NAEMSE Educator Update - Winter 2014 by National Association of EMS Educators (NAEMSE)

EDUCATOR

WINTER

UPDATE

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

Also in this issue: HALF of WHAT WE TEACH IS WRONG WE JUST DON’T KNOW WHICH HALF by Christopher Thos. Ryther, MS, NREMT-P

INSIDE

TERMINAL EVALUATION

by Patricia L. Tritt, RN, MA

...AND MORE! This image originally from http://wall.alphacoders.com/wallpaper.php?i=124144

IN THIS ISSUE

WINTER

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

2014

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 John Creech, MEd, LP

WHAT’S INSIDE

Kim McKenna, M.Ed, RN, CEN, EMT-P Michael Miller, BS, MS, EMS, RN, NREMT-P Nerina Stepanovsky, PhD, MSN, RN, PM

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Donna Tidwell, MS, RN, EMT-P

NAEMSE NEWS

John Todaro, REMT-P, RN, TNS, NCEE Rebecca Valentine, B.S., EMT-P, EMT I/C, NCEE

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Bill Young, M.S., NREMT-P

Still in Favor of the Flip by Carl Straumsheim

National Office Staff

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Joann Freel, BS, CMP Executive Director, Editor

Domain

Stephen Perdziola, BS Business Manager Nora Davidson, BA Membership Coordinator

Terminal Evaluation

Brandon Ciampaglia, AS Communications Coordinator

by Patricia L. Tritt, RN, MA

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.

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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 Member Wins Alabama’s ‘EDUCATOR OF THE YEAR’ Mark Branon (MA, NREMT-P), Allied Health Department Chair at Calhoun Community College and NAEMSE member, is the first EMS instructor to ever win the prestigious Chancellor’s Award for Outstanding Technical Faculty at the Alabama Community College System’s annual conference in Birmingham earlier this month. Branon helped expand the college’s Health Sciences dual enrollment program by offering EMS classes in seven local high schools. Under his leadership, Calhoun was a finalist for a 2013 Bellwether Award that annually recognizes innovative programs and practices.

Maine Becomes Latest State to Accept the NAEMSE Instructor Course NAEMSE is proud to announce that the Maine EMS Board accepted the recommendation from the Maine EMS Education Committee to use the NAEMSE IC course as a primary form of IC instruction in the State of Maine. Maine becomes the 41st state to accept the NAEMSE Instructor Course. A huge thank you to the Maine EMS Education Committee for their support of EMS education. The NAEMSE Instructor course is the only national course that is built on the 2002 National Guidelines for Educating EMS Instructors and the National Education Standards. To date, over 6,500 EMS educators have successfully completed the course which is led by 50 faculty members across the United States and Canada. For more information regarding scheduled courses, please visit the NAEMSE website at www.naemse.org.

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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 Winter courses: INSTRUCTOR COURSE I

Lebanon, TN: January 17-20,2014 Held in partnership with Wilson County EMT Fac.

Macon, GA: February 7-9, 2014 Held in partnership with Central Georgia Technical College Sacramento, CA: February 21-23, 2014 Held in partnership with California Fire & Rescue Training Authority Orlando, FL: February 28-March 2, 2014 Held in partnership with Rescue Training, Inc.

Elizabeth City, NJ: March 14-16, 2014 Held in partnership with Union County College INSTRUCTOR COURSE II Houston, TX: Jan. 31-Feb. 1, 2014 Held in partnership with San Jacinto College Orland Park, IL: March 7-8, 2014 Held in partnership with Orland Fire District

For more information, please visit

NAEMSE.ORG

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STILL IN FAVOR OF THE FLIP

Still in Favor of the Flip By: Carl Straumsheim Go ahead and postpone the conversation about the backlash against the flipped classroom model. Supporters and skeptics alike -- and even the researchers behind a seemingly critical new report -- say the discussion continues to be positive. Flipping the classroom -- the practice of giving students access to lectures before they come to class and using class time for more engaging activities -- hasn’t been nearly as divisive as many other ed tech trends, such as massive open online courses or outsourcing digital services. So when USA Today last week reported on an experiment at Harvey Mudd College that had failed to improve student outcomes, it provided a rare contrast. Some students “said they felt the flipped classroom had a heavier workload,” and professors “had to spend considerably more time making and editing ... videos and crafting engaging, hands-on sessions for their classes.” A comparison between the flipped classrooms and their traditional counterparts found “no demonstrable difference” in student outcomes. The researchers, the newspaper wrote, “have bad news for advocates of the trend: it might not make any difference.” The study could have fit into a growing body of research calling the science behind flipping the classroom into question. Days later, however, the researchers behind the study said their results and words had been misinterpreted. Yes, the article did point out that the results were preliminary -- twice in one sentence, even -- but the headline (“ ‘Flipped classrooms’ may not have any impact on learning”) and hook drew too many conclusions about a study that is set to continue for another three years, they said. The researchers -- Karl Haushalter, Nancy Lape, Rachel Levy and Darryl Yong -- last year taught both the flipped and traditional sections of the courses, all of which were in the science, technology, engineering and math (or STEM) fields. They declined to be interviewed for this article, but explained their side of the situation in a social media post after the article was scrutinized by higher education consultant Phil Hill. “There could be an argument that this article is a case of a reporter trying to find a sensational topic from a nuanced report,” Hill wrote. “But the real problems in this article seem to be direct quotes from one of the research professors, despite the qualifier of ‘preliminary.’ “ Yong warned “that we should be cautious about extrapolating our experience here to other contexts.” Harvey Mudd’s roughly 800 undergraduates “already spend a lot of time working together in groups in and out of class,” and the college’s size means there are few of the large lectures that the flipped classroom model aims to supplant. “Our goal is to better understand the conditions under which flipped classrooms lead to better student outcomes,” Yong wrote.

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“[G]iven our study design and Mudd context, we have not yet seen any difference in student outcomes. Of course, this was only the first year of the study and we are admittedly working out all of the kinks in our flipped classes.” Widespread Support More college and universities are growing comfortable with the idea of recording lectures and making them available online. According to data compiled by the Campus Computing Project, more than two-thirds of institutions see lecture capture as an important tool to deliver instructional content. That share has grown steadily in the past few years. The widespread support may be why Jonathan Bergmann and Aaron Sams, two of the earliest advocates of the flipped teaching model, said they have not seen a recent surge in criticism. Bergmann called the study out of Harvey Mudd an outlier. “They’re saying they’re still in the early stages,” Bergmann said. “Most people who have done this have seen positive -- and in some case dramatically positive -- results.” In one such example, Mike Garver, a professor at Central Michigan University, flipped his classroom and “noticed a huge increase in the number of students earning top marks on his (admittedly) toughest test.” Bergmann and Sams co-wrote the book Flip Your Classroom: Reach Every Student in Every Class Every Day, which some credit with starting the flipped classroom trend. Today, they serve on the board of the Flipped Learning Network. Criticism of the flipped classroom model usually stems from arguments between the didactic and progressive camps within higher education, Bergmann said. Members of the didactic camp oppose flipping the classroom to preserve the role of the lecturer, while the progressive camp instead advocates for a move toward project-based learning and inquiry. “That’s where I’m seeing the rub,” he said. There’s also the knee-jerk reaction to something new. Students in flipped classroom can no longer expect to sit through a lecture and complete work on their own time. When coupled with challenging course material and a shaky internet connection, the change has led many to voice their frustration on social media. The same goes for professors, who can no longer expect to give 90-minute presentations. The extra work that goes into recording videos and planning classroom session has led many faculty members to report an exhausting first year of flipping the classroom. “Change is a process,” Bergmann said. “By year three it’s culture.” Even Gary Stager, an education speaker and consultant who has been one of the most vocal opponents of the flipped classroom model, could not point to an intensified debate. “My first inclination is that when anything becomes that popular, you should be suspicious of it,” Stager said. “In my experience, bad ideas are timeless. In education, good ideas are incredibly fragile. I’m not so optimistic there’s going to be a big backlash.”

STILL IN FAVOR OF THE FLIP Other critics, like Ian Bogost, a professor at the Georgia Institute of Technology who placed himself in the “cautiously cautious” camp on flipped classrooms, said the model is only one of many factors in the larger debate about technology-based educational reform. “It’s not the flipped classroom specifically,” Bogost, a game designer and professor in the School of Literature, Media and Communication, said. “It’s kind of the evolving anxiety involved with ... the operation and ownership of institutions.”

Stager agreed, saying institutions will continue to experiment with flipping the classroom as long as there is a promise of reduced costs. “I suspect that people who have been cheerleading it without evidence will continue to do so,” he said. “There will be academics who continue to demonstrate that it’s ineffective. The question nobody asks is ‘Where’s the bibliography?’ ”

Bogost, who has written critically about flipped classrooms, said experiments such at the one at Harvey Mudd could provide valuable data to determine the effectiveness of larger online courses. “There is reason to believe that continued investment in even the local, non-scaled, modest version of flipped classrooms will at the end of the day benefit these MOOC-like solutions because they will provide evidence and fodder and materials in general,” he said.

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

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DOMAIN WINTER 2014

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 (PART 2) pg

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

18 Half of What We Teach

is Wrong — We Just Don’t Know Which Half by Christopher Thos. Ryther, MS, NREMT-P

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

Maddie O’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 2)

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). 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 provided 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. A detailed description of each offering is provided in Table 1.

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). Discussion The aim of this review was to describe the emotional toll of delivering death notifications on the survivors and EMS providers as well as to explore the current state of death notification training.

Death notification training is available to EMS providers and other health professionals in online, lecture, and workshop formats.

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DOMAIN3 Grief is a unique and complex journey and the survivors are at risk of developing symptoms of PTSD and prolonged grief when they experience losses that are sudden; preventable; accidental; or violent (Currier, Holland, & Neimeyer, 2006; Smith et al., 1999; Stewart, 1999;). In these situations, the impact of a death notification on the survivors can be significant and the needs of the family must be considered. These needs include knowing the condition of the family member; being informed regarding the status and care of the family member; and being present at the time of death (Cook, 2006; Currier, Holland, & Neimeyer, 2006; Hampe, 1974; Stewart, 1999). EMS providers are in a unique position to meet the family’s needs in cases of OHCA. During the resuscitation, EMS providers are able to develop a rapport with the family as they gradually communicate information about the patient’s condition throughout the course of the resuscitation (Holzhauser & Finucane, 2008). In addition, witnessing the resuscitation helps to reinforce the family’s faith that everything was done to help the patient (Booth, Woolrich, & Kinsella, 2004; Chalk, 1995; Critchell & Marik, 2007). In this situation, the family may be more prepared for the death (Timmermans, 1999). After the patient is declared dead, the survivors are more concerned with receiving a calm, personal communication than with who delivers the death notification (Edwardsen et al., 2002). As such, providers are able to meet the family’s needs by communicating with and supporting the family throughout the resuscitation.

The results indicate that EMS providers receive training that results in changes in their knowledge; confidence; and attitudes towards this challenging task, however some of this training may not be universally applicable to EMS providers. For example, the MADD curriculum was adapted from training designed for law enforcement officers making next-of-kin notifications to survivors. This scenario is different from the situation commonly encountered by EMS providers, in which over half of family members witness the patient collapse; call 911; and initiate care prior to the arrival of EMS (Barrat & Wallis, 1998; Holzhauser, Finucane & De Vries, 2006; Meyers et al., 2004). In these cases, the family possesses a very intimate perspective on the patient’s death and subsequent emotional support and EMS provider training must be provided with this unique view in mind.

The training programs explored employed a variety of teaching methods. Of considerable importance is the fact that experiential teaching methods were used in only half of the courses (Hobgood et al., 2005; Ponce et al., 2010; Smith-Cumberland, 2006), despite the significant improvement that these methods can have on communication skills and perceived comfort with communicating a death notification as well as with supporting the survivors (Fallowfield et al., 2004; Smith-Cumberland & Feldman, 2006). These findings are similar to that of Smith et al. (1999), who found that experiential methods were used in less than one quarter of death notification courses. The lack of concrete experience in these programs limits the opportunity for reflection on, and improvement of, problem-solving and communication skills related to death notification. As a result, death notification EMS providers can also meet the needs of the training could be improved for EMS providers by infamily by cultivating an awareness of the social and corporating experiential methods such as small group cultural context of the illness and death by comteaching; case studies; and role-play into the curricumunicating with the family throughout the resuslum (Steinert, & Snell, 1999). This would help create citation. Development of cultural competence will death notification training that reduces death anxiety; help providers to better support the survivors when decreases the stress associated with communicating communicating with survivors of cultures different a death notification; and results in long-term behavfrom their own (Hobgood et al., 2005). Training iour change for EMS providers (Durlak & Riesenberg, designed with these goals in mind can help EMS 1991; Smith et al., 1999; Smith-Cumberland, 2006). providers to better meet the family’s needs and to provide culturally competent care following a Of particular importance is the psychological impact death. that death and dying has on EMS providers. The emotional toll of delivering a death notification can be significant and EMS providers are over five times as likely to develop PTSD as the general population (Kessler et. al, 2005). EducatorUpdate Update| |www.naemse.org www.naemse.org 5 910| |Educator

DOMAIN3 In addition, EMS culture stigmatizes feelings of vulnerability; showing your emotions is perceived to bring your ability to do your job effectively into question. Training focused on managing providers’ reactions to death building emotional resiliency is lacking (MADD, 2004). In order to cultivate a workplace culture of acceptance and to preserve the psychological well-being of EMS providers, training should also include an emphasis on selfcare and use of effective coping mechanisms. These training strategies are supported in the literature (Douglas et al., 2012; Ptacek & Eberhardt, 1996; Robinson et al., 2004).

It is important to note that implementation of death notification training also assumes institutional support for this training. One reason may be that death notification is not included as a competency for EMS providers across North America, despite recommendations that training on this topic be included in EMS provider training (Marco, 2001). This may be attributed to the content of provincial and national competency frameworks that govern EMS provider practice. For example, the Canadian Medical Association’s National Occupational Competency Profiles for EMS Providers do not make explicit reference to communicating death notifications. The standards require paramedics to provide support to patients and family exhibiting emotional reactions; to utilize active listening skills; and to use appropriate verbal and nonverbal communication skills. (Paramedic Association of Canada, 2011). The National Standard Curriculum for Emergency Medical Technician-Paramedics (EMT-P) outlines objectives for management of death in the field (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), which are based on Elisabeth Kübler-Ross’ stages of grief (Kübler-Ross, 1969). This model for death notification training may not be effective for EMS providers because they do not always witness the later stages of grief and because grief is an experience unique to each individual (Smith-Cumberland, 2006).

As such, death notification should be included as a competency for all levels of EMS providers. In addition, developing death notification guidelines and incorporating them into EMS provider training programs will ensure that EMS providers are better prepared to engage in these difficult conversations. In order to mitigate the stress on the survivors and the providers, it is important that EMS providers receive formal, culturally relevant, and interactive training in communicating death notifications. This will ensure development of a curriculum that reflects the unique challenges of communicating death notifications in the field. Limitations This review has some limitations. Most studies recruited convenience samples of respondents, which increases the possibility of selection bias (Polit & Hungler, 1999). In some cases, respondents were recruited who had previously completed the death notification training being researched. This additional source of bias limits generalization of the results to all EMS providers. Survey response rates ranged from 26% to 91%. The low response rates may be attributed to the level of EMS providers who responded. For example, almost half of the EMS providers who responded to one survey were classified as Emergency Medical Technician Level II (EMT-II). These providers do not normally communicate death notifications (Norton et al., 1992). The high response rates may be due to respondents who supported the education program, taught the curriculum, were interested in the field of death and dying, or had more emotional difficulty with death notifications (Norton et al., 1992). Regardless, almost all of the studies did not have an acceptable response rate of 80% (Murphy-Black, 2006). Another limitation of the research is that the survey instruments were not well described. Only two studies used previously validated surveys (Edwardsen et al., 2002; Ponce et al., 2010). The sample sizes were also low and only one study reported completing a power calculation (Smith-Cumberland & Feldman, 2006). Almost all of the research subjects were EMS providers working in rural areas of the United States.

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DOMAIN3 Over half of the EMS providers in one study did not communicate a death notification three months after the educational interventions and, subsequently, their attitudes could not be measured for the research (Smith-Cumberland, 2006). There is also the possibility that EMS education curricula do provide substantial death notification training, but it is simply not reported in peer-reviewed literature. A detailed critique of each study is presented in Table 1. Given these limitations, it would be difficult to generalise the results of this review beyond North America. More rigorous qualitative research is required in order to gain a broad perspective on EMS providers’ attitudes to death notification and the format and content of death notification training. Qualitative research approaches are suitable to study death notification because they allow insights into people’s perceptions, behaviour, and motivations (Parahoo, 2006). Future research should focus on expanding samples to include urban EMS providers. Recommendations Given the challenging nature of this experience and task for survivors and EMS providers alike, the development of formal, culturally relevant, and interactive training is essential to help EMS providers improve their skill in delivering death notifications and providing support to the survivors. Recommendations for developing death notification training are provided in Table 2. Table 3 provides general guidelines for communicating a death notification in the field. Conclusions As more patients are declared dead in the field, this burden increasingly shifts to EMS providers, who may be psychologically and academically ill-prepared to assume such a role. EMS providers typically receive some training in how to communicate a death notification, but this training has been adapted from other practice settings and does not always reflect the unique environment in which EMS providers work. Training is insufficient for this task and should include strategies for supporting survivors and for developing resilience in EMS providers.

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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. - 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.

DOMAIN3 - 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 Table 1 Death Notification Education and EMS Providers' Attitudes Toward Death Notification Study Norton et al., 1992 USA

Method Mail survey To determine how frequently EMTs find managing death in the field stressful To identify factors that increase stress

Response Rate Emergency Medical Technicians (EMTs) n=2500 EMT-I (4%) EMT-II (43%) EMT-III (18%) EMT-IV(33%)

Method 26% (n=654)

Study Smith & Walz, 1998 USA

Method Exploratory study To investigate death education instructors in paramedic programs

Response Rate Paramedic program death educators n=537

Method 45.4% (n=244)

Smith et al., 1999 USA

Review of the Emergency Death Education and Crisis Training (EDECT) curriculum

Paramedics, nurses and physicians

Not applicable

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Results 77% find communicating a death notification to be emotionally challenging. Significant correlation between hours worked per month and death notification being less difficult and less emotionally stressful (r=0.64, p<0.0001) 83% of prehospital death notifications communicated by EMTs. 67% had formal training in death and dying Results 78% of death education instructors are paramedics; 66% nurses; 32% physicians. 68% have no formal training in death education A two- day workshop consisting of lecture, discussion, and small-group exercises used to teach attendees about communicating death notifications, death in the emergency setting, and managing familiesâ&#x20AC;&#x2122; reactions

Critique Strengths Content validity of survey instrument discussed. Analysis of survey responses well described Limitations Low response rate. EMTs with more emotional difficulty may have responded to survey

Conclusion Death notification in the field is emotionally difficult for EMTs and is not lessened by training. EMTs with lower levels of training and less experience have more difficulty with patient death

Critique Strengths Relationship between type of program (collegebased vs. private) and instructors discussed Limitations Survey instrument did not clarify type of death education training Strengths Course delivery is flexible. Needs of professionals and the bereaved are discussed Limitations Curriculum not evaluated

Conclusion Death education instructors are not formally trained or multidisciplinary staff. Death education raining may improve the experiences of the bereaved EDECT course is flexible and may be used for CE sessions or EMS provider training

DOMAIN3 Study Stewart et al., 2001 USA

Method Mail Survey To determine respondents’ experiences, education needs and satisfaction with MADD death notification program

Response Rate Law enforcement officers, EMTs, victim advocates, coroners, clergy, and other health professionals n=636

Method 39% (n=245)

Edwardsen et al., 2002 USA

Prospective cohort study Telephone survey and interview To determine family members’ acceptance of nontransport of OHCA patients

Family members n=33 Not transported n=21 Transported n=12

Not reported

Study Robinson et al., 2004 USA

Method Semi-structured interviews, focus groups, and telephone surveys To assess the uses of the Education for Physicians in End-of-life Care (EPEC) project

Response Rate Medical leaders in EOL Physicians who attended EPEC Physicians in EOL field who did not attend EPEC Physicians not involved with EOL care n=555

Method 40% (n=200)

Ferrel et al., 2005 US, Virgin Islands. Peurto Rico

Mail survey To discuss the development and implementation of the End-of-life care Nursing Education Consortium (ELNEC)

Nursing faculty member ELNEC course attendees n=547

91.7% (n=502)

Results 41% of respondents had no death notification training 55% and 49% report no classroom and experiential training, respectively. Needs included: how to perform a death notification, the steps of a death notification, how to respond to survivors, and how to manage own reactions 100% of families of nontransported patients satisfied with medical care and emotional support provided by EMS, law enforcement personnel and medical examiner. Nontransport group reported more positive adjustment to grief Results 62% report that EPEC training improved their knowledge of EOL care and most report 8/10 ability to provide EOL care. 72% reported “greatly improved” ability to teach EOL care. 48% plan to increase EOL care training. Professionals from other fields interested in EPEC Attendees rated their graduates’ effectiveness in providing EOL care higher than in pretest. Significant difference in hours spent on EOL curriculum in posttest. Significant improvement in overall test scores (p<0.006)

Critique Strengths Many types of death notifiers surveyed Limitations Validity and reliability of research instrument not addressed. Low response rate. No randomization

Conclusion Respondents received minimal education in death notification

Strengths Validated grief assessment survey used Limitations No comment on statistical significance of results. Few grief support personnel available to implement protocol. Recall bias Critique Strengths Independent research firm used Limitations Response bias. Participants familiar with EPEC interviewed. Effect size not reported

Families accept death at home when OHCA occurs and are not negatively impacted. Families satisfied with care and support from EMS providers

Strengths Posttest survey at 12 months Limitations Respondents evaluated their own EOL curricula. No control group

Nurses are open to EOL care education and the ELNEC curriculum is widely used

Conclusion EPEC curriculum provides a standard for EOL care for physicians

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DOMAIN3 Study Hobgood et al., 2005 USA

Method Pre-post retention repeated measures design To determine if a two-hour education session can improve residents’ competence, confidence, and communication skills when delivering death notifications Smith-Cumberland, Quasi2006 experimental USA pretest-posttest comparison design To evaluate the effectiveness of two death education programs by comparing pretest and posttest behavioural intentions and reported behaviours of EMTs during a death in the field Study Method Smith-Cumberland Quasi& Feldman, 2006 experimental, USA randomized, control group pretest-posttest study To determine if EMTs’ attitudes to death will change after death education

Barnett et al., 2007 UK

Mail Survey To determine Consultants’ experiences with education in communicating bad news

Response Rate Emergency Medicine Residents in postgraduate years 1, 2, and 3 n=23

Method n=20 Data from 3 participants not analyzed due to technical difficulties

Results Significant improvements in residents’ confidence and competence prepost, respectively (F=16.7, p<0.0001), (F=4.7, p=0.04). No significant change in communication scores

EMTs from multiple rural EMS agencies n=83

Not reported

EMTs in 16-hour group intended to change their behaviour more often than EMTs in two-hour group No significant difference between treatment groups Attitudes are the most important motivator for behavioural intentions (BI)

Response Rate Rural EMTs n=83 Two-hour CE n=30 16-hour Experimental group (EDECT) training) n=24 Control group n=29

Method Not reported

Consultants in clinical specialties n=274

63% (n=173)

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Results After training both groups reported that their actions affect the families’ recovery. 92% of experimental group and 43% of control group felt prepared to communicate a death notification; 100% and 70% felt that their training to help families was adequate in posttest. No significant difference in attitudes based on certification level. Effect size 0.87 Most consultants communicate bad news >1-2 times weekly; 49% have no formal training 72 recommended training at all levels; 47 recommended role play in training

Critique Strengths Education format validated. Attitudes tested 3 months after education Limitations Small sample size limits generalization of results. Survivors’ emotions not investigated. No control group Strengths Assessed BI 3 months after intervention Limitations 60% of EMTs did not communicate a death notification after three months. Sample form rural agencies cannot be generalized to all EMTs. No control group

Conclusion Death education using mini-lectures, small-group discussions, and role play can improve residents’ communication skills

EMTs more likely to: allow families to view deceased, use successive preannouncements, use the 4-step death notification process, use deathrelated words, and leave follow-up information after both interventions. BI resulted from a change in attitudes vs. motivation to conform to norms

Critique Strengths Sample size provided power of 0.80 and effect size of 0.87 Limitations No questions regarding previous death education. Sample not diverse. Participants not randomly assigned to groups. Principal investigators took part in evaluation

Conclusion Most EMTs are not comfortable communicating death notifications and have inadequate training. Death education can change EMTs attitudes to death in the field. Death education is needed in training programs and CE

Strengths Representation of 97% of specialties Limitations Attitudes not measured

Consultants communicate bad news frequently. They are willing to participate in experiential education

DOMAIN3 Study Halpern et al., 2009 Canada

Method Semi-structured interviews and focus groups To characterize critical incidents for ambulance workers and elicit suggestions for interventions

Response Rate Ambulance workers n=56 Supervisors n=4

Method Not reported

Ponce et al., 2010 USA

Pilot Study To study the feasibility of an educational intervention to improve prehospital providersâ&#x20AC;&#x2122; confidence with breaking bad news and familywitnessed resuscitation(FWR)

Prehospital providers (paramedics, nurses, first responders, and EMS administrators) n=45 Standardized encounter n=20

Not reported

Results Considerable experience with critical incidents and symptoms that disrupted work and personal lives. Avoidance and distraction used to cope with feelings. Interventions included: education, improving workplace stressors, and recognition of emotions

100% participated in a cardiac arrest resuscitation; 62.2% communicated a death notification; 55% want to improve their death notification skills; 61.2 % answered 5/6 knowledge questions correctly after lecture

Critique Strengths Representative sample of gender and level of ambulance workers Limitations Self-selection of participants. Small sample size

Conclusion Critical incidents are stressful for ambulance workers. Education may reduce perceived barriers to accessing support

Strengths Validated scales used to assess attitudes and knowledge Limitations Small sample size. Selection bias in report of attitudes

Training can improve prehospital providersâ&#x20AC;&#x2122; comfort with death notification

2014 Call for Abstracts Now Accepting Research Abstracts for Presentation. Submit your abstract or learn more via online at: www.pcrf.mednet.ucla.edu Category: Deadline: Presented at:

Educational st March 31 , 2014 NAEMSE Conference 2014

Category:

Clinical, system, management, or personnel st October 31 , 2014 EMS Today Conference 2015

Deadline: Presented at:

For additional questions contact the Prehospital Care Research Forum at: Telephone: (310) 312-9315

Email: pcrf@mednet.ucIa.edu

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DOMAIN3 Table 2 Recommendations for developing death notification training Training Recommendations 1. Identify death notification as a competency in the National Occupational Competency Profiles for paramedic practitioners 2. Develop formal, culturally relevant, and interactive training to improve providersâ&#x20AC;&#x2122; skills and reduce the stress of communicating death notifications 3. Training must include strategies to support survivors and to develop resilience in EMS providers 4. Promote death notification education in EMS provider training programs, EMS systems, and governing organizations

Table 3 Guidelines for communicating a death notification in the field Death Notification Guidelines 1. Cultivate a relationship with the family by keeping them informed of the patientâ&#x20AC;&#x2122;s condition and involving them in patient support as much as possible 2. Communicate with the family about their needs and goals during the resuscitation 3. Communicate the death notification with a partner in a clear, compassionate manner 4. Acknowledge the survivorsâ&#x20AC;&#x2122; emotions and the uniqueness of their experiences 5. Support the survivors by allowing them to view the body and conduct any cultural or religious customs 6. Provide assistance with post-mortem arrangements and answer questions 7. Acknowledge the emotional toll of patient death on EMS providers and promote positive self-care strategies

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DOMAIN3 Half of What We Teach is Wrong — We Just Don’t Know Which Half

By: Christopher Thos. Ryther, MS, NREMT-P

“Half of what you will learn here is wrong, we

just don’t know which half”, is sometimes said by Emergency Medical Services (EMS) educators, along with educators in other healthcare disciplines, to highlight the ever-changing nature of scopes of practice, protocols, and standards of care. The best practices of adult education are still evolving 1,2,3 and we should take an evidence-based approach to EMS education and training, just as we do toward clinical practice. This article examines some of the emerging approaches specific to EMS instruction and to adult education in general as well as some of the ways that EMS educators can apply these concepts.In lectures, topics are most commonly introduced in linear fashion and overworked educators commonly find it tempting to prepare their lecture presentations in the order in which the content is organized in the assigned textbook or other source materials. There is little evidence that the traditional format of EMS education and training is the most effective. In fact, many of the best teaching methods and assessment tools were developed through modeling the past practices of other professions, traditional pedagogy, e.g., High School classes, and unsystematic trial and error. Approaching this reflectively, we might ask: Is it possible to discern ways to develop lessons that are superior to the traditional methods? For instance, would it be better to defer certain topics that have traditionally been taught early in a course until the end of a course, when the student has a better understanding of the roles and responsibilities of an EMS provider? Could some medical and trauma topics be approached in a parallel fashion? Are there some knowledge sets, skills or abilities so pervasive in the curricula that they are most appropriately, or ideally, addressed on their own? Here are a few examples:

• Medical terminology is sometimes a daunting subject for students and one that is scattered throughout the course. Common prefixes and suffixes as well as much of the common EMS jargon is best dealt with at the beginning of a course. In an entry level course the terms “hypoxia”, “anoxia” and “hypoxemia” should be parsed and the trainee should be told that they are often used interchangeably. For more advanced students a discussion of “sympathetic” versus “adrenergic” might inspires some useful review of the autonomic nervous system and its functions. To explain a reoccurring structure in the body one would introduce the term “anastomosis” or to minimize confusion with a discussion of how to define “unconscious” versus “unresponsive”. • Airway management and ventilation skills are often taught at the beginning of both basic and advanced courses since it is a part of any patient care scenario performed in the lab setting. Also, after laying the groundwork, issues of respiration, ventilation and oxygenation can be dealt with much more easily as they appear throughout the curriculum. Increasingly, different mechanisms of shock are covered early on its own and not part of a medical or trauma lecture. Since the issue of hypoperfusion appears so often, it is then not necessary to divert from the topic at hand to discuss its causes and implications. Many of the medical, legal and ethical considerations - as well as the communication and documentation skills - lack context when they are taught as a “preparatory” topics to the entry level student. For the advanced student, it fills up several weeks and crowds more dense topics, such as cardiology and trauma care to the end of the didactic course. Many of these topics can be taught, or reviewed only as necessary, in parallel over time or deferred to a point when the student will be able to confront the dilemmas and practice the techniques in a more organic fashion. When it comes to evidence-based teaching methodology, let us first consider the technique called “chunking”. It aims to create the right sized chunks of information that can be best managed by short term or “working memory”1. There are several types of chunks, but for our purposes, they typically represent concepts or procedures organized in a way that aids recall.

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DOMAIN3 Furthermore, the items in the chunk and the collection of chunks should total no more than seven, plus or minus two1, slightly more than what we would consider an appropriate administrative, or supervisory, “span of control.” Some examples: ● ECG Interpretation can be taught with each rhythm defined by specific qualities and then grouped into small clusters, or classes, i.e., atrial rhythms, ventricular rhythms, etc. Since dysrhythmia recognition requires accessing a lot of rules and definitions, learning starts by memorizing the ECG analysis tool to determine rate and rhythm then to measure the waveform and establish its morphology. This exercise uses the limit of working memory but once the data is acquired that memory space is free to consider which pattern it most closely resembles. Again, the knowledge is best accessed in small chunks by next considering whether the rhythm is atrial, junctional, or ventricular. Only then does the student settle on a diagnosis among the limited options available. At each step the number of items being considered in working memory remains somewhere between three to seven. ● Anatomy and physiology of hypoperfusion can be taught as a derangement of either the pump, the volume or the container. It would include a comprehensive overview and would examine one category at a time with all the overlapping terminology explained and the mechanisms examined. Hemorrhagic shock would be compared to hypovolemic shock; neurogenic shock would be contrasted with the other vasodilatory and distributive forms. Some special considerations would be discussed such as assessing spinal shock in the partially paralyzed victim or the difficulty in recognizing septic shock. ● Psychomotor skills all can be “chunked” at any level of instruction, especially in those students with some level of testing anxiety. In the left column on the right are all of the steps of the NREMT Patient Assessment/Management – Medical skill sheet distilled into a chunk that most people can memorize. The flow of the skill is reinforced by lecture material including the phases of a call and medical pathophysiology.

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If the student advances through the skill in the proper order, then at the next step he or she would access the chunk associated with that particular step. In the outline below, the chunk associated with the Primary Survey includes three smaller chunks on Approaching the Patient, Airway and Breathing, and Circulation. Guided practice is still critical but competence and confidence may come more easily since at no point is the student’s working memory overwhelmed. Also included in the chunk is a checklist that helps prevent the omission of a critical item. Advanced providers should be more adept at skill acquisition but this technique could still be useful in high acuity, low frequency skills such as cricothyroidotomy and pediatric intubation. Pt. Ax/Management - Medical BSI considered throughout the call Scene Size-Up x 5 Primary Survey x 3 Transport Decision HPI x 8 A.M.P.L.E. Secondary Survey x 5 Vital Signs x 4 Ix2 Rx2

Approach Pt. x 3 General Impression AVPU Chief Complaint A and B x 3 Assess Airway Assure Ventilation Oxygen Cx3 Major Bleeding Radial or Carotid Pulse Skin C.T.C

Another technique that builds on the previous one is Mind-Mapping or Concept-Mapping, which develops the ability to organize chunks so that the student sees the relationship between them and can more easily access each one in long-term memory. The mapping of chunked material has been well described by EMS authors as a teaching tool1,2, and as a necessary precursor to the critical thinking exercise of differential diagnosis3. In other words, in order to map or organize the material we commit to long term memory it must be packaged in manageable chunks that you can access and use in your working memory - even during an emergency. Examples could include: • A mind-map diagram, created by students and guided by the instructor, of the mechanism of increased intracranial pressure and how it is expressed in signs and symptoms. This might be done as group work or as a wiki that is revisited over the hours or days that the topic is covered. On the next page is a draft version created by paramedic students as a part of a high-fidelity patient simulation assignment. Most of the learning takes place while creating the diagram using knowledge the students already possess. It might also be helpful as a study aid.

DOMAIN3

Both of the above methods are examples of “scaffolds” that break learning into smaller steps that are built on foundational concepts and support the higher orders of learning. Scaffold techniques interconnect and relate large amounts of conceptually complex and challenging material. The use of these “temporary supports” will assist the student in obtaining mastery of the skills and concepts presented in the course1. An example of a temporary support might be the use of a digital calculator and formula chart, or a commonly used mnemonic device, which might be effective to demonstrate to the student that the task is both doable and “not scary.” It is important, however, that after the applied skill is learned, the temporary supports must be removed and the skill must be practiced competently (smoothly and free of aides). Also, the device must also be appropriate for the learner and its use monitored to minimize or eliminate misunderstandings or mistaken application. Some examples include: • Providing the student a standardized format for radio reports and transfer of care, then slowing increase the expectation that it is done with minimal note-taking during patient care and often without using the job aid you initially allowed.

• An assessment-based mnemonic for basic

level students (such as OPQRST or OPASTE) is not a complete cardiac or respiratory history but it can be very helpful in getting the entry level students off on the right track. The same tool for altered mental status, AEIOU TIPS, is diagnosis-based and requires the user to know the signs and symptoms for all of the conditions listed in it. Therefore, it may only be appropriate for experienced EMTs or advanced providers more familiar with what causes a decreased level of orientation or responsiveness. • Another method of support employs the use of modeling concepts and procedures, verbalizing decision making aloud, and practicing in groups. It is important, however, that as the student develops greater alacrity as he or she approaches competency that the support is either removed or diminished in steps so that the student becomes bored with the skill practice or knowledge review and is challenged to continuing building toward mastery. When using these techniques, educators should be mindful of how deeply they are involved in the learning process. Instructional methods should be tailored to the knowledge base and experience level of the students. An overly coached approach is boring and offensive for an advanced student and a minimal guidance approach is inappropriate, frustrating and ineffective for novices.

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DOMAIN3 It is clear that students who are not yet familiar and/or comfortable with the equipment and material require fully guided instruction in order to succeed1. Once the student practices in an internship or work environment then his or her knowledge and skills can be refined and modified to fit the environment in which they practice. Until then, the principles and practices of prehospital care should be actively explained, reinforced, practiced and reviewed. For example:

Many EMS educators have used case studies, patient simulation and concept mapping effectively, but how and when these techniques are used should be based on the preparation of your students and their comfort with a particular topic (e.g. an anatomy and physiology prerequisite or previous EMS experience). When addressing new material, the instructor should be guiding the student every step of the way while laying the groundwork for the student to master the material and practice independently.

• To the EMS novice, a high acuity, high pressure skill such as trauma assessment and management seems complex and fraught with opportunities for failure. The experienced provider may consider it “an easy call to run but an easy call to mess up”. The former needs to learn how to play their musical instrument and succeeds through regular, predictable exercises in order to acquire the chops necessary to play from the NREMT songbook. It is best for the latter learner, however, to discover his or her own flaws, develop their own leadership style, incorporate the suggestions of others and to move on something more akin to jazz improvisation.

The evidence points in the opposite direction for experts in their field or at least those students that have demonstrated mastery in a particular topic1. Coined the “expertise reversal effect”2 it indicates that what works with novice students can be detrimental to those who already have reasonably well constructed understanding of a particular learning objective. Sometimes these are chunks - such as the pathophysiology of congestive heart failure - and sometimes it is a psychomotor skill, such as applying a traction splint. At this point, demonstrations, modelling, and lecture or guided instruction are probably counterproductive as one is attempting to add to long term memory something that is already there13. Rather, we should be challenging the student to fill in the gaps in their memories and understanding by arranging for learning to occur through experience, discovery or self-assessment.

• The repetition of preparatory materials, such as the history of EMS and gross anatomy, account for some of the bulk of EMS textbooks. The entry level student requires explanation, context, practice and review in order to organize this material and move it to long term memory. For a more advance provider, lecturing on such topics competes with the already committed long term memories on the subject. Rather than confuse them or duplicate knowledge, other instructional methods should be used assess their level of understanding and allow them to fill in the gaps as needed. Conscientious educators also want students to develop good critical thinking and diagnostic skills; however, it is important to be careful when using problem-based learning (PBL). To teach with this excellent andragogy (the adult version of pedagogy), the educator must make certain that the proper scaffolding is in place1 and that all the relevant concepts have been covered or reviewed. It should also be noted that PBL is still a controversial practice in medical education1.

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This being the case, then the importance of educational assessment cannot be understated. It becomes imperative to find out who needs review and coaching and who does not. There is also evidence to indicate that the most effective teachers ensure “that students [have] efficiently acquired, rehearsed, and connected knowledge” and, if appropriate, “went on to hands-on activities, but always after, not before, the basic material was learned”1 [original emphasis]. This can be done by questioning students, through quizzes and essays but, above all, through a mechanism that leads the student back to the specific material, learning objective or measurable outcome that needs review. Learning how to re-answer a specific test question or giving the student an overall score leaves the student to re-construct the topic in their long term memory rather than to merely tinker with it.

DOMAIN3 Many EMS instructors routinely review recent material and emphasize key terminology and core concepts. What may be needed in addition is a mechanism to do a validation check for student understanding immediately after the instruction. The goal here is to ease the transition from working memory to long-term memory.15 The educational literature suggests that when students are guided through content in the classroom, they should practice the material with an 80% success rate in order to minimize the gaps and errors in their long term memory15. Ideally, some kind of manual or automated response system should be used to gauge the understanding of the group as well as some kind of individual self-assessment before moving on to an activity or new lecture topic. In order to measure what is retained in long term memory the periodic assessment of students should be simply that - an assessment only. Eventually, a final grade must be assigned, but it should be based on summative performance, not on the stumbles along the way or early attempts at a skill. Likewise, it seems necessary for students, or the educational institution, to purchase access to validated exams based on national standards. Too many of assessments and tests used in EMS education are based on the convenience sample of questions in the unsecure database provided by a publisher or on the instructor’s unconscious bias or are driven by the regional standard of care. Lastly, the fact that students have differing levels of academic preparation and EMS experience brings us to the notion of competency based education (CBE). Although a full discussion of CBE is not in the scope of this article it is worth mentioning because of its potential impact. Essentially, the student starts work on the next set of learning objectives or outcomes after they demonstrate competency in the prerequisite material1. They may finish earlier than their colleagues and have to wait to continue or they may progress at their own pace, depending on how the program is organized. In an online or distributed learning environment this may be easy to accomplish but will be difficult to adapt traditional EMS lecture and lab to a CBE format. Also, it presupposes that the student will maintain their enthusiasm for the course and complete the course elements in a timely fashion.

The EMS profession has reached a point where its system of education must serve both national standards and parochial interests. Moreover, the increasing amount of material in entry level courses creates an increasing burden on both the student and the instructor. It also leaves less time for skill mastery and reinforcing the affective domain. EMS education needs to become more efficient as well as effective in order to serve the student better and to increase success on certifying and licensing exams. Embracing evidence-based teaching methods will bring our profession closer to these goals, promote competency based on national standards and allow for local adaption. Many of these concepts and approaches show promise but a more extensive project may need to be undertaken to rate the effectiveness of these techniques and validate their use in EMS education and training. Knowles, Malcolm S, Elwood F Holton III, and Richard A Swanson. The adult learner. Routledge, 2012. Merriam, Sharan B, and Ralph G Brockett. The profession and practice of adult education: An introduction. John Wiley & Sons, 2011. Rachal, John R. “Andragogy’s detectives: A critique of the present and a proposal for the future.” Adult Education Quarterly 52.3 (2002): 210227. Jarvis, Peter. An international dictionary of adult and continuing education. Routledge, 2013. Morgan, Ronald R, Judith A Ponticell, and Edward E Gordon. Enhancing learning in training and adult education. Greenwood Publishing Group, 1998. “Student-Centered Solutions for EMS Education, Part 2.” 2013. 1 Dec. 2013 <http://www.emsworld.com/article/10984050/using-technology-in-ems-education> Beebe, MS, RN, NRP, Rich. “Chalk Talk with Rich Beebe.” emsworldexpo.com. EMS World Magazine, n.d. Web. 30 Nov. 2013. <http:// emsworldexpo.com/z-pdf/2013/handouts/Chalk_Talk_Beebe.pdf>. Sowerbrower, Chuck. “Paramedic Differential Diagnosis Flowchart.” Educator Update Summer (2009): n. pag. NAEMSE. Web. 30 Nov. 2013. Rosenshine, B., & Meister, C. (1992). The Use of Scaffolds for Teaching Higher-Level Cognitive Strategies. Educational Leadership, 49(7), 26-33. Kirschner, P. A., Sweller, J., & Clark, R. E. (2006). Why minimal guidance during instruction does not work: An analysis of the failure of constructivist, discovery, problem-based, experiential, and inquiry-based teaching. Educational psychologist, 41(2), 75-86. Hmelo-Silver, C. E., Duncan, R. G., & Chinn, C. A. (2007). Scaffolding and achievement in problem-based and inquiry learning: A response to Kirschner, Sweller, and Clark (2006). Educational Psychologist, 42(2), 99-107. Neville A, J, Problem-Based Learning and Medical Education Forty Years On. Med Princ Pract 2009;18:1-9. Clark, R. (2012). Putting Students on the Path to Learning - American Federation of Teachers. Retrieved from http://www.aft.org/pdfs/americaneducator/spring2012/Clark.pdf. Kalyuga, S., Chandler, P., Tuovinen, J., & Sweller, J. (2001). When problem solving is superior to studying worked examples. Journal of educational psychology, 93(3), 579. Rosenshine, B. (2012). Principles of Instruction: Research-Based Strategies That All ... Retrieved from https://www.aft.org/pdfs/americaneducator/spring2012/Rosenshine.pdf. Competency-Based Learning or Personalized Learning. (n.d.). U.S. Department of Education. Retrieved December 5, 2013, from http://www. ed.gov/oii-news/competency-based-learning-or-personalized-learning ###

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TERMINAL EVALUATION

Terminal Evaluation by: Patricia L. Tritt, RN, MA HealthONE EMS

Paramedic education is (or should be) competency based. This implies frequent evaluation of each student to determine competency, both at the formative and summative stages. Formative assessment occurs throughout the program of study: in the classroom using cognitive instruments; in the laboratory documenting skill mastery; in the clinical arena under the supervision of preceptors; and in the field internship as the student progresses from team member to team leader. Programs are also required to assess competency in the terminal phase of the program. An increasingly common scenario encountered by CoAEMSP site visitors is the program that administers a ‘final’ cognitive exam at the end of the classroom portion of the program and then sends students to the clinical setting and/or the field internship and never administers a final competency assessment at program completion. The usual rationale is to give the ‘final’ exam before the students forget the material! However, the clinical and field internship should solidify cognitive learning and increase the student’s critical thinking skills. The Standards Interpretation document for Standard IV.A.1. states:

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“Achievement of the competencies required for graduation must be assessed by program criterion-referenced, summative, comprehensive final evaluations. Summative program evaluation is a capstone event that occurs after all components of the program are complete. Summative comprehensive evaluation must include cognitive, psychomotor, and affective domains.” So how is this put into practice? The summative program evaluation is an exit exam and should, at a minimum, include cognitive assessment and evaluation of skill or scenario based psychomotor and critical thinking performance. Comprehensive, of course, infers a sampling of all course content and not just the most recent semester. Other additional options that some programs incorporate include a final oral examination with the Program’s Medical Director and/or faculty or a final graded clinical shift with the Medical Director. However, the summative program evaluation does not preclude a program from administering a comprehensive evaluation/examination prior to entry into field internship to assess if the student is academically prepared for this next phase. As a terminal evaluation event: • All components of the summative evaluation are administered following delivery of all didactic course content, all laboratory and simulation events, and the clinical and field rotations. • All of the above must be successfully completed prior to exit testing/evaluation. • Occasionally a student may still have a limited number of clinical or field rotations to complete due to scheduling issues or availability. However, the number of shifts/hours should be limited. • The option to allow retests and/or remediation is a program decision.

TERMINAL EVALUATION • The final evaluations are high-stakes exams and the student must achieve a ‘passing’ score in each exam (i.e., cognitive and psychomotor) to successfully exit the program and be eligible to sit for the National Registry or State certification examination The passing or cut score is established by the program. • The traditional exit psychomotor examination has consisted of a series of skill stations, and perhaps one or two static scenarios. However, programs may instead choose to use well constructed scenario or simulation events to determine competency. The number of skills, stations, or scenarios is determined by the program and should be designed to determine competency at the entry Paramedic level.

Cohort results on terminal evaluations should be routinely compared to credentialing exams and the results analyzed, trends noted, and curriculum and formative exams should be revised as necessary. Student success is crucial and the goal of evaluation should always be to measure competency: not just to ‘pass the credentialing test!’

* 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.

Of course, cognitive instruments must be constantly evaluated for reliability and validity. If test banks are used, either commercial or program developed, item analysis is still required.

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