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Effectiveness of mitigation interventions on occupational violence against emergency service workers: a mixed methods systematic review protocol

Drew, Peter1; Tippett, Vivienne1,2; Devenish, Scott1

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JBI Database of Systematic Reviews and Implementation Reports: May 2018 - Volume 16 - Issue 5 - p 1081-1086
doi: 10.11124/JBISRIR-2017-003412
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Occupational violence (OV) is defined as the external abuse, threat or assault of an employee in the context of their work and involves a clear or implied challenge to the employee's personal health, safety or well-being.1 Occupational violence is a significant issue within the context of pre-hospital health care, with as many as 90% of paramedics reporting some form of abuse, intimidation, physical or sexual assault during the course of their employment.2-5

The consequences of exposure to OV are varied but can far exceed the immediate physical or mental injuries associated with the incident.2 Anxiety, depression, post-traumatic stress, increased sick leave, and premature retirement are all common problems negatively associated with paramedic OV.6,7 It is these consequences, in conjunction with a moral and legal obligation of employers to maintain a violence-free workplace, that has resulted in significant resources dedicated towards paramedic OV mitigation interventions.8,9

Occupational violence mitigation interventions are approaches to violence prevention that aim to equip staff with the right knowledge, skills and environment to help reduce the threat of violence. These interventions or programs educate staff on topics such as hazard identification, conflict management, and self-defense techniques.10 The importance of these programs as preventative measures in OV mitigation is such that virtually all published guidance on OV recommends their implementation.1

However, while there is a significant body of work about the structure, objectives and content of OV mitigation interventions, there only exists limited supporting evidence to validate the efficacy of such practices.11 This is reflected in the dearth of peer-reviewed literature examining the subject of OV mitigation interventions within paramedic practice. Furthermore, a preliminary search of the Cochrane Library and the JBI Database of Systematic Reviews and Implementation Reports did not reveal any systematic reviews on this subject. The only related literature located during this search focused on OV mitigation interventions for all healthcare workers,11 or more specifically in the acute hospital setting.12 These reviews, though of some interest, are constrained by an absence of paramedic studies and a focus on the hospital environment.

The lack of paramedic research within the healthcare literature is noteworthy for two key reasons. Firstly, rigorous evaluation of OV mitigation interventions is a necessity if purposeful, safe and relevant interventions are to be successful at minimizing the incidence of OV.11,13 Secondly, existing healthcare literature neglects a key element of paramedic practice. As opposed to the dependable nature of a hospital setting, paramedics operate in an environment which is dynamic, inconsistent, and with a vulnerability and isolation that does not exist within other healthcare professions.14-16 It is this environmental context that essentially differentiates paramedics from other healthcare workers.16

The environmental context in which paramedics operate is unique within healthcare due to the significant role it plays in both defining and dictating decision-making processes and social interactions.17 The ability to manage and control this environment is a key component of OV mitigation interventions and is achieved through the utilization of elements within the work setting to reduce exposure of employees to dangerous situations.18 Indeed, the failure to adapt and modify these environments is recognized as a common reason for OV mitigation intervention failure.1,11,19

Though unique to healthcare, paramedics are not isolated in operating in such dynamic environments. Paramedics share this space and cooperate with both police and firefighters under the broader heading of Emergency Service Workers (ESW). Emergency Service Worker is a classification provided to police, firefighters and paramedics who respond to emergencies and threats within the community. The work of ESW is physically demanding and punctuated by periods of high level stress and activity and in locations that are both varied and chaotic. Emergency Service Workers protect public health and safety while exposing themselves to personal danger through frequent contact with the public and often during instances of negative emotions and frustrations.16 Importantly, like paramedics, all ESW are at a relatively high risk of exposure to OV during the course of their work.16,20,21 A comparison study examining the frequency of OV in ESW, determined that 79% of paramedics, 48% of firefighters, and 88% of police officers had been confronted with some form of physical or psychological violence within a 12-month period.16

Although there are important differences between the ESW professions regarding the object of control (i.e. patient or perpetrator), and the nature of their work situations (i.e. fire suppression or medical assistance),16 it is their similarities and their distinctive environmental relationships that provide the opportunity to examine in detail the effectiveness of their individual OV mitigation intervention strategies. Indeed, a preliminary search of the literature identified the existence of primary research studies, from both a quantitative and qualitative perspective, examining ESW OV mitigation interventions from both police and firefighter backgrounds.20,22,23

The frequency and severity of paramedic OV highlight the necessity of OV mitigation. However, peer-reviewed literature supporting the effectiveness of these interventions is limited. The similarities that exist between paramedics and other occupations that define ESW provide an opportunity to review relatable OV mitigation interventions. It is anticipated that through a broader examination of the ESW OV literature, effective interventions can be identified for the purpose of translating this practice or education in the paramedic milieu. This review will be of importance because no previous study has been identified which evaluates the effectiveness of OV mitigation interventions for ESW.

Inclusion criteria


The quantitative and qualitative components of this review will consider any ESW of any age or gender who interact with the public during their work. This will include:

  • Paramedics, ambulance officers and emergency medical technicians.
  • Police and law enforcement.
  • Firefighters, first responders and rescue professionals.

The quantitative and qualitative components of this review will exclude any studies that include:

  • Participants who work in a controlled environment such as a hospital.
  • Participants whose exposure to violence is domestic in nature.


The quantitative component of this review will include any studies examining education and training interventions delivered to ESW to improve their knowledge and proficiency in minimizing OV directed toward them. Interventions may include:

  • Verbal communication.
  • Physical restraint.
  • Chemical restraint or sedation.
  • De-escalation strategies.
  • Use of body language.
  • Behavior management.

Phenomena of interest

The qualitative component of this review will include any studies that explore the perceptions and experiences of ESW on the effectiveness and suitability of OV mitigation interventions.


This review will consider quantitative studies that include the following outcome measures:

  • Incidence of OV.
  • Incidence of OV resulting in psychological or physical injury or impairment.
  • Individual knowledge and skills relating to OV mitigation.
  • Occupational violence prevention and control measures.


The qualitative component of this review will explore any studies that investigate OV mitigation interventions for ESW.

Types of studies

The quantitative component of this review will consider both experimental and quasi-experimental study designs including randomized controlled trials, non-randomized controlled trials, before and after studies and interrupted time-series studies. In addition, analytical observational studies including prospective and retrospective cohort studies, case-control studies and analytical cross-sectional studies will be considered for inclusion. This review will also consider descriptive observational study designs including case series, individual case reports and descriptive cross-sectional studies for inclusion.

The qualitative component of this review will consider studies that focus on qualitative data including, but not limited to, designs such as phenomenology, ethnography, grounded theory, and action research.


Search strategy

The search strategy will aim to find both published and unpublished studies. An initial limited search of CINAHL and PubMed has been undertaken followed by analysis of the text words contained in the title and abstract, and of the index terms used to describe article. This informed the development of a search strategy which will be tailored for each information source. An initial search strategy for CINAHL is detailed in Appendix I. The reference list of all studies selected for critical appraisal will be screened for additional studies. This review will examine English language studies from 1990 through to present. This timeline was selected because this is the period of the earliest identified paramedic literature on OV.24

Information sources

The databases to be searched include: PsycINFO, Science Direct, Cochrane Central Register of Controlled Trials, ProQuest Criminal Justice, Violence and Abuse Abstracts, Web of Science, ERIC, Scopus and Embase.

The search for unpublished studies will include: ProQuest Dissertations and Theses and Trove.

Study selection

Following the search, all identified citations will be collated and uploaded into EndNote (Clarivate Analytics, PA, USA) and duplicates removed. Titles and abstracts will then be screened by two independent reviewers for assessment against the inclusion criteria for the review. Studies that may meet the inclusion criteria will be retrieved in full and their details imported into Joanna Briggs Institute System for the Unified Management, Assessment and Review of Information (JBI SUMARI).25 The full text of selected studies will be retrieved and assessed in detail against the inclusion criteria. Full text studies that do not meet the inclusion criteria will be excluded and reasons for exclusion will be provided in an appendix in the final systematic review report. Included studies will undergo a process of critical appraisal. The results of the search will be reported in full in the final report and presented in a PRISMA flow diagram. Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer.

Assessment of methodological quality

Selected studies will be critically appraised by two independent reviewers at the study level for methodological quality in the review using the standardized critical appraisal instruments from the Joanna Briggs Institute for the following study types:

  • Quantitative papers selected for retrieval will be assessed using the JBI meta-analysis instrument available in JBI SUMARI.26
  • Qualitative papers selected for retrieval will be assessed using the JBI qualitative assessment and review instrument available in JBI SUMARI.26

Any disagreements that arise will be resolved through discussion, or with a third reviewer. All studies, regardless of their methodological quality, will undergo data extraction and synthesis (where possible).

Data extraction

Quantitative and qualitative data will be extracted from papers included in the review using the standardized data extractions tool available in JBI SUMARI.26 The data extracted will include specific details about the interventions, populations, study methods and outcomes of significance to the review question and specific objectives.

If there is missing information or data that needs clarification, the authors of primary studies will be contacted. Any disagreements that arise between reviewers will be resolved through discussion with a third reviewer.

Data synthesis

Research papers will, where possible, be pooled in statistical meta-analysis using JBI SUMARI.26

Quantitative results will be subject to double data entry. Effect sizes expressed as odds ratio (for categorical data) and weighted mean differences (for continuous data) and their 95% confidence intervals will be calculated for analysis. Heterogeneity will be assessed statistically using the standard Chi-square and explored using subgroup analyses based on the different study designs included in this review. Where statistical pooling is not possible the findings will be presented in narrative form including tables and figures to aid in data presentation where appropriate. As it is the intent of the authors to generalize the results beyond the included studies, a random-effects model for meta-analysis will be employed.

Qualitative results will involve the aggregation or synthesis of findings to generate a set of statements that represent that aggregation, through assembling the findings (level 1 findings) rated according to their quality, and categorize findings on the basis of similarity in meaning (level 2 findings). The categories will be subjected to a meta-synthesis to produce a single comprehensive set of synthesized findings (level 3 findings) that can be used as a basis for evidence-based practice. Where textual pooling is not possible, the findings will be presented in narrative form.

The findings of each single-method synthesis included in this review will be aggregated using the JBI mixed methods aggregation instrument. This will involve the configuration of the findings to generate a set of statements that represent that aggregation through coding any quantitative to attribute a thematic description to all quantitative data; assembling all of the resulting themes from quantitative and qualitative syntheses; and the configuration of these themes to produce a set of synthesized findings in the form of a theoretical framework, set of recommendations or conclusions.

Appendix I: Search strategy for CINAHL via EBSCOhost

S1: MW (violen OR assault OR attack OR aggression OR anger OR angry OR hostil OR bully) NOT MW domestic violence

S2: MW occupation OR profession OR work OR job OR employment OR vocation

S3:S1 and S2

S4: MW emergency service OR paramedic OR ems OR emergency medical service OR emt OR emergency medical technician OR prehospital OR pre-hospital OR ambulance OR police OR law enforcement OR cop OR police service OR police department OR firefighter OR first responder

S5:S3 and S4

S6: MW education OR training OR development OR inservice OR learn OR teach OR preparation OR program OR systems OR management

S7:S5 and S6

S8: MW study OR effective OR evaluation OR assessment OR appraisal OR prevent OR control OR intervention OR reduc OR improve

S9:S7 and S8


This systematic review is being conducted as part of the higher education studies of PD.


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emergency service workers; mitigation; occupational violence; paramedic; prehospital