Care for people with psychiatric comorbidity in a general emergency unit: vision of the nurses

Abstract

OBJECTIVE

To analyze the difficulties encountered by nurses when providing care to people with psychiatric comorbidity in the general emergency unit and their suggestions for improving the care of these patients.

METHOD

This is a qualitative, descriptive, and exploratory study conducted with twelve nurses at a general hospital in southern Brazil, in 2016. Information was collected during an interview and the results were evaluated using content analysis.

RESULTS

Data interpretation led to two categories: Difficulties of nurses when providing care to people with psychiatric comorbidity and Nurses' suggestions to improve care for people with psychiatric comorbidity. The first category is related to the physical structure and material resources of the service, overcrowding, and lack of preparation of the team and professionals who provide psychiatric consultations. In the second category, the workers suggested a care flow chart, psychiatric consultations, and team training.

CONCLUSIONS

We must transcend the fragmentation of care from the education years of health professionals, emphasize the need for training, and make greater investments in health education.

KEYWORDS:
Nursing; Mental health; Emergency service; hospital

Resumo

OBJETIVO

Analisar dificuldades encontradas pelos enfermeiros no cuidado à pessoa com comorbidade psiquiátrica em uma emergência geral e suas sugestões para melhoria do cuidado à estas neste serviço.

MÉTODO

Estudo qualitativo, descritivo e exploratório, realizado com doze enfermeiros em hospital geral do sul do Brasil em 2016. Para a coleta de informações utilizou-se entrevista e os resultados foram avaliados por Análise de Conteúdo.

RESULTADOS

Emergiram duas categorias: Dificuldades encontradas pelos enfermeiros no cuidado à pessoa com comorbidade psiquiátrica e Sugestões dos enfermeiros para qualificar o cuidado à pessoa com comorbidade psiquiátrica. A primeira relacionada à estrutura física e recursos materiais; superlotação; falta de preparo da equipe e de consultoria psiquiátrica e a segunda indicou fluxograma de atendimento; consultoria psiquiátrica e capacitação para a equipe.

CONCLUSÕES

Deve-se transcender a fragmentação do cuidado desde a formação dos profissionais de saúde, trazendo a necessidade de capacitações e de maior investimento na formação acadêmica.

PALAVRAS-CHAVE:
Enfermagem; Saúde mental; Serviço hospitalar de emergência

Resumen

OBJETIVO

Analizar dificultades encontradas por los enfermeros en el cuidado a la persona con comorbilidad psiquiátrica en una emergencia general y sus sugerencias para mejorar el cuidado a éstas en este servicio.

MÉTODO

Estudio cualitativo, descriptivo y exploratorio, realizado con doce enfermeros en hospital general del sur de Brasil en 2016. Para la recolección de informaciones se utilizó entrevista y los resultados fueron evaluados por Análisis de Contenido.

RESULTADOS

Emergieron dos categorías: Dificultades encontradas por los enfermeros en el cuidado a la persona con comorbilidad psiquiátrica y Sugerencias de los enfermeros para calificar el cuidado a la persona con comorbilidad psiquiátrica. La primera relacionada con la estructura física y los recursos materiales; hacinamiento; falta de preparación del equipo y de consultoría psiquiátrica y la segunda indicó diagrama de atención; consultoría psiquiátrica y capacitación para el equipo.

CONCLUSIONES

Se debe trascender la fragmentación del cuidado desde la formación de los profesionales de salud, trayendo la necesidad de capacitaciones y de mayor inversión en la formación académica.

PALABRAS CLAVES:
Enfermería; Salud mental; Servicio de urgencia en hospital

INTRODUCTION

Emergency services are the point of access to health care. These services are available to people with clinical or surgical problems with the aim of reducing morbidity and mortality and disabling sequelae. The overall population seeks these services as an alternative to conventional health care since they believe the emergency unit has the resources they need, such as consultations, medication, nursing procedures, laboratory tests, and admissions, to solve their health problems more rapidly¹.

The open-door nature of this service creates an easily accessible solution for people that want to solve their health problems. A significant number of people with psychiatric comorbidities suffers from undiagnosed somatic diseases that may be related to etiology or to the exacerbation of a mental disorder. About 5% of emergency calls to general hospitals are from patients with behavioral alterations, and part of these alterations are related to psychomotor agitation and aggressive behavior².

People with psychiatric comorbidities also seek emergency services for depressive symptoms, attempt suicide or suicidal ideation, and other biological, clinical, surgical, and/or obstetric needs. It is not uncommon for these people to have other potentially compromising issues that are important to consider, such as dependence on alcohol and other drugs and physical and social diseases³.

Moreover, they have difficulties accessing out-of-hospital services due to financial restrictions and geographical distance, in addition to the resistance of other services in assisting these people, especially in primary care¹. Such a situation resembles a study conducted in Bogotá that highlighted the inability of the service to absorb the demand of psychiatric patients⁴.

In this context, the nursing staff of the emergency units in general hospitals must face a series of challenges when providing care for users with psychiatric comorbidities, such as having to manage possible aggressiveness since the admission of violent patients is allowed, verbal aggression, extreme agitation, delusion, and episodes of acute psychosis and mental confusion⁵.

The literature shows that difficulties managing people with psychiatric comorbidity are common even in specific sectors or services for this population⁵. Therefore, the care provided by health teams in non-specialized units should be considered from the perception of the nurses responsible for such care.

The nurses who work at these services must combine their theoretical foundation with leadership, work, judgment, initiative, teaching ability, maturity, and emotional stability. The large flow of users, the dynamism of the work routine and the essential nature of the care nurses provide means their actions must be effective and efficient. Nursing care is fundamental in the work process not merely for emergency care, but also for effectively managing and organizing the unit to ensure everyone’s needs are addressed⁶.

Nursing care for people with psychiatric comorbidity demands stronger person-family ties and participative action in treatment for care to be effective⁵. The nursing staff in hospital emergency rooms help users with psychiatric comorbidity administer medication, manage crises, engage in self-care, adopt a healthy diet, identify mental alterations, and, above all, they listen to patients, which supports their discharge from hospital.

In addition, the emergency nursing staff should facilitate the continuity of care for these patients in out-of-hospital services, such as psychosocial care centers and basic health units. Such interaction with the health care system ensures assistance and prevents readmissions.

The lack of studies on nursing care for people with psychiatric comorbidities in emergency services calls for an investigation into the care provided by non-specialized teams from the perspective of the nurses responsible for such care.

Consequently, the research question of this article was "what are the difficulties encountered by nurses who provide care to people with psychiatric comorbidity in a general emergency service and what are their suggestions for improving care?". The aim of this paper is to analyze the difficulties encountered by nurses in the care of people with psychiatric comorbidity in a general emergency service and their suggestions for improving such care.

METHODOLOGY

This is a descriptive and exploratory study with a qualitative approach. The qualitative approach seeks to understand the phenomenon and the context in which it occurs based on a universe of meanings, values, and attitudes observed in human actions and relations, in the hope of gaining a more profound and broader understanding of information⁷.

We interviewed 12 nurses - two in each work shift - from 42 nurses who worked at the ER. These professionals worked in six shifts: morning, afternoon, night 1, night 2, night 3, and 6^th shift (which refers to the weekend shift).

The number of participants was defined using a criterion of saturation based on the knowledge of the researcher, in the field, as he or she sufficiently acquired an understanding of the homogeneity, diversity, and intensity of information, and considered it sufficient for the research⁷.

The inclusion criteria for the study were workers who were formally employed at the general hospital and provided care in the emergency room (ER). The exclusion criterion was workers on medical leave or on vacation.

The study was conducted at a general hospital in the South of Brazil. The hospital in question is a member of the university hospital network of the Ministry of Education and it is academically linked to a federal university. The investigated ER is on the ground floor of the hospital, in an area of 1700 m², and it has five service sectors. Moreover, it has 41 beds registered at the national registry of health establishments. The average number of patients under observation or hospitalized, however, is 150⁸.

Data were collected from July to September 2016. We used a script to conduct a semi-structured interview consisting of open- and closed-ended questions. The closed-ended questions identified the profile of the respondents, such as sex, age, years of nursing education, and years working at the studied service. The open-ended questions were related to the research subject, namely: 1^st: Do you have difficulties providing care for people with psychiatric comorbidity at the ER? If so, which? 2^nd: How would you improve this care?

The interviews, which lasted 20 minutes on average, were conducted in a room booked in advance at the ER in a reverse shift to the shift of the worker being interviewed. The respondents were identified with the letter N for nurse, followed by the first letter of their work shift and the number of the interview. For example, NM1 refers to the first interview of the nurse of the morning shift.

Data were subjected to content analysis, which consists of three stages: 1) Pre-analysis, skim reading of all the material collected in the interview transcripts. 2) Exploration of the material, in which the data are analyzed to separate important excerpts and fragments. These sections were divided into topics. Next, all the units with similar information were clustered to create the units of meaning. The clusters and an analysis of the units of meaning resulted in the analytical categories that guide the study. 3) Treatment of results and interpretation of information, consisting of an interpretive synthesis of the processed results, which are subsequently subjecting to complex or simple interventions to highlight the research data⁷.

Research observed the bioethical prerogatives, according to Resolution No. 466, 12 December 2012, of the National Health Council of the Ministry of Health⁹. This research was approved by the Research Ethics Committee of the Hospital de Clínicas de Porto Alegre, under Opinion No. 1,600,517, in June 2016. The study participants signed two copies of an informed consent statement - one for the respondent and another for the researcher. The interviews were recorded and fully transcribed literally to ensure the veracity of the information. The recordings will be stored by the researchers for five years after which they will be destroyed.

RESULTS AND DISCUSSION

The participants of this study were mostly women (10) and the average age was 39.5 years. Four of the nurses had finished school more than 20 years ago, three had finished school less than 10 years ago, and five had finished school between 10 and 20 years ago. Half the nurses had been working at the ER between five and ten years, which is considered enough time to know the dynamics of the units and its strengths and weaknesses.

In the following sections, we reveal the results according to the perceptions of the participants, divided into the thematic categories. The categories that emerged were: 1) Difficulties encountered by the nurses when providing care to people with psychiatric comorbidity and 2) Nurses’ suggestions to improve the care of people with psychiatric comorbidity.

Difficulties encountered by the nurses when providing care to people with psychiatric comorbidity

Since the psychiatric reform in Brazil, in the early 1970s, care for people with psychiatric comorbidity has been provided by the community and the health care services, mainly in primary care units, outpatient units, and at general hospitals, including the ER. The psychiatric reform is considered a significant achievement in mental health care because it gave institutionalized people a voice and ensured their civil right to receive care at the health services².

The difficulties reported by the nurses when providing care for people with psychiatric comorbidity at the ER were related to the physical structure and material resources, overcrowding, lack of preparation, and lack of psychiatric consultations.

They stated that the inadequate physical structure and setting of the ER, the lack of suitable materials for procedures and for the family to accompany patients with psychiatric comorbidity interfered with the care they provided.

[...] the unit not being prepared to assist these people. We don't have the adequate constraints, they are often put on stretchers, [...] the stretchers are small and you cannot constrain them properly. We do not have accommodations for him (NN1).

It's one thing to write on the chart 'patient with suicide risk, requires isolation and security' but then you find you do not have these conditions [...] (NN3).

It is no use medicating patients in a setting like ours, full of stimuli (NN6).

The family cannot accompany them because there are no chairs for them to sit on. We lack the conditions for the family to stay in there, with a stretcher next to the other, no chairs (NT1).

The care setting must provide a quality therapeutic environment where people feel welcome and protected. Thus, the respondents' concern in relating the quality of care with the suitability of the environment is relevant. They are aware that the care of people with psychiatric comorbidity has been inadequate and precarious in terms of the physical structure of the service.

In addition, structural problems, such as the lack of chairs, prevent the families from accompanying patients in the ER.

Environments that restrict quality care can prevent workers from recognizing the subjectivities of users and inhibit interactions between workers and users. Quality care requires adequate working conditions with sufficient physical and human resources and coherent institutional processes that ensure a safe practice¹⁰.

Moreover, material resources are critical in the care process. It is also important to manage such resources so care is not interrupted due to the insufficient quality or quantity of materials. Thus, workers must have the appropriate materials for the procedures to ensure their actions are carried out satisfactorily, as prescribed and required for people with psychiatric comorbidity¹⁰.

The issue of structure in the statements of the respondents corroborates the findings of an Australian study, in which the emergency unit is considered unsuitable for patients with psychiatric comorbidities because of the overcrowding, noise, and lighting. The same study points out that the highly stimulating atmosphere of these services can trigger changes in behavior and hinder any preventive interventions and even the care itself¹¹.

Therefore, adequate material resources and an appropriate physical structure are essential for the care of people with psychiatric comorbidity. According to the law, emergency sectors must adapt to serve this population and ensure they receive care in a setting that substitutes the psychiatric hospital, which is a right of people with psychiatric comorbidity.

Overcrowding at the ER was considered a major challenge in the care of the person with psychiatric comorbidity. Essentially, the team believed that overcrowding prevented them from providing appropriate care to these patients and that this care was treated as secondary in relation to other patients and pathologies.

It’s the overcrowding, it’s not being able to manage the patient. [...] They end up with many others with many other comorbidities, so, in the end, they are just another patient [...]. Patients with mental illness are secondary. They are sidelined a bit (NN5).

The greatest difficulty is that they are in the middle of everyone else. You can't stop to stimulate these patients, give them the attention they need (NN6).

If we can't get close to the patient, I think that is a challenge. The psychiatric patients are sort of pushed aside [...] (NM1).

Overcrowding in emergency units and the shortage of beds to meet the demands and needs of users compromise the quality of care. Studies associate overcrowding in health care services with increased costs, reduced efficiency and quality of care, and a greater incidence of adverse effects and mortality, resulting in poor performance¹².

Thus, overcrowding in the emergency units is also an international concern associated with increased mortality rates and poor quality of care. In addition, the demand for emergency services increased by 32% in the United States from 1999 to 2009, and the demand is even greater for patients with more critical health conditions¹³.

In this scenario, the impaired quality of care is stressed by the respondents when they perceive that people with psychiatric comorbidity are not given the same care as others with other clinical diseases. In addition, the excessive demand and overcrowding may interfere with the work process and cause tension and conflicts between the team, the users, and their families.

Therefore, we understand that overcrowding in the emergency service affects the care provided to people with psychiatric comorbidity and to the population in general. To prevent overcrowding, the emergency services require greater public investments and territorial services, such as primary care and psychosocial support centers, require reinforcement since they are responsible for managing crises and can relieve the burden of the ER.

According to the respondents, the difficulties they encounter when providing care for people with psychiatric comorbidity are strongly related to the lack of specific knowledge in mental health. They mention little or no preparation in this area and their consequent inability to provide quality care to this population.

I think it's lack of preparation actually, of the entire team, because they have never worked with this type of patient, they haven´t the slightest idea of what to do (NT2).

We aren’t prepared for that. We have never been trained to deal with psychiatric patients [...]. The team is not prepared [...]. No one knows how to act with psychiatric patients. It's a total lack of preparation (NN6).

Professional training for people with psychiatric comorbidity is crucial to good care; however, when care is provided in the emergency services of general hospitals, it becomes a different and unusual experience for professionals. In these services, people with psychiatric comorbidity who seek care at a non-specialized unit will mostly be assisted by workers with no expertise or experience in mental health¹⁴.

In addition, some of the nurses we interviewed believe that their difficulties involved more than a lack of training and stated their lack of personal preparation because of previous bad experiences with this population. Such unpreparedness generates insecurity in the workers and they do not always feel capable of providing quality care to these patients.

Unpreparedness can also result from a lack of opportunities to deal with people with psychiatric comorbidities¹⁴. The unpreparedness reported by some respondents was associated with little or no previous experience assisting people with psychiatric comorbidities.

Furthermore, in this context, it is also important to rethink professional training. In Brazil, undergraduate nursing courses include disciplines and classroom hours for the study of mental health given the complexity involved¹⁵. Since it is during undergraduate studies that the perception and practices of future professionals are formed, disciplines on mental health should be better explored and enable students to experience care for individuals with mental suffering.

Another obstacle mentioned by the respondents is the lack of support of a specialized mental health team, especially in times of crisis with a patient in the ER.

We don't have adequate support, a psychiatric evaluation from the units (NN1).

Psychiatry does not come down to assess patients in the ER (NN4).

The hospital's psychiatric team does not take over, it does not come here. The clinic pushes them to psychiatry, psychiatry does not take over. So much so, that psychiatry does not even bother to come and look at the patient, they only come occasionally; they don´t come (NN6).

Including psychiatric consultations in the ER could help the health team acquire more information, education, and training in mental health and enhance the quality of care provided to these patients. The psychiatric consultation work establishes an interdisciplinary approach that leads to effective and qualified responses to the needs of patients and to the training requirements of the health team since all care is provided by the team itself¹⁶.

In the statements, we noticed that the consultation service in the studied ER is rarely used, leading the respondents to believe psychiatric evaluations are not available to patients. Consequently, the clinical team is forced to assess, manage, and treat people with psychiatric comorbidity, which generates discomfort and insecurity among the workers. It is, therefore, necessary to coordinate the work of the ER team and the psychiatric consultation team to ensure people with psychiatric comorbidity receive qualified care.

In the studied ER, the team has a psychiatric consultancy unit but the lack of coordination with the health team has fragmented the care. This fragmentation prevents the patients from getting the qualified care they need and causes discontent among the workers and possible work-related stress.

In fact, we perceive the importance of psychiatric consultations in the ER and the need to invest in dialogue, case discussions, and team meetings to address this topic.

Nurses’ suggestions to improve the care of people with psychiatric comorbidity

Simply pointing out difficulties is not enough to solve these difficulties if we do not propose suggestions for improvement. Based on the perceptions of the nurses, this category presents their suggestions to improve the care they provide to people with psychiatric comorbidity in the emergency service. Three important elements emerged in this category: service flowchart, psychiatric consultation, and team training.

In general, the respondents believe there should be a service flow for people with psychiatric comorbidity in the ER to ensure they are referred to the health system or admitted to hospital Furthermore, they mention the need to follow a specific care protocol for these patients.

We need a service flowchart for these users. I think it should have a flowchart that gives priority to hospitalizing these patients (NM1).

We need a different service flow for them. [...] a specific flow for them in the psychiatry department with special beds for emergencies. [...] We have to improve the flow to remove these patients from the ER. Try to give these patients a destination as soon as possible (NM2).

If we could follow a protocol, I think it would be better. [...] Continue with the protocol, align it better, and guide the teams, talk about it in meetings, I don´t know exactly how; put the routines up on the board. The patient should be referred according to the routine of the protocol (NT1).

The flowchart outlines the path of decisions from the moment users access the service. Protocols function as a "step-by-step" guide for professionals in decision making and they serve as update tools in care to reduce inappropriate variations in the clinical practice¹⁷.

The ER in our study has a care protocol for people with psychiatric comorbidity since 2014, but it is mostly unknown and rarely used by the workers. This protocol indicates that these patients should be classified as orange according to the Manchester triage system. Once classified, the health team must investigate the patient’s complaints and, in case of a psychiatric emergency, refer the patient to a local health unit. As shown in the statement of NT1, use of the protocol would improve the work process and, consequently, the quality of care for people with psychiatric comorbidity.

The existence of a service protocol can improve care, provided it is accompanied with training that helps the nurses understand people with psychiatric comorbidity and their subjectivity¹⁷. The statements of the respondents reveal that the use of a flowchart and a service protocol for people with psychiatric comorbidity could benefit care in the ER both when they arrive and when they leave the unit. Moreover, a service protocol and a standard flow in the ER can unify care and help the workers feel more confident in their actions.

In contrast, in light of the psychiatric reform, the emergency service should meet the mental health demands and address the clinical issues of people with psychiatric comorbidities. This requirement, however, is not being observed when the workers suggest a service flow that removes the patients from the ER.

Corroborating the difficulties arising from the lack of a specialized mental health team at the ER, the respondents believe an effective consultation service would support and expedite the treatment of people with psychiatric comorbidity.

I think they should receive very early assessments from psychiatry, start with the medication. [...] The psychiatric evaluation would have to be more effective [...]. Even in nursing, when it calls psychiatry, we could also call psychiatric nursing so it can analyze these risks (NM1).

I think firstly they should be seen by a physician, check the proper treatment, and then a psychiatrist. I think they should see the patient together so treatment is more effective (NS1).

As a suggestion, in addition to the psychiatric evaluation, the respondents included psychiatric nursing consultation as a care tool. Nursing consultations are a strategy that is used to share care with other nurses and ensure they participate in various practice scenarios. It is also an institutional tool used to promote cooperation when nurses meet the care demands of inpatients¹⁸.

The hospital in our study has a psychiatric nursing advisory team that creates strategies to strengthen the relationship between the nursing teams of the inpatient units and patients with psychiatric comorbidities. However, this service is mostly unknown and rarely used in the hospital. The fact that the workers are not using the service significantly reduces the quality of care for people with psychiatric comorbidity in the ER.

The support of a specialized team and the inclusion of early psychiatric evaluations could extend the possibilities of easy access and ensure the early diagnosis of problems and appropriate and immediate interventions, as well as create a non-stigmatizing environment and promote continuing education¹⁶.

Training, continuing education, and spaces for team discussions with the ER team, psychiatric consultants, and other sectors must be strengthened. These benefits would allow more comprehensive and all-inclusive care in mental health, according to the psychosocial care model established by the psychiatric reform.

In addition, the interviewed nurses strongly suggested the hospital provide training for the ER team since one of the main difficulties they encounter when providing care for people with psychiatric comorbidity is lack of preparation. They also believe that updated information and training can qualify care for these individuals.

They can offer courses; we manage to clarify queries on the spot, but it is lost afterward, so if we had something continuous [...] (NT2).

I think we should get specific training to assist that kind of patient [...] to be able to identify, to know what to do, and even see what the outcome will be, what to do when the patient leaves. We could have more knowledge, have some type of exchange (NN4).

The chance to discuss the cases would be very interesting. And not only the medical team but discuss the cases in all the areas, in a multidisciplinary way. I think that discussing the cases is a form of training (NS2).

The forms of training suggested by the respondents include courses, integrated work with the psychiatric team at the hospital, and team meetings to acquire professional skills. Continuing education should not merely focus on disciplinary or professional technical knowledge; it should also include the skill to cope with unforeseen situations¹⁹.

However, in addition to qualifying workers, it should observe the assumptions of Continuing Education in Health Care, which serves as a tool to transform health workers into professionals who have a profound knowledge of their local reality. The collective spaces that enable the exchanging of knowledge, reflection, and assessments outline new models of producing care based on the apprehension of reality; not to adapt to this reality, but to intervene in it²⁰.

Professional training has become crucial to adapt the care models to the psychiatric reform and, consequently, guarantee the inclusion and assistance of people with psychiatric comorbidity in general hospitals.

FINAL CONSIDERATIONS

This paper reveals that the difficulties nurses encounter in the care of people with psychiatric comorbidity at the emergency service include an appropriate physical structure and overcrowding.

Moreover, according to the respondents, the difficulties they encounter in the care of the person with psychiatric comorbidity are strongly related to a lack of expertise in mental health. Another obstacle stated by the respondents is the lack of a team that specializes in mental health, especially to assist the health team during crises.

Regarding suggestions for improving the care of people with psychiatric comorbidity, the participants stressed the need to establish a flow of care for these patients at the ER that gives priority to referrals within the health systems or to hospitalization. In addition, they believe that effective consultations and the presence of a psychiatrist to assess patients would support and expedite treatment. The respondents also included consulting in psychiatric nursing as a care tool. They strongly suggested the institution provide training for the ER team since one of the main difficulties in the care of people with psychiatric comorbidity is the lack of preparation.

Many of the respondents acknowledged that there is room to discuss this topic in the studied location and believed the study enabled them to talk about an often under-addressed subject. Therefore, it is important to transcend the fragmentation of care provided to people with psychiatric comorbidity from the years of health education, especially among nurses, since they lack the knowledge and preparation to provide this care effectively.

This paper contributes to the discussion on the need to invest in nurses’ training for the care of people with psychiatric comorbidity. Health institutions should encourage the pursuit of knowledge and educational institutions must include mental health in emergency units in the syllabus to better qualify future professionals in these areas.

Finally, the limitation of this study is the impossibility of generalizing the results; since this research was based on the qualitative approach, the results are related to the trajectory, experience, and meanings of the participants. In addition, the data from this study can encourage further studies that support the adaptation, adequacy, and qualification of nursing care for people with psychiatric comorbidity in the emergency services of general hospitals, considering this is an area of care for these users.

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Publication Dates

• Publication in this collection
  10 June 2019
• Date of issue
  2019

History

• Received
  26 Apr 2018
• Accepted
  17 Dec 2018