1 Introduction

The pre-hospital emergency system operates with a defined mission and encompasses a range of actions. It starts at the telephone communication centre where requests for emergency aid are received, followed by the dispatch of an ambulance to the incident site (Kashani et al. 2018). Upon reaching the scene, the emergency personnel assess the patient's condition, prioritise the care needed, deliver necessary assistance and make decisions about hospital transfer (Razzak and Kellermann 2002; van Vught et al. 2019). The immediate patient transfer to the hospital is considered a crucial part of emergency care (Droogh et al. 2015; Vähäkangas et al. 2023). Emergency care providers maintain the continuity of patient care as the main goal of patient transfer (Delbridge et al. 2015; Flink et al. 2018) by effectively communicating clinical information and transferring care responsibility to hospital staff upon arrival (Johnson et al. 2016).

2 Background

Patient transfer has been widely acknowledged as a challenging, risky and logistically problematic process in the international literature (Droogh et al. 2015; Eiding et al. 2019). The challenges encompass a spectrum of factors including the diversity of patients' conditions, the coordination of care between distinct pre-hospital and hospital systems, collaboration among clinical experts from various disciplines, restricted access to comprehensive patient medical records, high personnel workloads, managing a multitude of transitional patients and navigating within constrained timeframes (Dawson et al. 2013; Shook et al. 2016). Moreover, the patient's relatives play a crucial role in the patient transfer process (Primc et al. 2023; Grønlund et al. 2023). They can serve as callers, initiating requests for assistance and directing ambulances to the scene. Additionally, they may administer first aid, offer reassurance to the patient, recount the events leading up to the emergency, provide background information about the patient and act as proxy decision-makers on behalf of the patient (DeJean et al. 2016). Since various individuals involved in patient transfer may interpret emergency events differently (DeJean et al. 2016), the active involvement of the patient's relatives can facilitate optimal patient treatment by emergency care providers (Primc et al. 2023; Grønlund et al. 2023). However, they can cause interruptions in patient care and treatment (Shook et al. 2016) and potentially compel emergency staff to administer unnecessary resuscitation efforts (Grønlund et al. 2023).

Emergency Medical Services (EMS) professionals often receive inadequate training in managing interactions with the family members of patients and balancing their needs. Due to the diversity of cultures and the advancements in medical technology, many EMS professionals find it difficult to interact with family members during emergency situations (Loyacono 2001).

In pre-hospital settings, emergency responders may encounter a wide range of conditions or complaints that necessitate thorough investigations and effective communication. However, communication and information exchange in emergency situations need to be performed quickly due to time constraints (Eadie et al. 2013), which create stressful experiences for most people (Satchell et al. 2023). Such conditions demand personnel to maintain an open and flexible approach, necessitating extensive knowledge and skill sets and special competence to effectively meet patients' needs (Sundström and Dahlberg 2012). Emergency care providers need to possess professional competencies and an understanding of different conditions (Wilson et al. 2015). However, the qualifications of personnel providing emergency services vary from country to country, influenced by cultural, economic, organisational and social factors (Dúason et al. 2021). Consequently, the standards and quality of care exhibit significant variations (Xavier et al. 2008; Lozano et al. 2012).

Emergency care providers, responsible for assessing and treating patients in the prehospital setting, also manage their transfer to hospital emergency departments (Sanjuan-Quiles et al. 2019). They face daily emergencies requiring immediate action and must manage chaotic, high-risk scenarios while maintaining composure (Oliveira et al. 2019). Evidence indicates that in 50% of cases, patients assessed in the prehospital setting have non-urgent conditions that do not require immediate medical intervention (Ek et al. 2013). Operational staff are uniquely positioned to assess the actual need for patient transfers (Mulholland et al. 2005). However, some evidence challenges the accuracy of judgements and decisions made by staff regarding the need for transfer (Mulholland et al. 2005; Brown et al. 2009; Fullerton et al. 2012), as these decisions are often based on mental processes and the emergency context rather than scientific evidence (Fullerton et al. 2012). This discrepancy may stem from the varying levels of knowledge, expertise, clinical judgement and decision-making abilities among pre-hospital emergency service staff (Ebrahimian et al. 2012). Additionally, issues such as conflict, pressure, heavy workload, poor communication, lack of social support, hierarchical communication and limited control over work and organisational decisions contribute to the challenges faced by these workers in the pre-hospital environment (Oliveira et al. 2019). Therefore, it is crucial to understand the primary challenge or concern faced by emergency care providers amid the many challenges they encounter. Key questions include What conditions contribute to this main concern? What strategies do they use to manage it, What are the outcomes? What factors facilitate effective management and what barriers hinder their ability to address the main issue effectively?

Currently, there is a growing interest in pre-hospital emergency research. However, many studies in this field are limited in scope, focusing only on specific issues within pre-hospital emergency care. To align with broader healthcare systems, it is crucial to continually enhance the quality of prehospital emergency services, relying on the best available evidence. Additionally, the process of patient transfer in prehospital emergency care has not been thoroughly evaluated. Therefore, conducting qualitative research using grounded theory methods to explore various facets of the patient transfer process is essential. This approach can offer a more detailed and comprehensive understanding of the challenges and nuances associated with transporting patients during prehospital emergencies.

3 The Study

This study aimed to explore the patient transfer process from pre-hospital to the hospital emergency department, identify the areas of main concern in this process, the strategies that emergency care providers used to address these concerns, the consequences of these strategies and finally develop a coherent underlying theory. Accordingly, the research question was How do emergency care providers manage the patient transfer process from pre-hospital settings to the emergency department?

4 Methods

5 Findings

The participants included 13 personnel working in the pre-hospital emergency (10 operational personnel and 3 dispatchers); 5 personnel working in the hospital emergency (3 emergency nurses and 2 triage nurses), 2 patients and 4 patients' relatives. The average working experience of the participating personnel was 9.3 years. The average age of the participants was 28.7 years. Also, 65.4% were men, and 34.6% were women (Table 1).

The data analysis led to the development of six main categories: ‘responsible transfer of the patient’, ‘exposure of personnel to extreme anxiety and violence of the patient's relatives’, ‘judicious control of tension’, ‘compulsory acceptance’, ‘conflict of will-will’ and ‘unsafe emergency services’ (Table 2).

The study found that emergency care providers' main concern was ‘the tension of delay in safe transfer and the threat to patient survival’. Several individual, organisational and social factors contributed to this concern. The central variable, ‘diligent avoidance of tense confrontation’, was identified as a set of strategies, including situational resourcefulness, persuasive communication and forbearance. While this strategy is a conscious effort to manage tension in various situations, its effectiveness can be influenced by several factors. The efforts of emergency care providers resulted in outcomes ranging from successful persuasion and smooth patient transfer to unsuccessful persuasion, avoidance of responsibility, and lasting hidden tension. Ultimately, a theory of diligent avoidance of tension-causing confrontation in the patient transfer process was developed through the integration and refinement of related concepts (Figure 2).

5.2 The Context

Various factors contributed to ‘the tension of delay in safe transfer and patient survival threat’. They encompassed various elements such as the perceived urgency of the patient's condition by bystanders, uncertainty regarding the patient's prognosis, perceptions of staff negligence, negative attitudes towards personnel performance, disagreements among individuals involved in patient transfer, limited understanding of emergency services, inadequate information regarding the patient and the scene and insufficient facilities for emergency care provision. These factors have been classified into three overarching levels: ‘individual’, ‘organisational’ and ‘societal’ (Figure 1).

The tension surrounding the delay in safe patient transfer and the threat to patient survival stemmed from various underlying factors such as the perceived imminent risk of the patient's death by relatives due to a lack of timely access to specialised services, the deterioration of the patient's condition during transfer, uncertainty among relatives about the patient's future, perceived negligence of personnel in executing timely and accurate actions, conflicts between individuals and organisations involved in patient transfer, negative perceptions of emergency service providers' performance based on prior experiences, suspicion and lack of confidence in personnel competence, insufficient knowledge among patient relatives regarding emergency service protocols, inadequate information available to personnel regarding the accident site and patient history, shortages and depletion of pre-hospital emergency equipment and encountering overcrowding in the emergency department upon the patient's arrival at the healthcare centre.

I was driving to the hospital with the siren blaring, and the patient's companion was very stressed, very upset, he kept saying: ‘Go quickly, why don't you go faster?’ [loudly], he was talking to me in a very bad tone, from the window of the ambulance, he had turned his head outside, and he was saying to the people: ‘Go away, my patient is very sick and unwell.’ (Operational personnel, p 8)

It took us 7 min from the moment we departed the base until we arrived at our destination. Despite our prompt response, they still claimed that we were arriving late. It's perplexing; I wonder what misconceptions have circulated about the pre-hospital emergency department, consistently leading them to believe that we are tardy. (Operational personnel 9)

5.7 The Central Variable and Integration of the Categories

Emergency care providers, throughout all stages of the patient transfer process, work diligently to address patients' care and treatment needs. They seize every opportunity for involvement and rely on the support of the patient's companions and relatives to expedite the transfer. While family involvement helps meet the patient's biomedical needs and ensures a safer transfer, providers still face the pressure of delays and the threat to patient survival during pre-hospital emergency transfers. A careful examination of this situation, along with a review of relevant notes and theoretical considerations, allows for the identification of underlying causes, an analysis of the strategies used to manage tension and an exploration of the positive and negative outcomes of these strategies. Additionally, we must consider the factors that either facilitate or hinder effective tension management.

From this analysis, the concept of ‘diligent avoidance of tense confrontation’ emerges as a central variable. This concept encapsulates the collective efforts of all those involved in the patient transfer process, who confront the tension of delays and patient survival threats. It highlights a conscious, deliberate effort to avoid confrontations that could escalate tension. In summary, emergency care providers strive to prevent reactions or confrontations that could intensify tension during patient transfer. Ultimately, the theory of diligent avoidance of tense confrontation in the patient transfer process was developed through the integration and refinement of these concepts (Figure 2).

6 Discussion

The objective of this study was to explore the patient transfer process from pre-hospital to the hospital emergency department, identify the areas of concern in this process and strategies that emergency care providers used to address these concerns. The data analysis revealed that the primary concern of the emergency care providers was the tension of delay in safe patient transfer and patient survival threat. While they maintained their focus on the provision of care to the patient by using the main strategy of diligent avoidance of tension-causing confrontation, they made efforts to manage tension and transfer the patient safely. In this basic psycho-social process, some factors act as facilitators and others are barriers. Time is a crucial role in the effective management of high-risk health situations (Herlitz et al. 2010; Collet et al. 2018). The critical and unpredictable condition of patients exacerbates families' distress. Also, any delay in the provision of emergency care becomes intolerable, fostering dissatisfaction and sometimes even erupting into extreme acts of violence (Nord-Ljungquist et al. 2020). Pre-hospital delay, defined as the time elapsed from the onset of symptoms in a patient to the receipt of definitive care (Alidoosti 2004), has been identified in prior research as a primary or pre-disposing factor for the emergence of violence and aggression in emergency situations (Rees et al. 2023; Bernaldo-De-Quirós et al. 2015; Sheikh-Bardsiri et al. 2013). This issue can occur as a result of the difference between what is desirable and what can be achieved in reality (Dollard et al. 2013).

In this study, unreasonable expectations and lack of public awareness were among the underlying factors of tension. Since any event that requires an emergency response by an ambulance can be very stressful for the people involved (Nord-Ljungquist et al. 2020), extreme stress and anxiety of relatives are considered one of the main reasons for acts of violence (Karlsson et al. 2020). In contrast to this finding, Philippe Charrier et al. showed that violence and conflict are not always related to the anxiety of patients or their companions, but the patients or their relatives do not have the basic etiquette necessary to interact with others (Charrier et al. 2021) caused by their ignorance of the appropriate methods of interaction in emergencies. In any setting where interaction and communication occur, conflict and disagreement are bound to arise, particularly in pre-hospital emergencies where time is constrained and communication spans across diverse professional backgrounds (Karlsson et al. 2020; Bremer et al. 2009a).

This study revealed that pre-hospital delays stemmed from a spectrum of reasons. Tangible factors such as unclear patient addresses, traffic impediments, and inadequate transportation resources both ground and air as well as staff negligence contributed to these delays. The emergency care providers employed various strategies, including making contingency decisions, to mitigate these issues. However, unrealistic factors such as ignorance, negative attitudes and lack of trust in personnel competence often triggered significant stress among patients' families. Consequently, anxiety surrounding delayed safe transport and the threat to patient survival intensified. Similar studies also showed that the process of transferring a loved one affects the whole family, so they experience various negative emotions (Herlitz et al. 2010). They experienced a range of extreme emotions from hope to despair (Bremer et al. 2009a), from calmness to chaos (Nord-Ljungquist et al. 2020) and confusion and disturbance (Jarneid et al. 2020; Paavilainen et al. 2017). Therefore, they perceived the elapsed time differently than the actual time (Huabbangyang et al. 2022). In these unstable conditions, both the patient and their relatives find themselves in a state of vulnerability and incapacity (Bremer et al. 2009b; Holmberg et al. 2016), necessitating assistance and support as fellow human beings (Gustafsson et al. 2013). While emergency care providers are tasked with making rapid decisions and ensuring proper patient care, the anxiety and distress experienced by the patient's relatives add an extra layer of responsibility and care burden for them to manage (Kamphausen et al. 2019). Hence, the presence of family members during emergencies imposes significant responsibilities on personnel, demanding the capacity to recognise, adapt decision-making processes and respond effectively to their needs. The shift from patient-centred care to family-centred care necessitates a transition from a structured response to a more situational one, where personnel must navigate a delicate balance between rational decision-making and emotional responsiveness based on the circumstances at hand (Gallo et al. 2016). However, sometimes due to feelings and emotional reactions, personnel cannot afford to prioritise these responsibilities selectively in their decision-making processes. Failing to do so puts them at risk of reaching incorrect conclusions and fostering caregiving relationships based on false elements such as unrealistic hopes (Bremer et al. 2012).

In this study, the utilisation of expedient lies by the emergency care providers, such as the unrealistic and demonstrative performance of cardiopulmonary resuscitation on a deceased patient, aimed at instilling hope among the patient's companions. As noted in this research, amidst the tense atmosphere, the emergency care providers bolstered the level of support provided to patient companions by leveraging resources such as experience, professional demeanour and appearance. Additionally, they employed the strategy of skilful avoidance of confrontations that could escalate tension as a primary tactic for tension management. This strategy is consistent with the belief of emergency personnel in refraining from reactive measures and prioritising the respect for the rights of patients and their families as the utmost form of response (Sheikhbardsiri et al. 2022). In line with the main request of the patient's relatives, they diligently tried to speed up the patient transfer process by using strategies such as focusing on immediate vital actions for the patient and safe transfer of the patient as their main mission and using strategies such as expediency, patience and establishing persuasive communication to reduce the tension as much as possible and safely transfer the patient to health care centres. Previous studies also show that where ambulance personnel communicate more effectively with the patient's relatives, they feel informed and included in the care process. In contrast, in instances where inadequate communication is reported, families often experience feelings of confusion and isolation (Gallo et al. 2016).

In this study, the emergency care providers tried to calm the patient's relatives and obtain their cooperation by keeping the relatives constantly informed about the patient's condition and giving timely and appropriate feedback. These efforts, along with the influence of various intervening factors, ultimately led to gaining the trust of patients and their companions and calming them down. In many other cases, these approaches may prove ineffective, leading to consequences such as unsuccessful persuasion, acquiescence to unprofessional demands from attendants and attempts to shift responsibility for the patient's care by expediting their transfer to healthcare centres. While providing honest information and instilling a sense of hope, along with reassuring the patient's relatives about the quality of care being provided, can indeed enhance their ability to cope with anxiety and stress (Dadashzadeh et al. 2019). Nevertheless, effective communication and cooperation in emergency situations can be disturbed due to a lack of trust, unfavourable perceptions and high expectations of patients and their relatives (Afshari et al. 2023). Based on existing evidence, one solution employed by emergency care providers to disengage from stressful situations involves physically removing themselves from the scene to avoid potential confrontation (Charrier et al. 2021; Dadashzadeh et al. 2019).

Our finding also showed that when the personnel were not successful in managing the tension, they tried to alleviate the pressure from companions by expediting the handover of the patient to emergency department staff, aiming to minimise the duration of direct interaction and the associated stress. However, this approach can lead to conflict and disruption of communication between the employees of these two departments, along with the complex and often chaotic nature of the emergency department (Owen et al. 2009). It has the potential to seriously endanger the exchange of important patient information and jeopardise patient safety (Bost et al. 2012; Safety and Care 2010).

This study revealed that surrendering to the unprofessional demands of the patient's companions is a consequence of ineffective efforts by emergency care personnel to control tension. While this approach may prevent the continuation of the tension at the moment, it can have adverse psychological effects (Gusmão et al. 2018) on emergency care providers and, in the long run, has a high potential to reduce job satisfaction and cause turnover (Dadashzadeh et al. 2019).

The failure of strategies to manage tension resulted in long-term hidden tension according to our findings. Emergency care providers are often subjected to high-stress situations, which means that they are susceptible to experiencing stress like patients and their relatives. The emotional weight of being first responders at the forefront of the healthcare system heightens the risk of secondary trauma, a type of stress induced by assisting individuals in distress (Regehr, Goldberg and Hughes 2002; Regehr, Goldberg, Glancy, et al. 2002). This finding confirms that emergency care providers are at risk of compromised psychological safety due to their daily exposure to stressful factors (Regehr 2005; Alexander and Klein 2001). Consequently, this can have a detrimental impact on the long-term quality of emergency care (Hadian et al. 2022). Hence, policymakers must give particular attention to this issue and devise solutions to mitigate its effects.

7 Strengths and Limitations

According to our knowledge, this is the first study to comprehensively investigate the main concerns and management strategies during the patient transfer process from pre-hospital to the hospital emergency department. The study involved all parties involved in patient transfer, including hospital emergency personnel, pre-hospital personnel, patients and their relatives. This facilitated the attainment of a more thorough and precise understanding of the complexities involved in patient transfer by emergency care providers, aiding in the development of suitable strategies to address them. One limitation of this study is that while the main author had frequent access to the hospital emergency environment for collecting documents and observing patient delivery processes between pre-hospital emergency personnel and hospital emergency departments, similar access was not available in the pre-hospital environment. The main author could only attend the telephone communication centre and pre-hospital emergency bases in limited cases.

Recommendations for further research: Further research should explore patient- and family-centred care during transfers, examine verbal and non-verbal communication strategies, develop evidence-based guidelines for assessing and mitigating transfer risks, and assess whether specialised training in transfer procedures, communication skills, and conflict resolution enhances outcomes.

8 Conclusion

The patient transfer process in pre-hospital emergencies typically commences with a call for assistance from non-professional individuals at the scene and ideally concludes with the safe handover of the patient to specialised healthcare facilities by professional ambulance personnel. Throughout this transfer, these professionals face pressure from the patient's relatives to expedite the transfer to healthcare centres, often enduring insults, threats and even violence. Consequently, they must transition from a patient-centred to a family-centred approach, which transcends mere clinical knowledge and technical expertise.

Emergency care providers encounter various tensions during this process, with the delay in safe transfer and the threat to patient survival emerging as primary concerns. In response, they employ diverse strategies, yielding outcomes ranging from positive to negative. While positive strategies contribute to the development of clinical guidelines for real-world scenarios, negative consequences such as communication breakdowns, relatives' refusal to cooperate with pre-hospital emergency services, formal complaints, surrendering, shifting patient responsibility and prolonged underlying tensions underscore the urgent need for effective support and more efficient tension management strategies for emergency care providers during patient transfer.

Author Contributions

The authors contributed to the design and implementation of the research, to the analysis of the results and to the writing of the manuscript. M.J., F.A., M.K., M.V.: Study design and conceptualization. F.A.: Data collection. M.J., F.A., M.K., M.V.: Data analysis and interpretation. M.J., F.A., M.K., M.V.: Manuscript writing. F.A., M.K., M.V.: Study supervision.

Conflicts of Interest

The authors declare no conflicts of interest.