This qualitative study was conducted from November 2020 to November 2021.The content analysis methodologies were applied in this qualitative study, which took place.

This qualitative study took place in Iran, with 15 nurses and 13 pre-hospital paramedic workers as participants. A total of 16 men and 12 women between the ages of 21 and 52 were interviewed. A purposeful sampling strategy was used to choose the participants. Participants having a bachelor's degree in nursing or an associate's or bachelor's degree in prehospital emergency nursing, at least 1 year of work experience in a prehospital emergency center, and willingness to participate in the study met the inclusion criteria. The lack of consent to participate in the study and employees who have not had direct contact with patients with COVID-19 were exclusion criteria. Sampling continued until data saturation was reached, at which point the researcher judged that more interviews would not yield new information (23). Participants in this study were selected from centers that have been in direct contact with COVID-19 patients. Participants were also purposefully selected from all provinces of Iran country and data collection continued until data saturation.

In-depth interviews were used to conduct this qualitative study, which began with open questions and progressed to more specific questions, Showed in Table 1. Before the start of each interview, the research team talked about the importance of this study. Also, the research conditions were described and advice on how researchers conduct interviews that do not endanger their health or the health of other participants was sought. The interviews were recorded and lasted somewhere between 25 and 74 min. The time and place of the interviews were set by agreement between the researcher and the participants. Depending on the time of the interviews, the interviews are conducted in person in metropolitan areas and absentia in other provinces and by telephone. During the interviews, field notes were made to accurately describe and understand the responses.

The data acquired in this step was examined using Graneheim and Lundman's method of content analysis (24). The researcher examines the transcribed materials multiple times to fully comprehend them in this inductive approach. Then, the meaning units (words, sentences, or paragraphs) that responded to questions about pre-hospital emergency challenges and issues in handling the COVID-19 pandemic were identified, reduced, and coded. Similar codes were separated into subcategories, which were then concatenated to produce a category (manifest level). Each category arose from a collection of related ideas, making the categories internally homogeneous yet externally heterogeneous. The key subject emerged as the interaction between the underlying meanings in categories, which express the latent meaning. The interviews were conducted by E.H and HSH individually. The process of data collection was under the supervision of D.A.J.The MAX QDA 16 Software was used to handle the coding process.

For reliability and validity tests, this study used Lincoln and Guba's recommendations (25). Lincoln and Guba evaluation method for validation of qualitative research is based on four axes validity, verifiability, reproducibility and provability. These criteria are widely used in the validation of qualitative research. For this reason, in internal studies, these two researchers are better known for the issue of validity and reliability in qualitative research. To ensure reliability, four requirements of creditability, dependency, conformability, and transferability are required, according to this suggestion. The researchers spent 11 months interacting with data and the environment, constantly making observations and compiling field notes, to improve data reliability. Peer check procedures were used to determine the data's dependability. Monthly peer checks were conducted to ensure that the study team had a full discussion of the newly discovered data. Background information and the researchers' interests in the respective topics, as well as document upkeep, were used to assess data conformability. The context of the interviews, codes and extracted categories were analyzed by the research team, as well as other experts and three professionals in the field of qualitative research. Using maximum variation sampling, the researchers were able to collect a diverse range of comments, observations, and interpretations.

This study was authorized by the Isfahan University of Medical Sciences Ethics Committee. All methods were carried out in compliance with the applicable standards and regulations, and no animal research was carried out by any of the authors. Individual participants in the study gave their written informed permission. The participants' confidentiality and identities were maintained by the questioners' coding. Participants in the study were made aware of their right to withdraw from the study at any time without having to defend their decision.

There were 28 nurses and paramedic technicians in the study, with an average age of 36.5 ± 4.8 years and a range of 21–52 years. Their average work experience was 12.25 ± 3.4 years, and all of the participants had worked in EMS for more than 2 years, Showed in Table 2.

The various ethics and morality issues stemming from the pandemic's public policy challenges, particularly as it relates to medical care decision-making and the fairness of measures established to contain the pandemic and care for its victims, are one of the key concerns. According to one of the participants:

lack of public knowledge, widespread panic and worry among the general community due to an unknown sickness, as well as poor health facilities, provide particular obstacles and a significant threat to the population. One of the participants stated that:

In the COVID-19 pandemic, a better understanding of the obstacles faced by EMS staff could aid in enhancing the quality of pre-hospital emergency care. According to one of the participants:

Understanding the thoughts and worries of EMS personnel in the aftermath of an infectious or contagious disease pandemic, such as the current COVID-19, can aid in the development of effective disaster management methods and improve the quality of pre-hospital emergency care. According to one of the participants:

The proper training on how to utilize personal protective equipment (PPE) to protect EMS personnel from infectious diseases is crucial to keeping a stable workforce ready for COVID-19 outbreaks. During the COVID-19 pandemic, there have been few descriptions of EMS personnel's perceptions on PPE knowledge, use, and training. One of the participants stated that:

Healthcare administrators should conduct regular demand analyses and allocate resources based on the number of healthcare providers and the expected patient volume. According to one of the participants:

Financial performance as a metric for determining how well a corporation manages its financial resources. One of the participants stated that:

A majority of the participants in the study pointed to the challenges of increasing demand and calls to the EMS center due to public anxiety. Public anxiety and worry in such epidemics are normal but will cause problems in providing pre-hospital services. Al Amiry et al. (9) suggested that during the development of COVID-19, there was a global phenomenon of exponential increase in EMS calls. In New York City alone, for example, the volume of EMS calls increased from the usual daily high of 4,000 to more than 7,000, and this dramatic increase in call volume is expected to put a lot of pressure on EMS centers, as indicated in the present (9). According to research by Ferron et al. during the first 5 months of the COVID-19 outbreak, however, EMS calls in the Niagara area declined dramatically (16) which was inconsistent with the results of the present study. Nevertheless, the massive influx of call volumes requires EMS systems to re-examine their IT infrastructure and personnel to increase their call capacity (9).

Concerning service delivery challenges in providing services, the participants believed that there was no fair distribution of personal protective equipment. A similar study by Maguire et al. (26) suggested that challenges for EMS staff may be more difficult because they are one of the groups most likely to be affected by COVID-19. Thus, having proper PPE affects their performance (26). Another service delivery challenge highlighted in the present study was the lack of protocols for patients. As a result, Mohammadi et al. emphasized the importance of developing a thorough and systematic pre-hospital care procedure for EMS staff (27). The findings of this study concerning infrastructural challenges in service delivery highlighted the inadequacy of specialized and coded ambulances. Similarly, One of the significant challenges in the correct handling of the COVID-19 pandemic in pre-hospital emergency care, according to Mohammadi et al. (27). is the lack of ambulances specifically tailored for COVID-19 cases

The outcomes of this study reveal that one of the issues of pre-hospital emergency services is EMS worker stress and burnout during the current COVID-19 pandemic. Healthcare management, according to Parvaresh-Masoud et al. (28), should take steps to guarantee the psychological safety of EMS staff and prevent burnout. Because these factors have the potential to influence the quality of care (28). The lack of personnel training and competence was cited as a significant barrier to providing EMS services by the participants in this study. Cash et al. found that despite their education, 40% of EMS professionals in the United States still need to be trained in the N95 fit testing process (29).

The participants in the present study believed that fear of developing the disease and involvement with it in the workforce was one of the challenges in providing pre-hospital services. Similarly, Labaf et al. showed that the fear of COVID-19 in medical and hospital staff due to their direct exposure to patients or its transmission to others and family members is one of the most important human resource challenges (30). Furthermore, (31) referred to the presence of moderate to severe depression and anxiety in more than half of the pre-hospital emergency staff and stated that EMS staff play an important role in improving and promoting the health of people in the community, eliminating the underlying factor, causing emotional reactions in them should be considered a health priority. In addition, Siman-Tov et al. (32) believed that extreme concerns about transmission of the disease made medical staff fearful of transporting patients to the hospital in an emergency. This is also a real concern because patients with critical conditions that showed obvious signs of deterioration due to negligence admitted that they had delayed seeing a doctor for fear of spreading COVID-19 in the hospital (21, 32).

Khankeh et al. Also mentioned the challenge of nurses' burnout along with constant stress, insufficient support, inability to manage human resources and disregard for their needs and stressed that due to long working hours and multiple increases in the number of patients hospitalized. And high workload has reduced the mental strength and physical, emotional and mental fatigue of health care workers (33). Therefore, due to the increase in the number of hospitalized patients and the extensive workload of these employees and their frustration, it requires better management. Findings from the study of Garosi et al. (34) also show that many psychosomatic problems have affected nurses. Physical and mental fatigue, skin problems, chronic headaches, and anxiety disorders are some of these, many of which have been cited and accounted for a significant volume of studies (34).

The issue of “manpower shortage” was another challenge mentioned by the participants. Labaf et al. also emphasized the challenge in their study by expressing the shortage of specialized manpower (35). In this regard, Garosi et al. Also mentioned the lack of specialized and experienced nurses, unconventional work schedules, involuntary transfer of power between departments, insufficient support of the organization and insufficient specific training for Coronavirus as important problems for nurses in this period (34).

Interviewees pointed to the lack of equitable distribution of personal protective equipment, and Labaf et al. (35) noted that there is a challenge in controlling the consumption of protective equipment concerning important management challenges. There is enough equipment, but there is no control over their consumption and distribution (35).

“Poor training of medical staff” is also an important challenge, and neglecting this issue leads to insufficient knowledge and hinders their ability to work safely. Similar studies such as Sun et al. (36), Yin and Zeng (37), and (38) report the importance of nursing education during the Corona epidemic. Lack of awareness is one of the main causes of insecurity and providing training in the prevention and control of COVID-19 can also reduce the psychological burden and insecurity of nurses (36, 37).

One of the challenges highlighted by the participants in this study was the lack of medical equipment and supplies. A similar study by Al Amiry et al. showed that worldwide quarantine disrupted the global supply chain, including the medical sector, leading to a shortage of medical resources and equipment, and significantly affecting countries with poor health infrastructure and limited resources (9). The findings of the Razu study show that incentives such as financial support, continuous monitoring, adequate protective equipment and adequate manpower can encourage health workers to be more involved in epidemic conditions (39). Another important difficulty affecting the care offered to COVID-19 patients in pre-hospital emergency care, according to the participants, was the unavailability of special personal protective equipment and inadequate personal protective equipment allocation. (40) also pointed out the inadequacy of specific personal protective equipment, as was supported in the present study. Thus, it is essential to allocate personal protective equipment fairly and effectively.