Journal of Psychosocial Nursing and Mental Health Services

CNE Article 

Connecting Law Enforcement and Emergency Department Providers to Improve Access to Mental Health Services

Kari Hickey, PhD, RN; Carol Walther, PhD; John King, MS; Hunter Layne, BS; Carly Besler, MA; Victoria Andrzejewski; Jennifer Gijada, BA

Abstract

An electronic survey was sent to local law enforcement agencies and hospital emergency department (ED) staff to assess communication processes when law enforcement brings individuals in mental health crisis to the ED. Law enforcement and ED staff view HIPAA/privacy concerns as barriers to communication. Law enforcement believed that communication needs to be improved, whereas ED staff believed they communicated well with law enforcement. Although both groups noted a need for more mental health services in the community, law enforcement noted they wanted more communication as to the disposition of the individuals they bring to the ED. There are areas for improvement in communication between law enforcement and ED staff when receiving a patient in mental health crisis. Psychiatric–mental health nurses are an integral part in transitioning individuals in mental health crisis in the ED to the appropriate level of care. Effective communication between ED staff and law enforcement will benefit all involved. [Journal of Psychosocial Nursing and Mental Health Services, 58(8), 24–30.]

Abstract

An electronic survey was sent to local law enforcement agencies and hospital emergency department (ED) staff to assess communication processes when law enforcement brings individuals in mental health crisis to the ED. Law enforcement and ED staff view HIPAA/privacy concerns as barriers to communication. Law enforcement believed that communication needs to be improved, whereas ED staff believed they communicated well with law enforcement. Although both groups noted a need for more mental health services in the community, law enforcement noted they wanted more communication as to the disposition of the individuals they bring to the ED. There are areas for improvement in communication between law enforcement and ED staff when receiving a patient in mental health crisis. Psychiatric–mental health nurses are an integral part in transitioning individuals in mental health crisis in the ED to the appropriate level of care. Effective communication between ED staff and law enforcement will benefit all involved. [Journal of Psychosocial Nursing and Mental Health Services, 58(8), 24–30.]

Mental illness is common in the United States, with approximately one in five adults having a mental health condition. In 2017, there were an estimated 46.6 million adults age ≥18 with mental illness (National Institute of Mental Health [NIMH], 2018). In addition, mental, behavioral, and neurodevelopmental disorders is the fifth most common primary diagnosis code in emergency departments (EDs), equating to 5.5 million ED visits resulting in this diagnosis (U.S. Department of Health and Human Services et al., 2016). It is estimated that only 50% of people with mental illness receive treatment (NIMH, 2018).

With so many people without treatment for mental illness, there is an increased risk for encounters with law enforcement. Mental illness is correlated with a higher prevalence of arrest and victimization history (Fisher et al., 2011; White et al., 2006). According to Livingston (2016), 25% of people with a mental health disorder have been arrested at some point in their lives, and 12% of people with mental health disorders have had police involved in their pathway to mental health services. In a 2011 Bureau of Justice survey of jail inmates, 44% had been told sometime in the past they had a mental health disorder by a mental health professional and 26% of inmates met the criteria for serious psychological distress (Bronson & Berzofsky, 2017). It is clear that law enforcement has a role in access to the mental health care continuum.

As first responders, law enforcement are often called to assist with mental health crises. Police officers in the United States play a greater role in connecting people to mental health services when compared to other countries (Council of State Governments [CSG], 2019). Livingston (2016) suggests that U.S. police officers are more actively involved, compared with their counterparts in other countries, in facilitating diversion processes aimed at preventing people with mental health disorders from further involvement with the criminal justice system. Law enforcement agencies across the country are being challenged by a growing number of calls for service involving people who have mental health needs or are in a mental health crisis; often, police officers are the first, and sometimes only, responders.

Many communities continue to face extensive gaps in mental health services, especially crisis services (CSG, 2019). Without crisis services in place, the burden of care may be placed on local law enforcement agencies. If police officers are not equipped with knowledge of community-based mental health and social services, they are left with few options, including leaving people in potentially harmful situations, arrest, or transport to a local ED. There is increasing urgency to ensure that police officers and ED personnel have the training, tools, and support to safely connect people to needed mental health services.

Understanding the need for effective collaboration, researchers from the School of Nursing and Department of Sociology of Northern Illinois University partnered with a city police department and a hospital ED to assess current status of police officer interactions with individuals with mental health disorders. One area of notable concern was communication between law enforcement and ED providers. Results of a survey to local law enforcement agencies and ED staff are presented to better understand communications when police officers bring individuals with mental health needs to the ED for care.

Background

A notable amount of police work involves interaction with individuals with mental illness; approximately 10% of all calls involve someone who is experiencing a mental health crisis (Livingston, 2016). The demand for law enforcement to intervene during a mental health crisis shows no indication of diminishing. For example, approximately 30 years ago, Gillig et al. (1990) reported 60% of officers surveyed had responded to at least one mental health call, whereas 42% had responded to more than one mental health call. Officers also indicated they needed access to an individual's medical history as well as access to a mental health or mobile crisis team to assist in determining the most effective disposition of care (Gillig et al., 1990). Furthermore, according to Watson and Wood (2017), police officers will continue as mental health first responders and be on the frontlines of mental health services delivery for as long as community-based mental health services are under-resourced. Wood et al. (2018) go further to state that most law enforcement encounters with individuals with mental health needs are not due to major crimes or violence, rather due to unmet service and treatment needs.

Little is published specific to communication between law enforcement and ED personnel as it relates to care provisioning for individuals in mental health crisis. Much of the published evidence examines law enforcement interactions with individuals in mental health crisis and the effects of Crisis Intervention Teams (CIT). The CIT program is a first responder model of police-based intervention training with the goal of providing access to mental health/addictions treatment rather than invoking the criminal justice system while promoting safety of the officer and individual (Crisis Intervention Team International Inc., n.d.). Canada et al. (2012) found that CIT training provided officers in Chicago with more effective tools to use in encounters with individuals with mental health needs compared to non-CIT trained officers. Specific to ED use, non-CIT trained officers were more likely to determine their options were limited to hospitalization. The CIT-trained officers reported that they transport people in emergency situations to the hospital but also provide referrals to community agencies and transportation to community-based treatment providers.

There is also a dearth of literature examining communication between law enforcement and ED providers. However, information passed between professionals in law enforcement and health care has potential to impact care and affect the health care experience of all involved. Kubiak et al. (2017) found non-CIT officers believed mental health service agencies were not on the same page as law enforcement; therefore, non-CIT officers often believed jail was the only option for individuals experiencing a mental health crisis. Officers were frustrated in that when they took individuals in mental health crisis to a hospital, they feared the individual would not get the care they needed. Officers reported being turned away from crisis centers. Officer responses indicate that law enforcement and local mental health systems are not working with a shared understanding of needed mental health services.

Previous research reveals that communication issues between health care providers and law enforcement are long-standing problems. Gillig et al. (1990) interviewed police officers to determine what type of information or health-related services would be useful in their interactions with individuals in mental health crisis. Officers indicated that they most needed access to information about an individual's history of violence or suicide attempts and quick onsite assistance by mental health professionals in assessing individuals who may be suicidal or hostile. Federal laws protecting mental health (i.e., Health Insurance Portability and Accountability Act [HIPAA], 1996) are often significant barriers to information sharing. Although it is imperative to protect the privacy of patients, there are justifiable and legal reasons to share health-related data.

Schmit et al. (2019) reported a cross-sectional data-sharing initiative in Peoria, Illinois. The county jail, Emergency Response Agency, ambulance service, and fire/emergency medical services sent data points (e.g., first and last name, age, zip code, number of contacts with agency [i.e., dispatches, bookings]) to the local health department. The data were then merged by the health department to provide targeted individual care and case management. Although this is not a direct point of care communication (i.e., ED staff to law enforcement), the authors noted that a centralized data-sharing system was created that protected patient information (Schmit et al., 2019).

In efforts to improve information sharing and transfer, McGlen et al. (2008) found there was no quick, systematic, easy, and consistent way for law enforcement to transfer information about mental health emergencies to ED staff. The authors created a tool to assist police officers in assessment and communication of a mental health emergency. The A (appearance and atmosphere), B (behavior), C (communication), D (danger), E (environment) assessment tool is meant to improve law enforcement communication of mental health emergencies to health care staff (McGlen et al., 2008).

Nursing has identified the importance of communicating and educating law enforcement of the needs of individuals in mental health crisis. Loucks (2013) reported a nurse-led educational program, “Close Encounters: Managing Field Encounters With Persons With Mental Illness,” to police officers that included training about psychiatric disorders and interventions that may assist in police encounters with individuals with mental illness in the field. Loucks (2013) sent a survey to police officers in Orange, California to determine topics for the educational program to enhance knowledge and competency in interactions with individuals with mental illness. Although the program was not formally evaluated, it was deemed effective as the chief of police received numerous reports from the community that encounters with officers were positive and officers were described as compassionate and caring. In 2012, the National Board of Directors for the American Psychiatric Nurses Association endorsed the program (Loucks, 2013).

Psychiatric–mental health nurses (PMHNs) are important contributors to a health care delivery system that addresses specialized health care needs for a vulnerable population. Ellis (2011) described the CIT program from a PMHN perspective. In addition to becoming CIT trained, nurses can be involved as educators, researchers, consultants/liaisons, and contact resources; a significant portion of the 40-hour CIT training includes some form of hospital site experience where nursing professionals can participate as educators and facilitators.

From the literature, it is clear that a complete understanding is lacking regarding communication between law enforcement and ED personnel when transferring care of individuals in mental health crisis. This lack of understanding is troubling, as law enforcement officers have voiced concerns at transfer of care regarding health systems not “being on the same page,” frustration that the individuals they bring to the ED do not receive necessary care (Kubiak et al., 2017), and not receiving information about the individuals they encounter in the field (Gillig et al., 1990). Nursing has identified a unique position to assist in training law enforcement on mental health (Ellis, 2011; Loucks, 2013) and improving communication with health providers (McGlen et al., 2008). It appears there are efforts to address this issue. However, there is a dearth of research to inform interventions; thus, research examining communication between law enforcement and ED staff in this important care transition is needed.

Method

Recruitment and Participants

Law enforcement officers and ED staff were recruited on a voluntary basis from a Midwest county in Illinois with a population of approximately 105,000. Law enforcement participants were recruited from two municipal, one university, and one county department. There are two hospitals in the county; ED staff were recruited from the largest hospital, which has 98 beds. Inclusion criteria were age ≥18, able to read English, and employed by a local law enforcement agency or the local hospital ED. Convenience sampling was used due to law enforcement and ED staff being the targeted participants in this study. Surveys were first sent out to key stakeholders in law enforcement and the ED. Key stakeholders then sent the survey via email to law enforcement and ED staff. ED staff comprised physicians, nurses, social workers, behavioral health associates, administration workers, health unit coordinators, and ED technicians. Law enforcement personnel comprised administrators, supervisors, and patrol officers.

Data Collection

Data were collected confidentially via online survey. Researchers worked with representatives from law enforcement and ED staff to finalize survey questions. Face validity was established as survey questions were approved for use by both disciplines. ED staff and law enforcement participants were asked similar questions regarding HIPAA and privacy laws interfering with law enforcement and health care staff communicating about individuals with mental health disorders; feelings about the consistency in how mental health cases are managed in the ED; awareness of the frequency of medical outcomes/treatment dispositions of individuals with a mental health disorder who had been brought to the ED from the police department; knowledge of the process for obtaining/determining treatment and/or placement for individuals with mental health disorders who are brought to the ED by police; feelings toward effective communication with ED staff in promoting positive patient outcomes; and suggestions to improve process and patient outcomes when bringing individuals with mental health issues to the ED. Survey questions are shown in Table A (available in the online version of this article).

Table A:

A law enforcement–specific question was reasons for bringing an individual with a mental health disorder to the ED. Questions specifically for ED staff were most frequent diagnosis of patients with mental health disorders brought to the ED by law enforcement and the perceived barriers in providing care to these individuals. In addition, questions about position held, full-time or part-time status, and number of years worked in current position, as well as demographic questions were asked.

Data Analysis

Data from the survey were analyzed using SPSS version 25. Descriptive statistics were used to find the mean and median of each question as well as standard deviation to measure the variability.

Ethical Considerations

An informed consent form was available electronically at the beginning of the survey detailing information about the study and who to contact if participants had any questions. Approval for this research project was obtained from the University Institutional Review Board.

Results

Forty responses to the survey were received. Of these, 37 participants identified as White and three identified as non-White. Of respondents, 53% were male and the median age was 49. Eighty-five percent of respondents were employed full time and had an average length of employment of 8 years, with 50% of participants in their position for >10 years. Approximately one half (49%) of participants worked in the ED and 51% worked in law enforcement (Table 1).

Professional Role of Law Enforcement and Emergency Department Staff (N = 40)

Table 1:

Professional Role of Law Enforcement and Emergency Department Staff (N = 40)

The electronic survey asked law enforcement and ED staff a multitude of questions focusing on communication. The first set of questions focused on the process of transportation of a person with a mental health disorder to the ED. All law enforcement officers (n = 23) stated they had brought individuals with mental health issues to the ED. All law enforcement participants also stated that they were not routinely or formally notified of medical outcomes and/or treatment dispositions of these individuals.

ED staff reported that individuals with mental health disorders were in the ED often. They were asked: “In the past week, how many times did law enforcement present a person to the ED stating that their reason for coming was due to a mental health concern(s)?” Four ED staff reported that they were not sure how often law enforcement brought a person in with mental health issues. Other responses ranged from daily to once per week. One ED staff participant wrote “several times,” but was not more specific as to why a person was brought to the ED other than the person was “drunk or crazy.” Overall, ED staff noted that people with mental health issues are being brought to the ED often.

ED staff were asked: “What is the process for obtaining/determining treatment and/or placement for those with mental health disorders who are brought to the ED by police?” Two ED staff participants stated that they did not know or were unsure, whereas two others noted self-harm. For instance, respondents wrote, “If they are suicidal with plan” and “self-harm.” The majority of ED staff suggested an intensive process once a person reached the ED. One ED staff participant wrote, “Working with our team of social workers who seek placement on our behalf after the patient has been medically cleared.” Another ED staff participant responded, “Evaluation by social worker and then decision made in collaboration with the physician to place or discharge.” Moreover, another ED staff participant wrote, “Complete Involuntary Committal form, see a mental health counselor, verify insurance eligibility, find a mental health bed (if applicable).” Most ED staff noted an extensive process for obtaining and determining treatment and/or placement for individuals with mental health disorders, especially those who indicated self-harm.

When asked about perceptions of outcomes of people brought to the ED by law enforcement, ED staff and law enforcement had different perceptions of client outcomes (Table 2). Of law enforcement, 38.5% were unsure of the outcome of individuals with mental health issues they brought to the ED. On the other hand, ED staff (34.6%) believed most patients brought in by law enforcement were transferred to an inpatient setting. Although 19.2% of ED staff believed patients were referred to an outpatient setting, only 7.7% of law enforcement believed the same. Approximately 8% of law enforcement believed individuals they brought in were discharged from the ED without referral; ED staff perceived no individuals brought in by law enforcement in mental health crisis were discharged without referral.

Perceived Outcome of Individuals Brought to the Emergency Department (ED) by Law Enforcement

Table 2:

Perceived Outcome of Individuals Brought to the Emergency Department (ED) by Law Enforcement

Table 3 displays ED staff perceived barriers to providing care to individuals who come to the ED with mental health problems/diagnoses via law enforcement. ED staff noted access to inpatient care as the largest barrier (47%). The second largest barrier was the need for more community resources for individuals with mental health disorders (35%). ED staff noted there is one low income mental health service and the community lacks an inpatient treatment facility. Six percent of ED staff reported communication with law enforcement as a barrier to providing care. Both groups were asked if they believed they communicated effectively with the other when managing persons with mental health issues. Ninety percent of ED staff believed they communicated effectively with law enforcement, whereas 46% of law enforcement reported they were able to effectively communicate with ED staff.

Perceptions of Barriers to Providing Care to Individuals Admitted to the Emergency Department with Mental Health Problems/Diagnoses Via Law Enforcement

Table 3:

Perceptions of Barriers to Providing Care to Individuals Admitted to the Emergency Department with Mental Health Problems/Diagnoses Via Law Enforcement

Law enforcement noted several barriers community members face when accessing mental health care, such as lack of services (n = 5) and lack of community resources (n = 4). Two law enforcement respondents noted insurance and transportation issues. Two law enforcement respondents noted that ED staff do not follow through with patients with mental health issues brought to the ED. Most law enforcement respondents noted structural issues, such as lack of insurance, services, and transportation.

ED staff had similar responses to barriers to accessing care for individuals with mental health issues in the community. Six ED staff stated lack of resources, such as funding, facilities/beds for unfunded patients and patients with medical issues, counseling services, limited access to a psychiatrist, and transportation. Four ED staff participants suggested that insurance/payment is the issue. For instance, one ED staff participant wrote, “insurance issues surrounding placement, especially when patient has been to the ED for multiple visits for the same thing” and “money.” Five ED staff noted few or no treatment facilities located within the county. One ED staff participant wrote:

NO psychiatry in this facility, current outpatient resources bogged down/at or beyond capacity, increased homeless population; not enough inpatient facilities to accept patients in a timely fashion; patients are being held in ED for extended length of time, like a jail cell; NO availability for those with disabilities

Three ED staff participants noted characteristics of individuals brought to the ED, such as “mental illness and alcohol or drug abuse concurrently adversely affect patient's seeking and following through on suggested care,” “education on what they need as far as care,” and “stigma, motivation.”

When asked about consistency of management of mental health patients in the ED, 35% of law enforcement and 70% of ED staff stated that the management of care was consistent. Law enforcement and ED staff were found to agree regarding HIPAA and privacy concerns. Most law enforcement officers see HIPAA as a barrier to communication. Fifty-eight percent of law enforcement and 50% of ED staff reported that HIPAA and privacy concerns are a barrier to communication (Table 4).

Comparison of Law Enforcement and Emergency Department (ED) Staff Responses

Table 4:

Comparison of Law Enforcement and Emergency Department (ED) Staff Responses

Discussion

People who have a mental health illness are more likely to have contact with law enforcement and the ED. In the current study, all law enforcement noted that they brought people with mental health issues to the ED for suicidal reasons. Furthermore, ED staff reported that people with mental/behavioral health issues were in the ED often. These findings demonstrate that law enforcement and ED staff are often the first responders for those in mental health crisis.

The current study also demonstrates gaps in mental health services within this community. Law enforcement and ED staff reported lack of resources. The community does not have an inpatient mental health facility. In addition, the number of medical personnel within the ED has decreased. Social institutions, such as medical facilities, physicians, and counselors are not available for people who are in mental health crisis. Lack of resources may support the NIMH (2018) in stating only 50% of individuals with mental health illness receive treatment.

Similar to findings from Kubiak et al. (2018) and Gillig et al. (1990), there is lack of communication between law enforcement and ED staff. In the current study, only 46% of law enforcement, compared to 90% of ED staff, believed they communicated effectively. None of the law enforcement participants knew where individuals went after dropping them off at the ED. Two law enforcement officers reported ED staff do not follow through on treatment of mental health for individuals they bring to the ED. This finding brings to question the “need to know” of law enforcement. Law enforcement and ED staff agree that HIPAA and privacy concerns are barriers to communication. Future research should more closely examine the perceived lack of communication between law enforcement and ED staff.

Limitations

One limitation of the current study is the small sample in one community, which impacts the ability to find significant relationships in the dataset and generalize the results to other populations. In addition, the true response rate is unknown, as agency contacts were unable to give an accurate count of the potential participants who received the electronic survey. Lastly, truthfulness of respondents could not be verified or followed up due to the confidential nature of the survey.

Implications for Practice

PMHNs working in EDs can assist in facilitating improved communication with law enforcement. In addition to providing needed education, PMHN–led mental health training for law enforcement personnel (Loucks, 2013; Melnikov et al., 2017) can develop and maintain collaborative relationships with local law enforcement agencies. Nursing skills such as education, communication, leadership, and case management combined with rich clinical experiences of PMHNs provide the platform to engage in training and shared understanding of the needs of patients in mental health crisis prehospitalization.

Nurses working in psychiatric–mental health settings are also well positioned to participate in police/mental health collaboration strategies as outlined by the CSG (2019). The CSG has identified the following strategies to promote information sharing between police and those working in mental health: take it on together and develop shared goals; clarify terminology for shared understanding; and provide training on relevant legal basics. In addition, PMHNs have the experience to serve as integral members on a research team. Our research team had two academic researchers from nursing and sociology, one member from law enforcement, and one member of a community-based mental health center.

Conclusion

The creation and deployment of the current survey to local law enforcement agencies and hospital ED staff is the first reported to better understand communication when officers bring individuals with mental health needs to the ED for care. Without effective communication between law enforcement and ED personnel, individuals in mental health crisis will continue to experience barriers to safe and effective mental health care and treatment. In addition to not receiving care, individuals with chronic and sustained mental health issues will continue to impact how law enforcement and mental health care providers communicate and work to assist those in need.

References

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Professional Role of Law Enforcement and Emergency Department Staff (N = 40)

Professional Rolen (%)
Law enforcement administrator3 (7.5)
Law enforcement supervisor5 (12.5)
Law enforcement patrol officer15 (37.5)
Physician1 (2.5)
Nurse11 (27.5)
Social worker/therapist5 (12.5)

Perceived Outcome of Individuals Brought to the Emergency Department (ED) by Law Enforcement

Perceived OutcomeResponse Rate (%)
Law EnforcementED Staff
Transferred to an inpatient setting3.834.6
Referred to outpatient treatment7.719.2
Discharged without referral7.70
Unsure38.57.7

Perceptions of Barriers to Providing Care to Individuals Admitted to the Emergency Department with Mental Health Problems/Diagnoses Via Law Enforcement

Perceived BarrierResponse Rate (%)
Access to inpatient care47
Access to community-based mental health services35
Communication with law enforcement6
Other12

Comparison of Law Enforcement and Emergency Department (ED) Staff Responses

Survey QuestionYes Response (%)
Law EnforcementED Staff
Consistent management of behavioral health cases in the ED3570
Able to communicate effectively with ED staff/law enforcement to promote positive client outcomes4690
HIPAA and/or privacy concerns as a barrier to communication5850
Law Enforcement QuestionsFor what reasons do you bring people with behavioral health disorders to the ED?

Suicidal/Homicidal

Disorderly conduct

Other

If other, please specify: Are you notified of the medical outcomes and/or treatment disposition of those you bring to the ED with behavioral health disorders?

Yes

No

To your knowledge, what is the process for obtaining/determining treatment and/or placement for those with behavioral health disorders who are brought to the ED by police? Do you feel there is consistency in the management of behavioral health cases in the ED?

Yes

No

Do you feel you are able to communicate effectively with ED staff to promote positive client outcomes?

Yes

No

If no, where do you see areas of improvement? Do you see HIPAA and/or Privacy concerns as a barrier to communication?

Yes

No

Do you have any suggestions to improve process and patient outcomes when bringing ‘people’ to the ED? Emergency Department Staff QuestionsIn the last month, what is the most frequent outcome/disposition of behavioral health patients brought in by the police departments?

Inpatient setting

Refer to outpatient treatment

Discharge without referral

Unsure

What is the ‘process’ for obtaining/determining treatment and/or placement for those with behavioral health disorders who are brought to the ED by police? Do you feel there is consistency in how behavioral health cases are managed in the ED?

Yes

No

What do you perceive as barriers to providing care to those who come to the ED with behavioral health problems/diagnoses via the police department?

Communication with law enforcement

Access to inpatient care

Access to community based behavioral health services

Other

If other, please specific: Do you feel you are able to communicate effectively with law enforcement staff to promote positive client outcomes?

Yes

No

If no, where to you see areas for improvement? Do you see HIPAA and Privacy Laws as barriers in communicating with law enforcement?

Yes

No

Do you have any suggestions to improve process and patient outcomes for those brought in by the police department? In the past week, how many times did law enforcement present a person to the ED stating their reason for coming was due to a behavioral health concern(s)? In the past week, how many times have you encountered a patient with a primary mental/behavioral health diagnosis brought in by law enforcement? What do you see as barriers to accessing care for those with behavioral health issues in our community?
Authors

Dr. Hickey is Associate Professor and Director of Undergraduate Studies, School of Nursing, Dr. Walther is Associate Professor, Mr. King is Retired Director of Student Professional Development, Mr. Layne is Graduate Student, Ms. Besler is Graduate Student, Ms. Gijada is Undergraduate Student, Department of Sociology, and Ms. Andrzejewski is Undergraduate Student, Department of Psychology, Northern Illinois University, Dekalb, Illinois.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Kari Hickey, PhD, RN, Associate Professor and Director of Undergraduate Studies, School of Nursing, Northern Illinois University, 1240 Normal Road, Dekalb, IL 60115; email: Khickey1@niu.edu.

Received: March 21, 2020
Accepted: May 18, 2020
Posted Online: July 01, 2020

10.3928/02793695-20200624-02

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