Health emergencies can occur at any time, on any day, anywhere, and may affect all groups of people, including students ( WHO & ICRC, 2018 ; Rani et al., 2022 ). These emergencies include injuries and infections, heart attacks and strokes, acute complications of pregnancy, and chronic diseases ( WHO & ICRC, 2018 ). The focus on school and college health has shifted from just the classroom to a more comprehensive approach, emphasising students’ behaviour and a supportive school environment ( Akumiah et al., 2023 ). In colleges, the head of the institution, the college nurse, hall warden, hall master/mistress, and counsellors are designated gatekeepers whose duties are to assess, protect, and promote the health of students and the entire school community. According to Ferris et al. (2001) , each of these gatekeepers has specific roles, but generally, they provide college health services such as access to, and or referral for, primary health care services, encourage appropriate use of primary health care, and, among other responsibilities, deliver emergency care for illnesses or injuries.

Another study, Cagginello et al. (2011) , asserts that college authorities, the school nurse, and health personnel have defined guidelines and protocols for accessing emergency health care. The college nurse plays a critical role, as they are often the sole professional health worker on campus and are expected to identify potential health problems within the college environment, coordinate first aid and CPR training for staff, evaluate first aid and emergency training and exercise, and develop emergency plans for students with known health problems ( Schoolnurse.doc, 2009 ; Cagginello et al., 2011 ). The inaccessibility of the college nurse in emergency care leads to a delay in giving care to the attendant, which leads to life-threatening consequences, including death, as stipulated by Rani et al (2022) .

The hall master/mistress is the first point of call when emergency care is required for a student, as all non-academic issues, including the well-being of students, are entrusted to him/her. The swiftness with which the hall master/mistress responds to emergencies serves as a necessity. While many studies on school health services and emergency care focused on the school nurse, few studies have incorporated other key persons who also serve as gatekeepers in the college: the head of the institution, hall warden and the hall masters/mistresses ( National Association of School Nurses, 2019 ; Centers for Disease Control and Prevention, 2021 ; Rani et al., 2022 ). These individuals are key players who aid in the delivery of college health services, including emergency care, even though they are not health professionals. Though these individual perform their duties effectively in aiding the school nurse, they tend to delay in performing their duties, delay in communicating emergencies, and they are sometimes not found in the offices or on their post. However, irrespective of their roles determine the extent of success attained regarding emergency care in the college.

The negative attitudes of gatekeepers and the communication gap between adults and adolescents remain a challenge to emergency care concerning adolescent reproductive issues ( Kumi-Kyereme et al., 2014 ). Despite these challenges, gatekeeping is associated with the quality of care and referral to the appropriate health facility for further attention ( Poompong et al., 2019 ).

The current study intends to bridge the gap at the micro level by adopting a more holistic approach to extending the study’s coverage to all health gatekeepers in the Colleges of Education and exploring how they help to communicate, collaborate, coordinate, and cooperate during student emergency care.

The framework of the 4Cs of emergency management, which comprises communication, coordination, collaboration, and cooperation, is used to prevent, mitigate, or alleviate challenges associated with emergency management, which either inter- or intra-sectoral system ( Martin et al., 2016 ). This framework was used as a guide to the research question of the current study to answer the question of what the roles of gatekeepers in emergency care are. Through a qualitative methodology to explore the gatekeeper roles in emergency care over the more typical survey-based approaches, the topic was explored in greater depth, to understand not only what but also why and how the roles impact emergency care.

The results from students focused on who constitutes the gatekeepers of emergency management in the college, which were categorised into broad themes. What defines the gatekeepers’ roles in relation to communication, coordination, collaboration, and cooperation, respectively? Which roles do you believe are most important in emergency management? Explain any challenges you have identified concerning the role of gatekeepers in emergency management within the college.

Responses from students indicated that not all responsible adults in the college are gatekeepers of emergency management, but those who have been assigned specific health service roles in the college are gatekeepers in emergency management. They include the head of the institution, hall warden, hall masters/mistresses, college nurses, and other health professionals on campus.

“Not all senior members on campus are health gatekeepers; only those with specific mandates such as the head of the institution, hall masters/mistresses, and the college nurse are considered gatekeepers responsible for student well-being.” (Std. Int. 11)

“The college nurse who has the primary duty to administer first aid is part of the gatekeepers. Our hall masters and mistresses who take care of us in the various halls must be part as well as the head of the institution who has the overall responsibility for the care of students.” (Std. Int. 5)

There was a further question: which of the gatekeepers do you consider to be very important in emergency care? Most students’ responses indicated that the College Nurse, per her nature of the work, was very important in emergency care.

Considering the communicative roles of school gatekeepers in emergency management, many students viewed this as the first role of any gatekeeper, especially the hall master/mistress, who is often closer to the students. The hall masters/mistresses must communicate clearly to the college nurse the type of emergency, whether critical, urgent, or non-urgent, for the nurse to prepare ahead of time. Other participants also indicated that communication among school gatekeepers, parents, and health care providers is very important for the timely delivery of emergency services.

“I felt unwell in the morning with headaches and body weakness but still went for lectures. During class, I started vomiting and was assisted to the college clinic. A colleague called the hall master, who said he would inform the college nurse about the emergency.”(Std. Int. 8)

“I missed a step on the staircase and twisted my wrist it became swollen and very painful. I reported it to my hall mistress, who contacted the college nurse. After assessing me, the nurse said I needed a hospital referral, informed the hospital, and even accompanied me. My parents were also informed by the hall mistress.”(Std. Int. 37)

The role of coordinating the college gatekeepers was the second dimension of the college emergency management. Most students commented on the role and impact of coordination on emergency management in schools. The students again indicated that where there is strong leadership and, in a situation, where leaders demand accountability from departments and units, coordination is effective. They further indicated that on issues of emergency health management, all affected departments and units in the school, including the gatekeepers, work in synchronization.

“I collapsed in the lecture room. When I regained my consciousness, I saw the lecturer, the hall master and school nurse running around in support of my care.” (Std. Int. 4)

“The day I twisted my wrist and was in so much pain, the swift way the hall mistress coordinated with the college nurse and the nurse’s quick referral to the hospital showed me they work in harmony in their different roles.” (Std. Int. 37)

Collaboration in emergency management was seen to be very important by a few students, as the college alone would not have all the needed resources to manage emergencies. The college collaborated with other clinics and hospitals on referral cases. Students from the college would always receive exceptional attention due to the long-term relationship between the college and the respective health facilities.

“The college nurse had no difficulty referring me to the District Hospital due to their long-standing relationship. She just filled the referral form and accompanied me.” (Std. Int. 1)

“The college nurse seemed familiar with the hospital staff, so they readily accepted us and began attending to me upon referral.” (Std. Int. 27)

While most students felt cooperation among the college gatekeepers in emergency management was cordial, a few spoke about negative experiences due to the lack of support. The absence of the Hall Master and the College Nurse, and delays in communication and referral were cited.

“I felt neglected because the college nurse was not at post when I was rushed to the clinic, and it took time to locate her. I don’t understand why the hall master couldn’t inform her on time.” (Std. Int. 20)

“The day I was referred to the hospital, it took a long time for the college driver to transport the nurse and me. Several calls had to be made to the Transport Unit before a vehicle finally came.” (Std. Int. 12)

These findings have shed light on the perspectives of students who have received emergency care from the selected Colleges of Education in Ghana, reflecting on the roles of gatekeepers in the college. Anchoring the results and analysis on the concept of the 4Cs in emergency management was very appropriate, as these concepts formed the basis for analyzing the key roles of gatekeepers in either large-scale disasters or small-scale emergency management situations ( Martin, Nolte, & Violo, 2014 ). Within each dimension, the analysis explored how emergency management was promoted or delayed.

Considering the first dimension of emergency management, the students discussed the role of communication as they saw the roles gatekeepers play during the period they received emergency care in the college clinic. When the students were engaged, it came up that effective communication plays an essential role in any emergency management situation. This finding is consistent with ( Schoolnurse.doc, 2009 ) and ( FEMA, 2014 ), where delivering effective emergency communication is an essential part of emergency management. FEMA (2014) underscored the importance of emergency communication during an incident and likened it to the importance of food and water for life. It may include alert, warning, direction, and other self-protective actions.

This study further found that the timely release of information by the gatekeepers of the colleges is essential for emergency management. This finding is in line with the Riskonnect.com, Riskonnect (2023) study, which suggests that quick and proactive communication could help avoid additional damage from an incident and minimize miscommunications. Nowell & Steelman (2014) have indicated that well-conceived and effectively delivered emergency messages can help ensure public safety, protect property, facilitate response efforts, elicit cooperation, and instill public confidence ( Schoolnurse.doc, 2009 ), in describing the role of the school nurse, added, among others, communicating with parents, healthcare providers, and school personnel, as appropriate for the incident.

Other studies have found that well-functioning information and communication technologies positively affect emergency response and facilitate coordination among individuals and organizations ( Celik & Corbacioglu, 2010 ). Failure to communicate can lead to failure in coordination. All emergency communication must be clear, contain specific and adequate information, be in sync with other information being disseminated, and be accessible ( FEMA, 2014 ; Potter et al., 2024 ).

The coordination of emergency management was the next dimension of the discussion. According to the World Health Organization (WHO), coordination of emergency care is a proactive approach to bring together care professionals and providers to meet the needs of service users to ensure that they receive integrated, person-focused care across various settings” ( WHO, 2018 ). Most respondents saw the coordinating role of gatekeepers in emergency management as important when there is strong leadership in the college to direct and control emergencies. FEMA (2014) posits that leadership and influence are required for planning, preventing, and responding to emergencies and that being able to lead others and motivate them to commit their energies and expertise to achieve the shared mission and goals of the emergency management system is a necessary and vital part of every emergency manager, planner, and responder. These skills, according to FEMA (2014) , are necessary whether dealing with subordinates, those with more authority, peers in partner organizations, volunteers, or the public. Gooding et al. (2022) concur with FEMA (2014) and the current study on the need for coordinating bodies to have clear leadership roles, adequate mandates, and authority, since insufficient clarity on their roles and overlapping mandates hinder emergency responses.

Still, on the leadership of coordinators, it was found that where accountability was demanded of gatekeepers such as the college nurse, hall masters/mistresses, and hall wardens, emergency operations were done than where there were lapses in supervision. Erkineh (2021) and Gooding et al. (2022) corroborate this study, which indicates the lack of clear responsibility and structure in other ministries and units weakened effective participation in multi-sector coordination for accountability of action.

Synthesis on collaboration, as a dimension for college emergency management, was considered by a few respondents as an important component due to the college’s ability to establish a long-standing relationship with other health professionals and nearby hospitals during emergencies. This was done with the understanding that emergency management requires a multi-sectoral approach because resources are scattered, responsibility is dispersed, and no single unit, department, or organization can manage ( Waugh & Streib, 2006 ; Oduro, 2015 ; WHO & ICRC, 2018 ; Jin et al., 2023 ). Jin et al. (2023) indicate that emergency response is more effective when well-established and strong relationships exist among response departments, units, and the entire community. Building these relationships nurtures trust, promotes team spirit, facilitates communication, and encourages the community to work together.

Respondents of this current study did not touch on collaborative planning teams. The formation of such a team is more important in emergency management than just having an emergency plan. According to FEMA (2023) , collaboration begins by establishing a planning team. Forming such a team promotes mutual understanding and engages the whole community, with the greatest challenge being mistrust.

The last of the 4Cs to analyze is cooperation, and it refers to short-term, often informal and voluntary relationships between organizations or parts of the organization that are characterized by low levels of intensity and risk ( Odlund, 2010 ). While most respondents felt cooperation among the college gatekeepers in emergency management was cordial, and such cordial relationships fostered smooth response, a few spoke about negative experiences because of a lack of support due to poor relationships. The absence of the hall master or college nurse and delays in communication and referral were cited. This finding concurs with the studies of Gooding et al. (2022) and Martin et al. (2016 ) on the need to strengthen partnerships and relationships among experts in health system emergency preparedness and response.

This study employed a relatively small and purposively selected sample of 40 students from various Colleges of Education across Ghana’s Northern, Middle, and Southern Belts. While the aim was not statistical generalization, the limited sample size restricts the extent to which findings can be extrapolated to the wider student population in Ghana’s tertiary institutions. Nevertheless, the study’s strength lies in its attempt to bridge a critical knowledge gap at the micro level by exploring students’ lived experiences with the roles of all health gatekeepers in emergency management, a topic largely underexplored in prior research.

Although previous studies have predominantly focused on school nurses and other trained health professionals, this study is unique in its holistic consideration of the collective roles of all designated gatekeepers, including hall wardens, hall masters/mistresses, and institutional heads. This broader scope provides a more inclusive understanding of how non-health professionals influence student health outcomes during emergencies.

The exploratory qualitative design, while offering rich, in-depth insights, inherently carries limitations. The interpretation of data was subject to the researcher’s positionality as a public health specialist and college administrator. Although measures such as the use of a directed content analysis approach and independent coder validation were employed to mitigate bias, complete objectivity cannot be assured.

Moreover, the study relied exclusively on self-reported accounts from students who had accessed emergency care services between January and December 2023. Such reliance introduces potential recall bias and social desirability effects, which may affect the accuracy or completeness of participants’ responses. Additionally, the absence of triangulation with the perspectives of the gatekeepers themselves (e.g., college nurses, hall staff, institutional heads) limits the study’s ability to fully capture the operational dynamics and challenges faced by these stakeholders during emergency management.

Despite these limitations, the findings offer a foundational understanding that can inform future, more comprehensive studies and interventions aimed at strengthening emergency care structures within Ghana’s Colleges of Education

This study has significantly enhanced the understanding of the roles played by college gatekeepers in managing student health emergencies within Ghana’s Colleges of Education. By drawing on the lived experiences of students who received emergency care or were referred to health facilities between January and December 2023, the research uncovered critical insights into the influence of communication, coordination, collaboration, and cooperation collectively known as the 4Cs in emergency management. The findings emphasize that effective communication and the timely release of information by gatekeepers, particularly hall masters/mistresses and college nurses, are essential to prompt and efficient emergency responses.

It was further established that coordination among gatekeepers is most successful when strong leadership and clear accountability structures are in place. The ability of institutions to maintain long-term relationships with local health facilities also proved valuable in promoting smooth referral processes and strengthening collaborative care. However, the study also revealed that poor interpersonal relationships, absenteeism, and delayed communication among some gatekeepers hinder cooperation and, by extension, the effectiveness of emergency management. The findings collectively offer a comprehensive perspective that college authorities and researchers can draw upon to improve emergency preparedness and response systems in tertiary educational institutions.

To address the challenges identified in this study and improve emergency management across Colleges of Education, several key recommendations are proposed. First, institutions should prioritise organising sensitisation workshops that focus on teamwork, emotional intelligence, and synergy-building among staff. These initiatives will foster stronger interpersonal relationships and encourage a cooperative culture among gatekeepers involved in emergency response.

Second, a formal training programme should be introduced for all designated gatekeepers, particularly non-health professionals such as hall wardens and hall masters/mistresses. These programmes should cover basic emergency protocols, communication procedures, and first-line response techniques to ensure that all gatekeepers are well-prepared to act swiftly and effectively during emergencies.

Third, colleges should strengthen their partnerships with nearby health facilities by establishing formal agreements and engaging in regular collaborative activities. These relationships will support smooth referrals and ensure that students receive timely and appropriate care when needed. Fourth, the development of a comprehensive emergency preparedness plan is essential. Such a plan should outline clear roles and responsibilities for all stakeholders, include communication flowcharts and referral pathways, and be tested through periodic simulation exercises.

Finally, institutional leadership must ensure that accountability mechanisms are in place to monitor the performance of gatekeepers and address any lapses in emergency response. Strong leadership and oversight are vital for building a responsive and reliable emergency management system. Collectively, these recommendations provide a practical roadmap for improving emergency care and strengthening institutional resilience within Ghana’s Colleges of Education.

To address the concern of a lack of support among gatekeepers due to poor relationships, which negatively impact cooperation in emergency management, it was recommended that sensitization workshops on teamwork, building synergies, and emotional intelligence must be organized for all staff to promote partnership among staff. It is also recommended that the response to emergency preparedness efforts should include effective collaboration of all gatekeepers in the college.

The author wishes to express sincere gratitude to the management of the selected Colleges of Education for granting access to their respective college health units, which made this study possible. Special thanks are extended to the dedicated personnel of these health units and the students who generously shared their experiences and provided valuable primary data for the research. Gratitude also goes to the Science Department of the Presbyterian College of Education for their thoughtful peer review and constructive feedback on this paper.

Ethical approval was not sought from any ethical review committee, but the study followed all the ethical considerations concerning respondent selection, interview processes, confidentiality, and data analysis protocols.