Communication in rural trauma medicine: a practice/art unto itself.

Avtgis, Theodore A. ; Polack, E. Phillips

The importance of efficient triage and treatment of trauma patients have been evident since the Napoleonic Wars when Jean Larrey developed the ambulance volantes (flying ambulance) as a means of reducing the time interval from initial injury to treatment (Trunkey, 1983). The 'golden hour' for treatment of trauma patients was first conceptualized by Cowley (1975) using French data obtained from the treatment of soldiers during World War I (Santy, 1918). These data suggest that patients treated within the first hour of injury have a mortality rate of 10% versus a mortality rate of 75% if treatment occurred within eight hours of injury. Therefore, the reduction in time in the practice of trauma medicine is one of the most significant factors in the ongoing education efforts to improve outcomes (continuous quality improvement--CQI) for patients.

Waller, Curran, and Noyes (1964) reported that when treated within the 'golden hour', 44% of rural trauma deaths were salvageable compared with 36% of urban trauma deaths. Simply put, time loss is a major contributor to trauma patient mortality and if it had not been for the loss of time, chances of survival would have been significantly increased. It was determined that rural fatalities resulted from less severe injuries than those observed in urban settings. Delays in accident reporting as well as extended transport times were identified as contributing to preventable mortality of rural trauma patients (Waller et al., 1964). Given the increased mortality rates associated with rural trauma patients, investigating all of the factors contributing to time delay becomes necessary in efforts to work toward more efficient treatment and transport of trauma patients. Such factors include the processes and procedures related to medical triage, the level of coordination and collaboration among the trauma team, and the extramural trauma network as a whole. In terms of the communicative and psychological aspects of coordination and collaboration in trauma, communication researchers have begun interdisciplanry collaboration to investigate such processes and phenomena (see, for example, Avtgis, Polack, Martin, & Rossi, in press). However, even in light of these efforts, there are a myriad of research and education efforts that are still in need to be developed. The current study traces a comprehensive interdisciplinary effort to improve trauma care through the efficient exchange of medical information in communicatively competent ways.

The National Academy of Science (1966) identified trauma as a major health concern given its ubiquity and both socio-cultural and economic impact on society. This public health concern was obvious to many of the surgeons returning from the battlefields of Vietnam in that these veteran surgeons have been major contributors to the advancement of trauma system development throughout the United States and the world (Eiseman, 1967). The need for coordination and control of triage and trauma care are universal and thus the lessons learned in the jungles of Vietnam are readily applicable to other trauma systems and environments. Although the term trauma, whether occurring in urban or rural locations, has been treated as functionally equivalent, research findings indicate dramatic patient outcome differences existing between urban and rural trauma regardless of the formalization of the organized state-wide trauma system (Gonzales, Cummings, Mulekar, & Rodning, 2006). Therefore, the two distinct arenas of the rural environment and the urban environment in terms of trauma are truly unique from one another and as such have communication practices that are contextually unique. Therefore, efforts to improve care and process should be tailored toward not only the commonalities of trauma patient treatment but also the unique features of the environment within which the medicine is practiced.

Differentiating Rural Trauma

The United States Bureau of the Census defines rural as an area with an urban population of 50,000 or less and a population density not exceeding 1000 people per square mile (Rogers, Shackford, Osler, Vane, & Davis, 1999). The American College of Surgeons, Committee on Trauma defines rural as "an area where geography, population density, weather, distance or availability of professional or institutional resources combine to isolate the trauma victim in an environment where access to definitive care is limited" (Rogers et al. 1999, p. 75). An estimated 65 million people live in rural regions within the United States with the average age of rural residents being older than their urban counterparts (Rural Task Force Report to the Secretary, 2002). While approximately one-third of the American population resides in a rural area, only 9% of the U.S. physicians reside in these areas (Rural Trauma Committee of the American College of Surgeons Committee on Trauma, 2006; Rogers, Osler, Turner, Shackford, Camp, & Lesage, 1999). Therefore, this large doctor to patient ratio serves as a significant hurdle to effective treatment making competent and efficient communication among trauma team personnel that much more important. Traumatic injury is the leading cause of death in the 1 to 44 age group and the third most common cause of death for all age groups. Yet in comparing rural and urban trauma, rural residents are 50% more likely to die from trauma than their urban peers (Esposito, Sanddal, Hansen, & Reynolds, 1995; Peek-Asa, Zwerling & Stallones, 2004). Motor vehicular crashes are the single greatest cause of mortality for both urban and rural trauma victims, however more than half of these fatal crashes occur in rural areas (Karsteadt, Larsen, & Farmer, 1994; Rogers, Shackford, et al., 1999). Given the population disparity between urban and rural settings, the fact that half of motor vehicular crashes occur in rural areas is alarming. This is of special concern when combined with the greater mortality rate of rural trauma patients as a whole.

The evidence reviewed thus far clearly indicates that given the number of factors involved, the practice of surgery in rural areas is quite different from that of urban surgery. It is in these differences where communication training, if it is to be effective, needs to also be uniquely tailored to the specific challenges faced by medical personnel.

Interdisciplinary Conceptualization

When analyzing practices and processes involved in the practice of medicine and medical care, researchers and scholars tend to rely on discipline-specific theories in which to develop approaches to improve practice and patient safety (see, for example, Thompson, Dorsey, Miller, & Parrott, 2003). The current study conceptualizes trauma care as an organizational communication practice and as such, is conceptualized in these terms. When considering the time dependent practice of trauma medicine, we are referring to a practice that seeks maximum efficiency among its members with the maximum reduction of possible impeding factors. This efficient process is one of organization, not of medicine in that trauma care involves coordination, logistics, as well as technological and human synchrony to be effective (Avtgis et al., in press).

Medicine, one of the most well-established hierarchies in the world, is embedded in the concept of power, status, and privilege differences (Starr, 1982). Given this, any application of theory needs to account for such an embedded structure when developing approaches targeted at greater efficiency (Polack, Avtgis, Rossi, & Shaffer, in press). One such theory of organizational communication which considers such embedded power differences is the Theory of Independent Mindedness (TIM) (Infante, 1987a, 1987b). The TIM advocates congruity between the culture created within a specific organization (i.e., the microculture) and the larger culture (i.e., macroculture) within which it operates (Infante, 1987b). The TIM has been shown to be an effective theory of organizational productivity across cultures where power differences exist and are readily acknowledged by societal members (Avtgis & Rancer, 2007a). Within the practice of medicine, the power structure is clear, the duties and responsibilities of the trauma team members can shift based on the immediate needs of the specific situation. For example, it is common for a patient to be sent to the nearest healthcare facility for stabilization and triage. Once stabilized, the decision is made as to whether or not the patient should be transferred. These initial treatment facilities may not necessarily be equipped for definitive trauma care or contain personnel adequately trained to administer definitive care. Due to these factors, although power differences are emphasized throughout traditional medical care, such power differences become subordinate to the immediate needs of the patient and the patient's survival. That is, basic life saving roles need to be adequately filled by existing personnel regardless of their status or "official" occupational duties. For example, it is not uncommon in remote healthcare facilities for maintenance workers to fill critical roles in efforts to stabilize the trauma patient. Power and status in situations such as these serve as a deterrent to effective patient care.

According to the TIM, personnel at all levels should be active members in decision making as well as feel free to engage in a robust exchange of information and debate with any member of the work team (Avtgis & Rancer, 2007b). Therefore, developing communication systems targeted at effective information exchange must include all members of the organizational community, not only those who have the requisite background and title for such practices (e.g., surgeon, doctor, nurse). The nature of trauma medicine is one of chaos and sense making. Therefore, power, status, and structure, which are effective mechanisms in stable and static environments can become inhibitors in chaotic environments where flexibility in roles and rules are common and effective practice. The following sections describe the comprehensive effort that was undertaken throughout the trauma network system in the state of West Virginia to create communication curricula for trauma medicine targeted at increasing patient survival and safety.

Phase One

Phase one of this effort consisted of identifying the specific communication problems that exist throughout the state-wide trauma network as well as the communication problems specific to each individual trauma facility within the network. Twenty-four trauma personnel at different levels in the authority structure were surveyed to identify problematic communication. More specifically, six physicians, eleven nurses, and seven trauma registrars (N = 24) completed an open ended questionnaire responding to the following questions about the trauma transfer process: a) What do you feel are the biggest problems in the trauma transfer process? b) What are the biggest problems associated with the incoming trauma transfer process? and c) What are the problems associated with the outgoing trauma transfer process?

Utilizing assertion analysis which provides the frequency with which certain objects are characterized in certain ways (Stewart & Shamdasani, 1990), results indicated that there were significant concerns about interpersonal relationships between the lower level trauma centers [Level III and Level IV trauma facilities which are primarily concerned with the stabilization of the patient in preparation for transfer to definitive care facilities] and the higher level trauma centers [Level I and Level II which are facilities equipped to deliver definitive care to the trauma patient]. More specifically, personnel at Level III and Level IV trauma facilities reported being unappreciated and condescended to by personnel at Level I and Level II facilities. On the other hand, personnel from Level I and II trauma facilities reported the inefficiency with which relevant information was relayed as well as having too much extraneous information provided by personnel at Level III and Level IV facilities. From these findings, it was determined that communication competency training along with training in a hierarchical standardization of trauma patient information be developed and instituted system-wide in order to address the concerns of relational and information exchange difficulties.

RTTDC Training. The Rural Trauma Team Development Course (RTTDC[c]) was developed by the Ad Hoc Rural Subcommittee of the Committee on Trauma: American College of Surgeons to address the unique geographic and demographic attributes as well as limited resources that are constant barriers in rural trauma care. Several studies have evidenced the delays and longer time periods involved in the pre-hospital phase of a rural trauma when compared to an urban trauma of equal injury (Champion, Augenstein, Cushing, et al., 1999; Gonzales et al., 2006; Greer, Kispert, Lane, Lin, & Gupta, 2007). Additional delays were also noted following the patient's arrival at the initial rural trauma facility and transfer to a definitive care facility to combat such delays and challenges (Champion et al., 1999; Kappel, Rossi, Polack, Avtgis, & Martin, 2009).

The RTTDC[c] curriculum was designed to train/educate personnel in trauma facilities in a team approach to the initial assessment and resuscitation of the injured patient. The team approach requires a reduction in the authority gradient so that role-taking in the practice of trauma medicine can be assumed by any team member (Kappel et al., 2009). The authority gradient refers to the embedded hierarchy and power differences inherent in the medical profession. The RTTDC[c] optimally advocates that the decision to transfer the injured patient to a definitive care facility should be rendered within 15 minutes of patient arrival to the facility. In an effort to standardize information transfer, participants were trained in the acronym S.I.R. which represents vital Signs, Injury to the patient, and the Response or treatment that has been rendered to the patient. It is believed that by creating such a concise framework through which information is communicated, there will be a significant reduction in the noise or extraneous information that is often experienced during the trauma treatment process resulting in both inaccurate information and time loss.

RTTDC[c]-Communication. The practices of competent communication by healthcare professionals are an integral part of improving patient safety (Polack et al., 2008). As has been mandated by professional organizations such as the Centers for Medicare and Medicaid (CMS), the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), and the Accreditation Council for Graduate Medical Education (ACGME), the ability to effectively and appropriately communicate is inextricably linked to patient safety and medical error reduction. According to Infante, Rancer, and Avtgis (2010), competent communication is defined as the ability to relay information in an effective and appropriate way. Existing research indicates that competent communication results in the reduction of medical error (Britten, Stevenson, Barry, Barber, & Bradley, 2000), reduction in medical liability (Beckman, Markakis, Suchman, & Frankel, 1994), improved patient adherence to treatment regimens (Garrity, 1981), and increased satisfaction between patient and physician (Bartlett, Grayson, Barker, Levine, Golden, & Libber, 1984).

One of the central aims of communication training is the development of an affirming communicator style. Affirming communication is communication that affirms or validates the experience of the person with whom we are interacting while simultaneously contributing to a relational climate that is less aggressive, more productive, more accurate, and more pro-social (Avtgis & Chory, 2010; Infante, 1988; Polack, Avtgis, Kappel, & Martin, 2010; Rancer, & Avtgis, 2006). The assumption of increased effectiveness and appropriateness associated with affirming communication is evidenced in several studies indicating that affirming communicators or more apt to achieve their interactional goals (Norton, 1983), more appropriate in conflict situations (Jordan-Jackson, Lin, Rancer, & Infante, 2008), and used as a means of improving coordination and logistics associated with the trauma transfer process (Avtgis et al., in press). Therefore, affirming communication is an integral part of communication training and can be especially effective in an environment such as trauma medicine where disorganization, chaos, and uncertainty are common factors.

The RTTDC[c]-Communication curriculum was based on the Berlo (1960) source, message, channel, receiver model of communication (SMCR). This basic model is one of the most popular ways to understand the human communication process. Although some scholars have questioned the accuracy of process or linear models of communication, the Berlo model contains components that are easily recognizable and understandable by people in other disciplines beside communication. As such, the SMCR served as the basis for training in affirming communication. Given that members of trauma teams have little time for the acquisition of information, relaying only the most relevant and parsimonious information is the central focus of communication competence training. More specifically, the current curriculum adhered to the assumptions that communication information to be used in the training will be new and/or foreign to the trainees and therefore must be simplistic in nature, the training content has to be delivered by a source or sources who are credible within the field of trauma medicine as opposed to credible in a social science such as Communication Studies. Based on the limited time constraints and these two basic premises, three objectives were derived. More specifically, to increase the participants' knowledge of the basic elements and processes of human communication, illustrate how engaging in affirming communication results in improved teamwork (which includes reduction in power differences, reduction in the authority gradient, and improved patient safety), and understanding how the practice of affirming and competent communication has system-wide benefits for all people involved in trauma medicine as well as for the entire structure under which they work.

Phase Two

The second phase of this effort consisted of testing the RTTDC[c] and RTTDC[c]-Communication curricula on trauma personnel knowledge retention and a reduction on trauma patient transfer times.

Method

Participants

Both the RTTDC[c] and the RTTDC[c] Communication were administered to members of the West Virginia State Trauma and Emergency Care System (WVSTECS). WVSTECS is an all inclusive trauma system that is voluntary in nature where member facilities agree to uphold particular standards of care and procedures in exchange for being granted a $500,000 medical liability cap. These standards include being periodically reviewed, documenting performance, implementing improvement measures, and maintaining quality standards as mandated by WVSTECS. These quality standards are consistently monitored through a statewide trauma registry.

The acute care facilities included in the study were designated in accordance with the 2006 Resources for Optimal Care of the Injured Patient of the American College of Surgeons, Committee on Trauma as trauma receiving facilities. The 32 participating trauma facilities included two Level I, four Level II, three Level III, and 23 Level IV facilities. As indicated earlier, Level I and Level II facilities are those trauma centers that are equipped with both technology and personnel to provide definitive care to the critically injured trauma patient with the lower Level III and Level IV facilities have a much more limited capacity to provide definitive care and are primary concerned with resuscitation and stabilization of the trauma patient.

Complete data were collected from 18 of the 32 facilities resulting in a total sample of 308 trauma patients. One hundred seventeen patients were processed through facilities whose personnel received the seven hour RTTDC[c] training, 36 patients were processed through facilities whose patients received the seven hour RTTDC[c] training and the one hour RTTDC[c]-Communication training, and 191 patients were processed through facilities whose personnel received neither the RTTDC[c] nor the RTTDC[c]-Communication training (i.e., control group).

Procedures

This quasi-field experiment utilized a pre-test/posttest non-equivalent groups design. All training was conducted at the respective trauma facilities with the same group of instructors administering the training to all participants. That is, the instructors used in the study were well respected trauma surgeons known throughout the entire statewide trauma network. For assessing the effectiveness of the RTTDC[c] curriculum in terms of cognitive knowledge, a fifteen item multiple choice test (possible score ranged from 0 correct to 15 correct) was administered at four times: a) pre-RTTDC[c] training; b) immediate post RTTDC[c] training; c) three month post RTTDC[c] training; and d) six month post RTTDC[c] training. Assessment of the RTTDC[c]-Communication curriculum assessment consisted of a nine item multiple choice measure (possible score range from 0 correct to 9 correct). Unlike the RTTDC[c] pre-test post-test assessment, the RTTDC[c]-Communication assessment consisted of a post-test only assessment. This type of assessment was utilized to reduce any sensitization effect of the pre-test which has historically had adverse effects on communication skills training (Avtgis, Rancer, & Madlock, 2010). The RTTDC[c]-Communication assessment was administered at three different times: a) immediate post RTTDC[c]-Communication training; b) three months post RTTDC[c]-Communication training; and c) six month post RTTDC[c]-Communication training.

To assess the differences in trauma patient transfer times, two traditional bottlenecks in the transfer process and a logistic variable that are commonly associated with trauma transfer delays were identified and used as measurement markers. More specifically, the time of trauma patient arrival to the time of the decision to transfer the patient to the definitive care facility, the time from decision to transfer the trauma patient to the definitive care facility until the transport squad arrives, and how many number of transporting squads (e.g., helicopter or ambulance) were contacted until a successful transport could be arranged and coordinated.

Results

Knowledge Assessment

RTTDC[c]. To test the efficacy and longitudinal effects of the RTTDC[c] curriculum, t-tests were utilized. Results indicated significant differences in knowledge of trauma treatment procedures between pre-training knowledge scores (M = 8.60, SD = 2.50) and post-training knowledge scores (M = 9.96, SD = 2.22), t (141) = -8.26, p < .001. Assessment at three months post-training revealed no significant differences between immediate post-training scores (M = 10.04, SD = 2.14) and three month post-training scores (M = 9.75, SD = 2.45), t (47) = .81, p = .42. Comparisons between three month post-training scores (M = 9.55, SD = 2.17) and six month post-training scores (M = 9.79, SD = 2.42), t (32) = -.87, p = .39) were not significant. Therefore, knowledge of the RTTDC[c] curriculum does have longitudinal and lasting effects on the personnel.

RTTDC[c]-Communication. To test the efficacy and longitudinal effects of the RTTDC[c]-Communication curriculum, t-tests were utilized. Results indicated significant differences in knowledge of the communication process between immediate post-training scores (M = 6.56, SD = 1.28) and three month post-training scores (M = 6.14, SD = 1.56), t = (79) = 2.58, p < .05). Comparison between three month post-training scores (M = 5.98, SD = 1.71) and six month post--training scores (M = 5.77, SD = 1.53) revealed no significant differences (t [47] = .83, p = .41).

Trauma Transfer Time

To assess differences in the trauma patient transfer times at the two bottleneck points as well as the number of squads contacted, a series of One-Way Analysis of Variance (ANOVA) tests were performed with followup analysis (Duncan) where appropriate. Results indicated significant differences among RTTDC[c], RTTDC[c]-Communication, and control groups regarding time of arrival to decision to transfer (F [2, 336] = 3.38, p < .05) with the RTTDC[c]-Communication trained trauma personnel and the RTTDC[c] trained trauma personnel reporting significantly lower decision making times than trauma personnel receiving no training. Table 1 reports the means and standard deviations.

For time from decision to transfer until transport squad arrives, RTTDC[c]-Communication trained trauma personnel reported significantly shorter wait times for transport squad arrival than both RTTDC[c] trained trauma personnel and personnel in the control group (F [2, 336] = 7.37, p < .01). Table 2 reports the means and standard deviations.

In terms of the number of squads contacted, significant differences were observed (F[2, 314] = 4.54, p < .01) with RTTDC[c]-Communication trained trauma personnel contacting significantly fewer transport squads than both RTTDC[c] and the control group. Table 3 reports the means and standard deviations.

Discussion

The results of this research effort offers promising directions for the interdisciplinary study of trauma medicine. More specifically, scholars have long advocated the need to integrate communication into the practice of medicine (Rogers, Osler et al., 1999; Rogers, Shackford et al., 1999) but only recently have these efforts been attempted (Rossi, Polack, Kappel, Avtgis, & Martin, 2008; Rossi, Polack, Kappel, Avtgis, & Martin, 2009).

The fact that communication training as a whole, and affirming communication in particular can result in an actual decrease in transfer times concretizes the concept that effective communication in the practice of trauma medical care can indeed save lives. Several studies have demonstrated marked improvement for the trauma patient following the development of an organized trauma system (Nathens, Jurkovich, Rivara, Maier, 2000; Shackford, Hollingworth-Fridlund, Cooper, & Eastman, 1986). However, researchers argue that part of having an organized trauma system involves the implementation of mechanisms beyond simple organization that results in the reduction of trauma transfer times (Rossi et al., 2008, 2009). For example, technological advancements are only as effective as the personnel operating the technology. The use of communication technology is fully dependent not only on the technological competence of the operator, but also on their interpersonal and overall communication competence. More specifically, the medical knowledge contained in the curriculum was not only retained by participants via post training assessment, but the temporal effects were lasting as evidenced by the lack of significant changes in knowledge scores observed when comparing three month and six month assessments. Although the content of communication training was retained by participants via post training assessment, this was a dissipation effect occurring between the immediate post training and three month assessment. This dissipation effect that was observed in the three month assessment remained stable as evidenced by a lack of statistically significance difference observed when comparing the three month and six month assessment scores.

These differing findings between the retention of medical knowledge and communication knowledge should not be of surprise. That is, the medical knowledge being taught through the RTTDC[c] consisted of material that had to be utilized in a mindful fashion. By mindful, we are referring to particular procedures that must be executed in sequence. In contrast, the communication training was focused on the development of communication competence in general, and affirming communication in particular. The practice of such communication behavior, unlike medical procedure, is not one of the mindful sequence following as much as a style that one acquires and utilizes in a more second-nature fashion. When considering the differing approaches of teaching medical versus communication knowledge, one would expect that there would be a decrease in cognitive knowledge retention of communication terms and concepts as the focus of the training was on the development of an affirming communication style and not necessarily on an increase in concept definition and cognitive recall.

In light of the overarching findings of this research effort, the RTTDC[c]-Communication curriculum, given its efficacy in the reduction of trauma patient transfer times should be incorporated in the establishment of any rural trauma network. In fact, the RTTDC[c] and RTTDC[c]-Communication curricula developed and tested in these studies have been recognized as the standard for medical information and communication exchange in rural trauma by the Ad Hoc Rural Trauma Committee of the American College of Surgeons Committee on Trauma and are now part of the 3rd edition of the RTTDC[c] manual. This training is advocated for all rural trauma medical systems, not just those within the United States.

The results have demonstrated the effectiveness of both the RTTDC[c] and the RTTDC[c]-Communication as cost effective alternatives to the other system-wide efforts. Previous efforts have included new systems integration, alternative transport modalities, and equipment or technological acquisition to augment efficiency in the transfer and transport of trauma patients. Unfortunately, all of these are accompanied by large financial burdens for the individual institution and the entire trauma system as a whole. The following axioms are proffered as a direct result of the current research effort.

- Standardization of medical information and the effective communication of that information must be instituted system wide.

- Human communication synchrony among trauma team members within and between each facility is vital for efficient process coordination resulting in increased patient safety and quality care.

- Human communication training is a vital skill for efficient and effective trauma medical care.

- Effective rural trauma medical care is predicated on the trauma team's ability to effectively relay all necessary information in concise and competent ways.

These axioms, which are interdisciplinary in nature, provide the foundation from which the unique challenges of rural trauma should be conceptualized and approached. Given the ubiquitous nature of trauma medicine, there is truly a cross-cultural application to combining communication and medical knowledge in the most concise forms possible yet to do so in a way that also serves to respect the sanctity and cohesiveness of the trauma team and its members.

Limitations

Although there were limitations to this study such as unequal group sizes and subject attrition, these issues are commonly encountered with field experiments (see, for example, Rancer, Whitecap, Kosberg, & Avtgis, 1997) and as such, should be considered in the interpretation of the overall findings. It is in interdisciplinary efforts such as the one described here that better patient care, improved patient safety, and better trauma team coordination can be achieved thus improving any rural trauma system regardless of culture.

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Theodore A. Avtgis, West Virginia University

E. Phillips Polack, West Virginia University

Correspondence to:

Dr. Theodore A. Avtgis

Department of Communication

West Virginia University

108 Armstrong Hall

PO Box 6293

Morgantown, WV 26506-6293

Table 1. Means and Standard Deviations for
Time of Arrival until Decision to Transfer

Condition              M                  SD

RTTDC                  [95.72.sub.a]      92.07
RTTDC-Communication    [77.17.sub.b]      69.95
Control                [114.35.sub.ab]    82.97

Note: Means sharing subscripts differ at the p
< .05 level based on Duncan follow-up analyses.

Table 2. Means and Standard Deviations for Time
from Decision to Transfer until Squad Arrives

Condition              M                 SD

RTTDC                  [67.19.sub.ab]    55.26
RTTDC-Communication    [31.13.sub.b]     30.45
Control                [77.35.sub.b]     67.13

Note: Means sharing subscripts differ at the p
< .01 level based on Duncan follow-up analysis.

Table 3. Means and Standard Deviations
for Number of Squads Contacted

Condition             M               SD

RTTDC                 [1.13.sub.ab]   .49
RTTDC-Communication   [.86.sub.a]     .35
Control               [1.19.sub.b]    .67

Note: Means sharing subscripts differ at the p
< .01 level based on Duncan follow-up analysis.