Barriers to ethical decision-making for pre-hospital care professionals

Abstract

Background:

Emergency care providers are frequently faces with situations in which they have to make decisions quickly in stressful situations. They face barriers to ethical decision-making and recognizing and finding solutions to these barriers helps them to make ethical decision.

Objectives:

The purpose of this study was to identify barriers of ethical decision-making in Iranian Emergency Medical Service personnel.

Methods:

In this qualitative research, the participants (n = 15) were selected using the purposive sampling method, and the data were collected by deep and semi-structured interviews. Finally, the data are analyzed using the content analysis approach.

Ethical considerations:

Permission to conduct the study was obtained from the Ethics Committee of the Shahid Beheshti University of Medical Sciences. The objectives of the study were explained to the participants and written consent was received from them. Also, participants were assured that necessary measures were taken to protect their anonymity and confidentiality.

Findings:

The results of the analysis are classified in five main categories. It encompasses the following areas: perception of situation, patient-related factors, input and output imbalance, uncoordinated health system, and paradoxes.

Conclusion:

Emergency Medical Service personnel make ethical decisions every day. It is important that prehospital personnel know how to manage those decisions properly so that clients’ moral rights are respected. Hence, by identifying the dimensions and obstacles of ethical decision-making in Emergency Medical Service personnel, it is possible to enhance the moral judgment and ethical accountability of the personnel and develop the strategies necessary for ethical decision-making in them.

Keywords

Content analysis Emergency Medical Services ethical decision-making prehospital

Introduction

All professional carers face ethical challenges in all contexts of care. Prehospital emergency care is not excluded from this rule.¹ Emergency Medical Service (EMS) is part of the chain system for the care of patients. Its purpose is to transport acutely ill or injured patients to medical centers and provide advanced emergency services and medical care fairly, quickly, and efficiently.² EMS personnel to prevent death and permanent disabilities immediately have to make decisions and treat patients urgently.³ Ambulance personnel often confront perilous and unpredictable situations in which decision-making puts great pressure on them, particularly when they face ethical dilemmas.⁴

In Iran, EMS response begins with a telephone call to 115. The EMS dispatcher transfers the information about the medical emergency to the nearest prehospital emergency station, if necessary. EMS personnel arrive on the scene in the shortest possible time. This process can be divided into two general categories: (1) From the telephone call until the arrival on the scene (before intervention) and (2) from the arrival on the scene until the emergency medical care (intervention process) is provided. While performing these steps, the EMS personnel must take an appropriate decision when they face ethical challenges. The ethical challenges before the intervention starts include fighting stigma⁵ and maintaining the security of the ambulance and themselves (the workers). The challenges during the therapeutic intervention include beneficence/non-maleficence (do no harm), informed consent,^6,7 refusal of treatment and transport,⁸ transporting non-emergency patients,⁹ respecting privacy,^10,11 encounter with terminally ill patients, and futile resuscitation.¹² Gunnarsson and Warrén Stomberg, during an interview with ambulance nurses, delineated five main categories of factors that affect decision-making. These include the type of event (factors related to the patient), external factors (time and distance, environment, security), communication and collaboration (with dispatch room, colleagues, senior’s performance), knowledge, and ethical problems.¹³ Also, in a qualitative study, the main factors for the treatment and transport of prehospital patients were proposed as “the patient’s condition,” and “the unique characteristics of EMS missions and personnel.”¹⁴ Research has shown that differences in the approach of EMS personnel to individual and organizational ethical reasoning have an effect on their ethical decision-making (EDM) method.¹⁵ Iserson et al.¹⁶ also stated that in difficult circumstances, the decision to stay or leave ultimately depends on an individual’s risk assessment and value system.

Many of the ethical conflicts faced by prehospital staff are common with nurses working in a hospital. EMS personnel, like nurses, have a wide range of ethical elements to take ethical decisions that affect and determine their actions. The multidimensional nature of the factors affecting the ethical decision, with ethical, scientific, professional, legal, social, and cultural elements, leads to greater complexity and uncertainty in nurses when faced with ethical challenges.¹⁷ Of course, despite the existence of common elements affecting decision-making, due to difference in decision-making context and conditions, the EDM barriers and strategies are different in hospital and prehospital situations.

Various structural models for EDM in nursing have been introduced by different authors, often overlapping in the decision-making process.¹⁸ In the prehospital setting, there are few EDM models, but we have little knowledge of their strategies and barriers of EDM.

Knowing systematic decision-making models and exploring the experiences of care providers help identify gaps in understanding the issue or differences in value systems (controversies) among stakeholders (interdisciplinary teams) through transparent communication.^18,19

The results indicated that different factors affect healthcare providers’ EDM process. There are many questions on this topic. For example, what issues and ethical challenges do EMS personnel face? And, what are the obstacles to EDM for EMS personnel? Furthermore, the identification of obstacles to EDM reduces stress and anxiety for the personnel,^14,20 and increases motivation, job satisfaction, competence, and the healthcare quality by the personnel.^2,21 Qualitative research involves asking participants about their experiences of things that happen in their lives. This type of research has an exploratory nature, and to describe a phenomenon, words are used instead of numbers.²² It is difficult to investigate participants’ reasoning in decision-making with statistical values. Therefore, it seems that qualitative research is a proper way to identify ethical reasoning and the analysis and perception of the conditions and factors that affect EDM. On the contrary, due to the limited number of qualitative studies on EMS personnel’s EDM obstacles in Iran, this study was conducted to identify the barriers to EDM for EMS personnel.

Objectives

The purpose of this study was to identify barriers of EDM in Iranian EMS personnel.

Methodology

This qualitative study was carried out in Iran, using content analysis approach, in 2015. Qualitative content analysis is one of research methods used to analyze text data. Techniques of qualitative content analysis seek to classify the discussion material into an efficient number of categories that represent similar meanings. Depending on the relationships between subcategories, researchers can organize or combine this larger number of subcategories into fewer categories. According to Hsieh and Shannon, qualitative content analysis can be defined as a “the research method for the subjective interpretation of the content of text data through the systematic classification process of coding and identifying themes or patterns.” In other words, content analysis permits researchers to interpret subjective data in a scientific style, without using preconceived categories.²³

Participants

The participants of this study included EMS personnel working in some of the major cities of Iran, including Tehran and Hamadan (nine and six samples, respectively). Participants of the study included five Bachelor of Science (BS) in EMS, three emergency medical technicians (EMTs), five BS in nursing, and two Master of Science (MSc) in nursing. Participants’ age range was 26–43 years. They had a mean work experience of 7.5 years. In all, 15 EMS personnel, working in urban and roadside prehospital emergency centers, were selected through the purposive sampling method and the sampling continued until data saturation. After 12 interviews, no new data were obtained indicating data saturation; however, to further ensure, three other interviews were performed. The inclusion criteria to participate were as follows: being a volunteer for participation and at least 3 years work experience. To ensure diversity, participants were chosen from different age groups with various educational levels and work experiences.

Data collection

In-depth semi-structured interviews were used for data collection. The interviews were recorded as audio files (MP3) and subsequently transcribed verbatim. All interviews, in a quiet place and outside of working time, were conducted by the first author and lasted between 45 and 70 min. Before starting the main questions of the interview, the researcher gave explanations and examples of ethical challenges and moral dilemmas to participants in order to have an obvious understanding of the concept. The interviews began with demographic information and then open and general questions were asked about decision-making obstacles when facing ethical issues; that is, “can you tell me about the dilemmas and obstacles you encountered when EDMs.” Then, in order to better understand and identify the EDM obstacles, other questions were raised in conformity with the goals of the research. The questions included “Have you encountered an ethical dilemma that you could not make the right decision?” “Can you explain more about it?” and “Can you give an example?”

Data analysis

In analyzing data, researchers have the choice between two main pathways: inductive content analysis (conventional content analysis) or deductive content analysis (directed content analysis). In inductive content analysis, coding categories are derived directly and inductively from the raw data. In this study, data analysis was conducted to coincide with data collection based on Lundman and Graneheim proposed method.

Interviews were read several times to understand the participants’ statements from their point of view. Extracted codes were categorized at the same time based on similarities and differences. The categories were compared with each other and main categories, and more abstract themes were extracted from analysis and interpretation of data.²³

Rigor

Several methods were applied to determine the credibility of data, such as prolonged engagement of researcher with the data, member, and the peer-checking techniques. To confirm the results given to contributing members, the participants were asked to check the data and confirm the results with the researcher’s interpretation. To perform peer check, the codes and themes obtained from the findings of this study were given to two faculty members specializing in qualitative researchers, and they approved the accuracy and conformity of the data with the codes and categories. Also, these codes and categories were reviewed and approved by two expert personnel who were involved in the study. To ensure transferability of the study, the researcher prepared a detailed description of research process, and interviews and participants were selected purposively. Also, to ensure dependability of findings in this research, two researchers were asked to do an accurate audit of the process of data collection and analysis. To help conformability of the research, the whole stages of the research, as a detailed report, were documented including details of purposive sampling and data collection and analysis process.

Ethical considerations

The research project was approved by the Ethics Committee of Shahid Beheshti University of Medical Sciences (code: SBMU2.REC.1394.119) before the study began. Written informed consent was obtained from all participants prior to enrolment and they were assured that their private information would remain confidential and their audio files will be deleted after data analysis.

Results

After data analysis, About 590 initial codes were gathered from all the interviews. Moreover, after reviewing several times, the codes were briefed and classified based on resemblance and appropriateness. Finally, five main categories and several subcategories were extracted including situation perception, patient-related factors, input and output imbalance, uncoordinated health system, and paradoxes. The main categories and subcategories are shown in Table 1.

Table 1.

Main categories and subcategories of the research.

Subcategories	Main categories
Situation perception	The atmosphere on the scene
	Futile care
	Stigma/prejudge
Patient-related factors	Patient’s characteristics
Patient-related factors	Economic and cultural status
Input and output imbalance	Expectations
	Lack of knowledge/experience
	Weakness of support/welfare services
	High workload
Uncoordinated healthcare system	Poor therapeutic communication
Uncoordinated healthcare system	Mutual distrust
Paradoxes	Conflict between law and ethics
Paradoxes	Conflict of values and beliefs

Situation perception

The atmosphere on the scene. Prehospital personnel cannot have a clear plan for their mission, and they often make decisions based on the situation on the event scene.

It is true that we prepare ourselves before entering a scene, but our decision depends on the atmosphere and the circumstances of the scene…Sometimes, because of the circumstances, we might do something which is not beneficial for the patient, but we have to do it. (Participant No. 12)

Futile care. Feeling useful and valuable in the process of the patient’s resuscitation is one of the most important incentives that encourage EMS personnel to perform a task.

To start CPR, the most effective factor is the chance of the patient’s survival. We usually do not resuscitate if the patient is elderly and resuscitation is not likely to be useful for the patient. (Participant No. 3)

Stigma/prejudge. One of the factors affecting EMS personnel’s EDM before medical intervention is prejudice. Examples include providing care to terminally ill cancer patients, drug addicts, alcoholics, sex workers, and the like.

While dealing with addicts, I was sometimes impressed and I did work beyond duty. But sometimes, because of his/her character, I did not think the patient deserved intervention. (Participant No. 6)

Patient-related factors

Patient’s/illness characteristics. Some characteristics, such as the patient’s age and decision-making competence, life expectancy, and chronic diseases, affect the EMS personnel’s EDM.

If the patient’s condition is critical, we make all effort to save him/her. But, if we transport end-stage and elderly patients with chronic problems, we face a lot of pressure and unrealistic expectations of patients. (Participant No. 11)

Economic, cultural, and religious status. Familiarity with the patient’s economic and cultural status, religious beliefs, and his or her family might have an influence on the EDM of the EMS personnel.

We often help transport those who have financial difficulty or those who live alone, and sometimes, my colleagues have even financially helped patients and their families. (Participant No. 7)

Input and output imbalance

Means of input and output imbalance is inequality between the haves and the expectations that others have of personnel EMS. For example, factors such as the lack of welfare facilities, the lack of clinical decision-making protocols, and high work pressure are not proportionate to the expectations of authorities and patients from the personnel EMS.

Expectations. Sometimes, patients and their families resist emergency personnel’s decisions and make unreasonable requests to transport non-emergency patients. In such circumstances, not only do these requests go against organizational rules, but they also increase the workload of the personnel.

We said it was not an emergency, and the physician must simply prescribe an analgesic. They (the patient’s family) said they knew it was not an emergency; they wanted to transport the patient to the hospital anyway. (Participant No. 9)

Lack of knowledge/experience. The most important factor mentioned by the EMS personnel was their personal experience of missions and collaboration with experienced colleagues.

I did it when I had little experience, but I will never do it again and transport the patient. Bad experiences guide me in similar cases in the future. (Participant No. 10)

Support/welfare services weakness. Weak organizational support, the lack of clear protocol, uncertain authorities, inadequate funding, and liability insurance might affect EMS personnel’s decisions.

Even if a patient has written consent for do not resuscitate (DNR), we do not have written permission to ignore it and we have to perform it for our job safety. (Participant No. 6)

Even if a patient has given us written consent for not conducting resuscitation, we don’t have the written permission to ignore it, and we have to do it for our job safety. (Participant No. 10)

High workload. Factors like out-of-scope duties, a large number of missions, and control room operators sending an ambulance without investigating whether there is a real need for emergency services could lead to fatigue, reduced physical capacity, and reduced motivation among EMS personnel.

Sometimes, we give services that are not in our scope of professional practice. For example, we may have to go to a car repair shop during the work shift. Obviously, we cannot make the right decision when we are so tired. (Participant No. 10)

Uncoordinated healthcare system

Weak therapeutic relationship. Weak therapeutic relationships impair the personnel’s roles and responsibilities, and the achievement of healthcare objectives becomes almost impossible. Sometimes, the interactions between the EMS personnel and the patients are disrupted due to weakness in therapeutic relationship skills, emergency situations, emotional load, different cultural areas, family problems, and life-threatening diseases.

Most of the time, we do our work properly. But if it is not explained to the patient, we face trouble that is rooted in weak communication skills. (Participant No. 11)

We were under a lot of pressure and didn’t know what to do…When the police arrived, instead of calming down the atmosphere, they made it even tenser. (Participant No. 13)

Mutual distrust. Legally, the decision to start any medical intervention should be taken after consultation with the medical director. However, sometimes, EMS personnel refrain from this consultation. One of the main reasons is distrust in the director, which may be due to the latter’s lack of experience and/or awareness about the facilities and conditions of EMS, as well as the possibility that she or he may give instructions that are inappropriate for the situation.

Sometimes, some of my colleagues and I don’t consult with the physician (medical director). It is mainly due to inappropriate behavior and their low scientific knowledge. (Participant No. 10)

Paradoxes

Conflict between law and ethics. Respecting the patient’s wishes is an ethical principle that must be considered. But the EMS staff may not accept the patient’s request in special situations and to avoid legal trouble.

It is not always possible to perform all emergency services in the framework of law…Sometimes, it is necessary to support the family, which is time-consuming. On the other hand, we are also under pressure to complete the mission quickly. (Participant No. 8)

Conflict of values and beliefs. The personal values and beliefs of the EMS personnel do not always conform to their professional ethical values, the patient’s values, or the organization’s values. This makes EDM difficult for the EMS personnel.

When we entered the wedding, the patient and her attendants/family members were not dressed appropriately (hijab)…We were not comfortable. (Participant No. 8)

Discussion

EDM refers to the process of evaluating and choosing between options in a manner consistent with ethical principles. EDM helps individuals make difficult choices when faced with an ethical dilemma, a situation in which the right or wrong answer is vague. Making ethical decision, especially in emergency situations, is not easy and there are many obstacles in this regard.

According to the findings, the barriers to EDM were classified into five main categories. These included “situation perception,” “patient-related factors,” “input and output imbalance,” “uncoordinated health system,” and “paradoxes.”

The category of “situation perception” includes the subcategories of “the atmosphere on the scene,” “futility,” and “stigma/prejudge.”

The role of the atmosphere on the scene in decision-making: Decision-making in fast-paced and uncertain environments, in which the patient and bystanders may behave violently, can create distractions and disrupt care delivery.²⁴ In a qualitative study, Svensson and Fridlund²⁰ stated that a factor that creates stress for ambulance nurses is uncertain emergency situations. Results have shown that before carrying out any intervention, EMS personnel first consider the scene situation and the consequences of their decisions.³ Ebrahimian et al. found that undesirable emotional conditions on an accident scene might affect EMS personnel’s decision to transport the patients to hospital. So, if they are late in arriving on the accident scene, they usually transport patients immediately to reduce tension and minimize challenge.¹⁴ Gunnarsson and Warrén Stomberg showed that the time limit and unpredictability of the event could affect ambulance nurses’ decision-making. The accident scene, the presence of bystanders, and their expectations might also affect their EDM.¹³ The results of these studies were consistent with the experiences of EMS personnel.

The role of the futile care in EDM: Futile care should be determined according to physiological criteria and not value-based criteria. But, in some cases, the attendants’ expectations and pressure—especially, if it is someone close to the patient—could make the EMS personnel perform a futile CPR.¹³ According to Gunnarsson and Warrén Stomberg,¹³ being under pressure to start CPR while you know that it is useless is an ethical dilemma, and ambulance nurses behave in a way they would themselves like to be treated in the same condition.

The role of the stigma/prejudge in EDM: Stigmatization in prehospital situations may occur in relation to the patient’s disease (mental and end-stage patients), location, and providing care to alcoholics, drug addicts, or sex workers. Prejudices and stigmas can affect the medical care by EMS staff.⁵ The participants’ experience showed that they do not have a positive image when they face addicts or mental patients. The EMS staff reluctantly provide primary care to them. Pluralism is the dominant culture of Iran, which is evident from the social interactions, high interdependence among individuals, and the collective determination of values and norms. Patients and their family members are mostly concerned with their reputation and the attitude of people rather than the negative effects of problems like addiction, mental disease, or AIDS on the patient and themselves.²⁵ Despite religious and cultural beliefs related to helping people, there are some stigmatized attitudes among Iranian nurses and healthcare service providers. In the present study, stigmatized behaviors were observed in our participants.

Role of the patient-related factors (such as age, sex, and disease’ severity) in EDM: EMS personnel may treat pediatric patients like their own children and pay more attention to them. On the contrary, they may be less willing to offer life-supporting treatment to old patients with chronic diseases or those in a critical state. In their study, Gunnarsson and Warrén Stomberg¹³ emphasized that age is one of the most important factors that affect decision-making. These results are in line with the findings of the present study.

Role of the economic, cultural, and religious status of patients in the EMS staff’s EDM: When faced with poor families, the EMS personnel usually pay more attention to the patient’s expectations out of sympathy and compassion, regardless of their legal duties. In contrast, when a patient from an affluent family has a lot of expectations, they meet the expectation legally and within the scope of their professional duties.

The category of input and output imbalance comprises four subcategories: expectations, lack of knowledge and experience, weakness of support/welfare services, and high workload.

Inappropriate and irrational requests (such as unnecessary transport to hospital), a barrier to EDM: Results have shown that excessive and inappropriate use of EMS is a common problem for prehospital healthcare providers.²⁶ These causes lead to an increase in the workload and impose a significant financial burden on the prehospital care system.²⁷ Borhani et al.²⁸ also stated that factors like “families’ unrealistic expectations and lack of education about how to communicate with patients and their families” were the barriers to end-of-life care. These results are in line with those of the present study. The results of some studies have revealed that experience increases the scope of responsibility.²⁰ Also, previous experiences are tools to mentally prepare ambulance personnel for subsequent situations.^29,30 The results of some studies have shown that knowledge and experience are the most important factors to influence EDM and ethical reasoning.^13,31 These research findings are in line with the results of the present study.

The weakness of support/welfare services, a barrier to EDM: The results of a study have shown that EMS personnel who perceived weak support tended to transport all patients—even those who did not really need transportation to hospital.¹⁵ Salminen-Tuomaala et al.² found that receiving support and encouragement from the management promotes staff’s motivation. This result also supports the findings of the present study.

High workload, another barrier to EDM: the large number of missions, especially those after midnight which turn out to be non-emergency, decrease the motivation and concentration of EMS personnel.³² The study results indicated that a large number of missions, the lack of EMS stations, little sleep at night, the distance from the scene, and heavy traffic were among the factors that led to fatigue and lack of concentration of EMS personnel.^33,34 Patterson et al.³⁵ stated that a big proportion of EMS personnel suffer severe fatigue at work and generally have poor sleep quality, which contributes to adverse events or medical errors, and safety-compromising behavior.

Uncoordinated health system is another main category of EDM obstacles. It includes the subcategories of “poor therapeutic communication and mutual mistrust.”

Poor therapeutic communication, a barrier to EDM: Creating a good group relationship can improve work incentive and diminish medical errors by care professionals by giving them more chance to participate in decision-making and developing care quality.²¹ The results of some studies have shown that nurses’ EDM in resolving patients’ needs is influenced by the relationship of patients and their families with the medical care providers.^21,31

Mutual distrust between the medical director and EMS personnel, another barrier to EDM: Sometimes, because of unavailability and the lack of experience of physicians, the EMS staff are forced to consult their colleagues or other sources. It makes them to not have a desire to communicate with the medical director. Ebrahimian et al. noted that the availability of the medical director was an important factor in taking a decision on the patient. They also stated that novice physicians usually recommend that the patient is shifted, while the experienced physicians provide more constructive consultation.¹⁴ The lack of physicians in prehospital situations, medicines, medical equipment, and facilities in the ambulance posed decision-making dilemmas for EMS personnel.²

The conflict between law and ethics, and values and beliefs—barriers to EDM: In some situations, there is no specific protocol to guide the latter. Ignoring the ethical values of the personnel and patients which are inconsistent with the law is considered a dilemma and an impediment to EDM. Values lie at the core of the diverse world of human behavior. They are expressed in every human decision and action,³⁶ and are good scales for professional performances.²⁸ The root of the values’ conflict may be in religion or philosophy, which impedes EDM. As healthcare professionals encounter ethical problems, their individual values, self-view, and worldview influence the process of arriving at ethical decisions. Organizational culture and values also influence these decisions.³⁷ The EDM process is not formed only on the basis of personal values but is also influenced by the values of the organization and colleagues. These values mostly conflict with each other. So, while deciding on a patient, there is a struggle between personal and professional values, until a proper conclusion is reached.³⁸ Some studies have shown that conflicts arise among personal, professional, social, and institutional values in medical professions.^39,40 According to the findings of Siebens et al.,⁴¹ nurses cannot act according to their ethical values or share ethical issues with other members of the group. Although they have to repeatedly implement decisions that might be ethically wrong, they are expected to do it.⁴² The results of French and Casali revealed a gap between individual EDM approaches and organizational EDM in EMS. Hence, to maintain current standards of care, there seems to be a necessity to manage ambulance professionals’ stress and conflict levels caused by the differences between personal ethics and beliefs and the professional role and the organization.¹⁵ Casterle et al. indicated in their study that professional norms, laws, and rules influence most of the nurses’ decisions. Therefore, they may hold back their principles and values to conform to the ideas and expectations of others.⁴³ The results of these studies are in line with the findings of this research.

Conclusion

EMS personnel encounter different ethical conflicts every day. These conflicts involve the issues of resuscitation, futile therapy, consent, refusal of care, legality, and confidentiality. EMS personnel have difficulties in identifying moral dilemmas and determining the appropriate method to solve these moral dilemmas. They consider all aspects and consequences of their decision-making. However, in EDM, they face obstacles like work overload, insufficient time, organizational and financial constraints, lack of protection, the atmosphere of the event scene, conflicting values and norms, and inappropriate expectations of patients. EMS personnel’s decision-making in dealing with ethical challenges is affected by different factors that the discovery of the EDM barriers and resolving them can play an important role in reducing moral distress.

Advancing the knowledge of the EDM process can help professionals and practitioners identify and prevent situations in which immoral behavior may occur. Also, it can help them avoid a range of unethical decisions, from egregious mistakes to more trivial ones, which may lead to violations of ethical or professional behavior. Also, the findings of this study can be used to develop EDM models and organize EMS ethical codes.

Limitations and future research

This study has several limitations. The researcher tried to create a supportive and comfortable environment during the interviews. Nonetheless, some of the participants might have taken into account different personal and organizational considerations when sharing their experiences. Also, most participants in this study were nursing staff and not EMS providers (EMT, Paramedic); this can lead to difference in their decision-making due to a differing background in ethics and decision-making.

Given the fact that the history of the establishment of the EMT course in Iran is less than 12 years old, staff working in EMS centers, who have high work experience, are often nurses. Therefore, considering the diversity of academic courses and the different participants’ experiences in this study, it is difficult to generalize the participants’ experiences in this study to other studies. Therefore, it is recommended that researchers use staff with the same academic courses for future researches.

Barriers presented in this article are only some examples of those impeding EDM. Further research is required to assess the factors influencing EDM and provide practical strategies for EDM in prehospital personnel.

Footnotes

Acknowledgements

The authors thank all EMS staff who shared their valuable experiences through participating in this study.

Conflict of interest

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: The budget of this research was supported by Shahid Beheshti University of Medical Sciences, Tehran, Iran.

ORCID iD

Mohammad Torabi

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