Police face daily challenges in carrying out their duty to protect the general public. Within the literature, different terms are used to identify the area where detainees are held by police including the cell block, custody suite, and detention center. Throughout this article, this police detainee holding area will be referred to as a detention center. One challenge that has been debated within both police and other professions are decisions related to the health needs of detainees in the detention center (Allen, 2013; Association of Chief Police Officers, 2012; Bond, Kingston, & Nevill, 2007; Burns, 2013; Glasper, 2014; Hurley, Linsley, Elvins, & Jones, 2013; Norman, 2014). Because of situational factors, police are often required to make health-related decisions regarding detainees without the level of medical or healthcare training required for optimal decision making. The result is most often a transfer of the person, along with at least one police officer to escort him or her, to an emergency room (ER) for assessment and/or treatment. Approaches to address improved healthcare for detainees, such as access to crisis intervention teams, street triage, nurses in custody suites, and court liaison and diversion staff, were reviewed at length in a previous article (Woods, Leidl, Butler, Stonechild, & Luimes, 2017). On the basis of this review, an innovative approach to providing the healthcare needs of individuals held in police detention centers through the use of advanced technologies was proposed. Remote presence technology, a mobile, robotic communications platform, can enable remote access to health (InTouch, 2010). This technology has the potential to link outside healthcare experts from many professions including nursing with individuals in custody requiring health assessment, opening up a new pathway of care (Woods et al., 2017).
Mendez and Van den Hof (2013) indicate that remote presence technology “can connect a primary care physician or specialist to the point-of-care setting, promoting real-time assessment and monitoring of the patient through wireless networks” (p. 1512) and that “dedicated remote-presence medical devices have encryption protocols for secure communication, as well as high-resolution cameras and ports for the attachment of peripheral diagnostic devices such as portable ultrasound machines or digital stethoscopes” (p. 1513). There are many dedicated remote presence devices available and in use within the justice system (Rappaport, Reynolds, Baucom, & Lehman, 2018). The authors have experience with these devices and their use in a police detention center. In selecting the best technology for use in the detention center, the portability of a remote presence device enables the delivery of clinical services in a timely manner to achieve quality care (InTouch Health, 2016).
Evidence has been reviewed that reports on remote presence technology, in both healthcare in general and correctional healthcare more specifically (Woods et al., 2017). Some of this literature has highlighted cost savings as a significant benefit (Doarn, Justis, Chaudhri, & Merrell, 2005; Gandsas, Parekh, Bleech, & Tong, 2012; Grohs, 2014; McNelis, Schwall, & Collins, 2012; Mendez, Jong, Keays-White, & Turner, 2013; Raths, 2014; The PEW Charitable Trusts & MacArthur Foundation, 2013; Vespa et al., 2007; Wexford Health Sources Incorporated, 2015). Satisfaction from users as a benefit has also been reported (Al-Khathaami et al., 2015; Doarn et al., 2005; Magaletta, Fagan, & Peyrot, 2000; McNelis et al., 2012; Mendez, Jong, et al., 2013; Mendez, Song, Chiasson, & Bustamante, 2013; Myers, Valentine, Morganthaler, & Melzer, 2006). The literature further suggests similar or improved assessment and/or clinical outcomes when utilizing remote presence technology in varied populations including neonatal intensive care, glycemic management in corrections, and correctional adolescent and youth services (Fox, Somes, & Waters, 2007; Garingo et al., 2012; Jameson, Zygmont, Newman, & Weinstock, 2008; Mendez, Song, et al., 2013; Myers et al., 2006).
The purpose of this research was to examine how and if a new intervention pathway using remote presence technology to aid in health assessment of individuals detained in police service detention centers could be implemented. The key research question was how a new intervention pathway for individuals detained in police service detention centers could be implemented. This pathway would involve linking the police service detention center to the ER via remote presence technology.
An exploratory qualitative research design was used to examine the research question. This research approach is particularly useful when new insights are required to help answer such questions as who, what, how, when, and where. Exploratory research is “designed to increase the knowledge of a field of study” (Grove, Burns, & Gray, 2013, p. 370). Data were collected through in-person interviews from a purposeful sample of both police and health professionals in the province of Saskatchewan, Canada. The guiding questions used to explore participant views on the use of remote presence technology to care for individuals held in a police detention center are outlined in Table 1. To familiarize participants with remote presence technology, participants were provided with a one-page information sheet and an online video on remote presence technology, before any interviews took place.
All interviews were audiotaped, transcribed verbatim, and imported into NVivo for the analysis. Participants were sent the complete transcript of their interview and offered the opportunity to add, alter, and delete information from the transcript as appropriate. They were asked to acknowledge that the transcript accurately reflected what they had said in the interview. Interview data were thematically analyzed to uncover patterns within data that formulated themes. Thematic analysis has been described as a six-phase process: becoming familiar with the data, generating initial codes, searching for themes among codes, reviewing themes, defining and naming themes, and producing the report (Braun & Clarke, 2006). Categories emerging from these themes were coded, clustered, and assigned meaning through meetings between members of the research team.
Ethical review and institutional approval was given by the University of Saskatchewan Behavioural Research Ethics Board, Regina Qu'Appelle Health Region Research Ethics Board, and Prince Albert Parkland Regional Ethics Committee. Operational approval was given by Saskatoon Health Region. Police services at all three locations (Prince Albert, Saskatoon, and Regina) agreed to participate after university ethics approval. Written informed consent was obtained from all participants before they were interviewed. No participant was identifiable as no demographic data were collected.
Potential and appropriate participants for the study were identified either by an inspector within the local Saskatchewan police service or by a local Saskatchewan ER manager. Police participants included superintendents, inspectors, detention center sergeants, and patrol officers. Healthcare participants included ER nurse managers, emergency medical service coordinators and attendants, and ER directors. All participants identified were formally invited and voluntarily participated in the interviews. Interviews were undertaken at their place of work by one of the researchers and the research assistant. Interviews ranged from 30 to 60 minutes in length. Eighteen interviews were conducted with police service participants (n = 12) and ER healthcare participants (n = 6) in Prince Albert, Regina, and Saskatoon.
Collectively, four clear themes emerged from Questions 1 through 6 (see Table 2). From the remaining three questions, the potential collaborative learning opportunities that would exist with this type of pilot research were identified along with the optimal (the most appropriate) healthcare professional for the intervention pathway.
Theme 1: Role Conflict
Numerous concerns were expressed related to responsibility over the healthcare needs of the detainee, safety, quality of care, and the removal of healthcare burden from police services. Police participants highlighted internal role conflict between managing their primary role of protecting the public with the incidental role of determining the health needs of detainees. Police participants overwhelmingly described this as something they felt unqualified to manage. When the interview focused on how remote presence technology could fit within police services, police service participants stated that the pressure they felt to provide services for which they are not trained, such as assessing detainee health, could be relieved by leveraging technology to link health and police services. Healthcare participants echoed the same sentiments, identifying the detention center as a difficult place to provide healthcare services and that there is a lot of pressure on police services to provide services they are not comfortable or qualified to provide. The following quotes show how these differing perspectives are associated with role conflict:
Police could focus on the street rather than tying up members providing healthcare services to an inmate. (Police service participant)
I'd like to think I can tell when someone's being genuinely sick or hurt. But quite often, I don't know how serious it is, if it's not visible or it's not trauma or something. (Police service participant)
The benefit to having those (remote presence) is that you have a specialist who's able to observe a patient without needing to transfer the patient off site. (Healthcare participant)
Probably less time in the ER. Less cost in the ER, safer if they're violent. (Healthcare participant)
To be quite honest, we have the perspective of, which is far different than a medical perspective. So when we see a person who's intoxicated and laying on the ground, to us that's a criminal, and to a doctor that's a patient. And so just the way we treat that person and the care we give that person is far different. (Police service participant)
Theme 2: Risk Management
The theme of risk management was also supported by statements regarding the management of healthcare needs for those in detention while still in a secure environment, thus promoting public and provider safety. Concerns about liability, responsibility of care, safety and security for detainees, and health services were also noted under the risk management theme. Police service participants were interested in the potential benefits of being able to dedicate more time on policing, reducing the time spent in the emergency department, and reducing liability on police services with regard to the healthcare status of detainees. Healthcare service participants recognized the challenges faced by police services regarding the provision of care in the detention centers, identifying safety risks for both police services and detainees. Liability management within the detention center was identified as a benefit by police service participants but not necessarily by the healthcare service participants, who had some concerns about their own liability.
When a detainee is brought into the detention suite, there's a level of liability that goes along with that in terms of the medical well-being of that person. So from a police services perspective, they, you know, to take that liability away from having them, you need to have some sort of a medical personal to assess the patients. (Healthcare participant)
So in the cells, obviously confidentiality with medical would be important to you. You'd have to have a secure room. (Healthcare participant)
So if we can keep them here without having to move them from that cell, that's the ultimate goal. (Police service participant)
It's going to be used more to triage the patients initially. But I think full scope would be that, it'll be used for assessment. (Healthcare participant)
Having it all happen in the cell I think is the, the big benefit to it. So a lot of community resources would be saved and, to be redistributed I guess in most communities, as opposed to tying up with this process. (Healthcare participant)
So in a bigger scope of things, I really do think that it would affect negative interactions with the public right across the board, so we will have improved investigations. (Police service participant)
Police service participants identified issues associated with the implementation of the technology, specifically regarding the use and maintenance of the equipment and what would happen to data collected during its use. Risk management with regard to the safety of the healthcare professional operating the equipment, as well as that of the equipment itself, was also identified as a major concern. Additional concerns related to risk management voiced by healthcare participants regarding the pace of change in healthcare delivery, detainee safety, equipment safety, confidentiality, data protection, and the limitations of technology in the provision of care.
Theme 3: Resource Management
Police and healthcare participants identified similar monetary and human resource implications of using remote presence technology in the detention center. The responses clustered around concerns of the management of resources such as time dedicated to use, the role of police services and healthcare professionals in its application, and which personnel would ultimately be responsible for its use. Responses from healthcare participants related to resource management focused on the enhanced utilization of police human resources and concerns related to the flow of patients through emergency services. Additional costs associated with equipment and labor were also identified. Efficient utilization of resources by healthcare and police services was a common human resource concern voiced by both services. Timely access to specific healthcare triage and assessment resources was identified as being a significant perceived benefit from the resource management perspective.
Saving the resources and being more strategic with utilizing the resources that we are responsible for. So if we could eliminate Hospital wait times, then that's maybe on average 4 hours of time on task for two officers that they could be out doing protective enforcement or responsible enforcement and that's is a huge issue. (Police service participant)
In detention, I won't leave the medic alone with the prisoner. So, if this is going to take, too much time, a police officer has to be with the medic and the prisoner, right. (Police service participant)
So for the most part they'd benefit, because you're, again keeping the police from escorting and sitting, with the patient in the ER for hours sometimes, which, occurs. (Healthcare participant)
There needs to be a lot of trust between the person that is on scene assessing and, you know, laying eyes on the patient and the person who's on the other end of the screen giving order. (Healthcare participant)
Concern was expressed with who would pay for and manage the remote presence equipment, but also excitement about the impact that this technology would have on police services, if more time was dedicated to conducting policing. Cost of the program and who would pay for it were also identified as major challenges by both police and healthcare service participants.
It's going to tie up a lot less resources that if we had to escort that person up to the hospital. (Police service participant)
“High potential for (remote presence equipment) getting damaged. (Police service participant)
Where does the money come from? (Police service participant)
Cost, cost, space, user functionality, the IT support behind it. (Healthcare participant)
Theme 4: Access to Services
Enhanced access to healthcare services for detainees was seen as a great way to reduce police service concerns related to detainee liability and was perceived by police service participants as possibly the greatest benefit. The “access to services” theme included topics such as expedited access to triage, assessment, and interventions. With the range of services being bound to the professional skill level of the healthcare professional in the detention center, scope of practice was also identified as an area of importance in relation to this theme. Many of the healthcare service responses were associated with implementation, specifically related to enhanced access to assessment and triage services.
It would definitely expedite getting assessment compared to what we are dealing with now. (Police service participant)
It would improve the care in cases where we ignored it. (Police service participant)
I think it's a lot depending on who's on the police end, for the healthcare. As to what medications they could administer, and what assessment skills and tools they have on that end. I think the Doc can see, a lot, of what's going on and make decisions, either to transport or not transport. (Healthcare participant)
It would be a huge benefit, I mean. If there's somebody there watching these patients 24/7 basically. I mean, what better thing could there be. Like really. (Healthcare participant)
Improves relationships between ER staff including doctors, nursing, police and ER staff including doctors and nurses. (Healthcare participant)
Potential Collaborative Learning Partnerships
Participants were also asked to identify potential collaborative learning opportunities that could stem from the implementation of remote presence technology in the detention center (see Table 3). Police service participants identified connections including those between emergency department healthcare services and police, as well as police services with community healthcare services. Healthcare service participants saw opportunities for collaborative learning taking place between ER staff and police services, between paramedics and police services, and among the healthcare professionals within the ER.
We currently still have issue in how we do what we do, between physicians and nurses and RTs, and pharmacists, so we truly haven't reached that level of collaboration that we need to be at. But in theory what this would do is, is bring together people. (Healthcare participant)
I think it would enhance relations between, you know, our departments and staff, and the city police, or whoever we're connecting with. But I think you have to look at the, the resourcing around, how do we then add this to the burden that's already here. (Healthcare Site 2)
Optimal Healthcare Provider for a Future Pilot Project
Discussion on the role of the healthcare professional working in police services and the optimal (or the most appropriate) care provider resulted in numerous responses that overlapped with each other (see Table 4). Respondents helped to explain the types of healthcare concerns experienced by those in the detention center and identified the scope of professional practice needed to address the issues. Police and healthcare responses to the role of the healthcare professional were organized under the theme role of the healthcare provider and included specific healthcare tasks associated with patient assessment, triage, intervention, safety, and consultation. Few specific healthcare concerns were identified by participants in their responses with the exception of simple cuts and bruises that many detainees were described to have at the time of being detained. The scope of practice necessary to address to the healthcare needs of those in detention was vague and difficult to categorize within available data.
I guess, triggering the call to the ER Doc would be one piece. So having the assessment skills to say, you know, we should probably bring them to the ER Doc and have them look at this patient versus, you know, it's fine, it's an abrasion. Triaging when to use the device.
Well the assessment would be the biggest thing. So the hands on, the physical and visual assessment, and the history. (Healthcare participant)
Just to ensure the safety and well-being of the people that are held in custody, and not only that, but lift a lot of, potential liability from our organization. (Police participant)
Prison is not a very kind way to deal with health. (Police Service participant)
Police and healthcare service participants identified service providers including physicians, nurses, nurse practitioners (NPs), emergency medical technicians, and paramedics as being desirable to utilize the remote presence technology in the detention center and address the healthcare needs of those in detention. However, participants did not think it was realistic for a physician to assume this role, instead viewing registered nurses, NPs, or paramedics as a more practical option. Healthcare participants had a similar perspective, sharing that it was not an optimal use of provider scope of practice to place a physician or NP full-time in a detention center. “Registered nurses” was the most popular response, followed by paramedics or emergency medical technicians as an optimal choice.
So from a clinical standpoint I think what you'd want is either. You know, you're probably going to want a nurse that does Northern Nursing. You're going to want an NP. You're going to want an ER style nurse. If not, an advanced care paramedic. (Healthcare participant)
Well the most qualified ultimately would be the best but that's not the most responsible and it's not the most realistic. So if we had a qualified NP, that is amazing, or anybody who could operate this instrument, and appease a physician who is on the other end of it. So if that is a paramedic, I think that's a viable option as well. (Police service participant)
The emergent themes from this research reveal important facilitators and barriers to attending to health needs within the police detention center through the utilization of advanced technologies such as remote presence. Attention to role conflict, risk management, resource management, and access to services, as well as correct fit and type of healthcare provider, are important in the development and implementation of a strategy that meets the needs of police, healthcare, detainees, and the public. Education of all employees would be important before introducing remote presence technology within the detention center.
Issues related to role conflict are an ongoing concern in police services, with existing research identifying role conflict concerns related to many topics including noble cause corruption (Cooper, 2012), victim services (Zaykowski, 2014), and role expectations (Huey & Ricciardelli, 2015). Police service responses were also consistent with the research related to the benefits of interprofessional collaborations including the relief of role conflict, risk management, and resource management (Grantham, 2011; Knopf, 2011). Although the introduction of remote presence technology into detention centers is a new idea, concerns and benefits identified were similar to those of previous innovations and collaborations between healthcare and police services.
It was clear that concerns around the impact of liability and risk management would need to be given close attention with any introduction of remote presence technology within the detention center. An inconsistent definition of “risk” was identified as contributing to police service concerns with liability (Cukier, Barkel, Vaughan, & Gekas, 2012). When different departments, levels of leadership, and/or administration have different criteria and scales to assess risk, misunderstandings and problems commonly occur.
Concerns related to innovation and the use of technology in healthcare have been well documented over time in both police and healthcare literature (Lavoie, Wong, Katz, & Sinclair, 2016; Miller et al., 2005; Roundfield & Lang, 2017) and policing (Cooper, 2012; Huey & Ricciardelli, 2015; Zaykowski, 2014). Comments from healthcare participants related to risk management are also consistent with nursing research related to problems associated with innovation and the implementation of best practice in the clinical environment (Roundfield & Lang, 2017). Closely related are concerns about the cost of innovation and the introduction of technology in healthcare service delivery, which were also consistent with existing nursing research (Miller et al., 2005). This consistency with the existing nursing research provides hope that previous models, frameworks, or solutions discovered in previous projects could be applied to a future pilot project implementing remote presence technology into police detention centers.
The significance of interprofessional collaboration and consultation when developing innovative solutions to multisectoral problems was evident with both groups of participants clearly articulating their areas of expertise and deficit. Responses from the healthcare participants reflect the nursing literature on the benefits of interprofessional collaborations in healthcare. These include more empowered teams, enhanced role clarification, fewer communication gaps, better client care, lower readmission rates, and enhanced promotion of patient-centered care (Corbridge, Tiffen, Carlucci, & Zar, 2013; Lamb, 2015).
In addition to the insights provided that were supported by existing literature, the interviews identified knowledge and insights that could be used to guide the successful implementation of remote presence technology in the detention center. This knowledge addresses risk management and liability concerns related to the detention center, the utilization of resources (i.e., costs, personal, facilities, technology), and provider role and responsibilities as well as helping to articulate the overall goals of both police and healthcare services. It is also important to note that risk management and resource management were repeated themes emerging across six of the questions from both healthcare and police participants. Concerns that were expressed related to access to service, also consistent with existing research into barriers to healthcare service access experiences in rural and northern communities (Lavoie et al., 2016).
An unanticipated barrier that was identified through the interviews related to healthcare provider comfort in using advanced technologies to provide healthcare to detainees. It is possible that some of this discomfort relates to inexperience and lack of sufficient education for providers in the use of remote presence technology. These findings have been consistently evident within previous research related to the implementation of innovation into healthcare (James et al., 2015; Lavoie et al., 2016). Educational institutions could play an important role in addressing this barrier through developing competencies and training programs for providers and integrating such content into curricula. Piloting the remote presence technology with a less complex population may also be advantageous, allowing providers to become familiar with the use of the technology and its capabilities in assessing and managing less high-risk individuals.
There was a distinctive split between police and healthcare participants' perspectives on the proposed pathway for supporting detainee health. Police participants clearly identified a need in the detention center and were strongly supportive of the implementation of remote presence technology, with many participants expressing an interest in future pilot projects. Healthcare participants were more skeptical on the idea, clearly indicating that any pilot project that significantly increased the workloads of ER staff would not be successful. Police services and healthcare have different purposes and priorities; thus, different perspectives on this pathway were not unexpected. In the detention setting, healthcare services focus on the provision of patient care and police services focus on custody and security (Pickersgill, 2012).
Whereas police services are asking for help in the detention center to meet the healthcare needs of detainees, adding additional responsibilities to busy ERs was a cause of concern from a healthcare perspective. This concern highlights the importance of resource management in developing care pathways that may have implications for service delivery and workload of existing personnel within the healthcare system. Workload and burnout in ER departments associated with the implementation of a new service policy and/or service innovation are a real concern for healthcare services (Adriaenssens, De Gucht, & Maes, 2015). These issues would have to be taken into careful consideration when planning any future pilot project in this direction.
During the interviews, alternative pathways for enhancing detainee health were identified that had minimal impact on ER staffs' workloads. These included remote-site ER consultants, the expansion of existing paramedic and police collaborative services, and paramedic-delivered community-focused healthcare services. Exploring these alternative pathways has potential to promote attainment of project goals through maximizing the benefit to police services while minimally impacting the operations and functionality of existing healthcare services.
Regarding the participants' views on the optimal healthcare provider for this care pathway, past experiences may have influenced the responses provided, as each police service participant interviewed identified the optimal healthcare professional in the detention center to be the profession with whom they had the most experience. Lack of understanding of the scope of practice is a known barrier to optimal utilization of professionals within interdisciplinary teams (Supper et al., 2015). The scope of practice of the healthcare professional providing service in the detention center should consider factors beyond familiarity with a certain provider type to reflect the healthcare needs of detainees as well as appropriate resource allocation. Funding would be associated with the choice of provider due to the different professional pay scales and salaries between healthcare professionals.
Although this research may be limited in its generalizability because of the small purposeful sample, it has significance to shape future research in the use of advanced technologies such as remote presence in the police detention center. The outcome of this project provides insights for consideration in conducting future research. It will be important to address provider scope of practice, expertise, and role, when identifying which health discipline can optimally manage the health needs of detainees in the detention center. Attention also needs to be given to risk and resource management when creating pathways that will directly impact the healthcare system. The use of advanced technologies to support detainee health outcomes could require a significant fiscal and human resource investment that will need to be balanced between implementation costs and access to services, over time. Furthermore, the opportunities for intersectoral collaboration that enhances interprofessional dialogue between policing and healthcare providers for optimal care delivery of detainees will be essential if government funding is to be realized for changes in both policing and health service delivery for detainees. Future research into this alternative pathway needs to recognize the importance of leveraging existing healthcare services to maximize impact on detainee health while minimizing system strain. Nursing has a major role to play in any future implementation of remote presence in the detention center either through more advanced practice roles or through collaboration with other professions such as medicine as a conduit for assessment and intervention.
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