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.


Background
A Community First Responder (CFR) "is a member of the public who receives basic emergency care training and volunteers to help their community by responding to appropriate medical emergencies while an ambulance is en route" [1]. They complement the work of the ambulance service. Their work is particularly valuable in rural communities, where it might take ambulances longer to reach medical emergency situations.
Community First Responder schemes have been providing prehospital emergency care since the 1990s, enabling patients to receive early medical attention while awaiting an ambulance response [2]. The ambulance service deploys an estimated 2,500 CFR schemes, with over 11,000 volunteers in the United Kingdom [1,3]. They are usually charities, either independent or run through ambulance trusts [4]. Currently, no national standards exist concerning CFR service provision, training and support of volunteers or quality of services provided. Local schemes have developed independently of each other and reflect each area's priorities. Many CFR schemes only respond to cardiac events, whilst others may also attend road traffic collisions and trauma incidents. Such diversity of provision also carries varying degrees of training and support of volunteers which could impact on effectiveness, safety and retention of personnel [1].
Some UK regions, such as the East Midlands, have both independent CFR schemes and schemes run by ambulance services. For example, Lincolnshire Integrated Voluntary Emergency Service (LIVES) is an independent voluntary scheme working collaboratively with but not managed by the regional ambulance service, whereas the CFR scheme in Nottinghamshire is run by the ambulance service. Both, like many other CFR schemes, have volunteers trained up to 'first person on scene' level [3].
The Government has called for greater co-ordination and collaboration between ambulance services, the 111 call service, which provides advice for urgent but nonemergency cases, urgent care and out-of-hours services in The NHS 5 year forward view [5]. Such changes are likely to affect CFR schemes within ambulance trusts and CFR schemes working with other agencies to ensure a more integrated and needs-led service [6,7]. Therefore, it is timely to evaluate the CFR role and service provision and explore their potential for future development.
Research on the benefits of CFR schemes to both patients and ambulance services for health outcomes and ambulance response times have been published for other countries [8] but there has been no review of published literature on CFR schemes in the UK. 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 aimed to map existing published literature relating to current UK-based CFR schemes in order to identify gaps for future research to explore. To do so, we conducted a systematic scoping review of published research on CFR schemes and CFRs including any interventions, comparisons and outcomes. The purpose of the study was to understand, map and synthesise the range of published literature, regardless of quality [9].

Inclusion criteria
The inclusion criteria for selecting publications were that they had to be published in English and from the year 2000 onwards in order to reflect current UK CFR schemes. All studies had to be UK-based, so non-UK studies were excluded. The final agreed search terms were as follows: "emergency responder*" OR "lay responder*" OR "first person on scene" OR "community first respon*" OR "community respon*" OR "first respon*" OR "first-respon*" OR "Community" AND "first" AND "responder"

Data sources
The following databases were searched: CINAHL; MED-LINE; PsycINFO; Applied Social Sciences Index and Abstracts (ASSIA); International Bibliography of the Social Sciences (IBSS); Published International Literature on Traumatic Stress (PILOTS).

Search strategy
Search results were scanned individually for relevance. Selection at this stage included direct relevance to the research question (i.e. included key search terms in title/ abstract) or potential usefulness as background information. Articles deemed relevant from each database were exported into an individual EndNote library. This resulted in 979 articles, of which 174 duplicates were removed, leaving 805 articles for screening. Screening by title and abstract excluded a further 177 articles. Since we wished to focus on UK-based CFR schemes, of the remaining 628 articles, 528 were rejected because they referred to schemes outside the UK. The 100 papers left included 56 studies of CPR methods, mass casualty terror acts, etc., which were removed. Two researchers (IT and FT) conducted a full-text review of the remaining 44 articles, in which a further 35 publications were excluded. This left nine publications in the scoping review ( Fig. 1). Data were extracted for each study describing 'aims and objectives' , 'sample population' , 'methods and 'results'. Scoping reviews by their nature do not exclude studies with higher risk of bias, so no risk of bias analysis was undertaken.

Results
Of these nine publications, one was a systematic review, four were qualitative studies, three used quantitative methods, and another employed a mixed-methods approach ( Table 1).
We used a narrative approach to summarise the main findings in themes described below.

Motivations and reasons to become a CFR
Several studies showed that volunteers cited altruistic reasons for becoming CFRs [10,11]. Becoming a CFR was often seen as a way of giving something back to the community by helping others [4,[10][11][12]. The role was also seen as a way of enhancing employability within the ambulance care sector [13]. Some CFRs joined because they were already healthcare professionals who felt that it provided a good learning experience for them in a different setting [13].

Experiences of being a CFR
CFRs felt their role was rewarding, although they expressed a need for praise for the work they did [4] and a concern about the limited opportunities for operational debriefing on their activities [10,14,15] CFRs felt they were limited in what they could do because they lacked the skills of paramedic staff. [1,12] In some instances, this manifested in a concern that they were not doing the right thing [1], while some felt they could and should be able to do more to help patients [16].

Training
We found no evidence around the content of the initial training of CFRs, but this identified the need for research on the requirements for ongoing training and support. Previous studies pointed to a mandatory period of experience required of CFRs before they were allowed to progress to higher levels of expertise [16]. CFRs felt that ongoing training was essential to enable them to progress. [12,15]. However, retraining and keeping up to date in a timely manner was considered difficult [1,15]. CFRs expressed concerns that despite the ongoing training, this training would become less relevant if they had not been called out to patients [1,12,15] Furthermore, CFRs felt that provision of training demonstrated how their organisation valued the contribution they made to patient outcomes [12]. Conversely, a lack of training led to frustration among CFRs about not having the skills required to help patients [1].
In terms of the types of training that CFRs undertook, scenario-based training was considered to be the most effective [15]. Training was sometimes considered to be too focused on skills, with a greater need to emphasise the emotional side of being a CFR [1,15].

Patient outcomes and feedback
CFRs were not usually given feedback about patients they had attended. This was something that CFRs wished to see change [1,15]. They felt that evidence of improved patient outcomes could enhance their profile in the local community and offer greater personal recognition of the work they did [4,12]. Even without formal feedback mechanisms, some CFRs derived satisfaction from contributing positively to patient outcomes [10].  Timmons and Vernon-Evans (2012) [11] To understand why people volunteer for, and continue to be active in CFR groups.
CFR volunteers from one English region. Although, as a qualitative study, a statistically representative sample was not needed, the geographical region was intended to generate a mixture of CFR groups from urban, suburban and rural communities and being mixed in terms of Given that the participants are volunteers who only meet infrequently as a group, focus groups were the most efficient and cost-effective way of collecting data.
The most common route was finding out about CFRs through an advertisement in the local newspaper. Many participants joined to 'get involved' or 'get out in the community', as each first responder group is a local charity and relies on volunteers and financial support from within the community.

Public understanding of CFRs
There was a low level of public recognition of the CFRs' role. There was perceived public confusion about how their role related to that of the ambulance service. [4] For example, the public were concerned that CFRs may adopt roles traditionally associated with ambulance staff, reducing the effectiveness of the ambulance service [12]. Recruitment was often poor in areas where the ambulance service was perceived to be performing well [12]. In order to tackle low levels of recognition, CFR programmes felt they needed to work closely with stakeholders and consumers to improve the way they publicised themselves [4,11].

Relationship between CFRs and the ambulance service
There was a perception of ambivalence in the relationship between CFRs and the ambulance service [12]. This stems partly from some confusion over accountability between the ambulance service and CFR schemes. Some CFRs felt undervalued by ambulance service staff [1].

Emotional impact
Much of the literature around CFRs centred on the emotional impact of the role. Despite call handlers giving CFRs an indication of the nature of the incidents that they were responding to, CFRs maintained a flexible approach on reaching the patient [10], because what they found at the scene might have been very different to what had been communicated by call handlers. The role also necessitated an ability to switch off from the often traumatic nature of the incidents they attended to [1,10] There were particular concerns about the potential for lone working to have a high emotional impact [14]. That said, some CFRs valued having support mechanisms to call upon when needed [1,14].

Suggestions for improvement
CFRs expressed a need for ongoing training and support in order for them to feel valued and appreciated. To do this, it was felt that shared governance, collaboration with statutory providers to fully fund training, and assistance with resources would greatly help [11].
In terms of how CFR schemes develop further, there was strong support for local autonomy together with greater collaboration between schemes [11,15]. A key strength of CFR schemes was that they reflected local needs and demands. If they are to be rolled out more widely, then new schemes could follow best practice from existing schemes that have been shown to work effectively. This potentially conflicted with the suggestion for nationwide minimum standards for CFRs [2].

Main findings
People became CFRs mainly to help others and put something back into their communities. CFRs also wanted to be appreciated and recognised for their work, perhaps through integrating formal feedback mechanisms into practice. Both are relevant considerations for CFR schemes needing to recruit and retain volunteers.
CFRs particularly valued scenario-based training which they felt would most effectively improve their range of skills. Maintaining the realism of scenario-based training, as well as encouraging CFRs to improve their skills will enable them to attend to a greater range of incidents, which is what they want. A key factor in getting people to volunteer, but more importantly to stay, was the flexibility of the role and the nature of the role itself. Participants valued their role as an assistant to the paramedic. The experiences with the ambulance service had not always been good. The flexible nature of the CFRs' commitment may have played a part in this. CFR groups rely on money from the local community and they spend a lot of time raising funds at local events. Participants highlighted the significance of the community supporting their local group, and how locals like to see good work being done that directly affects them and their community.
CFRs valued the flexibility and availability of support mechanisms to help them cope with the stressful incidents, which they inevitably have to attend to from time to time. Nevertheless, the scoping review raised awareness of some of the known risks associated with attending to particular incidents. It also identifies the stress factors of other, non CFR-related, pressures a responder may struggle with.
While this is a UK-based scoping review, it is important to draw some comparisons with how CFR schemes work in other countries. In the UK, CFRs are volunteers equipped with some basic skills in life support to enable them to respond to medical emergencies. Their purpose is to do the preparatory work at the scene prior to ambulance service staff arriving. In the US, first responders can include Police Officers, firefighters and other emergency services staff, as well as lay people [17,18]. Australian volunteer response resembles the UK model in that it relies on lay people volunteering to help emergency services respond to incidents [19].

Strengths and limitations
The precise search criteria applied to this scoping review produced nine UK-based publications. The low number may be because research into CFRs is relatively recent, with most studies being from 2005 onwards. Because much of the research into CFRs was recent, the included publications tended to be more descriptive than analytical. Indeed, the existing literature mainly comes from the perspective of 'experts'.

Implications for policy and research
Future research should explore the perspectives of the patients who had received care from CFRs as well as that of CFRs, commissioners, policymakers and academics. Perceptions of patients are important because there is limited understanding of patients' experiences of the service as well as limited public awareness and understanding of what CFRs do.
Patients were sometimes unable to distinguish between CFRs and ambulance crews. In some instances, patients were less concerned about the respective roles of each but instead were grateful and reassured about the presence of someone with expertise and skills and to help them in a highly stressful situation. Some CFR schemes had attempted to rectify this situation by raising awareness in their communities about how they operated.
Clarifying the role of the CFR is important as their relationship with the ambulance service was sometimes mixed. Sometimes, ambulance crew were grateful for the preparatory work that CFRs did prior to their arrival. In other instances, staff from ambulance and other statutory services viewed CFRs with suspicion because of a lack of understanding about when the CFR's role ends and the ambulance crew's begins. This suggests that future research could usefully explore the perceptions of ambulance service staff towards CFRs.
This tension and confusion around roles is partly reflected in the low public awareness about differences between CFRs and ambulance crews. To address this confusion, there needs to be greater clarity over the roles of ambulance staff and CFRs.
There is an opportunity to explore the proportion of ambulance service cases that are attended to by CFRs and the contribution that CFRs make to response time targets or patient outcomes. Outcomes research could focus on overall caseload or specific time-sensitive conditions, such as cardiac arrest. The scoping review identifies that these are matters of policy which should be clarified in operational practice. Once these are in place, research might generate an evidence base upon which decisions can be made about the formal and informal status of CFR services and their role within the communities they serve.
The local nature of CFR schemes means that by definition, they are driven by local contextual factors, such as demographics, geography, demand and available skills sets. It might be more appropriate to have minimum standards of training for CFRs. Urban and rural service settings may require different operational policies, training priorities, safety measures and follow-up arrangements for CFRs. Outcome standards could vary between local schemes to reflect such local factors. Local CFR schemes need to be clear about what the priorities are in their area. This should then inform their desired outcomes and objectives. Once local schemes are clear about their desired outcomes and objectives, then they can have a better idea of what role their volunteers should have and tailor their training programmes accordingly. Future research can clarify the extent to which aims and objectives are locally defined as well as how CFR schemes operate to give a more nuanced perspective about the links between local provision and local needs. Once more is known about how schemes operate, there is greater potential for best practice to be shared, especially between localities with similar demographics, context and need.
CFRs felt strongly about the effectiveness of scenariobased training and the desirability of having formal feedback mechanisms, therefore, it would be helpful to involve them in deciding how these might be incorporated into local schemes.

Conclusions
This scoping review has identified and highlighted numerous opportunities for future research. These include: exploring patients' experiences and other stakeholder views; evaluating the effectiveness; costs; and support needed to ensure quality of CFR schemes. Such evidence may inform the way that CFR schemes develop services in future as well as training mechanisms to ensure that CFRs feel valued and well-supported. Further understanding of the stressors associated with the role should assist in limiting turnover rates. This will help to secure the long-term future of the CFR schemes and the vital services they provide in complementing the statutory emergency care services.