Police and mental health clinician partnership in response to mental health crisis

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Feature Article Police and mental health clinician partnership in response to mental health crisis: A qualitative study Brian McKenna,1,2 Trentham Furness,1,2 Jane Oakes1,2 and Steve Brown3 1 School of Nursing, Midwifery and Paramedicine, Australian Catholic University, 2 NorthWestern Mental Health, The Royal Melbourne Hospital, and 3 The Northern Hospital, Northern Health, Melbourne, Victoria, Australia
ABSTRACT: Police officers as first responders to acute mental health crisis in the community, commonly transport people in mental health crisis to a hospital emergency department. However, emergency departments are not the optimal environments to provide assessment and care to those experiencing mental health crises. In 2012, the Northern Police and Clinician Emergency Response (NPACER) team combining police and mental health clinicians was created to reduce behavioural escalation and provide better outcomes for people with mental health needs through diversion to appropriate mental health and community services. The aim of this study was to describe the perceptions of major stakeholders on the ability of the team to reduce behavioural escalation and improve the service utilization of people in mental health crisis. Responses of a purposive sample of 17 people (carer or consumer advisors, mental health or emergency department staff, and police or ambulance officers) who had knowledge of, or had interfaced with, the NPACER were thematically analyzed after one-to-one semistructured interviews. Themes emerged about the challenge created by a stand-alone police response, with the collaborative strengths of the NPACER (communication, information sharing, and knowledge/skill development) seen as the solution. Themes on improvements in service utilization were revealed at the point of community contact, in police stations, transition through the emergency department, and admission to acute inpatient units. The NPACER enabled emergency department diversion, direct access to inpatient mental health services, reduced police officer ?downtime?, improved interagency collaboration and knowledge transfer, and improvements in service utilization and transition. KEY WORDS: crisis intervention, mental health nurses, mental health, police.
Police officers are often the first responders to acute mental health crisis in the community. In metropolitan Melbourne, Australia, within one police division, 41% of police officers reported they responded to calls involving people with mental illness at least weekly (Hollander et al. 2012). Furthermore, 21% of police officers reported transporting people with mental illness for emergency mental health care at least weekly (Hollander et al. 2012). The transportation by police officers of people experiencing a mental health crisis for mental health assessment is supported in Victoria by mental health legislation, if risk is apparent to the individual or others (State Government of Victoria 1986; 2014).
As such, people experiencing a mental health crisis have predominantly been transported to Victorian hospital emergency departments (ED) (State Government of Victoria 2005). Unfortunately, the processing of people experiencing mental health crises through the ED for the purposes of mental health assessment is problematic on several counts, such as long length of stay (Kalucy et al. 2005; Knott et al. 2007; Shafiei et al. 2011) and the use of restrictive interventions such as physical restraint (Al-Khafaji et al. 2014; Knott et al. 2007). Nationally, the number of people in mental health crises presenting to the ED is rising to nearly a quarter of a million in 2010? 2011, of which two-thirds were sent home at discharge from the ED (Australian Institute of Health and Welfare 2012). Internationally, efforts to improve first responder police officers? efficiency and quality of care during mental health crises have been attempted with mental health education and training models (Compton et al. 2008; Steadman et al. 2000). However, a limited body of evidence supports such police education and training interventions to connect people in mental health crisis to appropriate mental health care after contact with police officers (Compton et al. 2008). An alternate is for first responder police officers attending to a mental health crisis in the community to then call/initiate a specialist second responder team (Lamb et al. 1995). The second responder comprises at least a law enforcement officer and a mental health clinician, usually a mental health nurse (Lamb et al. 1995). The goal of the second response team is to reduce the potential for violence, prevent unnecessary custodial incarceration, and provide alternate care in less restrictive environments through interagency collaboration (Lamb et al. 1995). However, the effectiveness of such interventions is barely known (Shapiro et al. 2014). The selection and implementation of a first or second responder intervention/model has been left to decisions based about the context of service delivery and resource constraints among health and emergency services (Fisher & Grudzinskas, 2010). As such, in late 2012, the Victoria Police along with Northern Area Mental Health, which serves a combined population of 575 000 people (Australian Bureau of Statistics 2014) in metropolitan Melbourne, established the Northern Police and Clinician Emergency Response (NPACER) team. The team resembles a second response model (Lamb et al. 1995) comprising a police officer and a senior mental health clinician attending to a mental health crisis in the community, after an initial police response requires the person to be assessed by a mental health practitioner under mental health legislation. First responder police ensure the incident is resolved or contained on a safety first basis, prior to the introduction of the NPACER unit. The NPACER team is tasked to provide mental health assessment, reduce the risk of behavioural escalation, and provide a better outcome for those people with mental health needs through diversion to appropriate mental health and community services. The model has a focus on ED diversion with the capacity to directly admit people to acute inpatient services. The NPACER team consists of a mental health nurse and a police officer. Clinicians are drawn from a limited pool of senior emergency mental health nurses in the service, while the police officers are drawn from a wider pool of rostered staff, cognisant of experience and support for the NPACER initiative. The NPACER team operates 7 days a week, every afternoon/evening (15.00?23.30 hours). The aim of this study was to describe the perceptions of major stakeholders on the ability of the NPACER model to reduce behavioural escalation and improve the service utilization of people in mental health crisis. METHODS Research design An exploratory research design, which is used when a problem is not clearly defined (Stebbins 2001), was used to meet the descriptive research aims. This research was approved by the Melbourne Health Office for Research (QA2013141). Participants A purposive sample of key stakeholders interfacing with people in mental health crisis and who had broad knowledge of the NPACER (consumer advisors as the voice of consumers, carer advisors as the voice of carers, mental health staff, ED staff, police officers, and ambulance officers) were recruited and provided informed voluntary consent to participate in one-to-one semistructured interviews from January to July, 2014. Procedures The literature-informed interview schedule enquired about perceptions of the NPACER: (i) benefits; (ii) limitations; (iii) outcomes; and (iv) the impact on the work environment including job satisfaction and collegial relationships. Prompts were levelled at perceptions of the ability of the NPACER to manage mental health crisis, collaboration between agencies present during the crisis, and communication between all those involved. For example, ?Discuss how NPACER has impacted on col laboration between police officers and inpatient or ED mental health staff?. Respondents were asked to provide specific pragmatic examples from their experience. The interview schedule was identical across all participants. The same researcher (B. M.) conducted all one-to-one interviews. Responses were recorded to an audio-digital recorder (ICD-PX333M; Sony, Tokyo, Japan). Data analysis A thematic analysis of the qualitative data was undertaken using a general inductive approach. This approach allows defensible analysis of qualitative data that may initially be varied raw text and allows it to be condensed into brief summaries (Thomas 2006). Data were transcribed verbatim and organized using colour coding. The codes were developed through continuous independent reading and agreement among the researchers (B. M. and J. O.). As necessary during analysis, codes were either collapsed or split into developing themes, until central relationships began to emerge (Patton 2002). Each theme was examined for supporting quotes from the data. Rigor was further enhanced by collective agreement among the research team on the thematic analytic framework, emergent patterns, and supporting evidence (Guba & Lincoln 2005; Mays & Pope 1995). RESULTS Sample description A total of 17 participants who interfaced with the NPACER provided informed voluntary consent to participate in this research. The sample included three consumer advisors and three carer advisors (who had spoken with consumers/carers with experience of the NPACER); the manager of the acute mental health inpatient service and two senior staff nurses from the unit all with direct experience of the NPACER (as the voice of inpatient mental health staff); the associate unit manager, clinical director, the manager of mental health staff, and a mental health crisis nurse, all stationed in the ED with direct experience of the NPACER (as the voice of ED staff); two police officers and the police station commander all with direct experience (as the voice of police staff); and a manager of the ambulance service with direct experience of the NPACER. Major themes The participants in this study readily discussed their perceptions of how the NPACER functioned to reduce behavioural escalation, improve consumer outcomes, and improve access to appropriate mental health care. A major theme emerged about the challenge created by a stand-alone police response that existed prior to the NPACER. A theme then emerged as a solution to this challenge focused on the collaborative strength of the NPACER. This collaboration was exemplified in the subthemes of communication, information sharing, and knowledge/skill development. The third theme focused on improvements in the person?s pathway through service utilization towards resolution of the crisis. Four areas along this pathway were highlighted as subthemes; at the point of community contact, the use of police stations, progress through the ED, and admission to acute mental health inpatient services. Finally, the means of enhancing the NPACER arose as a distinct theme from the data. The challenge: A stand-alone police response The discussions of the NPACER compared the model with a stand-alone police response which involved practices which were perceived by consumer and carer advisors as traumatic and distressing. Incidents were described involving the use of restrictive interventions including handcuffs: I?ve had quite a few people talk about how terrible that is and to have to see your loved one be handcuffed, being put in a van. . . . (Carer advisor) The use of restrictive interventions by the police was perceived as stemming from a lack of understanding and a limited repertoire of strategies to manage people in mental health crisis. This limited repertoire was perceived as leaving people in crisis disempowered in their time of need: Police don?t have an understanding of people living with mental illness and often the procedures of even putting people in handcuffs, if somebody?s not aggressive. . . . Handcuffing somebody is absolutely re-traumatizing them . . . they (the consumers) don?t feel like they?ve got any control. (Consumer advisor) The default local practice of a stand-alone police response at a mental health crisis was the transportation under mental health legislation of people to the ED for mental health assessment. This was perceived as causing congestion in the ED. The associated ?bottleneck? was frustrating for both staff and the person in crisis. For the ED staff, there was an acknowledgement that a lot of the people eventually returned home, which led them to question whether they should be there in the first instance. The congestion led to increased waiting time which elevated psychological distress for the person in crisis: A lot of patients who present (under police custody mandated by mental health legislation) do get discharged home and when they were presenting in high numbers there isn?t a resource to actually see them in a timely manner, which then escalates their behaviour. (Voice of ED staff) A statutory requirement is for the police to remain in the ED with the person until the mental health assessment has taken place. However, the ?bottleneck? created in the ED was perceived as having ramifications for the police, in that time spent in the ED awaiting mental health assessment delayed return to the community, to focus on other law enforcement requirements: At the end of the day, if our police are tied up with assessments and/or we?re waiting at a hospital environment for a clinician to conduct that assessment, that?s problematic for us. (Voice of police staff) The volume of people in mental health crisis processed through the ED was reflected in communication breakdown between the police and the ED staff, whereby people were escorted by police into the ED without any prior notification to the service: They (the police) don?t tell us that they?re coming, they just walk the patient in, who?s screaming, carrying on, you know. It?s a really dangerous situation. (Voice of ED staff) The solution: Collaboration through the NPACER The challenges posed through a stand-alone police response to mental health crises were seen as being addressed through the collaborative endeavour of police and mental health nurse expertise embodied in the NPACER. This collaborative working relationship was developed by the parties working side-by-side from the same location, over shifts that extended to each day of the week: The simple model is this: You get people working together for a sustained period of time, they start to learn each other?s strengths and weaknesses and appreciate their strengths and weaknesses. So it?s a ?no-brainer? to me that the collaboration model has yielded fruit. (Voice of police staff) Such collaboration enabled the development of a clearly understood modus operandi in managing safety associated with the crisis and then facilitating the pathway through services to address the crisis. Joint decisionmaking was at the heart of the management: There?s some very clear protocols in respect to when the NPACER can activate. Now, if a clinician?s not comfortable they will make it very clear, ?I?m not comfortable with this? and unless both parties agree they don?t enter that arena. (Voice of police staff) The strength of the collaboration was exemplified through the subthemes of communication, information sharing, and knowledge/skill development. Communication Collaboration was exemplified in the trust arising from direct face-to-face communication between the police officer and the mental health nurse as part of an integrated team response. This circumvented communication from a distance with agencies such as the dispatch authority and the ED, who may have a limited ability to impact on the actual management of the crisis: Yeah, what it does, it cuts out people from that communication loop who aren?t really necessary to it as well. (Voice of police staff) This improved communication resulted in each partner having a greater appreciation of the attributes of the other: Just being able to go out on the road with them and see and be a part of the assessments and listen to the sorts of questions that they ask, what they?re looking for . . . the relationship building, networking, lines of communication . . . it?s just made a world of difference. (Voice of police staff) Information sharing Collaboration enabled information sharing between the police and mental health nurses. Accurate information enabled each role to function to its potential in maintaining safety: The benefit that has been provided to police when they?re entering critical incident areas has really been quite phenomenal and that benefit of information sharing, you just can?t put a value to that. (Voice of police staff) Accurate information sharing was also extended to the service receiving the person in crisis. Information sharing was achieved by the police officer and mental health clinician both having access to real-time secure databases and sharing that information as appropriate and permitted by law. The process enabled more timely and improved decision-making via a synthesis of clinical and criminal justice information that provided a holistic picture of risk, safety, and disposition options. This also enabled prior planning to safely transition the person along the pathway of engagement toward eventual resolution of the crisis:
That information, accurate information, relayed for instance to the inpatient unit, so they understand the seriousness or the gravity of the situation, so they?re able to then more effectively manage the person. (Voice of police staff) Knowledge/skill development Close collaboration enabled both parties to acquire and develop new knowledge and skills to refine their roles. For the police, the starting point was an increased understanding of the relationship between symptoms of mental illness and the person?s presenting behaviour. This increased understanding enabled a more tolerant and effective management of people in crisis, which resulted in the police avoiding the use of force. The presence of a mental health nurse trained in de-escalation enabled a modification of the approach resulting in a less traumatic experience for the consumers and their carers: I think it can boost their (police) confidence so that they feel like they?ve got the knowledge that they need. . . . I think if people have a better understanding and they build up some skills they?re less likely to respond in an inappropriate way to consumers. Hopefully it builds confidence, knowledge, and skills for (police) to be able to do their jobs. (Consumer advisor) Improvements in the person?s pathway Contact between the person in crisis and the police initiated a pathway of service utilization toward eventual resolution of the crisis. This can involve a number of services, but primarily the ED and mental health services. The NPACER was seen as effective in streamlining this pathway by diverting people to less restrictive alternatives (i.e. to their home, to a GP, or to another community service) and by creating ?smoothness? by easing the transition along the pathway when the journey required engagement with multiple services (e.g. the NPACER clinician contacting en route the receiving ED to prepare for arrival). At the point of community contact The intent of the NPACER was initial assessment followed by the diversion of people to have their needs met, away from the ED, by referral to appropriate community options. Those interviewed perceived this to be the case: They may decide to refer that person back to a private psychiatrist, or a GP for a mental health plan, or drug and alcohol services or contact one of those multitude of services that are available out there in the community, in which case they would then do follow-up phone calls to whoever it was who was going to be following that person up and linking them back into that service. (Voice of police staff) Subsequently, consumers were managed in the least restrictive environment (i.e. their own homes or the community in which they lived). This alternative was perceived as a more dignified process for people than transporting them to the ED, which was dislocated from their social reality: The person isn?t displaced and . . . having to go to an emergency department. They can be seen in their own environment. (Voice of inpatient mental health staff) There were clinical advantages for this approach in that it facilitated a holistic assessment of the person in the social and environmental context within which the person functioned: The clinician is seeing them in that environment, in that context as well, and so they?re actually able to make a much more accurate assessment. (Voice of police staff) Use of police stations There were examples described of the use of police stations in the pathway toward crisis resolution. This followed circumstances whereby a person was transported to police holding facilities following alleged serious offending. Concern about the persons mental health status at this point then led to involvement of the NPACER and potential diversion to address mental health needs: The (police) can take somebody who they might arrest, somebody who they believe is performing a criminal act and then they take them back to the police station and during the course of the interview they might have concerns that that person?s actually mentally unwell and then they may say ?look, I?m holding you here under Section 10 and we?re going to get the NPACER?. (Voice of police staff) Progress through the ED The impact of the NPACER on the ED was viewed positively. Improved communication between police officers, mental health clinicians, and ED staff was cited as aiding the smooth pathway of people in crisis through the ED. Diversion of those not requiring ED assessment was viewed as enabling those presenting with physical healthcare needs to receive optimal care: If you?re in the ED of an evening shift and you?ve come there with a physical complaint, now you? However, those in mental health crisis with co-existing physical health-care needs were still appropriately prioritized to the ED: There might be queries about the person?s physical health-care needs as well as mental health-care needs. . . . If my crew assess and find anything physical then that?s the priority, they must go through the ED for that. (Voice of police staff) When situations arose for people in mental health crisis who required the services of the ED to address physical needs, there was prior communication between the NPACER and the ED staff, which allowed preparation before arrival to ease the person through the ED experience. Furthermore, faster turnaround for people in the ED was facilitated by mental health assessments being completed in the community by the NPACER team: You get the phone call that you know when they arrive in the ambulance bay. They don?t just walk the patient into a chaotic situation. You assess the patient outside; you bring them in. It?s all very planned and well set up and the resources are there. You know what to expect. (Voice of ED staff) Admission to acute mental health inpatient services A role of NPACER is to divert acutely unwell people in crisis directly to acute mental health inpatient services for admission. This timely and efficient diversion was positively reported: You take the right patient to the right place at the right time. (Voice of ED staff) Timely admission to the acute mental health inpatient services was also viewed as advantageous for the police: The ED is probably going to be a minimum of 3 hours. Now that?s 3 hours we can commit to the community. So in terms of a win for us, if we can have direct admissions and stay out of the ED environment, then we can get back on the road. (Voice of police staff) Means for improving the NPACER In considering improvements, there were one-off comments regarding: (i) the need for more on-call support from a psychiatrist; and (ii) the need for professional development to manage people in crisis from culturally and linguistically diverse communities. However, there were more consistent calls from participants for additional resources to expand the NPACER from more than one work shift throughout the day: Maybe the possibility of increased hours. (Voice of police staff) Extending the hours and, of course, increasing the resource. (Voice of ED staff) A cautionary note emerged that the perceived success of the NPACER did not necessarily mean that it was a model that could be easily translated to mental health services in other areas. The high volume of mental health crises attended by the police was singled out as a defining reason for the model working in this particular area: We have a high need for the NPACER. If that need?s not there, I don?t think the collaboration model would be very effective at all. . . . I believe it works well because of the high demand we have in that mental health space. (Voice of police staff) DISCUSSION The major finding of this study was the perceived ability of the NPACER, a specialist second responder team to people in mental health crisis, to reduce behavioural escalation, improve consumer outcomes, and improve access to appropriate mental health care. Specifically, participants described the important role the NPACER played in: (i) diverting consumers from the ED to more appropriate and timely mental health care; (ii) allowing direct access to inpatient mental health services; (iii) releasing police officers to other non-mental health-related tasks; (iv) increasing knowledge transfer and building rapport among interagency teams; and (v) reducing adverse events that may be associated with a stand-alone police response. Emergency department clinicians have expressed concern about the safety of people in mental health crisis and a lack of resource to support mental health crisis presentations to the ED (Al-Khafaji et al. 2014; Jelinek et al. 2013; Kerrison & Chapman, 2007). The results of the current study support such sentiments about the challenge created by a stand-alone police response that existed prior to the NPACER. Furthermore, as collaboration across services is fundamental to the consumer?s pathway through mental health crisis (Boscarato et al. 2014; Morphet et al. 2012) and to provide appropriate care (Lamb et al. 1995), the results of the current study highlight the benefit of interagency collaboration due to a specialist second responder team and the resulting improvements in service utilization. Interestingly, as staff occasionally do not respect professional abilities of staff from interfacing services (Hollander et al. 2012), there much more likely to get a better service than you would preNPACER. (Voice of police staff) results of the current study highlight the knowledge and skill development a specialist second responder team was able to foster. Police have reported that reducing ?down-time? in hospital EDs is important for improving police morale and efficiency (Borum et al. 1998; Shapiro et al. 2014). Responses of police in the current study indicate the ability of a specialist second responder team to achieve such ends by quickly releasing police to respond to other jobs and resolving crises in the community without the need for the ED transportation. This study also indicated the use of police station holding facilities as part of improving the pathway of service utilization for people in mental health crisis. Given the difficulties of police detecting people with mental illness in police holding cells (Baksheev et al. 2012), there is potential for responses such as the NPACER to assist in this regard. However, this study tells us little about the experience of people transported to police stations or the appropriateness of this diversion. As such, there remains the need for further research regarding police interaction with people with mental health crisis in such facilities (Chappell & O?Brien 2014). Limitations This study attempted to access the views of a large number of stakeholders interfacing with a combined police and mental health nurse team responding to people in mental health crisis. However, this was a single second response team in metropolitan Melbourne. Furthermore, representatives of the stakeholder groups were purposively selected for interview. Finally, consumer and carer advisors were interviewed, who had spoken to their peers about their experience of the NPACER, rather than those directly involved. As such, data may not represent all the experiences or perspectives of consumers who were responded to by the NPACER, and data may also not generalize to joint police and clinical specialist second responder teams that may operate under different models of care either in Australia or internationally. CONCLUSION The aim of this study was to describe the perceptions of major stakeholders on the ability of the NPACER model to reduce behavioural escalation and improve the service utilization of people in mental health crisis. This specialist second responder team enabled the ED diversion, direct access to inpatient mental health services, reduced police officer ?down-time?, improved interagency collaboration and knowledge transfer, and improvements in service utilization and transition through such services, compared with a typical stand-alone police response to people experiencing mental health crisis in the community. ACKNOWLEDGEMENTS The authors acknowledge Sergeant Andrew Hiam (Epping Police Station), Mr Peter Kelly (Operations Manager, NorthWestern Mental Health), Robynne Cook (Acting CEO, the Northern Hospital), and those people interviewed for their support of this project.
AUTHOR CONTRIBUTIONS All authors contributed to the conceptualization and conduct of the research. All authors contributed to and approved the final version of the manuscript. B. M. collected data, and B. M. and J. O. analyzed data.
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