Posttraumatic Stress Symptomatology in Pre-Hospital Emergency Care Professionals Assaulted by Patients and/or Relatives

Abstract

Exposure to violence from patients or relatives causes problems in emergency departments. To assess the development of posttraumatic symptoms in pre-hospital emergency care professionals assaulted by patients and/or relatives, it may be crucial to establish preventive measures at different levels. This study examined 358 pre-hospital emergency care professionals assaulted by patients and/or relatives. The aims of the present study were (a) to assess the presence of posttraumatic symptoms and posttraumatic stress disorder (PTSD) and (b) identify compliance diagnoses for PTSD depending on the experience of aggression (presence of fear, helplessness, or horror during the aggression), the perceived severity of aggression, and socio-demographic variables (gender, age, profession, employment status, and work experience). The results show that the experience of aggression with fear, helplessness, or horror is associated with the presence of posttraumatic symptoms related to re-experiencing but is not related to avoidance and emotional numbing and arousal. Furthermore, the perception of aggression as severe was associated with the presence of symptoms related to re-experiencing. These results are presented and discussed.

Keywords

posttraumatic stress workplace violence pre-hospital emergencies

Introduction

About 25% of violent incidents in the workplace take place in the health sector, with 50% of workers in the sector having been subject to some violent incident during their working lives (Bureau of Justice Statistics, 2011). Health care professionals who work in emergency departments have greater exposure to different types of violence (Pawling, 2008). Thus, different studies have reported that exposure of professionals to violence by patients, relatives, or other accompanying people causes problems in emergency departments (Gillespie, Bresler, Gates, & Succop, 2013; Kowalenko, Gates, Gillespie, Succop, & Mentzel, 2013). Exposure to physical and/or verbal aggression compromises the integrity of professionals as this experience can bring physical and psychological harm to the individual.

Studies performed with health care professionals show statistically significant connections between exposure to violence experienced by health care professionals and psychological consequences, notable among them being the presence of burnout syndrome (Gascón et al., 2013; Merecz, Drabek, & Mościcka, 2009), effects on normal health levels (Lam, 2002), the presence of depressive and/or anxious symptoms (Belayachi, Berrechid, Amlaiky, Zekraoui, & Abouqal, 2010), and the presence of posttraumatic symptoms (Richter & Berger, 2006; Shahzad & Malik, 2014; Zafar et al., 2013).

In studies that have examined exposure to violence in professionals who work in emergency departments in the health sector, it is noteworthy that the vast majority of these have focused on determining the frequency of attacks and the associated risk factors (Joa & Morken, 2012; Petzäll, Tällberg, Lundin, & Suserud, 2011; Pinar & Ucmak, 2011). Only a few studies (Alameddine, Kazzi, El-Jardali, Dimassi, & Maalouf, 2011; Belayachi et al., 2010) have centered their research on determining the psychological consequences of exposure to violence in emergency departments. These have focused mainly on studying the presence of anxiety symptoms and burnout syndrome after exposure to physical and/or verbal aggression and to a lesser extent on analyzing the presence of posttraumatic symptoms after suffering an aggression (Gillespie et al., 2013). In this latter study, more than half of the participants (60%) did not meet any diagnostic criteria for posttraumatic stress disorder (PTSD) and the most frequently found diagnostic criterion was re-experiencing (36.7% in the case of verbal aggression and 28.9% when both verbal and physical aggression were present). Avoidance and emotional numbing were found with lower frequency (2% in the case of verbal aggression and 7.5% in the case of verbal and physical aggression).

The development of posttraumatic symptoms and/or PTSD has been associated with different risk factors (Brewin, Andrews, & Valentine, 2000; Zafar et al., 2013) related to aspects of the individual’s history (previous personal and/or family psychiatric history, childhood abuse), socio-demographic variables (female, educational level, young), and the experience of aggression (emotions emerging during aggression such as fear and the assessment of the severity of the aggression suffered). Other variables such as coping strategies and social support were also considered to be predictors of development of PTSD.

Studies focused on assessing these consequences in pre-hospital emergency care are scarce, whereas studies focused on analyzing the presence of posttraumatic symptoms are practically non-existent. The aims of the present study were (a) to assess the presence of posttraumatic symptoms and PTSD for professionals assaulted and (b) identify PTSD diagnosis depending on the experience of aggression (presence of fear, helplessness, or horror during the aggression), the perceived severity of aggression, and socio-demographic variables (gender, age, profession, employment status, and work experience).

Method

Participants

This study was carried out in the Emergency Medical Service of Madrid, (SUMMA-112, in Spanish), which provides health care for emergencies and disasters in the Community of Madrid.

The sample size (n = 441 of a total population of 1,310 professionals) was calculated using the Raosoft sample size calculator program for a confidence level of 99% and a confidence interval of 5%. A stratified random sample ensured to represent each stratum (physicians, nurses, and emergency care assistant). The inclusion criteria were health care worker (physician, nurse, or emergency care assistant) working for at least 12 months in the SUMMA-112 service who agreed voluntarily to take part in the study.

A total of 545 health care professionals were contacted: 41 (7.5%) did not meet the inclusion criteria; of the 504 who met the criteria, 35 (6.9%) declined to participate and 18 (3.6%) did not return the questionnaire. The response rate was therefore 89.5%, with 10 (1.98%) discarded because of incomplete data. The final sample was thus composed of 441 health care workers: 135 physicians, 127 nurses, and 179 emergency care assistants. Of the total sample, 80 participants reported not to have suffered any kind of aggression and 3 participants did not complete the assessment battery properly. Therefore, the data presented in this work represent a total of 358 participants, those who had experienced some kind of aggression; 63.7% of the participants were men, with a mean age of 44 years old, married or living with a partner (64.4%). The majority (84.5%) had a permanent employment contract and an average professional experience of 18 years, having worked 11 years in their current job; 38% of the participants were emergency care assistants, 31% nurses, and 31% physicians.

Procedure

To evaluate all the professionals, eight external evaluators were trained to apply the assessment battery. Through the SUMMA-112 service, an SMS and an email were sent to all professionals informing them of the objectives and characteristics of the study, start date, and the way the evaluation would be carried out. The evaluators went to each service on the stated day and after a brief screening interview to ensure that the professionals met the study’s inclusion criteria, they explained the purpose of the study and requested the informed and written consent of the participants, guaranteeing them anonymity. They then delivered and explained the questionnaires, resolving any doubts and set a time later in the same day when they would collect the batteries. Following the assessment in each service, evaluators delivered the assessment batteries to the supervisor of the study.

Measures

Demographic information was gathered including questions about gender, age, marital status, profession, current employment status, years of work experience, and experience at present workplace.

Frequency of the experiences of aggression by patients, relatives, and/or other accompanying people was assessed by a questionnaire, based on Martínez-Jarreta et al. (2007). The first part of this two-part questionnaire focused on the frequency with which the health care professional suffered an aggression of any kind (physical aggression, threats, insults/verbal abuse) during their professional career in the SUMMA-112 service, defining in each case the behavior in each type of aggression (Winstanley & Whittington, 2004). If the participants had experienced violence, they described the most serious incident, answering questions on the type of violence, the specific acts of the aggressor, and assessment of the perceived severity of the assault. The severity was assessed using a 3-point Likert-type scale where 0 = mild, 1 = moderate, 2 = severe, and 3 = extreme.

The Global Assessment of Posttraumatic Stress Scale (Escala Global de Evaluación del Estrés Postraumático [EGEP]; Crespo & Gómez, 2012) assessed posttraumatic symptoms and full compliance with the diagnostic criteria of Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association [APA], 2000). The EGEP is an instrument aimed at assessing the presence and intensity of posttraumatic symptoms and diagnosis of PTSD in adults. This scale in its full version consists of 64 items organized into three sections: (a) experience of the aggression, if the person experienced the attack with fear, helplessness or horror, through Yes/No answers; (b) presence and intensity of posttraumatic symptoms; and (c) functional impairments. In addition, the EGEP allows the assessment of other posttraumatic symptoms (nine symptoms, called subjective clinical symptoms) often showed by people exposed to assaults (Foa, Tolin, Ehlers, Clark, & Orsillo, 1999). The EGEP has proven to be a highly reliable instrument, with Cronbach’s alpha coefficients of .92. It also has an acceptable internal consistency in relation to the scales of PTSD symptoms, with values of .73 for re-experiencing, .71 in avoidance and emotional numbing, and .59 in arousal (Crespo & Gómez, 2012). The present study produced Cronbach’s alpha coefficients of .80 in the re-experiencing scale, .80 in avoidance and emotional numbing, .84 in arousal, and .93 for the total scale.

Statistical Analyses

SPSS 18.0 version was used to analyze the data. Descriptive statistics were used to summarize the demographics, frequency and nature of exposure to violence, frequency and intensity of posttraumatic symptoms, and PTSD.

To compare the presence of posttraumatic symptoms and PTSD depending on the experience of the event (fear, helplessness, and horror), perceived severity, and socio-demographic variables, the chi-square test was applied for qualitative variables and the Kruskal–Wallis test for quantitative variables.

Results

Frequency of Exposure to Violence

Just over a third of the participants (34.5%) had been physically assaulted by patients or relatives/accompanying people during their work in the SUMMA-112 service, with 6.1% of the cases suffering physical attacks continuously. Much higher was the percentage of those who had suffered threats, insults, or injuries, which affected more than three quarters of the participants (specifically, 75.3% for insults and 76.2% for insults or slander). In addition, some participants had witnessed violence against a partner, reaching 15.2% for physical aggression, 8.2% for threats, and 7.5% for insults or slander. Thus, only 18.1% of participants had not experienced any aggression directly in the performance of their work.

A considerable proportion, 47.2%, had been victims of some verbal abuse (threats, insults, slander), whereas 34.2% had suffered both verbal and physical aggression. Only a small minority (0.5%, corresponding to two individuals in the sample) had suffered physical abuse only.

The aggression that at this time caused the most distress among professionals was, for more than 85% of participants, the experience of threats, insults, and threatening behaviors. Frequent actions were also coercions (43.2%), grabbing or pushing (42%), property damage (41.4%), and throwing objects. To a lesser extent, the aggressions took the form of kidnapping (17.9%), kicking (17.9%), slapping or punching (14.9%), and stabbing (11.3%). Table 1 shows the concrete actions that involved the aggression and the presence of posttraumatic symptoms related to it.

Table 1.

Characteristics of the Most Serious Incident According to Different Diagnostic Criteria, n (%).

	Re-Experiencing (n = 126)	Avoidance and Numbing (n = 20)	Arousal (n = 54)	PTSD (n = 8)	Overall (N = 358)
Insults	118 (94.4)	18 (90)	49 (90.7)	8 (100)	293 (87.2)
Threats	120 (95.2)	19 (95)	52 (96.3)	8 (100)	293 (87.2)
Threatening behaviors	114 (90.5)	18 (90)	47 (87)	8 (100)	281 (83.6)
Coercions	67 (53.2)	13 (65)	31 (57.4)	6 (75)	145 (43.2)
Kidnapping	31 (24.6)	6 (30)	12 (22.2)	3 (37.5)	60 (17.9)
Damage to furniture	61 (48.4)	11 (55)	21 (38.9)	5 (62.5)	139 (41.4)
Grabbing or pushing	57 (45.2)	11 (55)	25 (46.3)	4 (50)	141 (42)
Slapping or punching	17 (13.5)	2 (10)	5 (9.3)	1 (12.5)	50 (14.9)
Kicking	26 (20.6)	4 (20)	10 (18.5)	1 (12.5)	60 (17.9)
Biting	6 (4.8)	1 (5)	2 (3.7)	1 (12.5)	14 (4.2)
Pulling hair	7 (5.6)	2 (10)	3 (5.6)	2 (25)	15 (4.5)
Scratching	12 (9.5)	3 (15)	5 (9.3)	2 (25)	31 (9.3)
Throwing objects	41 (32.5)	8 (40)	13 (24.1)	4 (50)	86 (25.6)
Chocking	0 (0)	0 (0)	0 (0)	0 (0)	7 (2.1)
Stabbing	15 (11.9)	3 (15)	6 (11.1)	1 (12.5)	38 (11.3)
Shooting	8 (6.3)	2 (10)	3 (5.6)	0 (0)	16 (4.8)
Spitting	4 (3.2)	0 (0)	0 (0)	0 (0)	6 (1.8)
Others	1 (0.8)	0 (0)	1 (1.9)	0 (0)	2 (0.6)

Presence and Intensity of Posttraumatic Symptoms

For all groups of symptoms (see Table 2), a high percentage of participants indicated not having any of them. Specifically, 49.7% of the participants had no symptoms of re-experiencing, 61% did not show any symptoms of avoidance or numbing, and up to 71.9% showed no symptoms of arousal. About 66.1% of the participants did not show any subjective clinical symptoms.

Table 2.

Presence and Intensity of Posttraumatic Symptoms (N = 358).

	Presence
Symptoms	% (n)	M (SD)
Re-experiencing
Recurrent and distressing memories of the event	25.0 (85)	1.56 (0.79)
Recurrent distressing dreams of the event	3.7 (12)	1.50 (1.00)
Acting or keeling as in the event was happening again	15.25 (52)	1.63 (0.74)
Psychological distress at exposure to cues of the event	26.0 (85)	1.47 (0.74)
Trembling, sweating, increased heart rate, and so on, to reminders of the event	5.9 (20)	1.70 (0.97)
Avoidance and numbing
Efforts to avoid thoughts. Feelings or conversation	11.8 (37)	1.35 (0.97)
Efforts to avoid activities. Places or people	13.0 (39)	1.79 (0.97)
Inability to recall important aspects of the event	6.7 (19)	1.32 (0.74)
Dismissed interest or pleasure in activities	4.5 (16)	1.50 (0.51)
Feelings of detachment or estrangement from others	3.9 (13)	1.77 (0.59)
Difficulties to experience some feelings	5.1 (18)	1.61 (0.85)
Feelings if future plans or hopes will not come true	4.5 (16)	1.88 (1.08)
Arousal
Difficulties falling or staying asleep	15.1 (49)	1.76 (0.80)
Irritability or outburst of anger	12.0 (38)	1.53 (0.83)
Problems to concentrate	10.5 (34)	1.59 (0.70)
Constant alert or vigilance state	16.9 (53)	1.67 (0.92)
Easily startled	9.3 (30)	1.67 (1.03)
Subjective clinical symptoms
Blame of self about what you made or did not make	10.4 (35)	1.46 (1.03)
Blame of self about surviving the event	0.6 (2)	2.0 (1.41)
Blame of self about the event	3.4 (10)	1.50 (0.52)
Feeling that you are no longer able to rely on people	11.2 (38)	1.84 (1.05)
Feeling that the world is dangerous	20.8 (67)	1.76 (0.83)
Feeling detached from world around	9.8 (34)	1.38 (0.73)
Experiences of unreality of one’s surroundings	12.1 (40)	1.40 (0.84)
Feeling as an outsider observer	3.4 (12)	1.33 (0.88)
Feeling of worsen self-value	4.8 (17)	2.06 (1.02)

PTSD Diagnosis

According to the DSM IV-TR criteria for PTSD, 38% of the participants met the criterion related to re-experiencing whereas only 6% met the criterion for avoidance and emotional numbing and 16% for arousal. These symptoms were present in most of the individuals for more than a month, meaning that 89% of participants met the criterion for duration of symptoms. About 16% of participants met criteria for possible clinical distress or functioning impairment after the presence of traumatic symptoms. Finally, 2.2% of participants met diagnostic criteria for PTSD.

Completion Criteria for PTSD Based on the Experience of the Event, Perceived Severity, and Socio-Demographic Variables

The study of the relation between the presence of posttraumatic symptoms for PTSD and the emotions experienced by professionals during the aggression has shown that the experience of the event is significant for the development of posttraumatic symptoms related to re-experiencing (see Table 3). Thus, 69.8% of participants who experienced the event with fear, met the diagnostic criteria for re-experiencing symptoms, compared with the 30.2% who, despite experiencing fear during the event, did not meet this criteria. Significantly higher percentages of compliance with the criteria for re-experiencing were also seen when the professional experienced the aggression with helplessness (79.4%) and horror (32.5%). In addition, the experience of the event with helplessness or horror was significant for the development of PTSD.

Table 3.

Compliance With the Criteria Related to Re-Experiencing, Avoidance and Emotional Numbing, Arousal, and PTSD Based on the Emotional Experience of Aggression.

	Fear				Helplessness				Horror
	n (%)				n (%)				n (%)
	Yes	No	χ²	p	Yes	No	χ²	p	Yes	No	χ²	p
Re-experiencing	88 (69.8)	38 (30.2)	17.078	<.001	100 (79.4)	26 (20.6)	16.161	<.001	85 (67.5)	41 (32.5)	11.989	<.001
Avoidance and numbing	13 (65)	7 (35)	0.891	.345	17 (85)	7 (15)	3.530	.060	7 (35)	13 (65)	2.101	.147
Arousal	38 (69.1)	17 (30.9)	5.067	.052	44 (80)	11 (20)	6.028	.065	17 (30.9)	38 (69.1)	2.909	.088
PTSD	6 (75)	2 (25)	1.293	.256	0 (0)	8 (100)	4.267	.039	5 (62.5)	3 (37.5)	7.507	.006

Note. PTSD = posttraumatic stress disorder.

However, compliance with the criteria for avoidance and emotional numbing and arousal symptoms showed no significant differences between professionals who experienced it with fear, helplessness or horror. It should also be noted that the experience of aggression with horror showed higher percentages of non-criteria compliance related to avoidance and emotional numbing and arousal symptoms. This was also true when the aggression was experienced with helplessness, resulting in considerably higher percentages showing non-compliance for PTSD than compliance when the event was experienced with this emotion.

The analysis of the perceived severity of the event only showed significant differences in the compliance criteria for re-experiencing (see Table 4). In addition, there was an increase in the percentage of individuals who presented posttraumatic symptoms and PTSD when the aggression was perceived as severe.

Table 4.

Compliance With the Criteria Related to Re-Experiencing, Avoidance and Emotional Numbing, Arousal, and PTSD Based on the Perceived Severity of the Attack.

	Mild	Moderate	Severe	Extreme
	n (%)	n (%)	n (%)	n (%)	χ²	p
Re-experiencing	6 (4.7)	21 (16.7)	69 (54.8)	30 (23.8)	20.864	<.001
Avoidance and numbing	0 (0)	3 (15)	12 (60)	5 (25)	4.661	.198
Arousal	4 (7.4)	10 (18.5)	28 (51.9)	12 (22.2)	3.241	.356
PTSD	0 (0)	1 (12.5)	4 (50)	3 (37.5)	3.658	.297

Note. PTSD = posttraumatic stress disorder.

The analysis of compliance of different diagnostic criteria (see Table 5) considering socio-demographic variables—gender, age, professions, employment status (permanent contract/temporary contract), and work experience—did not show significant differences in any of the cases (re-experiencing, avoidance and emotional numbing, arousal, and PTSD).

Table 5.

Demographics of Sample According to Different Diagnostic Criteria.

	Re-Experiencing (n = 126)	Avoidance and Numbing (n = 20)	Arousal (n = 54)	PTSD (n = 8)	Overall (N = 358)
Gender n (%)
Male	73 (57.9)	14 (70)	31 (57.4)	6 (75)	228 (63.7)
Female	53 (42.1)	6 (30)	23 (42.6)	2 (25)	130 (36.3)
Age M (SD)	43.47 (8.89)	44.60 (9.14)	44.50 (9.46)	44.38 (9.48)	44.04 (9.37)
Professions n (%)
Emergency care assistant	49 (38.9)	9 (45)	20 (37)	4 (50)	136 (38)
Nurse	35 (27.8)	5 (25)	15 (27.8)	2 (25)	111 (31)
Physician	42 (33.3)	6 30)	19 (35.2)	2 (25)	111 (31)
Current employment status n (%)
Permanent contract	107 (84.9)	16 (80)	43 (79.6)	6 (75)	304 (8.48)
Temporary contract	19 (15.1)	4 (20)	11 (20.4)	2 (25)	54 (15.2)
Working experience M (SD)	18.54 (8.28)	18.21 (8.18)	18.47 (9.56)	18.30 (8.80)	18.52 (8.50)

Note. PTSD = posttraumatic stress disorder.

Discussion

The present study evaluated the psychological consequences of aggression and the presence of posttraumatic symptoms and PTSD in pre-hospital emergency care. It was carried out in the largest pre-hospital emergency service in Europe, and one of the most important worldwide, and may be an excellent indicator of the problem existing in this sector. The results indicate that for the professionals who participated in the study, a higher proportion (76%) had suffered verbal abuse than in other studies (64%) and physical assaults were slightly higher (42% to 51.4%) than the figures reported in other studies (34.5%; Boyle, Koritsas, Coles, & Stanley, 2007; Joa & Morken, 2012; Petzäll et al., 2011).

The analysis of posttraumatic symptoms suffered by the professionals and related to aggressions of any kind (either verbal or physical) has shown, with reference to other studies (Gerberich et al., 2004; Richter & Berger, 2006), that exposure to aggression is related to posttraumatic symptoms. Thus, around 50% of the professionals showed symptoms related to re-experiencing, avoidance and emotional numbing, and arousal.

Although it is true that the results agree with other studies (Gillespie et al., 2013), it should be noted that some differences were found with regard to the percentages referring to both posttraumatic symptoms and diagnosis of PTSD itself. Thus, in this study, symptoms presented more frequently in all the three groups of professionals are those related to re-experiencing, whereas in other studies (AbuAlRub & Al-Asmar, 2011; Richter & Berger, 2006), the most common symptoms are those related to avoidance and arousal. However, it is important to note that both studies were performed in Mental Health Hospitals and Institutions and not in the field of emergency. Similarly, there are discrepancies between the percentages of participants diagnosed with PTSD. The percentage of professionals exposed to aggression and developing PTSD was significantly lower (2.2%), whereas in the literature, percentages of 17% have been reached (Richter & Berger, 2006).

It is possible that these discrepancies are related to two issues. First, the instruments used to assess PTSD were different in each study making comparison difficult. Second, when the evaluation is performed can be decisive when establishing percentages for both posttraumatic symptoms and PTSD. Different studies (Richter & Berger, 2006; Vázquez, Pérez-Sales, & Matt, 2006) have found that the responses in relation to posttraumatic symptoms may be transitory, with prevalence rates of PTSD sometimes falling by half in just 6 months.

Finally, the experience of aggression with fear, helplessness, or horror is associated with the presence of posttraumatic symptoms related to re-experiencing but not to avoidance and emotional numbing and arousal. Furthermore, perceiving aggression as severe is associated with the presence of symptoms related to re-experiencing. These results may be based on the dual representation theory (Brewin, Dalgleish, & Joseph, 1996), which described how exposure to traumatic situations of high emotional intensity caused the activation of the amygdala and therefore storage of information by momentarily accessible memory, allowing the presence of re-experiencing symptoms.

Non-association between the experience of aggression with fear and the development of PTSD has been confirmed in other studies (Friedman, Resick, Bryant, & Brewin, 2011; McNally, 2009) that have shown the importance of emotional responses for developing posttraumatic symptoms but not necessarily PTSD. These results, related to posttraumatic symptoms, could be partially generalized to the PTSD concept included in the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; APA, 2013), as the experience of the aggression with fear, helplessness, and horror seems to be related to re-experiencing symptoms, and this diagnostic criterion has no changes regarding Diagnostic and Statistical Manual of Mental Disorders (4th ed; DSM-IV; APA, 1994) in the symptoms that compose it.

In relation to socio-demographic variables, there is some inconsistency in the literature on the link between these variables and the development of posttraumatic symptoms. Despite being related to predictors of the development of posttraumatic symptoms in different studies (Adriaenssens, de Gucht, & Maes, 2012; Lavoie, Talbot, & Mathieu, 2011), other researchers (Gillespie et al., 2013; Zafar et al., 2013) have shown the same findings as this present study, that is, little or no relation exists between socio-demographic variables and the development of posttraumatic symptoms and/or PTSD.

Limitations

The limitations to be taken into account when drawing conclusions from these findings are as follows: first, the cross-sectional and retrospective design of the study; second, other risk factors that the literature has considered as potential facilitators of posttraumatic symptoms, such as social support and coping styles that have not been included in this study.

Conclusion

In conclusion, pre-hospital emergency care staff who have experienced physical and/or verbal aggression show posttraumatic symptoms, mainly related to re-experiencing, and these are present in most cases for more than a year after suffering the attack that is currently causing them the most discomfort. In addition, symptoms related to re-experiencing may appear if the aggression is experienced with fear, helplessness, or horror. Furthermore, these symptoms appear to be more prevalent if the aggression is experienced as severe. Therefore, it seems appropriate to establish support measures for the professionals who are suffering this type of violence, with the aim of minimizing the impact of the psychological consequences that this may have.

In particular, it seems appropriate to develop protocols that allow an analysis of how the professionals experience aggression and perceive its severity to offer preventive measures to avoid or minimize the possibility of developing posttraumatic symptoms and/or to take action as soon as possible with those professionals who already have posttraumatic symptoms to facilitate their treatment. Prevention of these negative effects may involve the development of overall psychological coping strategies (empathy, communication skills, problem-solving, etc.), the identification of problems from the beginning, and the development of regular group sessions with all professionals to analyze conflict situations and their actions (Bernaldo-de-Quirós, Labrador, Piccini, Gómez, & Cerdeira, 2014).

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Funding was provided by MAPFRE Foundation (Fundación de la Mutua de accidentes del trabajo y enfermedad profesional-Fundación MAPFRE) in Support to Research 2011.

Author Biographies

M. Mar Gómez-Gutiérrez is a professor in clinical psychology at the Complutense University of Madrid since 2006. She received her BSc in psychology (2001) and PhD in clinical psychology (2010) from the Complutense University of Madrid (Spain). She has published articles and book chapters, mostly in the areas of stress, particularly in posttraumatic stress disorder. She provides psychological treatment for victims of different traumatic events and has received the European Certificate in Psychology (2013).

Mónica Bernaldo-de-Quirós has been a professor in clinical psychology at the Complutense University of Madrid (Spain) since 1994. She received her BSc in psychology (1991), MA in clinical and health psychology (1993), and PhD in clinical psychology (1999) from the Complutense University of Madrid (Spain). She has published more than 30 articles and book chapters, as well as two books, mostly in the areas of the effectiveness of psychological treatments, stress, burnout, and workplace violence in health care workers.

Ana T. Piccini is a PhD student in the Department of Clinical Psychology at the Complutense University of Madrid (Spain). She received her BSc in psychology from the University of Lima (Peru) in 2004 and her MA in clinical and health psychology from the Complutense University of Madrid (Spain) in 2007.

Jose C. Cerdeira is an assistant director of emergency nursing in SUMMA-112, which is responsible for pre-hospital Accident & Emergency care in the Madrid region (Spain). He received his BSc in registered nursing from the Complutense University of Madrid (Spain) in 1982 and his specialty in Mental Health in 2010.

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