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Khazaeietal. BMC Emergency Medicine (2024) 24:38
https://doi.org/10.1186/s12873-024-00955-6
RESEARCH
Perceptions ofprofessional challenges
byemergency medical services providers:
aqualitative content analysis study
Afshin Khazaei1 , Ali Afshari2* , Mahnaz Khatiban3 , Seyed Reza Borzou2 , Khodayar Oshvandi4 ,
Majedeh Nabavian5 and Maryam Maddineshat6
Abstract
Introduction Emergency medical services (EMS) providers encounter a variety of challenges due to the unpredict-
able, uncontrollable, and dynamic conditions in the pre-hospital field. This study explored the perceived professional
challenges among EMS providers.
Materials andmethods This study was conducted using a qualitative research approach and the method of con-
tent analysis. Eighteen EMS providers were purposively selected from EMS stations in Hamadan, Iran. The collected
data were then analyzed based on the Granheim and Lundman’s method.
Results Based on data analysis, five categories and one theme were identified. The extracted theme was professional
challenges. The five categories were as follows: Ineffective policies; multicultural and multidisciplinary factors; ambu-
lance dispatch route problems; legal issues; and abuse against the emergency medical services
Conclusion In general, it has been found that EMS providers encounter numerous and complex professional chal-
lenges during their work. EMS managers can utilize the findings of the present study to develop strategies for reduc-
ing the professional challenges faced by EMS providers. By doing so, they can improve the quality of care in the pre-
hospital field.
Keywords Emergency medical services providers, Professional challenge, Pre-hospital field
Introduction
e emergency medical services (EMS) plays a vital role
in the health care system [1]. Providing care to patients
in the pre-hospital field is different from the hospital
environment for reasons such as being in unpredict-
able situations, lack of personnel and hospital equip-
ment resources, not having complete information from
patients, providing care to patients in their own living
place, providing care in public communities, and care
at crime scenes [2, 3]. All health care providers face
challenges when providing care to patients, and in the
pre-hospital field, emergency medical services (EMS)
providers are no exception to this rule [4]. Pre-hospital
care presents unique complexities compared to hospital
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BMC Emergency Medicine
*Correspondence:
Ali Afshari
a.afshari@umsha.ac.ir
1 Department of Medical Emergencies, Asadabad School of Medical
Sciences, Asadabad, Iran
2 Chronic Diseases (Home Care) Research Center, Department of Medical
Surgical Nursing, School of Nursing and Midwifery, Hamadan University
of Medical Sciences, Hamadan, Iran
3 Mother and Child Care Research Center, Department of Medical Surgical
Nursing, School of Nursing and Midwifery, Hamadan University of Medical
Sciences, Hamadan, Iran
4 Mother and Child Care Research Center, Department of Nursing,
Hamadan University of Medical Sciences, Hamadan, Iran
5 Department of Nursing and Midwifery, Comprehensive Health Research
Center, Babol Branch, Islamic Azad University, Babol, Iran
6 Department of Nursing, School of Malayer Nursing, Chronic Disease
(Home Care) Research Center, Hamadan University of Medical Sciences,
Hamadan, Iran
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Page 2 of 8
Khazaeietal. BMC Emergency Medicine (2024) 24:38
care, and EMS providers in this field are more likely to
encounter additional challenges compared to hospital
staffs [5].
Emergency medical service providers in Iran are also
at the forefront of the healthcare system and operate
under the Medical Emergency Organization, providing
emergency care to patients and accident victims. Multi-
ple studies have been conducted on pre-hospital care in
Iran, with some indicating that emergency medical ser-
vice providers experience high levels of job stress [6, 7].
Other studies have shown that musculoskeletal injuries
are more common in this group than in hospital nurses
[8]. One study identified crisis conditions and personal
and professional conflicts as the main sources of work-
related stress for emergency medical service providers
[9]. Another study identified health-threatening factors
during missions as a major source of stress in this pro-
fession [10]. A study on ethical decision-making in pre-
hospital care found that barriers included understanding
the situation, patient-related factors, input-output imbal-
ance, and inconsistencies in the healthcare system [11].
While most studies in Iran have been quantitative, there
has been a lack of qualitative research on identifying pro-
fessional challenges faced by emergency medical service
providers.
Identifying these challenges requires conducting quali-
tative studies. Qualitative studies can help achieve a deep
understanding and identify various aspects of a concept,
as qualitative approaches examine a concept in itscul-
tural contextfrom the perspectives of individuals who
have had long engagement with the concept in ques-
tion [12]. erefore, a qualitative approach can be used
to discover and better understand the professional chal-
lenges in the work environment of medical emergency
personnel. On the other hand, improving and enhancing
thequality of carein pre-hospital field will not be pos-
sible without understanding the professional challenges
through the experiences of EMS providers. Accordingly,
the present study was conducted using a qualitative
approach to provide a deep description of the challenges
facing EMS providers in one of the cities located in west-
ern Iran.
Materials andmethods
Study design andsetting
is qualitative study was conducted using the con-
ventional content analysis approach. Content analysis
is an analytical approach that provides insights into
understanding the phenomenon being studied [13]. We
have followed the COREQ guidelines when reporting
the findings of this qualitative study [14]. e present
study was conducted in the emergency medical system
of Hamadan, a western city in Iran. e Emergency
Medical Services in Iran were established in 1978. is
organization is a part of the Ministry of Health, Treat-
ment, and Medical Education. EMS delivery is funded
by the government and is provided free of charge. At
the beginning of the establishment of Emergency
Medical Services, staff members would start work-
ing after completing a six-month theoretical and
practical course. In 2002, some universities of medi-
cal sciences began to student admission in the field of
emergency medicine, and in 2006, the admission of
emergency medicine students in universities of medi-
cal sciences across the country began in two levels of
"associate" and "bachelor" only for male candidates. In
2020, admission conditions for pre-hospital emergency
medicine were announced for both male and female
candidates. Participants are invited to take part in the
interview stages, examination, psychological tests, and
physical readiness after passing the theoretical exam.
Some special admission conditions in this field include:
not suffering from chronic, infectious, or incurable
diseases, height over 170 cm, maximum age of 24, no
addiction, and no history of misconduct. e associate
degree in emergency medicine has 68 academic units
and usually takes 2 years. In the bachelor’s degree pro-
gram, students must pass 130 academic units including
theoretical courses, practical courses, and internships,
which usually take 4 years. e faculty members of the
emergency medicine group include individuals from
nursing, emergency medicine, emergency medicine
specialists, and anesthesiologists departments. e
education of emergency medicine students is carried
out theoretically and practically in educational classes
and clinical skill halls of the faculty as well as in real
pre-hospital and hospital environments. e activity
of the Emergency Medical Services (EMS) system in
Iran is independent of other emergency and security
systems (Red Crescent, Fire Department, and Police).
is system has a unique number, 115, for public access
and assistance 24/7. Recent government policies aim to
expand ambulance bases in cities, intercity roads, and
main rural roads.
According to the latest guidelines from the Minis-
try of Health in Iran, cities with a population of 50,000
must have at least one base for deploying personnel and
ambulances. On the other hand, for every additional
60,000 people above the base population, an extra ambu-
lance station is needed. According to these instructions,
there should be an ambulance station every 30 kilome-
ters along the main roads that connect cities. e EMS
providers in Iran consist of a combination of nurses and
EMTs (Emergency Medical Technicians). e system’s
missions are carried out by two EMS providers. e per-
sonnel sent to the scene of the accident, along with the
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Khazaeietal. BMC Emergency Medicine (2024) 24:38
consulting physician in the dispatch unit, are responsible
for providing medical services to patients and transport-
ing them to the hospital.
Participants
e participants included operational EMS providers
who worked in both urban and rural areas in the emer-
gency medical service of Hamadan, Iran. In addition,
they had at least one year of work experience in the
field of pre-hospital emergency care and held academic
degrees in emergency medical technician or nursing.
Working in the medical emergency system is always chal-
lenging for various reasons. us, it can be argued that
all emergency medical personnel face professional chal-
lenges in this field. Permission was obtained from the
managers of the emergency medical system to conduct
the research and select the participants. e study’s pur-
pose was explained to the emergency medical personnel,
and informed written consent was obtained from the
EMS providers. e first person selected for an interview
had 15 years of work experience. Subsequently, individu-
als from urban and road bases with varying work experi-
ence, degree, and ages were also included in the study. In
this way, we attempted to select a sample with the maxi-
mum diversity. In this study, a total of 18 participants
were included, with 11 from urban bases and 7 from rural
bases. In the present study, data saturation was achieved
after interviewing 14 participants. In total, eighteen male
EMS providers were selected using the purposive sam-
pling method.
Data collection
In this study, semi-structured and face-to-face interviews
were conducted to collect the necessary data. Interviews
were conducted outside of the work shift and with prior
coordination of the participants in the meeting room of
the Central Building of the Emergency Medical System.
Interviews were conducted by the Corresponding author
and lasted between 45 and 60 minutes. e interviews
continued until data saturation was reached. All inter-
views were conducted in Persian. e first question of
the interview was an open-ended one: “Could you please
talk about your occupational experiences?” en, based
on participants’ responses, the interviews continued with
more detailed questions such as "Have you encountered
any challenges in your missions?" and "Are there any chal-
lenges at work or in relation to your colleagues?" Can you
explain your feelings in those situations?" However, open-
ended questions may not always elicit all the information
needed to answer the research questions. erefore, fol-
low-up or guiding questions may be necessary to clarify
or expand on the participant’s response. ese guiding
questions aim to provide more context and detail to the
participant’s initial response, allowing the researcher to
better understand the participant’s perspective and expe-
riences. Examples of guiding questions include "Can you
explain more?" or "What do you mean by this?"
Data analysis
e data were analyzed according to the Graneheim and
Lundman five step method including 1. Transcribing the
interviews and studying them repeatedly to obtain a gen-
eral concept from them 2. Dividing the text into meaning-
ful units 3. Summarizing meaningful units and extracting
codes 4. Placing codes in subcategories and categories
based on their similarities and differences 5. Organ-
izing and extracting themes from the hidden content
of interview text [15]. First, the interviews were coded
after conducting the interviews and transcribing them
into a Word file. e created codes were then placed in
the appropriate classes. During the process of collecting
information, these classes expanded, and some classes
were added, removed, or merged. en, the researcher
attempted to obtain a comprehensive understanding of
the subject by connecting these classes together. Finally,
the main category was determined by considering the
number of words, phrases, themes, or concepts present
in each category. e collected data were analyzed in
MAXQDA v. 2010.
Rigor
e criteria used to assess the accuracy of Lincoln and
Goba’s research were validity, validity, reliability and
transferability. e researchers thoroughly and exten-
sively analyzed the data to ensure its credibility. Fur-
ther, they employed the member check review method,
in which they provided the participants with the text
of the interviews and codes after extracting the initial
code from the interviews. is allowed the participants
to modify or confirm the codes. Furthermore, to ensure
confirmability in interpreting the data, the peer review
method was employed. Two experts in the field of quali-
tative research coded a number of unnamed interviews.
Regarding dependability, the research team was divided
into two groups, and each group performed the coding
process individually. en, they reached a consensus
during a meeting after presenting the codes. To ensure
transferability, participants of different ages, different
educational degree and with different work experience
took part in the study.
Ethical considerations
e project was approved by the Ethics Committee
of Hamadan University of Medical Sciences (Code:
IR.UMSHA.REC.1396.870). First, the purpose of the
interview was verbally explained, and then informed
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Khazaeietal. BMC Emergency Medicine (2024) 24:38
consent was obtained to allow the recording of the inter-
views and the use of the information while ensuring its
confidentiality. e participants were assured that their
anonymity would be preserved, and they could withdraw
at any stage of the survey.
Results
All participants were male. irteen participants were
married and eleven were working in urban EMS stations
.e other demographic characteristics of the partici-
pants are shown in Table1. Analyses of the data obtained
from the interviews resulted in finding one theme and
five categories (Table2).
Ineective policies
EMS providers expressed concerns about the functions,
practices, and policies of organizational leaders and offi-
cials, which posed a professional challenge. e main
categories of Ineffective policies included "ambiguity in
pre-hospital guidelines," "inappropriate executive consid-
erations," and "inadequate staffing preparation."
Multicultural andmultidisciplinary factors
EMS providers highlighted factors related to interper-
sonal behaviors and interactions with colleagues, as well
as hospital staff, especially with the emergency depart-
ment of the hospitals and care and treatment in the
pre-hospital field as professional challenges. e main
category of multicultural and multidisciplinary fac-
tors was formed from three subcategories including
“Incompatibility with colleagues", "difficulties with the
non-homogeneous patient and “inconsiderate behavior
toward patients/family.
Ambulance dispatch route problems
Ambulance dispatch route problems refer to any dif-
ficulties or challenges that may arise during the process
of dispatching an ambulance to an emergency situation.
e main category of Ambulance dispatch route issues
was formed from three categories, including Ambulance
crashes, traffic congestion, and weather conditions.
Legal issues
is concept emerged from participants’ perceptions of
numerous problems with legal and regulatory issues and
complaints against technicians related to prehospital
emergency work and the prosecution of this matter by
judicial organizations. Most EMS providers pointed out
Table 1 Characteristics of the participants
Characteristics of Participants N (%) or
Range
(Median)
Educational degree
EMT 3(17)
BS in EMS 7(39)
BS in Nursing 5(28)
MSc in Nursing 3(16)
Years in Practice 3 – 25(13)
Age 25 – 51(36)
Gender
Male 18(100)
Marital Status
Married 13(72)
Single 5(28)
Ambulance station location
Urban 11(61)
Rural 7(39)
Table 2 Themes and categories extracted from content analysis
Theme categories Subcategories
professional challenges Ineffective policies Ambiguity in pre-hospital guidelines
inappropriate executive considerations
inadequate staffing preparation
multicultural and multidisciplinary factors Incompatibility with colleagues
difficulties with the non-homogeneous patient
inconsiderate behavior toward patients/family
Ambulance dispatch route problems Ambulance crashes
traffic congestion
weather conditions
legal issues complaints against technicians
lack of legal knowledge
abuse against emergency medical services Misuse of the Emergency Medical Services by Individuals
interference of the people and patient’s family in Relief process
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Khazaeietal. BMC Emergency Medicine (2024) 24:38
these issues in their interviews, noting that complaints
against technicians have become a routine issue.
Abuse againsttheemergency medical services
is concept was derived from the EMS providers’ per-
ceptions of patient, family, and community behavior in
the prehospital field. Participants reported misunder-
standings, inappropriate behavior, and misconceptions of
people during the interviews. e main category of abuse
against the emergency medical services was formed from
two categories, namely misuse of emergency medical ser-
vices by individuals and interference of the people and
patient’s family in relief process.
Discussion
is study aimed to explore perceived professional chal-
lenges among EMS providers. e professional chal-
lenges faced by EMS providers are numerous and
complex. Findings revealed that the main perceived pro-
fessional challenges among EMS providers were Ineffec-
tive policies, multicultural and multidisciplinary factors,
ambulance dispatch route problems, legal issues, and
abuse against emergency medical services. ese findings
are discussed in what follows.
Applying and effectively implementing the guidelines
can improve patient outcomes [16]. Despite the instruc-
tions and protocols, there is still a gap between the
established guidelines and clinical practice [17, 18]. e
present study showed that EMS providers use established
protocols at the scene in a limited number of missions.
Moreover, despite the improvements in providing and
developing care and treatment protocols related to pre-
hospital missions, emergency medical personnel often
consult with a physician at a communication center to
manage such missions. However, the physician’s orders
may not always align with the best interest of the patient
or may result in unnecessary and futile interventions by
technicians. is can be attributed to their lack of con-
fidence in assessing and obtaining accurate information
from patients, lack of accountability for specific cases,
and fear of legal consequences. For the same reason, the
participants said that they avoided consulting in most of
the missions, and admitted that the lack of consultation
with the physician harmed some patients in some mis-
sions. When EMS personnel do not follow the protocols
and instructions, emergency patients in this field may not
receive proper care [19].
One of the challenges of EMS providers in the work
environment is the decisions of organizational managers
regarding performing some tasks outside of duty such as
deploying ambulances in some ceremonies, sports com-
petitions or some gatherings. If an accident occurs in the
area of the relevant base while deploying an ambulance,
due to the dispatch of an ambulance from neighboring
and farther bases from the scene of the accident, rescue
will be delayed and perhaps the patient’s injuries will
increase. e lack of support of organizational manag-
ers for the main goals and mission of the emergency
medical system and also the lack of specific guidelines
and protocols for prioritizing ambulance dispatches can
be involved in this matter. Sandeman and Nordmark
highlighted the issue of dispatching ambulances for
non-emergency missions due to the absence of specific
protocols for prioritizing within the emergency medical
system [3]. Access to health care and fair distribution of
health services should not be hindered by factors such as
age, sex, financial and economic status of the patient, or
anything else [20]. In the present study, equipped ambu-
lances are located in the areas of the city where people
have a higher economic status. us, people receive bet-
ter facilities and services compared to those residing in
other areas.
e participants who took part in this study said that
graduates in the EMT were not competent and skilled
enough, which led to problems and outcomes such as
more harm to the patients and a lot of stress for their co-
workers. Afshari etal., in their qualitative study, evaluated
the educational challenges faced by medical emergency
students. is study identified three main categories of
reasons for the graduates’ lack of competence in medical
emergencies in Iran: inadequate teaching methods, dis-
crepancy between theory and practice, and curriculum
reform in medical emergencies [21]. erefore, it is rec-
ommended that medical emergency training programs
in Iran should incorporate more practical, simulation,
and realistic scenarios to bridge the gap between theory
and practice and enhance the competence of graduates.
Blackwell and Brown, in their studies on the educational
issues of medical emergencies, recommended that these
students, as well as other medical emergency staff, should
receive training in realistic settings to enhance their skills
and abilities [22, 23].
e proper relationship between healthcare workers
in the workplace is essential for improving patient out-
comes, staff productivity, and safety culture [24], is
is particularly important in the pre-hospital field where
there is a low number of personnel per mission, often
with only two technicians present at the scene. Work-
ing in the pre-hospital emergency field requires collabo-
ration, overlap, and assistance among technicians [25].
When technicians disagree on how to treat and manage
patients, and these issues are influenced by their personal
experiences and feelings, they face professional chal-
lenges [26]. In addition, communication with the staff of
other units in the healthcare system is another issue that
is addressed in terms of professional communication,
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Khazaeietal. BMC Emergency Medicine (2024) 24:38
which can lead to some challenges. e personnel from
different units may encounter conflicts when making
decisions regarding patients dispatched by the medical
emergency system [4]. In the present study, participants
also mentioned these issues.
In the Iranian medical emergency system and dispatch
unit, only male personnel are currently active. e Ira-
nian people have religious and cultural beliefs related
to Islam [23]. ese beliefs, attitudes, and perceptions
of Muslim women have a direct impact on their access
to health and medical services. erefore, most fami-
lies prefer that their patients be cared for by nurses and
technicians of the same sex [27, 28]. e participants in
this study talked about this issue as a professional chal-
lenge in dealing with these missions while not provid-
ing proper care to female patients. Access to emergency
medical services is a basic right that every person should
have access to regardless of gender, race and religion.
However, in some Islamic societies, women face signifi-
cant challenges in accessing emergency medical services,
especially insituations where only men make up emer-
gency medical personnel. Women’s access to emergency
medical services in Islamic societies where only men
make up emergency medical personnel is a complex issue
that requires a multifaceted approach. By addressing cul-
tural, religious, and educational issues, we can work to
ensure that all women have equal access to emergency
medical services, regardless of gender or any other factor.
In recent years, some universities of medical sciences in
Iran have started recruiting female students to take train-
ing courses in the field of emergency medicine. Currently,
female technicians graduated from universities are work-
ing and providing rescue in ambulance stations in limited
areas of some cities.
In Iran, each shift in the emergency medical system
lasts for 24 hours. Some studies have indicated that
emergency medical personnel experience higher levels of
fatigue and stress compared to firefighters. is is attrib-
uted to the higher number of missions they undertake
in their field [29]. Awareness, concentration, judgment,
mood, and performance of emergency medical person-
nel are significantly affected by fatigue [30]. Furthermore,
fatigue can lead to memory impairment, lack of concen-
tration in problem-solving, and decision-making, which
can ultimately reduce the efficiency and effectiveness of
patient care [31]. e participants in the present study
reported that they were not adequately prepared to han-
dle the demands of future missions during shifts with a
high number of missions and fatigue. As a result, they
were unable to provide proper care to the patients while
carrying out their missions.
Richard et al. indicated that ambulance accidents
among EMS providers were about 20 times more
frequent than those among other staff members [32].
Alexander evaluated the impact of ambulance crashes
on the mental health of technicians and found that the
technicians would experience long-term psychological
problems as a result of being involved in accidents and
causing harm to others [33]. e results of the Brent
and Beland study showed that traffic causes delays in
the arrival of ambulances and fire trucks to the scene
of an accident and this will increase the response time.
ey also showed that traffic congestion increases
response times by 3.4% for EMS and 4.7% for fire [34].
Studies have shown that weather conditions such as icy
or wet road surfaces and foggy air can cause problems
on the road by reducing visibility and vehicle control.
Also, in inclement weather conditions, emergency
medical services may have more demand [35]. e
results obtained in the aforementioned studies are con-
sistent with the findings conducted in this study.
Inevitably, the occurrence of grievances among emer-
gency medical personnel is recognized as a prevalent
concern within this profession. In this study, the main
sources of complaints about the care providers were the
patients (53%), the medical staff (19%), and the patient’s
family (12%). e complaints were related to the lack
of skills among the staff (20%), problems in the trans-
mission pathway (18%), and the loss of patient’s equip-
ment (13%) [36]. Technicians in this study expressed
concerns about anxiety and exhibited cautious behavior
during most missions to avoid any potential complaints.
Dejean etal. reported that several factors contribute
to the inappropriate use and misuse of the emergency
medical system. ese factors include people’s lack of
awareness about the medical emergency system, limited
transportation options, the patient’s inability to walk,
and the absence of efforts to pursue conventional treat-
ments [37]. Furthermore, Pekanoja etal. concluded that
38% of the missions did not need to transfer to the hos-
pital, and 80% of the missions only required a visit from
a general physician [38]. Additionally, Patel etal. evalu-
ated trauma delays in road traffic injury patients and
identified several contributing factors, including lack
of public education, road traffic congestion, shortage of
personnel and ambulances, and inappropriate location
of stations [39]. Pourshaikhian etal described violence
against personnel as linguistic threats, physical con-
flicts, insults and flout, and similar cases and empha-
sized that these behaviors by the people and patient’s
family or people on the scene could interfere with the
rescue [40]. In the present study, participants reported
facing non-emergency situations, misuse of emergency
medical services by people, and delays in rescue due to
inappropriate interference by individuals at the scene.
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Khazaeietal. BMC Emergency Medicine (2024) 24:38
Conclusion
e results of the present study have shown that a
wide range of interpersonal, social, and organizational
factors contribute to professional challenges among
EMS providers. While further research is needed to
better understand the occupational and professional
challenges in the pre-hospital field, emergency medi-
cal system managers can use the results of this study
to develop effective programs to address workplace
problems and challenges. ese programs may include
addressing staff issues at emergency medical bases,
providing periodic training for new personnel, intro-
ducing the emergency medical system to the public
through media, providing legal training and counseling
to EMS providers, and modifying certain organiza-
tional guidelines.
Abbreviations
EMS Emergency medical services
BS Bachelor of Science
MSc Masters of Sciences
EMT Emergency Medical Technician
Acknowledgements
The authors thank all EMS personnel who shared their valuable experiences
with research team through participating in this study.
Authors’ contributions
AA did all the interviews, the thematic analysis, gaining ethical approval, and
drafted the manuscript. SB and MKH were involved in the study conception
and design, analysis, and interpretation of the results. KHO and AKH and
MN participated to the study design, analysis and results interpretation and
writing-up of the manuscript. AA and MN contributed to analyze and interpret
the data. MM contributed to study design and results interpretation. All
authors reviewed and edited the manuscript and approved the final version of
the manuscript.
Funding
This work was funded by Vice-chancellor for Research and Technology, Hama-
dan University of Medical Sciences (No: 9612228243).
Availability of data and materials
The datasets used and/or analysed during the current study are available from
the corresponding author on reasonable request.
Declarations
Ethics approval and consent to participate
Ethical approval for this study was obtained from the Ethics Committee of
Hamadan University of Medical Sciences (IR.UMSHA.REC.1396.870). Before
interviews, interviewees were verbally informed about the study aim and
methods, confidential data management, and their freedom to voluntarily
withdraw from the study. Written informed consent was obtained from each
participant. All methods performed in the study were in accordance with the
relevant guidelines and regulations.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Received: 12 August 2023 Accepted: 22 February 2024
References
1. Becker TK, Gausche-Hill M, Aswegan AL, Baker EF, Bookman KJ, Bradley
RN, et al. Ethical challenges in Emergency Medical Services: controversies
and recommendations. Prehosp Disaster Med. 2013;28(5):488–97.
2. French E, Casali GL. Ethics in emergency medical services–Who cares? An
exploratory analysis from Australia. 2008.
3. Sandman L, Nordmark A. Ethical conflicts in prehospital emergency care.
Nurs Ethics. 2006;13(6):592–607.
4. Ripley E, Ramsey C, Prorock-Ernest A, Foco R, Luckett S Jr, Ornato JP. EMS
providers and exception from informed consent research: benefits, ethics,
and community consultation. Prehosp Emerg Care. 2012;16(4):425–33.
5. Bremer A, Herrera MJ, Axelsson C, Martí DB, Sandman L, Casali GL.
Ethical values in emergency medical services: a pilot study. Nurs Ethics.
2015;22(8):928–42.
6. Afshari A, Torabi M, Navkhasi S, Aslani M, Khazaei A. Navigating into the
unknown: exploring the experience of exposure to prehospital emer-
gency stressors: a sequential explanatory mixed-methods. BMC Emerg
Med. 2023;23(1):136.
7. Mirzaei A, Mozaffari N, Soola AH. Occupational stress and its relationship
with spiritual coping among emergency department nurses and emer-
gency medical services staff. Int Emerg Nurs. 2022;62:101170.
8. Afshari A, Khalili A, Dehghani M, Beiramijam M, Lotf M, Noodeh F, et al.
Comparing the frequency of occupational injuries among medical emer-
gency staff and nurses of intensive care units in Hamadan. Ann Trop Med
Public Health. 2017;10(3):646–50.
9. Afshari A, Borzou SR, Shamsaei F, Mohammadi E, Tapak L. Perceived
occupational stressors among emergency medical service providers: a
qualitative study. BMC Emerg Med. 2021;21(1):1–8.
10. Afshari A, Borzou SR, Shamsaei F, Mohammadi E, Tapak L. Emergency
medical service providers’ perception of health-threatening stress-
ors in emergency missions: a qualitative study. Ethiop J Health Sci.
2021;31(3):517–24.
11. Torabi M, Borhani F, Abbaszadeh A, Atashzadeh-Shoorideh F. Barriers to
ethical decision-making for pre-hospital care professionals. Nurs Ethics.
2020;27(2):407–18.
12. Lewis S. Qualitative inquiry and research design: Choosing among five
approaches. Health Promot Pract. 2015;16(4):473–5.
13. Hsieh H-F, Shannon SE. Three approaches to qualitative content analysis.
Qual Health Res. 2005;15(9):1277–88.
14. Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative
research (COREQ): a 32-item checklist for interviews and focus groups. Int
J Qual Health Care. 2007;19(6):349–57.
15. Graneheim UH, Lundman B. Qualitative content analysis in nursing
research: concepts, procedures and measures to achieve trustworthiness.
Nurs Educ Today. 2004;24(2):105–12.
16. Lugtenberg M, Burgers J, Westert G. Effects of evidence-based clinical
practice guidelines on quality of care: a systematic review. BMJ Qual Saf.
2009;18(5):385–92.
17. Grol R, Grimshaw J. From best evidence to best practice: effective imple-
mentation of change in patients’ care. Lancet. 2003;362(9391):1225–30.
18. Van Achterberg T, Schoonhoven L, Grol R. Nursing implementation sci-
ence: how evidence-based nursing requires evidence-based implemen-
tation. J Nurs Scholarsh. 2008;40(4):302–10.
19. Ebben RH, Vloet LC, Verhofstad MH, Meijer S, Mintjes-de Groot JA, van
Achterberg T. Adherence to guidelines and protocols in the prehospital
and emergency care setting: a systematic review. Scand J Trauma Resusc
Emerg Med. 2013;21(1):9.
20. Symons P, Shuster M. International EMS Systems: Canada. Resuscitation.
2004;63(2):119–22.
21. Afshari A, Khodaveisi M, Sadeghian E. Exploring the educational chal-
lenges in emergency medical students: a qualitative study. J Adv Med
Educ Prof. 2021;9(2):79.
22. Blackwell TH, Halsey RM, Reinovsky JH. Emergency medical technician
training for medical students: a two-year experience. Prehosp Emerg
Care. 2016;20(4):518–23.
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Page 8 of 8
Khazaeietal. BMC Emergency Medicine (2024) 24:38
23. Brown D, Zimitat C. On the road: medical students’ experiences on para-
medic placements. Med Teach. 2012;34(1):e9–14.
24. Almost J, Wolff AC, Stewart-Pyne A, McCormick LG, Strachan D, D’souza
C. Managing and mitigating conflict in healthcare teams: an integrative
review. J Adv Nurs. 2016;72(7):1490–505.
25. Larkin GL, Fowler RL. Essential ethics for EMS: cardinal virtues and core
principles. Emerg Med Clin North Am. 2002;20(4):887–911.
26. Gunnarsson B-M, Stomberg MW. Factors influencing decision making
among ambulance nurses in emergency care situations. IntEmerg Nurs.
2009;17(2):83–9.
27. Borhani F, Abbaszadeh A, Moosavi S. Status of human dignity of
adult patients admitted to hospitals of Tehran. J Med Ethics Hist Med.
2014;7:132–40.
28. Shahriari M, Mohammadi E, Fooladi MM, Abbaszadeh A, Bahrami M. Pro-
posing codes of ethics for Iranian nurses: a mixed methods study. J Mixed
Methods Res. 2016;10(4):352–66.
29. Takeyama H, Itani T, Tachi N, Sakamura O, Murata K, Inoue T, et al.
Effects of a modified ambulance night shift system on fatigue and
physiological function among ambulance paramedics. J Occup Health.
2009;51(3):204–9.
30. Dawson D, Zee P. Work hours and reducing fatigue-related risk: good
research vs good policy. JAMA. 2005;294(9):1104–6.
31. Jansen N, Van Amelsvoort L, Kristensen T, Van den Brandt P, Kant I. Work
schedules and fatigue: a prospective cohort study. Occup Environ Med.
2003;60(suppl 1):i47–53.
32. Reichard AA, Marsh SM, Tonozzi TR, Konda S, Gormley MA. Occupational
injuries and exposures among emergency medical services workers.
Prehosp Emerg Care. 2017;21(4):420–31.
33. Alexander DA, Klein S. Ambulance personnel and critical incidents:
impact of accident and emergency work on mental health and emo-
tional well-being. Br J Psychiatry. 2001;178(1):76–81.
34. Brent D, Beland L-P. Traffic congestion, transportation policies, and the
performance of first responders. J Environ Econ Manag. 2020;103:102339.
35. Rhodes N, Pivik K. Age and gender differences in risky driving: The roles of
positive affect and risk perception. Accid Anal Prev. 2011;43(3):923–31.
36. Colwell CB, Pons PT, Pi R. Complaints against an EMS system. J Emerg
Med. 2003;25(4):403–8.
37. Dejean D, Giacomini M, Welsford M, Schwartz L, Decicca P. Inappropri-
ate ambulance use: a qualitative study of paramedics’ views. Healthcare
Policy. 2016;11(3):67.
38. Pekanoja S, Hoikka M, Kyngäs H, Elo S. Non-transport emergency medical
service missions–a retrospective study based on medical charts. Acta
Anaesthesiologica Scandinavica. 2018;62(5):701–8.
39. Patel A, Vissoci JRN, Hocker M, Molina E, Gil NM, Staton C. Qualitative
evaluation of trauma delays in road traffic injury patients in Maringá,
Brazil. BMC Health Serv Res. 2017;17(1):804.
40. Pourshaikhian M, Gorji HA, Aryankhesal A, Khorasani-Zavareh D, Barati A.
A systematic literature review: workplace violence against emergency
medical services personnel. Arch Trauma Res. 2016;5(1):11–25.
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