Chelsea Jones, PhD*, Shaylee Spencer, MSW*, Brenda Juby, MN*, Elly O’Greysik, BScN*, Lorraine Smith-MacDonald, PhD*, Michelle Vincent, PhD*, Suzette Brémault-Phillips, PhD*
ABSTRACT
Public safety personnel (PSP) are at risk of experiencing operational stress injuries (OSIs). The functional impairments caused by OSIs can contribute to challenges with returning to pre-injury operational requirements. A Canadian municipal policing agency developed a peer-led workplace reintegration program (RP) to assist PSP in their workplace reintegration after an illness or injury. Although this RP has been used internationally, there is a paucity of research on this program and its implementation by PSP organizations. The perspectives of key stakeholders are important for capturing the current state of RPs and future directions for the advocacy, implementation, sustainability, and spread of the RP, and to set the stage for future research. The purpose of this study was to explore the experiences and perspectives of key stakeholders engaged in the creation, implementation, facilitation, and execution of RPs in Alberta, Canada. This will help identify strengths, barriers, facilitators, needs, processes, and attitudes associated with the RPs and direction for future research. A qualitative thematic analysis of focus groups (N=8) involving key stakeholders (N=30) from five PSP organizations with RPs was conducted using a community-engaged research approach as part of a larger mixed-methods study. Four key themes emerged from the participants: (1) Integral elements of success, (2) Integral needs, (3) Key areas of growth, and (4) Evolution of the Program. While RPs are highly regarded by the key stakeholders, it is essential that evidence-based research guide the evaluation, modification, implementation, spread, and scale of RPs globally.
Key Words: First responders, return to work, workplace reintegration, operational stress injuries, mental health, post-traumatic stress, mental illness, return to duty
Public safety personnel (PSP) is an evolving term that encompasses personnel who ensure the safety and security of Canadians (e.g., border services officers, public safety communications officials, correctional workers, firefighters, Indigenous emergency managers, operational intelligence personnel, paramedics, police, search and rescue personnel, etc.; CIPSRT, 2019). PSP are at an elevated risk of experiencing operational stress injuries (OSIs), which are work-related psychological distress, mental illness, and workplace injuries that result from exposure to events and tasks that can be unpredictable, traumatic, and high-risk (CIPSRT, 2019). OSIs include a broad range of conditions, including post-traumatic stress disorder (PTSD), depression, anxiety, and other mental health disorders, that interfere with daily functioning (CIPSRT, 2019) as well as moral injury (Lentz et al., 2022). Operational stressors such as shift work, media involvement, and culture also contribute to the experience of OSIs (Carleton et al., 2019).
A Canadian study surveying 5813 PSP in Canada found that 36.7% of municipal police, 34.1% of firefighters, 50.2% of Royal Canadian Mounted Police (RCMP), and 49.1% of paramedical staff screened positive for a mental health condition such as PTSD, depression, anxiety, or substance abuse (Carleton et al., 2018). These conditions have the potential to impact an individual’s quality of life and can result in decreased community integration, diminished cognitive functioning, increased social isolation, greater difficulty forming and maintaining meaningful relationships, increased workplace absenteeism, and increased prevalence of substance use disorders (Bisson et al., 2021; Edgelow et al., 2019). After a PSP has taken leave from their position due to illness or injury, functional impairments can contribute to challenges with returning to work in a present, meaningful, and engaged manner. A recent study found that PSP diagnosed with a psychological injury were less likely to return to pre-indicent work levels, and taking a longer time to do so, compare to PSP and civilians with only musculoskeletal injury (Gross et al., 2021).
Peer support programs have been recognized by some PSP organizations as a component of an overall work reintegration strategy that may help PSP return to work following injury. Peer support refers to a variety of mental health supports and resources implemented via programs or services and offered by a peer who provides social or emotional assistance to a peer (Price et al., 2022). Higher quality effectiveness studies that incorporate stronger study designs, rigour, validity, and reliability are still needed to determine both the short- and long-term effectiveness of such initiatives (Price et al., 2022; Beshai & Carleton, 2016). A 2022 paper by Sutton and Polaschek reviewed the literature on initiatives that have been designed to support PSP in their workplace reintegration or continuation after critical incidents. They identified the incorporation of peer support, with a strong focus on stress and well-being outcomes and education, across all types of studies, but noted “a dearth of research into the influence of critical incident interventions on work performance, attitudes or experiences” (Sutton & Polaschek, 2022).
In 2009, the Edmonton Police Service (EPS) identified a need to assist police officers who were off work following a critical incident (e.g., officer-involved shootings). In response, they formalized workplace reintegration efforts by providing officers with peer support to process their critical incident and regain confidence with operational skills. Over time, the EPS Reintegration Program (RP) evolved, and it has spread to several other PSP organizations across Canada, the United States, and New Zealand. Although RPs may include elements specific to each PSP organization and profession, the goal of the programs remains to assist PSP to return to work as soon as possible following a critical incident, illness, or injury, while diminishing the potential for long-term psychological injury (Edmonton Police Service, 2018).
The RP incorporates both a short- and long-term critical incident RP stream (Edmonton Police Service, 2018). Detailed descriptions of the RP have previously been published (Klose et al., 2017). The RP includes relationship building, reintroduction to equipment, skill building, and exposure to operational scenarios; the participating PSP is guided by a trained peer RP Facilitator through a step-by-step process that addresses the unique stressors that the PSP may experience (Edmonton Police Service, 2018). Support offered by RPs is complementary to clinical interventions but outside the scope of what officers receive from their healthcare professionals (i.e., psychologists, occupational therapists, etc.; Edmonton Police Services, 2018). RPs may assist worker’s compensation organizations to facilitate positive outcomes for officers attempting reintegration after developing an OSI. To date, however, information regarding the potential success of the program has been largely anecdotal. Although there has been preliminary research regarding the effect of the RP Facilitator Training Program developed by EPS on the mental health knowledge, attitudes (Jones et al., 2022), and perspectives of attendees (Jones et al., 2021), the RP itself has not been formally studied.
The experiences and perspectives of RP key stakeholders can facilitate a better understanding of the current state of the RPs and provide future direction for the advocacy, implementation, feasibility, sustainability, and spread of the RP. They may also set the stage for future research that would more rigorously analyze the effectiveness of the RP, as recommended in previous publications (Beshai & Carleton, 2016; Sutton & Polaschek, 2022).
The purpose of this qualitative study was to explore the experiences and perspectives of key stakeholders engaged in the creation, implementation, facilitation, and execution of RPs within the province of Alberta, Canada. We aimed to gather information regarding the strengths, barriers, facilitators, needs, processes, and attitudes that contribute to the current RPs within five Alberta PSP organizations. Through this study, we hope to set the stage for future research regarding the effectiveness, safety, efficacy, and feasibility of RPs in various jurisdictions.
This qualitative study utilized a community-engaged research approach to collect data from key stakeholders of the RP in Alberta (Barkin, et al., 2013; Esmail et al., 2015). Ethical approval was received from the Research Ethics Board at the University of Alberta (Pro00118357).
Study participants included RP facilitators as well as health, wellness, human resources, and mental health services personnel, organizational leaders, and policy-makers within participating PSP organizations. Key stakeholders were engaged if they were able to offer insights into practice, policy, or practical considerations regarding the RP, or had experience and involvement with the implementation of the RP within their organizations.
Study participants were recruited through snowball and purposeful sampling. Key contacts within PSP organizations helped disseminate recruitment emails through their networks. Potential participants were asked to contact the research team directly and were screened for inclusion before consenting to study participation.
Data was collected between September and November 2022. Consent and demographic questionnaires were administered via REDCap (Research Electronic Data Capture), which is a secure, web-based software platform (Harris et al., 2019). A semi-structured focus group script was designed by the research team, which contributed to deductive data collection. 60-minute focus groups (n=8) were conducted and recorded via videoconferencing with Zoom according to existing literature and guidelines (Stewart et al., 2007). Each focus group was specific to a single PSP organization, but heterogeneous with respect to professional representation and experience. This allowed for broad discussion and the collection of rich, comprehensive data. Data collection continued until information power was reached based on the process outlined by Malterud et al. (2016). Information power considers study aim, sample specificity, established theory, quality of dialogue, and analysis strategy, which would ideally also correlate with data saturation.
Quantitative data was analyzed descriptively with Microsoft Excel software. Audio or video-recorded focus groups and interviews were transcribed and thematically analyzed deductively and inductively following an iterative process (Braun & Clarke, 2006). Through an inductive process, initial codes were developed by identifying themes that presented from the data. Three researchers independently conducted open coding for each focus group, after which an arm’s length researcher reviewed and provided feedback on the codes. An analysis of the preliminary themes followed, with discussion around any conflicting ideas. Once the final themes were determined, key quotes were isolated to illustrate the themes and the final presentation of the thematic analysis was prepared.
Demographic details of study participants (N=30) are presented in Table I. Study participants belonged to one of five participating PSP organizations and had varying levels of experience and involvement within their respective RPs. It was noted that three of the five organizations had implemented both the short-term critical incident and long-term RP streams. Although not explicitly captured through the questionnaires, it was observed that some stakeholders had also engaged in the RP as a PSP participant and utilized this in their own return to work following an illness or injury.
TABLE I Demographic information of the key stakeholder participants
The data exhibited dense sample specificity, and strong, focused dialogue, which allowed the perceived information power to be reached with fewer participants than originally anticipated (Malterud et al., 2016). The research team experienced saturation, where no new patterns emerged from the data thereafter, after four focus groups and 12 participants. Through the thematic analysis, four main themes were identified: (1) Integral elements of success, (2) Integral needs, (3) Key areas of growth, and (4) Evolution of the program (Figure 1). The themes are summarized below, with detailed descriptions and supporting quotes within Tables II to V.
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FIGURE 1 Results of thematic analysis: Four themes | ||
TABLE II Integral elements of success
TABLE V Evolution of the program
Overall, two key elements to the success of the RP were identified by stakeholder participants. Credibility and buy-in were identified as the most integral elements, followed by collaboration between internal and external stakeholders at varying levels within and outside the respective PSP organization (Table II).
Key stakeholder participants identified integral needs of the RP centering around staffing challenges. RP facilitator positions were observed to have substantive workload demands while being emotionally demanding. Such a tempo creates potential for staff to experience their own psychological injury. Also highlighted was the imperative to have the “right person for the job,” and the challenges in assuring the best candidate for the RP is selected to support the program. Participants further identified the need for a diverse team with RP facilitators who are respected and knowledgeable in their field (Table III).
Participants identified several means of strengthening the RP, including enhanced communication, education, and training processes. They credited education and communication stemming from the RP as components of recent growth in organizational acknowledgement and acceptance of mental health challenges. Participants celebrated this growth while also acknowledging that additional short- and long-term goals and initiatives are needed to facilitate continued forward movement and improved organizational culture (Table IV).
Key stakeholder participants were enthusiastic to share the history of implementation of their respective RPs, as well as describe the current state of their program. Although there are differences between the RPs, such as engagement with rural versus urban areas, resource and staffing allocations, program size, and stage of implementation, there were multiple similarities in both the origins, present state, and future vision of the RPs (Table V).
The purpose of this qualitative study was to explore the experiences and perspectives of key stakeholders engaged in RPs within Alberta. We uncovered perspectives regarding the current state of the RPs across PSP organizations to better understand the unique strengths, barriers, facilitators, needs and processes, as well as cultural aspects and attitudes associated with the RP. The themes that emerged from the data are reflected in the existing literature regarding the mental health and wellbeing of PSP and their respective organizations.
In the first theme, widespread credibility and buy-in throughout the organization was noted to be paramount to the program’s implementation and sustainability. This is consistent with existing literature demonstrating that programs valued by PSP organizations and stakeholders will encourage greater participation and engagement (Sutton & Polaschek, 2022). Conversely, a negative reception of a program may indicate that participants regard the content as irrelevant or may perhaps point to deeper problems with organizational culture (Lennie et al., 2020). Peer-led programs are also generally regarded favourably by PSP (Sutton & Polaschek, 2022). The key stakeholder participants regarded their respective RPs highly. They believed the RPs contributed to better return-to-work outcomes and had a high economic return on investment. They also noted that collaboration, both internal and external to their respective organization, was another key to the success of the RP.
Within Theme 2, high workload demands for RP facilitators was the most notable challenge identified. Participants noted that a lack of attention to the evolving staffing needs and operational demands within the RP could be a major threat to the programs and potentially contribute to OSIs among RP staff themselves. A recent literature review addressing the impact of organizational factors on the mental health of PSP organizations found that high workload and limited resources were negative organizational factors frequently cited by paramedics and firefighters that contribute to negative mental health outcomes (Edgelow et al., 2022). This was reflected in the data among the PSP stakeholders, as it pertained to PSP’s role in operating the respective RPs. Adequate staffing levels, along with co-worker and supervisor support, are positive organizational factors that facilitate better mental health among PSP organizations (Edgelow et al., 2022). Additionally, the sub-theme of, “the right people for the job,” has been found in previous literature regarding the RP Facilitator Training Program (Jones et al., 2021).
Future planning, development, organization, implementation, and spread of education, training, and communication policies and processes internal to the respective PSP organizations as well as to external stakeholders was identified in the third theme as an area of growth. Further, education, training, and communication among PSP regarding mental health topics has been shown to improve organizational wellness among PSP (Edgelow et al., 2022). For police, workplace culture was the most frequently encountered negative organizational factor that affected the mental health of staff (Edgelow et al., 2022). Efforts to improve workplace culture, reduce stigma, and provide organizational support could contribute to better mental health among PSP. The RP, through promotion and education, has been shown to play a role in these efforts. Furthering engagement internal and external to PSP organizations through educational efforts as well as expanding resources to help more PSP with workplace reintegration across Canada was envisioned by participants, all of whom were positive about the future direction of the RPs as noted in Theme 4.
Based on the existing evidence-based literature and the results of the current study, the authors have provided key recommendations for future implementation, sustainability, and spread of the RP. As one participant expressed, recommendations include access to, “the right people, right budget, and appropriate sphere of influence:”
■ Buy-in must be facilitated, communicated, and modeled from the top down to influence sustainable cultural change throughout all levels of the organization (Jones et al., 2021).
■ Stable and rewarding RP facilitator positions must be created with designated full-time equivalents as opposed to voluntary positions or work done in addition to regular duties (Jones et al., 2021).
■ Strong communication policies, plans, and practices must be developed that allow for increased awareness and understanding of the RP as well as the process, information, and referral flow for internal and external stakeholders alike.
■ Hiring policies and practices must be delineated that allow candidates to be vetted for RP positions to ensure they are a good fit for RP work and exhibit authenticity, motivation, mental health knowledge, resilience, and insight into their own mental and emotional well-being.
■ Integration of support initiatives and access to services must be facilitated in the event RP staff are experiencing mental health distress as a result of their reintegration work. This may include integration of other allied health professionals into the program to support staff directly.
■ High-quality RP effectiveness studies that incorporate stronger study designs, rigour, validity, and reliability are needed (Beshai & Carleton, 2016). A determination of long-term effects of the RP is also required, together with an assessment of potential risk of harm to the participants and facilitators (Jones et al., 2022).
■ As the goal of the RP is to enhance workers’ effective return to work, future research should incorporate constructs and conditions which may correlate with success in sustained return to work such as measures of absenteeism, presenteeism, organizational injustice, work function and performance, perceived stigma, as well as mental health knowledge and attitudes (Sutton & Polaschek, 2022).
■ If research is favourable, use of effective implementation science approaches would best facilitate sustainable spread and scale of the RP, enabling more PSP and civilian professions to receive support in their return to work (Jones et al., 2022).
Several limitations are associated with the study. First, a convenience sample which drew on pre-existing relationships with a small number of PSP organizations was used. Second, significant work demands, related and unrelated to the RPs, limited the ability of many key stakeholders to engage in the study. Third, focus groups were used, which does not allow for complete anonymity of participants. As a result, some participants may not have been as open with their responses with their peers present. Finally, as with all PSP research, the hierarchical nature of PSP organizations may affect a participant’s ability to discuss these topics openly.
Engagement with key stakeholders of the RP over the course of this study provides additional insights into the elements of success, needs, areas of growth, and evolution of the RP. While this RP holds promise, a strong standardized evidence base is essential to guide the implementation, evaluation, modification, spread, and scale of it globally. Continued research, collaboration, and evaluation of the RP may allow for the development of a best practice model. Such a model may assist PSP with workplace reintegration after illness and injury while contributing to continued growth in PSP organizational cultures with respect to mental health knowledge, stigma, and support.
The research team at the Heroes in Mind Advocacy and Research Consortium (HiMARC) would like to thank Edmonton Police Services, Calgary Police Services, Alberta Health Services Emergency Medical Service, the Royal Canadian Mounted Police K-Division, and St. Albert Fire Services for their participation in and support of this study.
The authors declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
*Heroes in Mind Advocacy and Research Consortium, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada..
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Journal of CSWB, VOLUME 8, NUMBER Suppl 1, February 2023
