Background
Internationally, rural communities experience difficulties in accessing health care for reasons such as challenging geography, distance from service centres and reluctance of specialist health professionals to work in remote locations [
1,
2]. Rapid access to emergency healthcare can be crucial for outcomes in critical health situations and rural residents are thus disadvantaged. Paradigmic change in public service provision from welfare state to self and community responsibility [
3] have led to discussion, and increasingly realisation, of reconfigured rural health care delivery [
4]. New policy messages encourage communities to build their capacity from within, to be resilient [
5] and to “co-produce” basic needed services [
6]. These messages are predicated on citizen’s rights to services being counter-balanced by their responsibilities to participate in production as well as consumption of services [
7‐
9]. Exemplifying a new era of volunteering for co-production, Community First Responders (CFRs) act within the emergency care arena to provide local emergency care with ambulance services and other available health professionals.
Literature relating to community capacity suggests that rural areas may be ideal spaces for co-production as rural communities are richer in social capital [
10] and have higher rates of volunteering [
11], compared with urban communities. As the policy idea of co-production is relatively new, the literature tends to feature discussion of its potential rather than evaluation of its introduction.
We were interested to explore the experience of co-production in health care for rural lay persons. Timmons and Vernon-Evans [
12] note there are few studies depicting the experiences of CFRs as literature tends to focus on their role in affecting health outcomes. This paper will examine the results of two research studies into first response in Scotland, in which a theme of liminality emerged as central to the role of first responders. Grounded in social anthropology of Van Gennep [
13] and later applied to modern societies by Turner [
14] the concept of liminality refers to transition, outside the everyday environment, for a period where the participant lacks social status or position within a particular community or group – an intermediate stage of being “in between”. In contemporary thinking, “liminality” may depict times of political or cultural change, and Turner argues liminality creates the idea of “communitas”, or an egalitarian sense of community and social togetherness that can occur within groups transitioning, in this case between lay community member and health professional.
In particular, this paper explores the experience of CFR liminality as lay persons exposed to helping fellow community members in stressful situations, with limited training and constrained scope of practice. We present our findings and discuss the emerging evidence, within this context, of the liminal first response role and argue that the foundation of such volunteering is in the creation of communitas.
This paper uses data from two mixed methods studies conducted in rural Scotland between March 2009 and September 2011. It presents the actual contribution of CFRs to community health and juxtaposes this with perceptions of CFRs and other community health stakeholders, about the CFR role. We use the data to depict CFR’s liminality and consider the implications for extending rural co-production.
CFRs fulfil an increasingly accepted community-based voluntary role in emergency service provision internationally, trained to provide basic level of ‘first person on the scene’ (FPOS) first aid training that includes patient resuscitation, basic wound care, and use of defibrillators. Evidence suggests that such trained community response during a medical emergency can affect patient survival, particularly for cardiac arrest [
15,
16]. A systematic “chain of survival” during the first crucial minutes of an emergency response - early access, resuscitation, defibrillation and early advanced life support can increase an individual’s chance of survival [
17]. Survival from defibrillation within three minutes of ventricular tachycardia/fibrillation (VT/VF) inception can be as good as 70-80%. In non-VT/VF arrest and VT/VF arrest without a defibrillator, survival using cardio-respiratory resuscitation (CPR) techniques alone can be as low as 2-8%, increasing to 20-30% in communities offering bystander CPR and rapid arrival of trained personnel [
18], particularly those able to use Automated External Defibrillators (AEDs) effectively and in safety [
19]. Therefore, CFRs can be an effective strategy for helping to reduce mortality in the community from cardiac arrest [
20].
Diverse CFR models exist, with differences in types of emergency call attended, drugs CFRs are trained to administer, and additional clinical training. An English study showed diversity across different CFR schemes even within the same country; for example while some schemes responded solely to cardiac incidents, others attended diverse calls. Similarly, the study found that there was variation in the ability to provide medication other than basic oxygen between schemes [
21]. Some schemes have contributed significantly to trauma care [
22] where pre-hospital response times can be lengthy [
23]. In Israel, for example, a dispersed model exists where volunteers carry a mobile telephone with an app that alerts the CFR nearest to the emergency [
24]. Travelling predominately by motorbike for speedy response, this first responder model has had significant impact in Israel’s rural areas. In rural Australia there are volunteer systems where ambulance crew finance their own training and communities purchase ambulances and equipment when required [
25]. This enables isolated communities to sustain feasible urgent care arrangements [
26]. In spite of these benefits, introducing CFR schemes as a support to local health professionals, has sometimes occurred in situations of community protest. In an Australian community, O’Meara, Kendall & Kendall (2004) described that local people were placing unreasonably high expectations on small teams of resident health professionals and it took community development interventions for the community to accept a CFR scheme as part of local services [
26]. The Healthcare Commission report [
21] in England commented that CFRs benefit local communities in several indirect ways, including motivating people to be proactive in relation to their health, but there is little research evidence.
CFR schemes were first introduced to Scotland in 2002 and their number has increased since. Some schemes in Scotland have been established by the Scottish Ambulance Service (SAS), in areas identified as high need. Other CFR schemes have been established autonomously by members of the community. Scottish CFRs provide basic life-saving treatment as FPOS at selected emergency calls. When an appropriate call is received by an Emergency Medical Despatch Centre (EMDC), there is a synchronised response between the ambulance service and the CFR team, who then may arrive at the scene more quickly. Some schemes have elected to undertake further additional accredited training to FPOS intermediate level, which enables volunteers to attend a wider range of emergencies. There are now more than 120 schemes across Scotland [
27]. At the time of these studies schemes were managed by five Community Resuscitation Development Officers (CRDOs), SAS employees whose role is to support and train volunteers. Some CFR schemes were supported financially by SAS, including for some, provision of a first response vehicle. Conversely, schemes established by communities were often reliant on local fundraising. Most schemes involved volunteers, although alternative models, such as retained ambulance services or joint first responder/fire service schemes were emerging. Volunteer numbers varied by scheme as did hours covered. Scottish CFR schemes existed in rural, remote and urban settings. Some flourished, while others experienced opposition, often because they were associated with perceived local service reduction [
28].
The spread of CFRs has occurred in parallel with public service retrenchment and the emergence of policy encouraging greater societal input, and community participation and resilience; for example, increasing lay first responder schemes is cited as a pillar of Scottish rural health strategy [
1].
While policy encourages citizen participation in basic service provision, research evidence delineates the ways in which challenges of co-productive involvement for volunteers are identified and addressed [
29,
30]. First response to emergencies can be a traumatic role [
31,
32]. Although the SAS strive to protect volunteers from extreme situations, in rural areas this maybe more difficult, with the added complication that people know each other, potentially bringing personal burdens of embarrassment, grief or responsibility. Policy depicts volunteering roles as positive, with benefits for communities and individuals. Such an approach adopts the principles of co-production – sharing information and encouraging collaborative decision making amongst service users and providers. Health research tends to focus on measuring objective health outcomes. The realities of the human experience within co-production, and what this means for increasing co-production, seem thus far to have been largely overlooked in the literature.
The few studies of rural people’s co-production experiences highlight the limitations of co-production, particularly given rural ageing populations. Studies in Canadian rural communities [
31] have highlighted the almost unbearable burden of volunteering as services withdraw [
33]. In Farmer & Bradley’s [
34] study of impacts of developing rural social enterprises, they noted that the same people tended to take on more volunteering, rather than volunteering spreading more widely. This meant a heavy and stressful burden for a small number of residents.
Co-production therefore represents a paradigm change in service delivery. With volunteers on the threshold between lay citizen and skilled professional, such experiences require greater exploration in reality. Pragmatically, O’Meara et al. [
35] highlight features of successful CFR schemes and Timmons and Vernon-Evans [
12] explain volunteers’ motivations. We sought to assess if the features these researchers highlighted are more generalisable, and applicable to our Scottish context and highlight the new evidence which suggests CFRs occupy a liminal space in contemporary communities, between citizen and health practitioner.
Methods
This paper uses findings from two studies. Study 1 (March 2009 – December 2010) evaluated the introduction of a CFR scheme in an isolated region with difficulties created by geography where the drive time to the nearest hospital with a major A & E department was more than 90 minutes. Study 2 (October 2010 – September 2011) investigated the contribution of six CFR schemes in urban, suburban and remote Scottish settings. Table
1 summarises the included schemes.
Table 1
CFR schemes by urban rural classification [
36]
Scheme 1 | 2 | 8 | Scheme described by the ambulance service as established. | Remote rural |
Scheme 2 | 2 | 2 | Remote island location with small number of volunteers. | Remote rural |
Scheme 3 | 2 | 10 | Co-response scheme with the Fire Brigade. | Rural area |
Scheme 4 | 2 | 6 | Newly established suburban scheme | Other urban area |
Scheme 5 | 2 | 30 | Larger number of volunteers, busy, urban scheme near to city area. | Other urban area |
Scheme 6 | 2 | 21 | Larger scheme, covering a collection of small towns | Small town |
Scheme 7 | 1 | 9 | Recently established scheme, remote & rural location. | Remote rural |
Data collection during both studies were mixed methods. The aim was to capture the CFR activity data at the same time as gathering in depth, robust qualitative material. Included were stakeholder interviews (e.g. with representatives of national and local government, health authority, health professionals, and community members), and focus groups with individual CFRs. Routine anonymised data provided by SAS about callouts were analysed. Both studies were classified as service evaluations by local ethics committees (North of Scotland Research Ethics Service). All participants received information sheets clearly stating anonymity and confidentiality procedures and informed consent was provided by signed consent forms prior to participation.
Routine SAS data
For Study 1, SAS activity data were obtained covering the first year of CFR scheme operation (2009–2010). For Study 2, SAS activity data for a six month period during 2011 for all six case sites were obtained. These were analysed to identify activity and case mix of contacts at all sites. CFR contacts are recorded on SAS contact sheets (including time of call, response, and arrival of ambulance, presenting complaint, and actions taken).
Study interviews
Interviews for both studies were conducted either face-to-face or by telephone. Participants included purposely selected representatives from the Scottish Government (in the area of performance management for emergency medicine), Scottish Ambulance Service personnel, community engagement representatives from the Scottish Health Council, local after-hours service managers and General Practitioners (GPs). All individuals who were approached agreed to participate.
Interviews were conducted with community members, including formal community representatives (e.g. community council members) and ‘lay’ community members. Community members were initially contacted through community councils and pre-existing community groups (such as older people’s and parents groups). After initial contact had been made, snowball sampling [
37,
38] was employed to contact further community members, often gaining introductions first from other community members to avoid unanticipated contact. One of the limitations of snowball sampling is that the sample it yields may not be representative [
37,
39,
40] and it may be influenced by gatekeeper bias [
41]. Hence, initial community contacts may intentionally exclude certain potential participants from their referrals. Conversely, Atkinson and Flint [
40] note that snowball sampling provides a method for gaining access to closed or unknown communities and can be useful for ‘outsiders’ (such as ourselves as researchers) attempting to gain entrance. They also suggest the chain referral process may be more effective than other methods at fostering the inclusion of some who would be hard to identify by outside researchers.
Interviews were semi-structured, following a broad topic guide - but were informal enough to allow respondents to raise their own issues. Topic guides covered topics identified from existing CFR literature [
42]: i) the benefits and limitations of CFR schemes, ii) obstacles and enablers, iii) views on the value of emergency response volunteering, iv) perceptions of potential further developments. In addition, lay community members were asked about their knowledge of the local CFR scheme, how it functioned, firsthand experience of using the scheme, and their thoughts about CFR schemes in local terms, and in general.
With consent, interviews in both studies were audio-recorded and transcribed verbatim. Analysis followed the framework approach [
43] involving familiarisation with the data, identification of a thematic framework, indexing, charting, and finally mapping and interpreting the qualitative data. All transcripts were coded by AR and samples for verification, by AN, JF and DH. AR and AN conducted data analysis supported by NVivo 7 management software.
CFR focus groups
CFR schemes were approached through their supporting SAS CRDO (Community Resuscitation Development Officer). Once initial agreement was obtained, researchers liaised with schemes to distribute information, obtain consent and arrange times and locations for focus groups. These took place at the usual meeting place for responder schemes (community hall, high school or GP Practice). Consent was obtained prior to arranging focus groups. With the explicit consent of all participants, groups were digitally sound recorded and transcribed verbatim. Discussions from both studies aimed to investigate CFR’s views about their role, training, support, relationships with other providers and community impacts. Focus group data were transcribed, coded and analysed as for the individual interviews, described above.
Discussion
Our two studies revealed that Scottish CFRs were able to respond to incidents more quickly than ambulance services. This is potentially beneficial to the impact on clinical outcome and thus, in health terms, CFRs were an important feature of local community health and security. CFRs were motivated by helping, perhaps having had personal experience of emergencies in the community, and wished to use their skills and, in some cases, to gain experience. This finding resonates with recent evidence about why CFRs volunteer [
12]. The CFR role can be considered ‘liminal’ as these health volunteers lacked either a clear eminence as citizen in the community or status as a health practitioner during their voluntary experiences. In terms of lay contributions to the health system, CFR schemes exemplify a move to community members increasing role in co-producing basic services. Thus much can be learned from their experiences that can inform the increasing introduction of laypersons into what was formerly the domain of paid public service employees.
Co-production of services in rural areas, and CFR scheme in this instance, are underpinned by the concept of community resilience. It can also be argued that the foundation of such volunteering is contributing to a sense of communitas. Governments want communities to become less state-reliant and more self-reliant. In their enforced transition community members will need to move into different roles, flexibly and easily with a sense of communitas to achieve more self reliance and cause community members to unite and do things for themselves.
What this paper illustrates, however, is that the role of CFR also creates a liminal state for
individual community members which causes them to pull together as a group within the community. While there is evidence that a sense of communitas is fostered
within CFR groups, this paper also shows that the CFR role can foster a discomfiting liminality for participants – they are viewed as no longer wholly community members, but also not professionals, with the benefits that may bring. CFRs attract both gratitude and suspicion, and this very liminality brings stress for rural volunteers. The stress may be exacerbated in rural and remote areas if the introduction of CFRs is associated with withdrawal of statutory health services, due to the particularly high symbolic value that rural community members place on their traditional health services [
45]. In other words, the presence of health professionals in rural areas is linked to perceptions of community sustainability. Therefore innovations which appear to threaten this sustainability will be met with suspicion.
This is not to say that CFRs were not found to contribute to rural communitas. There was evidence that community members reported feeling safer with CFR schemes in place, and that they were grateful for volunteers’ hard work. Likewise, CFRs cited a sense of community and reciprocity as motivations for volunteering. This paper does point out, however, that the CFR role is much more complex than portrayed in policy and SAS rhetoric.
CFRs navigate the tricky and stressful threshold between being a community member who knows their fellow citizens and a health worker who may have to assist in an emergency situation. It is this blurring of a traditionally professional role that often makes community members nervous. This could change as co-production roles become more embedded and thus is worthy of ongoing research.
As highlighted here, CFR schemes are not always welcomed. The introduction of rural CFRs occurs within a context of decreasing access to established service models, which if not always unequivocally effective, were embedded and normatively understood. Additionally, some ambulance personnel were suspicious of CFR schemes, perceiving them as threatening their jobs. This situation was compounded by poor communication and misinformation and inconsistent ‘branding’ that left community members and local health professionals confused as to where CFRs ‘fit’. The well-meaning community volunteer was placed at the centre of this paradigmic change.
CFRs are lay people who can actively save lives, but this liminality also brings the discomfort for some of feeling they could or should be doing more, and for others, of fear of being required to do more. Other discomfort arose from the potential of having to assist known people at times of extreme vulnerability and from being restricted in finding out about their health after an emergency incident. Thus, the remote and rural context may have exacerbated the sense of liminality for some volunteers, in the same way that it does for rural health care professionals [
46,
47], in that it can be difficult to exist both as a ‘practitioner’ and as a community member when providing a service that includes confidentiality [
48,
44]. It is also likely, however, that the liminality of CFRs was increased by poor communication and a lack of understanding of the CFR role. In areas with more mature schemes, there did appear to be less resistance to the concept as a whole.
Some challenges for our study participants may arise from distinct dissonance with the factors of a successful CFR scheme, as highlighted by O’Meara et al. [
35]. In contrast to success factors highlighted in Australian research, several of the Scottish CFR schemes showed a lack of integration with mainstream ambulance services and variable and inconsistent resourcing.
Strengths of this study were its inclusion of CFR schemes across Scotland, and the use of mixed methods for data collection, thus allowing the voices of multiple types of stakeholders to be heard for verification of themes. The findings about inconsistent organisation and scheme type and discrepancies in communication, validate findings from an English study [
21] about a rapidly growing service area.
Limitations
A relatively small number of CFR schemes were included (n = 7) out of more than 100 schemes across Scotland. Each scheme was purposively selected to capture a variety of different geographical settings and stages of development. This selection process may have had an impact upon how fully comprehensive the results can be interpreted. Most of the CFRs in both studies had less than 3 years of experience in their role, primarily due to how newly established CFR schemes are in Scotland. CFR views and experiences of first response may change as schemes become further established.
Our studies were unable to link SAS activity data with clinical outcomes or measure the patient and carer perception of emergency care. The relationship between community resilience and uptake of co-production also requires further study.
Competing interests
The authors declare they have no competing interests.
Authors’ contributions
DH and JF designed both studies. AR and AM assisted to design the studies. AR and AN carried out the research for both studies, with ongoing support and contribution from JF and DH. All authors also contributed towards the analysis and interpretation of both the qualitative and quantitative data. AN, JF and DH also contributed towards the preparation and drafting of this manuscript, led by AR. All authors contributed fully to a final read, edit and approval of this manuscript.