Qualitative Evaluation of the Coach Training within a Community Paramedicine Care Transitions Intervention.

OBJECTIVE: The Care Transitions Intervention (CTI) has potential to improve the emergency department (ED)-to-home transition for older adults. Community paramedics may function as the CTI coaches; however, this requires the appropriate knowledge, skills, and attitudes, which they do not receive in traditional emergency medical services (EMS) education. This study aimed to define community paramedics' perceptions regarding their training needs to serve as CTI coaches supporting the ED-to-home transition. METHODS: This study forms part of an ongoing randomized controlled trial evaluating a community paramedic-implemented CTI to enhance the ED-to-home transition. The community paramedics' training covered the following domains: the CTI program, geriatrics, effective coaching, ED discharge processes, and community paramedicine. Sixteen months after starting the study, we conducted audio-recorded semi-structured interviews with community paramedics at both study sites. After transcribing the interviews, team members independently coded the transcripts. Ensuing group analysis sessions led to the development of final codes and identifying common themes. Finally, we conducted member checking to confirm our interpretations of the interview data. RESULTS: We interviewed all 8 participating community paramedics. Participants consisted solely of non-Hispanic whites, included 5 women, and had a mean age of 43. Participants had extensive backgrounds in healthcare, primarily as EMS providers, but minimal experience with community paramedicine. All reported some prior geriatrics training. Four themes emerged from the interviews: (1) paramedics with positive attitudes and willingness to acquire the needed knowledge and skills will succeed as CTI coaches; (2) active rather than passive learning is preferred by paramedics; (3) the existing training could benefit from adjustments such as added content on mental health, dementia, and substance abuse issues, as well as content on coaching subjects with a range of illness severity; and (4) continuing education should address the paramedic coaches' evolving needs as they develop proficiency with the CTI. CONCLUSIONS: Paramedics as CTI coaches represent an untapped resource for supporting ED-to-home care transitions. Our results provide the necessary first step to make the community paramedic CTI coach more successful. These findings may apply to training for similar community paramedicine roles, but additional research must investigate this possibility.

A randomized controlled trial testing the effectiveness of a paramedic-delivered care transitions intervention to reduce emergency department revisits.

BACKGROUND: Approximately 20% of community-dwelling older adults discharged from the emergency department (ED) return to an ED within 30 days, an occurrence partially resulting from poor care transitions. Prior published interventions to improve the ED-to-home transition have either lacked feasibility or effectiveness. The Care Transitions Intervention (CTI) has been validated to decrease rehospitalization among patients transitioning from the hospital to the home but has never been tested for patients transitioning from the ED to the home. Paramedics, traditionally involved only in emergency care, are well-positioned to deliver the CTI, but have never been previously evaluated in this role. METHODS: This single-blinded randomized controlled trial tests whether the paramedic-delivered ED-to-home CTI reduces community-dwelling older adults' ED revisits in the 30 days after an index visit. We are prospectively recruiting patients aged≥ 60 years at 3 EDs in Rochester, NY and Madison, WI to enroll 2400 patient subjects. Subjects are randomized into control and treatment groups, with the latter receiving the adapted CTI. The intervention consists of the paramedic performing one home visit and up to three follow-up phone calls. During these interactions, the paramedic follows the CTI approach by coaching patients toward their goals, with a focus on their personal health record, medication management, red flags, and primary care follow-up. We follow patient participants for 30 days. All receive a survey during the index ED visit to capture baseline demographic and health information and two telephone-based surveys to assess process objectives and outcomes. We also perform a medical record review. The primary outcome is the odds of ED revisit within 30 days after discharge from the index ED visit. DISCUSSION: This is the first study to test whether the CTI, applied to the ED-to-home transition and delivered by community paramedics, can decrease the rate at which older adults revisit an ED. Outcomes from this research will help address a major emergency care challenge by supporting older adults in the transition from the ED to home, thereby improving health outcomes for this population and reducing potentially avoidable ED visits. TRIAL REGISTRATION: ClinicalTrials.gov Registration: NCT02520661 . Trial registration date: August 13, 2015.

Multiple compliant processes: A reply to Haslam and Reicher on the engaged followership explanation of 'obedience' in Milgram's experiments.

Haslam and Reicher (2018, Br. J. Soc. Psychol., 57, 292-300) offer a thoughtful rejoinder to our critique (Hollander & Turowetz, 2017, Br. J. Soc. Psychol, 56, 655-674) of their theory of engaged followership, currently the most important explanation of 'obedient' behaviour in the Milgram paradigm. Our immersion in Milgram's archived audio recordings has led us to new findings about participants' perspectives, as well as to dissatisfaction with the theory in its present version. Following a brief discussion of our findings, which cast the theory in doubt, we respond to Haslam and Reicher's argument that these data may in fact be consistent with it. Our response identifies three limitations of engaged followership emerging from this debate. Despite the strengths of the theory and these authors' impressive re-analysis of our findings, important reasons remain for scepticism that engaged followership operated in Milgram's experiments in the way, and to the extent, that they claim. Rather, 'obedience' appears amenable to multiple empirically grounded explanations, only one of which is engaged followership.

Improving the ED-to-Home Transition: The Community Paramedic-Delivered Care Transitions Intervention-Preliminary Findings.

OBJECTIVES: To describe a novel model of care that uses community-based paramedics to deliver a modified version of the evidence-based hospital-to-home Care Transitions Intervention (CTI) to a new context: the emergency department (ED)-to-home transition. DESIGN: Single-blind randomized controlled trial. SETTING: Three EDs in 2 cities. PARTICIPANTS: Through June 2017, 422 individuals discharged home from the EDs who provided consent and were randomized to receive the modified CTI. INTERVENTION: We modified the hospital-to-home CTI, applying it to the ED-to-home transition and delivering services through community paramedics, allowing the program to benefit from the unique attributes of paramedics to deliver care. MEASUREMENTS: Through surveys of participants, medical record review, and documentation of activities by CTI coaches, we characterize the participants and program, including feasibility and acceptability. RESULTS: Median age of participants was 70.7, 241 (57.1%) were female, and 385 (91.2%) were white. Coaches successfully completed 354 (83.9%) home visits and 92.7% of planned telephone follow-up for call 1, 90.9% for call 2, and 85.8% for call 3. We found high levels of acceptability among participants, with most participants (76.2%) and their caregivers (83.1%) reporting themselves likely or extremely likely to choose an ED featuring the CTI program in the future. Coaches reported delivering expected services during contact at least 88% of the time. CONCLUSION: Although final conclusions about program effectiveness must await the results of the randomized controlled trial, the findings reported here are promising and provide preliminary support for an ED-to-home CTI Program's ability to improve outcomes. The coaches' identity as community paramedics is particularly noteworthy, because this is a unique role for this provider type. J Am Geriatr Soc 66:2213-2220, 2018.

Normalizing trust: Participants' immediately post-hoc explanations of behaviour in Milgram's 'obedience' experiments.

We bring an ethnomethodological perspective on language and discourse to a data source crucial for explaining behaviour in social psychologist Stanley Milgram's classic 'obedience' experiments - yet one largely overlooked by the Milgram literature. In hundreds of interviews conducted immediately after each experiment, participants sought to justify their actions, often doing so by normalizing the situation as benign, albeit uncomfortable. Examining 91 archived recordings of these interviews from several experimental conditions, we find four recurrent accounts for continuation, each used more frequently by 'obedient' than 'defiant' participants. We also discuss three accounts for discontinuation used by 'defiant' participants. Contrary to what a leading contemporary theory of Milgramesque behaviour - engaged followership - would predict, 'obedient' participants, in the minutes immediately following the experiment, did not tend to explain themselves by identifying with science. Rather, they justified compliance in several distinct and not entirely consistent ways, suggesting that multiple social psychological processes were at work in producing Milgram's 'obedient' outcome category.

The repertoire of resistance: Non-compliance with directives in Milgram's 'obedience' experiments.

This paper is the first extensive conversation-analytic study of resistance to directives in one of the most controversial series of experiments in social psychology, Stanley Milgram's 1961-1962 study of 'obedience to authority'. As such, it builds bridges between interactionist and experimental areas of social psychology that do not often communicate with one another. Using as data detailed transcripts of 117 of the original sessions representing five experimental conditions, I show how research participants' resistance to experimental progressivity takes shape against a background of directive/response and complaint/remedy conversational sequences--sequence types that project opposing and competing courses of action. In local contexts of competing sequential relevancies, participants mobilize six forms of resistance to the confederate experimenter's directives to continue. These range along a continuum of explicitness, from relatively subtle resistance that momentarily postpones continuation to techniques for explicitly trying to stop the experiment. Although both 'obedient'- and 'defiant'-outcome participants use all six of the forms, evidence is provided suggesting precisely how members of the two groups differ in manner and frequency of resistance.

Asking to Speak to Another: A Skill for Soliciting Survey Participation.

This paper is in the vein of applied conversation analysis, dealing with a problem of declining participation rates for survey interviews. When calling a household to request participation in a survey, interviewers may ask for a pre-selected "sample person." We first explore how interviewers design this request in a more or less presumptive way, depending on how and when they identify themselves. Secondly, we analyze different linguistic structures that embody degrees of entitlement. Thirdly, we examine greeting items for their degree of ceremoniousness and in terms of what work they do when not part of an explicit greeting sequence. We examine other features of asking to speak to another as well, including "please" and references to the sample person. Our strategy for analyzing survey interview data is to explore the design of "switchboard" requests in ordinary telephone calls. We relate our analysis to previous research that addresses whether the detailed practices for asking to speak to another matter for obtaining consent to do an interview. We draw implications for obtaining participation in the survey interview and other kinds of phone call solicitations. Data in American English.