Explaining the experience of telephone cardiopulmonary resuscitation in Kermanshah emergency medical dispatch: A qualitative, phenomenological study

Abstract

Background

Telephone Cardiopulmonary Resuscitation (T-CPR), administered by Emergency Medical Dispatchers (EMDs) to bystanders at the scene of an out-of-hospital cardiac arrest (OHCA), faces significant challenges. These challenges arise when collaboration for CPR is difficult due to the bystander’s condition or when the patient’s condition is not visible. Limited research exists on T-CPR, which is why our study aims to explore the experiences of Kermanshah EMDs in providing T-CPR.

Method

This descriptive phenomenological (because there is lack of information and study about this subject in Iran and importance of a deep understanding to examine different aspect of the subject) study was conducted with 12 EMDs from a total of 20 in Kermanshah EMDs. Data were collected through in-depth, semi-structured interviews with participants selected via purposive sampling. The study was qualitative and the questionnaire was not validated. Interviews consisted of both open-ended and probing questions. This research was carried out in 2020–2021. Data were analyzed thematically using Collizi’s seven-step.

Result

Analysis of the 12 interviews conducted with dispatchers who had an average age of 28.33 years and 2.33 years of work experience resulted in the identification of 456 codes. These codes were categorized into three main themes: (1) “Perceived Nursing Care in T-CPR,” which includes sub-themes such as Ethical and Emotional Management in Care, Empathetic Care, Crisis Management and Stress Control; (2) “Professional Abilities of EMDs,” which includes sub-themes like Perceived Professional Skills and Satisfaction from Successful Performance; and (3) “Cultural Necessities Related to Telephone Resuscitation,” with sub-themes such as Challenges of Training, Communication Barriers and the Need for Public Education and Cultural Change.

Conclusion

Participants reported that T-CPR is often unsuccessful due to factors such as non-collaboration from bystanders or improper execution, stemming from low education levels, cultural barriers and a general lack of public awareness about emergency procedures. Successful T-CPR requires dispatchers to skillfully communicate with anxious bystanders and correct misconceptions that CPR may worsen the patient’s condition. Additionally, fluency in various accents, improving public education, and implementing effective stress management strategies are essential for improving outcomes. Addressing these issues through better education and cultural change is vital for enhancing T-CPR effectiveness.

Introduction

Cardiac arrest (CA) is a leading cause of death and presents a major challenge for healthcare systems worldwide [1]. It is projected to be one of the top causes of mortality globally by 2030 and it can occur at any time and in various locations [2]. Research indicates that a significant number of CA occur in homes and public places, with the majority being OHCAs [3]. Recent studies shows that OHCA is the leading cause of death every 12 min globally which requires significant attention [4], however despite nearly 50 years since the introduction of CPR [5] public awareness about importance and execution remains low [6] and mortality rates continue to be high. This highlights the need for widespread public training [7].

According to the suggested content, immediate CPR by bystanders is crucial to prevent brain damage and increase the chances survival and it also bridges the critical gap until Emergency Medical Services (EMS) arrive the scene [8]. Also EMDs play a vital role in managing emergency calls and guiding bystanders for resuscitation process (First EMDs ask the bystander to shout (Mrs/sir) and shake his/her shoulders to determine the level of patient’s consciousness then ask to count the patient’s breathing in 10 s by looking at the chest. T-CPR starts if the patient is not conscious and number of breaths is one or less). Often in stressful situations, when the bystander is aggressive and anxiety or EMDs who doesn’t have enough experience for T-CPR, different language between the bystander and EMDs, there won’t be effective communication, or when the bystander doesn’t have enough skill and previous training about CPR, it can complicate the acquisition of accurate information & correct implementation of this [9].

In Iran, the success rate of bystander-performed CPR is reported to be less than 6% (It means that the success rate of CPR by bystanders who didn’t collaborate to perform CPR or didn’t do it properly), compared to 11% in the United States [10]. Factors Contributing to this include limited CPR knowledge, fear of exacerbating the patient’s condition, lack of resuscitation skills, ineffective communication with EMDs, and difficulty in recognizing CA symptoms [11]. Research indicates that effective CPR increase the likelihood of survival for CA patients by 2 to 4% [12]. Studies also emphasize the importance of bystander CPR [13] and the role of EMDs in improving survival rates and reducing mortality of OHCA [14].

The primary focus of this study is to identify factors that affect the success rate of resuscitation by bystanders. Also according to statistics from Kermanshah University of Medical Sciences, 40–50% of deaths in Kermanshah are due to cardiac causes [15] and dispatchers are often the first responders in OHCA cases also no study of T-CPR importance has been conducted in this city so we aim to investigate their perspectives on T-CPR, the challenges they face and the quality of T-CPR implementation in Kermanshah. By addressing the challenges faced by dispatchers and improving education for both EMDs and the public, we can reduce the mortality rate associated with out-of-hospital cardiac arrest in Kermanshah.

Methods

Design

This study utilized a qualitative descriptive phenomenology design to explore EMDs experiences of T-CPR, 12 EMDs out of a total of 20 participated in this study. Qualitative descriptive studies are particularly studied for investigate individual experiences and specific phenomena. Interpretive phenomenology seeks to understand the human lived experience and is the method of bringing out and making visible human experiences that are normally hidden [16]. The study adhered to the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist to ensure methodological rigor [17].

Participants

The participants were EMDs of Kermanshah province of Iran, their average age is 28–32 years old, 6 of them are single and 6 married and all have bachelor’s degrees in nursing Because all emergency dispatchers in Kermanshah are female (mentioned in the “Limitations”).with at least 1 year of work experience in EMD and selected using purposive sampling. Participants were selected based on their willingness to participate and their experience with performing T-CPR (by asking the participant who has experienced T-CPR and by checking the recorded sounds after obtaining the necessary permissions) and be employed in Kermanshah EMD.Interviews were conducted with 12 dispatchers and two of them did not want to participate in the study (2 others were replaced). Written informed consent was obtained from the participants for recording their voices and participation in the research. Interviews were scheduled at mutually agreed times and locations.

Data collection

The interviews were conducted by first author who is a colleague of the participants in dispatch of Kermanshah and the participants know her which made the participants cooperate more. In-depth, face-to-face interviews were conducted using open-ended questions to collect data. Before this, demographic information such as age, sex, education degree, work experience, and marital status were taken. The average time of each interview was 45 min to 1 h. Follow-up questions were posed based on participants’ responses to further clarify their answers. Interviews took place at a location chosen by the participants, typically their workplace, and were recorded with their consent. Notes were taken during the interviews, and participants’ phone numbers and work shift schedules were collected to verify statements or arrange additional interviews if necessary. Data collection continued until saturation was reached. Data collection continued until saturation was reached [18] after the 10th interview, ensuring no new concepts emerged. To confirm this, 2 more interviews were conducted and no new code was extracted.

Data analysis

The data were analyzed using Collizi’s 7-steps to qualitative data analysis [19], after obtaining consent, the interview was recorded with a mobile phone then typed. The transcriptions were analyzed in MAXQDA-10 software. Also notes were reviewed multiple times to capture participants’ feelings and experiences. Then the codes was carried out from the sentences (a label for each sentences which explain the concept) it means that statements related to the phenomenon were underlined to identify significant sentences. Important phrases were distilled into core concepts (first, each sentence was given a code whose represents its meaning then the codes that had similar meanings were stratified, in the sub-themes. finally, the sub-themes that had similar meanings were stratified into the main themes) that represented the essence of participants’ thoughts. The researcher grouped these concepts into categories based on similarities. Results were synthesized to form general categories and provide a comprehensive description of the phenomenon. A detailed description of the phenomenon was developed based on the integrated categories. The final step was to check the trustworthiness of the data. For validity and reliability of the study, the results of the research were given to two expert researchers with a PH.D degree in nursing in Kermanshah University and their opinions were used and also we asked participant’s opinion about extracted codes.

Trustworthiness

Rigor was held on Lincoln and Guba’s approach [20]. For credibility, we were involved in the data collection for six months and variation in participant’s characteristics in terms of age and work experience was maintained. Codes and themes were also provided to the participants (member check) and co-workers (peer check). After addressing their comments, approved by theme. For dependability, we elaborated in detailed and step by step the collecting process of data, the purpose of the research, limitations, analysis and extracting themes, so they can be properly audited by external observers. In line with confirmability, the researcher tried to extract the cods and themes from the participant’s descriptions then the results were given to research colleagues to check the accuracy. For transferability, the results of the study were provided to three EMDS who did not participate in the study and their experiences were commensurate, results and quotations were clearly stated.

Result

Twelve participants from Kermanshah EMDs participated in the study. Demographic characteristics of the participants are summarized in Table 1. A total of 456 codes were extracted from the interviews, which were organized into three main themes: (1) “Perceived Psychological Nursing Care in T-CPR,” including sub-themes like Ethical and Emotional Management in Care, Empathetic Care, Crisis Management, and Stress Control; (2) “Professional Abilities of EMDs,” including sub-themes like Perceived Professional Skills of EMDs and Satisfaction from Successful Performance; and (3) “Cultural Necessities Related to T-CPR,” including sub-themes such as the Challenges of Training, Communication Barriers, and the Need for Public Education and Cultural Change (Table 2).

Table 1.

* Work experience (year) = Numbers of years she has worked in the dispatch

Participant number	Sex	Work experience(year)	University degree	Marital status
1	female	4	Bachelor of nursing	married
2	female	4	Bachelor of nursing	married
3	female	4	Bachelor of nursing	married
4	female	2	Bachelor of nursing	married
5	female	2	Bachelor of nursing	married
6	female	3	Bachelor of nursing	married
7	female	1	Bachelor of nursing	single
8	female	1	Bachelor of nursing	single
9	female	3	Bachelor of nursing	single
10	female	2	Bachelor of nursing	single
11	female	1	Bachelor of nursing	single
12	female	2	Bachelor of nursing	single

Table 2.

Extracted themes, subthemes and cods of the study

Theme	Sub theme	Example of cods
Perceived psychological Nursing Care in T-CPR	Ethical and Emotional Management in Care	Moral conscience * Moral commitment of nursing care* stress management
	empathic care	Sense of philanthropy * Identify* sympathy* compassion
	Crisis Management and Stress Control in T-CPR	management aggressive bystander * management dispatcher’s anxiety* bystander’s circumstance management
Professional abilities of EMDs	Perceived Professional Skills of EMDs	Unsuccessful resuscitation associated with insufficient experience*Effective communication with the caller*Perfect implementation of T-CPR
	Satisfaction Related to Successful Performance	successful resuscitation with all the problems
		Happiness associated with saving the patient
		Proud of doing the correct resuscitation
Cultural Necessities related to T-CPR	The Challenges of Training	Low CPR knowledge level of the bystanders*Lack of sufficient dispatcher training in T-CPR
	Communication Challenges	Lack of public awareness about CPR* Different language of the bystander
	Perceived Need for Public Education and Culture	Fear of worsening the patient’s condition after resuscitation*T-CPR training is a waste of time*The duty of the dispatcher is only to send an ambulance

* Codes are labels used to represent the meaning of the participants’ sentences, Codes that have the same meaning are placed in the sub-theme and similar sub themes in main themes groups

Perceived psychological nursing care in T-CPR

This theme was derived from the responses of 12 participants and extracted 130 codes. It highlights how the characteristics of EMDs influenced by their personality and personal experiences impact their performance. Many participants noted that their sense of altruism, empathy, and professional conscience significantly affects their T-CPR and motivates them to exert the most effort to assist patients and their families which it has psychological effects such as depression, sad or happy to save a life, anger at non- collaboration on the EMDs. The sub-themes identified Ethical and Emotional Management in Care, empathic care, Crisis Management and Stress Control in T-CPR.

Ethical and emotional management in care

This sub-theme derived from 70 codes based on the statements of 12 participants addresses the anxiety experienced by both EMDs and bystanders during T-CPR. The feeling that a person is dealing with death and the bystander’s lack of knowledge and ability to collaborate and perform effective resuscitation, along with the lack of experience and awareness to perform telephone resuscitation by the EMDs or not having an ambulance in the area near the patient, will all be very stressful conditions. The critical nature of cardiac arrest, coupled with the need for effective time management, contributes to heightened anxiety in bystanders, which often transfers to EMDs. Participant No. 3 (who was talking with an anxious bystander who reported that his grandfather with a history of heart disease had not been breathing for 5 min and was turning blue): “I also felt anxious and struggled to concentrate. To manage this, I take deep breaths, focus on the task, training and remind myself of the importance of my role. When bystander starts CPR and the ambulance arrives, my stress usually subsides.” Participant NO. 5(who spoke to a woman whose her father had a cardiac arrest and the ambulance that was closest to the caller was in mission (: “If bystanders don’t have collaboration or an ambulance is dispatched to the patient from a far distance, I am still stressed and anxious until the ambulance arrives; sometimes I cannot even sit in a chair.”

Empathic care

Extracted from the statements of 10 participants and 30 cods, this sub-theme involves showing empathy towards bystanders often influenced by the EMDs’ own experiences or emotional responses. EMDs frequently align with the bystander’s distress driven by a sense of altruism and humanity. Participant No. 9 (she has a same experience with bystander and her father had a cardiac arrest and died 2 years ago): “Sometimes I put myself in the place of the patient’s family and try to use all my power to help the patient and her family”. Participant NO. 2 (she identifies with bystander): “I put myself in the place of the bystander and empathize and think that if this happened to my loved ones, I would have expected my colleague to do best”.

Crisis management and stress control in T-CPR

This concept derived from 30 codes from 9 participants reflects the commitment of EMDs to provide high-quality care regardless of the patient’s age, ethnicity, gender, or illness. Participants emphasized the principle that saving one life equates to saving all lives. Participant No. 9 believes that: “It is inhumane to provide anything less than high-quality service to any patient. My goal is to serve every patient impartially and I believe that my work should be perform with integrity.” Participant NO. 8 (in relation to providing quality services equally to all patient) says: “Humanity dictates that all people should be helped equally, regardless of age, sex, etc. and I am afraid that one day the same situation will happen to my loved ones and as I don’t different between my loved ones I will use my whole power to help all patients”.

Professional abilities of EMDs

This theme extracted from 154 codes based on comments from 8 participants and show the role of individual abilities and professional skills in performing T-CPR. Key skills include Communicating effectively with an anxious and aggressive bystanders, crisis management such as investigating perform resuscitation by unstable bystander in unstable prehospital condition, traffic hours with the lack of ambulances and the ability to keep calm (when the angry caller swears and ignores your advice(. To increase and strengthen this skill, the training program for EMDs who are newly hired in dispatch and the monthly monitoring of quality of the performance through the saved audios of the EMDs and training workshops for the need of them which are provided by the pre-hospital emergency training unit considered.

Perceived professional skills of EMDs

This sub-theme indicates the importance of managing critical situations and effective communication despite stress. Early in their careers, many EMDs experienced anxiety and confusion, which decreased as they gained experience and proficiency. Participant No. 6 (she explains how conditions of telephone cardiopulmonary resuscitation affect her mental state): “I felt a lot of anxiety during cardiac arrest situations, especially with uncooperative bystanders. However as my experience grew, my anxiety decreased significantly and I now handle these situations with greater confidence.” Participant NO.4 (Making decisions about situations that cannot be seen): “EMDs must decide whether or not to send an ambulance without observing the patient’s condition and based on the questions asks bystanders which is often incorrect and this requires a lot of professional skill.”

Satisfaction related to successful performance

This sub-theme, derived from 48 codes from 6 participants, refers to the positive feelings EMDs experience when achieving successful outcomes. The participants believed that when science and experience end up with a good result and a human life is saved, it is the best reward and the most valuable inner feeling. This satisfaction, influenced by skill and experience, contributes to job fulfillment and improved quality of care that save the patient’s life from death which is the nursing commitment. Participant No. 2 ( The caller is a 32-year-old woman whose 6-month-old baby has suffocated due to milk aspiration(: “When I successfully assisted a bystander whose newborn was not breathing, and later heard the baby cry, it was the most rewarding experience.” Participant NO.1: “I am satisfied because I know that God will bless me for saving the lives of patients.

Cultural necessities related to T-CPR

This theme derived from 174 codes based on statements from 12 participants, emphasizes the need for cultural adaptations to improve T-CPR outcomes. Key cultural needs identified include public CPR education (education in schools and through television and radio programs, making documentaries about cardiac arrest patients, how emergency and dispatcher’s tasks). Cultural awareness about benefits of CPR and addressing communication barriers such as EMDs proficient in several language) Since there are many ethnic groups with different dialects in Kermanshah, such as the Lak, Jafi, Horami and even Turkish peoples, the problem of establishing communication will be more challenging) and attempting to eliminate the misconception that performing resuscitation worsens the patient’s condition and consider bystander as the cause which is possible with extensive education to the general public. Sub-themes include: The Challenges of Training, Communication Challenges, Perceived Need for Public Education and Culture.

The challenge of training

Extracted from 70 codes based on 10 participants’ statements, this sub-theme addresses difficulties related to the bystander’s literacy level and the urgency of the situation, which often hampers effective training and collaboration. In fact, the low level of literacy of the recipient prevents the correct training EMDs or the lack of previous knowledge about how to do resuscitation of bystander makes it impossible to train in an auditory way during a critical period by the phone. Participant No.6 (explain the bystander’s fear of performing resuscitation): “Sometimes bystanders are hesitant to perform CPR due to fear of blame if something goes wrong. This reluctance often due to a lack of knowledge, highlights the need for broader public education.” And often People’s lack of familiarity with how EMDs work creates the wrong belief that EMDs should only send an ambulance and not ask any questions or they consider the efforts of the EMDs to perform resuscitation as a waste of time and to avoid sending an ambulance, Participant No. 11(When the dispatcher asked the caller about the condition of the patient, she said that you should just send an ambulance and don’t ask questions):“People have no knowledge about the dispatch’s tasks and their only mentality about our work as EMDs is that we are just send ambulance and when we ask them or the companions of the patient to perform resuscitation and carry out our training, they think that we don’t want to send an ambulance, which is useless and a waste of time”.

Communication challenges

Derived from 19 codes based on 4 participants’ statements, this sub-theme highlights that many factors can be effective in establishing effective communication between the bystander and EMD such as different language, call interrupt and caller doesn’t answer the call, The environment around the bystanders is crowded and noisy or the negative impact of people around them who are aggressive and want an ambulance to be dispatched as soon as possible or say that there is no benefit in doing resuscitation are barriers to do CPR. Participant No.8 (The surroundings of bystander were noisy and he spoke with a different Kurdish accent that the dispatcher hardly understood): “Different accents have occasionally hindered communication, leading to misunderstandings and unsuccessful attempts at providing assistance. This underscores the need for clearer communication strategies. “Participant NO.1 (she says her idea about low bystander’s collaboration, she spoke with a Turkish language person and She did not understand what he was saying ): “Sometimes there are challenges that prevent this happening, for example the bystander speaks another language, is afraid to perform cardiac massage or is worried or anxious and does not collaborate. No matter how much I ask to convince them, unfortunately they do not want”.

Perceived need for public education and cultural changes

This sub-theme, derived from 85 codes based on 12 participants’ statements, stresses the importance of enhancing public awareness and education about CPR and emergency procedures to improve T-CPR effectiveness. Participant No. 6 (bystander said that she will not perform resuscitation because it is useless and she thinks the patient is dead): “When bystanders are unware and hesitant about the importance of CPR, it reveals the critical need for public education and awareness about emergency procedures.”

Discussion

The analysis of the data revealed several key findings. First “perceived psychological Nursing Care in T-CPR” shows EMD’s experiences in stressful conditions and psychological pressure caused by critical patient who may die, a bystander who doesn’t do CPR or an ambulance being far from the patient and the most important factors are low job experience and not seeing the patient’s condition. They try to manage these situations (by controlling anger or environment and calming the bystanders and herself) based on nursing care until deliver EMS to patient, because these emotional challenges (Anxiety Care, Empathic Care and Crisis Management and Stress Control in T-CPR) put a lot of psychological pressure on the dispatchers, especially PTSD, aggression, severe anxiety. According to a study conducted by Meysam Safi-Keykaleh and her colleagues, two of the most important factors affecting emergency decision-making are stress and anxiety which is one of the important findings of the current study [21]. Also a study has been conducted that confirms this, or in 2016 a study by Jessica Lee suggested that EMDs frequently encounter stress, including significant emotional challenges during their duties which complicates their role and their emphasis to perform quality of T-CPR is reduced [16]. In other hands the continuous mental-psychological pressure of the dispatchers makes them burnout and a study has mentioned this. Similarly, Beck, Arnold and Talsky (2009) identified that healthcare providers face emotional communication challenges such as grief, hope, empathy, and fear that can contribute to job burnout [17].

Another concept that exists in this study, “cultural Necessities Related to T-CPR” point out that need for Training about CPR, improve cultural status of society (It includes correcting people’s misconceptions about CPR and Communication Barriers. As said before, many bystanders hesitate to perform resuscitation due to a lack of knowledge about its importance, how to do and sometimes they believe that doing CPR may make Patient’s condition worth and this often cause of ineffective bystander’s collaboration with EMDs. A study has focused on the importance of educating the general public and increasing their awareness regarding the importance and method of performing cardiac resuscitation in increasing the survival of cardiac arrest’s patients, which confirms the findings of the study, Hye.J. Park and colleagues suggested that public awareness regarding CPR is generally low, indicating a critical need for public education to improve cardiac resuscitation success rates [18]. Also, low awareness and education levels among bystanders frequently result in improper execution of provided instructions, which can disrupt the diagnosis and treatment process. Scott Stangens and colleagues (2020) emphasized that early and accurate diagnosis of a patient’s condition by communication personnel is vital and is often hampered by the bystander’s insufficient knowledge and training [19].

In other side, Participants noted that skill development is crucial for handling stressful situations themselves and the bystanders, effective communication between EMDs and bystanders to providing T-CPR training.Effective T-CPR requires that both EMDs and bystanders possess adequate skills and knowledge (Professional abilities of EMDs). Camila Hardland and her colleagues (2017) found that the survival rate for out-of-hospital cardiac arrest patients improves when the first person at the scene performs resuscitation and communicates effectively with emergency lines. Key abilities include accurately diagnosing symptoms and following instructions. The bystander’s ability to receive and apply training correctly is crucial for successful T-CPR [20].Wenche Toron Matthiessen (2021) further noted that maintaining composure and accurately following training are essential for effective resuscitation, and trust in one’s ability to perform resuscitation without fear of worsening the patient’s condition is critical [21, 22]. In the review of past studies, results inconsistent with the findings of the current study were not found.

Limitation

Despite the researcher’s efforts for effective communication with explain the confidentiality of the study, some participants didn’t share complete information. All the participants are women because in Kermanshah only women have been hired for this unit since 2016 and we didn’t have access to male colleagues who were previously in dispatch, it has a negative effect on the transferability, comparing opinions and skill differences (how to manage stressful situations and communicate with agitated people, etc.) of the opposite sex. On the other hand, the relatively low history of all the participants, due to the lack of dispatcher’s job experience can’t be compared with people who have more experience and can be considered in future studies.

Cultural factors and concerns about potential work-related repercussions contributed to their hesitancy.

The study’s design, geographical context, and phenomenological approach necessitate the inclusion of individuals with specific CPR experience. As a result, the findings cannot be generalized to all individuals, groups, or communities, similar to other qualitative research. The prevailing culture and educational background in the study’s geographical area should be considered when attempting to generalize the results to other regions. Differences in cultural and educational contexts may affect the applicability of the findings to different populations.

In this research, it was tried to reduce this problem as much as possible by explaining the exact details of the process, clarifying all the aspects and findings obtained.

Conclusion

The findings of this study suggest that the quality of T-CPR is influenced by a variety of factors including: EMDs’ ability to communicate interpersonally with an aggressive bystander (presence of dispatchers who know different languages ​​and accents can be used to communicate despite this problem), calm them and then herself down also try to delete stressors in the environment around the bystander to increase her concentration and collaboration by saying these sentences: get away from the tense environment or those who are agitated and good reaction, planning & resolution for problems related to the heavy urban traffic, improve popular cultural and wrong people’s believe change about CPR to increase people’s collaboration with EMDs or popular education about perform CPR and also promote importance of CPR.

The results of the current study by clarifying the problems and challenges of T-CPR that have caused the disruption of the transfer of patients and on the other hand, Clarifying the operation of dispatchers and factors affecting its quality, it will lead to more familiarity and the attention of the officials of the health organization to solve the existing problems and has a positive effect on the improvement of telephone resuscitation.

Also, the necessary follow-up should be done by the relevant managers to use CCTV cameras in the city to reduce the problems caused by the not seeing the patient’s condition and to improve the quality of triage for dispatchers.

It is suggested that for reduce the mentioned problems, requests from the head of Kermanshah EMS to increase the number of ambulances and equipment is done. Necessary follow-up should be done by the training unit to hold workshops and training documents from telephone resuscitation, dispatch and public training, especially training of volunteers. Establishing periodic meetings with the police to investigate traffic problems and similar acts.

Author contributions

1. Alireza abdi designed the work; wrote article, analysis and interpretation of data and he was supervisor. 2. Fateme zaheri wrote the article, collected data, corresponding and the creation of new software used in the work. 3. Mahmoud rahmati was a consultant for writing and analysis the article.

Funding

The study was funded by Kermanshah University of Medical Science.

Data availability

Data would be available via contacting the corresponding author (fatemeh zaheri).

Declarations

Ethical approval

Research ethics committee of Kermanshah University of Medical sciences. The study received approval from the Ethics Committee, number IR.KUMS.REC.1399.992. Participants were fully informed about the research title, objectives, and duration. They were also given an opportunity to ask questions and receive answers about the study.

Informed consent

was obtained from all participants for both the interview and audio recording. This consent was sought voluntarily, ensuring participants understood their right to withdraw at any time without consequence. Participants were assured of their anonymity and the confidentiality of their information. All measures were taken to protect participants’ identities and personal data. The study adhered to strict confidentiality principles throughout the research process. Participants were informed of their right to access the research results upon request. The researcher committed to honest publication of the findings and to respecting the rights of the participants. The research was conducted with the utmost respect for participants’ rights and ethical standards, ensuring the integrity of the study and the welfare of its participants. By fully explaining the details of the research to the participants and obtaining their informed consent to participate in the study, as well as observing the principle of confidentiality of the participants’ information. The ethical principle of “Helsinki” has been observed in this study.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.