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Lessons learned from the implementation of an intersectoral cross-training approach to improve justice outcomes for homeless adults with mental illness

Published onApr 28, 2023
Lessons learned from the implementation of an intersectoral cross-training approach to improve justice outcomes for homeless adults with mental illness
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Abstract

Purpose. This paper describes lessons learned from the implementation and evaluation of a cross-training event that was held in response to continuing education needs expressed by stakeholders of health, social, justice and public safety sectors regarding individuals who experience multiple exclusion homelessness. Method. The intersectoral training was documented through the administration of online questionnaires on cross-sector practices, clinical vignettes, an appreciation questionnaire in addition to the use of a Lessons Learned framework through the planning, implementation and evaluation phases. Discussion. The results indicate no significant differences before and after the training on the participants’ knowledge of one’s and others’ roles and responsibilities, available resources and helpful practices, but a significant improvement in the perceived benefits of cross-sector practice in terms of knowledge and understanding of other contexts of practice and other actors’ interventions. Conclusions. The Lessons Learned framework was useful to identify factors supporting the implementation of cross-sector training. Structural and systemic factors, such as silos between research and practice, and tensions between social justice and public safety roles, emerged as barriers to cross-sector learning.

Corresponding author

Laurence Roy

Associate Professor, School of Physical and Occupational Therapy, McGill University

Douglas Mental Health University Institute Research Center

[email protected]

School of Physical and Occupational Therapy, McGill University 3654, Promenade Sir-William-Osler, Montréal (Québec), Canada, H3G 1Y5

Keywords

Collaboration, community, continuing education, cross-sector, mental health, police

Introduction

This paper describes lessons learned from the implementation and evaluation of a form of intersectoral pedagogical approach, the “cross-training model”, which involves elements of positional clarification, modelling, and, in some cases, role rotations (Perreault et al., 2020; Perreault et al., 2009). The cross-training approach was used in the current study as a means to improve justice outcomes for adults experiencing multiple exclusion homelessness, defined as homelessness accompanied by mental illness and justice involvement. The approach was within a larger-scale integrated knowledge exchange (IKE; Gagliardi, Berta, Kothari, Boyko, & Urquhart, 2016) strategy at the intersection of research on mental health and homelessness. The IKE strategy was developed through a Canadian Institutes of Health Research (CIHR) Knowledge-to-action grant by a team formed of academics in the field of mental health, law and public safety, and knowledge users composed of managers from leading public institutions in health, homelessness and public safety. We used the CIHR knowledge-to-practice framework (Stras, Tetroe, & Graham, 2013) throughout the design and evaluation of the IKE strategy.

The broad objectives of this IKE strategy were to work collaboratively with service users and providers to: (1) identify factors leading to criminal justice involvement (CJI) for persons experiencing homelessness and mental illness, including professional development needs for service providers, (2) to implement targeted knowledge exchange activities that address those factors, and (3) to document the effects and the implementation process of these activities. Throughout the study, an advisory group (AG) comprised of a peer support worker with lived experience of homelessness, police officers, health and social service providers, community advocates, and researchers, oversaw the process, and collaborated to plan, deliver and evaluate the IKE strategy, including the cross-training event we describe below.

The first phase of the IKE strategy aimed to identify promising practices, and associated challenges, to prevent and reduce CJI in this population. This phase consisted of individual interviews with homeless adults with mental illness on their experiences of CJI (Roy et al, 2020a) and focus groups with service providers regarding practices they engaged in to prevent and reduce CJI in this population (Roy et al., 2020b). In the focus groups, service providers described the challenge associated with navigating the ethical and legal dimensions of practices at the intersection of health, social, housing, public safety, and justice services. They provided detailed examples of such cross-sector issues with regards to the legal and ethical dimensions of practice, including difficulties in appraising whether a person is able to consent to care, whether the situation fits the legal criteria for requesting a court-ordered psychiatric evaluation, and how to interpret confidentiality in various contexts. Many participants discussed coming into conflict with colleagues or with other actors over the interpretation of legal and ethical procedures, and lacking in-depth knowledge of the particular and sometimes complex legal situations of homeless persons with mental illness. Challenges also arose in the absence of shared interpretation of the meaning of disturbing behaviours, or when frontline practitioners could not figure out the motivations and rationale of service providers from other sectors. Even within a specific sector (for instance, police officers), divergent understandings of the issue often led to different and sometimes inconsistent interventions. For instance, some police officers would quickly bring homeless individuals with disturbing behaviours to crisis services, while others would adopt a “wait-and-see” approach, or simply relocate individuals to other areas. Overall, these issues contributed to difficulties in cross-sector communication and collaboration, delays in responses to complex situations, and feelings of distress and helplessness among practitioners (Roy et al., 2020b).

In light of results from the first phase of our IKE strategy, the research team and the AG chose to seek out and select a form of cross-sector training specifically centered on the ethical and legal dimensions of practices at the intersection of justice, mental health and homelessness. We opted to design and implement the cross-training model to enhance communication and collaboration practices among providers from different sectors likely to be involved in justice-related interventions with homeless persons with mental illness: health and social service providers, community workers and advocates, police officers, and correctional and other justice service providers. The objectives of the cross-sector training event were for attendees to:

  • Understand the legal and deontological framework applicable to different situations they experience within their daily practice;

  • Collaboratively apply this legal and deontological framework to complex frontline situations with people experiencing homelessness and mental illness;

  • Understand the role, reasoning, intentions and values of other service providers in decision-making processes with this population.

Background

While interdisciplinary and interprofessional continuing education and training approaches have been well documented (Reeves et al., 2016; Regnier, Chappell, & Travlos, 2019), less pedagogical approaches have been developed for continuing education and learning that bring together practitioners from different sectors. Homelessness is one of the social issues for which the need for collaboration across sectors has been identified as crucial (Nichols & Doberstein, 2016), given the multiple, co-occurring needs of service users in the area of housing, physical and mental health, justice involvement, interactions with law enforcement, addictions, and social inclusion (Kouyoumdjian et al., 2019; Zhang et al., 2018), and the current fragmentation of services for this population (Nichols & Doberstein, 2016).

The added challenge of designing and delivering pedagogical content for practitioners situated within different sectors is that not only do participants have different knowledge and set of professional practices, but they are also likely to have different, even sometimes opposing, visions and mandates within a given situation. For instance, both police officers and community nurses are likely to work with homeless individuals who display disruptive behaviours in public spaces; however, their roles and interests in these situations will be radically different (Hurtubise & Rose, 2016). Thus, cross-sector pedagogical approaches hold many promises. They can support practitioners in understanding what knowledge they can expect other actors to hold in a given situation, and how to contribute their own professional knowledge to “unlock” the situation (Frederico, Jackson, & Dwyer, 2014).

In the field of homelessness, some examples of cross-sector pedagogical approaches include community dialogue (Woolrych, Gibson, Sixsmith, & Sixsmith, 2015), participatory action research with integrated training for community actors (Neale, Buultjens, & Evans, 2012) and simultaneously training practitioners from different sectors in using a specific approach (trauma-informed care, for instance; see Haskett, Tisdale, & Leonard Clay, 2017; Nichols, 2016). However, most of those practices have not been formally evaluated, and rather consist of descriptions of approaches, or reporting on the common themes or priorities that were identified by participant/learners. One notable exception is the work conducted by Cornes et al. (2014) who report on the process and outcomes of a long-term cross-sector community of practice for practitioners working with homeless persons experiencing multiple exclusion in the United Kingdom. This study highlights how a community of practice became a “shelter” in the busy professional lives of practitioners, by providing a confidential, safe space for participants to share and discuss practical and empirical knowledge, thus fostering reflexive practice (Cornes et al., 2014). One of the caveats of cross-sector communities of practice is its time-consuming nature, and the relatively small number of practitioners it can reach.

Here, we report on the implementation and potential outcomes of specific form of intersectoral pedagogical approach, the “cross-training approach” (Perreault et al., 2020; Perreault et al., 2009). This approach relies on the central concept of interpositional knowledge, which consists of a shared knowledge of other actors’ roles, responsibilities, resources, and duties, as well as the knowledge of how one’s and others’ specialized knowledge can be combined in a given situation. Increased interpositional knowledge has been associated with a decreased tension among team members, and improved communication and collaboration, particularly in complex situations (Ellis & Pearsall, 2011). Cross-training activities aim to improve interpositional knowledge in three ways (Cannon-Bowers, Salas, Blickensderfer, & Bowers, 1998; Perreault et al., 2020): positional clarification (providing information to actors from other sectors through discussions, seminars/conferences, or meetings), positional modelling (verbal information and observation of one’s tasks), and positional rotation (active participation in the tasks of an actor from another profession or sector). Cross-training activities have been implemented both in interprofessional (intervention workers from different professions or different contexts of practice within the same sector, such as health – see for instance Taylor, Swetenham, Myhill, Glaetzer, Picot & van Loon, 2012) and intersectoral practice (intervention workers from different sectors, such as health and public safety – see for instance Perreault et al, 2020).

The purpose of this study was to implement and evaluate a cross-training event that combined positional clarification and modelling, based on the professional development needs identified in phase 1 of this IKE project. Cross-training activities have been particularly developed in the context of Montreal-based health and social services, particularly at the intersection of co-occurring mental health and addictions services (Perreault et al., 2020).

The implementation of the cross-training event occurred alongside an evaluation study. The objectives of the study were to:

  1. Evaluate the effect of the training on the attitudes towards and perceived benefits of cross-sector work;

  2. Evaluate the effect of the training on the knowledge of one’s and others’ roles and responsibilities, available resources and helpful practices in complex situations involving homeless persons with mental illness;

  3. Document the implementation process, in particular the facilitators and barriers to the mobilization and exchange of knowledge across sectors.

Method

Cross-training event

The one-day cross-training event took place in Montreal in February 2018 and consisted in a series of activities: presentations on various topics related to legal and ethical issues at the intersection of justice and homelessness, from different standpoints (experiential/grounded knowledge, practical knowledge, empirical knowledge), and small-group workshops based on clinical vignettes. Social activities were also included to foster relationship-building across practitioners. Small-group workshops were designed so that each table (8-10 participants by table) included representatives from different sectors (police/public safety, public sector health care and social service providers, community workers, advocates) to allow for positional clarification and modelling. Members of the AG developed several clinical vignettes based on their own experiential and practical knowledge of CJI with this population. Vignettes were characterized by the AG as “moderately complex” (less actors and sectors involved) or as “highly complex” (more actors and sectors involved). Some of the vignettes were used in the cross-training workshops, while others were used for the evaluation component. In the first round of small-group workshops, each participant provided information on their understanding of the situation presented in the vignettes, their role, their potential course of action, and the objectives they wished to attain with the selected action. A moderator was present at each table and encouraged practitioners from different sectors to ask each other clarification questions. Each table was then asked to answer questions related to the “ideal course of action” in the situation, and the resources that they could provide as part of their professional mandate. In the second round, participants were provided with a synthesis of all of the tables’ discussions, and identified a plan to implement this knowledge in each of their organizations. One hundred and fifty-one participants, roughly equally divided between public safety/police personnel (n=45), health and social service providers (n=51), and community workers/advocates (n=55), attended the cross-training event, as well as 40 non-practitioners attendees (members of the advisory committee, researchers and research personnel, graduate students).

Study design

The implementation of the cross-training event was initially planned to occur alongside a mixed-methods quasi-experimental study design with the use of a matched comparison group. The comparison group was planned to consist of colleagues of the services providers who performed a similar function within their organization, but who did not attend the cross-training event. However, organizational patterns and constraints (which we discussed in the Lessons Learned section of the Results) impeded the recruitment of an adequately-sized comparison group. Hence, we report on the quantitative pre-post results and on the qualitative findings of the implementation study component, using the Lessons Learned framework. The (blinded for review) research ethics board approved the study.

Participants

Study participants were selected if they were over 18 years of age, if they were in regular (at least weekly) professional contact with homeless persons with mental illness, and if they attended the cross-training event. Regular professional contact was defined as at least weekly contact for at least one year, in order for participants to have enough practical knowledge to be meaningfully involved in the event. Potential participants received information on the study when they registered online to the event; they then received an email linking them to the consent form and study questionnaires. All participants provided written informed consent.

Procedure

Lessons learned. Lessons learned are a central component in program evaluation research, particularly in the field of implementation science. We documented the process of planning, implementing and evaluating the cross-sector training through a standardized Lessons Learned strategy (Project Management Institute, 2013) that was applied to the minutes of each meeting and transcript of every communication of the AG before, during and after the cross-sector training event. We used an extraction grid adapted from the one recommended by the Centers for Disease Control and Prevention (Centers for Disease Control and Prevention, 2010) that contained information on the date of the meeting, the identity and role of the AG member(s) making an observation on the study process, the type of knowledge this reflected (practical, empirical, experiential), the content of the observation, and the recommendation or suggested change stemming from the observation. This mechanism enables teams to identify and document new knowledge gained throughout the life course of a project. The goal of using the Lessons Learned strategy is to share new knowledge about the implementation of complex practices to support the recurrence of desirable outcomes and prevent the recurrence of undesirable ones (CDC, 2010).

Pre-post evaluation. The evaluation of the cross-training event occurred on three time points through online questionnaires: a week before the event (T1), in the two weeks after the event (T2), and six months after the event (T3). At T1 and T3, participants were asked to complete an online version of the Interdisciplinary Collaboration Questionnaire (Questionnaire de la collaboration interdisciplinaire; Sicotte, D'Amour, & Moreault, 2002), adapted for cross-sector practice with permission of the authors. The questionnaire examines the participants’ perception of cross-sector collaboration practices in five sections, including how interdisciplinary and intersectoral work is organized in their workplace, the quantity, quality and type of interdisciplinary and intersectoral relationships they have, service user trajectories and service delivery approach, and descriptive information on the participant and their organization.

At T1 and T3, participants were also presented with a clinical vignette, and were asked to answer six questions rated on a five-point Likert scale with responses ranging from 1 = strongly disagree to 5 = strongly agree: (1) “I understand my role and my responsibilities in this situation.”; (2) “I know of resources or strategies I could rely on to better understand and assess the situation.”; (3) “I can identify a course of action that will help solve the situation.”; (4) “I believe the person should be receiving health services at this point in the situation.”; (5) “I consider this to be an emergency situation.”; (6) “The person should be receiving care against their will at this point.”.

At T2, participants filled in a questionnaire as to their reactions to and appraisal of the training, including strengths and areas for improvement. This questionnaire, based on the one developed by Perreault et al (2020), with the authors’ permission, included 13 close-ended questions (e.g. “The event improved my knowledge of the legal framework regarding the exchange of service user information with actors from other sectors”) rated on a five-point Likert scale with responses ranging from 1 = strongly disagree to 5 = strongly agree, and six open-ended question (e.g. “What resources did you learn about during the event?”).

Data analysis

Responses to close-ended questions from the QCI (Sicotte et al., 2002), the clinical vignettes, and the appreciation questionnaire were analysed using descriptive statistics. All the data were visually examined to identify trends and residuals. T-tests were conducted to compare the total scores on the QCI subs-sections and the answers to the questions on the clinical vignettes between T1 and T3. Answers to open-ended questions in the appreciation questionnaire were compiled and a thematic analysis was performed (Paillé & Mucchielli, 2003).

For objective 3, we compiled all the entries in the Lessons Learned extraction grid. The data was analyzed thematically with entries classified into categories using a coding grid based on emerging themes (Paillé & Mucchielli, 2003). The first author performed thematic data analysis, and the findings were discussed among the members of the advisory committee.

Results

Forty participants completed the T1 questionnaires: 20 participants from the community sector, 13 from the police sector, and 7 from the public health and social services sector. Most participants were in their late thirties (average age: 38.9; ranging from 22 to 59 years old); 23 participants identified as women, 16 as men, and one as non-binary. On average, participants had been working with individuals experiencing homelessness and mental illness for nine years. Thirty-four participants completed the questionnaires at T2, and 17 at T3.

Reactions to the cross-training activity

The descriptive analyses of the 13 close-ended questions asked at T2 revealed a high level of satisfaction, with scores ranging from 3.8 to 4.3 on 5 for all questions. The thematic analysis revealed that the two elements of the cross-training activity that were most appreciated were the clinical vignettes, which were perceived as “very realistic”, as well as the ample opportunities to exchange knowledge and information with actors from other sectors. Perceived benefits included an increased knowledge of resources, fostering more profound, “face-to-face” relationships with key persons in other organizations, as well as an enhanced understanding of others’ perception of justice involvement among homeless service users, as noted by a participant from the community sector who appreciated “…the possibility of exchanging with some professionals who are less accessible to me in my daily practice. The opportunity to share different visions and develop my own by better understanding how the healthcare system works.”

The thematic analysis also uncovered barriers to participation in the cross-training activities, and further professional development needs. Several participants indicated wanting even more time for discussion and exchange to deepen the relationships that they had started to build. Some participants noted that most of the issues discussed were related to urban areas, and would have liked to see more attention devoted to issues specific to homelessness in rural and remote areas. Many participants appreciated the inclusion of persons with lived experience of homelessness in leadership roles in the cross-sector activities, which made them reflect on the challenges of “how to include peer support workers in our resources and in our practices.”

Finally, some tensions emerged with regards to the inclusion of participants from the public safety sector. Some participants from the community sector mentioned preferring that police officers would not wear their uniforms during a professional development event. Conversely, some police officers expressed discomfort and felt excluded from some conversations in which they perceived “negative stereotyping of the correctional and police sectors”.

Pre-post evaluation of the cross-training event

The analysis revealed no significant differences between T1 and T3 on the participants’ general attitudes towards cross-sector work, and on their knowledge of one’s and others’ roles and responsibilities, available resources and helpful practices in complex situations involving homeless persons with mental illness. One notable exception is the perceived benefits of cross-sector practice, for which a statistically significant (p<0.004) improvement was noted at T3.

Table 1. Knowledge and attitudes towards cross-sector practice before and after the event

Variable

T1

T3

t

Mean

Standard deviation

Mean

Standard deviation

Understanding of one’s roles and responsibilities (moderately complex clinical vignette)

4.02

0.83

4.22

0.97

0.61

Understanding of one’s roles and responsibilities (highly complex clinical vignette)

3.89

1.02

4.44

0.72

1.53

Identification of appropriate resources (moderately complex clinical vignette)

3.62

0.83

3.77

1.30

0.45

Identification of appropriate resources (highly complex clinical vignette)

3.73

0.80

3.89

0.78

0.54

Identification of course of action (moderately complex clinical vignette)

3.67

0.86

4.0

1.32

0.93

Identification of course of action (highly complex clinical vignette)

3.76

0.83

3.77

0.97

0.65

Attitudes towards cross-sector work

75.8

12.0

79.6

12.7

0.90

Perceived benefits of cross-sector work

26.41

3.7

29.5

1.7

2.76*

* indicates p < 0.01.

Lessons Learned

Thirty-one “lessons learned” were entered in the standardized grid throughout the course of the study. Five themes emerged from the thematic analysis.

Roles and composition of the advisory committee. Various characteristics of the advisory committee were identified as facilitators for the implementation of the cross-training activity. First, its relatively small size allowed for the creation and maintenance of personal relations between members. The representation of all the sectors identified as potential knowledge users allowed for different forms of knowledge (experiential, empirical, practical-oriented towards care, practical-oriented towards advocacy, practical-oriented towards safety) to be discussed, which then translated into a representation of those forms of knowledge in the pedagogical activities used in the cross-training event. Specific strategies were used to ensure that some forms of knowledge did not take precedence over others; for instance, the spaces used for advisory committee meetings alternated so that each committee member would introduce others to their workspace. The timing of the creation of the advisory group was also perceived to judicious, as the advisory committee was created at the end of phase 1, during the analysis and interpretation of the data from the focus groups and individual interviews. This timing allowed the advisory committee members to be free of the more tedious tasks of participant recruitment (including the labour-intensive task of obtaining administrative approval from all the sectors involved) and to be involved in the more creative and dialectic step of synthesizing the knowledge emerging from these initial stages of research. Finally, we kept a constant focus on sustainability beyond the implementation of the cross-training event, and beyond the lifespan of the IKE grant. At the end of the grant, committee members were invited to participate in the activities of a provincially funded research observatory to ensure that their perspectives and experience would not be lost. This speaks, however, to some misalignment between the short-term financial infrastructures that support knowledge mobilization efforts, at least in Canada, and the circular shape of the IKE framework (Stras et al., 2013).

Valuation of experiential knowledge. Throughout the IKE process, we actively sought out and foregrounded experiential knowledge through interviews with individuals who experienced homelessness, mental illness and justice involvement, through the participation of a peer support worker with experience of homelessness in the advisory committee, and through presentations by individuals with lived experience during the cross-training event. This allowed the team and the participants at the cross-training event to uncover some blind spots in our representation of justice involvement for individuals situated at the intersection of multiple devalued identities. This also triggered a reflection among participants on the potential value of experiential knowledge in their daily practice, including through the inclusion of peer support workers in their workspace.

Creation of reflexive spaces. The cross-training event, and more broadly the entire IKE process, made it possible for practitioners to “take a break” from their daily practice often characterized by a fast pace and sense of urgency, and to step into a space described as slower, where dialogue, exchange, and reflection were encouraged. The creation of this type of space is highly valued by service providers, particularly in the context of cross-sector practice. Creating such spaces in a sustainable way for practitioners involved in frontline work remains a challenge, and requires a re-thinking of organizational structures to formally include such reflective and relational work.

The “missing ones”. Many discussions during the cross-training events centered on the challenges experienced in attempting to reach, even through an IKE strategy, key actors in the judicial trajectories of homeless adults with mental illness. Those “missing ones” included first and foremost the representatives of the medical profession (general physicians, psychiatrists, and neurologists, in particular), although representation of the correctional and peer support sectors was also deemed insufficient.

Adapting IKE strategies to the needs of diverse knowledge users. While the opportunity to bring together knowledge users from different organizations and sectors was highly valued, it created challenges to adapt the content of some presentations. For instance, while notions of consent to care might be very familiar to licensed nurses or social workers, police and correctional officers might have very little knowledge of the concept. This needs to be considered in the pedagogical approaches used in cross-sector training activities, so that basic knowledge and a common language are presented to all, while recognizing and valuing the specialized knowledge of some actors.

The diversity of knowledge users and of the structure of their respective organizations creates additional challenges for attempts to formally evaluate cross-sector pedagogical activities. It proved extremely difficult to recruit participants for a comparable control group; some community organizations who participated in the event, for instance, have a tradition of sending the majority or entirety of their staff to training activities, eliminating the possibility of recruiting non-participating colleagues for a comparison group.

Structural and organizational factors. The implementation of the IKE strategy was greatly impacted by major structural changes in both the organization of the Quebec health and social services, and in the governance structure of the local Montreal police. This brought the advisory committee to identify how the implementation of knowledge mobilization and learning activities relied on the complex (and often changing) organizational structures in which frontline service providers are situated, and on which they have no control. One of the barriers to implementation was the lack of opportunity for the research team and advisory committee to gain knowledge on how professional development needs were assessed, responded to, and managed internally by each organization.

Finally, while the role of knowledge users as co-researchers is valued and supported by granting agencies such as CIHR, participation in research activities for managers and practitioners was not promoted in every organization. The peculiar position of knowledge users as co-researchers situates them on the border between practical and empirical knowledge holders, which may be hard to sustain within workplaces that clearly separate practice from research.

Discussion

The aim of this paper was to document the process and outcomes of a specific form of intersectoral pedagogical approach to professional development known as the cross-training model. The findings from this study add to the growing evidence supporting the use of cross-training events based on the concept of interpositional knowledge to facilitate cross-sector communication and collaboration (Dunnack, 2020; Perreault et al., 2020). Both quantitative and qualitative evaluation strategies indicate that participants’ perception of cross-sector collaboration improves after attending a cross-sector training event. This identification of the perceived benefits of cross-sector collaboration occurs through the possibility of engaging face-to-face with actors from other sectors, of listening to their perspectives on a concrete clinical situation, and of dialoguing about the appropriate course of action in such a concrete situation. This is aligned with previous research on the importance for practitioners to have regular space and time outside of their clinical practice to engage in interdisciplinary and intersectoral reflexive exchange and dialogue (Cornes et al., 2014; Gillett, Loader, Doherty, & Scott, 2016; Grace, Coventry, & Batterham, 2012). Emerging evidence suggests that the need to provide practitioners with diverse opportunities for reflexive practice, exchange and dialogue increased in the context of the COVID-19 pandemic, where practice is characterized by its focus on urgent care, technical knowledge and professional isolation (Goldberg, Johnson, & Murphy, 2020; Sockalingam, Clarkin, Serhal, Pereira, & Crawford, 2020).

A specific challenge pertaining to cross-sector, rather than interprofessional, pedagogical activities, arose with regards to acknowledging and addressing tensions between two professional cultures: police departments and the community/advocacy sector. These tensions emerge from the historical, political, and socioeconomic context in which both the community and the police sector are embedded (Roy et al., 2020a), particularly around matters of public safety and criminality (Castillo & Goyette, 2020). At the core of these tensions lies the difficulty for actors from different sectors to balance concerns for public safety, and concerns for social justice and equity for historically marginalized groups.

One of the main themes emerging from documenting the implementation and evaluation of the cross-training event is the value of considering various forms and sources of knowledge to improve collaborative work in an area as complex as homelessness and criminal justice involvement. This can reduce “epistemic injustice” (Abma et al., 2017) where some forms of knowledge – however rigorously gathered - are disqualified in defining a situation. As in previous studies in the area of homelessness and housing precariousness, the participation of persons with “grounded expertise” (Phipps et al., 2020) helped uncover largely systemic and structural issues that contributed to the CJI of homeless individuals, including class-based, racial and ableist discriminatory practices in their interactions with police, health, and social services (Roy et al., 2020a). We reiterate the value of foregrounding the knowledge of individuals with lived experience, particularly in large events or training initiatives like this one, as service providers are likely to bring back this knowledge into their institutions or organizations.

Theoretical implications

These concerns for social and epistemic justice raise questions about the ability of cross-sector practices, including professional development and training, to move past the technical dimensions of service provision. Over the past few years, emerging models of knowledge translation that consider structural issues in the creation of health and social inequities have been developed (Dyck, Snelling, Morrison, Haworth-Brockman, & Atkinson, 2018; Masuda, Zupancic, Crighton, Muhajarine, & Phipps, 2014). Equity-focused knowledge translation models posit that a traditional approach “misses a crucial point: it assumes that health inequities are the result of a knowledge deficit or a knowledge-to-action gap, rather than due to intentional priorities, and interests such as productivity, prosperity, austerity, or competitiveness, common in neo-liberal approaches to health governance.” (Masuda et al, 2014, p. 458). We suggest that using equity-focused knowledge translation models might be particularly useful for the development of cross-sector practices, as a way to uncover how “intentional priorities and interests” across and between sectors affect knowledge production, circulation, and exchange.

The findings also align with recent research that advocates for interprofessional or intersectoral team training to move beyond strictly behavioural approaches, with their focus on communication and collaboration skills, to consider more complex cognitive, affective, and relational dimensions of service provision (Fernandez, Shah, Rosenman, Kozlowski, Parker & Grand, 2017). The concepts of “team cognition”, “team mental models” and “team memory systems” (Fernandez et al, 2017), while central to understand how different actors function together in a situation, has not been widely used in the field of intersectoral practice. The findings of the current study indicate that future research could investigate further how the concepts of team cognition can be understood and adapted in the context of complex cross-sector practice such as multiple exclusion homelessness.

Strengths and Limitations

The limitations of this study include the small sample size for the pre-post evaluation, high attrition rate, and our inability to recruit a control group. It is also possible that the participants who chose to complete the evaluation already had a stronger interest in research, which might have influenced the results. More broadly, it is possible that the service providers attending the cross-sector event might already be more favourable to cross-sector work than their peers from a similar sector. While the use of both clinical vignettes and the QCI was seen as strength, the results indicate a ceiling effect, which may have restricted our ability to detect change between T1 and T2.

While taking these limitations into account, the study provides an original contribution to the field through a multi-method evaluation of a specific pedagogical approach throughout the life course of the project. Such an evaluation strategy proved useful to better understand both the processes and outcomes related to the implementation of the cross-training approach, and could be used to evaluate other implementation or knowledge mobilization activities.

Concluding remarks

Our findings highlight important elements that support cross-sector professional development strategies, and that might be applicable to practices in other areas than homelessness, mental illness, or criminal justice involvement. Those elements include the importance to carefully design the role of a cross-sector advisory committee, to foreground experiential knowledge, and to create spaces for reflexive dialogue. Structural and systemic factors, such as silos between research and practice, and tensions between social justice and public safety roles, need to be considered in both the implementation and evaluation of such pedagogical strategies. Future work in this area could rely on novel framework for knowledge exchange and translation that take into consideration concerns for equity and justice. Future studies also could move beyond the identification of impact on service providers to also include how cross-sector professional development activities impact service user outcomes.

References

Abma, T. A., Cook, T., Rämgård, M., Kleba, E., Harris, J., & Wallerstein, N. (2017). Social impact of participatory health research: collaborative non-linear processes of knowledge mobilization. Educational Action Research, 25(4), 489-505. doi: 10.1080/09650792.2017.1329092

Cannon-Bowers, J. A., Salas, E., Blickensderfer, E., & Bowers, C. A. (1998). The Impact of Cross-Training and Workload on Team Functioning: A Replication and Extension of Initial Findings. Human Factors, 40(1), 92-101. doi: 10.1518/001872098779480550

Castillo, E. G., & Goyette, M. (2020). L’intervention communautaire en criminologie vue par le biais d’une approche gramscienne: Étude d’un cas québécois. ENJEUX CRIMINOLOGIQUES CONTEMPORAINS, 237.

Centers for Disease Control and Prevention. (2010). Document library matrix: Lessons learned templates. Retrieved August 20th, 2014

Cornes, M., Manthorpe, J., Hennessy, C., Anderson, S., Clark, M., & Scanlon, C. (2014). Not just a talking shop: practitioner perspectives on how communities of practice work to improve outcomes for people experiencing multiple exclusion homelessness. Journal of Interprofessional Care, 28(6), 541-546.

Dunnack, H. J. (2020). Health care providers’ perceptions of interprofessional simulation: A meta-ethnography. Journal of Interprofessional Education & Practice, 21, 100394. doi: https://doi.org/10.1016/j.xjep.2020.100394

Dyck, L. A., Snelling, S., Morrison, V., Haworth-Brockman, M., & Atkinson, D. (2018). Equity reporting: a framework for putting knowledge mobilization and health equity at the core of population health status reporting. [Intégrer la notion d’équité : création d'un cadre d'action pour placer la mobilisation du savoir et l’équité en santé au coeur des rapports sur l’état de santé des populations]. Health promotion and chronic disease prevention in Canada : research, policy and practice, 38(3), 116-124. doi: 10.24095/hpcdp.38.3.02

Ellis, A. P. J., & Pearsall, M. J. (2011). Reducing the negative effects of stress in teams through cross-training: A job demands-resources model. Group Dynamics: Theory, Research, and Practice, 15(1), 16-31. doi: 10.1037/a0021070

Fernandez, R., Shah, S., Rosenman, E. D., Kozlowski, S. W. J., Parker, S. H., & Grand, J. A. (2017). Developing Team Cognition: A Role for Simulation. Simul Healthc, 12(2), 96-103. doi: 10.1097/sih.0000000000000200

Frederico, M., Jackson, A., & Dwyer, J. (2014). Child Protection and Cross-Sector Practice: An Analysis of Child Death Reviews to Inform Practice When Multiple Parental Risk Factors Are Present. Child Abuse Review, 23(2), 104-115. doi: https://doi.org/10.1002/car.2321

Gagliardi, A. R., Berta, W., Kothari, A., Boyko, J., & Urquhart, R. (2016). Integrated knowledge translation (IKT) in health care: a scoping review. Implementation Science, 11(1), 38. doi: 10.1186/s13012-016-0399-1

Gillett, A., Loader, K., Doherty, B., & Scott, J. M. (2016). A multi-organizational cross-sectoral collaboration: empirical evidence from an ‘Empty Homes’ project. Public Money & Management, 36(1), 15-22. doi: 10.1080/09540962.2016.1103413

Goldberg, L. S., Johnson, L. T., & Murphy, S. F. (2020). Online Tea Cafés: Using Caring Science to Transform Digital Learning Spaces and Advance Nursing Leadership. Quality Advancement in Nursing Education-Avancées en formation infirmière, 6(3), 6.

Grace, M., Coventry, L., & Batterham, D. (2012). The role of interagency collaboration in “joined-up” case management. Journal of Interprofessional Care, 26(2), 141-149. doi: 10.3109/13561820.2011.637646

Haskett, M. E., Tisdale, J., & Leonard Clay, A. (2017). Interagency Collaboration to Promote Mental Health and Development of Children Experiencing Homelessness. In M. E. Haskett (Ed.), Child and Family Well-Being and Homelessness: Integrating Research into Practice and Policy (pp. 83-99). Cham: Springer International Publishing.

Hurtubise, R., & Rose, M.-C. (2016). L'action intersectorielle clinique: L'expérience d'EMRII, une équipe mixte pour les personnes en situation d'itinérance. In N. Nichols & C. Doberstein (Eds.), Exploring effective systems responses to homelessness (pp. 47-70). Montreal: The Homeless Hub.

Kouyoumdjian, F. G., Wang, R., Mejia-Lancheros, C., Owusu-Bempah, A., Nisenbaum, R., O’Campo, P., . . . Hwang, S. W. (2019). Interactions between Police and Persons Who Experience Homelessness and Mental Illness in Toronto, Canada: Findings from a Prospective Study. The Canadian Journal of Psychiatry, 0706743719861386. doi: 10.1177/0706743719861386

Masuda, J. R., Zupancic, T., Crighton, E., Muhajarine, N., & Phipps, E. (2014). Equity-focused knowledge translation: a framework for “reasonable action” on health inequities. International Journal of Public Health, 59(3), 457-464. doi: 10.1007/s00038-013-0520-z

Neale, K., Buultjens, J., & Evans, T. (2012). Integrating service delivery in a regional homelessness service system. Australian Journal of Social Issues, 47(2), 243-261. doi: 10.1002/j.1839-4655.2012.tb00245.x

Nichols, N. (2016). Coordination at the service delivery level: the development of a continuum of services for street-involved youth. In N. Nichols & C. Doberstein (Eds.), Exploring effective systems responses to homelessness. Toronto: The Homeless Hub Press.

Nichols, N., & Doberstein, C. (2016). Exploring Effective Systems Responses to Homelessness. Toronto: The Homeless Hub Press.

Paillé, P., & Mucchielli, A. (2003). L'analyse qualitative en sciences humaines et sociales. Paris: Armand Colin.

Perreault, M., Milton, D., Alunni-Menichini, K., Archambault, L., Perreault, N., & Bertrand, K. (2020). Montreal Cross-Training Program: The contribution of positional clarification activities to help bridge fragmented prevention and treatment services for co-occurring disorders. Health & Social Care in the Community, 28(3), 1090-1098. doi: https://doi.org/10.1111/hsc.12942

Perreault, M., Wiethaueper, D., Perreault, N., Bonin, J.-P., Brown, T., & Brunaud, H. (2009). Meilleures pratiques et formation dans le contexte du continuum des services en santé mentale et en toxicomanie: le programme de formation croisée du sud-ouest de Montréal. Sante Mentale Au Quebec, 34(1), 143-160.

Phipps, E., Butt, T., Desjardins, N., Schonauer, M., Schlonies, R., & Masuda, J. R. (2020). Lessons from a rural housing crisis Grounded insights for intersectoral action on health inequities. Social Science and Medicine. doi: https://doi.org/10.1016/j.socscimed.2020

Project Management Institute. (2013). A guide to the project management body of knowledge - 5th edition. Newton Square, PA: Project Management Institute.

Reeves, S., Fletcher, S., Barr, H., Birch, I., Boet, S., Davies, N., . . . Kitto, S. (2016). A BEME systematic review of the effects of interprofessional education: BEME Guide No. 39. Medical Teacher, 38(7), 656-668. doi: 10.3109/0142159X.2016.1173663

Regnier, K., Chappell, K., & Travlos, D. V. (2019). The Role and Rise of Interprofessional Continuing Education. Journal of Medical Regulation, 105(3), 6-13. doi: 10.30770/2572-1852-105.3.6

Roy, L., Leclair, M., Côté, M., & Crocker, A. (2020a). Itinérance, santé mentale, justice : expérience et perceptions des utilisateurs de services à Montréal. Criminologie, 53(2), 359-383. doi: https://doi.org/10.7202/1074199ar

Roy, L., Crocker, A.G., Hurtubise, R., Latimer, E., Côté, M., Billette, I., Boissy, F. (2020b). Reducing criminal justice involvement of individuals experiencing homelessness and mental illness: Perspectives of frontline practitioners. Canadian Journal of Criminology and Criminal Justice. doi: 10.3138/cjccj.2019-0056

Sicotte, C., D'Amour, D., & Moreault, M.-P. (2002). Interdisciplinary collaboration within Quebec community health care centres. Social Science & Medicine, 55(6), 991-1003.

Sockalingam, S., Clarkin, C., Serhal, E., Pereira, C., & Crawford, A. (2020). Responding to Health Care Professionals' Mental Health Needs During COVID-19 Through the Rapid Implementation of Project ECHO. Journal of Continuing Education in the Health Professions, 40(3).

Stras, S., Tetroe, J., & Graham, I. D. (2013). Knowledge translation in health care: moving from evidence to practice: John Wiley & Sons.

Taylor, J., Swetenham, K., Myhill, K., Glaetzer, K., Picot, S., & van Loon, A. (2012). IMhPaCT: an education strategy for cross-training palliative care and mental health clinicians. International Journal of Palliative Nursing, 18(6), 290-294.

Woolrych, R., Gibson, N., Sixsmith, J., & Sixsmith, A. (2015). “No Home, No Place”: Addressing the Complexity of Homelessness in Old Age Through Community Dialogue. Journal of Housing For the Elderly, 29(3), 233-258. doi: 10.1080/02763893.2015.1055024

Zhang, L., Norena, M., Gadermann, A., Hubley, A., Russell, L., Aubry, T., . . . Palepu, A. (2018). Concurrent Disorders and Health Care Utilization Among Homeless and Vulnerably Housed Persons in Canada. Journal of Dual Diagnosis, 14(1), 21-31. doi: 10.1080/15504263.2017.1392055

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