting an initial literature review based on the 131 articles. During Phase 

3, an additional 33 articles were identified from a secondary literature review, bringing 

the new total of articles needing review to 164. This was done in an effort to collect any 

publications that had been released since the initial literature search. The literature from 

the secondary literature search followed the same selection processes of the first. During 

this phase, literature was carefully examined to create the most comprehensive illustration 

of existing research pertaining to violence faced by firefighters and EMS responders to date.
8 Mitigation of Occupational Violence to Firefighters and EMS Responders

Criteria for inclusion and exclusion

Inclusion and exclusion factors were decided based upon inter-rater reliability between 

researchers. To ensure that all literature on the topic was captured in the search, no 

restriction on publication date was established. All literature relating to the issue of violence 

in EMS published up until Dec. 31, 2016, was considered. The exclusion process was iterative 

and based on pragmatic reasoning, elimination of duplicative evidence, and irrelevance 

to violence experienced by EMS responders. Articles were excluded if they did not discuss 

violence to EMS providers, they were published in a non-English language, full-text options 

were unavailable, or they were not set in an emergency department or prehospital 

environment. Special effort was made to find evaluated studies that would give rise to an 

evidence-base of effective violence prevention interventions. While academic research 

allows for enumeration and quantification of violence, industry publications discuss specific 

knowledge often neglected by scientific literature and provide a rich contextual portal into 

the realities of EMS work. Therefore, it was determined early on in the literature search 

that industry-specific publications, such as trade journals, magazines and news features, 

would be included in this review. Endnote and Endnote Web, a referencing software tool, 

were used to assist with de-duplication, ease of access, and citation.

From 164 articles, 103 were retained for analysis — 34 were from industrial trade journals 

and 69 were from academic journals (Appendix A). Of the 69 peer-reviewed articles, 26 

articles provided estimates of violence. Of the 26 articles measuring prevalence of violence, 

only 10 articles defined or described the types of violence being measured (Appendix B).
Literature review key findings 9

Literature review key findings

Historical and contextual grounding

Acknowledging the medical, historical and social forces that influenced the establishment 

of the EMS system in the U.S. is crucial to understanding the experiences and challenges 

facing EMS responders today.

ĵ The EMS Services Development Act in 1973 favored the decentralization and divestment 

of power from the federal government to state authorities (Shah, 2006).

ĵ The absence of an overarching EMS authority has created challenges for the structure 

and functioning of the EMS system; this is best demonstrated by the nonexistence of 

uniform federal legislation and standards in EMS (Shah, 2006).

ĵ As a result, a centralized data collection surveillance system has never been 

implemented, which is the cause for the limited availability of EMS data (Shah, 2006).

These deficiencies within the EMS system have tremendously impacted the understanding 

of issues that are specific to EMS patients, identification of EMS needs, and best practices 

within EMS (Shah, 2006). Without a comprehensive national data collection system, 

monitoring occupational exposures and injuries related to occupational hazards, such as 

violence, is difficult. This situation was also found to be evident in the literature.

Less than a decade after the formal recognition of the EMS system, industry publications 

mentioning violent patient encounters began to surface. By the 1970s, the issue of violence 

had been noted as well as documented in the hospital setting; however, the prehospital 

setting had not yet received similar attention (Lewis, 1978). The year 1978 marks the 

beginning of a decades-long conversation by the EMS industry in regards to violence 

experienced in the workplace in which Lewis was the first to note the phenomenon that 

“aggression begets aggression.” Similar sentiments continue to be voiced by emergency 

medical providers four decades later (Taylor et al., 2016).

From a public health standpoint, EMS serves a crucial role in meeting persistent and 

emerging community health needs (Studnek, Ferketich, & Crawford, 2007). As a result, 

EMS responders are often providing patient care in unpredictable and increasingly hostile 

environments (Miller, 2001).

ĵ Consequently, issues concerning scene safety and personal security are distinct for 

each patient encounter (Corbett et al., 1998).

ĵ Academic and industry publications have equally postulated the phenomenon that 

EMS personnel have internalized the belief that violence occurs as a result of it being 

a “part of the job” (Bigham et al., 2014; Boyle et al., 2007; Erich, 2001; Goldstein, 1991; 

Kirkwood & Tietsort, 2012; Munding, 2006; Nordberg, 1999; Pozzi, 1998; Suserud, 

Blomquist, & Johansson, 2002; Yilmaz, Dal, Yaylaci, & Uyanik, 2015).

ĵ There have been attempts by the industry to remedy this belief by stating that the 

purpose of EMS is to save lives, but not at the expense of their own (Goldstein, 1991). 

This duality between treating patients versus protecting personal safety has led to an 

ongoing debate on how to best mitigate and prevent violence in the prehospital setting.
10 Mitigation of Occupational Violence to Firefighters and EMS Responders

The literature search also revealed the lapse in time between the first industry publication 

(1978) and the first academic publication (1993) regarding violence against EMS responders 

(Lewis, 1978; Tintinalli & McCoy, 1993). This example was found to be a meaningful 

representation of the knowledge gap between researchers and providers, and therefore 

chose to embark on a novel approach to include both peer-reviewed and academic 

literature in this review as it creates a deeper understanding of the issue.

The first industry publication on the topic recognized the two settings in which 

potentially violent situations can occur: the emergency department (ED) and the external 

environment (e.g., EMS, ambulance staff, and other community-based staff) (Lewis, 1978).

The earliest academic study recognizing violence as a source of injury for EMS responders 

found that 17 percent of injuries in a small, urban fire system were a result of assault 

(Hogya & Ellis, 1990). At this point in time, occupational injury profiles of EMTs and 

paramedics were not well described, and Hogya and Ellis did not define assault, nor did 

the study include assault in their discussion. Tintinali & McCoy’s “Violent Patients and the 

Prehospital Provider” published in 1993, is the first and seminal scientific investigation 

that addresses violence against EMS responders. Subsequent literature added estimates 

describing violence in EMS. Generally, the research that has been conducted in the U.S. 

uses cross-sectional design with small convenience samples. As such, there are very few 

studies that employ a rigorous scientific standard and occur longitudinally.

Evolution of the definition of violence

The CDC and NIOSH define WPV as “violent acts (including physical assaults and threats 

of assaults) directed toward persons at work or on duty” (Jenkins, 1996).

The definition of WPV used by the World Health Organization (WHO) includes “incidents 

where staff are abused, threatened or assaulted in circumstances related to their work, 

including commuting to and from work, involving an explicit or implicit challenge to 

their safety, well-being or health” (2002). The WHO definition includes the psychosocial 

component of violence that is often unrecognized and therefore underestimated. 

Acknowledging that psychological violence accumulates through repeated exposures is 

critical to understanding outcomes that EMS responders experience as a result of their 

work environment (WHO, 2002).

Across selected studies, there was no standardized definition of violence used. Of studies 

measuring the frequency of violence, 61.5 percent (16 out of 26) did not define or did not 

differentiate between types of violence (Cheney et al., 2006; Corbett et al., 1998; Grange 

& Corbett, 2002; Heick, Young, & Peek-Asa, 2009; Hogya & Ellis, 1990; Maguire, O’Meara, 

Brightwell, O’Neill, & Fitzgerald, 2014; Maguire & Smith, 2013; Mechem, Dickinson, Shofer, 

& Jaslow, 2002; Pozzi, 1998; Reichard & Jackson, 2010; Schwartz, Benson, & Jacobs, 1993; 

Thomsen, Sayah, Eckstein, & Hutson, 2000; Tintinalli & McCoy, 1993; Yilmaz et al., 2015). 

And in some cases, violence was determined after using other proxy terms, such as 

homicide and injury (Maguire et al., 2005; Maguire et al., 2002).

The first definition of WPV in EMS from industrial literature was in 1984 when 

Infantino defined “violent client behavior” as a physical activity “destructive to self, 

others or property” (1984). The definition of violence has evolved to encompass more 

comprehensive descriptions, which include psychological impacts, such as cumulative 

stress and burnout. The following terms have appeared most frequently throughout the 
Literature review key findings 11

literature when describing violent encounters: verbal abuse, property damage or theft, 

physical abuse, sexual harassment, sexual assault, and intimidation (Boyle et al., 2007; 

Koritsas et al., 2009; Kowalenko et al., 2013; Kowalenko et al., 2005).

In violence related research, definitions of violence vary and have been operationalized 

by the researcher (Larsson & Gill, 2013). It is noted that, frequently in EMS literature, 

no definition of violence is presented. In studies where no definition of violence is 

predetermined for the survey participants, it may be concluded that the definition of 

violence may vary significantly from participant to participant (Larsson & Gill, 2013). This 

is problematic when attempting to describe the prevalence of violence, risks of exposure, 

and types of violence experienced. The American College of Emergency Physicians has 

recognized this limitation and has emphasized the importance of categorizing violence 

against EMS responders (NHTSA, HRSA, EMSC, & ACEP, 2013). In response, the work of 

Koritas et al. is included, categorizing sources of violence against EMS responders. Koritas 

et al. defined violence against EMS responders in the following ways:

ĵ Verbal abuse: A patient/client, their friend(s), family member(s), other professional(s), 

or work colleague(s) use offensive language, yell or scream with the intent of offending 

or frightening you. It can include threats of abuse over the phone, but excludes sexual 

harassment and sexual assault.

ĵ Property damage or theft: A patient/client, their friend(s), family member(s), other 

professional(s), or work colleague(s) cause damage to, or steal property belonging to 

you, your family or your workplace. It includes damage to or theft of a vehicle, personal 

effects, home contents, office equipment and supplies, or office furnishings. Attempted 

theft of the above items is also included.

ĵ Intimidation: A patient/client, their friend(s), family member(s), other professional(s), or 

work colleague(s) threaten, follow, or use gestures to purposely offend or frighten you.

ĵ Physical abuse: A patient/client, their friend(s), family member(s), other professional(s), 

or work colleague(s) physically attack you, or attempt to attack you. It includes behaviors 

such as punching, slapping, kicking, or using a weapon or other object with the intent 

of causing bodily harm.

ĵ Sexual harassment: Any form of sexual propositioning or unwelcome sexual attention 

from a patient/client, their friend(s), family member(s), other professional(s), or work 

colleague(s). It includes behaviors such as humiliating or offensive jokes and remarks 

with sexual overtones; suggestive looks or physical gestures; inappropriate gifts or 

requests for inappropriate physical examinations; pressure for dates; and brushing, 

touching or grabbing, excluding sexual touching (e.g., the genital or breast area).

ĵ Sexual assault: Any forced sexual act, rape or indecent assault perpetrated by a patient/ 

client, their friend(s), family member(s), other professional(s), or work colleague(s). 

It includes brushing, touching or grabbing of the genitals or breast. It also includes 

attempted sexual assault (Koritsas et al., 2009).

Variations of these definitions have been used by other researchers in the field (Bigham et 

al., 2014; Boyle et al., 2007). For this report, the phrase “violence against EMS responders” 

is deemed to be inclusive of the above violence terms as they relate to EMTs, paramedics, 

firefighters and first responders. Other terms that have been used to describe the 

phenomenon of violence against EMS responders in the literature include: patient initiated 

violence (Taylor et al., 2016) and patient initiated workplace aggression (Oliver, 2015).
12 Mitigation of Occupational Violence to Firefighters and EMS Responders

There is an important distinction to be made between intentional and unintentional 

violence (Mechem et al., 2002).

ĵ Unintentional violence arises from compromised patients who may be intoxicated 

and under the influence of drugs or alcohol, have mental health diagnoses, or existing 

health conditions, such as a diabetic incident, dementia, altered mental status or 

consciousness, fear, hypoxia, or a closed head injury (Bigham et al., 2014; Rollert, 

2007). The industry literature points out that EMS responders often feel that patients 

in those states who commit violence are a result of survival instinct and not mal-intent 

(Rollert, 2007).

ĵ Intentional violence is premeditated and intended to cause harm, injury or death to 

other individuals by patients, families or bystanders (Mechem et al., 2002).

Depending on how violence is classified, there may be deep legal implications that affect 

the patient (or other perpetrators of violence) and the responder. In many cases, the 

lack of clarity between intentional and unintentional violence and the imperfect legal 

protections provided to EMS presents challenges for EMS responders seeking justice 

(Augustine, 2014; Erich, 2001; Taylor et al., 2016; Wirth, 2000). Similar challenges in 

seeking judiciary justice exist in other health care fields, such as emergency medicine 

and psychiatry (van Leeuwen & Harte, 2011).

Characteristics of patients/perpetrators of violence

A large body of evidence points to patients as the most common perpetrators of violence 

(Bigham et al., 2014; Gormley, Crowe, Bentley, & Levine, 2016; Grange & Corbett, 2002; 

Heick et al., 2009; Infantino, 1984; Maguire et al., 2002; Mock et al., 1998; Petzäll, Tällberg, 

Lundin, & Suserud, 2011; Pozzi, 1998; Rahmani, Hassankhani, Mills, & Dadashzadeh, 2012; 

Schwartz et al., 1993; Suserud et al., 2002; Taylor, Davis, Barnes, Lacovara, & Patel, 2015).

ĵ One study involving a convenience sample of all EMS responders in six New England 

states showed the patient to be the assailant in 84 percent of all violent encounters 

measured over a six-month period (Schwartz et al., 1993).

ĵ A study investigating injury and fatality data in EMS from a four-year period collected 

by the U.S. Department of Labor found that the patient was shown to be the cause of 

injury in 37 percent of all reported injury cases (Maguire & Smith, 2013).

Patients may make threatening postures, use verbal threats, or be agitated (Infantino, 

1984). The literature identifies characteristics of violent patients as: age, gender, mental 

status, substance abuse, and underlying health conditions. However, many findings are 

contradictory, so there is difficulty predicting when possession of these characteristics 

will presage violence. No data exist to show which of these characteristics is the most 

frequent. What is known is described below.

Age

Researchers in Spain found that the most typical profile of a patient committing violence 

against an EMS responder was a male aged 30 to 50 years, which is consistent with 

findings from ED studies (Bernaldo-de-Quirós et al., 2014). The elderly were also found 

to pose a significant risk to EMS responders (Flannery, Walker, & Flannery, 2006; Somes, 

Donatelli, & Kuhn, 2011).
Literature review key findings 13

Gender

Males have been reported as the most frequent perpetrators of violence (Grange & 

Corbett, 2002; Petzäll et al., 2011; Bernaldo-de-Quirós et al., 2014). However, a separate 

study found female patients of the mean age of 32.5 years +/- 8.1 years to be the most 

frequent perpetrators (Cheney et al., 2006; Mock et al., 1998).

Mental status, substance abuse, underlying health conditions

Some study findings suggest that patients committing violence in EDs were more likely 

to be suffering from an altered mental capacity compared to violent patients committing 

violence against EMS responders (Bernaldo-de-Quirós et al., 2014). In the Spanish study, a 

majority (55.2 percent) of violent patients had no known altered mental capacity, and less 

than half of violent perpetrators had a psychiatric disorder or were under the influence of 

drugs and alcohol (Bernaldo-de-Quirós et al., 2014). Industry perspectives were uniform 

that one of the major patient characteristics is intoxication, drugs and mental illness (Erich, 

2001; Miller, 2001). Several academic studies support this claim (Bigham et al., 2014; Cheney 

et al., 2006; Mock et al., 1998; Petzäll et al., 2011; Suserud et al., 2002). Other research 

suggests that any condition that causes an altered mental status or consciousness, such 

as trauma and diabetes, may lead to patients committing violent acts (Bigham et al., 2014; 

Cheney et al., 2006; Erich, 2001; Mechem et al., 2002; Miller, 2001; Petzäll et al., 2011; Rollert, 

2007; Somes et al., 2011). For instance, in a retrospective review of ambulance call reports 

from a six-month study period, insulin dependent diabetics experiencing hypoglycemic 

episodes were the cause of 9 percent of violent incidents (Tintinalli & McCoy, 1993).

Bystanders

Research indicates that patients are not the only assailants of violence against EMS 

responders. Violence has also been documented as being initiated by nonpatients, such 

as family members and bystanders (Gormley et al., 2016; Lucas, 1999; Mechem et al., 

2002; Mock et al., 1998; Petzäll et al., 2011; Pozzi, 1998; Rahmani et al., 2012; Suserud et 

al., 2002). In a prospective, observational case-series study of 297 EMS runs conducted 

over 737 hours of observation, the violent person was not the patient in one-third (5 out 

of 16) of violent calls (Mock et al., 1998). Furthermore, one study found that verbal abuse 

in the form of intimidation occurred most frequently from colleagues, such as partners, 

managers, police officers, nurses, and physicians (Bigham et al., 2014). Colleagues were 

also frequent perpetrators of sexual harassment and sexual assault (Bigham et al., 2014). 

Weapon possession

Weapons were present in less than 12 percent of violence related cases throughout the 

majority of the select studies measuring weapon possession (Mock et al., 1998; Pozzi, 

1998; Tintinalli & McCoy, 1993). Although these studies suggest a relatively low incidence 

of weapons possessed by violent or combative patients, research shows that many EMS 

responders may not be equipped to deal with the issue. In a study of EMS responders 

from Boston and Los Angeles metropolitan areas, 42 percent of respondents indicated 

that they did not regularly search their patients for weapons (Thomsen et al., 2000). 

Yet, as many as 79 percent of respondents in another study reported having seen or 

found a weapon on a patient (Corbett et al., 1998). Tintinalli makes the observation that 

EMS responders experience increased susceptibility because almost anything in the 

ambulance can be used as a weapon (Tintinalli & McCoy, 1993). This lack of clarity in 

existing literature describing who the perpetrators of violence are, how violence plays out, 

and the circumstances surrounding violence signals the need for future scientific inquiry.
14 Mitigation of Occupational Violence to Firefighters and EMS Responders

Other potential factors affecting the tendency for violent patient behaviors include:

ĵ Dissatisfaction with promptness of ambulance arrival.

ĵ Lack of understanding of treatment and care needs (often coupled with ignorance of 

illness and their symptoms).

ĵ Frustration and/or anger from feeling helpless in a time of emergency.

ĵ Wishes to refuse transport.

ĵ Culture clash.

ĵ Language inadequacies (Behnam, Tillotson, Davis, & Hobbs, 2011; Bernaldo-de-Quirós 

et al., 2014; Mock et al., 1998; Petzäll et al., 2011).

Estimates of violence

Cross-sectional surveys, direct observations, and injury reports have been the 

key methods used to quantify the problem of violence against EMS responders. 

Methodological variations do not permit cross-comparisons between studies for the 

following reasons: because they do not contain the same population denominator, and 

intervals of measuring violence vary.

While some studies assess career exposure, some studies compare rates of violence 

occurring over the last 12 months, three months, or one month. Thus, only the estimates 

and ranges of violence that exist compared to the population from which they were 

collected can be described within the appropriate time frame measured.

To date, there have been only four studies conducted in the U.S. that may be considered 

nationally representative. These four studies used survey data from nationally certified 

EMS responders participating in the Longitudinal EMT Attributes and Demographics Study 

(LEADS) (Gormley, 2016; Oliver, 2015; Blau, Chapman, Gibson, & Bentley, 2011; Studnek 

et al., 2007). These data are the most comprehensive information on demographic 

characteristics and occupational injuries and exposures in EMS responders. Gormley 

et al. (2016) notes that, while the National EMS Certification is only required in 46 

states, nationally certified EMS responders are found in each state, thereby favoring 

generalizability to the entire EMS responder population in the U.S.

In studies measuring career prevalence, between 57 and 93 percent of EMS responders 

reported having experienced an act of verbal and/or physical violence at least once during 

their career (Bigham et al., 2014; Boyle et al., 2007; Corbett et al., 1998; Koritsas et al., 

2007; Petzäll et al., 2011; Pozzi, 1998; Suserud et al., 2002; Thomsen et al., 2000; Tintinalli 

& McCoy, 1993).

In a 2013 study using data from the LEADS database collected by the National Registry of 

Emergency Medical Technicians (NREMT), it was found that among the 1,789 respondents, 

69 percent experienced at least one form of physical and/or verbal violence in the past 12 

months (Gormley et al., 2016). Furthermore, 43.6 percent experienced one or more forms 

of physical violence over the same study period (Gormley et al., 2016). Non-U.S. studies 

find similar rates, with one study reporting that 87.5 percent of respondents reported 

some form of WPV in the last 12 months (Boyle et al., 2007). Similarly, 75 percent of 

paramedics from two Canadian provinces reported experiencing violence in the past 12 

months (Bigham et al., 2014). Suserud et al., conducted a small, mixed-methods study of 

violence on urban and rural EMS in Swedish responders and found that rates of verbal 

and physical violence in the last 12 months were 78 percent and 67 percent, respectively 

(2002). Additionally, Suserud et al., found that 35 percent of survey participants reported 
Literature review key findings 15

being victimized at least every three months (2002). In another study conducted in New 

England, the prevalence rate of violence was 20.3/100 full-time employees per year. 

Additionally, 38 percent of those surveyed in New England reported multiple assaults 

within the past six months, and one EMT reported being assaulted nine times during that 

same six-month period (Schwartz et al., 1993). Conversely, crude estimates from a study 

conducted in Southern California found a much lower frequency of 0.4 assaults per year 

per prehospital care provider (Corbett et al., 1998).

Overall, the types of violence frequently encountered include verbal abuse, physical 

assaults and intimidation (Bernaldo-de-Quirós et al., 2014; Bigham et al., 2014; Boyle et 

al., 2007; Corbett et al., 1998; Mock et al., 1998; Pozzi, 1998).

ĵ Verbal violence is the most prevalent form of occupational violence to which EMS 

responders are exposed (Bernaldo-de-Quirós et al., 2014; Bigham et al., 2014; Boyle 

et al., 2007; Gormley et al., 2016; Mock et al., 1998; Pozzi, 1998; Rahmani et al., 2012; 

Suserud et al., 2002; Thomsen et al., 2000).

ĵ Verbal violence if ever experienced by EMS responders is estimated to be between 21 

percent and 82 percent (Boyle et al., 2007; Grange & Corbett, 2002; Mock et al., 1998; 

Suserud et al., 2002).

ĵ The range of physical violence if ever experienced by EMS responders is estimated 

between 22.6 percent and 90 percent (Heick et al., 2009; Pozzi, 1998).

Sources of physical violence are varied. The most frequent sources of physical violence are:

ĵ Struck by attempts.

ĵ Punching, slapping or scratching.

ĵ Spitting.

ĵ Biting (Bigham et al., 2014; Cheney et al., 2006; Gormley et al., 2016; Mechem et al., 

2002; Pozzi, 1998).

The least frequent types of physical violence experienced by EMS personnel were:

ĵ Stabbing or stabbing attempts.

ĵ Shooting or shooting attempts (Gormley et al., 2016).

Minor injuries from these actions of violence include minor bruises and abrasions, 

whereas more serious injuries have included contusions, hematomas, sprains and strains, 

eye injuries, facial injuries, bites, lacerations, dislocations and fractures (Corbett et al., 

1998; Mechem et al., 2002; Petzäll et al., 2011).

While the majority of literature focuses on the frequency of violence experienced, others 

focus upon the volume of violence experienced by EMS responders. A retrospective review 

of ambulance reports in a metropolitan area revealed an overall rate of violent encounters 

to be 0.8 percent of the ambulance call reports that were reviewed over a 3.5 year period 

(Tintinalli & McCoy, 1993). This is in comparison to a prospective, observational case-series 

report from the Metropolitan Nashville/Davidson County, Tennessee, fire departmentbased EMS system in which 5 percent of calls during the study period (297 EMS runs over 

737 hours of observation) involved a violent situation directed at EMS responders (Mock 

et al., 1998). In 14 percent of calls in this study, violence was mentioned to have occurred 

prior to the arrival of EMS responders. Consequently, Mock purports that between 5 

percent and nearly 20 percent of sampled EMS calls in the urban EMS system were related 
16 Mitigation of Occupational Violence to Firefighters and EMS Responders

to either physical or verbal violence (Mock et al., 1998). The overall frequency of violencerelated EMS incidents directed at EMS responders thus ranged from 0.8 to 5 percent of 

all dispatched calls (Mock et al., 1998; Tintinalli & McCoy, 1993).

The literature notes a growing concern associated with violence-related injuries (Reichard 

& Jackson, 2010; Reichard, Marsh, & Moore, 2011). In Australia, an examination of injury 

reports determined that paramedics had an injury rate of 80 serious cases per 1,000 

workers per year. Out of 6,728 injury reports examined over the 10 year study period, 

170 cases resulted from violence described as “assaults or bullying” (Maguire et al., 2014). 

The risk of injury in Australia was found to be comparable to the rates found in the U.S. 

(Maguire et al., 2014). One survey of 490 EMS responders revealed that 61 percent had 

been assaulted on the job, with 25 percent sustaining an injury from the assault (Corbett 

et al., 1998). Additionally, “struck by” injuries (e.g., struck by an object) accounted for 8 

percent of injuries, and an average of over 100 assaults per year were reported (Maguire 

& Smith, 2013). Eight percent of fatalities (five cases) were due to assaults (Maguire & 

Smith, 2013). One study found that 4 percent of occupational injuries in one urban fire 

department resulted from assault. Medical attention was sought in 81.8 percent of 

incidents in which a responder incurred an injury. The percent of injuries classified as 

intentional violence was 59.1 percent, and 38.6 percent were classified as unintentional 

(Mechem et al., 2002).

EMS responder risk factors

Much of the literature focuses on the prevalence and frequency of violent acts against 

EMS responders. Few studies focus on factors that may predict episodes of violence. The 

literature reveals eight characteristics as potential predisposing risk factors to violence: 

age of responder, gender of responder, years of experience, type of service (e.g., fire 

versus EMS-based departments), occupational characteristics (e.g., firefighter, paramedic, 

EMT, first responder), population served (e.g., urban, suburban, rural environments), shift, 

and violent call type. The literature provides no clear evidence on which characteristics 

pose a greater risk for violent patient encounters. What is known is summarized below.

Age

Age was found to be a significant indicator for increased risk of violence in most 

studies (Bigham et al., 2014; Gormley et al., 2016; Mechem et al., 2002). In a nationally 

representative sample of EMTs in the U.S., responders who experienced physical violence 

from a patient were 1.9 years younger than those who did not experience violence in the 

past 12 months (Gormley et al., 2016). One survey of Canadian paramedics found that 

with each additional year, medics were less likely to be exposed to violence (Bigham et 

al., 2014).

Gender

Conflicting evidence was found pertaining to gender as a risk factor. This factor among 

EMS responders was not studied under more rigorous conditions until Gormley et al. and 

Oliver et al. used a longitudinal cohort design. While some studies indicated that men are 

more likely to experience violence (Grange & Corbett, 2002; Mechem et al., 2002; Mock 

et al., 1998; Schwartz et al., 1993), others yielded results that women are more at risk 

(Bigham et al., 2014; Cheney et al., 2006). One study concludes that, among nationally 

registered EMTs, women are at an increased risk for physical violence, while men were 

found to be at an increased risk for verbal violence (Gormley et al., 2016). Others found 
Literature review key findings 17

that female gender was a predictor only for cases of sexual assault and sexual harassment 

(Boyle et al., 2007), and another found women at significantly higher risk in regards to 

sexual assault, sexual harassment and verbal violence (Koritsas et al., 2009). In contrast, 

an international Canadian study found that women were more often victims of violence 

of all types (Bigham et al., 2014). Further confounding are the results from one study that 

female paramedics were more likely to report episodes of violence compared to their male 

coworkers (Bigham et al., 2014).

Other research found that gender was not a risk factor for threats or violence (Petzäll et al., 

2011; Taylor et al., 2016). In a systematic review of verbal violence in the general workplace, 

the majority of studies concluded that gender was not a significant risk factor for violence. 

In studies with significant results, men were more likely to be at risk for violence compared 

to women (Guay, Goncalves, & Jarvis, 2014). In an ED setting, though females did not 

experience a higher rate of violence compared to males, they felt significantly more unsafe 

and at risk of injury from violence than males (Gates et al., 2011).

Years of experience

Some research shows that work experience is not a significant risk factor for encountering 

violence (Bigham et al., 2014; Petzäll et al., 2011). Other findings contradict this. Gormley 

et al. found that personnel who had experienced violent patient encounters had more 

than double the median years of experience in a longitudinal cohort study of nationally 

registered EMTs (2016). Likewise, Oliver et al. found that EMTs or their partners with more 

than 10 years of work experience were more likely to experience violence (2015). The 

latter studies measure cumulative exposure and differ from Bigham and Petzäll due to 

stronger study design.

Type of service (nonfire based, fire based, volunteer, municipal or commercial)

In New England, providers working for commercial agencies (private, for-profit agencies) 

were found to experience the highest rate of violence while on the job compared to 

municipal and volunteer agencies (Schwartz et al., 1993). One study yielded results that 

agency type was not significantly associated with patient violence, but was associated with 

violence from patient family member and bystanders, with 911 agencies experiencing 

more risk compared to other agency types (Gormley et al., 2016).

Occupational characteristics

In Philadelphia, one study analyzed an injury database of all injuries that were reported 

between January 1996 to December 1998. Of 1,100 injury reports related to violent 

incidents, 93.2 percent of documented assaults occurred during patient care activities, 

suggesting that EMS calls versus fire calls pose more risk (Mechem et al., 2002). Only 

one study showed that professional level was not associated with violence (Petzäll 

et al., 2011). All other selected research yielded results showing provider level to be 

significantly associated with increased risk of violent interactions. Robust evidence points 

to paramedics being at increased risk for violence compared to firefighters (Gormley et 

al., 2016; Mechem et al., 2002; Taylor et al., 2016). A study of paramedics and firefighters 

in Philadelphia found that occupation completely mediated the association between 

gender and WPV (Taylor et al., 2016). Upon further evaluation, Taylor et al. found that 

the odds of paramedics being assaulted compared to their firefighter counterparts were 

14-fold higher, further indicating the association between occupation and WPV exposures 

(2016). Firefighters may be less likely to be assaulted due to the nature of their calls 
18 Mitigation of Occupational Violence to Firefighters and EMS Responders

typically being in response to a fire and not to a patient scenario (Mechem et al., 2002). 

Correspondingly, responders who spent more time providing direct patient care were 

at increased risk for violence (Koritsas et al., 2009). Therefore direct patient contact and 

in-person communication may be a predisposing factor for why direct patient care results 

in greater exposures to violence (Koritsas et al., 2009).

Other research focused on the distinctions between EMT provider level as a risk factor 

for violent exposures. Some studies have found that paramedics are at increased risk 

for physical violence when compared to EMTs (Gormley et al., 2016; Mechem et al., 

2002; Schwartz et al., 1993). In a national cohort study, over twice as many paramedics 

compared to EMTs experienced physical violence (Gormley et al., 2016). Additionally, paid 

providers were more likely to be assaulted and were 2.72 times more likely to report an 

assault compared to volunteers (Heick et al., 2009). Other studies also found volunteers 

to be at less risk compared to career EMS responders (Gormley et al., 2016).

Population served/Community size

Though there are limited studies assessing population served or community size as a 

risk factor for violence, available evidence purports that EMS providers working in urban 

environments have increased odds of experiencing physical violence (Gormley et al., 2016; 

Suserud et al., 2002). One study found that population served was a predictor only for 

violence classified as sexual harassment and sexual assault, with urban EMS responders 

experiencing higher risk (Boyle et al., 2007).

Shift

One study showed that 52.3 percent of violent calls occurred during the night shift (6 p.m. to 

8 a.m.), while 47.7 percent occurred during the day. Furthermore, 45.5 percent of violent 

encounters occurred on a weekend (Friday, Saturday, Sunday) (Mechem et al., 2002). 

Some studies found that time of day was significantly associated with increased violence 

exposures. The midnight to 6 a.m. shift was found to have 1.5 greater odds of experiencing 

a violent patient encounter (Cheney et al., 2006).

Violent call type

Violent call type is an understudied characteristic of the occupation that may be predictive 

of exposures to violence. One study found that while only 5 percent of calls during the 

study period (297 EMS runs over 737 hours of observation) involved a violent situation 

directed at EMS responders, an additional 14 percent of calls in this study were flagged 

as locations where violence was mentioned to have occurred prior to the arrival of EMS 

responders (Mock et al., 1998). The 14 percent indicates a potentially hostile environment 

for responders upon arrival. Consequently, Mock et al. purports that between 5 percent 

and nearly 20 percent of sampled EMS calls in the urban EMS system were related to either 

physical or verbal violence (1998). Conversely, violent calls are not always predictable. In 

an analysis of near-miss and injury events reported to the National Fire Fighter Near-Miss 

Reporting System, responder narratives revealed that violence may not be anticipated by 

responders in many cases, as violence can often erupt instantaneously (Taylor et al., 2015).

Psychosocial impact

Violence, or the threat of violence, to EMS responders can have a major impact on the 

victims and their colleagues (Mechem et al., 2002). While robust evidence of the expected 

physical outcomes of violence against EMS responders was noted, equally concerning 
Literature review key findings 19

information was discovered about the psychosocial impact of experiencing violence in 

this work. There is consensus within the profession that EMS is a stressful occupation 

(Nordberg, 1992a). The constant threat of physical injury often increases the likelihood 

that an EMS provider experiences stress (Nordberg, 1992a). Violence exposure in the 

prehospital setting has been associated with increased levels of stress, fear and anxiety 

in EMS responders (Gómez-Gutiérrez, Bernaldo-de-Quirós, Piccini, & Cerdeira, 2016). 

Stress is often a result of exposure to traumatic incidents in the field. Between 82 and 

100 percent of EMS responders have experienced a traumatic event (Donnelly & Siebert, 

2009). Traumatic events greatly impact the tendency of EMS responders to develop severe 

mental health conditions. This is represented by the fact that numerous studies place 

prevalence rates of post-traumatic stress disorder (PTSD) in EMS responders to be greater 

than 20 percent (Bennett, 2004; Grevin, 1996; Marmar, 1996; Jonsson, 2003; Clohessy, 

1999; Newland, Barber, Rose, & Young, 2015).

Some research suggests that social support is significantly related to mental health among 

EMS responders (Prati & Pietrantoni, 2010). The study conducted by Prati et al., supports 

the conclusion that social support serves a vital role in regard to resilience, especially 

following traumatic exposures. There may also be effects on EMS responders’ social 

interactions and personal relationships. Moodiness, including increased anger; withdrawal 

from social situations, family and friends; increased distrust of people; and apprehension 

in social settings were also indicated as ways in which responders cope with the effects 

of violence (Bigham et al., 2014). Divorce and relationship breakups were also reported 

(Bigham et al., 2014). It has been further suggested that social support may influence first 

responder’s recollection and interpretation of the event and their attribution patterns. 

Cumulative exposures to stress and traumatic incidents can lead to burnout, which may 

result in deterioration of quality patient care (Boudreaux, Jones, Mandry, & Brantley, 1996).

Additionally, the presence or absence of a supportive work environment can impact 

readiness and judgment for each call’s special needs. This has been posited to affect a 

responder’s ability to competently deliver high quality patient care and conduct expected 

job duties. For example, responders may need to respond from one call to another with 

little to no recovery time due to understaffing or pressures to be in constant service.

Descriptions of the work environment often detail the unpredictability of the job. 

Literature highlights the exposure to trauma and their mobile workplace (e.g., moving 

vehicles, difficult terrain, and people’s homes) as uncontrollable features of their 

profession (Maguire et al., 2014).

Stress has not only been categorized by exposure to traumatic incidents, but also the 

monotonous operational characteristics of EMS organizations, such as paperwork, lack 

of administrative support, low wages, long hours, irregular shifts, and cynical societal 

attitudes toward public safety officers (Boudreaux, Mandry, & Brantley, 1997). Cumulative 

stress associated with the monotonous duties or low acuity calls has led to feelings of 

desensitization for patients, and their job as a whole (Cannuscio et al., 2016). Concerns 

have also been raised regarding sleep quality and fatigue and the impact it has not only 

on the provider, but also job performance and patient outcomes (Patterson, Suffoletto, 

Kupas, Weaver, & Hostler, 2010). Some research has posited that organizational stress 

often contributes more to the development of PTSD than traumatic events (Maguen, 

2009; Regehr, 2007). Also noteworthy is the notion that paramedics are often the source 

for a lot of criticisms by society for the decisions they make in determining life or death 

situations for patients and themselves (Nordberg, 1992a). This can affect EMS providers 

in many ways and may contribute to the slow decline in provider morale.
20 Mitigation of Occupational Violence to Firefighters and EMS Responders

Burnout, defined as a “syndrome of emotional exhaustion and cynicism” (Maslach & 

Jackson, 1981), is one of many organizational outcomes that may arise as a result of violence 

experienced by EMS responders. Studies of burnout in EMS have been described as lacking 

(Vettor, 2000). The question of whether or not violence would eventually lead to burnout 

was first raised in the early 1990s (Nordberg, 1992a). Exposures to violence were noted 

as a reason many EMTs, especially volunteers, left the profession (Nordberg, 1992a). In an 

early study from 1998, 7 percent of survey respondents within one urban fire department 

considered leaving EMS as a direct result of an abusive situation they encountered while on 

the job (Pozzi, 1998). Knowing how to emotionally cope following a tough incident can help 

to reduce anxiety and burnout (Hopson, 1997). Mixed methods studies conducted in the 

U.S. and Sweden found that violent encounters altered the patient-provider relationship 

(Suserud et al., 2002; Taylor et al., 2016). Yet, some in the industry feel that exposures 

to violence do not cause stress or negatively impact providers (Erich, 2001). This lack of 

effect has been attributed to the internalization of the mentality that violence is a part 

of the job (Erich, 2001). It has been posited that years of experience may be a protective 

factor that allows more experienced responders to experience less stress and anxiety after 

violent events (Erich, 2001; Mock, Wrenn, Wright, Eustis, & Slovis, 1999). Another possible 

explanation for the protective factor is that EMS responders with greater experience may 

have developed a deeper capacity to cope with violent situations (Mock et al., 1999).

For many EMTs, working in environments where traumatic exposures are frequent can 

trigger thoughts and emotions that are not easily forgotten. Some responders engage 

in coping mechanisms, such as detachment, in order to continue carrying out their job 

duties. Industry journals describe the phenomenon of detachment through descriptions 

such as “divorcing yourself from personal feelings” (Nordberg, 1992b) and making light 

of situations through humor (Morrison, 2014). The coping mechanisms just described are 

often encouraged by others in EMS to help oneself make it through the “toughness of the 

job” (Nordberg, 1992b). Nordberg cites keeping familial communications open in order to 

help responders cope with the stress and trauma of the job (1992b). However, coping is not 

possible for all responders. In many cases, EMS responders express that they felt some 

level of fear, either due to overt acts of violence or the potential for violence (Mechem 

et al., 2002). Fear toward patients and potential violent encounters can create feelings 

of insecurity resulting in reduced quality of care for the patient (Petzäll et al., 2011). 

Additionally, in response to the fear that they may feel, EMS responders may request 

police backup more often (Bigham et al., 2014).

Evidence weighing the social and economic costs associated with increased violence and 

burnout is based mostly upon anecdotal evidence, with no assessments conducted on 

monetary value. Some suggest that, as violence increases, the need for police backup also 

increases, thereby increasing response time and delaying potentially critical care to a patient 

in need (Nordberg, 1992a). Other concerns include altered operations for the private sector 

of EMS (Nordberg, 1992a). Intent to leave the profession is also a concern. As more EMS 

responders leave the profession, numerous organizational and patient impacts have been 

hypothesized, including increased costs for training new EMTs and paramedics, greater 

numbers of inexperienced paramedics serving at any one point in time, and increased error 

rates committed by new and inexperienced paramedics (Federiuk, O’Brien, Jui, & Schmidt, 

1992; Patterson, Jones, et al., 2010). EMS responders also report seeking a job change away 

from their ambulance role. In some cases, responders stated they lost interest in fieldwork 

and tried to get off the road and into desk positions. A few had left full-time positions and 

were working part time while considering a career change (Bigham et al., 2014). 
Conceptual diagram 21

Reporting/Under-reporting

One of the limitations that is frequently mentioned in both academic and industrial 

publications is the perception that assaults are inherent to the profession, and reporting 

violent incidents implies an inability to perform the job competently (Corbett et al., 1998). 

Such attitudes might lead to significant under-reporting of violence in the field (Pozzi, 

1998). One study of 1,500 medical providers in New Mexico found that 56 percent of EMS 

respondents stated that violence is “just a part of the job” (Feiner, 1995). Although a large 

percentage believe violence is a part of the job, 40 percent believe that if no one was 

injured during the incident, there was no need to report (Feiner, 1995). Other studies show 

higher frequencies, up to 71 percent, believing that violence is a part of their job (Pozzi, 

1998). In a Canadian study, 62 percent of participants stated that no actions were taken 

by most paramedics in response to the violent events (Bigham et al., 2014). In the same 

study, 61 percent of participants did not report the violence to a superior or authority, and 

81 percent did not formally document the occurrence in the patient care report (Bigham 

et al., 2014). Similarly, one study found that only 31 percent of all violent encounters were 

properly mentioned in the paramedic narrative (Mock et al., 1998).

Conceptual diagram

The literature review also contributed to the development of a conceptual diagram (mind 

map) as a pre-analytic and noncausal depiction of the various aspects of the EMS work 

environment that relate to violence against EMS responders.

The map offers a concise overview of the broad themes of the work environment that 

were found to impact the EMS profession. It highlights the various occupational elements 

that influence EMS responders in the line of duty, as they relate specifically to exposure to 

violent patients, family and bystanders. Each category and subsequent nodes emanated 

from the academic peer-reviewed literature and industry publications.

The mind map provides a global look at the complexity and different factors that relate to 

this work in the EMS industry. The literature pertaining to violence in EMS also offered a 

myriad of other organizational factors that influence EMS responders at the organizational 

level and during their day-to-day duties. This map was designed to recognize all of these 

operational facets of the job.

The mind map diagram (Figure 3) and key follow on the next pages.
22 Mitigation of Occupational Violence to Firefighters and EMS Responders

Figure 3. Mind map of factors related to violence against fire and EMS.

Mind map

Domains on the diagram are listed on the following pages. Please refer to the color next 

to each header to locate its place on the map. Please refer to the key after this list for 

descriptions of each domain.

FACTORS RELATED TO

VIOLENCE AGAINST FIRE

AND EMS

Structure, policy,

procedures and

practices

Work environment

Societal perceptions

Team cohesion

Duty

Workplace culture

Emergent versus nonemergent response as

stressors

Types of violence

"Official-ness"

Machoism

Policies/National

standards

Recruitment and

retention issues

Workforce

Urban versus rural

Career versus volunteer

Transport versus response

Nature of 911 reporting

Legal protections

Injury reporting

practices

Awareness of protected

class status

Trainings Conflict management

Defensive tactics

PPE

Body armor

De-armament skills

Educational

interventions

Evidence of successful

online training in

nursing (NIOSH)

On-the-job training

Types of calls

Crime scene

Medical

Nonmedical

Trauma

Roadway response

Needs evaluation DT4EMS

Staffing models

In need of

recommendations on

staffing possibilities for

EMS departments

National training

standards NREMT

Media

Language use in

headlines

Events they choose to

cover

Police reinforcement

Fire versus nonfire based

Job title

EMT

Paramedic

Firefighter

Ambulance driver

Inter-industry support

Police

Trauma-informed care Cultural competence

Restraints

Coping with violent

patients

Controlling violent

patients

Requesting backup

Scene safety

Responders' role in

communities

Hours on duty

Shift work

First responder

Morale/Engagement

Dispatch

Responding services

Transfer of care

Bullet proof vests

Mace

Guns

Simulation training

Web-based

interventions

NEMSMA

Types of calls

Unintentional

Intentional

Taxi service

Hiring and recruitment

NHTSA

Crisis intervention

Patient de-escalation

techniques

Hospitals

Leadership support

Outcomes

Physical injury causes

Psychosocial/Emotional

injuries

Patient caused

Equipment-based

injuries

Overexertion

Assault

Bombings/Explosives

Active/Mass shootings

Domestic violence

Known history of

violence

Dispatch

Known to EMS

Gang violence

Domestic terrorism

Workplace violence

Health conditions (ie.

diabetic)

Drugs/Alcohol

Mental illness

Motor vehicle crashes

Anxiety, depression,

PTSD

Job satisfaction/morale

Risk-taking behaviors Alcohol and drug abuse

Burnout

Personal

LODD, homicide

Suicide

Work environment

Coping mechanisms and

resilience

Staffing

Verbal

Physical

Job demand and

control

Rest and recovery

Self-preservation

TV and movie

stereotypes

Interventions

Police reinforcement

Example: Chicago Fire

Department

Patient outcomes

Patient safety

Patient satisfaction

Quality of care

Taser

Call pathway

Community need
Conceptual diagram 23

Structure, policy, procedures and practices (green) ĵ Work environment. ĵ Workplace culture. Ý Injury reporting practices. Ý Morale/Engagement. Ý Leadership support. Ý Team cohesion. ĵ Job title. Ý EMT. Ý Paramedic. Ý Firefighter. Ý Ambulance driver. Ý First responder. ĵ Policies/National standards. ĵ Nature of 911 reporting. Ý Dispatch. f Call pathway. Ý Responding services. Ý Transfer of care. Ý Community need. ĵ Hiring and recruitment. ĵ Workforce. Ý Urban versus rural. Ý Career versus volunteer. Ý Transport versus response. f Fire versus nonfire based. Ý Legal protections. Ý Inter-industry support. f Police. f Hospitals.

Work environment (yellow) ĵ Duty. Ý Hours on duty. Ý Shift work. ĵ Staffing. ĵ Recruitment and retention issues. ĵ Job demand and control. Ý Emergent versus nonemergent response as stressors. ĵ Rest and recovery. ĵ Types of calls.

Types of calls (purple) ĵ Nonmedical. ĵ Medical. ĵ Trauma. ĵ Crime scene. ĵ Roadway response.
24 Mitigation of Occupational Violence to Firefighters and EMS Responders

Types of violence (gray)

ĵ Unintentional.

Ý Health conditions (ie. diabetic).

Ý Drugs/Alcohol.

Ý Mental illness.

ĵ Intentional.

Ý Bombings/Explosives.

Ý Active/Mass shootings.

Ý Domestic violence.

Ý Known history of violence.

f Dispatch.

f Known to EMS.

Ý Gang violence.

Ý Domestic terrorism.

Ý Workplace violence.

Outcomes (orange)

ĵ Physical injury causes.

Ý Equipment-based injuries.

Ý Patient caused.

Ý Overexertion.

Ý Motor vehicle crashes.

ĵ Psycho-social/Emotional injuries.

Ý Anxiety, depression, post-traumatic stress disorder (PTSD).

Ý Job satisfaction/morale.

Ý Risk-taking behaviors.

f Alcohol and drug abuse.

Ý Burnout.

Ý Coping mechanisms and resilience.

Ý Personal.

ĵ Assault.

Ý Verbal.

Ý Physical.

ĵ Line-of-duty death (LODD), homicide.

ĵ Suicide.

ĵ Patient outcomes.

Ý Patient safety.

Ý Patient satisfaction.

Ý Quality of care.

Trainings (blue)

ĵ National training standards

Ý National Highway Traffic Safety Administration (NHTSA).

Ý NREMT.

Ý National Emergency Medical Services Management Association (NEMSMA).

ĵ Cultural competence.

Ý Trauma-informed care.

ĵ Scene safety.

ĵ Police reinforcement.
Conceptual diagram 25

ĵ Conflict management.

Ý Coping with violent patients.

f Patient de-escalation techniques.

Ý Controlling violent patients.

f Restraints.

Ý Crisis intervention.

Ý Self-preservation.

Ý Requesting backup.

ĵ Defensive tactics.

Ý De-armament skills.

Ý Defensive Tactics 4 Escaping Mitigating Surviving (DT4EMS).

f Needs evaluation.

ĵ Personal protective equipment.

Ý Body armor.

f Bullet proof vests.

Ý Mace.

Ý Guns.

Ý Taser.

Interventions (aqua)

ĵ Staffing models.

Ý In need of recommendations on staffing possibilities for EMS departments.

ĵ Police reinforcement.

ĵ Educational interventions.

Ý Web-based interventions.

f Evidence of successful online training in nursing (NIOSH).

Ý On-the-job training.

Ý Simulation training.

f Example: Chicago Fire Department.

Societal perceptions (pink)

ĵ “Official-ness.”

ĵ Machoism.

ĵ Awareness of protected class status.

ĵ Media.

Ý Language use in headlines.

Ý Events they choose to cover.

Ý TV and movie stereotypes.

ĵ Responders’ role in communities.

ĵ Taxi service.

Mind map key: Factors related to violence against fire and EMS responders

This mind map serves as a visual representation of the factors relevant to the issue 

of assault and violence toward EMS. EMS includes first responders, firefighters, EMTs 

and paramedics. The mind map is divided into eight categories: structure, policy, 

procedures and practices; work environment; types of calls; types of violence; outcomes; 

trainings; interventions; and societal perceptions. Each category is designed to feature a 

comprehensive inclusion of factors specific to EMS in relation to violence experienced in 

the line of duty. Each category and subsequent nodes are evidence-based and rooted in 

the academic peer-reviewed research and industry publications.
26 Mitigation of Occupational Violence to Firefighters and EMS Responders

Structure, policy, procedures and practices

This dimension represents the organizational framework and environment in which 

EMS operates. Organizational climate and work environment are important aspects 

of any occupation. Support and encouragement at the organizational level can greatly 

influence the engagement of an individual in one’s work. Research illuminates that the 

level of support responders are receiving may vary depending on their department’s 

work environment and leadership. Support networks outside of EMS are also valuable in 

the form of interorganizational cooperation with industries, such as police who provide 

reinforcement and hospitals that help provide quality transitions of patient care. A high 

level of cooperation, coordination, respect and support at an organizational level sets the 

stage for responders to be able to do their job safely, professionally and enthusiastically.

Work environment

This dimension represents the elements of the EMS work environment that impact 

the ability of responders to effectively meet community needs. EMS is a high-stress, 

high-risk profession, and the demands of the job may leave responders with little 

opportunity to recover from these occupational demands. Responders are working in a 

mobile environment that is constantly shifting based on the nature and location of calls. 

Responders experience stress from emergent and nonemergent calls. Nonemergent calls 

can leave responders feeling that their service is abused and their time is not valuable. 

For responders, a positive work environment can significantly impact engagement, job 

satisfaction, morale and empathy for the patient and communities to whom they are 

responding. A negative work environment can poorly impact a responder’s health and 

their ability to provide quality patient care in a professional manner.

Types of calls

This dimension represents the types of calls from the community. Nonmedical, medical, 

trauma, crime scene, and roadway responses come with their own unique stressors. For 

example, medical calls bear the risk of communicable disease transmission, and roadway 

responses place responders in hazardous settings exposing them to many risks, such as 

being hit by inattentive drivers. This dimension is related to work environment in that 

the presence or absence of a supportive work environment can impact readiness and 

judgment for each call’s special needs. This has been posited to affect a responder’s 

ability to competently deliver high quality patient care and conduct expected job duties. 

For example, responders may need to respond from one call to another with little to no 

recovery time due to understaffing or pressures to be in constant service.

Types of violence

This dimension represents the types of violence known to be happening based on existing 

literature. Violence toward EMS providers takes on two forms: unintentional and intentional. 

Unintentional violence arises from compromised patients who may be under the influence, 

have mental health issues, or existing health conditions that result in aggressive behaviors 

and actions. Intentional violence is patient-caused violence that is premeditated and was 

intended to cause harm, injury or death to other individuals. In some cases, responding 

personnel and agencies may be aware of the potential for violence. Dispatch is a vital stage 

of response in terms of monitoring and preparing the appropriate resources for a potentially 

violent situation. The literature identifies many sources where intentional violence occurs, 

including overt situations, such as bombings, active shooters, domestic violence, gangs, 
Conceptual diagram 27

WPV, and terrorism, as well as more inconspicuous situations, such as “normal” responses 

to residences for cardiac events. Each source of violence has a different set of protocols and 

procedures that responders follow, yet the unpredictable nature of these scenarios often 

places added danger and pressure upon responders. Responders may rush into a residence 

to treat a critical patient and find that they have placed themselves in harm’s way by not 

ensuring proper scene safety and reinforcement. There are ample opportunities to create 

safer practices and procedures that protect responders against the harms experienced as 

a result of unintentional and intentional violence.

Outcomes

This dimension encompasses the various outcomes that result from violence encountered 

on the job. The prevalence of assaults and resulting outcomes are described in a multitude 

of research studies. Much of the literature is acquired through convenience samples 

and may not accurately represent estimates. Under-reporting may also be affecting 

the findings in many of these academic studies. Despite these limitations, the literature 

does support the conclusion that assaultive patients expose responders to a myriad of 

injuries that are both physical and psychological in nature, and may also result in LODD 

and homicide. Psychosocial or emotional injuries are a significant threat to responders’ 

health and well-being. Assault may result in not only physical injuries to the responder, 

but lingering anxiety, depression and PTSD. Poor work environments and deficient social 

networks, in combination with anxiety, depression and PTSD, have been known to lead 

to suicidal ideation, and in some cases, suicide completion. Suffering responders often 

experience burnout, use poor coping mechanisms, and develop risk-taking behaviors, such 

as drug and alcohol abuse. These negative outcomes not only affect the responders, but 

also their interpersonal relationships and demeanor with families, friends and patients.

Training

This dimension characterizes the important role of training in providing safety and 

protection from violent patients. EMS trainings and initiatives exist from federal agencies, 

including NIOSH, NHTSA and NEMSMA, that highlight violence as an important factor to 

consider during training. Yet none of these trainings are standardized and disseminated 

nationally to all responders. Due to the fact that EMS provides their services through many 

avenues, such as municipalities, hospitals and third party providers, standardized trainings 

and comprehensive injury surveillance systems have not been created. Developing a 

standardized, comprehensive and evidence-backed training program is a crucial element 

to protecting the health and safety of all responders. The literature highlights the need to 

develop and sharpen culturally competent and trauma-informed care among responders 

in order to provide them with the full skill set needed for stressed communities. This 

includes cross training with law enforcement to develop mutual cooperative practices and 

defensive training, such as tactical and de-armament skills.

Interventions

This dimension denotes various opportunities for intervention to reduce violence 

and mitigate its incidence. Staffing models are potentially beneficial interventions 

yet remain largely unstudied in EMS. Other health care industries have adopted or 

legislated staffing ratios, but there are no standardized staffing models that EMS can 

adopt to ensure appropriate community response and proper patient care. Ensuring 

that adequate resources are in place is the first step in creating a more positive work 

environment for responders. Increased staffing would allow for greater recovery times 
28 Mitigation of Occupational Violence to Firefighters and EMS Responders

between calls, reduced work hours, and the creation of more amenable shifts. Educational 

interventions are prevalent in EMS, yet are similarly understudied and underused. 

Educational interventions can be implemented to increase competencies and confidence 

in responders’ abilities to respond to violent patients. Simulation training is a particularly 

salient tool and intervention opportunity that allows for hands-on training, which 

encourages confidence and builds upon practical skill sets.

Societal perceptions

This dimension illustrates the societal views of EMS as perceived by communities. 

Responders conduct their work in highly visible environments. Responders are typically 

perceived as the “helpers” in society, and this plays a role in shaping community 

perceptions. Although EMS is a public service created for those who are in need of help, 

abuse of the system (in terms of nonemergent calls) contributes to a negative work 

environment. This contributes to the stress and job dissatisfaction that responders face. 

Great progress can be made by using social resources, such as the media, to highlight 

positive facets of EMS. For example, media can help create awareness of a responder’s role 

as an emergency response system and making it known that responders are a protected 

class. This kind of social support has the potential to significantly reduce pressures and 

stress on responders in their day-to-day operations.

Best practices

The literature has addressed that there is a problem with violence against EMS providers, 

but the question remains of how responders entering violent situations should best 

protect themselves. No evidence or evaluations in the academic literature focus on best 

practices for mitigating violence. As a result, industry trade publications have proved 

a vital outlet for the EMS profession to express their firsthand experiences, thoughts 

and suggestions. Policies and procedures developed by the industry were identified and 

appropriate for inclusion, due to their relevance and expertise derived from facing the 

day-to-day challenges of working in high-risk environments.

Within the existing literature, many of the best practices developed by the EMS industry 

have a focus on trainings, plans, policies and procedures. A compilation of the guidelines 

suggested throughout the literature can be seen in Table 2. Many of these practices use 

preventative measures as a tactic to keep EMS providers from entering into a potentially 

harmful situation. The most common preventative measure is assessing the scene or 

performing a “windshield survey” in which those arriving at the scene look at past history 

of the neighborhood and the current situation of the scene they are entering, among other 

attributes, to decide whether or not it is safe for them to proceed further (Ferrell, 1987; 

Atkinson, 1993; Goldstein, 1990; Hopson, 1997; Perry, 1995; Nordberg, 1996; Vernon, 2013; 

Wolfberg & Wirth, 2015). If the scene is deemed unsafe or there is a history of violence, 

then current procedures recommend requesting police backup, although this is not a 

guarantee of safety as the police force are a separate entity and follow separate protocols 

(Ferrell, 1987; Atkinson, 1993; Goldstein, 1990; Hopson, 1997; Perry, 1996; Staten, 1992; 

Nordberg, 1996; Augustine, 2014; Holliman & Wuerx, 1994). It is very important for the 

EMS industry to build relationships with those they work amongst, both external and 

internal organizations, as mentioned in the table, in order to gain a better understanding 

of how they can work together to provide the best possible outcome for any situation 

that may arise (Ferrell, 1987; Atkinson, 1993; Goldstein, 1990; Perry, 1996; Staten, 1992; 

Nordberg, 1996; Augustine, 2014; Holliman & Wuerx, 1994; Hopson, 1997).
Best practices 29

Table 2. Emergency medical services best practices to avoid violence.

Partnerships Build relationships with the local police, fire service, dispatch, schools 

and community to have a better sense of potential danger.

Appearance

Make sure “EMS” is clearly stated in your appearance, so there is no 

confusion of your intentions. Be sure to conceal any body armor or 

items that could be seen or used as a potential weapon by the patient 

(jewelry, pens, scissors, etc.).

Awareness

Use your senses (sight, hearing, smell, etc.) and acquired street 

smarts to assess the scene and determine its safety.

Never take your eyes off of the patient or bystanders. Work as a team 

with your partner(s) to keep a 360-degree view.

Conciliation

Use compassionate social skills to promote a calm, soothing 

attitude, and avoid sensitive subjects allowing you to gain trust 

and cooperation with the patient and/or bystanders. If a patient 

encounter begins to become unsafe, use these same tactics to calm 

the situation.

Negotiate and provide care from a safe position. Avoid close contact 

with the patient when possible, and avoid providing care in dangerous 

environments, such as the kitchen, where many objects can be used 

as weapons.

Police 

assistance

Request police backup whenever the potential for violence is present. 

Do not, however, rely on police to ensure your safety. Take measures to 

ensure the proper steps are taken in securing your safety.

Planning

Plan ahead with your team on all possible entrances, exits and escape 

routes, and ensure your team is on the same radio frequency during 

patient care and transport, in case an emergency arises.

Documentation

Record and document detailed narratives of the encounter no 

matter whether an injury has occurred from the violent encounter 

or whether the patient experienced an altered mental state — all 

encounters should be documented.

Priority Most importantly, remember you are the number one priority, and it 

is OK to leave a patient to protect your safety.

While the suggested guidelines featured in Table 2 relate to the average EMS call, the 

literature also addresses trainings for specific situations likely to be associated with 

violence, such as domestic violence, mass shootings, bombings and the like. This could 

include gaining assistance and knowledge of how to properly work with hazardous items 

and substances, such as bombs and explosives, to what questions to ask, and how to 

prevent escalation in a domestic violence event (Allen, 1996; Schiavone, 1994).

The protocols on handling any of the above situations, while useful, may not always 

remove the hazard, causing EMS to resort to other strategies. While verbal de-escalation 

techniques, such as having a calm and nonthreatening demeanor, are the first steps in 

settling a violent encounter, there are times when more force is needed. It has become 

commonly accepted for EMS to be trained in self-defense techniques, which can include 

such practices as martial arts, to be able to restrain the patient when necessary (Rollert, 

2007; Perry, 1996). In addition to self-defense techniques, other forms of protection have 

been proposed and used throughout time.
30 Mitigation of Occupational Violence to Firefighters and EMS Responders

There has been discussion on introducing weapons, such as guns, Tasers, mace and 

pepper spray, into the field as additional forms of protection (Nordberg, 1996; Taylor et 

al., 2016). Many departments believe that if protection is needed, the police will provide 

it; however, others question what happens when a situation arises quickly and police 

backup is not readily available (Nordberg, 1996). While these protection methods are to be 

used as a last resort, there are many differing and controversial views as to whether their 

implementation is needed, and there are no current standard regulations (Holliman & 

Wuerx, 1994; Nordberg, 1996). Furthermore, it has been posited that protocols to increase 

the safety of communities, in addition to training to provide confidence in confronting 

violent episodes, might supplant the need for EMS personnel to carry weapons for 

personal protection (Corbett et al., 1998).

One form of protection that is less controversial is the use of body armor. While there 

are some claims that items such as bulletproof vests provide significant protection from 

gunshots, blows to the trunk, and knives, many see body armor as uncomfortable and 

restricting (Holliman & Wuerx, 1994; Benson, 1994). There is also a belief that the visual 

representation of body armor sends a certain message to the community, which exhibits 

a non-neutral appearance among EMS, with the potential to encourage shooters to act 

(Benson, 1994; Atkinson, 1993). Additionally, the authoritative look of EMS responders that 

often coincide with uniforms of police may contribute to defensive attitudes of patients, 

families and bystanders (Parlin, 1984). Arguments have been raised that if EMS responders 

are expected to respond to violent situations, they should be prepared and properly 

equipped. OSHA’s “general duty clause” has been used as evidence that EMS agencies 

should be providing their responders with proper protective equipment designed to keep 

them safe in the workplace (Wolfberg & Wirth, 2015). 

While there are many measures that can be taken to protect the EMS industry, overall it 

is stated that there are significant improvements needed in the quantity and quality of 

trainings offered (Perry, 1996). A lack of training leads individuals to use excessive force 

or “pick the wrong tool to solve the problem” (Perry, 1996; Kirkwood & Tietsort, 2012). 

In addition to the recommendations listed in Table 2, Munding offers a list of possible 

violence mitigation techniques, including training in: scene size up, weapons awareness, 

weapons management, approaching the scene, approaching a vehicle, entering a 

structure, conflict management, searching for and confiscation of weapons, self-defense 

techniques, the legal issues surrounding self-defense, and the use of force and cover and 

concealment techniques (2006).

Inventory of best practices and intervention opportunities

In fire and EMS, there is an obvious need for training and interventions to prevent and 

mitigate violence. There is limited evidence regarding the availability and effectiveness of 

such interventions (Gates et al., 2011). Much of the current violence prevention training 

that exists consists of generic programs that are not tailored to the unique setting of 

the patient care provider, and primarily focus on self-defense techniques rather than 

prevention (Gates et al., 2011). Researchers note the guidelines developed for violence 

reduction in ED settings do not work well in the EMS industry (Corbett et al., 1998).

In EMS, violence is a topic rarely addressed in clinical training programs, leaving most 

responders with a hazy “understanding of the phenomenon and few coping strategies” 

(Infantino, 1984). In one study, as few as 26 percent of respondents reported having ever 

received formal training in the management of violent encounters (Corbett et al., 1998). 
Best practices 31

One department studied did not provide any training to their EMS members (Pozzi, 1998). 

This deficiency in trainings and preparedness was noted in other studies as well (Thomsen 

et al., 2000; Tintinalli & McCoy, 1993).

While violence may be a topic of instruction for some EMS responders, violence 

management is often presented in distinctly different formats and learning objectives 

(Infantino, 1984). Suggested inclusions for an intervention program include topics 

of: environmental considerations, self-assessment, prevention, verbal intervention 

(calming/defusing techniques), escape and release procedures, control and restraint 

procedures, staff anxiety and depression, and post-incident follow-up (Infantino, 1984). 

Additional suggestions for violence prevention in the prehospital setting include creating 

specialized training for EMS personnel; creating prevention programs aimed to increase 

communication skills with patients and/or relatives and bystanders; identifying risk 

situations and implementing safety measures; and psychological care to professionals 

who have suffered from WPV (Bernaldo-de-Quirós et al., 2014).

There is limited evidence regarding the availability and effectiveness of interventions 

designed for preventing and mitigating violence in EMS (Gates et al., 2011). Best practices 

that have evidence of evaluation are indicated below.

1. In 1998, the U.S. Department of Transportation (USDOT) developed a new paramedictraining curriculum that included expanded topics of abuse, assault and violence. The 

curriculum is noted to have included learning objectives concerning how to handle 

victims, diffuse violent situations, and ensure personal safety (Pozzi, 1998). Since 

authority over EMS initiatives lies within state jurisdiction, individual states can choose 

not to adopt certain training interventions or curriculums (Pozzi, 1998). There has been 

no evaluation on the effectiveness of the USDOT violence training objectives.

2. The National Fallen Firefighters Foundation Firefighter Life Safety Initiative 12. There 

have been calls for development of protocols at the national level in response to 

violent incidents. Initiative 12 states the need for development and implementation 

of practices and policies to reduce the likelihood that EMS responders will encounter 

violence, to standardize response protocols, and to increase survivability for fire and 

EMS personnel when violent situations are unavoidable (Vernon, 2013).

3. Self-defense for firefighters and EMTs is a training program developed by the Firefighters 

Support Foundation. This program is available for free through an online download 

in two formats: a 70 slide PowerPoint program and a 90-minute video program which 

presents the PowerPoint material and presents hands-on instruction in defensive 

techniques (http://www.fireengineering.com/articles/2010/06/fsf-self-defense.html). 

Self-defense for firefighters and EMTs has not been evaluated for effectiveness.

4. In response to the growing issue of violence, some departments have taken it upon 

themselves to investigate causes of violence and to respond proactively. Departments 

in Chicago, as well as Wake County, North Carolina, have implemented simulation 

trainings as a way to monitor and prepare the EMS personnel through life-like scenarios 

(http://www.naemsp.org/Documents/2017%20Annual%20Meeting%20Handouts/

ATMD/NAEMSP.AMD.In.Harm’sWay.01.22.17.pdf#search=violence).

5. The Center for Leadership, Innovation, and Research (CLIR) in EMS has launched 

the EMS Voluntary Event Notification Tool (E.V.E.N.T.) to assist in data collection of 

adverse events occurring in EMS. In 2010, CLIR partnered with the National EMS 
32 Mitigation of Occupational Violence to Firefighters and EMS Responders

Management Association and the End Violence Against Paramedics initiative to include 

violent procedures in their data collection processes which can be used to inform the 

development of interventions (Hagen, 2013). E.V.E.N.T. is a tool designed to improve the 

safety, quality and consistent delivery of all EMS by ground, air and water ambulance 

services operating in all delivery models. It collects data submitted anonymously by 

EMS practitioners. The data collected will be used to develop policies, procedures and 

training programs to improve the safe delivery of EMS. A similar system used by airline 

pilots has led to important airline system improvements based upon pilot reported “near 

miss” situations and errors. Any individual who encounters or recognizes a situation in 

which an EMS safety event occurred, or could have occurred, is strongly encouraged 

to submit a report by completing the appropriate E.V.E.N.T. The confidentiality and 

anonymity of this reporting tool is designed to encourage EMS practitioners to readily 

report EMS safety events without fear of repercussion.

6. DT4EMS Violence. The mission of DT4EMS is “to empower cultural and behavioral 

modification through enforcement of exemplary customer service, reasonability and 

industry best practices that yield a reduction in employer liability and culminates 

in an increase of employee safety and security” (www.dt4ems.com). DT4EMS has 

been in existence for 20 years, and combines the experiences and lessons of police 

officers, military veterans, lawyers, hospital administrators, risk managers, patient 

safety officers, hospital security, nurse managers, doctors, firefighters, battalion 

chiefs, respiratory therapists, corrections officers, former military elite (pararescue 

jumpers (PJ)/Special Forces(SF)), law enforcement defensive tactics instructors, EMS 

administrators, dispatchers, nursing supervisors, and EMS supervisors, as well as 

nurses, paramedics, EMTs and doctors. DT4EMS offers four courses. DT4EMS also 

offers the Escaping Violent Encounters (EVE) courses which provide training needed to 

change the safety culture in EMS/fire in the following domains: patient versus attacker 

recognition, assault response guidelines, proper documentation, principles of cover 

and concealment, mental preparation for the violent encounter, physical and emotional 

stress and their effects on the human body during a violent encounter. DT4EMS and 

the EVE4EMS/Fire courses have not been evaluated for effectiveness.

7. NIOSH webinar, “Workplace Violence Prevention for Nurses” (https://www.cdc.gov/

niosh/topics/violence/training_nurses.html). “This free, interactive course is designed 

to help healthcare workers better understand the scope and nature of violence in the 

workplace. Upon successful completion of the course, healthcare professionals can 

earn continuing education units (CEUs). Course modules include: Definition, types, 

and prevalence, WPV consequences, Risk factors for type II and III violence, Prevention 

strategies for organizations, Prevention strategies for nurses, Post event response.” 

An evaluation of the webinar found the following: 

To meet the primary objective of evaluating the effectiveness of this course with 

a nursing student population, a pre-/post-/post-test survey design was employed 

to assess changes in awareness and knowledge after completing the course. 

Results from a one-way repeated measures ANOVA indicated that participation 

in NIOSH’s online workplace violence prevention best practices course increased 

nursing students’ awareness of and knowledge about workplace violence. This 

awareness and knowledge was sustained four weeks after completing the course. 

Qualitative thematic analysis revealed suggestions for encouraging participation 

from the focus group discussants, including offering CEUs or requiring training 

for employment. Participants also commented that messages could be retained 
Best practices 33

by incorporating knowledge-check questions, focusing on real-life experiences, 

and providing summary handout sheets. By educating nursing students about 

workplace violence, nurses will be better equipped to prevent and manage 

workplace violence once they enter the workforce, which will provide a safer 

environment for everyone who interacts in health care settings. (https://aphanew.

confex.com/apha/143am/webprogram/Paper331816.html)

While NIOSH has not developed an EMS specific intervention, they have several 

recommendations for fire departments to prevent and mitigate violence at both the 

organizational and employee levels (https://www.cdc.gov/niosh/docs/2006-144/

pdfs/2006-144.pdf).

Table 3. NIOSH recommendations.

1. Develop standard operating procedures for responding to potentially violent situations.

2. Develop integrated emergency communication systems that include the ability to 

directly relay real-time information between the caller, dispatch, and all responding 

emergency personnel.

3. Provide body armor or bullet-resistant personal protective equipment; train on, 

and consistently enforce its use when responding to potentially violent situations.

4. Ensure all emergency response personnel have the capability for continuous radio 

contact, and consider providing portable communication equipment that has 

integrated hands-free capabilities.

5. Consider requiring emergency dispatch centers to incorporate the ability to archive 

location, or individual, historical data, and provide pertinent information to responding 

fire and emergency medical services personnel.

6. Develop coordinated response guidelines for violent situations, and hold joint training 

sessions with law enforcement, mutual-aid and emergency response departments.

In 2004, NIOSH released EMS specific recommendations on methods to best mitigate 

violence following the investigation into the death of a female firefighter who responded 

to the scene of a civilian shooting (Table 3).

While the recommendations have been released, no formal intervention program has 

been developed, nor has a formal evaluation of the recommendations been conducted. 

Furthermore, NIOSH has recommended that employers establish a zero-tolerance policy 

for all incidents of violence, train workers on recognizing and preventing WPV, investigate 

all reports of violence, and work with police to identify dangerous neighborhoods where 

special precautions need to be taken, and provide that information to employees. From 

the employee’s standpoint, NIOSH recommends the following in response to violent 

workplace incidents: employees should participate in violence prevention training and 

report all incidents of violence, no matter how minor (NIOSH Fast Facts, 2012). Other 

recommendations include concurrent dispatching of police in all high-risk situations 

associated with violence or the potential for violence (e.g., suicide, homicide, domestic 

violence, intoxication, and psychiatric illness) (Corbett et al., 1998; Mechem et al., 2002).
34 Mitigation of Occupational Violence to Firefighters and EMS Responders

Summary

From this examination of the literature, insufficient evidence exists in order to properly 

describe the issue of violence being experienced by EMS responders. The following 

content areas were identified and are in need of further development:

1. Standardizing the definition of violence used in EMS research.

2. Creating reliable and consistent epidemiological data on violence against EMS responders 

through data systems development and recurring surveys.

3. Conducting rigorous scientifically-designed studies.

4. Securing funding for scientific research on EMS violence.

5. Identifying and quantifying risk factors of providers, patients and communities, inclusive 

of stress, trauma and mental health outcomes.

6. Understanding the roles of coping, resilience and social support in EMS.

7. Developing practices, procedures and policies that support EMS responders.

8. Training all responders to recognize and respond to violence on the job.

9. Conducting evaluations of existing trainings to measure their effectiveness.

10. Developing new trainings as needed and evaluating their effectiveness.

11. Conducting economic analyses on the psychosocial impact of violence in EMS.

12. Assessing the impact of EMS on patient care and quality.
References 35

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Acronyms 45

Acronyms

CDC Centers for Disease Control and Prevention

CEUs continuing education units

CINAHL Cumulative Index to Nursing and Allied Health Literature 

CLIR Center for Leadership, Innovation, and Research

DT4EMS Defensive Tactics 4 Escaping Mitigating Surviving

ED emergency department

EMS Emergency Medical Services

EMTs emergency medical technicians

EVE Escaping Violent Encounters

E.V.E.N.T. EMS Voluntary Event Notification Tool

LEADS Longitudinal EMT Attributes and Demographics Study

LODD line-of-duty death

NEMSMA National Emergency Medical Services Management Association

NHTSA National Highway Traffic Safety Administration

NIOSH National Institute for Occupational Safety and Health

NREMT National Registry of Emergency Medical Technicians

OSHA Occupational Safety and Health Association

PJ pararescue jumpers

PTSD post-traumatic stress disorder

SF Special Forces

USDOT U.S. Department of Transportation

WHO World Health Organization

WPV workplace violence
46 Mitigation of Occupational Violence to Firefighters and EMS Responders

Appendices

Click here to view Appendix A.

Click here to view Appendix B.
For more information or copies 

of this publication, please contact:

16825 South Seton Ave.

Emmitsburg, MD 21727

800-561-3356

www.usfa.fema.gov

June 2017