Review
Emergency department nurses’ care of psychiatric patients: A scoping review

https://doi.org/10.1016/j.ienj.2020.100929Get rights and content

Highlights

  • Emergency department nurses face many challenges when caring for individuals with mental illness.

  • Experiences of stigma and diagnostic overshadowing impact emergency department nurses’ delivery of care to individuals with mental illness.

  • Lack of knowledge and confidence have been found to impede emergency department nurses’ care of individuals with mental illness.

  • The general emergency department environment is not conducive to providing therapeutic and quality care to individuals with mental illness.

Abstract

The emergency department (ED) is a difficult place for psychiatric patients. However, individuals with mental illness often use the Emergency Department as a primary source of healthcare. This study was conducted to identify and examine published literature related to ED nurses’ care of individuals with mental illness and to identify associated research gaps. A scoping review within the Arksey and O’Malley [11] framework was undertaken to answer, “what factors influence ED nurses’ care of individuals with mental illness?” Sixteen studies met the inclusion criteria. The PRISMA method [16] was used to illustrate the flow of studies. The review resulted in three main themes influencing ED nurses’ care for psychiatric patients. These were concerns related to environment; beliefs and perceptions; and knowledge and confidence. The results are described and framed within Biddle's role theory [33], and the gaps in the literature related to research and recommendations for specific investigations are presented.

Introduction

Emergency department (ED) nurses are well-trained to care for individuals presenting with acute physical complaints and emergencies; However, they lack training and confidence in caring for psychiatric patients [1]. Consequently, individuals presenting to the emergency department with mental illness receive care that is traditionally based on a medical model which also holds a different belief of recovery [2]. Due to the healthcare disparities, poor health outcomes, and high ED utilization, ED nurses have a significant role in effecting change. Therefore, it is critical to understand the factors that influence the ED nurses’ care of psychiatric patients.

In comparison to the general population, individuals with mental illness die on average twenty-five years sooner from treatable medical conditions [3]. The mortality rate is higher among mentally ill patients with medical comorbidities when compared to those without medical comorbidities [4]. Serious mental illness costs America nearly $193.2 billion in lost earnings per year [5]. The Agency for Healthcare Research and Quality [AHRQ] [6] reported that one in eight patients present to the emergency departments because of mental health and substance abuse complaints; this is nearly 12 million visits per year. There has been a 55% increase of individuals visiting the ED with mental illness since 2008 and an increase of 415% of patients presenting to the ED with suicidal ideation, often attributed to limited care options [6]. Despite these statistics, emergency department nurses report feeling unprepared to identify and meet the needs of individuals presenting to the ED with mental illness [7], [8], [9]. The statistics suggest that individuals with mental illness experience healthcare disparities, and have limited access to resources and care options [6], [10].

Adequate care for individuals with mental illness is dependent on competent providers as well as adequate healthcare systems. Nurses, as the largest group of healthcare professionals, are at the frontline and the most impacted by the surge of patients seeking care for mental illness in the ED. The nursing care of individuals with mental illness in the ED is complex.

A scoping review is undertaken to contextualize knowledge on the nursing care of psychiatric patients in the ED, determine the current understanding, and identify gaps in the literature. A scoping review is a study that allows for the mapping of key concepts and relevant literature in a field of interest [11]. The purpose of this review is to 1) determine what is known about the nursing care of psychiatric patients in the ED and 2) discover the factors that impact the quality of nursing care of psychiatric patients in the ED. This is significant because an understanding of the barriers that ED nurses face in caring for psychiatric patients can enhance the experience and quality of care provided which will lead to better patient outcomes, decreased recidivism, and decreased mortality. Hospital administrators could allocate efforts to design training and competencies tailored to the care of individuals with mental illness in the ED setting. By doing so, ED nurses will be better equipped to recognize their potential biases, and provide safe, quality, respectful and dignified care to psychiatric patients. Lastly, findings from this review can also inform policy makers to create appropriate resources and assistance for individuals with mental illness.

Section snippets

Methodology

A scoping methodology was used to explore the breadth of literature on ED nurses’ care of psychiatric patients. A scoping review differs from a systematic review in that a scoping review allows for the mapping of relevant literature in a field of interest [11]. Scoping studies “aim to map rapidly the key concepts underpinning a research area and the main sources and types of evidence available, and can be undertaken as stand-alone projects in their own right, especially where an area is complex

Results

The Table of Evidence Summarizing the Articles Reviewed for ED Nurses Care for Psychiatric Patients appears in Table 1. This scoping review includes sixteen studies (see Table 1). The majority of the studies were qualitative (n = 10), including dissertations (n = 2) as part of the grey literature; quantitative studies (n = 3), and mixed-method studies (n = 3). The studies were mostly international originating from Australia (n = 8); U.S. (n = 5); Canada (n = 2); and Brazil (n = 1). All the

Discussion

This scoping review revealed the complexities of the nursing care of psychiatric patients in the ED framed within the role theory [33]. According to Biddle [33], human beings behave in ways that are predictable based on their social identity and position. The literature reviewed confirmed that in many instances the ED nurses’ behaviors were predictable when caring for psychiatric patients as these were repeating themes. Nurses expressed fear, frustration, lack of knowledge and confidence when

Implications and recommendations

Based on this review of the limited number of published research studies, it is not possible to develop practice recommendations. The majority of the studies in this review were undertaken in international EDs which may have different culture, workflow and beliefs than those in the U.S. Many of the studies were also qualitative in methodology and used focus groups for data collection. Therefore, future qualitative research studies are warranted to explore the experiences and process of ED

Scoping review limitations

Having a one-person reviewer was a limitation of this review. More than half of the studies occurred outside of the US (n = 11). This is a limitation because of the variations in culture, processes, and environments across international settings.

Conclusion

This scoping review synthesized and summarized the existing literature on the nursing care of psychiatric patients in the ED framed within Biddle’s [33] role theory. ED nurses’ care of psychiatric patients is an important and complicated topic. Understanding the factors that impact the care is essential as it will provide greater insight for the basis of the ED nurses’ role and behaviors. Additionally, findings for this review can be used to design and implement meaningful educational resources

Declaration of Competing Interest

The author declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Acknowledgement

The author wishes to acknowledge Jane H. White, PhD, PMH-CNS, BC, FAAN, Vera E. Bender Professor of Nursing, Adelphi University College of Nursing and Public Health for her invaluable support, mentoring, and editing of multiple iterations of this article.

Ethical statement

The author has met all ethical standards related to the research and writing of this manuscript.

Funding Source

The author denies receiving any financial support for this manuscript

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