Building Partnerships With First Responders to Explore Strategies to Improve Delivery and Access of Mental Health Services
Conditions: Mental Health Wellness 1
Sponsor: University of Arkansas

 
 
 
Date: July 20, 2020 
Study Title: 
Building Partnerships with First Responders to Explore Strategies 
to Improve Delivery and Access of Mental Health Services 
 
NCT Number:  
NCT03801408 
 
Principal Investigator:  
Sara Jones, PhD, APRN, PMHNP-BC 
 
Assistant Professor 
University of Arkansas for Medical Sciences, College of Nursing 
4301 W. Markham Street, Slot # 529 
Little Rock, AR 72205 
Telephone:  501-526-7846 
Email:  SLJones@uams.edu 
 
 
 
Sub-investigators: 
Jean McSweeney, PhD, RN 
Professor and Associate Dean for Research, College of Nursing 
Telephone: 501-296-1982 
Email: McSweeneyJeanC@uams.edu 
 
Geoffrey Curran, PhD,  
Professor, Departments of Pharmacy Practice and Psychiatry 
Director, Center for Implementation Research 
Telephone: 501-686-7610 
Email: CurranGeoffreyM@uams.edu 
 
Virginia Austin, MS, LCSW 
Research Program Manager, UAMS College of Nursing 
Telephone: 501-603-3518 
Email: VAAustin@uams.edu  
 
 
Study location: 
University of Arkansas for Medical Sciences 
 
4301 W. Markham Street, Slot # 529 
 
Little Rock, AR 72205 
 
Support Funding: 
NIH/NIMH 
 
 
 
 
 

Title: Building Partnerships with First Responders to Explore Strategies to Improve Delivery and 
Access of Mental Health Services  
PI: Sara Jones, PhD, APRN 
Institution: University of Arkansas for Medical Sciences 
Sponsor: NIH/NIMH 
 
 
 
 
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Date: July 20, 2020  
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Table of Contents 
 
Table of Contents ............................................................................................................................ 2 
Background and Rationale .............................................................................................................. 3 
Specific Aims .................................................................................................................................. 8 
Study Design and Procedures ......................................................................................................... 9 
Study Population ........................................................................................................................... 11 
Inclusion Criteria ...................................................................................................................... 11 
Exclusion Criteria ..................................................................................................................... 11 
Risks and Benefits......................................................................................................................... 14 
Data Handling and Recordkeeping ............................................................................................... 16 
Data Analysis ................................................................................................................................ 17 
Phase 2…………………………………………………………………………………………………….19 
Ethical Considerations .................................................................................................................. 22 
Implications and Dissemination of Data ....................................................................................... 22 
References ..................................................................................................................................... 24 
 
 

Title: Building Partnerships with First Responders to Explore Strategies to Improve Delivery and 
Access of Mental Health Services  
PI: Sara Jones, PhD, APRN 
Institution: University of Arkansas for Medical Sciences 
Sponsor: NIH/NIMH 
 
 
 
 
IRB# 228929                           
Date: July 20, 2020  
Page 3 
 
 
Background and Rationale 
Sentinel events, such as the attacks on September 11, 2001 (9/11), have focused attention on 
the magnitude of traumatic exposure experienced by first responders (FRs).11 In the United 
States (U.S.), firefighters and EMT/paramedics respond to more than 50 million emergency calls 
annually.1,2 Although many FRs serve entire careers without responding to events like those of 
9/11, the daily operations and experiences they expect and accept as part of their jobs expose 
them to a myriad of traumatic events (e.g. fatal vehicle accidents, suicides, school shootings). 
The nature, frequency, and intensity of duty-related traumatic exposures place FRs at significant 
risk for developing mental health (MH) problems.3  
An estimated 18-37% of FRs worldwide meet criteria for posttraumatic stress disorder 
(PTSD),8 a rate similar to that among military veterans (10-31%),19 and much higher than that in 
general populations (8.7%).4,12,13 MH problems among FRs are not limited to PTSD; prevalence 
rates for other problems are: 7-22% for depression,14,15 4-22% for anxiety,4,16  34-56% for binge 
drinking,17,18 and 58-70% for sleep problems.14,19 MH problems can emerge in training14 and 
continue long after retirement, with approximately 15% of suicides among FRs occurring in 
retirees.20,21 In one study (n=1027), 15.5% of FRs reported at least one suicide attempt during 
their careers,5 much higher rates than those in general adult populations (1.9-8.7%).5,8,22  
However, we were able to locate virtually no published research on rates of help-seeking 
and service utilization among FRs with MH problems. Less than 40% of the general population 
who experience MH problems seek help,6 and help-seeking is expected to be even lower among 
FRs because of the stigma associated with mental illness and the emphasis that FR culture puts 

Title: Building Partnerships with First Responders to Explore Strategies to Improve Delivery and 
Access of Mental Health Services  
PI: Sara Jones, PhD, APRN 
Institution: University of Arkansas for Medical Sciences 
Sponsor: NIH/NIMH 
 
 
 
 
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Date: July 20, 2020  
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on strength and self-reliance.5,7 According to published personal accounts, MH problems are 
viewed as signs of vulnerability; acknowledging them can lead to mistrust and raise questions 
about personal safety of others within FR departments.8 There is apprehension about allowing 
“outsiders” into the culture, which creates isolation and inhibits help-seeking.9 Yet, there is 
minimal research to corroborate these personal testimonies. We urgently need to understand 
FRs’ perspectives about accessing and engaging in MH services to guide development of a MH 
service model they will be willing to access and use.   
Evidence is scarce regarding FRs’ barriers to help-seeking. Two recent studies described 
both structural and cultural barriers, such as cost and availability of resources,23 perceived 
accessibly of treatment, and concern about stigma.24 Hom et al. found that firefighters who 
experienced suicidal thoughts/behaviors, but did not utilize services reported more concerns 
about reputation and embarrassment than those who did use services.25 The literature on U.S. 
military veterans and law enforcement officers (LEOs), similar cultural groups, provides useful 
clues.8 For instance, veterans report barriers to accessing MH services to include concerns about 
negative consequences of disclosing MH problems, discomfort with help-seeking, and negative 
values/ beliefs regarding MH treatment.26,27 Strategies to reduce stigma and improve MH care 
among veterans suggest the importance of non-stigmatizing language related to MH, anonymity, 
and peer-to-peer support.28 LEOs are concerned that help-seeking indicates weakness; they also 
fear loss of confidentiality and threats of job loss.29,30 Although literature on veterans and LEOs 
is suggestive, FRs (as defined by this study) are unique in structural and cultural ways that may 
influences help-seeking and require tailored approaches to address their MH problems. 

Title: Building Partnerships with First Responders to Explore Strategies to Improve Delivery and 
Access of Mental Health Services  
PI: Sara Jones, PhD, APRN 
Institution: University of Arkansas for Medical Sciences 
Sponsor: NIH/NIMH 
 
 
 
 
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Date: July 20, 2020  
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The need for research and resources to address MH problems among FRs is well recognized 
by national FR organizations. The National Fallen Firefighters’ Foundation (NFFF), Initiative 
13: Psychological Support, emphasizes the need for resources to help FRs cope with duty-related 
complications, especially regarding emotional and psychological stress. The 2015 National Fire 
Service Research Agenda recommends research to identify individuals who are at high risk for 
health problems, especially those related to repeated trauma exposures. In particular, the agenda 
gives high priority to efforts to “identify, develop, and refine evidence-based tools and 
approaches for behavioral health screening, assessment, and intervention” (p.17).31 NFFF also 
highlights the need for a new model of MH screening and interventions that better reflects the 
variability in how FRs respond to traumatic incidents. The importance of tools that reflect 
variability is supported by a survey conducted by National Volunteer Fire Council (n=849). Over 
75% of firefighters indicated greater willingness to utilize a program that was tailored to their 
needs compared to a national suicide hotline.14 This supports the need for research to develop a 
tailored MH service model to support early identification and treatment of FRs’ MH problems.31 
Evidence of the effectiveness of MH services commonly available to FRs is lacking. Many 
FR departments offer limited MH services, with the two most common being Critical Incident 
Stress Debriefing (CISD) and Employee Assistance Programs (EAPs). However, empirical 
evidence for these interventions is inconsistent. CISDs are in-house debriefing sessions 
implemented within 72 hours after an incident; the limited published research on CISD does not 
provide strong evidence for its effectiveness.32 Previous studies have shown that CISD can 
actually increase the risk of PTSD among those that receive debriefing (OR 2.51; 95% CI 1.24 to 

Title: Building Partnerships with First Responders to Explore Strategies to Improve Delivery and 
Access of Mental Health Services  
PI: Sara Jones, PhD, APRN 
Institution: University of Arkansas for Medical Sciences 
Sponsor: NIH/NIMH 
 
 
 
 
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Date: July 20, 2020  
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5.09).33,34 Qualitative research regarding this topic is limited to one national study (n=423) that 
explored firefighters’ perceptions about CISD; some FRs reported CISD to be beneficial, others 
found it to be intrusive and distressing.35 Still, CISD continues to be used by FRs nationwide.35 
EAPs are outside agencies contracted to provide MH services to FR departments. Although they 
are widely used, we were unable to find research on FRs’ perceptions of EAPs or their 
effectiveness in meeting FRs’ MH needs.  
Preliminary Studies (PS) 
PS#1: Funded by a UAMS College of Nursing intramural grant (January, 2017). The PI used 
community engagement to establish partnerships with key FR stakeholders across AR to discuss 
FRs’ MH-related issues, including the: Director of Emergency Medical Services (EMS), AR 
Department of Health; Fire and EMS Coordinator, AR Department of Emergency Management; 
President of AR Professional Firefighters Association, local EMS directors, and multiple fire 
chiefs statewide (see Letters of Support). They expressed concern about the increased prevalence 
of MH problems among their FRs, and attributed the increase in number of suicides and early 
retirements over the past decade to MH problems. They also reported a lack of help-seeking even 
when MH problems were apparent and EAP and/or CISD were available. All community 
partners were highly motivated to address MH problems among FRs, but have lacked resources 
and expertise to do so. For example, the President of AR Professional Firefighters Association 
reported that they have pushed legislation to address MH issues in the fire service for years, but 
have been unsuccessful. These partnerships will be critical to the successful conduct of the 

Title: Building Partnerships with First Responders to Explore Strategies to Improve Delivery and 
Access of Mental Health Services  
PI: Sara Jones, PhD, APRN 
Institution: University of Arkansas for Medical Sciences 
Sponsor: NIH/NIMH 
 
 
 
 
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Date: July 20, 2020  
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proposed research as well as future implementation, dissemination, and sustainability of the 
resulting MH service model for FRs. 
PS#2: Funded by an International Society of Psychiatric Nursing Foundation Research grant 
(March 2017). The specific aims for this ongoing PS are to 1) assess the feasibility of using a 
community-engaged approach with FRs, 2) characterize the MH profile of Arkansas’ FRs, and 3) 
explore individual FRs’ perceptions of MH problems and use of MH services, including barriers 
and facilitators to help-seeking. To achieve Aim 1, the PI collaborated with PS#1 community 
partners to refine recruitment methods; these methods will be used in the proposed study 
(described below). Recruitment was successful and resulted in ample and continued access to 
this population, including presentations at four FR-related state conferences. To achieve Aim 2, 
FRs statewide were invited to complete an anonymous online survey that incorporated brief 
assessments of various MH problems,42 as well as questions addressing demographics and 
factors that can pose as potential risk/protective factors (e.g., marital status, military service).10,42 
A total of 220 FRs started the survey and 87% completed it. Of completers, 86% were male and 
95% were Caucasian; the average length of time as a FR was 16.2 years; 23% reported a 
previous MH diagnosis and 25% reported previous MH treatment. The high rates of self-reported 
MH problems found were: 26% for PTSD; 28% for moderate to severe anxiety; 14% for major 
(moderate-severe to severe) depression; 20% for harmful/ hazardous drinking; and, 34% for 
high-risk for suicidal behaviors, highlighting the need for the proposed study.  
To achieve Aim 3, we conducted in-depth, ethnographic interviews with individual FRs. 
Thirty-two FRs were interviews; of those interviewed, 36% reported a previous MH diagnosis, 

Title: Building Partnerships with First Responders to Explore Strategies to Improve Delivery and 
Access of Mental Health Services  
PI: Sara Jones, PhD, APRN 
Institution: University of Arkansas for Medical Sciences 
Sponsor: NIH/NIMH 
 
 
 
 
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Date: July 20, 2020  
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and 40% reported previous MH treatment. Experience with Aim 3 demonstrates the willingness 
of FRs with MH problems to participate in qualitative research. Grounded theory-informed, 
qualitative analytic methods (as described below) were used to identify common themes. The 
main the themes included: knowledge, barriers and facilitators to help-seeking, effects of the job 
and coping with them, non-duty stressors, pros and cons of existing MH services and delivery 
methods, and novel delivery approaches.  
Specific Aims 
Based on preliminary data and current literature, there is crucial need to reduce barriers to 
access and promote engagement in MH services to address FRs’ MH needs. To develop an 
effective MH service model that will be accessed and used by this high-risk group, we must 
understand and incorporate FRs’ preferences for MH service and delivery methods. We propose 
a two-stage exploratory, qualitative study that will use a statewide community-engagement 
approach to conceptualize a MH service model that would motivate FRs to be more engaged in 
services. In Stage 1, we will conduct qualitative focus groups (and individuals interviews, as 
needed; see below) with firefighters and EMTs/ paramedics across Arkansas. In Stage 2, we will 
use a product development process grounded in these findings to conceptualize a MH service 
model feasible for implementation in real world settings. (Protocol for Stage 2 will be submitted 
for IRB approval at a later time.) 
Phase 1-Specific Aim 1: Identify FRs’ preferences and priorities regarding MH service and 
delivery methods, including the feasibility, acceptability, and value of each method. (Method: 
Qualitative interviews- focus groups and individual) 

Title: Building Partnerships with First Responders to Explore Strategies to Improve Delivery and 
Access of Mental Health Services  
PI: Sara Jones, PhD, APRN 
Institution: University of Arkansas for Medical Sciences 
Sponsor: NIH/NIMH 
 
 
 
 
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Phase 2, Specific Aim 2: Conceptualize a MH service model, in partnership with FRs statewide, 
that is applicable, acceptable, and feasible for implementation. (Method: Virtual Delphi group of 
consensus formation) 
Through this multi-phase work, we will generate the scientific foundation to develop a 
comprehensive, MH service model that diverse FRs will be willing to access and use. Based on 
FRs preferences and priorities, we expect this model will encompass a range of services, such as 
education and awareness initiatives, prevention and screening strategies, and crisis and 
maintenance interventions, to meet their MH needs throughout the course of illness. 
Study Design and Procedures 
This qualitative study will use a statewide community-engagement approach to explore FRs 
preferences for MH service and delivery methods. In a community-engagement approach, 
researchers form collaborative partnerships with key stakeholders; together, they identify areas 
of interest and concern.45  
Phase 1-Specific Aim 1: Identify FRs’ preferences and priorities regarding MH service and 
delivery methods, including the feasibility, acceptability, and value of each method. 
Instruments and Measures 
Prior to starting the focus group/interview, the PI or research associate (RA) will distribute a 
one-page document to reference during the informed consent process; the document will describe 
the study purpose, procedures, risks, and benefits (Human Subjects Protection); time will be 
allowed for questions. Participants will be advised that participating implies consent and they 

Title: Building Partnerships with First Responders to Explore Strategies to Improve Delivery and 
Access of Mental Health Services  
PI: Sara Jones, PhD, APRN 
Institution: University of Arkansas for Medical Sciences 
Sponsor: NIH/NIMH 
 
 
 
 
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Date: July 20, 2020  
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may withdraw at any time. (We received a waiver of documentation of consent for the interviews 
in PS#2; we will seek the same for this study). Rules of confidentiality will also be discussed.  
Following the consent process, participants will be asked to complete a brief form to collect 
data about demographics (i.e., age group, race/ethnicity, gender) and potential risk/protective 
factors (e.g., time in service, military service, medical problems).  
The PI and/or RA will facilitate the focus group (FG) discussions using a semi-structured 
question guide (Table 2), which will have undergone review by our community partners. (In 
addition to content, we will ask them for feedback regarding language, ensuring it is non-
stigmatizing.)  
To start the group discussion, the PI/RA will use a PowerPoint presentation to highlight the 
various MH services discussed in the PS interviews. Group participants will be asked to discuss 
the pros and cons of existing MH services and delivery methods, and novel approaches that 
emerged during the interviews. They will be asked 
to discuss their own experiences related to each; 
based on their experiences, they will be asked to 
make recommendations for services/delivery 
methods that would motivate FRs to be more 
engaged in services. We will ask them “where to 
start” when implementing a MH service model; 
follow-up questions will include probes related to 
Table 2. Qualitative Question Guide 
Main Question 
Which of these services and methods of delivery 
do you recommend? 
Probe 
Questions 
What do you like and not like about each of these 
services and delivery methods?  
 
Do you foresee any additional barrier to using 
these services? Barriers to implementing them?  
 
Could they be modified/adapted to better fit the 
first responder culture and environment?  
 
Would you suggest any additional services or 
methods that we haven’t discussed yet? 
 
What do you think we should start with first?  

Title: Building Partnerships with First Responders to Explore Strategies to Improve Delivery and 
Access of Mental Health Services  
PI: Sara Jones, PhD, APRN 
Institution: University of Arkansas for Medical Sciences 
Sponsor: NIH/NIMH 
 
 
 
 
IRB# 228929                           
Date: July 20, 2020  
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acceptability and feasibility. (Similar methods were effectively used in a study conducted by Co-
investigator Curran and colleagues).51  
In concluding the FGs, we will offer optional telephone follow-ups to participants who may 
be reluctant to express their views in the group. Participants will also receive a blank piece of 
paper, along with a web link to an anonymous form in Survey Monkey. Here, they can add 
information they may not be comfortable discussing in the FG; text data from these options will 
be included in data analysis. Additionally, the PI/RA will record field notes during each FG, 
noting information about context, nonverbal communication, and interactions observed during 
the FG.52 
Research Team 
The PI is psychiatric advanced practice registered nurse whose qualifications to serve as PI 
on this project stem from: 1) well-established community partnerships with FRs across the state; 
2) having completed a systematic review and pilot studies related to the MH of FRs36, 37; 3) 
previous clinical and research experience with individuals that have experienced trauma; and, 4) 
interdisciplinary collaboration with experts in the fields of emergency medical services and 
qualitative research. Co-I McSweeney is an expert in qualitative methods. She will attend 
monthly team meetings to evaluate the FG processes, including development of the FG question 
guide and assist in qualitative data analysis (as described in Data Management and Analysis 
section). Co-I Curran is an expert in implementation science and has conducted multiple 
qualitative studies related to help-seeking and use of MH services. He will attend monthly team 
meetings regarding these aspects of study implementation, including the FG method (which was 

Title: Building Partnerships with First Responders to Explore Strategies to Improve Delivery and 
Access of Mental Health Services  
PI: Sara Jones, PhD, APRN 
Institution: University of Arkansas for Medical Sciences 
Sponsor: NIH/NIMH 
 
 
 
 
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Date: July 20, 2020  
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successfully used in his previous studies). The RA is a licensed social worker (LCSW) with over 
10 years’ experience, and a local volunteer firefighter.  
Study Population 
Participants will include a convenience sample of firefighters and EMTs/paramedics from 
across Arkansas.  
Inclusion criteria 
• ages 18 and over;  
• volunteer and career personnel;  
• active, inactive, and retired 
Exclusion criteria 
• Non-english speaking (due to the nature of FG/interview discussions).  
Recruitment 
 
We will use opt-in methods, facilitated by our community partners, to recruit participants. 
The PI will visit recruitment sites, provide refreshments, distribute promotional materials, and 
discuss long-term study goals. She will send emails to community partners that include study 
information, invitations to participate, and suggested text for 
email reminders.50 Partners will then distribute the emails 
throughout their departments; the State EMS Director will 
distribute through the state EMS registry, which includes all 
certified EMT/paramedics in the state. Emails and promotional 

Title: Building Partnerships with First Responders to Explore Strategies to Improve Delivery and 
Access of Mental Health Services  
PI: Sara Jones, PhD, APRN 
Institution: University of Arkansas for Medical Sciences 
Sponsor: NIH/NIMH 
 
 
 
 
IRB# 228929                           
Date: July 20, 2020  
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materials will instruct FRs to contact the PI or research assistant (RA) by telephone for more 
study information. They will also have the option to follow a web link (available as a Quick 
Response [QR] code) where they can read more about the study and/or submit their name (first 
name, last initial), phone number and/or email address to be contacted with more study 
information. They will also be asked which region of the state they respond in; no additional 
information will be requested online. 
Many community partners are involved in FR-related organizations; she may be invited to 
present and recruit at state meetings. Some of the departments also distribute monthly/ quarterly 
newsletters; study information will be published therein (with approval from the administration). 
The flyer will also be placed on social media sites, such as Facebook and Instagram.  
Sampling and Sample Size. An essential part of grounded theory-informed methods is the 
use of theoretical sampling.49 In grounded theory research, we do not know the important themes 
in advance; instead, they emerge and are refined over time as data are collected and analyzed. In 
general, exploration of a certain theme is stopped when “saturation” is reached, that is, no new 
themes emerge from the data (discussed below). Therefore, theoretical sampling does not 
provide a detailed sampling schema or calculation for number of participants beforehand. For 
this study, we will recruit FRs to participate in up to 25 FGs that will include 5-12 participants 
per group. Eighteen of these groups will be open to all FRs from different regions across the 
state. Evidence suggests that call volume and career vs. volunteer service influence FRs’ MH.42 
The 2 most populous regions in Arkansas (Central and Northwest) have higher EMS call 
volumes and a greater number of career fire/ambulance services than the other 4 regions; the 

Title: Building Partnerships with First Responders to Explore Strategies to Improve Delivery and 
Access of Mental Health Services  
PI: Sara Jones, PhD, APRN 
Institution: University of Arkansas for Medical Sciences 
Sponsor: NIH/NIMH 
 
 
 
 
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Date: July 20, 2020  
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latter are more rural and are served primarily by volunteer fire/ambulance services (Figure 2). 
Therefore, we propose to conduct 1) five FGs in each of the two most populous regions 
(total=10), and 2) two FGs in each of the other four regions (total=8).  
Since the majority of FRs are white males,1,62 female and minority FRs may be reluctant to 
openly discuss MH-related issues in a diverse group. We will conduct  a minimum of 2 of the 25 
FGs with an ethnically diverse group of females only, and an additional 2 FGs with minorities 
only (males and females) (total=4). This will ensure that at least 10-15% of participants are 
females and minorities. We will make every effort to recruit these participants from across AR, 
but due to the distribution of FRs across AR, we expect these FGs will take place in Central and 
Northwest AR. 
Sample Size 
An essential part of qualitative methods is the use of theoretical sampling. Theoretical 
sampling does not provide a detailed sampling schema or calculation for number of participants 
beforehand. Instead, exploration of a certain theme is stopped when “saturation” is reached, that 
is, no new themes emerge from the data (see Analysis section).  
Compensation 
 
Participants will receive a $25 Walmart gift card upon completion of the FG or interview.  
Limitations 
A possible barrier to this study may be recruitment concerns. To date, all chiefs contacted 
have understood the significance of this study and have agreed to encourage participation. 
However, individuals may also be reluctant to participate. During recruitment, we will explain 

Title: Building Partnerships with First Responders to Explore Strategies to Improve Delivery and 
Access of Mental Health Services  
PI: Sara Jones, PhD, APRN 
Institution: University of Arkansas for Medical Sciences 
Sponsor: NIH/NIMH 
 
 
 
 
IRB# 228929                           
Date: July 20, 2020  
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the confidential manner of this study to all potential participants: that is, all data will be 
unidentifiable and individual responses will not be shared with employers and administrators.  
Risks and Benefits 
Adult Minimal Risk: Any activity where the probability and magnitude of harm or discomfort 
anticipated in the research is not greater in and of themselves than those ordinarily encountered 
in daily life or during the performance of routine physical or psychological examinations or tests.  
Participants may experience distress at the time of, or because of the focus group/interview 
discussions. Prior to starting participation, they will be advised that if this occurs, they can 
choose to stop meet with the PI/RA individually. They will also be advised that the PI/RA may 
ask them to discontinue participation or ask to meet afterwards if a significant level of distress is 
observed. In meeting with the participant individually, the PI, an experienced psychiatric-mental 
health nurse practitioner, or RA, a licensed social worker (LCSW) with over 10 years’ 
experience, will briefly evaluate him/her and conduct a suicide risk assessment if indicated. 
Based on the evaluation, the participant may be referred for services, including (but not limited 
to) a local emergency department (if currently experiencing active suicidal ideations), the locally 
contracted EAP, or other MH services.  
The PI has received permission from various MH providers, including therapists and nurse 
practitioners, which have agreed to be listed as an available resource for the purposes of this 
study. This list of compiled resources, along with a list of phone numbers, will be available at all 
sites and online at the link provided on the flyer. The phone numbers will include 911 (for 
emergencies), local and/or national suicide hotline numbers, and the PI’s phone number. If 

Title: Building Partnerships with First Responders to Explore Strategies to Improve Delivery and 
Access of Mental Health Services  
PI: Sara Jones, PhD, APRN 
Institution: University of Arkansas for Medical Sciences 
Sponsor: NIH/NIMH 
 
 
 
 
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Date: July 20, 2020  
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called, the PI (or consulting provider) will conduct an appropriate evaluation, including a suicide 
assessment, and make referrals as appropriate (as mentioned above). Documentation and follow-
up will also be completed as applicable. This information (available resources and phone 
numbers) will also be provided upon completion of the group/interview and maintained online at 
the link provided in the email. 
Suicide Risk Assessment and referral. The PI/RA will use the Suicide Assessment Five-step 
Evaluation and Triage (SAFE-T) for Mental Health Professionals to assess risk of suicide and 
make referrals (uploaded in attachments). SAFE-T is a resource recommended by SAMSHA and 
published by the National Suicide Prevention Lifeline. This 5-step assessment guides the 
provider to: 1) identify risk factors, 2) identify protective factors, 3) conduct suicide inquiry, 4) 
determine risk level/ intervention, and 5) document.  
To reduce risk of breach of confidentiality, audio-recordings of the focus groups/interviews 
will be stored in a locked filing cabinet and all transcriptions will be electronically documented. 
All electronic data will be maintained on a password-protected server to which only the research 
team will have access. The HIPAA compliant version of SurveyMonkey will be purchased; only 
aggregate data from the surveys will be reported.  
Benefits 
There may be no personal benefits to the individual participants at the time of the study. It is 
possible, however, that participating in this study will increase participants’ awareness of, and 
decrease stigma related to, mental and substance use disorders, which may prompt some to seek 
services. Further, findings from this study will guide future studies to develop tailored prevention 

Title: Building Partnerships with First Responders to Explore Strategies to Improve Delivery and 
Access of Mental Health Services  
PI: Sara Jones, PhD, APRN 
Institution: University of Arkansas for Medical Sciences 
Sponsor: NIH/NIMH 
 
 
 
 
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Date: July 20, 2020  
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and treatment strategies that are accessible across Arkansas to improve the overall mental and 
emotional well-being of FRs.  
Data Handling and Recordkeeping 
The PI will carefully monitor study procedures to protect the safety of research subjects, the 
quality of the data and the integrity of the study. All data will be recorded without identifiers and 
will be anonymous. Audio-recordings will be stored in a locked filing cabinet and all 
transcriptions will be electronically documented. All electronic data will be maintained o on a 
password-protected UAMS server, both located behind locked doors in a restricted access area of 
the UAMS campus. Only the PI, Co-Is, and Research Assistant (to be determined) will have 
access to the data. 
Data Analysis 
The RA will enter quantitative participant data (i.e. demographics, risk/protective factors) 
into SPSS (V24).53 Data will be analyzed using standard statistical techniques to summarize data 
distributions and to model associations among risk and status variables. FGs and interviews will 
be audio recorded, transcribed verbatim, and entered into a professional software program 
designed to facilitate the data analysis process and produce an audit trail.54 Data submitted online 
will also be entered.  
We will analyze data using grounded theory-informed methods of content analysis and 
constant comparison.43 Content analysis is a systematic, objective analysis designed to identify 
key words, phrases, and topics, which guides top-level coding.55 This process is followed by 
constant comparison, second-level coding, an iterative process designed to identify common 

Title: Building Partnerships with First Responders to Explore Strategies to Improve Delivery and 
Access of Mental Health Services  
PI: Sara Jones, PhD, APRN 
Institution: University of Arkansas for Medical Sciences 
Sponsor: NIH/NIMH 
 
 
 
 
IRB# 228929                           
Date: July 20, 2020  
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themes by comparing one set of data to another.49 We will also use this process to compare data 
across sub-groups (e.g. urban/rural, male/female). The PI has experience in qualitative methods; 
both co-Is have expertise in qualitative methods; and the RA will be trained in these methods. 
Top-level coding. The PI, co-I (McSweeney), and RA will independently review the 
transcripts from the first 3 FGs. Using content analysis, similar data from these transcripts will 
be identified, grouped, and assigned a label, referred to as a code.47 These codes will reflect the 
themes and subject areas that, by virtue of their recurrent nature, seem most important to 
answering the key research questions. The research team will meet to compare coding and reach 
consensus on coding that differs. This process will continue with additional transcripts until they 
reach consensus on a set of initial top-level codes and definitions for each code, which will 
comprise the code book. This process will ensure inter-rater reliability, that is, consistency in 
coding.56 Thereafter, the PI and RA will individually code the remaining transcripts using the 
codebook. To ensure coding consistency, they will review each other’s work monthly and meet 
to discuss and resolve any differences. In the event that new themes emerge after the codebook is 
agreed upon, the research team will meet again to define emerging codes; previously coded 
transcripts will be recoded to reflect the additions(s).  
Second-level coding. Second-level coding is a process to further refine the constructs 
indicated by top-level codes. The final codebook will be used to “sub-code” data within each 
code. That is, data within codes will be compared across transcripts to find similarities, 
differences, associations, and relationships to determine patterns and thematic categories, 

Title: Building Partnerships with First Responders to Explore Strategies to Improve Delivery and 
Access of Mental Health Services  
PI: Sara Jones, PhD, APRN 
Institution: University of Arkansas for Medical Sciences 
Sponsor: NIH/NIMH 
 
 
 
 
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creating these sub-themes. The process of inter-rater reliability (discussed above) will be used to 
establish reliability. 
Saturation. In general, exploration of a certain theme is stopped when “saturation” is 
reached, that is, when no new concepts or properties emerge from the data after the thematic 
categories are identified. Given the potential size of the overall sample from the FGs (n=132-
220) and individual interviews (n=44), we will have no difficulty in achieving overall saturation. 
Additionally, based on the anticipated diversity of the FGs, we expect to be able to achieve 
saturation for both urban (n=60-100) and rural (n=48-80) FRs, as well as for female (n=12-20) 
and minority (n=12-20) FRs. We will use standard qualitative guidelines for trustworthiness by 
Lincoln and Guba (1985) to maximize the project’s validity and reliability.57 A data table will be 
constructed to provide an audit trail that identifies the thematic categories, frequencies of 
explanations, and examples of raw data that exemplify each theme. The field notes recorded by 
the RA will also be used in this iterative analysis process.  
Phase 2, Specific Aim 2: Conceptualize a MH service model, in partnership with FRs 
statewide, that is applicable, acceptable, and feasible for implementation. 
Product development activity: Delphi technique 
After all focus groups have been analyzed, we will initiate a series of product development 
activities. We will use a virtual Delphi technique of consensus formation to conceptualize a MH 
service model that is acceptable to FRs and feasible to implement in real world settings. This 
method has been successful in fostering a sense of ownership and the engagement of diverse 
stakeholders in an iterative decision-making process.58  

Title: Building Partnerships with First Responders to Explore Strategies to Improve Delivery and 
Access of Mental Health Services  
PI: Sara Jones, PhD, APRN 
Institution: University of Arkansas for Medical Sciences 
Sponsor: NIH/NIMH 
 
 
 
 
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Participants 
We will invite individuals from our community partners (i.e., Arkansas Department of 
Health, Professional Firefighters Association, etc.) to participate in these Delphi groups, as well 
as a minimum of 12 diverse FRs who participated in the Phase 1 focus groups. We will aim to 
include participants from all 6 regions across the state (see page 12). In this way, we will capture 
the perspectives of both administrative and in-line FRs.  
Procedures 
Due to extended proximities and current COVID related guidelines, all discussions will be 
conducted virtually using Zoom. The initial meeting with be conducted by the PI and RA.  The 
PI will explain the discussion panel’s purpose and procedures, including the process, timeline, 
and expectations. Then, the RA will distribute a handout that briefly describes existing MH 
services and delivery methods; she will review the Aim 1 findings, including the 
recommendations and priorities that arose from the groups. After the first meeting, the PI and 
RA will compile results of the discussion to conceptualize a MH education program. Then, this 
information will be disseminated to the FR panel for review prior to the next meeting. To allow 
all individuals to privately agree or disagree with each, a survey will be distributed via Survey 
Monkey that includes the essential components discussed in the group. Each individual will 
indicate if they agree or disagree and be able to write additional comments if needed. 
The subsequent meetings will aim at reaching consensus on all components of the program.  
The RA will lead a series of discussions every other week via Zoom, covering the essential 
components of a MH service model, including (but not limited to) implementation and 

Title: Building Partnerships with First Responders to Explore Strategies to Improve Delivery and 
Access of Mental Health Services  
PI: Sara Jones, PhD, APRN 
Institution: University of Arkansas for Medical Sciences 
Sponsor: NIH/NIMH 
 
 
 
 
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Date: July 20, 2020  
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engagement strategies, feasibility, and outcome measures. They will also discuss how to meet the 
diverse needs within FR populations if differences emerge (e.g. fire vs. ambulance services; 
urban vs. rural communities) so that the service model will be generalizable to all FRs. 
Following each meeting, we will aim for consensus on the key components discussed during the 
group using the survey method discussed above. This technique will allow us to confirm and 
document that we have reached consensus. 
 
When employing a Delphi technique, each round of discussion will involve up to three 
iterations of deliberations that will seek agreement on essential components of a MH service 
model. We will plan to have a minimum of 5 meetings: one for introduction, three for discussion 
and deliberations, and one for final presentation. Using multiple rounds of deliberation, along 
with a pre-set percentage of agreement, will facilitate a stable and reliable consensus-building 
process. In the remote chance that consensus is not reached, we will schedule an additional 
called meeting to additional to further discuss and deliberate 
We estimate to have a total of 22-24 participants in the Delphi activities. Upon inviting 
participants, we will ask them to agree only if they can commit to all meetings, with an 
allowance of 1 absence, to assure quorum. Specifically, we will use a minimal consensus level of 
75% panel agreement for each component.60   
Compensation 
First responders and associated agencies are already strained with the current pandemic, so 
we want to adequately compensate them for their time. Those that commit to and attend at least 
4/5 meetings will receive a $50 Walmart gift card.  

Title: Building Partnerships with First Responders to Explore Strategies to Improve Delivery and 
Access of Mental Health Services  
PI: Sara Jones, PhD, APRN 
Institution: University of Arkansas for Medical Sciences 
Sponsor: NIH/NIMH 
 
 
 
 
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Ethical Considerations 
This study will be conducted in accordance with all applicable government regulations and 
University of Arkansas for Medical Sciences research policies and procedures. This protocol and 
any amendments will be submitted and approved by the UAMS Institutional Review Board 
(IRB) to conduct the study. The PI will carefully monitor study procedures to protect the safety 
of participants, the quality of the data, and the integrity of the study.  
A waiver of documentation of consent is also requested. We will use an IRB-approved 
study information sheet to discuss the study and complete the consent process before beginning 
the focus groups and interviews. All participants will be provided with an information sheet that 
describes this study and provides sufficient information in language suitable for them to make an 
informed decision about their participation in this study. The researcher will thoroughly explain 
each element of the document and outline the risks and benefits, and requirements of the study. 
Questions regarding participation will be answered, no coercion or undue influence will be used, 
and participants can leave the group or stop the interview at any time. The informed consent 
process will be documented in a process note for each group/interview. 
If at any time there is concern that child or elder abuse has possibly occurred, or a participant 
discloses a desire to harm self or others, it will be reported to the appropriate authorities.  
Implications and Dissemination of Data 
Based on information generated by this project, we will pursue a multi-stage research 
agenda. Using this study’s findings, the next step will be to develop a tailored MH service model 
consisting of services and delivery methods that can be generalizable to FRs statewide, and to 

Title: Building Partnerships with First Responders to Explore Strategies to Improve Delivery and 
Access of Mental Health Services  
PI: Sara Jones, PhD, APRN 
Institution: University of Arkansas for Medical Sciences 
Sponsor: NIH/NIMH 
 
 
 
 
IRB# 228929                           
Date: July 20, 2020  
Page 23 
 
 
pilot test it for feasibility and acceptability. To do so, we will apply for funding, such as an R34 
through the NIMH Division of Services and Intervention Research. Future research will include 
a full-scale trial of the model statewide, revised based on pilot results, and then a hybrid 
effectiveness-implementation trial.  
Results of this study may be used for presentations, posters, or publications. The publications 
will not contain any identifiable information that could be linked to a participant. Dissemination 
of findings to FRs and MH providers through publications and conferences can extend to 
national arenas to better meet the needs of all FRs. With continued efforts and partnerships, 
findings can be integrated into policy and funding-related decisions to sustain the delivery of 
high-quality MH services for FRs in Arkansas and across the nation.   
 
 
 
 
 
 
 
 
 
 
 

Title: Building Partnerships with First Responders to Explore Strategies to Improve Delivery and 
Access of Mental Health Services  
PI: Sara Jones, PhD, APRN 
Institution: University of Arkansas for Medical Sciences 
Sponsor: NIH/NIMH 
 
 
 
 
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Title: Building Partnerships with First Responders to Explore Strategies to Improve Delivery and 
Access of Mental Health Services  
PI: Sara Jones, PhD, APRN 
Institution: University of Arkansas for Medical Sciences 
Sponsor: NIH/NIMH 
 
 
 
 
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Title: Building Partnerships with First Responders to Explore Strategies to Improve Delivery and 
Access of Mental Health Services  
PI: Sara Jones, PhD, APRN 
Institution: University of Arkansas for Medical Sciences 
Sponsor: NIH/NIMH 
 
 
 
 
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Title: Building Partnerships with First Responders to Explore Strategies to Improve Delivery and 
Access of Mental Health Services  
PI: Sara Jones, PhD, APRN 
Institution: University of Arkansas for Medical Sciences 
Sponsor: NIH/NIMH 
 
 
 
 
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Title: Building Partnerships with First Responders to Explore Strategies to Improve Delivery and 
Access of Mental Health Services  
PI: Sara Jones, PhD, APRN 
Institution: University of Arkansas for Medical Sciences 
Sponsor: NIH/NIMH 
 
 
 
 
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Title: Building Partnerships with First Responders to Explore Strategies to Improve Delivery and 
Access of Mental Health Services  
PI: Sara Jones, PhD, APRN 
Institution: University of Arkansas for Medical Sciences 
Sponsor: NIH/NIMH 
 
 
 
 
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Title: Building Partnerships with First Responders to Explore Strategies to Improve Delivery and 
Access of Mental Health Services  
PI: Sara Jones, PhD, APRN 
Institution: University of Arkansas for Medical Sciences 
Sponsor: NIH/NIMH 
 
 
 
 
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