Mental Health Emergency Department: Reducing Stress in General A&E

This literature review investigates whether establishing a specific emergency department for individuals experiencing a mental health crisis can alleviate stress within general emergency departments. The study employs a systematic review of existing literature, adhering to ethical considerations and utilizing the PICO framework to formulate the research question. The methodology involves searching databases like PubMed, CINAHL, and PsycINFO for relevant peer-reviewed articles published within the last decade, focusing on studies with observational or focus group designs to capture staff and patient perspectives. The review analyzes themes related to the impact of mental health patients on emergency department stress levels, the experiences of both care users and healthcare professionals, and the potential benefits of specialized mental health EDs. The discussion synthesizes findings from selected articles, critically appraising their relevance and validity using the CASP tool, and ultimately aims to provide evidence-based recommendations for enhancing the quality of care and minimizing stress in emergency department settings.

Would a specific emergency department for those in mental health crisis reduce stress
for the emergency department?

Table of Contents
Introduction.................................................................................................................................................3
Aims/Objectives..........................................................................................................................................4
Ethical considerations..................................................................................................................................4
Method........................................................................................................................................................5
Results.........................................................................................................................................................7
Discussion....................................................................................................................................................7
Key findings of the study.............................................................................................................................9
Conclusions/recommendations.................................................................................................................11
References.................................................................................................................................................13

Introduction
In recent years, Emergency Departments in hospital settings are experiencing a high inflow
of patients. Thus the professionals have to be ready at all the times to address their queries and
concerns. This research study has been carried out with the intention to address the question as to
whether a specific emergency department for those in a mental health crisis can reduce stress for
the emergency department or not (Lacy & Chan, 2018). The quality of service that is delivered
by the Emergency Department staff members is directly linked to the environment in which the
professionals operate. In case they get stressed or burdened because of the work, it has a major
implication on the care users with mental health conditions as well as the care professionals that
are offering the services.
Due to the increase in the work pressure in the Emergency Department of hospitals, the
quality of the healthcare service and experience of the care users gets affected. Any form of help
and support to the professionals can have a constructive impact on the care setting and the
quality of service that is offered to the patients with mental health conditions (McGuire et al.,
2016). A wide range of research studies has been carried out in the past in order to capture how
the experiences of the Emergency Department staff members get affected. These studies have
shed light on how the perception of the quality of care service changes in the minds of the
patients who have some kind of mental illness.
In order to carry out the research prices, secondary sources of data have been used so that a
whole idea can be highlighted in the research study. The perception and views of the care users,
as well as the nurses and staff members working in Emergency Departments, have been
presented and analyzed in the research study. Such an approach has helped to take an unbiased
stand on the research topic and address the research question in the best possible manner. The
main elements that have been captured in the research study include the ethical elements that
have been taken into consideration while carrying out the research process, the aims and
objectives of conducting the study, the method that was used to select relevant research papers
and journal articles for the research process, the results of the research, the analysis and
discussion relating to the key findings of the study and the recommendations (Duffy, Avalos &
Dowling, 2015). All the sections of the research study play a vital role to address the research
question relating to whether a specific emergency department for those in mental health crisis

could reduce the level of stress for the emergency department or not. Based on the data that has
been collected for the research process, suitable recommendations have been presented that
would enhance the quality of the care service and minimize the stress level of the professionals
that function in the Emergency Departments of hospitals (Mangoulia et al., 2015).
Aims/Objectives
The aim of the research is to identify supportive evidence that a separate mental health ED
offering care to people in mental health crisis would benefit nursing staff in a general acute A&E
department. A systematic literature review will be carried out of appropriately linked literature
attempting to identify key evidence that could support or oppose the aforementioned question.
To formulate the research question, the Population, Intervention, Control, and Outcomes (PICO)
method (Aslam and Emmanuel, 2010) was used.
**PICO TABLE HERE**
Ethical considerations
All the ethical elements have been taken into account throughout the research process so
that the outcome will be just, fair and unbiased. In order to conduct the research study on the
sensitive research topic relating to the healthcare setting, all ethical considerations were taken
into account (Carstensen et al., 2017). The secondary data collection process was used which
itself is known as a highly ethical process while conducting a research study. It helped to capture
a comprehensive idea about the entire research topic. Ethical steps were followed while
collecting and analyzing to address the research questions (Research ethics in secondary data:
what issues, 2019). The selected articles and papers that were considered for further analysis
were peer-reviewed and this aspect increased their overall credibility and reliability in this
research study. The critical examination of the data was carried out in an unbiased manner so
that the research outcome would not be affected in any manner. No personal data relating to any
actual care user and care professional was disclosed in the research study so that their privacy
could be respected and safeguarded throughout the research process. The entire literature-based
research was carried out in an ethical and professional manner so that an accurate research
outcome could be arrived at (Research ethics in secondary data: what issues, 2019).

Method
This research is based on conducting a systematic literature review to answer the research
question. The research question is formulated on the basis of the Population, Intervention,
Control and Outcomes (PICO) method (Aslam and Emmanuel, 2010). The inclusion criteria for
the search strategy of this research encompasses the inclusion of the peer reviewed articles
published with the period of last ten years. The articles published in English and those from
Canada and Australia were included for the purpose of this research. The main strength of a
systematic literature review is that it has a rigorous methodology that is used to analyze and
evaluate the current and existing evidences.
The literature review has mainly included the studies that are observational or includes a focus
group. The main purpose of including such study for this research is to understand and analyze
the staff’s and patient’s perspective towards the problem of mental health crisis in emergency
department (Carstensen et al. 2017). The papers were searched on the basis of appropriate
keywords and the title and abstracts of the searched articles were checked for their relevance in
study. The studies that included the data related to the adults above the age of 18 years, were
only included in the paper. Therefore, only the open published papers available with full text
were included for the review. This research excludes the secondary sources, new paper article,
online articles or website.
An extensive search strategy was adopted by the researcher for the search of high-quality
evidences. Therefore, the wide array of nursing and medical databases were used including,
PubMed, CINAHL, and Psychlnfo (ProQuest). The access available to free and subscription only
literature was gained through the University subscription. PubMed has been identified as the
most significant and reliable database that is specifically tailored to provide the mental health
and psychiatric research material. Although, this is an Australian database, yet it provides some
significant research evidences that could be applicable in NHS and UK.
CINHAL is also specifically tailored for the research of nursing specialties and allied healthcare
professions. This database includes around 1,200 journals related to the healthcare and nursing
Psychlnfo helps in providing the various journals and studies related to Psychiatric, which could
be essential in providing some beneficial evidences. The large database of the indexed article are

used, which provide free access to all articles in order to base this research on evidence-based
practice.
Article 2: Emergency department from the mental health client’s perspective. Diana E
Clarke.
Canada
Eight focus groups were held with mental health patients and their families to determine
their satisfaction with care received in regional ED’s.
Themes identified
Waiting in the ED
Attitudes of treatment staff
Diagnostic overshadowing
‘Nowhere else to go’
Family needs
Wish list for ideal services
Sample
27 clients, 7 family members and 5 stakeholders.
Eight focus groups: Five groups of clients, one group of community service providers and
representatives from self-help organisations, one family group, and a mixed group of client
and family members. Client groups were comprised of reported diagnosis of psychotic and
depressive illness, post-traumatic stress disorder, personality disorder and co-occurring
health and substance use disorders. Most reported extensive experience with ED visits at
multiple locations in the region.
Discussion in focus groups facilitated by 3 main questions
1. What was your experience with seeking mental health services in a general hospital
emergency department?
2. What was your experience in being looked after by a psychiatric emergency nurse?
3. What is missing from the range of emergency psychiatric services?
Ethics
Research was funded by a grant from the Grace General Patient Services Foundation,
Winnipeg, Canada.
Ethical approval obtained through The University of Manitoba Faculty of Medicine Ethical
Review Board.

Limitations
 Focused on those who attended ED’s frequently, did not hear from infrequent or one
time users.
 Sample was exclusively urban
 Data appeared biased to negative experiences, whether this is ‘the state of affairs’ or
those who had concerns volunteered is unclear
Qualitative CASP Tool used.
Results
The searches we carried out achieved various results on different data bases, by using the
Boolean logic commands ‘Mental Health Crisis AND Stress AND Accident and Emergency OR
A&E OR Emergency Department’ returned a total of 757 results. On CINAHL we received 69
results, PsycINFO (proquest) came back with 50 results, PubMed we didn’t receive any results
and finally on summon there were 638 results of relevant literature related to our question.
These results were too high for a 3000 word literature review, so by adding the filters shown
below the number of results was reduced to four. Due to ethical considerations throughout our
searches we chose to exclude: paediatric and CAMHS related papers, European based
research and published papers, unreliable sources such as newspapers and other healthcare
related articles that were of a more biased nature. We also chose to exclude papers that had
been funded by a single organisation or corporation as again this could form a bias result and
could lead to the results being effected (however we acknowledged that although some of the
results from certain articles may be biased due to the roots of their research and funding, we felt
it was important to acknowledge that organisations such as NHS, NMC, RCN would have
appropriate and valid points of view.
The search strategy which lead to the final articles for review is summarised in the Preferred
Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) diagram below (Figure
1). A PRISMA diagram is recommended by Liberati et al., (2009) in order to ensure complete
reporting of findings during a systematic review. The PRISMA diagram clearly demonstrates the
exclusion process following the final search in order to obtain the final four articles to be
included in this literature review. The articles selected for review were appraised using the
Critical Appraisal Skills Programme (CASP) tool (appendix 1) in order to assess each article’s
relevance and validity prior to inclusion in the review (Critical Appraisal Skills Programme
[CASP], 2014). Following appraisal, the articles were presented in the matrix (Appendix 2-3) in
order to facilitate a thorough analysis and provide a clear summary of each. All four articles
describe the results of ??quantitative,qualitative, research evaluating whether having a specific
emergency department for those in a mental health crisis could reduce stress on A&E
department and thus defining the benefits for patient care and reduced stress on the A&E staff.
The articles were classified by the method used, leading to the thematic matrix (appendix 4).
Discussion
The data that has been collected relating to the research topic titled ‘Would a specific
emergency department for those in mental health crisis reduce stress for the emergency

department?’ has been critically analyzed and discussed in this section. The selected literature
have been examined and reviewed with the objective to ascertain whether the professionals in the
emergency department need external help in order to minimize their level of stress or not
(Adams, Shakespeare-Finch & Armstrong, 2015). A number of themes have been captured in the
selected research studies namely the limited amount of time that these professionals spend with
the patients, the attitude and stigma, the lack of mental health education for the A&E nurses and
the environment. It has been observed that each of the four studies have some core themes that
impact the professionals operating in the emergency departments.
The article by Donna Marynowski-Traczyk assesses the Australian Emergency
Departments to capture the experience of the nurses in the unit. The main themes that have
emerged from the study include the ‘time’ as a causative factor, environment and the impact of
surroundings and the proper understanding of the patients' journey (Marynowski-Traczyk &
Broadbent, 2011).
Diana E Clarke and Debra Dusome in their article have tried to carry out a thorough study
from the perspective of the mental health patients that are treated in the Emergency Departments.
Some of the key themes that have been identified here include the waiting time in the Emergency
Department, the attitudes of the treatment staff members, diagnostic overshadowing, ‘no where
else to go’, family needs and a wish list for the ideal services (Clarke, Dusome & Hughes, 2007,
p 2).
Kelli Innes and Julia Morphet in their journal article have captured the perspective of the
nurses and the care professionals that are responsible to take care of the mentally ill individuals
in the Emergency Department. The study highlights some of the main barriers that exist in the
healthcare setting and has an adverse implication on mentally ill patients (Innes et al., 2014).
There exist multiple inconsistencies and deficits in the educational preparation of the emergency
department professionals which affects how they manage a patient with mental illness. In
addition to that, there exists an inadequate physical environment which contributes to challenges
in assessing and managing the vulnerable patients (Leon et al., 2017).
Diana Clarke and Rachel Usick have identified four main themes that exist in the
Emergency Department namely consumer perspectives, staff-reported attitude and influencing

factors, the environmental climate in the Emergency Department and the interventions that have
been introduced in order to evaluate the change in the attitude (Clarke et al., 2014).
These four research articles have been referred to and they have helped to arrive at
appropriate data and information relating to the research topic. These pieces of literature when
combined together have presented a holistic picture to address the research questions.
Key findings of the study
Challenged faced by ED staff members
The roles and responsibilities of a nurse that functions in the Emergency Department is not
a cakewalk. The professionals act as the very first point of contact in the mental healthcare
system. They have to be on their toes round the clock so that they can address the needs of the
mentally ill patients, their guardians and others. They have to face this hectic schedule on a daily
basis. Based on the findings by Marynowski-Traczyk, there has been a gradual increase in the
total number of mentally ill patients that enter the Emergency Department on a frequent basis
(Marynowski-Traczyk & Broadbent, 2011). Due to this, time constraint acts as a major challenge
which has an adverse impact on the nurses working the Emergency Departments as well as the
patients who are admitted in the unit. In addition to the time factor, the existing environment in
the department seems to be inappropriate as it does not allow the professionals to offer optimal
care to the patients who have specific care needs. Due to the gaps that exist in the prevalent
Emergency Departments, the nurses find it really difficult to conceptualize the proper role of an
Emergency Department in the patient’s personal journey (Marynowski-Traczyk & Broadbent,
2011). Thus the professionals in ED need additional assistance in the sensitive care setting so
that they can be empowered to effectively function in the cares setting without any kind of stress
or challenge.
The perspective of the clients
The people with psychological challenges and issues go to the General hospital Emergency
Departments with the intention to seek high-quality care and treatment from the experts. But the
existing mental health presentation does not seem apt for them as there exist a number of
loopholes. As per the research study by Clarke and Dusome, in the present times, the
professionals working in the Emergency Departments create various kinds of tensions around the

care of the patients with mental illness (Clarke, Dusome & Hughes, 2007). Due to the poor
quality of care service that is offered by the professionals, the n and professionals that has been
described as ‘traumatizing’, there is the need to extend support and assistance to them so that
their stress level can be reduced and they can deliver quality service to the care users (Kingston
et al., 2015).
The perspective of the ED professionals
In order to comprehend whether the emergency department needs help so that their level of
stress reduces can be reduced or not, it is necessary to get a holistic idea about the topic. Innes
and Morphet have captured the perspective of healthcare professionals about the research topic.
As per the findings, the professionals have themselves identified a number of critical areas that
need to be strengthened so that the issues that they face can be effectively addressed. The
educational preparedness of the professionals seems to be inadequate which makes it challenging
for them to offer quality care service to the mentally ill patients (Innes et al., 2014). In addition
to this there exist environmental obstacles in the physical setting which makes it difficult for the
nurses and the staff members to manage the care needs of the patients. There is the need to
educationally prepare the ED staff members so that they can be empowered to take care of the
care needs of the mentally ill patients. Different kinds of intervention techniques can be
introduced in order to address the existing gaps and issues that are aced by the ED experts and
nurses (Guest, Guest & Martins-de-Souza, 2016).
Poor attitude of the ED staff
As per Diana Clarke, the clients with mental conditions that visit ED do not get treated
well by the professionals. The poor attitude of the professionals has been identified as the main
area that adversely affects the ultimate experience of the care users (Clarke et al., 2014). The
experience of the clients that have been captured here is generally negative due to the bad
attitude of the professionals (Kaakinen et al., 2018). Various factors come into play and impact
the professionals’ attitude such as their age, work experience, and confidence. As per the
findings of the study, suitable intervention techniques can be introduced to alter the negative
attitude of the ED staff in form of intensive education and extending additional support.
Addressing the research questions

There is the need to introduce a specific emergency department for those in mental health
crisis as it could play a vital role to reduce the level of stress for the emergency department. At
present, the professionals feel highly pressurized as many patients with psychological health
conditions come to the Emergency Department on a regular basis (Marynowski-Traczyk &
Broadbent, 2011). Meet the high volume of work in the sensitive professional setting is not easy
as it takes a toll on them. Due to the work pressure, they feel stressed and this reflects in the
quality of service that is offered to the care users with mental health issues (Yuwanich,
Sandmark & Akhavan, 2016). The other factors which indicate that the emergency departments
need assistance to reduce the level of stress include the need for enhancing the environment in
the sensitive professional setting, need to introduce suitable mental health training, the
implementation of a referral service and the requirement of additional staff members. Thus the
role of a specific emergency department would be of paramount importance as it could minimize
the work burden and overall stress that the ED professionals face on a regular basis (Innes et al.,
2014).
Strengths and limitations of the research
This research study has a number of strengths and limitations that have a major impact on
the ultimate outcome of the research process. Some of the major strengths include the holistic
study of the topic to comprehend whether a specific emergency department can help minimize
the stress of Emergency Department or not (Krystal et al., 2017). The perception of the
individuals with mental health issues and the Emergency Department professionals that serve
them has helped to identify the main areas that get adversely that need to be improved in order to
upgrade the service delivery by the Emergency Department staff members.
The main limitation of the research study includes a limited amount of time that was
available to carry out the research study. In addition to this, the primary source of data could not
be collected which could have strengthened the overall outcome of the sensitive research topic
(Scheid & Wright, 2017).

Conclusions/recommendations
The staff members that function in the Emergency Department of hospitals face a high
degree of stress and pressure on a daily basis due to the rise in the total number of mentally ill.
Due to the hectic work setting that they have to operate in, their quality of work gets adversely
affected and the perception of the customers relating to the services declines (Clarke, Dusome &
Hughes, 2007). In order to maintain the proper quality of the care service that is offered by ED
staff members and minimize their level of stress, a specific emergency department can be
introduced as it can come to their professional rescue.
The following recommendations that have been highlighted below could benefit the care
users that have mental illness and the care professionals that function in the Emergency
Department: A specific emergency department with highly educated experts and staff members
could be introduced so that the work burden and stress of the professionals could be optimally
managed (Clarke, Dusome & Hughes, 2007). In addition to this, education and innovation could
be introduced so that the proper management of multiple groups of patients with poor mental
health could be possible. Such a holistic approach would play a vital role to minimize the stress
level of the ED professionals and enhance the quality of the care service. Such an approach could
constructively impact client perception as well as the healthcare professional relating to the
service quality (Evans et al., 2018).