Introduction
Studies from the United States and the United Kingdom indicate that mental health issues account for an estimated 3-13% of emergency department (ED) presentations.1-4 Trend data from these countries and Canada also indicate annual proportional increases for those who attend the ED for mental health issues.5-7 The most commonly cited mental health presentations include mood disorders (43%) or anxiety disorders (26%), and substance disorders (24%).3 The ED is often the first point of contact for patients with a mental health issue, especially during the out-of-hours service period.8 A lack of available mental health services often leaves these individuals and their families with no other option but to attend their local ED.8 However, given the nature of ED services, this environment is often ill-equipped to assist these patients, who have wide-ranging service requirements. By definition, the ED is designed to treat large numbers of attendees as quickly as possible. Overcrowding and a lack of capacity require the prioritization of the most urgent, critical cases.9 As a result, patients with mental health issues often experience longer waiting times in an environment that may further contribute to distress.10 For example, one qualitative study from the United Kingdom11 observed that a lack of privacy and levels of noise in EDs, in particular, are unsuitable for many patients with mental health issues, while another qualitative study from Australia highlighted how this environment can impede the effective assessment and management of these patients.12
Social and emotional challenges, such as stigma, discrimination and marginalization, are also recognized as important issues experienced by patients in this context. One ED-based narrative review reported that many patients believe that their mental health presentation/status negatively affects their quality of care.13 Additionally, another study indicates that "nurses in general medical settings often held negative attitudes of fear, blame and hostility towards patients with psychiatric illness" .14(p.565) From a staff perspective, feelings of fear and anger around unpredictable behavior were reported, as well as frustration and hopelessness with the frequency of repeat presentations and lack of follow-up services.13 Although this review, published 10 years ago, was not systematic and was specifically concerned with attitudes, it highlights the range of challenges for staff, especially considering the broad spectrum of mental health presentations.
Nursing staff in the ED are involved in key clinical decision making, as well as hands-on care, for all patients from the commencement of triage to ED discharge.15 Despite this, a number of qualitative studies suggest that ED nurses, who do not have mental health specialist training, often do not feel equipped to assess and manage the complex needs of patients who present with mental health issues.10,16,17 To address this, many national organizations in Australia, the United States and the United Kingdom)18-20 have developed, or recommended the development of, guidelines for staff (i.e. those who are not trained in mental health) to manage and care for people with mental health issues in an effective and responsive way. For example, one qualitative study from the United Kingdom that explored nurse experiences advocated for a triage process.21 This involved using mental health nursing staff within EDs to improve services, provide focused support for people with a mental illness and further integrate EDs within the community mental health model.21 An Australian qualitative study12 concluded that there should be a greater focus on educating all ED staff on the policies and strategies for improving the care of patients presenting with a mental health problem. Another qualitative study based in Australia10 highlighted important gaps in learning related to mental health-related issues, such as workplace aggression and violence, psychiatric theory, mental health assessment and chemical dependence. Additional research revealed that ED nurses lacked confidence, particularly with regard to mental health presentations, which was related to feelings of isolation and lack of context-specific education and training.22
Although the ED may not be the optimal environment for an individual with mental health issues, individuals and their families continue to attend hospital EDs for a variety of reasons, predominately due to difficulties accessing mental health support services. It is therefore essential to have a thorough understanding of how ED nurses' experiences affect their clinical decision making. Clinicians can be better equipped to handle patients with mental health issues through the development of evidenced-based guidelines, which will help them support patients more effectively. This will lead to enhanced patient outcomes and a more positive ED experience.
A preliminary search was conducted in January 2019, which included the JBI Database of Systematic Reviews and Implementation Reports, the Cochrane Library, the Centre for Reviews and Dissemination-University of York, MEDLINE, CINAHL and PROSPERO. This search found several relevant papers, including two literature reviews,13,23 that focused solely on attitudes of ED nurses. However, no systematic reviews on the topic have been published to date, providing a strong rationale for this review. This systematic review intends to address this gap and identify, appraise and synthesize all available evidence related to the experiences and perceptions of ED nurses regarding people with any mental health issue who present at the ED.
Review question
What are the experiences and perceptions of ED nurses in relation to people who present with mental health issues at the ED in hospital settings?
Inclusion criteria
Participants
This review will consider studies that include all ED nurses, with or without mental health specialist training, working in urban and rural EDs (emergency rooms, accident and emergency rooms) of healthcare settings worldwide.
Phenomena of interest
This qualitative review will consider studies that explore the experiences and perceptions of ED nurses regarding people who present with mental health issues in the ED setting. The term "experiences and perceptions" will encompass all ED nurses' interactions with people who present at the ED with mental health issues. Although a diagnosis in accordance with the Diagnostic and Statistical Manual of Mental Disorder, 5th edition (DSM-5)24 may be present, this review will not be limited to those with a diagnosis, and it will include people who present with other mental health issues.
Context
This review will consider studies that are set in an ED (emergency rooms, accident and emergency rooms) in all healthcare facilities in any geographic region.
Types of studies
This review involves nurse experiences and perceptions in relation to the topic. To answer the review question, qualitative components of mixed methods studies and qualitative studies including, but not limited to, designs such as ethnography, qualitative description, grounded theory, action research, case studies, and phenomenology will be considered. Studies published in black or gray literature will be obtained through a comprehensive search strategy.
Studies available in English will be considered for inclusion in this review. The review team members do not have resources for translation. No date limits will be set for the database searches.
Methods
The proposed systematic review will be conducted in accordance with the JBI methodology for systematic reviews of qualitative evidence.25 The review title will also be registered in PROSPERO and the registration number reported in the full systematic review.
Search strategy
The search strategy will aim to find both published and unpublished studies. A limited search of MEDLINE and CINAHL was undertaken to identify articles on the topic. The text words contained in the titles and abstracts of relevant articles, and the keywords used to describe the articles, were used to develop a full search strategy for MEDLINE (Appendix I). The search strategy, including all identified keywords and index terms, will be adapted for each included information source. The reference list of all studies selected for critical appraisal will be screened for additional studies.
Information sources
Information sources will include electronic databases, relevant websites and, where necessary, contact with study authors. The databases to be searched include: CINAHL complete, MEDLINE, PsycINFO, Embase, Scopus, Web of Science and Google Scholar. The search for unpublished or gray literature will include: ProQuest Dissertations and Theses, HSRProj, Grey Matters, Web of Science Conference Proceedings, OpenGrey, Lenus, RIAN and Grey Literature Report (U.S. context).
The key terms that will inform the development of strategies for each database are derived from MEDLINE and will be revised and combined with free text terms before the full search is conducted in the relevant databases.
Study selection
The results of the search will be collated and uploaded to EndNote X7 (Clarivate Analytics, PA, USA). All duplicate studies will be removed. Titles and abstracts will then be screened by two independent reviewers for assessment against the inclusion criteria for the review. Potentially relevant studies will be retrieved in full and their citation details imported into the JBI System for the Unified Management, Assessment and Review of Information (JBI SUMARI) (Joanna Briggs Institute, Adelaide, Australia). The full text of selected citations will be assessed in detail against the inclusion criteria by two independent reviewers. Reasons for exclusion of full-text studies that do not meet the inclusion criteria will be recorded and reported in the systematic review. Any disagreements that arise between the reviewers at each stage of the study selection process will be resolved through discussion, or with a third reviewer. The results of the search will be reported in full in the final systematic review and presented in a Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA)26 flow diagram.
Assessment of methodological quality
Qualitative papers selected for retrieval will be assessed by two independent reviewers for methodological quality prior to inclusion in the review. The standardized critical appraisal instrument from the JBI SUMARI will be used.25 Authors of papers will be contacted to request missing or additional data for clarification, where required. Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer.
All studies, regardless of the results of their methodological quality, will undergo data extraction and synthesis (where possible). The critical appraisal results will be reported in narrative form and in a table. Again, any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer.
Data extraction
Qualitative data from papers included in the review will be extracted using the standardized data extraction tool from JBI SUMARI.25 The data extracted will include specific details about the populations, context, culture, geographical location, study methods and the phenomena of interest relevant to the review objective (i.e. the experiences and perceptions of ED nurses regarding people who present with mental health issues in the ED setting). The extracted findings from each paper will be examined for congruency and agreement by the primary and secondary reviewers. If any relevant key data are missing from studies, additional information will be sought from study authors.
Data synthesis
Qualitative research findings will be pooled using JBI SUMARI with the meta-aggregation approach.25,27 This will involve the aggregation or synthesis of findings to generate a set of statements that represent that aggregation, through assembling the findings and categorizing these findings based on similarity in meaning. These categories will then be subjected to a synthesis to produce a single comprehensive set of synthesized findings that can be used as a basis for evidence-based practice. Where textual pooling is not possible, the findings will be presented in narrative form. The findings will be interpreted and compared in accordance with different settings where studies were based.
Assessing confidence in the findings
The final synthesized findings will be graded according to the ConQual approach for establishing confidence in the output of qualitative research synthesis and presented in a Summary of Findings.25,27 The Summary of Findings includes the major elements of the review and details on how the ConQual score is developed. Included in this table are the title, population, phenomena of interest and context for the specific review. Each synthesized finding from the review will then be presented along with the type of research informing it, a score for dependability, credibility and the overall ConQual score.25,27
Appendix I: Search strategy for MEDLINE
Concept 1 AND Concept 2 AND Concept 3 AND Concept 4 AND Limits
Searched on January 16, 2019
References