"We need to accept our limited resources": a qualitative study exploring ambulance clinicians' experiences of working conditions when caring for patients with breathlessness

Breathlessness is a common and potentially life-threatening symptom among patients and constitutes a frequent reason for ambulance dispatches. Within ambulance care, ambulance clinicians (ACs) are often required to make rapid clinical assessments and decisions under complex and unpredictable conditions. Despite this, there is limited knowledge of how ACs experience their working conditions in ambulance care when caring for patients with breathlessness. Little is known about how these working conditions influence their ability to balance clinical responsibility, patient needs, and environmental constraints in the ambulance care setting. This study aimed to explore how ACs experience their working conditions in connection with the care of patients with breathlessness.

This qualitative exploratory sub-study included a sample of 16 ACs from southwestern Sweden, all with at least one year of clinical experience. Data were collected through semi-structured dyadic interviews following a simulation exercise and analyzed using reflexive thematic analysis.

The ACs experiences of their working conditions in connection with the care of patients with breathlessness is captured in three main higher-order themes: navigating constraints of the care environment, navigating professional judgment within institutional boundaries, and navigating responsibility in uncertain and distant care situations. ACs highlighted situations in which high-acuity care is delivered in environments that do not consistently ensure clinician safety. Clinical guidelines support decision-making in high-stress situations but may become restrictive when patients' conditions fall outside standard recommendations or when interventions are contraindicated. To address these constraints, ACs develop adaptive strategies. Non-conveyance decisions involving patients with breathlessness are described as particularly complex and burdensome, a challenge intensified by a shift toward selective transport and increased reliance on individual clinical judgment under uncertainty.

The findings show that working conditions in ambulance services influence how care for patients with breathlessness is provided and experienced. Care is delivered in contexts marked by urgency, uncertainty, and constrained resources, requiring ACs to navigate patient needs, safety considerations, and organizational expectations. While acceptance of limitations functions as a professional strategy, it carries ethical implications for patients' safety, dignity, and care.