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Staff perceptions of the management of mental health presentations to the emergency department of a rural Australian hospital: qualitative study

Introduction Current research demonstrates higher prevalence of mental health related emergency department (ED) presentations in rural areas, despite similar overall prevalence of these conditions in rural and metropolitan contexts. This stems from shortages in availability of specialised mental health professionals, greater stigma against mental illness, greater socioeconomic disadvantages, and access to means of self-harm in rural regions. Little is known, however, about the specific characteristics of mental health presentations to rural emergency departments (EDs) in Australia. Additionally, studies have shown that ED staff feel uncomfortable managing mental health presentations to ED due to factors such as lack of confidence and stigma against mental illnesses. Aim This qualitative study sought to examine ED staff perceptions regarding the management of mental health presentations in a rural Australian ED. Methods A qualitative study design was used, incorporating semi-structured interviews of current ED staff. Ten interviews were conducted in person or over the phone by two researchers and thematically analysed to draw out key themes from the data. Results Staff perceived deficiencies in availability of mental health expertise, de-escalation, and referral pathways as major barriers to effective patient management. These factors contributed to increased retention of mental health patients in ED due to uncertainties regarding their definitive care. Despite acknowledging the value of practical experience with mental health presentations as the best way of increasing clinician confidence, staff expressed a desire for more face-to-face training to better equip them to respond to mental health presentations. Conclusion A combination of departmental and hospital-wide issues in conjunction with individual staff attitudes regarding mental health conditions contributes to issues in mental health patient care in this ED. In particular, limited training in mental health and resources available to ED staff affects confidence in managing mental health presentations and contributes to prolonged time to definitive treatment.

of psychological distress in 2019 [2]. The prevalence of mental health conditions is similar between metropolitan and rural areas [3], however, higher rates of self-harm and suicide are found in rural areas [4], with a significant proportion of completed suicides involving gun use [5].
Hospital emergency departments (EDs) can often be the first point of health service contact for individuals with mental health conditions [6]. In 2015-16, approximately 3.7% of all Australian public hospital ED presentations were due to a primary mental health condition [7]. Statistics show higher rates of ED presentation per 10,000 population in rural and remote areas [4]. Proposed reasons for this include: a shortage of specialised mental health professionals in rural areas [4]; differing help-seeking behaviours in rural areas particularly due to high levels of stigma in smaller communities [4,5]; greater socioeconomic disadvantage, access to means of self-harm and greater social isolation in rural and remote locations [8]; and the impact of environmental factors such as prolonged droughts which contribute to mental illness and higher self-harm rates [4].
Given such factors promoting the higher prevalence of mental health presentations to rural EDs, it is important to evaluate the expertise and resources within EDs to accommodate this demand. Regarding management in ED, generally fast-paced ED environments may adversely impact on patients with mental health presentations. An Australian report indicated that mental health presentations to EDs often involved longer waiting times compared to other presentations and they were more likely to leave the ED against medical advice [9]. Potential reasons include the complexity of mental health presentations and the perception of these requiring less urgent interventions, thereby delaying treatment provision [10]. A study on the attitudes of ED staff towards mental health presentations found that some considered ED inappropriate for the treatment of mental health patients, due to noise levels and relative lack of privacy [10]. Personal prejudices regarding mental health conditions also potentially impact care provided [10]. One qualitative study found greater staff negativity towards these presentations, less inclination to provide help, and perception of mental health presentations as "ingenuine" [ 10,11]. Comparing rural to urban EDs, an Australia-wide study of ED clinicians found views of poorer mental health patient care and prejudicial attitudes in rural areas [12]. This was attributed to lower education and training opportunities and discrepancies between available staff and workload within ED [12].
Over the preceding decade, rural NSW has experienced a prolonged drought, proceeded by a bushfire crisis, and more recently, the Covid-19 pandemic. The compounding impacts of these events on the mental health and wellbeing of regional communities is acknowledged [13]. It is therefore timely to examine the preparedness of rural EDs to respond to mental health presentations. This study sought to examine the perceptions and attitudes of ED staff regarding care of mental health presentations at a rural hospital in NSW, Australia.

Study design & ethics
A qualitative study design was employed. Ethics approval was obtained from the Greater Western Human Research Ethics Committee (HREC; 2019/ETH116131) and the Western Sydney University HREC (H133831).

Recruitment & data collection
Eligible participants were those clinicians employed within a rural hospital ED during the study period (June 2019 to March 2020). Participants were recruited by email invitation and by study promotion during ED team meetings. Interviewees participated in semi-structured, face-to-face or telephone interviews conducted by Authors 1-4. The interviewers may have been known to the interviewees as they were 5 th year medical students undertaking their rotations at this hospital at the time of data collection. The interviewers were trained in qualitative data collection procedures by investigators 5 and 6, to ensure consistency in data collection.
Interviews were audio-recorded and transcribed verbatim. Interviews last for 15 to 30 minutes and consisted of four open ended questions and related probes to elicit further details ( Table 1). The interview schedule was developed by the researchers based on a previous survey of Australian ED clinicians [14], and adapted to the study setting.

Data analysis
De-identified interview transcripts were analysed by Authors 1, 2 and 4 under the guidance of Authors 5 and 6. Close reading of the transcripts prior to commencing analysis ensured familiarisation with the data. The first cycle of coding was used to generate a preliminary codebook which was discussed and reviewed. The codebook was refined through subsequent cycles of coding until a consensus was reached regarding the emergent themes [15].

Study context
The rural hospital ED which was the site of this study typically has about 1200 mental health presentations per year in an average 20,000 total presentations. The majority of mental health presentations are voluntary and the most common presentation is suicidal ideation/ self-harm. The majority of all presentations are managed and discharged within ED without admission. The ED has three mental health clinical liaison nurses who are rostered on from Monday to Friday from 8:00am to 9:00pm, and on weekends from 8:30am to 4:30pm. After hours mental health support is available through the Mental Health Care Emergency Care Rural Access Program which is accessed by telehealth linkup to a nearby facility.

Findings
Clinician perspectives on mental health presentations to ED Ten participants were interviewed; eight nurses and two doctors. The nurses had worked in the ED for three or more years while the doctors had worked in the ED for at least eleven weeks each year, as per their hospital terms. Five main themes and several subthemes were identified as summarised in Table 2. Exemplar quotes for each theme are provided in Tables 3, 4, 5 and 6 and are labelled according to participant type (nurse or doctor) and number.

Clinician perceptions of mental health patients in ED
Participants described varying perceptions of mental health patients in the ED. For some, they described mental health patients as disruptive and a cause of stress because of the unpredictable, and potentially unsafe, behaviours they were concerned would occur with mental health patients. For others, this was seen as par  for the course in ED and that the behaviours of mental health patients were not dissimilar to those of a confused patient or a patient with dementia (Table 3a). The impact of staff perceptions on mental health patient care was also reported variably. Whilst some participants reported that negative perceptions (should they exist) do not impact patient care, others thought that such negative perceptions do negatively impact patient care (Table 3b).

Challenges in current treatment practices in this rural ED
The current elements of mental health patient care at this ED were discussed by participants, including both broader departmental level and individual staff-patient level issues. Mental health patient care was described as a tug-of-war between efficiency and comprehensive patient care, and at the same time, between duty of care and defensive medical practice. The type of mental health presentation negatively affected many staff experiences due to the need for increased monitoring and resource allocation for risky or disruptive patients. This was particularly challenging when there were already high patient loads in ED and this challenge is exacerbated due to the inconsistency in the quality of security services available in ED to assist clinicians (Table 4a).
The particular challenges associated with mental health related presentations were reported by participants to lead to the adoption of a defensive clinical practice by many clinicians in the ED. Due to the perceived potential risk that mental health patients may represent to themselves and the community if discharged, participants reported a perception that clinicians prolonged the ED stay to prevent themselves being culpable for a mental health patient's behaviour (Table 4b).
The ED was considered by participants as an inappropriate setting overall for mental health patient care for the reasons outlined above. The impact on mental health patients themselves of being in the ED environment was considered to be negative and conversely the impact of mental health patients on other patients in the ED was also viewed as being negative (Table 4c).
The safe room in this ED was regarded as an essential component in caring for mental health patients, particularly those with potential for self-harm. It was considered a means of improving mental health patient privacy within the busy ED environment. The safe room however was also used for detaining mental health patients whilst awaiting transfer to a nearby facility, and thus carried the risk of deprioritising mental health patients and contributing to stigmatisation by virtue of separation (Table 4d).
Participants described the triage of patients with situational issues, drug and alcohol or acute behavioural disturbance under mental health as inappropriate, and a contributing factor to both overutilization of resources and staff frustration. This was partly attributed to the broad spectrum of mental health conditions and the difficulty in differentiating psychiatric disorders from acute medical problems such as intellectual disability and delirium, which can mimic depression and psychotic states (Table 4e).
The difficulty in accessing referral pathways was also highlighted, especially afterhours due to the lack of availability of MHCLs (Table 4f ). This contrasted with medical patients in ED, for whom clearly defined, and easily accessible specialist medical guidance was consistently available. Additionally, local mental health facilities were not accessible to ED staff for referral of mental health patients requiring further evaluation, as these were privately run (Table 4f ).

A. Mental Health patients in ED as disruptive and a cause of stress/concern
I have concerns about mental health patients who are involuntary, who are say booked to go to [  We quite often will get them reviewed quite quickly. It' s the waiting for that secondary review and them saying let them sleep overnight and get them followed up by the [mental health clinical liaison nurse], that' s an ongoing concern that they're pushing back to the resources that are here. [Nurse 4] Long waiting times for definitive management is a common issue raised (Table 4g). Several participants reported wait times in excess of 3-4 hours for a video link after hours when a MHCL was unavailable for face-toface consultation within the ED. Patients often waited in the ED safe room overnight for review the next morning, which was difficult logistically and distressing for these patients. Some participants however attributed long wait times to a hospital-wide systemic issue, indicating them to be no different to long wait times experienced by medical patients (Table 4g).

Availability of mental health expertise in the ED
Availability of staff with adequate mental health experience and expertise was judged an important factor impacting on patient care in this ED. A lack of staff skilled in the treatment of MH patients was reported by participants, which in turn prolonged waiting times for definitive care and contributed to greater staff workloads (Table 5a). Additionally, staff with expertise in mental health case management were reported to be useful for other ED staff in improving understanding and application of the legalities around mental health patients in ED, whilst also being able to enhance the experience for patients themselves (Table 5a). Regarding available staff, participants highlighted the importance of the ED's MHCL in improving mental health patient care and resource management in the ED as they assisted with earlier provision of management plans (Table 5b). Afterhours patient management, when availability of MHCLs or other similar staff is limited, was considered a major problem by participants, compounding patient waiting times, ED patient load and overall inefficiency of the system (Table 5c). Some participants discussed the need for an on-call psychiatrist, favouring this for improved patient care (Table 5d). In contrast, however, other participants found minimal additional value in the presence of an on-site psychiatrist as their role carried the potential for resource inefficiencies, being essentially fulfilled by the MHCL.

ED staff experience of training in mental health
Practical experience with mental health presentations was reported as a significant contributor to the level of confidence amongst ED staff. In particular, staff reported that regardless of their background education, it was exposure to mental health patients in hospital that improved their confidence with these cases (Table 6a). Despite acknowledging practical experience as the best method of increasing confidence, participants also expressed a desire for more in-hospital training particularly face-to-face (Table 6b). Suggestions included training about legal issues, acute management of mental health presentations, and de-escalation techniques for agitated patients.
The majority of participants agreed that opportunities for mental health training were limited at this facility (Table 6c). Where training has been provided onsite, challenges with late scheduling of training dates and conflicts with ED rosters were noted (Table 6b-c). Key barriers to out-of-hospital training were the cost for the facility, both in terms of the actual training cost and the cost of providing backfill to someone's role, and balancing work-life commitments (Table 6d). One participant noted that even the completion of mandatory online modules had been difficult for staff members with poor internet access. Overall, most participants expressed a desire to seek further education and training in mental health if resources and support were more easily accessible.

Discussion
This study aimed to identify clinician perceptions of mental health patient care in a rural ED. The core findings of this study were that perceived deficiencies in staff expertise, de-escalation techniques and referral pathways contributed to increased mental health patient retention in ED, thereby increasing staff workloads.
Staff at this ED felt under-trained in responding to mental health presentations, and deficient in their understanding of mental health legislation, de-escalation techniques for agitated patients, and confidence in caring for acute presentations. They encounter several barriers to accessing adequate mental health training outside of hospital to enable them to upskill, including costs, lack of backfill for their role, work-commitments, poor internet access and rural location. This is consistent with the findings of two Australian studies regarding clinicians' confidence in responding to mental health presentations to rural EDs [16,17]. To mitigate these factors, participants in our study requested more traditional 'face-to-face' teaching in-hospital as this would overcome the need to travel to access training and thereby reduce the amount of time they need away from the ED to upskill. A 2020 Australian qualitative study found that a single four-hour simulation-based educational workshop run by, and for, ED staff members improved understanding of mental health legislation and patient treatment [18], thereby providing a potential strategy to improve staff confidence.
In this ED, clinicians deferred to their MHCLs for responding to mental health presentations, due to their greater training and experience in assessment of and provision of treatment plans and pathways. However, the MHCL was not available after hours in this ED. An extensive body of research attests to the valuable role a MHCL can play in an ED setting providing timely, specialist mental health support for patients [19][20][21][22][23]. The importance of consistent staffing availability for such as role has also been noted in metropolitan research [24]. Participants in this study reported similar benefits of their MHCLs. A key barrier for providing effective mental health care in this ED was cited as the lack of availability of their MHCLs after hours to facilitate local referrals and quick assessment and care of mental health presentations. However, it is still vital for all ED staff to be equipped with the skills to respond to mental health related presentations. Poorer ED staff confidence in mental health conditions can potentially lead to delayed definitive management and contribute to overall greater patient and resource loading within the ED [25].
Increased retention of mental health patients is further compounded by systemic barriers within ED, such as inaccurate triage, overcrowding and an unsuitable physical environment. These barriers contribute to inefficient resource allocation, defensive clinical practice and create a potentially distressing patient experience, leading some participants to question the appropriateness of ED for mental health care. Difficulty in triaging mental health patients via the Australasian Triage Scale was raised by participants, and has similarly been reported in surveys of ED clinicians [26,27]. This is partially attributable to insufficient training and difficulty in applying standard medical triage protocols to mental illness [26]. Uncertainty regarding triage severity may lead to underestimation of triage categories, increased workload and inefficient resource allocation [26], with subsequent reliance on available specialist mental health expertise or a defensive approach to provision of care until such expertise is available.
Many participants reported employing defensive practices in mental health patient care, such as unnecessary hospital admission or refusal to discharge patients, as a response to inadequate skills, insufficient psychiatric expertise and concerns regarding clinician safety and liability. Defensive medicine is a common practice amongst ED clinicians, supported by a study of psychiatric nurses and psychiatrists in New Zealand [28], which found that concerns regarding patient risk to self and others led to delayed discharge and hospital admissions. A study of ED nurses in a Western Australian hospital, further suggests that defensive attitudes may escalate potentially violent patients [17]. Participants highlighted that the noisy environment of ED and lack of privacy may be potentially distressing to mental health patients, and added to difficulties in patient assessment. This must be considered in this ED where seventy-three percent of presentations in 2018 were treated and discharged within ED without admission. Studies have suggested that such busy ED settings and associated sensory overstimulation may limit the appropriateness of ED in mental health patient management [29]. This raises the question of appropriate safe room use for patient assessment, a topic on which our participants were divided. Some felt that safe rooms exacerbated the issue of deprioritisation, while others felt a safe room was essential for patient safety and privacy.
Overall, systemic barriers and delays in management of mental health patients are co-existing issues that affect the efficiency of patient management in the ED.
The combination of limited resources, inadequate referral pathways and inefficient patient transport culminates in delays in patient transfer and definitive management. Our study identified a significant shortage of specialist psychiatric services and guidance for ED clinicians, particularly overnight/after hours. Despite the implications of inaccessible specialist psychiatric expertise, participants were divided on the need for an on-site psychiatrist, as the theoretical benefits did not seem to balance the costs in an already busy ED. As discussed previously, participants believed increased MHCL staff coverage after hours would improve wait times, reduce patient load, and minimise backlog for offsite mental health assessment units. One study demonstrated that ED clinicians experience greater confidence in treating mental health patients when specialist mental health staff, such as MHCL nurses, are based in the ED overnight [30]. These factors, in combination with delays in patient transport and transfer by ambulance, have contributed to the long wait times for definitive management experienced by mental health patients. Australian findings show that mental health patients consistently wait longer than patients with physical illness for assessment and treatment, and have longer durations of stay in ED, a finding also noted here. With many of the mental health presentations to this ED involving suicidal ideation or self-harm, these wait times are concerning.
We acknowledge certain limitations to our study. Our sample consisted predominantly of nurses, with only a few junior doctors participating and no senior doctors, which may limit the applicability of our findings to a general population of ED clinicians. Nonetheless, data saturation was deemed to have been achieved with this participant group. It is also noteworthy that it is typically the nurses and junior doctors on the ground who provide the hands on patient care in this ED setting. Therefore, while we were not able to capture the perspectives of some of the senior clinicians, our data provide insight into the perspectives of those staff at the coalface delivering care to mental health patients. Future research could attempt to directly link clinician perspectives with presentations they are responding to in real time such as with a clinician survey completed after each encounter. This would enable us to directly link specific characteristics of each presentation with the particular barriers encountered in this ED setting during the provision of care. At the same time, the perspectives of mental health patients could also be examined to determine their experiences of care in the ED. Our clinician participants noted the limited availability of community services for mental health care in this rural location. By engaging directly with patients, this would enable us to delve further into the specific barriers they encounter with seeking support and care in the primary healthcare setting and community setting in this rural location. As this was a case study at a single site, future research should also seek to compare with other rural locations and with urban locations to determine which issues are specific to this rural location and which are more widespread in our healthcare system.

Conclusion
A combination of departmental and hospital-wide issues, in conjunction with individual staff attitudes regarding mental health conditions, contributes to issues including increased time to definitive treatment of mental health patients in this rural ED. Previous studies have highlighted negative staff attitudes towards mental health conditions and concerns regarding the appropriateness of ED in responding to such presentations. However, this study demonstrates specific challenges facing rural EDs including staff undertraining in mental health, inadequate MHCL coverage and inconsistencies in triage and available referral pathways. These factors lead to greater departmental and resource loading and may incite negative views of mental health presentations amongst ED clinicians due to work disruption and exposure to aggressive patients.