Community First Responders' Contribution to Emergency Medical Service Provision in the United Kingdom.

STUDY OBJECTIVE: We aimed to investigate community first responders' contribution to emergency care provision in terms of number, rate, type, and location of calls and characteristics of patients attended. METHODS: We used a retrospective observational design analyzing routine data from electronic clinical records from 6 of 10 ambulance services in the United Kingdom during 2019. Descriptive statistics, including numbers and frequencies, were used to illustrate characteristics of incidents and patients that the community first responders attended first in both rural and urban areas. RESULTS: The data included 4.5 million incidents during 1 year. The community first responders first attended a higher proportion of calls in rural areas compared with those in urban areas (3.90% versus 1.48 %). In rural areas, the community first responders also first attended a higher percentage of the most urgent call categories, 1 and 2. The community first responders first attended more than 9% of the total number of category 1 calls and almost 5% of category 2 calls. The community first responders also attended a higher percentage of the total number of cardiorespiratory and neurological/endocrine conditions. They first attended 6.5% of the total number of neurological/endocrine conditions and 5.9% of the total number of cardiorespiratory conditions. Regarding arrival times in rural areas, the community first responders attended higher percentages (more than 6%) of the total number of calls that had arrival times of less than 7 minutes or more than 60 minutes. CONCLUSION: In the United Kingdom, community first responders contribute to the delivery of emergency medical services, particularly in rural areas and especially for more urgent calls. The work of community first responders has expanded from their original purpose-to attend to out-of-hospital cardiac arrests. The future development of community first responders' schemes should prioritize training for a range of conditions, and further research is needed to explore the contribution and potential future role of the community first responders from the perspective of service users, community first responders' schemes, ambulance services, and commissioners.

Common hierarchies, varied rules - the problem of governing community first responders in prehospital care for quality standards: documentary discourse analysis.

A key focus is placed on engaging communities to become involved in making decisions to support health and care services in healthcare policies in England, UK. An example is the deployment of volunteers such as community first responders (CFRs), who are members of the public with basic life support skills, trained to intervene in emergency situations prior to the arrival of ambulance services. CFR policies have been devised by National Health Service (NHS) Trusts as a way of governing these and related activities. This paper critically examines the discourse around CFR policies to understand how CFR roles are organised and monitoring governance mechanisms are delineated in ensuring quality care delivery. We collected ten CFR policies from six ambulance services. Inductive analysis, guided by Foucault's theory, enabled the identification of themes and subthemes. We found that Trusts have a common goal to make care quality assurances to regulatory bodies on CFR roles, and this is depicted in common hierarchies of individual responsibilities across Trusts. However, policies that govern approaches to CFRs activity vary. Firstly, the paper highlights institutional approaches to ensuring public safety through the application of organised surveillance systems to monitor CFR activities, and draws parallels between such surveillance and Foucault's docile bodies. Secondly, the paper discusses how varying rules in the surveillance system compromises safety by decentralising knowledge to regulatory bodies to whom NHS Trusts must make safety assurances. We suggest that stronger interrelationships between Trusts in considering the CFR role has potential to increase public safety and outline a clearer direction for CFRs.

Consensus on innovations and future directions of community first responder schemes in United Kingdom: a national nominal group technique study.

AIM: We aimed to achieve consensus among NHS and community stakeholders to identify and prioritise innovations in Community First Responder (CFR) schemes. METHODS: We conducted a mixed-methods study, adopting a modified nominal group technique with participants from ambulance services, CFR schemes and community stakeholders. The 1-day consensus workshop consisted of four sessions: introduction of innovations derived from primary research; round-robin discussions to generate new ideas; discussion and ranking of innovations; feedback of ranking, re-ranking and concluding statements. Innovations were ranked on a 5-point Likert scale and descriptive statistics of median and interquartile range calculated. Discussions were recorded, transcribed, and analysed thematically. RESULTS: The innovations found were classified into two categories: process innovations and technological innovations. The process innovations included six types of innovations: roles, governance, training, policies and protocols, recruitment, and awareness. The technological innovations included three aspects: information and communication; transport; and health technology. The descriptive statistics revealed that innovations such as counselling and support for CFRs (median: 5 IQR 5,5), peer support [5 (4,5)], and enhanced communication with control room [5 (4,5)] were essential priorities. Contrastingly, innovations such as the provision of dual CFR crew [1.5 (1,3)], CFR responsibilities in patient transport to hospital [1 (1,2)], and CFR access to emergency blue light [1 (1,1.5)] were deemed non-priorities. CONCLUSIONS: This article established consensus on innovations in the CFR schemes and their ranking for improving the provision of care delivered by CFRs in communities. The consensus-building process also informed policy- and decision-makers on the potential future change agenda for CFR schemes.

Community First Responders' role in the current and future rural health and care workforce: a mixed-methods study.

Background: Community First Responders are trained volunteers dispatched by ambulance services to potentially life-threatening emergencies such as cardiac arrest in the first vital minutes to provide care until highly skilled ambulance staff arrive. Community First Responder schemes were first introduced to support ambulance services in rural communities, where access to prehospital emergency care is more likely to be delayed. Evidence is lacking on their contribution to rural healthcare provision, how care is provided and how this might be improved. Objectives: We aimed to describe Community First Responder activities, organisation, costs of provision and outcomes of care together with perceptions and views of patients, public, Community First Responders, ambulance service staff and commissioners of their current and future role including innovations in the rural health and care workforce. Design: We used a mixed-methods design, using a lens of pragmatism and the 'actor', 'behaviour change' and 'causal pathway' framework to integrate quantitative routine and qualitative (policy, guideline and protocol documents with stakeholder interview) data from 6 of 10 English ambulance services. We identified potential innovations in Community First Responder provision and prioritised these using a modified nominal group technique. Patients and public were involved throughout the study. Results: In 4.5 million incidents from six English regional ambulance services during 2019, pre COVID-19 pandemic, Community First Responders attended first a higher proportion of calls in rural areas (almost 4% of calls) than in urban areas (around 1.5%). They were significantly more likely to be called out to rural (vs. urban) areas and to attend older (vs. younger), white (vs. minority ethnic) people in more affluent (vs. deprived) areas with cardiorespiratory and neurological (vs. other emergency) conditions for higher-priority emergency or urgent (category 1 and 2 compared with category 3, 4 or 5) calls but did also attend lower-category calls for conditions such as falls. We examined 10 documents from seven ambulance services. Ambulance policies and protocols integrated Community First Responders into ambulance service structures to achieve the safe and effective operation of volunteers. Costs, mainly for training, equipment and support, varied widely but were not always clearly delineated. Community First Responders enabled a faster prehospital response time. There was no clear benefit in out-of-hospital cardiac arrest outcomes. A specific Community First Responder falls response reduced ambulance attendances and was potentially cost saving. We conducted semistructured interviews with 47 different stakeholders engaged in Community First Responder functions. This showed the trajectory of becoming a Community First Responder, the Community First Responder role, governance and practice, and the positive views of Community First Responders from stakeholders despite public lack of understanding of their role. Community First Responders' scope of practice varied between ambulance services and had developed into new areas. Innovations prioritised at the consensus workshop were changes in processes and structures and an expanded scope of practice supported by training, which included counselling, peer support, better communication with the control room, navigation and communication technology, and specific mandatory and standardised training for Community First Responders. Limitations: Missing data and small numbers of interviews in some stakeholder groups (patients, commissioners) are sources of bias. Future research: Future research should include a robust evaluation of innovations involving Community First Responders. Trial registration: This trial is registered as ClinicalTrials.gov, NCT04279262. Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR127920) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 18. See the NIHR Funding and Awards website for further award information.

Community First Responders are volunteers who attend emergencies, particularly in rural areas, and provide help until the ambulance arrives. We aimed to describe Community First Responder activities, costs and effects and get the views of the public, Community First Responders, ambulance staff and commissioners on the current and future role of Community First Responders. Our study design combined different approaches. We examined routine ambulance patient information, reviewed ambulance policies and guidelines, and gathered information from interviews to make sense of our findings. Through interviews we learned about ways that the work of Community First Responders had been enhanced or could be improved. In a 1-day workshop, a group of lay and professional experts ranked in order of importance ideas about future developments involving Community First Responders. Community First Responders arrived before ambulance staff for a higher proportion of calls in rural than in urban areas. They attended people with various conditions, including breathing problems, chest pain, stroke, drowsiness, diabetes and falls, and usually the highest-priority emergencies but also lower-priority calls. Policies aimed to ensure that Community First Responders provided safe, effective care. Costs, mainly used for management, training and equipment, were sometimes incomplete or inaccurate and varied widely between services. Community First Responders attending meant faster responses and positive experiences for those patients and relatives interviewed. A Community First Responder scheme responding to people who had fallen at home led to fewer ambulances attending and possible financial savings. Survival among people attended because their heart had stopped was no better when Community First Responders arrived early. Interviews revealed why and how Community First Responders volunteered and were trained, what they did and how they felt. Interviewees were largely positive about Community First Responders. Improvements suggested included support from colleagues or counsellors, better communication with ambulance services, technology for communication and locating patients, and better training. Community First Responders have benefits in terms of response times and patient care. Future improvements should be evaluated.

"It's like a swan, all nice and serene on top, and paddling like hell underneath": community first responders' practices in attending patients and contributions to rapid emergency response in rural England, United Kingdom-a qualitative interview study.

BACKGROUND: Community First Responder (CFR) schemes are a long-established service supplementing ambulance trusts in their local community in the United Kingdom. CFRs are community members who volunteer to respond to people with life-threatening conditions. Previous studies highlighted the motivations for becoming CFRs, their training, community (un)awareness and implications of their work on themselves and others. The practices of CFRs in prehospital care remain underexplored. Therefore, we aimed to explore real-world practice of Community First Responders and their contribution to prehospital emergency care. METHODS: We conducted 47 interviews with CFRs (21), CFR leads (15), ambulance clinicians (4), commissioners (2) and patients and relatives (5) from six ambulance services and regions of England, United Kingdom. Thematic analysis enabled identification of themes and subthemes, with subsequent interpretation built on the theory of practice wisdom. RESULTS: Our analysis revealed the embeddedness of the concept of doing the right thing at the right time in CFR practice. CFRs' work consisted of a series of sequential and interconnected activities which included: identifying patients' signs, symptoms and problems; information sharing with the ambulance control room on the patient's condition; providing a rapid emergency response including assessment and care; and engaging with ambulance clinicians for patient transfer. The patient care sequence began with recognising patients' signs and symptoms, and validation of patient information provided by the ambulance control room. The CFRs shared patient information with ambulance control who in turn notified the ambulance crew en-route. The practices of CFRs also included delivery of emergency care before ambulance clinicians arrived. Following the delivery of a rapid emergency response, CFRs engaged with the ambulance crew to facilitate patient transfer to the nearest medical facility. CONCLUSION: The sequential CFR practices supported ambulance services in delivering prehospital and emergency care in rural areas. CFR practices were founded on the principle of practice wisdom where CFRs constructed their practice decisions based on the patient's condition, their training, availability of equipment and medications and their scope of practice.

Developing criteria to assist in the palliative phase of COPD.

For people with chronic obstructive pulmonary disease (COPD), hospital admission can be associated with a poor prognosis. Consequently, the end-stage of the illness needs to be recognized for timely palliative care to be initiated. Tools to enhance the palliative phase, such as the Gold Standards Framework and the Liverpool Care Pathway, rely on the recognition of the final phase of a person's life. The illness trajectory of cancer makes this recognition far easier than for COPD, and as a result, many patients and their families manage at home with limited support. The Lincolnshire Respiratory Network has developed criteria to help recognize the end stage of COPD, which correlate well with recommendations from the Consultation on a Strategy for Services for COPD in England (Department of Health, 2010). However, there needs to be appropriate training to assist practitioners in their confidence to refer patients with end-stage COPD to palliative care providers.

COPD: criteria to assist in the identification of the palliative phase.

For people with chronic obstructive pulmonary disease (COPD), hospital admission can be associated with a poor prognosis. Consequently, the end stage of the illness needs to be recognized for timely palliative care to be initiated. Tools to enhance the palliative phase such as the Gold Standards Framework and the Liverpool Care Pathway rely on the recognition of the final phase of a person's life. The illness trajectory of cancer makes this recognition far easier than for COPD, as a result many patients and their families manage at home with limited support. Lincolnshire Respiratory Network has developed criteria to help recognize the end-stage COPD, which correlate well with recent recommendations from the Consultation on a Strategy for Services for COPD in England (Department of Health, 2010). However, there needs to be appropriate training to assist practitioners in their confidence to refer patients with end-stage COPD to palliative care providers.

Perceptions and experiences of community first responders on their role and relationships: qualitative interview study.

BACKGROUND: Community First Responders (CFRs) are lay volunteers who respond to medical emergencies. We aimed to explore perceptions and experiences of CFRs in one scheme about their role. METHODS: We conducted semi-structured interviews with a purposive sample of CFRs during June and July 2016 in a predominantly rural UK county. Interviews were transcribed verbatim and analysed using the Framework method, supported by NVivo 10. RESULTS: We interviewed four female and 12 male adult CFRs aged 18-65+ years with different levels of expertise and tenures. Five main themes were identified: motivation and ongoing commitment; learning to be a CFR; the reality of being a CFR; relationships with statutory ambulance services and the public; and the way forward for CFRs and the scheme. Participants became CFRs mainly for altruistic reasons, to help others and put something back into their community, which contributed to personal satisfaction and helped maintain their involvement over time. CFRs valued scenario-based training and while some were keen to access additional training to enable them to attend a greater variety of incidents, others stressed the importance of maintaining existing abilities and improving their communication skills. They were often first on scene, which they recognised could take an emotional toll but for which they found informal support mechanisms helpful. Participants felt a lack of public recognition and sometimes were undervalued by ambulance staff, which they thought arose from a lack of clarity over their purpose and responsibilities. Although CFRs perceived their role to be changing, some were fearful of extending the scope of their responsibilities. They welcomed support for volunteers, greater publicity and help with fundraising to enable schemes to remain charities, while complementing the role of ambulance services. DISCUSSION: CFR schemes should consider the varying training, development and support needs of staff. CFRs wanted schemes to be complementary but distinct from ambulance services. Further information on outcomes and costs of the CFR contribution to prehospital care is needed. CONCLUSION: Our findings provide insight into the experiences of CFRs, which can inform how the role might be better supported. Because CFR schemes are voluntary and serve defined localities, decisions about levels of training, priority areas and targets should be locally driven. Further research is required on the effectiveness, outcomes, and costs of CFR schemes and a wider understanding of stakeholder perceptions of CFR and CFR schemes is also needed.

Community first responders and responder schemes in the United Kingdom: systematic scoping review.

BACKGROUND: Community First Responder (CFR) schemes support lay people to respond to medical emergencies, working closely with ambulance services. They operate widely in the UK. There has been no previous review of UK literature on these schemes. This is the first systematic scoping review of UK literature on CFR schemes, which identifies the reasons for becoming a CFR, requirements for training and feedback and confusion between the CFR role and that of ambulance service staff. This study also reveals gaps in the evidence base for CFR schemes. METHODS: We conducted a systematic scoping review of the published literature, in the English language from 2000 onwards using specific search terms in six databases. Narrative synthesis was used to analyse article content. RESULTS: Nine articles remained from the initial search of 15,969 articles after removing duplicates, title and abstract and then full text review. People were motivated to become CFRs through an altruistic desire to help others. They generally felt rewarded by their work but recognised that the help they provided was limited by their training compared with ambulance staff. There were concerns about the possible emotional impact on CFRs responding to incidents. CFRs felt that better feedback would enhance their learning. Ongoing training and support were viewed as essential to enable CFRs to progress. They perceived that public recognition of the CFR role was low, patients sometimes confusing them with ambulance staff. Relationships with the ambulance service were sometimes ambivalent due to confusion over roles. There was support for local autonomy of CFR schemes but with greater sharing of best practice. DISCUSSION: Most studies dated from 2005 and were descriptive rather than analytical. In the UK and Australia CFRs are usually lay volunteers equipped with basic skills for responding to medical emergencies, whereas in the US they include other emergency staff as well as lay people. CONCLUSION: Opportunities for future research include exploring experiences and perceptions of patients who have been treated by CFRs and other stakeholders, while also evaluating the effectiveness and costs of CFR schemes.

The importance of the patient-clinician relationship in adherence to antiretroviral medication.

The aim of the study was to assess dimensions of the patient-clinician relationship in relation to adherence with antiretroviral medication in a sample of HIV patients. This was a correlational evaluation, using a cross-sectional design. Thirty-eight HIV patients in two UK HIV units provided complete data. Analysis suggested that the elements of the patient-clinician relationship contributing to adherence with medication were the patient perception of being valued and respected by the clinician, the patients' ability to initiate discussions about the treatment, empowerment and level of trust placed in the nurse. The latter, and the time since starting antiretroviral treatment, were the only two variables that could predict adherence in a regression model, explaining 41% of the variance in adherence. Building trusted relationships with the patients and investing in educational and communication techniques to improve the therapeutic relationship could strongly contribute to HIV patients to maintaining high adherence rates.

Exploring community nurses' perceptions of life review in palliative care.

AIMS AND OBJECTIVES: This exploratory study aimed to identify community nurses' understanding of life review as a therapeutic intervention for younger people requiring palliative care. The objectives set out to: (i) Describe the participants' understanding of reminiscence and life review (ii) Detail their current ideas regarding a structured approach to using life review in the community setting. (iii) Outline their understanding of the possible advantages and limitations of life review in relation to palliative care. (iv) Identify future training requirements. BACKGROUND: The literature review illustrated how the eighth developmental stage of Erikson's theory, ego-integrity vs. despair, is a 'crisis' often faced by older people entering the final stage of life. Life review is considered a useful therapeutic intervention in the resolution of this crisis. Younger terminally ill people in the palliative stage of an illness may face the same final crises due to their reduced lifespan. Therefore, this study explored the benefits and limitations of life review as an intervention in palliative care. METHOD: The study used a purposive sample of community nurses responsible for delivering generic and specialist palliative care. A qualitative method of data collection in the form of three focus group interviews was used. Subsequent data were manually analysed, categorized and coded with associations between the themes identified. RESULTS: The findings suggested that community nurses have limited knowledge pertaining to the use of life review and tend to confuse the intervention with reminiscence. Furthermore, they believed that life review could potentially cause harm to practitioners engaged in listening to another person's life story. However, the participants concur that with appropriate training they would find life review a useful intervention to use in palliative care. CONCLUSIONS: The results led to the identification of a number of key recommendations: Community nurses require specific education in the technicalities of life review and additional interpersonal skills training. The need for formalized support through clinical supervision is also recognized and discussed. Finally, suggestions are offered regarding the need to generate wider evidence and how, possibly, to integrate life review into existing palliative care services. RELEVANCE TO CLINICAL PRACTICE: This study has demonstrated that community nurses are keen to extend the support offered to younger terminally ill people who are in the palliative stage of their illness. Despite having limited knowledge of life the main components and underpinning theory pertaining to life review participants could appreciate the potential of life review as a therapeutic intervention in palliative care and were keen to learn more about its use and gain the necessary knowledge and skills.