california state university, northridge

CALIFORNIA STATE UNIVERSITY, NORTHRIDGE

TRAINING PARAMEDICS TO DELIVER EFFECTIVE AND COMPASSIONATE

DEATH NOTIFICATIONS

A graduate project submitted in partial fulfillment of the requirements

For the degree of Master of Arts in Education,

Educational Psychology

Mark Malonzo

August 2013

Copyright page

Copyright by Mark Malonzo 2013

Signature page

The graduate project of Mark Malonzo is approved:

Adele Gottfried, Ph.D. Date

Jonah Schlackman, Ph.D. Date

Dr. Carolyn Jeffries, Chair Date

California State University, Northridge

Acknowledgements

I have never intended to develop an educational product as a culminating project

until my experiences in Dr. Carolyn Jeffries’ Instructional Design class. As my chair, she

has helped me turn an idea without direction into a simulation guide with purpose. Thank

you for guiding me through my graduate studies. Most importantly, thank you for being a

genuine advocate of EMS, EMS education, and those affected by what we do.

I would also like to acknowledge my other committee members, Dr. Adele

Gottfried and Dr. Jonah Schlackman. Dr. Gottfried, thank you for encouraging me to

pursue my interests rather than taking the path of least resistance. It was also great

working with you as your Research Assistant. That opportunity has made me a more

critical consumer of literature. Dr. Schlackman, your dedication and passion for

education and your students will always inspire me. Thank you both for your guidance in

the development of this project.

Lastly, I would like to acknowledge my colleagues and mentors at the UCLA

Center for Prehospital Care. Thank you for being supportive throughout my graduate

studies and professional career as an EMT, paramedic, and EMS educator.

Dedication

I dedicate this to my son, Justin, and my wife, Rachele.

Thank you for believing in me.

I love you.

Table of Contents

Copyright page .................................................................................................................... ii

Signature page .................................................................................................................... iii

Acknowledgements ............................................................................................................ iv

Dedication ........................................................................................................................... v

Abstract ............................................................................................................................ viii

Chapter One – Introduction ................................................................................................ 1

Need/Problem ................................................................................................................. 2

Purpose of Graduate Project ........................................................................................... 8

Terminology .................................................................................................................... 8

Chapter Two – Literature Review .................................................................................... 10

Introduction ................................................................................................................... 10

EMS Death Education and Notification Programs ....................................................... 10

Bad News Delivery Strategies ...................................................................................... 18

GRIEV_ING. ............................................................................................................ 19

SEGUE. ..................................................................................................................... 21

SPIKES. .................................................................................................................... 22

Simulation ..................................................................................................................... 24

Synthesis ....................................................................................................................... 26

Chapter Three – The Project ............................................................................................. 28

Introduction ................................................................................................................... 28

Development of the Product ......................................................................................... 28

Adult learning theory. ............................................................................................... 28

Dick and Carey Instructional Design Model. ........................................................... 30

Product Description ...................................................................................................... 35

Physical description. ................................................................................................. 35

Organization. ............................................................................................................. 35

Environment and Equipment. ................................................................................... 36

Intended Audience and Personal Qualifications ....................................................... 36

General Guide Contents. ........................................................................................... 38

Chapter Four - Conclusion ................................................................................................ 40

Summary ....................................................................................................................... 40

Evaluation ..................................................................................................................... 40

Formative Evaluation. ............................................................................................... 40

Summative Evaluation .............................................................................................. 43

Future Work .................................................................................................................. 43

References ......................................................................................................................... 45

Appendices ........................................................................................................................ 48

Appendix A ................................................................................................................... 49

Appendix B ................................................................................................................... 50

Appendix C ................................................................................................................... 51

ABSTRACT

Abstract

TRAINING PARAMEDICS TO DELIVER EFFECTIVE AND COMPASSIONATE

DEATH NOTIFICATIONS

Mark Malonzo

Master of Arts in Education,

Educational Psychology

Several studies have shown that Emergency Medical Services (EMS) providers feel

inadequate in their abilities to communicate distressing news to patients’ families and

other survivors. Although mastery of this skill requires practice, a lack of foundational

training also has an influence on this deficit. Paramedics are exposed to a high incidence

of death outside of the hospital; therefore, they must have effective communication skills

to deliver difficult news. This graduate project justifies a need for training through

supportive literature, includes a description of the development and evaluation process,

and concludes with sample pages of the final product: Death Notification Training for

Paramedics: A Simulation Guide for EMS Educators. The purpose of this project is to

provide EMS educators with an effective evidence-based resource to facilitate a

simulation training session on delivering a death notification and providing support to

grieving families.

Chapter One – Introduction

Emergency Medical Services (EMS) is a relatively new health care profession

that has been in existence for only 40 years. The National Highway Traffic Safety

Administration (NHTSA) stated that “EMS is still in its early developmental stages

(2009).” The roles and responsibilities of EMS providers change progressively as EMS

continues to develop. In the early 1970s, Emergency Medical Technicians (EMTs) had

minimal health care training and were often referred to as “just ambulance drivers.”

Present day paramedics are advanced-level EMTs who are extensively trained to manage

out-of-hospital medical emergencies, make critical patient care decisions, and provide

advanced life-saving interventions.

The nature of the EMS profession commonly challenges EMS providers (both

EMTs and paramedics) to deal with patients’ deaths and their grieving families. In 2013,

the Center for Disease Control and Prevention (CDC) reported that fewer people are

dying in hospitals, and more people are choosing to die at home (CDC, 2013). The

number of in-hospital deaths dropped 8% from 776,000 in 2000 to 715,000 in 2010. This

is not proportionate to the 11% increase in total hospitalizations in the same decade. On

the other hand, the CDC also reported that the incidence of deaths at home grew from

23% to 27%. They speculate that this is partially due to the increased availability of

hospice care and the rising health care expense particularly at the last few months of life.

The increase of out-of-hospital deaths will, in turn, result in more EMTs delivering

difficult news to families (Smith & Walz, 1995). However, most EMTs feel

uncomfortable and unprepared delivering a death notification (Smith-Cumberland &

Feldman, 2006).

The most recent editions of the American Heart Association (AHA) Guidelines for

Cardiopulmonary Resuscitation and Emergency Cardiovascular Care (2005, 2010)

provide recommendations and principles for terminating or withholding resuscitation.

These best practice guidelines affect the roles and responsibilities of EMS providers. At

the turn of the last century, most cardiac arrests were transported to the emergency

department and death notifications were performed by the physicians at the hospital.

Current guidelines recommend withholding or terminating futile efforts and determining

death at the scene. This leaves the EMS provider with the added responsibility of

providing support and consolation to the family. Several studies show that these roles are

uncomfortable and stressful, particularly for inexperienced healthcare professionals

(Norton et al., 1992; Parker-Raley et al., 2007; Rosenbaum et al., 2004). Norton et al.

(1992) reported that 83% of all deaths that occur outside of the hospital are

communicated by EMTs to family members. Although this research is slightly dated, it

shows that the majority of death notifications were being performed by EMS by the end

of the 20th

century.

Need/Problem

Despite extensive training to save lives, dealing with patient deaths and grieving

survivors will always be a common occurrence for EMS providers. Communicating

difficult news such as death to a patient’s family and friends is now a regular

responsibility of EMS providers. However, several research studies show that paramedics

are ill-prepared to communicate difficult news (Douglas, Cheskes, Feldman, &

Ratnapalan, 2013; Nordby & Nohr, 2011; Norton et al., 1992; Ponce et al., 2010; Smith

& Walz, 1995; Smith-Cumberland & Feldman, 2006; Stone et al., 2013). Smith and Walz

(1995) also noted that there is minimal attention given to the strategies for paramedics to

use at the time of death despite their presence at most out-of-hospital deaths.

Stone et al. (2013) surveyed 236 paramedics from Denver and Los Angeles about

end-of-life skills, which included understanding advanced directives such as DNR forms,

knowing when and how to honor requests to withhold resuscitation, and communicating

bad news. One of their results showed that 79% of paramedics rated “communicating

death to family and friends” as “very important.” However, only 48% felt “well-

prepared.” There is clearly a gap between perceived importance in paramedics’ everyday

practice and preparation to perform the task. Stone et al. (2013) strongly suggest that

there is a significant under preparation in end-of-life skills and paramedics need more

training.

A qualitative study conducted by Nordby and Nohr (2011) showed that all

paramedics surveyed did not find communication challenges around the technical aspects

of providing medical care. Rather, these paramedics found it personally and

professionally difficult to “find the right words” during difficult interpersonal relations.

Nordby and Nohr (2011) stated that emergency personnel need education and training in

preparing for emotional work and challenging patient communication that are

characteristic of the EMS profession. These results complement the research of Smith-

Cumberland and Feldman (2006). Their research showed that most EMTs did not feel

comfortable making death notifications. Eighty-four percent of EMTs in the study also

felt that their training was inadequate in making death notifications or helping the

families grieve. Several studies show that death education and training to deliver difficult

news in paramedic programs is suboptimal (Smith & Walz, 1995; Smith-Cumberland &

Feldman, 2006). These results are also congruent with numerous studies in health care

communication that show that physicians have reported receiving no formal education in

effectively communicating bad news (Rosenbaum, Furguson, & Lobas, 2004;

Fallowfield, 1996, 2004).

In 2009, NHTSA released an updated version of The National EMS Education

Standards. Commonly referred to as “The Standards,” this version dictates the minimum

entry-level competencies that EMS training programs are required to integrate into their

curricula. “Dealing with Death and Dying” is only one objective under The Standards’

Stress Management section. There is no other mention of this specific objective or any

other death-related objective throughout the entire 387-page document (NHTSA, 2009).

These open-ended guidelines give each program the freedom to choose how much time

and resources are needed to reach entry-level paramedic competency. Since dealing with

death-related issues only appears minimally in The Standards, programs that adhere to

these standards are likely to include little instruction on this important topic (Smith &

Walz, 1995).

Smith and Walz (1995) surveyed 537 paramedic programs, and received a

response from over half of all programs in the United States. They wanted to gather

information about current death education in programs, instructional delivery methods,

and assessment techniques. Almost all (95%) stated that their programs offered death

education. The face value of this result seems promising. However, most instructional

time was spent covering only legal and ethical issues that were relevant to death, rather

than the psychosocial issues such as bereavement and consoling friends and family.

Smith and Walz (1995) also stated that there are few educational resources in death

education for EMS, and that the typical method of delivering death education in

paramedic programs is ineffective. Their results showed that the majority of programs

taught death education through a lecture rather than through experiential modules such as

simulation or role-play. The entry-level competency on death education was usually

measured using closed-ended exams. This suggests that paramedic students were

assessed only via multiple choice exams. They also noted that the majority (80%) of

paramedic graduates read less than one page of death-related texts. Furthermore, their

survey found that there are very few other death-related instructional materials, such as

video tapes, that are relevant to EMS providers.

To my knowledge, there has not been another nationwide survey of death

education in paramedic programs since that of Smith and Walz (1995). Although this is

fairly dated research, there are other indicators that suggest that there have been no

significant changes in EMS death education within the last 18 years. First, the 1998

National Standards Curriculum – Paramedic is similar to the 1999 Standards in regards

to death education (NHTSA, 1998; 2009). Death education and difficult communication

training remain minimal in The Standards, which will most likely translate to minimal

training in paramedic programs. Secondly, more recent studies show that most

prehospital care providers feel unprepared to deliver death notifications (Douglas et al.,

2013; Ponce et al., 2010; Smith-Cumberland & Feldman, 2006).

Several studies also show that the instructional methods used to teach death

education throughout different fields of healthcare education are absent or ineffective

(Jacques et al., 2011). In EMS textbooks, there is usually only one page of death related

material in textbooks which commonly covers the stages of grief. Therefore, there is a

lack of foundational instruction in death education and a paucity of effective educational

resources (Smith & Walz, 1995; Smith-Cumberland & Feldman, 2006).

Difficult communication does not always involve death notification. Nordby and

Nohr (2011) conducted a qualitative study on health communication between paramedics

and patients with prolonged cancer. Interestingly, all participants in the sample did not

find communicative challenges around providing medical care. Rather, many of the

paramedics expressed that it was difficult to “find the right words” during “quiet

transports” where there is not much to be done. One of their findings was that none of the

paramedics found it difficult to deliver straightforward factual information. These

researchers wanted to investigate how paramedics communicated, interacted, and

empathized with patients who were on the verge of death. Nordby and Nohr (2011)

emphasized that prehospital care providers need the education and training to prepare for

an emotionally intense career with difficult communication challenges. This is in line

with the recommendations from previous studies (Smith & Walz, 1995; Smith-

Cumberland & Feldman, 2006). It is well-documented that paramedics are frequently

exposed to situations involving death and communicating difficult news to grieving

families. The evidence clearly shows that that many EMS providers are not prepared.

Literature on the importance of communication and interpersonal relations

between health care professionals and their patients is abundant. It has resonated

throughout several research studies that the manner in which a health care provider

delivers difficult news can affect the grieving process (Fallowfield, 2004; Nordby &

Nohr; Smith & Walz, 1995; Smith-Cumberland & Feldman, 2006; Stewart, 1995).

Fallowfield (2004) advised that poor delivery of bad news can cause confusion, long-

lasting distress, and resentment. In contrast, properly communicated difficult news may

assist with understanding, acceptance, and adjustment. Since EMS providers are often

present at the time of death, they are in a unique and sensitive position to influence the

grieving process (Smith & Walz, 1995).

The challenge is to create a paradigm shift among EMS providers. Delivering

death notifications is a relatively new role for EMTs and paramedics. Fewer cardiac

arrests are being transported to the hospital and more families and friends are being

notified by EMS personnel. A pre-intervention survey conducted by Smith-Cumberland

& Feldman (2006) showed that only less than 43% reported that their role as an EMT

should include making a death notification. A study by Ponce et al. (2010) showed that

only 55% of participants had an interest in improving their death notification skills. There

is still a prevalent “that’s not my job” mentality. EMS providers were not required to

deliver death notifications; therefore, they were not expected to develop that unique and

sensitive skill. Recent nationwide changes to protocols and practice have made delivering

difficult news a common responsibility of EMS providers.

Paramedics need to feel confident, comfortable, and skilled in delivering difficult

news. The amount of death education in paramedic curricula is not proportionate to the

high frequency of out-of-hospital deaths that paramedics encounter. The lack of depth

and breadth of death education objectives in The Standards has influenced how it is

taught and evaluated in paramedic curricula. It is evident that EMS providers must be

better prepared to handle common challenges found in their jobs. Most paramedics lack

effective communication skills to deal with death and grieving families. One factor that

contributes to this deficiency stems from a lack of education and exposure in their

foundational training. Paramedic education programs need to adequately equip their

students with the skills needed to address the everyday communication demands of the

profession.

Purpose of Graduate Project

The purpose of Death Notification Training for Paramedics is to provide EMS

educators with an effective evidence-based resource to facilitate a simulation training

session using standardized actors. It is designed to engage paramedic students in realistic

simulations that will expose them to challenging EMS situations, such as patient death,

and enhance their communication skills in difficult situations.

Terminology

This section provides definitions of critical terms used in the discussion, design,

development, and implementation of this graduate project. These definitions are based on

scholarly research and educational literature.

Andragogy: The art and science of adult education. (Misch, 2002)

Bad news: Situations where there is either a feeling of no hope, a threat to a person’s

mental or physical well-being, a risk of upsetting an established lifestyle, or where a

message is given which conveys to an individual fewer choices in his or her life. (Bor,

Case-based learning: A learning model founded upon a student centered approach,

whereby students use the following: discovery, responsibility, empowerment,

emancipation and motivation and rely less on teachers simply dispensing knowledge.

(Boyle, Williams, & Burgess, 2011)

Debriefing: The time for critical reflection after a simulation session when the

facilitators guide the students through the case and provide feedback. (Wang, 2011)

Emergency Medical Services (EMS): Collective name for all levels of certification or

licensure for individuals who provide out-of-hospital patient care. (NHTSA, 2009)

Family-witnessed-resuscitation: A resuscitative effort in which the family is present at

the scene of the cardiac arrest. (Ponce et al., 2010)

Human simulation: A variety of technologies that allow residents to work through

realistic patient problems so as to allow them to make mistakes, learn, and be evaluated

without exposing a real patient to risk. (McLaughlin, Doezema, & Sklar, 2002)

Patient-centered communication: A style of communication where the physician

conveys the information according to the patient’s needs, checks for understanding of

provided information, and shows empathy (Mast, Kindlimann, & Langewitz, 2005).

Simulation: A technique – not a technology – to replace or amplify real experiences with

guided experiences that evoke or replicate substantial aspects of the real world in a fully

interactive manner. (Wang, 2011)

Transition to Next Chapter

The following chapter will thoroughly review literature relevant to the design of

this project. The areas covered are: 1) current EMS death education and notification

programs, 2) strategies to deliver bad news, and 3) simulation as an effective tool.

Chapter Two – Literature Review

Introduction

This chapter contains is a literature review of issues directly related to the

development of Death Notification Training for Paramedics: A Simulation Guide for

EMS Educators. It begins with research relevant to the design and delivery of effective

death education training programs for EMS. This is followed by a review of various

methods used to communicate difficult news. A review of simulation with standardized

patients as a learning and evaluation tool is the last area of investigation. This chapter

concludes with a synthesis of the discussed literature and its implications to the design of

this project.

EMS Death Education and Notification Programs

A need for difficult communication skills training for EMS providers is evident

from the literature. However, there is currently no standard program specifically designed

for primary paramedic education. The need for an educational intervention is clear, but

more research still has to be done to find the most effective method of implementation.

Two pilot death education and notification programs have been conducted and evaluated

for effectiveness. Smith-Cumberland and Feldman (2006) conducted a study to test their

hypothesis that EMTs’ attitudes toward death will change after an educational

intervention. Dr. Tracy Smith-Cumberland developed a two-day course that was

specifically designed to change death-related attitudes and behaviors of EMS providers.

Emergency Death Education and Crisis Training (EDECT) is a 16-hour seminar that

includes a lecture, discussions, small-group exercises, and role-playing. A sample of 83

rural EMTs participated in this pretest-posttest study, and each participant was randomly

assigned into one of three groups. The control group (n = 29) received a two-hour

program on a topic unrelated to death or difficult communication. Their “long-

intervention group” (n = 24) received the two-day 16-hour EDECT program. The “short-

intervention group” (n = 30) received a two-hour continuing education session which

focused primarily on delivering a death notification, which is one component of the eight-

module EDECT program.

The 83 EMTs completed a questionnaire were structured in a five-point Likert

format from “strongly agree” to “strongly disagree.” It gathered information about their

behaviors and attitudes about death. This instrument was reviewed by several EMS

experts, and the authors conducted a pilot test to ensure reliability and stability. The five

items specific to the EMTs’ attitudes and behaviors were “1) whether their actions as

EMTs impacted the grief of family members, 2) whether their training to help the

families was adequate, 3) whether their training prepared them to make compassionate

death notifications, 4) whether they felt comfortable making death notifications, and 5)

their attitudes toward the EMTs’ role to make death notifications on scene (Smith-

Cumberland & Feldman, 2006, p. 91).”

The first research question asked EMTs whether they believed that their actions

affected the patient’s family. Prior to any of the sessions, 77% of all three groups agreed

or strongly agreed that their actions affected grief. The second research item asked

whether EMTs believed that it was their role to communicate death notifications. Pretest

results showed that 57% of EMTs disagreed or strongly disagreed that it was a part of

their duties. However, after the sessions, more EMTs in the intervention groups reported

that their role as EMTs included making a death notification. Ninety-two percent of the

long-intervention group and 83% of the short-intervention group reported that it was part

of their responsibilities.

The third question obtained information about EMTs comfort level with making

death notifications on scene. Only 1% felt comfortable and 15% reported that they were

somewhat comfortable with making a death notification. The majority of EMTs (84%)

reported that they were uncomfortable delivering death notifications before the sessions.

The long-term intervention group showed the most significant change. The fourth and

fifth items inquired about preparation and training to help families at the time of death. At

the pretest, most EMTs (83%) felt 1) unprepared to deliver a death notification and 2)

that their training was inadequate. The posttest results showed that all participants in the

long-intervention group felt prepared to deliver a death notification and most (70%) in

the short-intervention felt that their training was adequate.

Smith-Cumberland and Feldman (2006) shed light on several important issues

relevant to the design and delivery of an effective death education program for EMS

providers. First, they showed that there must be a paradigm shift or a change in attitude

among EMS providers. Most EMTs did not feel that delivering a death notification was

their responsibility. After the two-hour continuing education session and 16-hour EDECT

course, most felt that it was their duty and most felt prepared to do so. Moreover, this

study showed that EMS providers are receptive to death education. In regards to program

structure, Smith-Cumberland and Feldman (2006) showed that attitudes and behavior can

be changed through a brief two-hour educational intervention.

There are some limitations to this study. The principal investigator also taught the

short and long-intervention courses. The authors did mention that they made an attempt

to find an unaffiliated instructor, but they were unsuccessful in finding instructors who

are experts in death and dying. This may have introduced bias into the evaluation of

effectiveness. However, it is still promising to see an upward trend in several

measurements. Secondly, a survey of a more diverse group of EMS providers may result

in different outcomes. All 83 EMTs were from rural Wisconsin. General attitudes about

death education and the relatively new role of EMTs may differ geographically.

Furthermore, much more investigation has to be done with educational interventions

within primary training programs. The participants of this survey were already certified

EMTs or licensed paramedics, and both educational interventions were designed as

continuing medical seminars. Results may differ if these programs were integrated into

primary foundational training. Lastly, the short-intervention group only received a two-

hour lecture about the death notification procedure. Unlike those in the long-intervention

group, they did not receive any experience delivering a death. Consequently, the EMTs in

the short-intervention group did not feel as adequately trained as compared to those who

engaged in the EDECT program. Further investigation of different program duration and

content may show that a two-hour session is too condensed, and the two-day EDECT

workshop is too extensive to cover the necessary objectives. All participants of a four-

hour educational session with an experiential component (role-play or simulation) may

report feeling adequately trained.

Smith-Cumberland and Feldman (2006) evaluated the effectiveness of their

educational interventions only through self-report measures. The intent to change attitude

and behavior was surveyed, rather than the actual assessment of a delivered death

notification. The effectiveness of death education and notification training would be best

measured after real notifications were delivered. However, given the nature of the EMS

profession and confidentiality laws, it would be very difficult to survey families of the

deceased or directly observe the process as an evaluator.

Ponce et al. (2010) studied the effectiveness of a pilot educational intervention on

EMS providers’ comfort with family-witnessed resuscitation (FWR) and death

notification. A sample of 45 EMS professionals completed a 60-minute training on FWR

and death notification delivery. The authors stated that the training was conducted by a

physician who is a national expert on end-of-life care. This hour-long session emphasized

“the steps for performing FWR resuscitation; how to communicate bad news to patients

and families; and how to assess and respond to a family’s needs for psychological,

spiritual, and social support during and after resuscitation” (Ponce et al., 2010, p. 538).

The lecture session concluded with a demonstration of a death notification using

actors as simulated family members. Each participant was then instructed to complete a

preintervention attitudinal survey and a postintervention test to measure knowledge

retention from the lecture. Participants of the large group session were given the option to

also participate in a 45-minute interactive session after the lecture. During the small

group session, the participants were given the opportunity to practice delivering a death

notification and receive feedback from observers. Twenty of the 45 participants

volunteered to engage in the standardized death notification exercise.

At the end of the session, the participants completed another attitudinal and

confidence survey on FWR and delivering a death notification. The majority of

participants were paramedics (n = 25), and were involved in at least one cardiac arrest

resuscitation. Seventy percent of participants reported having performed a death

notification. After the large and small group sessions, the results showed that EMS

providers felt more comfortable with the presence of family during a resuscitation, and

more confident in delivering a death notification. Prior to the sessions, 50% of EMS

providers reported that family presence during a resuscitative effort was inappropriate or

disruptive. After the sessions, 80% percent reported that family presence was beneficial

to families. Furthermore, 80% to 90% of the participants felt confident in their abilities to

deliver a death notification and provide comfort to family members.

This pilot study by Ponce et al. (2010) suggests that a two-hour educational

module may improve EMS providers’ confidence with death notification and interacting

with family members. Similar to the research of Smith-Cumberland and Feldman (2010),

this pilot study only assessed self-reported measures rather than actual long-term attitudes

and skill retention. Less than half of the participants (n = 20) volunteered for the small

group session where they were given the opportunity practice a death notification or give

feedback to peers. It would be valuable to survey the 25 participants who left after the

large group session. Doing so may provide insight and feedback that would influence the

design and delivery of such programs.

If many EMS providers feel that delivering a death notification is not their

responsibility (Smith-Cumberland & Feldman, 2006), then motivation to participate in an

educational seminar would be expected to be low. Using this knowledge, Ponce et al.

(2010) may have yielded different results if the EMS providers were not given the option

to leave the seminar. The participants who left after the large group session may have

benefited from the entire educational intervention the most. In contrast, those EMS

providers who stayed may have already perceived death notification training as

important. This limitation of selection bias was also noted by the authors in their

discussion. Further investigation needs to be done on EMS providers’ motivation to

engage in death education programs.

Douglas, Cheskes, Feldman, and Ratnapalan (2013) conducted focus group

sessions with 28 paramedics in Ontario, Canada. The interviews focused on the

paramedics’ experiences with death notification education. The authors were specifically

interested in discovering the format and content that most paramedics would like

incorporated in an ideal death notification program. Themes were generated from the

analysis and comparison of interview transcripts. The authors noted that the sample size

is small (N = 28), however, participants were continuously recruited until no new

information was obtained from the focus groups.

The results showed these paramedics were motivated to learn about death

notification through evidence-based continuing education sessions conducted by a trained

facilitator or through independent study online. Some of the paramedics who indicated

independent study preferred not to be placed in a situation where they would be forced to

discuss their personal experiences. Douglas et al. (2013) suggested that a trained peer or

health care professional with similar experiences would be best to teach paramedics about

death notification. Furthermore, they also reported that paramedics want to specifically

learn about the “practical aspects of communicating death notifications” (Douglas et al.,

2013). The results also showed that the paramedics wanted to know how to interact with

family members during resuscitation. These paramedics did not just want to learn about

the psychological aspects of sudden death or theories of best practices. They wanted to

develop practical skills that would immediately affect their professional lives. Lastly, the

interviews also indicated that paramedics wanted to receive feedback about their death

notification performance.

This qualitative study has paramount implications in the design of an EMS-

specific death notification program. Prehospital emergency care is a unique field of

medicine, and the results suggest that an effective program must focus on the specific

needs of EMS providers. Other death notification training programs, such as one

developed by Mothers Against Drunk Driving (MADD), may not be suited for EMS

because it is designed for a broad audience of professionals who deliver bad news: law

enforcement, EMS personnel, counselors, and clergy. Their strategies for bad news

delivery are too general, and some are not directly applicable to EMS. Douglas et al.

(2010) also suggests that EMS providers may be most receptive to death notification

education that is conducted by a trained and qualified peer who shares similar

experiences. In reference to the pilot study by Ponce et al. (2010), it may be of value to

investigate if any participants left after the large group session because they felt

disconnected from the facilitator.

This study also has a few limitations. The focus group was conducted in urban

and rural Ontario. The role of a paramedic is similar internationally, but the perceived

importance of death notification education may differ regionally. The results of a focus

group of paramedics in Los Angeles, which is largely an urban fire-department-based

system, may differ from another part of North America, where EMS is a separate entity

from the fire department. Therefore, the 28 paramedics in the focus group may not be

representative of all paramedics. Moreover, although the input of paramedics in the focus

group is important, they may not know the best evidence-based method to deliver death

notification education. The results only suggest their preference for specific educational

content and delivery methods. Paramedics may report that they prefer online independent

study, but that may not be an effective instructional delivery method. Some EMS

providers may prefer online education solely because of its convenience. Others may be

terrified of role-play or simulation activities, or are uncomfortable being evaluated by

peers. Further research needs to be done to determine if online independent study is an

effective method to teach practical difficult communication skills to EMS providers.

Implications. These findings have several implications for the design and

development of Death Notification Training for Paramedics. The research of Smith-

Cumberland and Feldman (2006) and Ponce et al. (2010) showed that EMS providers can

benefit from a two-hour educational intervention. Also, these two pilot programs also

included a lecture component prior to engaging in experiential sessions. Incorporating a

lecture prior to simulation or role-play sessions is an important element in their design.

Moreover, Douglas et al. (2010) suggest that EMS providers would be most receptive to a

trained peer, such as another paramedic, who has experience delivering a death

notification in the EMS setting. These findings have influenced the development of the

guide. Death Notification Skills for Paramedics is designed to be conducted in

approximately two-hour sessions by a trained and experienced paramedic.

Bad News Delivery Strategies

Several studies reported that the majority of practicing physicians have received no

formal training in communicating bad news (Fallowfield, 2004; Jacques et al., 2011;

Mast, Kindliman, & Langewitz, 2005). Traditionally, most health care practitioners

learned to give patients bad news through trial and error or through direct observation of

a preceptor or a more experienced colleague. Several strategies to deliver difficult news

have been developed to meet the needs of physicians who often do so. Emergency

medicine physicians and oncologists, in particular, routinely deliver difficult news to

patients and their families. Most components of the following mnemonic-based strategies

(GRIEV_ING, SEGUE, and SPIKES) are transferable and applicable to prehospital

emergency care. These three strategies all provide a planned structure for communication

and interpersonal relations.

GRIEV_ING. Dr. Cherri Hobgood, from the University of North Carolina

School of Medicine, developed an educational session structured around the mnemonic

“GRIEV_ING”. This is two-hour death notification workshop that is specifically

designed to meet the unique needs of emergency medicine physicians. Hobgood,

Harward, Newton, and Davis (2005) noted that there were established death notification

programs in use by other medical specialties, but the format was not tailored to the needs

of emergency medicine. These programs were one- to two-day sessions or retreats, and

the schedule was not conducive to the “busy clinical shifts and limited conference time”

of emergency medicine. Furthermore, the strategies were not always applicable. Death

notification in the emergency department is, in some ways, different from other areas of

medicine, but shares several similarities with prehospital emergency care. Emergency

medicine physicians and paramedics both deal with unexpected or traumatic death, and

their first encounter with families is near the time of death. In contrast, oncologists

typically have an established relationship with patients and their families. Therefore, the

dynamics of the death notification is different between the two specialties.

Dr. Hobgood performed an extensive literature review and developed

GRIEV_ING by incorporating the most important elements of a death notification. These

included “correctly identifying both the deceased and the survivors to be notified;

explaining the events of the death and the medical procedures (if any) that were used to

treat injuries; telling the survivors directly about the death without using euphemisms;

allowing adequate time for questions; viewing the body shortly after the notification if it

is available; and providing assistance (Hobgood, Tamayo-Sarver, Hollar, & Sawning,

2009, p. 207).” As a comprehensive program, GRIEV_ING consists of an introduction,

small-group activity, mini-lecture, and a simulated survivor encounter. The mnemonic,

GRIEV_ING, provides a mental checklist for the deliverer and gives the death

notification process a sequenced structure. This is designed to reduce the stress of an

emotionally-charged interaction (Hobgood et al, 2009).

This method has been tested for effectiveness with fourth-year medical students

as well as emergency medicine residents through two independent studies (Hobgood et

al. 2005; 2009). Hobgood et al. (2005) analyzed data from 20 residents obtained before

and immediately following the intervention, and three months after. Their results

demonstrated that this structured method of delivering bad news based on the

GRIEV_ING mnemonic can improve physician confidence and competence in death

notification.

More recently, Hobgood et al. (2009) conducted a study to evaluate if the

GRIEV_ING workshop improved the death notification skills of medical students. A

capstone course, which included GRIEV_ING, was attended by 138 fourth-year medical

students. Each participant completed a self-efficacy survey and was evaluated performing

a death notification before and after the GRIEV_ING intervention. Trained actors

completed a 12-item GRIEV_ING competency instrument and a 9-item interpersonal

skills instrument. The results showed that all participating medical students increased in

competence and confidence. Unexpectedly, overall interpersonal communication scores

declined.

The decline of interpersonal skills scores after an educational intervention to

improve difficult communication skills was unanticipated and surprising. Hobgood et al.

(2009) postulated a few explanations for this finding. Prior to the GRIEV_ING

workshop, the participants possessed limited skills and had no plan for how to deliver a

death notification. Consequently, they may have been perceived to be more personable

and at ease. After the training, the participants may have been too focused on their mental

checklist and completing all of the key GRIEV_ING elements. This may have resulted in

a more rigid, rehearsed, and impersonal interaction with the standardized survivor. This

decrease in interpersonal skills scores is particularly important in the development and

evaluation of any death notification program. Confidence and competence to deliver

difficult news are both important, but are independently ineffective without excellent

interpersonal skills. Delivering a death notification is more than a series of steps.

Hobgood et al. (2009) emphasized the importance of compassionate interpersonal skills

and establishing a human connection with families.

SEGUE. Dr. Gregory Makoul, an expert in medical communication, developed a

comprehensive checklist which covers tasks in most medical encounters. It serves as a

reminder for five general focus areas: Set the stage, Elicit information, Give information,

Understand their perspective, and End the encounter. SEGUE is a checklist of general

communication tasks that guides the flow of the interaction from beginning to end. It

incorporates most of the components found in the GRIEV_ING method, but SEGUE is a

general strategy rather than one specifically designed for difficult news delivery.

However, SEGUE provides an adaptable framework for EMS-specific difficult

communication tasks. Makoul (2001) stated that it can be used as a “structural foundation

to teach, assess, study, and improve communication skills.”

Makoul (2001) surveyed 99 medical schools about the assessment and instruction of

communication skills. The results indicated that the SEGUE framework was the most

widely used framework because it can be adapted and used in different medical fields.

Furthermore, SEGUE, as a checklist, has demonstrated reliability and validity as an

assessment tool. However, Skillings, Porcerelli, and Markova (2010) suggested that

SEGUE is not an ideal instrument to measure the quality of the interaction since the

checklist only indicates if an action is completed. Therefore, it would be difficult to

differentiate between beginner, intermediate, and advanced levels of communication

skills.

SPIKES. Baile et al. (2000) synthesized evidence-based techniques and developed a

six-step protocol to deliver bad news to cancer patients. This SPIKES model was slightly

modified by Park, Gupta, Mandani, Haubner, and Peckler (2010) for delivering death

notification in the emergency department. Park et al. (2010) developed a five-hour death

notification workshop for EM residents. The initial lecture gave detailed instruction of

the SPIKES protocol, and stressed the importance of empathetic communication. This

was followed by role play exercises where the residents played the physician, survivor, or

an observer. The SPIKES competence form was used by the observer as a checklist for

required tasks. Lastly, the participants were expected to deliver a death notification to a

simulated session with standardized survivor. The session concluded with an extensive

debriefing with the use of video playback.

The 14 emergency residents were surveyed after the five-hour session. All

residents reported that the educational experience to learn death notification skills was

necessary and that the workshop was useful. Furthermore, the residents reported that their

patient care would improve after the workshop. These residents were also surveyed about

what workshop session was the most useful. Forty-three percent reported the simulation

with standardized survivors was the most useful. Fourteen percent indicated role play,

and only 7% reported the initial lecture as the most useful. The remainder of participants

reported that each session was equally useful. The authors suggest that using simulation

and role play exercises with the integration of the SPIKES protocol is an effective way to

teach difficult news delivery.

Implications. “Mental rehearsal is a useful way for preparing for stressful tasks”

(Baile et al., 2000, p. 305). Research findings imply that the use of mnemonics and

checklists decrease the stress of the EMS provider when delivering a death notification.

GRIEV_ING, SPIKES, and SEGUE all provide a plan, structure, and strategy to

communicate with patients and their families. As suggested by Hobgood et al. (2009),

these mental checklists may also negatively affect interpersonal skills. An effective

strategy for EMS would integrate key components from all three protocols with a few

modifications. These protocols were designed as communication guides rather than

regimented tasks. Reliance on GRIEV_ING, SPIKES, and SEGUE as black-and-white

scripts may result in rigid communicators. In the guide’s debriefing section, the facilitator

is given instructions to also give specific feedback on interpersonal skills. Death

Notification Training for Paramedics includes a modified SEGUE checklist for

paramedic training. Permission from Dr. Makoul will be obtained prior to use or

publication.

Simulation

Simulation has been utilized in medical education as an important method for

improving clinical training, communication, and patient safety (Wang, 2011). This ranges

from low-fidelity simulation manikins, such as latex IV arms, to high-fidelity simulation

experiences that immerse the learner in close to authentic environments. Simulation

incorporates principles of adult learning theory, and has been shown to be more effective

in teaching bad news delivery than traditional methods (Jacques et al., 2011).

McLaughlin, Doezema, and Sklar (2002) examined the effectiveness of human

simulation in emergency medicine resident training. In addition to assessing core

technical competencies, the medical residents were also objectively evaluated on their

interpersonal skills. “Although limited by the fact that residents know the encounters are

staged, simulated encounters with family members, difficult patients, and a variety of

hospital personnel can be used for teaching communication skills and professionalism

(McLaughlin et al., 2002, p. 1314).” They also found that simulation improves the

retention of knowledge as compared to traditional lecture formats. However, the authors

clarified that simulation is not an assessment tool by itself, and that it is challenging to

develop valid and reliable assessment tools with “psychometric integrity.” Therefore,

most of these validated tools are borrowed from other fields of medicine.

In a recent publication, Educating the Delivery of Bad News in Medicine:

Preceptorship vs. Simulation, Jacques et al. (2011) described the benefits of simulation in

the instruction of bad news delivery versus the traditional model of medical education. In

the apprenticeship approach, “role modeling and imitation are emphasized, learning is

clinically oriented, feedback is limited, and active supervision is minimal (Jacques et al.,

2011).” On the other hand, simulation is an interactive experience that actively involves

the learner and incorporates theories of adult learning (Wang, 2011). Unlike traditional

methods, using simulation as a teaching tool involves self-reflection, peer-to-peer

feedback, and debriefing. Jacques et al. (2011) stated that simulation training can help

develop the skills needed to effectively and empathetically deliver bad news

Rosenbaum et al. (2004) reviewed effective strategies taught to medical students

and residents. They concluded that there are several educational methods, but an effective

curriculum would give learners “opportunities for learners to discuss relevant issues, and

practice and receive feedback on their skills (Rosenbaum et al., 2011).” This suggests that

effective teaching methods of bad news delivery must engage students in the learning

process. Rosenbaum and Kreiter (2002) suggested that the use of multiple standardized

patients and family in difficult communication training can increase student comfort.

Implications. Widespread evidence throughout literature suggests that death

notification skills should be delivered through an experiential method. A death

notification training program would not be most effective through a lecture format.

Simulation with the use of standardized actors immerses the learner in a pseudo-authentic

environment with similar stressors. The core components of this project are simulation

activities with standardized actors and debriefing sessions.

Synthesis

Substantial evidence found in various areas of literature clearly justifies and

supports the best way to design this guide: Effective Difficult Communication Skills for

the Paramedic. The synthesis of research findings suggests that an effective program

should have certain characteristics and components with specific regards to duration,

content, and method of implementation.

Nearly all educational interventions discussed in this literature were two to five hours

in length. It has been shown that self-efficacy and competence have increased in as little

as two hours. In contrast, a two-day 16-hour educational program similar to EDECT may

not be ideal for primary paramedic education. As mentioned by Smith and Walz (1995), a

standalone program is nearly impossible since many paramedic programs are offered in

an accelerated program. Therefore, it must be introduced into curricula in smaller

sections. Although the EDECT program suggested the highest effectiveness, it may not

be practical for paramedic training programs to allocate 16 hours for death education. The

educational intervention must be easily integrated into current curricula. The activities in

this simulation guide are designed to be conducted in approximately two hour segments.

Studies show that paramedics are most receptive to death notification education if

the workshop is facilitated by a peer with similar experiences. Trained and qualified EMS

educators would be best suited to teach paramedics. Furthermore, the evidence also

suggests that an effective program must be tailored specifically for EMS. The formal

workshops designed for emergency residents, such as GRIEV_ING, would not directly

transfer into paramedic education. It would require modification and customization to

meet the needs of paramedics.

Investigation into difficult communication methods shows that there are different

ways to deliver bad news. The research suggests that effective difficult communication

education should include a plan or strategy. Components of all three protocols have been

incorporated into Effective Difficult Communication Skills for the Paramedic.

Lastly, there is overwhelming evidence that effective programs include an

experiential component. Educational interventions discussed in this literature review

involved a standardized simulation session where participants were given the opportunity

to experience communicating difficult news and receive feedback. Smith and Walz

(1995) noted that most death education was offered through lecture format and

competency was assessed through closed-ended assessments. The literature strongly

suggests that experiential methods, such as simulation with standardized patients and

actors, are the most effective way to learn difficult communication skills. This project

incorporates simulation into the core of its design.

Death Notification Training for Paramedics is an evidence-based instructional

resource tailored to meet the specific needs of EMS education and practice. This project

was built upon the valuable knowledge shared among literature, and will be one of the

pioneer educational resources for difficult communication training in EMS.

Chapter Three – The Project

Introduction

Studies show that instructional products similar to Death Notification Training for

Paramedics is a much needed resource for EMS education and that there are proven

methods for effectively teaching this skill. This chapter begins with a discussion of how

adult learning theories are incorporated into the design. This is followed by an overview

of the instructional design model used to create the guide. Chapter 3 will conclude with a

product description, which includes a discussion of its layout, contents, and physical

appearance.

Development of the Product

Adult learning theory. This product incorporates principles of adult learning

theory into its design and development. The term andragogy is the art and science of

teaching adults (NAEMSE, 2013). It has become synonymous with Malcolm Knowles’

“adult learning theory.” He extensively investigated how adult learning differed from

pedagogical approaches, and developed a conceptual frame work around andragogy. His

work resulted in six assumptions of adult learners (Knowles, Holton, & Swanson, 2005),

which were all integrated into the design of this project.

Knowles’ first assumption was that adults want a sense of control over their

learning experiences. This simulation guide gives the paramedic students autonomy

through its flexible nature. They can choose how they deliver bad news as long as their

method meets recommended principles. There is not a regimented script that must be

memorized, nor an exact sequence of events that must be followed. This gives the adult

learner a chance to develop their own style.

Knowles’ second assumption was that adults are only open to learning things that

are immediately applicable to their lives. Adults, in particular, must value the material in

order for the learning process to begin. The instructor will put the activity into context

during the debriefing of a death notification simulation. The facilitator will ask: “Did you

know that many paramedics find it difficult to console family members and notify them

that their loved one has died?” This will make the paramedic student more aware that

these difficult situations are “typical calls,” and that this activity has immediate relevance

to their responsibilities as a paramedic.

Knowles’ third assumption was that adults’ experiences serve are a rich resource

for learning. Moreover, the educator should value these personal and professional

experiences and not just assume that their students are a blank slate. All paramedic

students are experienced EMT-Basics before they are advanced in their training.

Therefore, they already have experience as prehospital care provider. Involving and

valuing the paramedic students’ previous experiences in the learning process is a direct

application of Knowles’ third assumption.

Knowles’ fourth assumption and fifth assumptions go hand in hand. Adult

learners need to know why they are learning something. There must be purpose in the

learning experience. Furthermore, Knowles assumed that adults’ learning orientation was

more problem-centered rather than subject-centered. Adults are more open to learning if

it the newly acquired knowledge or skills will help them solve practical problems in real

life. Death Notification Training for Paramedics uses a case-based scripted simulation to

engage the paramedic student in a practical learning experience. Delivering difficult news

can also be taught on a PowerPoint presentation to a classroom full of adults, but it does

not have a hands-on problem-centered approach. This guide is a tool to facilitate

simulation sessions that immerse paramedic students in situations that are directly

relevant to their careers.

Knowles’ sixth assumption is that adults are more motivated by intrinsic factors

such as self-esteem and self-efficacy. This guide involves a debriefing after each session.

The participants will be asked to give each other constructive feedback regarding several

aspects of their performance. Most importantly, the student under evaluation will be

asked to do a self-assessment. This introspection will give the paramedic student an

opportunity to diagnosis their own needs. Knowles’ sixth assumption suggests that doing

so may increase a learner’s internal motivation.

Dick and Carey Instructional Design Model. The Dick and Carey instructional

design (ID) model was used to design and develop Effective Difficult Communication

Skills for the Paramedic. It is also known as the Systematic Design of Instruction. This

ID model starts by identifying instructional goals and ends with a summative evaluation.

I chose to use this particular model because it is an ongoing process of evaluation and

refinement. This dynamic eight-step formative process allowed for constant revision

where needed.

Stage 1: Identify instructional goals. The first stage of this ID model is to

identify what I want the paramedic trainees to do when they finish with instruction. This

involved performing a needs assessment and identifying a gap between the desired goals

and the current status of education. Extensive review of literature supported my

observations as an EMS educator and licensed paramedic. The instructional goal of

Death Notification Skills for the Paramedic is the following: “On every dispatched call,

paramedics will use effective and compassionate communication techniques with patients

and families for both non-emergency and emergency situations. Although the guide

focuses on difficult communication skills such as death notifications, the instructional

goal is to improve overall communication skills for all patient encounters.”

Stage 2: Conduct instructional analysis. The second stage was to conduct an

instructional analysis. This involved investigating how difficult communication skills

were currently taught to paramedic students and identifying specific communication

skills that are needed to accomplish goals.

Stage 3: Analyze learners and context. After analyzing goals, the next step was

to analyze the leaners and the contexts in which the learners will take place. This also

involved identifying the learners, and examining entry behaviors, knowledge, and skills.

All paramedic students are experienced and certified EMT-Basics. Many of them have

witnessed a paramedic deliver a death notification or have been involved in other

situations that required effective communication skills. This is important in the design

process because it influenced the guide’s content, structure, and expectations from

learners.

Stage 4: Performance objectives. The fourth step involved developing

performance objectives. These are specific statements that the learners will be able to do

when they complete instruction. One performance objective is: “When delivering

difficult news, the paramedic intern will always use clear phrases that are not subject to

misinterpretation.”

Stage 5: Develop assessment instruments. The fifth step involved developing

measurement tools to evaluate performance and learning. The SEGUE – Paramedic was

adapted from Dr. Makoul’s SEGUE evaluation tool. It encompasses all the key elements

of difficult communication skills.

Stage 6: Instructional strategy. The development of the instructional strategy is a

result of a synthesis of evidence-based best practices. The educational session will begin

with a brief lecture to put subsequent activities in context. This will be followed by small-

group simulation sessions with standardized actors. The following are some instructional

strategies that are incorporated into Death Notification Training for the Paramedic:

Relevance. This guide leverages students’ past EMS experiences in several ways.

The simulation scripts are written in a manner that assumes that the learner has

foundational experience. The post-simulation debriefing tool instructs the facilitator to

ask the group: “Have you experienced a similar situation in your experience as an EMT?

What did you learn from it?”

Accountability. This guide holds learners accountable by including the modified-

SEGUE checklist which they will use to evaluate themselves and their peers. The last

activity is a self-reflection assignment. “Put yourself on the receiving end of EMS. You

are a family member standing next to your mother, father, or spouse. Two paramedics, a

captain, three EMTs, and two police officers are in your living room. How do you expect

them to communicate with you and your loved one? What would make you upset?”

Modality. Conducting simulations in a vignette room with a scripted standardized

actor creates a multi-sensory learning experience. The simulation rooms should not just

be a classroom with tables and chairs pushed aside. A training lab, or vignette room,

should be used to create the most authentic experience. These rooms should accurately

resemble the details in the script.

The learners are expected and encouraged to perform as if it was a real

emergency. They will be allowed to touch the patient, take vital signs, do CPR, and move

furniture as necessary. The actors and bystanders will be scripted to raise their voices,

cry, or stay quiet. A loud radio will be on in one of the scenarios, and the paramedic

student will be expected to adjust the volume.

Organizers. The SEGUE mnemonic will be taught to the paramedic students prior

to the simulation exercises. This instructional strategy organizes the death notification

process from beginning to end.

Examples. Section III contains good and bad examples of each SEGUE step.

Instead of just stating “Don’t use medical jargon,” the supplement this recommendation

by giving an example: “We tried to resuscitate your father, but he didn’t respond to our

interventions. We intubated him and put him on the cardiac monitor… and still nothing.”

The more appropriate manner immediately follows the bad example. This gives the

learner an opportunity to compare the two.

There are also two sample “trainer speeches” included in Section II: The

Importance of Communication in EMS. The guide invites the instructor to share a story

about how communication skills affect their careers as paramedics prior to beginning the

simulations. These two examples are concise, personal, and practical. Lastly, the Self-

Assessment Assignment in Section VI also contains examples of thorough and

inadequate reflections.

The paramedic students will also see one example of a properly delivered death

notification at the conclusion of the pre-simulation lecture. Unlike the simulation

sessions, this will not involve a standardized actor. The instructor will read the script on

the screen and will deliver the notification to a volunteer in the class. This exercise will

end with a brief discussion of how the instructor implemented each component of

SEGUE.

Practice. The simulation sessions give the paramedic trainees opportunities to

practice delivering a death notification to a standardized survivor. This instructional

strategy of integrating an experiential component is the core of Death Notification Skills

for the Paramedic. The lecture in Section III is only designed to set the tone for the

simulation exercises and to introduce SEGUE. The simulation and debriefing sessions is

where most learning will occur. Practicing how to deliver death notifications in a

simulated environment will decrease the students’ stress in real-life high stress situations.

Stage 7. Instructional materials. After determining the instructional strategy, the

following step was to evaluate what materials, equipment, and resources were required.

Standardized actors, simulation rooms, and a qualified facilitator are few necessary

resources to execute the instructional strategy.

Stage 8. Formative evaluation. This phase involved collecting data to evaluate

stages in the instructional design process that need to be revised or improved. Preliminary

feedback was given by the audience in a graduate-level instructional design class. Subject

matter experts were also surveyed and most of their feedback resulted in changes to the

design. Details of this evaluation process and the resulting product modifications are

presented in Chapter 4.

Stage 9. Summative evaluation. This phase involves gathering pre and post data

on the paramedic trainees. The goal is to evaluate the effectiveness of the Death

Notification Skills for Paramedics after it has been implemented in a real-world

environment. Plans for a summative evaluation are discussed in Chapter 4.

Product Description

Physical description. This guide is spirally bound between clear semi-rigid

plastic covers. Appendix A presents pictures of the front and back covers. The front has a

picture of three EMS providers standing behind an ambulance. The back cover has two

pictures of EMS providers in action. All of these graphics were strategically chosen to

make it apparent that EMS is the intended audience.

All 62 pages of the guide, including the front and back covers, are printed on

standard 8.5”x11” paper. The forms in Section VI are laminated to provide added

durability for repetitive duplication. Section IV is subdivided by blue hard stock paper

with graphics depicting the following scenario. This vibrant blue paper also serves as a

guide so the facilitator can easily navigate between scenarios. Lastly, a compact disc is

attached to the inside of the back cover. This contains the PowerPoint slides printed in

Section III of the guide.

Organization. The simulation guide is divided into seven sections. The first

section, How to Use This Guide, gives the EMS educator instructions on how to

efficiently use it as learning tool. This section also includes suggests of how to integrate it

into their paramedic program. The second section discusses the importance of

communication in the EMS profession. The third section includes a 36-slide PowerPoint

presentation entitled: Setting the Tone. This puts the simulation activity in context and

introduces the death notification strategy. The fourth section contains three scripted

scenarios with details needed to conduct the simulation. It discusses the required

equipment, “actors,” environment, and objectives of the exercise. The fifth section

discusses the importance of the debriefing component of the simulation. The sixth section

of the guide consists of the SEGUE-Paramedic checklist, a debriefing tool, and a self-

reflection exercise. Section VII lists resources relevant to death notification in EMS.

Environment and Equipment. All components in a simulation need to be as

realistic as possible. In this manner, the paramedic student would be better able to

transfer learned skills to a real situation. Each of the three scripts in the third section lists

what items, actors, and environmental factors are needed. For example, in the first

scenario, an elderly male is unable to wake his wife from sleep in the morning. This

requires a simulation room that is setup similar to a real bedroom. Other equipment

required includes the typical gear paramedics bring to every emergency such as an airway

bag, cardiac monitor, a clipboard, and a gurney. Audiovisual (AV) recording will also

make the debriefing experience more effective.

Intended Audience and Personal Qualifications. The full product name is

Death Notification Training for Paramedics: A Simulation Guide for EMS Educators.

“EMS Educator” is a general title for anyone who teaches in any level EMS. Those who

solely lecture in the classroom are referred to as “lecturers,” and those who teach in small

group hands-on sessions are called “skills instructors.” It is common for educators to

teach in both areas, but in larger paramedic programs the lecturers and skills instructors

have separate roles.

Paramedic skills instructors are the primary audience for this guide. Practicing

paramedics and nurses with emergency department backgrounds are usually in this

position. Furthermore, it is also intended for experienced educators who are able to

conduct a simulation and debriefing, use time efficiently, and engage critical thinking.

This involves a high degree of comfort with teaching in groups of five to six paramedic

students. Other qualifications include the ability to multi-task and pay attention to detail.

Newer instructors are usually assigned to teach skills sessions that are more black and

white, such as the application and use of a device. Inexperienced instructors who have

never conducted a simulation session at the paramedic level may feel overwhelmed and

unable to give accurate feedback. The paramedic skills instructor should also have first-

hand experiences delivering a death notification.

The paramedic students are also a part of the intended audience, but the guide is

developed for the instructor. It is not designed for paramedic students to gain death

notification skills through self-study. An experienced skills instructor will use the guide

to conduct Death Notification Training for Paramedics. This first edition guide currently

has no formal training for paramedic instructors. However, the directions throughout the

guide are delivered in a manner in which most experienced paramedic instructors can

comprehend and carry out. The use of simulation is currently common practice in

paramedic training programs. Skills instructors are familiar with conducting simulation

sessions in small groups. Future editions will include formal training for instructors in

collaboration with other death and dying professionals such as grief counselors, clinical

social workers, experts in thanatology, and psychologists.

It is also necessary to distinguish between two levels of EMTs. Paramedics are

EMTs with advanced training and licensure, and EMT-basics have a lower certification

level. All paramedic students are experienced EMT-basics pursuing advanced training.

Therefore, most EMT-basics in paramedic school have worked alongside a paramedic.

These prior experiences in real emergency situations will serve as a valuable foundation

in death notification training.

Most paramedic trainees are young adults in their twenties and thirties who come

from diverse backgrounds. In the early years of EMS, the typical paramedic student was a

high school graduate who took a basic EMT course and worked on an ambulance prior to

pursuing more training. In the present day, paramedic students have more diverse

educational and professional backgrounds. Many are still the high school graduates who

joined the EMS workforce as EMT-basics in their late teens to early twenties. However,

there are also many paramedic students who have completed college and have non-EMS

professional work experience. A significant number of students are also veterans with

technical skills gained from military training.

The collective motivation of students can vary among paramedic schools, and at

times, between classes in the same program. There are civilians who are in school full-

time, supporting themselves through loans, and paying their own tuition. The others are

employed fire fighters who are receiving a salary while in school. Some of these fire

fighters chose to advance their careers by becoming licensed paramedics while others

were mandated to pursue paramedic training. There is usually low motivation to engage

in learning from students who are forced to be in school. On the other hand, there is

typically a higher motivation to learn from those who have “more on the line” (e.g. paid

their way through school, hoping to start a career, etc).

General Guide Contents. The following are the six sections of Death

Notification Training for the Paramedic.

I. How to Use This Guide

II. Importance of Effective Communication Skills in EMS

III. Pre-simulation lecture: Setting the Tone

IV. Scripted Scenarios

V. Debriefing

VI. Forms

a. Debriefing guide

b. SEGUE – Paramedic Checklist

c. Self-Evaluation Assignment

d. Trainer Feedback Form

VII. Resources

Transition to Next Chapter

Chapter Four will summarize the preceding chapters, discuss formative and

summative evaluation of Death Notification Skills for the Paramedic, and conclude with

future plans. The actual product can be seen in Appendix H.

Chapter Four - Conclusion

Summary

Several studies have shown that paramedics, and health care providers alike, feel

inadequate in their abilities to delivery difficult news. Although this skill requires

repetition and practice, a lack of foundational training also has an influence on this

deficit. As part of their work, paramedics are exposed to a high incidence of death outside

the hospital setting. Therefore, they must have effective and compassionate

communication skills to deliver difficult news. This project justifies a need through

supportive literature, includes a description of the development and evaluation process,

and concludes with a final product: Death Notification Training for Paramedics. The

purpose of this project is to provide EMS educators with an evidence-based resource to

facilitate a simulation session on difficult communication. Ultimately, paramedics with

more effective and compassionate communication skills will provide better care for

patients and their families.

Evaluation

This guide has undergone a continuous evaluation process and several revisions

have already been made. A more comprehensive evaluation must be done to fine-tune

this guide and determine its effectiveness in training paramedic students to deliver death

notifications.

Formative Evaluation. Preliminary feedback from a presentation in an

instructional design class (EPC 615) resulted in a few significant changes. The audience

was comprised of graduate students from various professional fields, which included

education, counseling, business, and human factors. One recommendation was to put the

name of each section on the tabs, rather than just a number. The implementation of this

change resulted in a more professional and user-friendly appearance. Other feedback

included adding more pictures and diagrams; particularly to aid in describing the

simulation scenarios. I have included visual representations for each scenario in Section

Death Notification Skills for Paramedics was professionally reviewed by three

EMS educators from different training programs. The evaluation form consisted of three

sets of questions (see Appendix B). The first is: How does your paramedic program

currently train students to deliver a death notification? Evaluator A said: “The program

as a whole prepares them for this, maybe not the didactic (lecture) section, but their field

internship surely does. Field internship is still a part of the program. But there is no focus

on this specific skill before they deal with real patients as interns.” Evaluators B and C

said that their programs did not specifically teach nor assess death notification skills in

any aspect. This question did not yield feedback relevant to the design of Death

Notification Skills for the Paramedic. It simply reinforced the needs assessment.

The second question was: Would you implement this product into your paramedic

training program? If yes, how would you use it? All three evaluators indicated that they

would use this guide. Evaluator A said that it could be integrated into several skills days

throughout the program. “On a typical skills day, we have 6 rotations of 6 to 7 students

each. I would use simulations in this guide in one of the rotations.” Evaluator B said that

it would be difficult to implement this guide into their program. “We’re already looking

for more time for our students to get practice on other skills such as Advanced Cardiac

Life Support. Yes, we would implement it, but it will be hard to justify why we’re

making time for this and not areas where our students need help.” Evaluator C indicated

that this guide could be “used toward the end of the first phase of paramedic school right

before the interns hit the field. This would put things into perspective and give them a

broader view of what to expect. We would make it one of the small group rotations in one

of the skills days.”

The third question was: “How would you improve this guide?” Evaluator A said

that there are too many scenarios in Section IV. “It would better to have three awesome

simulation scripts than one excellent and four mediocre. Polish up three of them and add

more details to how the actors should behave. Your directions are too loose and can be

translated in many ways. Three is plenty. Four, maybe. Six is too many.” Evaluator B

said: “Make this look more like a guide than a book. I don’t think instructors want

another book to join the others on their shelves. Also, make sure that the scenarios don’t

neglect the ‘medicine’ part of this all. They’re still going to go in and do a medical

assessment, not just practice communication. Also, there is no point in separating Section

VII if it’s just forms.” Evaluator C said: “Make sure that other programs can also use this

guide. Not every program has multiple skills rotations per day or even skills rooms. Some

small programs have two people teaching the entire thing and their main classroom is

their skills room.”

The pre-evaluation version of this guide consisted of six different scenarios. I

took the advice of Evaluator A and removed two. This also gave me the opportunity to

refine three of the scenarios and elaborate on details. Having six scenarios made the final

product look physically thicker and more comprehensive. However, that is not the goal.

The aesthetic effect of removing a few pages also made the book look more user-friendly

and less intimidating. I also took Evaluator B’s advice regarding “neglecting the

medicine.” A few of the scripts did not have thorough medical information, such as vital

signs and a medical history, for the simulation. All the scenarios are now scripted in a

medically sound manner. Lastly, Sections VI and VII were “Debriefing Tool, SEGUE-

Paramedic Checklist, Self-Evaluation Assignment, and Trainer Feedback Form.” I

consolidated the last two sections into Section VI per Evaluator B’s advice.

Summative Evaluation. A summative evaluation will be done after the guide has

been implemented into paramedic curricula and the students are practicing paramedics.

This would involve a pre and post-intervention study of two experimental groups. One

group of trainees will undergo Death Notification Training for Paramedics. Another

group will participate in another communication skills training workshop of the same

duration. The control group will receive a two hour continuing education seminar on a

subject unrelated to communication skills. The purpose of the summative evaluation is

to show that Death Notification Training for Paramedics is an effective educational

resource. Ideally, I would also survey patients and families to collect qualitative data

about their experiences with EMS. However, this may be difficult due to patient

confidentiality laws and the logistics of tracking patients and their families.

Future Work

Future plans include creating a website for EMS providers and educators to share

scenarios that particularly involved difficult communication skills. This information

could be used to script more scenarios that are relevant to EMS. A repository of scenarios

could be shared with the EMS community to conduct simulations with standardized

actors. The next edition of this guide will also be available in an electronic book format

that will be accessible on a tablet.

Other plans also include integrating role play activities with well-scripted

vignettes from real life EMS situations. This will allow the learner to experience multiple

perspectives of the death notification process. Including role play and simulation

activities in this current version will lengthen the sessions. At this point, two hours should

be the maximum until further evaluation is conducted. This first edition of Death

Notification Skills for the Paramedic will be a step forward in creating a paradigm shift in

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Educational Technology, 25(3), 421-439.Appendices

Appendices

Appendix A

Front and Back Covers

Appendix B

Death Notification Skills for the Paramedic Professional Evaluation

1. How does your paramedic program currently train students to deliver a death

notification?

2. Would you implement this product into your paramedic training program? If yes,

how would you use it?

3. How would you improve this guide?

Comments:

Appendix C

Sample Pages from Death Notification Training for Paramedics

Section I

HOW TO USE THIS GUIDE

This guide is for you: The EMS Educator! It is designed to help

you facilitate a simulation-based session in a training lab or vignette

room. It is not designed to deliver instruction through lecture format.

There are 3 fully scripted scenarios with all the details that you need.

Feel free to adjust the details of each scenario to make it more relevant to

your geographic area, local protocols and student population.

Your communication skills training sessions will require pre-class

planning. Look at the “What do you need?” details in Section 3 for each

scenario. You will need to secure volunteer actors prior to your training

for each rotation, and may need specific props.

Use this guide as an adjunct to your training curriculum. You can

integrate one of these scenarios into a pre-scheduled skills day. For

example, you can integrate Scenario A into your Cardiac Skills day, and

Scenario B when you cover pediatric emergencies. This may be the most

cost-effective option.

Section II

THE IMPORTANCE OF EFFECTIVE

COMMUNICATION IN EMS

Section III

SETTING THE TONE

This lecture will “set the tone” for the simulation sessions. It will

begin with a brief history of EMS and how it has evolved as a profession.

You will notice that the slides contain minimal text and will require you

to use the presentation as an adjunct to facilitate a lecture. If you are the

type of instructor who reads the words off the screen and clicks away,

then you will speed through the lecture. This lecture requires

preparation. Review the slides prior to delivering this brief lecture so

you know its contents. This will also help you pace yourself and make

you look more confident in front of the audience.

Prior to dividing the class into small groups, it would be ideal to

keep them in the lecture room (typically the primary classroom) and

present this lecture. It should take 20 to 30 minutes including the sample

“good” and “bad” death notification and any questions at the end.

If simulation sessions will occur immediately following this

lecture, your standardized actors and instructors (if there are others)

should be preparing in the sim/training rooms while you’re speaking.

The groups should seamlessly start their simulation session without

unnecessary preparation delay.

The following 36-slide lecture is included in the CD as a

PowerPoint file. The notes are intended to guide your lecture.

PowerPoint 2010 has a “Presenter View” feature so you can see your

notes on a personal screen while you lecture. The notes will not show

up on the main screen.

Section IV

SCRIPTED SCENARIOS

Section V

DEBRIEFING

Section VI

Section VII

RESOURCES

About the Author

Mark Malonzo has been involved in EMS since 1999. He is currently a

California-licensed and nationally registered paramedic. Mark has worked for

private ambulance companies and a municipal fire department. He has

experience in “9-1-1” medical response, non-emergent transport, and special

event medical standby. Mark currently works part-time as a paramedic for the

Sierra Madre Fire Department.

Mark is a full-time EMS Educator with the Center for Prehospital Care

at the UCLA David Geffen School of Medicine. He began his career with

“The Center” in 2002 as a CPR and EMT instructor. Mark has worn many

hats in the last decade as an instructor in EMT and Paramedic programs. It

was through these valuable experiences where he learned how to facilitate

small group simulation sessions. Some of his current responsibilities include

overseeing the Paramedic Preparatory program, Prehospital Trauma Life

Support program, and the National Registry Paramedic Psychomotor

examination.

Mark holds a bachelor’s degree in Biology with a minor in Psychology

from Loyola Marymount University. In 2013, he will be finishing a Master of

Arts degree program in Educational Psychology from California State

University Northridge. His graduate education focused on human

development, learning, instruction, and evaluation. Mark also has a

California Designated Subjects credential in Career Technical Education.

Mark is particularly interested in adult education and experiential learning.

california state university, northridge

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