Symptomology, Outcomes and Risk Factors of Acute Coronary Syndrome Presentations without Cardiac Chest Pain: A Scoping Review.

For patients experiencing acute coronary syndrome, early symptom recognition is paramount; this is challenging without chest pain presentation. The aims of this scoping review were to collate definitions, proportions, symptoms, risk factors and outcomes for presentations without cardiac chest pain. Full-text peer reviewed articles covering acute coronary syndrome symptoms without cardiac chest pain were included. MEDLINE, CINAHL, Scopus and Embase were systematically searched from 2000 to April 2023 with adult and English limiters; 41 articles were selected from 2,954. Dyspnoea was the most reported (n=39) and most prevalent symptom (11.6-72%). Neurological symptoms, fatigue/weakness, nausea/ vomiting, atypical chest pain and diaphoresis were also common. Advancing age appeared independently associated with presentations without cardiac chest pain; however, findings were mixed regarding other risk factors (sex and diabetes). Patients without cardiac chest pain had worse outcomes: increased mortality, morbidity, greater prehospital and intervention delays and suboptimal use of guideline driven care. There is a need for structured data collection, analysis and interpretation.

Analysis of Violent Incidents at Five Regional and Remote Australian Emergency Departments: A Retrospective Descriptive Study.

Introduction: Workplace violence is endemic, destructive, and escalating in frequency and severity in healthcare. There is a paucity of research on workplace violence in regional and remote hospital emergency departments (EDs). Objective: The aim of this study was to identify the perpetrator and situational characteristics associated with violent incidents in the ED across five regional and remote Australian sites. Method: This study audited hospital summary data, incident reports, and medical records for a 12-month period in 2018 to examine the perpetrator and situational characteristics of workplace violence incidents in five regional and remote Australian EDs. Results: Violent incidents were evenly spread throughout the week and across shifts. Most incidents were triaged as urgent, occurred within the first 4 hr, and had multidisciplinary involvement. Almost one in every six incidents resulted in an injury. Perpetrators of violence were predominantly young and middle-aged males and almost always patients, with most presenting with mental and behavioral disorders, or psychoactive substance use. Conclusions: Understanding the characteristics of perpetrators of violence can help in seeking to tailor interventions to reduce further violent behaviors. These findings carry implications for optimizing patient care, staff safety and resource management.

Implementing community paramedicine: A known player in a new role. A narrative review.

BACKGROUND: Community Paramedicine is a model of care which is effective and accepted by health professionals and the community. Community paramedicine delivers low acuity primary care to disadvantaged communities and addresses service gaps. We aimed to identify successful implementation of community paramedicine models and signalled opportunities and challenges. METHODS: A narrative review was conducted. We identified 14 literature reviews from four databases EMBASE, CINAHL, PubMed, Cochrane. The results from the thematic analysis were structured along the quadruple aim for healthcare redesign framework. RESULTS: The reviews supported acceptability of the model. Patients are satisfied and there is evidence of cost reduction. Long term evidence of the positive effects of community paramedicine on patient, community health and the health system are lacking. Equally, there is unfamiliarity about the role and how it is part of an integrated health model. CONCLUSIONS: Community paramedicine could alleviate current stresses in the healthcare system and uses an available workforce of registered paramedics. To facilitate integration, we need more evidence on long-term effects for patients and the system. In addition, the unfamiliarity with the model needs to be addressed to enhance the uptake of the model.

No Two Systems Are the Same: Paramedic Perceptions of Contemporary System Performance Using Prehospital Quality Indicators.

Introduction In recent years, researchers have identified two new models of paramedicine within the Anglo-American paramedic system known as the Directive and Professionally Autonomous paramedic systems. The research team now seek to compare paramedic perception of system performance between the two systems using prehospital quality indicators. Methods Paramedics employed within Anglo-American paramedic systems undertook a survey evaluating their experience and perception of system performance against a set of modified prehospital quality indicators. Data were collected using a survey combining single-choice questions with matrix multiple-choice questions. Key results were cross-tabulated with demographic (informant) and system factors to compare performance between the two new paramedic systems. Results The survey indicated a substantial difference in perceived clinical and operational performance between the Professionally Autonomous and Directive paramedic systems, with the Professionally Autonomous paramedic system performing consistently better in all 11 prehospital quality indicator domains. Conclusion The results of this survey are a vital step in helping paramedics, health leaders, and academics understand the complex relationship between paramedic system design and system performance, and, for the first time, provides empirical evidence upon which to make a conscious decision to adopt one system or the other.

Shaping the future design of paramedicine: A knowledge to action framework to support paramedic system modernization.

BACKGROUND: Over the past two decades, the demands placed on modern paramedic systems has changed. Paramedic services can no longer continue to operate on a traditional response model where more ambulances are deployed to meet the rising demand of patients calling for their health needs. Recent research has explored system design in paramedicine and its relationship with organizational performance. Two subsequent paramedic systems have been identified with one, the Professionally Autonomous paramedic system, being linked to higher performance. Yet, how to operationalize this model for system modernization continues to be a gap in practice. OBJECTIVE: To provide health leaders and policy makers with a framework from which to drive paramedic system modernization. METHODS: This study uses the Knowledge to Action framework to develop an implementation plan for systems that seek to modernize their service delivery model toward that of a Professionally Autonomous paramedic system. RESULTS: A detailed plan of the steps required to undertake system transformation are outlined. Whilst this framework outlines the components required for system modernization, it does not propose an in-depth outline of each of the steps required to achieve each component. Rather, end users are encouraged to develop individual implementation plans tailored to the local context using the comprehensive tools outlined within. CONCLUSION: This knowledge to action framework provides health leaders and policy makers with a uniform roadmap for paramedic system modernization intended to improve health (clinical) outcomes as well as health system outcomes through the Professional Autonomous paramedicine model.

A conceptual framework for the exploration of the relationship between systems of paramedicine and system performance.

BACKGROUND: Over the past 60 years since its inception, the Anglo-American Paramedic System has continued to grow and evolve. While brief and fragmented accounts of the differences between systems have been noted in the literature, until recently there has been a paucity of research that explores and identifies sub-models of paramedicine within the Anglo-American Paramedic System. OBJECTIVES: This article describes a conceptual framework that sets a roadmap for defining and comparing two newly identified sub-models of the Anglo-American Paramedic System. METHODS: A conceptual framework for the exploration of these novel sub-models was developed on the basis of the work completed by Donabedian as well as Turncock and Handler. These two sub-models worked to develop a model for quality assessment and performance measurement in the public health system. RESULTS: The conceptual framework consists of six components that are strongly related to each other: system design, macro context, mission and purpose, structure, service delivery models and quality outcome measures. While this framework relates specifically to two novel paramedic systems known as the Professionally Autonomous an Directive paramedic systems, it can be used to measure any integrated health model. CONCLUSION: The conceptual framework described in this paper provides a stepwise roadmap for the definition and comparison of the newly identified paramedic systems to better inform future research that defines and compares paramedic system design and performance.

The development of community paramedicine; a restricted review.

Community paramedic roles are expanding internationally, and no review of the literature could be found to guide services in the formation of community paramedicine programmes. For this reason, the aim of this restricted review was to explore and better understand the successes and learnings of community paramedic programmes across five domains being; education requirements, models of delivery, clinical governance and supervision, scope of roles and outcomes. This restricted review was conducted by searching four databases (CENTRAL, ERIC, EMBASE, MEDLINE and Google Scholar) as well as grey literature search from 2001 until 28/12/2021. After screening, 98 articles were included in the narrative synthesis. Most studies were from the USA (n = 37), followed by Canada (n = 29). Most studies reported on outcomes of community paramedicine programmes (n = 50), followed by models of delivery (n = 28). The findings of this review demonstrate a lack of research and understanding in the areas of education and scope of the role for community paramedics. The findings highlight a need to develop common approaches to education and scope of role while maintaining flexibility in addressing community needs. There was an observable lack of standardisation in the implementation of governance and supervision models, which may prevent community paramedicine from realising its full potential. The outcome measures reported show that there is evidence to support the implementation of community paramedicine into healthcare system design. Community paramedicine programmes result in a net reduction in acute healthcare utilisation, appear to be economically viable and result in positive patient outcomes with high patient satisfaction with care. There is a developing pool of evidence to many aspects of community paramedicine programmes. However, at this time, gaps in the literature prevent a definitive recommendation on the impact of community paramedicine programmes on healthcare system functionality.

From stretcher bearer to practitioner: A brief narrative review of the history of the Anglo-American paramedic system.

BACKGROUND: This narrative review presents a brief chronological history of the Anglo-American paramedic system, combining decades of stories from across ambulance services in western, English-speaking developed countries METHODS: Databases, including Embase, MEDLINE, Web of Science, CINAHL and Google Scholar were searched from the inception of the databases. A grey literature search strategy was conducted to identify non-indexed relevant literature along with forwards and backwards searching of citations and references of included studies. Two reviewers undertook title and abstract screening, followed by full-text screening. Included studies were summarised using narrative synthesis structured around the exploration of the history of the Anglo-American paramedic system. RESULTS: The research team structured the narrative in chronological order and used metaphorical models based on philosophical underpinnings to describe in detail each era of paramedicine. The narrative explores several key milestones including, industrial orientation, scope of practice, innovation, education and training, regulation as well as significant clinical and technological advancements in the delivery of traditional and non-traditional paramedic care to patients. CONCLUSIONS: Paramedicine, like other allied health professions, has successfully navigated the pathway toward professionalisation in a considerably short period of time. From its noble beginnings as stretcher bearers in times of war, the profession has looked outwards to emulate the success of our healthcare colleagues in establishing its own unique body of knowledge supported by strong clinical governance, national registration, professional regulatory boards, self-regulation, and a move towards higher education supported by the development of entry-to-practice degrees. Whilst the profession has achieved many great milestones, their application across multiple jurisdictions within the Anglo-American paramedic system remains inconsistent, and more research is needed to explore why this is.

Workplace violence against emergency health care workers: What Strategies do Workers use?

BACKGROUND: Workplace violence by patients and bystanders against health care workers, is a major problem, for workers, organizations, patients, and society. It is estimated to affect up to 95% of health care workers. Emergency health care workers experience very high levels of workplace violence, with one study finding that paramedics had nearly triple the odds of experiencing physical and verbal violence. Many interventions have been developed, ranging from zero-tolerance approaches to engaging with the violent perpetrator. Unfortunately, as a recent Cochrane review showed, there is no evidence that any of these interventions work in reducing or minimizing violence. To design better interventions to prevent and minimize workplace violence, more information is needed on those strategies emergency health care workers currently use to prevent or minimize violence. The objective of the study was to identify and discuss strategies used by prehospital emergency health care workers, in response to violence and aggression from patients and bystanders. Mapping the strategies used and their perceived usefulness will inform the development of tailored interventions to reduce the risk of serious harm to health care workers. In this study the following research questions were addressed: (1) What strategies do prehospital emergency health care workers utilize against workplace violence from patients or bystanders? (2) What is their experience with these strategies? METHODS: Five focus groups with paramedics and dispatchers were held at different urban and rural locations in Canada. The focus group responses were transcribed verbatim and analyzed using thematic analysis. RESULTS: It became apparent that emergency healthcare workers use a variety of strategies when dealing with violent patients or bystanders. Most strategies, other than generic de-escalation techniques, reflect a reliance on the systems the workers work with and within. CONCLUSION: The study results support the move away from focusing on the individual worker, who is the victim, to a systems-based approach to help reduce and minimize violence against health care workers. For this to be effective, system-based strategies need to be implemented and supported in healthcare organizations and legitimized through professional bodies, unions, public policies, and regulations.

Perpetrator and situational characteristics associated with security alerts in regional Australian emergency departments.

BACKGROUND: Workplace violence is a regular feature of emergency departments (ED) and reported to be increasing in frequency and severity. There is a paucity of data from regional EDs in Australia. The aim of this study was to identify the perpetrator and situational characteristics associated with security alerts in regional emergency departments. METHODS: This retrospective descriptive study was conducted in two regional Australian hospital EDs. All incident reports, hospital summary spreadsheets, and patient medical records associated with a security alert over a two-year period (2017 - 2019) were included. The situational and perpetrator characteristics associated with security alerts in the ED were recorded. RESULTS: One hundred fifty-one incidents were reported in the two-year period. Incidents most frequently occurred on late shifts and in an ED cubicle. Most incidents included multiple disciplines such as ED staff and paramedics, police and psychiatric services. One hundred twenty-five incidents had sufficient information to categorise the perpetrators. Mental and behavioural disorders (MBD) were the most frequent perpetrator characteristic present in security alerts (n = 102, 81.6%) and were associated with increased severity of incidents. MBDs other than psychoactive substance use (PSU) were associated with 59.2% (n = 74) of incidents and 66.7% (n = 18) of injuries. PSU was associated with 42.4% (n = 53) of incidents. Following PSU and MBDs other than PSU, repeat perpetrators were the next most prominent perpetrator category (24.8% n = 31) and were almost always associated with an MBD (93.5% n = 29). CONCLUSIONS: Violence incidents in the ED are often complex, patients present with multiple issues and are managed across disciplines. Interventions need to extend from one size fits all approaches to targeting specific perpetrator groups. Since MBDs are one of the most significant perpetrator factors, interventions focussing on this characteristic are needed to address workplace violence in EDs.

Defining two novel sub models of the Anglo-American paramedic system: A Delphi study.

INTRODUCTION: While brief and fragmented accounts of the differences between systems have been noted in the literature, until recently there has been a lack of research that explores and identifies new sub-models of paramedicine within the Anglo-American paramedic system. METHODS: A Delphi method was used to gain consensus among international paramedic experts regarding two new models of paramedicine known as the Directive and Professionally Autonomous paramedic systems. Following the development of a preliminary definition, a set of questions were established for experts aimed at defining the new sub-models; the responses were reviewed and amended based on feedback before being re-distributed to an expanded group of participants for further rounds of questions. Rounds continued until consensus was achieved. RESULTS: Consensus was achieved for both statements regarding the Professionally Autonomous paramedic system definition in round 2, 85.7% (n = 18). Following analysis and revision of the definition, the additional two statements regarding the Directive paramedic system achieved consensus in round 3, 100% (n = 19). CONCLUSION: This Delphi study was the first study to explore a standardised definition for two newly identified sub-models of the Anglo-American paramedic system with the overall results used to help inform high performing system design for modern Anglo-American paramedic systems into the future.

Mental health and well-being impacts of COVID-19 on rural paramedics, police, community nurses and child protection workers.

OBJECTIVE: To investigate the impact of COVID-19 on the mental health and well-being of rural paramedics, police, community nursing and child protection staff. METHOD: An online survey was distributed to investigate the sources of stress and support across individual, task and organisational domains. SETTING AND PARTICIPANTS: The survey was completed by 1542 paramedics, police, community nurses and child protection workers from all states and territories of Australia. This study describes the data for the 632 rural participants. MAIN OUTCOME MEASURES: The main measures of well-being were the Public Health Questionnaire (PHQ9), the Generalised Anxiety Disorder (GAD7), the Maslach Burnout Inventory (MBI), workplace engagement, intention to quit and COVID-19-related stress. RESULTS: The mean depression and anxiety scores were 8.2 (PHQ9) and 6.8 (GAD7). This is 2-3 times that found in the general community. Over half (56.1%) of respondents showed high emotional exhaustion (burnout). The emotional exhaustion, depersonalisation and personal accomplishment mean scores were 28.5, 9.3 and 34.2, respectively. The strongest associations with burnout and psychological distress were workload, provision of practical support, training and organisational communication. A significant proportion of respondents were seriously considering quitting (27.4%) or looking for a new job with a different employer (28.5%) in the next 12 months. CONCLUSIONS: COVID-19 has increased the workload and stress on rural front-line community staff. The major sources of stress were related to organisations' responses to COVID-19 and not COVID-19 per se. The data suggest the most effective mental health interventions are practical and preventive, such as firstly ensuring fair and reasonable workloads.

Investigating first-year graduate paramedics' reason for current work location: A cross-sectional, data linkage study.

OBJECTIVE: This study aims to describe the demographic and employment characteristics of first-year graduates from a Victorian-based paramedicine course and investigate factors that influenced their choice in place of practice. DESIGN: Cross-sectional study using data from the Nursing and Allied Health Graduate Outcomes Tracking study. SETTING: Victoria, Australia. PARTICIPANTS: First-year graduates (2019) from the Monash University range of paramedicine programs. MAIN OUTCOME MEASURES: Variables of interest included principal place of practice and the reasons for working in the current location. RESULTS: Over half of the 2018 paramedicine course graduates responded to the 2019 Graduate Outcomes Survey. Nearly all were registered as paramedics (including double registrants as nurses), and over a fifth were from a rural background; however, less than that were working in a rural area. Of those with complete data, the most cited reasons for current work location were 'spouse/partner's employment or career', 'opportunity for career advancement' and 'scope of practice within the role'. CONCLUSION: This study provides important insight into the factors associated with rural practice location amongst paramedicine graduates, specifically rural origin or personal, lifestyle and professional influences. The study adds to the sparse literature about paramedic practice location decision-making and highlights the need for further systematic longitudinal research examining the 'where' and 'why'.

Barriers, enablers, and opportunities for organisational follow-up of workplace violence from the perspective of emergency department nurses: a qualitative study.

BACKGROUND: A lack of follow-up of violence incidents and assaulted staff has been associated with high levels of workplace violence. There is a paucity of literature on the barriers, enablers and opportunities for organisational follow-up of workplace violence. The aim of this study was to explore the barriers, enablers and opportunities for organisational follow-up of workplace violence from the perspective of Emergency Department nurses. METHODS: This qualitative study comprised two focus groups with Emergency Department nurses. Data were analysed thematically. COREQ guidelines were followed for the design and reporting of the study. RESULTS: The barriers to follow-up in this study relate to the type of perpetrator, the initial incident response, the incident reporting process and organisational action. The enablers included hospital initiatives to manage violence and support staff wellbeing. The opportunities included strategies to improve follow-up and ideas for new follow-up strategies. CONCLUSIONS: Organisational follow-up is important for the emotional and professional wellbeing of staff who experience workplace violence. Opportunities for follow-up include exploring different approaches to patients with mental health issues and focussing on reoffenders by providing appropriate support and consequences. Managers should advocate for efficient and standardised reporting processes and ensure assaulted staff have a clear perception of follow-up and are included in the follow-up process. Including the perpetrators in the follow-up process may reduce workplace violence.

Reshaping healthcare delivery for elderly patients: the role of community paramedicine; a systematic review.

BACKGROUND: Healthcare systems are overloaded and changing. In response to growing demands on the healthcare systems, new models of healthcare delivery are emerging. Community paramedicine is a novel approach in which paramedics use their knowledge and skills beyond emergency health response to contribute to preventative and rehabilitative health. In our systematic review, we aimed to identify evidence of the community paramedicine role in care delivery for elderly patients, with an additional focus on palliative care, and the possible impact of this role on the wider healthcare system. METHODS: A systematic review of peer-reviewed literature from MEDLINE, Embase, CINAHL, and Web of Sciences was undertaken to identify relevant full-text articles in English published until October 3, 2019. Additional inclusion criteria were studies focussing on extended care paramedics or community paramedics caring for elderly patients. Case studies were excluded. All papers were screened by at least two authors and underwent a quality assessment, using the Joanna Briggs Institute appraisal checklists for cross sectional, qualitative, cohort, and randomised controlled trial studies to assess the methodological quality of the articles. A process of narrative synthesis was used to summarise the data. RESULTS: Ten studies, across 13 articles, provided clear evidence that Community Paramedic programs had a positive impact on the health of patients and on the wider healthcare system. The role of a Community Paramedic was often a combination of four aspects: assessment, referral, education and communication. Limited evidence was available on the involvement of Community Paramedics in palliative and end-of-life care and in care delivery in residential aged care facilities. Observed challenges were a lack of additional training, and the need for proper integration and understanding of their role in the healthcare system. CONCLUSIONS: The use of community paramedics in care delivery could be beneficial to both patients' health and the wider healthcare system. They already play a promising role in improving the care of our elderly population. With consistent adherence to the training curriculum and effective integration within the wider healthcare system, community paramedics have the potential to take on specialised roles in residential aged care facilities and palliative and end-of-life care.

Organisational interventions for preventing and minimising aggression directed towards healthcare workers by patients and patient advocates.

BACKGROUND: Workplace aggression is becoming increasingly prevalent in health care, with serious consequences for both individuals and organisations. Research and development of organisational interventions to prevent and minimise workplace aggression has also increased. However, it is not known if interventions prevent or reduce occupational violence directed towards healthcare workers. OBJECTIVES: To assess the effectiveness of organisational interventions that aim to prevent and minimise workplace aggression directed towards healthcare workers by patients and patient advocates. SEARCH METHODS: We searched the following electronic databases from inception to 25 May 2019: Cochrane Central Register of Controlled Trials (CENTRAL) (Wiley Online Library); MEDLINE (PubMed); CINAHL (EBSCO); Embase (embase.com); PsycINFO (ProQuest); NIOSHTIC (OSH-UPDATE); NIOSHTIC-2 (OSH-UPDATE); HSELINE (OSH-UPDATE); and CISDOC (OSH-UPDATE). We also searched the ClinicalTrials.gov (www.ClinicalTrials.gov) and the World Health Organization (WHO) trials portals (www.who.int/ictrp/en). SELECTION CRITERIA: We included randomised controlled trials (RCTs) or controlled before-and-after studies (CBAs) of any organisational intervention to prevent and minimise verbal or physical aggression directed towards healthcare workers and their peers in their workplace by patients or their advocates. The primary outcome measure was episodes of aggression resulting in no harm, psychological, or physical harm. DATA COLLECTION AND ANALYSIS: We used standard Cochrane methods for data collection and analysis. This included independent data extraction and 'Risk of bias' assessment by at least two review authors per included study. We used the Haddon Matrix to categorise interventions aimed at the victim, the vector or the environment of the aggression and whether the intervention was applied before, during or after the event of aggression. We used the random-effects model for the meta-analysis and GRADE to assess the quality of the evidence. MAIN RESULTS: We included seven studies. Four studies were conducted in nursing home settings, two studies were conducted in psychiatric wards and one study was conducted in an emergency department. Interventions in two studies focused on prevention of aggression by the vector in the pre-event phase, being 398 nursing home residents and 597 psychiatric patients. The humour therapy in one study in a nursing home setting did not have clear evidence of a reduction of overall aggression (mean difference (MD) 0.17, 95% confidence interval (CI) 0.00 to 0.34; very low-quality evidence). A short-term risk assessment in the other study showed a decreased incidence of aggression (risk ratio (RR) 0.36, 95% CI 0.16 to 0.78; very low-quality evidence) compared to practice as usual. Two studies compared interventions to minimise aggression by the vector in the event phase to practice as usual. In both studies the event was aggression during bathing of nursing home patients. In one study, involving 18 residents, music was played during the bathing period and in the other study, involving 69 residents, either a personalised shower or a towel bath was used. The studies provided low-quality evidence that the interventions may result in a medium-sized reduction of overall aggression (standardised mean difference (SMD -0.49, 95% CI -0.93 to -0.05; 2 studies), and physical aggression (SMD -0.85, 95% CI -1.46 to -0.24; 1 study; very low-quality evidence), but not in verbal aggression (SMD -0.31, 95% CI; -0.89 to 0.27; 1 study; very low-quality evidence). One intervention focused on the vector, the pre-event phase and the event phase. The study compared a two-year culture change programme in a nursing home to practice as usual and involved 101 residents. This study provided very low-quality evidence that the intervention may result in a medium-sized reduction of physical aggression (MD 0.51, 95% CI 0.11 to 0.91), but there was no clear evidence that it reduced verbal aggression (MD 0.76, 95% CI -0.02 to 1.54). Two studies evaluated a multicomponent intervention that focused on the vector (psychiatry patients and emergency department patients), the victim (nursing staff), and the environment during the pre-event and the event phase. The studies included 564 psychiatric staff and 209 emergency department staff. Both studies involved a comprehensive package of actions aimed at preventing violence, managing violence and environmental changes. There was no clear evidence that the psychiatry intervention may result in a reduction of overall aggression (odds ratio (OR) 0.85, 95% CI 0.63 to 1.15; low-quality evidence), compared to the control condition. The emergency department study did not result in a reduction of aggression (MD = 0) but provided insufficient data to test this. AUTHORS' CONCLUSIONS: We found very low to low-quality evidence that interventions focused on the vector during the pre-event phase, the event phase or both, may result in a reduction of overall aggression, compared to practice as usual, and we found inconsistent low-quality evidence for multi-component interventions. None of the interventions included the post-event stage. To improve the evidence base, we need more RCT studies, that include the workers as participants and that collect information on the impact of violence on the worker in a range of healthcare settings, but especially in emergency care settings. Consensus on standardised outcomes is urgently needed.

Violence against Emergency Department nurses; Can we identify the perpetrators?

INTRODUCTION: Violence against health care workers is a major issue in health care organisations and is estimated to affect 95% of workers, presenting an enormous risk for workers and employers. Current interventions generally aim at managing rather than preventing or minimising violent incidents. To create better-targeted interventions, it has been suggested to shift attention to the perpetrators of violence. The aim of this study was to identify and discuss the perceptions, held by Emergency Department nurses, about perpetrators of occupational violence and aggression. METHODS: Two focus groups were conducted with Emergency Department nurses at a major metropolitan hospital in Australia. In the focus groups, the nurses' perceptions about perpetrators of violence against health care workers were identified and discussed. The results were analysed using descriptive analysis. RESULTS: This study confirmed that violence is a major issue for Emergency Department nurses and has a considerable impact on them. Participants acknowledged that violence at work had become an intrinsic part of their job and they tend to focus on coping mechanisms. The nurses identified six overlapping groups of perpetrators and described their approach to dealing with these perpetrators. The results highlighted additional factors that impact on the occurrence and management of violence, such as the presence of security, wait times, and the triage system. CONCLUSIONS: Based on the focus groups with Emergency Department nurses we conclude that violence at work is an everyday danger for Emergency Department nurses, who feel vulnerable and recognise that it is not within their power to solve this issue given the societal component. Our conclusion is that attention needs to shift from equipping workers with tools to manage violence to the perpetrator and the development of interventions to reduce violence from targeted perpetrator groups.

The ageing farming workforce and the health and sustainability of agricultural communities: A narrative review.

OBJECTIVE: To review and synthesise research related to the ageing farming workforce influence on the health and sustainability of agricultural communities. DESIGN: Using the PRISMA framework as a guide, the CINHAL and Medline databases were searched. Search 1 used the key search terms of ageing OR aging, farm*, workforce. Search 2 used health, sustainability and 'agricultural OR farm communit*. Search 3 combined Searches 1 and 2. Search 4 followed journal citations to identify other relevant articles. A process of narrative synthesis was applied to the results through the prism of rural social capital that described the current state of knowledge and understanding under four themes. RESULT: Database searches and searching of citations identified 16 contemporary articles. Seven of the papers were from Australia, and the balance from five other high-income countries. The four that themes emerged are: vulnerabilities of ageing farmers; economic and climatic drivers; social capital and sustainability; and integrative strategies, that might offer a way forward. CONCLUSION: Integrating these forces of nature, economics and sociology to address the ageing farming workforce and the associated health and sustainability of agricultural communities remains a major challenge for researchers, governments, the agricultural sector and rural communities.

Perspectives from the frontline of two North American community paramedicine programs: an observational, ethnographic study.

INTRODUCTION: Community paramedicine is one emerging model filling gaps in rural healthcare delivery. It can expand the reach of primary care and public health service provision in underserviced rural communities through proactive engagement of paramedics in preventative care and chronic disease management. This study addressed key research priorities identified at the National Agenda for Community Paramedicine Research conference in Atlanta, USA in 2012. The motivations, job satisfaction and challenges from the perspectives of community paramedics and their managers pioneering two independent programs in rural North America were identified. METHODS: An observational ethnographic approach was used to acquire qualitative data from participants, through informal discussions, semi-structured interviews, focus groups and direct observation of practice. During field trips over two summers, researchers purposively recruited participants from Ontario, Canada and Colorado, USA. These sites were selected on the basis of uncomplicated facilitation of ethics and institutional approval, the diversity of the programs and willingness of service managers to welcome researchers. Thematic analysis techniques were adopted for transcribing, de-identifying and coding data that allowed identification of common themes. RESULTS: This study highlighted that the innovative nature of the community paramedic role can leave practitioners feeling misunderstood and unsupported by their peers. Three themes emerged: the motivators driving participation, the transitional challenges facing practitioners and the characteristics of paramedics engaged in these roles. A major motivator is the growing use of ambulances for non-emergency calls and the associated need to develop strategies to combat this phenomenon. This has prompted paramedic service managers to engage stakeholders to explore ways they could be more proactive in health promotion and hospital avoidance. Community paramedicine programs are fostering collaborative partnerships between disciplines, while the positive outcomes for patients and health cost savings are tangible motivators for paramedic services and funders. Paramedics were motivated by a genuine desire to make a difference and attracted to the innovative nature of a role delivering preventative care options for patients. Transitional challenges included lack of self-regulation, navigating untraditional roles and managing role boundary tensions between disciplines. Community paramedics in this study were largely self-selected, genuinely interested in the concept and proactively engaged in the grassroots development of these programs. These paramedics were comfortable integrating and operating within multidisciplinary teams. CONCLUSIONS: Improved education and communication from paramedic service management with staff and external stakeholders might improve transitional processes and better support a culture of inclusivity for community paramedicine programs. Experienced and highly motivated paramedics with excellent communication and interpersonal skills should be considered for community paramedic roles. Practitioners who are proactive about community paramedicine and self-nominate for positions transition more easily into the role: they tend to see the 'bigger picture', have broader insight into public health issues and the benefits of integrative health care. They are more likely to achieve higher job satisfaction, remain in the role longer, and contribute to better long-term program outcomes. Paramedic services and policymakers can use these findings to incentivize career pathways in community paramedicine and understand those changes that might better support this innovative model.