Fears and Concerns of Bystanders to Help People Injured in Traffic Accidents: A Qualitative Descriptive Study

In most traffic accidents, bystanders arrive at the scene before the rescuers. If they provide the right help, they can play an important and effective role in reducing the number of deaths and complications caused by these accidents. However, in many cases, fears and concerns prevent bystanders from providing assistance. This study aims to investigate and understand the fears and concerns of bystanders when they decide to help in traffic accidents. In 2022, this study was carried out in Iran using a qualitative content analysis approach. The data was collected through semistructured interviews. Participants were 15 males and females who had experience providing assistance in traffic accidents. Interviews, after digital recording, were transcribed verbatim. A purposeful and theoretical sampling method was performed. Data analysis and the determination of codes, categories, and subcategories were done using qualitative analysis software. O'Brien's qualitative research reporting standard was used. The results of the study include a category of fears and concerns and five subcategories. The subcategories include fear and concern caused by lack of information, fear of legal troubles, stress caused by previous experience, fear and anxiety caused by anticipation, and anxiety of unknown origin. The results of this study showed that some of the fears and concerns of the bystanders were related to a lack of information about providing assistance. By increasing bystanders' information about assistance, such as first aid training, fear and anxiety caused by a lack of information can be reduced. Another part of the fear and concern of bystanders is due to legal issues. Passing and implementing laws that protect bystanders can help reduce this fear and concern. Bystanders should be trained to provide assistance according to the rules of assistance so that they do not get into legal problems. A part of the bystander's fear and concern stems from their previous experiences providing assistance in traffic accidents. These experiences can also affect the fear and anxiety caused by anticipation. It is necessary to conduct more studies on the role of bystanders' experiences in creating fear and anxiety in them, as well as their effect on anticipatory fear.


Introduction
Trafc accident injuries are the eighth leading cause of death in all age groups [1].Providing help in the frst few minutes of the accident is important [2][3][4].In 85 to 97 percent of these accidents, bystanders arrive on the scene within the frst few minutes after the accident [5,6].In only 11% of cases, they provided frst aid [7], and in 68% of cases, they did not take any action and just watched the scene [7].One of the important reasons for the lack of participation of bystanders in providing help is their fear and concern about helping out [8][9][10].
It is common for bystanders to experience fears and concerns during assistance [11].Many mental and emotional factors afect their fears and concerns.Te personalities of the bystanders and the circumstances of the incident can afect these factors [12].Human behavior in social environments and conditions is diferent due to diferences in the ability to learn, perceive, and interpret stimuli as well as their natural tendency to help [7,13].Bystanders act based on the representation, interpretation, and perception they have of reality, not on reality itself.Mental states such as intentions, beliefs, and desires have roles [13].In addition to these, a set of situational and sociological factors afect the decision-making and performance of bystanders [14].Care management at the scene of an accident is diferent from treatment environments such as hospitals.Also, facing many challenges, such as the unpredictable characteristics of the injured, emergency conditions, and the need to make quick decisions, can be efective.Panic, shock, and disbelief; conficts requiring moral decisions [15,16]; and anxiety [17] afect the way bystanders perceive and experience these fears and concerns.As a result, it afects the way bystanders make decisions to help [12,13,18].
While fears and concerns play a vital role in how bystanders make decisions to help victims of trafc accidents, there is limited information about them [8,11,19,20].By knowing more about the perspectives and experiences of bystanders in relation to fears and concerns and their related factors, it is possible to potentially improve guidelines [13,21].Knowing more about this phenomenon can also improve performance, confrm and support bystanders, reduce fear, and increase their participation in providing assistance [22].For this purpose, this study was conducted with the aim of investigating the fears and concerns that infuence the decisions of bystanders to provide assistance using the method of qualitative content analysis.Qualitative methods can play an important role in advancing the research agenda in emergency scenes.Tese kinds of studies allow researchers to gain a deep understanding of health problems or specifc populations by examining the experiences and perspectives of participants [23].

Materials and Methods
Tis study was conducted using the qualitative description method [24].Data analysis was done by the content analysis method [25].Te participants are all lay people from different cities in Iran who witnessed the scene of a trafc accident and tried to help the victims of the accident.Entry criteria were to have experience providing assistance in trafc accidents, the ability to speak Persian, and the desire to participate in the study.People with expertise in the feld of assistance who happened to be present at the scene of the accident could also participate in the study.Sampling was done purposefully, and in the continuation of the research, theoretical sampling was done.

Data Collection.
In-depth, semistructured interviews with open-ended questions based on an interview guide (Table 1) were used to collect data.Such questions included, "If you have ever witnessed a trafc accident, please describe your experience."Follow-up and exploratory questions were used.All interviews were conducted in Persian.Interviews were recorded by a digital audio recorder.All interviews were transcribed verbatim immediately after recording.Te text of the interviews was entered into the qualitative analysis software MAXQDA2020.Te duration of the interviews ranged from 30 to 60 minutes.Te average was 45 minutes.Te data collection spanned about two years, from April 2020 to April 2022.Te data analysis was done simultaneously with their collection.Te analysis of the text of the interviews was done in Persian.Te results, codes, and classes from all the interviews were extracted in Persian and then translated into English.Te number of participants until reaching conceptual saturation [26] was 15 (Table 2).
All interviews were conducted by the frst author.He is a doctoral candidate in nursing education.At the doctoral level, he received the necessary training to conduct interviews and qualitative research.Te researcher has certifcates from workshops on data collection methods in qualitative research, proposal writing in qualitative research, and data analysis in qualitative research.All interviews were conducted with the guidance and supervision of other authors, who are all experienced professors in the feld of conducting qualitative research.
Te start of sampling in this research almost coincided with the start of the spread of the COVID-19 disease around the world.Te research team tried to conduct sampling and interviews in such a way that the participants as well as the research team did not pose a risk of getting infected.On the other hand, the participants were afraid of conducting face- 2 Emergency Medicine International to-face interviews.Tis caused the sampling process to be slow, especially in the frst six months of the pandemic.After that, the research team decided to conduct some interviews by phone in order to protect the rights and health of the participants and members of the research team.With the passage of time, the scientifc knowledge of the research team about COVID-19 increased.Te research team took into account all the necessary health protocols to prevent disease transmission.We respect the rights of the participants, and if they agreed, nine interviews were conducted face-to-face.At the end of each interview, the participant was asked if there was anything left to say about the incident he witnessed.He/she was also asked to mention if he had any suggestions to solve the problems he was facing.In the frst 3 interviews, questions were asked based on the interview guide presented in Table 3.After that, due to the identifcation of some dimensions of fears and concerns, the process and type of questions changed a little.Ten more focus was placed on fnding the characteristics and dimensions of the fears and concerns found.Participants were chosen using theoretical sampling to assist in the development of less developed dimensions and characteristics of fears and concerns.[26].With the permission of the participants, all interviews were recorded using a digital audio recorder.After the end of the interview, the audio fle was listened to by the frst author and transcribed verbatim.Te similarity of the audio fle of the interview with the transcribed text was checked.Ten the text of the interview was entered into the MAXQDA software.Te transcript fle was provided to all authors.Te interviews were coded separately by the frst, second, and third authors.Disputed items were settled by consensus in the presence of all authors.After the consensus of all authors regarding the coding and analysis of each interview, based on the results obtained in each interview, the next interview was conducted.Te interview guide was changed based on the results obtained in each interview.Te frst, second, and third authors did the coding simultaneously but separately with the help of the software.After coding each interview, the resulting fles were shared.If there is a diference in the codes, a discussion and exchange of opinions were done in the presence of the fourth and ffth authors until reaching a consensus.

Data Analysis. Data analysis was done according to the steps proposed by Grandheim and Lundman
Te text of the interview was read once in its entirety to get a general picture of it in the author's mind.Ten sentences or an entire paragraph of text were determined as units of meaning.Ten, each sentence and each paragraph were read several times.By considering the mental states and feelings of the participants, the authors tried to extract the hidden content and symbolic meaning of the sentences.First, primary codes were extracted from them.Primary codes that were similar to each other or formed diferent dimensions of a concept were placed in one category by using the code creation part of the MAXQDA software.Tese categories formed the primary concepts.Similar primary concepts were combined into more comprehensive classes, and fnally the hidden content and symbolic meaning in the data were determined.
After extracting the results, the results were shared with all participants, and they were asked to provide feedback on the results.Tey were also requested to suggest an appropriate solution to solve the problems found according to the study's results.Te participants were asked to give a score from 1 to 10 to diferent challenges related to bystanders' fear and concern. 1 is the least fear and concern, and 10 is the most fear and worry.Based on the scores of the participants, the greatest fear and concern related to getting involved in legal issues and the fear of a lack of information to provide assistance were determined.Participants suggested reducing these fears and concerns by teaching frst aid to community members and educating everyone in public media.

Trustworthiness.
To validate the results, the following were done: Using an interview guide, allocating enough time to conduct interviews, continuous comparative analysis of data and classes in terms of similarities and diferences, evaluation and confrmation of codes by other members of the research team, who were all expert professors in the feld of conducting qualitative research, reaching a common consensus, checking and confrming the fndings by several contributors, and long-term engagement with the data.Te results of this research were reported using the O'Brien standard [27].

Ethical Considerations.
Tis study is part of the results of the Doctorate in Nursing thesis entitled "Explaining the decision-making process of bystanders to provide assistance in trafc accidents."All research stages are supervised and coordinated by the Research Ethics Committee of the University of Social Welfare and Rehabilitation Sciences, with IR code USWR.REC.1398.023.Terefore, all participants voluntarily participated in the study; explaining the purpose and method of the study comprehensively to the participants; understanding the participants about the possibility of withdrawing from the study at any stage they wish; reading and signing the informed consent form by the participants; obtaining permission from the participants to record the interviews; ensuring the confdentiality of information in all stages of the research; and publishing the results are among the ethical considerations that were followed in this study.

Results
Tere were 15 participants, ten of whom (66%) were men and fve (34%) were women.Nine interviews were conducted face-to-face, and Six interviews were conducted over the phone.Te average age of the participants was 37.83 years, and their age range was from 28 to 52 years.Other demographic characteristics of the participants are presented in Table 2. Emergency Medicine International and concern caused by anticipation, fear and concern due to lack of information, fear and concern related to the relief forces, and concerns of unknown origin (Table 3).Te fear of not having enough information about laws can be due to a lack of training, insufcient training, or a lack of stability in the laws related to assistance.Te fear of being accused is another fear related to the fear of legal trouble.In this case, the bystander is worried about being accused by other witnesses, injured relatives, or legal authorities of being the cause of the accident or of causing more damage to the injured person.Participant number 7: "I think people don't help because they are afraid of the consequences, and they don't have much knowledge about how to help properly."In the aforementioned accident, many people said, "Don't touch it; it might move badly, and the problem will get worse," or something to that efect, but he said, "If I help, the really bad guy might escape, and they will catch me."

Stress Caused by Previous
Experience.Fear and concern in bystanders are caused by the information and experiences they have in relation to providing assistance.For example, if a bystander in the previous incident witnessed that another bystander, by providing incorrect assistance, caused more injuries and problems for the injured, in the current incident he or she may be fearful and concerned by observing the gathering of bystanders and seeing similar conditions.In this case, the source of fear and concern is mainly the bystander's own experiences and not the way other bystanders act.Participant No. 8: "At that moment, I wasn't really afraid, but I was anxious and worried."I was worried that they wouldn't move the injured man.We already had several other cases in the family where people were moved and their spinal cords were severed."It was, and I was very stressed about this."

Fear and Concern Caused by Predicting.
Te fear and concerns of the bystander are related to the predictions that the bystander himself makes regarding the conditions and situations that may occur.Tese predictions can be related to dangers, such as the fear of an explosion, that the bystander knows about and predicts will happen.Although this explosion may never happen, the fear of its occurrence can afect how a bystander decides to help.In some cases, it may even cause the bystander to decide not to help.In order to make a rational decision, the bystander must have some necessary information to decide.In the event of an accident, for some reason, the bystander cannot get the necessary information.Some of these reasons include the suddenness of the accident, not having enough time to decide, needing to act quickly and make quick decisions, and not having enough time or resources to get the required information.Tis lack of necessary information can cause fear, concern, and anxiety in the decision-maker.Te fear and concern caused by the lack of information can also be caused by the fear of not checking the risks.In this case, the bystander did not check the risk of the accident scene due to reasons such as a lack of time, and this caused fear and concern in him.
Participant No. 1: "I said that I was a little scared because I didn't even look for a second to see if it was oil, gasoline, or whatever.But it was as if I heard them say that it was gasoline, that it spilled on the ground, and that the car may explode at any moment.I decided to take them out before it exploded." 3.1.5.Te Stress of the Rescuers' Delay.Te longer the rescuers arrive at the scene of the accident, the more concerned the bystanders are, and they may feel more responsible for providing help.Tis stress may be caused by the delay of the rescue forces due to the bystander's perception that the rescue forces are late.In this case, even though the emergency services arrive at the scene of the accident at a reasonable time, the bystander imagines that they are delayed.Tis perception of delay causes stress and concern for the bystander.

Participant No. 11: "I really don't know why I had pressed my fngers so hard on my palm; maybe for a day or two, the marks of my nails were on my palm because of the anxiety I felt because of the late arrival of these [rescue forces]."
3.1.6.Anxiety of Unknown Origin.Part of the fear and concern of the bystanders may be due to reasons that are not known to the bystanders themselves.Trafc accidents are stressful by nature.Tis can cause a bystander to feel fear and concern even without a known reason, which can be called anxiety in this case and whose origin is not known.Tis anxiety can cause the bystander to unconsciously decide and act on some issues.In this case, the reason for that decision is not clear to the bystander himself.

Discussion
According to the fndings of this study, one of the bystanders' fears and concerns in providing assistance is the fear of getting into legal trouble.Part of this fear is due to a lack of knowledge about the laws related to aid delivery.Tis can be caused by a lack of education, a lack of stability in the law, multiplicity, and diversity in the laws and lawmaking organizations.Another part of the fear of legal trouble is the fear of being accused; in this case, the person is afraid of being accused and sued for participating in helping.
Tese results are similar to those of other studies [28][29][30].In Hall's study, one of the important factors of fear in providing help in emergency situations is the fear of legal consequences and being sued.Hall's study showed that this fear increases when the person receiving help is a stranger and has no relationship with the bystander [11].
In most similar studies, having previous experience providing assistance is considered a factor in increasing one's self-confdence and the ability of bystanders to help.Lack of experience providing assistance is regarded as a factor that increases bystanders' fear and concern to assist [11,30].Furthermore, the fndings of other studies have shown that not having prior experience providing assistance can cause people to be unsure of what to expect at the scene of an accident and whether or not they can provide appropriate intervention [11].Te results of the present study, in addition to confrming these results, show that some experiences of witnesses in providing previous assistance can increase the incidence of fear and anxiety in order to provide assistance in the current incident.Tis requires further study.
In the fear and concern caused by predicting, the problem that the bystander is afraid of happening has not yet happened.Te bystander predicts that the problem will happen according to the existing conditions.Tis prediction flls him or her with dread.Several studies have shown that predicting the occurrence of possible dangers and issues can cause the witness to decide not to help [8,31,32].Te results of the present study also show that these predictions may, in some cases, reduce the willingness of bystanders to help.Furthermore, in some cases, depending on the circumstances of the accident and the injured, they may cause the bystander to prevent the occurrence of the issues that he has predicted and take action to help.
In the fear and concern caused by a lack of information, the origin of it is a lack of information regarding the issue bystanders want to decide about.Te results of other studies in this feld are consistent with the results of the present study.Moreover, other studies show that if the frst aid trainings are better, more qualitative, and more practical, and the bystander is more profcient in their implementation, these fears and concerns are reduced at the time of decision-making.In this situation, the willingness of bystanders to help will increase [10,33].Fear and concern about further harming the victim, leading to litigation, have been identifed in many studies as barriers to the decision to provide assistance.It appears that bystanders who lack confdence in their knowledge of frst aid do not consider themselves competent to help and are therefore less willing 6 Emergency Medicine International to help [8,32].Moreover, when the bystander is afraid of doing the wrong thing or of causing more harm, there is mainly a fear of legal conficts [11,34].Part of this fear and concern can be attributed to a lack of knowledge about the laws that protect bystanders who want to help [35][36][37].
Te results of our study showed that a part of the fear and concern of the bystanders was due to a lack of information.Tis lack of information may be related to assistance information or a lack of information related to legal issues.Lack of information can reduce the willingness of bystanders to help because they fear that, due to not having enough information, they will cause more harm to the injured or that they will have legal problems.Other studies have also shown that sometimes bystanders do not intervene at the scene of an accident out of fear of not being able to help the injured person.Fear of doing the wrong thing, usually due to a lack of frst aid training, is one of the most common reasons why bystanders refrain from taking lifesaving measures for the injured [7].People experience a sense of uncertainty in emergency and unexpected situations [38][39][40][41].Tis sense of uncertainty is caused by the lack of information [39,40].Tis uncertainty afects how they make decisions and help [39,41].Bystanders are afraid to ignore important information to save the victim's life [39].Some people also fear legal consequences, criticism, or disciplinary actions [42].
Te results of our study showed that, in addition to the lack of information, sometimes having some information and experiences can also cause fear and concern.If a person has had an unpleasant experience in his previous experience of helping, this experience can cause fear and concern in the next helping.Tis unpleasant experience can be related to mistakes in assistance, the behavior and performance of other bystanders, or legal problems.Te personal experiences and beliefs of participants are known as a lens for understanding situations and afect their willingness to help [38,43].Differences in personal experiences can cause people to not always agree with other people's decisions.In Anderson et al.'s study, a number of more experienced participants stated that, in some cases, their experience indicated that they should refrain from performing resuscitation and stop providing aid.Tese individuals expressed frustration that other colleagues initiated or continued resuscitation eforts in such situations [43].
Although the results of our study showed that a part of the fear and concern of bystanders is due to the lack of information regarding legal issues, the results of other studies have shown that even in situations where there are rules and guidelines for helping and people are aware of them, the confict between these guidelines and the ethical standards of the helping person or the wishes of the patient may cause bystanders to not act according to instructions [39,44,45].Correct ethical decisions may sometimes lead to deviations from guidelines or laws [42,45].Reforming laws on assistance and passing laws that protect bystanders can reduce the fear and concern caused by laws [46,47].
Tere is literature on where bystander training happens.Bystander training can occur in a variety of settings, including schools, workplaces, and community centers [7,22,48].Te specifc location of the training will depend on the target audience and the goals of the training program.For example, training for school-aged children may take place in schools, while training for adults may take place in workplaces or community centers.Some training programs may also be delivered online or through mobile applications.Te efectiveness of bystander training programs may depend on factors such as the content of the training, the delivery method, and the level of engagement and participation from the trainees [49,50].

Conclusion
According to the results of this study, a major part of the bystanders' fears and concerns are due to their lack of information regarding how to provide help as well as the laws related to providing help.Tis can be reduced by providing practical and appropriate training.Te fear of legal trouble is one of the reasons for fear and concern among bystanders.Lack of legal information, a lack of up-to-date information about existing laws, a lack of bystander protection laws, and bystanders not being aware of the protection law are some of the things that cause this fear and concern.In the bystanders' previous experiences, the type and manner of the bystander's experiences, the mental point of view, and the way of perceiving and interpreting the conditions of the injured and the incident have a signifcant impact on fear and concern.Terefore, it is suggested that in the training of frst aid courses, the previous experiences of bystanders and how those experiences infuence their decision-making should be included in the training.Another part of fear and concern comes from anticipation.It seems that the bystander's previous experiences afect his or her prediction of possible future dangers.Terefore, it is proposed that in future studies, with quantitative research and questionnaires, the experiences of bystanders who have experience providing assistance should be identifed and taught to other people in helper training programs.If people know the experiences and perceptions of a bystander at the time of providing assistance, they can better meet their need for knowledge and advice during training.

Relevance to Clinical
Practice.Te results of this research increase the knowledge of bystanders' fears and concerns about providing help.Tis recognition can be used to reduce the fears and concerns of bystanders in providing assistance, increase their participation in providing assistance, and, as a result, reduce deaths and complications caused by trafc accidents.

Limitations.
Considering that the scene of a trafc accident is stressful for bystanders and participating in providing assistance can create risks for these people, these factors can cause bias in witnesses' memories.To reduce the efect of memory bias, we tried to focus on the experiences of bystanders rather than the exact details of what happened in this study.Due to the spread of the COVID-19 virus, access to the participants was more limited, and to protect their health, some interviews were conducted over the phone.

3. 1 .
Fears and Concerns.Based on the results of this study, fears and concerns include the following subcategories: fear of legal trouble, stress caused by previous experience, fear Emergency Medicine InternationalTable 2: Te demographic characteristics of the participants.

Table 1 :
Guide to conducting the interview.

Table 3 :
"Fear and concerns" with subcategories and open codes.