Leveling of triggers: a comprehensive summative content analysis of factors contributing to physical violence in emergency medical services

BMC Emergency Medicine Torabi et al. BMC Emergency Medicine (2025) 25:22 https://doi.org/10.1186/s12873-025-01181-4 Open Access RESEARCH Leveling of triggers: a comprehensive summative content analysis of factors contributing to physical violence in emergency medical services Mohammad Torabi1 , Ali Afshari2 , Rasoul Salimi3 and Afshin Khazaei4* Abstract Background The literature has identified numerous factors that contribute to workplace violence, ranging from environmental stressors to interpersonal conflict. However, a gap remains in our understanding of the specific factors associated with physical violence, particularly concerning its frequency and perceived significance. Methods A summative content analysis was conducted via the electronic survey platform Porsline in Iran for data collection. In April 2024, EMTs working in urban, road, and air bases in western Iran participated in the study. In total, 358 EMTs were selected via convenience sampling. They provided open-ended responses to the following question: “What do you believe are the most significant factors contributing to physical violence in your workplace?” Results The analysis resulted in a comprehensive list of 1,407 descriptions, organized into 20 subcategories and further consolidated into ten main categories. The category with the highest frequency was “legal and policy deficiencies,” with a frequency of 3103, and the category with the lowest frequency was “workplace culture and professional satisfaction,” with 579. The categories based on frequency and significance included “legal and policy deficiencies,” “cultural and societal barriers,” “insufficient training and practical skills,” “shortcomings in organizational safety and support,” “interpersonal and operational pressures,” “organizational culture and workforce dynamics,” “barriers to effective prehospital care,” “resource and infrastructure limitation,” “challenges in interagency coordination and support,” and “workplace culture and professional satisfaction.” Conclusion Legal reforms addressing legal inadequacies, enhancing organizational support systems, and implementing targeted training programs to mitigate conflicts are essential for fostering a safer working environment. By addressing these pressing issues, healthcare facilities can enhance emergency care, safeguard the well-being of emergency responders, and increase the quality of emergency medical services for communities. Keywords Emergency medical technicians, Workplace violence, Emergency medical service, Emergency care, Qualitative research *Correspondence: Afshin Khazaei Full list of author information is available at the end of the article © The Author(s) 2025. Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creati vecommons.org/licenses/by-nc-nd/4.0/. Torabi et al. BMC Emergency Medicine (2025) 25:22 Introduction Workplace violence (WPV) in prehospital systems is a critical issue that significantly impacts the safety and well-being of emergency medical service (EMS) personnel [1]. First responders, including EMTs and paramedics, often operate in unpredictable environments where they are vulnerable to various forms of violence, such as physical, verbal, and emotional attacks [2]. Recent studies have shown that a significant proportion of emergency responders experience WPV, with prevalence rates of physical violence (20.8%), verbal violence (66.8%), and sexual harassment (10.5%) [3]. WPV against EMS personnel can lead to physical injuries and have a profound impact on mental health, including PTSD, anxiety, and depression [4, 5]. The psychological toll of such violence is exacerbated by the high-stress nature of their work, which often involves responding to emergencies in chaotic environments where emotions run high and tensions may escalate quickly [6]. Factors contributing to WPV include environmental stressors such as inadequate staffing, a lack of security measures, and the presence of intoxicated or mentally unstable individuals, as well as interpersonal conflicts arising from the stressful situations encountered during emergency responses [7, 8]. Despite the documented prevalence of WPV in EMS settings, there remains a gap in understanding the specific factors associated with physical violence, particularly concerning the frequency and perceived significance of WPV among EMTs. This lack of clarity hinders the development of targeted interventions to reduce such incidents in terms of their importance. Qualitative studies are critical in this context, as they provide nuanced insights into the experiences and perceptions of EMS personnel regarding WPV. By exploring the lived experiences of first responders, qualitative research can uncover the complexities of WPV, revealing underlying themes and patterns that quantitative studies may overlook [9, 10]. Understanding the dimensions of WPV is critical for developing effective interventions to reduce violence in high-stress occupations. By systematically examining instances of physical violence within the prehospital system and focusing on the frequency and significance of identified factors, this study aims to provide valuable insights that can inform policy changes and training programs designed to increase the safety and well-being of EMS personnel. Ultimately, improving the working conditions for these first responders will protect them and strengthen the quality of care provided to patients in emergency situations. Therefore, the present study was conducted using a qualitative approach to prioritize factors that cause physical violence in EMS from the perspective of EMTs in the western region of Iran. Page 2 of 16 Methods Design This study utilized a summative content analysis approach beyond simple word counting to analyze underlying meanings (latent content) within the text [12]. This method, grounded in a social constructivist paradigm, allows for a deeper understanding of the text’s critical aspects and significance [13]. Before starting the study, ethical approval was obtained from the Eth (...truncated)