This sub-theme illustrates and explores participants' narratives surrounding their views identified as being in unfamiliar and unpredictable scenarios where first aid may be necessary.
The nature of these situations is implicitly one that is likely to be unpredictable, unfamiliar and unexpected. Health and safety law requires organisations,
employers and events’ organisers to put preparations in place for first aid for the general public (Tarlow, 2002; Raj et al., 2013). Professions such as the police have guidance and requirements for officers in such circumstances (Her
Majesty's Inspectorate of Constabulary, 2006). Professions such as the police, paramedics’ and firefighters’ key remits are about responding to the unexpected, however, nursing and midwifery are arguably so diverse in the nature of their demands that they cannot automatically be considered as similar. The NMC (2015) requires registrants to respond in some capacity however limited this may be, that is to say, to not ignore the need for assistance in line with Good
Samaritan principles84. The complex factors involved in any given scenario,
however, may bring together conflicting ideas and concerns about a response and the approaches to take. All participants alluded to standard assessment guidelines initially such as ABCDE when viewing the trigger image at the beginning of the interview85. Some participants noted how they were not
comfortable with this out of normal work situation when talking about assessing a situation and noted that the decision-making process is likely to be rapid and chaotic. This was often articulated as an internal conversation. Viv (RN)
explained how she’d witnessed a scenario in a church where a pregnant woman collapsed:
“Fortunately there were other people who were nurses – so it was good that people were helping each other - Many people perform quite well in
84 see Chapter 2 Literature Review and Theoretical Underpinning sub-section on Good Samaritan principles. 85 see Chapter 6 Theme 3 'Just Who I Am' sub-theme training and education influence.
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their own time and their own space, with the time to rationalize things – but if you are confronted with a situation which appears to be an
emergency out in the street, you are unsupported – don’t have the support of your peers. As a nurse, depending on which area you work in, you are confident in that area – out there, you’re not sure what is going to confront you. If I was in a strange environment, people panic, they expect you do to something quite quickly and get the situation under control”.
The link made with responding where first aid may be required and making decisions quickly and under pressure was held in common with 'out of work' situations and that an unfamiliar environment and incomplete information was a source of anxiety for participants. This could be considered an easier transition for nurses with acute or emergency care backgrounds to make compared with those from other clinical backgrounds. Although this cannot be assumed as Tom indicated:
Tom (RN) “Outside of hospital is a completely alien environment – you
have to think on your own, without all this equipment that you usually have, you panic a little bit, your colleagues aren’t there to support you – completely on your own”.
Being without peer support and alone was a sentiment that persisted throughout the data as Charlotte (RN) indicated:
“You need to be a bit careful when you have got your skills base and you’re trying to adapt it for a different scenario – I’m very happy in an intensive care scenario, ILS trained, a defib on hand and an E.T. tube and an anaesthetist. Take that out into the community – you don’t feel nearly as confident”.
Reflecting the need for skills in incident management, Claire (RN) noted: “You
could misread a situation – you’re on your own, you’re autonomous, you’re having to make decisions alone. It depends on your surroundings”. The NMC
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revised curriculum content requirements (NMC, 2010). Sandra (RM) spoke about how she assessed a situation from a midwifery perspective “You don’t
know what you’re going to find if you do get involved”. Sandra was clear that
other than a midwifery related emergency she would respond only as a member of the lay public.
Zayna (RN, RMN) cited her experiences and involvement at out of workplace scenarios, noting the uncommon and unfamiliar nature of such events:
“It’s not something that’s a very common occurrence. When it’s out on the street, I guess it’s very different – you’re on your own and you have to make a snap decision. Particularly as mental health nurses, it's not the kind of problems we come across very often. It's quite scary to be honest, it's not an everyday occurrence".
Zayna frequently used the term “Scary” when talking about outside work situations and emergencies, adding “Some people find it quite overwhelming”. This helps to contextualise why a nurse or midwife working in an emergency care area such as labour ward admissions may feel better prepared to respond at out of workplace situations. Georgina illustrates this: "Some midwives will respond to
emergencies better because you have to respond to key emergencies everyday in midwifery - like neonates needing resuscitation or a collapsed mother." As a
mental health nurse, Zayna explained how her role differed from general nurses who were much less prepared for mental health emergencies and that mental health nurses had a very different skill set in relation to responding at scenarios not specific to their role.
Decision making under pressure was a key feature of the sub-theme of 'Unfamiliar and Unpredictable Environment'. There is a significant amount of literature about decision making in healthcare although Pugh (2002) recognised that there was very limited amount of primary research relating to decision making under pressure in off-duty situations. Pugh's (2002) phenomenological work held relevance to this study mainly because of the focus on the nurse as a
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sole professional during in-flight emergencies generating themes that suggested a need for further research surrounding such emergencies. In a later grounded theory study Pugh (2009) generated a substantive theory calling it 'the Phoenix Process' surfacing nurses' fears and anxieties about both the personal and professional self in the face of worries about risk of professional misconduct and the impact of experiencing allegations of misconduct. Pugh (2002) concluded that support for nurses who made mistakes was needed rather than punitive measures. Whilst her findings were of some relevance to this study, Pugh's focus was chiefly about malpractice.
Helen (RN) echoed Zayna's sentiments, alluding to the often-chaotic nature of an event where she had provided first aid, “Because it’s an emergency and it’s
outside your comfort zone, you’ve a lot of things going on in your head.” Helen
spoke about multiple things occurring at once during a scenario where she had responded making a point about prioritising in an unfamiliar and changing environment:
“You do that clinical assessment – in your rear view, I can’t remember those type of details. Everything just happened so quickly”.
Katy gave accounts of situations outside of work where she’d helped, continuing to draw attention to the chaotic and unpredictable nature of such situations and how this increases anxiety about errors and scrutiny.
Katy (RN): “It’s scary because you don’t know what you’re facing. If you’re
in Tesco’s and somebody collapses in front of you, it is scary, it is scary.
I’m not scared at all – who I am”86.
Katy's reflection as she spoke moved her from 'scary' to consider her position as not scared as if she was stepping into a role with moral and practical tenets that appeared to override her fear, suggesting elements of moral agency. Zayna's
86 see Chapter 6 In vivo Theme 3 'Just Who I Am'.
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and Katy's narratives provide examples of an apparent mismatch between
anxiety about their response to a scenario whilst off-duty and a sense of stepping into a role or persona who is sufficiently equipped, able or prepared to offer assistance. John described a challenging scenario whilst on holiday:
"It’s very different to resuscitate somebody in a nice clean A/E department or a nice clean ward - its 40 degrees - a thousand screaming, wailing individuals all around – well-meaning individuals who think they know what they're doing, and aren't necessarily doing the right thing".
Kolyva, cited in Sprinks (2015), considers how nurses make rapid judgement decisions under pressure at work, and that it is rather different when outside that setting. Sprinks (2015) adds that environmental factors and personal
circumstances may impact on how they respond to scenarios during off-duty time where first aid may be indicated. Whilst the logic of this is clear, the complexities of an unfamiliar and unpredictable environment necessitate the importance of clear and practical guidance. The nature of the unfamiliar and unpredictable environment as identified and described by participants leads to some
consideration of the literature exploring human factors as key influences in the area (Reason, 2008; Dekker, 2011). This relatively new but important discipline pays attention to human behaviour and how the pressure of delivering healthcare in dynamic and unpredictable circumstances can compromise outcomes
impacting on the quality of care and potential for error resulting in increased costs (NHS England, 2013). Much of this sub-theme indicates that the NMC's (2010) inclusion of first aid and incident management in under-graduate nurse education curricula was a timely and entirely appropriate development.