CALIFORNIA STATE UNIVERSITY, NORTHRIDGE TRAINING

CALIFORNIA STATE UNIVERSITY, NORTHRIDGE
TRAINING PARAMEDICS TO DELIVER EFFECTIVE AND COMPASSIONATE
DEATH NOTIFICATIONS
A graduate project submitted in partial fulfillment of the requirements
For the degree of Master of Arts in Education,
Educational Psychology
By
Mark Malonzo
August 2013
Copyright page
Copyright by Mark Malonzo 2013
ii
Signature page
The graduate project of Mark Malonzo is approved:
Adele Gottfried, Ph.D.
Date
Jonah Schlackman, Ph.D.
Date
Dr. Carolyn Jeffries, Chair
Date
California State University, Northridge
iii
Acknowledgements
I have never intended to develop an educational product as a culminating project
until my experiences in Dr. Carolyn Jeffries’ Instructional Design class. As my chair, she
has helped me turn an idea without direction into a simulation guide with purpose. Thank
you for guiding me through my graduate studies. Most importantly, thank you for being a
genuine advocate of EMS, EMS education, and those affected by what we do.
I would also like to acknowledge my other committee members, Dr. Adele
Gottfried and Dr. Jonah Schlackman. Dr. Gottfried, thank you for encouraging me to
pursue my interests rather than taking the path of least resistance. It was also great
working with you as your Research Assistant. That opportunity has made me a more
critical consumer of literature. Dr. Schlackman, your dedication and passion for
education and your students will always inspire me. Thank you both for your guidance in
the development of this project.
Lastly, I would like to acknowledge my colleagues and mentors at the UCLA
Center for Prehospital Care. Thank you for being supportive throughout my graduate
studies and professional career as an EMT, paramedic, and EMS educator.
iv
Dedication
I dedicate this to my son, Justin, and my wife, Rachele.
Thank you for believing in me.
I love you.
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Table of Contents
Copyright page .................................................................................................................... ii
Signature page.................................................................................................................... iii
Acknowledgements ............................................................................................................ iv
Dedication ........................................................................................................................... v
Abstract ............................................................................................................................ viii
Chapter One – Introduction ................................................................................................ 1
Need/Problem ................................................................................................................. 2
Purpose of Graduate Project ........................................................................................... 8
Terminology.................................................................................................................... 8
Chapter Two – Literature Review .................................................................................... 10
Introduction ................................................................................................................... 10
EMS Death Education and Notification Programs ....................................................... 10
Bad News Delivery Strategies ...................................................................................... 18
GRIEV_ING. ............................................................................................................ 19
SEGUE...................................................................................................................... 21
SPIKES. .................................................................................................................... 22
Simulation ..................................................................................................................... 24
Synthesis ....................................................................................................................... 26
Chapter Three – The Project ............................................................................................. 28
Introduction ................................................................................................................... 28
Development of the Product ......................................................................................... 28
Adult learning theory. ............................................................................................... 28
Dick and Carey Instructional Design Model. ........................................................... 30
Product Description ...................................................................................................... 35
Physical description. ................................................................................................. 35
Organization.............................................................................................................. 35
Environment and Equipment. ................................................................................... 36
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Intended Audience and Personal Qualifications ....................................................... 36
General Guide Contents. ........................................................................................... 38
Chapter Four - Conclusion ................................................................................................ 40
Summary ....................................................................................................................... 40
Evaluation ..................................................................................................................... 40
Formative Evaluation. ............................................................................................... 40
Summative Evaluation .............................................................................................. 43
Future Work .................................................................................................................. 43
References ......................................................................................................................... 45
Appendices........................................................................................................................ 48
Appendix A ................................................................................................................... 49
Appendix B ................................................................................................................... 50
Appendix C ................................................................................................................... 51
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ABSTRACT
Abstract
TRAINING PARAMEDICS TO DELIVER EFFECTIVE AND COMPASSIONATE
DEATH NOTIFICATIONS
By
Mark Malonzo
Master of Arts in Education,
Educational Psychology
Several studies have shown that Emergency Medical Services (EMS) providers feel
inadequate in their abilities to communicate distressing news to patients’ families and
other survivors. Although mastery of this skill requires practice, a lack of foundational
training also has an influence on this deficit. Paramedics are exposed to a high incidence
of death outside of the hospital; therefore, they must have effective communication skills
to deliver difficult news. This graduate project justifies a need for training through
supportive literature, includes a description of the development and evaluation process,
and concludes with sample pages of the final product: Death Notification Training for
Paramedics: A Simulation Guide for EMS Educators. The purpose of this project is to
provide EMS educators with an effective evidence-based resource to facilitate a
simulation training session on delivering a death notification and providing support to
grieving families.
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Chapter One – Introduction
Emergency Medical Services (EMS) is a relatively new health care profession
that has been in existence for only 40 years. The National Highway Traffic Safety
Administration (NHTSA) stated that “EMS is still in its early developmental stages
(2009).” The roles and responsibilities of EMS providers change progressively as EMS
continues to develop. In the early 1970s, Emergency Medical Technicians (EMTs) had
minimal health care training and were often referred to as “just ambulance drivers.”
Present day paramedics are advanced-level EMTs who are extensively trained to manage
out-of-hospital medical emergencies, make critical patient care decisions, and provide
advanced life-saving interventions.
The nature of the EMS profession commonly challenges EMS providers (both
EMTs and paramedics) to deal with patients’ deaths and their grieving families. In 2013,
the Center for Disease Control and Prevention (CDC) reported that fewer people are
dying in hospitals, and more people are choosing to die at home (CDC, 2013). The
number of in-hospital deaths dropped 8% from 776,000 in 2000 to 715,000 in 2010. This
is not proportionate to the 11% increase in total hospitalizations in the same decade. On
the other hand, the CDC also reported that the incidence of deaths at home grew from
23% to 27%. They speculate that this is partially due to the increased availability of
hospice care and the rising health care expense particularly at the last few months of life.
The increase of out-of-hospital deaths will, in turn, result in more EMTs delivering
difficult news to families (Smith & Walz, 1995). However, most EMTs feel
uncomfortable and unprepared delivering a death notification (Smith-Cumberland &
Feldman, 2006).
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The most recent editions of the American Heart Association (AHA) Guidelines for
Cardiopulmonary Resuscitation and Emergency Cardiovascular Care (2005, 2010)
provide recommendations and principles for terminating or withholding resuscitation.
These best practice guidelines affect the roles and responsibilities of EMS providers. At
the turn of the last century, most cardiac arrests were transported to the emergency
department and death notifications were performed by the physicians at the hospital.
Current guidelines recommend withholding or terminating futile efforts and determining
death at the scene. This leaves the EMS provider with the added responsibility of
providing support and consolation to the family. Several studies show that these roles are
uncomfortable and stressful, particularly for inexperienced healthcare professionals
(Norton et al., 1992; Parker-Raley et al., 2007; Rosenbaum et al., 2004). Norton et al.
(1992) reported that 83% of all deaths that occur outside of the hospital are
communicated by EMTs to family members. Although this research is slightly dated, it
shows that the majority of death notifications were being performed by EMS by the end
of the 20th century.
Need/Problem
Despite extensive training to save lives, dealing with patient deaths and grieving
survivors will always be a common occurrence for EMS providers. Communicating
difficult news such as death to a patient’s family and friends is now a regular
responsibility of EMS providers. However, several research studies show that paramedics
are ill-prepared to communicate difficult news (Douglas, Cheskes, Feldman, &
Ratnapalan, 2013; Nordby & Nohr, 2011; Norton et al., 1992; Ponce et al., 2010; Smith
& Walz, 1995; Smith-Cumberland & Feldman, 2006; Stone et al., 2013). Smith and Walz
2
(1995) also noted that there is minimal attention given to the strategies for paramedics to
use at the time of death despite their presence at most out-of-hospital deaths.
Stone et al. (2013) surveyed 236 paramedics from Denver and Los Angeles about
end-of-life skills, which included understanding advanced directives such as DNR forms,
knowing when and how to honor requests to withhold resuscitation, and communicating
bad news. One of their results showed that 79% of paramedics rated “communicating
death to family and friends” as “very important.” However, only 48% felt “wellprepared.” There is clearly a gap between perceived importance in paramedics’ everyday
practice and preparation to perform the task. Stone et al. (2013) strongly suggest that
there is a significant under preparation in end-of-life skills and paramedics need more
training.
A qualitative study conducted by Nordby and Nohr (2011) showed that all
paramedics surveyed did not find communication challenges around the technical aspects
of providing medical care. Rather, these paramedics found it personally and
professionally difficult to “find the right words” during difficult interpersonal relations.
Nordby and Nohr (2011) stated that emergency personnel need education and training in
preparing for emotional work and challenging patient communication that are
characteristic of the EMS profession. These results complement the research of SmithCumberland and Feldman (2006). Their research showed that most EMTs did not feel
comfortable making death notifications. Eighty-four percent of EMTs in the study also
felt that their training was inadequate in making death notifications or helping the
families grieve. Several studies show that death education and training to deliver difficult
news in paramedic programs is suboptimal (Smith & Walz, 1995; Smith-Cumberland &
3
Feldman, 2006). These results are also congruent with numerous studies in health care
communication that show that physicians have reported receiving no formal education in
effectively communicating bad news (Rosenbaum, Furguson, & Lobas, 2004;
Fallowfield, 1996, 2004).
In 2009, NHTSA released an updated version of The National EMS Education
Standards. Commonly referred to as “The Standards,” this version dictates the minimum
entry-level competencies that EMS training programs are required to integrate into their
curricula. “Dealing with Death and Dying” is only one objective under The Standards’
Stress Management section. There is no other mention of this specific objective or any
other death-related objective throughout the entire 387-page document (NHTSA, 2009).
These open-ended guidelines give each program the freedom to choose how much time
and resources are needed to reach entry-level paramedic competency. Since dealing with
death-related issues only appears minimally in The Standards, programs that adhere to
these standards are likely to include little instruction on this important topic (Smith &
Walz, 1995).
Smith and Walz (1995) surveyed 537 paramedic programs, and received a
response from over half of all programs in the United States. They wanted to gather
information about current death education in programs, instructional delivery methods,
and assessment techniques. Almost all (95%) stated that their programs offered death
education. The face value of this result seems promising. However, most instructional
time was spent covering only legal and ethical issues that were relevant to death, rather
than the psychosocial issues such as bereavement and consoling friends and family.
4
Smith and Walz (1995) also stated that there are few educational resources in death
education for EMS, and that the typical method of delivering death education in
paramedic programs is ineffective. Their results showed that the majority of programs
taught death education through a lecture rather than through experiential modules such as
simulation or role-play. The entry-level competency on death education was usually
measured using closed-ended exams. This suggests that paramedic students were
assessed only via multiple choice exams. They also noted that the majority (80%) of
paramedic graduates read less than one page of death-related texts. Furthermore, their
survey found that there are very few other death-related instructional materials, such as
video tapes, that are relevant to EMS providers.
To my knowledge, there has not been another nationwide survey of death
education in paramedic programs since that of Smith and Walz (1995). Although this is
fairly dated research, there are other indicators that suggest that there have been no
significant changes in EMS death education within the last 18 years. First, the 1998
National Standards Curriculum – Paramedic is similar to the 1999 Standards in regards
to death education (NHTSA, 1998; 2009). Death education and difficult communication
training remain minimal in The Standards, which will most likely translate to minimal
training in paramedic programs. Secondly, more recent studies show that most
prehospital care providers feel unprepared to deliver death notifications (Douglas et al.,
2013; Ponce et al., 2010; Smith-Cumberland & Feldman, 2006).
Several studies also show that the instructional methods used to teach death
education throughout different fields of healthcare education are absent or ineffective
(Jacques et al., 2011). In EMS textbooks, there is usually only one page of death related
5
material in textbooks which commonly covers the stages of grief. Therefore, there is a
lack of foundational instruction in death education and a paucity of effective educational
resources (Smith & Walz, 1995; Smith-Cumberland & Feldman, 2006).
Difficult communication does not always involve death notification. Nordby and
Nohr (2011) conducted a qualitative study on health communication between paramedics
and patients with prolonged cancer. Interestingly, all participants in the sample did not
find communicative challenges around providing medical care. Rather, many of the
paramedics expressed that it was difficult to “find the right words” during “quiet
transports” where there is not much to be done. One of their findings was that none of the
paramedics found it difficult to deliver straightforward factual information. These
researchers wanted to investigate how paramedics communicated, interacted, and
empathized with patients who were on the verge of death. Nordby and Nohr (2011)
emphasized that prehospital care providers need the education and training to prepare for
an emotionally intense career with difficult communication challenges. This is in line
with the recommendations from previous studies (Smith & Walz, 1995; SmithCumberland & Feldman, 2006). It is well-documented that paramedics are frequently
exposed to situations involving death and communicating difficult news to grieving
families. The evidence clearly shows that that many EMS providers are not prepared.
Literature on the importance of communication and interpersonal relations
between health care professionals and their patients is abundant. It has resonated
throughout several research studies that the manner in which a health care provider
delivers difficult news can affect the grieving process (Fallowfield, 2004; Nordby &
Nohr; Smith & Walz, 1995; Smith-Cumberland & Feldman, 2006; Stewart, 1995).
6
Fallowfield (2004) advised that poor delivery of bad news can cause confusion, longlasting distress, and resentment. In contrast, properly communicated difficult news may
assist with understanding, acceptance, and adjustment. Since EMS providers are often
present at the time of death, they are in a unique and sensitive position to influence the
grieving process (Smith & Walz, 1995).
The challenge is to create a paradigm shift among EMS providers. Delivering
death notifications is a relatively new role for EMTs and paramedics. Fewer cardiac
arrests are being transported to the hospital and more families and friends are being
notified by EMS personnel. A pre-intervention survey conducted by Smith-Cumberland
& Feldman (2006) showed that only less than 43% reported that their role as an EMT
should include making a death notification. A study by Ponce et al. (2010) showed that
only 55% of participants had an interest in improving their death notification skills. There
is still a prevalent “that’s not my job” mentality. EMS providers were not required to
deliver death notifications; therefore, they were not expected to develop that unique and
sensitive skill. Recent nationwide changes to protocols and practice have made delivering
difficult news a common responsibility of EMS providers.
Paramedics need to feel confident, comfortable, and skilled in delivering difficult
news. The amount of death education in paramedic curricula is not proportionate to the
high frequency of out-of-hospital deaths that paramedics encounter. The lack of depth
and breadth of death education objectives in The Standards has influenced how it is
taught and evaluated in paramedic curricula. It is evident that EMS providers must be
better prepared to handle common challenges found in their jobs. Most paramedics lack
effective communication skills to deal with death and grieving families. One factor that
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contributes to this deficiency stems from a lack of education and exposure in their
foundational training. Paramedic education programs need to adequately equip their
students with the skills needed to address the everyday communication demands of the
profession.
Purpose of Graduate Project
The purpose of Death Notification Training for Paramedics is to provide EMS
educators with an effective evidence-based resource to facilitate a simulation training
session using standardized actors. It is designed to engage paramedic students in realistic
simulations that will expose them to challenging EMS situations, such as patient death,
and enhance their communication skills in difficult situations.
Terminology
This section provides definitions of critical terms used in the discussion, design,
development, and implementation of this graduate project. These definitions are based on
scholarly research and educational literature.
Andragogy: The art and science of adult education. (Misch, 2002)
Bad news: Situations where there is either a feeling of no hope, a threat to a person’s
mental or physical well-being, a risk of upsetting an established lifestyle, or where a
message is given which conveys to an individual fewer choices in his or her life. (Bor,
1993)
Case-based learning: A learning model founded upon a student centered approach,
whereby students use the following: discovery, responsibility, empowerment,
emancipation and motivation and rely less on teachers simply dispensing knowledge.
(Boyle, Williams, & Burgess, 2011)
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Debriefing: The time for critical reflection after a simulation session when the
facilitators guide the students through the case and provide feedback. (Wang, 2011)
Emergency Medical Services (EMS): Collective name for all levels of certification or
licensure for individuals who provide out-of-hospital patient care. (NHTSA, 2009)
Family-witnessed-resuscitation: A resuscitative effort in which the family is present at
the scene of the cardiac arrest. (Ponce et al., 2010)
Human simulation: A variety of technologies that allow residents to work through
realistic patient problems so as to allow them to make mistakes, learn, and be evaluated
without exposing a real patient to risk. (McLaughlin, Doezema, & Sklar, 2002)
Patient-centered communication: A style of communication where the physician
conveys the information according to the patient’s needs, checks for understanding of
provided information, and shows empathy (Mast, Kindlimann, & Langewitz, 2005).
Simulation: A technique – not a technology – to replace or amplify real experiences with
guided experiences that evoke or replicate substantial aspects of the real world in a fully
interactive manner. (Wang, 2011)
Transition to Next Chapter
The following chapter will thoroughly review literature relevant to the design of
this project. The areas covered are: 1) current EMS death education and notification
programs, 2) strategies to deliver bad news, and 3) simulation as an effective tool.
9
Chapter Two – Literature Review
Introduction
This chapter contains is a literature review of issues directly related to the
development of Death Notification Training for Paramedics: A Simulation Guide for
EMS Educators. It begins with research relevant to the design and delivery of effective
death education training programs for EMS. This is followed by a review of various
methods used to communicate difficult news. A review of simulation with standardized
patients as a learning and evaluation tool is the last area of investigation. This chapter
concludes with a synthesis of the discussed literature and its implications to the design of
this project.
EMS Death Education and Notification Programs
A need for difficult communication skills training for EMS providers is evident
from the literature. However, there is currently no standard program specifically designed
for primary paramedic education. The need for an educational intervention is clear, but
more research still has to be done to find the most effective method of implementation.
Two pilot death education and notification programs have been conducted and evaluated
for effectiveness. Smith-Cumberland and Feldman (2006) conducted a study to test their
hypothesis that EMTs’ attitudes toward death will change after an educational
intervention. Dr. Tracy Smith-Cumberland developed a two-day course that was
specifically designed to change death-related attitudes and behaviors of EMS providers.
Emergency Death Education and Crisis Training (EDECT) is a 16-hour seminar that
includes a lecture, discussions, small-group exercises, and role-playing. A sample of 83
rural EMTs participated in this pretest-posttest study, and each participant was randomly
10
assigned into one of three groups. The control group (n = 29) received a two-hour
program on a topic unrelated to death or difficult communication. Their “longintervention group” (n = 24) received the two-day 16-hour EDECT program. The “shortintervention group” (n = 30) received a two-hour continuing education session which
focused primarily on delivering a death notification, which is one component of the eightmodule EDECT program.
The 83 EMTs completed a questionnaire were structured in a five-point Likert
format from “strongly agree” to “strongly disagree.” It gathered information about their
behaviors and attitudes about death. This instrument was reviewed by several EMS
experts, and the authors conducted a pilot test to ensure reliability and stability. The five
items specific to the EMTs’ attitudes and behaviors were “1) whether their actions as
EMTs impacted the grief of family members, 2) whether their training to help the
families was adequate, 3) whether their training prepared them to make compassionate
death notifications, 4) whether they felt comfortable making death notifications, and 5)
their attitudes toward the EMTs’ role to make death notifications on scene (SmithCumberland & Feldman, 2006, p. 91).”
The first research question asked EMTs whether they believed that their actions
affected the patient’s family. Prior to any of the sessions, 77% of all three groups agreed
or strongly agreed that their actions affected grief. The second research item asked
whether EMTs believed that it was their role to communicate death notifications. Pretest
results showed that 57% of EMTs disagreed or strongly disagreed that it was a part of
their duties. However, after the sessions, more EMTs in the intervention groups reported
that their role as EMTs included making a death notification. Ninety-two percent of the
11
long-intervention group and 83% of the short-intervention group reported that it was part
of their responsibilities.
The third question obtained information about EMTs comfort level with making
death notifications on scene. Only 1% felt comfortable and 15% reported that they were
somewhat comfortable with making a death notification. The majority of EMTs (84%)
reported that they were uncomfortable delivering death notifications before the sessions.
The long-term intervention group showed the most significant change. The fourth and
fifth items inquired about preparation and training to help families at the time of death. At
the pretest, most EMTs (83%) felt 1) unprepared to deliver a death notification and 2)
that their training was inadequate. The posttest results showed that all participants in the
long-intervention group felt prepared to deliver a death notification and most (70%) in
the short-intervention felt that their training was adequate.
Smith-Cumberland and Feldman (2006) shed light on several important issues
relevant to the design and delivery of an effective death education program for EMS
providers. First, they showed that there must be a paradigm shift or a change in attitude
among EMS providers. Most EMTs did not feel that delivering a death notification was
their responsibility. After the two-hour continuing education session and 16-hour EDECT
course, most felt that it was their duty and most felt prepared to do so. Moreover, this
study showed that EMS providers are receptive to death education. In regards to program
structure, Smith-Cumberland and Feldman (2006) showed that attitudes and behavior can
be changed through a brief two-hour educational intervention.
There are some limitations to this study. The principal investigator also taught the
short and long-intervention courses. The authors did mention that they made an attempt
12
to find an unaffiliated instructor, but they were unsuccessful in finding instructors who
are experts in death and dying. This may have introduced bias into the evaluation of
effectiveness. However, it is still promising to see an upward trend in several
measurements. Secondly, a survey of a more diverse group of EMS providers may result
in different outcomes. All 83 EMTs were from rural Wisconsin. General attitudes about
death education and the relatively new role of EMTs may differ geographically.
Furthermore, much more investigation has to be done with educational interventions
within primary training programs. The participants of this survey were already certified
EMTs or licensed paramedics, and both educational interventions were designed as
continuing medical seminars. Results may differ if these programs were integrated into
primary foundational training. Lastly, the short-intervention group only received a twohour lecture about the death notification procedure. Unlike those in the long-intervention
group, they did not receive any experience delivering a death. Consequently, the EMTs in
the short-intervention group did not feel as adequately trained as compared to those who
engaged in the EDECT program. Further investigation of different program duration and
content may show that a two-hour session is too condensed, and the two-day EDECT
workshop is too extensive to cover the necessary objectives. All participants of a fourhour educational session with an experiential component (role-play or simulation) may
report feeling adequately trained.
Smith-Cumberland and Feldman (2006) evaluated the effectiveness of their
educational interventions only through self-report measures. The intent to change attitude
and behavior was surveyed, rather than the actual assessment of a delivered death
notification. The effectiveness of death education and notification training would be best
13
measured after real notifications were delivered. However, given the nature of the EMS
profession and confidentiality laws, it would be very difficult to survey families of the
deceased or directly observe the process as an evaluator.
Ponce et al. (2010) studied the effectiveness of a pilot educational intervention on
EMS providers’ comfort with family-witnessed resuscitation (FWR) and death
notification. A sample of 45 EMS professionals completed a 60-minute training on FWR
and death notification delivery. The authors stated that the training was conducted by a
physician who is a national expert on end-of-life care. This hour-long session emphasized
“the steps for performing FWR resuscitation; how to communicate bad news to patients
and families; and how to assess and respond to a family’s needs for psychological,
spiritual, and social support during and after resuscitation” (Ponce et al., 2010, p. 538).
The lecture session concluded with a demonstration of a death notification using
actors as simulated family members. Each participant was then instructed to complete a
preintervention attitudinal survey and a postintervention test to measure knowledge
retention from the lecture. Participants of the large group session were given the option to
also participate in a 45-minute interactive session after the lecture. During the small
group session, the participants were given the opportunity to practice delivering a death
notification and receive feedback from observers. Twenty of the 45 participants
volunteered to engage in the standardized death notification exercise.
At the end of the session, the participants completed another attitudinal and
confidence survey on FWR and delivering a death notification. The majority of
participants were paramedics (n = 25), and were involved in at least one cardiac arrest
resuscitation. Seventy percent of participants reported having performed a death
14
notification. After the large and small group sessions, the results showed that EMS
providers felt more comfortable with the presence of family during a resuscitation, and
more confident in delivering a death notification. Prior to the sessions, 50% of EMS
providers reported that family presence during a resuscitative effort was inappropriate or
disruptive. After the sessions, 80% percent reported that family presence was beneficial
to families. Furthermore, 80% to 90% of the participants felt confident in their abilities to
deliver a death notification and provide comfort to family members.
This pilot study by Ponce et al. (2010) suggests that a two-hour educational
module may improve EMS providers’ confidence with death notification and interacting
with family members. Similar to the research of Smith-Cumberland and Feldman (2010),
this pilot study only assessed self-reported measures rather than actual long-term attitudes
and skill retention. Less than half of the participants (n = 20) volunteered for the small
group session where they were given the opportunity practice a death notification or give
feedback to peers. It would be valuable to survey the 25 participants who left after the
large group session. Doing so may provide insight and feedback that would influence the
design and delivery of such programs.
If many EMS providers feel that delivering a death notification is not their
responsibility (Smith-Cumberland & Feldman, 2006), then motivation to participate in an
educational seminar would be expected to be low. Using this knowledge, Ponce et al.
(2010) may have yielded different results if the EMS providers were not given the option
to leave the seminar. The participants who left after the large group session may have
benefited from the entire educational intervention the most. In contrast, those EMS
providers who stayed may have already perceived death notification training as
15
important. This limitation of selection bias was also noted by the authors in their
discussion. Further investigation needs to be done on EMS providers’ motivation to
engage in death education programs.
Douglas, Cheskes, Feldman, and Ratnapalan (2013) conducted focus group
sessions with 28 paramedics in Ontario, Canada. The interviews focused on the
paramedics’ experiences with death notification education. The authors were specifically
interested in discovering the format and content that most paramedics would like
incorporated in an ideal death notification program. Themes were generated from the
analysis and comparison of interview transcripts. The authors noted that the sample size
is small (N = 28), however, participants were continuously recruited until no new
information was obtained from the focus groups.
The results showed these paramedics were motivated to learn about death
notification through evidence-based continuing education sessions conducted by a trained
facilitator or through independent study online. Some of the paramedics who indicated
independent study preferred not to be placed in a situation where they would be forced to
discuss their personal experiences. Douglas et al. (2013) suggested that a trained peer or
health care professional with similar experiences would be best to teach paramedics about
death notification. Furthermore, they also reported that paramedics want to specifically
learn about the “practical aspects of communicating death notifications” (Douglas et al.,
2013). The results also showed that the paramedics wanted to know how to interact with
family members during resuscitation. These paramedics did not just want to learn about
the psychological aspects of sudden death or theories of best practices. They wanted to
develop practical skills that would immediately affect their professional lives. Lastly, the
16
interviews also indicated that paramedics wanted to receive feedback about their death
notification performance.
This qualitative study has paramount implications in the design of an EMSspecific death notification program. Prehospital emergency care is a unique field of
medicine, and the results suggest that an effective program must focus on the specific
needs of EMS providers. Other death notification training programs, such as one
developed by Mothers Against Drunk Driving (MADD), may not be suited for EMS
because it is designed for a broad audience of professionals who deliver bad news: law
enforcement, EMS personnel, counselors, and clergy. Their strategies for bad news
delivery are too general, and some are not directly applicable to EMS. Douglas et al.
(2010) also suggests that EMS providers may be most receptive to death notification
education that is conducted by a trained and qualified peer who shares similar
experiences. In reference to the pilot study by Ponce et al. (2010), it may be of value to
investigate if any participants left after the large group session because they felt
disconnected from the facilitator.
This study also has a few limitations. The focus group was conducted in urban
and rural Ontario. The role of a paramedic is similar internationally, but the perceived
importance of death notification education may differ regionally. The results of a focus
group of paramedics in Los Angeles, which is largely an urban fire-department-based
system, may differ from another part of North America, where EMS is a separate entity
from the fire department. Therefore, the 28 paramedics in the focus group may not be
representative of all paramedics. Moreover, although the input of paramedics in the focus
group is important, they may not know the best evidence-based method to deliver death
17
notification education. The results only suggest their preference for specific educational
content and delivery methods. Paramedics may report that they prefer online independent
study, but that may not be an effective instructional delivery method. Some EMS
providers may prefer online education solely because of its convenience. Others may be
terrified of role-play or simulation activities, or are uncomfortable being evaluated by
peers. Further research needs to be done to determine if online independent study is an
effective method to teach practical difficult communication skills to EMS providers.
Implications. These findings have several implications for the design and
development of Death Notification Training for Paramedics. The research of SmithCumberland and Feldman (2006) and Ponce et al. (2010) showed that EMS providers can
benefit from a two-hour educational intervention. Also, these two pilot programs also
included a lecture component prior to engaging in experiential sessions. Incorporating a
lecture prior to simulation or role-play sessions is an important element in their design.
Moreover, Douglas et al. (2010) suggest that EMS providers would be most receptive to a
trained peer, such as another paramedic, who has experience delivering a death
notification in the EMS setting. These findings have influenced the development of the
guide. Death Notification Skills for Paramedics is designed to be conducted in
approximately two-hour sessions by a trained and experienced paramedic.
Bad News Delivery Strategies
Several studies reported that the majority of practicing physicians have received no
formal training in communicating bad news (Fallowfield, 2004; Jacques et al., 2011;
Mast, Kindliman, & Langewitz, 2005). Traditionally, most health care practitioners
learned to give patients bad news through trial and error or through direct observation of
18
a preceptor or a more experienced colleague. Several strategies to deliver difficult news
have been developed to meet the needs of physicians who often do so. Emergency
medicine physicians and oncologists, in particular, routinely deliver difficult news to
patients and their families. Most components of the following mnemonic-based strategies
(GRIEV_ING, SEGUE, and SPIKES) are transferable and applicable to prehospital
emergency care. These three strategies all provide a planned structure for communication
and interpersonal relations.
GRIEV_ING. Dr. Cherri Hobgood, from the University of North Carolina
School of Medicine, developed an educational session structured around the mnemonic
“GRIEV_ING”. This is two-hour death notification workshop that is specifically
designed to meet the unique needs of emergency medicine physicians. Hobgood,
Harward, Newton, and Davis (2005) noted that there were established death notification
programs in use by other medical specialties, but the format was not tailored to the needs
of emergency medicine. These programs were one- to two-day sessions or retreats, and
the schedule was not conducive to the “busy clinical shifts and limited conference time”
of emergency medicine. Furthermore, the strategies were not always applicable. Death
notification in the emergency department is, in some ways, different from other areas of
medicine, but shares several similarities with prehospital emergency care. Emergency
medicine physicians and paramedics both deal with unexpected or traumatic death, and
their first encounter with families is near the time of death. In contrast, oncologists
typically have an established relationship with patients and their families. Therefore, the
dynamics of the death notification is different between the two specialties.
19
Dr. Hobgood performed an extensive literature review and developed
GRIEV_ING by incorporating the most important elements of a death notification. These
included “correctly identifying both the deceased and the survivors to be notified;
explaining the events of the death and the medical procedures (if any) that were used to
treat injuries; telling the survivors directly about the death without using euphemisms;
allowing adequate time for questions; viewing the body shortly after the notification if it
is available; and providing assistance (Hobgood, Tamayo-Sarver, Hollar, & Sawning,
2009, p. 207).” As a comprehensive program, GRIEV_ING consists of an introduction,
small-group activity, mini-lecture, and a simulated survivor encounter. The mnemonic,
GRIEV_ING, provides a mental checklist for the deliverer and gives the death
notification process a sequenced structure. This is designed to reduce the stress of an
emotionally-charged interaction (Hobgood et al, 2009).
This method has been tested for effectiveness with fourth-year medical students
as well as emergency medicine residents through two independent studies (Hobgood et
al. 2005; 2009). Hobgood et al. (2005) analyzed data from 20 residents obtained before
and immediately following the intervention, and three months after. Their results
demonstrated that this structured method of delivering bad news based on the
GRIEV_ING mnemonic can improve physician confidence and competence in death
notification.
More recently, Hobgood et al. (2009) conducted a study to evaluate if the
GRIEV_ING workshop improved the death notification skills of medical students. A
capstone course, which included GRIEV_ING, was attended by 138 fourth-year medical
students. Each participant completed a self-efficacy survey and was evaluated performing
20
a death notification before and after the GRIEV_ING intervention. Trained actors
completed a 12-item GRIEV_ING competency instrument and a 9-item interpersonal
skills instrument. The results showed that all participating medical students increased in
competence and confidence. Unexpectedly, overall interpersonal communication scores
declined.
The decline of interpersonal skills scores after an educational intervention to
improve difficult communication skills was unanticipated and surprising. Hobgood et al.
(2009) postulated a few explanations for this finding. Prior to the GRIEV_ING
workshop, the participants possessed limited skills and had no plan for how to deliver a
death notification. Consequently, they may have been perceived to be more personable
and at ease. After the training, the participants may have been too focused on their mental
checklist and completing all of the key GRIEV_ING elements. This may have resulted in
a more rigid, rehearsed, and impersonal interaction with the standardized survivor. This
decrease in interpersonal skills scores is particularly important in the development and
evaluation of any death notification program. Confidence and competence to deliver
difficult news are both important, but are independently ineffective without excellent
interpersonal skills. Delivering a death notification is more than a series of steps.
Hobgood et al. (2009) emphasized the importance of compassionate interpersonal skills
and establishing a human connection with families.
SEGUE. Dr. Gregory Makoul, an expert in medical communication, developed a
comprehensive checklist which covers tasks in most medical encounters. It serves as a
reminder for five general focus areas: Set the stage, Elicit information, Give information,
Understand their perspective, and End the encounter. SEGUE is a checklist of general
21
communication tasks that guides the flow of the interaction from beginning to end. It
incorporates most of the components found in the GRIEV_ING method, but SEGUE is a
general strategy rather than one specifically designed for difficult news delivery.
However, SEGUE provides an adaptable framework for EMS-specific difficult
communication tasks. Makoul (2001) stated that it can be used as a “structural foundation
to teach, assess, study, and improve communication skills.”
Makoul (2001) surveyed 99 medical schools about the assessment and instruction of
communication skills. The results indicated that the SEGUE framework was the most
widely used framework because it can be adapted and used in different medical fields.
Furthermore, SEGUE, as a checklist, has demonstrated reliability and validity as an
assessment tool. However, Skillings, Porcerelli, and Markova (2010) suggested that
SEGUE is not an ideal instrument to measure the quality of the interaction since the
checklist only indicates if an action is completed. Therefore, it would be difficult to
differentiate between beginner, intermediate, and advanced levels of communication
skills.
SPIKES. Baile et al. (2000) synthesized evidence-based techniques and developed a
six-step protocol to deliver bad news to cancer patients. This SPIKES model was slightly
modified by Park, Gupta, Mandani, Haubner, and Peckler (2010) for delivering death
notification in the emergency department. Park et al. (2010) developed a five-hour death
notification workshop for EM residents. The initial lecture gave detailed instruction of
the SPIKES protocol, and stressed the importance of empathetic communication. This
was followed by role play exercises where the residents played the physician, survivor, or
an observer. The SPIKES competence form was used by the observer as a checklist for
22
required tasks. Lastly, the participants were expected to deliver a death notification to a
simulated session with standardized survivor. The session concluded with an extensive
debriefing with the use of video playback.
The 14 emergency residents were surveyed after the five-hour session. All
residents reported that the educational experience to learn death notification skills was
necessary and that the workshop was useful. Furthermore, the residents reported that their
patient care would improve after the workshop. These residents were also surveyed about
what workshop session was the most useful. Forty-three percent reported the simulation
with standardized survivors was the most useful. Fourteen percent indicated role play,
and only 7% reported the initial lecture as the most useful. The remainder of participants
reported that each session was equally useful. The authors suggest that using simulation
and role play exercises with the integration of the SPIKES protocol is an effective way to
teach difficult news delivery.
Implications. “Mental rehearsal is a useful way for preparing for stressful tasks”
(Baile et al., 2000, p. 305). Research findings imply that the use of mnemonics and
checklists decrease the stress of the EMS provider when delivering a death notification.
GRIEV_ING, SPIKES, and SEGUE all provide a plan, structure, and strategy to
communicate with patients and their families. As suggested by Hobgood et al. (2009),
these mental checklists may also negatively affect interpersonal skills. An effective
strategy for EMS would integrate key components from all three protocols with a few
modifications. These protocols were designed as communication guides rather than
regimented tasks. Reliance on GRIEV_ING, SPIKES, and SEGUE as black-and-white
scripts may result in rigid communicators. In the guide’s debriefing section, the facilitator
23
is given instructions to also give specific feedback on interpersonal skills. Death
Notification Training for Paramedics includes a modified SEGUE checklist for
paramedic training. Permission from Dr. Makoul will be obtained prior to use or
publication.
Simulation
Simulation has been utilized in medical education as an important method for
improving clinical training, communication, and patient safety (Wang, 2011). This ranges
from low-fidelity simulation manikins, such as latex IV arms, to high-fidelity simulation
experiences that immerse the learner in close to authentic environments. Simulation
incorporates principles of adult learning theory, and has been shown to be more effective
in teaching bad news delivery than traditional methods (Jacques et al., 2011).
McLaughlin, Doezema, and Sklar (2002) examined the effectiveness of human
simulation in emergency medicine resident training. In addition to assessing core
technical competencies, the medical residents were also objectively evaluated on their
interpersonal skills. “Although limited by the fact that residents know the encounters are
staged, simulated encounters with family members, difficult patients, and a variety of
hospital personnel can be used for teaching communication skills and professionalism
(McLaughlin et al., 2002, p. 1314).” They also found that simulation improves the
retention of knowledge as compared to traditional lecture formats. However, the authors
clarified that simulation is not an assessment tool by itself, and that it is challenging to
develop valid and reliable assessment tools with “psychometric integrity.” Therefore,
most of these validated tools are borrowed from other fields of medicine.
24
In a recent publication, Educating the Delivery of Bad News in Medicine:
Preceptorship vs. Simulation, Jacques et al. (2011) described the benefits of simulation in
the instruction of bad news delivery versus the traditional model of medical education. In
the apprenticeship approach, “role modeling and imitation are emphasized, learning is
clinically oriented, feedback is limited, and active supervision is minimal (Jacques et al.,
2011).” On the other hand, simulation is an interactive experience that actively involves
the learner and incorporates theories of adult learning (Wang, 2011). Unlike traditional
methods, using simulation as a teaching tool involves self-reflection, peer-to-peer
feedback, and debriefing. Jacques et al. (2011) stated that simulation training can help
develop the skills needed to effectively and empathetically deliver bad news
Rosenbaum et al. (2004) reviewed effective strategies taught to medical students
and residents. They concluded that there are several educational methods, but an effective
curriculum would give learners “opportunities for learners to discuss relevant issues, and
practice and receive feedback on their skills (Rosenbaum et al., 2011).” This suggests that
effective teaching methods of bad news delivery must engage students in the learning
process. Rosenbaum and Kreiter (2002) suggested that the use of multiple standardized
patients and family in difficult communication training can increase student comfort.
Implications. Widespread evidence throughout literature suggests that death
notification skills should be delivered through an experiential method. A death
notification training program would not be most effective through a lecture format.
Simulation with the use of standardized actors immerses the learner in a pseudo-authentic
environment with similar stressors. The core components of this project are simulation
activities with standardized actors and debriefing sessions.
25
Synthesis
Substantial evidence found in various areas of literature clearly justifies and
supports the best way to design this guide: Effective Difficult Communication Skills for
the Paramedic. The synthesis of research findings suggests that an effective program
should have certain characteristics and components with specific regards to duration,
content, and method of implementation.
Nearly all educational interventions discussed in this literature were two to five hours
in length. It has been shown that self-efficacy and competence have increased in as little
as two hours. In contrast, a two-day 16-hour educational program similar to EDECT may
not be ideal for primary paramedic education. As mentioned by Smith and Walz (1995), a
standalone program is nearly impossible since many paramedic programs are offered in
an accelerated program. Therefore, it must be introduced into curricula in smaller
sections. Although the EDECT program suggested the highest effectiveness, it may not
be practical for paramedic training programs to allocate 16 hours for death education. The
educational intervention must be easily integrated into current curricula. The activities in
this simulation guide are designed to be conducted in approximately two hour segments.
Studies show that paramedics are most receptive to death notification education if
the workshop is facilitated by a peer with similar experiences. Trained and qualified EMS
educators would be best suited to teach paramedics. Furthermore, the evidence also
suggests that an effective program must be tailored specifically for EMS. The formal
workshops designed for emergency residents, such as GRIEV_ING, would not directly
transfer into paramedic education. It would require modification and customization to
meet the needs of paramedics.
26
Investigation into difficult communication methods shows that there are different
ways to deliver bad news. The research suggests that effective difficult communication
education should include a plan or strategy. Components of all three protocols have been
incorporated into Effective Difficult Communication Skills for the Paramedic.
Lastly, there is overwhelming evidence that effective programs include an
experiential component. Educational interventions discussed in this literature review
involved a standardized simulation session where participants were given the opportunity
to experience communicating difficult news and receive feedback. Smith and Walz
(1995) noted that most death education was offered through lecture format and
competency was assessed through closed-ended assessments. The literature strongly
suggests that experiential methods, such as simulation with standardized patients and
actors, are the most effective way to learn difficult communication skills. This project
incorporates simulation into the core of its design.
Death Notification Training for Paramedics is an evidence-based instructional
resource tailored to meet the specific needs of EMS education and practice. This project
was built upon the valuable knowledge shared among literature, and will be one of the
pioneer educational resources for difficult communication training in EMS.
27
Chapter Three – The Project
Introduction
Studies show that instructional products similar to Death Notification Training for
Paramedics is a much needed resource for EMS education and that there are proven
methods for effectively teaching this skill. This chapter begins with a discussion of how
adult learning theories are incorporated into the design. This is followed by an overview
of the instructional design model used to create the guide. Chapter 3 will conclude with a
product description, which includes a discussion of its layout, contents, and physical
appearance.
Development of the Product
Adult learning theory. This product incorporates principles of adult learning
theory into its design and development. The term andragogy is the art and science of
teaching adults (NAEMSE, 2013). It has become synonymous with Malcolm Knowles’
“adult learning theory.” He extensively investigated how adult learning differed from
pedagogical approaches, and developed a conceptual frame work around andragogy. His
work resulted in six assumptions of adult learners (Knowles, Holton, & Swanson, 2005),
which were all integrated into the design of this project.
Knowles’ first assumption was that adults want a sense of control over their
learning experiences. This simulation guide gives the paramedic students autonomy
through its flexible nature. They can choose how they deliver bad news as long as their
method meets recommended principles. There is not a regimented script that must be
memorized, nor an exact sequence of events that must be followed. This gives the adult
learner a chance to develop their own style.
28
Knowles’ second assumption was that adults are only open to learning things that
are immediately applicable to their lives. Adults, in particular, must value the material in
order for the learning process to begin. The instructor will put the activity into context
during the debriefing of a death notification simulation. The facilitator will ask: “Did you
know that many paramedics find it difficult to console family members and notify them
that their loved one has died?” This will make the paramedic student more aware that
these difficult situations are “typical calls,” and that this activity has immediate relevance
to their responsibilities as a paramedic.
Knowles’ third assumption was that adults’ experiences serve are a rich resource
for learning. Moreover, the educator should value these personal and professional
experiences and not just assume that their students are a blank slate. All paramedic
students are experienced EMT-Basics before they are advanced in their training.
Therefore, they already have experience as prehospital care provider. Involving and
valuing the paramedic students’ previous experiences in the learning process is a direct
application of Knowles’ third assumption.
Knowles’ fourth assumption and fifth assumptions go hand in hand. Adult
learners need to know why they are learning something. There must be purpose in the
learning experience. Furthermore, Knowles assumed that adults’ learning orientation was
more problem-centered rather than subject-centered. Adults are more open to learning if
it the newly acquired knowledge or skills will help them solve practical problems in real
life. Death Notification Training for Paramedics uses a case-based scripted simulation to
engage the paramedic student in a practical learning experience. Delivering difficult news
can also be taught on a PowerPoint presentation to a classroom full of adults, but it does
29
not have a hands-on problem-centered approach. This guide is a tool to facilitate
simulation sessions that immerse paramedic students in situations that are directly
relevant to their careers.
Knowles’ sixth assumption is that adults are more motivated by intrinsic factors
such as self-esteem and self-efficacy. This guide involves a debriefing after each session.
The participants will be asked to give each other constructive feedback regarding several
aspects of their performance. Most importantly, the student under evaluation will be
asked to do a self-assessment. This introspection will give the paramedic student an
opportunity to diagnosis their own needs. Knowles’ sixth assumption suggests that doing
so may increase a learner’s internal motivation.
Dick and Carey Instructional Design Model. The Dick and Carey instructional
design (ID) model was used to design and develop Effective Difficult Communication
Skills for the Paramedic. It is also known as the Systematic Design of Instruction. This
ID model starts by identifying instructional goals and ends with a summative evaluation.
I chose to use this particular model because it is an ongoing process of evaluation and
refinement. This dynamic eight-step formative process allowed for constant revision
where needed.
Stage 1: Identify instructional goals. The first stage of this ID model is to
identify what I want the paramedic trainees to do when they finish with instruction. This
involved performing a needs assessment and identifying a gap between the desired goals
and the current status of education. Extensive review of literature supported my
observations as an EMS educator and licensed paramedic. The instructional goal of
Death Notification Skills for the Paramedic is the following: “On every dispatched call,
30
paramedics will use effective and compassionate communication techniques with patients
and families for both non-emergency and emergency situations. Although the guide
focuses on difficult communication skills such as death notifications, the instructional
goal is to improve overall communication skills for all patient encounters.”
Stage 2: Conduct instructional analysis. The second stage was to conduct an
instructional analysis. This involved investigating how difficult communication skills
were currently taught to paramedic students and identifying specific communication
skills that are needed to accomplish goals.
Stage 3: Analyze learners and context. After analyzing goals, the next step was
to analyze the leaners and the contexts in which the learners will take place. This also
involved identifying the learners, and examining entry behaviors, knowledge, and skills.
All paramedic students are experienced and certified EMT-Basics. Many of them have
witnessed a paramedic deliver a death notification or have been involved in other
situations that required effective communication skills. This is important in the design
process because it influenced the guide’s content, structure, and expectations from
learners.
Stage 4: Performance objectives. The fourth step involved developing
performance objectives. These are specific statements that the learners will be able to do
when they complete instruction. One performance objective is: “When delivering
difficult news, the paramedic intern will always use clear phrases that are not subject to
misinterpretation.”
Stage 5: Develop assessment instruments. The fifth step involved developing
measurement tools to evaluate performance and learning. The SEGUE – Paramedic was
31
adapted from Dr. Makoul’s SEGUE evaluation tool. It encompasses all the key elements
of difficult communication skills.
Stage 6: Instructional strategy. The development of the instructional strategy is a
result of a synthesis of evidence-based best practices. The educational session will begin
with a brief lecture to put subsequent activities in context. This will be followed by smallgroup simulation sessions with standardized actors. The following are some instructional
strategies that are incorporated into Death Notification Training for the Paramedic:
Relevance. This guide leverages students’ past EMS experiences in several ways.
The simulation scripts are written in a manner that assumes that the learner has
foundational experience. The post-simulation debriefing tool instructs the facilitator to
ask the group: “Have you experienced a similar situation in your experience as an EMT?
What did you learn from it?”
Accountability. This guide holds learners accountable by including the modifiedSEGUE checklist which they will use to evaluate themselves and their peers. The last
activity is a self-reflection assignment. “Put yourself on the receiving end of EMS. You
are a family member standing next to your mother, father, or spouse. Two paramedics, a
captain, three EMTs, and two police officers are in your living room. How do you expect
them to communicate with you and your loved one? What would make you upset?”
Modality. Conducting simulations in a vignette room with a scripted standardized
actor creates a multi-sensory learning experience. The simulation rooms should not just
be a classroom with tables and chairs pushed aside. A training lab, or vignette room,
should be used to create the most authentic experience. These rooms should accurately
resemble the details in the script.
32
The learners are expected and encouraged to perform as if it was a real
emergency. They will be allowed to touch the patient, take vital signs, do CPR, and move
furniture as necessary. The actors and bystanders will be scripted to raise their voices,
cry, or stay quiet. A loud radio will be on in one of the scenarios, and the paramedic
student will be expected to adjust the volume.
Organizers. The SEGUE mnemonic will be taught to the paramedic students prior
to the simulation exercises. This instructional strategy organizes the death notification
process from beginning to end.
Examples. Section III contains good and bad examples of each SEGUE step.
Instead of just stating “Don’t use medical jargon,” the supplement this recommendation
by giving an example: “We tried to resuscitate your father, but he didn’t respond to our
interventions. We intubated him and put him on the cardiac monitor… and still nothing.”
The more appropriate manner immediately follows the bad example. This gives the
learner an opportunity to compare the two.
There are also two sample “trainer speeches” included in Section II: The
Importance of Communication in EMS. The guide invites the instructor to share a story
about how communication skills affect their careers as paramedics prior to beginning the
simulations. These two examples are concise, personal, and practical. Lastly, the SelfAssessment Assignment in Section VI also contains examples of thorough and
inadequate reflections.
The paramedic students will also see one example of a properly delivered death
notification at the conclusion of the pre-simulation lecture. Unlike the simulation
sessions, this will not involve a standardized actor. The instructor will read the script on
33
the screen and will deliver the notification to a volunteer in the class. This exercise will
end with a brief discussion of how the instructor implemented each component of
SEGUE.
Practice. The simulation sessions give the paramedic trainees opportunities to
practice delivering a death notification to a standardized survivor. This instructional
strategy of integrating an experiential component is the core of Death Notification Skills
for the Paramedic. The lecture in Section III is only designed to set the tone for the
simulation exercises and to introduce SEGUE. The simulation and debriefing sessions is
where most learning will occur. Practicing how to deliver death notifications in a
simulated environment will decrease the students’ stress in real-life high stress situations.
Stage 7. Instructional materials. After determining the instructional strategy, the
following step was to evaluate what materials, equipment, and resources were required.
Standardized actors, simulation rooms, and a qualified facilitator are few necessary
resources to execute the instructional strategy.
Stage 8. Formative evaluation. This phase involved collecting data to evaluate
stages in the instructional design process that need to be revised or improved. Preliminary
feedback was given by the audience in a graduate-level instructional design class. Subject
matter experts were also surveyed and most of their feedback resulted in changes to the
design. Details of this evaluation process and the resulting product modifications are
presented in Chapter 4.
Stage 9. Summative evaluation. This phase involves gathering pre and post data
on the paramedic trainees. The goal is to evaluate the effectiveness of the Death
34
Notification Skills for Paramedics after it has been implemented in a real-world
environment. Plans for a summative evaluation are discussed in Chapter 4.
Product Description
Physical description. This guide is spirally bound between clear semi-rigid
plastic covers. Appendix A presents pictures of the front and back covers. The front has a
picture of three EMS providers standing behind an ambulance. The back cover has two
pictures of EMS providers in action. All of these graphics were strategically chosen to
make it apparent that EMS is the intended audience.
All 62 pages of the guide, including the front and back covers, are printed on
standard 8.5”x11” paper. The forms in Section VI are laminated to provide added
durability for repetitive duplication. Section IV is subdivided by blue hard stock paper
with graphics depicting the following scenario. This vibrant blue paper also serves as a
guide so the facilitator can easily navigate between scenarios. Lastly, a compact disc is
attached to the inside of the back cover. This contains the PowerPoint slides printed in
Section III of the guide.
Organization. The simulation guide is divided into seven sections. The first
section, How to Use This Guide, gives the EMS educator instructions on how to
efficiently use it as learning tool. This section also includes suggests of how to integrate it
into their paramedic program. The second section discusses the importance of
communication in the EMS profession. The third section includes a 36-slide PowerPoint
presentation entitled: Setting the Tone. This puts the simulation activity in context and
introduces the death notification strategy. The fourth section contains three scripted
scenarios with details needed to conduct the simulation. It discusses the required
35
equipment, “actors,” environment, and objectives of the exercise. The fifth section
discusses the importance of the debriefing component of the simulation. The sixth section
of the guide consists of the SEGUE-Paramedic checklist, a debriefing tool, and a selfreflection exercise. Section VII lists resources relevant to death notification in EMS.
Environment and Equipment. All components in a simulation need to be as
realistic as possible. In this manner, the paramedic student would be better able to
transfer learned skills to a real situation. Each of the three scripts in the third section lists
what items, actors, and environmental factors are needed. For example, in the first
scenario, an elderly male is unable to wake his wife from sleep in the morning. This
requires a simulation room that is setup similar to a real bedroom. Other equipment
required includes the typical gear paramedics bring to every emergency such as an airway
bag, cardiac monitor, a clipboard, and a gurney. Audiovisual (AV) recording will also
make the debriefing experience more effective.
Intended Audience and Personal Qualifications. The full product name is
Death Notification Training for Paramedics: A Simulation Guide for EMS Educators.
“EMS Educator” is a general title for anyone who teaches in any level EMS. Those who
solely lecture in the classroom are referred to as “lecturers,” and those who teach in small
group hands-on sessions are called “skills instructors.” It is common for educators to
teach in both areas, but in larger paramedic programs the lecturers and skills instructors
have separate roles.
Paramedic skills instructors are the primary audience for this guide. Practicing
paramedics and nurses with emergency department backgrounds are usually in this
position. Furthermore, it is also intended for experienced educators who are able to
36
conduct a simulation and debriefing, use time efficiently, and engage critical thinking.
This involves a high degree of comfort with teaching in groups of five to six paramedic
students. Other qualifications include the ability to multi-task and pay attention to detail.
Newer instructors are usually assigned to teach skills sessions that are more black and
white, such as the application and use of a device. Inexperienced instructors who have
never conducted a simulation session at the paramedic level may feel overwhelmed and
unable to give accurate feedback. The paramedic skills instructor should also have firsthand experiences delivering a death notification.
The paramedic students are also a part of the intended audience, but the guide is
developed for the instructor. It is not designed for paramedic students to gain death
notification skills through self-study. An experienced skills instructor will use the guide
to conduct Death Notification Training for Paramedics. This first edition guide currently
has no formal training for paramedic instructors. However, the directions throughout the
guide are delivered in a manner in which most experienced paramedic instructors can
comprehend and carry out. The use of simulation is currently common practice in
paramedic training programs. Skills instructors are familiar with conducting simulation
sessions in small groups. Future editions will include formal training for instructors in
collaboration with other death and dying professionals such as grief counselors, clinical
social workers, experts in thanatology, and psychologists.
It is also necessary to distinguish between two levels of EMTs. Paramedics are
EMTs with advanced training and licensure, and EMT-basics have a lower certification
level. All paramedic students are experienced EMT-basics pursuing advanced training.
Therefore, most EMT-basics in paramedic school have worked alongside a paramedic.
37
These prior experiences in real emergency situations will serve as a valuable foundation
in death notification training.
Most paramedic trainees are young adults in their twenties and thirties who come
from diverse backgrounds. In the early years of EMS, the typical paramedic student was a
high school graduate who took a basic EMT course and worked on an ambulance prior to
pursuing more training. In the present day, paramedic students have more diverse
educational and professional backgrounds. Many are still the high school graduates who
joined the EMS workforce as EMT-basics in their late teens to early twenties. However,
there are also many paramedic students who have completed college and have non-EMS
professional work experience. A significant number of students are also veterans with
technical skills gained from military training.
The collective motivation of students can vary among paramedic schools, and at
times, between classes in the same program. There are civilians who are in school fulltime, supporting themselves through loans, and paying their own tuition. The others are
employed fire fighters who are receiving a salary while in school. Some of these fire
fighters chose to advance their careers by becoming licensed paramedics while others
were mandated to pursue paramedic training. There is usually low motivation to engage
in learning from students who are forced to be in school. On the other hand, there is
typically a higher motivation to learn from those who have “more on the line” (e.g. paid
their way through school, hoping to start a career, etc).
General Guide Contents. The following are the six sections of Death
Notification Training for the Paramedic.
I.
How to Use This Guide
38
II.
Importance of Effective Communication Skills in EMS
III.
Pre-simulation lecture: Setting the Tone
IV.
Scripted Scenarios
V.
Debriefing
VI.
Forms
a. Debriefing guide
b. SEGUE – Paramedic Checklist
c. Self-Evaluation Assignment
d. Trainer Feedback Form
VII.
Resources
Transition to Next Chapter
Chapter Four will summarize the preceding chapters, discuss formative and
summative evaluation of Death Notification Skills for the Paramedic, and conclude with
future plans. The actual product can be seen in Appendix H.
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Chapter Four - Conclusion
Summary
Several studies have shown that paramedics, and health care providers alike, feel
inadequate in their abilities to delivery difficult news. Although this skill requires
repetition and practice, a lack of foundational training also has an influence on this
deficit. As part of their work, paramedics are exposed to a high incidence of death outside
the hospital setting. Therefore, they must have effective and compassionate
communication skills to deliver difficult news. This project justifies a need through
supportive literature, includes a description of the development and evaluation process,
and concludes with a final product: Death Notification Training for Paramedics. The
purpose of this project is to provide EMS educators with an evidence-based resource to
facilitate a simulation session on difficult communication. Ultimately, paramedics with
more effective and compassionate communication skills will provide better care for
patients and their families.
Evaluation
This guide has undergone a continuous evaluation process and several revisions
have already been made. A more comprehensive evaluation must be done to fine-tune
this guide and determine its effectiveness in training paramedic students to deliver death
notifications.
Formative Evaluation. Preliminary feedback from a presentation in an
instructional design class (EPC 615) resulted in a few significant changes. The audience
was comprised of graduate students from various professional fields, which included
education, counseling, business, and human factors. One recommendation was to put the
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name of each section on the tabs, rather than just a number. The implementation of this
change resulted in a more professional and user-friendly appearance. Other feedback
included adding more pictures and diagrams; particularly to aid in describing the
simulation scenarios. I have included visual representations for each scenario in Section
IV.
Death Notification Skills for Paramedics was professionally reviewed by three
EMS educators from different training programs. The evaluation form consisted of three
sets of questions (see Appendix B). The first is: How does your paramedic program
currently train students to deliver a death notification? Evaluator A said: “The program
as a whole prepares them for this, maybe not the didactic (lecture) section, but their field
internship surely does. Field internship is still a part of the program. But there is no focus
on this specific skill before they deal with real patients as interns.” Evaluators B and C
said that their programs did not specifically teach nor assess death notification skills in
any aspect. This question did not yield feedback relevant to the design of Death
Notification Skills for the Paramedic. It simply reinforced the needs assessment.
The second question was: Would you implement this product into your paramedic
training program? If yes, how would you use it? All three evaluators indicated that they
would use this guide. Evaluator A said that it could be integrated into several skills days
throughout the program. “On a typical skills day, we have 6 rotations of 6 to 7 students
each. I would use simulations in this guide in one of the rotations.” Evaluator B said that
it would be difficult to implement this guide into their program. “We’re already looking
for more time for our students to get practice on other skills such as Advanced Cardiac
Life Support. Yes, we would implement it, but it will be hard to justify why we’re
41
making time for this and not areas where our students need help.” Evaluator C indicated
that this guide could be “used toward the end of the first phase of paramedic school right
before the interns hit the field. This would put things into perspective and give them a
broader view of what to expect. We would make it one of the small group rotations in one
of the skills days.”
The third question was: “How would you improve this guide?” Evaluator A said
that there are too many scenarios in Section IV. “It would better to have three awesome
simulation scripts than one excellent and four mediocre. Polish up three of them and add
more details to how the actors should behave. Your directions are too loose and can be
translated in many ways. Three is plenty. Four, maybe. Six is too many.” Evaluator B
said: “Make this look more like a guide than a book. I don’t think instructors want
another book to join the others on their shelves. Also, make sure that the scenarios don’t
neglect the ‘medicine’ part of this all. They’re still going to go in and do a medical
assessment, not just practice communication. Also, there is no point in separating Section
VII if it’s just forms.” Evaluator C said: “Make sure that other programs can also use this
guide. Not every program has multiple skills rotations per day or even skills rooms. Some
small programs have two people teaching the entire thing and their main classroom is
their skills room.”
The pre-evaluation version of this guide consisted of six different scenarios. I
took the advice of Evaluator A and removed two. This also gave me the opportunity to
refine three of the scenarios and elaborate on details. Having six scenarios made the final
product look physically thicker and more comprehensive. However, that is not the goal.
The aesthetic effect of removing a few pages also made the book look more user-friendly
42
and less intimidating. I also took Evaluator B’s advice regarding “neglecting the
medicine.” A few of the scripts did not have thorough medical information, such as vital
signs and a medical history, for the simulation. All the scenarios are now scripted in a
medically sound manner. Lastly, Sections VI and VII were “Debriefing Tool, SEGUEParamedic Checklist, Self-Evaluation Assignment, and Trainer Feedback Form.” I
consolidated the last two sections into Section VI per Evaluator B’s advice.
Summative Evaluation. A summative evaluation will be done after the guide has
been implemented into paramedic curricula and the students are practicing paramedics.
This would involve a pre and post-intervention study of two experimental groups. One
group of trainees will undergo Death Notification Training for Paramedics. Another
group will participate in another communication skills training workshop of the same
duration. The control group will receive a two hour continuing education seminar on a
subject unrelated to communication skills. The purpose of the summative evaluation is
to show that Death Notification Training for Paramedics is an effective educational
resource. Ideally, I would also survey patients and families to collect qualitative data
about their experiences with EMS. However, this may be difficult due to patient
confidentiality laws and the logistics of tracking patients and their families.
Future Work
Future plans include creating a website for EMS providers and educators to share
scenarios that particularly involved difficult communication skills. This information
could be used to script more scenarios that are relevant to EMS. A repository of scenarios
could be shared with the EMS community to conduct simulations with standardized
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actors. The next edition of this guide will also be available in an electronic book format
that will be accessible on a tablet.
Other plans also include integrating role play activities with well-scripted
vignettes from real life EMS situations. This will allow the learner to experience multiple
perspectives of the death notification process. Including role play and simulation
activities in this current version will lengthen the sessions. At this point, two hours should
be the maximum until further evaluation is conducted. This first edition of Death
Notification Skills for the Paramedic will be a step forward in creating a paradigm shift in
EMS.
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References
Baile,W., Buckman, R., Lenzi, R., Glober, G. , Beale, E., Kudelka, A. (2000). Spikes: a
six-step protocol for delivering bad news: Application to the patient with cancer.
The Oncologist, 5(4), 302-311.
Boyle, M., Williams, B. , & Burgess, S. (2007). Contemporary simulation education for
undergraduate paramedic students. Emergency Medicine Journal : EMJ, 24(12),
854-857.
Douglas, L., Cheskes, S., Feldman, M., & Ratnapalan, S. (2013). Death notification
education for paramedics: past, present and future directions. Journal of
Paramedic Practice, 5(3), 152-159.
Fallowfield, L. , & Jenkins, V. (2004). Communicating sad, bad, and difficult news in
medicine. Lancet, 363(9405), 312-319.
Hobgood, C. , Harward, D. , Newton, K. , & Davis, W. (2005). The educational
intervention "GRIEV_ING" improves the death notification skills of residents.
Academic Emergency Medicine, 12(4), 296-301.
Hobgood, C., Tamayo-Sarver, J., Hollar, D., & Sawning, S. (2009). GRIEV_ING: death
notification skills and applications for fourth-year medical students. Teaching and
Learning in Medicine, 21(3), 207-219.
Jacques, A. , Adkins, E. , Knepel, S. , Boulger, C. , Miller, J. , et al. (2011). Educating the
delivery of bad news in medicine: Preceptorship versus simulation. International
Journal of Critical Illness and Injury Science, 1(2), 121-241.
Knowles, M., Holton, E., & Swanson, R. (2005). The Adult Learner. (6 ed.). Burlington,
MA: Elsevier.
45
Lammers, R. , Byrwa, M. , Fales, W. , & Hale, R. (2009). Simulation-based assessment
of paramedic pediatric resuscitation skills. Prehospital Emergency Care : Official
Journal of the National Association of EMS Physicians and the National
Association of State EMS Directors, 13(3), 345.
Mast, M. S., Kindlimann, A., & Langewitz, W. (2005). Recipients’ perspective on
breaking bad news: How you put it really makes a difference. Patient Education
and Counseling , 58, 244_251.
Makoul, G. (2001). The segue framework for teaching and assessing communication
skills. Patient Education and Counseling, 45(1), 23-34.
McLaughlin, S. , Doezema, D. , & Sklar, D. (2002). Human simulation in emergency
medicine training: A model curriculum. Academic Emergency Medicine, 9(11),
1310.
National Association of EMS Educators. (2013). Foundations of education: An ems
approach. (2 ed.). Clifton Park, NY: Delmar.
Nordby, H. , & Nøhr, Ø. (2011). Care and empathy in ambulance services: Paramedics’
experiences of communicative challenges in transports of patients with prolonged
cancer. Journal of Communication in Healthcare, 4(4), 215-226.
Norton, R., Bartkus, E., Schmidt, T., Paquette, J., Moorhead, J., & Hedges, J. (1992).
Survey of emergency medical technicians' ability to cope with the deaths of
patients during prehospital care. Prehospital and Disaster Medicine, 7(3), 235242.
Park, I. , Gupta, A. , Mandani, K. , Haubner, L. , & Peckler, B. (2010). Breaking bad
46
news education for emergency medicine residents: A novel training module using
simulation with the spikes protocol. Journal of Emergencies, Trauma, and Shock,
3(4), 385-388.
Rosenbaum, M. , Ferguson, K. , & Lobas, J. (2004). Teaching medical students and
residents skills for delivering bad news: A review of strategies. Academic
Medicine : Journal of the Association of American Medical Colleges, 79(2), 107117.
Rosenbaum, C., & Kreiter, C. (2009). Teaching delivery of bad news using experiential
sessions with standardized patients. Teaching and Learning in Medicine, 14(3),
144-149.
Shield, R. R., Tong, I., Tomas, M., & Besdine, R. W. (2011). Teaching communication
and compassionate care skills: An innovative curriculum for pre-clerkship
medical students. Medical Teacher, 33(8), e408-e416.
Skillings, J. , Porcerelli, J. , & Markova, T. (2010). Contextualizing segue: Evaluating
residents' communication skills within the framework of a structured medical
interview. Journal of Graduate Medical Education, 2(1), 102-107.
Smith, T. , & Walz, B. (1995). Death education in paramedic programs: A nationwide
assessment. Death Studies, 19(3), 257-267.
Smith-Cumberland, T. , & Feldman, R. (2006). Emts' attitudes' toward death before and
after a death education program. Prehospital Emergency Care, 10(1), 89-95.
Stewart, M. (1995). Effective physician-patient communication and health outcomes: A
review. CMAJ : Canadian Medical Association Journal = Journal De
L'Association Medicale Canadienne, 152(9), 1423-1433.
47
Stone, S. , Abbott, J. , McClung, C. , Colwell, C. , Eckstein, M. , Lowenstein, S. (2009).
Paramedic knowledge, attitudes, and training in end-of-life care. Prehospital and
Disaster Medicine, 26(6), 529-534
Wang, E. (2011). Simulation and adult learning. Disease-a-month : DM, 57(11), 664-678.
Williams, B. (2009). Do undergraduate paramedic students embrace case based learning
using a blended teaching approach? a 3-year review. Australasian Journal of
Educational Technology, 25(3), 421-439.Appendices
Appendices
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Appendix A
Front and Back Covers
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Appendix B
Death Notification Skills for the Paramedic Professional Evaluation
1. How does your paramedic program currently train students to deliver a death
notification?
2. Would you implement this product into your paramedic training program? If yes,
how would you use it?
3.
How would you improve this guide?
Comments:
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Appendix C
Sample Pages from Death Notification Training for Paramedics
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Section I
HOW TO USE THIS GUIDE
This guide is for you: The EMS Educator! It is designed to help
you facilitate a simulation-based session in a training lab or vignette
room. It is not designed to deliver instruction through lecture format.
There are 3 fully scripted scenarios with all the details that you need.
Feel free to adjust the details of each scenario to make it more relevant to
your geographic area, local protocols and student population.
Your communication skills training sessions will require pre-class
planning. Look at the “What do you need?” details in Section 3 for each
scenario. You will need to secure volunteer actors prior to your training
for each rotation, and may need specific props.
Use this guide as an adjunct to your training curriculum. You can
integrate one of these scenarios into a pre-scheduled skills day. For
example, you can integrate Scenario A into your Cardiac Skills day, and
Scenario B when you cover pediatric emergencies. This may be the most
cost-effective option.
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Section II
THE IMPORTANCE OF EFFECTIVE
COMMUNICATION IN EMS
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Section III
SETTING THE TONE
This lecture will “set the tone” for the simulation sessions. It will
begin with a brief history of EMS and how it has evolved as a profession.
You will notice that the slides contain minimal text and will require you
to use the presentation as an adjunct to facilitate a lecture. If you are the
type of instructor who reads the words off the screen and clicks away,
then you will speed through the lecture. This lecture requires
preparation. Review the slides prior to delivering this brief lecture so
you know its contents. This will also help you pace yourself and make
you look more confident in front of the audience.
Prior to dividing the class into small groups, it would be ideal to
keep them in the lecture room (typically the primary classroom) and
present this lecture. It should take 20 to 30 minutes including the sample
“good” and “bad” death notification and any questions at the end.
If simulation sessions will occur immediately following this
lecture, your standardized actors and instructors (if there are others)
should be preparing in the sim/training rooms while you’re speaking.
The groups should seamlessly start their simulation session without
unnecessary preparation delay.
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The following 36-slide lecture is included in the CD as a
PowerPoint file. The notes are intended to guide your lecture.
PowerPoint 2010 has a “Presenter View” feature so you can see your
notes on a personal screen while you lecture. The notes will not show
up on the main screen.
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Section IV
SCRIPTED SCENARIOS
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Section V
DEBRIEFING
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Section VI
FORMS
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Section VII
RESOURCES
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About the Author
Mark Malonzo has been involved in EMS since 1999. He is currently a
California-licensed and nationally registered paramedic. Mark has worked for
private ambulance companies and a municipal fire department. He has
experience in “9-1-1” medical response, non-emergent transport, and special
event medical standby. Mark currently works part-time as a paramedic for the
Sierra Madre Fire Department.
Mark is a full-time EMS Educator with the Center for Prehospital Care
at the UCLA David Geffen School of Medicine. He began his career with
“The Center” in 2002 as a CPR and EMT instructor. Mark has worn many
hats in the last decade as an instructor in EMT and Paramedic programs. It
was through these valuable experiences where he learned how to facilitate
small group simulation sessions. Some of his current responsibilities include
overseeing the Paramedic Preparatory program, Prehospital Trauma Life
Support program, and the National Registry Paramedic Psychomotor
examination.
Mark holds a bachelor’s degree in Biology with a minor in Psychology
from Loyola Marymount University. In 2013, he will be finishing a Master of
Arts degree program in Educational Psychology from California State
University Northridge. His graduate education focused on human
development, learning, instruction, and evaluation. Mark also has a
California Designated Subjects credential in Career Technical Education.
Mark is particularly interested in adult education and experiential learning.
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