The intention and practice of CFRs to attend patients in emergency conditions were an attempt to stabilise the patient’s condition and to bridge the time gap to arrival of ambulance clinicians, in line with the notion of “doing right thing at the right time” [17, 28] in the practical wisdom theory. The CFR roles and practices to respond to patients in emergencies were consistent with their broader goal and motivation of serving the community, and highlighted CFRs’ decision making as well as practical wisdom in their efforts to discover the appropriate decision in each situation. Analysis of the CFR practices revealed a series of sequential and interconnected activities, such as identifying patients’ signs, symptoms and problems; information sharing with the ambulance control who would share this with the ambulance clinicians on the patient’s condition; providing a rapid emergency response including assessment and care; and engaging with ambulance clinicians on arrival. Although these CFRs' practices, from identifying signs and symptoms to engaging with ambulance clinicians, were not the same for all cases, the most salient themes emerging from the data are presented below.

Identification of patients’ signs and symptoms

When arriving at the scene, CFRs attempted to verify information provided by the ambulance control centre by compiling and comparing it with their own observations as well as that from patients and family members, while assessing possible risks by paying attention to various signs and symptoms. Following this process of information validation, the CFRs constructed their initial impression of the patient’s condition by assessing the patient's body posture, breathing pattern, suspected bleeding, and pulse rate. They also employed a variety of instruments and diagnostic procedures to validate their assessment and the severity of the patient's condition. In addition, CFRs noted their initial impression and filled out a clinical record, the Patient Record Form (PRF), which was in electronic form in some regions.

Often the patient information received from the control room did not match with CFRs’ first-hand observations recorded, as one CFR noted:

It immensely varies on what sort of cases I attend. A lot of times things [patient information] will come through and it [control room] will say unconscious, not breathing or whatever, and I walk in the room and they're [patients] sat at the kitchen table conscious and breathing. But in some cases, patients’ conditions are severe than what they [control room] said. (WMAS_CFR_300921)

The quote above illustrates the discrepancy between what CFRs were briefed in relation to the patients’ condition and what they encountered on scene. Hence, CFRs were unable to rely on the preliminary information and often needed to assess a patient’s condition on arrival. In most instances CFRs expressed this mismatch in information provided that assessed the condition as being serious, and prompted them to inform the ambulance control about the actual patient condition. This information was also shared with the ambulance clinicians en route to alert them to the actual situation or patient condition, discussed in the next section.

Information sharing

An explicit information structure was apparent, and reflected in the process of information gathering and sharing by CFRs. Information sharing practices required time and effort during a critical period for the patient, with information imparted through informal telephone conversations or formal documentation. The formal approaches were automated and standardised in some regions where the CFRs were required to use an electronic patient record form (e-PRF). CFRs documented the patient’s condition and key measurements on the e-PRF which was often automatically electronically shared with the ambulance crew and the ambulance service control room. Elsewhere, paper-based PRFs were used to document and share information with the ambulance crew while performing handover, as demonstrated in the following excerpt:

Most of us have paper PRFs, whereas the [anonymised-ambulance service] CFRs have tablets. So when we are on-scene, observing blood pressure, temperature, respiration rates, oxygen saturation, we document them on our paper PRF, and hand that over to ambulance crew when they arrive. (SCAS_CFR_181021)

We found the information-sharing practices of CFRs emphasised a collaborative relationship between ambulance services and CFRs. Timely information-sharing practices were performed as a critical step in providing care. CFRs were the first contact point between the patients and emergency care providers within the community, and precise information gathered was seen as important for the patient care process. These information-sharing practices helped ambulance staff to anticipate and recognise the severity of the patient illness or signs of patient deterioration and enabled them to plan their care strategies and triage treatment decision-making. These early assessment and care strategies were also helpful in minimising the time for appropriate medical intervention.

Once we reach, we do a proper assessment and take observations, patient history. if they [patient] are sick enough, we get back in touch with the desk [control room], and tell them the severity of the patient, we need help quicker, when is help coming? We also ring up to the clinical team if we need more help and support from what we have found. (EMAS_CFR_210921)

Similarly an ambulance clinician noted:

When we respond to emergency calls, generally we see a CFR already on scene and have started patient assessment and sometimes treatment too. We listen to what they have to say first before handover. (SECAMB_Ambulance _111021)

The above excerpt emphasises the significance of CFRs’ practices of information-sharing with the ambulance control as well as the ambulance clinicians. These practices also aligned with the concept of practice wisdom [18], which refers practitioners to do the “right thing at the right time” (p03). The embeddedness of practice wisdom was exemplified in the CFRs’ practices of expediting ambulance arrival on-scene when the intensity of the patient condition required this, particularly in rural areas with poor roadways.

They do. If they have valuable information to give us, this is what's going on, this is the location you need to go to. (SECAMB_Ambulance_111021)

The information sharing practices of the CFRs were valued by the ambulance clinicians in optimising the pathways of providing medical care to patients in emergencies: “Some crews really value the input of the CFR and the information… So communication is really good and important.” (YAS_CFR_ 180,721)

Information gathering and sharing were crucial and led to the decision-making for delivering appropriate and timely emergency care within the communities, which we will discuss in the next section.

Rapid emergency response

Rapid emergency response practices followed and were informed by the information sharing step. Emergency responses provided by CFRs were dependent on the patient’s condition and their scope of practice. CFRs often attended patients with breathing difficulties, chest pain, acute coronary syndrome, stroke, epilepsy, cardiac arrest, burns, trauma, asthma, diabetes, unconsciousness, and falls. The most commonly reported forms of rapid emergency responses included: oxygen administration; defibrillation; clearing airways obstruction; cardiopulmonary resuscitation (CPR); and lifting older patients who had fallen.

For example, the process of oxygen administration was informed through oxygen saturation measurement, which CFRs conducted in the identification of signs and symptoms step. CFRs attending patients with lethargy or restlessness or difficulties in breathing, on measuring oxygen saturations identified the requirement for immediate oxygen administration, which they were equipped with and which was within their scope of practice.

If there's anything we can do for them in terms of what we carry, we do the best possible. for example if somebody has got difficulty breathing, and need oxygen or salbutamol, then we administer the oxygen and give them salbutamol. (SECAMB_CFR_ 111,021)

A patient noted:

I’ve never really thought is it something that happens before an ambulance. But a CFR came last time, administered oxygen and that was a quick relief. (YAS_Patients_120521)

Patients with cardiac disorders were another frequent category of patients attended by CFRs. CFRs performed CPR and defibrillation and responded to patients with heart failure, acute coronary syndrome and myocardial infarction by assessing their condition. In a range of instances, these rapid measures were crucial for stabilising the patients’ condition in the community, while waiting for the ambulance. Although CFRs performed CPR and defibrillation, they expected the ambulance to arrive quickly considering the patient’s condition, which was often critical or deteriorating, in the face of CFRs’ more limited skills, resources and scope of practice.

It depends on what it is really. If it is a cardiac arrest, then we will just start CPR and defibrillation immediately, and we will get on with that and when they [ambulance crew] turn up, they will take over. If we suspected it was a heart attack, there's nothing we can do. We don't have anything that will stop that happening, but what we can do is keep them calm, put them in a good position and do some observations. If it's a stroke, there's nothing we can do to make any difference, except again to keep them calm and do observations, monitor it and report back to the desk if things are deteriorating; which we do. (EMAS_CFR_270921)

In contrast, the CFR response was more limited in cases where the interventions required were beyond the scope of CFR practice, and where CFRs were obliged to follow the guidelines set out by the ambulance service which they were affiliated to. Our findings suggest the types of patients which CFRs were less likely to attend were maternity cases (particularly during labour), road traffic collisions, fire emergencies, patients with mental health disorders, and children. The practice of not delivering an emergency response in such cases was aligned with the practical wisdom of waiting for additional support before making harsh or difficult decisions. These CFR practices were important for patient safety and to ensure legitimate boundaries of practice for CFRs.

We basically just be there to monitor the patient until the crew comes; once they arrive we handover the observation, help the crew if they need, else we leave if they don’t need us. (SECAMB_CFR_111021)

In summary, emergency response practices of CFRs contributed to the overall purpose of stabilising the patients’ condition before the arrival of the ambulance. In addition to these technical contributions, the CFRs frequently interacted with patients and their family in order to (re)assure them that clinical attention was on its way. Skills in patient communication were not substantially a part of their training and these skills were personal to individual CFRs. The CFRs’ communication comprised patient information in connection with their current state, information about early interventions they could provide and maintaining optimism in relation to treatments and outcomes.

I think communication with people is the biggest part of our role. It's like a swan, all nice and serene on top, and paddling like hell underneath. Sometimes you can’t do a lot but you have to reassure them [patients and relatives]. The biggest skills is communication. I say this to any new CFRs. there are two sides that you have to develop as a CFR, one is the communication side, and the others. (EMAS_CFR_200921)

The above excerpt suggests that the rapid emergency response of CFRs included not only technical measures but also a substantial communication component, which was linked with the broader principle of CFR schemes stabilising patients in the community before EMS arrival.

The decision-making in relation to the emergency response was made by CFRs in line with the availability of on-scene treatment or services. The decision making was dependent on the type of case, context and speed or timing of arrival. For example, in instances when CFRs and ambulance arrived together, CFRs were less likely to conduct assessments and ambulance clinicians eventually took over care.

Engagement with ambulance clinicians

Before the ambulance arrived, CFRs delivered patient care as noted above in the rapid emergency response section, and then handed over to ambulance clinicians, followed by completing a structured PRF, either on paper or digital format. CFRs recognised the arrival of ambulance clinicians and handover as final part of their direct role in patient care and approached the ambulance clinicians to support them in any measures required to facilitate patient transfer. Often ambulance clinicians sought assistance from the CFRs in the patient transfer, however, in some instances, CFRs were asked to leave.

I was staying and help and because I am on duty. Sometimes I help them to take the stretcher out, prepare other ambulance process to load the patient. They [ambulance crew] also appreciate it. (YAS_CFR _180721)

The engagement of CFRs with the ambulance crews comprised of several activities, including preparing the ambulance to carry the patient, repositioning the ambulance vehicle, and using a riser for falls patients.

They [ambulance crew] say – Here’s the keys can you go and put down the rear doors. Here are the keys, can you drive further up or reverse in. (EMAS_CFR _130921)

A couple of times in the past I've been asked to be a third man on the back of an ambulance to help transporting patients to hospital. (WMAS_CFR _290721)

I attended a cardiac arrest patient. A CFR was already there, doing CPR and giving oxygen. That was a busy day, and no other ambulance and support available. So we used CFR as our second resource, and it turned out to work. The patient was in bad shape, and the CFR knew what to do. (WMAS_Ambulance_070921)

The above excerpts illustrate how CFRs engaged and supported the ambulance crews within the community. Often, these CFR practices exceeded their obligations, as the CFR policies usually limited the responsibilities of CFRs. The embeddedness of practice wisdom by doing the right thing at the right time was evident in the CFRs’ engagement with ambulance clinicians by moving beyond the policy obligations of CFRs. CFRs’ engagement facilitated crews’ efforts lifting and transferring patients to the ambulance, enhancing conveyance to hospital, timely intervention and patient survival.