Study design & methodology
The use of a qualitative exploratory approach was compatible with the objectives of the study. The rationale for using a qualitative exploratory approach in this study was based on the lack of empirical knowledge about the phenomenon in relation to the situation, group, activity or processes which needed to be explored and examined and contained elements worth discovering [60]. Reid-Searl & Happell, (2012) suggested that a qualitative exploratory design enables the researcher to investigate and comprehend a subject when the literature is limited and enables participants to contribute to the development of new knowledge in the area under investigation. This shows that exploratory researchers who focus on the study's intended phenomenon have better capability in expressing and reporting findings [62]. Polit & Beck, (2012) stated that exploratory research fits within the naturalistic approach because it seeks to understand a phenomenon in depth and incorporates the perspectives of participants, particularly those who are experiencing the phenomenon under investigation [60]. Lederman, (1993) stated that exploratory research can be beneficial when the phenomenon is unclear or has received little investigation, as was the case in this study.
Data Collection
In exploratory research, individual face-to-face interviews and focus groups are used, and in this study a series of individual semi-structured interviews were completed with SRCA and ED staff. Semi-structured interviews are used when the researcher has a broad question which needs to be addressed, as was the case in this current study [65]. Face-to-face interviews are the most common data collection technique in qualitative research because of the informal and comfortable atmosphere created between an interviewer and the interviewee [62]. This technique was appropriate for use in this study because time and place are sensitive issues for HCPs who work in the SRCA and hospital EDs [66]. A semi-structured interview guide provided a set of questions which was informed by the aim and objectives of this study.
Research settings and sampling
This study was undertaken in two different healthcare organizations, the SRCA and three ED in Riyadh. Riyadh is the capital city of the KSA and is located in the centre of the kingdom. It has previously experienced a number of emergency situations [4]. In Riyadh, there is one operations centre and 46 ambulance care services.
This study included participants from the operations centre and two of the ambulance stations. The remaining ambulance care centres were not included in this study because of their wide geographical spread.
The second population involved in data collection was HCPs in three ED (these hospitals are referred to as A, B and C respectively in the current study). The participants recruited were those who were authorised to communicate and coordinate with various professionals during emergency situations in terms of response and disaster management priorities.
The inclusion criteria for a sampling strategy should be developed in such a way that they contribute to the generation of detailed information and are consistent with the methodological approach used [67]. Using the SRCA’s own classification of the professionals who work in the SRCA, Researchers identified the professionals involved in communications as potential participants. These were call takers, medical dispatchers, field supervisors and paramedics.
In the ED, the inclusion criteria helped me to identify different professionals who were responsible for communicating with various key personnel inside and outside the hospital environment. These were ED nursing managers, ED physicians/consultants and senior paramedics
Data Analysis
Qualitative data analysis involves a range of processes whereby the researcher moves from data collection into a form of explanation, understanding and interpretation of the phenomenon being investigated [68]. According to [69], data analysis in qualitative research is a continuous process which lasts from the beginning to the end of data collection. The purpose of qualitative data analysis is to organize and provide a structure for eliciting meaning from the data [63]. Patton, (2014) confirmed that qualitative analysis involves transforming data into findings. Speziale et al., (2011) pointed out that qualitative data analysis highlights the experience of the participants whose lives are deeply involved with the phenomenon under investigation. The data analysis approach adopted in this study was thematic analysis. This has been defined by [1] as an approach designed to identify, analyse and discover models within the data in order to organise and describe the data set in an in-depth way.
These models can provide the researcher with a greater insight into the interpretations and experiences put forward by the participants involved in the study [1]. The thematic analysis method developed by [1] involves six phases: familiarizing oneself with data, generating initial codes, searching for themes, reviewing themes, defining and naming themes, and producing a report. A total of 62 interviews were fully transcribed and translated and the transcripts were read and re-read line by line and imported into NVivo 11 software (NVivo, 2021). This was phase one of Braun & Clarke, (2006) thematic analysis approach. This was followed by phase two, which involved generating initial codes from the data [1].
Saldaña, (2021) described a code in qualitative research as a word or short phrase which symbolises and captures an attribute from language or visual data, in this case, the interview transcripts. After completing the coding process, an initial list of codes and the frequency of their occurrence was produced. I then moved to searching for themes, which is phase three of the thematic analysis framework. During this stage, I created a table of codes to help to generate themes and related sub-themes. The themes generated at this stage were reviewed and further refined with the research team (BA, KG, GP and KM) to ensure that codes were relevant to each theme. In phase four, all the themes generated in phase three were reviewed, information which was deemed irrelevant was removed and some themes were collapsed into each other. The final themes were then checked by the supervisory team. A written analysis was produced relating to the theme-based analysis of the literature and research questions.
Findings
Participants
Semi-structured interviews were conducted with 62 participants from both the SRCA (n=18) and from ED hospitals (n=44). Data were collected from face-to-face interviews with participants from SRCA settings. Ten were recruited from the SRCA operations centre and included call-takers, dispatchers and field supervisors, and eight paramedics were recruited from two ambulance care services. All participants from the SRCA were Saudi, male and aged between 25 and 40+ years (in the KSA, before 2020, females were not permitted to work in the SRCA as paramedics or in the operations centre). All participants from the SRCA had more than five years of experience of working with the SRCA. (Table 1)
In the EDs hospitals, a total of 44 participants aged between 25 and 40+ years participated. The sample comprised 19 ED nurse managers (males and females) from diverse backgrounds; six were from the Philippines, four from India, two from South Africa, one from Egypt, with five from Jordan and one from the KSA. The study also included 12 ED physician consultants and 13 ED paramedics, all of whom were male (there are female ED physicians in KSA, but all of the ED physician consultants who volunteered to participate in this study were male). ED participants were recruited from three different ED hospitals referred to as A, B and C (Table 2, Table3, and Table4)
In this study, data saturation was achieved once no new themes or subthemes were identified by the research team [66]. The interviews were completed between February and April 2019.
Key themes
Findings are presented in three themes with illustrative quotes to convey the perspectives ideas and beliefs of the participants captured through the thematic analysis.
Theme 1. The emotional impact on SRCA staff performance
This theme focuses on the emotional well-being of SRCA operations centre staff. These staff members described feelings of anxiety, nervousness, sadness, fearfulness, frustration and/or tiredness in relation to their work. These workplace-related emotions appeared to have consequences for their decisions regarding receiving and dispatching emergency medical calls to the relevant staff and also played a role in the delayed response discussed below in theme 2. SRCA operations centre staff described the degree to which they felt supported by their organisation. Daily work in an environment which required them to constantly understand and relay information about traumatic incidents appeared to have an impact on their emotional state. This was illustrated by one of the call-takers:
I start my day receiving bad information about incidents ... can you imagine that we spend eight hours every shift just listening to negative news? Receiving calls about the injured, families telling us their loved one has died, or someone reporting a mass causality incident, and more than this ... sometimes I think about these incidents and I feel fear, and I call my wife to check on her and my children.
RCC2, call-taker, SRCA
In addition to the distress caused by the content of the telephone calls, many structural factors appeared to compound the stress. Among these factors were the limited number of staff at the SRCA operations centre (two call-takers and two dispatchers per shift) and the 60-second time limit for each call prescribed by their organisation. SRCA participants indicated that they receive a huge number of emergency calls for the entire Riyadh region, and the majority of the call-takers and dispatchers described how these issues increased their anxiety:
We cover all the Riyadh emergency medical calls. Usually, two call-takers work each shift, and sometimes one person will cover all the Riyadh emergency medical calls, if the other staff are on sick leave or absent, or any reason ... in each shift, we receive 800-1000 calls.
RCD1, dispatcher, SRCA
it’s stressful that our performance related to the time spent on a call is monitored. If we spend more than 60 seconds on each call, we will be under investigation.
RCC3, call-taker, SRCA
SRCA operations centre staff described how callers’ misbehaviour combined with the burden of the workload were particularly stressful during emergency situations. A number of call-takers described instances of callers raising their voices over the phone, making it difficult for them to retrieve important information. These call-takers explained that they kept telling some callers not to raise their voice when they became emotional, and they reported that some female callers cried on the phone. These participants said that this behaviour from callers made them feel tense and sometimes led to them receiving unclear information, making their task of providing the appropriate help to the caller more difficult. One of the call-takers stated that:
… some people will keep shouting all the time, but I keep reminding them that if you want help, you must calm down and let me help you.
RSC3, call-taker, SRCA
… Sometimes the information on the location that we get from the caller is not clear. If the caller is a female, she will cry and scream during the call, which makes me feel nervous.
RCD1, dispatcher, SRCA
Non-emergency calls such as prank and fake calls made some of the call-takers uncomfortable as they were required to respond to each call and there were no protocols in place in the SRCA in relation to how to deal with such nuisance calls. It appears that this may have added to the workload of the call-takers and potentially increased the emotional impact as it limited their ability to respond to genuine emergencies in a suitable time frame:
… we receive hundreds of hoax calls, and there is no way to know if a call is genuine or not. We still send our paramedics based on the information that we get, and they will tell us if there is a genuine incident or not ...
RCC1, call-taker, SRCA
… we are required to respond to all calls and not to ignore any … sometimes, which happens a lot, there are some callers who just want to talk and make a joke … and the only thing I can do is to close the telephone, like this call may hinder another serious call.
RCC3, call-taker, SRCA
A similar issue was found with a number of SRCA paramedics who said that they felt discouraged when they arrived at the location of an incident and there was no incident. The need to respond to all incident reports, whether they are real or not, seemed to cause distress:
I feel frustrated when we receive a notification from the dispatcher about a case that needs to be transported and then it turns out not to be genuine. It is a stressful feeling that we must respond to all notifications, whether true or not.
RCP4, paramedic, SRCA
Limitations on organizational support made some call-takers feel frustrated in the absence of protection from these inappropriate calls. These call-takers mentioned that the only possible recourse is to complain about these prank or fake calls, not to the SRCA, but instead to the Emirate of the Riyadh region, which is a difficult and time-consuming process. It would seem that due to the serious impact which these hoax calls have on both call-takers’ and paramedics’ time, and the impact this might have on their ability to respond to real emergencies, the participants felt that they should have a mechanism in place to support them in dealing with such nuisance callers:
… There is one way to do this, which is to take the details of these callers and then to complain to the Emirate of the Riyadh region. But it takes time to get disciplinary action against those callers, it’s a complex, bureaucratic process.
RCC1, call-taker, SRCA
Unfortunately, there is no certain law in the SRCA to stop those people [hoaxers] from behaving like this ... we are disappointed from no support for us in this regard.
RCC2, call-taker, SRCA
It also seemed that many participants were worried about the impact of the workplace environment on their physical health. The majority of the SRCA operations centre staff described feeling unwell as a result of being in an enclosed space surrounded by communication devices with high oscillation. They described having some negative health symptoms and attributed these to the devices which they used at work:
When I receive a lot of calls by phone, I get earaches from time to time.
RCC1, call-taker, SRCA
We are surrounded by these devices and our room is full of high electronics and I always have headaches and sleep problems.
RCD1, dispatcher, SRCA
It is interesting to note that although these participants attributed these physical problems to their devices, they did not mention the possibility that working in a stressful environment could give rise to these issues. During the interviews, some participants from the SRCA operations centre said that they were aware that counselling for SRCA staff is present within the system, but this is mainly for on-site paramedics and not for operations centre staff. These staff used various strategies to deal with stress. One of the dispatchers explained that he reduced stress by engaging in some activities such as travelling in his free time and turning his phone off and not thinking about work when he was at home:
In the SRCA there is psychological support, but it is only given to the paramedics who need it ...
RCC3, call-taker, SRCA
... the only thing I do is travel on my days off, or when I go home I detach my mind from the work and I switch off my mobile.
RCD4, dispatcher, SRCA
counselling because of the ways that issues surrounding mental health and well-being are framed in Saudi culture. These participants believed that if colleagues learnt that they were seeking psychological support, their emotional stability might be put into question and they might lose the confidence of colleagues regarding their ability to perform their work effectively:
We suffer psychologically from seeing accident scenes and feel upset about some crisis situations ... The problem is that as soon as you say that you want psychological support no one will trust you because they think that those who ask for help are suffering from a mental illness, meaning that they’re crazy. This concept [seeking support] is still not acceptable in our culture ... so there’s nothing you can do except try to forget what you saw, which is difficult.
RCF3, field supervisor, SRCA
Theme 2. The effectiveness of the emergency response
Concerns with coordination and communication between SRCA and ED staff during disasters were described as often leading to unnecessary delays in responding to emergencies and in reaching and transporting casualties to EDs. Two subthemes, coordination between SRCA and EDs in responding to disasters, and the perceived effectiveness of the ICT used by EMTs, are included and discussed in detail in the section below along with related quotes.
Coordination between SRCA and EDs in responding to emergency situations
Coordination between SRCA medical dispatchers, SRCA paramedics and ED staff was found to be crucial for a fast response and the sharing of important information about an incident in a timely manner. Coordination between SRCA and EDs in relation to incident notification mainly occurs through SRCA dispatchers liaising between the ambulance services centre and ED hospital staff. The SRCA paramedics said that in the past they were informed only about an incident and that their responsibility after that was to communicate with the hospital and directly arrange the transportation of casualties. They described this process as being a waste of their time which impacted patients’ lives. Eventually, their organization delegated the tasks of searching for other hospitals to the SRCA dispatchers:
Before, we were only informed about an incident, and we had to respond and find a hospital that was able to accept the patient. This process was time-consuming for us and for the patient, and sometimes when we went to a hospital, they refused to receive the transferred case, either due to their lack of appropriate medical specialization or because there wasn’t enough bed capacity in the hospital.
RCP4, paramedic, SRCA
To facilitate patient transportation, it is important that ED staff are updated about the patient’s status. With this in mind, SRCA dispatchers provide ED staff with some information about the patients. However, SRCA paramedics are not permitted to call ED paramedics directly while on route from the site of an incident to the ED. As illustrated by some comments of SRCA paramedics below, this has an impact on the relationships between SRCA paramedics and ED staff because paramedics with injured patients often appear unannounced at the ED without having been able to give the ED prior warning:
… we are not allowed to contact ED paramedics to update them about the patient who’s being transported. Our dispatcher contacts the ED paramedics.
RCP6, paramedic, SRCA
… when we hand over a patient to the ED paramedics or ED nurses, they ask us why we didn’t call them first, but we are not allowed to.
RCP4, paramedic, SRCA
Some of the SRCA paramedics perceived that permitting them to make calls to the ED to update about the case transported might decrease the intensity of the conflict which happens with some hospitals during the handover between them. This was illustrated by some of SRCA paramedics as follows:
... I think if there is a prior call between us and with ED staff, just to update about injured that we transport, that may not have a conflict during the handover.
RCP2, paramedic, SRCA
As a result of this, ED physician consultants felt anxious about some SRCA paramedics not providing accurate information about the transported injured. According to some ED paramedics, exchange of patient information occurs during a face-to-face handover immediately upon the ambulance’s arrival at the hospital:
… There is no clear information in the handover with SRCA paramedics. In some cases, some of the SRCA paramedics bring the patient without handover, and some of the SRCA paramedics do the handover …
EDC1, ED physician consultant, hospital C
… Sometimes the SRCA operations centre sends us incomplete information or wrong diagnoses.
EDC1, ED physician consultant, hospital C
Some of the ED paramedics highlighted difficulties related to coordination with dispatchers. Participants stated that they received casualties in the emergency ward from the SRCA paramedics without being informed about them beforehand by the dispatcher:
… our problem with the dispatchers is always in coordination. Sometimes they inform us about incoming patients in five minutes before their paramedics arrive at our ED gate, and sometimes they will surprise us when we see them in the triage area with a patient without any prior call …
EBP2, ED supervisor paramedic, hospital B
In circumstances where prior notification from the SRCA is not provided, some of the ED nursing supervisors stated that this caused significant challenges and pressure related to a lack of forward information about new arrivals. One ED nursing supervisor said that preparing to receive a patient is time-consuming in the ED and involves the process of coordinating with other hospital wards to facilitate the evacuation of patients who had been admitted before the disaster and whose conditions were not related to the disaster:
… in major incidents, the process of patients’ admission takes some time. We have to evacuate the old patients in the ED to another ward in the hospital, and we have to contact the bed management, extra staff, and speciality team ...
EAN2, nursing supervisor, hospital A
As a result of the lack of communication, one ED nursing supervisor stated that on one occasion they received a number of critically injured cases at the same time due to RTIs which impacted on their ability to handle these patients, and during that incident, the hospital disaster code was set off:
… one time, we received twelve RTIs from the Red Crescent and it is not logical to send twelve injuries to one hospital without a prior call … and we activated the hospital disaster code.
EAN5, nursing supervisor, hospital A
Most of the participating SRCA paramedics highlighted issues related to coordination, saying that the information which they received from dispatchers was incomplete and sometimes incorrect, and that in some incidents which they attended did not conform to what the dispatcher had described. Participants said that they are only required to share information with the dispatcher on four occasions: to record the time of departure, to record the time of arrival at the incident, to record the time of departure from the incident, and finally to report arrival at the hospital and to seek guidance about where to go next:
… and unfortunately, some incidents that I attended were different from the information I received, and it depends on who informed the call-taker. The call-taker has the responsibility to clarify more about the information from the callers … The dispatcher will inform the paramedics about the basics of an incident, just the type of incident and the name of the street, and no other details.
RCP4, paramedic, SRCA
… we report to the dispatcher about the time of arrival, the time when we move from the location, and the time we leave the hospital after we transported the injured. Then we wait for the dispatcher’s order either to return to the location of the incident or to go to another incident site.
RCP7, paramedic, SRCA
Coordination between ED staff and other hospital departments often occurs through the Chief Executive Officer (CEO). ED nursing supervisors perceived that contacting the CEO facilitates their coordination with other hospital departments Some ED nursing supervisors reported difficulties when trying to contact some hospital departments such as the pharmacy in relation to accessing required medication for their patients when they had an influx of patients. This was illustrated by one of the ED nursing supervisors:
… we receive many different types of disaster on a daily basis … when the CEO is present, he solves everything very quickly with some departments in the hospital … he gives us the power to act, and each department in the hospital works collaboratively with us …
EDB6, ED physician consultant, hospital B
One time, within four hours we received 130 patients with bronchial asthma who’d had an adverse effect from the heavy rain. There was a delayed response from the pharmacy when we requested medical supplies like Ventolin, magnesium sulphate and oxygen cylinders. I contacted the CEO after the pharmacy refused to supply us because they said that we had used large quantities of these medications …
EDN2, ED nursing supervisor, hospital C
Although ED nursing supervisors felt confident about contacting the CEO directly, a number of ED paramedics felt frustrated that their work was not being valued and many suggested that their role was reduced to providing patient transportation within the hospital. The ED physician consultants are informed by ED paramedics about medical cases received from SRCA dispatchers. ED physician consultants alone have the power to decide whether or not to receive patients inside the hospitals. The opinions of ED paramedics are not given any importance and these ED paramedics believe that they are not treated as members of the professional health-care team:
… in relation to cases transported to us by SRCA paramedics, our responsibility as the EMS in the hospital is only to relay information that we have received from the SRCA dispatcher to the ED physician consultants ... We don't have any authority to accept or refuse a case and we have no authority to provide care to transported patients. We are frustrated that our work in the hospital is limited to internal and external transportation ... we feel undervalued by other hospital staff who see us only as ambulance drivers.
EBP2, ED supervisor paramedic, hospital B
ED paramedics within each health sector have their own rules which provide them with little authority. This was explained by a number of paramedics, who said that there are some differences in what they are permitted to do and that for some the restrictions are less than others. For example, paramedics working in hospitals not under the control of MoH management (for example, military hospitals and the King Faisal research specialist hospital) it appears have more scope for extended practice:
We are different from the ED paramedics who are working in different hospitals which are not under the MoH rule, such as King Faisal and in military hospitals, where they are allowed to treat the critical patients and they can help the ED physicians, they are more skilful than us ...
EBP3, ED paramedic, hospital B
The perceived effectiveness of the ICT used by EMTs
The data acquired from the interviews demonstrated that SRCA staff and hospital EDs communicate primarily through telephone systems, including landlines, a wireless radio system called TETRA and mobile phones. A significant number of participants reported how using these tools facilitates their needs in response through communication within and between SRCA and ED hospital staff. A number of participants thought that the provision of accurate information from the dispatcher to the paramedics regarding the location of the incident was important for a fast response. SRCA staff described how they felt that unnecessary delays in response to incidents were related to the communication systems which they used. For example, some of the SRCA paramedics stated that they were not provided with navigation devices in their ambulances, which meant that they had to receive information on the location of an incident verbally from the dispatchers on their TETRA device. The location information which was received from the SRCA dispatchers was often inaccurate, leading to time being wasted trying to find the incident location. As a result, these participants reported that they used Google Maps on their mobile phones, which they regarded as being easier to use than having to listen for the location of the incident through the TETRA device:
… we receive the location of the incident from the dispatcher through TETRA. Sometimes the location of the incident that we receive is unclear and it takes time for us to get to the location ... we are not provided with screen navigation in our ambulances. We use Google maps on our personal mobile phones to identify the location of the incident, which is better than getting the location from the dispatcher through TETRA.
RSP6, paramedic, SRCA
The inappropriateness of the CAD system for determining the location of an incident was identified as an issue by some of the call takers. The CAD system is dependent on GPS, which does not always relay information about the exact location of an incident. As one of the call takers said:
… the problem is that our GPS navigator in the CAD system is not accurate, and it shows us the nearest cell tower from the location of the caller not the location of the incident.
RCC4, call taker, SRCA
As can be seen from the next quotation from one of the ED physician consultants, limited coordination between SRCA and the police in facilitating measures to reach an incident fast can impact on lives:
… in a major oil tank explosion, people were stuck in the entrance and exit of the road that goes to the incident, and no arrangements were made for the movement of traffic during the first moments of the incident. I remember that the first patient who went to the nearest ED had 90% burns. He walked to the hospital by himself and when he got to the gate of the ED, he died. The ambulance arrived too late to transport that patient.
EDB4, ED physician consultant, hospital B
Another ED physician described his negative experience; however, this was not directly related to a disaster, rather it was when he called for an ambulance because his father was having a heart attack (a myocardial infarction). According to this participant, because of the delay on the part of the ambulance staff searching for the location of their house, his father died:
I lived it as a physician and as a relative of the patient. My experience with the Red Crescent was not good. My father was very sick, and I was doing CPR for him, my mother phoned the SRCA, they were not able to identify our location. I stopped doing the chest compressions for my father and I described the location of our house to them … and my father died in front of me.
EDC1, ED physician consultant, hospital C
According to some EMTs, because EDs were often delayed in responding to their telephone calls, the SRCA introduced TETRA devices as a unified communication system between the two organisations to be used alongside the telephones:
... when we contact the hospital through the landline, it is difficult to get a response … sometimes they don’t answer our calls …
RCD3, dispatcher, SRCA
… in [2018] … SRCA distributed this device to some of the tertiary hospitals in Riyadh … each of the hospitals has a dedicated channel that we can contact them through.
RCD1, dispatcher, SRCA
Positive experiences of using TETRA were reported by some of ED paramedics because it contributed to linking them with SRCA dispatchers:
… we used TETRA … It's become easy to be in contact with the dispatcher …
RCP1, paramedic, SRCA
However, SRCA field supervisors said that the process of receiving and sending information through TETRA was sometimes slower. These participants explained that when the TETRA is down during updates, calls might be unexpectedly cut off for a few seconds:
… the device has some disadvantages – it constantly updates automatically, and if I am calling, I will be cut off for up to 60 seconds.
RCF1, field supervisor, SRCA
The majority of SRCA paramedics and ED paramedics stated that because of poor network connections in some parts of Riyadh and in some areas in the EDs, TETRA was rarely used. SRCA paramedics pointed out that because there were no backup communication systems in place, if they encountered a technical issue, they had to use their personal mobile phones to contact the dispatchers:
… in some areas in the Riyadh region and inside the city, the TETRA network is not well covered … we are not supported with an alternative device ... we use our mobile phone to call the dispatcher if there is no signal.
RCP8, paramedic, SRCA
In addition to the need for prior notification, one of the ED nursing directors suggested a system electronically connected with SRCA which they could use for tracking the patients that they will receive:
I suggest that we have a patient tracking system connected with the Red Crescent, rather than getting the information about the incoming patient through phones or TETRA.
EAN1, ED nursing director, hospital A
All hospitals use electronic patient records systems. Despite this, some ED physician consultants said that during a disaster they often turn to using paper because the computer systems have not been tested in disaster drills. According to a number of ED nurses, although the use of paper is reliable compared with a potentially failing computer system, it is time-consuming to have to manually enter all the information into the systems from paper records:
… We have a system for recording and storing patient health records, but we don’t use it during disasters. We do everything manually because we don't know if the system can work with an influx of patients.
EDA1, ED physician consultant, hospital A
... we are not using the computer for patient registration and for other processes in disasters, we use paper instead ... we put all the patients’ documents in a new file. Later on, we enter them into the system this process. It takes time but it is trustworthy.
EBN1, ED nursing supervisor, hospital B
The use of the mobile phones provided to ED physicians at hospitals as a tool for internal communication was perceived to be faster than landlines. One of the ED physicians stated that:
We use landlines and mobile phones. In fact, the hospital mobile phone is the main device that we use and we can depend on the use of it more than the landline … you know, it is quicker to find someone through it …
EDP3, ED physician consultant, hospital B
However, the majority of the ED nursing supervisors stated that unlike ED physicians, they were not provided with official communication systems, which led them to use non-official systems such as WhatsApp on their personal smartphones. WhatsApp was perceived as easy to use and useful with multiple functionalities including voicemail and video. ED nursing supervisors reported creating a WhatsApp chat group, and they included the key personnel in the hospital. They perceived that the participation of the key personnel in the WhatsApp group contributed to them sharing information about incidents with other ED staff:
... We are not supported with an official system such as that given to the ED physicians.
ENB3, ED nursing director, hospital B
… we created a WhatsApp group and included key personnel such as ED physicians, the CEO, he CNO [chief nursing officer], and the manager on duty along with the ED manager. The WhatsApp group made things easier and in emergency situations, it helped us much more than before, as staff information is more updated.
ENC1, ED nursing director, hospital C
Not all the ED staff wanted to use WhatsApp; some ED nursing managers for example, perceived WhatsApp as not a trustworthy tool for sharing patient information because it could be easily accessed and had confidentiality issues. These participants also added that WhatsApp relies on an internet connection and their hospital currently lacks reliable and comprehensive internet coverage. These participants highlighted that they used their own internet resources and when they ran out of credit or data, they were not able to use WhatsApp:
… I prefer not to use WhatsApp groups to send information related to an incident. It is not safe to share patients’ information through it.
EAN7, in-charge nurse, hospital A
… there are no internet services covering the entire ED. There are some internet services in some areas of the hospital but not everywhere. I use the WhatsApp group from my internet but if I run out of data, this is a big problem.
EBN6, ED nursing supervisor, hospital B
Language barriers and inaccuracies in locating the incident were identified as an issue by a number of call-takers, which again led to delays in responses. These participants experienced difficulties understanding the callers who did not speak Arabic:
One time, I received a call from a resident who was not an Arabic speaker, and she did not know exactly where her location was. It took time for us to get her location ... I contacted the Emirate of Riyadh Province, and they identified her location exactly. They have advanced and high-quality communication systems, which were able to determine her exact location.
RCC3, call taker, SRCA
… all call-takers speak Arabic, we are not provided with a multi-language service.
RCC1, call taker, SRCA
Furthermore, the limited understanding of the Arabic language by non-Arabic-speaking staff influenced their relationship and coordination with Arabic-speaking staff in the hospital. This was described by non-Arabic-speaking ED nursing supervisors who pointed out that the majority of the hospital workforce are non-Saudi nationals, but that despite this they commented that the administrative staff in their hospitals would make announcements in Arabic, which was highlighted as a further cause of concern:
… I do not speak Arabic. One time when there was an announcement for patient evacuation because of a fire, the instruction was in Arabic and we could not understand what they wanted.
EBN6, ED head nurse, hospital A
A number of ED head nurses who also did not speak Arabic commented that ED paramedics do not speak English very well, and because they have difficulties understanding each other, ED nurses sometimes have to ask other members of staff to act as interpreters. Clearly these participants were dissatisfied with the written English produced by some paramedics in documents:
Some of our paramedics don’t speak English ... I ask other staff who speak Arabic to help me if I need anything … they have problems in writing documentation. What they write is not clear and they have a weakness in understanding some medical terminology.
ECN3, ED head nurse, hospital C
… nurses who do not speak Arabic are always asking me to translate what paramedics want or vice versa ...
ECN4, ED head nurse, hospital C
To resolve this issue, there had been some attempts to encourage staff to learn Arabic and this was perceived as important for facilitating better communication and to address this issue, one ED nursing supervisor reported that they had taken the initiative and learned just some basic Arabic words which were considered to be valuable:
There are a number of staff in hospitals who do not speak Arabic … I’ve learned some basic words … it is difficult for me … we face some challenges with staff who speak Arabic only …
EBN6, ED nursing supervisor, hospital B
Theme 3. EMTs’ perceptions of the emergency preparation
Two subthemes emerged from the data under this theme: (1) disaster simulation exercises, which describes what training SRCA, and ED received and their experiences of these training courses; and (2) debriefing following an incident in order to provide SRCA paramedics and ED staff with opportunities to share their experiences. These themes are discussed separately next.
Disaster simulation exercises
This subtheme discusses the disaster simulation exercises available for EMTs related to disaster preparedness. There are some training courses for all the emergency services and some courses are mainly for hospital staff or for SRCA staff. This section starts by describing simulation exercise courses which have been provided for all the emergency services, then discusses the training courses for operations centre staff, and finally the simulation exercise courses for hospital staff are outlined. In relation to simulation exercises, one-day courses on disaster preparedness are provided by the hospitals for SRCA and MoH staff, involving SRCA paramedics, ED hospital staff and key stakeholders from the Ministry of Interior (MoI), such as the civil defence force and the police. These courses were discussed by the majority of the SRCA paramedics and ED hospital staff who stated that they were related to disaster preparedness and that parts of the courses dealt with communication. These participants also commented that although these courses were provided within the hospital, they were mostly unrelated to their speciality. They described these courses as unclear in their message. In addition, a number of SRCA paramedics stated that the communication devices which were used for training purposes during these courses were not the same as those used in their everyday working lives:
… SRCA and MoH provided some one-day disaster training courses with the participation of the police and civil defence … these courses have theory and practice elements such as drills and table-top training ... classes were conducted in hospitals … communication formed part of these courses, but it was more related to the incident commanders from each sector ...
RCP5, paramedic, SRCA
I have attended one course about disaster preparedness, and in those courses, they taught us about how to use the wireless communication device that they gave to us. I have never seen this device in reality and I think it is for training purposes only.
RCP6, paramedic, SRCA
One of the ED nursing heads highlighted the fact that ED nursing staff who participated in these courses had not been provided with an opportunity to take part in simulations. One nursing head said that the material covered in these courses did not reflect their needs and consequently their value was questionable:
… I have had some training. Actually, these courses do not include details such as communication with the Red Crescent, and I don't know why nurses on these courses are excluded from practice in the communication scenarios. In reality we have to deal with more than what is in these courses.
EAN5, ED nursing head, hospital A
In the operations centre, the staff took part in a training course which was mostly related to the use of the CAD system. The call takers and dispatchers in the operations centre said that they had attended a short training course in relation to receiving information from callers. These participants acknowledged that apart from this short training course, there were no specific courses for them, and that the available courses were for field staff such as field supervisors and paramedics:
… I never attend any courses related to disasters. Our department is more focused on educating the paramedics and field supervisors and other leaders in the operation centre ... the only thing that we received is training about how to use the CAD system, during which we were under supervision for one to two weeks. This was related to how to handle calls from callers including call input, call dispatching, filling in event notes, tracking calls, and following up with SRC paramedics. After that, they allowed me to work alone without supervision.
RCC1, call taker, SRCA
Call takers highlighted that there was no training in how to deal with traumatized family members, who will be in severe distress and require specific and meaningful care and support. This was reported as a considerable weakness in the range of supportive care and support that can be provided:
We don’t have training related to how to deal with families when they scream and cry. Our skills are based on only our prior experience.
RCC3, call taker, SRCA
It was considered important for most of the paramedics and dispatchers to have training based on protocols which offer clear guidance on how communication with dispatchers and field supervisors should be operationalised and in doing so to ensure better communication in relation to their responses. This training and preparation were absent in their workplace, and staff were required to rely solely on their personal experiences and what they feel is best in communicating with each other. This ad hoc strategy by individuals clearly impacts upon the quality of service and was illustrated by one SRCA paramedic who said:
... we were not given training in a specific protocol that we could follow regarding the best way to communicate when reporting through TETRA. What we have comes through our experience.
RCP5, paramedic, SRCA
Although ED paramedics had apparently received the TETRA device from the SRCA without training related its use, some of these participants reported that training was minimal in that they were only shown the channel number and how to turn it off and on, which meant that there was complete lack of guidance and the equipment was consequently useless:
… when SRCA gave us the TETRA device, they just showed us … the number of our channel and the ‘off’ and ‘on’ switches, and that’s all.
EBP3, ED paramedic, hospital B
ED hospital nurse directors perceived hospital disaster simulation exercises and routine emergency drills as not very meaningful or helpful mostly because they did not reflect reality, and they were not convinced that staff were better prepared for emergency events having gone through an agreed drill. This was reported by one of ED hospital nurse directors as follows:
... the last time we had a drill in the hospital it was very weak, and there was no collaboration between hospital departments … our disaster drill is not related to our daily work.
EAN2, ED nursing director, hospital A
Furthermore, hospital disaster simulation exercises were conducted too infrequently. The majority of the ED nursing supervisors and ED heads of nursing staff said that a hospital disaster simulation exercise was conducted only once a year and that in all probability they would not remember the instructions which they received during those exercises in the event of a real disaster:
we need to have a disaster drill frequently to test the system and at the same time to sort out all the issues that come up from this drill.
EDB1, ED physician consultant, hospital B
… you know, the problem with our disaster drill is that it’s conducted once a year. Of course, I’m going to forget what I’ve learned if there’s no continuous training.
EBN5, ED nursing supervisor, hospital B
In addition, the simulation exercises were under the command of the Hospital Incident Command Systems (HICS), a system based on the existing hierarchy in a hospital and headed by the CEO which has been established in order to ensure co-ordination and speed of response in communications between leaders and their subordinates during a disaster. One of the ED physicians stated that HICS is not given a high priority by hospital leaders and described how the CEO had allowed him only ten minutes to explain the importance of HICS training for key personnel in the hospital:
… once I asked to meet the CEO to explain the importance of training the key persons for the incident command. He told me that I had ten minutes to explain it. Impossible! He did not give more time, and I refused his offer.
EDB3, ED physician, hospital B
Debriefing following an incident
Ideally, debriefing following an incident should allow responders to discuss and reflect on an event and attempt to assimilate what they have learned into preparation for the next event. EMTs participants described their involvement in several types of debriefing session following an incident: some debriefing sessions involved stakeholders, others took place between staff from the SRCA and ED hospitals, and there were also separate debriefing sessions for each ED hospital.
Some of the SRCA field supervisors and ED staff spoke about the importance of debriefing with other emergency services following an incident. They stated that there are debriefings at the regional level after each major incident which are attended by leaders from each emergency service, including the SRCA and the MoH. These participants highlighted that debriefing following an incident among professionals from multiple agencies helps to highlight both negative and positive aspects related to their response in an incident, which in turn provides some solutions for preparedness:
… there is an incident debriefing after each an MCI, but I have never been involved in these debriefings … they are held at regional level … They usually include the leadership such as the representatives from each sector … debriefing can help to spread the lessons learnt from an incident…
EDB3, ED physician, hospital B
… the debriefing is helpful for improving our preparedness for all incidents. After debriefing, each organization will know their deficiencies.
RCF3, field supervisor, SRCA
However, both SRCA field supervisors and ED physician consultants stated that they were not invited to participate in the debriefings conducted at the regional level. In addition, one field supervisor stated that they were not made aware of any change in practice or protocols as a result of these debriefings:
… there was an incident debriefing that took place in the Emirate of Riyadh province. The attendance at this meeting was limited to the leaders of each side … we were not asked to participate, and we don’t know about the recommendations that came out from this debriefing …
RCF1, field supervisor, SRCA
Field supervisors reported that issues relating to communication did not receive much attention from either SRCA or ED in the recommendations presented at the debriefings:
Communication during a disaster is a problem with hospitals … issues related to communication are very rarely discussed in the debriefing.
RCF3, field supervisor, SRCA
The findings showed that there is no debriefing between hospitals and the SRCA. One of the ED physician consultants described some factors which fail to encourage participation in debriefings between ED hospitals and the SRCA. This consultant said that representatives of the hospitals, such as ED directors, were too busy to attend debriefings and had to give up their days off to attend and did not receive any remuneration for attending:
Ideally, all stakeholders have to do a debriefing after each incident, mainly between SRCA and ED, but usually they don’t because people get exhausted, ED physicians don’t have time, and it is difficult to bring them back together after the incident because they are busy with their work, and they have a shortage of staff. Also, they don’t get paid overtime for a meeting or anything that they do for an extra hour.
EDC1, ED physician consultant, hospital C
Each ED hospital has its own debriefing meetings and exercises during which ED staff share, discuss and reflect on their response to an event with other departments in the hospitals. To provide future and appropriate solutions and ensure proper preparedness such as improving the disaster simulation exercises, much greater planning and scheduling of sessions is required. During debriefings, there is a further issue with some representatives of departmental managers who are quite defensive and resistant to change in practice in preparing for disaster simulation exercises. This was articulated by some of the ED nursing supervisors and ED physician consultants who said:
… even though we have a debriefing in the hospital after each incident and after each disaster drill, some departmental managers do not accept criticism of their work and they continue to defend their work and their team.
EDB2, ED physician consultant, hospital B
Additionally, some of the ED physician consultants stated that some of these departmental managers do not seem to want to quickly solve issues which are raised in relation to real incidents or disaster drills; it appears that they would rather delay the implementation of recommendations, whilst other recommendations are disregarded, which is very concerning:
In fact, the problem is that whilst some of the departmental managers took the time to implement the recommendations raised in the meeting, some of them took it personally and ignored it.
EDA1, ED physician consultant, hospital A