Psychosocial risks of relief professionals: violence in pre-hospital settings

Background: Violence is a severe psychosocial risk in the workplace, but it is little studied in the area of pre-hospital care. It represents a concern for professionals. Objective: To know the point of view of chief officers on workplace violence in a pre-hospital setting against firefighters. Methodology: A study of a qualitative nature using the Delphi method with semi-structured interviews and content analysis, taking place between May and December 2017. Twenty-four interviews were conducted at the national level. Results: The chief officers considered that violence episodes occur frequently. Although there were reports of physical violence, psychological violence was the most significant. Conclusion: Violence against firefighters occurs daily, but underreporting undermines understanding the real extent of the problem.


Introduction
Psychosocial risks in the workplace are contemporary and constitute a threat to the safety and well-being of professionals and impact significantly on organizations and the country's economy. Occupational health is an area of nursing intervention which aims to prevent and protect professionals against occupational risks and promote health (Direção-Geral da Saúde [DGS], 2016) because, when professionals are healthy and motivated at work, this reflects in the care provided. Among the various psychosocial risks that may arise in the workplace, violence stands out, with its harmful effects and potential to create other problems that will also affect professionals (Agência Europeia para a Segurança e Saúde no Trabalho [AESST], 2003). Globally, health professionals are at high risk of experiencing a violent event in the workplace and, according to the World Health Organization (WHO, 2018), the most exposed target population are the professionals who work directly in the care to the victim, inside and outside the hospital, as, for example, nurses. Workplace violence is a current topic, discussed worldwide, but it has been further explored in the hospital environment (Bernaldo-De-Quirós, Piccini, Gómez, & Cerdeira, 2015). Although it is less studied within the context outside the hospital, violence is a frequent phenomenon in pre-hospital emergency care, to which professionals are intensely exposed (Mello, 2012). That makes them easy targets for individual, collective, and even religious and political violence, particularly in disaster and conflict areas (WHO, 2018). One of the many features of pre-hospital context is requiring the professionals to travel to the place where the victim is, which implies they introduce themselves to a potentially vulnerable and unprotected environment. This uncertainty may lead to themselves becoming circumstantial victims (Bernaldo-De-Quirós et al., 2015;Mello, 2012;Petzäll, Tällberg, Lundin, & Suserud, 2011). Firefighters operate in a vast field of action, mainly in pre-hospital emergency and fires. The year of 2017 was a particularly severe year regarding the intensity and violence of fire affecting continental Portugal, in human, as well as economic and social losses (Instituto da Conservação da Natureza e das Florestas [ICNF], 2016), which also resulted in increased violence against firefighters. In the study by Mello (2012) and according to WHO (2018), the prevalence of violence is a workplace reality and tends to increase in a street situation, as professionals interact directly with the aggressors, which usually are the victim, the family and, sometimes, third parties, such as other professionals. The objective of this study is to understand the perspective of the chief officers on workplace violence in the pre-hospital context against firefighters. The obtained data aim to support a national study on this topic and in this target population, but due to the lack of official data, this preliminary study was performed to understand the feasibility and pertinence of a future study.

Background
Violence became a dilemma of industrialized society, emerging as a threat to the professionals and the institutions. This problem affects the different sectors and professional categories, in addition to undermining health care (Organización Internacional del Trabajo [OIT], 2002). Violence is the result of a set of factors, such as personal, sociocultural, and environmental characteristics, and interpersonal relationships (Dahlberg & Krug, 2007). Due to the different difficult-to-control variables, this issue becomes complex and difficult to manage, which entails enormous financial losses for the sector (WHO, 2018). Violence is the use of force against others and can cause physical or psychological damage as a result of their means of performance (Mello, 2012). While working, many professionals are often exposed to verbal violence, including threats, which makes it a more dominant type of violence (AESST, 2003;Bernaldo-De-Quirós et al., 2015;Bigham et al., 2014;Deniz, Saygun, Eroğlu, Ülger, & Azapoğlu, 2016;Petzäll et al., 2011;WHO, 2018). The analysis of data noted that only 8 to 38% of the professionals, at some point in their career, were physical violence victims (WHO, 2018 conspicuous and devalued sociocultural roots (Dahlberg & Krug, 2007). Verbal/psychological violence is the most frequent type of violence and, when one analyzes local culture, many professionals often feel that violence is part of the work, which leads them to pursue a silence culture (Dahlberg & Krug, 2007). Consequently, scarcity of data undermines the implementation of appropriate strategies, so an analysis of the true reality must be conducted. Violence has a personal, social, and professional impact because it ultimately negatively affects professionals. Exposure to these events can lead to healthcare quality and safety risks, reduce professionals' income, and, sometimes, cause work withdrawal (OIT, 2002). Scientific evidence shows that, over the course of a career, the majority of professionals (doctors, nurses, EMS technicians, firefighters) was a victim of violence or attempt of violence (Al-Turki, Afify, & AlAteeq, 2016; Bigham et al., 2014;Deniz et al., 2016;Mroczek, Mormul, Kotwas, Szkup, & Kurpas, 2014;Petzäll et al., 2011). The undervaluing and underreporting eventually hide the true extent of this problem and, as a result, the implementation of mitigation measures (Al-Turki et al., 2016). There is no simple solution to deal with this issue, but the need to construct measures to minimize its impact is known (Al-Turki et al., 2016;Xing et al., 2016). Psychosocial risks became a new challenge for the occupational safety and health of institutions. The increasing transformation of institutions and the rapid changes experienced by society cause severe consequences for the psychosocial well-being of the workers. However, a field study is required for the production of data which determine the true reality of the problem.

Methodology
The scarcity of data on violence in pre-hospital settings does not allow understanding the real challenges of this phenomenon. For an overview of the phenomenon, chief officers were interviewed, the highest operational ranks in fire departments. In 2017, 1,269,196 emergency resources were activated. 161,424 activations were performed by the emergency medical ser-vices vehicles operated by technicians from the Medical Emergency National Institute (Instituto Nacional de Emergência Médica -INEM), and 752,521 were performed by emergency medical officers of fire departments. We chose firefighters as the target population because they are a nationally representative population of pre-hospital emergency care provided in basic life support ambulances (INEM, 2018). This study is the result of limited data supporting the pertinence of a national study and this population's representativeness. This study is qualitative, using the Delphi method with semi-structured interviews. A semi-structured interview script was drown with questions addressing the importance of conducting in the future a study on pre-hospital care. The starting question was: What is the reality of workplace violence in pre-hospital settings for firefighters? The semi-structured interview script was composed of thematic groups: group A -presentation (refers to the interviewee's demographic background); group B -opinion and knowledge (inquires about his/her opinion on the importance and feasibility of the study, quantifies the violence episodes, and identifies the aggressor); group C -consequence and absences (generally describes the effects on the firefighter); group D -incident report (mentions whether there are reported cases, adopted resources and procedures); group E -conclusion (interrogates about the most viable way to apply the questionnaire). The goal was to understand, from the perspective of the chief officers, being the highest ranks of each fire department, the reality of workplace violence of firefighters as violence victims in pre-hospital settings. Comparing their opinions with the official and unofficial data from their fire department, we aimed to determine the reality of each fire department on third-party violence against firefighters. The fire chiefs were contacted and informed about the objective of the study. Subsequently, taking into account that each fire department may have 1 to 5 chief officers according to the fire department type, we were informed about the chief officer(s) most suitable for the study. Firstly, the interviews were conducted as a pre-test and, then, after carrying out the suggested amendments, interviewed 24 chief officers of voluntary fire departments, until it reached saturation of data. The interviews were conducted from north to south, covering the interior and coastal regions of mainland Portugal. It was consider that a balance between the number of interviews conducted in rural and urban areas must exist. The chosen method was the non-probabilistic network sampling, also known as snowball sampling. The initial sample was composed of four known chief officers, to whom we then requested to name one more chief officer, and so forth. The semi-structured interviews included questions about the pertinence of the study, the frequency of violence episodes reporting, the means of communication, and the impact on the institution/firefighter. As each association is autonomous, its fire chief is sovereign. Therefore, the authorization to carry out the study was given verbally by each fire chief and no request was submitted to an ethics committee. Each interviewee agreed to participate willingly, with no financial compensation and provided his/her verbal and written informed consent. The data collection occurred at the fire station, for an average of 17 minutes, and was previously scheduled. At that time, it was explained to them the objectives, the interviewed confidentiality, the association's anonymity, the voluntary nature of their participation, and their ability to stop the interview at any time. The data were analyzed qualitatively through descriptive content analysis based on the method of Bardin, and the interviewed was encoded with the letter I and their identification number, data only known by the lead author. The closed questions were analyzed quantitatively through statistics and data presentation by tables.

Results
The data were divided according to the objectives of the interview and gathered in groups according to the pertinence of the topic. We performed a quantitative approach through data analysis and a qualitative approach through content analysis. Table 1 shows the sociodemographic analysis of the sample. Fifteen interviews were conducted in the north region, five in the central region, and four in the south region, half belonged to urban areas and the other half to rural areas. One of the chief officers was female, and the participants were aged between 30-59 years old. The most common age group was 30-39 years, with nine individuals, followed by seven between 40-49 years old and eight between 50-59 years old, although the mean age was 43 years old. Regarding academic qualifications, 13 of the interviewees had secondary education, 10 were graduated, and one had a master's degree.   The frequency of reporting violence episodes varies, whether it is official, unofficial, and when compared to the previous 12 months and 5 years. Table 3 shows that, despite not having happened in the fire departments of all interviewees, the frequency of reporting violence episodes decreased over the past 5 years. However, we noted that the unofficial reporting of verbal/psychological violence episodes over the last 12 months increased. We emphasize that there is violence in forest fires, as most of the chief officers consider it to be a widespread occurrence which should be studied. Regarding the knowledge about who commits the different types of violence, the interviewees stated there are different aggressors. All of them explained that the victim is the main aggressor, 16 interviewees reported that the family also committed violence, and four chief officers stated that there are also third-party aggressors.
The analysis was structured in Table 4, composed of three items: category, subcategory, and unit of entry. The category column identifies the interview script group, the subcategory column shows the questions, and the unit of entry's column lists the meaning of the chief officers' reports. After analyzing the data from the most mentioned unit of entry, we note that violence results in possibly long-lasting consequences and damage for institutions and firefighters. The chief officers considered that firefighters often do not report violence incidents of which they are victims, so they attempt to avoid dispatching, in the case of professional firefighters, and refuse it, in the case of volunteers, as we can observe in the following statements: "They get upset about the situation and hide what happened." (I10, September 2017); "Volunteers refuse to perform the work because they do not want to get beaten (physical or verbal violence). There is a psychological impact on the professional because he/she has to perform the service and ... is already thinking it can happen again" (I4, May 2017); "They refuse to do the work because they are traumatized. Everything that affects them psychologically affects the institution also." (I21, December 2017). The chief officers consider that the gratuitous violence experienced by firefighters ultimately leads to feelings such as outrage, discouragement, mistrust, emotional drainage, resulting in decreased performance and changes in the victim's mental and social well-being, as exemplified by the testimonies of the interviewees: "There is outrage because their job is to help. Volunteers feel discouraged." (I5, July 2017); "The other firefighters are also outraged because these situations still occur in the 21 st century. We are behind on our culture and education, compared to Europe" (I3, May 2017); Physical violence leads to physical aftereffects, but verbal violence triggers future issues within interpersonal relations with other people, but not within the working field ... there are personal and professional limitations, and one often takes the problems home. It is worrisome (I7, August 2017); "They get psychologically traumatized, feel powerless and degraded, want to give up." (I14, November 2017); "Firefighters feel outraged, disappointed, often desperate and dismayed." (I11, September 2017); "In situations they feel may be conflicted, firefighters feel afraid, do not feel like dispatching to such occurrences because they might be attacked again" (I2, May 2017). Firefighters who are violence victims consider that these events disgrace themselves and the institution, leading to medium-and longterm presenteeism, impacting on personal and financial profitability, and, in more severe cases, to the abandonment of the institution. The chief officers expressed in their inter- views great concern about the impact of violence: "It demeans the firefighter image, and if firefighters are not content, professionalism is endangered." (I16, November 2017); "Lack of attendance, discouragement, and, if they are volunteers, abandonment of the institution." (I24, December 2017); "The consequences are, above all, psychological." (I6, August 2017); "The professionals show lack of performance, lack of productivity." (I4, May 2017); "The withdrawal of professional firefighters does not often occur because they are professionals. On the other hand, volunteers might leave because they do not depend on firefighting financially." (I10, September 2017). The work of firefighters, as in any specialized profession, requires specialized training, constant training to enhance skills and love for these activities. The refusal to perform their duty reduces the headcount and endangers the functionality of institutions, which worsens in the event of abandonment: They may have to close the fire department because there are no firefighters to perform rescue because they leave ... The volunteers have a cause and being assaulted can make the firefighters lose their will and give up. They do not want to endure these situations. They simply refuse to dispatch, which is a problem in itself. (E15, November 2017) The chief officers stated that the procedure for reporting the incident differs between associations and is nonexistent in four of the studied fire departments. The most frequent communication route implemented is written. There is a physical paper form in 16 of the sampled fire departments. They usually send it by e-mail, but only 10 chief officers mention it. As the internal communication process starts, the association activates its mechanisms to analyze and address adequately the incident. The necessary actions may range from adopting preventive measures to avoid future episodes, submitting a complaint to the local authorities, providing external psychological support, or requesting psychological support teams, to providing legal support. The lack of standard guidelines is evident in the following testimonials: "First, we find out the truth, hear the parties involved. Moreover, we take preventive measures to ensure it does not happen again." (I5, July 2017); "It (violence) is common in some places, and the Republican National Guard (GNR) is called to the site. Depending on the severity, one can even call them on site and wait inside the ambulance" (I10, September 2017); "The Board provides legal aid, pays the costs of the proceedings, helps to make the complaint to the police… If needed, we offer psychological support." (I1, May 2017); "Firstly, we communicate it to the authorities. Secondly, we provide legal support to the firefighter, and thirdly, the institution makes the complaint on behalf of the association because the association is also concerned." (I14, November 2017). Most associations provide legal support, but as there is no specific legislation regulating this matter, some associations do not feel obligated to support the proceedings financially. This lack of accountability is why the firefighter, a violence victim, has to bear all the costs of legal proceedings: The association has insurance, but it shoulders other expenses not covered by insurance. It insists on knowing the status of the firefighter and assist him in what he/she needs. The chief officers and the board provide all kind of support. (I3, May 2017) "None. Firefighters have to pay their legal counsel because no law states that the association has to bear the costs. The board does not care. No legislation protects firefighters." (I15, November 2017). In most violence episodes, as it is not considered a public offense, the complaint is only made if the firefighter so desires or when there is material damage for the association. Many situations do not go to court due to several reasons, such as lack of supporting evidence or apology from the aggressor. The testimonies of the interviewees corroborate these assumptions: "In verbal violence, it is hearsay and sometimes one reports, but 90% does not. They confide it in coworkers." (I11, September 2017); "With verbal aggression, nothing happens, and often people apologize." (I21, December 2017); "The firefighters themselves withdraw the complaint, they forgive." (I5, July 2017); "If it is verbal, the firefighter decides. If there is damage, the association makes the complaint." (I10, September 2017); "Some cases did not go to court, but firefighters were physically assaulted, and then nothing came of it." (I16, November 2017).

Discussion
Violence is a social, complex, and severe phenomenon and must be regarded as a disturbance that affects professionals at a personal and professional level (Dahlberg & Krug, 2007;Mroczek et al., 2014). The growing industrialization and management's and clients' demands do sometimes ignore that professionals are human beings with feelings and in risk of becoming long-term traumatized victims, who, though frequent, are not properly known. In this respect, the WHO (2018), the International Labour Organization (ILO, 2018), and AESST (2003), as well as all interviewed chief officers, share the opinion that a study on psychological violence is very pertinent, and the scarcity of studies does not allow knowing the true extent of the phenomenon, which may hinder the implementation of more effective preventive measures. The scarcity of studies on the topic generates a wrong feeling of workplace safety. More than half of the sample reported having received official reports of violence episodes, but they believe it does not represent the true extent of the problem. According to scientific evidence, violence is acknowledged as an existing phenomenon, but it still is little reported by professionals (Al-Turki et al., 2016;Lima & Sousa, 2015). Although the incidence of physical violence is low (Al-Turki et al., 2016;Xing et al., 2016;AESST, 2003), one must consider that 4% of the entire working population has already experienced a physical violence episode, which must be validated due to its severity (AESST, 2003). When the chief officers were questioned about the importance of conducting a national study on the types of violence, more than half of them considered that, although physical violence remains scarce over the years, it would be highly relevant to know the extent of the phenomenon. In comparison with non-physical violence, the majority of the sample stated there is a widespread incidence in the study population, even in the events made known unofficially. Verbal violence has a higher incidence because it is easier to commit (Bernaldo-De-Quirós et al., 2015;Deniz et al., 2016;Petzäll et al., 2011). During the interview, the sample often referred to violence arising during the performance of firefighters at the fires. One of the firefighters' duties is fighting against forest fires, which because of climate change can happen at any time, although its incidence increases in the warmer months. Violence in fires tends to increase with their severity, although studies are officially scarce or nonexistent. The chief officers consider that violence occurs in this activity more often than in pre-hospital settings, and aggravates because it is usually accompanied by the person affected by the fire or by a group of people who joins at the moment. Comparing with pre-hospital care, we note that the main aggressor is mostly the victim, that is, the interested party in the situation, followed by the present family (Al-Turki et al., 2016;Bernaldo-De-Quirós et al., 2015;Campo & Klijn, 2017; DGS, Departamento da Qualidade na Saúde, 2015) and, sometimes, others who may be simply spectators or professionals who were on site (Campo & Klijn, 2017;DGS, Departamento da Qualidade na Saúde, 2015). The chief officers stated that violence causes harmful medium-and long-term effects to firefighters, such as emotional drainage, psychological trauma, outrage, mistrust, discouragement, workplace absence or withdrawal, fear of dispatching and refusal to dispatching for similar occurrences, or loss of profitability, ultimately impacting the institution. In recent years, the conclusions of studies of authors such as Morris et al. (2014), Khatiban, Hosseini, Bikmoradi, Roshanaei, and Karampourian (2015), and Mroczek et al. (2014) have been consistent with the data from this study. Depending on how, how often, and to which extent it is committed, violence can lead to psychological trauma, decrease of empathy towards others, changes in interpersonal relations at work (DGS, Departamento da Qualidade na Saúde, 2015), while the negative impact reflects itself on the team, its motivation, and the quality of care provided by professionals (WHO, 2018). The interviewees stated that, despite being a relevant and frequent phenomenon, there usually is a low reporting of psychological violence episodes. The underreporting and the withdrawal of complaints to the authorities or the legal proceedings already underway in court exemplify the lack of relevance given to the phenomenon. There are several reasons, the main one being that professionals regard it as useless or that the experienced event was not significant (Al-Turki et al., 2016;Bernaldo-De-Quirós et al., 2015;Campo & Klijn, 2017;Lima & Sousa, 2015), or that it is interpreted as something inevitable and accepted with passivity. Violence is a contemporary and little publicized social phenomenon, but it affects the professionals directly or indirectly in any moment of their careers (Al-Turki et al., 2016;Petzäll et al., 2011). It is notoriously difficult to quantify the events and to give importance to what is given little importance. In the interviews, few chief officers reported that their fire departments resorted in recent years to the court. Moreover, one interviewee stated that there is no support of any kind because the law does not obligate the fire department to provide such assistance, which may also be the reason why four chief officers do not possess, in their fire department, an internal action procedure for such an event.
The majority of the sample mentioned there was legal aid, authority´s request, and psychological support teams. Although they are not obligated to do it, this attitude demonstrates that measures are taken and chief officers are interested in helping firefighters whenever possible. The support and encouragement of reporting these events are critical to ensure that the institution can promote a healthy and violence-free workplace (Klijn & Field, 2017). It is consider as a limitation of this study the duration of implementation of the interviews. Since 2017 was a disastrous year concerning fires, it was necessary to reschedule some interviews because the chief officers were unavailable. Although we reached saturation of data, we expected to conduct more interviews, which was not possible due to the unforeseen fires.

Conclusion
In the last decade, violence has become a worrisome phenomenon, studied in several countries. However, some societies still accept it as normal. Due to the scarcity of studies in Portugal, we aimed to collect data to understand the viability of a national study within the pre-hospital context. Considering the number of official occurrences in 2017, we selected the firefighters' chief officers to convey their opinion on the subject. We conclude that, according to the interviewees' perspective, violence is a current and underreported phenomenon that should be acknowledged. It became apparent that professionals experience feelings of distrust, discouragement, outrage, fear, causing harmful effects on professionals' health, sometimes leading to refusal, absence, and withdrawal from work. Professionals must be encouraged to report these episodes; chief officers must be motivated to adopt strategies to mitigate and prevent the problem and employ measures to dissuade aggressors. The results of this research should contribute to the analysis of this complex topic and encourage the conduction of a national study.