Emergency Room Health Care Professionals Need Ongoing Education in Caring For the Mental Health Patient: A Literature Review

Introduction

According to a 2015 survey, there were 5.7 million visits to the emergency department related to mental health disorders (NHAMCS, 2015). Some of these patients present in an acute psychosis or other mental state that requires health care professionals (HCPs) to act swiftly and carefully, for the safety of the patient and themselves. There is a lack of formal education provided to those who work in the emergency department and care for this population of patients. The ENA [1] reported that “emergency department caregivers in general do not feel comfortable in providing care for emergency psychiatric patients…and commonly perceived themselves as lacking knowledge, skills and expertise”. This lack of confidence can lead to a deficiency in patient care, including emotional and physical harm in the most acute emergencies for those involved.

The prevalence of mental health patients presenting to the emergency department is not to be overlooked as, according to the Agency of Healthcare Research and Quality, one out of every eight visits is related to mental health [1]. The point of this statistic was addressed by multiple studies that aim to highlight the state of this current situation. To further illustrate the presence of mental health patients in the emergency department, the length of stay is 18-24 hours on average, with restraint use increasing this by 4-6 hours [2]. If the patient needs placement in a psychiatric facility, they can find themselves confined to an exam room for days. Psychiatric beds in treatment facilities have disappeared due to cuts in mental health funding and the closing of psychiatric facilities. The cost associated with this prolonged boarding of mental health patients was estimated to be $2,264 per visit [2]. The availability of facilities to treat these patients presents another obstacle, which further complicates the issue, as patients far outnumber open psychiatric beds for transfer. When mental health patients are forced to wait for an accepting facility, the amount of time they are present in the emergency department subsequently increases. This heightens the risk that restraints will be needed, related to symptom exacerbation and attempt to elope [2]. The high volume of psychiatric patients present in emergency departments across the country, warrants attention to the competence of HCPs to treat and care for these patients.

Feelings of emergency department HCPs towards caring for mental health patients have been researched and documented across a small number of studies seeking to understand their viewpoints. Through this research, unique and comparable findings have been uncovered regarding the presence of these patients in the emergency department. Although minimal in quantity, the existing research shows that HCPs generally do not feel competent to care for these patients, with lack of education seen as a primary factor [1, 2, 3, 4, 5]. Emergency department staff is frequently tasked with handling episodes of aggression and violence, with research showing that these frequently occur in the first hour of patient presentation [3]. Without specialized education to help staff learn to properly handle these situations, feelings of powerlessness and incompetence have emerged [4]. Many of the studies regarding lack of education report that nurses do not feel as though their undergraduate classes properly prepared them, with this trend extending to their current employers and departments [1, 2, 4, 5]. Now, frustrations have emerged as some nurse’s report feeling insufficient to provide these patients with the level of care they deserve and need [5]. One study documented a feeling of being “ill-equipped to triage and manage” the presenting mental health patient. Another study by Jelinek, et al. [7] reports the following concerns of knowledge deficit by emergency department staff: “developing care plans, conducting mental status examinations, assessing risk for self-harm, pharmacological management, and responding effectively to patient aggression”.

How do healthcare providers cope regarding mental health patients,? Research has addressed feelings directed towards patients with mental illness. The study by Beks, et al. [6] reports an empathetic outlook, with one participant stating, “people who are presenting to the hospital with an issue, a presentation that is related to mental health, must be really wanting some help, some support”. Unfortunately, the majority of studies more frequently cited negative stigmas of caregivers to these patients. Medical staff have been found to consider them “less ill”, with Stefan noting “ambivalence…as to whether persons with psychiatric crises belong in the emergency department” [1, 2, 8] made specific mention to this bias, with evidence that these patients can be labeled as difficult, with a corresponding attitude of pessimism and apprehension. The theme of pessimism was found in a report published by the ENA, et al. [1] who noted the emotion of frustration by staff who cared for patients repetitively attempting to self-harm. A combination of these conflicting views were documented by Reed and Fitzgerald, et al. who found feelings of fear and dislike “with a strong desire ‘to do the right thing’ by their patients but lacking resources, skills and knowledge to do so” [8].

It is clear that caring for psychiatric patients incites many emotions among healthcare workers. For some these can be positive, while for others this leads to feelings of frustration, incompetence, and uncertainty as to whether the patient should have presented to the emergency department [1, 6, 8]. Some studies have found that feelings towards mental illness, and the stigmas associated with it, run parallel between healthcare providers and the general public ENA, 2013 [1]. There exists minimal research supporting the need for formal education regarding the care of mental health patients by emergency department HCPs. What do exist are the aforementioned studies that stress caregiver’s feelings of incompetency in caring for this population of patients. The ENA (2013) [1], Plant, et al. [4], Rutledge, et al. [9], and Winokur, et al. [2] all mention that emergency department nurses do not feel as though their nursing education properly equipped them with the skills to care for psychiatric patients. The research conducted by Plant, et al. [4] found that participants felt their lack of education was a barrier to providing care, leading to their struggle at effective communication during assessment and treatment. The ENA [1] targets both nurses and physicians, by including research that expresses “emergency nurses and non-psychiatric physicians commonly perceived themselves as lacking knowledge, skills, and expertise to provide appropriate care and treatment to psychiatric emergency patients”.

It is important to discuss the safety concerns related to caring for mental health patients, to provide further support for education. A study documented the following statistics of units housing mental health patients: “97.4% of nurses are exposed to assaultive or abusive behavior in a given year on non-mental health units, 63.3-83.3% reported physical assault and 80.6-100% reporting verbal assault dependent on the clinical area” [10]. Further evidence from the Emergency Nurses Association Violence Survey showed that 97.1% of the violence encountered by emergency department staff is by patients, with mental health diagnoses being implicated in 43% [1]. The study by Beks, et al. (2018) [6] documented the following participant response when caring for a mental health patient: the patient “was punching out at every one and kicking…so I was keeping my distance”. Many studies have documented feelings of incompetence to deescalate these situations by HCPs, specifically a study by Innes, et al. [5] showed concern by staff to whether they could properly handle physical or verbal aggression. Zicko, et al. [10] assessed staff assault and injury reports in a non-mental health unit and found that patients and staff “were experiencing harm due to a lack of expertise” and “skill, in responding to behavioral emergencies”. The ENA specifically delineates the imperative use of de- escalation techniques in preventing agitation from turning into violence and the need for education of staff as imperative [1].

The studies by Winokur, et al. [2] and Rutledge, et al. [9] used the Behavioral Health Care Competency (BHCC) instrument to allow nurses to rank their perceived competency to care for behavioral health patients. The survey covers the ability to assess, intervene, recommend psychotropic medications, and ability to access adequate resources, with the results showing providers feel only slightly above average in their competencies [2, 9]. Rutledge, et al. [9] surveyed 844 nurses using the BHCC to show they feel incompetent in their ability to implement treatment and de-escalate mental health patients. In the study by Winokur, et al. [2], participants completed a seven hour nursing conference providing focused education on the assessment and management of behavioral health patients in the emergency department. At the end of the conference, the BHCC was administered again and showed a significant increase in feelings towards competencies [2]. In another study by Hall, et al. [11], staff was provided with formal education looking into the impact previous trauma can have on emergency department mental health patients. Through this study, the education helped some shift their outlook on mental health patients and positively impacted their perceived ability to prevent traumatizing these patients [11]. The study conducted by Zicko, et al. [10] provided de- escalation education to staff in a non-mental health unit and subsequently found a measurable increase in staff confidence and decrease in the number of assaults, use of restraints, need for security presence in behavioral emergencies.

The evidence collected in the aforementioned studies, it is shown that education can assist in positively impacting attitudes and improve competency of caring for the mental health patient presenting in the emergency department [2, 9, 10, 11]. While this provides sound data that demonstrates this effect, more research is needed to support this finding. Similar research has been conducted in other countries, but U.S. studies lack in volume and subsequent support of the positive impact of mental health education.

Through a review of the literature it is apparent that emergency departments are caring for a growing number of mental health patients. The thoughts and feelings of HCPs treating these individuals around the United States have not been examined thoroughly, but have been previously mentioned [4]. This area of study could benefit from more research conducted in the United States, as other countries have shown the findings that could lead to positive change. Studies performed in other countries have found that emergency department HCPs have expressed apprehension with the care of psychiatric patients due to lack of education and preparation [4, 8]. It was found that many receive a restricted education regarding mental health in school [2]. One study performed in Australia compared formally trained psychiatric nurses and emergency department nurses during an initial assessment of mental health [4]. The study’s findings allowed researchers to recommend that emergency department nurses receive more training and education in the proper assessment of mental health patients [4]. This study is one of few that specifically assess the areas where lacking education has impacted HCPs. There is a lack of research demonstrating the gap in knowledge and conflicts of caring for mental health emergencies by HCPs in the emergency department [4]. One randomized control trial conducted in Ireland by Treloar and Lewis, did find evidence that education to emergency department nurses regarding their psychiatric patients increased nurse satisfaction, which shows the beneficial nature of conducting these studies [4]. This literature review showed that studies specifically addressing the impact of formal mental health care education for emergency department nurses are seriously lacking, with studies conducted in the United States being even scarcer.

In 2018, it was estimated that out of the 248,000 nurse practitioners in the United States, about 5.9% (14,632) reported practicing in the emergency department setting. American Academy of Emergency Nurse Practitioners [12], for those that practice in this setting, the high volumes of mental health patients that present to the emergency department need specialized assessment and treatment. Ensuring that these practitioners have the resources and education to feel competent to care for this population of patients is crucial. As the aforementioned statistics show the emergency department cares for many mental health patients on a regular basis.

Recommendation and Conclusion

Further education is needed for healthcare providers that care for mental health patients. Education has proven, to increase the confidence of healthcare providers when caring for patients. Hospitals need to recognize the imperative nature of providing this education to their staff, as the mental illness epidemic needs emergency

Summary of Literature Review Articles

First Author,

Year Participants/Method Objective Outcomes Recommendations

Descriptive qualitative

To explore the experience of rural nurses in managing acute MH patients in the design n = 13 ED and Beks, et al.

UCC RN staff with primarily > 10 years of [5]

experience ED.

To discuss issues related

to the presence of MH patients in the ED and ENA [1] N/A

outline the ENA’s recommendations to

minimize them.

To investigate the challenges of health care Giandinoto

professionals caring for patients with co-morbid & Edward

Systematic Review

[7]

physical and mental illnesses.

To evaluate the effectiveness of TIC education for ED nursing Exploratory with a mixed methods design n Hall, et al.

= 34 ED RN staff with 1-

staff and describe subsequent clinical practice that was trauma [10]

10 years of ED

experience informed.

Mixed method approach

To identify the issues ED

with surveys and focus clinicians feel they Innes, et groups. n=61 ED staff without MH education encounter when managing ED patients al. [4]

and MH nurses

with mental illness.

departments to be equipped to provide safe and informed patient care.

Perceptions of lacking

confidence, knowledge and skills Targeted MH education and collaboration with in caring for MH patient was across the MH teams is needed.

sample of nurses.

Gaps in the literature regarding care of MH

patients in the ED were identified and problems present in Multiple recommendations for each issue are the care of these presented.

patients were discussed.

Education and support

Challenges related to

in caring for mental fear, negative attitudes, and poor mental health literacy health patients is warranted for health care professionals were discovered.

working in acute settings.

ED nurses were educated on the role trauma plays upon a Further studies regarding the use of TIC in the ED to understand if it patient’s mental health and showed decreases traumatization and the interest in its application in use of restraints.

practice.

Areas found to need

improvement were need for electronic ED staff need education case notes, improvements to the ED environment, MH related to policies and strategies to improve the care and management of patients presenting with a MH problem.

training, implementation of a referral service, and increasing the number of staff.

Abbreviations: BHCC: Behavioral Health Care Competency; ED: Emergency Department; ENA: Emergency Nurses Association; MH: Mental Health; RN: Registered Nurse; TIC: Trauma Informed Care; UCC: Urgent Care Centers.