Nancy: Research Class Assignment

INTERPERSONAL RELATIONS AND GROUP PROCESSES

Bystander Response to Arterial Bleeding: Helping Skills, the Decision-Making Process, and Differentiating

the Helping Response

R. Lance Shetland and William D. Heinold Pennsylvania State University

Using a mock injury involving arterial bleeding, we explored the impact of variables on two different decisions in the decision-making process leading to help. Expertise (Red Cross Training), ambiguity, and number of bystanders were manipulated in a 2 X 2 X 2 design. We observed the following responses: (a) nonhelp, (b) ineffective direct help, (c) indirect help, and (d) direct help. The decision to help or not was affected by ambiguity, sex, and the presence or absence of other bystanders. Greater ambiguity led to less help; women helped less than men; and fewer people helped when other bystanders were present. Expertise affected the decision leading to the type of help used but not the decision to help. Although training did not raise the intervention rate, it did dramatically change the effectiveness of the help used and could yield as many as 28 more saved lives out of 80 such incidents. The number of bystanders affected both the decision to help and the type of help used. Ineffective direct help occurred most frequently when the bystander was alone. The presence of other bystanders also affected the type of indirect help that was used.

The end of the second decade of research on the bystander response to emergencies is approaching. Surprisingly, after this length of time, little is known in three important areas about helping. First, there is only sparse knowledge concerning the impact of helping skills on the behavior of bystanders to emer- gencies. This is so despite a research literature on "competency," which one might expect to provide such an answer. Second, despite a number of studies (see Piliavin, Dovidio, Gaertner, & Clark, 1981, pp. 110-111) in which researchers have found bystanders re- sponding in both direct and indirect fashions, little is known about the variety of helping responses and the conditions that produce these different responses. Third, there has

William D. Heinold was an Instructor, Health Educa- tion, at the Pennsylvania State University during the time of the study and is now a Visiting Lecturer at Huaibei Teachers College, Huaibei, Anhui Province, Peo- ple's Republic of China.

Requests for reprints should be sent to R. Lance Shetland, Department of Psychology, 543 Moore Building, Pennsylvania State University, University Park, Pennsyl- vania 16802,

been little or no research that indicates the role that different variables play on each decision that leads to a helping response. These are the areas that we have investigated. We begin our discussion of the literature by examining studies in which the "competence" of bystanders on helping has been investigated. We then discuss the literature pertinent to the decision-making process that leads to a helping (or nonhelping) response.

Form and Nosow (1958), reporting on the aftermath of a major disaster, suggested that the expertise of bystanders was an important determinant of helping. Since that time, sev- eral investigators have looked at the perception of expertise by a bystander and its relation to helping, A number of investigators have used a "false feedback" strategy to induce "competence" and then tested the impact of this variable on helping, using experimental laboratory tasks. Midlarsky (1971) and Mid- larsky and Midlarsky (1973) induced subjects to believe that they could withstand electric shock better or worse than the average subject and then placed these subjects in a position in which thev could receive an electric shock

Journal of Personality and Social Psychology, 1985, Vol. 49, No. 2, 347-356 Copyrighl 1985 by ihe Amerkan Psychological Association, Inc. 0022-3514/B5/S00.75

347

348 R. LANCE SHOTLAND AND WILLIAM D. HEINOLD

for someone else. Schwartz and Ben David (1976) manipulated subjects' perceptions of their ability to handle rats. Subjects then found themselves in a situation in which they could help by capturing an escaped rat. Ka7- din and Bryan (1971) manipulated in subjects relevant (physical factors) or irrelevant (cre- ativity) competence pertaining to the act of donating blood. Those authors used a behav- ioral measure of the propensity to donate blood as a dependent measure. Ashton and Severy (1976) manipulated competence by informing subjects that they scored at the 90th or 50th percentile on generalized com- petence, and then placed subjects in a position so that they could respond to an accident.

The results of these investigations generally suggest that competence either produced more or quickened the rate of helping. An exception to this generalization was the study by Ashton and Severy (1976), which did not show a significant effect of competence on helping. In addition, Midlarsky and Midlarsky (1973) found that highly competent subjects helped more only when costs were low. Interestingly, Kazdin and Bryan (1971) discovered that both relevant and irrelevant competence pro- duced greater helping. It then seems that an alternative interpretation of this literature may be that these manipulations resulted in more help by producing positive mood states rather than or in conjunction with perceptions of efficacy.

Two studies provided subjects with knowl- edge pertinent to the helping situation. Bea- man, Barnes, Klentz, and McQuirk (1978) gave subjects information concerning psycho- logical factors that normally inhibit helping in emergencies. They found that those who had been exposed to these facts helped more frequently. Pantin and Carver (1982) showed subjects films that detailed various first-aid procedures. They found that subjects who had not seen the films responded more slowly in large groups than in small ones. Subjects who had seen the films responded more quickly regardless of group size.

There are several other studies in which the authors examined the competency vari- able but in either a nonexperimental or a correlational fashion. Clark and Word (1974) found that people with knowledge of electric- ity tended to help more frequently during an

electrical emergency. Shetland and Stebbins (1980) and Huston, Ruggierio, Conner, and Geis (1981) found that people who believed themselves to be physically able or competent were more likely to help directly in crime situations. In addition, Huston et al. found that these people were more likely to have been involved in a number of different formal training programs.

The medical literature includes several studies in which researchers implemented compound manipulations in order to raise the survival rate of'Victims of acute myocar- dial infarction by creating bystander and victim awareness of early warning signs and upgrading other areas of emergency care. Unfortunately no attempt is usually made to evaluate the effectiveness of individual com- ponents of these manipulations (e.g., Cramp- ton, Aldrich, Gascho, Miles, & Stillerman, 1975). Eisenberg, Bergner, and Hallstrom (1979) evaluated a program in Kings County, Washington, that trained large numbers of bystanders and instituted other changes. Those authors did attempt to evaluate the effective- ness of bystander training apart from other changes, using logistic regression procedures. They stated that the initiation of cardiopul- monary resuscitation (CPR) was an important factor and suggested that bystander-initiated CPR can be substituted for this factor. The conclusion that can be drawn is that by- stander-initiated CPR is an important predic- tor of survival rates for myocardial infarctions. Because CPR is a technique requiring train- ing, one can infer that training is correlated with the reduction of death rates. However, from the study's design, one cannot infer that the relation is a causal one.

From the review of the literature, it is clear that little is known about the impact of learned skills on the intervention rate of bystanders. Our purpose was twofold. First, we wished to test the impact of learned skills on both the quantitative (amount of help) and qualitative (type of intervention) aspects of bystander intervention. For example, Shot- land and Stebbins (1983) proposed in their "limited altruism" model that the lack of learned skills is one cause of indirect help. Furthermore, we intended to evaluate this impact in a causal manner.

A second but related purpose is to explore

BYSTANDER RESPONSE TO ARTERIAL BLEEDING 349

how the independent variables affect specific decisions that lead to a helping response. Latane and Darley (1969) suggested that the decision-making process consisted of five se- quential stages: (a) noticing the event, (b) interpreting the event as an emergency, (c) deciding that the bystander has a responsibility to act, (d) deciding on the form of assistance to implement, and (e) deciding how to im- plement the assistance. Schwartz (1977) pre- sented a decision-making model consisting of six sequential stages. The two models are similar in many respects, but Schwartz's model provides somewhat more detail. For example, Latane and Darley's first two steps appear to be combined in Schwartz's first step: awareness of a state of need. Another point of correspondence is Latane and Dar- ley's third step of personal responsibility and Schwartz's fifth step of activation of "moral responsibility." However, between Latane and Darley's second and third steps, Schwartz placed two additional steps. The authors all agreed that the last step or steps involve decisions concerning how to help. We are interested in how the independent variables affect (a) the feeling of responsibility and the decision of whether to act and (b) the decision and implementation of how to help.

The bystander literature suggests several important factors that have been shown to affect helping. These variables may interact with or possibly inhibit any effect of skills training and may affect the decision-making process at different stages. One such factor is ambiguity (e.g., Clark & Word, 1972; Yaki- movich & Saltz, 1971). In ambiguous situa- tions, trained people may be more likely to investigate the potential problem because they do know how to solve the problem, whereas untrained individuals may reinterpret it as a nonemergency because they cannot provide assistance. A second important factor in the helping area is the impact of the number of bystanders potentially able to help. Training may inhibit the use of social cues in the interpretation of the incident and diminish the diffusion of responsibility (Latane & Dar- ley, 1969). This occurs because training may cause people to have greater confidence in their ability to meet the emergency; hence trained bystanders may feel less need to rely on others either to interpret or to share the

responsibility to help. Therefore, our inde- pendent variables consist of training, ambi- guity, and the number of bystanders.

These independent variables should affect different stages of the decision-making pro- cess. We expected training to affect how people help and possibly whether they help by instilling confidence. We expected ambi- guity to affect the rate of helping, but not the mode of help delivered. We made this predic- tion because ambiguity should affect only whether the situation is interpreted correctly; after this judgment, it should have no impact on the decision-making process. We expected that the number of bystanders should affect the rate of helping and possibly the mode of helping. Other bystanders serve as a resource and could be asked to provide assistance.

Our dependent variable of helping was examined in a different fashion than is cus- tomary. Several authors have suggested that the act of intervention can be carried out in different ways, namely, directly intervening or responding in some indirect fashion, such as calling for help (Piliavin & Piliavin, 1972; Shetland, 1976). In fact, as we mentioned previously, in a dozen studies (see Piliavin et al., 1981) three types of helping, direct, in- direct, and nonhelp are categorized. Shetland and Stebbins (1980) found that helping could be separated into four categories: (a) direct, (b) "passive" or ineffective, (c) indirect, and (d) nonresponding. Clearly, in a situation that requires training to solve, direct help can be both effective and ineffective.

Helping categories can be ranked according to their utility to the bystander. One might expect people to resort to direct appropriate helping if they know how. If they lack the knowledge, one might expect bystanders to resort to indirect helping (i.e., finding others who can help appropriately). Alternatively, they can attempt to help directly, but to do so inadequately, or simply not respond to the emergency. We now describe the outcome of skills training on these different types of responding.

Method

Training Program

Each term the Health Education Department of Penn-

sylvania State University offers a two-credit course covering a wide variety of trauma topics. On successfully com-

350 R. LANCE SHOTLAND AND WILLIAM D. HEINOLD

pleting the course, a student obtains American Red Cross certification in Advanced First Aid and Emergency Care. The usual course enrollment is approximately 250 students and is instructed by 15 Red Cross certified first-aid

instructors. The types of trauma dealt with in the course include severe bleeding, poisoning, skeletal injuries, pul- monary and cardiac, arrest, and so on. One of the course requirements has been participation in out-of-class re- search projects. One of the experimental manipulations was an aspect of the training received in this course.

Emergency

The emergency chosen as a test was an injury involving serious arterial bleeding. It was chosen because it is an injury that is clearly defined as an emergency once the injury is seen (Shetland & Huston, 1979). Severe arterial bleeding can be considered a life-threatening emergency, and death could occur from such a wound in a period of 4-10 min if approximately a quart of blood were lost by an adult (Hafen, 1981). Second, on sight the problem is obvious because blood rhythmically spurts from the

wound. Third, there are standard accepted intervention procedures that are easily observed and recorded and

would not injure a confederate. The proper intervention for external bleeding is simply to apply direct pressure to the wound and solicit outside help (Hafen, 1981). Other emergency procedures such as CPR or the Heimlich

maneuver could lead to confederate injuries.

Independent Variables

Three variables were manipulated in a 2 X 2 X 2 (Ambiguity X Number of Perceived Bystanders X Level of Training) design. Because training in control of bleeding procedures was not presented until the beginning of the fourth week of instruction, training was manipulated in a pretest/posttest manner. Following the model of Yaki- movich and Saltz (1971), we manipulated ambiguity so

that in the low-ambiguity condition the victim screamed for help, and in the high-ambiguity condition there was

only the sound of the accident that produced the arterial bleeding. The perceived number of bystanders was ma- nipulated such that subjects were either alone or in a group (one male and one female confederate in all cases).

Confederates were trained to show no visible reactions to the accident stimuli, but to react normally to any directions that subjects might issue to them during the course of the emergency.

Subjects

Students taking the training course who had had previous first-aid training were eliminated from the subject population. Eligible students were randomly assigned to one of the eight cells of the design. Thus pretraining subjects were randomly assigned to Weeks 1, 2, or 3, whereas posttraining subjects were randomly assigned to Weeks 8, 9; or 10 of a 10-week term. Subjects then self- selected a time of the week from available appointments in which to report to an ostensible interview concerning student health services, conducted jointly by the College of Health Planning and Administration and the U.S. Department of Health and Human Services. One hundred ten subjects were assigned to each of the pretraining and

posttraining groups; 105 and 104 prospective subjects, respectively, signed up. Eighty-three usable subjects re- sulted from the pretraining group and 80 from the posttraining group. Subjects were lost because of missed appointments, arriving with friends, coming up the back steps and thereby not passing the location where the accident was to occur, and so on. The usable subjects were 100 female and 63 male students.

Procedure

As subjects arrived at the campus ROTC building (at

45-min intervals) for their interviews, they necessarily passed a worker in the foyer adjacent to the hall leading

to the interview room on the third floor. The worker was standing atop a 7-foot steptadder, ostensibly repairing an overhead glass lighting fixture. From the time subjects entered the building until the "accident," the worker made working sounds using an electric drill, hammer, and screwdriver. Subjects walked by the workman, through the propped-open door of a set of double doors, in order to enter a hail approximately 30 m long that led to the interview room. The second door was forced closed by work equipment. This arrangement allowed the worker

to observe subjects unobtrusively in the hall, but provided concealment for the set-up and execution of the forth- coming accident. After subjects walked through the double

doors they could not observe the workman in the foyer area.

When subjects arrived at the interview room, approx- imately 10 m from the foyer, they saw a sign posted to the door indicating that the interviewer had been called downstairs and would return immediately. They were instructed that they were meanwhile to begin filling out one of the interview forms provided. If the subject was

to be with confederate fellow bystanders, the female confederate was seated and working on the form and the male confederate arrived shortly thereafter: When the worker saw that Uie subjects (and confederates) were

seated in the hall, he moved behind the closed door out of view, and prepared for the accident.

He first changed into a second pair of white painters' pants which were hidden at the work site. These trousers were identical to the pair he was wearing except equipped

with special devices for simulating an arterially bleeding wound below the right knee. A realistic imitation wound,

plastic tubing, a hand pump, and theatrical blood were used to create the pulsating bleeding emanating from his leg.' The "wound" was glued under a jagged tear in the right pants leg just below the knee. The tubing was strapped inside the trousers and ran from the wound to the hand pump, which the worker could operate to pulsate blood to the wound.

The worker made a pool of "blood" approximately 6 in. in diameter in the location where his right knee was going to be and placed shards of broken glass around the puddle. After the "stage" was set, the workman toppled the ladder, causing a loud crash as ladder and tools (hammer, saw, screwdriver, wood slats, and metal screws, etc.) hit the linoleum-tiled floor. In the high-

1 All these components are commonly found in moulage kits used to imitate wounds and bleeding and are some- times used in the filmmaking industry.

BYSTANDER RESPONSE TO ARTERIAL BLEEDING 351

ambiguity condition it was clear that an accident of some type had occurred, but not whether help was needed. In

the low-ambiguity condition, the worker yelled, "Help" immediately after the accident sound, thereby providing

that information. The exact nature of the accident was not known to subjects unless they reentered the foyer, as the incident could not be seen from the hallway. Lying motionless and turned on his left side, the "victim" pumped between 5- and 1-in. streams of "blood" at

approximately 1-s intervals with his right hand, which was laid across his chest. This position completely con- cealed the apparatus.

From the time of the end of the sound of the accident, subjects were given 1 min to rise from their chairs. Those

subjects who remained seated after the minute had elapsed were considered nonresponders and their trials were terminated. If subjects who initiated a response passed through the double doors to the foyer, they were given an additional minute to complete a response. The trial was terminated before this additional minute was over if the subject made an effort to leave the floor and came into contact with our "containment" men. These men were stationed on the landing below each of the two stairways that provided access to the top floor, where the emergency took place. Subjects who initiated contact with the containment person and described the emergency

or asked for help were counted as indirect interveners. The trial was also terminated if subjects applied direct pressure to the "wound"

Subjects were under constant surveillance through

hidden video cameras and their responses were coded from the video monitors. Coding was cross-checked for accuracy in a later viewing of the videotapes. No coding

errors were detected because the behavioral incidents of interest were easily observed and were qualitative in character All procedures were cleared through the Uni- versity Behavioral Science Ethics Committee.

Results

The scene was believable. Of 163 subjects, only 6 showed any sign of suspicion. All six became suspicious only after making a direct pressure response. One of the suspicious sub- jects was a surgical nurse who had slipped through the subject screening and had applied direct pressure to the wound before realizing that the blood did not "smell right." The other subjects who became suspicious felt the wound shift because of the pressure applied to it.

As hypothesized, four different clusters of responses were observed and coded. The first category consisted of nonhelpers, who either never explored the situation or explored but offered no help. They generally remained seated and did not exhibit much arousal. The three remaining categories were composed of people who wanted to help and explored the situation after the sound of the emergency. These subjects appeared to exhibit extreme

arousal, characterized by such behaviors as trembling and the initiation, but did not complete a number of different acts such as approaching the victim, starting to leave the scene, and so on. These categories were as follows: ineffective helpers, who tried to help directly and touched the victim without of- fering appropriate first aid; indirect helpers, who offered no appropriate first aid but sought outside intervention; direct interveners, who offered appropriate first aid consisting of di- rect pressure. Although subjects are classified by their response into only one category, they may have exhibited other types of behavior as well. Hence bystanders were categorized by their most helpful response. Direct inter- veners may have started "helping" with an ineffective response (e.g., checking for a pulse) then switched to direct pressure and shouted for help. Given that the most immediate need was stopping the blood, the person was clas- sified as a direct responder. Indirect responders frequently began with an ineffective response, then made the second best response (the best being to apply direct pressure themselves), which was to try to find someone else who could handle the situation. Ineffective helpers attempted only ineffective help. Nonrespond- ers produced no behavior that could be con- strued as an attempt to help. The number of subjects in each of the four response categories by experimental condition is presented in Table 1.

Statistical Testing Procedures

The statistical tests consisted of three sepa- rate multiway contingency table analyses (Bishop, Fienberg, & Holland, 1975). In the three analyses, we made use of the same 2 X 2 X 2 X 2 (Training X Number of Confererate Bystanders X Ambiguity X Sex) factorial de- sign.2 The dependent variables differed in the three analyses. The first enabled us to analyze all four helping categories and was used to determine which independent variables caused differences in the modes of responding. This analysis provided the only accurate portrayal of the fit of a complete model in which one can use all of the response categories.

The second analysis was designed to answer

2 Sex was not incorporated into the original design, but was later included in the analysis.

352 R. LANCE SHOTLAND AND WILLIAM D. HEINOLD

Table 1

Percentages and Frequency Distribution of Subjects by Response Type for Training Level, Ambiguity Level, and Number of Perceived Bystanders (Collapsed Across Sex)

Untrained group Trained group

Ambiguous Unambiguous Ambiguous Unambiguous

Response type

Nonhelp % n

Ineffective help % n

Indirect help % n

Direct help % n

Alone

62 13

14 3

19 4

5 1

Group

75 15

0 0

20 4

5

1

Alone

14 3

14 3

64 14

9 2

Group

25 5

10 2

65 13

0 0

Alone

35 7

15 3

15 3

35 7

Group

60 12

0 0

10 2

30 6

Alone

20 4

10 2

20 4

50 10

Group

30 6

0 0

25 5

45 9

the question "What factors determine whether bystanders try to help?" This is the classical helping behavior analysis. All three helping categories were collapsed into a single helping category so that there were two categories: helpers and nonhelpers.3 The third analysis was used to determine which factors caused bystanders to choose a specific helping strat- egy. Therefore the three different types of help (direct, indirect, and ineffective) were the three dependent categories in this analysis.

Overall model. The "overall analysis," or the analysis in which we used all four response categories, yielded a model of best fit con- taining the following four main effects: (a) the presence of confederate bystanders,4 (b) amibiguity, (c) sex, and (d) training: x2(33, N = 163) = 25.38, p > .83.5 An alternative which was similar to the accepted model but differed because it contained the interaction of ambiguity and sex was rejected. The inter- action did not significantly improve the fit of the model, G2(3) = 7.41, and the inclusion of the term would have created a less parsi- monious model. The accepted model provided an excellent fit to the data.

Helper versus nonhelper model. The anal- ysis used to differentiate people who made an attempt to help from those who did not yielded a model of best fit that contained the main effects of (a) ambiguity, (b) sex, and (c) the presence of bystanders x2(12, N = 163) = 17.87, p > .12. Although the model is acceptable, the fit is poor, indicating the

involvement of other unspecified factors in the model (e.g., individual differences). Again, an interaction of sex and ambiguity did not improve the fit of the model over the main effects, <?2(1) = 2.97, and therefore was not included.

Helper model. The analysis that was used to differentiate the three different attempts to help contained only one variable: training.

The accepted model provided an excellent fit to the data, x2(28, N = 98) = 17.91, p > .92.

3 The coding system that is most frequently used in bystander intervention research is a binary system; the person is coded as either helping or not helping. In general, when data is analyzed and reported, it is the percentage of people that help that is presented. To analyze and then report the rate of nonhelping would provide totally redundant information and therefore is not done. In the coding system used in this study, the normal helping response is divided into three categories. Results that are equivalent to a standard binary analysis are presented in the discussion of variables that affect the rate of nonresponding. Hypothesis-testing statistics should be equivalent, and one can obtain the rate of responding by subtracting the proportion of nonresponders from 1.0.

4 The partial association tables indicated that the num- ber of bystanders present was only marginally significant and could be included or excluded from either the overall or helper-versus-nonhelper models. Given the over- whelming support in the literature for the presence of the effect (see Latane, Nida, & Wilson, 1981), we included it in both models.

' All chi-squares associated with the multiway contin- gency table analyses are likelihood ratio chi-squares. G2

is a likelihood ratio chi-square and is an indication of the relative fit of the model.

BYSTANDER RESPONSE TO ARTERIAL BLEEDING 353

We now provide a description of the effects of the independent variables on each of the four response categories in turn. Any discrep- ancies between the results derived from each model are described and discussed.

Responses

Nonhelping response. Approximately 40% of the subjects did not respond to the emer- gency. Of these individuals, 97% did not explore the reasons for the sound (two non- responders had explored).

The helpers-versus-nonhelpers analysis in- dicated that the level of ambiguity in the emergency was important in determining the rate of intervention. More nonresponders were in the ambiguous situation (58%) than were in the nonambiguous situation (22%; X = 4.65, p < .001). Female subjects (50%) were more frequent nonresponders (50%) than were male subjects (24%; X = 3.39, 'p < .001).

The presence of other bystanders tended to increase the rate of nonresponding. Subjects with confererate bystanders were nonrespon- sive 48% of the time in comparison with lone subjects' rate of 33% (X = 1.73, p < .09). These results are consistent with the eifects found in the overall analysis, the major dif- ference being that the trend associated with lone bystanders reached statistical significance (X = 2.00, p < .05).

Ineffective direct response. Approximately 8% of the subjects responded by approaching and touching the victim, but not making a correct first-aid response and not seeking other help. Of the subjects who were alone, 13% responded with ineffective direct help in comparison with 2.5% of subjects who were with other bystanders. This effect is estimated to be only marginally significant as estimated from both the analysis of helpers (X = 1.53, p < ,13) and the overall analysis (X = 1.84, p < .07). In addition, as we mentioned pre- viously, the variable did not add significantly to the fit of the model that differentiated among the three helping categories. However, there is more support for an effect of the number of bystanders on the mode of help; we present evidence of this support in the Discussion section.

Indirect response. Approximately 30% of subjects either yelled for help or searched for

outside intervention without providing ade- quate first aid. These two responses occurred with approximately equal frequency. These individuals were apparently searching for someone who might be able to help. To confederate bystanders, they frequently re- sponded, "Call an ambulance!", "Get some help!", "This guy's hurt!", and so on.

The only variable that distinguished indi- rect responders from the other helping re- sponders was training. Indirect responses oc- curred more frequently among untrained (42%) rather than trained subjects (18%; X = 3.37, p< .001).

A discrepancy between the overall analysis and the analysis of the helping responses was that the overall analysis indicated that sex and ambiguity were significantly related to indirect helping. These effects are artifacts of the statistical dependency between the four response categories. If people in the ambig- uous condition and women are frequently among the nonresponders, there are fewer women helpers and helpers in the ambiguous condition left to respond indirectly or in any other fashion. When one drops nonhelpers from the analysis and reconditionalizes the data, ambiguity and sex do not differentiate among direct, indirect, or ineffective helpers.

Direct pressure response. Twenty-two per- cent of the subjects responded with a direct pressure response, the prescribed method of controlling arterial bleeding. The only variable that separated direct pressure responders from other helpers was training. Only 5% of the subjects in the untrained condition responded in this fashion, whereas 39% of subjects in the trained group responded with direct pres- sure (X = 4.31, p < .001, helper analysis). Over 70% of the subjects who applied direct pressure also called for help, the most desir- able response and the response taught in training.

Discussion

The four helping responses just illustrated are not unique to the literature. Three of these helping responses were observed in previous investigations, and a similar pattern of four responses (if "passive helping" is equivalent to "ineffective helping") was found with a simulated rape (cf. Shetland & Steb-

354 R. LANCE SHOTLAND AND WILLIAM D. HEINOLD

bins, 1980). What is the difference between the research in which two categories of helping are found and the research in which either three or four are found? On the basis of the "Limited Altruism" model of Shetland and Stebbins (1983, p. 109) and the results of this study, we conclude that the lack of knowledge of how to solve the problem directly is one cause of indirect helping. As Piliavin et al. (1981) and Shetland and Stebbins (1980) suggested, studies that obtain indirect helping tend to involve more severe emergencies than do the ones that obtain two responses. Shot- land and Huston (1979) found that both a "rape in progress" and "a cut artery" were rated by subjects as "definite" emergencies. In the studies cited by Piliavin et al., seizures, unconscious victims, physical attacks, thefts, and so on, were portrayed. In most laboratory simulations yielding two responses, research- ers use situations that are not as severe. The more severe the emergency is, the more likely it is that bystanders do not know or are not confident enough to use needed specialized knowledge, and thus they resort to indirect helping. An ineffective direct response may also occur partly for the same reason. How- ever, as we more fully describe later, this response also occurs because some avenues of indirect helping are also closed off to these bystanders.

Obviously, the complexity of the dependent variable(s) also depends on when the investi- gator terminates the bystanders' responses. If subjects are stopped before they can try to help, valuable data are lost. It seems that if helping behavior researchers explore the full range of bystander responses, more could be learned about both the dynamics of bystander behavior, the decision-making process, and the individual differences that lead to differ- ential responding.

One of the most striking results of this study is the efficaciousness of training. Put in its starkest context, with a real injury of the magnitude of the simulation, the victim could have died without first aid in 4-10 min. In the untrained group, only 4 of 83 victims had a reasonable chance of survival. In the trained group, 32 of 80 victims had that chance. Thus the effect of training had a net value of saving as many as 28 lives. Training appears to be an important practical variable.

Twenty-eight more subjects in the trained group than in the untrained group used direct pressure in their response. Before training, what type of response would these subjects have made? Clearly, most of the direct-pressure responders before training would have been indirect helpers, the other response type affected by training. Because training caused 28 more direct-pressure re- sponses, it also caused 21 fewer indirect re- sponses.

In other words, skills training seems to significantly change not the rate of responding but rather the types of responses of people who try to help. Thus skills training affects the decision concerning how to help rather than the decision of whether to help. One might ask why is it that indirect responders are affected by training.

Perhaps indirect responders felt, in Schwartz's (1977) terms, a "moral obligation" to help. Perhaps this moral obligation was lacking among many of the nonresponders, who showed fewer signs of arousal and concern. Apparently, nonresponding does not primarily result from a lack of knowledge of the correct course of action, but indirect helping does. Thus training raises the rate of appropriate behavior by teaching skills to people who are motivated to help. Training for an appropriate response does not seem to significantly change the rate of responding of those not motivated to help.

The rate of nonresponding was affected by three main effects: sex, ambiguity, and the number of bystanders. The sound of the emergency indicated that the workman could have been seriously injured, although alter- native explanations were still possible, for the emergency was heard but not seen, at least initially. The cry for help provided further evidence that the worker needed help; thus more subjects chose to explore or try to help. Women may have helped less frequently be- cause they felt less competent than men to face a victim with a serious injury. Perhaps women feel less adept at moving heavy fallen objects, or are socialized to take less initiative unless the situation is unambiguous (see Deaux, 1976). The explanations for the im- pact of the number of bystanders on the rate of helping are well known (cf. Latane & Darley, 1969; Latane, Nida, & Wilson, 1981) and do not need further discussion.

BYSTANDER RESPONSE TO ARTERIAL BLEEDING 355

The results suggest that lone bystanders were more likely to be ineffective direct help- ers than were bystanders who were in the presence of others. Why should the presence or absence of other bystanders affect the methods of help?

The easiest explanation is that when by- standers are alone, they are less likely to think that others who possess greater first aid knowledge are immediately available. There- fore, the responsibility is theirs to do the best they can without the aid of others; that is, no diffusion of responsibility can take place (Latane & Darley, 1969). In this case the best they could do was not good enough because either they had no training or they did not remember their training.

If other bystanders had been present, we would have expected many more ineffective helpers to have resorted to indirect helping because these ineffective helpers would have known that calling for help would have at least been heard. In fact, some of the indirect helpers did, before calling for help, produce some direct ineffective responses. Additional support for this expectation was provided from 10 direct-pressure helpers who did not include a call for help, which they were trained to do. This lapse is perfectly reason- able once it is understood that 9 of these 10 bystanders were alone. Moreover, as we pre- viously mentioned, approximately half of the indirect helpers shouted for help, whereas the other half searched for help. As one would expect, 70% of those who shouted were in groups, whereas 78% of those who searched for others to help were alone (Z = 3.84, p < .001).6 In summary, a bystander who is alone is less likely to consider at least one form of indirect responding, namely, calling out for help. Instead, bystanders may do the best they can by themselves. Thus in a certain percentage of the time, ineffective direct help- ing occurs.

Our data supports the conclusion of Schwartz and Gottlieb (1970, 1980) that the number of bystanders affects the interpreta- tion of the event as well as the decision concerning whether to help. In addition, our data would support the proposition that if a bystander is alone, it affects the decision concerning how to help as well.

We conclude therefore, that the ambiguity and sex variables affect the decision of whether

to help, but not how to help. (With other types of emergencies, it seems reasonable that sex may have different effects on whether and how one helps; cf. Deaux, 1976.) Skills train- ing affects the decision of how to help but not that of whether to help, whereas the presence of other bystanders affects both the decision concerning whether to help and the decision concerning how to help.

We also note that 98% of the subjects who entered the foyer attempted to help the victim. This is an indication that "the approach," the ubiquitous dependent variable in by- stander research, is a valid measure of the intent to help. However, our data would suggest that the intent to help is not synon- ymous with having actually provided aid. If our victim required help within 4 to 10 min, only 37% of the victims in which bystanders had tried to help would have had a good chance at survival because of the use of a direct-pressure response. Indirect helping may or may not have been successful, depending on the time required to obtain a solution.

We would be remiss to end without dis- cussing the potential threats to the validity of our conclusions concerning the training variable. As should be clear from our descrip- tion of the method, the training variable was tested in a pretest/posttest manner without a control group. Do problems with this design affect the validity of the conclusions drawn from the training variable? As Campbell and Stanley (1963) and Cook and Campbell (1979) point out, this type of design is open to alternative explanations because of threats to internal validity. Threats that are due to mortality and history appear to be relevant to this study. Mortality does not seem to be a threat because there was no differential loss of subjects in comparing the attrition rates from the pre- and posttraining groups in terms of subjects either signing up for or showing up for appointments. In addition, each of the 163 subjects with usable data had completed the course. Therefore, it appears that the randomization of subjects was not disturbed because of subject attrition.

History potentially poses a problem in that there was an assassination attempt on Presi-

6 The statistical comparison was between the 78% of those who were alone and searched for another helper and the 30% of those in groups who chose that strategy.

356 R. 1ANCE SHOTLAND AND WILLIAM D. HEINOLD

dent Reagen in the period between the run- ning of the pre- and posttraining groups. However, the impact of this event does not affect the general overall rate of responding (pretraining 57%, posttraining 64%), the basic type of response one might expect to be affected by such an event. In addition, no decrease resulted in the rate of nonresponding, either as a main effect of training or as an interaction between training and some other variable. In fact, the basic changes we did discover were changes in the type of reaction responders took. Nothing surrounding the assassination attempt or any other historical event appears to have the capability to have taught the proper direct pressure response or a decrease in indirect helping. The same evidence can be used to indicate that knowl- edge of the experiment did not spread through the class. We would have expected both the rate and the effectiveness of the response to have improved if information had been dif- fused. We uncovered no indications that knowledge about the experiment might have been diffused.

References

Ashton, N. L., & Severy, L. J. (1976). Arousal and costs in bystander intervention. Personality and Social Psy- chology Bulletin, 2, 268-272.

Beaman, A. L., Barnes, P. J., Klentz B., & McQuirk, B. (1978). increasing helping rales through information dissemination. Personality and Social Psychology Bul- letin, 4, 406-411.

Bishop, Y. M., Fienberg, S. E., & Holland, P. W. (with the collaboration of R. J. Light & F. Mosteller). (1975). Discrete multivariale analysis: Theory and practice.

Cambridge, MA: MIT Press.

Campbell, D. T., & Stanley, J. C. (1963). Experimental and quasi-experimental designs for research. Chicago: Rand McNally.

Clark, R. D., Ill, & Word, L. E. (1972). Why don't bystanders help? Because of ambiguity? Journal of Personality and Social Psychology, 24, 392-400.

Clark, R. D., Ill, & Word, L E. (1974). Where is the

apathetic bystander? Situational characteristics of the emergency. Journal of Personality and Social Psychology, 29, 279-287.

Cook, T. D., & Campbell, D. T. (1979). Quasi-experi- mentation design and analysis issues for field settings.

Chicago: Rand McNally. Crampton, R. S., Aldrich, R. E, Gascho, J. A., Miles,

J. R., & Stillerman, R. (1975). Reduction of prehospital, ambulance and community coronary death rates by the community-wide emergency cardiac care system. The American Journal of Medicine, 58, 151-165.

Deaux, K. (1976). The behavior of women and men. Monterey, CA: Brooks/Cole.

Eisenberg, M. S., Bergner, L., & Hallstrom, A. (1979). Cardiac resuscitation in tlte community: Importance of rapid provision and implications for program plan-

ning. Journal of the American Medical Association, 241, 1905-1907.

Form, W. H., & Nosow, S. (1958). Community in disaster. New York: Harper & Row.

Hafen, B. Q. (1981). First aid for health emergencies (2nd ed.). SI. Paul, MN: West.

Huston, T., Ruggiero, M., Conner, E, R., & Geis, G. (1981). Bystander intervention into crime: A study based on naturally occurring episodes. Social Psychol- ogy Quarterly, 44, 14-23.

Kazdin, A. E., & Bryan, J. H. (1971). Competence and volunteering. Journal of Experimental Social Psychol- ogy, 7, 87-97.

Latane, B., & Darley, J. M. (1969). Bystander "apathy." American Scientist, 57(2), 244-268.

Laiane, B., Nida, S., & Wilson, D. (1981), The effects of group size on helping behavior. In J. P. Rushlon & R. M. Sorrentino (Eds.). Altruism and helping behavior (pp. 287-314). Hillsdale, NJ: Erlbaum.

Midlarsky, E. (1971). Aiding under stress: The effects of competence, dependency, visibility, and fatalism. Jour- nal of Personality, 39. 132-149.

Midlarsky, E., & Midlarsky, M. (1973). Some determinants of aiding under experimentally induced stress. Journal of Personality, 41, 305-327.

Pantin, H. M., & Carver, C. S. (1982). Induced compe- tence and the bystander effect. Journal of Applied Social Psychology, 12, 100-111.

Piliavin, J. A., & Piliavin, 1. M. (1972). Effect of blood on reactions to a victim. Journal of Personality and Social Psychology, 23, 353-361.

Piliavin, J. A., Dovidio, J-, Gaertner, S., & Clark, R. D. (1981). Emergency intervention. New York: Academic

Press. Schwartz, S. H. (1977). Normative influences on altruism.

In L. Berkowitz (Ed.), Advances in experimental social psychology (NA 10, pp. 221-279). New York: Academic Press.

Schwartz, S., & Ben David, A. (1976). Responsibility and helping in an emergency: Effects of blame, ability and

denial of responsibility. Sociometry, 39, 406-415. Schwartz, S., & Gottlieb, A. (1970). Bystander reactions

to a violent theft: Crime in Jerusalem. Journal of Personality and Social Psychology, 34, 1188-1199.

Schwartz, S., & Gottlieb, A. (1980). Bystander anonymity and reactions to emergencies. Journal of Personality

and Social Psychology, 39, 418-430, Shotland, R. L. (1976). Spontaneous vigilantism: A by-

stander response to criminal behavior. In H. J. Rosen- baum &. P. C. Sederberg (Eds.), Vigilante politics (pp. 30-44). Philadelphia: University of Pennsylvania Press.

Shotland, R. L., & Huston, T. L. (1979). Emergencies: What are they and do they influence bystanders to intervene? Journal of Personality and Social Psychology, 37, 1822-1834.

Shotland, R. L., & Stebbins, C. A. (1980). Bystander response to rape: Can a victim attract help? Journal of Applied Social Psychology, 10, 510-527.

Shotland, R. L., & Stebbins, C. A. (1983). Emergency and cost as determinants of helping behavior and the

slow accumulation of social psychological knowledge. Social Psychology Quarterly, 46, 36-46.

Yakimovich, D., & Saltz, E. (1971). Helping behavior: The cry for help. Psychonomic Science, 23, 427-428.

Received June 22, 1983

Revision received September 4, 1984 •