Psychological First Aid Training of Police Officers.

A significant lack of evidence regarding the effectiveness of psychological first aid (PFA) training of first responders to emergency settings has been reported. The aim of the present study was to assess the effectiveness of a PFA training program on the feeling of confidence on providing help in crisis, knowledge, attitudes, and skills of police officers. Fifty police officers were trained in PFA, using an adapted version of the World Health Organization's program, and they were compared to a control group of 53 police officers. A PFA questionnaire was used to compare the two groups, before and after the implementation of the PFA training. Results revealed significant improvementson confidence, knowledge, attitudes, and skills of trained police officers, in comparison to controls. Thus, the present results suggest that PFA training programs are effective and should be offered to police officers in order to enhance their capacity to provide PFA in emergency settings.

Introduction

Psychological first aid (PFA) is a widely known psychological approach, developed to be used in emergency settings and aiming to provide appropriate support to survivors of potentially traumatic events (Brymer et al. 2006; World Health Organization et al. 2011). PFA was designed to promote elements that are considered crucial in the aftermath of a crisis, in particular the sense of safety, calmness, self-efficacy, connectedness, and hope (Hobfoll et al. 2007). First responders in emergency, such as paramedics, dispatchers, police officers, and firefighters, are usually the persons that immediately contact with people who are affected by a disaster, or other adverse events. Thus, this group of professionals and volunteers has been considered as the most suitable providers of PFA in emergency settings (Allen et al. 2010; World Health Organization et al. 2011).

While several PFA training models have been developed, three of them have been widely used for the training of first responders in emergency settings. Firstly, the Psychological First Aid Field Operations Guide (2006) was published by The National Child Traumatic Stress Network (NCTSN), in collaboration with the National Center for Posttraumatic Stress Disorder, in USA to provide an evidence-informed method to first responders in emergency settings (Brymer et al. 2006). The goal was to reduce initial distress in the aftermath of a disaster, enhancing short- and long-term adaptive coping mechanisms of survivors. Secondly, the Johns Hopkins Model of Psychological First Aid, known as the RAPID-PFA model (Everly et al. 2014), was designed to train first responders in emergencies and includes five core actions: Reflective listening, Assessment of needs, Prioritizing the basic needs, Intervention, and Disposition.

Thirdly, in 2011, the World Health Organization, War Trauma Foundation, and World Vision, based on a review commissioned by WHO (Bisson and Lewis 2009), originated a publication of a PFA guide for field workers. According to the guide published by World Health Organization et al. (2011), participants are educated on the basic PFA concepts on how to approach crisis situations safely, how to support affected, distressed people, avoiding causing further harm. Recently, due to the COVID-19 pandemic, Inter-Agency Standing Committee-IASC (2020) has published special guidelines on how to provide PFA, following safety protocols to prevent the spread of the virus. It is considered crucial to properly educate first responders to use appropriate technological equipment, which promotes communication and respects the safety protocols, in order to provide PFA to citizens during and after the control of the current pandemic (Shah et al. 2020).

Despite PFA training popularity and excessive use worldwide (for a review, see Dieltjens et al. 2014; Fox et al. 2012), it has been widely acknowledged that there is a need to build an evidence base for the PFA effectiveness (Dieltjens et al. 2014; Fox et al. 2012; Horn et al. 2019; Sijbrandij et al. 2020). The results of previous reviews regarding the effectiveness of PFA training (Dieltjens et al. 2014; Fox et al. 2012) have reported that PFA should be considered as an “evidence-informed,” rather than an “evidence based,” intervention as a lack of randomized controlled experimental studies is noted. Recently, however, some controlled experimental research on the effectiveness of PFA training of first responders in emergency settings has been published. These studies have shown that the group of first responders that received the PFA training scored higher than controls on PFA knowledge (Kang and Choi 2021; Sijbrandij et al. 2020), self-efficacy, and disaster preparation (Kang and Choi 2021; Kilic and Simsek 2019; Park and Choi 2020), while their PFA performance competence in a simulation-based PFA training was elevated (Kang and Choi 2021; Park and Choi 2020).

Nevertheless, these studies recruited mainly health care workers (nurses, mental health workers, paramedics etc.), while there is limited research evidence regarding the effectiveness of PFA training on public safety personnel, such as fire workers and policemen. More precisely, the police force is consisted from professionals called to respond to critical and traumatic events. Research data have revealed that occupational stress and trauma exposure have a negative influence on physical and mental health of policemen (Andersen et al. 2015). During the pandemic, policemen were tasked with promoting compliance with the new laws concerning regional lockdowns and the use of protective measures from the public, while they had to be informed for all the constantly modified laws. These changes were found to increase the levels of stress and decline the ability to respond to other, unrelated to the pandemic, critical incidents (Stogner et al. 2020).

Despite the fact the policemen are frequently trained to handle various types of critical incidents, the application of training programs regarding mental health, such as psychological resilience (Arble et al. 2017; Arnetz et al. 2009), or peer support programs, such as Trauma Risk Management – TRiM (Hunt et al. 2013), does not seem to be a part of their regular training (Andersen et al. 2015). However, several training programs of policemen have been shown to be effective in promoting psychological resilience (Arble et al. 2017; Arnetz et al. 2009), mindfulness (Christopher et al. 2015), emotional intelligence (Romosiou et al. 2019), and decreasing negative effects of high trauma exposure (Hunt et al. 2013).

With regard to PFA training, Lewis et al. (2014) have previously assessed the effects of a PFA training based on the principles of NCTSN and the National Center for PTSD. A total of 582 Australian police officers were trained on PFA and post-training assessment revealed significantly enhanced confidence on providing PFA, better self-assessed competence in providing help in disasters and traumatic events, as well as increased PFA knowledge. More recently, during the pandemic, a novel tele-mentoring model, named First Responders Resiliency ECHO project, was applied to first responders, among whom a group of policemen (Katzman et al. 2021). The project contained a PFA program among others (critical incident debriefing, burnout, compassion fatigue etc.). Data from 45 participants revealed significantly higher confidence to providing PFA and trauma-informed care, as well as improved managing of mental illness emergencies and self-care practicing. However, both the aforementioned studies (Katzman et al. 2021; Lewis et al. 2014) were single group studies, as no control group was used, and thus the interpretation of the results should be cautious.

Considering the aforementioned shortage of experimentally tested studies on the effectiveness of PFA training of police officers, the aim of the present study was to evaluate the effectiveness of a properly adapted PFA training of police officers, through a randomized control group pre-test-post-test design. The research hypotheses were formed as follows: (a) trained police officers are expected to report significantly enhanced confidence on providing PFA, both in a within-subjects evaluation (comparing pre- and post-training self-evaluations) and in a between-subjects evaluation (when compared withnon-trained police officers-control group); (b) trained police officers are expected to report significantly increased PFA knowledge, attitudes, and perceptions, again in a within-subjects evaluation (comparing pre- and post-training self-evaluations) and in a between-subjects evaluation (when compared with non-trained police officers-control group).

Materials and Methods

Participants

In total, 103 police officers serving in various Police Departments of the General Police Doctorate of Southern Aegean voluntarily participated in the study. They were randomly allocated in two groups: 50 police officers participated in the intervention group and were trained in PFA, while 53 police officers formed the control group.

With regard to the demographics, in the intervention group, 9 from the 50 participants were women (18%), the mean age of all the 50 participants was 35.10 years (S.D = 7.12), and the mean time of police service was 14.40 years (S.D = 8.40). The majority of the participants were working at police departments or police stations at the time of the research (76%) and for the most of the time of their work in the police force (78%), while 6 police officers (12%) stated that they had participated in another PFA program through the past years.

In the control group, 8 from the 53 participants were women (15.1%), the mean age of all the 53 participants was 36.77 years (S.D = 7.20), and the mean time working in the police force was 17.04 years (S.D = 7.28). The majority of the participants were working at police departments or police stations at the time of the research (69.8%) and for the most of the time of their work in the police force (62.3%), while 8 police officers (15.1%) stated that they had participated in another PFA program through the past years.

Material

A 9-item questionnaire presented in the PFA trainers’ handbook, published by World Health Organization (2013), was used to assess the feeling of confidence in providing PFA. All items were answered using a 5-point Likert scale format, ranging from strongly disagree (1 point) to strongly agree (5 point). Internal consistency was measured by Cronbach’s alpha in the total sample, which had the value .91, both in pre- and post-training questionnaire completion. Thus, the administered questionnaire, measuring the feeling of confidence in providing PFA, was found to have excellent internal consistency.

Moreover, a 15-item questionnaire, also adapted from WHO’s PFA trainers’ handbook (2013), was used to assess PFA knowledge, attitudes, and perceptions. All 15 items were dichotomously answered (true–false) and 1 point was scored for each correct answer (minimum score: 0, maximum score: 15). Cronbach’s alpha was measured for the total sample in pre-training (α = .61) and post-training (α = .70) questionnaire completion. Thus, the PFA knowledge, attitudes, and perceptions questionnaire was found to have acceptable internal consistency.

An additional PFA training evaluation form was administered to the intervention group. All items were answered using a 5-point Likert scale format, ranging from strongly disagree (1 point) to strongly agree (5 point) and Cronbach’s alpha received the value .91 for the PFA training group, indicating an excellent internal consistency.

Remote PFA Training

The present PFA training was based on the PFA guide published by WHO (2011, 2013) and the additional guidance material for the PFA delivery during the COVID-19 pandemic (Inter- Agency Standing Committee Reference Group on Mental Health and Psychosocial Support 2020). A detailed outline of the PFA program applied is available after contact with the authors.The total duration of the training was 90 min, from which 20 min was used for questions and discussion of the incidents from daily experience of the police officers.

Procedure

A written permission to conduct the present study was granted from the appropriate department of Hellenic Police. A pilot study was performed: the WHO questionnaires were adapted and administered to a small number of police officers (n = 5). They evaluated all the questions as clear, comprehensive, and appropriate. Moreover, they attended the PFA program in order to highlight any difficulties in comprehending the material and to consider any suggestions. All the participants noticed that the program material was very comprehensive and they suggested that more examples from the police practice should be incorporated. Indeed, examples from the police practice were discussed thoroughly throughout the PFA training.

Participants were informed for the purpose of the study through invitations sent to the official emails of the Police Departments. Participation was voluntarily stated in the participation form, which was included in the invitation. In the participation form, participants were also asked to choose between two options: participation in the PFA training and filling out the study questionnaires, before and after receiving the training, or only to complete, in two time points, the study questionnaires, without participating in the PFA training. Thereby, participants were randomly allocated in two groups, the intervention and the control group and measures were obtained both pre- and post-training (randomized control group pre-test-post-test design).

Statistical Analysis

The statistical package Statistical Product and Service Solutions (SPSS 23.0) was used for the data processing and analysis. A Kolmogorov–Smirnov test was used to assess the normality assumption. Data were not found to be normally distributed; thus, non-parametric tests were chosen and applied. Mann–Whitney U and X2 tests were used to estimate differences in demographics between the two groups (intervention and controls). Mann–Whitney U test was applied to measure differences between the two groups in PFA knowledge, attitudes, perceptions, and the reported feeling of confidence in applying PFA. Wilcoxon signed-rank test was used to assess differences within each group, i.e., for the intervention group, differences in PFA knowledge, attitudes, perceptions, and the reported feeling of confidence were assessed, before and after receiving the PFA training, while the control group was tested on the same two time points without receiving the PFA training.

Results

No statistically significant differences were found between the PFA training group and the control group in demographic variables sex, age, years of police service, participation in another PFA program, and type of police department, as it is presented in Table 1. Mann–Whitney U test results are presented in Table 2. It was found that the two groups did not present significant differences in pre-test scores regarding both the feeling of confidence on providing PFA (intervention group: Mean score = 3.70, control group: Mean score = 3.52, U = 1107.000, p = .150) and their knowledge, attitudes, and perceptions scores (intervention group: Mean score = 9.32, control group: Mean score = 8.39, U = 1038.500, p = .056), while post-test scores revealed that the PFA training group had higher scores in PFA knowledge, attitudes, perceptions (intervention group: Mean score = 11.50, control group: Mean score = 8.53, U = 473.500, p = .000), and the reported feeling of confidence in applying PFA (intervention group: Mean score. = 3.94, control group: Μean = 3.51, U = 858.500, p = .002). Moreover, Wilcoxon signed-rank test results (Table 3) revealed that post-training scores were statistically higher than the pre-training scores in the PFA training group. More specifically, the mean pre-training score of the feeling of confidence in providing PFA was 3.70, while the mean post-training was 3.94 (Z = −2.771, p = .006). Likewise, the mean pre-training score on knowledge, attitudes, and perceptions was 9.32, while the mean post-training was 11.50 (Z = −5.411, p = .000). No statistical differences were found in the control group (see Table 3). With regard to the evaluation of the training program, participants evaluated the PFA training positively, reporting among other statements that the presented information was comprehensive and estimated that it will be usefully applied during their police duties.

Table 1

Demographic data of intervention and control group

	Intervention group(n = 50)	Control group(n = 53)	U	Χ.2	p
	Mean (S.D.)	Mean (S.D.)
Age (in years)	36.93 (9.55)	36.77 (7.20)	1163.000		.284
Years in police service	14.40 (8.40)	17.04(7.28)	1115.500		.166
Gender	41 men 9 women	45 men 8 women		0.158	.793
Type of police department at the present time	42 in police stations 11 in police directorates	44 in police stations 6 in police directorates		1.431	.292
Type of police department for the majority of the past years	42 in police stations 11 in police directorates	43 in police stations 7 in police directorates		0.814	.441
Past participation in a PFA program	8 yes 45 no	6 yes 44 no		0.210	.776

Table 2

Mann–Whitney U test results for the intervention and control group (between subjects effects)

	Intervention group(n = 50)	Control group(n = 53)	U	p
	Mean (S.D.)	Mean (S.D.)
“Pre-test – feeling of confidence”	3.70 (0.71)	3.52 (0.68)	1107.000	.150
“Post-test – feeling of confidence”	3.94 (0.51)	3.51 (0.69)	858.500	.002
“Pre-test – knowledge, attitudes, perceptions”	9.32 (2.19)	8.40 (2.36)	1038.500	.056
“Post-test – knowledge, attitudes, perceptions”	11.50 (2.19)	8.53 (2.30)	473.500	.000

Table 3

Wilcoxon signed-rank test results for the intervention and control group (within subjects effects)

	“Pre-test – feeling of confidence”	“Post-test – feeling of confidence”	“Pre-test – knowledge, attitudes, perceptions”	“Post-test – knowledge, attitudes, perceptions”	Z	p
Intervention group (n = 50)
Mean (S.D.)	3.70 (0.71)	3.94 (0.51)			−2.771	.006
Mean (S.D.)			9.32 (2.19)	11.50 (2.19)	−5.411	.000
Control group (n = 53)
Mean (S.D.)	3.52 (0.68)	3.51 (0.69)			−0.191	.849
Mean (S.D.)			8.40 (2.36)	8.53 (2.30)	−1.548	.122

( = 50)

( = 53)

Discussion

The aim of the present study was to investigate the effectiveness of a PFA training on police officers. The results revealed that the police officers, who received PFA training, significantly increased their PFA knowledge, attitudes, and perceptions and presented increased sense of confidence on their capacity to provide PFA. These results are in line with previous findings reporting that first responders showed similar improvements after participating in PFA training programs (Kang and Choi 2021; Kilic and Simsek 2019; Park and Choi 2020; Sijbrandij et al. 2020).

Furthermore, the present findings provide further support and extend the findings of both Katzman et al. (2021) and Lewis et al. (2014). More precisely, these studies reported significant benefits from PFA training in police officers: significantly increased confidence on providing PFA, competence in providing help in traumatic events, increased PFA knowledge, and self-care practicing were reported (Katzman et al. 2021; Lewis et al. 2014). In the present study, trained police officers were compared to a control group, which received no training in order to control for influences of other variables, mainly the influences of questionnaire re-administration. Results revealed that trained police officers benefited from the PFA training and showing significantly increased PFA knowledge, attitudes, perceptions, and sense of confidence on their capacity to provide PFA. The non-trained control group of police officers did not present significant changes.

Although only a few studies were found to measure the effectiveness of PFA on policemen, several studies have investigated the effectiveness of other mental health promoting programs in police force (Arble et al. 2017; Arnetz et al. 2009; Christopher et al. 2015). For example, Arnetz et al. (2009) assessed the effectiveness of a program of psychological resilience on decreasing the effects of traumatic experiences in a randomized control study. The intervention group participated in a 12-week program promoting psychological resilience and skills to respond to traumatic incidents. All participants were called, 1 year after the training, to take part to a simulation of a traumatic event. Participants in the intervention group were found to present better indexes of stress, i.e., less heart rate reactivity and larger increase in antithrombin, decreased negative emotions, and better police performance, when compared to controls (Arnetz et al. 2009). Furthermore, Hunt et al. (2013) assessed the effects of Trauma Risk Management (TRiM), an organizational peer support program, on sickness absence, which was used as an index of mental health status. They found that engagement in TRim intervention was associated with reduced sickness absence and they suggested that it can be used to mitigate the negative effects of trauma exposure (Hunt et al. 2013). Thus, it has been shown by several studies that peer support and training programs of police force on several aspects of mental health are effective and significantly improve critical and traumatic police response.

It is worth mentioning that the circumstances of COVID-19 did not allow applying an in vivo training, so the present PFA training program was adapted and initiated online. Although role playing and simulation scenarios were not applied, the participants showed significant improvements and they positively evaluated the experience of the training. It has been acknowledged that the pandemic poses extra pressure on first responders through the necessity to receive strict measures of protection and the increased possibility to get infected by the virus and that the training of first responders on PFA should be delivered through the usage of novel technology that promotes communication and support, in order to safely provide PFA during the pandemic (Shah et al. 2020). The present results provide evidence on the effectiveness of on-line PFA training, suggesting that remote PFA training can be used to enhance PFA sense of confidence, knowledge, attitudes, and perceptions.

With regard to the limitations of the present study, the sample of police officers that participated was relatively small; thus, the results are discussed with the appropriate reservations. Furthermore, the on-line application of the training and its limited duration is probable to affect the power of the effectiveness of the training both in short and long term. Moreover, follow-up evaluations were not implemented; thus, long-term effects of the training were not evaluated in the present study. Subjective self-evaluations were mainly used in the present study as outcome measures, while objective measures, such as biological indexes or/and sickness absence from police service length, would have contributed to draw more spherical conclusions.

In conclusion, the present study revealed that the on-line PFA training of police officers significantly enhanced their PFA knowledge, perceptions, attitudes, and the sense of confidence in providing PFA. Taking into account the existence of limited studies on the effectiveness on PFA training, the present findings provide significant support regarding the effectiveness of PFA training of police officers. Further research should be conducted in a larger sample of police officers, using both short- and long-term evaluations, more objective outcome measures, and a critical incident simulation, in order to extend the findings of the present study.