The Emergency Care Competence Needed for Police Patrol Officers According to the Experts

1. Introduction

Police patrol officers (PPOs) face multifaceted, everyday challenges that demand professionals capable of adapting to a wide range of situations and decisions. One of their most important societal functions is to protect and save lives, and PPOs may on many occasions be the first authority at a scene in out-of-hospital emergencies (Hawkins et al., 2007; Klassen et al., 2018). A study from the United States (US) covering 41 states in 2014 indicates that assignments where PPOs deliver care prior to the arrival of the ambulance service mostly concern cardiac arrest and traumatic events (Klassen et al., 2018). Other findings in studies from the US also indicate that PPOs face challenges in a wide range of situations involving medical and mental health related complaints and emergencies (Hawkins et al., 2007; Rosen & Travers, 2021). Being first on the scene as a first responder may be chaotic and frightening, while awaiting the ambulance service creates feelings of loneliness in a perceived eternity. However, having had training in a systematic way of providing emergency care creates feelings of security in these chaotic situations (Elmqvist et al., 2010). The emergency care training and equipment provided for PPOs to act as first responders varies between different countries (Dekanoidze, 2018; Hawkins et al., 2007). Despite these variations, PPOs worldwide face a somewhat similar type of challenge when awaiting the arrival of emergency medical support or when transporting acutely ill or injured persons to health care facilities. Earlier research from the US indicates that PPOs themselves support the call for additional training in emergency care (Alonso-Serra et al., 1997) and a need to develop police-specific emergency care training has been emphasized (Sztajnkrycer et al., 2007). Furthermore, calls have also been made for a better understanding of the challenges PPOs face concerning emergency care in order to develop their training and policy recommendations (Klassen et al., 2018). There is little research from a European perspective and none at all from a Swedish perspective.

2. Methods

An exploratory design was adopted using a Delphi technique (Keeney et al., 2011).

3. Results

The results indicated that basic life support measures received the highest levels of agreement in terms of the necessary emergency care competence for Swedish PPOs (Table 3). The top ten areas, achieving an almost 100% level of agreement, represent abilities to perform CPR with AED (areas 1, 2 and 8), to stop massive hemorrhaging (areas 3, 4 and 10), and measures for basic airway management (areas 5 and 6), while simultaneously concerning working in a hazardous environment (areas 7 and 9). Many of the areas with the highest level of agreement are concerned with traumatic injuries (e.g., areas 3, 4, 7, 10 and 12) and the ability to assess and take care of these in a systematic way, using the S-CABCDE template as a support for doing so (area 14).¹ When addressing more advanced assessments, and taking care of acutely ill people, the level of agreement was reduced (e.g., areas 20, 24, 35 and 43). The levels of agreement also indicate some uncertainties concerning the abilities to assess and care for people with mental illness (areas 39, 46 and 47), and people with alcohol and/or drug use (areas 41 and 48). Moreover, consensus was not achieved for four of these (areas 41, 46, 47 and 48) until Round 3. Furthermore, the results revealed some outliers such as performing CPR on adults (area 1) where all experts agreed (M=5, SD=0, R=5-5), whereas performing CPR on children (area 19) had (M=4,7, SD=0,77, R=1-5). There were also lower levels of agreement and a wide range (1–5) in terms of identification and evaluation of threats to life (areas 20 and 21) compared with the high levels of agreement concerning applying suitable measures for the aforementioned threats to life (areas 1–10), such as life-saving actions. There were also lower levels of agreement and a wide range concerning assessing respiration/consciousness (areas 26 and 30) but a 100% agreement on performing CPR (areas 1 and 2). However, there is a clear distinction in the results, where the abilities to assess and identify specific diseases (area 49), to identify the causes of and the prevention of burns (area 50), and to assess and take care of sports injuries (area 51) were all identified as competencies that are not needed.

Table 3

4. Discussion

The procedure of selecting the participants, which is a core part of Delphi studies, followed an ongoing critical review among all the authors of the selection of experts (Wakefield & Watson, 2014). The expert group was homogeneous in relation to the focus of the study and heterogeneous in terms of its variation of backgrounds as educators, instructors, or PPOs. A potential limitation is that there may be gatekeepers in the organizations who identified the experts, and there may thus be experts who are not included in the study. On the other hand, the ambition in the Delphi process of selecting a group of highly trained and competent experts within the specialized field of knowledge related to the target issue is considered as a strength of the study (Hsu & Sandford, 2007). All the eligible experts from the currently available cohort of active experts in the subgroups of instructors and educators were included. In order to strengthen the empirical perspective on the data, the subgroup of PPOs with direct experience of the practical field and who represented all the police regions in Sweden were the largest group of the experts. The size of the group of experts (n=43) correlates with the sizes referred to in the literature (Hsu & Sandford, 2007). However, consensus concerning the optimal number of experts in a Delphi study has not been achieved in the literature, with variations from approximately 10 to several hundred (Keeney, Hasson & McKenna, 2011; Powell, 2003). Having a small number of experts can entail a risk that the outcome of the study is not representative. On the other hand, a larger number of participants could entail a risk of a lower response rate. The 100% response rate throughout all four rounds is considered to be a strength.

The experts were encouraged in Round 1 to define in free text what a Swedish PPO needs to know in order to help acutely ill or injured people. The use of free-text answers in Round 1 can be seen as a strength as it provides the participant with the opportunity of reflecting upon and answering a question without being influenced by an interviewer. Interviews can provide the possibility of posing follow-up questions in order to gain clarity and interpretation of the answers, and the researcher retains some influence over the generation of data. This, on the other hand, should be decreased in order to maintain an inductive approach (Wakefield & Watson, 2014). In order to reinforce the results from Round 1 and reduce the risk of bias due to the composition of the questionnaire, the free-text answers were subjected to a test of their face validity by a group of five clinically experienced PPOs and police program educators. The data collected in Round 1 was considered to be rich as it resulted in 76 necessary emergency care competence areas.

The 75% consensus cut-off point was predetermined and arbitrary. However, the percentage, which was considered to be reasonable by the authors, was supported by the literature (Keeney et al., 2011; Hsu & Sandford, 2007) and relevant for the aim of the study. This predetermined consensus rate could benefit and strengthen the outcome of the study in the ambition of exploring areas of competence in emergency care among PPOs. On the other hand, a lower consensus cut-off rate would have led to a larger number of areas with consensus.

The study results reveal three domains, containing several related areas of necessary emergency care competence for Swedish PPOs: (i) Performing basic life support measures preferably in a CPR situation or when encountering traumatic injuries, (ii) Assessments and measures for acutely ill people, and (iii) Initiating care responses for people with mental illness. The results also indicate a consensus regarding lower levels of agreement, for example, for the assessments concerning respirations/consciousness, identification, and evaluation of threats to life. These assessments form the basis for making a decision about which measures are to be applied in situations that concern life threats, which had in themselves received high levels of agreement (e.g., CPR, haemorrhage control measures). These potentially equivocal results could be interpreted as being difficult, possibly indicating ambiguities among the experts concerning the PPOs first responder role, responsibilities, needed emergency care training, and competence.

The PPOs are seen worldwide as a key component in the out-of-hospital chain of survival by sometimes being first on the scene, performing lifesaving interventions whilst awaiting ambulance service arrival (Klassen et al., 2018: Hollenberg et al., 2009; Husain & Eisenberg, 2013; Krammel et al., 2020). The results of this study indicate the highest level of consensus in terms of areas related to actions where the PPOs perform basic life support measures, with the two areas with the highest level of agreement linked to the ability of performing CPR. This could be due to the PPOs in Sweden, more often in urban areas, being dispatched as the first responders to out-of-hospital cardiac arrests (OHCA), where they then await the arrival of the ambulance service (Hollenberg et al., 2009). This intervention has shown to be successful in terms of the PPOs’ ability to ensure a quick response and to start CPR, which has led to an increased rate of OHCA survival (Husain & Eisenberg, 2013). Moreover, areas where PPOs perform lifesaving interventions on people suffering from a trauma have a high level of agreement. This may indicate that the PPOs often encounter situations where people are exposed to traumas, and, by being ambulatory, they can ensure a quick response. As in OHCA situations, a quick response to a trauma is crucial (Blackwell & Kaufman, 2002), especially in situations where a person suffers from a massive hemorrhage (Kragh et al., 2009). However, being first on the scene, encountering a person suffering from acute illness or injuries and making decisions as a PPO prior to the arrival of the ambulance service, is described as stressful (Hasselqvist-Ax et al., 2019; Backteman-Erlanson et al., 2011). PPOs state that they have great expectations from society concerning managing emergency care as first responders on the scene of an accident (Elmqvist et al., 2010), where a lack of appropriate emergency care training is mainly expressed as a cause of the stress (Hasselqvist-Ax et al., 2019). However, training in a systematic way of assessing and applying measures to acutely ill and injured persons creates the prerequisites for feelings of security as a first responder (Elmqvist et al., 2010) and may improve the outcome for the persons in need of care (PHTLS, 2020).

Despite consensus being achieved regarding the ability to assess and take care of acutely ill people, these areas had a lower level of agreement. In addition, consensus was not achieved for areas concerning competence in identifying or assessing specific diseases necessary for PPOs emergency care competence, and little is known about which type of medical emergencies Swedish PPOs respond to. Three British studies (Payne-James et al., 2010; McKinnon & Grubin, 2012; Miles et al., 2020) focusing on healthcare problems for detainees in police custody reveal that, despite containing a fairly young population (≈ 40 years), nearly 40% of the detainees had previous significant medical conditions, of whom more than one third had previous significant surgical conditions (Payne-James et al., 2007). Similar results were shown by McKinnon & Grubin (2013), where one fourth of all detainees under custody suffered from abdominal symptoms, and 19% had cardiovascular complaints over the past month. In addition, 16% of detainees suffered from asthma, 5% from diabetes and 2% from epilepsy (McKinnon & Grubin, 2013). Moreover, the main reason for referral from custody to hospital for medical problems was chest pains and diabetic ketoacidosis (Miles et al., 2020). These research findings may also be critically reflected upon in the light of Swedish legislation (FAP 023-1) regarding the fact that PPOs are assigned to people whose consciousness is affected by suspected drug or alcohol use. The Swedish PPOs dealt with approximately 50–60,000 assignments annually related to suspected drug or alcohol use during the years 2018–2020 (5–6% of all registered incidents) (Polisen.se, 2020). PPOs are, according to the aforementioned legislation (FAP 023-1), directed to decide whether the person should be taken to police custody or taken to the hospital for a medical examination. This may be seen as a qualified medical assessment, and great responsibility is, thus, placed on the PPOs’ emergency care competence in assessment and decision-making.

The results further indicate consensus regarding assessing and taking care of people with mental illness, although there was a low level of agreement about this competence. However, research studies from other countries show that the most common primary diagnosis for patient transport to emergency departments by PPOs is often mental illness (Crilly et al., 2019; Rosen & Travelers, 2021). Mental illness can be seen as a spectrum that includes both severe disorders/diseases and common mental health problems and/or mild symptoms of distress; examples include schizophrenia, anxiety, bipolar disorder, substance use disorder, depression, self-harm, sleeping difficulties, and distress (Bremberg & Dalman, 2015). Mental illness is a global public health problem (WHO, 2017; WHO, 2013), and people with mental illness are a significant group encountered in police work. The police in Sweden registered approximately 52,000 incident reports in 2019 (5% of the total of incident reports in 2019) where the PPOs encounter people with mental illness (Polisen.se, 2021a) and in 2020, an average of 60 calls per day were received by the police command centers, which deal with people who do not want to live any longer (Polisen.se, 2021b). Mental illness is also a common feature, for example, in fatal violence within the family (Brå, 2019). The need for PPOs to improve their competence in encountering people with mental illness is not a new demand (Meehan, 1995) and neither is the PPOs experience of frustration when they encounter people with mental illness that need care and do not receive it (McNiel et al., 1991). The results should be viewed in the light of encountering people with mental illness being a part of the PPOs’ everyday work, where each encounter is unique (Brink et al., 2011). The encounter requires competence in assessing the situation, for example, occurrence of suicide risk, danger, and the need for care. The PPOs need to make decisions about how to best respond in the encounter (Watsona et al., 2014). In order to succeed in this, the PPOs need the capability to approach the person with both comfort and respect in addition to having greater knowledge (Soares & Costa, 2019). There are several examples of co-responder models that support PPOs in their encounters with people with mental health care needs in the US, Australia, the UK, and Canada, e.g., phone support, extended educational support, or by a police-mental health co-responder team. The co-response models were associated with a reduction in the use of police powers of detention and a reduction in detainment in police custody (Puntis et al., 2018). The use of PAM (Psychiatric Acute Mobility) ambulances in mostly urban areas is increasing in Sweden to meet the growing needs of people with mental health problems (Lindström et al., 2020). However, both Lindström et. al. (2020) and Puntis, et. al. (2018) conclude that there is a need for more research to evaluate the outcomes of co-response models. In the light of the international initiatives to address the growing needs of people with mental health problems (WHO, 2019), it is, thus, somewhat surprising that the level of agreement for assessing and caring for people with mental illness was low in the present study findings. The reasons for this are not evident and have not been focused on. However, the distinction between emergency care and mental health care in the syllabus and police training could possibly contribute to an explanation. This is unfortunate since more than 50,000 assignments a year, which corresponds to approximately 5% of the daily workload of Swedish PPOs, require a competence in the assessment and care of people with mental ill health for identifying their individual needs.

5. Conclusions and implications

Swedish PPOs are expected to deal with a wide range of situations demanding acute assessments, measures, and decisions regarding people suffering from mental health problems, traumatic injuries, and medical illnesses. Educators at the police programs and instructors in the Swedish Police Authority need to acknowledge and support PPOs with emergency care training that corresponds to the responsibility Swedish legislation and their everyday police work places on them. The detailed presentation of necessary emergency care competence in the study may inform all stakeholders in the educational planning and execution of emergency care training for PPOs. The identified competence should be supported during the police programme training and followed up with an annual mandatory training to support the PPOs’ ability to cope with emergency care situations. The present study primarily systematizes the wealth of experience originating from the experts’ combined theoretical education and practical training. It could be said that the results mirror proven experience in this field. However, the education of professionals (PPOs included) is to be explicitly founded on proven experience and science. We hope that researchers can obtain empirical material in subsequent studies which more objectively highlights the practical expectations on PPOs. Close collaboration with the Police Authority is an essential element for attaining this. A development of the index codes for emergency care incidents in the Swedish police assignment databases needs to be initiated in order to obtain more detailed and complete data for analysis. Otherwise, researchers may have difficulties in coping successfully with the data analysis. Various co-response models and educational interventions should be further developed and researched in order to support PPOs and people with mental health care needs.

Acknowledgement

We acknowledge and appreciate all experts who participated in our study.