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

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

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

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

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

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

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

需闭手季手 99 3 ooNa 示8 err988 640

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

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

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

T Smith-Cumberland Information was also elicited about recent critical incidents. as it was unclear if the attitudes of EMTs who experienced one of these incidents were different from emts who have not had one A critical incident is an EMS call that involves the fatality of a victim(s) and overwhelms the psychological coping capacity of the EMT. The pretest scores for the four EMTs who reported a recent critical incident(6 months)did not differ from the group; thus, they were included in the final data set Materials Ajzen and Fishbein(1980) suggest very specific guidelines for creation of an instrument to test the TPB. Following these guide lines, an instrument was created by soliciting EMTs(not included in the study) for their salient behavioral (attitudes),(subjective) normative,and perceived behavioral control beliefs to each of the behavioral goals from the program(Ajzen, 1985). This data led to the creation of six questions in each of the follor areas: BI, ATT, PBC, and 12 questions from the Sn area as IT's identified two subjective norms(supervisors and other paramedics). The subscales, which were created by totaling the uestions in each of the four areas, were used to test the corre- lation of att. PbC. and sn to bl. several filler items were placed intermittently throughout the scale to counter response bias;thus, the final instrument contained 37 items. Each question was presented in a 5-point Likert format from strongly agree or very beneficial (1) to strongly disagree or(5)very harmful (See Table 1 for a list of the BI items). In the follow-up questionnaire, the items were in a yes/no format, e.g,"I allowed The instrument was then reviewed by several EMS experts for content and face validity. The instrument was cognitively-tested by EMTs(not from the sample) who read the instrument verbally and silently to elicit problems in structure and word content. These oblems were corrected and the instrument was pilot-tested among 35 EMTs enrolled in a CMe program not related to death The instrument was stable over one week with the correlation coefficients for the subscales ranging from .73 to. 82(Smit Cumberland, 2004). Reliability coefficients ranged from.74 to 83 for the subscales (alpha =.74 for ATT,83 for PBC. 74 for

Information was also elicited about recent critical incidents, as it was unclear if the attitudes of EMTs who experienced one of these incidents were different from EMTs who have not had one. A critical incident is an EMS call that involves the fatality of a victim(s) and overwhelms the psychological coping capacity of the EMT. The pretest scores for the four EMTs who reported a recent critical incident (6 months) did not differ from the group; thus, they were included in the final data set. Materials Ajzen and Fishbein (1980) suggest very specific guidelines for creation of an instrument to test the TPB. Following these guide￾lines, an instrument was created by soliciting EMTs (not included in the study) for their salient behavioral (attitudes), (subjective) normative, and perceived behavioral control beliefs to each of the behavioral goals from the program (Ajzen, 1985). This data led to the creation of six questions in each of the following three areas: BI, ATT, PBC, and 12 questions from the SN area as EMTs identified two subjective norms (supervisors and other paramedics). The subscales, which were created by totaling the questions in each of the four areas, were used to test the corre￾lation of ATT, PBC, and SN to BI. Several filler items were placed intermittently throughout the scale to counter response bias; thus, the final instrument contained 37 items. Each question was presented in a 5-point Likert format from strongly agree or very beneficial (1) to strongly disagree or (5) very harmful (See Table 1 for a list of the BI items). In the follow-up questionnaire, the items were in a yes=no format, e.g., ‘‘I allowed the family to view the body.’’ The instrument was then reviewed by several EMS experts for content and face validity. The instrument was cognitively-tested by EMTs (not from the sample) who read the instrument verbally and silently to elicit problems in structure and word content. These problems were corrected and the instrument was pilot-tested among 35 EMTs enrolled in a CME program not related to death. The instrument was stable over one week with the correlation coefficients for the subscales ranging from .73 to .82 (Smith￾Cumberland, 2004). Reliability coefficients ranged from .74 to .83 for the subscales (alpha ¼ .74 for ATT, .83 for PBC .74 for 642 T. Smith-Cumberland

Evaluation of EMTS"' Attitudes Towards Death SN, and. 78 for BI) and 94 overall(Smith-Cumberland, 2004).The initial alpha for the attitude subscale was. 69; however, one item was deleted for this study raising the alpha to. 74 procedure After sufficient responses to the recruitment letters, EMS agencies were randomly assigned to one of three groups; the two-day death ducation;the two-hour CME session; or the control group who received a two-hour lecture on advanced airway techniques. Due to travel distance and schedules, individual participants could not be randomized to treatments groups. The courses were free to the participants, and they received cme credits for the number of hours spent in the session. All participants received the question naire prior to the intervention and at the end of the intervention After three months, all participants received a follow-up letter eliciting information about six behaviors when they responded to a call involving a death. These behaviors corresponded directly to the behavioral intention items Three weeks after the first letter a second letter was sent to the non-respondents urging them to respond. Additionally, the EMS agency was contacted to encour age the EMTs to return the follow-up information. A total of 45 (54%)of the 83 participants responded to follow-up Results A test of correlation suggested that a relationship existed between pretest and posttest measures; therefore, a covariate analysis of variance(ANCOva)was used to control these effects with the pretest entered as the covariate EMTs who attended the 16-hour program or the two-hour CME session intended to change their behavioral intentions more often than those in the control group (F2, 80)=11.62, p<.000, n= 225). In LSD post-hoc tests, sig- nificant differences occurred between both the 16-hour and the control group(p<. 000), and the two-hour CME session and the control group(p<. 001). The two treatment groups did not signifi ly differ from each other (see Table 1). However, the results show a trend for those EMTs who received the 16-hour seminar to intend to change their behaviors related to death more often than those emts who received the two-hour course

SN, and .78 for BI) and .94 overall (Smith-Cumberland, 2004). The initial alpha for the attitude subscale was .69; however, one item was deleted for this study raising the alpha to .74. Procedure After sufficient responses to the recruitment letters, EMS agencies were randomly assigned to one of three groups; the two-day death education; the two-hour CME session; or the control group who received a two-hour lecture on advanced airway techniques. Due to travel distance and schedules, individual participants could not be randomized to treatments groups. The courses were free to the participants, and they received CME credits for the number of hours spent in the session. All participants received the question￾naire prior to the intervention and at the end of the intervention. After three months, all participants received a follow-up letter eliciting information about six behaviors when they responded to a call involving a death. These behaviors corresponded directly to the behavioral intention items. Three weeks after the first letter, a second letter was sent to the non-respondents urging them to respond. Additionally, the EMS agency was contacted to encour￾age the EMTs to return the follow-up information. A total of 45 (54%) of the 83 participants responded to follow-up. Results A test of correlation suggested that a relationship existed between pretest and posttest measures; therefore, a covariate analysis of variance (ANCOVA) was used to control these effects with the pretest entered as the covariate. EMTs who attended the 16-hour program or the two-hour CME session intended to change their behavioral intentions more often than those in the control group (F(2, 80) ¼ 11.62, p < .000, g2 ¼ .225). In LSD post-hoc tests, sig￾nificant differences occurred between both the 16-hour and the control group (p < .000), and the two-hour CME session and the control group (p < .001). The two treatment groups did not signifi￾cantly differ from each other (see Table 1). However, the results show a trend for those EMTs who received the 16-hour seminar to intend to change their behaviors related to death more often than those EMTs who received the two-hour course. Evaluation of EMTS’ Attitudes Towards Death 643

T Smith-Cumberland TABLE 2 Correlations Among Subscales for Treatment Groups 4 1. Intention 92* 3. Subjective 4. Attitude Note."p<.00l:p<0l;"p<.05. Of the 45(54%)participants who responded to the follow-up measure, 18(40%)stated they had made a death notification; how- ever,the small sample size limited the statistical analysis using the BI scale. The trends show that the EMTs in the 16-hour program changed their behaviors most often, where as the EMTs in the two-hour CME session changed less often, but more than the control group After consulting with EMS experts and a thorough review of the literature, it appeared that attitudes were the most important motivator for Bl. Therefore, ATT was entered first, followed by PBC, and finally Sn in a hierarchical multiple regression, in which ATT accounted for 85% of the variance in BI (F1, 82)=464.36 p<.001). The remaining regression coefficients for PBC(0.2) and Sn(0.4)were non-significant(see Table 2 for correlations Discussion Present data indicate that this 16-hour seminar and a two-hour CME session changed EMTs' behavioral intentions. After either likely to intend)to allow familie the deceased, use successive preannouncements, use the four-step death notification process, use death-related words instead of euphemisms, and leave follow-up information Changes tended to be greater for the 16-hour seminar than the two-hour group When reporting their behaviors, more than two-thirds(7 /9)of the 16-hour group and two-thirds(6 / 9)of the two-hour group ported that they used the words“dead”or“died” to make the death notification, whereas only one-third(1/ 3)of the control group reported that they had used one of these words. Only three

Of the 45 (54%) participants who responded to the follow-up measure, 18 (40%) stated they had made a death notification; how￾ever, the small sample size limited the statistical analysis using the BI scale. The trends show that the EMTs in the 16-hour program changed their behaviors most often, where as the EMTs in the two-hour CME session changed less often, but more than the control group. After consulting with EMS experts and a thorough review of the literature, it appeared that attitudes were the most important motivator for BI. Therefore, ATT was entered first, followed by PBC, and finally SN in a hierarchical multiple regression, in which ATT accounted for 85% of the variance in BI (F(1, 82) ¼ 464.36, p < .001). The remaining regression coefficients for PBC (0.2) and SN (0.4) were non-significant (see Table 2 for correlations). Discussion Present data indicate that this 16-hour seminar and a two-hour CME session changed EMTs’ behavioral intentions. After either course, they were more likely (to intend) to allow families to view the deceased, use successive preannouncements, use the four-step death notification process, use death-related words instead of euphemisms, and leave follow-up information. Changes tended to be greater for the 16-hour seminar than the two-hour group. When reporting their behaviors, more than two-thirds (7=9) of the 16-hour group and two-thirds (6=9) of the two-hour group reported that they used the words ‘‘dead’’ or ‘‘died’’ to make the death notification, whereas only one-third (1=3) of the control group reported that they had used one of these words. Only three TABLE 2 Correlations Among Subscales for Treatment Groups 12 3 4 1. Intention .77


.26

.92


2. Perceived control .19
.80


3. Subjective norm .21
4. Attitude Note.


p < .001;

p < .01;
p < .05. 644 T. Smith-Cumberland

Evaluation of EMTS"' Attitudes Towards Death out nine in the 16-hour group, and two out seven in the two-hour group, but none of the control group left follow-up information with the family. Many of the EMTs reported using successive preannouncements prior to the death notification(16- hour=7 /9, two-hour= 3/6, and control= 2/3). At least half of the EMTs(16-hour= 5/8, two-hour= 3/6)who had received the intervention, but none of the control group, reported using the our-step death notification process. The majority of the EMTs llowed a viewing by the family(16-hour=6/ 6, two-hour=4/ 5, cont A multiple regression indicated the EMTs' behavioral inten- tions stemmed from changes in their attitudes, not their perceived behavioral control or motivation to comply with their subjective norms. The large amount of variance accounted for by the EMTs attitudes indicate they hold positive beliefs that performing these six behaviors will lead to positive outcomes. The data also suggest that EMTs are not perceiving social pressure to perform these behaviors from other EMTs or their supervisors. Furthermore the EMTs feel confident to perform these behaviors. Thus, EMTS who believe that these six goals will help themselves or the victims families will be more likely to perform these behaviors than EMTs who hold less favorable beliefs Several limitations to the study include a sample rawn iron a single region, which might not represent EMTs nationwide, and only three months from intervention to follow-up, so that many of the Emts had made no death notification. Finally, lack of ran domization of individuals to treatment conditions must be taken into account when interpreting the data Despite these limitations, this study shows EMTs are respon sive to death-related programs. The results indicate that a short CME session can effect changes in EMTS. Courses that meet the unique needs of EMTs need to include detailed instruction how to make a death notification or handling the post-mortem arrangements. Current educational curriculums that teach the five stage psychosocial model designed by Kubler Ross may not be effective for EMTS, as EMTs often do not see the later stages, such as acceptance. These results demonstrate that theory can be used to evaluate EMTs programs and that the theoretical underpinnings of course success can be identified, which can help educators restructure their programs to become more beneficial to EMTS

out nine in the 16-hour group, and two out seven in the two-hour group, but none of the control group left follow-up information with the family. Many of the EMTs reported using successive preannouncements prior to the death notification (16- hour ¼ 7=9, two-hour ¼ 3=6, and control ¼ 2=3). At least half of the EMTs (16-hour ¼ 5=8, two-hour ¼ 3=6) who had received the intervention, but none of the control group, reported using the four-step death notification process. The majority of the EMTs allowed a viewing by the family (16-hour ¼ 6=6, two-hour ¼ 4=5, control ¼ 2=3). A multiple regression indicated the EMTs’ behavioral inten￾tions stemmed from changes in their attitudes, not their perceived behavioral control or motivation to comply with their subjective norms. The large amount of variance accounted for by the EMTs’ attitudes indicate they hold positive beliefs that performing these six behaviors will lead to positive outcomes. The data also suggest that EMTs are not perceiving social pressure to perform these behaviors from other EMTs or their supervisors. Furthermore, the EMTs feel confident to perform these behaviors. Thus, EMTs who believe that these six goals will help themselves or the victims’ families will be more likely to perform these behaviors than EMTs who hold less favorable beliefs. Several limitations to the study include a sample drawn from a single region, which might not represent EMTs nationwide, and only three months from intervention to follow-up, so that many of the EMTs had made no death notification. Finally, lack of ran￾domization of individuals to treatment conditions must be taken into account when interpreting the data. Despite these limitations, this study shows EMTs are respon￾sive to death-related programs. The results indicate that a short CME session can effect changes in EMTs. Courses that meet the unique needs of EMTs need to include detailed instruction on how to make a death notification or handling the post-mortem arrangements. Current educational curriculums that teach the five stage psychosocial model designed by Kubler Ross may not be effective for EMTs, as EMTs often do not see the later stages, such as acceptance. These results demonstrate that theory can be used to evaluate EMTs programs and that the theoretical underpinnings of course success can be identified, which can help educators restructure their programs to become more beneficial to EMTs. Evaluation of EMTS’ Attitudes Towards Death 645

T Smith-Cumberland EMS educators and administrators should strive to provide quality training in this important area of education for EMTS References Ajzen, I.(1985). From intentions to actions: a theory of planned behavior. In J. Kuhland &J. Beckman(Eds ) Action control From cognitions to behavior pp. 11-39). Heidelberg: Springer Ajzen, I& Fishbein, M. (1980). Understanding attitudes and predicting social behavior Upper Saddle River, N: Prentice Hall Ajzen, I.& Madden, T.J. (1986). Prediction of goal directed behavior: Attitudes, intentions,and perceived behavioral control. Journal of Social Psychology, 22, 53-474. Coleman, T.(1993). The effect of an instructional module on death and dying on the death anxiety of emergency medical technician trainees. Omega, 2 123-129 Critz, S. H.(1989). The attitudes and experiences of families with death determi nation in the home. American Journal of Hospice Care, Sept/Oct, 38-43 resuscitation and emergency cardiovascular care. Cial card Cummings, R. O.(2000). International guidelines 2000 for cardiopulmonary Dalbridge, T.R, Fosnecht, D. E, Garrison, H G, Aublee, T. E (1996).Field termination of unsuccessful out of hospital cardiac arrest resuscitation Acceptance by family members. Annuals of Emergency Medicine, May 27, 649654 Dubin, W.R.& Sarnoff, J. R( 1986). Sudden unexpected death: Intervention ith the survivors. Annals of Emergency Medicine, 15, 54-57 Durlak, J. A.& Riesenburg, L. A (1991). The impact of death education. Death Studies, 15, 39-58 Field,D& Howells, K (1988). Dealing with dying patients: Difficulties and stra- tegies in final year medical students. Death Studies, 12, 9-20 Gifford, B. J& Cleary, B. B (1990). Supporting the bereaved. American Journal of Nursing, February, 49-55 Leash, R. M. (1993). Death notification: A practical guide to the process. Hinesburg, VT: Upper Access Books. Maglio, C.J.& Robinson, S. E.(1994). The effects of death education on death anxiety: A meta analysis. Death Education, 18, 319-335 National Highway Traffic Safety Administration (1998a). EMT Basic national stan dard curriculum. Washington, DC: U.S. Government Printing Office National Highway Traffic Safety Administration. (1998b). Paramedic national stan dard curriculum. Washington, DC: U.S. Government Printing Office. Norton, R. L, Barkus, E. A, Schmidt, T. A, Paquette, J. D, Moorhead, J. C,& Hedges, J. R.( 1992). Survey of emergency medical technicians'ability to cope with the deaths of patients during prehospital care. Prehospital and Disaster Medicine, 7, 23 Smith, T. L.& Walz, B. J(1995). Death education in U. S. paramedic prog A nationwide assessment. Death Studies, 19, 257-267

EMS educators and administrators should strive to provide quality training in this important area of education for EMTs. References Ajzen, I. (1985). From intentions to actions: A theory of planned behavior. In J. Kuhland & J. Beckman (Eds.), Action control: From cognitions to behavior (pp. 11–39). Heidelberg: Springer. Ajzen, I. & Fishbein, M. (1980). Understanding attitudes and predicting social behavior. Upper Saddle River, NJ: Prentice Hall. Ajzen, I. & Madden, T. J. (1986). Prediction of goal directed behavior: Attitudes, intentions, and perceived behavioral control. Journal of Social Psychology, 22, 453–474. Coleman, T. (1993). The effect of an instructional module on death and dying on the death anxiety of emergency medical technician trainees. Omega, 27, 123–129. Critz, S. H. (1989). The attitudes and experiences of families with death determi￾nation in the home. American Journal of Hospice Care, Sept=Oct, 38–43. Cummings, R. O. (2000). International guidelines 2000 for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation, 102(8 Suppl). Dalbridge, T. R., Fosnecht, D. E., Garrison, H. G., & Aublee, T. E. (1996). Field termination of unsuccessful out of hospital cardiac arrest resuscitation: Acceptance by family members. Annuals of Emergency Medicine, May 27, 649–654. Dubin, W. R. & Sarnoff, J. R. (1986). Sudden unexpected death: Intervention with the survivors. Annals of Emergency Medicine, 15, 54–57. Durlak, J. A. & Riesenburg, L. A. (1991). The impact of death education. Death Studies, 15, 39–58. Field, D. & Howells, K. (1988). Dealing with dying patients: Difficulties and stra￾tegies in final year medical students. Death Studies, 12, 9–20. Gifford, B. J. & Cleary, B. B. (1990). Supporting the bereaved. American Journal of Nursing, February, 49–55. Leash, R. M. (1993). Death notification: A practical guide to the process. Hinesburg, VT: Upper Access Books. Maglio, C. J. & Robinson, S. E. (1994). The effects of death education on death anxiety: A meta analysis. Death Education, 18, 319–335. National Highway Traffic Safety Administration. (1998a). EMT Basic national stan￾dard curriculum. Washington, DC: U.S. Government Printing Office. National Highway Traffic Safety Administration. (1998b). Paramedic national stan￾dard curriculum. Washington, DC: U.S. Government Printing Office. Norton, R. L., Barkus, E. A., Schmidt, T. A., Paquette, J. D., Moorhead, J. C., & Hedges, J. R. (1992). Survey of emergency medical technicians’ ability to cope with the deaths of patients during prehospital care. Prehospital and Disaster Medicine, 7, 235–242. Smith, T. L. & Walz, B. J. (1995). Death education in U. S. paramedic programs: A nationwide assessment. Death Studies, 19, 257–267. 646 T. Smith-Cumberland