Data analysis led to the development of 5 categories and 14 subcategories. The categories emerging from the data analysis included (1) Organizational and managerial challenges (2) human resources (3) infrastructure (4) educational system, and (5) ethical. These categories with their subcategories have been explained below (Table 2).
<<< Place Table 1and 2>>>>
3.1. Organizational and managerial challenges
This category represents the participants’ statements about the absence of a concentrated management and programming system and poor coordination among the organizations that provided services during disasters, which lead to the following subcategories:
3.1.1. Insufficient coordination and cooperation among health team member
The field hospitals available in the region were not affiliated with one specific organization. They were established by different organizations and had different equipment with no coordination and arrangement among them. Because of this, the financial and human resources were not used efficiently and, in many cases, continuity of services was halted.
One participant clearly said that“The field hospitals established by the army and the University of Medical Sciences were at different places. The army hospital was fully equipped and located away from the Sar Pol Zahab mobile hospital. However, nobody knew that it was there and for a simple chest-x-ray we had to dispatch patients to Kermanshah by a helicopter” (P10).
Another participant mentioned: “There were several medical teams in some places and rural area in particular, while there were none in other places” (P5).
Lack of unity in command 3. 1. 2.
The nurses who experienced the Kermanshah earthquake mentioned issues and challenges like inconsistency between the requested medicines and supplied items, several command authorities, and intervention by policy makers and state authorities. This indicates a lack of unity in command, which was an issue in providing services to the victims.
For example, a participant stated that “In many cases, serums and medicines would be supplied by other provinces without supervision and need assessment so that the large supply of unrequired medicine would only limit our operation spaces” (P13).
Another participant expressed: “There were several authorities who had different strategies” (P1)
3.1.3. Inadequate organizational management
The nurses highlighted chaos and overlapping of operations, ambiguity of tasks, and conflicts of interest among organizations due to the obscurity of roles. This indicates negligence of the importance of organizing.
A participant stated that “The Red Crescent is not directly the medical team, but they had erected their tents inside the hospital and converted the space into a place for distributing baby formula, clothes… and it was not easy for us to tell if someone needed medical attention or not. They also intervened with nursing services and created more problem for the nursing personnel” (P13).
Human resources 3.2.
Challenges realated human resources was another main category that was highlighted in many interviews. The participants mentioned the lack of a protocol to identify and prepare the volunteers for receiving health care. This resulted in the waste of energy and loss of quality of nursing services. Therefore, the following subcategories were emerged:
Weakness in provision of occupational health for the nurses 3.2.1.
Negligence of physical and mental health of the nurses was an issue. The majority of nurses would work nonstop; however, there were no proper welfare facilities for them. This lowered productivity of the workforces. In this regard, the participants stated:
“Because of the severity of the damages to the region, our nurses had almost lost their spirit. However, mental health of nurses was not important for anyone. The nurses were lost themselves” (P3).
“We did not have lavatory during the first 48 hours. There was no rotating work system or facilities for nurses, we had no place to sleep” (P15).
Poor management of volunteers 3.2.2
Negligence of the necessity of establishing teams and optimum use of the available forces, no list of the available skills, and inefficient distribution of relief forces lowered the efficiency of the personnel. This created a mess in terms of human forces and provision of health service during crisis. This finding was highlighted in the following statement:
“There were many nurses from different provinces who were not put in use properly. The least they could do was to let the local nurses to use vacation for a week to handle their personal affairs” (P7).
Another participant expressed: “Nursing students did not have any specific skills, they would gather around a bed trying to find a vein, but all they would do was causing more harm to the patient” (P2).
Lack of uniforms for health workers 3.2.3.
Failure to distinguish available forces based on their skills and establish specialized teams (many did not have an ID card or a proper uniform) created space for the opportunistic so that it was not easy for care-seekers and authorities to find a professional care giver.
One of the nurses said: “Many nurses and physicians in the region did not have an ID card or a uniform. There was this guy who claimed to be a pediatrician and took medicines to villages nearby. Later we found that he was a welder” (P4).
Nurses' concern for their own families 3.2.4.
The first concern for the local nurses was their families and their safety. This was a mental engagement for them that prevented them from providing quality care to the injured. In this regard, the participants stated:
“First, you need to make sure about your own family; otherwise, the concern affects your work. How can I stay at work when I am not sure if my family is alive or not” (P4).
Another participant mentioned: “My baby and husband were in the car outside the hospital. Every few hours I would return to them to breastfed my baby and then return to work. I was highly under pressure” (p8).
Another category extracted from the participants’ experiences was “challenges caused by infrastructure.” The findings showed that the participants encountered several challenges in this regard.
Communication disruption 3.3.1.
Immediately after earthquake, the telecommunication services in the region were halted so that communication for making arrangements to manage the crisis was a serious challenge for the personnel.
A participant said that “The telephone service was off and mobiles were not working. It was very hard to contact the province crisis control center and other relief centers” (P1).
Vulnerability of local health facilities 3.3.2
Chaos in primary medial aids, due to serious damages to the health infrastructure, power outage, and darkness had a negative effect on the quality of services provided by the nurses. One of the participants noted: “After the earthquake, almost all health care centers were out of commission. The staff would provide health service at the hospital yard (very cold weather) using their mobile light” (P14).
Difficult access 3.3.3.
Heavy road traffic due to the stampede and massive destruction on the streets near the hospital in particular was one of the main causes of disorder in providing health care by nurses. In this regard, one of them stated that“It was a real mess. There were many injured on the way to the hospital who were stuck in the traffic 1km away from the hospital. We would have been more helpful if we had access to the injured” (P12).
Educational system 3.4.
Challenges of the education system was another main category found in the study. Interviews showed that nurses were not prepared to face disasters and had not received adequate education in this area, which lead to the following subcategories:
3.4.1. Nurses’ poor knowledge in the field of disaster
Many of the participants acknowledged their lack of knowledge and skill for providing care to earthquake victims. They highlight this as a critical care void in their profession and emphasized on the necessity of education. In this regard, the participants stated:
“The nurses were not familiar with the protocols of carrying patient, safety, and flight physiology. They did not know how to carry patients by helicopter” (P8).
Another participant expressed: “Many of the injured had suffered crush syndrome; however, most of the nurses knew nothing about it” (P9).
3.4.2 Lack of comprehensive training program
The nurses mentioned their lack of readiness and they believed that it was due to a gap in the formal education system and in-service educations.
One participant highlighted this: “We had no education about crisis; all we had was a two-credit course in the bachelors’ program” (P11).
Another nurse expressed: “Due to the lack of integrity and harmony in educational programs on crises, our nurses were not able to demonstrate their true capabilities during the crisis” (P6).
Almost all the participants mentioned moral challenges they faced when providing health cares to the earthquake victims. They had also found these challenges disturbing optimal care. For this reason, their statements revealed following subcategories.
3.5.1 Ethical challenges related to prioritizing injured
As revealed by the interviews, when the disaster is large in scale, the nurses face hard decision-making situations. In many cases, they have to make unfair and unpleasant decisions and in some cases these decisions are about life or death. In this regard, the participants stated:
“It was a very frustrating situation, it was not easy to decide which one should be attended first, that child, that adult or that elderly….” (P5).
One of the participants noted: “One of the victims had an apnea and we needed resuscitation trolly, aftershocks would not stop and the building was collapsing. It was not able to decide whether or not should I risk my life and go inside the building to fetch the trolley” (P11).
3.5.2. Ethical challenges due to lack of resources
During disasters, material and human resources scarcity is common. As a result, staff being unable to provide all services in the event of a disaster, this creates specific moral dilemmas for the nurses. The nurses talked about their experiences as conflicts between their knowledge of standard performance and failure to meet the standard. This was a source of moral challenge for them.
One of the nurses stated: “We had to use one forceps for several patients with cuts; I do not if our job was ethical or not….” (p14).