Spotlight on Research

Julia Williams
Sunday, November 2, 2014

Supporting bystanders involved in out-of-hospital cardiac arrestOver the years it has been evidenced that early recognition and appropriate treatment of cardiac arrest can impact on survival rates, and this work emphasises the important role that bystanders can play in the management of out-of-hospital cardiac arrest (OHCA).This qualitative study was undertaken in Denmark between March and July 2013. It focuses on the concept of systematic debriefing of bystanders involved in OHCA, as well as exploring the effects that debriefing can have on these people.Data collection involved audio-recorded, semi-structured telephone interviews with a sample of 15 individuals who had participated in resuscitation attempts in OHCA, and who had also received telephone debriefing (audio-recorded) after the event.The debriefing was delivered by Emergency Medical Dispatchers (EMDs) who, in Denmark, are specifically trained paramedics or nurses. The debriefing guidelines were based on concepts of adult learning and adapted from the field of medical simulation encouraging participants to reflect on their performance.Twelve EMDs were trained in the debriefing process (although only nine participated in the study), and they were also taught how to recognise possible warning signs of people who were not coping. The project manager monitored the EMDs' approaches to debriefing throughout the study, and the debriefing guide was adjusted accordingly—although there is no specific information offered in the paper as to the extent of these changes.EMDs contacted the bystanders between two and four days after the cardiac arrest event to debrief them, and this interaction was opened by asking the bystander to describe their experiences. Subsequently, the EMD explored the bystander's coping strategies and, if the EMD felt it was necessary, they advised the bystander to contact their GP for additional support, which applied to two of the 15 participants in this study. All bystanders were given a dedicated phone number to call the dispatch centre if they had further questions after the debriefing.The follow-up interviews were carried out between one and two months after the debriefing and explored areas including the bystanders' reactions when receiving the debriefing, their perceptions of the effects of the debriefing and their views as to its value, and their recommendations for development of a systematic approach to debriefing.It is a strength of the paper that the interview schedule and the debriefing guide are included in the paper to inform the readers' understanding of these events.Using a phenomenological approach to analysis, six main themes were identified from the first set of data obtained during the debriefing itself. These related to: challenges when identifying OHCA; bystanders' emotions and perceptions of OHCA; working with health professionals; what happens to the patient in terms of outcome; how bystanders cope with the experience; and reflection on the event, which covered a wide range of topics including what more, if anything, could have been done and what to do to prepare for future events.From these interviews, it emerged that in relation to short-term effects, participants generally valued the debriefing, seeing it as a useful safety net in case any of the bystanders were not coping, plus it gave an opportunity to discuss and reflect on the event with a health professional rather than just friends and family.Some participants indicated that there were positive debriefing effects even at two months after the session, notably in terms of increased confidence in their own skills having had that opportunity to clarify any areas of uncertainty with a qualified health professional.Overall, participants were in support of this type of debriefing event after involvement in OHCA resuscitation attempts. They reported it was important that a health professional routinely initiated the interaction so that it was not seen as the bystander asking for help; they were in favour of the dedicated phone line to the EMDs viewing this as a positive mechanism of support; and they stressed the importance of qualities such as strong communication skills (including active listening) in the EMD facilitating the debriefing session.As with many research studies, this study has some limitations and questions around methodological decisions including the decision not to involve bystanders who were related to the person in cardiac arrest. The authors recommend that future research could address these deficits but emphasise that this is a preliminary, exploratory study which has begun to explore the role that debriefing could play on a bystander's experience of being involved in OHCA.Additionally, there needs to be consideration of the differences in organisational structure of emergency health care provision between Denmark and the UK before looking at transferability of the findings between the two countries.Nonetheless, this study raises important considerations which would be useful to explore within a UK context in order to see whether implementation of a similar process of support and reflection could impact on our bystanders' level of skills and motivation to engage in resuscitation attempts of people in out-of-hospital cardiac arrest.

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