Prehospital Providers' Perceptions on Providing Patient and Family Centered Care

ABSTRACT

Background: A gap exists in understanding a provider's approach to delivering care that is mutually beneficial to patients, families, and other providers in the prehospital setting. The purpose of this study was to identify attitudes, beliefs, and perceived barriers to providing patient and family centered care (PFCC) in the prehospital setting and to describe potential solutions for improving PFCC during critical pediatric events. Methods: We conducted a qualitative, cross-sectional study of a purposive sample of Emergency Medical Technicians (EMTs) and paramedics from an urban, municipal, fire-based EMS system, who participated in the Pediatric Simulation Training for Emergency Prehospital Providers (PediSTEPPS) course. Two coders reviewed transcriptions of audio recordings from participants' first simulation scenario debriefings and performed constant comparison analysis to identify unifying themes. Themes were verified through member checking with two focus groups of prehospital providers. Results: A total of 122 EMTs and paramedics participated in 16 audiotaped debriefing sessions and two focus groups. Four overarching themes emerged regarding the experience of PFCC by prehospital providers: (1) Perceived barriers included the prehospital environment, limited manpower, multi-tasking medical care, and concern for interference with patient care; (2) Providing emotional support comprised of empathetically comforting caregivers, maintaining a calm demeanor, and empowering families to feel involved; (3) Effective communication strategies consisted of designating a family point person, narration of actions, preempting the next steps, speaking in lay terms, summarizing during downtime, and conveying a positive first impression; (4) Tactics to overcome PFCC barriers were maintaining a line of sight, removing and returning a caregiver to and from the scene, and providing situational awareness. Conclusions: Based on debriefings from simulated scenarios, some prehospital providers identified the provision of emotional support and effective communication as important components to the delivery of PFCC. Other providers revealed several perceived barriers to providing PFCC, though potential solutions to overcome many of these barriers were also identified. These findings can be utilized to integrate effective communication and emotional support techniques into EMS protocols and provider training to overcome perceived barriers to PFCC in the prehospital setting.

Keywords:

• simulation
• patient and family centered care
• prehospital
• family presence
• qualitative

Introduction

Patient- and family-centered care (PFCC) is defined as a unique approach to the planning, delivery, and evaluation of health care that is grounded in mutually beneficial partnerships among health care providers, patients, and families.¹ In a 2006 joint policy statement, the American Academy of Pediatrics (AAP) and the American College of Emergency Physicians (ACEP) advise that hospitals implement policies for PFCC in the Emergency Department (ED).² The AAP and ACEP guidelines recognize the patient and family as key decision-makers in the patient's medical care by encouraging family-member presence and providing information to the family during interventions. Although there are several studies of hospital staff's views regarding provision of PFCC during invasive procedures and pediatric resuscitation,^3,4 prehospital providers' perspectives on PFCC have not been well described.

The prehospital setting is an essential component of the continuum of emergency care, and both the Centers for Disease Control and The Joint Commission identify the importance of collaboration across continuums of care.^5,6 The adoption of best practices in the prehospital setting, however, is at times delayed relative to practice in the emergency department.⁷ In a national survey of hospital-based pediatric transport team managers, there was a lack of agreement about allowing parents to accompany children during pediatric transports, although those that did noted the benefits of reassuring the child and keeping the parent informed.⁸ An Emergency Medical Services for Children (EMSC) and National Association of Emergency Medical Technicians (NAEMT) jointly endorsed guideline on prehospital PFCC notes that little is known about prehospital providers' opinions and practices related to PFCC and calls for future studies on the communication skills of EMS providers, including family satisfaction with the amount, content, and clarity of information given.⁹ While one cross-sectional survey of paramedics involved in interfacility pediatric transports showed that effective family counseling can be achieved in critical, time-limited situations, the study did not explore the paramedics' opinions or perceived barriers to delivering effective PFCC.¹⁰ Patient-family interaction was also identified as a priority study objective in a recent article regarding Pediatric Research Priorities in Prehospital Care.¹¹

Therefore, a gap exists in understanding the attitudes and beliefs of EMS providers regarding provision of PFCC. The objective of this study is to identify the attitudes to, beliefs regarding, and perceived barriers to providing PFCC in the prehospital setting and describe possible solutions to improve delivery of PFCC.

Methods

Study Population and Setting

Given that critical pediatric events are rare in the prehospital setting, we used a purposive sample of licensed Emergency Medical Technicians (EMTs) and paramedics from an urban, municipal, fire-based EMS system who participated in the Pediatric Simulation Training for Emergency Prehospital Providers (PediSTEPPS) course. PediSTEPPS was developed to provide simulation-based education for prehospital providers caring for critically ill children in the prehospital environment. The course includes a didactic lecture, pediatric skills stations, and four high fidelity simulation scenarios. Each scenario is followed by a scripted debriefing session, co-facilitated by trained EMS and pediatric emergency medicine (PEM) instructors.^12,13 The Baylor College of Medicine Institutional Review Board approved this study. Furthermore, all of the participants provided written informed consent to have the simulations video-recorded and have the debriefings audio-recorded, with the expectation that these recordings would be later analyzed for content with possible inclusion of anonymous quotes in research publications.

Study Design

This was a qualitative study of prehospital providers' knowledge, attitudes, beliefs, and perceived barriers to providing PFCC during pediatric emergency situations. The study design was based on grounded theory, which uses inductive analysis to explain a given social situation by identifying the core processes operating in it. Thus, this method generates theoretical explanations of social and psychosocial processes.^14–17 Themes regarding prehospital providers' attitudes about PFCC were explored through an iterative coding process until thematic saturation was achieved.

Inclusion Criteria

We included only the audio recordings of participants from the debriefing sessions that immediately followed each course day's first simulation scenarios in order to avoid participant fatigue or bias from previous debriefing sessions. The first scenario was either a case of respiratory distress/failure or non-accidental trauma, both of which were designed a priori to address issues related to PFCC.

Exclusion Criteria

Simulation debriefings were excluded if there was a technical malfunction during the simulation or if the audio recording was inaudible or did not contain the complete debriefing session. The video recording of the simulations was not used.

Data Collection

The audio-recorded debriefing sessions were derived from a natural group, as the group existed independently of our research study and were analyzed retrospectively.¹⁸ In addition to the providers and instructors; each debriefing session included the actress or actor who played the role of a standardized parent in the scenario and their responses were also recorded and analyzed thematically. The standardized caregivers were trained to respond naturally to how the EMS personnel interacted with them, and this training was based on real-world responses from caregivers in similar situations. In order to train the standardized caregivers to respond as a parent would in a similar situation, experienced paramedic and emergency physician course instructors provided feedback to the standardized caregivers during practice sessions via an earpiece as the simulation occurred and face-to-face after the practice simulation was completed. Paramedic and physician instructors based their feedback on responses they have received from real caregivers in similar situations in the prehospital and emergency department settings. Therefore, the standardized caregivers were included in the debriefings to provide feedback on the EMS providers' communication skills from the parent's perspective.

Member checking, known as respondent validation, is a technique used by researchers to help improve the accuracy, credibility, validity, and transferability of qualitative findings by checking the findings and interpretation with a similar group.¹⁸ Member checking was performed with two focus groups of PediSTEPPS participants, which involved integrating open ended questions to determine if their perspective was similar to initial findings of the study.¹⁸ We performed member checking with the focus groups to review themes and to check for accuracy and completeness of the findings. Two coders (EMA, EMS) evaluated the findings to allow for investigator triangulation and ensure trustworthiness.

Data Analysis

Audio recordings of the debriefings were transcribed into NVivo10 software.¹⁹ Two investigators (EMA, EMS) individually analyzed the audio recordings to identify major themes. The primary technique was “constant comparison analysis,” a process through which each piece of data is compared and contrasted with other data to build a conceptual understanding of the categories within the phenomenon of interest. Researchers repeatedly read through interview transcripts, formulated an initial framework of key codes, and refined these codes with successive readings of transcripts. Codes were then reviewed and revised, and any disagreements in coding were resolved by team consensus.

Memos of coding decisions were kept to provide consistency in coding as analysis progressed. The “thematic approach” is a widely utilized process in the analysis of qualitative data.^20,21 As individual and potentially related categories were explored, unifying themes were identified until “thematic saturation” was achieved, when no new themes emerged in successive interview transcripts.

Results

Thematic saturation was achieved after reviewing 16 audiotaped debriefing sessions, followed by member checking with two focus groups, involving a combined total of 122 EMTs and paramedics. A total of 20 members were in the focus groups.

Four overarching themes emerged regarding the experience of PFCC by prehospital providers (Table 1 and Figure 1): (1) Perceived barriers to providing PFCC in the prehospital setting; (2) Providing emotional support to caregivers; (3) Strategies for effective communication; and (4) Tactics to overcome perceived caregiver barriers. These themes are based on the prehospital providers and standardized caregivers opinions and perspectives on PFCC.

Table 1. Principle themes on barriers to and strategies for providing family centered prehospital care

Themes	Codes	Quotes	Ref^*
Barriers	Interference in Delivering Patient Care	“She was kind of hovering, so it was kind of hard to work, when a parent is hovering.”“My distraction was her [caregiver] because I was trying to help out with the team, but then she got more in the way … and so I had to get her out of the way, so they could do the job.”“Absolutely, so when you are taking care in critical situations, your focus has to be the medical care. Part of that, though, is you want to make sure you are creating a situation or atmosphere that's not going to be disruptive to your medical care. Sometimes if you don't update the family, they can start to become more disruptive than they already might be.”“To let them hold their hand could be good, but as things progressed with the patient and things get worse, that can make the parent that much more aggressive too and impede what we are trying to do. I've had that happen numerous times and the best thing to do at that point in time is to get that parent out of the room.”	33
	Manpower and Multitasking	“Yeah that's not going to happen, in a real world situation, you can get some information, but everybody's got something going on, so you are going to end up feeling like you are being left out. That's just real world truth.”“Everybody's got a job … I have had that parent … you can give them a brief description, but the reality is that everybody's got something to do.”	12
	Unfamiliar Environment	“You have to realize that we are in somebody else's home and we are on their turf. A lot of times I've found, when you start talking to people it calms people down, especially those that are very upset. It gives the impression that 1: you are including them; 2: you know what you are doing; 3: you can get a take on who your friends or your foes are.”	4
Providing Emotional Support to Caregivers	Empowerment	“[Make] them a part of what's going on, utilizing that particular resource. The more you ask questions [you] empower them by putting them in on some of the decision making. Explaining each step.”“It's always a feeling of empowerment to the family to have some type of close [proximity to the patient].”	18
	Calming Energy	“Y'all were actually very calm in the scenario. There wasn't a lot of useless conversation, but because I saw that y'all were calm, I in turn was calm. It translated trust for me; because y'all were collected and organized, I felt you were better taking care of my child.”“I felt very well taken care of … I do tend to react to energy in the room. So you were being very calm.”	17
	Providing Comfort and Empathy	“And I think originally when you came over first, you put a hand on my shoulder for just a moment, so I would know you were there, and that was comforting.”“One person was talking to me … you had a hand on my back the entire duration that you were talking to me which was empathetic … It played into my maternal instinct. It reminded me to breathe and relax.”“I have kids too, to feel like, oh, we're allies. That's a good way to be an ally to someone. I'm a Dad too; I know what that's like. If this were my kid, this is the way I would want to be treated. So I understand you're scared, just relating you understand as a parent.”	12
Strategies for Effective Communication	Designate Roles: The Family Point Person	“I guess somebody could be there from the word go … Be with her from the time we get there until it's over with … so she's not having to ask questions and get frustrated … If you have the resources and manpower … have somebody designated to update the caregivers.”“Sometimes we need to be directed. I've been on calls where everyone is going in different directions, and we forget all about the family; somebody has to step up.”“Someone needs to be delegated to the parent. At the same time you've got make sure that they're aware of everything that's going on, as long as they're not disrupting patient care, they need to be there, where they can see everything. Someone has to take that role.”	33
	Utilize Lay Language	“When you were talking to me, you started giving me what was going on, but it was all in medical terms, I didn't understand a word of it.”	12
	Utilize Downtime and First Impression	“You have done what you thought you could, and you were waiting for ALS to arrive, and I noticed you were doing something very nice … you were explaining everything to mom.”“Communication with the parents is key. A lot of people don't do that at the beginning, because they are just trying to figure out the scenario, but it help to calm them down.”	5
	Narration	“So it's like give you a play by play … The baby's heart rate is going too slow, so we are going to beat it for them to make it go faster … And we are going to put a tube it their throat so that we can breathe for them, because they stopped breathing.”	4
Tactics to Overcome PFCC Barriers	Line of Sight	“For us, trust me, I work out in the field. I understand. I think what we fail to realize, if you have a child, say it's your child, your baby, not so much take the parent out of the room; put them maybe at the front of the bed, because I guarantee if it's anyone of us, you aren't leaving the room.” “You took her around, because it seemed like she was getting in the way [and said], ‘I'm going to take you over here where you can still see what is going on.’ That line of sight is important, you want them out of the way, but you still want them to be able to see. It helps them still feel somewhat in control even though they aren't in control.”	33
	Situational Awareness	“It's a matter of self-preservation; you have to maintain a sense of professionalism. Hey guys, let's load and go … everybody knows if you say load and go, that means trauma.”“Anything outside of the realm that facilitates patient care, you should probably let it stay in its own lane. When you are in that situation you can be direct without being accusatory; control your emotions. It's not about you or how you feel. You are not the police; you are there to provide patient care … Proceed in a professional and controlled manner.”	4
	Time-out	“She wasn't being disruptive, so sometimes taking them out of the room could cause them to do that. And they are a source of information; having her there could be an asset.”“Just because you take someone out of the room doesn't mean you can't bring them back in.”	3

^* Number of times a coded sub-theme was referenced in audio transcript.

Figure 1. Conceptual framework of barriers and strategies to facilitate PFCC.

Barriers to Providing PFCC in the Prehospital Setting

During the debriefings, providers commonly noted several reasons why it was difficult to incorporate PFCC which included; interference with delivering patient care, especially since initial care is often in an unfamiliar environment, and limited personnel may hinder their ability to multi-task between patient care and communicating with the caregiver(s) on scene.

Interference in Delivering Patient Care

During the debriefings, many of the EMS providers reported that interference or distraction from the standardized caregiver in the scenario hindered their ability to provide effective patient care and communicate the care plan to the parent. It was “very difficult [to have] parents, family, that [make] your job hard as far as taking care of the patient” and they felt “intimidated if the parent is right there.” On the contrary, by removing a parent from the room, another provider emphasized, if you try to take the parent away when something is going on “you are going to have an irate parent.”

Overall, providers felt their primary obligation was to provide patient care. “In a life threatening situation, our priority is patient care, before parent care.” In contrast, other providers acknowledged the competing priorities of patient care and PFCC, and some made a point of stating that parents may escalate behavior if you do not involve them early. “If the parents are so hysterical it does no good to have them within 5 feet of the child … if they stay calm, I have no problem with it.”

Unfamiliar Environment

Because prehospital providers face the unique challenge of delivering care in the unfamiliar territory of the patient's home, many felt guarded or on edge being in an unaccustomed environment. EMS providers are “in someone else's home, so if [they] blow up and the parent blows up, [they] are on that parent's turf” and this may affect their interaction with families.

Manpower and Multitasking

Basic Life Support (BLS) providers typically arrive on scene with limited personnel, and one BLS provider noted, “We get there by ourselves, just me and him. We have a distraught parent all in our way. It's going to be difficult for us to render patient care. There are only two of us.” In most simulation scenarios, there were more providers initially than a two-provider EMS crew, however, “when it's just the two [person] BLS crew that shows up first, especially in a cardiac arrest, that would be a really tough situation.”

Providing Emotional Support to Caregivers

Both providers and the standardized parents cited the importance of providing emotional support to caregivers. This theme emerged indirectly when providers reflected on prior patient care experiences and directly from the interactions the providers had with the standardized parent during the scenarios and debriefings.

Calming Energy

The standardized caregivers often stated how they felt comforted when the providers “spoke in calm terms [with a] collected demeanor.” Furthermore many EMS providers expressed the same desired qualities from parents on calls, as this provider does when he discusses one of the caregivers in the scenario, “She was calm; she never got in the way. She answered questions; she was cooperative.”

Providing Comfort and Empathy

There was a positive response when the providers provided comfort and built trust with the standardized caregiver. There were multiple instances when providers empathized with parents on the basis of being parents themselves. Communication provided comfort “for a parent who has never seen her child in that situation.”

Empowerment

Incorporating the caregivers into the resuscitation was mentioned as an important aspect and allowed standardized caregivers to feel that they were welcomed rather than feeling ignored during the scenario. It was very difficult to “optimize patient care while balancing inclusion of those at the scene”; however, when done well it empowered the parent “by keeping her involved, not isolating her or secluding her from her child.”

Providers also noted that inclusion of the caregiver could be an asset, by “telling her what [they] were doing, she felt like she was more part of helping us instead of being an outsider.” “The more you ask [the family] questions … [You] empower them by putting them in on some of the decision making.”

Strategies for Effective Communication

In addition to elucidating the benefits of providing emotional support, comments from the debriefings also identified several useful strategies for communicating with family members on scene to enhance PFCC.

Designation of Roles: The Family Point Person

One of the most common tools for effective communication was having a dedicated role for someone to update and stay with the parent. When there is extra personnel, having “one person throughout the entire thing [for the caregiver] to talk to translates trust and prevents them from being pulled in many directions” and can “make it less confusing in the long run.” It helps the family “have a point person” and to hear “stay right here with me, I'll let you know what is going on.” Providers commonly identified either someone in a supervisory role or someone who was not immediately involved in direct patient care as the ideal person to communicate with the family.

Narration

In many situations, providers noted that there may not be enough personnel to allow for a dedicated person on scene to communicate with the family. One strategy identified by both providers and standardized parents was to narrate to the family as providers deliver care. A standardized parent stated that the family often “just needs to know what is happening,” and this can be as simple as “narrat[ing] what you are doing.”

Preempting

Standardized caregivers, as well as, providers felt it was helpful to prepare the parents by cautioning them of an event or procedure that was about to occur during the care of their child. Caregivers felt “it [was] helpful to have someone preparing [me] in advance before something happens.” For example, prior to placing an intraosseous needle, a provider stated that the procedure was difficult to watch, but that helped to “mentally prepare” the family.

Utilize Lay Language

Communicating with the standardized caregivers in “terms that [they] are able to comprehend” allowed the family to feel “comforted” and “translated trust.” Giving “them feedback on what's happening in the most laymen's terms,” was cited as important by several standardized parents and providers. Several participants acknowledged how medical terminology or “shop speak” can cause escalation or unnecessary anxiety with the parent.

Utilize Downtime and First Impression

Another simple tool that several providers suggested was utilizing the downtime on calls to update family members. After an initial assessment, or while waiting for another crew to arrive, providers commented that one member could communicate with the family to summarize initial impressions and anticipated plans of care. For example, start with “a one line sentence: your baby is critically ill right now; I need to pay attention to them. You have to be courteous … [but] we will talk to you more.”

Tactics to Overcome PFCC Barriers

Line of Sight

Whether it was at the foot of the bed or across the room, it was incredibly important to the standardized caregiver to be “allowed to touch [the child, and maintain] a line of sight.” Some providers noted that allowing the caregiver to maintain a view of the patient can help to prevent further escalation, especially in the case of a poor outcome. One provider stated, if that is the “last time that parent sees their child alive, that may help them process things in the long term.” Another cited prior experience when working “pediatric cardiac arrests and [letting] mom hold the baby's hand the whole time … it's better when they are right there.”

Time Out

At times interference and escalation with standardized caregivers was felt to be a barrier to delivering patient care, thus warranting provisional removal, or a “time out,” from the scene. Several providers suggested this as a temporary way to remove the parent from the situation to continue to allow others to deliver care while simultaneously updating the parent, and then permitting him or her to return to the child's line of sight when calm.

Situational Awareness

During debriefings following the non-accidental trauma scenario, several providers commented on the dilemma between sharing information with the caregiver and communicating potentially anger-provoking impressions to their colleagues. At times the crew felt like they could not freely talk to the caregiver nor their colleagues and had to “watch out what [they said].” One provider even “withheld information [from his partner] because the mom was there.” One provider suggested using a code phrase such as “load and go” to indicate the need to continue further discussion in the ambulance, since the parent “doesn't know the difference” and this may prevent them from feeling accused.

Discussion

The objective of this exploratory qualitative study was to identify attitudes, beliefs, and perceived barriers to providing PFCC in the prehospital setting. We also elicited several potential tools and strategies to facilitate communication and overcome perceived barriers to delivering PFCC.

The most frequently encountered barrier to communicating with the caregiver was parental interference and distraction in delivering care to the patient. Providers discussed feeling the need to remove the parent or caregiver from the situation for fear they would interfere with patient care, though this contradicts published recommendations regarding PFCC during pediatric resuscitation and procedures.²² Although the context of these recommendations and an AAP technical report is for emergent situations in the hospital, the concept of family presence is relevant in the prehospital setting.² There are many similarities between the challenges of providing PFCC in the prehospital and ED settings, including a new encounter in an unfamiliar setting without an ongoing provider-patient relationship in a potentially high acuity situation that may involve invasive procedures and the need for resuscitation.² A survey of 400 parents revealed that for a major resuscitation scenario, 80% of parents would wish to be present if their child were conscious, 71% would want to be present if their child were unconscious, and 83% would desire to be present if their child were likely to die during the resuscitation.²³ Manguren et al. reviewed numerous resuscitations and procedures in the ED with families present and found no interruptions in patient care.²⁴ Furthermore, nearly 95% of these families reported that being present helped them in the understanding of their child's condition.²⁴ Adult hospitals with a policy on family presence during resuscitation generally have no statistically significant differences in outcomes and processes of care as hospitals without this policy, suggesting that such policies may not negatively affect resuscitation care.²⁵ Despite this information, verbal and physical interference by family is a concern shared by both ED²⁶ and prehospital providers alike. Emotional response of caregivers of children relative to adults was also identified by EMS personnel as a barrier to providing patient care.²⁷

In a meta-synthesis of 30 qualitative primary studies on PFCC, we found many similar themes to our prehospital study.²⁸ This body of literature supports what we found; information conveyed to caregivers should be clear, consistent and repeated. Satisfaction with communication significantly determined whether the parent experienced the event positively or negatively. The majority of parents also reported decreased satisfaction with separation from their child, which correlated with the standardized caregivers' feeling of disempowerment when losing their parental role.²⁸

In the prehospital setting there remains the disadvantage of lack of time and relationships with family; however, we can extend the need for family presence to the prehospital setting. Providing comfort and empathy, empowering the family to feel involved in the care of the patient, encouraging line of sight, and providing a time-out or option for the family to return to the patient after becoming disruptive all support family presence and PFCC in the prehospital setting. Utilizing the child's name during the scenario was brought up as an important technique in communicating with families and building trust. It was perceived as a quick and simple way to increase rapport and provide reassurance to the family, but was not a recurrent theme likely due to the simulation setting.

Lack of manpower was a frequently cited barrier, and providers often recommended having a person solely designated to communicate with the family. A solution mentioned during the debriefings was that someone might need to have two jobs and periodically update the family as a narrator to explain things while also providing patient care. These short updates may continue to allow the family to feel empowered and included, thereby preventing escalation. There was an interesting dichotomy between providers who strongly believed they should try to keep the family involved and present whenever possible and others who felt they needed to remove families from the situation to provide effective patient care. Our findings offer some potential strategies and tactics for addressing common concerns.

Limitations

Our results were obtained retrospectively from simulated pediatric emergencies in the prehospital setting. Therefore, our findings may not be fully generalizable to real world situations. However, during the debriefings, providers frequently referred to their experiences in the field, so we feel many of the barriers and strategies elicited are applicable to prehospital care on a daily basis. Additionally, because the study was based on simulations, our results are based on the input of actors playing the caregiver or family role. However, the standardized caregivers were trained to respond naturally to how the EMS personnel interacted with them, and this training was based on real-world responses from caregivers in similar situations. Future study related to PFCC in the prehospital setting should include parental impressions of PFCC in real life situations.

In the two scenarios we utilized, both patients were infants; thus, we may not be able to fully apply our results to older children. Two coders (EMA, EMS) were used in the evaluation of the data, which may have introduced bias based on their feelings and experiences regarding PFCC. However, utilizing two coders allowed for investigator triangulation and ensured trustworthiness. Furthermore, member checking with two focus groups of 20 prehospital providers confirmed consistency and dependability of the findings. A limitation of simulated scenarios is being in a controlled environment. One specific area mentioned in focus groups that was not revealed in our analysis was the pivotal role of language barriers in PFCC, as well as, interference from the environment, such as a television in the background or violence from families.

Conclusion

We identified several perceived barriers to patient and family centered care in the prehospital environment, including limited manpower, multi-tasking medical care, and concern for interference with patient care. We also observed that providers and standardized caregivers recognized the importance of providing emotional support by maintaining a calm demeanor and empowering families to feel involved. By narrating actions and first impressions through a primary communicator who uses lay terms and the patient's name, prehospital providers can simultaneously calm and empower family members. In addition, maintaining a line of sight, preempting the next actions, removing and returning a caregiver to and from the scene, and providing situational awareness may be potential ways to overcome barriers. Incorporation of these strategies into EMS protocols may enhance PFCC in the prehospital setting

ORCID

Esther M. Sampayo http://orcid.org/0000-0002-4114-3759