Keywords
First response, community first responders, out-of-hospital cardiac arrest, prehospital emergency care, volunteerism, motivation, systematic review, qualitative synthesis
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Heffernan E, Oving I, Barry T et al. Factors that motivate individuals to volunteer to be dispatched as first responders in the event of a medical emergency: A systematic review protocol [version 1; peer review: 2 approved]. HRB Open Res 2019, 2:34 (https://doi.org/10.12688/hrbopenres.12969.1)
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Study Protocol
Factors that motivate individuals to volunteer to be dispatched as first responders in the event of a medical emergency: A systematic review protocol
[version 1; peer review: 2 approved]
PUBLISHED 03 Dec 2019
OPEN PEER REVIEW
REVIEWER STATUS
Abstract
Corresponding author:
Eithne Heffernan
Competing interests:
No competing interests were disclosed. TB is a general practitioner who participates voluntarily in cardiac arrest community first response, he has roles in cardiac arrest education, research, and clinical care.
Grant information:
Health Research Board, Ireland [APA-2016-1859].
This work was also supported by the National Ambulance Service and the Pre-Hospital Emergency Care Council.
The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Copyright:
© 2019 Heffernan E et al.
This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
How to cite: Heffernan E, Oving I, Barry T et al. Factors that motivate individuals to volunteer to be dispatched as first responders in the event of a medical emergency: A systematic review protocol [version 1; peer review: 2 approved]. HRB Open Res 2019, 2:34 (https://doi.org/10.12688/hrbopenres.12969.1)
First published: 03 Dec 2019, 2:34 (https://doi.org/10.12688/hrbopenres.12969.1)
Latest published: 14 Sep 2020, 2:34 (https://doi.org/10.12688/hrbopenres.12969.2)
This work was also supported by the National Ambulance Service and the Pre-Hospital Emergency Care Council.
The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
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of this article available.
Introduction
Volunteerism is crucial to the provision of prehospital care to patients undergoing medical emergencies, such as cardiac arrest, chest pain, and choking (Whittaker et al., 2015). It can be defined as freely and deliberately choosing to perform helping activities for causes or individuals who desire assistance in the absence of contractual or friendship/familial obligation and without expectation of financial reward (Snyder & Omoto, 2008; Whittaker et al., 2015). Volunteerism can be informal (i.e. spontaneous) or formal (i.e. organised). Informal volunteers self-deploy or offer assistance without being part of a coordinated response by a relevant authority, such as when bystanders to a cardiac arrest alert the Emergency Medical Services (EMS) and initiate cardiopulmonary resuscitation (CPR) without being part of the organised emergency response (Geri et al., 2017; Maurer et al., 2019; Whittaker et al., 2015). In contrast, formal volunteers provide assistance as part of their official affiliation with a relevant agency (Whittaker et al., 2015). A prime example of formal volunteers are Community First Responders (CFRs), who are dispatched by the EMS to medical emergencies in their locality (Barry et al., 2019a).
CFRs were primarily introduced to improve the management of out-of-hospital cardiac arrest (OHCA) (Hollenberg et al., 2013; Truong et al., 2015). OHCA is a leading cause of mortality worldwide (Myat et al., 2018). Survival from OHCA is negligible in the absence of good-quality CPR and defibrillation within 5–10 minutes of collapse (Monsieurs et al., 2015; Ong et al., 2018). Therefore, CFRs were instituted to help the EMS reduce the time taken to respond to OHCA events, particularly in rural areas (Hollenberg et al., 2013; Masterson et al., 2015). These volunteers have typically completed training in basic emergency care and many carry Automated External Defibrillators (Phung et al., 2017). They can include lay responders and/or professional responders (e.g. physicians, police officers, and firefighters). A recent Cochrane review confirmed that CFR schemes can result in increased rates of CPR or defibrillation performed prior to EMS arrival (Barry et al., 2019a). Since their introduction, CFRs have come to play an integral role in OHCA management in many countries, including Canada, Japan, Australia, New Zealand, UK, and the Republic of Ireland (Barry et al., 2018; O’Meara et al., 2012; Orkin et al., 2016; Phung et al., 2017; Toyokuni et al., 2013). Furthermore, the role of CFRs has been expanded in many regions such that they are dispatched to an array of medical emergencies, including stroke, choking, and chest pain (Phung et al., 2017).
Research has uncovered a variety of factors that motivate individuals to become CFRs, including a desire to help patients, to save lives, to contribute to their local community, to contribute to health and/or social care services, to acquire or enhance knowledge and skills, to obtain experience for a future career in healthcare, to enhance their self-esteem, and to enhance their social network (Phung et al., 2017; Timmons & Vernon-Evans, 2013). In addition, some become CFRs because past experiences, such as witnessing a medical emergency or working as a healthcare professional, have given them an appreciation of the importance of first response (Barry et al., 2019b; Roberts et al., 2014). There is also evidence to suggest that the motives of CFRs can be influenced by demographic factors (e.g. age, gender). For instance, an Australian study found that female volunteers tended to express altruistic values, whilst their male counterparts were more likely to express egoistic or self-oriented values (Calcutt, 2019).
Research has provided insights on the factors that encourage individuals to maintain their participation in CFR schemes over time. For example, organising CFRs in cohesive groups that have dedicated leadership can sustain engagement (Kasper et al., 2017; Rice & Fallon, 2011). In addition, the availability of appropriate support mechanisms is crucial for the continued involvement of any CFRs who experience adverse reactions following an emergency, including stress, sleep disturbance, intrusive thoughts, and weight loss (Kindness et al., 2014; Mathiesen et al., 2016; Phung et al., 2018; Zijlstra et al., 2015). Furthermore, it is thought that resilience can mitigate the impact of traumatic experiences on CFRs (Timmons & Vernon-Evans, 2013). Feedback and recognition may also preserve the motivation of CFRs. Specifically, volunteers have expressed a desire for formal feedback about patient outcomes, reassurance regarding their CPR performance, and recognition of their contribution by the public and their organisation/EMS (Mathiesen et al., 2016; Phung et al., 2017). Moreover, CFRs are more likely to feel valued when they have opportunities to contribute to decision-making and policy development in their organisation/EMS (O’Meara et al., 2012; Stirling & Bull, 2011).
Several studies have examined demotivation and turnover amongst CFRs. It has been reported that some CFRs find aspects of first response to be burdensome, particularly spending time away from family, being ‘on call’, and responding to night-time emergencies (Roberts et al., 2014). It can be onerous for members of small CFR groups to share responsibility for responding to emergencies with just a few volunteers (Rørtveit & Meland, 2010). Whilst participating in first response is too time-consuming for some, other CFRs are rarely dispatched to emergencies, which can lead to deskilling and demotivation (Timmons & Vernon-Evans, 2013). A minority of CFRs prove to be unsuitable for the role, particularly those who are motivated by the dramatic and exciting aspects of responding to emergencies and those who lack the requisite calm demeanour and interpersonal skills (Barry et al., 2019b). Finally, some CFRs have fears about performing CPR, including fears about contracting infectious diseases, causing injury, becoming embroiled in legal action, and being unable to resuscitate the patient, as well as general feelings of panic and shock (Malta Hansen et al., 2017; Savastano & Vanni, 2011).
It is vital to develop an in-depth understanding of the motivation of CFRs in order to enhance CFR recruitment and retention, to improve the training and psychological support received by CFRs, and to optimise the organisation and structure of CFR schemes. This, in turn, could improve the outcomes of patients who depend upon CFRs for their survival, as well as the significant others of those patients. One previous systematic scoping review examined the literature relating to the experiences of CFRs in the United Kingdom, including their motives for adopting the role (Phung et al., 2017). These motives included a desire to assist one’s community and to strengthen one’s employability. However, it is important to review the literature from nations other than the United Kingdom, as CFR systems vary considerably between and even within countries (Oving et al., 2019). For example, different regions utilise different categories of CFR (e.g. lay people, police officers, taxi drivers, and off-duty healthcare professionals) who are likely to have distinct motives. Furthermore, the status of CFRs varies across regions in terms of whether they are part of the EMS, complementary to the EMS, or separate to the EMS, which could also influence their motivation. Therefore, this review will expand upon its predecessor by considering the full breadth of the international literature on CFR motivation.
Aims and objectives
This review aims to identify the factors that motivate individuals to volunteer to be dispatched as first responders in the event of a medical emergency. The specific objectives of the review are to identify: (1) the factors that influence the initial motivation of individuals to volunteer to provide first response to medical emergencies, (2) the factors that influence these individuals to sustain their voluntary participation in providing first response over time, and (3) any factors relevant to demotivation and turnover in these individuals.
Methods
Eligibility criteria
The inclusion criteria are specified according to the domains of the SPIDER search strategy tool: Sample, Phenomena of Interest, Design, Evaluation, and Research type (Cooke et al., 2012). The SPIDER tool was designed as an alternative to the Population, Intervention, Comparison, and Outcomes (PICO) tool, which is predominant in systematic reviews of quantitative research.
Sample. The sample are Voluntary First Responders, also known as CFRs, lay rescuers, and citizen responders. They can be defined as individuals who have volunteered with the statutory ambulance services/EMS to be dispatched as a first responder in the event of a medical emergency in their locality (Barry et al., 2019a). They can include lay responders and professional responders (e.g. medical, fire service, or police personnel). They are activated by the EMS dispatch centre or equivalent (e.g. charities working with the EMS). They do not have a statutory obligation to respond to medical emergencies. Research on volunteers based in any geographical region or country will be eligible for inclusion. The review will exclude research on informal, non-dispatched Voluntary First Responders. This refers to individuals who are present at or near a medical emergency and who volunteer to provide emergency care opportunistically and spontaneously, such as when an individual who witnesses an OHCA opts to telephone the EMS and perform CPR under the instruction of an EMS call-taker.
Phenomena of interest. This review will examine Voluntary First Response, which is a complex intervention for prehospital medical emergencies, including cardiac arrest, choking, stroke, and chest pain. It entails the mobilisation of individual volunteers or groups of volunteers by the EMS or equivalent as a first response to medical emergencies in their locality. Only research relating to medical emergencies in community or prehospital settings will be eligible for inclusion. Research on emergency care provided during secondary transfer of patients between hospitals will be excluded. This review will also exclude research on hospital emergencies, non-medical emergencies, military combat, man-made disasters, and natural disasters, such as fires, terrorist attacks, earthquakes, hurricanes, and nuclear disasters.
Design. Primary research studies that produce data relating to the aims and objectives of the review will be considered. The methods employed in these studies can include individual interviews, group interviews, questionnaires, surveys, and observation. In addition to peer-reviewed journal articles, conference abstracts and conference proceedings relating to the review question will be considered for inclusion. The remainder of the grey literature (e.g. editorials, practice guidelines, case reports, and case series) will be excluded. Firstly, there is no agreed approach to extracting and synthesising evidence obtained from the grey literature in a transparent way. Secondly, excluding the grey literature reduces the likelihood of including poor quality studies (Maidment et al., 2018).
Evaluation. This review will analyse the factors that motivate individuals to participate in Voluntary First Response for medical emergencies. This includes both the factors that influence their initial motivation to become a Voluntary First Responder and the factors that sustain their involvement in first response over time. Any factors relevant to the de-motivation (e.g. ceasing participation in first response) of Voluntary First Responders will also be reviewed. If there are sufficient data, the impact of demographic factors (e.g. age, gender) and different categories of Voluntary First Responders (e.g. community groups, fire services, police officers) will be examined.
Research type. Qualitative studies, mixed-methods studies, and any other studies producing data relating to the review question will be eligible for inclusion. Articles that are entirely written in a language other than English, including their title, abstract, and main text, will be excluded because the research team do not have the resources to support translation.
Search method
The following online databases will be systematically searched: CENTRAL, MEDLINE, PubMed, Embase, CINAHL, Scopus, and PsychINFO. In accordance with the Preferred Reporting Items for Systematic review and Meta-Analysis Protocols (PRISMA-P) checklist (Moher et al., 2015), a draft of the search strings (i.e. keywords and Boolean operators) to be used for one electronic database (i.e. Embase) are provided in Table 1. The databases and search strings were selected, in consultation with an expert librarian, in order to source relevant research studies from a range of disciplines (e.g. emergency medicine, psychology).
Table 1. Search Strings.
Screening
All references will be imported into Endnote and duplicates removed. Two authors (EH and IO) will independently screen the title and abstracts of the retrieved articles against the eligibility criteria using Rayyan QCRI (Ouzzani et al., 2016). The full text of every potentially relevant article will be obtained and examined for eligibility. The two authors will review all full text articles. Any disagreements about the exclusion of articles will be resolved through discussion. Where necessary, a third author (SM) will be engaged to make the final decision. In addition, the authors of the retrieved articles will be approached for additional information and clarification as needed. Reasons for the exclusion of articles will be noted. The search strategy and study selection process will be reported in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement (Liberati et al., 2009; Moher et al., 2009). A PRISMA flow diagram will be presented.
Data extraction
One author (EH) will manually extract the data from the included studies and 10% of these will be randomly selected and checked for consistency by a second author (IO). Any discrepancies will be managed through discussion between the two authors or, where needed, consultation with a third author (SM). Information will be extracted via a data collection form for each of the SPIDER tool domains: Sample, Phenomena of Interest, Design, Evaluation, and Research type (Cooke et al., 2012). The form will also facilitate the extraction of general information about each study (e.g. title, date of publication, author details). The data collection form will be piloted and, where necessary, revised by the two authors responsible for data extraction (Maidment et al., 2018).
Data synthesis
A qualitative synthesis will be performed, which entails developing new explanations and interpretations of the study findings (Barnett-Page & Thomas, 2009). The specific qualitative synthesis methodology utilised will be a narrative synthesis. This approach comprises four main stages: (1) developing a preliminary synthesis of the results of the included studies (e.g. producing textual descriptions and tables), (2) exploring relationships within and between studies (e.g. undertaking conceptual mapping and subgroup analyses), (3) assessing the robustness of the synthesis (e.g. performing quality appraisal and critical reflection processes), (4) developing conclusions and recommendations (Arai et al., 2007; Lucas et al., 2007; Popay et al., 2006). QSR International’s NVivo Software (Version 12) will be used to support the organisation and analysis of the data. One author (EH) will carry out the data analysis. In addition, peer assessment/second coding will be conducted in order to enhance the rigour and validity of the data analysis (Heffernan et al., 2018; Yardley, 2008). Specifically, a second author (TB) will independently code at least 10% of the papers included in the analysis. The first and second author will meet to compare their codes and to resolve any discrepancies through discussion. The first author will also discuss the preliminary results with the research team to obtain their feedback and to ensure that the analysis is not limited to the viewpoint or preconceptions of the first author.
Quality appraisal
Study quality will be critically appraised using the Mixed Methods Appraisal Tool (Hong et al., 2018a). This validated tool was designed to enable systematic review authors to evaluate the quality of studies with diverse designs and paradigms (Hong et al., 2018b; Hong et al., 2019; Souto et al., 2015). It covers five methodological domains: qualitative research, randomised controlled trials, non-randomised studies, quantitative descriptive studies, and mixed methods studies. It is therefore suitable for this review, which is anticipated to primarily uncover qualitative and mixed methods studies. One author (EH) will assess the quality of papers selected for data extraction prior to inclusion in the review. A second author (TB) will assess 10% of the papers to check for consistency and to resolve any disagreements through discussion. A third author (SM) will be consulted as required. Furthermore, as part of the narrative synthesis process, the findings of the review itself will be critically appraised. This will involve examining the adequacy of the data supporting the findings and the contribution of lower quality studies to the findings. This appraisal will be carried out by one author and reviewed by a second.
Dissemination
The results of the review will be reported at academic conferences, as well as in a peer reviewed journal using the PRISMA guidelines (Liberati et al., 2009). The findings will also be disseminated at a national event organised by the authors to inform key stakeholders (e.g. patients, CFRs, paramedics, general practitioners, and researchers) about the research. Patient and Public Involvement representatives will be involved in dissemination that targets CFRs and members of the public. The findings will form part of the results of a larger study funded by an Applied Partnership Award from the Health Research Board of Ireland. The primary aim of the larger study is to develop recommendations regarding CFR data collection, integration, and analysis practices.
Protocol registration
This protocol is registered with the International Prospective Register of Systematic Reviews (PROSPERO). Any amendments to the protocol (ID: CRD42019145316) will be recorded via PROSPERO.
Discussion
Volunteerism is a vital component of prehospital care for medical emergencies (Whittaker et al., 2015). Out-of-hospital cardiac arrest (OHCA) is the most time-critical medical emergency (Ong et al., 2018). Specifically, survival from OHCA is greatly reliant on the rapid provision of cardiopulmonary resuscitation (CPR) and defibrillation (Hasselqvist-Ax et al., 2015; Myat et al., 2018). Therefore, OHCA management poses a considerable challenge for the EMS, particularly in remote or rural areas. Consequently, Voluntary First Response schemes have been established in many communities globally to improve emergency response times for OHCA patients (Hollenberg et al., 2013; Oving et al., 2019). This intervention entails the mobilisation of volunteers, known as Community First Responders (CFRs), by the EMS or its equivalent to respond to OHCA events in their locality (Barry et al., 2019a). Since its inception, this intervention has grown in scope such that CFRs in many regions are now dispatched to a wide range of medical emergencies, including stroke, choking, and chest pain. Furthermore, the role of CFRs is becoming increasingly complex as, in addition to basic emergency care skills (e.g. CPR), they are often required to have specialised non-clinical skills, including resource management, communication, teamwork, and conflict resolution (Phung et al., 2018; Wilson et al., 2015).
Developing an in-depth understanding of the motivation of individuals to participate in Voluntary First Response is vital to the optimisation of this intervention. The research to date indicates that a wide variety of factors can influence the motivation of individuals to join and remain engaged in Voluntary First Response schemes, including the availability of learning opportunities, feedback and recognition, psychological support, leadership, and consultation (O’Meara et al., 2012; Phung et al., 2017; Timmons & Vernon-Evans, 2013). Therefore, the findings of this review could be used to inform in the design and organisation of these schemes, including their recruitment, retention, training, and psychological support processes. This, in turn, could have benefits for all stakeholders involved in Voluntary First Response, including the volunteers themselves, EMS personnel, and emergency physicians, as well as the patients, their family members, and their local communities.
Data availability
Reporting guidelines
Open Science Framework (OSF): PRISMA-P checklist for factors that motivate individuals to volunteer to be dispatched as first responders in the event of a medical emergency: A systematic review protocol, https://doi.org/10.17605/OSF.IO/SQVCZ (Heffernan, 2019).
Data are available under the terms of the Creative Commons Zero “No rights reserved” data waiver (CC0 1.0 Public domain dedication).
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Heffernan E, Oving I, Barry T et al. Factors that motivate individuals to volunteer to be dispatched as first responders in the event of a medical emergency: A systematic review protocol [version 1; peer review: 2 approved]. HRB Open Res 2019, 2:34 (https://doi.org/10.12688/hrbopenres.12969.1)
NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article.
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ApprovedThe paper is scientifically sound in its current form and only minor, if any, improvements are suggested
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A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.
Not approvedFundamental flaws in the paper seriously undermine the findings and conclusions
Version 1
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PUBLISHED 03 Dec 2019
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How to cite this report:
Dainty K. Reviewer Report For: Factors that motivate individuals to volunteer to be dispatched as first responders in the event of a medical emergency: A systematic review protocol [version 1; peer review: 2 approved]. HRB Open Res 2019, 2:34 (https://doi.org/10.21956/hrbopenres.14054.r27393)
The direct URL for this report is:
https://hrbopenresearch.org/articles/2-34/v1#referee-response-27393
https://hrbopenresearch.org/articles/2-34/v1#referee-response-27393
NOTE: it is important to ensure the information in square brackets after the title is included in this citation.
Reviewer Report 18 May 2020
Approved
VIEWS 41
Thank you for the opportunity to review this SR protocol. This is an important topic and the authors have done an excellent job of outlining a thorough protocol. I just have a couple of comments/areas for clarification:
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HOW TO CITE THIS REPORT
Dainty K. Reviewer Report For: Factors that motivate individuals to volunteer to be dispatched as first responders in the event of a medical emergency: A systematic review protocol [version 1; peer review: 2 approved]. HRB Open Res 2019, 2:34 (https://doi.org/10.21956/hrbopenres.14054.r27393)
The direct URL for this report is:
https://hrbopenresearch.org/articles/2-34/v1#referee-response-27393
https://hrbopenresearch.org/articles/2-34/v1#referee-response-27393
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
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Author Response 18 Sep 2020Eithne Heffernan, Discipline of General Practice, Clinical Science Institute, School of Medicine, National University of Ireland, Galway (NUIG), Galway, H91 TK33, Ireland18 Sep 2020Author ResponseWe would like to thank the reviewer for their valuable feedback. Their comments have helped us to improve the protocol of this qualitative systematic review. We have provided a response ... Continue reading
COMMENTS ON THIS REPORT
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Author Response 18 Sep 2020Eithne Heffernan, Discipline of General Practice, Clinical Science Institute, School of Medicine, National University of Ireland, Galway (NUIG), Galway, H91 TK33, Ireland18 Sep 2020Author ResponseWe would like to thank the reviewer for their valuable feedback. Their comments have helped us to improve the protocol of this qualitative systematic review. We have provided a response ... Continue reading
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44
How to cite this report:
Smith CM. Reviewer Report For: Factors that motivate individuals to volunteer to be dispatched as first responders in the event of a medical emergency: A systematic review protocol [version 1; peer review: 2 approved]. HRB Open Res 2019, 2:34 (https://doi.org/10.21956/hrbopenres.14054.r27282)
The direct URL for this report is:
https://hrbopenresearch.org/articles/2-34/v1#referee-response-27282
https://hrbopenresearch.org/articles/2-34/v1#referee-response-27282
NOTE: it is important to ensure the information in square brackets after the title is included in this citation.
Reviewer Report 20 Apr 2020
Christopher M. Smith,
University of Warwick, Coventry, UK
Approved
VIEWS 44
A detailed and well-thought-out protocol. I have two minor comments:
- Those joining statutory/regulatory CFR schemes might (or might not) have very different reasons for volunteering than those joining up to ad-hoc schemes (e.g. GoodSAM, Pulsepoint, Heartrunner). A
CITE
HOW TO CITE THIS REPORT
Smith CM. Reviewer Report For: Factors that motivate individuals to volunteer to be dispatched as first responders in the event of a medical emergency: A systematic review protocol [version 1; peer review: 2 approved]. HRB Open Res 2019, 2:34 (https://doi.org/10.21956/hrbopenres.14054.r27282)
The direct URL for this report is:
https://hrbopenresearch.org/articles/2-34/v1#referee-response-27282
https://hrbopenresearch.org/articles/2-34/v1#referee-response-27282
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
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Author Response 18 Sep 2020Eithne Heffernan, Discipline of General Practice, Clinical Science Institute, School of Medicine, National University of Ireland, Galway (NUIG), Galway, H91 TK33, Ireland18 Sep 2020Author ResponseWe would like to thank the reviewer for their constructive and helpful comments. We welcome their suggestions on how to improve the protocol of this qualitative systematic review. We have ... Continue reading
COMMENTS ON THIS REPORT
-
Author Response 18 Sep 2020Eithne Heffernan, Discipline of General Practice, Clinical Science Institute, School of Medicine, National University of Ireland, Galway (NUIG), Galway, H91 TK33, Ireland18 Sep 2020Author ResponseWe would like to thank the reviewer for their constructive and helpful comments. We welcome their suggestions on how to improve the protocol of this qualitative systematic review. We have ... Continue reading
Comments on this article Comments (2)
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PUBLISHED 14 Sep 2020
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PUBLISHED 03 Dec 2019
Discussion is closed on this version, please comment on the latest version above.
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Author Response 18 Sep 2020Eithne Heffernan, Discipline of General Practice, Clinical Science Institute, School of Medicine, National University of Ireland, Galway (NUIG), Galway, H91 TK33, Ireland18 Sep 2020Author ResponseThank you for the above comment. We appreciate your insights on this topic, particularly your feedback that some community first responder programs have not yet been documented in the peer-reviewed ... Continue reading
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Discussion is closed on this version, please comment on the latest version above.
Alongside their report, reviewers assign a status to the article:
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Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions
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