In a 2014 study of paramedics in Ontario and Nova Scotia, 75% of participating paramedics reported being the victim of violence in the past year (2).

• 67% Had experienced verbal abuse

• 41% Had been threatened

• 26% Had been assaulted

• 14% Had been sexually harassed

• 3% Had been sexually assaulted

Despite the prevalance - and despite negatively impacting the paramedics' work and home lives - the majority (81%) of incidents were never formally reported. In reviews of workplace injury statistics in the United States, 8% of work-related injuries requiring medical treatment or resulting in lost-time from work were the result of an assault (4). Among fatalities, two separate studies reported that between 8% and 11% were the result of a violent act or assault (3), with women constituting the "majority" of EMS providers who had been killed in the line of duty (6). A recent review of research on violence against paramedics highlighted that - despite the seriousness - the true scope of the problem is unknown because of pervasive underreporting (5).

Going into the COVID-19 pandemic, paramedics in Canada had some of the highest rates of Operational Stress Injuries among Public Safety Personnel. In a 2017 survey of Public Safety Personnel, nearly 1 in 2 participating paramedics met the screening criteria for at least one mental illness (7). Among paramedics in the survey,

• 25% Screened positive for PTSD

• 33% Screened positive for depression

• 33% Screened positive for an anxiety disorder

• 45% Screened positive for chronic pain (8)

• 10% Had attempted suicide (9)

We know that exposure to potentially traumatic events - what have been described as critical incidents in the paramedic community - is associated with an increased risk of both OSI and suicide (10). Situations that threaten the physical safety of paramedics are widely recognized as critical incidents, but the specific issue of violence against paramedics remains both underreported and under-studied. With burnout among and hostility toward healthcare workers on the rise as a result of the COVID-19 pandemic, the problem has only gotten worse.

Violence Against Paramedics: Building the Case for Change is a collaborative, epidemiological study of workplace violence in paramedicine.

Using a newly developed External Violence Incident Report (EVIR), we are gathering comprehensive data about incidents of violence perpetrated against paramedics. The EVIR has been in use in Peel Region since February of 2021, and has since been adopted by more than a dozen paramedic services across Ontario. In partnership with our collaborating paramedic services, we are asking three important questions:

1. How common is violence against paramedics? In the past, researchers have surveyed paramedics and asked them whether or not they have experienced certain acts of violence in the past year. While helpful, this doesn't give us a clear picture of what percentage of emergency service calls involve exposure to violence and how frequently paramedics encounter violence in the course of their work.

2. What are the risk factors for violence? The existing research is mixed in telling us whether the risk of encountering violence differs across gender, age, or years of experience. We also want to know what service calls are more likely to involve violence against paramedics.

3. What are the health consequences for paramedics who have experienced violence at work? Although occupational injury statistics give us some information about physical injuries, this is just one part of a complex problem. We suspect that exposure to acts of violence - regardless of whether or not the paramedic physically injured - increase the risk for OSI. We are recruiting paramedics to fill out surveys that screen for symptoms of Post-Traumatic Stress Disorder (PTSD), depression, anxiety, burnout, and other forms of psychological distress. We can then examine for links between exposure to violent incidents and physical and psychological harm.

Answering these questions lets us develop evidence-based policies that mitigate the risk of violence, enhance paramedic safety, and better support paramedics who have been victimized.