Challenges for physicians in the prehospital environment can be understood as a process that involves a balance between;
a) organizational and individual factors linked to extreme environments.
b) manoeuvre in time and space, both individually and in teams.
c) the interaction between active and passive leadership, in extreme environments.
d) one's own and others' emotional states.
This theory of balancing different entities is based on four themes; thus the theory is the relation between the four themes: leadership, environment, emotion management and organization. Challenges for prehospital physicians can be understood as a process that involves a balancing act between different factors linked to the extreme environment in which they operate. This environment creates unique challenges not usually encountered in routine hospital practice, which results in trade-offs that they would not otherwise be faced with. Their individual situation needs to be balanced against organizational conditions, which means, among other things, that their medical decisions must be made based on limited information as a result of the constraints that exist in the pre-hospital environment. They must, both as individuals and as part of a team, manoeuvre in time and space for decision-making and practical tasks.
These conflicting challenges result in fluctuations between active and passive leadership with doctors needing to alternate between the two different methods in the extreme environment in which they operate. Leadership varies depending on the situation. Prehospital physicians are often surrounded by colleagues who are used to making decisions and so doctors can rapidly go from a passive to an active leadership style and then back to passive mode again during the same assignment. There seems to be a balance where they only take an active role when clearly required and as soon as there is an opportunity, they revert to a passive role again.
There is also a balancing act when it comes to their own and others' emotional states. They take great responsibility for the feelings of the patient, relatives and the rest of the team both during the assignment but also after the assignment.
The four themes: leadership, environment, emotion management and organization that make up the components of the theory are further explained below.
Theme: Leadership
Leadership in a prehospital environment refers to the physician's management of the work during an assignment. Looking at leadership, parts of followership also emerge and the challenges associated with making decisions. The theme of leadership contains four categories; leadership styles, reflexive leadership, the team and task, decision and responsibility.
The analysis of the interviews shows how the physicians work with different kinds of leadership styles depending on the situation and conditions. Several respondents describe that they avoid taking an active leadership role as long as the situation develops in a direction they wish. In the normal situation, physicians have an inclusive approach, but this changes when the situation becomes time-critical and then they move to an authoritarian leadership style. This seems to happen consciously and with the understanding that this can have negative consequences for teamwork. Below are two examples;
"Practically speaking, I usually initially, unless the situation requires a very urgent action, stay in the background…"
"It's usually about the patient being stabilized medically so that I do not have to be completely focused and active in the care anymore, so I like to hand over and it's a lot about freeing up mental space for oneself, maybe taking a step back, think, have we done everything, is there anything more that needs to be done?”
The analysis shows how the category reflexive leadership describes how the physicians reflect on their leadership in relation to the event they were involved in. All respondents describe how after a challenging event they have a conversation with the team about what happened and the majority of them also describe how after this conversation with the team, they have an ongoing process where they reflect on their decisions. They have an internal dialogue where they go through the event and think about the decisions that were made and how the situation developed. Some also use colleagues who did not participate in the event to continue to reflect on the situation they have been through.
I try to be self-critical in a balanced way, because what didn´t go well you have to acknowledge it, it did not go quite the way I wanted. It did not go badly but it did not go quite the way I wanted and then you have to be able to say that, yes, I can do better.
The category team shows how the physicians relate to the temporarily composed teams that they work with in the prehospital environment. Despite the non-existent preparation time, it is clear that the physicians are trying to get to know the team and what abilities they have. There is a respect and balance of power within the temporarily composed team and the physicians try to support the other individuals in the team, among other things through how they communicate.
"I think I may be more inclined to ask questions than to give directives…"
"Because prehospital activities are not just about medicine but about the ability to work in teams, it is about the ability to, in a bad situation with poor opportunities, try to communicate in a sensible way so that the team as a whole performs as well as possible… ”
The category task, decision and responsibility sheds light on how physicians feel responsible for the overall situation at the same time as facing demands and expectations from the temporary team. There are also challenges when it comes to decisions, analysis and priorities. Decisions that need to be made on limited information when time is short are challenging. Limited information also contributes to the fact that it is a challenge to obtain an overview of the situation. Priorities permeate many of these decisions, including which patient should receive more resources and what needs to be done first for any individual patient.
"Mentally, I probably do not let go of the perception that I am leading the situation, but I can accept letting go of the detailed control many times ..."
"The prehospital situation is about very limited decision basis, you have to dare to make decisions ..."
The constant switch between the passive and the active leadership is a conscious decision that is both affected by and affects the environment, especially the psychological environment. The reflexive leadership is closely connected to the emotional management where the consequences of the choices made lead to self-reflection among the physicians. Time management is constantly present and can be found in the theme task, decision and responsibility. The decision what to do and what to prioritize directs the communication and the chosen leadership route.
Theme: Environment
The theme environment describes how the work is affected by the prehospital environment and what challenges it entails. There are also aspects of how other challenges affect the environment as leadership affects their psychosocial environment. The theme contains three categories; external environmental factors, personnel and relational aspects as well as strategies for adapting to the environment.
The category of external environmental factors contains sections about how the physical environment affects the work, for example weather and wind, but also factors such as threats and violence in the prehospital environment. In addition, there are challenges in the form of complexity where the respondents describe how they simultaneously need to evaluate different information at different levels, for example taking care of one seriously ill patient while they receive a report about another patient and have to prioritize where they are needed most. Rare incidents also involve a challenge that most of the respondent’s mention; a demand upon on knowledge and skills that are rarely used. Injured children are specifically mentioned here.
"It is often a difficult context to get a grip on as quickly as you need it and you do not have time to be very thorough…"
"There are a lot of external factors, partly the environment, there can be different threats it can be difficult to get to the patient, it can be difficult to take the patient from there…"
The category of personal and relational aspects addresses the psychosocial environment and culture of prehospital care where, among other things, one is not expected to express feelings after difficult events but also there is a strong community in which people put in extra effort to solve situations. Collaboration with other prehospital actors is also addressed here and the challenges in understanding each other. What dominates this category are the different aspects of working alone, how as a physician you can be left without realistic opportunities to get help from someone else with more knowledge or skills.
"So it was extremely loyal, mandatory stand up for each other, do what you did it was a bit of a culture of honor, that honor stretched to keep the car clean and behave outside of work."
"I have behaved a bit like the old tribe who brushed off the feelings and moved on and I usually joke, am I a psychopath or am I just very suitable for my profession ..."
"You have to have a huge margin on it because no one else will come if you need help, no matter what experience or skills you have, you must have a safety margin in your way of working."
The category of strategies for adapting to the environment includes consequences of the environment. There are limitations in prehospital care to what is medically achievable and environmental factors distract and complicate this work. This category also contains sections on how to optimize the conditions and highlights that there is habituation to all aspects of the prehospital environment.
"So it means more steps and less prepared steps with fewer people, I think that is the biggest challenge."
The environment affects the conditions for the physicians with the physical environment being challenging in many ways, including weather, location of events and physical threats. The psychological challenges of this environment are also something that attracts the physicians to prehospital prehospital care.
Theme: Emotion Management
The theme of emotion management addresses how physicians need to navigate between various emotions, not only their own but also the emotions of the patient, relatives and the rest of the team. This theme contains four categories; ethical and emotional stress, emotional management, stress reactions and excitement attracts.
The category of ethical and emotional stress is described by all respondents as a challenge in the prehospital environment. Stress is highlighted both as a reaction to the patient's and relatives' feelings but also due to feelings about the patient's life story. It describes how the hospital environment protects against much of this stress and that the white clothes and sterile environment mean that there is a distance from the patient in the hospital that is not there prehospital. The different stress levels of the members of the team also create challenges for the doctors who will try to lead the team. Finally, the solo physician role, with the responsibility that the physician carries results in stress.
Interviewees also describe how the challenges are something that attracted them to take a prehospital position and the majority also describe a “blue light romance” with an attraction to being able to drive a car quickly and be able to represent high competence prehospital care.
"the environment in hospitals is a bit protective, you do not have that protection outside, there it becomes rawer and more naked and the risk is quite high that you are not injured but that you are hurt in some way"
different levels of stress and such things that make it difficult get through and sometimes you have to step in and take over and sometimes you have to stay passive and that is of course a challenge and something to adapt to every time, I think.
"It's like the protection you have, to be competent, to be able to handle things, it's a little bit scary to be so alone."
The category emotional management mainly consists of two different areas, emotional management of oneself and emotional management of others, which can be divided into; the team, the patient and relatives. The respondents describe how they take great responsibility for the stress of the environment and how they try to handle both that and their own stress.
"One way to make the situation less challenging is to try to lower everyone's stress level and your own or at least not show that you are stressed"
"On the way to a scene, you kind of have to prep a little, yes, tell yourself that it will go well."
The category of stress reaction consists of the acute reactions that occur in association with the work and delayed reactions that affect the physicians for a long time after the event. There are both physical reactions such as palpitations and mental reactions such as inability to sort impressions or inability to express oneself in a constructive way.
"The heart palpitations will return, but it's okay"
During 3–4 weeks that I actually slept badly from this case, woke up a few times at night, maybe once a night on average, sometimes not, sometimes twice and thought about it but after that it was all good and then it came back almost a year later
The category of excitement attracts describes how the combination of riding a helicopter or riding a car quickly attracted people to work prehospital, but how this freedom that exists when it comes to decision-making becomes a challenge that creates stress. The balance between being a hero or a failure is subtle and the feelings around the different positions are the opposite.
"It is a freedom that comes with a responsibility in that environment that poses other challenges for yourself."
"You drove fast and so on, that was probably what got me interest initially, I can say, I must admit."
The emotions of the team, the patient, relatives of the patient and of course the emotions of the physicians need to be balanced so that the team can perform well. The emotional management is closely related to leadership, where the physicians lead the patient and the team by managing feelings.
Theme: Organization
In the theme organization, the analysis shows that organization entails challenges in the form of; organizational and structural aspects, working conditions and knowledge and skills.
The category organizational and structural aspects describe how decisions are made about when and how patients are to be transferred. These decisions are important in the bigger picture because they also affect other resources and other patients who need healthcare. The respondents also describe how the equipment used is often developed for use in hospitals, which means limitations when it is used in the prehospital environment. It is not possible to bring all your equipment to the patient when working prehospital, which means that they often have to choose what they bring, which can cause constraints when they take care of patients. The equipment needs to be small and able to be used flexibly, and hence might have only the most basic functions, which in turn means that it might not fulfill its intended function and so risks not being used. Limited resources mean that the amount of equipment and the limited number of people working prehospital causes challenges. The small number of people available to take care of the patient means that there might be no one who can prepare for the next step and so everything takes longer.
"There is no one else who just does things so that you know that the next step is prepared."
What the problem is, I think, is how much should you be able to carry while taking care of the patient? What is most important? Too often, I think you have to choose between monitoring and patient care.
The category working conditions shows that there is a lack of long-term perspective and proactive management of prehospital resources. Many of the respondents describe an absence of governing documents on how different procedures should be carried out. Other things also highlighted here are financial arrangements for this work and lack of understanding from decision-makers, other parts of the healthcare system and other actors. Pre-hospital work differs in different places in the country and there are few pre-hospital medical services in Sweden, which creates competition for physicians interested in working in prehospital care.
"I think the biggest challenge is, what is the normal routine? What is a common way of working or approaching this challenge?"
The category knowledge and skills highlight the importance of having a certain level of knowledge to be able to do the job. Here, the respondents also highlight how the work has changed with more experience and how things that were important when they were new to the profession become unimportant with more experience. Disorders that you have not seen so often involve challenges, even if they are not time-critical, due to the fact that you are unfamiliar and have limited experience in the field. Research in prehospital medicine is limited and there are few managers in prehospital medicine who have research competence.
"Yes, with that is that you feel uncomfortable, you really have to go back to your first years as a physician to remember how to look in the ears of children, that's really it. It is a bit outside our comfort zone, even if it does not stress in that way. ”
The organization pre hospital is fundamentally different from that in hospital and just as the environment changes the conditions for the physicians, the organization sets limitations to what is possible prehospital. These limitations contribute to why decisions need to be made with limited information which in turn results in stress and a higher burden on the emotional management. One of the most obvious organizational challenges is the limited resources both in terms of equipment and the number of staff, which in turn puts a lot of pressure on the physicians to be able to manage.