Health Science Journal

Keywords

Prevalence; Violence ambulance care

Introduction

Workplace violence is a significant problem affecting many professions, and threats of violence in health sector seem to be increasing in particular. The WHO identified global healthcare providers as particularly vulnerable to workplace violence, which can substantially affect the welfare and retention of this vital workforce [1,2]. Workplace violence is simply described as “any incident or situation where staff members are abused, threatened, or assaulted in situations related to their work”. The health care industry has many unique situations that increase the risk of violence, including working directly with patients and their relatives, and providing non-stop care service. Most of the violence in the health institutions is per pet rated by patients and their relatives in the form of verbal abuse, psychological violence/ mobbing, physical assault, and sexual abuse [1]. Ambulance personnel are in the charge of providing pre-hospital service care in situations of emergency where personal or public health is under risk. Ambulance staff works in conditions that are often unpredictable, difficult, and sometimes dangerous, and in which it is difficult to provide adequate security. In addition, ambulance staff often interacts with psychiatric, delirious, alcoholic or forensic patients who have a higher potential for violence. Pre-hospital is an important part of health system that provides timely care to victims of emergencies and life-threatening injuries in order to prevent mortalities or complications. The frequency of workplace violence against EMS staffs is high. In two separate studies, it was shown that 80.3% and 66% (respectively) of ambulance staff faced with threats and/or violence, during one year. Such jobs, in which health care providers faced with nervous and worry patients or their relatives, are very prone to WPV and serious occupational health problems, resulting in individual (psychological and physical), social and organizational consequences including the consequences of workplace violence, decrease of well-being and quality of life of staffs as well as care of clients [3].

Workplace violence significantly affects all occupations in the health sector. Ambulance staff would appear to pay the highest price, their level of exposure to the risks of violence is not only extremely high in all countries investigated but cut across all types of violence [4].

Although different findings show high figure of workplace violence and data from developing nations are virtually non-existent, and the level of violence against nurses/healthcare workers in these countries is largely un-documented. Similarly in our country; Ethiopia there is no documented data on ambulance care providers pertaining to workplace violence. Thus this study was help to fill the gap and provide evidence based information on the prevalence of WPV and associated factors and its consequence in ambulance care providers to design various strategies to decrease the problems.

Statement of the problem

EMS staffs due to their frequent experience of violence, in addition to feelings of job insecurity, are faced with important physical and psychological injury. Also, WPV decreases the interest on the job, causes burnout, turnover, and feelings of inadequate support, reduce organization’s power and ultimately reduce the performance and reputation of the EMS organization [3]. Paramedics and other emergency medical services (EMS) providers work in a unique health-care setting, which requires care to be delivered in locations that can be uncontrolled and occasionally dangerous. Violence toward EMS providers has been reported in both media reports and the peer-reviewed literature.

Studies have shown that the increasing numbers of violence against pre hospital staff are a serious concern for the emergency health care system [5, 6]. Violence directed at ambulance staffs has attracted increasing public attention because of its major negative impact on the physical and psychological well-being of victims and productivity of organizations [7].

Most people who make use of emergency medical service have degrees of physical and psychosocial injuries, and are ready to make abnormal behaviors, including violence because of the need immediate response while they need the service. Ambulance personnel are often the first people to encounter patients needing emergency care if ambulance care providers fear a population they are serving, the quality of care they deliver may suffer as a consequence. As they are the first healthcare systems who interface the patients and their relatives so they are susceptible to threat reactions and violence [8-15]. Therefore in our country unclearness of the prevalence and associated factor of the ambulance staff was the purpose of this study.

Significance of the study

Since it is the first research on ambulance care providers Ethiopia, the finding of this study can serve as a baseline to provide government bodies, nongovernmental organizations, policy makers and health planners with relevant information for future planning and interventions of appropriate strategies to prevent the consequences of violence and it is also help for the Fire And Disaster Risk Management and other organization who work pre hospital to decrease worker overflow and increase workers safety and enhancing worker satisfaction [16-21].

Methods

Study area

The study was conducted in Addis Ababa city. Addis Ababa is the capital city of Ethiopia in the city there are 10 sub cities among this sub city the Fire and Disaster Risk Management Commission has nine branches and the only governmental organization provides free emergency care for the population who live in Addis Ababa sub city the nine branches are govern by one central organization. And this study was conduct in all 9 branches that have 270 workers in ambulance care department [22-27].

Study design and period

Institutional based cross-sectional study, from April 1 to August 2020

Source of population

All ambulance care providers who work in the fire and disaster risk management commission.

Study population

Study population was randomly selected ambulance care providers who work in Fire and Disaster Risk Management commission Addis Ababa Ethiopia.

Inclusion and exclusion criteria

Inclusion Criteria:

All ambulance care providers in Fire and Disaster Risk Management Commission.

Exclusion criteria:

Those who were not at work and with less than one service year were excluded from the study.

Variable

Dependent variable:

Workplace violence against ambulance care providers

Independent variable:

Socio demographic variable: - Sex, Age, Marital Status

Work organization variable: - Interaction with patient/client during work, Procedure for reporting of violence, and Encouragement of reporting workplace violence

Profession and experience variable:- Work profession and Service year (work experience).

Sample size determination and sampling technique

Sample size determination:

The study used the single population proportion sample size determination formula. Since similar study on workplace violence in the city as well as in Ethiopia was not found, in order to obtain optimum sample size, calculation was done using study conducted in south Africa the assumption of proportion (p) of work place violence against ambulance care providers was 50% [4], with 95% CI, and 5% marginal error (where n is desired sample size, Z is value of standard normal variable at 95% confidence interval and, p is maximum expected proportion which is 50% and d is which is 5%).

Therefore the value of n=384

Since the total numbers of ambulance care providers were less than <10, 000, (N=270) using correction formula for finite population:

And adding 10% for non-response rate (17), the final sample size became nf=177

Where ‘N’ is the total study population of the ambulance care providers and ‘nf’ is the final sample size.

Sampling technique:

Simple random sampling method was used to get the required sample size. The nine branches govern by the central organization so we take their information from payroll and simple random sampling was done and then Strata created based on profession. There were 2 categories of the staff in the organization, health care providers and ambulance drivers and fulfilled the inclusive criteria and stratified.

Data collection method:

A structured quantitative questionnaire developed by reviewing different literatures and adapted to local situation with necessarily modifications. The self-administered questionnaires were prepared originally in English and then translated in Amharic (local language) version then translated back to English version to check for its consistency. A one-day training of data collectors was given on how to collect data. Four staffs distributed questionnaires at the 9 branch who gave consent after clear explanation of the methods, tools, and how to handle ethical issues was discussed with the data collector; the data was collected from May 25 to July 3/2020. Regular supervision by the supervisor and principal investigator was made to ensure that all necessary data were properly collected [28-30].

Data processing and analysis

After data collection, each questionnaire was checked for completeness and code will be given before data entry. Data was entered and cleaned for missed values and analyzed using SPSS version 24 statistical packages. Binary logistic regression was performed to see the existence of association between workplace violence and independent variables. Then those independent variables which was significantly associated with workplace violence in binary logistic regression analyses with a P-value <0.05 was included in the multivariable logistic regression analysis to identify the independent predictors of workplace violence.

Finally odds ratio with its p-value and confidence interval of those independent variables that maintain their association with outcome variable (WPV) in multiple logistic regression model was reported. Different frequency tables and descriptive summary was used to describe the study variables.

Data quality control

The questionnaire was checked for completeness and consistency by the principal investigator. A continuous supervision and a daily meeting with data collectors were conducted while collecting data.

Operational definitions

Ambulance care provider: a health care provider trained and certified or licensed by the state, which practice emergency assessment and care in out of hospital setting.

Bullying/mobbing: when a person experienced repeated and persistent offensive behavior through vindictive, cruel, or malicious attempts to humiliate or undermine him/her [31].

Physical violence: when a person experienced any of beating, kicking, slapping, stabbing, shooting, pushing, biting, Spit on and/ or pinching, from others.

Sexual harassment: when a person experienced any type of unwanted, unreciprocated and unwelcome behavior of a sexual nature (words or actions) such as physical contacts or verbal comments, jokes, questions, and suggestions which is offensive to the person, that create a hostile work environment.

Workplace violence: when a person had experienced physical and/or emotional WPVs within the previous year. This may be an experience of physical WPV only, psychological WPV only, and/ or both physical and psychological WPV within the previous year.

Verbal abuse: when a nurse experienced sworn or cursed at, yelled or shouted at, threaten.

Ethical consideration

The ethical approval and clearance was obtained from the research ethics review committee of the school of public health, post graduate studies, Rift Valley University Abichu campus. Permission was sought from Addis Ababa’s Fire and Disaster Risk Management commission. The objective, methods, benefits and risks, if there is any, of the study, privacy, confidentiality and the possibility to refuse participation at any time of the data collection was explained orally to the ambulance care providers and informed written consent were sought accordingly.

Result

Socio demographic characteristics of respondent

In this study 177 participant were included with response rate of 171 (96.6 %). Of the total respondents, 94(55%) were males and 77 (45%) were females. According to marital status, 52% were single, 41.5% were married and 6.4% were divorced.

Work organization of respondent

The staff reported that 124 (72.5%) of them had interacted with patients/clients during their work and 121 (70.8%) had direct physical contacts (washing, turning, physical examination), while the rest had indirect Contact.

Work profession and experience of respondent

Concerning the field of work, 118 (69%) of the participants were Ambulance nurse by occupation, 53 (31%) of the participants were Ambulance driver.

Prevalence of workplace violence

The prevalence of workplace violence 42 (24.6%) reported exposure to physical violence, nearly 88 (51.5%) reported verbal abuse, 54 (31.6%) exposed to mobbed/bulled while 49 (28.7%) reported to have been sexually harassed. From 171 participants 4 (9.5%) reported that they have physical attack by patients/ clients, 13 (31%) reported attacked by relative of patient/client and 22(52.4%) reported attacked by general public while the rest 129 (75.4%) in the last 12 month.

From Sexual Harassment 30(61.2 %) of the participant had sexual harassment in their work setting by patients/client, 18 (36.7%) by general public, and 32 (65%) once, 16(33%) sometimes and 48 (97.96%) were female. Sexual Harassment 30(61.2 %) of the participant had sexual harassment in their work setting by patients/client, 18 (36.7%) by general public, and 32 (65%) once, 16(33%) sometimes and 48 (97.96%) were female. When we see the consequence of sexual harassment, 14 (28.6 %) moderately reported that “feeling like everything” an effort to do any activities, avoiding thinking about or talking about the attack or avoiding having feelings related to it was 14 (28.6 %), repeated, disturbing memories, thoughts, or images of the events was 14 (28.6 %), and being “super-alert” or watchful and on guard was 15(30.6 %).

Factors associated with workplace violence

Physical Violence during Binary logistic regression analysis; age, direct contact with patient/client were associated factors with physical violence at p-value <0.05. Verbal Violence during Binary logistic regression analysis, work experience, interaction with patient/client and direct physical contact with patient/client were associated factors with verbal violence at p-value <0.05.

Sexual harassment during

Binary logistic regression analysis, sex, age, work profession, and service year, and interaction and direct physical contact with patient/clients were associated sexual harassment significant at p -value <0.05. Mobbing /bulling during binary logistic regression analysis there is no associated factor with the independent variables. All variables with p-value <0.05 in the binary logistic regression were entered into multivariate logistic regressions and variables with p-value lower than 0.05 remained in the final model and taken as statistically significant.

After adjusting for potential confounders using Multivariate logistic regression analysis of physical violence, verbal violence, mobbed/bulled and sexual harassment in which enter method was employed, it was found that age, sex, marital status, profession, Interaction and direct physical contact has no statistical significant.

Discussion

This result indicated that the staff had been exposed to physical violence (24.6%), verbal violence (51.1%), mobbed/bulled (31.6) and sexual harassment (28.7%), respectively. The magnitude of verbal violence was in line with findings from a study conducted in South Africa (verbal violence 70%) and the magnitude of physical violence (50 %), bullying and mobbing (40%) and sexual harassment (30%) were lower in our study as compared with the study conducted in South Africa [18]. In addition bullying and mobbing were higher in this study as compared to a study conducted in Australia with bullying and mobbing of 2.5 % [17]. Study conducted in Slovenia 78 % are verbally abused, 49.6% has faced physical abused, 26.8 % of respondent experienced sexual harassment in our study except from the sexual harassment physical and verbal abuse are lower than our study [14]. In this study the highest form of violence were verbal violence which was similar to the study conducted in Australia Verbal abuse was the most prevalent form of workplace violence (82%), 70 per cent In South Africa had been subject to verbal abuse as compared to other violence so this is the most common type of violence at workplace [9,10]. In this study Patients/clients and relatives of patient/clients also responsible for violence second to general public [3].

In our study 97.96 % female is exposed to sexual harassment similarly study conducted on Australia show that female they were the victim in 42 % of cases of exposure to violence and 40% of harassment cases [13].

Other finding that by work profession ambulance nurse is higher to face violence than ambulance driver there is no study to support this but possible explanation might be because of the fact that ambulance driver are not more exposed and have no direct and routine contact with patient or client at scene, where us ambulance nurse have more frequent contact and communication and also nurse are responsible to manage the patient at scene this frequent contact may lead to ambulance nurse to violated by patient/relatives and general public.

Ambulance personnel who have interaction patient client 83.33 % have physical violence, 79.54% have verbal violence, 77.78% have mobbed and bulled and 83.67% has sexually harassed interaction with client/patient have high risk of workplace violence in work setting [26]. Study from Australia, the UK and the USA report face to face contact are particularly at risk of patient/client initiate violence [27].

Reporting procedure in this study it is surprising to know that more than 92 % responded there is respondent have say there is no reporting in the organization this also another associated factor large proportion of incidents of violence against EMS personnel may be unreported. Underreporting may occur because EMS personnel consider events insignificant, they view violent encounters as part of the job, or they are afraid to report them out of concern that they will be seen as not being able to handle the situation [22]. This also show lack of support from the organization and to detect the problem, materialistic and moral support in the profession or the support of directors in the case of difficult situations increase the success and feeling of belonging in the workplace, rendering the feeling of exhaustion less common among individuals who feel supported in the workplace [29].

Conclusion

Ambulance care providers are not free of suffering violent incidents when providing healthcare services. Verbal abuse is the most prevalent, followed by mobbing events have appeared among workers of ambulance care providers. This study highlighted that violence against ambulance staff was a very serious problem in fire and disaster risk management commission, where physical, verbal violence, and sexual harassment committed by patients/ client, general public and relatives of patient/client against ambulance staff were very frequent. The variables such as patient interaction modality, direct physical contact with patient, age and work experience are association factor with violence. Ambulance staffs tried to manage violence by took no action, told a friend and families, and informing to stop the action, try to defend by them self. Therefore, the techniques used by professionals to manage patients/client, general public and relatives who behave with aggressiveness were different but partially adequate to prevent workplace violence.

Recommendation

• Fire and Disaster Risk Management Commission

• Should have reporting procedure in the organization for violence

• It is absolutely necessary to encourage workers to report violence episodes that occur while providing healthcare services and those events that occur in the workplace in order to protect qualified professionals who attend medium to highly complex emergency calls, because the environment of these healthcare services must be free from any type of violence.

• Ambulance care providers need to be educated and trained to apply preventive solutions appropriately and should be supervised regularly to benefit from these solutions

• Give training for staffs to have good personal interaction with patient clients/relatives

• Enhancing good interaction with the patient/client their relatives and the general public

• Also they have ask the organization to develop violence reporting and polices for preventing violence.

• For Researcher Future research is recommended to know impact of societal factors on violence in the ambulance care provides or as part of such an expanded research agenda, the impact of economic globalization, restructuring, and downsizing on levels of violence, as well as on the general standard of health care provision, should be considered.

Acknowledgment

First of all, I would like to express my deepest gratitude to my advisors Tizita Dengia for her help, guidance, encouragement and their constructive comments and critiques. Secondly, I would like to acknowledge Rift Valley University, postgraduate public Health department for giving me this chance. Last but not least, I would like to acknowledge fire and disaster risk management for ethical approval and would like to extend their appreciation to data collectors, the study participants for their devoted cooperation and my friends and family I would like to acknowledge for supporting me.

Conflict of Interest

The authors have no conflict of interest to declare for this study.

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