Subjective Experiences of Mental Health Crisis Care in Emergency Departments: A Narrative Review of the Qualitative Literature

Emergency department care experience of suicidal patients: A qualitative analysis of patients' perspectives

INTRODUCTION

Individuals experiencing suicidal ideation or behavior frequently seek assistance at the emergency department (ED), yet the care they receive does not consistently align with their needs. This study explores the ED care experience of suicidal patients from their own perspective and offers recommendations to improve ED care for this population.

METHOD

This qualitative study uses a descriptive interpretative design. Semi-structured interviews were conducted with 7 individuals who sought care in an ED due to suicidal ideation or behavior. Transcripts were analyzed using thematic analysis.

FINDINGS

Participants' experiences were marked by an unsuited physical environment described as uncomfortable, noisy, and depressing. The organization of care was perceived as inadequate as patients complained about limited front-line access to mental health expertise, long waiting times, overworked staff, and inequities between patients with physical injuries and those with mental health concerns. Participants reported feelings of being trapped, left on their own and mistreated during their ED stay. Most found their care experience unhelpful or distressing, leaving them reluctant to reconsult. Specific recommendations based on patients' testimonials and literature are provided to enhance the ED care experience of suicidal patients.

CONCLUSION

This study highlights several areas for improvement of the ED care experience of suicidal patients. Changes in current practices are needed to offer suicidal patients the satisfying care experience they deserve.

I have not come here because I have nothing better to do: The lived experience of presenting to the emergency department for people with a psychosocial disability and an NDIS plan-A qualitative study

Almost 60 000 people have a psychosocial disability (PSD) and a National Disability Insurance Scheme (NDIS) plan. As PSD can be a fluctuating condition, people with a PSD and an NDIS plan, at times, may require crisis care and present to the emergency department (ED). This national study explored the experiences of people with a PSD and an NDIS plan when presenting to the ED. To understand the unique lived experience of people with a PSD and an NDIS plan, semi-structured interviews were conducted with 24 people between March and November 2022 and were analysed thematically. A lived experience advisory group was engaged as part of the research team. Participants were asked about their experiences in the ED including barriers to therapeutic care and what worked well. Participants reported emotional distress caused by receiving a biomedical rather than a person-centred mental health response. A previous mental health history overshadowed diagnostic decisions and most participants interviewed stated they would not choose to return to the ED. Half of the participants spoke of one presentation only where needs were met. Four main themes emerged from the data: (a) Diagnostic overshadowing; (b) Judgement and stigma; (c) Waiting without hope; and (d) If things went well. This study provides evidence of the unique lived experience of people with a PSD and an NDIS plan when presenting to the ED. The results highlight the need for clinicians in the ED to understand the complexity and nuances of supporting people with a PSD. Recommendations for a person-centred care approach are provided. Alternative support options for this group of people need to be explored.

Emergency Physicians' Knowledge, Attitudes, and Practices Related to Psychiatric Emergencies in Makkah's General Hospitals in Saudi Arabia: A Cross-Sectional Study

Purpose

This study aims to assess the knowledge, attitudes, and practices of emergency physicians (EPs) related to psychiatric emergencies (PEs) in Makkah's general hospitals.

Sample and Methods

This study was an observational cross-sectional study using an online survey distributed to 138 EPs in the emergency departments (EDs) of six public hospitals in Makkah City, Saudi Arabia, between March 15 and May 1, 2023. A convenience sample was used for data collection. The questionnaire was developed after related surveys in the literature were reviewed.

Results

59.9% of the physicians were aged 20-30 years. Most (68.8%) worked in hospitals that had psychiatric facilities. Regarding knowledge, only 30% of the emergency doctors were considered knowledgeable: the majority could identify PEs (79.7%), perform mental status examinations (71.0%), distinguish physical and mental symptoms (66.7%), and communicate with psychiatric patients (58.0%). However, only 52.9% could initiate management plans by prescribing psychiatric medication to patients. In relation to attitude, most physicians disagreed with the idea that healthcare practitioners do not need to advocate for psychiatric patients (67.4%), but many (62.3%) assumed that they do not have the responsibility to manage psychiatric patients, and they felt that conducting psychiatric evaluations in public hospitals is challenging because of the busy environment there. As regards practice, mentally ill patients (60.9%) were managed or referred by practices, and 56.5% of the EPs advised these patients upon discharge.

Conclusion

The study showed that EPs have positive attitudes toward psychiatric patients, but their knowledge varied based on age, occupation levels, and years of experience. There were significant knowledge gaps, particularly regarding effective communication with psychiatric patients. Additionally, many EPs manage psychiatric patients without being aware of the psychiatric resources in their hospital. Improving medical school curricula and postgraduate training can enhance care. However, more research in this field is needed.

Mental health care provision in community health centers and hospital emergency department utilization

OBJECTIVES

To examine whether community health centers (CHCs) are effective in offsetting mental health emergency department (ED) visits.

DATA SOURCES AND STUDY SETTING

The HRSA Uniform Data System and the HCUP State ED Databases for Florida patients during 2012-2019.

STUDY DESIGN

We identified CHC-year-specific service areas using patient origin zip codes. We then estimated panel data models for number of ED mental health visits per capita in a CHC's service area. Models measured CHC mental health utilization as number of visits, unique patients, and intensity (visits per patient).

PRINCIPAL FINDINGS

CHC mental health utilization increased approximately 100% during 2012-2019. Increased CHC mental health provision was associated with small reductions in ED mental health utilization. An annual increase of 1000 CHC mental health care visits (5%) was associated with 0.44% fewer ED mental health care visits (p = 0.153), and an increase of 1000 CHC mental health care patients (15%) with 1.9% fewer ED mental health care visits (p = 0.123). An increase of 1 annual mental health visit per patient was associated with 16% fewer ED mental health care visits (p = 0.011).

CONCLUSIONS

Results suggest that mental health provision in CHCs may reduce reliance on hospital EDs, albeit minimally. Policies that promote alignment of services between CHCs and local hospitals may accelerate this effect.

Exploring the lived experience of receiving mental health crisis care at emergency departments, crisis phone lines and crisis care alternatives

BACKGROUND

Mental health crisis care includes emergency departments (EDs), crisis phone lines and crisis alternatives. Currently, there is an overreliance on EDs to provide mental health crisis care, with evidence that responses are often inadequate to meet the needs of people experiencing mental health crises. However, the complexities of how individuals experience crisis care across the varying contexts of EDs, crisis phone lines and crisis alternatives remain underresearched.

METHOD

This study used a hermeneutical phenomenological approach to understand the lived experience of accessing care during a mental health crisis. Thirty-one Australian adults who had accessed crisis services at ED, phone lines and/or crisis alternatives participated in in-depth interviews.

RESULTS

The findings are organised across the temporal narratives of participants' experiences from (1) point of contact, (2) positive and negative care experiences and (3) enduring impacts. Several themes were generated during these phases. The findings demonstrate the interrelated nature of care experiences and enduring impacts. With some exceptions, care received within EDs was harmful, resulting in lasting adverse effects. Responses from crisis phone lines were mixed, with participants appreciating the accessibility of after-hour phone support but finding standardised risk assessments unhelpful. Responses from crisis alternatives to ED were promising, aligning with the need for validation and human connection, but were not always accessible or easy to mobilise during a crisis. Notably, across all settings, positive effects were firmly attributed to the quality of the relationship with specific crisis providers.

CONCLUSION

The findings bring into sharp focus the lived experience of people accessing crisis care and contribute to the shortage of literature on subjective experiences. Providers may better meet the needs of those experiencing mental health crises by understanding the enduring impact of these interactions and the role of human connection beyond a focus on risk assessment, thereby providing opportunities for a joint understanding of risk and meaning-making. Furthermore, understanding the subjective experience of crisis care can guide reforms to ED and develop crisis alternatives to better meet the needs of people in crisis.

PATIENT OR CONSUMER CONTRIBUTION

The first author and the third author are in designated lived experience (Consumer) roles. The first author conducted the interviews and was explicit regarding their lived experience when engaging with participants. Service users were involved as advisors to the study and provided input into the design.

'Everything would have gone a lot better if someone had listened to me': A nationwide study of emergency department contact by people with a psychosocial disability and a National Disability Insurance Scheme plan

Australians with a psychosocial disability (PSD) and a National Disability Insurance Scheme (NDIS) plan may at times require emergency care due to the fluctuating nature of their physical and mental health conditions or when their supports have become insufficient. This nationwide study investigated the experiences of people presenting to an emergency department (ED) who have a PSD and an NDIS plan. The objective was to understand current care and communication practices and to provide recommendations for service integration. Twenty-four interviews were conducted with people who had a PSD and an NDIS plan. Participants were asked semi-structured questions about their experiences when engaging with NDIS processes and when engaging with the ED as an NDIS recipient and how communication practices could be improved between the two services. A qualitative, descriptive thematic analysis approach was used. A lived experience advisory group participated in the research and provided commentary. The findings of this study indicate that the NDIS, as a personalised budget scheme, presents challenges for people with complex PSD and physical needs. ED clinicians appear to be unclear about what the NDIS provides and communication between the two systems is fragmented and inconsistent. The themes identified from the analysed transcripts are: (a) People with PSD experience distress when dealing with the NDIS; (b) There's a blame game between the ED and the NDIS; and (c) Inadequate service integration between the ED and NDIS. Recommendations to assist with service integration include building service capacity, providing overlapping care and bridging the diverse biomedical, psychosocial and disability care services.

Experiences of consumers, carers and clinicians during borderline personality disorder presentations to the emergency department-An integrative review

INTRODUCTION

People with a borderline personality disorder (BPD) diagnosis or symptoms may experience emotional crises which necessitate use of the emergency department (ED). No existing reviews focus specifically on experiences of consumersa , carersb and clinicians in relation to ED presentations by people diagnosed with BPD.

AIM/QUESTION

The aim of this study was to synthesise knowledge on consumer, carer and clinician experiences of BPD in the ED.

METHOD

An integrative review methodology was chosen as it best captures the complexity of varied perspectives and emergent phenomena from diverse literature sources. EMBASE, CINAHL, PsycInfo and Medline were searched for papers published before 16 February 2022.

RESULTS

Nine papers met the inclusion criteria (five qualitative, one quantitative, one mixed methods and two letters to the editor). Key themes were barriers to timely and adequate care, and stigmatising attitudes and practices towards people diagnosed with BPD. Negative attitudes were perceived to perpetuate harmful outcomes and further ED visits.

DISCUSSION

Predominantly negative ED experiences were expressed by clinicians, consumers and carers. Further work is needed in ED models of care and staff education to improve the experience of care for consumers, carers and clinicians alike.

IMPLICATIONS FOR PRACTICE

Opportunities for change will exist through co-designed innovation, education, advocacy and leadership.

The role of the dually certified primary care/psychiatric mental health nurse practitioner in treating high-needs/high-cost patients

ABSTRACT

National nursing organizations have called for nurses to provide leadership in care solutions for high-cost/high-needs vulnerable populations. In response to this call, important modifications are emerging in Doctor of Nursing Practice programs, including an increasing number of nurses pursuing dual certification in primary care and psychiatric mental health or primary care nurse practitioners returning for a postgraduate certificate in psychiatric mental health. This innovative role warrants examination, particularly because it relates to high-needs/high-cost patients such as those with serious mental illness (SMI). This article highlights two aspects of the role of the primary care/psychiatric mental health nurse practitioner (PC/PMHNP): one, to provide a vision of the PC/PMHNP as a unique solution for optimal care of vulnerable patients and two, to demonstrate potential contributions of the PC/PMHNP to the larger health care system. A case exemplar is used to illustrate role contributions of the PC/PMHNP in a high-needs/high-cost patient with SMI and complex co-occurring physical illness. Three capacities of the PC/PMHNP are discussed: depth and breath, expert engagement and rapport building, and full patient-centered care and flexibility. The case exemplar emphasizes the PC/PMHNP value through transitions across care settings and where gaps in service frequently occur. The impact of the PC/PMHNP on improved patient outcomes, patient and provider satisfaction, and cost savings are explored.

Clusters of substance use and mental health variables with emergency room visits in U.S. adults: The 2020 National Survey on Drug Use and Health

BACKGROUND

This study evaluated the prevalence of emergency room (ER) visits, given numerous substance use and mental health variables in the past year.

METHODS

Data from 5206 emergency room visits out of 27,170 adults were extracted from the 2020 National Survey on Drug Use and Health. Oblique principal component cluster analysis was used to classify 39 substance use and mental health variables into disjoint clusters.

RESULTS

In 2020, the overall prevalence of ER visits was 21.9 %. Being female, age above 65 years, with insurance, low income and low education levels, and being African American increased the risk of ER visit. Nine clusters were made out of 39 substance use and mental health variables. Multivariate stepwise logistic regression analysis showed 15 substance use and mental health variables were significantly associated with ER visits including heavy alcohol use past 30 days in cluster 3, nicotine dependence and cigarettes use in cluster 4, major depressive episode, serious psychological distress, and suicidal plans in past year in cluster 5, any psychotherapeutics use in cluster 7, tranquilizers use and lorazepam products use in cluster 8, and any pain reliever, pain reliever misuse, hydrocodone products use, oxycodone products use, tramadol products use, and codeine products use in cluster 9.

CONCLUSIONS

Several substance use and mental health problems, including nicotine dependence, illicit drugs, and serious mental health problems were among the common reasons for ER visits. These findings suggest the effective use of ER as the venue to implement interventions for substance use and mental health.

Help! Caring for People With Mental Health Problems in the Emergency Department: A Qualitative Study

INTRODUCTION

After coronavirus disease 2019, there has been an increase in patients in the emergency department with mental health conditions. They are usually received by professionals who are not specialized in mental health. This study aimed to describe nursing staff's experiences in the emergency department, in the care they provide to people with mental health problems who often feel stigmatized by society and also in health care settings.

METHODS

This is a descriptive qualitative study with a phenomenological approach. The participants were nurses from the Spanish Health Service from the emergency department of the Community of Madrid hospitals. Recruitment was performed by convenience sampling snowball sampling until data satruation was met. Data were collected through semistructured interviews conducted during January and February 2022.

RESULTS

The exhaustive and detailed analysis of the nurses' interviews made it possible to extract 3 main categories-health care, psychiatric patient, and work environment-with 10 subcategories.

DISCUSSION

The main study findings were the need to train emergency nurses to be prepared to care for people who experience mental health concerns including bias education and the need for implementation of standardized protocols. Emergency nurses never doubted their ability to care for people experiencing mental health disorders. Still, they recognized that they needed specialized professionals' support at certain critical moments.

Novice nurses' experiences in provision of mental ill health care within a regional emergency department: A descriptive qualitative study

Emergency departments are often the first point of contact for individuals presenting to healthcare services for assistance and treatment for mental ill health. Emergency departments, particularly those in regional areas, can experience high staff turnover and rely on novice nurses for workforce sustainability. The aim of this paper is to explore the experiences of novice nurses (nurses with <3 years of experience) in providing care to individuals presenting with mental ill health in the emergency department. Semi-structured interviews were conducted with novice nurses (N = 13) in a regional emergency department, using qualitative description as the guiding framework. The following three main themes were identified: (i) confidence in providing quality and safe nursing care, (ii) perceived barriers to providing quality and safe nursing care, and (iii) factors that increase confidence. Our findings indicate that proving safe and appropriate nursing care is affected in novice nurses by factors that lead to a perceived lack of confidence, such as how individuals present to the emergency department (e.g. intoxicated or violent), an inability to conduct conversations to assess accurately and perceived shortfalls in the emergency department environment itself. Future research should examine the curriculum for relevance of undergraduate education regarding acute mental health presentations and develop training strategies that enhance communication with individuals who present to the emergency department with mental ill health.

Getting the pieces to fit: NHS and third sector collaboration to enhance crisis mental health service provision for young people

BACKGROUND

The increase in demand for young people's mental health services has been met by a growth of co-located mental health service provision in the NHS and third sector. This research explores the benefits and challenges of the NHS collaborating with a charity to provide a step-down crisis mental health service for young people in Greater Manchester, and suggests how the collaboration between the NHS and third sector may be improved for future projects.

METHODS

Working from a critical realist paradigm, this qualitative case study utilised thematic analysis of 9 in-depth interviews with operational stakeholders from 3 operational layers, to explore insiders' perspectives of the benefits and challenges of collaboration between the NHS and third sector in the context of the 'Safe Zones' initiative.

RESULTS

Themes relating to perceived benefits of collaboration were: doing things differently, flexibility, a hybrid approach, shared expertise, and shared learning. These were counterbalanced by perceived challenges: getting the pieces to fit, obtaining a shared vision, geography, lack of referrals, and timing. The importance of effective communication (e.g. of shared vision, standard operating procedures, key performance indicators) was noted as central to addressing challenges and reaping benefits.

CONCLUSIONS

NHS and third sector collaboration can yield a range of benefits, some of which can mitigate against the perceived inflexibility and restrictive nature of usual mental health service provision, thereby providing a vehicle for innovation in step-down crisis care for young people.

Effecting change and improving practice in a regional Emergency Department: A Mental Health Nurse Practitioner's perspective

Providing appropriate, timely intervention and care to people who present with mental health issues to an Emergency Department presents unique ongoing challenges, often affecting patient experiences and outcomes. To address such concerns, a Mental Health Liaison Nurse role, led by a Mental Health Nurse Practitioner, was introduced to a regional Emergency Department. This role provided integrated emergency-based mental health clinical practice, with positive findings reported in a recently published multi-site translational research project. With sound quantitative and qualitative evidence detailing the benefits of this role, the experiential perspective from a clinician working in this frontline space further confirms the importance of having access to such a position in leading cultural and systemic change. This discussion article identifies key processes that align current research with the clinical perspective. Such processes recognize the challenges of implementing a new role and moving forward from these to embed consistent clinical practices. The need to build sound internal and external stakeholder partnerships, effect change implementation, and assign recommendations to ensure sustainability of improved practice and processes are highlighted in this paper. This article is, therefore, designed to assist other advanced practice nurses, who may be embarking on a similar journey and want to influence organizational policy and practice.

Working with People Presenting with Symptoms of Borderline Personality Disorder: The Attitudes, Knowledge and Confidence of Mental Health Nurses in Crisis Response Roles in Australia

Many people diagnosed with or presenting with borderline personality disorder (BPD) attend the emergency department (ED) when in crisis, and are often referred to mental health nurses for further assessment, and to arrange appropriate follow-up (MHNs). Little is known about the knowledge, skills, confidence and competence of MHNs working with this group in these specialist roles. This study sought to describe the attitudes of MHNs working in EDs and crisis services towards people who present with symptoms characteristic of BPD and to explore their knowledge of the diagnostic criteria of BPD. A descriptive survey tool comprised of 23 questions was adapted from a previously used survey with clinicians in a mental health service in Australia. Fifty-four nurses who identified as MHNs and were currently employed in EDs or crisis settings completed the survey online. These MHNs were found to hold positive attitudes towards people with BPD including being optimistic about recovery and treatment. The experience and education of MHNs now employed in EDs may have contributed to positive attitudes and self-reported confidence relative to other nurses. Further research ought to focus on how MHNs assist people with a diagnosis of BPD who present in crisis meet immediate needs and facilitate access to effective ongoing care and treatment.

Patient and Provider Perspectives on Emergency Department Care Experiences among People with Mental Health Concerns

Emergency departments (EDs) are an important source of care for people with mental health (MH) concerns. It can be challenging to treat MH in EDs, and there is little research capturing both patient and provider perspectives of these experiences. We sought to summarize the evidence on ED care experiences for people with MH concerns in North America, from both patient and provider perspectives. Medline and EMBASE were searched using PRISMA guidelines to identify primary studies. Two reviewers conducted a qualitative assessment of included papers and inductive thematic analysis to identify common emerging themes from patient and provider perspectives. Seventeen papers were included. Thematic analysis revealed barriers and facilitators to optimal ED care, which were organized into three themes each with sub-themes: (1) interpersonal factors, including communication, patient–staff interactions, and attitudes and behaviours; (2) environmental factors, including accommodations, wait times, and restraint use; and (3) system-level factors, including discharge planning, resources and policies, and knowledge and expertise. People with MH concerns and ED healthcare providers (HCPs) share converging perspectives on improving ED connections with community resources and diverging perspectives on the interplay between system-level and interpersonal factors. Examining both perspectives simultaneously can inform improvements in ED care for people with MH concerns.

More than Suicide: Mortality after Emergency Psychiatric Care and Implications for Practice

BACKGROUND

Emergency departments (EDs) provide vital mental health services. ED patients with behavioral health presentations, particularly suicidal ideation, are at increased risk of death by suicide, medical illness, trauma, or overdose. Causes of death for patients who receive specialty emergency psychiatric services remain undescribed.

OBJECTIVE

We describe the incidence and cause of death after care in a psychiatric emergency service (PES).

METHODS

Mortality data were obtained for all adult patients treated in a safety net ED from April 2016 to June 2020. Causes of death were categorized as medical, external (accidents, overdoses, and homicide), or suicide and compared between PES patients and ED patients who were not treated in the PES. Correlates of mortality were described for PES patients.

RESULTS

We analyzed 164,422 encounters including 6,063 PES visits. Mortality in the 30 days after discharge was 0.3% among PES patients and 0.6% among medical ED patients. At both 30 and 365 days, PES patients were more likely to die by suicide than were medical ED patients, and ED patients were more likely to die by medical causes. Among PES patients who died within 365 days, 46% died by medical causes, 32% by external causes, and 23% by suicide. In multivariable analyses, age was associated with all-cause, medical, and external mortality after a PES visit; opioid and stimulant use disorders were associated with all-cause and external mortality.

CONCLUSIONS

Most patients who die after receiving emergency psychiatric care die by medical and external causes such as accidents, overdose, and homicide. Patients who are older and have opioid or stimulant use disorders are at higher risk of non-suicide mortality. We propose interventions to re-imagine emergency psychiatric care and address non-suicide mortality among psychiatric patients treated in emergency and crisis settings.