Keywords

Emergency department, experience, mental health, nurse, perception

 

Authors

  1. Quirke, Mary B.

ABSTRACT

Objective: The objective of this review is to identify, appraise and synthesize available evidence related to the experiences and perceptions of emergency department (ED) nurses regarding people with any mental health issue who present at the ED.

 

Introduction: The ED is often the first point of contact for patients with a mental health issue, due to a shortage of available mental health services. Nursing staff in the ED are involved in key clinical decision making and hands-on care for these patients, despite a lack of mental health specialist training. In order to improve patient outcomes in the ED setting, it is necessary to have a thorough understanding of how ED nurses' experiences with this population affect their clinical decision making.

 

Inclusion criteria: This review will consider studies that include ED nurses, with or without mental health specialist training, working in urban and rural EDs in healthcare settings worldwide. Qualitative studies that explore the experiences and perceptions of ED nurses regarding people who present with mental health issues in the ED setting will be considered. Studies published in English will be considered, with no date limitations.

 

Methods: CINAHL complete, MEDLINE, PsycINFO, Embase, Scopus, Web of Science and Google Scholar will be searched, along with several sources of gray literature. Retrieval of full-text studies, assessment of methodological quality and data extraction will be performed independently by two reviewers. Findings will be pooled using meta-aggregation, and a ConQual Summary of Findings will be presented.

 

Article Content

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

 

1. Mahajan P, Alpern ER, Grupp-Phelan J, Chamberlain J, Dong L, Holubkov R, et al. Epidemiology of psychiatric-related visits to emergency departments in a multicenter collaborative research pediatric network. Pediatr Emerg Care 2009; 25 (11):715-720. [Context Link]

 

2. Centers for Disease Control and Prevention. Emergency department visits by patients with mental health disorders - North Carolina, 2008-2010. MMWR Morb Mortal Wkly Rep 2013; 62 (23):469-472. [Context Link]

 

3. Owens PL, Stocks C. Mental health and substance abuse related emergency department visits among adults in 2007. HCUP Statistical brief #92 [Internet]. Rockville MD: Agency for Healthcare Research and Quality; 2010 [cited October 11 2018]. Available from: https://www.hcup-us.ahrq.gov/reports/statbriefs/sb92.pdf[Context Link]

 

4. Hamilton S, Pinfold V, Cotney J, Couperthwaite L, Matthews J, Barret K, et al. Qualitative analysis of mental health service users' reported experiences of discrimination. Acta Psychiatr Scand 2016; 134 (Suppl 446):14-22. [Context Link]

 

5. Mapelli E, Black T, Doan Q. Trends in pediatric emergency department utilization for mental health-related visits. J Pediatr 2015; 167 (4):905-910. [Context Link]

 

6. National Health Service NHS Digital, Hospital Accident and Emergency Activity, 2015-16 [Internet]. 2017 [cited November 24 2018]. Available from: https://digital.nhs.uk/data-and-information/publications/statistical/hospital-ac[Context Link]

 

7. Newton AS, Hamm MP, Bethell J, Rhodes AE, Bryan CJ, Tjosvold L, et al. Pediatric suicide-related presentations: A systematic review of mental health care in the emergency department. Ann Emerg Med 2010; 56 (6): 649-59.e642. [Context Link]

 

8. Marynowski-Traczyk D, Broadbent M. What are the experiences of Emergency Department nurses in caring for clients with a mental illness in the Emergency Department? Australas Emerg Nurs J 2011; 14 (3):172-179. [Context Link]

 

9. Health Service Executive. National clinical programme for the assessment and management of patients presenting to emergency departments following self-harm: A report by the National Clinical Programme for Mental Health Clinical Programme, HSE Clinical Strategy and Programmes 210 Division [Internet]; 2016 [cited October 4 2018]. Available from: https://www.hse.ie/eng/services/publications/clinical-strategy-and-programmes/na[Context Link]

 

10. Kerrison SA, Chapman R. What general emergency nurses want to know about mental health patients presenting to their emergency department. Accid Emerg Nurs 2007; 15 (1):48-55. [Context Link]

 

11. Van Nieuwenhuizen A, Henderson C, Kassam A, Graham T, Murray J, Howard LM, et al. Emergency department staff views and experiences on diagnostic overshadowing related to people with mental illness. Epidemiol Psychiatr Sci 2013; 22 (3):255-262. [Context Link]

 

12. Innes K, Morphet J, O'Brien AP, Munro I. Caring for the mental illness patient in emergency departments - an exploration of the issues from a healthcare provider perspective. J Clin Nurs 2014; 23 (13-14):2003-2011. [Context Link]

 

13. Clarke D, Usick R, Sanderson A, Giles-Smith L, Baker J. Emergency department staff attitudes towards mental health consumers: A literature review and thematic content analysis. Int J Ment Health Nurs 2014; 23 (3):273-284. [Context Link]

 

14. Ross CA, Goldner EM. Stigma, negative attitudes and discrimination towards mental illness within the nursing profession: a review of the literature. J Psychiatr Ment Health Nurs 2009; 16 (6):558-567. [Context Link]

 

15. Schneider A, Weigl M. Associations between psychosocial work factors and provider mental well-being in emergency departments: A systematic review. PLoS One 2018; 13:e0197375. [Context Link]

 

16. Jelinek GA, Weiland TJ, Mackinlay C, Gerdtz M, Hill N. Knowledge and confidence of Australian emergency department clinicians in managing patients with mental health-related presentations: Findings from a national qualitative study. Int J Emer Med 2013; 6 (1):2. [Context Link]

 

17. Plant LD, White JH. Emergency room psychiatric services: A qualitative study of nurses' experiences. Issues Ment Health Nurs 2013; 34 (4):240-248. [Context Link]

 

18. New South Wales Ministry of Health. New South Wales Ministry of Health Mental Health and Drug and Alcohol Office, Mental Health for Emergency Departments - A Reference Guide [Internet]; 2015 [cited October 14 2018]. Available from: https://www.health.nsw.gov.au/mentalhealth/resources/Pages/mental-health-ed-guid[Context Link]

 

19. US Emergency Nurses Association. Safe practice safe care. White Paper on the care of the psychiatric patient in the emergency department [Internet]; 2013 [cited September 11 2018]. Available from: https://www.ena.org/docs/default-source/resource-library/practice-resources/whit[Context Link]

 

20. Healthcare Quality Improvement Partnership. National Confidential Enquiry Into Patient Outcome And Death [Internet]. London: National Health Service; 2018 [cited October 25 2018]. Available from: https://www.ncepod.org.uk/CommonThemes.pdf[Context Link]

 

21. Coristine RW, Hartford K, Vingilis E, White D. Mental health triage in the ER: A qualitative study. J Eval Clin Pract 2007; 13 (2):303-309. [Context Link]

 

22. Kidd T, Kenny A, Meehan-Andrews T. The experience of general nurses in rural Australian emergency departments. Nurse Educ Pract 2012; 12 (1):11-15. [Context Link]

 

23. Cleaver K. Attitudes of emergency care staff towards young people who self-harm: a scoping review. Int Emerg Nurs 2014; 22 (1):52-61. [Context Link]

 

24. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th edition.Washington, DC: American Psychiatric Association; 2013. [Context Link]

 

25. Lockwood C, Porritt K, Munn Z, Rittenmeyer L, Salmond S, Bjerrum M, et al. Chapter 2: Systematic reviews of qualitative evidence. In: Aromataris E, Munn Z (Editors). Joanna Briggs Institute Reviewer's Manual [Internet]. Adelaide: Joanna Briggs Institute; 2017 [cited October 10 2018]. Available from: https://reviewersmanual.joannabriggs.org/. [Context Link]

 

26. Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med 2009; 6 (7):e1000097. [Context Link]

 

27. Munn Z, Porritt K, Lockwood C, Aromataris E, Pearson A. Establishing confidence in the output of qualitative research synthesis: the ConQual approach. BMC Med Res Methodol 2014; 14:108. [Context Link]