Based on the analysis, there was five categories containing conceptual descriptions representing the SANs’ perceptions of working in situations involving OLV. Each individual interview contained two to five categories (see Table 2). The categories developed were Collaboration, Unsafe environments, Resources, Unequipped and Risk taking and self-protection. The categories will be presented in more detail below, illustrated by quotations with the participant number in brackets. In addition, they are presented in Fig. 1.

Table 2 Individual understanding of the participants’ perceptions of ongoing lethal violence events expressed in the 16 interviewsFig. 1

The SANs’ willingness to take risks and adopt self-protection strategies are decisive for how the OLV situation is handled in an unpredictable environment in which they feel unequipped, which is further reinforced by a lack of resources and challenging collaborations

Collaboration

The participants perceived that assignments involving OLV were dependent on collaboration between several organisations. Information passed between the organisations involved was considered a crucial part of collaboration. The participants described a lack of information from the emergency medical dispatch centre when they were assigned to a mission, possibly resulting in vital information that explicitly or implicitly pointed towards a potential OLV incident being left out. Generally, early information from the emergency medical dispatch centre consists of fixed classifications, e.g., "life threatening condition", which can include many possible scenarios in which the patient’s life is in danger, including trauma, medical conditions as well as various types of violence. The SANs believed that the emergency medical dispatch centre prioritises alerting an ambulance before gathering all the necessary information from the caller that could be passed on to the ambulance clinicians. Overall, the participants perceived that emergency medical dispatch centre staff do not possess sufficient knowledge to identify tacit information that could possibly indicate an OLV event and only pass on the information verbally stated by the caller.

Everyday clinical operations sometimes required collaboration with the police service. Even in these usually non-urgent situations, the participants reported difficulties in establishing contact via the designated collaboration radio channel, including inability to obtain feedback from police units who were the first on site. As the police service operated via a separate response channel, the SANs sometimes did not hear important information, which was unintentionally withheld. The perception was that especially in urgent, violent, or threatening situations, the police left the ambulance clinicians to themselves. This created frustration, even among experienced SANs, as without information they could not know what to expect or whether the location was considered sufficiently safe. Problems concerning collaboration were perceived as possibly delaying necessary medical interventions.

It became a..... you got a lump in your stomach, a feeling of insecurity when you were to continue and enter the scene, because you have to take care of your own safety because the police were not on the same designated collaboration radio channel and therefore the communication broke down, so we didn't know what we were getting into (P10)

Furthermore, the SANs stressed that the communication within and between organisations needed to be straightforward and clear, as the internal jargon within the respective organisations could hamper the situation. The SANs pointed out that despite the situation, they trusted police service representatives’ evaluation of whether the place was safe enough to enter.

The participants highlighted the fact that the phenomenon of “borderless routing” [the emergency medical dispatch centre can assign an ambulance to any location within the region] contributed to uncertainty. Ambulance assignments in their own familiar district meant that SANs had knowledge of e.g., residential areas where OLV events were more likely to occur, as well as local knowledge of exit or escape routes and the geography of surrounding areas.

In the past, the SOS [Emergency Medical Dispatch Centre] was tied to a certain catchment area. They had knowledge of the local geographical area. And it's the same with ourselves. Because of the borderless routing we cover a larger geographical area and can end up in places that are dangerous, although we don't know it ourselves. (P2).

It also emerged that the participants perceived operational collaboration and simulation with the local police service and fire brigades as advantageous to prepare for a future OLV incident. The participants also mentioned the need for operational interventions at the scene together with colleagues and organisations from geographical areas other than those they usually work with, as OLV events often result in many injuries and/or causalities.

Say that there is an ongoing shooting at for example the central station. I would not hesitate to team up with the police and enter the site to provide life saving measures here and now. A safe location… yes... what is a safe place? (P8).

Participants who had attended interprofessional simulations of OLV events perceived the ideas and advice provided by police departments as valuable, serving as a kind of mental preparation.

Unsafe environments

The participants reported that in assignments involving OLV incidents there was a high demand from the public and significant others to simultaneously attend to and save the lives of several severely injured individuals. Furthermore, demands from the public to enter situations or locations that were not considered safe enough were perceived as stressful, especially as the public and significant others generally have no knowledge of EMS working methods. The first ambulance unit at the scene is encumbered by the need to establish an operational management function, making it impossible to provide medical assistance other than trying to obtain a picture of the site and situation. Pressure and sometimes threatening behaviour from the public demand the SANs to save lives despite a lack of safe preconditions were perceived as stressful and challenging. In these situations, the participants requested police presence as a security measure. In addition, the participants strongly objected to being filmed involuntarily and thereafter posted on social media. The role of the media in an OLV situation was perceived as important, but in the short term there were concerns about being identified and possibly publicly questioned.

I feel that the public expect us to handle everything…//When you think about it, what the expectations consist of, it can feel like quite high demands or high expectations, and can we live up to it? Or can I live up to it? (P13).

Resources

The SANs expressed that they perceived a potential shortage of resources in terms of ambulance availability and personal protection gear in the event of an OLV situation. They pointed out that there is already a shortage of resources in their normal workday, which would become even more severe in the case of an OLV event. Bearing in mind that every minute counts, waiting times for additional ambulances in an OLV event were considered daunting.

It's not always that the Emergency Medical Dispatch Centre can immediately allocate ten ambulances to the scene and for you to establish a staff function, so before the ambulances actually arrive victims may have ended up dead (P11)

Personal protection gear was requested, e.g., protective vests, pepper spray or other types of personal protective equipment. However, it was discussed if wearing protective vests could generate a false sense of safety, possibly leading to exposing oneself to greater dangers than necessary. However, only wearing their ordinary protective clothing, jacket, coveralls and helmet, made the SANs feel unprotected. Furthermore, they pointed out a potential lack of medical materials in the event of OLV. They stressed the limited amount of e.g., tourniquets [stringing in case of limb injury], potentially preventing the ambulance clinicians from taking life-changing measures at an early stage of an OLV event.

Ehhmm so when thinking purely in terms of security, we don't have as much as...that we can protect ourselves with. We have no training in close combat and we have no protective clothing, other than our helmets and...and...so we are quite vulnerable. (P2).

Unequipped

The SANs perceived that operational experience was of significance in assignments involving OLV. However, because incidents with OLV were rare, the participants considered that they were not properly equipped for working under such conditions. They expressed that medical assessments and triage were performed in everyday clinical operations, but not to the extent necessary for special events such as OLV. The perception among the participants with longer operational experience was that any event that only occurs occasionally leads to a risk of becoming fragmented, forcing experienced ambulance clinicians to handle the event single-handedly, as well as having to supervise less experienced colleague.

The SANs considered that they possess adequate knowledge of how to treat injuries in an OLV event, e.g., controlling catastrophic haemorrhage or airway management with simple aids. However, the perception was that they are not equipped for working in potentially hazardous environments.

Why had no one been able to tell me this before? Is this less important than the fact that the airway should always be managed? I mean, I always know how to take care of the airway in my patient before I do anything else… but if I do not know about my safety or I do not know the situation with shootings... (P10)

The participants perceived a lack of tactical ability to act in OLV incidents and such events place high demands on ambulance clinicians. The SANs expressed a need for local training sessions where they could discuss possible scenarios. They stressed that mental preparation was more important than the practical training, but it would be best if the two could be combined. Like other workplace-based training situations such as cardiopulmonary resuscitation or medical management, the participants requested the preparation of structured action plans for OLV events, as they rarely occur. Structured care was perceived as valuable in such stressful and urgent situations by both experienced ambulance clinicians and new employees.

Risk taking and self-protection

The participants perceived that they had to act as their own safety advocate, due to lack of a fixed plan for assignments involving OLV incidents. The nature of the incident and the SANs’ willingness to take risks were perceived as decisive for how the situation was handled. The participants described that how the situation was interpreted was determined by any previous experience of OLV, earlier non-OLV professional experiences and the type of risk-taking each individual SAN was willing to be exposed to and act upon. Therefore, according to the participants, the outcome of an OLV event was dependent on the SANs’ assessment. The participants referred to the police service and fire brigade, both of which were perceived to have a fixed structured plan that everyone within the two organisations follows.

So, if you have taken this job, you must consider... that such things can happen and then you have to deal with them. Then you would be super stressed and incredibly... frightened ...for sure (P7).

In the case of an OLV event, the participants mentioned the importance of working with competent and experienced colleagues. Teaming up with colleagues who had several years of professional experience and/or experiences of incidents involving OLV was perceived to provide increased security for the ambulance team. The participants perceived and reflected on the fact that variation in individual risk-taking levels could have had an impact on teamwork at an OLV site due to conflicting views among the members of the ambulance team.

You do not rush into situations in the same way as new colleagues sometimes do, you slow down a bit and stop and think about your own safety in a different way... …you want to come home. (P7)

Consensus prevailed among the participants that personal safety took precedence over caring for patients and that SANs wanted to return home alive. However, the participants stated that risk-taking is part of the profession in certain circumstances.

We must also be able to take some form of risk, so to speak…. in this job it is included. Can I live with that notion? Good! Then I can work in the ambulance service. If I am unable to live with that notion, I am not suitable to for working in the ambulance service. You have to live with some risk. It is part of the profession... (P16).

The SANs faced hazards daily that were considered ordinary clinical events, e.g., traffic accidents, crowded public spaces and the cramped space in the ambulance. They were aware of such risks, realising that they are part of the profession, at least to some extent. Based on their experience, the participants reflected on their own behaviour and caring actions as well as place and space, which can be partially implemented in an OLV event.