The mean and standard deviation of the participants’ ages was 33.52±5.8 9 years. The mean and standard deviation of their work experience was 8.40 ±4.83 years. The personal characteristics of the participants are shown in Table 1. Analyses of the qualitative data yielded 4 categories and 23 subcategories (Table 2).
- Professional capabilities
“Professional capabilities” was the most noticeable theme extracted from the participants’ experiences. The most important components of professional capabilities as stated by the participants were: clinical knowledge, clinical experience, clinical skills, teamwork skills, time management skills, clinical judgment skills, emotional stability, and resilience. According to one of the participants:
One of the most important professional capabilities that emergency care personnel need to make quick and correct clinical decisions is clinical knowledge. Unfortunately, some of our colleagues here don’t have enough clinical knowledge. I mean, for example, they don’t know much about the physiopathology of diseases. How can you possibly make a good clinical decision and take effective clinical measures if you are ignorant about the causes and treatments of diseases? (P10).
Another participant stated that:
Some of our colleagues have a lot of clinical experience and can make a quick diagnosis at first glance at a patient and then make the right clinical decision accordingly. (P3)
Another subcategory of professional capabilities which was found to have an impact on clinical decision-making was clinical skills. One of the participants remarked:
There are people here who don’t have the required clinical skills. For instance, they can’t do a proper assessment of a patient’s status, or they don’t know how to use the equipment. On many occasions, when we were on a mission, one of my co-workers couldn’t use the cardiac monitoring device or the defibrillator the right way. If you can’t do a proper monitoring or assess your patients, how can you make the right clinical decision and do the right thing for them? (P7)
“Teamwork skills” was another component of professional capabilities referred to by many of the participants. Based on the participants’ experiences, having good teamwork skills can contribute to good decision-making and, as a result, providing quality care. Sometimes, the emergency care personnel encounter a large number of patients or casualties and need to possess satisfactory teamwork skills and time management skills to make good clinical decisions. According to one of the participants:
On some missions when we have to deal with a large number of casualties, my colleagues and I get confused and find it hard to make a good decision. In my experience, this is because we are not skilled enough in teamwork and time management. At the scene of accidents, everyone wants to be boss and tell the others what to do and that causes chaos which wastes our time and puts a patient’s life at risk. (P19)
Another aspect of professional capabilities with an impact on clinical decision-making is clinical judgment. From the participants’ experiences, good clinical judgment plays an important part in making correct and reasonable clinical decisions in all situations, especially in emergency situations where a quick diagnosis is necessary. As one of the participants pointed out:
A skillful and capable member of the emergency care personnel should be able to analyze and interpret the implicit and explicit symptoms of a patient and use that information to make a proper clinical judgment and clinical decision. (P12)
Another participant stated that:
One of the major challenges and problems which I have repeatedlyseen in the clinical decision-making of the emergency care personnel is poor clinical judgment. Some of my co-workers don’t have the necessary skills in this area and can’t come to a good conclusion and decision based on the status of a patient and analysis of their symptoms. And so they make mistakes in their decision-making and I’ve sometimes seen them put a patient’s life in danger. (P8)
Resilience is another component part of professional capabilities which the participants’ experiences showed to affect clinical decision-making. From the participants’ point of view, resilience means that the emergency care personnel should be flexible, should be able to adapt to the hard and unpredictable conditions of work in pre-hospital emergency care, and should possess great tolerance. One of the participants stated that:
Having a high tolerance threshold is an essential quality in pre-hospital emergency care personnel. I’ve witnessed cases where some personnel with good professional knowledge and skills lost their patience in critical conditions or when the number of the injured was high. They couldn’t manage the scene of the accident and make a logical clinical decision. (P16)
Another component of professional capabilities which has an impact on clinical decision-making is emotional stability. According to one of the participants:
Work conditions in pre-hospital emergency care are very complicated and unpredictable. So it is necessary for emergency care personnel to be emotionally stable so they can manage the scenes of accidents well, keep calm, make the right decision, and take effective clinical measures. (P25)
Another participant remarked that:
Unfortunately, some of my colleagues do not have emotional stability: they lose their temper easily and can’t manage their anger. Sometimes we come across patients who are very aggressive and irritable. If we don’t manage our feelings and emotions, we can’t make the right decision for them and may even put their lives in danger. (P2)
- Occupational and environmental factors
Another category of the major challenges and barriers which affect clinical decision-making is occupational and environmental factors. This category consists of the following subcategories: the time of missions, the location of missions (intercity emergency, inner-city emergency, and rural emergency), patients’ status and the conditions at the scene of accidents, fatigue and occupational burnout, and spread of infectious diseases.
One of the occupational and environmental factors referred to by the participants is the time of missions. At times, pre-hospital emergency care personnel have to go on a mission at night and in complete darkness or in bad weather conditions, which circumstances can adversely affect the speed and accuracy of the personnel’s decision-making. According to one of the participants:
Many times, I’ve had to be present at the side of a patient in unstable weather conditions, in foggy weather, or at night. It is really hard to work in such circumstances and to judge the situation and make the right clinical decision quickly. I would rather go on a hundred missions in one shift at day time than get dispatched at night or in bad weather. (P5)
Another occupational and environmental factor from the participants’ perspective is the location of missions in pre-hospital emergency care. One of the participants mentioned that:
Serving in inter-city stations and rural areas is much harder and more stressful than working in stations located in the city. Since we have to drive long distances and it takes much time to get to urban medical centers, when patients’ conditions are critical, we really get confused and can’t make the right decision immediately and provide the necessary care. (P9)
Patients’ status and the conditions at the scene of accidents are other factors which affect clinical decision-making. According to one of the participants:
Sometimes, the scene of an accident is very unsafe and full of hazards and these conditions have a negative impact on our decision-making. For instance, I’ve occasionally had to appear at the scene of a murder or shooting incident, or where there was an ongoing fight, or where a house or a vehicle was on fire. Well, under such unsafe circumstances, how am I supposed to care for a patient when my own life is in danger? (P11)
Another participant stated that:
Our decisions are also affected by the clinical conditions of a patient. For example, sometimes, the patient is unconscious or the patient is deaf or speech-impaired and can’t communicate with us. At such times, it is not possible to acquire reliable data about a patient’s status and make the right decision. (P6)
Another subcategory of the occupational and environmental factors which affect clinical decision-making is emergency care personnel’s fatigue and occupational burnout. As one of the participants remarked:
Working in pre-hospital emergency care is really demanding and there are not many who can bear the pressure. Sometimes, I’ve had to go on about 30 missions in a 24-hour shift. Work overload and shortage of experienced staff have caused fatigue and burnout in the personnel and these have negative effects on our concentration, mental acuity, and decision-making. (P13)
Spread of infectious diseases is another dimension of the occupational and environmental factors. According to one of the participants:
When there is an outbreak of a dangerous infectious disease, like Ebola, H1N1, or COVID-19, sometimes there is a conflict between the emergency care personnel’s decisions and what the patients want. Even if we judge a patient’s condition to be critical and decide that he or she should be transferred to the hospital, the patient or the patient’s family don’t care about our decision and refuse to have the patient transferred because of their fear of the epidemic. (P15)
On a similar note, another participant stated that:
On a mission, I had to give care to a patient who had symptoms of sudden cardiac arrest. Even though I told the patient and his family that the patient’s condition was serious, they ignored my decision and said because of the spread of the coronavirus, they wouldn’t have their patient taken to the hospital. (P17)
- Inefficient organizational management
Another category of the major challenges and barriers in clinical decision-making is inefficient organizational management which consists of the following subcategories: employment of inexperienced and inefficient personnel, management’s failure to support the personnel in the case of errors in decision-making and legal troubles, lack of a counseling doctor at the emergency dispatch centers, management’s failure to conduct root cause analysis and take corrective action in the case of errors in decision-making, conflicts in the regulations and lack of a clear operations manual, lack of workshops for the professional empowerment of the personnel, shortage of equipment, and inefficiency of the dispatch center.
Employment of inexperienced and inefficient personnel in pre-hospital emergency care by the senior managers is one of the issues under the category of inefficient organizational management which adversely affects clinical decision-making. One of the participants’ comments in this relation is as follows:
Employing personnel who don’t have the necessary expertise and skills in pre-hospital emergency care is actually gambling with people’s lives. Unfortunately, because of organizational benefits and lack of budget, the senior managers hire inexperienced individuals who don’t havethe necessary knowledge and skills in pre-hospital emergency care. On many occasions, I’ve seen some of my colleagues who lack expertise in making a diagnosis make wrong decisions and put a patient’s life in danger. When we object to the mangers, they say the budget is limited and they can’t afford to hire skilled workforce. (P23)
Another component part of inefficient organizational management from the participants’ perspective is the managers’ failure to support the personnel in the case of errors in decision-making and legal troubles. Many of the participants stated that they are not adequately supported by their mangers if legal issues arise and the patients press charges against the personnel. They also mentioned that the mangers do not take any effective measures toward analyzing the root causes of clinical errors and or take corrective action. According to one of the participants:
Unfortunately, in matters of legal issues and charges, the managers don’t support the personnel as much as they’re expected to. There are many cases in which, because of a clinical error, patients’ families have sued the personnel, but the management failed to give enough support. If you do a good job on a hundred tasks, they will tell you that you are just doing your duties. But if you make a single mistake, you’ll immediately get reprimanded. Out of this fear of being reprimanded or sued by patients, some of the personnel do not report the errors in their clinical decision-making. (P24)
“Conflicts in the regulations and lack of a clear operations manual” was another issue referred by the participants. In this relation, one of the participants stated that:
There is not a clear manual which describes the responsibilities of the emergency care personnel. For instance, according to the internal codes, the pre-hospital emergency care personnel should not administer intravenous medications and if they do and their action puts a patient’s life in danger, they will be held liable. Sometimes, we really don’t know what the right decision is and what kind of action we should take. When a patient is having a seizure, should I administer diazepam to them or not? (P20)
Another participant remarked that:
Once, I had a 45-year old patient with severe chest pains. Based on his symptoms, my diagnosis was cardiac arrest and we transferred him to the hospital. In the triage unit, the emergency medicine doctor scolded me for not having given an intravenous nitroglycerin injection to the patient. He said all we know is how to transfer patients! I explained to him that we’re not allowed to administer medicine intravenously. (P1)
Not organizing workshops for the professional empowerment of the personnel was another dimension of inefficient organizational management from the participants’ point of view. According to one of the participants:
Unfortunately, the administration does not take any special measures to update the knowledge and skills of the personnel. Over the past there, not a single workshop has been held and the knowledge of most of the personnel is not up-to-date. We have repeatedly asked for training courses in basic and advanced CPR and trauma emergency care, but the administration says it doesn’t have any budget for workshops. How can the personnel make good clinical decisions and do the right thing for their patients when their knowledge and skills are not up-to-date? (P10).
Another issue under the category of inefficient organizational management is shortage of equipment. One of the participants stated that:
Some of the ambulances in inter-city and rural emergency stations lack such medical devices as suction machines, cardiac monitors, pulse oximeter, and ventilators. Even now that we have to deal with the COVID-19 epidemic, we don’t have access to personal protective equipment, like masks, gloves, and special gowns, and our fear of getting the infection has a negative effect on our diagnoses and, in turn, our decisions and actions. (P24)
According to another participant:
When there is no heart monitor,pulse oximeter, or ventilator inside the ambulance, how am I supposed to diagnose a patient’s cardiac or respiratory problem and make a proper clinical decision that won’t be a threat to the patient’s life? (P18)
Inefficiency of the dispatch center is another aspect of the category of inefficient organizational management. One of the participants’ comments in this relation is as follows:
The dispatch center is the brains and director of the operations in pre-hospital emergency care. Unfortunately, employment of individuals who lack the required knowledge and skills in this field disrupts the operations. For instance, one time, the personnel at the dispatch unit announced that a patient had signs of weakness and dizziness and could have hypoglycemia. When we got to the patient’s side, we realized he’d had cardiac arrest and that the dispatch center had suggested hypoglycemia by mistake. Misleading information from the dispatch unit can prevent the personnel from making the right diagnosis and, consequently, the right decision. (P4)
- Ethical issues
The final category of the major challenges and barriers in clinical decision-making is “ethical issues” which consists of the subcategories of respect for patients’ physical privacy and respect for patients’ sexual privacy. Regarding respect for patients’ physical privacy, in the Iranian culture, it is important that patients’ physical privacy be maintained and that their private parts not be seen by caregivers, especially opposite-sex caregivers. According to a participant:
Sometimes, we must provide care to female patients, especially young females, who have palpitations or chest pains and are in need of immediate cardiac monitoring. It is not ethical for the patients or even for us who are in the Iranian culture to see the female patient’s body. It is really a tough job to make a decision at such times and the patients may get very uncomfortable. (P13)
The participants also mentioned that, considering the dominant Islamic culture in Iran, showing respect for the sexual privacy of patients is very important to patients and their families. One of the participants stated that:
While we were transferring a pregnant woman, we realized she had broken her water and was in labor. The baby was coming and we had to help her deliver it. The poor woman seemed very embarrassed and uncomfortable. It is so hard to make a decision in such conditions. After all, we are Muslim and our ethical principles dictate that at such times, care should be given by a person of the same gender as the patient. But in Iran, there are no female staff members in the pre-hospital emergency care. (P21)