ED Nurses Feel Unprepared for Mental Health Complaints
By Stacey Kusterbeck
ED nurses reported a general concern regarding treating patients with mental illness, according to the results of a recent qualitative study.1 “The motivation for the study came from my past experience as an ED social worker,” says Amanda Ryan, LMSW, the study’s lead author and a doctoral student/graduate research assistant at the University of Texas at Arlington School of Social Work.
Ryan and colleagues reviewed five studies and identified three themes: ED nurses feeling unprepared and unqualified to care for behavioral health patients, feeling anxious and hesitant, and feeling concerned about keeping the patient environment safe. As an ED social worker, Ryan heard many nurses share similar feelings. “My experiences with psychiatric patients are different than the nurses who care for them, and I believe it is vital for frontline nursing staff to share their own varying experiences,” Ryan says.
For ED triage nurses, behavioral health patients “can pose very high-risk situations,” says Seth Thomas, MD, FACEP, director of quality and performance for Vituity’s emergency medicine service line. ED nurses “need to get much more comfortable caring for these patients,” Thomas adds. There are some specific legal risks Thomas sees for ED nurses:
• Triage nurses could miss a life-threatening psychiatric emergency. “If the triage process isn’t running efficiently, it could delay evaluation of patients,” Thomas cautions.
Patients will not always directly say they are presenting for psychiatric reasons. Instead, they might report vague complaints, and ED nurses send these patients to the waiting room. “More people are suffering from mental health disease than ED nurses would expect,” Thomas offers.
Thomas suggests ED triage nurses expand their index of suspicion for a psychiatric emergency and document observations of the patient’s behavior and demeanor in addition to the chief complaint.
• Nurses might fail to monitor ED patients adequately, who then elope from the ED and harm themselves or others. “That patient could walk out and harm themselves or somebody else,” Thomas laments.
• Triage nurses might fail to follow policies. If so, “the hospital can be dragged into a lawsuit as a defendant,” Thomas cautions.
Typically, the EP and hospital are the main targets of malpractice litigation. “But if the plaintiff attorney discovers that an ED nurse stepped outside of their scope of practice, such as medicating or restraining a patient without a physician’s order, or failed to follow their hospital’s policies or procedures, that could be a significant risk for the nurse,” Thomas explains.
Good documentation helps nurses refute allegations in malpractice lawsuits involving psychiatric patients who spent a long time in the ED. “The boarding issue is only getting worse. The sheer number of patients and their length of stay is increasing tremendously,” Thomas notes.
That means psychiatric patients are staying in EDs for many hours, days, or even weeks.2 “Injuries often occur when patients escalate — not only to the patient, but the staff as well. Something will eventually happen if they stay in the ED long enough,” Thomas warns.
Engaging with the patient can help ED nurses avoid these risky situations. Nurses can notice subtle signs of escalation, treat with medications when appropriate, offer food, perform regular assessments, and facilitate hygiene. “The ED chart should always demonstrate that ED nurses were doing their best to care for the patient,” Thomas suggests.
It also is important for ED nurses to demonstrate they did everything in their power to transfer the patient to a higher level of care, if that is what the patient needs. “If a receiving hospital refuses acceptance, ED nurses should document the reason, and then try another hospital and document those encounters, too,” Thomas says.
Lack of capacity at inpatient facilities is a real problem for EDs. “But I think we tend to blame the system a little too much, rather than saying, ‘What can we do to help while they are here?’” Thomas observes.
It is reasonable for ED nurses to note “an inpatient bed was not available” or “a consultant was not available” or “the ED lacked a complete medication list.” However, the overarching message in the ED nursing notes should be, “But we tried nonetheless. Here’s what we did.”
Too often, nursing notes are sparse on what happened during a psychiatric patient’s stay. Sometimes, the chart states only the patient was medicated and restrained, which complicates malpractice defense. “You want to document the great care that you are giving patients, by illustrating that in the medical record,” Thomas says.
Frequent reassessments can demonstrate thorough care and reveal the patient actually received better care during the ED visit. “We strive to place patients in the least restrictive environment, which might be an outpatient crisis center. Or, it might even be home rather than in a hospital,” Thomas says.
For psychiatric discharges, nurses should consider whether the patient has decision-making capacity and fully understands the discharge plan, the patient has no intent to harm herself or others, and the patient received outpatient resources (if appropriate). “Like all other patients, nurses should document that the patient is a ‘safe discharge,’” Thomas adds.
Kimberly Nordstrom, MD, JD, says these are the top risk management concerns for ED nurses caring for psychiatric patients:
• Appropriate monitoring of the suicidal patient. “Hospitals have been aggressive in changing front-door policies,” says Nordstrom, an emergency psychiatrist at University of Colorado Anschutz.
Some EDs have implemented more screenings for suicidal thoughts. “But after the triage screening, not all hospitals have solid procedures in place to ensure safety for the suicidal patient,” Nordstrom laments.
EDs might lack 1:1 monitoring (or the ability to monitor patients in a room with a camera), fail to secure personal items (to prevent overdose on home medications or strangulation), or fail to have someone who evaluates the patient’s actual risk in a timely manner.
• Medication errors. “This is always a concern for nursing, but especially when working rapidly to help tranquilize an agitated patient,” Nordstrom says.
In these intense, high-stress interactions, mistakes can happen, such as giving too much medication or not reviewing the patient’s allergy list. During litigation, nurses can expect to be asked several questions: Did the nurse receive a verbal or written order for the medications? If verbal, was there a clear order with exact milligrams of each medication stated? Did the nurse repeat the order back to the physician to ensure accurate understanding?
• Treatment of the agitated patient. “Nurses do not tend to have a lot of training in de-escalation techniques,” Nordstrom notes.
Nurses are in the tough position of containing patients until security and/or behavioral health personnel are available. In some EDs, nurses play a role in physically restraining patients. “The priority is twofold: keeping both the patient as well as the staff safe. Nurses can get physically injured while keeping others safe,” Nordstrom observes.
ED nurses should understand applicable mental health laws. “Some laws are very strict around use of restraints and what needs to be documented to support use,” Nordstrom cautions.
Requirements may differ depending on the setting, such as an ED or inpatient mental health unit. In Colorado, requirements are more stringent for facilities that are specifically designated for mental health treatment, according to Nordstrom. “Most of the EDs have opted out of this designation and, because of this, have less stringent rules,” she says.
EDs might be required to document that less restrictive measures were tried and found not to be successful, or that the patient was informed of the reason for restraints and/or what needs to occur to be taken out of restraints. “When a person screens positive for suicide risk, having ED policies that clearly outline next steps in care — further evaluation or safety protocols — is essential,” Nordstrom adds.
- Ryan A, Herrera S, Patel M. Emergency nurses’ experiences in treating patients with mental illness: A qualitative, interpretive metasynthesis. J Emerg Nurs 2021 Apr 26;S0099-1767(21)00077-5. doi: 10.1016/j.jen.2021.03.010. [Online ahead of print].
- Nolan JM, Fee C, Cooper BA, et al. Psychiatric boarding incidence, duration, and associated factors in United States emergency departments. J Emerg Nurs 2015;41:57-64.
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