THE EVALUATION OF TWO DEATH EDUCATION PROGRAMS FOR EMTS USING THE THEORY OF PLANNED BEHAVIOR

eath Studies30:637-647,2006 LLC Routledge SN: 0748-1187 print/1091-7683 onlir DOI:10.1080/07481180600776028 THE EVALUATION OF TWO DEATH EDUCATION PROGRAMS FOR EMTS USING THE THEORY OF PLANNED BEHAVIOR TRACY SMITH-CUMBERLAND Department of Emergency Health Services, University of Maryland Baltimore The goal of this study was to evaluate the effectiveness of tuo death education by comparing pretest and posttest scores of behavioral intentions and (reported) behavior of EMts when at the scene of a death. After the interventions, the majority of EMTs intended to change their behavior at the scene of a death when compared to the control group. In a three-month follow-up study, the majority of EMTs who received the intervention(and made a death notification) changed their behavior. In this sample, these programs were effective in changing the behavioral intentions of EMts. Several levels of Emergency Medical Technicians(EMTs), EMT Basic(Emt-B), EMT-Intermediate(EMT-I), and EMT Paramedi (EMT-P) were used in this study and are collectively labeled as EMTs. Due to new trends in end-of-life care and changes in proto- cols, the role of the EMT has changed. EMTs now use protocols or follow doctors'orders to terminate resuscitation and pronounce death on scene(Cummings, 2000; Dalbridge, Fosnecht, Garrison, aublee, 1996). Consequently, EMTs have the responsibility of making the death notification and consoling the family, as well as pronouncing death. One survey reported that Emergency Medi- cal Services(EMS)providers convey 83% of death notifications that occur outside of the hospital (Norton et al, 1992). EMS provi- ders who make death notifications also counsel families and provide emotional support. These roles are uncomfortable and unfamiliar for most EMS providers( Coleman, 1993; Leash Received 26 April 2005; accepted 20 January 2006 ddress correspondence to Tracy Smith-Cumberland at the Department of Em ency Health Services, University of Maryland Baltimore County, 1000 Hilltop Ci Baltimore, MD. 21250, USA. E-mail: tlsmith@umbc. edu 637

THE EVALUATION OF TWO DEATH EDUCATION PROGRAMS FOR EMTS USING THE THEORY OF PLANNED BEHAVIOR TRACY SMITH-CUMBERLAND Department of Emergency Health Services, University of Maryland Baltimore County, Baltimore, Maryland, USA The goal of this study was to evaluate the effectiveness of two death education programs by comparing pretest and posttest scores of behavioral intentions and (reported) behavior of EMTs when at the scene of a death. After the interventions, the majority of EMTs intended to change their behavior at the scene of a death when compared to the control group. In a three-month follow-up study, the majority of EMTs who received the intervention (and made a death notification) changed their behavior. In this sample, these programs were effective in changing the behavioral intentions of EMTs. Several levels of Emergency Medical Technicians (EMTs), EMT￾Basic (EMT-B), EMT-Intermediate (EMT-I), and EMT Paramedic (EMT-P) were used in this study and are collectively labeled as EMTs. Due to new trends in end-of-life care and changes in proto￾cols, the role of the EMT has changed. EMTs now use protocols or follow doctors’ orders to terminate resuscitation and pronounce death on scene (Cummings, 2000; Dalbridge, Fosnecht, Garrison, & Aublee, 1996). Consequently, EMTs have the responsibility of making the death notification and consoling the family, as well as pronouncing death. One survey reported that Emergency Medi￾cal Services (EMS) providers convey 83% of death notifications that occur outside of the hospital (Norton et al., 1992). EMS provi￾ders who make death notifications also counsel families and provide emotional support. These roles are uncomfortable and unfamiliar for most EMS providers (Coleman, 1993; Leash, Received 26 April 2005; accepted 20 January 2006. Address correspondence to Tracy Smith-Cumberland at the Department of Emerg￾ency Health Services, University of Maryland Baltimore County, 1000 Hilltop Circle, Baltimore, MD, 21250, USA. E-mail: tlsmith@umbc.edu 637 Death Studies, 30: 637–647, 2006 Copyright # Taylor & Francis Group, LLC ISSN: 0748-1187 print/1091-7683 online DOI: 10.1080/07481180600776028

T Smith-Cumberland 993. One study showed the ineffectiveness of EMTs in these roles(Critz, 1989). It is not surprising that many EMTs seek edu- cation on delivering effective death notifications and mitigating the family's grief(Coleman, 1993; Norton et al., 1992) Educational courses for EMTs must be unique when com- pared to death education courses for other allied health provi ders. These courses must encompass the diversity of the different types of death, yet focus specifically on the differences between hospital and prehospital death. The trauma of grief after a death in the emergency setting requires special knowledge and a unique repertoire of skills(Dubin Sarnoff, 1986; Gifford Cleary, 1990). Few death and dying courses teach medical profes- sionals to interact appropriately with families at the moment of death(Field Howells, 1988; Tye 1996), and most courses do not cover the unique features of death in the prehospital setting (Smith Walz, 1995). The national curricula, published by the National Highway Traffic and Safety Administration(NHTSA for EMT Basics(NHTSA, 1998a)and EMT Paramedics NHTSA 1998b)contain few objectives related to death and are not EMTs seeking classes to meet their professional needs will find traditional death and dying courses unacceptable. From these concerns arose the Emergency Death Education and Crisis Train- ing Program(EDECT). The EDECTm program, 16 hours in length, was often a large time commitment for many organizations thus, a two-hour Continuing Medical Education(CME)session also arose( Smith, Walz, Smith, 1999). These two courses vide education about death and dying designed specifically for emergency responders. Course participants learn how to reduce the trauma of a death notification, help mitigate grief, and respond to legal and ethical issues surrounding death. Yet, formal evalua tions of these programs were lacking, so it remained unclear whether these programs benefited EMS providers and bereft families, and if so, why they were effective The EMTs in the EDECT program received a two-day consecutive days), 16-hour seminar which included a variety of teaching methods: lecture with computer presentation, small group discussion, multiple videotapes including videos of actual death notifications, case studies, self-assessments, and role-playing of death notifications by the participants. A debriefing followed each

1993). One study showed the ineffectiveness of EMTs in these roles (Critz, 1989). It is not surprising that many EMTs seek edu￾cation on delivering effective death notifications and mitigating the family’s grief (Coleman, 1993; Norton et al., 1992). Educational courses for EMTs must be unique when com￾pared to death education courses for other allied health provi￾ders. These courses must encompass the diversity of the different types of death, yet focus specifically on the differences between hospital and prehospital death. The trauma of grief after a death in the emergency setting requires special knowledge and a unique repertoire of skills (Dubin & Sarnoff, 1986; Gifford & Cleary, 1990). Few death and dying courses teach medical profes￾sionals to interact appropriately with families at the moment of death (Field & Howells, 1988; Tye 1996), and most courses do not cover the unique features of death in the prehospital setting (Smith & Walz, 1995). The national curricula, published by the National Highway Traffic and Safety Administration (NHTSA), for EMT Basics (NHTSA, 1998a) and EMT Paramedics (NHTSA, 1998b) contain few objectives related to death and are not specific to EMTs. EMTs seeking classes to meet their professional needs will find traditional death and dying courses unacceptable. From these concerns arose the Emergency Death Education and Crisis Train￾ing Program (EDECTsm). The EDECTsm program, 16 hours in length, was often a large time commitment for many organizations; thus, a two-hour Continuing Medical Education (CME) session also arose (Smith, Walz, & Smith, 1999). These two courses pro￾vide education about death and dying designed specifically for emergency responders. Course participants learn how to reduce the trauma of a death notification, help mitigate grief, and respond to legal and ethical issues surrounding death. Yet, formal evalua￾tions of these programs were lacking, so it remained unclear whether these programs benefited EMS providers and bereft families, and if so, why they were effective. The EMTs in the EDECTsm program received a two-day (consecutive days), 16-hour seminar which included a variety of teaching methods: lecture with computer presentation, small group discussion, multiple videotapes including videos of actual death notifications, case studies, self-assessments, and role-playing of death notifications by the participants. A debriefing followed each 638 T. Smith-Cumberland

Evaluation of EMTS"' Attitudes Towards Death role-play activity. Specific behavioral goals to this program included using death words (not euphemisms) during a death notification, using successive preannouncements during a death notification, allowing families to view the deceased, following the four-step death notification process, and leaving follow-up infor mation. The seminar covered the behavioral goals(see Table 1), thoroughly including the supporting literature and potential effects arising from their use. a detailed outline including the goals, units, and resources of the elects curriculum is found in the litera- ture, but the program has not been published in its entirety (Smith et al. 1999 The EMTs in the two-hour CME group received a lecture- style presentation enhanced with computer generated slides and videotapes of death notifications. After an introduction and review of the four-step death notification process, participants evaluated three videotaped death notifications. The participants were exposed to the behavioral goals briefly; however, they were given little information regarding the research that guides them, and had no opportunity to practice them. Participants in the control group received a didactic presen tation on advanced airway management of unconscious patients The two hours consisted of a lecture-style presentation enhanced with audiovisuals. This presentation did not include death-related information Ajzen's Theory of Planned Behavior (TPB; Ajzen, 1985; Ajzen Fishbein, 1980) was chosen to provide insight into course effec- tiveness, to aid in the development of future courses, and to pro- vide answers to why EMTs choose to engage in death-related behaviors. This theory allows for the prediction of behavior by examining changes in attitude, perceived behavioral control subjective norms (what others think we should do), behavioral intent, and behavior(Ajzen Madden, 1986). According to the TPB, attitudes towards a behavior(ATT), perceived control over behavior(PBC), and subjective norms(SN)lead to one's inten tions to change a behavior(behavioral intent. Behavioral intention (BI)then leads to actual behavior. Examples of questions used in when making a death noti the words“deat” 'died or"dead this study include "My cation is beneficial /harmful""(ATT);"I am confident that I could use the four-step death notification process during a death notification(PBC); "My supervisors think

role-play activity. Specific behavioral goals to this program included using death words (not euphemisms) during a death notification, using successive preannouncements during a death notification, allowing families to view the deceased, following the four-step death notification process, and leaving follow-up infor￾mation. The seminar covered the behavioral goals (see Table 1), thoroughly including the supporting literature and potential effects arising from their use. A detailed outline including the goals, units, and resources of the EDECTsm curriculum is found in the litera￾ture, but the program has not been published in its entirety (Smith et al., 1999). The EMTs in the two-hour CME group received a lecture￾style presentation enhanced with computer generated slides and videotapes of death notifications. After an introduction and review of the four-step death notification process, participants evaluated three videotaped death notifications. The participants were exposed to the behavioral goals briefly; however, they were given little information regarding the research that guides them, and had no opportunity to practice them. Participants in the control group received a didactic presen￾tation on advanced airway management of unconscious patients. The two hours consisted of a lecture-style presentation enhanced with audiovisuals. This presentation did not include death-related information. Ajzen’s Theory of Planned Behavior (TPB; Ajzen, 1985; Ajzen & Fishbein, 1980) was chosen to provide insight into course effec￾tiveness, to aid in the development of future courses, and to pro￾vide answers to why EMTs choose to engage in death-related behaviors. This theory allows for the prediction of behavior by examining changes in attitude, perceived behavioral control, subjective norms (what others think we should do), behavioral intent, and behavior (Ajzen & Madden, 1986). According to the TPB, attitudes towards a behavior (ATT), perceived control over a behavior (PBC), and subjective norms (SN) lead to one’s inten￾tions to change a behavior (behavioral intent). Behavioral intention (BI) then leads to actual behavior. Examples of questions used in this study include ‘‘My using the words ‘‘death,’’ ‘‘died,’’ or ‘‘dead’’ when making a death notification is beneficial=harmful’’ (ATT); ‘‘I am confident that I could use the four-step death notification process during a death notification’’ (PBC); ‘‘My supervisors think Evaluation of EMTS’ Attitudes Towards Death 639

需闭手季手 99 3 ooNa 示8 err988 640

TABLE 1 Pretest Posttest Means (and Standard Deviations) for Behavioral Intent Control Group (n ¼ 29) 2 Hour CME (n ¼ 30) 16-Hour Group (n ¼ 24) (Intend to ...) Pre Post Pre Post Pre Post Use the words dead or died 1.76 (.79) 1.69 (.76) 2.20 (1.06) 1.27 (0.64) 3.08 (1.06) 1.17 (.38) Allow viewing of body 1.72 (1.06) 1.72 (.70) 1.97 (.81) 1.40 (.81) 2.00 (.83) 1.17 (.38) Leave follow-up information 1.76 (.69) 1.83 (.80) 2.03 (.89) 1.37 (.62) 2.17 (.70) 1.50 (.66) Use successive preannouncements 2.86 (.58) 2.79 (.56) 2.89 (.57) 1.47 (.51) 2.82 (.59) 1.25 (.44) Use four-step DN process 2.66 (.25) 2.86 (.58) 2.86 (.44) 1.63 (.67) 2.83 (.38) 1.33 (.48) Help the family’s grief 2.00 (8.86) 2.21 (.77) 2.30 (1.06) 1.47 (.86) 1.75 (.73) 1.25 (.44) Note. DN ¼ Death Notification, Scores range from 1 (Strongly Agree) to 5 (Strongly Disagree). 640

aluation of EMTS Attitudes Towards death 41 hat I should allow the family to view the body"(SN); "I intend to leave follow-up information with the family after a death""(BI Using the objectives from the EDECt curriculum and the Theory of Planned Behavior, the goal of this study was to investi- gate if exposure to a long experiential or short didactic death- related program would impact an EMTs intentions to perform six death-related behaviors on scene of a patient's death more than a control lecture. This goal was based on the following: EMTs in the treatment groups will intend to (a) use the words"death," died, "or"dead""during the death notification process;(b)use successive preannouncements during a death notification;(c)leave follow-up information;(d) allow the family to view the deceased (e)use the four-step death notification process; and, (f)assist the family in managing their grief, more often than EMTs in the con- trol group. The secondary goals were to determine actual (reported)behavior and to determine the theoretical underpin nings associated with any changes by examining the correlations of t the constructs in the tpb Method Participants This study incorporated a quasi-experimental pretest-posttest com- parison design using two experimental groups and one control group. A large group of EMTs from several EMS agencies in rural Wi isconsin volunteered to participate in the study. A volunteer ample provided the most appropriate sampling frame, as students enrolling in future course offerings will do so voluntarily. All EMTs in the study sample worked as EMTs in Wisconsin and held National Registry of EMTs certifications either EMT-B, EMT-I, or EMT-P(The pre-test data did not differ between the levels of EMTs). The final sample size of 83 participants (48 men and 35 omen) was determined adequate after reviewing effect sizes from the available literature(Durlak Riesenburg, 1991; Maglio Robinson, 1994). They averaged 32.9 years in age; all were white and about half (43, 52%)were married. They ranged from less than 1 to 33 years of EMs service with an average of 5.3 (SD=5.24), and they averaged 46.8 calls per month

that I should allow the family to view the body’’ (SN); ‘‘I intend to leave follow-up information with the family after a death’’ (BI). Using the objectives from the EDECTsm curriculum and the Theory of Planned Behavior, the goal of this study was to investi￾gate if exposure to a long experiential or short didactic death￾related program would impact an EMT’s intentions to perform six death-related behaviors on scene of a patient’s death more than a control lecture. This goal was based on the following: EMTs in the treatment groups will intend to (a) use the words ‘‘death,’’ ‘‘died,’’ or ‘‘dead’’ during the death notification process; (b) use successive preannouncements during a death notification; (c) leave follow-up information; (d) allow the family to view the deceased; (e) use the four-step death notification process; and, (f ) assist the family in managing their grief, more often than EMTs in the con￾trol group. The secondary goals were to determine actual (reported) behavior and to determine the theoretical underpin￾nings associated with any changes by examining the correlations of the constructs in the TPB. Method Participants This study incorporated a quasi-experimental pretest-posttest com￾parison design using two experimental groups and one control group. A large group of EMTs from several EMS agencies in rural Wisconsin volunteered to participate in the study. A volunteer sample provided the most appropriate sampling frame, as students enrolling in future course offerings will do so voluntarily. All EMTs in the study sample worked as EMTs in Wisconsin and held National Registry of EMTs certifications either EMT-B, EMT-I, or EMT-P (The pre-test data did not differ between the levels of EMTs). The final sample size of 83 participants (48 men and 35 women) was determined adequate after reviewing effect sizes from the available literature (Durlak & Riesenburg, 1991; Maglio & Robinson, 1994). They averaged 32.9 years in age; all were white; and about half (43, 52%) were married. They ranged from less than 1 to 33 years of EMS service with an average of 5.3 (SD ¼ 5.24), and they averaged 46.8 calls per month. Evaluation of EMTS’ Attitudes Towards Death 641