Educator Update - Fall 2013 by National Association of EMS Educators (NAEMSE)

EU EDUCATOR

FALL

UPDATE

DEATH NOTIFICATION IN EMS: A NORTH AMERICAN PERSPECTIVE by LeeAnne Douglas MScCH, AEMCA and Savithiri Ratnapalan, MBBS, MEd, MRCP(UK), FRCPC, FAAP

Also in this issue:

EYEWITNESS ON SYMPOSIUM - 2013

THE CHALLENGES and OPPORTUNITIES of TEACHING “GENERATION Y”

A LOOK IN THE MIRROR:

Evaluating Program Strengths and Weaknesses

by Jodie Eckleberry-Hunt, PhD, ABPP and Jennifer Tucciarone, MD

by Patricia L. Tritt, RN, MA

y Sherry Clark

INSIDE

...AND MORE!

Image source: http://www.retroroadmap.com/2009/06/25/vacation-viewer-do-you-know-what-this-is-called/

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laerdal.com/us/resuscitation * Meaney PA, Bobrow BJ, Mancini ME, Christenson J, de Caen AR, Bhanji F, Abella BS, Kleinman ME, Edelson DP, Berg RA, Aufderheide TP, Menon V, Leary M; on behalf of the CPR Quality Summit Investigators, the American Heart Association Emergency Cardiovascular Care Committee, and the Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation. Cardiopulmonary resuscitation quality: improving cardiac resuscitation outcomes both inside and outside the hospital: a consensus statement from the American Heart Association. Circulation. 2013;128:417–435

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IN THIS ISSUE

FALL

National Association of EMS Educators 250 Mount Lebanon Boulevard Suite 209 Pittsburgh, PA 15234 Phone: 412-343-4775 Fax: 412-343-4770

2013

2013-2014 Board of Directors Scott Bourn, PhD, RN, NREMT-P President Michael Nemeth, AEMCS(f), EMT-P, ICP, MA(c) Vice President Connie Mattera, MS, RN, EMT-P Treasurer Richard Beebe, MS, RN, REMT-P Secretary

WHAT’S INSIDE

John Creech, MEd, LP

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NAEMSE NEWS

Michael Miller, BS, MS, EMS, RN, NREMT-P

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EYEWITNESS ON SYMPOSIUM (2013)

Donna Tidwell, MS, RN, EMT-P

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2013 HERO AWARDS - PRESENTATION by Mike Miller

Rebecca Valentine, B.S., EMT-P, EMT I/C, NCEE

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The Challenges and Opportunities of Teaching “Generation Y” by Jodie Eckleberry-Hunt, PhD, ABPP and Jennifer Tucciarone, MD

Kim McKenna, M.Ed, RN, CEN, EMT-P

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‘Amplifying’ Education’s Value by Elizabeth Redden

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Domain

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A Look in the Mirror: Evaluating Program Strengths and Weaknesses by Patricia L. Tritt, RN, MA

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Nerina Stepanovsky, PhD, MSN, RN, PM John Todaro, REMT-P, RN, TNS, NCEE Bill Young, M.S., NREMT-P

National Office Staff Joann Freel, BS, CMP Executive Director, Editor Stephen Perdziola, BS Business Manager Nora Davidson, BA Membership Coordinator Brandon Ciampaglia, AS Communications Coordinator Laurie Davin, AS Education Coordinator

Larissa Kocelko, BA Administrative Assistant William Raynovich, MPH, NREMT-P, Ed.D Editor, Domain3

Submission Guidelines

Unsolicited submissions are welcomed. Members of the NAEMSE Publications Committee review Domain3 manuscripts. Acceptance of a manuscript for publication is contingent upon completion of the editing process.

‘What Our Stories Teach Us’ by Scott Jaschik

www.naemse.org | Educator Update |

Manuscripts should be e-mailed to submissions@ naemse.org. Submit a cover letter with each manuscript indicating: Author name, credentials, title, and affiliation. A title letter should also be included disclosing any commercial associations that could post a conflict of interest. If you have an idea brewing that you’d like to submit, please contact us. We would be happy to discuss it. New authors are welcome and encouraged.

NAEMSE NEWS

NAEMSE NEWS NAEMSE Collaborates with U.S. Dept. of Homeland Security on Important Webinar

INSTRUCTOR COURSE DATES NAEMSE continues to bring its heralded EMS instructor course to all corners of the country. If you have never attended, you can reserve your spot online. If you’re an instructor, spread the good news to your colleagues in the EMS community. The following are upcoming Fall courses: INSTRUCTOR COURSE I

Carbondale, IL: October 11-13, 2013 Held in partnership with Southern Illinois Uni.

To combat human trafficking, the Department of Homeland Security (DHS) is targeting every possible route available to reach and help victims through the Blue Campaign. The Blue Campaign seeks to combat human trafficking by uniting DHS components with partners and stakeholders across government, law enforcement, first responders, prosecutors, judges, non-governmental organizations and the private sector. DHS has created a variety of mechanisms and resources to support this effort including enhanced public awareness, training, victim assistance and law enforcement investigations. While progress is being made, the DHS still needs your help. The Office of Health Affairs is specifically reaching out to the First Responder/Emergency Medical Services (EMS) community to build awareness and provide access to Blue Campaign tools, training and resources that can help them combat human trafficking as they go about their day-to-day operations. The First Responder/EMS community is a critical component to the success of the Blue Campaign since they are often the first or only contact that a victim may have with the outside world. Raymon Mollers (External EMS Program Manager, Medical First Responder Coordination Branch, Workforce Health and Medical Support Division, Office of Health Affairs, Department of Homeland Security) will present this incredibly important cause via a very special NAEMSE Webinar on the following day:

OCTOBER 9th, 2013 @ 3pm (EST) Please visit http://www.naemse.org/webinars/ for more information or contact us at (412) 343-4775 and reference ‘NAEMSE Webinars’. This is a free event for members and $10 for non-members. 1-hour of Continuing Education credit will be provided. Join us as we learn more about the ways in which we can help put an end to this crime; this human rights abuse in the form of modern day slavery.

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Buffalo, NY: October 23-25, 2013 Held in partnership with NY Vital Signs Conf. Lexington, KY: November 1-3, 2013 Held in partnership with Kentucky Board of EMS

Chula Vista, CA: November 8-10, 2013 Held in partnership with BORSTAR Special Operations Detachment San Diego Sector US Border Patrol Columbus, OH: November 15-17, 2013 Held in partnership with Columbus Div. of Fire INSTRUCTOR COURSE II Brooklyn, NY: October 4-5, 2013 Held in partnership with Kingsborough Community College Greenville, SC: October 18-19, 2013 Held in partnership with Greenville Technical College

For more information, please visit

NAEMSE.ORG

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www.naemse.org | Educator Update |

EYEWITNESS ON SYMPOSIUM (2013) What I did on my summer vacation.

EYEWITNESS

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Gathering with and learning from colleagues who share my passion for excellent EMS education is always a highlight of my year. I came away from the NAEMSE conference professionally invigorated and armed with a host of new strategies to apply in the classroom. The content presented had a broad range of appeal and was incredibly timely in providing great insights into areas of current national discussion and debate. It was wonderful to re-engage with friends that we only see once a year, rekindle those relationships, and share our special kinship experiences and challenges. As a Board member it was particularly rewarding to connect with new members, valued legacy members, and provide encouragement to prospective members so we can advance the mission and vision of the organization with great synergy and shared enthusiasm. We are most persuasive when we speak with one voice. The Freedom House presentation was inspirational in affirming that there’s a national EMS platform that needs to hear from all of us relative to the many facets of EMS education and we gain strength from our diversity, locking arm in arm to accomplish our unified goals. If you could not attend this year, mark your calendar now and make plans to join us in 2014. We’d love to see you in Reno!

Connie J. Mattera, MS, RN, EMT-P, TNS EMS Administrative Director Trauma Nurse Specialist Course Coordinator Northwest Community EMS System Northwest Community Hospital

The highlights of the 2013 Symposium depend on who you talk to. For my wife, it was Washington DC. She went from 8:00 in the morning to 9:00 at night seeing the sights and every minute was scheduled. Not going everywhere on her schedule was a highlight for me. After nearing forty years as an EMS educator, conferences and symposiums become more about the networking and between session interactions. If you take away a couple good things from the conference, you are satisfied. At this year’s symposium, I took away a couple great tidbits from every session I attended. Was this better selection of sessions on my part or great sessions overall? I believe we had great sessions to choose from and I found it very worthwhile. Oh, and thanks to all of you who shared information outside of the sessions also. Thanks NAEMSE and I look forward to “vacationing” in Reno next year.

As always, the annual NAEMSE Conference provided a variety of topics and opportunities to learn from our peers. A highlight this year was Greg Margolis’s closing presentation on the future: the future of healthcare reform and the challenges and opportunities for the EMS community. As educators, it is important for us to stay abreast of the changes in the EMS service arena and the potential gaps in educational theory and curriculum. It is truly an exciting time and calls for creativity and innovation. It was also exciting to watch the interest of EMS educators involved in Paramedic education in the accreditation process. Educators wanted to learn from each other and share not only their questions, but also best practices and their sometimes creative approaches to not only meeting the Standards, but upping their game!

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By Les Chatelain Director of the Center for Emergency Programs, University of Utah

Developing the next generation of educators will be crucial and the ‘professional’ educator will be essential – and the NAEMSE Conference provides valuable tools for everyone. Thanks!

- Pat Tritt

EYEWITNESS ON SYMPOSIUM (2013) I had not initially planned on going to the Freedom House presentation. My friend /colleague was arriving at the conference that evening and I figured we would do dinner and reconnect. However, he notified me late that afternoon that his flight was going to be late so I thought I would “kill time” by sitting in on the first bit of the presentation. When the movie started it took all of 5 minutes to hook me. I started hoping that maybe his plane would be a little bit later or that it would take a long time to get his bag and find a hotel shuttle. Then he texted me that he had arrived, but they had had lost his luggage, so he would be a while. Now, a friend would feel bad for you if you told them your luggage was lost. Did I feel bad? Well, maybe, but only a little ---- a VERY little. Now I could stay and see the entire presentation – “Yippee!”, I thought. (How bad is that?) My friend ended up texting me about 30 minutes later that he was in the lobby checking in (right after he had texted me about the lost bags, they were found) so I DID end up leaving before the end of the presentation, and I must say, I left begrudgingly. It was SOO interesting . . . .too interesting. But a friend is a friend. However, I think I got the best of both worlds – I was able to attend most of an AMAZING presentation, plus I was able to reconnect with a pretty amazing friend, who actually was doing EMS himself back at the time of Freedom House, when “ambulances” were station wagons owned by mortuaries. - Karen Petrilla

Hello, As an attendee the highlight for me was attending Heather Davis' presentation "Research Now." Heather's hour long session was informative, well organized, and kept me engaged. She quickly overviewed the process of conducting classroom research, demonstrated that process, and then made a spirited call for us all to join her in conducting more EMS education research. The Prehospital Care Research Forum oral abstract presentations, the next item on the program, were great examples of how my peers use the process that Heather just taught to conduct and report their research findings. During the presentation I gave Saturday morning, Handheld Wizardary, I asked attendees to share their favorite smartphone apps. I asked this question by text/email message using Remind101.com, which I used throughout the presentation and afterwards to send key points and additional resources to the attendees. Many attendees replied with their favorite smartphone apps. • • • • • • • • • • • • • • •

Action Movie FX Chrome Browser Dropbox Epocrates Facebook Google Translate Instagram NAEMSE Symposium Guidebook Paramedic Protocol Provider Pepid Pocket RX Safe Dose Pro Show Me Socrative Twitter

Remember iOS and Android dominate the smartphone market. If you are a Blackberry or Windows Mobile OS user you might be missing many opportunities to recommend apps to your students. - Greg Friese Photos of Instructor Course Level II class (above) and Drew Dawson, Director of the Office of EMS (below) © Joann Freel, 2013

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2013 NAEMSE HERO AWARDS

2013 NAEMSE Hero Awards Presentation & Recipiants

TRACEY CRAWFORD, BSN

By: Michael Miller, M.S., B.S. EMS, R.N., NREMT-P National Association of EMS Educators 18th Annual Symposium and Trade Show Washington, D.C. – Omni Shoreham Hotel Annual Membership Meeting – Awards Presentation August 8, 2013 Introduction: On behalf of YOU the NAEMSE Membership, the Board of Directors, NAEMSE Staff, and the Recognition Committee, I would like to extend a special note of thanks to the achievement you all accomplish everyday serving students and the greater EMS community. This morning it is an honor to be able to recognize the outstanding accomplishments of those who have displayed an unwavering commitment to excellence – those who reflect the very best characteristics of the EMS profession in and out of the classroom. The Recognition Committee has been challenged by the Board of Directors to seek out and recognize the many displays of excellence in EMS education. I would like to thank the current members of the Recognition Committee for their diligence in reviewing, selecting and preparing this morning’s Awards Ceremony. If you would like to join this committee, we are meeting tomorrow morning in the Executive Room, 8:00-8:45AM and all are welcome.

The first recipient is described by her peers as a “champion” for EMS Education. She is caring, compassionate, and devoted to EMS Education, yet no one calling 911 knows what she does to make a difference in the care they receive. Recognizing the need for a 12 lead ECG prehospital notification project, this recipient led the way in securing funding for equipment and education for all the ambulance services in the area. Quarterly, this EMS Educator hosts a forum for thirty or more EMS Educators to continue their EMS educator development as well as an opportunity for peer collaboration. Furthermore, this educator instituted an annual conference attended by 300 or more EMS personnel drawing attendees from four states. When learning of her nomination for this award, those responsible for assembling the packet said Tracey asked them not to, stating: “I don’t do this because of any recognition, I do this because I love the people I serve.” A statement that epitomizes the UNSUNG hero award. From Kentucky, please join me in recognizing the outstanding achievements of Tracey Crawford.

JULIE WILLIAMS, NREMT-P, NCEE

UNSUNG HERO AWARD: NAEMSE, with sponsorship from Delmar Cengage Learning, created the Unsung Hero Award to be presented to educators from across the globe who serve with distinction and are recognized for their excellence in EMS Education. The purpose of the award is to recognize those unsung men and women who serve our profession each and every day. Criteria include: a strong passion for teaching and evidence of excellence in providing EMS education; integrity, professionalism, and sacrifice in the interests of students; and evidence of effectiveness as an educator. Nomination packets include a review of testimonials of students (present and former), colleagues, interdisciplinary healthcare team members, and regulatory officials.

This year NAEMSE will be recognizing two Unsung Hero recipients:

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Our second UNSUNG Hero Award is presented to a paramedic and EMS Educator who has worked in EMS for over 20-years. More recently she has been sharing her expertise as a speaker at several EMS conferences. She is described as a person who never seeks the spotlight, quietly working behind the scenes to get things done and make a difference, with unwavering dedication and passion to her craft in the classroom as well as caring for patients.

Recognizing a need for ongoing EMS instructor development, this recipient took the initiative to develop and implement instructor development seminars benefiting all of the instructors in her state. Her service extends beyond the classroom as she serves as an appointed member of the South Carolina EMS Advisory and Education Committees. Furthermore, Julie has served two terms as President of the South Carolina EMS Educators Association, and is a recipient of the South Carolina EMS Professional of the Year Award. Please join me in recognizing the outstanding achievement of Julie Williams, NAEMSE Unsung Hero!

LEGENDS THAT WALK AMONG US: Legends that Walk Among Us is an award that honors those men and women who have been pivotal in advancing the EMS profession with their energy and talents through educational activities on a statewide or a national level over at least a decade. This award allows us to say thank you to those individuals who have and continue to mentor us, motivate us, and inspire us through their commitments to our profession.

FALLEN HEROES: This award posthumously honors those individuals who contributed greatly to EMS Education who are no longer with us. While we cannot thank them personally, it is fitting that we pause and value their enduring contributions to our profession. Today we reflect and remember the contributions made by four Fallen Heroes to our profession and the many students, patients, and colleagues they touched during their service. In memoriam, this year NAEMSE remembers: 1. Bryan Cox, Tennessee 2. Gary Dubinski, Massachusetts 3. Tim Peebles, Georgia 4. Chy Miller, Kansas

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MICKEY MOORE, AAS, EMT-P

In your own way, please reflect on these and the other countless members of the EMS profession who have sacrificed in serving pivotal roles to so many.

A YEAR IN REFLECTION:

Mickey Moore currently serves as the Deputy State Director of EMS for the State of Georgia. His EMS service and career spans more than 30-years beginning as a Berrien County EMT in 1982! Those familiar with the NAEMSE Symposium know Mickey as an expert AV consultant. His technological expertise goes beyond helping instructors make the electrical connections and crossing your fingers that everything will work. Mickey’s EMS classroom includes providing technical and educational support for over 19,000 students in the Georgia EMS Online Classroom, as well as the production of over 30 training videos. Mickey is a Charter Member and former NAEMSE Board member. Mickey has been described as a person tirelessly giving of himself to EMS. He has never asked for center stage at NAEMSE but makes sure that center stage is ready for all those stepping to the microphone, year after year. He is a tireless leader who has exhibited the many characteristics we cherish – leadership, professionalism, integrity, compassion, and competence. . A mentor of many present in this hall, Mickey has spent his whole life as a public servant, facing each day with dignity and perseverance. Mickey exemplifies legendary status and we are honored to recognize him as the 2013 NAEMSE Legend That Walks Among Us!

A year never seems to go by where several major events impact and shape who and what we are all about in emergency medical services – the first responders who continue to answer the call no matter the challenges before us. Most if not all of us have been or currently are in the thick of serving our communities as emergency care responders. As educators we teach, mentor, and mold students into the future care providers that are serving throughout our communities. Reflectively, I am in awe of the number of patients we touch indirectly through our students. We have an awesome responsibility and what you do indelibly affects the lives of many. In an effort to reflect and honor the magnitude each of you contribute to the quality of life of others in the most difficult time of their lives, we honor the work of so many of our fellow EMS workers this last year.

CONCLUDING COMMENTS: Special thanks to Becky Valentine and Brandon Ciampaglia for their efforts in producing this morning’s awards presentation, and the NAEMSE staff for coordinating all of the behind the scenes logistics. The NAEMSE Recognition Committee is accepting nominations for next year’s awards. Help us seek out EMS education excellence wherever you see it. Thanks you for your service!

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THE CHALLENGES AND OPPORTUNITIES OF TEACHING “GENERATION Y”

The Challenges and Opportunities of Teaching ‘‘Generation Y’’ By: Jodie Eckleberry-Hunt, PhD, ABPP Jennifer Tucciarone, MD Generation Y, otherwise known as the millennial generation, refers to individuals born between 1982 and 2005.1 This is the newest generation to enter the workforce. Leaders across disciplines are taking note of the challenges and opportunities associated with training this unique group. In contrast, medical education appears to be lagging behind in understanding the different learning needs of Generation Y and the ramifications this has for advanced training. This can lead to misunderstanding and frustration. Consider this example: A young resident advances in training but does not seem to be taking on additional responsibilities as would be developmentally expected. In fact, he calls faculty to ask if he is expected to see his panel of patients while they are hospitalized. When the attending physician explains the concept of continuity of care to the resident, he provides a litany of reasons why he should not be responsible for seeing his patients in the hospital. This resident begins to get a reputation for doing the minimum amount. The faculty mentor meets with the individual to discuss faculty concerns, particularly that he is always asking what is expected. The resident says, ‘‘I don’t know what to do with this feedback. Are you telling me I can’t ask for help?’’ The mentor feels frustrated because the resident does not seem to understand the bigger picture. The resident is frustrated because he does not understand the expectations of faculty. Unfortunately, there is very little in the research to suggest what teaching strategies work with Generation Y.2 One exploratory study suggests that unstructured learning environments in medical schools may be ill matched with the high need for structure of Generation Y,3 but these findings are preliminary and may be speculative. In this article, we draw from other disciplines, such as nursing and business, to review the strengths and challenges of Generation Y. We discuss how to match medical education teaching strategies to their particular preferences, based on what we do know, and hopefully provide guidance to educators faced with issues related to generational differences. Both authors are at Beaumont Health System. Jodie Eckleberry-Hunt, PhD, ABPP, is Associate Director of Behavioral Medicine, Troy Family Medicine Residency Program; and Jennifer Tucciarone, MD, is Medical Director, Troy Family Medicine Residency Program. Corresponding author: Jodie Eckleberry-Hunt, PhD, ABPP, Beaumont Health System, 44250 Dequindre Road, Sterling Heights, MI 48314, 248.964.0417, JEckleberryHunt@beaumont.edu DOI: http://dx.doi.org/10.4300/JGME-03-04-15

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Characteristics of Generation Y The early years of Generation Y were marked by uncertainty.4 Significant events included events of September 11, 2001, other threats of terrorism, globalization, a severe economic recession,1 school violence, and an outbreak of severe acute respiratory syndrome.5 Generation Y has been a highly protected and overscheduled generation.6,7 They were raised by parents who told them they were special and winners for no other reason than they arewho they are.8 Core workplace values include online social connectedness, teamwork, free expression, close relationships with authority figures (as they had with parents), creativity, work-life flexibility, and use of technology.1,9 Generation Y prefers to work in groups with hands-on experiences.2,5 They enjoy trial and error.2 Generation Y does not highly value reading and listening to lectures as has been traditional in medical education.2 They want learning to be creative, interactive, and fun; and they enjoy thinking outside the box.8 Generation Y has unique characteristics that affect learning in positive and negative ways. To ensure success, medical educators need to understand that Generation Y cannot be forced into the mold of past generations. Differences are not necessarily weaknesses. On the basis of relevant literature, we believe educators in graduate medical education should focus on 4 core areas: (1) interactive teaching with technology, (2) professionalism, (3) mentoring (or parenting), and (4) communication and feedback (T A B L E ). Interactive Teaching With Technology Generation Y is technology savvy9 and advanced in readiness to use new medical technologies. Medical educators need to stay abreast of new technologies and incorporate them into teaching. Successful strategies will involve hands-on teaching with simulations and group discussion. Collaborative learning coupled with immediate feedback within a practical context is key.2 Teachers should not rely on lectures as a primary teaching method. When lectures are used, they should incorporate multimedia presentations or bring in live patients for case discussions with audience participation. Educators should involve residents in a project or case study that requires active problem solving on their part. Educators not as conversant with technology could use Generation Y’s expertise by involving them in a technology advisory committee.

THE CHALLENGES AND OPPORTUNITIES OF TEACHING “GENERATION Y” TABLE

Challenges and Strategies for Educating Generation Y

Challenges Technology

Strategies Avoid traditional lecture formats Teach contextually (multimedia formats, case presentations, audience participation, hands-on teaching, group discussions) Role model and provide opportunities to be present without multitasking Involve residents in developing and using new technologies Identify technology-free times and encourage being mindfully present

Professional behaviors

Comprehensively review rules and consequences in a structured environment Define appropriate and inappropriate behavior Develop a professionalism contract Schedule monthly mentoring with detailed guidance Faculty role modeling External rewards/consequences Involve residents in projects and committees

Mentoring

Feedback provided within a stable, monthly mentoring relationship Have residents reflect on struggles and successes before giving feedback. Give concrete behaviors on which to improve. Provide immediate and summative feedback Discuss defensiveness openly Involve residents in remediation plans Self-reflection exercises Basic education on scheduling time

Communication

Discuss appropriate boundaries of communication Use 360-degree evaluations Give written feedback Use praise and positive comments in public Give consistent message Accept honest and open feedback without becoming defensive Give concrete, immediate feedback

On the other hand, Generation Y is likely to inappropriately multitask with technology. They are accustomed to using technology when they should be studying or are in class.10 They do not understand how this multitasking may be perceived as rude or distracting. Clear rules about multitasking are essential.10 Faculty should role model appropriate technology use by avoiding multitasking (eg, avoid use of a hand-held device during lectures or meetings). Programs should champion ‘‘technology-free’’ periods and encourage opportunities to practice stillness and self-reflection through journaling or creative arts. Professionalism Medical educators are very concerned with a perceived lack of professionalism among Generation Y.11

Educators tend to view Generation Y as lazy, unmotivated, and selfish, and this view is shared in the business world.4 Generation Y counters that they simply want work-life balance. In other words, work does not come first.7,9 Millennials do not look at an organization to see how they will fit into it; rather, they look at how that organization will fit into their lives.4,6,8 This is a challenge for older generations of physicians to understand, and to respect younger physicians’ desire to work less.11 Medicine requires a strong work ethic, and this cannot be compromised. However, the debate over professionalism across the generations is one that occurs every time a new generation enters medicine.12 It is important to understand that professionalism is a journey rather than an end state.12 Although teachers and mentors can require certain behaviors, they cannot demand on-the-spot changes in life philosophy. Journal of Graduate Medical Education, December 2011

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THE CHALLENGES AND OPPORTUNITIES OF TEACHING “GENERATION Y” The question is how can program leaders attend to concerns about work-life balance as a crucial issue in recruiting and retaining physicians,4 particularly if they want the best and the brightest? At the same time, how can they convince young physicians of the importance and value of self-sacrifice for a greater good? Although these are more long-term considerations, programs can begin by focusing on expected behaviors in the present. Thus, teaching professionalism to Generation Y should emphasize observable behaviors.14 Medical educators should feel comfortable addressing even basic behaviors, such as appropriate professional dress. Millennials want an environment where the lines of communication and rules are explicit and firm.7 They dislike ambiguity.7 As a result, they seem to prefer a more lengthy orientation period to digest the information and understand what is expected.5 From the beginning of residency training, it is important to clearly delineate appropriate and nonappropriate behaviors, particularly regarding timeliness, dress, use of social networking, multitasking during lectures, and discussion of personal life details in professional settings.13 It is important not to assume that anything is ‘‘common knowledge.’’ When providing corrective feedback to residents, faculty should not tell them that they are unprofessional. Instead, the feedback should focus on the specific behaviors that are not appropriate and the reasons for this, and should delineate the consequences for repeated inappropriate behavior. Programs may even want to consider a professionalism contract. External rewards may be quite useful.8 During this time of professional identity formation, residents need a strong faculty presence. Persevere even when you want to look the other way. Professionalism is a very difficult domain to define,14 let alone teach, and with Generation Y, more than with any other group, faculty will need to be creative and patient. Mentoring (or Parenting) Generation Y Generation Y wants to have a close relationship with authority figures, just as they did with their parents.7 They want to feel that supervisors care about them personally.7 They want to feel special.7 Generation Y prefers to work with superiors who are approachable, supportive, good communicators, and good motivators.7 One side effect of a close relationship, however, is that Generation Y may inappropriately share private, even shocking, information in informal ways.8 Additionally, millennials feel comfortable sharing their opinions and feedback without respect to the appropriate organization hierarchy.4,7 They have been taught that whatever you feel is okay, thus it is okay to talk about it.4 This can unsettle medical educators who are not accustomed to such open communication.

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Espinoza and colleagues6 suggest that successful managers must have a strong sense of self to hear this type of feedback and not become defensive. While open vertical communication may present some challenges (eg, openly challenging authority),4 it can be a strength for the residency program if handled correctly. Faculty physicians need to learn to be comfortable with Generation Y residents’ communication. It is a great opportunity for faculty to role model how to accept feedback. Program leadership should be ready to interact with Generation Y and be open to that interaction because Generation Y is likely to start at the top. Program directors should be open to honest feedback from residents and use it for positive change in the program. Residents should not expect that their opinions will be directly translated into program changes. On the other hand, their honest feedback can be crucial to making important programmatic changes. Espinoza et al6 identified that successful managers of Generation Y individuals are good at forming mentoring relationships. Successful managers set expectations and patiently mentor millennials to goals. Medical educators may not understand the demands for a close relationship, particularly in a medical culture that is so hierarchically structured. They may feel like micromanagers or even worse, parents, but this is the comfort zone for Generation Y.10 Tulgan4 calls this ‘‘in loco parentis management,’’ whereby managers function as parent figures to help Generation Y succeed. The ongoing, robust relationship with a mentor provides a safe environment for nondefensively hearing and growing from feedback, and this is key.7 One approach is to reconceptualize the role of academic advisor to include more of a parental function with regular meetings and personal attention. The mentor could meet monthly with residents to discuss professionalism questions or issues. Mentor meetings would focus on summarizing progress, reinforcing messages of professionalism, and teaching problem solving. Faculty should become comfortable with a strong, directive role, not dissimilar to the parenting role, where rules are clear and firm. This can be exhausting, as the focus may be on basic areas such as study skills, time management, and organization skills.10 Educators are wise to identify residents early who are perpetually running behind or appear scattered and help them develop a basic schedule. At the same time, mentoring also may address deeper-level growth. Residents should be asked to self-reflect on strengths and weaknesses before providing feedback or to reflect on reasons for struggles or successes. Mentoring should also focus on developing priorities and independent decision making.10 Mentoring is needed to teach skills of stillness, contemplation, and self-reflection.

THE CHALLENGES AND OPPORTUNITIES OF TEACHING “GENERATION Y” Communication and Feedback Millennials want to know immediately what they are doing right and wrong.5–7 At the same time, they may feel ill equipped to handle negative feedback as they have been told so often by parents that they are truly wonderful.7,8 In fact, because of the way Generation Y was parented, they tend to have difficulty with problem solving, failure, accepting and learning from mistakes, and having realistic expectations.8 There is decreased accountability, responsibility, and independence.8 Regular meetings with mentors are a good way to provide summary data, but educators are encouraged to provide a lot of on-the-spot feedback. Tell residents what they need to learn and why.13 Generation Y is particularly concerned with what peers think, so providing that objective information is useful.8 Feedback should be immediate, behaviorally based, and specific, and should be as clear and simple as possible. Use of 360-degree evaluations (including faculty, interdisciplinary staff, peers) to offer feedback from multiple sources will be highly valued. Verbal and written feedback are useful tools. When weaknesses and struggles are identified, mentors should assist residents in taking an active role in developing a plan for improvement. If residents become defensive, mentors should let them knowthey see the defensiveness and discuss how this may interfere with learning. This could evolve into a discussion about accepting feedback as an attribute of professionalism and practice-based learning and improvement. Programs should ensure that all faculty give the same message. On the positive side, a particularly effective tool for motivating Generation Y is praise from superiors and coworkers.8 Faculty and mentors should find creative ways to recognize the positives. For example, mentors may collect positive quotes from faculty, peers, and staff, and provide residents with a printed list. Residents will also appreciate it when successes are publicly acknowledged, and when positive patient feedback is shared with the entire program. Conclusion The case example provided in the introduction was resolved through the use of Generation Y teaching strategies. The faculty mentor provided the resident with concrete examples of his behavior that demonstrated a lack of initiative and responsibility. His initial response was to become defensive, and the mentor reflected back to the resident the observed defensiveness. The mentor pointed out that in the end, the ‘‘why’’ behind his behavior did not matter. Faculty are more concerned with the end result of good patient care. The mentor provided the resident with straightforward instructions to use when he is unsure of the faculty expectations: ‘‘When you ask yourself, ‘Do I have to do the extra step related to patient care?’ the answer is yes.

There is no need to consult others.’’ ‘‘When you ask yourself, ‘How do I do this?’ it is always OK to ask for help.’’ The resident reluctantly accepted the basic, concrete feedback and no further issues have arisen. In fact, the resident has even demonstrated improved leadership skills. In the end, flexibility and adaptability are required to successfully work with Generation Y. Although faculty may feel it is unfortunate that the members of this generation think and behave the way they do, it is what it is, and medical education needs to find a way to work within that framework. Having a better understanding of Generation Y’s life experience will assist educators who confront the obvious challenges and frustrations illustrated in the introductory case example. There is much we do not know. Admittedly, the strategies described here are supported only by knowledge and advice gleaned from other disciplines and anecdotal experience. In medicine, as in business, however, we believe that Generation Y needs strong medical education leadership to succeed.4 Rules must be clear, and the message should be unambiguous. In many respects, as educators we have to be in loco parentis, and to be good parents, faculty have to be mentally and physically present. We have to persist even when we feel persistence is not working and take comfort in the knowledge that we do not get the pleasure of seeing that all of the hard work has paid off until the kids have moved out of the home. References 1 Howell LP, Joad JP, Callahan E, Servis G, Bonham AC. Generational forcecasting in academic medicine: a unique method of planning for success in the next two decades. Acad Med. 2009;84:985–993. 2 Mangold K. Educating a new generation: teaching baby boomer faculty about millennial students. Nurse Educ. 2007;32:21–23. 3 Borges NJ, Manuel S, Elam CL, Jones BJ. Comparing millennial and generation X medical students at one medical school. Acad Med. 2006;81:571–576. 4 Tulgan B. Not Everyone Gets a Trophy. San Francisco, CA: Jossey-Bass; 2009. 5 Carver L, Candella L. Attaining organization commitment across different generations of nurses. J Nurs Manag. 2008;16:984–991. 6 Espinoza C, Ukleja M, Rusch C. Managing the Millennials. Hoboken, NJ: John Wiley & Sons; 2010. 7 Epstein M, Howe P. The millennial generation: recruiting, retaining, and managing. Today’s CPA. Sept/Oct 2006;24–27. 8 Lipkin NA, Perrymore AJ. Y in the Workplace. Franklin Lakes, NJ: Career Press; 2009. 9 Pew Research Center. Millennials: A Portrait of Generation Next. Washington, DC: Pew Research Center; 2010. 10 Pardue KT, Morgan P. Millennials considered: a new generation, new approaches, and implications for nursing education. Nurs Educ Perspect. 2008;29:74–79. 11 Smith L. Medical professionalism and the generation gap. Am J Med. 2005;118:439–442. 12 Johnston S. See one, do one, teach one: developing professionalism across the generations. Clin Orthop Relat Res. 2006;449:186–192. 13 Moreno-Walton L, Brunett P, Akhtar S, DeBlieux PM. Teaching across the generation gap: a consensus from the council of emergency medicine residency directors 2009 academic assembly. Acad Emerg Med. 2009;16:S19–S24. 14 Lesser CS, Lucey CR, Egener B, Braddock CH, Linas SL, Levinson W. A behavioral and systems view of professionalism. JAMA. 2010;304:2732–2737.

*Originally published in the Journal of Graduate Medical Education, December 2011

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12 A

‘AMPLIFYING’ EDUCATION’S VALUE

‘Amplifying’ Education’s Value By: E lizabeth Redden The latest edition of the Organization for Economic Cooperation and Development’s “Education at a Glance” report highlights the relationship between educational attainment and employment, finding that the gap in employment rates between those with high and low levels of education widened during the recession. On average across the OECD member countries, the proportion of postsecondary degree holders who were unemployed increased by 1.5 percentage points from 2008 to 2011, to 4.8 percent, while it increased by 3.8 percentage points for individuals without a secondary degree, to 12.6 percent. In the United States, the situation for lower-skilled workers is particularly stark. Unemployment rates for those without a secondary education climbed 6 percentage points from 2008 to 2011, to 16.2 percent, while the proportion of postsecondary-educated individuals who were unemployed increased 2.5 percentage points, to 4.9 percent. “The crisis has really amplified the value of a good education,” Andreas Schleicher, the deputy director for education and skills and special advisor on education policy to the OECD’s Secretary-General said during a Tuesday webinar coinciding with the report’s release. “Those who are well-educated have generally fared well during the years of the economic crisis while those without baseline qualifications, who didn’t complete high school or didn’t get a good vocational education, have really paid the price for the crisis.” When asked about concerns regarding college graduates who are unemployed or stuck in unpaid internships, “We do see graduate unemployment but it’s in many cases a transitional phenomenon,” Schleicher said.

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“If you actually add it up over a sufficient number of years, the likelihood of being unemployed as a university graduate is below 5 percent. It hasn’t actually changed very much.” “What we have to basically acknowledge – and it’s always been the case – is that for people who go to college the transition to the labor market is often longer and more protracted,” he said. The “Education at a Glance” report considers comparative indicators of educational inputs and performance across the 34 member countries of the OECD (an organization of predominantly wealthy states) as well as select countries with rapidly emerging economies (including Brazil, China, India, and Russia). The 436-page report encompasses education at all levels, from pre-kindergarten to higher education, and considers a wide range of indicators including enrollment and graduation rates, employment rates and average earnings, and educational expenditures. Among the many findings, the United States’ historical advantage in producing higher education graduates has eroded: it ranks fifth in terms of postsecondary education attainment among 25-64-year-olds, but 12th when only 25- to 34-year-olds are considered. In 2011, 43 percent of 25- to 34-year-olds in the U.S. had obtained a higher education credential, which exceeds the OECD average of 39 percent but is significantly below the 64 percent figure boasted by South Korea, the world leader in this regard. The U.S. is one of five countries surveyed that cut back on public educational expenditures during the recession (the other four countries being Estonia, Hungary, Iceland and Italy). However, despite a 1 percent reduction in public expenditures, the U.S. maintains a relatively high level of education expenditures, spending 7.3 percent of its GDP on education at all levels – an amount well above the 6.3 percent OECD average.

‘AMPLIFYING’ EDUCATION’S VALUE

The U.S. spends 2.8 percent of its GDP on higher education -- more than any other country and nearly twice the OECD average of 1.6 percent -- largely because it can mobilize private resources in the form of high tuition fees. The public/private funding balance for higher education in the U.S. is nearly the reverse of what it is internationally. In the U.S., 36 percent Simulaids of funding comes from public sources andDivision 64 NAEMSE percent private, compared to a 68/32 public/priSept 2013 vate split across all OECD countries. Number of Students Enrolled in Higher Education Outside their Country of Citizenship, Worldwide

YEAR

NUMBER

1975

0.8 million

1980

1.1 million

1985

1.1 million

1990

1.3 million

1995

1.7 million

2000

2.1 million

2005

3 million

2010

4.1 million

2011

4.3 million

However, America’s share of the international student pie has declined by six percentage points since 2000, and Germany’s share has fallen by 3 percentage points. “In principle what we’re currently seeing in the numbers is simply that other countries [aside from the U.S.] have pursued internationalization policies, and some quite successfully so,” Schleicher said. Reprinted from INSIDE HIGHER ED June 26, 2013 with the permission of Inside Higher Ed, copyright 2013. Inside Higher Ed is the free daily news Web site for people who work in higher education. Breaking news, lively commentary and thousands of job postings bring more than 800,000 people to the site each month. Read more: http://www.insidehighered.com

Source: OECD and United Nations Educational, Scientific and Cultural Organization Institute for Statistics

Meanwhile, the number of students pursuing postsecondary degrees outside their country of citizenship continues to increase (see above chart) to 4.3 million in 2011. More than half of these globally mobile students (53 percent) are from Asia, with the largest numbers coming from China, India and South Korea. In absolute terms, the U.S. hosts more international students than any other nation (17 percent), followed by the United Kingdom (13 percent), Australia (6 percent), Germany (6 percent), France (6 percent), and Canada (5 percent).

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DOMAIN FALL 2013

Providing a Voice for EMS Educators

Official Publication of the National Association of EMS Educators

Death Notification in Emergency Medical Services: A North American Perspective pg

by LeeAnne Douglas MScCH, AEMCA and Savithiri Ratnapalan, MBBS, MEd, MRCP(UK), FRCPC, FAAP

Biocontainment Patient Transport: A Missouri to Nebraska Exercise pg

by Elizabeth Beam MSN, RN, Chris Zirges

RN, ACNS-BC, CIC, Cathy Carroll MLT, CIC, Shawn Gibbs PhD, Steven J. Lawrence MSc, MD, Philip W. Smith MD, and Angela L. Hewlett, MS, MD

Editorial Review Board William Raynovich Les R.Becker Bruce Butterfras Todd Cage Lynne Dees Kim McKenna Mike G. Miller

Maddie Oâ&#x20AC;&#x2122;Donnell Michael D. Pante Richard A. Walker David Blevins Greg LeMay Beth Ann McNeill Fred W. Wurster

NAEMSE MISSION: To inspire and promote excellence in EMS education and lifelong learning within the global community.

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DOMAIN3 Death Notification In Emergency Medical Services: A North American Perspective By: LeeAnne Douglas MScCH, AEMCA and Savithiri Ratnapalan, MBBS, MEd, MRCP(UK), FRCPC, FAAP

(PART 1)

As a result, EMS providers are uniquely positioned to either positively or negatively influence the grieving processes of the survivors. Maximizing the ability of EMS providers to have a positive influence on the survivor’s grief response means providing them with appropriate training to deliver compassion death notifications and providing the survivors with appropriate support as they come to terms with their loss.

Introduction

The EMS Providers

Out-of-hospital cardiac arrest (OHCA) is a

The emotional toll of communicating a death notification and providing emotional support to the survivors can be significant. EMS providers report feeling uncomfortable communicating death notifications and these experiences can be very stressful, particularly for inexperienced providers (Douglas, Cheskes, Feldman & Ratnapalan, 2012; Norton et al., 1992; Smith-Cumberland & Feldman, 2006). In addition, almost one-third of Canadian providers surveyed experienced emotional distress after the death of a patient in their care (Regehr & Bober, 2005), with up to 22% of providers experiencing Post-trauamtic Stress Disorder (Bennet, Williams, Page, Hood, & Woollard, 2004).

significant source of mortality, with over 200 000 patients being resuscitated by EMS each year in North America (Rea & Page, 2010). Survival rates vary between 5% and 10% with the majority ultimately succumbing to the event (Lerner et al., 2012). EMS providers play an important role in OHCA care by responding rapidly to cases of cardiac arrest, providing early cardiopulmonary resuscitation (CPR), and advanced life support. Increasingly, the benefit of continued resuscitation with resultant transportation to hospital has come into question (Morrison et al, 2010) and guidelines have been developed that aim to appropriately terminate resuscitation in patients unlikely to survive (Morrison et al., 2006). This means that EMS providers are terminating resuscitation in cardiac arrest victims more often and that they have to perform the unpleasant task of informing the survivors of the patient’s death and providing initial grief support to the bereaved (Douglas, Cheskes, Feldman & Ratnapalan, 2010; Morrison et al. 2010; Norton et al., 1992; Ponce et al., 2010; Roth et al., 1984; Smith et al., 1999; Smith-Cumberland and Feldman, 2006). The Survivors

Death Notification Training Despite the emotional challenges of delivering a death notification, many EMS providers do not receive death notification training and, of the few that do, many rate their training as inadequate (Ponce, 2010; Smith-Cumberland & Feldman, 2006; Stewart, Harris-Lord, & Mercer, 2001). Training can improve EMS providers’ confidence and competence when delivering death notifications; (Hobgood et al., 2005; Robinson et al., 2004) however, this training does not always reflect providers’ and survivors’ unique needs when death is encountered in the field (Ferrel et al., 2005; Hobgood, Harward, Newton, & Davis 2005; Robinson et al., 2004; Smith et al., 1999; Smith-Cumberland, 2006; Smith-Cumberland & Feldman, 2010).

Grief is a complex and multifactorial process; factors that are likely to contribute to a prolonged or complicated grief response in survivors include death in the field; sudden death; and lack of supIt is evident that training can give EMS providers port following the death (Edwardsen et al., 2002; the necessary knowledge and tools to communicate Smith et al., 1999). Complicated grief describes compassionate death notifications and to provide prolonged yearning for the deceased combined support to the survivors. Training may also, to some with signs of compromised social and psychologextent, attenuate the degree of emotional distress ical adaptation to the loss (Jordan and Neimeyer, experienced by EMS providers; however, the degree 2007). In the latter case, the EMS providers’ and adequacy of this training is unclear. actions can directly affect the survivor’s grieving processes. (Smith-Cumberland & Feldman, 2006). www.naemse.org | Educator Update | 16

DOMAIN3 This review aims to describe the impact of communicating death notifications on the survivors and the providers. The current state of death education for EMS providers will be described and recommendations to inform future death education curricula will be provided. Methods Medline (R) (1946 to present); Cumulative Index to Nursing and Allied Health Literature (CINAHL) (1982 to present); and Excerpta Medical Database (EMBASE) (1947 to 2013 June 11) databases were searched for relevant articles using the following key words: “emergency medical technician;” “emergency medical services;” “death;” “attitude to death;” “bereavement;” “grief;” “dying;” “training;” and “continuing education.” All combinations of search terms were used. The word “Paramedic” was not used as it was not identified as a search term by any of the databases. The term “EMS provider” includes the following personnel: Paramedics; Emergency Medical Technicians (EMTs); Law Enforcement Officers; and Fire Department personnel. Depending on jurisdiction, all of these personnel are involved in the response to and resuscitation of victims of cardiac arrest. The search was limited to English articles in peer-reviewed journals. Exploratory studies; prospective cohort studies; quasi-experimental studies; pilot studies; and qualitative studies were included. The setting was not limited to North America. Results The literature search identified 258 English articles Of these, 245 articles were excluded based on review of the abstracts. After hand-searching the references for additional articles and review of the articles by LD and SR, 13 articles from four countries (Canada; United States; Puerto Rico; and US Virgin Islands) that described EMS providers’ attitudes to death or death education training were included in the analysis. Three articles investigated provider attitudes to death or death notification training. Six articles reviewed or evaluated death notification training or instructors. Two articles outlined the changes in providers’ attitudes after death notification training.

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Single articles reviewing EMS providers’ experiences with death and families’ attitudes to death in the field were included. EMS Providers Outside of the hospital, 83% of death notifications are given by EMS providers (Halpern, Gurevich, Schwartz, & Brazeau, 2009). Qualitative analysis of interview and focus group data from 60 Canadian EMS providers and EMS supervisors found that the occurrence of critical incidents such as patient death produced feelings of vulnerability and helplessness in providers (Halpern et al., 2009). In a recent qualitative study, Douglas et al. found that deaths that are unexpected; traumatic; visually disturbing; involve children; share characteristics with which the EMS provider identifies; or are the provider’s first experience increase the stress of communicating a death notification. In general, EMS providers and other health professionals fear not knowing the ‘right’ answers; expressing their emotions; and being blamed for the death when they communicate death notifications to the survivors (Iserson, 1999; Buckman, 1984). Consequently, the emotional impact of delivering a death notification can be significant (Smith et al., 1999) and there is a high prevalence of Posttraumatic Stress Disorder (PTSD) among EMS providers (up to 22%) compared to a rate of 3.5% in the general population (Bennet, Williams, Page, Hood, & Woollard, 2004; Kessler, Chiu, Demler, & Walters, 2005; Streb, Haller, & Michael, 2013). The Survivors Eighty-five percent of OHCAs occur in the victim’s residence and over half of families witness their loved one collapse and subsequently contact EMS (Barrat & Wallis, 1998; Holzhauser, Finucane & De Vries, 2006; Meyers et al., 2004; Vaillancourt & Stiell, 2004). When sudden, unexpected deaths occur in the field, the survivors may have difficulty coping with this loss because they have no time to prepare for it (Cook, 2006). Additionally, losses that are preventable, accidental, or violent put the survivors at an increased risk of developing symptoms of PTSD or experiencing prolonged grief (Stewart, 1999; Currier, Holland, & Neimeyer, 2006).

DOMAIN3 Social; religious; and ethnic factors also influence how individuals and families respond to death in the field and failing to acknowledge the family’s cultural and spiritual needs may lead to increased emotional distress for the survivors (Lickiss, 2003; Zalenski, Gillum, Quest, & Griffith, 2006). These cultural factors can also affect how EMS providers view death and how they interact with the survivors (Corr & Corr, 2006). Death Notification Training Over the past two decades, most EMS provider training programs have developed death notification training; (Smith et al., 1999) however, some programs are based on training designed for other health professionals and have been adapted for EMS education. Current death notification training for EMS providers and other health professionals will be discussed with this in mind. Death notification training is available to EMS providers and other health professionals in online; lecture; and workshop formats. Simple tools such as mnemonics are commonly used in order to guide health professionals through the notification process (Buckman, 2010; Hobgood et al., 2005; Iserson, 1999). EMS providers’ needs regarding death notification training include: knowledge of the steps of a death notification; how to communicate a death notification; how to respond to the survivors’ initial reactions; and how to manage their own reactions (Stewart et al., 2001). Mothers Against Drunk Driving (MADD) offers an online asynchronous course that was originally developed to assist law enforcement officers with the death notification process, but has since been adapted for health professionals (Stewart et al. 2001). This need was evident, given that almost half of the participants surveyed reported never having received death notification training (Stewart et al., 2001). Course length ranges from a one-hour lecture up to a two-and-a-half-day course (Ponce et al., 2010; Smith-Cumberland, 2006).

Regardless of the length, death notification training can improve EMS providers’ knowledge of death notification and family-witnessed resuscitation (Ponce et al., 2010); significantly improve provider’s competence and confidence with communicating death notifications (Hobgood et al, 2005); and increase their perceived ability to provide end-of-life care (Robinson et al., 2004). Most notable is the 2-day Emergency Death Education and Crisis Training (EDECT) curriculum. When compared with a two-hour discussion-based continuing education session created using the curriculum, both courses prompted intentions to change practice among EMS providers with respect to communicating a death notification and supporting the survivors (Smith et al., 1999; Smith-Cumberland, 2006). The communication skills learned were also transferrable to other emergency settings, including mental health crises and cases of sexual assault (Smith et al., 1999). Overall, the EDECT curriculum was found to change EMS providers’ attitudes to death in the field. An effect size of 0.87 and power of 0.80 was reported (Smith-Cumberland & Feldman, 2006). PART 2 of “Death Notification in Emergency Medical Services: A North American Perspective” will be featured in the Winter 2014 Issue of Domain 3. Along with the article, Tables will be provided for your reference.

References (Parts 1 & 2) - Barratt, F., Wallis, D.N. (1998). Relatives in the resuscitation room: Their point of view. Journal of Accident and Emergency Medicine, 15(2), 109-111. - Buckman, R. (2010). Practical plans for difficult conversations in medicine: Strategies that work in breaking bad news. Baltimore, MD: Johns Hopkins University Press. - Booth, M. G., Woolrich, L., & Kinsella, J. (2004). Family witnessed resuscitation in UK emergency departments: A survey of practice. European Journal of Anesthesiology, 21(9), 725-728. - Buckman, R. (1984). Breaking bad news: Why is it still so difficult? British Medical Journal, 288(6430), 1597-1599. - Chalk, A. (1995). Should relatives be present in the resuscitation room? Accident and Emergency Nursing, 3(2), 58-61. - Cook, A. The family, larger systems, and loss, grief, and mourning. In D. Balk (Ed.), Handbook of thanatology: The essential body of knowledge for the study of death, dying, and bereavement (pp. 167-172). Florence, KY: Routledge. - Corr, C. A., & Corr, D. M. Culture, socialization, and dying. In D. Balk (Ed.), Handbook of thanatology: The essential body of knowledge for the study of death, dying, and bereavement (pp. 3-10). Florence, KY: Routledge.

- Critchell, C. D. & Marik, P. E. (2007). Should family members be present during cardiopulmonary resuscitation? A review of the literature. American Journal of Hospice and Palliative Care, 24(4), 311-317. - Currier, J. M., Holland, J. M., & Neimeyer, R. A. (2007). Sense-making, grief, and the experience of violent loss: Toward a meditational model. Death Studies, 30(5), 403-428.

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DOMAIN3 - Douglas, L., Ratnapalan, S., Cheskes, S., Feldman, M. (2010). Death notification in the field: A pilot survey study, Canadian Paramedicine, 34(5) 27-29. - Douglas, L., Ratnapalan, S., Cheskes, S., Feldman, M. (2012). Paramedics’ experiences with death notification: A qualitative study. Journal of Paramedic Practice, 4(9), 533-539. - Durlak, J. A. & Riesenberg, L. A. (1991). The impact of death education. Death Studies, 15(1), 39-58. - Edwardsen, E., Chiumento, S., & Davis, E. (2002). Family perspective of medical care and grief support after field termination by emergency medical services providers: A preliminary report. Prehospital Emergency Care, 6, 440-444. - Fallowfield, L., Jenkins, V., Farewell, V., Saul, J., Duffy, A., & Eves, R. (2004). Efficacy of a cancer research UK communication skills training model for oncologists: A randomized controlled trial. Lancet, 220(359), 650-656. - Ferrel, B. R., Virani, R., Grant. M., Rhome, A., Malloy, P., Bednash, G., & Grimm, M. (2005). Evaluation of the end-of-life nursing consortium undergraduate faculty training program. Journal of Palliative Medicine, 8(1), 107-114. - Halpern, J., Gurevich, M., Schwartz, B., & Brazeau, P. (2009). What makes an incident critical for ambulance workers? Emotional outcomes and implications for intervention. Work and Stress, 23(2), 173-189. - Hampe, S. O. (1974). Needs of the grieving spouse in a hospital setting. Nursing Research 24, 113. - Hobgood, S., 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. - Holzhauser, K., & Finucane, J. (2008). Part B: A survey of staff attitudes immediately post-resuscitation to family presence during resuscitation. Australasian Emergency Nursing Journal, 11, 114-112. - Holzhauser, K., Finucane, J., & De Vries, S. (2006). Family presence during resuscitation: A randomised controlled trial of the impact of family presence. Australasian Emergency Nursing Journal 8(4), 139-147. - Iserson, K. V. (1999). Grave words: Notifying survivors about sudden death. Tucson, AZ: Galen Press Ltd. - Jordan, J. R., & Neimeyer, R. A. (2007). Historical and contemporary perspectives on assessment and intervention. In D. Balk (Ed.), Handbook of thanatology: The essential body of knowledge for the study of death, dying, and bereavement (pp. 213-225). Florence, KY: Routledge. - Kübler-Ross, E. (1969). On death and dying. New York, NY: Macmillan. - Lerner, E. B., Rea, T. D., Bobrow, B. J., Acker III, J. E., Berg, R. A., Brooks, S. C., Cone, D. C., Gay, M., Gent, L. M., Mears, G., Nadkarni, V. M., O’Connor, R. E., Potts, J., Sayre, M. R., Swor, R. A., & Travers, A. H. (2012). Emergency medical service dispatch cardiopulmonary resuscitation prearrival instructions to improve survival from out-of-hospital cardiac arrest. Circulation, 125, 648-655. - Marco, C. A. (2001). Resuscitation research: Future directions and ethical issues. Journal of Emergency Medicine, 8, 839-843. - Meyers, T. A., Eichhorn, D.J., Guzzetta, C.E., Clark, A.P., Klein, J.D., & Taliaferro, E. (2004). Family presence during invasive procedures and resuscitation: the experience of family members, nurses, and physicians. (2004). Topics in Emergency Medicine, 26(1), 61-73. - Mothers Against Drunk Driving. (2004). Death notification training. Retrieved from: http://www.madd.ca/english/volunteer/training.html. - Murphy-Black, T. (2006) Using questionnaires. In K. Gerrish & A. Lacey (Eds.), The research process in nursing, (5th ed.). (pp. 367–382). Oxford, UK: Blackwell Publishing Ltd. - Norton, R. L., Bartkus, E. A., Schmidt, T. A., Paquette, J. D., Moorhead, J. D., & Hedges, J. R. (1992). Survey of emergency medical technicians’ ability to cope with deaths of patients during prehospital care. Prehospital Disaster Medicine, 7(3), 235-242. - Parahoo, K. (2006) Nursing research: Principles, process and issues. (2nd ed.). Hampshire, UK: Palgrave Macmillan. - Paramedic Association of Canada. (2011). National occupational competency profiles for paramedic practitioners. Kamloops, BC. - Ponce, A., Swor, R., Quest, T. E., Macy, M., Meurer W., & Sasson, C. (2010). Death notification training for prehospital providers: A pilot study. Prehospital Emergency Care, 14, 537-542. - Ptacek, J. T., & Eberhardt, T. L. (1996). Breaking bad news: A review of the literature. Journal of the American Medical Association, 276, 496-502. - Rea, T. D. & Page, R L. (2010). Community approaches to improve resuscitation after out-of-hospital sudden cardiac arrest. Circulation, 121, 1134-1140. - Regehr, C. & Bober, T. (2005). In the line of fire: Trauma in the emergency services. New York, NY: Oxford University Press.

- Robinson, K., Sutton, S., von Gunten, C. F., Ferris, F. D., Molodyko, N., Martinez, J., & Emanuel, L. L. (2004). Assessment of the education for physicians on end-of-life care (EPEC) project. Journal of Palliative Medicine, 7(5), 637-645. - Smith, T. L., Walz, B., & Smith, R. (1999). A death education curriculum for emergency physicians, paramedics, and other emergency providers. Prehospital Emergency Care, 3, 37-41. - Smith-Cumberland, T. (2006). Evaluation of two death education programs for emergency medical technicians using theory of planned behaviour. Death Studies, 30(7), 639-647. - Smith-Cumberland, T., & Feldman, R. H. (2006). EMTs’ attitudes toward death before and after a death education program. Prehospital emergency care, 10, 89-95. - Steinert, Y., & Snell, L. (1999). Interactive lecturing: Strategies for increasing participation in large group presentations. Medical Teacher, 21(1), 37-42. - Stewart, A. E. (1999). Complicated bereavement and posttraumatic stress disorder following fatal car crashes: Recommendations for death notification practice. Death Studies, 23(4), 289-321. - Stewart, A., Harris-Lord, J., & Mercer, D. L. (2001). Death notification education: A needs assessment study. Journal of Traumatic Stress, 14(1), 221-227. - Streb, M., Haller, P., & Michael, T. (2013). PTSD in paramedics: Resilience and sense of coherence. Behavioural and cognitive psychotherapy, 1-12. doi: http:// dx.doi.org/10.1017/S1352465813000337 - Timmermans, S. (1999). Sudden death and the myth of CPR. Philadelphia, PA: Temple University Press. - United States Department of Transportation, National Highway Safety Administration and Department of Health and Human Services, Health Resources Administration, Maternal and Child Health Bureau. (1998). Emergency medical Technician–Paramedic: National standard curriculum (EMT-P). Washington, DC. - Vaillancourt, C., & Stiell, I. G. (2004). Canadian Cardiovascular Outcomes Research Team (CCORT) Cardiac arrest care and emergency medical services in Canada. Canadian Journal of Cardiology. 20(11), 1081-90. - Zalenski, R., Gillum, R. F., Quest, T. E., Griffith, J. L. (2006). Care for the adult family members of victims of unexpected cardiac death. Academic Emergency Medicine. 13, 1333-1338.

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DOMAIN3 Biocontainment Patient Transport: A Missouri to Nebraska Functional Exercise By: Elizabeth Beam MSN, RN, Chris Zirges RN, ACNS-BC, CIC, Cathy Carroll MLT, CIC, Shawn Gibbs PhD, Steven J. Lawrence MSc, MD, Philip W. Smith MD, and Angela L. Hewlett, MS, MD Introduction Historically, biocontainment patient care in the United States has been delivered in military settings, both in transportation1 and in specialized patient care.2 As a result of significant concerns regarding the safe treatment of highly infectious disease (HID) patients, over 47 isolation units have been established in European Union member countries3,4 but only 4 such units currently exist in the United States.3-6 The units utilize engineering controls, administrative controls, and other safety measures typically found in Biosafety Level-3 and 4 laboratories to ensure hospital staff, patients, and the community are maximally protected from the pathogens housed within.7 With so few facilities in the United States to give this specialized care, an index patient may very likely require medical transportation. In February of 2012, the leadership team of the Nebraska Biocontainment Patient Care Unit (NBPCU) collaborated with the Midwest Regional Center of Excellence for Biodefense and Emerging Infectious Diseases Research to perform a multi-state functional exercise where a simulated index patient was identified in Missouri and required specialized transport to Nebraska for biocontainment care. The purpose of this exercise was to test existing plans for infectious patient transport as well as to identify logistical and legal issues that may occur in the event of an actual patient transfer. Methods and Results Exercise Planning The goal of the exercise was to transfer a patient with a HID to a care facility where the healthcare professionals are routinely trained to care for patients requiring the highest levels of isolation. Two videoconference planning meetings were conducted over a 12 month period. Timing of exercise activities overlapped at the two sites where the functional exercise was conducted (Table 1). Exercise objectives were established from the target capabilities8 tested (Table 2).

Each site had a volunteer to simulate the patient who required transfer. The main focus of activity in Missouri was the patientâ&#x20AC;&#x2122;s initial presentation and isolation for transport. In Nebraska, the focus was receiving the transport vehicle and safely transferring the patient to the NBPCU. The exercise lasted approximately 2 hours. A 30 minute debriefing was conducted at each site, and then it was immediately followed by a videoconference debriefing session connecting Missouri and Nebraska participants. Case Scenario The scenario began with a volunteer patient presenting to the emergency department (ED) of a community based hospital located in St. Louis County, Missouri. The case patient had complaints of fever and rash, and voiced concern of a potential viral hemorrhagic fever outbreak that occurred during recent travel to the Democratic Republic of Congo. The ED staff determined that the patient needed to be transferred to the NBPCU through contact with public health authorities. The NBPCU is opened by a joint decision of the NBPCU medical director and the Nebraska Department of Health and Human Services. Transfer involves two separate and at times competing needs: 1) patient support and 2) protection of health care providers and the public during transfer. The transport vehicle may serve as the isolation chamber, or may simply transport the patient inside a separate portable isolation unit. If the patient is critically ill or combative, transfer is not appropriate.9 Multiple considerations regarding infection prevention during and after transfer include vehicle cleaning, transfer team decontamination, handoff of the patient to properly attired personnel, and post-transfer surveillance of the transfer team.10 In preparation for the exercise, processes in Europe were also reviewed and discussed amongst the exercise planning team.11 Exercise Evaluation and Improvement Planning The major outcomes for this exercise included 1) review of initial isolation processes, 2) ambulance preparation and medical transportation, and 3) NBPCU preparations. Initial isolation processes. The patient was placed in a negative airflow isolation room and an N95 respirator was used by the healthcare worker after additional information regarding the patient was given. The ED staff recognized the contagious illness, but they did not consult the existing isolation or Management of Agents of Bioterrorism Plan until after conferring with the hospital infection preventionist. The Missouri after action report suggested using a different title for the plan or another method of directing healthcare workers to consult with

the appropriate resources and guidelines.

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DOMAIN3 For patient care in the isolation room, contact and airborne precautions were used. The path to transfer the patient from the ED room to the ambulance was uneventful since the negative airflow isolation room was close to the external door and ambulance bay. The patient wore a standard surgical mask during the transfer to minimize the spread of respiratory particles. With respect to environmental infection prevention, the processes outlined in the Management of the Agents of Bioterrorism plan mirror those recommended by the CDC.12 Once staff referenced this plan, the appendices outlining transportation, environmental cleaning and laundry procedures were easily found and verbalized. Employee exposure identification was implemented using an employee line list because potential exposures may have occurred. Ambulance preparation and medical transportation. The CDC guidelines for Category A or B bioterrorism agents state the transfer team should be in full personal protective equipment (PPE) including powered air purifying respirators (PAPRs) and the patient should be enclosed in a negative pressure isolator or transport device with high-efficiency particulate arresting filtration of exit air.7 If an individual patient isolator is available with exit air filtration, the isolator would be the best mechanism for safe transfer within the transport vehicle. Commercially available patient isolators may not meet Federal transportation safety standards, so state regulators may need to be consulted about what is acceptable. A standard surgical mask should be placed on the patient. Any connection between the driving area and the patient care area should be sealed off to protect the driver, and the air coming into the driving area should not be recirculated. For the Missouri portion of the exercise, the transport team focused on covering critical patient care equipment and removing items in the vehicle that would likely not be needed in the transport. The need for duct tape and heavy duty plastic sheeting was recognized after consultation with the NBPCU team. In Omaha, the ambulance was not completely wrapped but a careful seal of the patient care area to the cab of the ambulance was made using the plastic sheeting and duct tape noted earlier. The Omaha Fire Department paramedic in the back of the ambulance with the patient donned a protective suit and a PAPR while the driver wore an N95 respirator and gloves. In the scenario, the driver did assist with removing the patient from the ambulance, but only attended to the foot end of the gurney in open air with the patient wearing a gown, gloves, and surgical mask.

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Direct communication with the medical director for the ambulance service and with the receiving hospital medical director throughout an HID patient transfer is imperative in the event of unexpected changes in the patient’s health status or potential issues with the transport vehicle. Due to the risk of aerosolizing infectious particles, clinical actions for airway management or emergency care may be limited. If a patient’s health status declined during the transport and the patient expired, the transport would continue to the destination and the remains would be properly handled upon arrival. NBPCU Preparations. The NBPCU is a specialized unit within The Nebraska Medical Center designed to care for patients with HID.13 The unit activation process includes the use of a comprehensive checklist, which prompts the team to gather supplies, notify involved hospital departments, and prepare the necessary patient care materials within 4 hours of notification. A modified activation checklist was made specifically for the exercise with red text for the special notes related to the exercise. When a HID patient arrives at The Nebraska Medical Center ED, they must be safely transported to the NBPCU in the ISO-PODTM device (Immediate Response Technologies; Glendale, Maryland, United States), which is utilized for transport of the patient to the NBPCU. Assembly of the ISO-PODTM was recognized as a skill to be reviewed at future meetings and drills . Another challenge recognized during the exercise was the logistics of PPE use . Discussions included processes for decontaminating multiple PAPRs as personnel exit the room and developing a “reset” plan after each staff member exits. These concepts were integrated into individualized training for team members following the exercise. Discussion and Conclusions Collaboration is needed from many disciplines in the United States for regional coordination of response to bioterrorism.14-16 We believe this is one of the first interstate biocontainment patient transfer exercises of its kind performed in the United States. Coordination of a drill which spans two states is a tremendous challenge. It was important to have clear communications to all players, as well as champions at both exercise locations to guide and lead the activities in each state. All participating agencies agreed that in order to develop further emergency medical services processes which are evidence-based, a full-scale exercise where a simulated patient would experience an actual transport from a substantial traveling distance is needed. More education between the Missouri and Nebraska about the resources available related to the care of patients with HIDs is also planned.

DOMAIN3

1. Christopher, G. W., & Eitzen, E. M. Air evacuation under high-level biosafety containment: The aeromedical isolation team. Emerg Infect Dis. 1999; 5: 241-246. 2. Marklund, L. A. Patient care in a biosafety level-4 (BSL-4) environment. Crit Care Nurs Clin North Am. 2003. 15: 245-255. 3. Bannister, B., Puro, V., Fusco, F. M., Heptonstall, J., Ippolito, G., & the EUNID Working Group. Framework for the design and operation of high-level isolation units: Consensus of the European Network of Infectious Diseases. Lancet Infect Dis. 2009. 9: 45-56. 4. Fusco, F.M., Schilling, S., De Iaco, G., Brodt, H., Brouqui, P., Maltezou, H. C., Bannister, B., Gottschalk, R., Thomson, G., Puro, V., Ippolito, G., & EuroNHID Working Group. Infection control management of patients with suspected highly infectious diseases in emergency departments: Data from a survey in 41 facilities in 14 European countries. BMC Inf Dis. 2012.12: 1-7. 5. Clinical Center News May 2010. New unit provides unique support for research. http:// www.cc.nih.gov/about/news/newsletter/2010/ may10/CCNewsMay10.pdf 6. Risi, G. F., Bloom, M. E., Hoe, N. P., Arminio, T., Carlson, P., Powers, T., Feldmann, H., & Wilson, D. Preparing a community hospital to manage work-related exposures to infectious agents in biosafety level 3 and 4 laboratories. Emerg Infect Dis. 2010. 16: 373-378. 7. Smith, P.W., Anderson, A. O., Christopher, G. W., Cieslak, T.J., Devreede, G. J., Fosdick, G. A., Greiner, C., B., Hauser, J. M., Hinrichs, S. H., Huebner, K. D., Iwen, P. C., Jourdan, D. R., Kortepeter, M. G., Landon, V. P., Lenaghan, P. A., Leopold, R. E., Marklund, L. A., Martin, J. W., Medcalf, S. J., Mussack, R. J., Neal, R. H., Ribner, B. B., Richmond, J. Y., Rogge, C., Daly, L. A., Roselle, G. A., Rupp, M. E., Sambol, A. R., Schaefer, J. E., Sibley, J., Streifel, A. J., Essen, S. G., and Warfield, K. L. Designing a biocontainment unit to care for patients with serious communicable diseases: A consensus statement. Biosecur Bioterror, 2006. 4: 351-365. 8. United States Department of Homeland Security. Target capabilities list: A companion to the National Preparedness Guidelines. 2007. http://www.fema.gov/pdf/government/training/tcl.pdf 9. Teichman, P. G., Donchin, Y., & Kot, R. J. International aeromedical evacuation. N Engl J Med. 2007. 356: 262-270. 10. Tsai S., Tsang, C., Wu, H., Lu, L., Pai, Y., Olsen, M., & Chiu, W. Transporting patient with suspected SARS. Emerg Infect Dis. 2004. 10:1325-1326.

11. Schilling, S. Follin, P, Jarhall, B., Tegnell, A., Lastilla, M., Bannister, B., Maria Fusco, F., Biselli, R., Brodt, H. R., & Puro, V. European concepts for the domestic transport of highly infectious patients. Clin Microbiol and Infect. 2009. 15: 727-733. 12. Centers for Disease Control and Prevention. Guidelines for Environmental Infection Control in Health – Care Facilities. 2003. Retrieved February 19, 2013 from: http://www.cdc.gov/mmwr/preview/ mmwrhtml/rr5210a1.htm 13. Beam, E., Boulter, K., Freihaut, F., Schwedhelm, S, & Smith, P. W. (2010). The Nebraska experience in biocontainment care. Public Health Nurs. 2010. 27: 140-147. 14. Rubinson, L., Nuzzo, J. B., Talmor, D. S., O’Toole, T., Kramer, B. R., & Inglesby, T. V. Augmentation of hospital critical care capacity after bioterrorist attacks or epidemics: Recommendations of the working group on emergency mass critical care. Critical Care Med. 2005. 33: 2393-2403. 15. Gerberding, J. L., Hughes, J. M., & Koplan, J. P. Bioterrorism preparedness and response: Clinicians and public health agencies as essential partners. JAMA. 2002. 287: 898-900. 16. Evans, R. G. & Lawrence, S. J. Preparing for and responding to bioterrorist attacks: The role of disease management initiatives. Disease Management & Health Outcomes. 2006. 14: 265-274.

References

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DOMAIN3

TABLE REFERENCES Table 1: Master Sequence of Events List Time zero

SENDING SITE: Barnes-Jewish West County Hospital Patient identified and isolated at hospital. Suspicion highly contagious, dangerous illness. Public health contacted and connection with Nebraska DHHS is made.

30 minutes later

Coordinate transportation with local transportation service, local authorities, and NBPCU.

60 minutes later

Prepare patient, vehicle, and transport care team for transfer.

90 minutes later

Coordinate surveillance activities in-hospital for monitoring and any post exposure prophylaxis. Coordinate cleaning and disinfection of isolation room (this may just be securing the room if no definitive dx is available).

120 minutes later

Depart BJ West for Omaha.

150 minutes later: Key outcomes:

RECEIVING SITE: Nebraska Biocontainment Unit, The Nebraska Medical Center Call received about likely transport to the Nebraska Biocontainment Patient Care Unit. NBPCU Director and state medical director have decided to open. Activation processes initiated. Staff arrives and (pre-determined items done) checklist is completed (One NBPCU staff member will go down and help the paramedic get dressed in ED).

Patient arrives in Omaha at TNMC emergency entrance. NBPCU team transfers patient to isopod and transports through hospital to unit.

Patient has arrived in the NBPCU safely and patient care begins (conduct initial laboratory draw per procedure). Appropriate isolation for identified patient is maintained at hospital. o Negative airflow room o Safe transport route to ambulance (within hospital) o Proper use of available PPE (PAPRs, Respirators) Vehicle and EMS staff is prepared for patient transport. o Removal of equipment/Altered Standards of Care o Donning and doffing Level C PPE o Plan for hospital room cleaning

Patient safely transported from ED to unit via isopod. All notifications and preparations made related to patient arrival (per checklist – specific for drill). Laboratory draw procedure simulation completed.

Table 2: Exercise Objectives by Target Capability 1. Communication. Assess the ability to establish and maintain interstate communications during a response to a dangerous, contagious biological incident. 2. Isolation and quarantine. Assess the capability and adequacy of agency plans for responding to a potential biological incident. This includes issues at the sending facility (BJ West), in transportation, and at the receiving facility (Nebraska Biocontainment Unit) related to patient isolation, responder quarantine, room/device cleaning, logistics, and legal issues. 3. Public Health Laboratory Testing. • A simulated laboratory specimen will be collected and sent to the Nebraska Public Health Laboratory (NPHL) using the NBPCU protocols. Orders for malaria testing will be placed in the computer by the NBPCU staff (a positive test would obviate the need for use of the NBPCU). • The NPHL will receive a simulated blood sample and run a test on the I-stat and prep slides for malaria smears. • Test results will be relayed to the NBPCU staff testing both computer reporting and communications. 4. Responder Safety and Health. Responders in both locations (TNMC and BJ West) may have been potentially exposed to the contagious, dangerous illness. Each location will discuss public health interventions needed (possibly expanding existing policies).

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DOMAIN3

A LOOK IN THE MIRROR: EVALUATING PROGRAM STRENGTHS AND WEAKNESSES

A Look in the Mirror: Evaluating Program Strengths and Weaknesses by: Patricia L. Tritt, RN, MA HealthONE EMS

Where to start? 1. Begin with a re-review of the Standards and Guidelines from a fresh perspective. Ask the tough questions: not only do we do this (the Standard), but what does the Standard really mean, how do we do it, how well do we do it, and what do we need to change? 2. Avoid answering what you can do and instead focus on what should you do. 3. Determine strengths and weaknesses using these practices and mechanisms:

• Students evaluate faculty/instructors fre-

The accreditation process is outcome based. In other words, the focus of the education program -- and therefore the review of the program -- is on the performance of the graduates rather than on the process of the education. What does this mean for programs? For example: Are you teaching to a text or are you teaching to develop a competent entry level Paramedic? Texts are teaching tools, not an education. Are you teaching to have students pass a certifying exam -- while admittedly important--or are you teaching to develop a competent entry level Paramedic? Exams of any kind are merely snapshots in time. The laser focus must always be on producing a competent product -- in this case, Paramedic graduates. Frequent assessment of the students and of the education program is essential to determine program strengths and weaknesses (opportunities). Programs are typically familiar with--and comfortable with -- student assessment, but have a much less structured approach to looking in the mirror for an adequate -- and frank -- assessment of the program.

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quently. Incentives are provided for open, frank, constructive feedback. Feedback is acknowledged and information is relayed on what changes have been made or will be made based on their input. • Students evaluate program courses or components frequently with the same caveats as above. • Students evaluate adjunct or skill instructors frequently. • Faculty, Advisory Committee members, the Program Medical Director, and any other stakeholders complete the Program Personnel Resource Survey at least annually and responses are analyzed and recommendations are implemented. • Students complete the Student Resource Survey annually, at least. • Graduate and Employer Surveys are completed six months following program completion and responses are analyzed and recommendations are implemented. • Preceptors evaluate your program. • Students evaluate their preceptors. • Students evaluate the clinical sites and experiences. • Faculty members observe and provide feedback to each other.

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A LOOK IN THE MIRROR: EVALUATING PROGRAM STRENGTHS AND WEAKNESSES 4. Complete a SWOT analysis (strengths, weaknesses, opportunities, threats). This process can include any and all stakeholders. Think broadly and use a brainstorming approach. 5. Evaluate the clinical and field resources and student experiences. Do students have difficulty meeting program minimum requirements for patient assessments and skills? 6. Determine the student pass rates on the state or National Registry (NREMT) certifying exams and the first-time pass rate. 7. Determine the attrition/retention rate and identify, categorize, and analyze the factors.

9. Write and track all of these assessments and documents and document the resulting changes. Create an intuitional memory. Finally, visit or speak with other programs and compare your experiences. We often become insular and find it difficult to think outside of our own â&#x20AC;&#x2DC;boxâ&#x20AC;&#x2122;. Educators are usually willing to share, so actively seek outside perspectives. Outcome-based education must assess and document entry level competence. Assessment requires multiple levels and techniques of evaluating our strengths and weaknesses and a willingness to look in the mirror.

* Disclaimer: Ms. Tritt is a member of the Board for the Committee on Accreditation of Educational Programs for the Emergency Medical Services Professions (CoAEMSP) and a long time accreditation site visitor. However, the views and advice expressed here are her own and should not be interpreted as CoAEMSP policy.

8. Determine the placement rate for graduates. Do graduates have difficulty finding Paramedic positions and if so why? Do employers report that your graduates require more orientation and precepting than graduates from other programs?

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‘WHAT OUR STORIES TEACH US’

‘What Our Stories Teach Us’ by: Scott Jaschik

The end of every semester leaves faculty members considering what worked and what didn’t work in their courses. A new book, What Our Stories Teach Us: A Guide to Critical Reflection for College Faculty (Jossey-Bass), argues for a more critical examination of teaching and learning experiences, with the goal of becoming more effective. The author -- Linda K. Shadiow, professor emeritus of educational foundations at Northern Arizona University -- responded in an e-mail interview to questions about the book’s ideas. Q: What are professors’ “educational biographies” and why are they important? A: What we remember about classrooms we have been in (as students and as teachers) and about the interactions we’ve had in educational settings (from the earliest to the most recent) constitutes our educational biography. Along with the degrees we carry into our work as college professors, there are stories we could tell about what influenced our attaining those degrees. While the impact of our graduate school mentors is often acknowledged as it relates to how we approach our own scholarship, we rarely consider the impact of the legacy of stories from our years in other people’s classrooms. Into the courses we teach just as into the research or creative activity we do, we carry these stories. Some key ones influence how we approach students, see content, and define learning no matter what discipline we work in. A question raised by Aase about her son Peer Gynt in the Ibsen play by that name applies as much to our teaching as it did to young Peer’s growing up: “Who would have thought the stories would cling to him so?” In our professorial work, the related question is, “Which stories from our educational biographies ‘cling’ to us, and with what consequences?” Taking the time to reflect critically on key stories can help us learn about the teaching we do, the assumptions that undergird the approaches we choose, and the goals to which we aspire.

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Q: Everyone has positive and negative experiences, both as a student and as an instructor. How does one discover the really important instances on which to focus? A: All the stories we might remember and tell from our educational biographies are not equally influential in our work. If we tell someone about something that happened in a class -- present or past -- we are not likely to consider it as anything other than an anecdote. There are some features, however, that distinguish the entertaining or illustrative story from critical incidents, and understanding how pivotal incidents continue to echo through our instructional work begins with this distinction. Among the distinguishing features: the most significant stories persist in our memories; when prompted, we can reflect on them as having shifted a perspective we had at the time; their details remain so vivid that the story still evokes an emotional response. Discovering a few prominent stories with these characteristics can lead to some insights about the roots of our teaching, but more significantly, placing a series of such stories side-by-side and looking at what they have in common is richly productive. There is a story that links our critical incidents, and uncovering that story is a powerful key to growth. Q: How does a faculty member turn these reflections into a path to improve one’s teaching? A: At a campus coffee shop a few years ago I had a very candid discussion with a colleague about teaching. In telling each other about recent classroom frustrations, we admitted that even after years of teaching, certain classroom challenges are flashpoints that can lead to our taking actions -- often unproductive, in that they can contradict how we view ourselves as teachers who impact student learning. There are layers of stories, a family tree of sorts, that exist beneath what rewards and what frustrates us in our instructional work just as in our research.

‘WHAT OUR STORIES TEACH US’ Unearthing these stories and paying them a deepened level of deliberate attention can lead to discovering patterns of priorities we have and assumptions we act on in classrooms. Paths to growth emerge from linking the themes in critical incidents to their unarticulated influence on how we enact what we see as the purposes and means of instruction. We can rediscover our teaching by asking what those influences enable and constrain in our work, what they include and exclude in the choices we make. Our coffee conversation acknowledged tensions in our teaching, but there was not time to explore why those tensions exist and how to learn from and grow beyond them.

A graduate student I once worked with wrote that there are “roots” in our stories that lead to “routes” we take in our teaching. This mixed metaphor suggests a goal to using both formal and informal feedback is to describe where those “routes” lead students and then to reflexively learn from that. Q: Higher education is currently debating the arrival of MOOCs in which a single professor teaches hundreds of thousands, but may have no personal interaction with students. Can your approach be applied to mass teaching?

A: I can only respond to your question with more Q: Many professors -- especially those questions, because the work of critical reflection on without tenure -- fear negative student teaching is personal to each of us who undertakes it. evaluations of their teaching. Do you think In that respect, it is as important for instructors no student evaluations (whether formal or of matter what our instructional contexts to become the RateMyProfessors variety) should play aware of what undergirds our teaching. What will a role in the reflections you encourage? be enabled if we can articulate our strongly held definitions of what it means to “teach” and “learn” A: As I seek to learn about which stories in my whether in history, engineering, or anthropology educational autobiography “cling” to me and thus for instance, or whether the setting is face-to-face, influence the assumptions I bring to teaching, I online, personalized learning or MOOC? When a simultaneously ask, “and with what consequenc- new semester begins, what collection of expectaes?” I could not answer this question without tions do we bring with us as we develop curriculum taking student feedback into account. But, this and meet students? How do we envision the role has shifted how I look at formal student course of the student, the instructor, and the content? Are evaluations. They are only one way to learn about our definitions context-dependent, and if so, with how students experience learning in a course I what consequences? So, the work of critical reflecteach. Because formal student evaluation items tion can inform what we do (and where and how often ask more about what students think about we do it). How can we strengthen our work through me rather than about what helped or hindered understanding what limits and what fuels our goals their learning, I draw from a constellation of for impacting student learning, no matter what the feedback approaches rather than focus on a single format or setting? source. My goal is to gain insight into the impact my assumptions have on student learning. I have heard the old adage that we teach the way we were taught. With critical reflection on the stories Two questions provide a frame for this: “What do about a range of our educational experiences and I hope to find in the evaluations and why?” And with some hard work to locate common themes for both the formal and informal feedback stuand assumptions in those stories, the way we were dents provide, “To what do I react most strongly taught can become a prism rather than a blueprint. (positively and negatively) and why?” Pathways We can grow into new stories informed by previous to growth in teaching open up when these links ones but not limited by their persistence. between stories, assumptions, and consequences Reprinted from INSIDE HIGHER ED June 27, 2013 with the permission of Inside Higher Ed, copyright 2013. are made. From this stance, the role of informal Inside Higher Ed is the free daily news Web site for feedback throughout a semester takes on heightpeople who work in higher education. Breaking news, ened importance. lively commentary and thousands of job postings bring more than 800,000 people to the site each month. Read more: http://www.insidehighered.com

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We are pleased to have Alexander Garza, MD, MPH as our opening Keynote speaker and Steve Berry, BA, NREMT-P as our closing Keynote speaker. Make sure you register today to hear what they have to say about the EMS industry!