Confidential - Company Proprietary An analysis of the strategic communication of emergency medical services within the North West Province MM Thamae orcid.org/0000-0002-3305-9637 Mini-dissertation accepted in partial fulfilment of the requirements for the degree Master of Business Administration at the North-West University Supervisor: Dr C Niesing Graduation: June 2025 ii Confidential - Company Proprietary DECLARATION SOLEMN DECLARATION OF OWN WORK BY THE STUDENT Module Name Mini-dissertation Module Code MBAC 873 Assignment Title An analysis of the strategic communication of the Emergency Medical Services within the North West Province Due date 27 November 2024 I, Mohau MacPhalen Thamae, declare herewith that the assignment which I herewith submit to the North-West University in partial compliance with the requirements set for the Master of Business Administration (MBA) degree is my original work, has been text- edited in line with professional communication standards, and has not already been submitted to any other institution for evaluation purposes. Potchefstroom Campus: (+27) 18 299 1406 Mahikeng Campus: (+27) 18 3 89 2 095 Vanderbijlpark Campus: (+27) 16 910 3011 Signature of student: Student initials and surname M. M.Thamae Student number 44265190 Date signed 15 November 2024 NWU Business School North - West University Private Bag x6001 Potchefstroom, 2520 https://www.nwu.ac.za/busines s - schoo l https://www.nwu.ac.za/business-school https://www.nwu.ac.za/business-school https://www.nwu.ac.za/business-school https://www.nwu.ac.za/business-school https://www.nwu.ac.za/business-school https://www.nwu.ac.za/business-school iii Confidential - Company Proprietary ABSTRACT This study analysed strategic communication techniques within Emergency Medical Services (EMS) in the North West Province of South Africa. It explores the importance of efficient communication and emphasises the crucial function of contemporary communication technology in enhancing response times and coordination during emergencies. The research employed a qualitative design and an inductive approach grounded in interpretive epistemology to analyse primary data collected from semi- structured interviews with EMS personnel. A deductive approach was used to address two secondary objectives through the literature. The socio-ecological model (SEM) served as a framework to evaluate the individual, organisational, societal, and policy aspects influencing communication efficacy. The results indicate that mobile phones have emerged as the principal communication device for EMS personnel, augmenting internet-based communication in operational facilitation. Notwithstanding the benefits of these technologies, restricted access and resource limitations endure, highlighting the desire for dependable alternatives such as two-way radios. The study recommends reintroducing two-way radios as auxiliary instruments, providing mobile devices, and augmenting training programmes for EMS personnel at all levels. These findings aim to assist policymakers and EMS management in improving communication and strengthening emergency response capabilities and outcomes in the North West Province. Keywords: Strategic communication, Emergency Medical Services, North West Province, Communication System, Mobile phones, Internet communication. iv Confidential - Company Proprietary ACKNOWLEDGEMENTS I want to express my heartfelt gratitude to several individuals whose unwavering support and encouragement have been instrumental in completing my MBA qualification. First and foremost, I extend my most profound appreciation to my beloved wife, Nokuzola “Malefa” Thamae, whose constant support, understanding, and encouragement have been my rock throughout these endeavours. I am also immensely grateful to my children, Mpho, Lunga, Karabo, and Thato. Their love and unwavering support have inspired me to achieve my goals. To my mother, Moliehi Tlhodi, whose boundless love and guidance have shaped me into who I am today, I owe a gratitude that words cannot fully express. Her unwavering support during the trying times of my life and belief in me have been a constant source of strength throughout this journey. I would also like to acknowledge my late Uncle Au Joseph Thamae and my late Aunt Modiegi Thamae, who played a significant role in my upbringing. Though they are no longer with us, their presence and influence guided me throughout my academic journey. Finally, I am deeply indebted to Prof Christi Niesing for her invaluable guidance and patience, for pushing me to think critically, and for her expertise throughout the completion of my mini-dissertation. Her mentorship and support have been crucial in navigating the challenges of academic research, and I am profoundly grateful for her dedication to my success. To all these individuals, I offer my sincerest thanks. Your support and encouragement have driven my achievement, and I am forever grateful for your presence in my life. v Confidential - Company Proprietary DEDICATION I dedicate this work and success to my mother, whose unwavering support and wisdom shaped my path with love and resilience. To my beautiful wife, you have always believed in me, and your support is highly appreciated. Finally, to all my siblings and children, Mpho, Lunga, Karabo, and Thato, you are my motivation, joy, and most significant legacy. This achievement is a testament to our bond's strength and shared dream. Together, we thrive. vi Confidential - Company Proprietary TABLE OF CONTENTS DECLARATION ............................................................................................................... ii SOLEMN DECLARATION OF OWN WORK BY THE STUDENT.................................... ii ABSTRACT .................................................................................................................... iii ACKNOWLEDGEMENTS ............................................................................................... iv DEDICATION .................................................................................................................. v TABLE OF CONTENTS .................................................................................................. vi LIST OF FIGURES ......................................................................................................... xi LIST OF TABLES .......................................................................................................... xii ACRONYMS AND ABBREVIATIONS ........................................................................... xiii 1.1 Introduction ................................................................................................. 1 1.2 Background ................................................................................................ 1 1.2.1 Emergency Medical Services in a Global Context ...................................... 3 1.2.2 Emergency Medical Service in Private Healthcare in South Africa ............. 5 1.2.3 Emergency Medical Services in Public Healthcare in South Africa ............ 5 1.2.4 Emergency Medical Service in South Africa ............................................... 7 1.3 Emergency Medical Service Responsibilities ............................................. 8 1.3.1 Dignity of Patients ....................................................................................... 8 1.3.2 Patient Information ..................................................................................... 8 1.3.3 Stakeholder’s Satisfaction .......................................................................... 8 1.4 Problem Statement ................................................................................... 11 1.5 Research Objectives ................................................................................ 13 1.6 Secondary Objectives ............................................................................... 13 1.7 Research Question ................................................................................... 13 1.8 Classification of the Field of the Study ...................................................... 13 1.8.1 Field of the Study ...................................................................................... 14 vii Confidential - Company Proprietary 1.8.2 Sector/Industry ......................................................................................... 14 1.8.3 Geographical Demarcation ....................................................................... 14 1.9 Research Methodology ............................................................................. 14 1.9.1 Research Design ...................................................................................... 15 1.10 Methodological Choice ............................................................................. 16 1.11 Population and Sampling .......................................................................... 17 1.12 Data Collection Method ............................................................................ 18 1.13 Data Analysis ............................................................................................ 20 1.14 Ethical Consideration ................................................................................ 22 1.14.1 Beneficence and Non-maleficence ........................................................... 22 1.14.2 Risk/Benefits Analysis .............................................................................. 22 1.14.3 Permission and Informed Consent ........................................................... 22 1.14.4 Confidentiality and Anonymity .................................................................. 23 1.14.5 Conflict of Interest ..................................................................................... 23 1.14.6 Monitoring ................................................................................................. 24 1.14.7 Rigour – Validity and Reliability ................................................................ 24 1.15 Contribution of the Study .......................................................................... 24 1.15.1 Strategy Formulation ................................................................................ 25 1.15.2 Policies ..................................................................................................... 25 1.16 Limitations and Delimitations of the Study ................................................ 25 1.17 Structure of the Document ........................................................................ 25 CHAPTER 2: LITERATURE REVIEW ......................................................................... 27 2.1 Introduction ............................................................................................... 27 2.2 Theoretical Review ................................................................................... 27 2.2.1 The Socio-Ecological Model (SEM) .......................................................... 28 2.2.2 Six Building Blocks of Health Systems According to the WHO ................. 30 viii Confidential - Company Proprietary 2.3 Conceptual Review ................................................................................... 32 2.3.1 Framework of Strategic Communication ................................................... 32 2.3.2 Foundations of Strategic Communication in EMS .................................... 33 2.3.3 Strategic Communication in an Emergency Situation ............................... 34 2.3.4 Role of Communication in Healthcare Service Delivery ........................... 35 2.4 Empirical Review ...................................................................................... 35 2.4.1 Global Perspectives on Strategic Communication in EMS ....................... 36 2.4.2 Regional Perspectives on Strategic Communication in EMS.................... 38 2.4.3 Local Perspectives on EMS - South Africa ............................................... 39 2.5 Chapter Summary .................................................................................... 42 CHAPTER 3: RESEARCH METHODOLOGY ............................................................. 45 3.1 Introduction ............................................................................................... 45 3.2 Empirical Investigation .............................................................................. 45 3.3 Research Design ...................................................................................... 45 3.4 Methodological Choice ............................................................................. 46 3.5 Research Paradigm .................................................................................. 47 3.6 Population and Sampling .......................................................................... 47 3.7 Inclusion and Exclusion ............................................................................ 48 3.7.1 Inclusions for the Study ............................................................................ 49 3.7.2 Exclusions for the Study ........................................................................... 50 3.8 Data Collection Method ............................................................................ 50 3.9 Rigour ....................................................................................................... 51 3.9.1 Credibility .................................................................................................. 52 3.9.2 Dependability ............................................................................................ 52 3.9.3 Transferability ........................................................................................... 52 3.9.4 Confirmability ............................................................................................ 53 ix Confidential - Company Proprietary 3.9.5 Triangulation ............................................................................................. 53 3.10 Data Analysis ............................................................................................ 53 3.10.1 Thematic Analysis .................................................................................... 53 3.11 Ethical consideration ................................................................................ 55 3.11.1 Informed Consent ..................................................................................... 55 3.11.2 Confidentiality ........................................................................................... 55 3.11.3 Voluntary Participation .............................................................................. 55 3.11.4 Minimisation of Harm ................................................................................ 56 3.11.5 Respect for Autonomy .............................................................................. 56 3.12 Chapter Summary .................................................................................... 56 CHAPTER 4: DATA ANALYSIS AND PRESENTATION ............................................. 57 4.1 Introduction ............................................................................................... 57 4.2 Socio-Ecological Model ............................................................................ 58 4.3 Participants Background Information ........................................................ 61 4.4 Analysis of Primary Data and Coding ....................................................... 63 4.4.1 Theme 1: Operational Challenges within EMS ......................................... 70 4.4.2 Shortage of critical resources required to facilitate EMS systems ............ 72 4.4.3 Theme 2: Communication System and Strategies within EMS ................. 73 4.4.4 Theme 3: Community Awareness Programmes for EMS ......................... 81 4.4.5 Theme 4: Employee Training for EMS Personnel ..................................... 83 4.4.6 Theme 5: Stakeholder and Community Awareness .................................. 87 4.4.7 Theme 6: Gaps Identified by EMS Employees ......................................... 89 4.5 Chapter Summary .................................................................................... 94 CHAPTER 5: CONCLUSIONS AND RECOMMENDATIONS ..................................... 95 5.1 Introduction ............................................................................................... 95 5.2 Discussion of Primary Objective ............................................................... 95 x Confidential - Company Proprietary 5.3 Discussions of Secondary Objectives ....................................................... 98 5.4 Achieving the Aims and Objectives of the Study ...................................... 99 5.5 Proposed Policy Brief ............................................................................. 100 5.5.1 Introduction ............................................................................................. 100 5.5.2 Key Findings ........................................................................................... 100 5.5.3 Policy Recommendations ....................................................................... 100 5.5.4 Investment in Communication Infrastructure .......................................... 101 5.5.5 Enhance Training Programmes for EMS Personnel ............................... 101 5.5.6 Strengthen Community Engagement Initiatives ...................................... 101 5.5.7 Develop Standardised Communication Protocols ................................... 101 5.5.8 Expected Outcomes ............................................................................... 102 5.6 Conclusion and Summary of the Study .................................................. 104 5.7 Personal Insights and Growth ................................................................. 105 APPENDICES ............................................................................................................. 131 Appendix A: Informed Consent Form .................................................................... 131 Appendix B: Declaration ........................................................................................ 135 Appendix C: Interview Guide ................................................................................. 137 Appendix D: Letter of Approval – DoH ................................................................... 139 Appendix E: Ethics Approval Letter Of Study ........................................................ 142 Appendix F: Proposed Policy for Strategic Communications – EMS ..................... 144 Appendix G: Certificate of Language Editing ......................................................... 146 xi Confidential - Company Proprietary LIST OF FIGURES Figure 1.1: Diagram adapted to illustrate Inductive and Deductive Reasoning (Trochim & Donnelly, 2008:23) ...................................................................................... 16 Figure 4.1: Socio-Ecological Model (Adapted) (Chynoweth et al., 2020) .................... 59 Figure 4.2: Application of Socio-Economic Model on the North West Province EMS. 61 Figure 4.3: Visual presentation for Theme 1 .............................................................. 70 Figure 4.4: Visual representation of Theme 2 ............................................................ 74 Figure 4.5: Visual Representation of Theme 3 ........................................................... 82 Figure 4.6: Visual Representation of Theme 4 ........................................................... 84 Figure 4.7: Visual Representation of Theme 5 ........................................................... 88 Figure 4.8: Visual representation of Theme 6 ............................................................ 90 xii Confidential - Company Proprietary LIST OF TABLES Table 4.1: Demographic information.......................................................................... 62 Table 4.2: Themes of the study ................................................................................. 65 xiii Confidential - Company Proprietary ACRONYMS AND ABBREVIATIONS ALS Advanced Life Support AUTHeR Africa Unit of Transdisciplinary Health Research BLS Basic Life Support CAD Computer-Aided Dispatch ECC Emergency Communication Centre ECP Emergency Care Practitioner EMS Emergency Medical Services EMT Emergency Medical Technician ECT Emergency Care Technician ILS Intermediate Life Support NWDoH North West Department of Health NWU North West University POPIA Protection of Personal Information Act UAN Universal Access Number UK United Kingdom 1 Confidential - Company Proprietary CHAPTER 1: INTRODUCTION TO THE STUDY 1.1 Introduction This chapter presents the research study, emphasising the strategic communication practices of emergency medical services (EMS) within the North West Province, South Africa. It offers pertinent background information and underscores the study’s significance, importance, geographical boundaries, and industry under investigation. The chapter articulates the research question and objectives; it also presents a concise overview of the research methodology, the instruments for data collection, and an outline of the subsequent chapters. 1.2 Background The effective and efficient provision of public services, especially healthcare, is paramount in modern society, particularly in rural areas. Clients (patients) in rural and urban areas are expected to have access to public facilities at all times; however, these services are not always available when needed (Habibi-Soola et al., 2022:1657). Despite South Africa’s advanced healthcare services, professionals (clinicians), mid- level workers (administrators), and reputable training institutes, the country continues to face considerable workforce shortages and access constraints (Degenaar et al., 2022:715). This is due to public and fundamental healthcare facilities’ restricted access to medical ambulance transportation during emergencies. Mechili et al. (2021:382) highlight that communication failures between primary and secondary healthcare stages can adversely limit patient management, resulting in extended waiting periods and inadequate coordinated care, which ultimately impacts patient outcomes and satisfaction. These issues stem from the unequal distribution of health workers between the well- resourced private sector and the poorly-resourced public sector and distributional disparities between urban and rural areas (Habibi-Soola et al., 2022:1658). Despite the efforts made by the South African government, individuals in rural and urban regions continue to have restricted access to healthcare facilities, which leads to human mortality (Degenaar et al., 2022:710). 2 Confidential - Company Proprietary In the 1970s, four provincial administrations, the Orange-Free State, Natal, Transvaal, and Cape Colony, provided EMS services to South Africans (Mohulatsi et al., 2023:381). Throughout this period, EMS was lacking in numerous regions of the country. Emergency Medical Services in South Africa are transforming emergency care education and clinical practice, notwithstanding expressed reservations about service delivery (PBEC, 2018; Rapanyane, 2022; SADoH, 2017). Despite national financing for EMS, rural areas in South Africa require improved service due to financial limitations and insufficient equipment availability (Mohulatsi et al., 2023:381). Given the intensified volatility in the business environment, effective communication is crucial for empowering individuals to take the initiative and improve organisational competitiveness through heightened productivity and sustained growth (Chukwuka, 2015). The cost of communication has significantly decreased due to technological advancements; therefore, employing appropriate communication strategies could yield favourable results for the organisation (Asuelimen & Omohimi, 2019:206). Effective communication is exchanging ideas, thoughts, opinions, knowledge, and data to convey and comprehend the message clearly and intentionally. This notion of effective communication within the healthcare system can be associated with EMS to meet the demands of both rural and urban South African communities. The EMS constantly seek to reduce their response times, as they take primary responsibility for pre-hospital care of life-threatening and emergency medical conditions, including trauma and heart attacks (Khaketla et al., 2022). Effective communication enables personnel to comprehend the operational duties of EMS. Martin et al. (2011) assert that all employees and managers regard communication as vital to a company's success. Degenaar et al. (2022:710-716) assert that EMS functions as a holistic system, coordinating personnel, facilities, and equipment to deliver efficient and timely health and safety services to individuals experiencing acute illness or injury. Moreover, pre- hospital EMS provides immediate and appropriate aid to patients in emergencies. As part of the traditional trade of first responders, it is understood that EMS is the first point of contact for any assistance required during an emergency and plays a vital role in disaster response (Khaketla et al., 2022). 3 Confidential - Company Proprietary This study will examine several facets of daily operations, particularly strategic communication related to EMS. It will analyse strategic communication in the North West Province, characterised as an organisation’s intentional employment of communication technologies to convey its strategic goals. 1.2.1 Emergency Medical Services in a Global Context There is a growing demand for EMS globally. To respond to this increasing demand, the EMS communities require adaptable and sustainable model systems that encompass unified standards of practice, training, and results with minimum risk (Sommer et al., 2022). Globally, millions of patients seek pre-hospital care each year regardless of the simplicity or complexity of their conditions or injuries. Thus, EMS personnel proficient in Basic Life Support (BLS), Intermediate Life Support (ILS), or Advanced Life Support (ALS), commonly referred to as paramedics in South Africa, conduct prompt assessments and administer treatment to the ill and injured before their transport to a hospital or clinic for additional evaluation (Kim & Oh, 2023). Expertise, proficiency, and discernment are crucial for exceptional emergency medical care. High-quality and skilled paramedics are essential to any healthcare system; thus, numerous research studies on pre-hospital services prioritise human factors, efficiency, and the ongoing enhancement of practice standards. Emergency Medical Services are divided into two main models worldwide, namely: • The German-Franco Model, in which physicians staff an ambulance and • The Anglo-American Model, where ambulances are staffed with EMTs trained in BLS, ILS, or ALS (Sommer et al., 2022). Both models employ contemporary methodologies, tools, and technology to mitigate medical uncertainty and achieve optimal quality in patient-centric pre-hospital care (Sommer et al., 2022). Numerous countries utilise these principles to improve their pre-hospital services and emergency medicine while making concessions to deliver excellent pre-hospital care within budgetary limits and existing infrastructural challenges (Mogharab et al., 2022:58). Emergency Medical Services in South Africa function under a multifaceted framework shaped by the German-Franco and Anglo-American styles of emergency treatment. The German-Franco approach, distinguished by ambulances staffed by physicians, 4 Confidential - Company Proprietary stands in stark contrast to the Anglo-American model, which generally utilises EMTs trained in BLS, ILS, or ALS (Sobuwa & Christopher, 2019:2). In South Africa, the prevailing model closely resembles the Anglo-American approach, wherein EMS personnel receive training at multiple care levels; however, the system is characterised by considerable challenges, including resource constraints and inconsistencies in training and service provision (Ntsiea, 2019). The increasing focus on education and professionalisation in the field has influenced the development of EMS in South Africa. The National Emergency Care Education and Training (NECET) policy seeks to establish a cohort of emergency care professionals endowed with the requisite clinical knowledge and decision-making capabilities to improve pre-hospital care (Sobuwa & Christopher, 2019). This initiative is vital for rectifying the historical deficiencies in emergency services, which a lack of formal training and professional acknowledgement has hindered. Consequently, the South African EMS sector has experienced a rise in the number of training providers and a corresponding increase in trained personnel, which is critical for enhancing the quality of care provided to patients in emergencies (Sobuwa & Christopher, 2019). Since the 1970s, the methodology of emergency healthcare provision in the pre- hospital setting has developed around these two primary models of EMS characteristics (Sommer et al., 2022). The categorical distinctions were apparent from the 1970s until the conclusion of the 20th century, during which the Franco-German model of EMS delivery was based on the “stay and stabilise” principle, aiming to provide healthcare services directly to the patient on the scene, stabilising the patient before transporting to the hospital (Pakdaman et al., 2023). The Anglo-American model entails the “Scoop and Run” mentality (Pakdaman et al., 2023) focusing on transporting the patient to the hospital with minimal intervention at the scene. These models aim to rapidly bring the patient to the hospital with less pre-hospital intervention (Nodirovna et al., 2022:184). Wu and Ho (2022:20) assert that the first-world healthcare model has progressed, leading emergency medical professionals globally to enhance their capabilities in addressing medical and trauma emergencies through modern clinical technologies. The rapid development of medical technology has also reformed international EMS 5 Confidential - Company Proprietary systems with the introduction of multifunctional compact monitoring systems, making monitoring patients manageable in an uncontrolled environment of pre-hospital settings (Sommer et al., 2022). 1.2.2 Emergency Medical Service in Private Healthcare in South Africa Physicians frequently engage with elements of EMS systems in routine emergency medical practice. Delivering exceptional treatment in the pre-hospital environment necessitates that emergency personnel stay informed to treat patients before they arrive at the emergency room (Degenaar et al., 2022:710). The technical advancements present in the private sector accentuate the inequalities in healthcare provision. The disparity is intensified by private healthcare institutions’ ability to provide more attractive pay and better working circumstances, drawing qualified experts from the public sector (Mametja, Letshweni, Semenya, Moyo, Whyte, Bultinck-Human & Moloabi, 2023). The private sector frequently leads in the adoption of breakthrough communication tools, which are less accessible in the public sector due to financial limitations. The private healthcare sector employs skilled and experienced paramedics utilising advanced technologies that are inaccessible in the public sector due to budgetary limitations. Contemporary technology, including digital software utilised by the private sector, enables structured communication among the caller, contact centre, and responding paramedic during emergencies. 1.2.3 Emergency Medical Services in Public Healthcare in South Africa The South African government offers emergency ambulance services across all nine provinces. The new method grants Emergency Care Technicians (ECT) and Emergency Care Practitioners (ECP) significant flexibility in interdependent practice (Nodirovna et al., 2022:182). The Emergency Care Qualification Framework (ECQF) established by the South African Department of Health seeks to standardise the qualifications and competencies of emergency care personnel, thereby promoting a more systematic approach to emergency care delivery (Rowland & Adefuye, 2022; Sobuwa & Christopher, 2019). The function of ECTs, Paramedics, and ECPs in South Africa is progressively acknowledged as that of independent practitioners. This reflects the paradigm of Paramedic Practitioners in the United Kingdom, where practitioners 6 Confidential - Company Proprietary function with a level of autonomy that facilitates critical decision-making in emergency scenarios (Sobuwa & Christopher, 2019; Sobuwa, 2020). The South African EMS system features a variety of practitioners, from Basic Ambulance Assistants (BAAs) to advanced life support paramedics, each contributing significantly to the emergency treatment continuum. The incorporation of these practitioners into a unified operational framework is crucial for efficient emergency response, especially in rural and underserved regions with restricted healthcare access (Tiwari, Naidoo, English & Chikte, 2021; Zaidi, Dixon, Lopez, De Vries, Wallis, Ginde & Mould-Millman 2019). 1.2.3.1 Staffing The implementation of advanced training programs and the creation of a three-tier qualification system have been crucial in enhancing the standards of emergency care (Rowland & Adefuye, 2022; Sobuwa & Christopher, 2019). This evolution seeks to improve care quality while tackling the issues of large patient volumes and resource limitations typical in the South African healthcare system (Tiwari et al., 2021; Christopher, Naicker & Naidoo, 2023). Advanced Life Support providers are assigned to rapid response vehicles to improve response times and are required to be dispatched in support of the ambulance crew to all priority 1(Code Red) patients (those with high-acuity conditions or injuries) (Degenaar et al., 2022:703-705). The national objective was to have one staffed emergency ambulance for every 10,000 people by 2010; however, in some parts of the country, this ratio is currently approximately one ambulance for every 30,000 people (Sommer et al., 2022). 1.2.3.2 Vehicles Emergency Medical Services vehicles are essential to the healthcare system, especially in prehospital treatment. These vehicles employed by EMS are predominantly ambulances designed to deliver emergency medical aid and transport patients to clinics and hospitals. The Western Cape Government Emergency Medical Services (WCG EMS) manages a fleet of 261 ambulances, employing around 1,823 personnel across 49 bases, catering to a population exceeding 6 million residents (Alshehri, Pigoga & Wallis, 2020:639). This comprehensive network highlights the significance of EMS in emergency management and the provision of prompt medical care. The ambulances utilised in South Africa exhibit considerable variation, encompassing essential life support (BLS) trucks and advanced life support (ALS) 7 Confidential - Company Proprietary units. BLS ambulances are often outfitted with vital medical supplies and manned by essential life support personnel. In contrast, ALS units are furnished with sophisticated medical apparatus and staffed by paramedics skilled in executing more intricate medical interventions (Mould‐Millman, Dixon, Burkholder, Pigoga, Lee, de Vries, Moodley, Meier, Colborn, Patel & Wallis, 2021:2). 1.2.3.3 Dispatch Research demonstrates that the duration for EMS to reach the location and convey patients to medical facilities substantially influences patient outcomes, especially in trauma situations (Möller, Hunter, Kurland & van Hoving, 2018:91). In South Africa, despite possessing one of the most advanced EMS systems in Africa, a significant percentage of patients (49%) continue to depend on private automobiles for transportation to healthcare institutions, indicating possible deficiencies in the EMS response system (Möller et al., 2018:91). This dependence on private transportation may result in delays in obtaining essential medical care, highlighting the necessity for enhanced EMS accessibility and response times. Historically, EMS dispatch has originated from various sources and often involved self-dispatch, a practice still utilised by modern operational organisations. The framework centralises dispatch from a minimum of two call centres in major cities across each South African province to provide an optimal response to communities. 1.2.3.4 Time Response The South African system currently lacks an official response time. A response time of fifteen minutes for high-acuity calls in urban areas is acceptable; however, in rural locations, response times for similar calls can reach up to forty minutes (Thielmann et al., 2022). 1.2.4 Emergency Medical Service in South Africa Emergency Medical Services in South Africa function within a multifaceted healthcare environment marked by considerable obstacles and prospects. The South African healthcare system confronts a “triple burden” of disease characterised by elevated incidences of communicable diseases, non-communicable diseases, and violence, hence requiring a comprehensive and adaptive EMS framework to tackle these complex health challenges (McAlpine, Hodkinson & Fleming, 2020:8). The EMS 8 Confidential - Company Proprietary frequently serves as the initial contact for numerous individuals pursuing healthcare, especially in rural regions with restricted access to primary care. This highlights the essential function of EMS in ensuring fair access to healthcare services. 1.3 Emergency Medical Service Responsibilities The principal duty of EMS is to deliver prompt medical assistance to individuals suffering from acute diseases or injuries. This is especially vital in South Africa, where the healthcare system encounters considerable obstacles, including a high incidence of both communicable and non-communicable diseases, along with interpersonal violence (McAlpine et al., 2020:9). The South African Constitution acknowledges emergency treatment as a fundamental human right, highlighting the necessity of an efficient EMS capable of responding efficiently to emergencies (Tiwari et al., 2021:3). The Directorate of Emergency Medical Services and Disaster Medicine of the National Department of Health regulates and provides policy advice for EMS, ensuring these services are sufficiently prepared to manage emergencies (Tiwari et al., 2021:3). 1.3.1 Dignity of Patients The EMS must have organisational policies and practices in place regarding patient rights that are consistent with sections 10 and 27 (1) (a) and (3) of the Constitution of the Republic of South Africa, 1996, and Chapter Two of the Act. 1.3.2 Patient Information Patients must be provided with adequate information regarding healthcare services, including information about the service made available to patients, costs for services, and the quality of service provided (Malatjie, 2023). 1.3.3 Stakeholder’s Satisfaction Processes and methods must be established to facilitate communication of care experiences among stakeholders and patients. Therefore, the EMS station and Emergency Communication Centre (ECC) must implement systems and processes to assess, monitor, and improve their stakeholder’s satisfaction with the service provided (Jejaw et al., 2023:76). 1.3.3.1 Complaints Management The EMS must have a system for monitoring, assessing, and responding to complaints as outlined in the sub-regulation (Nodirovna et al., 2022:186). Complaints must be 9 Confidential - Company Proprietary recorded and analysed to improve the quality of care provided to the patients. Additionally, patients should be provided with information regarding the complaint process. 1.3.3.2 Patient Health Records It is essential to ensure that patient health records are accessible and can be retrieved when needed. (Jejaw et al., 2023:76). The EMS must record accurate patient biographical information and document clinical procedures to facilitate continuity of care. 1.3.3.3 Clinical Management of Emergency Care Provision An efficient call management system must be implemented to facilitate access to service communication systems, ensuring adequate and appropriate emergency care (Gettel et al., 2022:268-269). 1.3.3.4 Dispatch of Emergency Vehicle Monitoring response times at each call management and dispatch stage is paramount (Degenaar et al., 2022:710-711). An effective vehicle dispatch system must be in place to ensure patients have rapid and safe access to services. For sub-regulation, the EMS must have a Computer-Aided Dispatch (CAD) system that facilitates vehicle allocation, routing, and tracking. When an ECC does not have a CAD system, a paper- based system must facilitate vehicle allocation, direction, and monitoring. 1.3.3.5 Response Management The South African healthcare system is marked by a considerable deficit of healthcare professionals, especially in rural areas, which intensifies the difficulties encountered by EMS in providing prompt and efficient care (Mchunu, Harris & Nxumalo, 2022; Maphumulo & Bhengu, 2019; Tiwari et al., 2021). The disproportionate allocation of healthcare resources, along with elevated patient volumes and insufficient facilities, necessitates a well-coordinated EMS response capable of addressing the varied demands of the community (Tiwari et al., 2021; Sobuwa & Christopher, 2019). The allocation of EMS personnel is essential for efficient emergency response. 1.3.3.6 Clinical Leadership Systems must be implemented to support quality healthcare services and prevent patient safety incidents (Degenaar et al., 2022:707). 10 Confidential - Company Proprietary 1.3.3.7 Facility Transfer Interfacility transfers must be carefully managed to maximise patient safety and address inadequate documentation of clinical parameters at referring institutions (Sommer et al., 2022). 1.3.3.8 Strategic Communication Strategic communication encompasses all critical communication necessary for an organisation’s existence and success. It entails an organisation’s deliberate utilisation of communication to engage in strategically significant dialogues around its objectives. Strategic communication is imperative for the organisation or entity, focusing on its strategies to attain specific objectives through communication amidst constraints of limited resources and uncertainty (Werder et al., 2018). Communication can play a distinctive role in the formulation, revision, presentation, execution, implementation, and operationalisation of strategies. Sommer et al. (2022) assert that effective communication within the healthcare system is essential for EMS to meet the expectations of communities in both rural and urban regions of South Africa. The role of EMS is to arrange personnel, facilities, and equipment for the effective, coordinated, and timely delivery of health and safety services to individuals experiencing sudden illness or injury (Gettel et al., 2022:264). Effective communication enhances comprehension of the essential responsibilities. Furthermore, pre-hospital EMS delivers prompt and appropriate assistance to patients in emergencies. Emergency Medical Services play a vital role in disaster response as part of the traditional duties of first responders (Malatjie, 2023). Research studies have demonstrated that heightened “awareness” alone cannot promote adopting new habits. This bottom-up communication framework necessitates participatory communication that engages the community, fosters involvement, employs evidence- based advocacy and prepares for risk communication to guarantee effective communication, health, and development (Sommer et al., 2022). The significance of communication in health and development is recognised, highlighting the imperative of strategic communication to inform, educate, and influence (Jejaw et al., 2023:76). Targeted communication strategies are developed to leverage various resources to achieve desired objectives in each context by addressing several health and development challenges, including illness management 11 Confidential - Company Proprietary issues. Research indicates that a community-centred examination of risk factors and the advancement of operational research communication theories have improved approaches and practices for outcome-oriented health and development communication. Consequently, strategies have been explored to enhance the understanding of strategic communication’s role in development and health, especially in disease management. This gap is especially alarming due to the essential function that efficient communication serves in emergency medical responses, which can profoundly influence patient outcomes. The survival of patients undergoing out-of- hospital cardiac arrest (OHCA) significantly depends on a coordinated response that encompasses early emergency recognition, swift activation of emergency medical services (EMS), and efficient communication among all stakeholders in the care continuum (Li, Li, Li, Cai, Liu, Li, Fan & Cao, 2023). The lack of research on strategic communication in EMS highlights the necessity for focused investigation to comprehend and enhance these procedures, especially in areas such as the North West Province. 1.4 Problem Statement Emergency Medical Services are vital for timely medical assistance during emergencies, significantly impacting patient survival and recovery rates. Effective strategic communication is essential for ensuring coordination, rapid responses, and optimal resource allocation within EMS. In the North West Province, significant challenges arise due to the complexities of geographic distribution, diverse demographic populations, and limited resources. Despite the critical importance of these communication systems, there is a notable lack of comprehensive studies assessing the effectiveness and challenges of strategic communication within EMS operations in this province. The present circumstances have engendered disillusionment within communities regarding EMS, as there have been reports of patients allegedly succumbing without any reaction from EMS (Nodirovna et al., 2022:184). The North West Province Department of Health has training facilities, yet there is a substantial competency deficit in the development and training of paramedics. Moreover, there are apprehensions regarding the departure of trained emergency professionals to other provinces due to employment churn. Research has highlighted the shortcomings in 12 Confidential - Company Proprietary the existing quality management frameworks within South African EMS, which are frequently obstructed by inadequate communication, inefficient leadership, and insufficient transparency (Howard, Cameron, Wallis, Castrén & Lindström 2020:3). Clear, continuous communication is crucial in emergency management, as emergency workers heavily rely on radio interoperability (Burroughs, 2017). Achieving effective integration communication is partially constrained due to inadequate bandwidth. As a result, emergency responders involved in a crisis frequently use their cell phones and social media as quick and dependable means to communicate the events, actions taken, and outcomes of the scenario (Brengarth & Mujkic, 2016; Tuite, 2012). Contemporary communication technology, encompassing computerised dispatch systems and real-time data sharing, has improved operational efficiency in emergency services. However, the extent of EMS adoption and utilisation of these technologies in the North West Province remains insufficiently researched. Understanding these aspects is essential for recognising potential barriers to the implementation and developing tailored solutions that could enhance the overall efficiency and effectiveness of EMS communication in the province. The existing communication mechanisms between the communities and EMS require fundamental adaptation. The necessity for a robust quality improvement framework is clear, as current systems are nascent and necessitate substantial enhancement to satisfy the requirements of a swiftly evolving healthcare landscape (Howard et al., 2020:4). The COVID-19 epidemic has intensified these issues, exposing institutional deficiencies and underscoring the urgent necessity for adjustments to enhance healthcare delivery (Christopher, 2023). Emergency Medical Services systems are initiated by a civilian utilising a Universal Access Number (UAN) to contact an emergency medical dispatch centre, where operators employ a systematic triage procedure to assess the severity of the EMS response. The EMS system can be beneficial when resources are utilised for critically ill patients. However, there is a rising trend in ambulance transports for non-emergency cases. This burdens the hospital system, congesting emergency departments with non-critical patients. It further diminishes the effectiveness of already-limited EMS systems, often leaving no units available to respond to additional incoming calls. 13 Confidential - Company Proprietary This study analyses the strategic communication practices of EMS in the North West Province, highlighting principal strengths, limitations, and potential for enhancement. The findings will provide policymakers and EMS managers with measures to improve communication systems while enhancing emergency response outcomes. 1.5 Research Objectives The objective was to analyse the efficacy of strategic communication methods in EMS within the North West Province, emphasising their influence on response times and coordination. 1.6 Secondary Objectives To attain the primary purpose, the following secondary objectives will be addressed: • To identify the main challenges and obstacles to effective communication faced by EMS workers in the North West Province. • To assess how modern communication technologies, like digital dispatch systems, can be used to improve EMS coordination and operations within the province. • To examine avenues for augmenting communication tactics that may enhance the efficiency and responsiveness of EMS in the North West Province. • To provide recommendations for policymakers and EMS managers on strategies for optimising communication practices in rural and resource-limited areas. 1.7 Research Question The primary research question for this study is: How effective are the existing strategic communication practices of EMS in the North West Province, and what improvements can be made to enhance their efficiency and emergency response outcomes? 1.8 Classification of the Field of the Study This study examines the communication techniques and obstacles encountered by EMS operations in the North West Province of South Africa. The research focuses on the public health sector, specifically targeting EMS, including dispatch centres, field responders, and their collaboration with other public healthcare facilities. 14 Confidential - Company Proprietary 1.8.1 Field of the Study The primary subject addresses the challenges of effective communication within EMS, emphasising the significance of strategic communication for coordinating activities, ensuring timely responses, and incorporating advanced communication technology to enhance reaction times and operational efficiency. The study examines the impact of these communication methods on the efficacy of emergency response and patient outcomes. The emphasis is on operational management, particularly in public healthcare administration within the North West Province. 1.8.2 Sector/Industry The study analyses communication practices, technologies, and obstacles within EMS operations in the North West Province, emphasising the comprehension of internal and external communication dynamics. It further seeks to elucidate how effective communication techniques may augment emergency response services, pinpointing essential areas for enhancement to serve the provincial population better. The study relates to EMS in the public sector and excludes the private sector. 1.8.3 Geographical Demarcation Holman and Wilholt (2022:212) contend that demarcation involves differentiating between research influenced by suitable conditions and that impacted by unsuitable ones. Considering this notion, it is imperative to delineate the study domains that are vital for preserving geographical accuracy. The geographic region of interest is the North West Province in South Africa. 1.9 Research Methodology This section explains the study’s research design, methodology, and framework, outlining the systematic data collection and analysis approach. It addresses the significance of the recruitment process and the imperative of acquiring informed consent. This section provides a brief synopsis of the selection of participants and the evaluation of data-gathering methods. Chapter 3 will provide a thorough methodology for this research. 15 Confidential - Company Proprietary 1.9.1 Research Design According to Gupta and Gupta (2022:20), research designs are plans and procedures for research that span the decision from broad assumptions to detailed data collection and analysis methods. The study will follow a qualitative research approach. According to Mey (2022:21-25), qualitative research explores and understands the meaning individuals or groups ascribe to a social or human problem. This method makes knowledge claims based on constructivist perspectives and collects open- ended merging data to deliver themes from the data. Qualitative research employs postpositivist assertions to generate knowledge. The research process encompasses formulating questions and methodologies, collecting data within the participant’s environment, and conducting inductive data analysis that progresses from specific instances to overarching themes. Additionally, it includes the researcher’s interpretation of the significance of the data (Gupta & Gupta, 2022:34-35). This research employed an inductive methodology consistent with the interpretive epistemological framework (Saunders et al., 2016). Figure 1.1 illustrates that a researcher has two methods for formulating a new theory: deduction or induction (Trochim & Donnelly, 2008:22). In deductive reasoning, a hypothesis constitutes the initial phase, followed by the formulation of a research method to evaluate that theory. This approach is termed a top-down strategy (Trochim & Donnelly, 2008:23). The second technique, termed inductive theory-building, commences with an extensive study that identifies patterns and correlations to develop a hypothesis about a specific event; it is frequently referred to as the bottom-up strategy (Trochim & Donnelly, 2008:23). Interpretivist principles were integrated into the investigation of textual material through an inductive methodology. 16 Confidential - Company Proprietary Figure 1.1: Diagram adapted to illustrate Inductive and Deductive Reasoning (Trochim & Donnelly, 2008:23) The goal of qualitative research design studies is to summarise events in the everyday terms of those events. Researchers engaged in qualitative descriptive studies must maintain a strong connection to their data to emphasise the explicit meanings of words and events. 1.10 Methodological Choice This study deployed a qualitative research design, generally linked to the interpretivism research paradigm. This design emphasises a smaller sample’s subjective perspective and beliefs (Wiid & Diggines, 2013:87). This methodology is optimal for collecting descriptive data that may be evaluated for patterns, themes, and relevance. Qualitative methods enable researchers to investigate complex, human- centred dimensions through several approaches, including narrative analysis, grounded theory, and ethnography (Hendren, Newcomer, Pandey, Smith, & Sumner, 2023:469). This method allows researchers to collect data from various sources through interviews and focus groups, including life experiences, revealing the complexities of social issues that quantitative methods can neglect. Qualitative research may elucidate the contextual significance of findings, ensuring that community needs and values are considered (Jenkins, Slemon, Haines-Saah, & Oliffe, 2018:1970). This methodology is appropriate for this study to investigate the 17 Confidential - Company Proprietary phenomena in its natural circumstances, aiming to extract significant insights from the collected data to fulfil the objectives and answer the research question. Qualitative descriptive designs comprise a diverse yet logical amalgamation of sampling, data collecting, analysis, and representation methodologies. Qualitative investigations frequently corroborate circumstantial assumptions, offering a more profound comprehension of the value and influence of programs beyond conventional analysis (Mundey, Dopp, Slemaker, Beasley, Silovsky, & Eisenberg, 2023:18). This is particularly relevant in sectors such as healthcare, where patients' emotional and psychological states can profoundly affect outcomes from treatment. Qualitative techniques enable researchers to capture these aspects, providing insights that can improve the design and execution of the intervention. This method is optimal when clear descriptions of phenomena are required. Processual reliability, which includes all research stages from conceptualisation to data collection and analysis, can significantly enhance the quality of qualitative health research (Hayashi, Abib, Hoppen & Wolff 2021:3). 1.11 Population and Sampling Collis and Hussey (2014) define a sampling frame as a record of the population from which a sample was extracted. A sample is a collection of people, things, or items selected for measurement from a larger population (Cash et al., 2022). The target population for this study was the EMS in the North West Province of South Africa. Participants were purposively selected using criteria sampling to identify information- rich cases aligned with the research objectives. The participants included EMS personnel. This research employed a purposeful non-probability sampling strategy, and the researcher chose participants according to their familiarity with the specified features (Latham, 2007). Participants were selected based on their experience and knowledge of the public health emergency work environment. The sample comprised of 15 participants who were assigned to the following groups: • EMS paramedics were selected based on their direct experiences with emergency communication techniques and challenges, which yielded essential insights into the research topic. Participants were recruited from various districts and expertise levels to provide a range of opinions. 18 Confidential - Company Proprietary • EMS dispatch officers who managed emergency calls and the deployment of first responders. Their experiences illuminated communication deficiencies that may affect service delivery. Purposive sampling is based on the notion that selecting ideal cases for the study produces more comprehensive data, with research results directly dependent on the selected instances. Purposive sampling is a systematic selection of persons based on particular qualities, utilising a non-random methodology (Mishra & Alok, 2022:16). It is a strategic sampling technique that aims to identify “information-rich cases” to fulfil the study objectives and successfully address the research issue. Maximum variance sampling within these groups included various criteria such as age, gender, race, experience, and qualifications. This approach improved the transferability of results. Participants were selected by stratified purposive sampling, and interviews were conducted until data saturation was reached. Stratified purposeful sampling seeks to capture notable variances rather than ascertain a common core, although the latter may also arise during analysis (Hendren et al., 2023:473). Data saturation, characterised by information redundancy or the juncture at which no new themes or codes arise from data, is a fundamental concept in thematic analysis (Mishra & Alok, 2022:23). Speight, Caiola, Tyndall & Scott (2022) assert that sample size and saturation criteria must be informed by stratification factors, which are considerations that researchers utilise when choosing participants to yield thorough insights into the study subject. This methodology enables researchers to elucidate the subtleties of diverse experiences and viewpoints, especially in investigations involving social dynamics and power connections. Moreover, Al-Walah, Donnelly and Heron (2024) emphasise that utilising homogeneous samples might be advantageous in qualitative research, particularly when prioritising data depth above volume. This suggests that stratification can be employed deliberately to ensure the sample accurately represents the intricacies of the researched population, hence improving the validity of the results. 1.12 Data Collection Method An interview guide, described as an outline of questions and topics that serve as a framework for a semi-structured interview, was adopted to collect data (Ahmadin, 19 Confidential - Company Proprietary 2022:110). The guide ensured consistency across interviews. Semi-structured interviews were utilised as this study’s primary data collection method. Pajo (2022:18) explains that a semi-structured interview is a qualitative data collection method that involves prepared open-ended questions to guide discussion while allowing flexibility to ask follow-up questions and probe for more detail based on participant responses. Open-ended questions allowed participants to respond in their own words rather than choose from fixed options (Ahmadin, 2022:109), eliciting richer, more descriptive data. This format allowed the researcher to prepare an interview guide with open-ended questions to explore participants’ perspectives and enable follow-up questions and discussion. Follow-up questions were asked to clarify and expand on points raised by participants during the interview. Follow-up questions emerged spontaneously based on interview dynamics. Individual interviews were conducted to encourage participants to express their candid insights. Each session took place in a private room with only the researcher and the participant present, ensuring privacy and confidentiality. Interviews lasted approximately 30 to 45 minutes. Following participants' permission, the researcher audio-recorded the sessions and transcribed the interviews verbatim. Verbatim transcription involves converting audio recordings into text transcripts by accurately copying the spoken words from interviews (Pajo, 2022:12). This method establishes a precise account of the interview material. Participants were informed they could refuse to answer questions or withdraw from the study without consequences. The researcher delineated methods to safeguard confidentiality, including the de- identification of transcripts, the use of participant codes, and the secure storage of data. Inquiries centred on participants’ experiences and viewpoints concerning the research objectives and questions. Demographic inquiries were confined to those necessary for characterising and contextualising the sample, including role, years of experience, and location. The researcher fostered rapport and encouraged subjects to share candidly. Saturation was attained with the seventh person; however, an eighth participant was included. Saturation refers to the stage in data collecting when no significant new information, codes, or themes arise from further data (Ahmadin, 2022:113). Saturation signifies that a sufficient sample size has been attained. The researcher continuously 20 Confidential - Company Proprietary evaluated transcripts during data collection to ascertain saturation, identifying when new themes or information ceased to emerge. Several strategies were deployed to minimise potential risks: • Providing clear information about the study purpose and procedures during recruitment. • Allowing participants to select the interview time and location. • Reminding participants that they could skip questions or end the interview. • Debriefing after the interview and checking on participant well-being. • Securely storing data and materials related to the study. These approaches were structured to collect data responsibly and ethically by proactively addressing privacy, confidentiality, informed consent, and participant rights in the specified procedures. 1.13 Data Analysis The content analysis involves examining the information collected from notes and interviews to discern the predominant themes emerging from participant comments (Kumar, 2018). High-quality research must generate interpretations consistent with the collected data (Hendren et al., 2023:475). Data analysis entails interpreting textual and visual data. It involves data preparation for study, conducting extensive research, and progressively deepening the comprehension of the data. The continuous process requires constant reflection on the data, posing analytical inquiries, and composing memoranda during the study. Data analysis entails the collection of open-ended data through inquiries and the subsequent development of an analysis derived from the information provided by participants (Pajo, 2022:18). Kumar (2018) delineates a four-step content analysis methodology as follows: • Step 1: Identify the main themes. After identifying the meanings of each participant's descriptive response to a question, it is necessary to sift through them to create overarching themes that consider these meanings. • Step 2: Give each of the significant themes a code. Assigning codes to the major topics will help the researcher count the times a subject has come up during the interviews. 21 Confidential - Company Proprietary • Step 3: Sort the answers into groups based on the main themes. The interview responses were categorised into groups based on the main themes that emerged from the thematic analysis. • Step 4: The main themes discovered during the content analysis phase are covered in the main body of the empirical study of the dissertation, along with theme integration. This approach ensured that data was analysed accordingly and that the themes and codes extracted answered the research question and the study's objectives. Data analysis followed an inductive thematic approach consistent with the qualitative methodology (Pajo, 2022:18). The researcher transcribed the audio recordings of the semi-structured interviews verbatim. Initial open coding was performed to identify salient points and recurring ideas relevant to the research objectives. The codes were compared and organised into broader categories and themes. Hofstee (2018) contends that it is crucial to elucidate the data analysis method to the reader before presenting the conclusions, as this enhances their comprehension of the study. According to Lincoln and Guba (1985), data in qualitative research must be dependable and trustworthy and demonstrate reasonableness, legitimacy, and integrity. The analysis entails extracting themes from the participants’ thinking around those emerging topics (Gupta & Gupta, 2022:23). Thematic analysis is a method through which researchers identify various interconnections between the data and the developing themes. A primary advantage of thematic analysis is its systematic methodology, which generally encompasses several discrete phases. As outlined by Braun and Clarke (2022), the process initiates with familiarisation with the data, proceeds to the generation of initial codes, followed by the identification of themes, the review of themes, the definition and naming of themes, and culminates in the production of a report (Bailey, Knight, Koolmatrie, Brubacher & Powell, 2019:188). Mishra and Alok (2022:29) assert that data analysis commences concurrently with data collection. Thematic analysis was employed to evaluate and examine the transcribed interviews. A more detailed analysis is presented in Chapter Three. Vaismoradi et al. (2013:398) 22 Confidential - Company Proprietary assert that thematic analysis facilitates identifying and interpreting concepts shared by participants. The data were systematically organised and analysed manually. 1.14 Ethical Consideration Ethical considerations are a collection of principles that govern a researcher’s study designs and procedures in research (Drolet et al., 2023:278). When gathering data from individuals, scientists and researchers must always follow the rules (James, 2023:335). Mohd Arifin (2018:30) contends that all research investigations must safeguard human participants by adhering to suitable ethical guidelines. In this study, the safety and privacy of participants were paramount. The anonymity of participants was maintained in all released materials through designations like Participant One or Participant Two. The research conformed to all ethical norms, including adherence to the Protection of Personal Information Act (POPIA). 1.14.1 Beneficence and Non-maleficence Before data collection, the researcher interacted with each participant to confirm their participation would not induce distress. All participants were informed of the ethical considerations related to the research process. 1.14.2 Risk/Benefits Analysis A fundamental ethical obligation in medical research is that the risks to individual participants must not be disproportionate. Although this need is widely supported, its implementation remains contentious (Drolet et al., 2023:280). The study posed no risk. Instead, the project enhanced service delivery for participants and communities through the North West Department of Health. 1.14.3 Permission and Informed Consent Informed consent is a crucial ethical and legal requirement for research involving human participants. Obtaining consent requires informing participants of their rights, the study's objectives, the procedures involved, potential risks and benefits, the study’s expected duration, and the confidentiality level concerning personal identification and demographic data. 23 Confidential - Company Proprietary Providing this information to participants ensures that participation is entirely voluntary (Drolet et al., 2023:283). The technique of informing participants of all relevant aspects of the study is essential for their decision-making. Participants were given all the relevant information related to the study, including the benefits, potential risks, if any existed, and the purpose of the study. Participants were allowed to ask questions freely, and the researcher emphasised that participation was based on willingness. Participants were told they could decline from the research study at any time or stage without impacting their well-being or standing. Permission was sought from the Department of Health North West, and the researcher was directed to where the participants were based. 1.14.4 Confidentiality and Anonymity Ethical considerations encompass the safeguarding of subjects and the adherence to ethical research norms. The four ethical principles of autonomy, non-maleficence, beneficence, and justice were initially highlighted (Drolet et al., 2023:274). These principles establish the foundation for safeguarding participants in qualitative research. Yu et al. (2022:245) assert that the principle is fundamental to societal convictions regarding the significance of individuals and their entitlement to privacy in personal matters. Assuring someone of confidentiality signifies that the communicated information will remain undisclosed or, at minimum, not shared without consent. The effectiveness of anonymisation is contingent upon the research situation (Liu et al., 2023:482). 1.14.5 Conflict of Interest A conflict of interest arises when the objectives of two parties diverge or when an individual can gain personal advantages from decisions made in a professional context, leading to the undue influence of a secondary interest on the primary interest (Golladay & Jain, 2022). The researcher had no conflicts of interest related to the study. 24 Confidential - Company Proprietary 1.14.6 Monitoring To maintain the integrity of the study effort, the researcher has systematically overseen compliance with all ethical norms using a self-created checklist. The researcher was accessible and amenable during all phases of the study for unannounced evaluations of research ethics-related activities by the Research Ethics Committee or its representatives. The monitoring encompassed signed informed permission forms, gathered data, documented individual interviews, and other sanctioned research methodologies. 1.14.7 Rigour – Validity and Reliability Qualitative validity refers to the researcher verifying the accuracy of findings through specific methods, whereas qualitative reliability signifies the consistency of the researcher’s methodology across several research and projects (Wright, 2023:12). Conversely, the validity represents a strength of qualitative research, contingent upon assessing the accuracy of findings from the perspective of the account's readers. Numerous terminologies in qualitative literature relate to this concept, such as trustworthiness, authenticity, and credibility, rendering it a contentious subject (Wright, 2023:15). Qualitative generalisation is utilised infrequently in quantitative research, as this approach does not seek to extend findings to specific locations or contexts outside those under investigation (Ahmadin, 2022:110). Trustworthiness refers to the quality, precision, and correctness of results in qualitative research. This study employed a qualitative technique. Conducting an audit trail will ensure rigour in this study. The researcher engaged an external auditor to transcribe the audio from the online interviews, in addition to the researcher transcribing the same recording, to provide a data audit trail. Comprehensive records are maintained, allowing moderators to examine and validate research findings for reporting analogous conclusions. This entails preventing researcher bias from influencing the interpretation of participants' statements to conform to a specific narrative. 1.15 Contribution of the Study Upon final analysis and submission, the study yielded the following contributions: 25 Confidential - Company Proprietary 1.15.1 Strategy Formulation Recommendations were provided to address the issues stemming from inadequate communication within the EMS in the North West Province. Chapters 4 and 5 articulate all these recommendations. 1.15.2 Policies A policy was established following these recommendations. 1.16 Limitations and Delimitations of the Study Theofanidis and Fountouki (2018:156) define limitations as potential problems in a study that frequently lie outside the researcher’s control, including aspects linked to research design, funding, or external influences. This study examined the strategic communication strategies of EMS in the North West Province. However, several limitations emerged from the study’s scope and environment. The availability and reliability of data from EMS operations were significant constraints, influenced by disparities in communication infrastructure across different locations within the province. Additionally, the study did not consider variations in communication patterns between public and private EMS providers but concentrated solely on public sector services. The researcher was constrained by time limits, which precluded field study across the province, resulting in a sample size of 15 participants. Theofanidis and Fountouki (2018) describe delimitations as boundaries established by the researcher to clearly define the study area, ensuring that the research objectives remain achievable. This study's primary delimitations concentrated solely on EMS communication patterns within the North West Province, intentionally excluding comparisons with other provinces or national data. The focus was on the communication among dispatch centres and EMS personnel and their collaboration with public healthcare facilities. This targeted approach enabled a more thorough analysis of strategic communication challenges and practices within emergency services, intending to generate insights relevant to the province’s distinct geographical and operational context. 1.17 Structure of the Document This mini-dissertation is systematically organised into five chapters, detailed as follows: 26 Confidential - Company Proprietary Chapter One delineated the significant problems and deficiencies in strategic communication techniques within EMS, particularly emphasising the North West Province. It underscored these obstacles and stressed the necessity for stakeholders, including EMS personnel, healthcare administrators, and policymakers, to follow best practices for effective communication. The chapter specified the research question, defined the problem statement, and discussed the study objectives. It summarised the research methodology, data sources, and the analytical approach to examining communication practices. Chapter Two expanded the discourse by examining the integration of strategic communication methods within EMS into the broader context of public health systems and emergency response strategies. It underscored the essential function of governmental regulations, communication protocols, and standards in facilitating coordinated and effective emergency responses. The chapter emphasised the necessity of a cooperative strategy among EMS providers, communication technology companies, and legislators to enhance communication systems. This method entailed evaluating communication requirements, analysing technological options, and making educated choices regarding adopting and utilising suitable communication technology. Chapter Two emphasised the necessity of evaluating the long-term sustainability and maintenance of communication technologies. Chapter Three outlined the research approach and encompassed the empirical investigations conducted. It examined the essential elements of the research, methodologies, and inherent constraints, including the data-gathering instrument. The chapter further elucidated the sampling methodologies and summarised the data analysis procedure. Chapter Four presented the research findings and discussions, encompassing coding analysis. The data was analysed, evaluated, and presented in tables and figures to facilitate understanding of the findings. Chapter Five summarised the study, delineated its advantages and disadvantages, and provided recommendations for further research. The chapter ended with an assessment of the achievement of the study's aims and the sufficiency of the answer to the research question. 27 Confidential - Company Proprietary CHAPTER 2: LITERATURE REVIEW 2.1 Introduction This chapter addresses the strategic communication for EMS. The North West Province faces substantial issues in its healthcare delivery system. The primary objective of this study is to analyse the efficacy of strategic communication methods in EMS within the North West Province, emphasising their influence on response times, coordination, and patient outcomes. The literature review will address three essential sections: theoretical review, conceptual review, and empirical review. Each part analyses academic literature pertinent to the secondary objectives of this research. The theoretical review examines various frameworks and paradigms that promote successful communication in health emergencies. The conceptual review examines concepts and fundamental principles of strategic communication, especially in emergencies. The empirical review examines previous studies and data to demonstrate the impact of inadequate communication on EMS performance. 2.2 Theoretical Review Boote and Beile (2005:4) highlight the importance of scholars comprehending previous work in the field. The obligation for researchers to cite prior studies relevant to their work underscores the scientific principle of cumulative research, which builds upon established knowledge, and the essential objectives that a literature review must achieve (Boote & Beile, 2005:4), namely: • It sets the broad context of the study. • It clearly demarcates what is and is not within the scope of the investigation. • It situates existing literature in a broader scholarly and historical context. Rocco and Plakhotnik (2009:121) concurred that theory is the foundation for literature reviews. Turner et al. (2018:34) assert that deficiencies in research occur when a hypothesis is selected at a given moment without regard for prior testing, verification, or falsification. These deficiencies result in a misleading or inadequate representation of the theoretical framework, impeding the research process’s rigour (Turner et al., 2018:34). Connelly (2014:188) emphasises that when research outcomes deviate from expectations, two possibilities arise: either the research design or variable 28 Confidential - Company Proprietary measurement was defective, or the theoretical framework guiding the research was incompatible with the context or population. 2.2.1 The Socio-Ecological Model (SEM) Initially formulated by Urie Bronfenbrenner, the SEM offers an extensive framework for comprehending human growth and health behaviour (Kilanowski, 2017:295). The SEM is an extensive framework highlighting the intricate interactions between human behaviours and the diverse environmental influences affecting health and well-being. At its core, SEM delineates four primary levels of influence: the individual level, which includes human characteristics such as knowledge, attitudes, and talents; the microsystem level, which includes relationships with family, peers, and other intimate social networks; the mesosystem level, It illustrates the relationships among several microsystems; and the ecosystems level, which involves broader social systems that indirectly influence an individual’s life, such as community resources and policies (Sell, Brandes, Brandes, Zeeb, Busse 2024; Hu, Zhou, Crowley-McHattan, & Liu 2021). This multi-tiered approach facilitates a detailed comprehension of the interactions among numerous elements that influence health outcomes. Within the realm of EMS and strategic communication, the SEM provides significant insights into the diverse elements affecting communication practices and results (Townsend & Foster, 2013:1101-1103). At the individual level, knowledge, attitudes, and perceptions about EMS services can affect communication patterns and emergency responses. Community dynamics, encompassing social norms and cultural perspectives on health and emergency response, function at the interpersonal and community tiers of the SEM, influencing communication pathways and access to EMS resources. Institutional variables, including EMS protocols, training programmes, and organisational culture, are essential for promoting successful communication among EMS teams and external stakeholders, such as patients and community members (Ma et al., 2017:2430). Ultimately, policy-level considerations, including governmental laws and funding distributions for EMS, affect the overarching framework for formulating and executing communication strategies. Due to its multifaceted structure, the SEM will help comprehend the strategic communication of the EMS in the North West Province, where the topic of communication permeates interconnected layers across multiple levels. Employing 29 Confidential - Company Proprietary SEM within EMS emergency communication would facilitate examining how various constituents at several levels influence the efficacy and obstacles of communication during emergencies. 2.2.1.1 Individual Level This level pertains to the individual traits of those involved in EMS: the EMS personnel, the patients, and the community members. The medical processes understood by EMS personnel in Northwest Province, along with their attitudes towards communication and familiarity with local languages or dialects, primarily influence their interactions with patients and the broader community. Furthermore, a patient's understanding of EMS services, attitude toward emergency care, and willingness to engage with medical workers may influence communication throughout the crisis. 2.2.1.2 Interpersonal and Community Levels At this level, communication is influenced by social conventions, cultural values, and interpersonal relationships within the community. The norms in the North West Province either facilitate or impede the utilisation of EMS, contingent upon individuals’ trust in the services or their acquaintance with them. Certain communities may maintain ideas around health, emergency, or traditional healing that influence their perception and utilisation of EMS. Establishing communication channels between the EMS and the community is governed by conventions, whether by word of mouth or local media outlets. The institutional level evaluates the organisational frameworks that regulate internal and external communications within the EMS teams. In the North West Province, training rules, organisational management frameworks, and the overarching culture of EMS services will likely influence communication among EMS teams. Efficient information dissemination during an emergency necessitates unambiguous communication routes, suitable training in communication, and adherence to established EMS standards. 2.2.1.3 Policy Level Greater regulatory and policy frameworks influence the communication strategy at this level. In the North West Province, government legislation, funding, and policies related to EMS directly determine the resources available for communication, including 30 Confidential - Company Proprietary technology and personnel. From this perspective, policies that will provide adequate funding for the service of the EMS operation, particularly in rural areas, can significantly enhance communication, while an underfunded system might generate problems such as inadequacy of the communication infrastructure or understaffing of the EMS. The SEM is a framework that illustrates the intricate links between individual behaviours and the broader social and environmental contexts in which they operate. Studies demonstrate that social support can encourage individuals to pursue help during emergencies, while the stigma associated with some health conditions can deter them from accessing vital services (Hayward, Vanqa, Makanda, Tisile, Ngwatyu, Foster, Mcinziba, Biewer, Mbuyamba, Galloway & Bunyula, 2024). This approach emphasises that health outcomes are influenced by numerous factors across different levels, including individual, interpersonal, organisational, community, and policy levels. The SEM suggests that substantial improvements in EMS delivery necessitate interventions at this level, including training programs that strengthen the skills of EMS personnel in handling diverse populations and complex situations (Amu, Adjei, Dowou & Bain, 2022:2). This discussion underscores the imperative for EMS providers to engage with communities to foster environments encouraging individuals to utilise emergency services when necessary. Partnerships between EMS and community organisations can enhance service delivery by equipping emergency responders with cultural competence and awareness of the distinct requirements of their communities (Dentoni, Pinkse & Lubberink, 2020:1218). 2.2.2 Six Building Blocks of Health Systems According to the WHO The 2030 Agenda for Sustainable Development, endorsed by the United Nations in 2015, centres on 17 Sustainable Development Goals (SDGs). These SDGs serve as a framework for ensuring peace and prosperity for humanity and the planet, both presently and in the future. One of these objectives is SDG3, the goal of Good Health and Well-being, which guarantees healthy lifestyles and fosters well-being for individuals of all ages. Advancements in the execution of SDG3 are assessed based on objectives aimed at decreasing mortality and morbidity via public health initiatives and the fortification of health systems (Bickenbach et al., 2023). 31 Confidential - Company Proprietary Foundations for a robust health system must be established during “normal” periods and across all health system sectors. Effective response plans must be devised in anticipation of shock. A crucial lesson from the COVID-19 pandemic is that the contextual characteristics of societies and subgroups significantly influence health systems’ capacity to withstand shocks, affecting the execution and efficacy of crisis management programs (Reiss et al., 2024). A health system encompasses all organisations, individuals, and activities designed to promote, restore, or sustain health (reference). A WHO framework delineates the functions of a health system as six interrelated components vital to its operation. The components must collaborate to address evolving health requirements to enhance health (Fridell et al., 2020:6). The WHO’s Six building blocks include: • Health Workforce: A healthy workforce that is responsible, competent, and responsive to community needs. • Service Delivery: Making healthcare available for all. • Health Information Systems: Refers to the critical, reliable information and data systems that monitor and evaluate data. • Health system financing: Equitable and sustainable financing for models to support healthcare systems. • Leadership And Governance: Accountability in healthcare systems by effective governance and leadership. • Medical Products: Accessibility to essential drugs and technology. EMS should require adaptable and sustainable model systems incorporating standardised procedures, training, and low-risk results to meet community demands (Sommer et al., 2022). Patients with uncomplicated or complex conditions or injuries seek pre-hospital care worldwide. A historical review of EMS human resources reveals an increasing demand for a well-distributed workforce adept at meeting the varied healthcare requirements of the population (Tiwari et al., 2021:3). The public sector EMS is chiefly governed by the National Department of Health, which offers oversight 32 Confidential - Company Proprietary and policy direction to provincial entities (Tiwari et al., 2021:3). The allocation of EMS personnel is frequently inequitable, resulting in inconsistencies in service provision, especially in rural and underprivileged urban regions (Tiwari et al., 2021:3). Expertise, proficiency, and discernment are essential for high-quality emergency medical treatment. Superior EMS and first responders are critical components of every healthcare system. Research on pre-hospital services prioritises human factors, efficiency, and the ongoing enhancement of practice standards. 2.3 Conceptual Review The conceptual framework provides numerous advantages to a study (Adom et al., 2018:439). It aids the researcher in recognising and formulating their perspective on the topic under investigation (Grant & Osanloo, 2014:12) and is also the most straightforward method by which a researcher proposes solutions to the identified problem (Liehr & Smith, 1999). This framework highlights the significance of a research issue, the researcher’s assumptions, the scholars with whom they concur or dissent, and the intellectual foundation of their methodology (Evans, 2007:212). 2.3.1 Framework of Strategic Communication Strategic communication in EMS entails deliberate and systematic dissemination of information to enhance the efficiency and effectiveness of emergency healthcare provision. The approach involves a comprehensive strategy for organising, implementing, and evaluating communication initiatives to ensure effective coordination and swift response to medical emergencies (Zerfass et al., 2020:158). In the realm of EMS, strategic communication involves more than merely conveying information to stakeholders such as healthcare professionals, emergency responders, and the public. It necessitates fostering collaboration and cultivating mutual understanding among these diverse groups (Nothhaft et al., 2018:354). Strategic communication in EMS encompasses various interrelated elements that enhance the functionality of the emergency healthcare system (Zerfass et al., 2020:158). The elements included in this context comprise but are not limited to, the following: prompt and transparent dissemination of emergency information to the public; effective collaboration between EMS personnel and other healthcare providers; 33 Confidential - Company Proprietary development and implementation of communication protocols specific to various emergencies; and continuous monitoring and evaluation of communication strategies to identify areas needing improvement (Nothhaft et al., 2020:30). In EMS, strategic communication necessitates a proactive stance on crisis communication, facilitating prompt responses and effective management of emergencies (Holtzhausen & Zerfass, 2014:76). Strategic communication in healthcare environments is grounded in theoretical principles from various disciplines, including communication theory, organisational theory, and public health theory (Falkheimer & Heide, 2018:89). The Diffusion of Innovations Theory and Social Cognitive Theory provides significant insights into the dissemination and adoption of new communication approaches within healthcare organisations (Balconi, 2010:160). Organisational theories offer conceptual frameworks for understanding EMS agencies’ communication structures and dynamics. They underscore the need for effective leadership and collaboration in achieving organisational goals (Berger, 2013:143). Moreover, strategic communication techniques aimed at fostering health behaviour modification and improving public health results are guided by public health theories (Higgins, 2022:360). By integrating these theoretical perspectives, EMS organisations may develop effective communication strategies that address emergency healthcare delivery’s specific challenges and needs. 2.3.2 Foundations of Strategic Communication in EMS Strategic communication is a crucial component of EMS, involving the planning, execution, and assessment of communication strategies to fulfil organisational goals and objectives during emergencies (Andersson et al., 2020). In the realm of EMS, strategic communication entails the organised dissemination of information among EMS personnel, dispatch centres, healthcare professionals, and other stakeholders to enable prompt and coordinated response initiatives. Jacobson et al. (2021:28) assert that strategic communication in EMS seeks to guarantee clarity, consistency, and accuracy in disseminating critical information, including incident specifics, patient condition, and resource availability, to facilitate effective decision-making and resource distribution. By implementing explicit communication protocols and utilising diverse communication channels, EMS organisations can improve situational 34 Confidential - Company Proprietary awareness, refine operational processes, and optimise resource allocation to provide timely and suitable care for needy patients (Gausche-Hill et al., 2021:91). 2.3.3 Strategic Communication in an Emergency Situation Strategic communication is the planning, implementation, and assessment of communication strategies to attain specified goals within an organisational or operational framework (Werder et al., 2020:19). The process entails the prompt and efficient dissemination of information among emergency responders and governmental bodies, media organisations, and impacted populations to guarantee a synchronised and unified response (Winkler & Etter, 2018:382). Strategic communication is an intricate discipline that aims to deliver precise and trustworthy information to the community, functioning as an essential tool for alleviating panic and confusion during crises. Alongside these core objectives, strategic communication aims to promote collaboration among diverse stakeholders, which is crucial for tackling the intricate issues that emerge during a crisis (Werder et al., 2020:19). This field focuses not only on information distribution but also on the broader goal of optimising resource mobilisation efficiently and effectiv