Caring science research in the ambulance services : an integrative systematic review.

(1)

integrative systematic review

Birgitta Wireklint Sundstr€om

RNAN, PhD (Professor)

1,2

_,

_{Anders Bremer}

_{RNPEN, PhD (Associate}

Professor)

1,2,3,4

,

Veronica Lindstr€om

CCRN, PhD (Associate Professor)

5,6

and

Veronica

Vicente

RNPEN, PhD (Medicine Doctor)

6,7,8

1

_PreHospen

_{– Centre for Prehospital Research, University of Boras, Boras, Sweden,}

2

_{Faculty of Caring Science, Work Life and Social}

Welfare, University of Bor

as, Boras, Sweden,

3

Faculty of Health and Life Sciences, Linnaeus University, V

€axj€o, Sweden,

4

Division of

Emergency Medical Services, Kalmar County Hospital, Kalmar, Sweden,

5

Division of Nursing, Department of Neurobiology, Care Sciences

and Society, Karolinska Institutet, Huddinge, Sweden,

6

Academic EMS, Stockholm, Sweden,

7

The Ambulance Medical Service in

Stockholm (AISAB), Stockholm, Sweden and

8

Department of Clinical Science and Education, Karolinska Institutet, S€odersjukhuset,

Stockholm, Sweden

Scand J Caring Sci; 2018

Caring science research in the ambulance services: an

integrative systematic review

Background: The ambulance services are associated with

emergency medicine, traumatology and disaster medicine,

which is also reflected in previous research. Caring science

research is limited and, since no systematic reviews have

yet been produced, its focus is unclear. This makes it

diffi-cult for researchers to identify current knowledge gaps

and clinicians to implement research findings.

Aim: This integrative systematic review aims to describe

caring science research content and scope in the

ambu-lance services.

Data

sources: Databases

included

were

MEDLINE

(PubMed), CINAHL, Web of Science, ProQDiss, LibrisDiss

and The Cochrane Library. The electronic search strategy

was carried out between March and April 2015. The

review was conducted in line with the standards of the

PRISMA statement, registration number: PROSPERO

2016:CRD42016034156.

Review methods: The review process involved problem

identification, literature search, data evaluation, data

analysis and reporting. Thematic data analysis was

under-taken using a five-stage method. Studies included were

evaluated with methodological and/or theoretical rigour

on a 3-level scale, and data relevance was evaluated on a

2-level scale.

Results: After the screening process, a total of 78 studies

were included. The majority of these were conducted in

Sweden (n

= 42), fourteen in the United States and

ele-ven in the United Kingdom. The number of study

partici-pants varied, from a case study with one participant to a

survey with 2420 participants, and 28 (36%) of the

stud-ies were directly related to patients. The findings were

identified under the themes: Caregiving in unpredictable

situations; Independent and shared decision-making;

Public environment and patient safety; Life-changing

sit-uations; and Ethics and values.

Conclusion: Caring

science

research

with

an

explicit

patient perspective is limited. Areas of particular interest

for future research are the impact of unpredictable

encounters on openness and sensitivity in the

profes-sional

–patient relation, with special focus on value

con-flicts in emergency situations.

Keywords: ambulance,

caring

science,

emergency

medical services, holistic approach, prehospital, patient

perspective, review, systematic.

Submitted 2 March 2018, Accepted 4 July 2018

Background

Prehospital emergency care is mainly provided by the

ambu-lance services as part of the Emergency Medical Services

(EMS) (1). While EMS systems are based on the same

principles in the delivery of emergency care for patients with

trauma and life-threatening illnesses, the systems differ

when it comes to care in non-life-threatening situations (2).

Generally, health care provided by ambulance

profes-sionals is often associated with emergency medicine,

traumatology and disaster medicine. This focus on

emer-gency, trauma and disaster is also reflected in previous

research, leaving a rather scant volume of research in

other areas such as caring science where the patients’

perspective on health care is taken into consideration (3).

Correspondence to:

Birgitta Wireklint Sundstr€om, Faculty of Caring Science, Work Life

and Social Welfare, University of Bor

as, SE-501 90 Boras, Sweden.

E-mail: birgitta.wireklint.sundstrom@hb.se

1 © 2018 The Authors.

(2)

in addition to paramedics, emergency medical technicians

(EMTs) and physicians. RNs’ entry into the context of

prehospital emergency care is in response to the need for

two valued and different but not contradictory sciences,

that is professional-based nursing science and

transdisci-plinary caring science that includes more than nursing

practice.

Nursing science focuses on the human-universe-health

pro-cess articulated in nursing frameworks and theories (4: 51).

This discipline-specific knowledge is focused on the

development and use of knowledge including nursing’s

unique phenomenon of concern. Caring science has been

developed as a human science based on existential

phi-losophy reviewing the spiritual basis of caregiving, in

which caring is the moral ideal of nursing (5). The five

core attributes of caring are relationship, action, attitude,

accep-tance, and variability (6: 641). In the Nordic tradition,

car-ing science is based on the patient perspective where the

patient’s world, vulnerability, health and suffering are primary

in the art and act of caring (7: 288). Lifeworld-led caring is

one theory in the Nordic tradition, developed from a

phenomenological lifeworld perspective (8).

Theoretical framework and the study aim

Caring science is an autonomous knowledge discipline

based on an ethical patient perspective with the research

interest directed at patients, spouses and families and

healthcare professionals. The aim was to understand

what good care is and how it can be achieved. Caring

science is characterised by a holistic approach to the

patient, thus also considering the existential dimension.

The research contributes to understanding of health,

environment,

suffering,

well-being

and

caring.

The

research results are the basis for the development of

the-ory of health and caring, which is applied in the patient

care process (7, 9).

When it comes to caring science research in the

pre-hospital emergency care context, there are no systematic

reviews that provide perspicuous knowledge on previous

research. Therefore, the aim of this integrative systematic

review has been to describe content and scope in caring

science research in the ambulance services.

Methods

An integrative systematic literature review method was

used that included studies with diverse methodologies,

with a process involving problem identification, literature

search, data evaluation, data analysis and reporting (10).

The review was conducted and reported in line with the

standards of the PRISMA statement (Preferred Reporting

Items for Systematic Reviews and Meta-Analyses) (11).

Ethical issues

Good ethical practice in preparing and publishing

system-atic reviews was applied, which means that the authors

have been aiming for transparency, accuracy and

avoid-ance of plagiarism (18). By following the PRISMA

state-ment and registration in PROSPERO, the authors avoided

redundant (duplicate) publications. Thus, this review

builds on a protocol consisting of a 17-item checklist that

describes the rationale and planned methods of the

review.

Literature search strategy

The literature search was carried out between March and

April

2015.

Databases

included

were

MEDLINE

(PubMed), CINAHL, Web of Science, ProQDiss, LibrisDiss

and The Cochrane Library. Medical Subject Headings

(MeSH) (12) were used when possible, but some suitable

search terms did not, however, exist as MeSH terms.

A series of comprehensive searches was carried out.

The

following

keywords

were

chosen:

‘Emergency

Medical Services’, ‘Emergency Care’, ‘Emergency

Medi-cine’, ‘Emergency Nursing’, ‘Evidence-Based Emergency

Medicine’, ‘Prehospital’/‘Prehospital Care’, ‘Ambulance

Service’, ‘Ambulance Diversion’, ‘Air Ambulance’,

‘Out-of-hospital’, ‘Out-of-hospital Cardiac Arrest’, ‘Emergency

Department’, ‘Emergency Room’, ‘Emergency Nurse’,

‘Emergency Nurse Practitioner’, ‘Paramedic’, ‘Emergency

Medical Technician’ and ‘Transportation of Patient’.

The inclusion criteria were (i) peer-reviewed studies, (ii)

published between January 2000 and April 2015, and (iii)

written in English, Spanish, Swedish, Norwegian or

Dan-ish. Exclusion criteria were studies in (i) healthcare

organi-sation and management; (ii) the context of Emergency

Departments that did not include the prehospital phase;

(iii) the ambulance professionals’ work environment not

involving patients; (iv) intrahospital transports; and (v)

areas involving the armed forces/military, and disaster.

Articles were divided between the authors and screened

independently in relation to the inclusion/exclusion

crite-ria, first the titles and later the abstracts. The researchers

had regular meetings to discuss the process and thus

strengthen selection reliability. The discussions continued

until consensus was reached between all four authors. In

total, 78 studies (73 articles and five monographies) were

deemed eligible for final inclusion (Fig. 1).

Data evaluation

Authenticity, methodological quality and data relevance

were considered in the evaluation process (10, 13).

(3)

Studies included were evaluated with methodological

and/or theoretical rigour on a 3-level scale (high,

med-ium or low) (14). The studies were also evaluated

accord-ing to data relevance on a 2-level scale (high or low) (see

Table 1). No study was excluded based on these two

evaluations.

Characteristics of studies

Most of the studies included were conducted in Sweden

(n

= 42), fourteen in the United States and eleven in the

UK. The number of participants varied, from a case study

with one participant to a survey with 2420 participants.

The studies were directly related to patients (n

= 28),

spouses and families (n

= 7), professionals (n = 35),

com-binations of these (n

= 7) and to students (n = 2).

Empir-ical qualitative studies dominated by totally 56 studies of

which one was a combination of theoretical and

empiri-cal study. The five monographies included focused on

ethical aspects, attitudes and cultural barriers. No

pub-lished article could be found associated with these

monographies.

Data analysis

Thematic

analysis

with a

systematic

and

inductive

approach was used (15

–17). Familiarisation with the data

involved careful reading and re-reading until researchers

reached an understanding of the wholeness in the studies

reviewed. Initial codes were generated according to the

researchers’ initial ideas about what the studies were all

about. A ‘data-driven’ and open coding was applied.

Codes were identified, and the studies were organised

into meaningful groups. Searching for themes was

intended to refocus on themes, which involved sorting

codes into potential themes, by considering how codes

could be combined into an overarching theme. Sorting

into themes and subthemes was done until the patterns

were meaningful in relation to the study aim. Reviewing

themes consisted of two levels of reviewing and refining

themes. Level one involved reviewing the coded data,

that is reviewing the affinity in the codes under the

respective themes. Level two involved a similar process,

but in relation to the entire data set. Defining and

nam-ing themes started when a thematic map with five

themes was developed. The interpretation was discussed

and finally agreed upon between all the authors.

Findings

The findings are presented with five themes: Caregiving

in unpredictable situations; Independent and shared

deci-sion-making; Public environment and patient safety;

Life-changing situations; and Ethics and values (Fig. 2). These

(4)

Table

1 Summary

of

the

reviewed

studies

(n=78)

Authors First author (Year) Country (Reference s) Research design Aim and objectives Sample Data coll ection, key meas urements Major finding s relevant to the review Methodological and theoretical rigour Data Abelsson et al. (2012) Sweden (31) Qualitative To describe specialist ambul ance n urses’ perceptio ns of assessing patien ts exposed to severe trauma Specialist ambul ance n urses (n = 15) In dividual interviews Phenomenogra ph y To be prepared for emergency situation s, con fidence in one’s own leadership and d eveloping professional knowled ge Medium Low Ahl et al. (2005) Sweden (57) Qualitative To examine dist inguishing characteristics o f ambul ance care Paramedics (n = 5), ambulance nurses (n = 5) In dividual interviews Qualitative content analysis Ambulance-b ased care is a complex field o f p ractice th at d emands flexibility and humility in caregivers when they meet patients. It calls fo r a great de al of experience-based kn owledge. The team spirit among amb ulance staff has both advantages and d isadvantages. It helps individual memb ers, p articular novices, to rely on colleagues in d emanding situations, but occasion ally blurs th e lin e between good caring and collegiality Low Low Ahl et al. (2006) Sweden (64) Qualitative To analyse patients’ experiences relate d to the decisi on to call an ambul ance an d the wait for it to arrive Patients (n = 20) In dividual interviews Qualitative content analysis Calling for an ambulan ce is a maj or decision th at is preceded by hesitation and attempts to h andle the situation by oneself Medium High Ahl et al. (2012) Sweden (26) Qualitative To interpret and explain experiences of carin g in preho spital care situ ations that are not defin ed as traumatic or life-th reatening Patients (n = 20) In dividual interviews Interpretative analysis Prehospital caring is an in terplay between career(s) and pati ents with potentials for p ositive as well as negative outcomes High High Al ex et al. (2013) Sweden (75) Qualitative To explore patients’ experiences of bei ng cold when in jured in a cold enviro nment Patients (n = 20) In dividual interviews Qualitative content analysis Patients suffered more from the cold than th e p ain from the injury. Patients who received active heat su pply experienced it in a positive way Medium High Al ex et al. (2013) Sweden (78) Quantitative Observation al To investigate injured and ill p atients’ experiences of cold exposu re an d to identify related factors Patients (n = 62) O bservation and structured questions In the ambulance, 85% of the patients h a d a fi nger temperature below comfort zone and 4 4 % experienced the ambient temperature in th e p atient compartme nt in the ambulance to b e col d High High

(5)

Table

1 (Continued)

Authors First author (Year) Country (Reference s) Research design Aim and objectives Sample Data coll ection, key meas urements Major finding s relevant to the review Methodological and theoretical rigour Data relevance Aronsson et al. (2014) Sweden (83) Qualitative To describe and explain older pa tients’ lived experiences of preho spital emergency care in cases of susp ected hip fractures Patients (n = 10) In dividual interviews Reflective lifeworld research The patients experienced to be ‘Glad to have b een rescued, despite bad experiences as well as g ood ’. Older patients were offered care in an op en and friendly atmosphere con currently with feeling anxiety about the treatmen t. Pati ents experienced confusion an d they n eeded to ask questions about what reall y h appened High High Berben et al. (2012) Netherlands (30) Qualitative To give insight into facilitato rs and obstacles in pain ma nagement in trauma patien ts in the chain of emergen cy care Managers (n = 10 ), Paramedics, physicians, emergency nurses (n = 23) In dividual interviews and focus group discuss ions Thematic content analysis Facilitators or obstacles were in accordance with kn owledge, attitude, professional commu nication, organisational aspects and p atient input Medium High Berg et al. (2012) USA (91) Quantitative Prospective cross-sectional A predictive model was hypoth esised to show that patien t p erceptions of technical care (competenc y) could be predicted b y judg ements of interp ersonal care (courtesy) Patients (n = 278 ) Tel ephone survey, questions Structural equation mod elling indicated a significant direct effect of perceptions of in terpersonal care on perceived technical care (PTC) and PTC on gl obal satisfaction Medium Low Berntsson et al. (2013) Sweden (24) Qualitative To explore how the preho spital nurse – patien t rel ationship is emergin g in specialist ambul ance n ursing stude nts’ descriptions of ambul ance mi ssions Student written reports (n = 17) Q ualitative content analysis Four phases of the prehosp ital nurse – patient rel ationship could be identified an d each p hase included several different parts. Furth ermore, the results showed that the p arts of each p hase could vary depending on th e p atient’s condition and the environmenta l circums tances of the ambulance mission Medium Low Braithwaite (2014) USA (93) Doctoral theses Qualitati ve To understand how paramedi cs p erceived ethics in p atient care, specifi cally th e p rocess of navigati ng ethical decisi on-making in emergent si tuations Paramedics (n = 13) In dividual interviews Interpretative analysis Participants did not rou tinely use a process-d riven application as they made emergent d ecisions. They did, however, frequently con sider feelings of empathy as they n avigated such decisions. The participants le arned ethical decision-making from peers an d mentors in a community of practice th rough experiential learning, and then criti cally re flected on ethical dilemmas within th e same com munity High High

(6)

Table

1 (Continued)

Authors First author (Year) Country (Reference s) Research d esign Ai m a n d objectives Sample Data collection, key measuremen ts Major findings relevant to the review Methodological and theoretical rigour Data Bremer et al. (2009 ) Sweden (69) Qual itative To d escribe patients’ experiences of surviving out-of-hospi tal cardiac arrest (OHCA), focusing on how OHCA influenced their well-being over time Patients (n = 9) Individu al interviews Lifeworld phenomenology Out-of-hospital cardiac arrest (OHCA) is a sudden an d elusive threat, an awakening in perplexity, and the memory gap is a los s o f coherence. Survival means a search for coherence with distres sing and joyful understan ding, as well as existential insecurity exposed by feeling s o f vulnerability. Well-being is fou nd through a sense of coherence and meaning in life. Survivors’ emotional needs and a poten tial for prehospital emergency personne l to support them as they try to make sense of what has happened High High Bremer et al. (2009 ) Sweden (72) Qual itative To d escribe the experiences of significant others present at out-of-hospital cardiac arrest, focusing on ethical aspects and values Significant others (n = 7) Individu al interviews Lifeworld phenomenology The phenomenon of OHCA can be stated as unreality in the reali ty, characterise d b y overwhelmin g resp onsibility. Significant others experience inad equacy and limitation, they move between hope and hop elessness, and they struggl e with eth ical considerations and an insecuri ty abo ut the future. The finding s show how significant others’ sense of an OHCA situatio n, wh en life is trembling, can threaten values deemed imp ortant for a good life Medium High Bremer et al. (2011 ) Sweden (94) Theoret ical, philosophi cal To exp lore and discuss the arguments supporting th e u se of futile CPR to benefit significant others a n d ambulance professi onals Theoretical study (n = 1), Case study (n = 1 ), Empi rical study (n = 1) Reflective equili brium Ethical and normative analysis The support for providing physi ologically futile cardiopul monary resuscitation (CPR) in the prehosp ital context fails. The strategy of ambulance profes sionals in the case of a sudden d eath should focus on the relevant care needs of the signi ficant others and provide sup port, arrange for a peaceful environment and ad minister acute grief counsell ing at the scene. This might call for a developed competen cy Medium High

(7)

Table

1 (Continued)

Au thors Firs t a u thor (Year) Cou ntry (Refe rences) Research design Aim and objectives Sample Data collectio n, key measu rements Major findings rel evant to th e review Methodological and theoretical rigour Data relevance B remer et al. (2012) Sweden (95) Qualitative To analyse EMS person nel’s experiences of caring for famili es when patients suffer cardiac arrest and sudde n death Paramedics (n = 2), Preh ospital emergency n urses (n = 5), Specialist n urses (n = 3) In dividual interviews Hermeneutic al, lifeworld phenomenolog y The personnel felt respon sible for both patient care and famil y care, and someti mes failed to pri oritise these responsibili ties as a result of thei r o wn p erceptions, feelings and reactions. Mo ving from patient care to family care imp lied a movement from well-structured gu idance to a situational response, forcing to bal ance b etween interpretive reasoning and a more di rect emo tional response. The ability to recogn ise and respond to people’s existential qu estions and needs was dependent on the pers onnel’s balance between closeness and di stance, an d o n their courage in facing the emoti onal expressions of the families, as well as the pers onnel’s own vulnerability High Low B ruce et al. (2005) Sweden (59) Qualitative To explore the experiences of nurs es receiving patien ts who were brought in to hospi tal as emergencies by ambulance crews throug h a n analysis of the hando ver and tri age process Emergency nurses (n = 6) In dividual interviews Lifeworld phenomenolog y The interplay between prehospi tal and hospital pers onnel is vital for the patients. Prehospital repo rting was experienced as a dialogue for pl anning, the symbolic handover and the id eal and nonideal handover Medium High B urrell et al. (2013) UK (32) Qualitative To examine the decision-making of ambu lance clinician s when attendin g to persons with epilep sy, explo ring their perceptio ns of which factors influ ence their decisi ons Paramedic (n = 9), EMT (n = 5), EC P (n = 1) In dividual interviews Thematic analysis Patients with epilepsy may be taken to the emergen cy dep artment (ED) no t b ecause of a sp ecific cli nical need but because the attend ing ambulance clinicians often do not feel su fficiently confident or informed to be abl e to a ssess the patients’ medical needs adeq uately Low Low Ch andran et al. (2014) USA & Pakistan (66) Qualitative To analyse patient perspectives of the ambulan ce system in Karachi to understan d how to improve ambulan ce us e Patients (n = 30) In dividual interviews Thematic analysis Major themes that affect patients’ decisio n-makin g with regard to ambulance use were a mis trust of the ambulance system or pro viders and a sense of inadequacy of the lo cal system as compared with international stan dards. There was a fundamental mis understanding of the role of ambulance services in th e healthcare infrastructure Low Low

(8)

Table

1 (Continued)

Autho rs First autho r (Year) Country (Reference s) R esearch design Aim and objectives Sample Data collection , key measuremen ts Major findings relevant to the review Methodological and theoretical rigour Data Chew et al. (200 8) Malaysia (86) Q uantitative Prospective cross-sectional To find out the public’s perception and expectations of the ambulance services in one university hos pital Patients (n = 87) Structured in dividual interviews The ambulance personnel were perceived as attentive and gen tle by th e p atients. The equip ment and comfort in the ambulance were rated as not so goo d b y the patients Low Low Cleaver (2012 ) U K (55) Do ctoral theses Mixed methods To explore the attitudes of emergency care staff towards young peo ple (aged 12 –18 years) who self-harm and to gain an understand ing of the basis of attitud es that exist Personnel in ED/ambulanc e (n = 1 43), Personnel in ED/ ambu lance (n = 12) Questi onnaire Individual interviews Triangulation and convergent design Age does influence attitudes toward s self-harm. Nurses have less p ositive attitudes than their peers worki ng in emergency services. The nurs es surveyed in this study obtained lower scores on th e scale u sed to measure attitud es than their medical and paramedical colleag ues. The interviews illustrated the difficu lties and frustration in managing the care of young peop le who self-harm, which centred on the pres sure to ‘move young peopl e o n’, p ressures that were exacerbate d by the need to do thi s within 4 hours. The paramedi cs in terviewed did not face these challen ges High High Compto n e t al. (2006) USA (45) Q uantitative Observational cross -sectional To describe EMS providers’ experiences with family member presence during resuscitation an d to determine whether those experiences are similar within u rban and suburban settings EMS providers (n = 128) Questi onnaire The majority of urban and suburban p roviders felt it was inapp ropriate for family to witness resusci tations. Many providers reported feeling u ncomfortable with family presence. A minori ty bel ieved that family were b etter prepared to accept the death o f th e p atient. Appro ximately h alf of the professionals felt comfortabl e p roviding emotional support after family presence du ring resuscitation. Urban pro viders more often reported feeling threatened b y famil y memb ers during resusci tation and felt that family members often int erfered with their ability to perform resusci tation Medium High

(9)

Table

1 (Continued)

Au thors Firs t a u thor (Year) Cou ntry (Referen ces) Research design Aim and objectives Sample Data collectio n, key measu rements Major findings rel evant to th e revi ew Methodological and theoretical rigour Data Co ttrell et al. (2014) USA (38) Qualitative To understand EMS providers ’ experien ce providin g emergency care for children and their perceptio ns of the range of factors that contribu te to o r in crease the risk of paedi atric safety events in the prehosp ital emergency setting Focus groups (n = 4) with EM S p roviders (n = 40) Focus gro up discussions Grounded theory-conte nt analysis Participants cited challenges such as lack o f app ropriately sized equipment or stan dardised paediatric medication dosag es, in sufficient human resources, paediatric train ing and aspects of Emergency Medical Services cultu re. Poo r commu nication among team members , commun ication problems with the chil d and family, and an overall lack of experien ce with chi ldren coupled with hei ghtened anxiety when responding to calls in volving children. And errors in assessment and d ecision-making High High Co x e t al. (20 06) UK (44) Qualitative To describe ambulance paramedics’ perceptio ns of their role in delivering thrombolytic treatment Focus group (n = 2) with Parame dics (n = 20) Focus gro up discussions Content analysis Paramedics’ perceptions of their role in preh ospital thrombolysis were mixed, encomp assing professional and po litical issues in cluding lack of ownership of the emerging nati onal strategy, desire for national certificatio n and financial reward Medium Low Do nohue et al. (2009) USA (67) Mixed methods To characterise parents’ perception o f b ack-transpor t o f very low-birth-weig ht infants from a regional referral neonatal in tensive (NICU) to a community hospi tal (CH) for convalescent care Parents (n = 236) Ind ividual telephone interviews Constant comparative analysis Overall, 20% of parents selected the CH to which thei r chi ld was transferred. Less than hal f o f th e p arents wanted the transfer. Psychol ogical comfort with the regional referral NICU was the mos t freq uently repo rted reason for opposing transfer. At the time of ho me d ischarged, most parents were sati sfied with transfer and felt prepared to care for their infan t a t h ome Medium Low Do ohan et al. (2015) Sweden (71) Qualitative To explore the survivors’ experiences after a major bus crash Patients (n = 54) Ind ividual telephone interviews Qualitative content analysis Prehospital discomfo rt, lack of compas sionate care, dissati sfaction with crisis support and sati sfactory in itial care and support are the categori es. Lack of compass ion caused di stress among survivors, and various needs for su pport were not met Medium High

(10)

Table

1 (Continued)

Authors First author (Year) Country (Reference s) Research design Aim and objectives Sample Data collection, key measuremen ts Major findi ngs relevant to the review Methodolog ical and theoretical rigour Data Edwardsen et al. (2002) USA (87) Quantitative Prospecti ve cross -sectiona l To determine the acceptanc e b y family memb ers regarding no ne transport of pati ents in cardiac arrest fol lowing unsuccessful resu scitation occurring in p rivate residence Family members (n = 33 ) Individual telephone interviews Satisfied with both th e med ical care an d the emotional support provided by EMS. Patient that had been transported by ambulance to hospital, the family members would have preferred to have the patient die at home instead of being transported Medium High Elmqvist et al. (2008) Sweden (27) Qualitative To describe and un derstand the patient’s firs t e n counter with preh ospital emergency care as experienced by the pati ent and the first resp onders Patients (n = 4 ), Next of kin (n = 1), Policeman (n = 8), Firemen (n = 2), ambulance staff (n = 3) Individual interviews Lifeworld phenomeno logy The patient needs to retain h is o r her identity by means of a communicat ive contact, to be confirmed in the lived encounter and to recapitulate the elapsed time of the unexpected event in order to regain a state of equilibrium. The variations of the patients ’ first encounter; the encounter with the helpless injured body, the confirmatio n in existential encounter, the encounter while waiting, the lived encounter and the recapitulated encounter Medium High Elmqvist et al. (2010) Sweden (25) Qualitative To describe and un derstand experiences of bei ng the first resp onder on the scene of an acciden t, as des cribed by policemen, fireme n and ambulance staff Policeman (n = 8 ), Firemen (n = 2), ambulance staff (n = 3) Individual interviews Lifeworld phenomeno logy Experiences of being the firs t responder on the scene of an accident are expectations of carrying out a systematic course of action, dressed in the role of a hero and at the same time being genuine in an interperso nal encounter. This entails a continuous movement between ‘being’ and ‘doing’. It is not a question of either-or, instead everything is to be understood in relation to each other at the same time Medium High Forslund et al. (2014) Sweden (70) Qualitative To elucidate meanings of peo ple’s lived experi ences of surviving an OHC A with vali dated myocardi al infarction (MI) aetio logy, 1 month after the event Patients (n = 1 1 ) Individual interviews Phenomenol ogy hermeneutic al There were two themes, (1) returning to life and (2) revaluing life, and five subthemes, (1a) wakin g u p and missing the whole picture, (1b) realising it was not time to die, (2a) won dering why and seeking explanations, (2b) feeling ambiguous in relations, and (2c) wondering whether life will be the same Medium High

(11)

Table

1 (Continued)

Authors First author (Year) Country (Reference s) Research design Aim and objectives Sample Data collection, key measuremen ts Major findi ngs relevant to the review Methodolog ical and theoretical rigour Data relevance Forslund et al. (2005) Sweden (62) Qualitative To illuminate how p atients with acute ches t p ain experience th e emerg ency call an d th eir prehospital care Patients (n = 1 3 ) Individual interviews Phenomenol ogy hermeneutic al The patients were grateful that thei r liv es had been saved and were generally satisfied with their contact with the emergency operator and the ambulance personnel. Sometimes, they felt that it took too long for the emergency operators to answer and to understand the urgency. In a life-threatening situation, feelings of vulnerabil ity a n d dependency were great. Time seemed to stand still while they were waiting for help during their traumatic experience. The situation was fraught with pain, fear and an experience of loneliness Medium High Forslund et al. (2008) Sweden (61) Qualitative To illuminate how spouses to persons with acute chest pai n experi enced the alarm situation, the emerg ency call an d the p rehospital emergency care Spouses (n = 19) Individual interviews Phenomenol ogy hermeneutic al Experienced in managi ng the challenges of responsibility, uneasines s and that a sense of aloneness rose. When their partners’ life was at risk, the spouses were in an escalating spiral of worry, uncertainty, stress, fear of loss, feeling of loneliness an d desperation High High Gunnarsson et al. (2009) Sweden (36) Qualitative To investigate the factors th at in fluence decision-maki ng among amb ulance nurses in emerg ency care situations Ambulance nu rses (n = 14) Individual interviews Qualitative content analysis The nurses’ experience is imp ortant for decision-making, with qualitative differen ces in comparison with novice nurses. External factors, such as uncertainty of a prehospital environment, expectations and pressures from other people and collaborating with many different operators, all contribute to making decisions in an urgent situ ation more complex Low Low

(12)

Table

1 (Continued)

Authors First author (Year) Country (Reference s) Research des ign Aim an d objectives Sample Data collection, key measuremen ts Major findings relevant to the review M ethodological an d theoretical ri gour Data Halter et al. (2011) UK (33) Quali tative To un derstand the decision-making processes of emergency ambulance staff with older people who have fallen Ambulance staff (n = 12) Individual in terviews Thematic analysis Assessment and decision-making p rocesses are identified . Pre-arrival: formi ng an early opinion fr om information from the emergency call. Initial contact: assessi ng the need for any immediate action and establish ing a rapport. Continuing assessment: gatheri ng and assimilating medical and social in formation. Making a conveyanc e decision: negoti ation, referral and professio nal defence, using professional experience and instin ct M edium High Henriksso n e t al. (2015) Sweden (76) Quanti tative. Observational cross-sectional To evalu ate th e effect on metabolic rate, body core temperature , skin temperature , total body heat storage, heart rate and cold discomfort in cold stressed subje cts Volunteers (n = 8) Observations Wet clo thing removal or the addition of a vapour barrier sign ificantly reduced metabolic rate and increased skin temp erature rewarming. Cold disco mfort was significantly lower with the addition o f a vapo ur barrier and with two woollen blan kets compared with one woollen bl anket alone M edium Low Holmberg et al . (2010) Sweden (19) Quali tative To des cribe RNs’ experiences of being responsible for the care of the patient in the ambulance service RNs in the ambulance service (n = 5) Individual in terviews Lifeworld phenomenology The essence of the phenomenon is to prepare and create conditions fo r care and to accomplish care close to the patien t. Three meaning consti tuents: prepare and create condition s for the nursing care; be there for the patient and sig nificant others; and create comfort for the patient and si gnificant others Hi gh High Holmberg et al . (2014) Sweden (85) Quali tative To elu cidate the meaning of the relationship with the ambulance clinicians as experienced by patients Patients (n = 20) Individual in terviews Lifeworld phenomenologic al hermeneuti cal The main theme: To surrender independence to another. The main theme inclu des four subthemes: Bein g in the hands of another, Being in a caring tempo rary p resence, B eing important while in volved and Being powerless while insig nificant Hi gh High Hultsj €oe t al. (20 05) Sweden (54) Quali tative To id entify whether staff in somatic and psychiatric emergency care experienced problems in the care of migrants, and if so to compare these ED personnel (n = 12), ambulance perso nnel (n = 12), Psychiatric intensi ve care perso nnel (n = 11) Focus group dis cussions Content analysis There were a lo t of nonemergenc y runs because of languag e b arriers between the emergency services centre and migrants M edium High

(13)

Table

1 (Continued)

Authors First author (Year) Country (Reference s) Research des ign Aim an d objectives Sample Data collection, key measuremen ts Major findings relevant to the review M ethodological an d theoretical ri gour Data relevance Iqbal et al . (201 3) UK (42) Quali tative To in vestigate patients’ and practitioners’ views and experiences of prehospital pain managemen t to inform improvemen t in care and a patient-centr ed approach to treatment Patients (n = 17), ambulance clinicians (n = 25), ED clinicians (n = 13) Focus group dis cussions Thematic content analysis Five mai n categories described: (i) consider beliefs of patien ts and staff in pain managemen t; (ii) widen pain ass essment strategies; (iii) optimi se nondrug treatment; (iv) increase drug treatment option s; an d (v) enhance communicat io n and coordination along the preho spital pain managemen t pathway. Patients and staff expected pain to be relieved in the ambulan ce; ho wever, refusal of or inadeq uate analgesia were common Hi gh High Jang et al. (2004) USA (34) Quanti tative. Cro ss-sectional To ass ess the religious spirituality of EMS personnel and their perception of the spiritual needs of ambulance patients EMT (n = 143), Paramedics (n = 89), Patients Questionn aire Ambulance personnel did not perceive spi ritual concerns as often as reported b y ambu lance patients, nor did th ey commo nly inquire about the religi ous/spiritual needs of patients Low Low Johansso n e t al. (2007) Sweden (74) Quali tative To des cribe variations in how individuals perceived suffering symptoms of an acute myocardial infarction Patients (n = 15) Individual in terviews. Phenomenogra phy To manage their situation, patients expressed a need to understand it an d to have a similar situation to comp are wit h. Th ey als o described copin g with the threat arising to their lives by self-medicati on or denying their symptoms. Patients express ed vulnerability, with feelings of anxiety, both as tri ggers and obstacles to seekin g medical care. In interaction with others , p sychosocial support and guidan ce from the envi ronment were fundamental in h elping the patients to manage the situatio n M edium High Johansso n e t al. (2008) Sweden (65) Quali tative To des cribe spouses’ conceptions of the prehospital phas e w h e n their partners suffered an acute myocardial infarction Spouses (n = 15) Individual in terviews Phenomenogra phy Two categories conceptualised the spouses ’ experiences. Being reso urceful contained: sharing the experien ce, havin g knowledge, understand ing the severity, being rational and consultin g others. Respecting independence contained: accepting the need fo r con trol, marital roles and experien ces, res training emotions and seeking agreement Hi gh High

(14)

Table

1 (Continued)

Authors First author (Year) Country (Reference s) Research des ign Aim an d objectives Sample Data collection, key measuremen ts Major findings relevant to the review M ethodological an d theoretical ri gour Data Johansso n e t al. (2011) Sweden (88) Quanti tative Cross-sectional To evalu ate p atient satisfaction within an ambulance care service using the Davis Consumer Emergency Care Satisfaction Scale Patients (n = 40) Questionn aire, Davis Consumer Emergency Care Satisfaction Scale © Patients were pleased with the care received and the competence of the ambulan ce staf f, and the patients experien ced a h igh level of psychologi cal an d physical sense of security M edium Low Jones et al. (2003 ) UK (39) Quali tative To expl ore paramedics’ perceptions of patients in pain and the paramedics’ perspective of prehospital pain managemen t Paramedics (n = 6) Individual in terviews Thematic content analysis Four main themes were described: The patient’s experience of pain , The evaluati on of pain, Decision-makin g and Alternative methods. The participan ts described factors that they felt influence a patient’s experien ce of pain, identifyin g a cul tural difference existing in pai n expression. Patients were not always perceived by the participants to be honest when describ ing their pain M edium Low Jonsson et al. (2003) Sweden (23) Quali tative To un cover th e e ssence of traumatic events experienced by ambulance personnel EMT and RN ambulance (n = 223 ) Written stories Pheno menology At the scene of the accident, the meeting with the unforeseen and mean ingless centred all attention on the victim. The ambul ance personnel experi enced strong compassion and identifi cation with the victim. Afterwards, it was impossib le to leave th e meaningles sness behind without gainin g understand ing of what happened Hi gh High Jonsson et al. (2004) Sweden (50) Quali tative To un cover an d deepen the understanding o f the way ambulance staff experience and handle traumatic events and to develop an understanding o f th e lifeworld of the participants Ambulance nurses and ambulance techni cians (n = 10) Individual in terviews Phenomenology To handle PTS symptoms and feelings, it is necessary to talk about them with fello w workers, friends or family members. By usi ng another person as a contai ner, it is possible to encapsulate the traumati c experien ce M edium Low Kober et al. (2002) Austria (82) Quanti tative Randomised Controlled Trial To test th e h ypothesis that oxygen administration red uces nausea and vomiting in patients with minor trauma during ambulance transport Patients (n = 100) Control grou p: b reathe air Intervention group: 100% oxygen at 10 L/minute through a facemask Pain, nausea, vomiting, anxiety and overall satisfaction rating on 100-mm scales. Supplemental oxygen during ambulan ce transport reduced nau sea scores by 50% and decreased vomiting fou rfold. Patients reported greater satisfa ction with their care when oxygen was administrated M edium High

(15)

Table

1 (Continued)

Auth ors First aut hor (Year) Coun try (Referen ces) Research design Aim and objectives Sample Data collectio n, key measur ements Major findings relevan t to th e review Methodological and theoretical rigour Data relevance Lang et al. (20 07) Austria (80)

Quantitative Randomised Controlled

Trial To evaluate the efficacy of transcutaneo us electrical nerve stimulati on (TENS) in acute post-traumati c h ip pain patien ts during emergency transport Patients (n = 63) Interven tion group: TENS (n = 30). Control group: standard treatment (n = 30) Questionnaires. Pain an d anxiety scale TENS is a valuable and fast-acting pain treatment un der the difficult circumstances. Patien ts scored significantly reduced pain and anxiety after TENS Medium High Larsso n e t al. (2013) Sweden (77) Qualitative To describe ambulance nurses’ experien ces o f nursin g patients suffering card iac arres t Ambulance nurses (n = 7 ) Ind ividual interviews Qualitative content analysis Mutual preparation, regul ar trai ning and educati on were im portant factors in the nurs ing of patients suffering cardiac arrest. Ambu lance nurses are placed in ethically deman ding situations regarding if an d for how lo ng they should continue cardio pulmonary resuscitation to accord with preh ospital cardiac guidelines and patien ts’ wish es Medium High Lund gren et al. (2004) Sweden (79) Quantitative Observational cros s-sectional To evaluate the effect on body core temperature , sensatio n o f shivering and cold dis comfort in cold stressed subjects by utilis ing additional insul ation on a spine board Volunteers (n = 19) Immob ilised on noninsulated (n = 10) Insulated (n = 9) spin e b oards Observation protocol There were no differences between the two grou ps regarding reduction in body core temperatu re o r col d discomfort. There was, however, a statistical ly significant increase in estim ated shivering for the subjects placed on non insulated spine boards Medium Low Mel by et al. (2005) Sweden & Norway (58) Qualitative To explore older people’s experiences in prehosp ital emergency care and identify benefits and d ifficulties associated with developin g a n urse-led ambulance service Focus groups (n = 3) with amb ulance nurses (n = 5) Paramed ics (n = 4), Nursing students (n = 4, Older p ersons (n = 11) Focus gro up discussion Individua l interviews Thematic analysis The care of older people in ambulance care; the main is sues comprising: Holistic care; Satis faction with care; Ed ucation and training vs. experience. The role of the nurs e in ambu lance care; the is sues underpinning this were as follo ws: Hol istic assessment and care; Rol e co nflict Low Low

(16)

Table

1 (Continued)

Authors First author (Year) Country (Reference s) Research des ign Aim an d objectives Sample Data collection, key measuremen ts Major findings relevant to the review M ethodological an d theoretical ri gour Data Nollette (2001 ) USA (40) Doctoral thes es Quantitative To examin e th e atti tudes of EMS personnel in Texas regarding death and dying EMS personnel (n = 228) Questionn aire Respondents reported very similar attitud es regarding death an d dying; and a large majority of them indicated th at th ey agreed that they had difficulty in deal ing with their feelings or the feeli ngs of their patients with regard to death and dying ; a g reed that EMS schools sh ould place more emphasis on communicat ion ski lls with dying patients and their families; dis agreed that training EMS personnel o n attitudes of death and dying was not appropriate; agreed th at d ying patients sho uld be allowed to die without making an effort to prolo ng their lives; and agreed that patients so metimes give up when the medical professi on gives up on them Hi gh High Nordby et al. (2012 ) Norway (47) Quali tative To un derstand how paramedics experience difficult ethical dilemmas regarding resuscitation of cancer patients Paramedics (n = 15) Individual in terviews Cognitive-emotional analysis The participants believed that it can be ethically correct not to resuscitate if the patient is expected to survive for onl y a sho rt time with a very low quality of life and severe negative illnes s experiences. This belief sometimes failed to match fo rmal or informal guidelin es and contextual factors such as expectations of relatives. The majori ty of th e paramedics relied heavil y o n the advice o f medical experts M edium High Nord en et al. (201 4) Sweden (41) Quali tative To des cribe ambulance nurses’ experiences of nursing critically ill or injured children Ambulance nurses (n = 8) Individual in terviews Qualitative content analysis The security of both child and parents was considered to be paramo unt. Ambulance nurses felt relieved when th ey han ded over the responsi bility. The ambulance nurses felt that more training, educati on and follow-up was desirable in ord er to in crease their security when nursing ch ildren M edium Low

(17)

Table

1 (Continued)

Authors First author (Year) Country (Reference s) Research design Aim and objectives Sample Data collection, key measuremen ts Major findi ngs relevant to the review Methodolog ical and theoretical rigour Data relevance O’Cathain et al. (2008) UK (29) Qualitative To explore patients’ views and experi ences of th e emerg ency an d urg ent care system to in form the development of a q u estionnaire for rou tine assessment of the system’s per formance from the pat ient perspective Focus group (n = 8) wi th patients (n = 47), individual interviews with patients (n = 13) Focus group discussions and individua l in terviews Qualitative content analysis Question naires designed to assess patients ’ views and experiences of emergency and urgent care should address system-level a s well as service-specific issues in order to address the full range of patient concerns Medium High Persse et al. (2002) USA (89) Quantitative Prosp ective cross -section al obser vational To determine where a feed back lo op providing par amedics with follow-up in formation about eld erly patients not tran sported by amb ulance would chan ge their decision-maki ng regarding amb ulance tran sportation as rep orted by the patients Patients (n = 3 49) Individual interviews by telephone Data collection, pre/post-intervention (feedback) The decision on n o t going to the hospital was the patient’s own decision and/or mutual. The risk of not be transported was explained to the patients by the paramedics in majority of the cases and the patients were satisfied with the care Medium Low Pugh (2002) Australia (37) Qualitative To describe flight nurs es in em ergency situations in wh ich they were the so le health professional Flight nurs es (n = 6) Individual interviews Thematic analysis Ways of knowing the patient were formed by intuitive, experiential and objective knowing. The context of knowing was formed by an aviation environment, no or minimised involvement in triage, knowing colleagues, sole practitioner, experiential level and practice guidelines Medium High Ridsdale et al. (2012) UK (63) Qualitative To explore the per spectives of adults with ep ilepsy who had atten ded the ED about who h a d made the call to th e E M S an d their rati onale Patients (n = 1 9 ) Individual interviews Thematic analysis A seizure alone was not the main explan ation for attending EMS; knowledge, experience and confidence of those nearby on what to do and seizure context were important. Additionally, fears of sudden death hel d b y the patients with epilepsy and others were reported Low High

(18)

Table

1 (Continued)

Authors First author (Year) Country (Reference s) Research design Aim and objectives Sample Data collection, key measuremen ts Major findi ngs relevant to the review Methodolog ical and theoretical rigour Data Sandman et al. (2006) Sweden (92) Qualitative To analyse and describe eth ical conflicts faced b y preh ospital emerg ency carers in th e EM S Focus group in terviews (n = 6) with RNs (n = 14), Paramedics (n = 15) Focus group discussions Con tent analysis Ethical conflict was found in different nodes of conflict: the patient/care r relationship, the patient’s self-determina tion, the patient’s bes t interest, the carer’s professional ideals, the carer’s professional role and self-iden tity, significant others and bystanders , oth er care professionals, organisati onal structure and resource managemen t, societal ideals, and other professionals Medium High Sharifi et al. (2012) Iran (90) Quantitative Cross-section al obs ervational To investigate the satisfaction of patients with Amb ulance Service services in Shahrekord Patients (n = 4 50) Satisfaction evaluation question naire Patients’ satisfactio n with emergency services and their quality is considered as one of the main concepts in prehospital emergency procedures, in the manner that the results of this study showed that patients’ satisfaction in different fields was high but that technicians should allocate much more time for interaction with patients in order to improve their satisfaction Low Low Stuhlmiller et al. (2009) USA (81) Quantitative Cross-section al obs ervational To evaluate the effect of mu sic on ground critical care transp ort (CCT)-rel ated subjective an xiety and as sessed for o bjective evidence man ifested by a change in vital signs Patients (n = 2 3 ) Questionnaires Patients reported a p o sitive impact of music on transport and that music made them feel more comfortable. There were no differences in patients’ vital signs when listeni ng to music during transport Medium Low Suserud et al. (2003) Sweden (21) Qualitative To describe the scope an d method of amb ulance nurse as sessment in p rehospital emergency care Ambulan ce nu rses (n = 6) Individual interviews Phenomenol ogy The ambulance nurs es use their experience before meeting patients and when necessary can carry ou t active prep aration by imaginative planning. When experienced nurses first meet patients, they need to be open to all information about the pati ent, situation and site appearance, whether in a home or at an accident site Low Low Suserud et al. (2013) Sweden (51) Qualitative To explore whether amb ulance clinicians in Sweden p erceive th eir worki ng environment to b e safe Ambulan ce nu rses (n = 24), Paramedics (n = 9) Individual interviews Qualitative content analysis The perceived safety of patient care in ambulances was affected by use of safety belts; driving at high speeds; patient firs t, safety second; equipment design and placement; noise; driving styles; presence of relatives; documentatio n Low Low

(19)

Table

1 (Continued)

Authors First author (Year) Country (Reference s) Research design Aim and objectives Sample Data col lection, key measuremen ts Major findin gs relevant to the review Methodologi cal and theoretical rigour Data relevance Thor en et al. (2010) Sweden (73) Qualitative To describe spouses’ experien ces o f witnes sing their partn ers’ cardi ac arres t at home, focusi ng on the time befo re th e event and when it hap pened Spouses (n = 15) Individual interviews Qualitative content analysis Before the cardiac arrest, there was a lack of early warn ing signs, difficulties in interp reting them, wh ich was o ften done in the light of previous illness. Denial of serious illn ess emerged. During the event, spouses perceived the seriousness, felt unable to influence, and did what was their power Low High Togher et al. (2013) UK (28) Qualitative To explore experiences of pati ents, who had accessed the amb ulance service for AMI or stro ke, and cli nicians regu larly treating pati ents for these cond itions in the preh ospital setting Focus groups (n = 1) with clinicians Interviews patients (n = 22), ambulance service staff (n = 17) Individual interviews and focus group discus sion Thematic analysis Four main themes emerged: communi cation, professionalism, treatment of conditio n and the transition from home to hospital. Patients focused on both personal and technical ski lls. Technical knowledge and relational skill s together contributed to a perception of professionalism in ambulan ce per sonnel Medium High Togher et al. (2015) UK (60) Qualitative To investigate the aspects of emergen cy ambu lance service care valued b y us ers Patients (n = 22 ), Spo uses (n = 8) Individual interviews Qualitative content analysis Users were often extremely anxious about their health, and the outcome they valued was re assurance provided by ambulance services staff that they were receivin g appropriate advice, treatment and care. A timely response was valued in terms of allaying anxiety quickly Medium High Toloo et al. (2013) Australia (68) Quantitative Cross-sectional observatio nal To study the role and effect of patients ’ percepti ons on reasons for us ing ambulance services ED patients transp orted by ambulance (n = 223), patients using own or public transport (n = 619), patients (n = 69) using other transports Questionnaires Ambulance users had significantly higher self-rated perceived seriousness, urgency and pain than self-transports. They were also more likely to agree that ambulance services are for everyone to use, regardless of the severity of their conditions High High Urbina (2001) USA (53) Doctoral theses Quanti tative To explore cultural barri ers to prehospital emergen cy medi cal care. Focused on clin ical and n onclinical factors Patients (n = 24 20) Participant observation Several nonclinical factors have a stron g effect on EMS patient diagnosis and treatment. There may b e con siderable differences in the diagnosis and treatment of patients who can and cannot speak English High High

(20)

Table

1 (Continued)

Auth ors First auth or (Year) Coun try (Referen ces) Research design Aim and objectives Sample Data collection , key measuremen ts Major findings relevant to the review Methodological and theoretical rigour Data Walker (2014 ) U K (46) Qualitative To explore the lived experience of lay presence durin g a n adult CPR attempt in primary (out-of-hos pital) and secondary (in-hospital ) care environments RN (n = 12), ambulance staff (n = 8) Ind ividual interviews Thematic analysis Participants portrayed a mixture of benefits and concerns . Famil iarity of working in the presen ce of lay peo ple, practical experience in emergen cy care and perso nal confidence were importan t a n tecedents. Divergent practices withi n and across the contexts of care were revealed Medium Low Warden (201 2) US A (96) Doctoral theses Qualitative To explore ethical quandari es that EMS personn el face and in a systematic way think through mo ral challenges th ey encounter EMT, Paramedics (n = 5) Case stud y A moral agency that combines adherence to ethical no rms with the inculcation of virtue will be bes t suited to assist EMTs and paramedi cs as they ren der care to th eir patien ts Medium High Vicente et al . (201 2) Sweden (35) Qualitative To identify and illuminate conditio ns that affect older peop le assessed with the assessmen t category ‘generally affected health conditio n’ Patients’ medical records (n = 88) Medi cal record s Qualitative content analysis The concept of frailty clarifies the state of ‘generall y affected heal th condition’, as either illn ess or ill-health. Progressive weakness and increased d ependence lead to overturning a control led and functioning life Low Low Vicente et al . (201 3) Sweden (84) Qualitative To describe patients’ lived experience of participatin g in the choice of health care when offered an alternative care pathway by the EMS, when the individu al patient’s medical needs made this choice pos sible Patients (n = 11) Ind ividual interviews Phenomenology The essence of the phenomenon is d escribed as ‘There was a ray of hope about a caring encoun ter an d about being treated like a uni que human being’. Five meaningful consti tuents: endurable waiting, speedy transferen ce, a concerned en counter, trust in competence and a choi ce bas ed on memories of sufferi ng from care High High

(21)

Table

1 (Continued)

Authors First author (Year) Country (Reference s) Research design Aim and objectives Sample Data coll ection, key meas urements Major finding s relevant to the review Methodological and theoretical rigour Data relevance Wiese et al. (2009) Germany (56)

Quantitative Prospective multicentre

To explore emergency physi cians experiences in deali ng with palliative care patients in o ut-of-hosp ital emergency situa tions and about their bel iefs and interest in pall iative care Emergency physicians (n = 104) Stru ctured interviews out of a questionnai re One-third of the EPs felt uns killed in emerg ency situations when caring for p alliative patients. The therapy carried out d uring the emergency situations coincides well with th e wishes of the palliative care p atients (50%). Nearly 20 per cent of the EPs rep orted that they were ab le to keep their p alliative care patient at home and avoiding h ospitalisation Medium Low Vilke et al. (2002) USA (52) Quantitative Cross-sectional observation al To obtain medical follow-up and d etermine reason s why eld erly patien ts access paramedi cs via 9-1 -1 and then refu se transp ort Patients (n = 100 ) Stru ctured interviews out of a questionnai re The reasons for not being tra nsported to the ED were as foll ows: th e p atient did not want to g o to the hospital, they were concerned o ver the cos ts, th e amb ulance personnel im plied no transport was needed and la nguage barriers appeared during the as sessment. The majority of patients were satisfied and confident with the care d elivered by the paramedics Medium High Wireklint Sundstr €om et al. (2011) Sweden (22) Qualitative To describe and illu minate prehospital emergency care with particul ar emp hasis on asses sment Paramedics (n = 6), RN (n = 3), Specialist ambulance nurses (n = 2) Parti cipant observation; field notes and individ ual interviews Lifeworld phenomenol ogy The carers’ openness to the situati on and to th e p atients’ suffering and needs vary from b eing of minor interest to complete focus of th e a ssessment. Assessments that focus solely o n a p atient’s medical condition can be an o bstacle to a full understanding of the in dividual and therefore the illness per se High High Wireklint Sundstr €om et al. (2012) Sweden (20) Qualitative To highlight prehos pital care and how ambul ance p ersonnel prepare for thei r everyday caring assig nments and avoid making p remature decisi ons Prehospital carin g situations (n = 25), ambulance personnel (n = 11) Parti cipant observation; field notes and individ ual interviews Lifeworld phenomenol ogy The feeling of certainty and the unkno wn in a n e w si tuation, which means that the amb ulance personnel are prepared at the same ti me as they are un prepared; in other word s, th ey are prep ared for the unprepared High High

(22)

Table

1 (Continued)

Authors First author (Year) Country (Reference s) Research design Aim and objectives Sampl e Data collection, key measuremen ts Major fi ndings relevant to the review Methodo logical and theoretical rigour Data Wireklint Sundstr €om et al . (201 3) Sweden (43) Qualitative To describe and anal yse how caring assessment is learnt in the Specialist Nursing, Prehospital Care Programme for educating specialist ambulance nurses Stud ents, RN (n = 37) Written data Themes of meani ng Lifeworld ph enomenology The learni ng process of caring assessment consists of the following th emes: 1 . Th e learning process is challen ged by care inadequacies; 2. The learning process g oes through participation in caring; 3. Th e learning process is in clos e rel ationship with the patient; 4. The learning process is influenced by the unpredictable carin g encounter; 5. The learning process relies o n support from the supervisor Medium Low Woodward et al. (2000 ) USA (49) Quantitative Cross-sectional observational To evaluate whether an increased level of parental involvement might benefit our patients, families and transport service Accompan ying parents (n = 46), Parents who did not accompany (n = 40) Questionnaires Twenty-fiv e per cent of all respon dent felt a parent should (4 or 5 o n a 5-poin t scale) be allowed to travel with their child (37% Group Allow, 5% Group DoNot). Twenty-nine per cent felt that the parent should not (1 or 2 on scale) accompany their child (6% Group Allow, 67% Group DoNot), and 46% felt that sometimes parental accompanim ent was appropriate (57% Group Allo w, 27 % G roup DoNot). There does not appear to be a national consensus Low Low € Oberg et al. (2015) Sweden (48) Qualitative To gain an unders tanding of how EMS personnel perceive ambulance transport of children Med ical technicians (n = 3), RN (n = 4), Prehospital emergency nurses (n = 5) Individual interviews Qual itative content anal ysis Transp orting children induces stress and is deemed a precarious task by EMS personnel mainly because children are considered mo re vulnerable than adults and becaus e o f th e necessity to separate the child from the parent during transport. There is a confl ict between medical and emotional well-bei ng and traffic safety during the transportatio n o f children and a fear of insufficient abil ity to care for the child. The EMS personnel’s vulnerability is evident in the compli cated care situation associated with transp orting children in an ambulance Medium High