EMTS ATTITUDES TOWARD DEATH BEFORE AND AFTER A DEATH EDUCATION PROGRAM Tracy L Smith-Cumberland; Robert H Feldman Prehospital Emergency Care; Jan-Mar 2006: 10, 1; ProQuest Health and Medical Complete pg EMTS ATTITUDES TOWARD DEATH BEFORE AND AFTER A DEATH EDUCATION PROGRAM Tracy L. Smith-Cumberland, PhD, PA-C, Robert H. Feldman, PhD ABSTRACT notification and consoling the family, as well as pro- Objective. To test the hypothesis that emergency medical nouncing the death. Of patients who die outside the technicians'(EMTs") attitudes toward death will change af convenience sample of 83 rural EA program. Methods. a remains unclear what attitudes EMTs have formed to- to a death education ITs ward these roles. For example, do EMTs feel that they oretest-posttest study after exposure to an educational pro- have adequate training to handle a patient's death? am related to death. Intact groups of EMTs were randomly The literature suggests that their training is less than assigned to one of three conditions. The short-intervention adequa group received a two-hour class solely on making death no Most EMTs receive their training from instructors tifications. The long-intervention group received a 16-hour, who follow the National Standard Curriculums, 5.6 two-day workshop based on the Emergency Death Education which cover very little information about death no and Crisis Training (EDECTSM) Program. The control group tifications and reacting to the family s grief. Further- received a program about toxicology. Each participant com- more, EMs textbooks do not cover these issues well? pleted a questionnaire with items structured in a Likert five Some courses such as Pediatric Advanced life Support point format with"strongly agree"and"strongly disagree as the anchors. Results. Before the training programs, most and Pediatric Education for Prehosptial Professionals (77%)participants reported that an EMTs actions impact the have sections on dealing with death; however, these familys grief. Less than half (43%)reported that an EMT's courses are not mandatory for EMTs, and they contain role should include making a death notification, The majorit limited information Overall, emts do not receive ade- (84%)reported that their training was inadequate to make a quate training in death and dying.2.3 Few studies have (84%)felt uncomfortable making a death notification. Those training. 8-10 Most did not explore EMTs'attitudes to- udies have examined likely(92%)to feel that their training was adequate after the the adequacy of training to complete these roles or how intervention when compared with those EMTs in the short comfortable emts felt about these roles 2.11 Therefore intervention group(43%)or those in the control group(21%). the purposes of this study were to ascertain EMTs'atti Conclusion. The data showed that EMTs attitudes toward death changed after exposure to a training program about tudes toward death and, secondly, to examine whether death. Key words: emergency medical technician; paramedic these attitudes change from exposure to a death-related death; dying; education; attitudes program PREHOSPITAL EMERGENCY CARE 2006: 10: 89-95 Emergency medical technicians(EMTs)of all levels THE PROGRAMS [EMT-Basics(EMT-Bs), EMT-Intermediates(EMT-Is), The Emergency Death Education and Crisis Training and EMT-Paramedics(EMT-Ps)] encounter death reg (EDECTSM)seminar is a theoretically based3-15 ex- ularly in the course of their jobs. In 2000, the American Heart Association published the futility protocol, related attitudes and behaviors of emergency medical service(EMS)Professionals. The teaching methods in- or not to start resuscitation in certain cases. more often lude lectures, discussions, small-group exercises, role now, EMIs have the responsibility of making the death playing, and workbook activities ticipants and ov of the Received May 13, 2005, from the Department of Public and Com- includes small-group activities and group-building ex- munity Health, University of Maryland College Park (TLS-C, RHF) College Park, Maryland. Current affiliation ercises that aid in the development of discussions, role Health Services, University of Maryland Baltimore County (TLs-C playing, and other seminar group activities. The next Baltimore, Maryland. Revision received August 16, 2005; accepted session covers the legal and ethical issues of deaths seen for publication September 2, 2000 by emerger was chosen to be Address correspondence and reprint requests because it is ful and practical fo Cumberland,PhD,PA-C, UMBC Department of EHS, 1000 Hilltop adult learners. It also serves to transition from the Circle, Baltimore, MD 21250. e-mail: . medical and technologic aspects of death to the more do10.1080/10903120500365955 psychological and social processes of death. This type Reproduced with permission of the copyright owner. Further reproduction prohibited without permission
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. EMTS' ATTITUDES' TOWARD DEATH BEFORE AND AFTER A DEATH EDUCATION PROGRAM Tracy L Smith-Cumberland; Robert H Feldman Prehospital Emergency Care; Jan-Mar 2006; 10, 1; ProQuest Health and Medical Complete pg. 89
PREHOSPITAL EMERGENCY CARE JANUARY /MARCH 2006 VOLUME 10/ NUMBER 1 of transition is needed especially for EMTs, who often a one-hour lecture and discussion(Cme class)on death maintain rigid attitudes. 6 After lunch on the first day, and dying to teach health professionals; however, they the program resumes with a session on the typology of did not provide an evaluation of their program. Other death. This first day concludes with an examination of studies support the use of a short course. For example, a the special issues in death, including the cultural and re- four-hour seminar detailing the death-notification pro- ligious influences, dealing with children after a death, cess helped those who make death notifications on a and the death of a child. On the second day, a brief frequent basis, and a two-hour experiential seminar review and introductory session helps to recreate the changed physicians'attitudes related to death. 7 Hoge earning environment The day proceeds with a session and Hirschman showed that brief training programs on communications, including interacting with the be-(two four-hour sessions )were effective to teach psycho- reaved and making the death notification. After lunch, logical interventions to EMTS. Many of these studies the program continues with sessions on grief reactions re methodologic flaws; thus, they must be inter and how to interact with bereaved persons effectively. preted with caution. Despite this, it seems that a two- The day and the seminar conclude with role-playing ex- hour course is an effective option for EMT education ercises and practice scenarios. In this last session, stu- dents learn to apply, in totality, skills learned earlier uation of a short CME course. A study using a short in the seminar. The last activity is completion of the curriculum of death-related topics would help identify posttest instruments whether brief training programs effectively teach death The curriculum for the two-hour continuing medi- and dying to EMS professionals. Without these stud cal education( CME) session is taken from Unit 6 of ies, it remains unclear whether short Cme sessions are the EDECTSM program and covers the four-step death- effective in teaching EMTs. It is reasonable that more notification process. A single instructor presents the changes will occur from the longer two-day seminar material in a lecture-style format aided by a computer- than the two-hour CME session; however, it is unclear generated presentation program. The session lasts ap- whether a short two-hour session can effect change proximately one hour and 40 minutes, allowing for a If it cannot, it may not be the best educational for- brief question-and-answer period. The question-and- mat to teach death and dying to EMS professionals. In answer period is spent in a large-group format; thus, this case, the longer intervention would be necessary he interactive discussion is limited to the large-group despite the time and monetary commitment required of a longer training program. Therefore, the two-hour These two programs center around death and dying course was included as an intervention to determine in the prehospital environment, with the entire instruc- whether it is an effective option to the longer training tional time being devoted to death in the prehospit progra ams setting. The EDECTSM program was found to be effe In summary, the two-hour CMe provided a lecture- tive in two different samples*; however, it should un oriented session enhanced with a computer presenta dergo further testing to determine its validity in other tion. It solely addressed the process of making a death populations. The two-hour CME session has been used notification. The EDECTM program is a 16-hour, two- effectively in multiple populations day program that provides a comprehensive examina- The two most common educational formats for tion of death in the prehospital setting. Both programs nd dying courses for EMS providers are two-day sem- help EMTs acquire new skills to use when making death inars (including workshops) and short CME sessions, notifications and when interacting with bereaved fam usually two hours. Wager suggested that initial train- ilies during the death process ing programs on death and dying take place in a work shop setting over a one- to two-day period, and that short review sessions follow these programs to enhance METHO the learning process, however, the author did not test these recommendations. The two-day seminar format Study design and Setting appears in many EMS educational offerings, i.e., Crit- The study used a quasiexperimental, randomized, ical Incident Stress Debriefing, Advanced Cardiac Life control-group, pretest-posttest design using three Support, and Pediatric Advanced Life Support, and has groups. Intact groups were randomized to one of been used effectively to teach EMTs about behavioral three conditions. The control group(n=29)received emergencies.Furthermore, death and dying educa- a two-hour EMS program about toxicology. The short- tors have found the seminar format successful to teach intervention group (n=30)received a two-hour CME bout making a death notification. The The short two-hour CME session provides another ef- long-intervention group (n=24)received a 16-hour, fective teaching format. It is convenient to EMS edu- two-day training program cators because it can be scheduled for a single session in All participants received their training program in the evening. Cowles and Swain supported the use of the educational center of a community college or Reproduced with permission of the copyright owner. Further reproduction prohibited without permission
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Smith-Cumberland and Feldman EMTs' ATTITUDES AFTER DEATH EDUCATION in the educational room of a fire department. The Methods of Measurement death ourses were taught by a Nationally Regis Each participant completed a questionnaire about and the toxicology course was taught by an EMS ed- leath behaviors and attitudes on scene. The five specific study. Instructors who were not part of the inves- 1)whether their actions as EMTs impacted the grief of death and dying eliminated the option of using outside families was adequate, 3)whether their training pre- pared them to make compassionate death notifications, ped the effers were part of a larger study that ex- 4)whether they felt comfortable making death notifi amined the effec cations, and 5) their attitude war ctiveness of these two programs in a to make death notifications on scene. These five items theoretical evaluation 4 In addition to this evaluation the author also elicited information about the eMTs at- (along with the other 32 items)were structured in a titudes and roles toward death. answers from these re- iker five-point format (5=strongly agree, 4=agree, sults provided the basis for this study and are presented 3=unsure, 2=disagree, and 1=strongly disagree here separately because they represent an independent The other 32 items elicited information about their be- main haviors on scene and pertained to the larger study. Selection of Participants Instrument Participants were recruited from EMS agencies in Wis- This study was limited to five times; it was not an op- consin. The EMS agency ensured that they were all prac tion to add additional items beyond the five ticing EMTs in the state of Wisconsin. The participants questions were added to the instrument used in the gave informed consent and were assured that the ques- larger study to break up response sets as suggested by tionnaires were anonymous and confidential Partici- the developers. 32 The instrument that contained these pants were blinded to the nature of the study; none items was reviewed by multiple experts in the EMS the participants knew of the different levels of intensity field, cognitively tested, and pilot-tested(n=35) prior until after the study concluded Intergroup rivalry was to use. Testing showed the instrument to be reliable and lot an issue because each group lived at a sufficient dis- stable( Cronbachs alpha=0.94). The test-retest relia- tance from the other groups Other than receiving CME bility showed the instrument to be stable in EMTs(re- credit for time spent in the training session, participants liability coefficient=0. 79) Intact groups from six fire departments and EMS Data Collection, Processing, and Analy agencies were used. Each group was randomized to one of the three treatment conditions: the short-intervention One hundred twenty EMTs were solicited for the esti- (two-hour CME session) group (n=30), the long- mated sample size of 72. Sample size was determined intervention(16-hour program) group (n=24), or the from a power analysis with power set at 0.80(1-beta control group (n=29). After randomization, the agen- or 1-20)and an effect size of 0.287. Effect size was de cies were contacted to schedule training times. All three termined from a review of the literature. 33,34 From this training courses occurred in the same week. process, 87 EMTs were recruited. Four participants did not finish the program or did not complete the posttest. Interventions Thus, the final sample was 83 EMTs A survey instrument was given to 83 EMTs before Few death education programs were found after an and after the training program. All groups received the exhaustive literature review of several health-related same instrument and the same instructions for complet databases, query of experts in the field, and pooling ing the instrument. Each participant created an iden of the authors knowledge of the 11,28-3 tification number that was used throughout the study thors chose the EDECtSM curriculum because of its rogram administrators collected the data immediately robustness, applicability to EMS providers, and famil- after the programs were completed. Once collected, the iarity to the authors. Furthermore, the program was data were entered(by identification number)into the evaluated and found effective. The EDECTSM curricu- SPSS package(SPSS Inc, Chicago, IL). The frequen- lum contains eight units taught over a two-day, 16- cies and descriptive data were examined on the entire hour period, and was used for the long intervention sample. Unit 6 of the EDECtSM curriculum was tr From a review of the literature, several demographic into a lecture-type presentation with a question-and- variables were identified. They were included on asep. answer period; this became the program for the short- arate questionnaire (gender, age, marital status, and ducational level). Several occupational variables were Reproduced with permission of the copyright owner. Further reproduction prohibited without permission
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PREHOSPITAL EMERGENCY CARE JANUARY/MARCH 2006 VOLUME 10/ NUMBER 1 alsoincluded (years in EMS, calls permonth, de eat c calls. These differences were controlled for with the use per month, death notifications per month, comfort level of covariate procedures in making a death notification, and previous education The participants were evaluated by level of certifica in death and dying ). Scores with partial years were ion because previous research has shown that EMTs rounded down to the closest whole number of years, titudes differed based on level of certification. 4 All e.g, 3.5 years was entered as 3 years. The demographic EMT-Bs and EMT-Is were coded into one group and nd occupational variables that were continuous (age, all EMT-Ps were coded into a second group. When the years of experience, etc. ) were recoded to categorical pretest data were examined to determine whether level variables. This recoding allowed the Kruskal-Wallis test of training affected differences in the EMTs'attitudes to explore the relationship between the demographics toward death, there were no significant differences group The Mann-Whitney U test(the nonparametric equiy In the hypothesis testing, an analysis of covariance alent of the ANCOVA) was used for the hypothesis (ANCOVA)controlled for differences in the demo- esting. The first research item asked EMTs whether graphic and occupational variables. The EMTs were they thought that an EMTs actions impacted the grief coded into the three treatment groups: the long. of the family. Before the interventions, the majority intervention group, the short-intervention group, and (77%)of all three groups agreed (or strongly agreed the non-death-related program, or the control group. that an EMTs actions on scene impac There were no pretest differences between the group cess of the family. After receiving the EDECTSM pro- gram, there were no statistical differences between the RESULTS groups; however, there was greater likelihood for the EMTs in the long -intervention group to respond that an The majority of the participants were white men whe EMT's actions affected the family s recovery than in the lived in rural areas of wisconsin. Analysis of the de- short-intervention group or in the control group [F(2, mographic variables showed no differences between the treatment and control groups. Several occupational The second research item asked whether emts characteristics were examined(see Table 1). The partic- thought that their role as an EMT included making a ts in the two-hour ME session ran fewer calls [ H death notification. On the pretest, many (57%)EMTs (2, n=83)=9.902, p<0.05] and fewer calls involving a disagreed (or strongly disagreed)that a death notifica death [H(2, n=83)=48.243, p<0.01] than the other tion was part of their duties. After receiving the educa- treatment group or the control group. The participants tional programs, more EMTs in the intervention groups in the two-hour CME group lived in very rural areas, reported that their professional role included making a and the EMS agencies they worked for ran fewer EMs death notification. The long-intervention group(92%) TABLE 1. Percentage Distribution of Occupational variables Control Group Two-Hour CME EDECTSM Variable (n=30) Number of years spent in EMS I year or less 2 to 3 years 0.17(5) 0.31(9) 0.20(6) 7 to 15 vears 0.14(4) 16 years or more 0.00(0) 0.17(5) 0.25(6) Number of EMS calls per month 10 or fewer calls 0.17(5) 0.07(2) 21-49 calls 0.21(6 50 or more cal 0.25(6) Calls involving a death notification per month" 2 or fewer calls 076(22) 1.00(29) 0.75(18) 3 or more calls 000( 025(6) Death notifications (DNS)per months 0.86(25) 0.91(2 3 to 5 DI 0.14(4) ormal death education 0.14(4) 08625 097(29) 83(20) CME=continuing medical education; EDECTSM- Emergency Death Education and Crisis Training; EMS= emergency medical services Note: missing data included one EMT in the two-hour CME group on calls involving a death notification per month, and one EMT in the EDECT group on the death notifications per month Reproduced with permission of the copyright owner. Further reproduction prohibited without permission
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Smith-Cumberland and Feldman EMTs' ATTITUDES AFTER DEATH EDUCATION 93 reported that this task was part of their duties more DISCUSSION often than the short-intervention group(83%). Most (75%) EMTs in the long-intervention group reported There were no significant differences between the they"strongly agreed"that this was part of their duties. groups when asked about their impact on families, be In the short-intervention group, only 27%"strongly cause most EMTs agreed with this item. While it was agreed. Thus, EMTs receiving the long intervention encouraging that most(77%) EMTs recognized theirim were most likely to agree that their role as an EMT in- pact on bereaved families, it was disappointing that cluded making a death notification. The EMTs in the more (all) EMTs did not recognize that they impact the short-intervention group also showed this change, but families when at the scene of a patient's death Further not to the same degree as the long-intervention group educational offerings in the area may pave the way for IF(2,79)=22910,P<0001 this number to approach 100% in the future. EMS edu The third item elicited information on EMts' atti- cators should not assume that all EMTs understand that tudes toward their comfort level on scene making a their actions impact the families; therefore, they should death notification. This item did not elicit any infor- provide education in this area. mation about training The pretest showed that only More importantly, this study shows that longer units 1% of EMTs were comfortable when making a death of instruction can help EMTs feel more comfortable notification on scene and few (15%)reported that they making a death notification, and that shorter units of were"somewhat comfortable" making a death notifi- instruction do not appear to effect these changes. This is cation. Thus, most(84%) EMTs reported that were not not surprising as the concepts in the two-hour session omfortable making death notifications prior to the in- are presented very concisely and quickly. Little instruc- terventions. After the training programs, the treatment tion is spent on expanding or reinforcing the concepts groups felt more comfortable making a death notifica- Unlike the students in the EDECTM program, the stu tion when compared with the control group, with the dents in the two-hour Cme group did not practice mak- long-intervention group showing the most significant ing death notifications. For these reasons, the students change [ F(2,79)=19486,P<0.001 in the two-hour CMe group gained no additional com The fourth item asked the EMTs whether they had fort in making a death notification, even though they dequate preparation to make a compassionate death did realize that it was part of their role. This finding may notification. Again, the intervention groups were sig be of concern because more EMTs realized itis a role, yet nificantly more likely to agree that they had adequate few felt comfortable in this role. These findings suggest, preparation to make death notifications. The long. that longer and more comprehensive units of instruc- intervention group showed greater changes than the tion, e.g., the EDECTSM program, provide instruction short-intervention group or the control group. Prior that increases an EMT's comfort level when making a to the training program, the long-intervention group death notification as well as clarifying his or her role in felt the least trained in making death notifications making death notifications. It is unclear whether this wever, after the training the EMTs in this group finding is a result of the time spent in the course or the were more likely to report they had adequate train- depth and breadth of the coursework ing than the other two groups [F (2, 79)=14. 715, In the two items related to training the Emts who p<0.001]. On the posttest, EMTs who received the received either intervention were more likely to report EDECTM training program(92%)were more likely that their training to make death notifications and a to report that their preparation to make a death noti sist the family was adequate. Prior to the interventions, fication was adequate than the other two groups or most EMTs(84%)reported that their training in making posttest scores(two-hour CME group=43%, control death notifications was suboptimal and 83% felt their group=21%) training to help families was inadequte. Based on the The fifth item asked whether the EMTs thought they review of the literature, this finding was expected. After help the families at the time of the interventions, the EMTs who received the EDECTS a death. At the time of the pretest, most EMTs felt that training program(92%)were more likely to rep rt that their training was inadequate(83%). However, at the their death notification training was adequate than the time of the posttest, the intervention groups were more other two groups. The EMTs in the short-intervention ikely to feel that their training was adequate when group also showed changes, but they did not feel as ade- compared with the control group [F (2, 82)=3. 245, quately trained as those in the long-intervention group p=0.044]. Again, the long-intervention group showed The second item on training showed that the the greatest change in their responses On the posttest, EDECTSM program increased the number of EMTs who all EMTs(100%)in the EDECT M program reported that felt that their training was adequate to help families af- their training to help families was adequate, whereas ter the death of a loved one. On the posttest, all the EMTs only 70% of the EMTs in the short-intervention group (100%)in the long-intervention group reported that reported that their training was adequate their training to help families was adequate, whereas Reproduced with permission of the copyright owner. Further reproduction prohibited without permission
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PREHOSPITAL EMERGENCY CARE JANUARY/ MARCH 2006 VOLUME 10/NUMBER 1 only 70% of the EMTs in the short-intervention group CONCLUSION reported their training as being adequate. This further supports the effectiveness of these training programs The EMS community must recognize that most EMTs nd suggests that these training programs warrant fur- believe their training in death and dying is not adequate ther validation in other samples Finally, education can help EMTs realize that mak not feel comfortable making death notifications. Editors ing a death notification is part of their professional of EMS trade magazines need to encourage submission duties. Prior to the interventions, many EMTs were un- of more articles about EMTs roles and their impact on sure whether their duties included making a death no. the scene of a death. Each article that discusses an EMT's units, most(87%)agreed that their duties as an EMT in- This will also serve to increase EMTS awareness of their cluded making a death notification. This study showed that education about death notifications changes EMTs Furthermore, EMS educators need to increase educa- attitudes toward their role to make death notifications tion in death and dying issues, especially making death Moreover, these changes can occur with short(two- notifications and responding effectively to initial grief hour) units of education related to death notifications reactions. EMs educators need to allot more time in primary training programs. Continuing education pro- grams need to be developed for existing EMTS. EMS LIMITATION educators should evaluate existing training programs The study would have been improved with an ex- and eliminate the parts(or all) that do not aid EMTs on ded pool of questions. For example, questions the scene of a patient's death. For example, centering the further explored previous training might have death-related education around the psychosocial stage been helpful. Other questions related to pronouncin heory of Elizabeth Kubler-Ross 5 may not be the most a death on scene could have added insight For exam effective approach for EMTs. The effectiveness of this le, Norton et al. elicited information on pronounc- approach, teaching EMTs the Kubler-Ross five stages ing a patient dead versus transporting the patient the hospital. More questions might have increased the proach to teaching EMTs about death and dying. EMS understanding of EMTs attitudes toward death by pro- educator should not assume it is an effective approach viding a more comprehensive look. However, these five simply because it had been the standard in textbooks items did shed new light on EMTs'attitudes, and they also provide stimulation for future studies in the area Death education courses can change EMTs' attitudes Creating a less heterogeneous sample by using EMTs toward death onscene. Therefore, it is important to pro- (EMT-Bs, EMT-Is, and EMT-Ps) from other states and vide courses that will help EMTs realize their impact urban areas would have helped improved the study. on families, recognize their professional duties on the Another study with a larger, more diverse population scene of a patient's death, help them feel more com would aid in generalizing these results to other popu- fortable with making a death notification, and provide lations of EMTS and other emergency providers, e.g nurses, physicians, and law enforcement officers reaved families Randomizing intact groups weakened the ability make valid comparisons between the groups, which References limits the internal validity of this study. The quasiex- perimental design used in this study would have been 1. Cummings RO. International Guidelines 2000 for Cardiopul strengthened with a true experimental design,e.g,ran monary Resuscitation and Emergency Cardiovascular Care. Cir domization of participants. Although it is logistically culation. 2000; 102(8 suppl): 112-121 problematic in EMS samples, future studies should try 2. Norton RL, Bartkus EA, Schmidt TA, et al. s medical technicians'ability to cope with the deaths of patients to use random assignment of participants to groups during prehospital care. Prehosp Disaster Med 1992; 7: 235-42 Finally, several sources of bias limit the interpretation 3. Smith TL, walz. B]. Death educa of the results. For example, the developer and instruc- a nationwide assessment. Death Stud. 1995: 19: 257-67 tor of the interventions was also the principal invest 4. Smith-Cumberland TL. The effect of two death education pro- tor and, thi part of the evaluation medical technicians. Dissertation Abstracts nternational. 2004: 65(3b), (UMI No. 3124727) Even though other individuals handled parts of the re- 5. National Highway Traffic Safety Administration. EMT-Basic Na search process, an outside evaluation would have re- tional Standard Curriculum. Washington, DC: U.S. Government duced this bias further. Of note the authors of this cur. riculum are not seeking any financial gain or other gain National Highway Traffic Safety Administration. Paramedic Na from their curriculum. Despite these limitations, thisre- tional Standard Curriculum, Washington, DC: U.S. Government Printing office, 1998 search provides a valuable contribution to the literature 7. Saunders M), McKenna K. Mosby's Paramedic Textbook, 2nd Ed about eMts' attitudes toward death St Louis, MO: Mosby- Yearbook Publishers, 2001 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission
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Smith-Cumberland and Feldman EMTs ATTITUDES AFTER DEATH EDUCATION 8. Jenkins SR. Coping, routine activities, and recovery from acute 21. Harnett AL. How we do it. J School Health. 1973: 43(8): 526-7 distress among emergency medical personnel after a mass casu- 22. Laube J. Death and dying workshop for nurses: its effects on their ty shooting incident. Curr Psychol. 1997: 16(1): 3-19 death anxiety level. Int J Nurs Stud. 1977: 14: 111-20 9. Morrison LJ, Cheung MC, Redelmeier DA Evaluating paramedic 23. Mitchell JT. Effects of stress management training on paramedic omfort with field pronouncement: development and validatio coping styles and perceived stress levels. Dissertation Abstracts of an outcome measure. Acad Emerg med. 2003: 10: 633-7 International 10. Regeher C, Goldberg G, Hughes J. Exposure to human tragedy, 24. Cowles KV, Swain HL. Preparing and presentin empathy, and trauma in ambulance paramedics. AmJOrthopsy one hour lecture/discussion on death and dying Death Educ. chiatry.2002;72:505-13 8:27-81 11. Coleman T: The effect of an instructional module on death and 25. Tolle SW, Cooney TC, Hickman DH. A program to teach residents of emergency medical technician humanistic skills of notifying survivors of a patient's death. Acad trainees, Omega. 1993; 27(2): 123-9 Med.198964:5056 12. Smith TL, Walz BJ, Smith RL. A death education program for 26. Schmidt TA, Norton RL, Tolle Sw. Sudden death in the ED: ed- and other emergency per- ucating residents to compassionately inform families. J Emerg onnel Prehosp Emerg Care. 1999; 3: 37-41 Med.199210643-7 13. Knowles MS. The Adult Learner: A Neglected Species, 2nd ed. 27. lological training of Houston, TX: Gulf Publishing O edical technicians: an evaluation. Am J Community Psyche 14. Bandura a. self-effi 84;12:127-31 change. Psychol Rev. 1997: 84: 191-215 28. Iserson KV. The gravest words: sudden-death notifications and 15. Corr CA. A model syllabus for death and dying courses. Death emergency care. Ann Emerg Med, 2000 36: 75-7 Educ.1978;1:433-5 29. McQuay JE, Schwartz R, Goldblatt PC, et al. Death telling research 16. Mitchell JT, Bray GP. Emergency services stress. Englewood Cliffs, roject Crit Care Nurs Clin North Am. 1995; 7(3): 549-55 N: Prentice-Hall, Inc., 1990 30. Stewart A, Lord H. Evaluation research finds MADD 17. Wager M. Teaching interns and residents about death and dying death notification seminars effective. Maddvocate. 1999: Winter: Am Osteopath Assoc. 1993 May: 93(5): 611-3 18. Bassuk EL, Apsler r, Jacobs L. Developing and assessing a train- 31. Ullman K Notifying next of kin. Firehouse. 1997; June: 34 ing program in prehos care of behavioral emergencies. Hosp Ajzen L, Fishbein M. Understanding Attitudes and Predicting So- trv.1983:34:962-4. cial Behavior. Upper Saddle River, NJ: Prentice Hall, 1980 19. Caty S, Downe-Wamboldt B, Tamyln D, Attitudes towards d 33. Durlack JA, Riesenburg LA Theimpact of deatheducation Deat implications for death education. Dimensions Health Serv. stud.1991;15:39-58 198259(8):20-1 34, Maglio C], Robinson SE. The effects of death education on death 20. Cohen R, Shapiro S, Rosner E. Three approaches to death edu a-analysis, Death educ. 1994: 18: 319-35. cation for physicians and allied health professionals. Loss Grief 35. Kubler-Ross E On death and dying. Macmillan Publishing Com Care.19882(1-2):8390 any: New York, 1969 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission
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