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.

Nurse-delivered sleep restriction therapy in primary care for adults with insomnia disorder: a mixed-methods process evaluation.

BACKGROUND: Sleep restriction therapy (SRT) is a behavioural therapy for insomnia. AIM: To conduct a process evaluation of a randomised controlled trial comparing SRT delivered by primary care nurses plus a sleep hygiene booklet with the sleep hygiene booklet only for adults with insomnia disorder. DESIGN AND SETTING: A mixed-methods process evaluation in a general practice setting. METHOD: Semi-structured interviews were conducted in a purposive sample of patients receiving SRT, the practice nurses who delivered the therapy, and also GPs or practice managers at the participating practices. Qualitative data were explored using framework analysis, and integrated with nurse comments and quantitative data, including baseline Insomnia Severity Index score and serial sleep efficiency outcomes to investigate the relationships between these. RESULTS: In total, 16 patients, 13 nurses, six practice managers, and one GP were interviewed. Patients had no previous experience of behavioural therapy, needed flexible appointment times, and preferred face-to-face consultations; nurses felt prepared to deliver SRT, accommodating patient concerns, tailoring therapy, and negotiating sleep timings despite treatment complexity and delays between training and intervention delivery. How the intervention produced change was explored, including patient and nurse interactions and patient responses to SRT. Difficulties maintaining SRT, negative attitudes towards treatment, and low self-efficacy were highlighted. Contextual factors, including freeing GP time, time constraints, and conflicting priorities for nurses, with suggestions for alternative delivery options, were raised. Participants who found SRT a positive process showed improvements in sleep efficiency, whereas those who struggled did not. CONCLUSION: SRT was successfully delivered by practice nurses and was generally well received by patients, despite some difficulties delivering and applying the intervention in practice.

Volunteering on Heritage at Risk sites and wellbeing: A qualitative interview study.

INTRODUCTION: We explored experiences of volunteering in Heritage at Risk (HAR) projects, intended to mitigate the deterioration to historic assets, and the relationship with wellbeing. We aimed to understand the value of HAR to volunteers' wellbeing and relationships between HAR programme characteristics such as location, asset type and type of activity. METHODS: We used a qualitative design with semi-structured interviews of a purposive sample of volunteers recruited via Historic England (HE), employing Systematic Grounded Theory involving open, axial and selective coding. FINDINGS: We interviewed 35 volunteers (18 male and 17 female) participating in 10 HAR projects. We identified six themes from the data analysis. (1) Purpose-was associated with volunteering motivations; there were some barriers to volunteering and many types of facilitators, including accessibility to local heritage sites. (2) Being-volunteers showed an appreciation and attachment to their place of residence. (3) Capacity-to learn heritage-specific skills and diversify experiences in learning new skills (life, technical and personal). (4) Sharing-community engagement, connectedness, and inclusivity captured diversity and inclusion within volunteers across age, ethnicity, ability, and gender. (5) Self-nurture-HAR volunteering created physical, psychological, and social benefits with limited risks and adverse outcomes. (6) Self-actualisation-described volunteers reflecting on their experiences. CONCLUSION: HAR volunteering was associated with positive physical, social and psychological wellbeing outcomes. The study provides an evidence base for specific wellbeing benefits of volunteering at Heritage at Risk sites, although we could not conclude that HAR project activity was the cause of increased wellbeing. PUBLIC CONTRIBUTION: Staff from HE were involved in designing the project brief. In selecting the HAR project sites, we took advice and recommendations from HE staff across all their six regional offices.

Clinical and cost-effectiveness of nurse-delivered sleep restriction therapy for insomnia in primary care (HABIT): a pragmatic, superiority, open-label, randomised controlled trial.

BACKGROUND: Insomnia is prevalent and distressing but access to the first-line treatment, cognitive behavioural therapy (CBT), is extremely limited. We aimed to assess the clinical and cost-effectiveness of sleep restriction therapy, a key component of CBT, which has the potential to be widely implemented. METHODS: We did a pragmatic, superiority, open-label, randomised controlled trial of sleep restriction therapy versus sleep hygiene. Adults with insomnia disorder were recruited from 35 general practices across England and randomly assigned (1:1) using a web-based randomisation programme to either four sessions of nurse-delivered sleep restriction therapy plus a sleep hygiene booklet or a sleep hygiene booklet only. There was no restriction on usual care for either group. Outcomes were assessed at 3 months, 6 months, and 12 months. The primary endpoint was self-reported insomnia severity at 6 months measured with the insomnia severity index (ISI). The primary analysis included participants according to their allocated group and who contributed at least one outcome measurement. Cost-effectiveness was evaluated from the UK National Health Service and personal social services perspective and expressed in terms of incremental cost per quality-adjusted life year (QALY) gained. The trial was prospectively registered (ISRCTN42499563). FINDINGS: Between Aug 29, 2018, and March 23, 2020 we randomly assigned 642 participants to sleep restriction therapy (n=321) or sleep hygiene (n=321). Mean age was 55·4 years (range 19-88), with 489 (76·2%) participants being female and 153 (23·8%) being male. 580 (90·3%) participants provided data for at least one outcome measurement. At 6 months, mean ISI score was 10·9 (SD 5·5) for sleep restriction therapy and 13·9 (5·2) for sleep hygiene (adjusted mean difference -3·05, 95% CI -3·83 to -2·28; p<0·0001; Cohen's d -0·74), indicating that participants in the sleep restriction therapy group reported lower insomnia severity than the sleep hygiene group. The incremental cost per QALY gained was £2076, giving a 95·3% probability that treatment was cost-effective at a cost-effectiveness threshold of £20 000. Eight participants in each group had serious adverse events, none of which were judged to be related to intervention. INTERPRETATION: Brief nurse-delivered sleep restriction therapy in primary care reduces insomnia symptoms, is likely to be cost-effective, and has the potential to be widely implemented as a first-line treatment for insomnia disorder. FUNDING: The National Institute for Health and Care Research Health Technology Assessment Programme.

"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.

'I Felt Welcomed in Like They're a Little Family in There, I Felt Like I Was Joining a Team or Something': Vape Shop Customers' Experiences of E-Cigarette Use, Vape Shops and the Vaping Community.

Background: Specialist electronic cigarette (e-cigarette) shops, known as vape shops, provide access to a less harmful alternative to smoking. This study aimed to understand customers' experiences of vaping and vape shops, and the extent to which smoking cessation advice is and should be provided in these shops. Methods: We conducted telephone interviews with 22 customers recruited in vape shops in the East Midlands region of England. Interviews explored participants' smoking histories, reasons for using e-cigarettes, the role of vape shops in their e-cigarette use, and whether smoking cessation was discussed in vape shops. Interviews were analysed following framework approach principles. Results: Most respondents regarded e-cigarettes as a quitting tool and reported very positive experiences of vaping. Vape shops were central to participants' positive experiences, in that they provided access to a wide variety of high-quality products and reliable product information and advice. The shop staff engendered a sense of loyalty in customers which, together with the community of other vapers, created a network that helped to support e-cigarette use. Vape shops were not regarded as a setting in which cessation advice was generally provided but were acknowledged as potentially appropriate places to provide quitting support. Conclusions: Vape shops have the potential to play an important role in tobacco harm reduction, which could be increased if their service model were to extend to help smokers to quit.

Exploring reasons for differences in performance between UK and international medical graduates in the Membership of the Royal College of General Practitioners Applied Knowledge Test: a cognitive interview study.

OBJECTIVES: International medical graduates (IMGs) perform less well in national postgraduate licensing examinations compared with UK graduates, even in computer-marked multiple-choice licensing examinations. We aimed to investigate thought processes of candidates answering multiple- choice questions, considering possible reasons for differential attainment between IMGs and UK graduates. DESIGN: We employed a semistructured qualitative design using cognitive interviews. Systematic grounded theory was used to analyse data from 'think aloud' interviews of general practitioner specialty trainees (GPSTs) while answering up to 15 live questions from the UK Membership of the Royal College of General Practitioners Applied Knowledge Test (AKT). SETTING: East Midlands, UK. PARTICIPANTS: 21 GPSTs including 13IMGs and 8 UK-trained doctors. OUTCOMES: Perceptions of participants on how they answered AKT questions together with strategies used or difficulties experienced. RESULTS: We interviewed 21 GPSTs (8 female, 13 male, 13 IMGs, 14 from black and minority ethnic groups, age 24-64 years) in years 1-3 of training between January and April 2017. Four themes were identified. 'Theoretical versus real-life clinical experience': participants reported difficulties recalling information and responding to questions from theoretical learning compared with clinical exposure; rote learning helped some IMGs recall rare disease patterns. Recency, frequency, opportunity and relevance: participants reported greater difficulty answering questions not recently studied, less frequently encountered or perceived as less relevant. Competence versus insight: some participants were over optimistic about their performance despite answering incorrectly. Cultural barriers: for IMGs included differences in undergraduate experience, lack of familiarity with UK guidelines and language barriers which overlapped with the other themes. CONCLUSIONS: The difficulties we identified in candidates when answering AKT questions may be addressed through training. IMGs face additional difficulties which impede examination success due to differences in educational experience, content familiarity and language, which are also potentially amenable to additional training support.

Vape shops: who uses them and what do they do?

BACKGROUND: 'Vape shops' are a popular source for buying electronic cigarettes (e-cigarettes) and related products. The products that vape shops sell, their marketing techniques and the extent to which they provide information or encouragement to smokers to quit tobacco use, as well as the patterns of tobacco and e-cigarette use of their customers are not well understood. METHODS: We conducted cross-sectional surveys in vape shops in the East Midlands region of the United Kingdom, one with shop staff (n = 41), and one with customers (n = 197). RESULTS: The majority of customers (84%) currently used e-cigarettes. Among current vapers, 19% were dual users and 78% had quit smoking. Over half of vapers reported using a lower level of nicotine in their current e-liquid than when they started using e-cigarettes. There was a wide variety in products and price ranges between the shops. Many staff reported that customers ask for information about quitting smoking (90%). Less than half reported providing smoking cessation advice, although 76% of staff reported feeling confident about delivering cessation advice to customers who ask for it. Just under half of customers and shop staff said they thought it was appropriate to deliver formal in-store smoking cessation support. CONCLUSIONS: The majority of vape shop customers are vapers who have quit smoking. Shop staff play a central role in providing customers with product information, and many provide smoking cessation advice. Further research is needed to investigate the potential for smoking cessation interventions in vape shops, including the extent to which these would appeal to non-vapers.

Age-related physical and psychological vulnerability as pathways to problem gambling in older adults.

Background To inform clinical treatment and preventative efforts, there is an important need to understand the pathways to late-life gambling disorder. Aims This study assesses the association between age-related physical health, social networks, and problem gambling in adults aged over 65 years and assesses the mediating role of affective disorders in this association. Methods The sample comprised 595 older adults (mean age: 74.4 years, range: 65-94 years; 77.1% female) who were interviewed using a structured questionnaire to assess physical frailty, geriatric pain, loneliness, geriatric depression, geriatric anxiety, and problem gambling. Results Pathway analysis demonstrated associations between these variables and gambling problems, providing a good fit for the data, but that critically these relationships were mediated by both anxiety and depression symptoms. Conclusions This study indicates that late-life problem gambling may develop as vulnerable individuals gamble to escape anxiety and depression consequent to deteriorating physical well-being and social support. When individuals develop late-life problem gambling, it is recommended that the treatment primarily focuses upon targeting and replacing avoidant coping approaches.

The experience of high-frequency gambling behavior of older adult females in the United Kingdom: An interpretative phenomenological analysis.

The prevalence of older adult female gambling participation and gambling disorder is increasing in the UK, and there is a paucity of published research available to understand possible risk factors for frequent gambling in this demographic. The aim of the current study was to identify and explore motivations and patterns of gambling behavior in high-frequency older adult female gamblers in the UK, from the perspective of the individual and in the context of their experience of aging. Ten UK older adult female high-frequency gamblers were recruited via stratified purposive sampling, with a mean age of 70.4 years. Data was collected via semistructured interviews and analyzed using interpretative phenomenological analysis. Three core themes representative of the experience of this phenomenon emerged from the transcripts, including: Filling voids, emotional escape, and overspending. The present study has provided a contextualized understanding of motivating factors and several age-related vulnerabilities that may account for high gambling frequency in this population.