In the field, emergency care personnel are faced with a variety of clinical challenges 3, some of which place them in ethical dilemmas and affect the quality of care [4,5]. Providing high-quality care combined with respect for the principles of professional ethics at the scene of accidents is an important ethical and professional responsibility of pre-hospital emergency care personnel. The findings of the present study can help determine pre-hospital emergency care personnel’s perception of the ethical dilemmas which they face in the field. Two main themes were extracted from the collected data: paradox in decision-making and patients’ ethics and values. Many national and international nursing organizations regard ethical care to be at the core of healthcare . Accordingly, systematic and ethical performance is one of the most important responsibilities of caregivers, including pre-hospital emergency care personnel, in healthcare systems . All pre-hospital emergency care personnel are expected to comply with the professional regulations and provide care in accordance with the guidelines [15, 16].
In the present study, it was revealed that at the scene of accidents, emergency care personnel often experience uncertainty (paradox) in their decision-making. This theme consists of four categories: choosing between patients, complying with the guidelines, complying with the regulations, and being committed to professional ethics. Similarly, recent studies report that pre-hospital emergency care personnel are unsure about their decisions, including how to triage the injured, and face ethical dilemmas, which is the result of the critical conditions of the injured, lack of workforce, and the large number of injured individuals who need immediate medical attention at the scene of accidents [17–20].
At the scene of accidents, emergency care personnel must perform the necessary medical procedures as well as they can and as fast as possible to save the injured. However, due to the pressing nature of emergency situations, systematic performance in accordance with the guidelines, especially during CPR, intubation, etc., may not be possible and the personnel cannot execute the procedures step by step as prescribed by the guidelines. At such times, the personnel become agitated and experience ethical distress, which is a major ethical dilemma in providing care to the injured in pre-hospital emergency care. Likewise, other studies show that the critical conditions at the scene of accidents, especially when the number of the injured is high, subject the emergency care personnel to great ethical distress and tension which can adversely affect their adherence to the prescribed guidelines [21, 22].
Complying with regulations was another important category under the theme of paradox in decision-making referred to by the participants. In pre-hospital emergency care in Iran, there are usually two staff members at each dispatch center who must arrive at the scene of accidents as soon as possible, be in touch with the doctor at the central department online, describe the conditions of the injured, and start their interventions after triage. However, the conditions in the field are sometimes so critical that if they try to contact the doctor, they lose the golden hour to provide care. Though the personnel try to contact the doctor at the central department at the first chance, they often have to take action on the spot, which places them in the ethical dilemma of whether to comply with the regulations or professional ethics. Similarly, according to Torabizadeh et al., at the scene of accidents, emergency care personnel sometimes experience indecision about whether to act according to the regulations or act ethically .
The participants also stated that, due to lack of equipment, they worry for their own safety in the face of dangerous epidemics; however, despite their uncertainty about providing care to the infected and their ethical dilemma, they usually stay committed to professional ethics. These caregivers are the main source of support for the injured. Similarly, other studies point out that the healthcare personnel, including the pre-hospital emergency care personnel, overcome their uncertainty and follow professional ethics when confronted with dangerously infected patients [23, 24].
The other main theme extracted in the present study was respect for patients’ ethics and values. All over the world, healthcare personnel must respect patients’ ethical values and principles which are rooted in their cultural, national, religious, ethnic, or age-related beliefs and provide care without bias . The theme of patients’ ethics and values comprises of the categories of respect for patients’ physical privacy, respect for patients’ sexual privacy, and respect for patients’ religious beliefs. One of the main responsibilities of medical personnel is to maintain patient privacy and patient dignity . Thus, while providing care, all caregivers are expected to show respect for the privacy of their patients and treat them with dignity [14, 26]. In the present study, one of the major ethical dilemmas, as perceived by pre-hospital emergency care personnel, is maintaining respect for the physical, sexual, and psychological privacy of the injured. A few other studies report similar results: showing respect for the physical, sexual, and psychological privacy of patients, including sick and injured individuals who are attended to by pre-hospital emergency care personnel in the field, is a major ethical dilemma in providing care to this group [24,27,28].
In addition, in line with their strong Islamic beliefs and values, Iranians believe that the genitalia and breast of individuals, especially women, must be covered and that men and women who are not related to each other must not have any visual or physical contact. Thus, toward maintaining the privacy of patients and the injured, even in pre-hospital emergency care, care should be provided by a caregiver of the same gender as the patient. However, in Iran, according to the law, women cannot work in pre-hospital emergency care centers; women are not even allowed to take the M. A. entrance exam for emergency care. The findings of the present study stress the need for revising the educational and professional programs in Iran.
The participants also emphasized the importance of respecting the psychological privacy of the injured at the scene of accidents where the injured and their companions are worried and may behave aggressively toward the emergency care personnel. At such times, the personnel should understand the situation of the injured and their companions, stay calm, help the injured relax, and manage the conditions at the scene of the accident. Similarly, several other studies stress the role of maintaining the psychological privacy of patients in providing ethical care [11, 29].
Another important ethical challenge referred to by the interviewed pre-hospital emergency care personnel in the present study is showing respect for the religious beliefs and values of the injured and their companions at the scene of accidents and while they are being transferred to a medical center. Occasionally, those beliefs and values interfere with the principles of care and infection control. However, many studies stress the need for showing respect for patients’ beliefs and values when they are receiving care [30–31].
In conclusion, the ethical dilemmas in caring for individuals with injuries at the scene of accidents are among the most important issues which pre-hospital emergency care personnel are faced with. Accordingly, educational and medical administrators and policy-makers need to become familiar with the critical conditions, unpredictable working environment, and ethical dilemmas which emergency care personnel have to deal with in the field and make the necessary changes in the emergency care curriculum and the working conditions of the personnel in the field, e.g. acceptance of females in the field of emergency care in universities and allowing them to work at pre-hospital emergency care centers.
One of the limitations of the present study is that data were collected through individual interviews and field notes only. Employment of other methods of data collection could have added to the richness of the results of this work of qualitative research. Accordingly, it is suggested that future studies employ other ways of collecting qualitative data, including observation and focus group interviews, in addition to individual interviews.