International Emergency Nursing (2011) 19, 5–11

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Threats and violence in the Swedish pre-hospitalemergency care

K. Petzall RNT, PhD (Senior Lecturer) a,1,J. Tallberg RN, MSc (Ambulance Nurse) b,2,T. Lundin RN, MSc (Ambulance Nurse) c,3,Bjorn-Ove Suserud PhD (Associate Professor in Emergency Care) d,*

a Faculty of Social and Life Sciences, Department of Nursing, Karlstad University, SE-651 88 Karlstad, Swedenb KAMBER Skane, SE-221 00 Lund, Swedenc The Fire Station in Bengtsfors, SE-666 30 Bengtsfors, Swedend University of Boras, The Prehospital Research Centre PreHospen, 50190 Boras, Sweden

Received 14 September 2009; received in revised form 13 January 2010; accepted 23 January 2010

17do

*

bj1

2

3

KEYWORDSAmbulance;Pre-hospital emergencycare;Violence;Threats;Working environment

55-599X/$ - see front matti:10.1016/j.ienj.2010.01.00

Corresponding author. TelE-mail addresses: kerstin.

ornove.suserud@hb.se (B.-OTel.: +46 54 700 23 96.Tel.: +46 46 15 36 50.Tel.: +46 531 52 68 90.

er ª 2014

.: +46 33petzall@. Suseru

Abstract

Although acts of threats and violence are problems that have received increased attention inrecent years within Swedish pre-hospital care, only a handful of scientific studies have beencarried out in this field. Threats and violence have a negative influence on the well-being ofambulance personnel. The aim in this study was both to investigate the incidents of threatsand violence within the Swedish ambulance service and to describe these situations.Data was collected with questionnaires answered by 134 registered nurses and paramedics from11 ambulance stations located in four counties. The respondents’ experiences of pre-hospitalcare varied from 3 months to 41 years (mean = 12 years, median = 8 years). The results showedthat 66% of the ambulance personnel experienced threats and/or violence during their workwhile 26% experienced threats and 16% faced physical violence during the last year. The mostcommon kind of threat was threats of physical violence with 27% of the respondents experienc-ing threats involving weapons. Commonly occurring physical violence was in the form of pushes,punches, kicks and bites. In most cases, the perpetrator was the patient himself often under

0 Elsevier Ltd. All rights reserved.

435 4776.kau.se (K. Petzall), john_tallberg@hotmail.com (J. Tallberg), tobias.lundin@ulfab.se (T. Lundin),d).

6 K. Petzall et al.

the influence of alcohol or drugs. The most serious situations occurred when the reason for rais-ing the ambulance alarm was intoxication or a decreased level of consciousness.

ª 2010 Elsevier Ltd. All rights reserved.

Introduction

Ambulance personnel are often the first people to encoun-ter patients needing emergency care. This can take placein all manner of places and involves those afflicted by illnessand those who are victims of accidents or physical abuse,and can sometimes be alcohol and/or drug related. Ambu-lance personnel are usually alone with patients, immediaterelatives and maybe even the perpetrator. This makesambulance personnel easy prey to acts of threats andviolence.

In the Swedish Ambulance Service the ambulance nurse issince year 2005 responsible for the care of the patient. Aregulation from the Swedish National Board of Health andWelfare implies that every emergency ambulance shouldbe staffed by at least one registered nurse (Suserud,2005). This is because only nurses are permitted to dispenseand administer drugs according to well defined standing or-ders. Without a registered nurse in the ambulance, no drugsmay be given to the patient. The ambulance nurse some-times works alongside a paramedic in the ambulance, butthe nurse is always responsible for the assessment andcontinuing care of the patient.

Oxford Advanced Learner’s Dictionary (2010) defines theword threat as ‘‘a statement in which you tell somebodythat you will punish or harm them, especially if they donot do what you want’’. Violence is defined as ‘‘violentbehaviour that is intended to hurt or kill somebody’’.

There are few published scientific studies on the subjectof threats and violence aimed at ambulance personnelalthough there are more studies concerning this kind ofbehaviour focusing on personnel working in emergencyrooms and nursing wards in hospitals (Catlette, 2005; Kow-alenko et al., 2005; Ryan and Maguire, 2006) and who areexposed to violence- and threat-proned patients. Menckeland Viitasara (2002) show that more than one in ten of thoseemployed within the healthcare system in Sweden havebeen subjected to some kind of threat or violence daily dur-ing the discharge of their duties, and as many as three infour had experienced threat or violence several times in amonth. An American study showed that during a recent12-month period around 75% of physicians had been threa-tened and that 30% had actually been very emotive withsome form of physical violence (Kowalenko et al., 2005).Ryan and Maguire (2006) reported an Irish study at twoemergency departments where more than 80% of the per-sonnel had been exposed to forms of verbal aggression.

In one American study (Pozzi, 1998), comprising a group of331 ambulance personnel, over 90% of the participants hadbeen subjected to physical violence in the form of physicalacts of violence during the performance of their duties.Corbett et al. (1998) found a somewhat lower figure where61% of the sample they investigated had experienced someformof physical violence. The ambulance personnel reportedhaving suffered different degrees of mental anguish after the

attacks. Eighty per cent of the respondents admitted havingexperienced anger and 69% considered themselves as becom-ingmore easily irritated after the event (Pozzi, 1998). Similarresults are reported by Corbett et al. (1998).

A Swedish study (Suserud et al., 2002), reported thatmore than 75% of ambulance personnel had experiencedthreats and/or violence in the course of performing theirduties. Of these, 67% were actually subjected to some kindof violence and 17% had even been threatened with one oranother kind of weapon. Workplace related violence aimedat ambulance personnel is reported from Australia as well(Boyle et al., 2007). The results from this study show that82% of the respondents were threatened verbally and that38% had experienced some form of physical violence duringthe preceding 12-month period.

The risks of being subjected to threats and violence bypatients constitute an especially important aspect of thepsycho-social work environment for all categories of person-nel working in the healthcare system. Some studies haveinvestigated how healthcare staff are affected by threatsand violence (Pozzi, 1998; Menckel and Viitasara, 2002;Aasa et al., 2005; Catlette, 2005; Ahl et al., 2005). Aasaet al. (2005) have shown that anxiety in connection withwork conditions and work environment appear to be a great-er risk factor for ill-health such as stomach troubles, head-aches and sleeplessness among ambulance personnel thanpsychological factors. Pozzi (1998) showed in his study thatthree quarters of his respondents considered that it was‘‘part of the work’’ to be threatened and mishandled.

Threats and violence are a recurring work-environmentproblem within ambulance care provision creating a feelingof insecurity among ambulance personnel and which, byextension, can negatively affect the treatment and careof patients. As few studies have been carried out in thisarea, it was judged as both urgent and relevant to take acloser look at the experiences in threats and violence ofambulance personnel. The aim in this study was both toinvestigate the incidents of threats and violence in theSwedish ambulance service and to describe these situations.

Methodology

This is a descriptive study using survey method.

Sample

Eleven ambulance stations from four different areas in Swe-den participated in the study (Table 1). The ambulance sta-tions were convenience selected in such a manner that theycollectively reflected a representative picture of the Swed-ish ambulance care service. The criteria for inclusion ofrespondents in the sample were: (a) at least three monthsof experience from their current place of employment and(b) at least 50% level of employment with duties requiring

Table 1 Geographical regions and number of ambulance stations and personnel who participated in the study.

Region Type of region Inhabitants Number ofambulance stations

Number ofambulance personnel

Number ofresponse rate

1 A province with a small town 50,000 4 35 282 Large-city municipality 300,000 3 77 573 Small-town municipality 16,000 1 21 194 A province with a small town 60,000 3 37 30

Total 426,000 11 170 134

Threats and violence in the Swedish pre-hospital emergency care 7

external ambulance work. All registered nurses and para-medics, who fulfilled the inclusion criteria and acceptedto participate in the study, were invited to participate.Altogether, 170 personnel were invited and 134 agreed toparticipate (79%). Personnel enrolled in the pilot study per-formed prior to the main study did not participate in themain study.

Measures

As there was no available questionnaire in this field, a newquestionnaire was designed. The questions were based on aliterature review and questionnaires used in previous stud-ies of threats and violence (Suserud et al., 2002; Ryan andMaguire, 2006). The first version of the constructed ques-tionnaire was then reviewed by a group of three expertswho are researchers with experience of research in thepre-hospital context. The preliminary questionnaire com-prised nine background questions, e.g. gender, age,employment, present position, and a set of 24 closed ques-tions and 11 open-ended questions on threats, violence, sit-uations of threats and/or violence as well as directives androutines for dealing with threats and violence. The closedquestions included such questions that required straight-forward responses ‘‘yes’’ or ‘‘no’’ as well as other closedquestions with different formulations and a variety offixed-choice alternatives (Polit and Beck, 2006).

The preliminary questionnaire was then tested in a pilotstudy during the spring of 2007. Five personnel from ambu-lance stations in a region other than those included in thestudy participated in the pilot study. The result of the pilotstudy revealed that almost all of the questions gave straightand consistent answers. Questions which were perceived asunclear were clarified accordingly in the final questionnairethat contained a total of 44 questions. The questions weredesigned to elicit responses on experiences of threats andviolence for the entire duration of their professional workin ambulance service and the experiences of the latest year(2007).

Requisite permission to carry out the study was obtainedfrom appropriate senior physicians overseeing ambulanceservices and from area directors. In order to encourage indi-viduals to participate in the study and to ensure a high levelof responses they were informed both verbally and in writ-ing. Using our established criteria of inclusion, we collectedname-lists of the employed through station heads and codedthe questionnaires with identification numbers in order tofacilitate any subsequent dispatch of reminders. In one re-gion data was collected through mailed questionnaires.One reminder was sent to those concerned.

Data analysis

The data collected was analysed by means of the StatisticalPackage for Social Sciences (SPSS) 16.0. Both descriptiveand inferential statistics have been used. The descriptivepart is presented with the help of tables. Inferential statis-tics are employed to show the influence of sex, professionalexperience and professional group using the Pearson chi-square test. Probability values of <0.05 were consideredas statistically significant.

Ethical appraisal

The study was approved by the Ethical Research Committeeat Karlstad University, Sweden (register number C2007/451).

Results

Altogether 134 of 170 personnel answered the questionnaire(79%) – 48 females (36%) and 85 males (64%). Of these, 84(63%) worked as ambulance nurses and 49 (37%) as ambu-lance paramedics. A clear majority of them, 125 (94%),worked full-time. One single respondent failed to answerthe question on sex, extent of employment and position.The age of the respondents ranged from 25 to 65 years(m = 42 years); they had been serving in the healthcare sys-tem for between 1 and 42 years (m = 18 years) and withinthe ambulance service for between 3 months and 41 years(m = 12 years; median = 8 years).

During the most recent year (2007), 35 (26%) of the 134who responded had been subjected to threats and 21(16%) of 132 were physically attacked while performingtheir duties (Table 2).

Neither sex, professional group nor work experienceseem to have had any importance on the risk of being ex-posed to threats or violence for the respondents duringthe most recent year. The chi-square tests showed no statis-tically significant difference between the different groups(Table 3).

Of the 134 respondents who participated in the study, 88(66%) acknowledged that they had at least on one or on sev-eral occasions been threatened. Threats are made most of-ten by the patients themselves and only to a lesser degreeby relatives or other persons. Threats of contacting themedia or reporting to superiors or the authorities concernedwere not experienced as particularly unpleasant or worryingby the majority of the respondents (Table 4). Threats of

Table 3 Threats and incidents of violence in the most recent year.

Sex Males (n = 85) Females (n = 48) P-value

n (%) n (%)

Subjected to threats from patient, relativeor other person (n = 134)

18 (21) 17 (35) 0.073

Subjected to physical violence by patient, relativeor other person (n = 132)a

10 (12) 11 (23) 0.085

Professional group Amb. paramedic(n = 49)

Amb. nurse(n = 84)

n (%) n (%)

Subjected to threats from patient, relativeor other person (n = 134)

10 (20) 25 (30) 0.237

Subjected to physical violence by patient, relativeor other person (n = 132)a

6 (12) 15 (18) 0.361

Experience of ambulance work 3 months–7 years(n = 67))

8–41 years(n = 65)

n (%) n (%)

Subjected to threats from patient, relativeor other person ((n = 134)

19 (28) 16 (25) 0.626

Subjected to physical violence by patient, Relativeor other person (n = 132)a

12 (18) 9 (14) 0.523

a Internal dropout: n = 2.

Table 4 Frequency, type of threat and experience of threat (n = 88).

Kind of threat and experienceof threat

n (%) Experience of threat

Very unpleasant Unpleasant Somewhat unpleasant Not at all unpleasantType of threat n (%) n (%) n (%) n (%)

Threat of contactingmedia (n = 88)

26 (30) 1 (4) 5 (19) 9 (35) 11 (42)

Threat of informing superioror authorities (n = 88)

30 (34) 2 (7) 1 (3) 11 (38) 16 (52)

Threat of physical violenceagainst amb. personnela

79 (91) 28 (35) 34 (43) 15 (19) 2 (3)

Death threat against amb. personnelb 22 (26) 11 (48) 7 (33) 2 (10) 2 (9)a Internal dropout: n = 1.b Internal dropout: n = 3.

Table 2 Number of respondents subjected to threats or violence during the most recent year.

Recent year Region 1 Region 2 Region 3 Region 4 Total

n (%) n (%) n (%) n (%) n (%)

Subjected most recent yearto threats by patient,relative or other person (n = 134)

8 (29) 15 (26) 8 (42) 4 (13) 35 (26)

Subjected most recent yearto physical violence by patient,relative or other person (n = 132)a

7 (25) 7 (12) 5 28) 2 (7) 21 (16)

a Internal dropout: n = 2.

8 K. Petzall et al.

Threats and violence in the Swedish pre-hospital emergency care 9

either physical violence or death-threats were experiencedas specially discomforting, and to a greater extent, by thosedirectly concerned.

In all, 36 (27%) of 134 of the respondents had been threa-tened with some kind of weapon, with the knife figuringmost frequently, accounting for 21 incidents. Firearms wereused in nine cases and on 19 occasions bottles, thick sticks,axes and brooms were brought into play. Firearms seemedto have been used primarily for the sake of threateningand no incident of actual firing or knifing was reported. Evendogs and the riding of a moped in a potentially dangerousway were used to threaten ambulance personnel.

The most common reasons for threats were: that the pa-tient was under the influence of alcohol or drugs; that thepatient and/or relative passed remarks on the promptnessof ambulance arrival, treatment and care needs often cou-pled to ignorance on illness and their symptoms; that thepatient suffered from some kind of mental trouble or men-tal illness; that the patient and/or relative had been frus-trated or angry on account of the feeling of helplessnessin a time of emergency. In some isolated cases culture clashand/or language inadequacy were felt to lie behind thethreats.

Fifty-six respondents (42%) admitted having been sub-jected to physical violence on at least one occasion. Pushingand hitting were among the most frequently cited forms ofviolent acts (Table 5). Among other acts of violence, grasp-ing and gripping, including stranglehold were also men-tioned. Moreover, some respondents described incidentsof near-wrestling encounters in the ambulance itself. Theperpetrator was often the patient him/herself but on occa-sions even a relative or other person was involved.

Of the 56 individuals 12 (21%) had sought medical atten-tion after being subjected to physical violence. The major-ity of these reported haematoma with swelling and wounds

Table 5 Acts of violence; the perpetrator and reason forcare (n = 56).

Acts of violence n (%)Kinds of acts of violence

Have been pushed 37 (66)Have been beaten 33 (59)Have been kicked 16 (29)Have been scratched/gashed 22 (39)Have been bitten 6 (11)Have been spat at 18 (32)Other acts of violence 10 (18)

PerpetratorPatient 49 (87)Relative 15 (27)Other 16 (29)No. of individuals seeking medicalattention after being subjectedto physical violence

12 (21)

Reason for requesting medical attentionTreatment of physical injuries 5 (9)Treatment of mental problems 1 (2)In order to obtain a doctor’s certificate 9 (16)In order to obtain a certificate for legal purposes 2 (4)

with minor bleeding. One respondent mentioned a spell ofswelling accompanied by pain around the neck, after havingbeen subjected to an attempt at strangling. Another respon-dent reported being attacked by a dog with a bite injury onone knee as a consequence. The most serious injury oc-curred after fist punches and kicks had been aimed at theface and head of a respondent. A further two people hadbeen beaten on the face resulting in torn lips and mild con-cussion. Three respondents reported having been put on sickleave following incidents of physical violence.

Intoxication and decreased level of consciousness werethe two single most important reasons for raising the alarmand where situations of threats or violence occur (Table 6).These reasons are often difficult to distinguish since intoxi-cation is always present as a differential diagnosis in casesof uncertain, diffuse aberration of consciousness. The thirdmost common reason for raising the alarm were differentforms of physical abuse and where the ambulance, in themajority of the cases, arrived at the scene before the policedid.

The reason for raising the alarm classified as ‘‘uncertainproblem’’ was used when the Emergency Service Centre haddifficulties in forming a picture of what had happened or be-cause the caller had problems in describing the situation forthe alarm operator. And then, of course, there were a num-ber of perfectly natural medical and surgical reasons forraising the alarm. Among other extraneous reasons, therewas for instance police interception and road accidents.

Situations of violence and threats occurred evenlythroughout the 24 h. A somewhat greater number of inci-dents occurred during weekends. A majority of the respon-dents found it difficult to remember days and times. Theincidents often occurred at the patient’s place ofresidence.

More than half of the respondents admitted that they hadchanged their behaviour in different ways following theirencounter(s) of threats and/or violence mentioning in-creased caution and suspicion against patients. A smallernumber of respondents described an immediate emotionalreaction in connection with the incident.

Situations of threats and violence materialised almostimmediately following contact with the patient and rela-tives or friends. In 14 of the situations described, violencecame to the surface when patients with a decreased levelof consciousness and/or intoxicated patients were exam-ined and came to. In more than half of the situations itwas judged that the perpetrator had been influenced byalcohol and/or drugs. About a third of the perpetrators weresaid to have been mentally ill or had been affected by someform of confused condition. In many cases the perpetratorwas deemed to have been both drug-influenced and men-tally ill at the same time. In nearly 90% of the cases the per-petrator was a male and, in most cases, was the patienthimself but in some cases they were relatives or friends ofthe patient.

Discussion

This study shows that threats and violence are a frequentlyoccurring work-place problem within ambulance services.As many as 66% of the respondents have, at one time or

Table 6 Reason for alarm; time, place and consequence(n = 88).

Serious threat and/or violence situation n (%)Most common reason for alarm fromEmergency Service centrea

Intoxication/overdose 15 (17)Unconsciousness or consciousness aberration 12 (14)Manhandling, fist-fighting, knife-fighting 11 (13)Suicide attempts 7 (8)Unclear/diffuse problems 5 (6)Isolated, other medical and surgical‘‘natural’’ reasons for alarm

21 (25)

Isolated other extraneous reasons 7 (8)Cannot remember 8 (9)

86 100

Time of day when incident occurredb

Daytime (06.00–18.00) 23 (26)Evening (18.00–midnight) 25 (29)Night (00.00–06.00) 25 (29)Cannot remember 14 (16)

87 100

Day of week when incident occurreda

Weekday (Mon 07.00–Fri 19.00) 24 (28)Weekend (Fri 19.00–Mon 07.00) 31 (36)Cannot remember 31 (36)

86 100

Place where incident occurredc

In the patient’s place of residence 48 (57)Outdoors 24 (29)In the ambulance 7 (8)Other 5 (6)

84 100

Consequence of violence and threatson ambulance personneld

Increased caution, alertnessand suspicion

52 (65)

Not affected 11 (14)Feelings of frustration,unpleasantness and fear

8 (10)

Other 9 (11)80 100

a Internal dropout n = 2.b Internal dropout n = 1.c Internal dropout n = 4.d Internal dropout n = 8.

10 K. Petzall et al.

another, been subjected to threats and/or violence whilstcarrying out their ambulance duties.

Discussion of methodology

A new questionnaire was developed for the study as therewere no previous ones to draw from. The questionnairewas pilot-tested on five ambulance nurses/ambulance para-medics who were not included in the main study. After someminor refinements the final version was fixed.

In order to facilitate the collection of data, and ensure ahigh level of responses, a limited number of ambulance sta-tions were chosen in some different locations in Sweden. Atthese stations all of the ambulance workers who fulfilled ourinclusion criteria were offered to participate in the study.The response frequency obtained was 79% indicating thatthe respondents perceived the questions as pertinent totheir work and also that they felt it worthwhile to answerthe questionnaire which enhances the reliability of thestudy (Polit and Beck, 2006).

What is perceived as a threat can differ between individ-uals; in particular, threats that are not illegal or are experi-enced as diffuse, can be interpreted differently by differentpersons. The definition of physical violence tends to bemuch clearer and on this matter there appears not to beany great hesitation among the respondents.

There are limitations of this study. One is that some ofthe respondents had long experience and can thereforehave forgotten situations implying threats and violence. An-other limitation is connected to the use of conveniencesamples not covering all big cities of Sweden which mayhave affected the result.

Discussion of results

An investigation from the National Board of OccupationalSafety and Health (Arbetarskyddsstyrelsen, 1998) on ambu-lance care services carried out in Sweden showed that 41%of the personnel had been threatened and that 16% werevictims of physical violence in the years preceding thestudy. Suserud et al. (2002) show that 78% had been threa-tened and 67% had been subjected to physical violenceduring their professional work in providing pre-hospitalcare. The study was however limited to a small geographicarea making it difficult to draw any general conclusionsabout the reasons for the differences. This study demon-strates that threats and violence in ambulance care provi-sion has actually increased in the last 10-year period. Itnevertheless appears to be significantly safer to workwithin the Swedish ambulance service compared to theUSA and Australia (Kowalenko et al., 2005; Boyle et al.,2007).

This study has not been able to show any differences inrisks for being subjected to threats or violence on the basisof sex, professional group or work experience during thepast year. The most common threats consisted of verbalexpressions of using physical violence but as many as 27%of the respondents had at some time been threatened withfirearms. This shows an increase from 2000 when only 17%had been similarly threatened, that is, by firearms (Suse-rud et al., 2002). This may very well indicate that threatsinvolving weapons have actually increased in frequency.Weapons, it seemed, were seldom used to cause any directphysical injury to the respondents in this study. In themajority of the cases described where arms were part ofthe picture, it appeared that the perpetrator had no inten-tion of harming or killing any person rather, the act wasmerely to threaten. In the majority of cases involving vio-lence, the perpetrators had accosted their victims withpushing, kicking, fisting and scratching. In some instances,ambulance personnel had been spat upon, and even bitten,

Threats and violence in the Swedish pre-hospital emergency care 11

something they experienced almost as a deathly threatbearing in mind the risks of being infected. The violencethat ambulance personnel in the USA put up with appearsto be much rougher considering that 37% of the respon-dents in the study by Corbett et al. (1998) had sought med-ical attention after having been physically assaulted, afigure that can be compared with the 27% shown in ourstudy.

Over half of the respondents considered alcohol anddrugs as the most usual contributing causes to situationsof threat and violence. This corresponds well with the re-sults of a number of other international studies carriedout in emergency departments. In Catlett’s study (2005),60% of the patients who had reacted aggressively withthreats and violence had been under the influence of alco-hol and/or drugs. Similar results were also obtained in thestudy by Kowalenko et al. (2005), where 45% of those whophysically attacked members of the ambulance service wereintoxicated.

Another quite common reason leading to threatening sit-uations was that patients and/or relatives had personalopinions on arrival time, treatment, and caring needs whileit was clearly apparent that they lacked knowledge on ill-nesses and their symptoms. A recurring description fromambulance personnel was that the patient or relative feltfrustrated because of the sheer feeling of helplessness andthat this frustration was directed towards ambulance per-sonnel by way of threats and physical aggression. The thirdmost important reason for threats from patients or relativeswas considered to be mental illness. That a mentally ill per-son shrieks and kicks around is associated more to illnessbehaviour rather than as a threat aimed at ambulancepersonnel.

In emergency and, sometimes chaotic situations, whichdemand provision of medical attention, there is a needfor unambiguous directives and treatment instructionswhich can guide the caregiver to decide on prioritiesand treatment in a structured manner. This is not alwayspossible when people hinder ambulance personnel andsubject them to threats and, in worse cases, to violence(Sandman and Nordmark, 2006). In a study by Pozzi(1998), threats and violence were ranked highest as theworst stress factor among personnel working within pre-hospital care. Considerable demands are therefore puton the way personnel communicate with patients andtheir relatives. A study focusing on patients in psychiat-ric-mental health care, explored the phenomenon of posi-tive encounters with violent and aggressive patients(Carlsson et al., 2000). These findings can also be applica-ble to pre-hospital care. This underlines the importanceof personnel who are trained in meeting patients in crisissituations. Problems related to threats and violence musttherefore be taken seriously by the employer and thequestion must be kept in constant review, just as educa-tion in dealing with aggressive patients is kept up-to-dateand made readily available.

Conclusion

Threats and violence in care provision within ambulanceservices is still a problem that needs to be addressed inmany more districts. The ambulance services need to havesupporting system for those who are subjected to threatsor violence. More studies that highlight the patient perspec-tive are also needed in order to contribute to a betterunderstanding of the origin of these negative incidents.

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