Implementation, Uptake, and Culture Change: Results of a Key Informant Study of a Workplace Mental Health Training Program in Police Organizations in Canada

Abstract

Background:

Organizational characteristics and attributes are critical issues to consider when implementing and evaluating workplace training. This study was a qualitative examination of the organizational context as it pertained to the implementation of a workplace mental health program called Road to Mental Readiness (R2MR) in police organizations in Canada.

Methods:

We conducted a qualitative key informant study in 9 different policing organizations in Canada.

Results:

The central theme of “successful cultural uptake” emerged as key to R2MR’s implementation and the ability to facilitate broader culture change. Successful cultural uptake was enabled by several contextual factors, including organizational readiness, strong leadership support, ensuring good group dynamics, credibility of the trainers, implementing widely and thoroughly, and implementing R2MR as one piece of a larger puzzle. Successful cultural uptake was also described as enabling R2MR’s impact for broader cultural change within the organization. This enablement occurred through enhanced dialogue about mental health and the introduction of a common language, a supportive workplace culture, increased help seeking, and organizational momentum for additional mental health programming and policy initiatives.

Conclusion:

Successful uptake of R2MR has the potential to lead to promote change within policing organizations. The model derived from our research may function as a tool or roadmap to help guide other organizations in the process of or planning to implement R2MR or a similar intervention.

Introduction and Background

Understanding the mental health needs of police officers is an area of increasing interest and concern, as high numbers of police workers seem to experience mental health problems. A recent study of public safety workers in Canada found that 50.2% of federal police (Royal Canadian Mounted Police) and 36.7% of municipal/provincial police screened positively for 1 or more mental disorders.¹ While the etiology of mental disorders is multifaceted and complex, the stressful nature of police work has been identified as one important factor.^2–5 Importantly, sources of stress do come not only from the nature of the police work itself (i.e., regular exposure to potentially traumatic events) but also from organizational factors, such as high job demands, low supervisor or collegial support, and low levels of control over one’s working conditions.^1–3 In fact, evidence suggests that organizational sources of job stress are better predictors of police distress than acute and potentially traumatic events.⁵

Mental illness–related stigma within policing is pervasive.^6,7 Stigma has been identified as a key barrier that prevents members from seeking help, and for those who do seek help, it can lead to ostracism from peers, lack of support from superiors, and perceived devaluation of their skills and abilities.⁶ Indeed, a recent Canadian study⁷ measuring levels of stigma within policing culture with an adapted version of Link’s Perceived Devaluation and Discrimination Scale—called the Police Officer Stigma Scale—found 85% of police officers agreeing that most police officers would not disclose to a supervisor/manager or colleague if they experienced a mental illness. Also, 62% agreed that most police officers would expect to be discriminated against at work if they experienced a mental illness. A similar proportion (59%) endorsed the belief that most police officers think being treated for a mental illness is a sign of personal failure.⁷ In addition to a focus on improved psychosocial care within police organizations, the mitigation of psychological injury requires meaningful attention to the problem of stigma and its underlying contributors, such as the cultural imperative towards emotional control and cultural gender role norms.^8,9

The Road to Mental Readiness (R2MR) for First Responders Program is a workshop-based intervention, adapted from previous work by the Canadian Department of National Defense, that was designed specifically for first responder populations to reduce mental illness–related stigma, improve resiliency skills, and encourage help seeking.^10,11 The program contains 3 main components: video contact-based education, the mental health continuum model, and the “Big 4” coping and resilience skills. A version for supervisors and leaders exists, with the same core components but additional education, discussion, and skills building for supervisors and leaders. One of the key evaluation outcomes of the R2M2 program is improved attitudes and behavioural intentions related to mental illness and help seeking (see Szeto et al.,¹⁰ this issue). As such, the longer term potential of this program may be identified as the facilitation of a broader cultural shift within the organization. This shift is one where mental health can be discussed openly and where the culture no longer associates the experience of having a mental health problem with prejudice and discrimination.

The organizational context is a critical aspect of cultural norms and possible change. A 3-year case study project with over 40 Canadian organizations and their experiences with uptake and implementation of Psychological Standard for Health and Safety in the Workplace¹² identified several key contextual factors that helped or hindered implementation. These factors included consistent leadership support and involvement, existing processes, policies and programs to support employee psychological health and safety, consistent data collection, and adequate structure and resources.¹³ In this context, Gursky¹⁴ and Kirkpatrick¹⁵ promoted evaluation models that emphasized the importance of understanding the effects of training at different organizational levels and argued that success at one level is necessary for success at the next level. Gursky’s¹⁴ model specifically includes the degree of organizational support and change, and it argues that when this factor is lacking, there is a negative effect on professional development efforts. The importance of organizational context provided the rationale for the current study, as it examined potential processes, practices, and cultural factors that may help or hinder the potential of R2MR to influence the broader organizational culture.

Methods

The objective of this study was to advance understanding of how organizational context influences implementation of a program such as R2MR and the extent to which this helps or hinders the ability of the training to affect larger cultural change within the organization. A qualitative key informant study¹⁶ of the R2MR program was conducted within police organizations in Canada. Ethical approval for the study was obtained from the University of Calgary’s Conjoint Faculties Research Ethics Board (REB16-0604), and all participants provided informed consent. We followed a purposeful sampling approach to data collection, and a benchmark of 10 to 15 interviews was used as a target number of interviews to conduct to achieve saturation in analysis.

A total of 11 key informants from 9 different policing organizations across Canada were interviewed by phone in March 2016. All respondents had played a key role in implementing the R2MR program in their organization. The participants were purposefully selected from a subset of organizations that had implemented the program within the previous 2 years. They were identified as those organizations that were far enough along in the implementation process that they could reflect on successes, failures, and perceptions of potential impacts (or lack thereof). Selection was based on representation from both large and small, as well as urban and rural police organizations. Each of the key informants participated in a single interview, lasting on average 45 minutes.

Interviews were semistructured and included 5 main topics for discussion: rationale and reasons for adopting R2MR, experiences with R2MR (including successes and challenges), perceived impacts of R2MR, organizational culture regarding mental health, and how R2MR fits (or does not fit) into the larger organizational context. Interviews were tape-recorded and transcribed and then imported into NVivo¹⁷ (version 10) software for qualitative analysis. The data were analyzed for major themes using established procedures for content analysis as described by Hsieh and Shannon.¹⁸ After each interview was read as a whole, analysis entailed line-by-line coding, consideration of key concepts, and the organization of codes into related categories. Two coders were used for analysis. In addition, researchers met regularly to discuss codes and to reach consensus on the description of categories. The dimensions of these categories were then further developed, leading to final analytic themes, which were reviewed with the larger research team. Reflexive questioning and dialogue were employed throughout this process to help identify and challenge any unquestioned assumptions or preconceptions that may occur in the process of interpretation. The research was led by an independent consultant (third author) with no ties to the R2MR program or the Mental Health Commission of Canada.

Results

Figure 1 depicts the integrated theoretical model derived from the analysis. Elements of this model are described in more detail below.

Figure 1.

Integrated theoretical model derived from the current analysis.

Successful Cultural Uptake

Informants made a clear distinction between organizational structure and culture, noting that while the organizational structure of policing made the implementation of a training program such as R2MR relatively straightforward, it was the extent of cultural uptake that ultimately determined the program’s ability to facilitate broader culture change. Informants emphasized that changing perceptions, attitudes, and behaviours related to mental health can be particularly challenging in a workplace culture where there are strong prevailing views of what workers “should” be like, as well as entrenched stereotypes that associate mental illness with weakness and shame:

When you are in a paramilitary organization it is very hard to change the culture. Ideas, beliefs, norms, values are entrenched in the culture. The idea is that you can take anything…there is a culture in policing that we are the cream of the crop, we can take anything, we are strong, we don’t break down—that has been a prevailing stereotype for decades and moving past that kind of stereotype doesn’t happen overnight. (Interview 4)

It was in this context that the analysis revealed the central theme of “successful cultural uptake” as a key implementation goal. Successful cultural uptake was articulated as the implementation achievement that enabled R2MR’s impact for broader cultural change within the organization. It was described as the process of cultural acceptance of R2MR and its key messages within the organization.

Definitely here we are starting to make a cultural shift with regard to mental illness—that’s probably the biggest thing…our organization has accepted for the most part that the change is ongoing. (Interview 4)

The factors that informants described as enabling “successful cultural uptake” included both organizational factors and implementation factors. Organizational factors included cultural readiness, strong leadership support, and implementing R2MR as one piece of the puzzle. Implementation factors included implementing widely and thoroughly, ensuring positive group dynamics, and ensuring credibility of the trainers.

The cultural impacts that could be realized through achieving successful cultural uptake included the following: more dialogue about mental health and the introduction of a common language, a more supportive workplace culture, increased help seeking, and organizational momentum for additional mental health programming and policy initiatives.

These themes are described in greater detail below.

Organizational Factors Contributing to Successful Cultural Uptake

Cultural readiness

While the predominant cultural reality may be characterized as reluctant to discuss or embrace openness to workplace mental health, key informants noted that there has started to be a greater recognition of the importance of mental health and illness within policing and that the mental health of police officers is an organizational responsibility:

I think there was a recognition that the police officers in our organization—and any really—were dealing with a lot of challenges, and there was a lack of awareness and stigma accessing mental health services. What happened with us is there’s been increasing emphasis on PTSD [posttraumatic stress disorder], officer suicide, and general mental health issues in media and among chiefs of police and recognition that we need to do more. (Interview 8)

It was in this context that informants identified these shifts in thinking as symbolic of an organizational and cultural “readiness” for change. This often went hand in hand with a greater recognition of organizational “need” to better address mental health in the workplace, thereby setting the stage for interventions such as R2MR to be sought out and implemented.

Strong support from leadership

Successful cultural uptake of R2MR was also described by informants as being affected by the strength of leadership support and buy-in. Respondents suggested that a lack of perceived or real acceptance from leadership was a barrier to the larger cultural uptake and acceptance of the program and its messaging. Examples of such issues include if officers do not believe their supervisor supports the program’s content, if the supervisor denigrates its value, or if leadership lag in their own completion of the training:

We’ve had a few differences. A particular area—some have said “my manager won’t support this, this is all for naught.…” We’ve reminded them it’s not just about the managers, but supporting each other and themselves. (Interview 5)

Conversely, key informants also mentioned that strong leadership support was a key enabling factor for program success in terms of ease of implementation as well as cultural uptake:

By getting the inspectors and superintendents on board, then they were supportive, because they had that aha moment that helped us carry this forward. It did take a while for people to warm up to it. It’s new—and there’s a lot of training out there. Taking people off the streets, or anyone in any organization, we have a lot of qualifications and training we have to take—so we have to justify why, how is this going to change things. (Interview 3)

While informants did not generally provide specific definitions of what they meant by leadership, their examples and comments suggested that leadership could include all levels of supervisory and management positions, as these individuals were seen as organizational culture carriers and that cultural uptake of a program like R2MR was ultimately helped or hindered by the perceived support and buy-in from these culture carriers.

Informants indicated there can be different ways to get leadership support and buy-in—acknowledging that if it is not there from the outset, it can be cultivated. Some respondents felt that training the leadership first in R2MR was a good way to do this. Others indicated that leveraging support from other organizational champions could also work:

Within our organization, it’s not about structure, but about individuals who believe in it. Our chaplain was a big part of the process, big part of being involved and validating. We have a health and safety officer who we had buy-in from and I had the buy-in from my boss. Easy to say get the buy-in from top down, but that’s not always easy. Sometimes good to get buy-in by working your way up the ladder—saying, “well he supports, and he supports, and he supports.” Need buy-in at all levels, really. Sometimes one can support the other. If it’s seen as a top-down thing, doesn’t always work. (Interview 7)

Implementing R2MR as one piece of the puzzle

R2MR was often described as fulfilling a specific function in terms of education and awareness, with the goal of reducing stigma and encouraging greater help seeking. Key informants emphasized that programs such as R2MR need to be rooted within a comprehensive set of broader mental health programs and policies to achieve maximal acceptance and uptake. In this context, the implementation of R2MR was seen to represent one element of a larger framework geared towards workplace mental health:

It’s important, as much as R2MR is great, you have to have the supports in place. We have a list of psychologists, and we make sure these resources are covered.…In R2MR we identify issues that need to be addressed—need to have supports in place for them. Goes hand in hand. If you didn’t have that, you’d have people needing help and looking for assistance—if you didn’t have that, there’d be questions about why we have the program. (Interview 9)

[R2MR] is for stigma reduction, or to be proactive—it’s not going to solve all problems, just another tool in the belt. You need to have EFAP [Employee and Family Assistance Program] or other resources in place. If someone comes out saying they are in the red, need to make sure they can provide support, have other systems in place, or it won’t be effective. Employees will come out needing help…[so you need to] have systems in place to deal with outcomes of training or to be more proactive. (Interview 5)

In this context, respondents believed that implementing R2MR as a “one-off” program without giving due attention to larger system concerns, such as access to mental health supports and workplace mental health policies, for example, as well as other identified mental health education and training needs, would hinder the likelihood of successful cultural uptake.

Many respondents also stressed the importance of sustaining the program and ensuring it is embedded into the organizational training structure, to maintain the momentum of cultural change. They again emphasized that providing training as a “one-off” activity will not reach everyone (e.g., due to staff turnover) and also that positive impacts risk being lost over time if the messages are not sustained and reinforced.

They need to understand that because you’re trying to make a cultural change, that you continue the messaging after the training is completed—not a one-off thing—that you need to continue forward providing messaging so that it’s consistent. Here, we created a website that members and families can access from home—with R2MR information, videos, etc. Also the marketing aspect—putting up posters, putting information in our bulletins about it, continuing to keep it on the forefront of people’s minds. (Interview 8)

Implementation Factors Contributing to Successful Cultural Uptake

Implementing widely and thoroughly

As noted above, interviewees commonly noted that the existing training structures within police organizations make a program such as R2MR relatively straightforward to implement. With mandatory training blocks already in place, many organizations incorporated R2MR into this structure, enabling the program to be delivered straightforwardly in a widespread and timely manner. All organizations participating in this study indicated that R2MR was being delivered organization-wide and as mandatory or essential training. This large-scale implementation strategy was identified by all respondents as central to the achievement of successful cultural uptake.

Specifically, respondents mentioned that while there was often somewhat of a cultural lag between the initial implementation of the program and its eventual acceptance amongst the staff, the process of cultural uptake progressed as more people became trained:

[There was] a lot resistance and fear around it when we first started. As we started training more and more and more talking about it—a dramatic shift, this is good stuff.…Incorporating [the program at] various levels of training and rank [is important]. Creates the expectation that you will see it constantly. (Interview 1)

Conversely, respondents emphasized that successful uptake could be hindered if the organization was running the program “off the side of their desk” or in only training some employees and not others (e.g., frontline staff only). Put otherwise, a certain level of organizational commitment and importance needed to be assigned to the implementation of R2MR so that the training had momentum within the organization. The growth in cultural acceptance that occurred as more and more people became trained was thus seen as an important link between implementation and uptake.

Ensuring positive group dynamics

Positive group dynamics in training delivery was identified as another implementation factor for successful cultural uptake. Successful group dynamics in training delivery helps to ensure openness in dialogue, group trust, and an overall sense of responsibility for one’s own and each other’s mental health:

Depending on how tight the group was—so if people were more tight they responded more positively—the stronger the team, the more engagement they had throughout the course of the training. (Interview 1)

We have noticed the level of openness in different classrooms depends on who’s in the classroom.…If there is someone from HR, nobody says anything. Depends on who’s in the class for openness of discussion. (Interview 2)

Some informants believed the best approach to ensure positive group dynamics in training delivery was to reflect organizational structure, for example, to have similar ranks and/or specific work areas attend together. Other informants, however, favoured mixed groups, with less attention to rank and role, as they felt this delivery model offered logistical advantages and maintained consistency with other training in the organization. While a more mixed-group approach to training was employed by a number of organizations, some informants noted that this approach sometimes limited the level of trust and openness experienced by participants:

When we do the course, anyone can sign up for it. We lump them all together, we take 24 to 30 at a time, and whatever mix we get, we get. Sometimes there’s the odd comment about not wanting things mixed up. We’ve also had the comment about wanting the supervisors in the room because some feel that supervisors aren’t getting it…[and] a couple of experiences where someone will say “dispatch stresses me out…” and dispatch might be there. (Interview 2)

Credibility of the trainers

Successful training dynamics were also described by informants as being heavily affected by the trainers themselves and that the credibility and trustworthiness of the trainers were central to successful participant engagement and acceptance. In this regard, respondents emphasized the importance of matching trainers to the group being trained, for example, having higher level trainers to train leaders. Key informants also emphasized the importance of finding the “right” trainers to deliver the R2MR program. In particular, respondents emphasized the importance of having trainers with lived experience of a mental illness, who were seen as credible and trustworthy by their peers. Respondents also emphasized that trainers would ideally be recruited from within, such that they would have personal experience and knowledge of both the organization and the nature of police work.

We had criteria for what we wanted in a trainer. Wanted people that were proud to carry the message. That made all the difference in the world. Had people trained internally, our troops talking to our troops, and that worked well. To have a psychologist talking wouldn’t have worked—but to have a staff sergeant with a lot of credibility talking about things he’s been through. [It’s about] getting the right people involved delivering your message. (Interview 7)

Potential Impacts of Achieving Successful Cultural Uptake

The achievement of successful uptake of R2MR was believed to lead to a number of positive cultural changes. Informants described 4 main ways the achievement of successful cultural uptake could positively influence the culture of mental health in policing: increased dialogue and openness about mental health in the workplace, less judgment about mental health–related matters, increased help seeking, and organizational momentum for the development of further initiatives and policies related to supporting workplace mental health. Informants described seeing these impacts within their own organizations to varying degrees.

Increased dialogue and the introduction of a common language

Many key informants described seeing increased positive dialogue about mental health in the workplace. Interviewees discussed the mental health continuum model in particular as being helpful in facilitating more openness and dialogue, as it provided a common language for staff to discuss mental health and to talk about their experiences in a nonthreatening way:

The continuum model. So hard for people to talk about this—great to have a common language. To be able to say a lot without saying much at all. (Interview 6)

People are more open to talk about it—our leaders take it more seriously. For example, someone might come to our door and say they’re in the yellow and I’ll talk to them about it. They’ve given us words to use that aren’t “depression” or “anxious.” (Interview 10)

Less judgment/more supportive culture

Another perceived cultural impact was that people were becoming more supportive and compassionate about colleagues who may experience challenges. In this context, many respondents said that that they had noticed fewer judgmental and negative comments being made towards mental health–related matters:

I think where we’ve failed along the way is we have not been as open to talking about mental health issues and mental wellness of members. “He’s off duty mad.”…“Of course he’s on stress leave, it’s the summer.”…I really believe that R2MR has really helped us improve in that area. Are we there yet? No, but we are certainly a long way closer than we used to be. We have members that have spoken to the press about their mental health—that wouldn’t have happened a few years ago…and there’s certainly much more compassion for people who are suffering. (Interview 4)

Increased help seeking

The third area in which informants described a positive organizational impact from R2MR was increased help seeking:

The Chief sent an email saying that the access to EFAP has gone up, and think it’s in the last 2 years—hard to say if it’s a correlation with R2MR…but we think that people feel more comfortable asking for help. Doesn’t seem to me that it’s a coincidence. (Interview 4)

My colleague went for training a group of about 25 to 30 senior police officers, people with years and years in the field—eight people went to the wellness unit in the next week to get services for them or their family. Very rarely do we have [a class that someone doesn’t ask for help or resources]. (Interview 6)

Key informants discussed the main areas of impact—more openness and positive dialogue, a more supportive workplace environment, and increased help seeking—as a mutually reinforcing process. Specifically, informants noticed that as people became more comfortable talking about mental health issues and the colours of the mental health continuum model, people also spoke more positively about mental health. This pattern both reflected and further reinforced improvements in attitudes, reductions in stigma, and more openness and dialogue, and it also led to increased motivation for help seeking and accessing resources and supports. The following comment illustrates how respondents described these cultural impacts working together to facilitate organizational change:

An example of how putting in place the R2MR was beneficial—a lieutenant with 30 plus years experience. When he gave the course, I don’t think a day went by that he didn’t come by after the course and say this person came up in tears asking for help. When it created dialogue, it created an opportunity for people to get help. He was seen as the godfather or mentor…sharing his experience. Giving not just the PowerPoint, but making it human—saying “here’s what I went through, here’s what a buddy went through.” This helped people share their experience, either during the course or afterward. Not sure if we saved lives, but I’m sure we made a difference in somebody’s life. That’s something really positive that came out of the R2MR. (Interview 7)

Creating momentum

While respondents observed varying degrees of positive organizational impacts, they also cautioned that these organizational impacts would not continue without a commitment to maintain the momentum of cultural change. Similar to the theme of seeing R2MR as only “one piece of the puzzle,” a number of key informants described how successful cultural uptake of the R2MR program could help to create additional momentum. In particular, R2MR was viewed as a stepping stone for further development of workplace mental health initiatives, whether by identifying existing gaps and/or by introducing additional supports and structures:

We could stand to improve [our policies], and this has come out because of discussions in R2MR. For example, policies not being applied the same in different areas.…It has really identified to us an area that we have some work to do—looking at policies/procedures and making sure they’re consistent. (Interview 11)

Discussion

It has been well established that organizational characteristics need to be considered when implementing and evaluating workplace training.^14,19 Indeed, context presents both constraints and opportunities for change and has the potential to shape the very meaning underlying various organizational behaviors and attitudes.¹⁹ However, organizational context tends to be insufficiently appreciated in research, even though context is almost always implicated in the organizational features needed to properly explain how individual activity translates into larger organizational outcomes.^19,20 This study addressed these issues by examining the potential processes, practices, and cultural factors that may help or hinder the implementation of a mental health program.

The current results reveal the importance of distinguishing between implementation and uptake when considering the impact of training programs such as R2MR and their potential to help facilitate cultural change within policing organizations. Key informants in this study revealed that both organizational structure and culture affect a program’s success and ability to facilitate broader culture change. More specifically, while the organizational structure of policing facilitates implementation of a training program such as R2MR, it is the successful cultural uptake of R2MR that enables cultural change within the organization. Achieving successful cultural uptake was revealed to be facilitated or hindered according to a number of key factors. These factors included organizational readiness, strong leadership support and support from organizational champions, ensuring good group dynamics, credibility of the trainers, implementing widely and thoroughly, and implementing R2MR as one piece of a larger puzzle.

The achievement of successful cultural uptake, in turn, was what informants identified as the pathway through which larger cultural change could be realized. In the case of R2MR program impacts, these changes included more dialogue about mental health and the introduction of a common language, a more supportive workplace culture, increased help seeking, and organizational momentum for additional mental health programming and policy initiatives.

The current results were based on qualitative data from the implementation of the R2MR program in different police organization across Canada. As such, the current findings and the visual model may function as tools or a roadmap to help guide other organizations in the process of implementing R2MR or a similar intervention. However, in as much as the model was generated from a limited number of program implementations and examined only the organizational context of policing in Canada, it remains unclear whether this model may translate to other first responder organizations where R2MR has been implemented. Indeed, different factors, strategies, and considerations may be needed in other organizational contexts such as paramedics, firefighters, 911 call centres, and corrections officers that are not reflected in the current model.

That said, positive results from extensive quantitative evaluation of R2MR regarding stigma reduction, intentions toward help seeking, and willingness to discuss and provide support to colleagues regarding mental health (see Szeto et al.,¹⁰ this issue) provide additional confidence about the connection between successful uptake and positive cultural change. The descriptions of the perceived organizational impacts of R2MR were also consistent with findings from another related qualitative study, which focused on the experiences of those who attended the R2MR program.²¹ This consistency in findings from multiple studies thus lends confidence to the current results.²² Future research should focus on the continued refinement of the current model and the investigation of contextual factors and considerations in other first responder organizations, as well as with police organizations in other jurisdictions.

The theoretical model derived from this research suggests that workplace mental health interventions have the potential to realize larger shifts in organizational culture, through the process of achieving successful cultural uptake. It is unclear from this research the extent to which the perceived cultural impacts were caused by the uptake of the R2MR program itself or the extent to which R2MR was implemented as a result of already occurring extant culture change. This does not change the value of the theoretical model, however, as the implementation model presented through these findings illustrates key factors that are believed to be necessary if a training program is to have potential as an agent of culture change, regardless of where on the spectrum of change the organization may be at the time. It would be beneficial for future research to examine the extent to which the main implementation and organizational factors that facilitate successful uptake may be more or less important in different contexts and situations.