Caring for patients with behavioral health (BH) concerns presents a number of challenges in the emergency setting. Studies have shown that such patients often experience long lengths-of-stay (LOS) while awaiting care from a specialist or referral to another facility. These problems, in turn, can lead to crowding, boarding, and other issues that ultimately affect non-BH patients in the ED as well.

What can EDs do from a nursing perspective to improve care for this patient population while also eliminating some of the spill-over effects on other patients? A new study from the Emergency Nurses Association (ENA) suggests nurses perceive that more guidance in terms of practice guidelines and specialized protocols is needed in this area. Further, they voice frustration about what they perceive as a lack of tailored education as well as resources to optimally care for BH patients presenting with mental health crises and concerns.

An analysis of survey data and information gleaned from focus group sessions suggests there are several interventions that, at least from a nursing perspective, could potentially improve the care BH patients receive in the emergency setting and shorten their stay there as well.1

Address gaps in training

The study involved a combination of self-report surveys and focus group responses on a range of issues not well covered in the literature, explains Lisa Wolf, PhD, RN, CEN, FAEN, the lead author of the study, director of ENA’s Institute for Emergency Nursing Research, and a clinical assistant professor of nursing at the University of Massachusetts in Amherst. “There was really not a lot of information on such things as LOS, models of care, or the role of nursing in the care of BH patients,” she says. “So we developed a survey to perhaps answer some questions about what kind of care models were being used, what nurses felt in terms of preparation, and what they felt about attitudes toward BH patients.”

The 35-item survey was developed in concert with a committee of emergency nurses with expertise in BH care, and it covered topics related to preparation/training, confidence levels, average LOS, the use of protocols, availability of dedicated BH staff, the use of chemical and physical restraints, and dedicated space for BH care.

“We sent out [the survey] and got about 1,230 responses, and then we triangulated that data, using focus groups at our annual conference in Nashville in 2013,” Wolf explains. “We had about 20 nurses split into two groups ... and we told them to tell us about their experience in caring for BH patients, and really put flesh on the bones of those quantitative [survey] questions.”

The survey responses and focus group comments indicate that while nurses want to provide good care to BH patients, they feel they are inadequately prepared to do so, Wolf explains.

“There is that sense of operating in an informational vacuum a little bit,” she adds. “Plus, our physician colleagues are also not well-prepared to care for these patients. They are very reluctant to do so. They don’t get a lot of training in emergency psychiatry.”

The researchers found a huge proportion of nurses had received no training in BH beyond nursing school. What this means, according to Wolf, is that while a nurse is likely to receive a lot of information about strokes, heart attacks, and similar crises, information about BH crises is not presented in a way that is clinically available. “That lack of understanding produces a lot of frustration,” she says.

For example, while it is quite common in any given ED to find emergency nurses who specialize in trauma, cardiac emergencies, or pediatrics, there also should be nurses trained in caring for people with BH emergencies, Wolf notes.

Employ BH nurses

Study participants reported that the average LOS for BH patients who present to the ED is 18.5 hours, a statistic that is problematic given that studies have shown that such lengthy stays adversely impact care. More than half of the participants (57%) noted their hospitals have no inpatient psychiatric unit, and 51% indicated their hospitals have no dedicated treatment area for BH patients. Just 35% of respondents reported their EDs had dedicated BH staff to assist with the management and care of BH patients, and 24% said they did not have a standardized protocol for managing this patient population.

What factors seemed to make the biggest difference on LOS? Researchers found the presence of a specially trained BH nurse reduced LOS substantially. “The limitation is that this is nurse-level data, but I would say anyone who uses electronic tracking can look at their board and get a pretty good idea of what the average LOS is in their department,” Wolf says. “Our finding of 18.5 hours is certainly not outside the realm of plausibility, but using that number, we do see a significant reduction in LOS, given the presence of a nurse trained in BH emergencies.”

Nurses trained in BH do not necessarily have to have prescribing ability to be effective, Wolf says. “When you have someone who has specific training in any given sub-specialty of emergency medicine, they know what the plan should be, and they know how to advocate,” she explains. “They can move the care of the patient along and advocate for them in a way that someone without that training might not be able to do.”

Another step that individual departments could initiate is to identify and adopt a protocol so that the care of BH patients is standardized, Wolf says. “Is everybody doing the same thing when a BH patient comes into the ED from triage to the physician? Is everybody on the same page? Protocols help you to do that,” she says. “I would say the first thing that most departments could probably put into place without an incursion of financial obligations is a protocol to move things along, to have a map for the care of these patients.”

Wolf also advises ED administrators to consider staff training on how to effectively care for patients with BH emergencies. “This can involve the suicidal patient, the schizophrenic patient who is off his or her medicines, the depressed patient who maybe doesn’t have a plan [for suicide] but you don’t really know for sure, or the potential overdose,” says Wolf. “How do we keep people safe when there are no external markers?”

Wolf adds that ED administrators should consider implementing a steady dose of in-service training to address such issues. “Dealing with patients with BH crises should be a part of every ED orientation,” she says. “If everyone is on the same page in terms of care, you have less agitation because everyone is clear and everyone is not adrift. They know what happens next — both nurses and patients. That is important.”

A more difficult problem to tackle is the lack of inpatient space for BH patients who are waiting for a bed. Researchers found that this problem certainly leads to extended LOS, but a solution to the problem requires attention at an institutional or societal level, Wolf acknowledges.

Stress education, support

EDs that have effective BH protocols in place as well as a trained BH nurse on site might want to proceed to the next level of care — the use of a psychiatric nurse practitioner, Wolf says. However, she observes that most EDs still have plenty of room to improve on the implementation of the earlier steps.

“The majority of EDs struggle with this because these long lengths-of-stay tie up beds, contribute to crowding, and reduce the ability of people to care for the other people in the ED,” Wolf notes. “The nurses we spoke to [as part of this study] were passionate in their wish to provide really excellent care to this population. Nurses want this education. They want to do this well, so if this study goes anywhere towards stressing education, training, and support for the nurses caring for BH patients, then we are on the right track.”


  1. Wolf L, et al. U.S. emergency nurses’ perceptions of challenges and facilitators in the management of behavioural health patients in the emergency department: A mixed-methods study. Australas Emerg Nurs J 2015 Apr 28 [Epub ahead of print].