Home healthcare nurses’ experiences of being on stand by as a first responder in a ‘While Waiting For the Ambulance’ assignment

Abstract

The aim of the study is to describe experiences of the ‘While Waiting for the Ambulance’ (WWFA) assignment, as described by home healthcare nurses (HHCNs). Since the early 1990s, municipal resources in Sweden, preferably firefighters, have been dispatched on WWFA. In order to further assist the local residents on an island in the southwest of Sweden, HHCNs have recently begun accompanying firefighters on WWFA. A reflective lifeworld approach was used for data analysis including in-depth interviews with eight HHCNs. When WWFA was established, the HHCNs experienced lack of clarity in where their responsibilities start and end. A split role is described, and there is a paradox in that the responders are meant to collaborate toward saving lives, when the assignment itself has a lack of collaborative structure. Ethical dilemmas and inner emotional worries led to the nurses expressing a need for support before, during and after WWFA.

Introduction

Research indicates the importance of aggregated community resources that can perform lifesaving actions.^1–3 With ambulance stations located in urban areas, there are long response times for ambulance personnel to reach acutely ill or injured patients who live in rural areas. ⁴ In situations where the ambulance response is expected to take considerable time, other actors can guarantee an early presence.^1,5 Since the early 1990s, municipal resource personnel (preferably firefighters) in Sweden have been dispatched on ‘While Waiting for Ambulance’ (WWFA) at times when the ambulance arrival time is expected to exceed the time period described in the quality targets for each ambulance organization. ⁶ At present, 266 out of 290 municipalities in Sweden dispatch WWFA personnel. ⁴ The probability of a firefighter arriving first to the person seeking help is high, seeing as there are about 700 fire stations that are staffed by full-time or part-time personnel or a combination of the two personnel categories ⁷ as opposed to about 271 ambulance stations. ⁸ During WWFA, the municipal resource personnel, equipped with a defibrillator and oxygen, should administer first aid and provide the care needed until an ambulance arrives. ⁹ Furthermore, distinct benefits of equipping community resource personnel with defibrillators and alerting them to cardiac arrest alarms have been noted both from a lifesaving perspective,^1,5,10 where time is a factor ¹¹ and from an economic perspective. ¹² However, Pons and Markovchick argue that there are more factors than the time it takes for the ambulance to arrive that affect survival in emergency situations. ¹³ Patients experience the benefits of early responder presence not only in regards to the emergency treatment they receive but also because of the important human presence and existential support. ¹⁴ The personnel who arrive first at the scene of a severely ill or injured person describe feelings of inadequacy and helplessness, despite adequate emergency care knowledge. This has been particularly clear in situations where they are alone at the scene while awaiting reinforcement.^15–18 Individual municipalities have recently decided to use home healthcare nurses (HHCNs) to conduct WWFA. In Sweden, an HHCN is defined as a registered nurse whose job is to provide home healthcare around the clock in patient residences. ¹⁹ In recent decades, home healthcare has gone through major changes, resulting in more care-intensive patients with complex medical conditions being treated in their own homes.^19–21 This has caused high workload for HHCNs, and nurses feel unable to complete their tasks. ²² Moreover, HHCNs’ experiences of joining WWFA have not yet been studied. The aim of the present study is thus to describe experiences of the ‘While Waiting for the Ambulance’ assignment, as experienced by home healthcare nurses.

Method

This study followed a descriptive design and was carried out with a reflective lifeworld research (RLR) approach, with the goal to search for and describe the essential meaning structures of the phenomenon, which in this study was HHCNs’ experiences of the new WWFA assignment. ²³

Context and implementation

The municipality for the study consists of 10 islands located outside the coast in southwestern Sweden. The islands have about 12,500 residents. Transportation to the mainland is by ferry. The municipality provides home healthcare through HHCNs who work around the clock in patient residences. In cases of emergency there is an ambulance stationed on the main island, with personnel who also manage an ambulance boat for transportation between islands that are not connected by bridges. On occasions where the ambulance is occupied, an ambulance or ambulance helicopter from the mainland is requested. Furthermore, since 2002 the local fire department has been alerted on WWFA. Since May 2013, municipality HHCNs have been accompanying firefighters in order to further assist local residents with skilled caretaking during WWFA. In preparation for this implementation, HHCNs received CPR training for adults and children as well as ABC training held by ambulance personnel Additionally, they met with the firefighters before the start of the new arrangement and they were invitedto accompany the ambulance for one or two days. Information about dispatching criteria and information about new pharmaceuticals to be given on WWFA assignments was provided by a physician. The nurses were given responsibility for WWFA medical care. WWFA were initiated on priority 1 alarms (alarms that are defined as acute life-threatening by the dispatch center) where HHCNs together with the firefighters were expected to arrive at the patient’s side before the ambulance. The nurses received the assignments via pagers and text messages on their cell phones. In the event of an assignment, the nurses were to first contact the firefighters by cell phone to decide on an appropriate place to meet. The nurses should, during day time, aside from their regular duties as HHCNs, accompany the firefighters on WWFA on the four islands connected by bridges. When on WWFA, the nurses were required to be dressed in the same kind of green uniform as the ambulance personnel. Upon arrival to the patient, the two WWFA units, consisting of the firefighters and the HHCN, where supposed to work together.

HHCNs

All employed HHCNs (N = 20) in the municipality were female registered nurses. The nurses received both oral and written information about the study from their unit manager. Participation was voluntary and the nurses gave their permission through written consent. All HHCNs were assured of confidentiality and that they could at any time withdraw their participation without giving a cause and without any repercussions. Those who wanted to participate in the study reported their interest to the first author who then, in consultation with the nurses, decided a time and place for interviews (n = 8). The HHCNs had an age range of 30–63 years and varying professional experience ranging between 5.5 and 32 years and with 3.5 to 16 years in home healthcare.

Ethical considerations

The study followed the principles outlined in the Declaration of Helsinki. ²⁴ An ethical committee approval was obtained from the Ethical Advisory Board in South East Sweden (dnr. EPK 249–2014).

Interviews

Data were collected by the first author in the form of interviews of eight HHCNs. At the time of the interviews, October to November 2013, the WWFA assignment had been running for five months. Initially, a pilot interview was conducted which, after consideration, was included in the study. The interviews were unstructured and open-ended ²³ and started with an open-ended question: ‘Would you like to describe your experiences of the new WWFA assignment?’ Depending on how the HHCNs answered, follow-up questions were asked in order to gain a deeper understanding of each HHCN’s lived experiences of the phenomenon. Examples of follow-up questions were: ‘How did you experience this?’ ‘Can you give me an example?’ ‘Could you tell me more about this?’ The interviews were conducted at the nurses’ workplace outside of working hours. All interviews were carried out without interruption and lasted between 40 and 57 minutes. If questions arose after the interview, the nurses were asked to contact the first author. The interviews were recorded and transcribed verbatim and anonymized before the analysis process began.

Data analysis

The data were analyzed in order to understand the meaning of the phenomenon, entitled: HHCNs’ experiences of the new WWFA assignment. The analysis process entailed a flexible movement between the whole to the parts and back to the whole again. ²³ The analysis began with repeated readings of all the interviews to gain an understanding of the material as a whole. Each interview searched for meanings of the phenomenon, and the text was divided into so-called meaning units. All meaning units were related to the phenomenon and in them the meaning of the phenomenon was sought. For example, a nurse said: ‘It is nothing I do in my ordinary work task. I have no experience of it, so it is a nightmare scenario’. Another nurse expressed: ‘I hardly ever am in touch with children. I have no knowledge of how to take care of them’. The meaning of the statements was that their inexperience of the situation scared them. With the phenomenon in focus the next step was to bring together meaning units to form clusters based on similarities and differences of the meanings. During this process it was important to keep an open attitude towards the phenomenon and to seek complete and careful descriptions of both the figure and background of the phenomenon. Meanings that are more or less hidden can be detected by taking up one cluster with its explicit meaning and watching it as a figure against the others as background and vice versa. ²⁵ For example, it became clear that the phenomenon was not only linked to the fact that the inexperience of dealing with emergency situations would be the barrier for the HHCNs to conduct WWFA. Against this background the analyses also showed that it could be attributed to clusters with its meanings of a too advanced preparatory training, the risk of knowing the patient as well as visualizing nightmare scenarios of what they thought they would encounter during WWFA. The clusters could, through this dynamic work between figure and background, be understood in relation to each other, which concludes in an description of the essence. ²⁵ In order to formulate the essence of the phenomenon, patterns of meanings were searched for, by seeking how the clusters were related to each other. Clusters, meanings and interviews were reread several times and the following question was asked: ‘How do the HHCNs’ experience the WWFA assignment?’ The essence emerged in this movement back and forth between the parts and the whole. ²⁵ Initially the result is presented with the more essential meaning, followed by the phenomenon’s constituents which provide more contextual nuances of the phenomenon. The constituents are further clarified with quotations from the interviews.

Results

To work with the new WWFA assignment involves bringing together different contexts, for example when HHCNs work side by side with firefighters, wearing uniforms identical to those of ambulance personnel. Boundaries of where HHCN responsibilities begin and end are in one way distinct and in another way unclear. Role confusion appears and expectations are difficult to fulfill. There is a paradox in that the responders are meant to collaborate toward saving lives when the assignment itself has a lack of collaborative structure. Ambivalence emerges – to want and not to want – with inner feelings of having no choices. In one way, to combine current work situations with WWFA requirements of being on stand by and having to drop present duties at any time. In another way, feeling redundant when arriving late at an emergency scene because dispatch is often delayed. Ethical dilemmas arise in daily work with feelings of being exposed and vulnerable where inner emotional worries calls for support before, during and after a WWFA assignment.

Indistinct boundaries

During the implementation of the new WWFA assignment the nurses experienced indistinct boundaries for the assignment. A forced start for WWFA with vague information reflects that the nurses experienced a lack of proper conditions for carrying it out. Despite the fact that the nurses experienced themselves as being a homogeneous group, a general mistrust occurred both within the group and towards the management:

It took a lot of energy at the beginning, of the whole group. We discussed and were upset, it was really tough, because we had too little information // It arousedconflicts in the group.

The nurses felt that they were met with irritation when they asked for clarity and they experienced a lack of continuity in project management. The lack of clarity made the WWFA feel like a forced assignment which led some HHCNs to consider changing jobs.

The nurses also experienced indistinct boundaries as to where their responsibilities began and ended. Predefined dispatch criteria often do not match information on text messages, and the nurses felt uncertain about whether the assignments applied to them or not. In the worst case this led to an assignment being disregarded. In the case of an assignment the nurses are supposed to consult the firefighters. Paradoxically, the firefighters do not always know that nurses are meant to come along on WWFA, and therefore question why they are calling:

At times when I feel unsure if the assignment applies to me I call them [firefighters] and ask whether I should come or not // well you know … like … ‘why are you calling?’ They haven’t been unfriendly by any means but they haven’t understood why I am calling.

HHCNs felt redundant since they received dispatching too late and therefore sometimes arrived at the scene after the ambulance or the ambulance helicopter. A feeling of uncertainty arises when they do not get any experience of WWFA. This makes them doubt the advantage of both their own work effort as well as the overall WWFA assignment.

Combining different contexts

When performing the new WWFA assignment, the nurses experienced ambivalence towards bringing together two such different contexts as those of home healthcare and emergency care. On one hand, the nurses described that they had chosen to work with home healthcare because they were not interested in conducting emergency treatment and that they do not work with emergency treatment. On the other hand, they felt capable of dealing with emergency situations in their daily work. However, they felt that home healthcare is not compatible with WWFA when they are forced to quickly leave a patient in their residence:

Of course it’s a lower priority to dress a wound compared to taking care of an unconscious person. But when you’ve just removed a bandage … It could be fistulas and it can become contaminated … It might not sound so serious in other people’s ears, but it actually is.

The nurses felt that they lack resources to combine WWFA, with their current high workload:

Every day I go to work I hope that there won’t be any WWFA assignments. I don’t have any room for it in my schedule. I have my meetings, I go to my house calls and I meet my terminally ill patients. My day is full as it is.

Nonetheless, the WWFA are being performed thanks to high work moral among the HHCNs.

Ambivalence is also experienced when the HHCNs have to wear the same green clothes as the ambulance personnel on days when their home health care work combines with WWFA. The green clothes do not match the home healthcare context where a home-like environment is sought. The green clothes signal that they do not have time for their patients:

I want them to feel that I’m there for them. When I come in my green clothes it’s like announcing, ‘Agda I’m here now but I can leave at any second’.

The green clothes also led to an incorrect impression of what their function is when they are out on a WWFA, with too high demands and expectations placed on them:

It’s like you are ambulance personnel when you arrive at the scene in those clothes. Everyone at the scene believed that the ambulance had arrived. It didn’t felt right in the situation.

On the scene, the HHCNs would rather have outfits corresponding to those of the firefighters. This would lower the expectations on them and also make them feel a part of the team.

Inner emotional worries

The nurses experienced ethical dilemmas with inner emotional worries when they were forced to prioritize between home healthcare and the new WWFA assignment. The worry becomes obvious in ordinary patient meetings when uncertainty as to whether or not WWFA will occur, disrupts patient meetings and make nurses wonder if they will have time for scheduled tasks:

At the same time, it disrupts a lot, if you sit with the relatives, and an assignment goes off it disrupts the whole meeting, the meeting stops for me to see what the assignment is about, turn it off, then call the firefighters, and then the whole meeting is ruined already.

To be forced to prioritize between ‘one’s own’ patients and the WWFA patients, while at the same time worrying about letting down a waiting patient, gives rise to feelings of guilt and fear of making the wrong decisions. The fear is of being questioned for prioritizing a WWFA patient, and nurses felt it is due to a lack of guidelines on how to prioritize between a patient within home health care and WWFA:

If there were an accident and I was not there … Why did you do like that? … Why did you make that decision and why not like this instead?

The fear is also connected to being solely accountable for making difficult medical decisions:

You are there alone so to speak. I have the firefighters with me, but I have no colleagues and hence I am alone in making all (medical) decisions.

Inner emotional worries also arose through HHCNs’ fear of not knowing what is expected of them on WWFA and the feeling of being inadequate. The training that is offered is experienced as being too advanced, and not compatible with WWFA. The nurses visualize nightmare scenarios of what they might encounter during WWFA. Many times it is about being the first to arrive at an accident where a child has been injured or killed. To live on an island and likely be personally acquainted with patients can be stressful. Within the home healthcare setting it is favorable to know the home healthcare patients and have an overview of their illnesses. However, during WWFA, HHCNs feel anxious about the responsibility for saving the lives of severely ill or injured patients they might know personally:

The body says: ‘Don’t go! Just call and say that you won’t come. Stay here. Don’t do it. Respiratory arrest, you don’t want to see it. Oh, that’s bad. What if it is someone you know?’ All that. At the same time I know that it is just an emotional reaction. I have to go there to help and save lives. It is such a huge conflict inside; it feels as if two people are pulling me in opposite directions.

When the desire to help conflicts with a fear of being unable to accomplish WWFA, the inner emotional worry is significant.

Support requires support

Support requires support when carrying out the new WWFA assignment. The nurses support patients and relatives during WWFA, and their medical competence complements and supports the knowledge of the firefighters:

When I think about it in hindsight, at least I stopped certain things. Maybe they [the firefighters] didn’t feel safer at all. But at least I had circulation under control, so that they [the firefighters] did not start something that was unnecessary.

Furthermore, they feel support from the firefighters during WWFA and from their own nurse colleagues after a WWFA. However, in order to support other people during WWFA, the nurses feel the need for additional support in order to feel secure in their professional roles and to avoid inner emotional worries.

The support is needed before, during and after a WWFA assignment. The nurses requested clearer organizational support with predefined dispatch criteria, patient prioritization and medical decision making, as well as the nurse being exempt from providing home healthcare when they are on WWFA. The importance of effective training and clear information about WWFA expectations from the start was deemed critical, as well as follow-up training and team training. HHCNs would like more unity with ambulance personnel at the scene, with more place for receiving feedback or for briefing together with the involved professionals after the incidents:

Then the ambulance came to pick him up. They showed no interest in our reports when we told them what had happened. They just brought him into the ambulance and left. I felt very disappointed. I would have loved to join them and hear what was said, what they concluded and how the others [firefighters] reacted? They are the ones we are supposed to work with, the firefighters. How do they experience this situation?

Discussion

Method

In the present study an RLR approach was used in order to describe HHCNs’ experiences of the new WWFA assignment. As the research group had experience within prehospital care they were required to reflect on how to bridle, i.e. adopt a self-critical attitude towards their pre-understanding during the analysis without compromising the demand for openness. This was done in order to not let the results be influenced by predetermined opinions or expectations. In order to retain openness and allow the invisible to become visible, it was important that the research process was characterized by a reflective process. During the analysis it was important to be open towards the data as they presented themselves by bridling the (pre-) understanding so that the text could present itself in all its otherness. ²⁶ By using an RLR approach where there are no predetermined questions, except for the initial question about experiences of the new WWFA assignment, the nurses were given an opportunity to openly describe their experiences of the phenomenon. The sample of informants showed a diversity of age and years of professional experience as a nurse as well as within home healthcare. By letting one person (the first author) conduct all interviews and then transcribe the interviews soon after the interviews took place, the risk of misunderstanding was reduced and a high level of accuracy and security was ensured. The analysis was conducted in cooperation with the last-named author, in order to strengthen the credibility and conformability of the study. This was further strengthened in the results section through quotations from the interviews. The results deepened the understanding of the HHCNs’ experiences of the new WWFA assignment and could also have a bearing on other areas in order to implement change in WWFA unseen occupational work conditions, particularly within similar contexts in Sweden.

Results

Different contexts were combined when WWFA was implemented on an island setting. The HHCNs in this study experienced a lack of clarity of where their responsibilities start and end. The HHCNs conducted WWFA together with firefighters while wearing clothes identical to the ambulance personnel. A split role was described, and inner emotional worries arose among the nurses, which could be limited by increased support before, during and after WWFA.

Due to heightened demands,^19–21 the HHCNs felt inadequately equipped to accomplish their tasks. ²² The Swedish National Board of Health and Welfare ¹⁹ points out that the workload for nurses within home healthcare is so high that high-quality care taking and patient safety are being jeopardized. However, a common issue within home healthcare is that nurses’ experiences of the workload do not correspond with the managerial view.^20,22,27 Our results point towards an ambivalence due to the complexity of bringing different contexts together. The current WWFA assignment does not provide nurses with the preconditions for performing both ordinary HHCN working routines and the new WWFA assignment in a satisfactory way. As the nurses experienced the implementations to be unclear and no additional resources such as time, personnel or monetary compensation were added, a general mistrust towards the new WWFA assignment arose. Salmela et al. point out the importance of a clear and open dialogue between managers and co-workers during organizational changes within the field of healthcare. ²⁸ An inefficient information flow between managers and co-workers during organizational changes can lead to conflict. This can often be explained by managers not communicating visions clearly enough about how change will proceed, ²⁹ which subsequently makes it impossible for co-workers to feel in control and understand the impeding change. ³⁰ Similar results can be seen in this study, where nurses experienced lack of communication and involvement during the implementation of the new WWFA assignment in their operational unit.

Furthermore, this study illustrates that having to choose or prioritize between home healthcare and WWFA patients leads to ethical dilemmas and inner emotional worries. No matter which patient is chosen, the nurses had feelings of guilt when having to prioritize or let down a waiting patient, either the home healthcare patient or the WWFA patient. Previous research describes constant feelings of guilt among the HHCNs, and the quality of the encounter with each patient suffers due to the nurses’ high workload.^22,27 Often, feelings of guilt arise from the experience of not being able to provide the care needed.^31,32 Home healthcare patients describe their expectations that nurses arrive on time for appointments. Patients become irritated when appointments are interrupted by phone calls from colleagues or other patients.^33,34 Since dispatching criteria were experienced as unclear by the nurses, misunderstandings of whether or not the assignment required their involvement occurred. The current dispatch criteria were neither formulated in an easily understandable way, nor were the nurses involved in formulating them. In order to follow clinical guidelines, in this case dispatch criteria, these must be easily understood and clearly formulated. Thereby increasing the likelihood that they will be used. ³⁵

Despite their experience with handling acute situations in their daily work, the nurses in this study expressed a lack of experience of performing emergency care. Stress and worry caused by being responsible for performing emergency care outside a hospital setting have been widely studied. This kind of stress and worry arises independent of the level of education or professional experience of the personnel^{16,18,36–38} and increases when personnel are exposed to situations that can be associated with their own living situations or when children are involved.^16,39 In this study, the HHCNs also experienced that their inner emotional worries increased when they were concerned that their own medical knowledge would not be sufficient in the WWFA scenes that they encountered. This led some HHCNs to consider changing jobs. Earlier research shows that feelings of being exposed to situations outside their own area of competence causes moral stress, ⁴⁰ which in turn can lead to nurses considering changing jobs. ⁴¹

Moreover, many factors can make HHCNs feel excluded from being part of a team with the firefighters when conducting WWFA. After a WWFA they are not given the chance to debrief together with the firefighters, and they expressed a need for joint exercises, which are considered crucial in this type of collaborative activity. ⁴² Instead, they have to return to their original assignments within home healthcare, feeling left alone with their thoughts without the possibility of discussing them with involved firefighters. In situations where different professionals have collaborated at the scene of a severe accident, the need for inter-professional briefings is often expressed.^15,43 Persons who take care of patients and who have been exposed to traumatic events, can over time, suffer from secondary traumatic stress.^44,45 In order to cope with these working conditions, personalized solutions are needed where the nurses are given the opportunity to debrief their experiences of stressful situations. ¹⁶ The importance of dialogue and interaction after severe situations has been thoroughly studied^16,18,36,46 and research points towards the importance of being offered both peer support ⁴⁷ and group supervision ⁴⁸ in order to influence negative thoughts connected to severe incidents. However, our study shows that the nurses experienced through the assignment that they could give support to patients and relatives, which corresponds with the benefits of early responder presence including emergency treatment as well as existential support. ¹⁴ The HHCNs experienced that their medical competence complements and supports the knowledge of the firefighters. How firefighters experience this collaborative assignment has been slightly researched. ⁴⁹

Conclusions and implications

It is important that different community resources cooperate to organize and perform WWFA, first and foremost to save more lives by early presence and also to provide injured or ill patients with their need for early human presence. However, when WWFA was implemented as a new assignment for HHCNs, different contexts were put together without additional resources, and feelings of ambivalence arose among the nurses. Ethical dilemmas and inner emotional worries resulted in nurses expressing a need for support before, during and after a WWFA assignment. It is essential to highlight that the implementation of WWFA in municipal-operated organizations requires a clear implementation process where all stakeholders are involved, both in the preparation and in the design of the process. Most important is the ability to determine when one can justifiably leave current work duties as an HHCN in favor of an early presence at the scene. Furthermore, successful implementation requires a clearly-formulated assignment description in relation to other professions (firefighters and ambulance personnel) at the scene. The description must provide clarity in dispatching criteria, an appropriate preparatory education in relation to clinical guidelines, and clothes appropriate for the assignment. It is also of great importance that the HHCNs are offered peer support as well as group supervision after WWFA. It would be interesting to do a follow-up study when the project has been running for a longer time. Moreover, to continue to successfully implement the WWFA function there is a need for further research about experiences of first response in emergency situations from different professional perspectives.