Use of Emergency Rooms for Mental Health Reasons in Quebec: Barriers and Facilitators

Reasons Explaining High Emergency Department Use in Patients With Mental Illnesses: Different Staff Perspectives

For patients with mental illnesses (MIs), emergency departments (EDs) are often the entry point into the healthcare system, or their only resort for quickly accessing mental health treatment. A better understanding of the various barriers justifying high ED use among patients with MIs may help recommend targeted interventions that better meet their needs. This explorative qualitative study aimed to identify such barriers and the solutions brought forth to reduce ED use based on the perspectives of clinicians and managers working in EDs, other hospital departments or the community sector. Interviews were conducted between April 2021 and February 2022; 86 mental health professionals (22% were nurses) from four large urban ED sites in Quebec (Canada) were interviewed. Barriers were identified in relation to patient profiles, healthcare system and organisational features and professional characteristics. The key barriers that were found to explain high ED use were patients having serious MIs (e.g., psychotic disorders) or social issues (e.g., poverty), lack of coordination and patient referrals between EDs and other health services, insufficient access to mental health and addiction services and inadequacy of care. Very few solutions were implemented to improve care for high ED users. Better deployment of ED interventions in collaboration with outpatient care may be prioritised to reduce high ED use for patients with MIs. Improvements to the referral and transfer processes to outpatient care, particularly through care plans and case management programs, may be implemented to reduce high ED use and improve outpatient care among patients with multiple health and social needs.

Barriers to Mental Health care in Canada Identified by Healthcare Providers: A Scoping Review

The mental health treatment gap remains wide across the world despite mental illness being a significant cause of disability globally. Both end-user and healthcare provider perspectives are critical to understanding barriers to mental healthcare and developing interventions. However, the views of providers are relatively understudied. In this review, we synthesized findings from current literature regarding providers' perspectives on barriers to mental healthcare in Canada. We searched Medline, PsycINFO, Embase, and CINAHL for eligible Canadian studies published since 2000. Analysis and quality assessment were conducted on the included studies. Of 4,773 reports screened, 29 moderate-high quality studies were reviewed. Five themes of barriers emerged: health systems availability and complexity (reported in 72% of the studies), work conditions (55%), training/education (52%), patient accessibility (41%), and identity-based sensitivity (17%). Common barriers included lack of resources, fragmented services, and gaps in continuing education. Interestingly, clinicians often cited confusion in determining the ideal service for patients due to an overwhelming number of potential services without clear descriptions. These five domains of barriers present a synthesized review of areas of improvement for mental healthcare spanning both patients and clinicians. Canadian mental health systems face a need to improve capacity, clinician training, and in particular service navigability and collaboration.

Barriers and Facilitators to High Emergency Department Use Among Patients with Mental Disorders: A Qualitative Investigation

This qualitative study explored reasons for high emergency department (ED) use (3 + visits/year) among 299 patients with mental disorders (MD) recruited in four ED in Quebec, Canada. A conceptual framework including healthcare system and ED organizational features, patient profiles, and professional practice guided the content analysis. Results highlighted insufficient access to and inadequacy of outpatient care. While some patients were quite satisfied with ED care, most criticized the lack of referrals or follow-up care. Patient profiles justifying high ED use were strongly associated with health and social issues perceived as needing immediate care. The main barriers in professional practice involved lack of MD expertise among primary care clinicians, and insufficient follow-up by psychiatrists in response to patient needs. Collaboration with outpatient care may be prioritized to reduce high ED use and improve ED interventions by strengthening the discharge process, and increasing access to outpatient care.

Exploring Frontline Shelter Staff Perspectives on the Healthcare Needs of Clients Experiencing Homelessness

PURPOSE

To examine healthcare service development needs for persons experiencing homelessness from the perspective of frontline staff at a homeless shelter in Montreal, Quebec.

DESIGN

Qualitative descriptive design.

METHODS

Purposive sampling, semi-structured interviews with frontline shelter staff (n = 8), and thematic analysis.

FINDINGS

Themes included: 1) Challenges meeting healthcare service needs in a shelter environment. 2) Visions for improving healthcare services while accounting for health issues and barriers to care. 3) Participants' own knowledge gaps around health and healthcare services.

CONCLUSIONS

Future research should emphasize this group's crucial role in homelessness healthcare services development.

Evaluating mental health decision units in acute care pathways (DECISION): a quasi-experimental, qualitative and health economic evaluation

Background

People experiencing mental health crises in the community often present to emergency departments and are admitted to a psychiatric hospital. Because of the demands on emergency department and inpatient care, psychiatric decision units have emerged to provide a more suitable environment for assessment and signposting to appropriate care.

Objectives

The study aimed to ascertain the structure and activities of psychiatric decision units in England and to provide an evidence base for their effectiveness, costs and benefits, and optimal configuration.

Design

This was a mixed-methods study comprising survey, systematic review, interrupted time series, synthetic control study, cohort study, qualitative interview study and health economic evaluation, using a critical interpretive synthesis approach.

Setting

The study took place in four mental health National Health Service trusts with psychiatric decision units, and six acute hospital National Health Service trusts where emergency departments referred to psychiatric decision units in each mental health trust.

Participants

Participants in the cohort study (n = 2110) were first-time referrals to psychiatric decision units for two 5-month periods from 1 October 2018 and 1 October 2019, respectively. Participants in the qualitative study were first-time referrals to psychiatric decision units recruited within 1 month of discharge (n = 39), members of psychiatric decision unit clinical teams (n = 15) and clinicians referring to psychiatric decision units (n = 19).

Outcomes

Primary mental health outcome in the interrupted time series and cohort study was informal psychiatric hospital admission, and in the synthetic control any psychiatric hospital admission; primary emergency department outcome in the interrupted time series and synthetic control was mental health attendance at emergency department. Data for the interrupted time series and cohort study were extracted from electronic patient record in mental health and acute trusts; data for the synthetic control study were obtained through NHS Digital from Hospital Episode Statistics admitted patient care for psychiatric admissions and Hospital Episode Statistics Accident and Emergency for emergency department attendances. The health economic evaluation used data from all studies. Relevant databases were searched for controlled or comparison group studies of hospital-based mental health assessments permitting overnight stays of a maximum of 1 week that measured adult acute psychiatric admissions and/or mental health presentations at emergency department. Selection, data extraction and quality rating of studies were double assessed. Narrative synthesis of included studies was undertaken and meta-analyses were performed where sufficient studies reported outcomes.

Results

Psychiatric decision units have the potential to reduce informal psychiatric admissions, mental health presentations and wait times at emergency department. Cost savings are largely marginal and do not offset the cost of units. First-time referrals to psychiatric decision units use more inpatient and community care and less emergency department-based liaison psychiatry in the months following the first visit. Psychiatric decision units work best when configured to reduce either informal psychiatric admissions (longer length of stay, higher staff-to-patient ratio, use of psychosocial interventions), resulting in improved quality of crisis care or demand on the emergency department (higher capacity, shorter length of stay). To function well, psychiatric decision units should be integrated into the crisis care pathway alongside a range of community-based support.

Limitations

The availability and quality of data imposed limitations on the reliability of some analyses.

Future work

Psychiatric decision units should not be commissioned with an expectation of short-term financial return on investment but, if appropriately configured, they can provide better quality of care for people in crisis who would not benefit from acute admission or reduce pressure on emergency department.

Study registration

The systematic review was registered on the International Prospective Register of Systematic Reviews as CRD42019151043.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 17/49/70) and is published in full in Health and Social Care Delivery Research; Vol. 11, No. 25. See the NIHR Funding and Awards website for further award information.

Racial disparities in emergency department utilization among patients with newly diagnosed depression

OBJECTIVE

To test the hypothesis that racial and ethnic minorities have increased emergency department visit rates, despite being established with a primary care provider.

METHODS

In this retrospective cohort study, ED visits without hospital admission in a 12-month period among patients with a new primary care provider-issued diagnosis of depression were assessed. Electronic medical record (EMR) data was obtained from 47 family medicine clinics in a large Michigan-based healthcare system. General linear regression models with Poisson distribution were used to predict frequency of ED visits.

RESULTS

A total of 4159 patients were included in the analyses. In multivariable analyses, Black / African American race was associated with an additional 0.90 (95% CI 0.64, 1.16) ED visits and American Indian or Alaska Native race was associated with an additional 1.39 (95% CI 0.92, 1.87) ED visits compared to White or Caucasians (null value 0). These risks were only exceeded by patients who received a prescription for a typical antipsychotic drug agent.

CONCLUSION

Despite being established patients at primary care providers and having follow-up encounters, Black / African American and American Indian or Alaska Native patients with depression were considerably more likely to seek ED treatment compared to White/Caucasian patients with depression.

A Qualitative Study of Emergency Physicians' and Nurses' Experiences Caring for Patients With Psychiatric Conditions and/or Substance Use Disorders

STUDY OBJECTIVE

Patients with psychiatric conditions and/or substance use disorders (SUDs) frequently seek care in emergency departments (EDs), where providing care for these populations can involve considerable challenges. This study aimed to develop a comprehensive data-driven model of the complex challenges and unique dynamics associated with caring for these populations in the ED, as well as the effect on patient care quality.

METHODS

We conducted a preplanned topical analysis of grounded theory data obtained from semistructured interviews with 86 ED physicians and nurses from 8 hospitals in the Northeastern USA. Participants provided detailed descriptions of their experiences and challenges in caring for patients with psychiatric conditions and/or SUDs. We identified themes inductively using constant comparative analysis and developed a grounded model of physicians' and nurses' perceptions of challenges, biases, and effects on patient care.

RESULTS

Emergency physicians and nurses described emotional, diagnostic, and logistical challenges that patients with psychiatric conditions and/or SUDs present. These challenges are magnified by existing health care system issues and social structures, which fuel and reinforce negative attitudes, expectations, and biases. In combination, these processes create negative health care experiences for patients, physicians, and nurses and can adversely affect patient care quality and ED staff well-being.

CONCLUSION

Our findings uncover a cyclical process whereby challenges and biases associated with patients with psychiatric conditions and/or SUDs can reciprocally threaten patient care quality. Systemic changes and localized interventions are urgently needed to mitigate challenges, reduce bias, improve patient care, and improve physicians' and nurses' experiences in the ED.

Service use preceding and following first referral for psychiatric emergency care at a short-stay crisis unit: A cohort study across three cities and one rural area in England

BACKGROUND

Internationally, hospital-based short-stay crisis units have been introduced to provide a safe space for stabilisation and further assessment for those in psychiatric crisis. The units typically aim to reduce inpatient admissions and psychiatric presentations to emergency departments.

AIMS

To assess changes to service use following a service user's first visit to a unit, characterise the population accessing these units and examine equality of access to the units.

METHODS

A prospective cohort study design (ISCTRN registered; 53431343) compared service use for the 9 months preceding and following a first visit to a short-stay crisis unit at three cities and one rural area in England. Included individuals first visited a unit in the 6 months between 01/September/2020 and 28/February/2021.

RESULTS

The prospective cohort included 1189 individuals aged 36 years on average, significantly younger (by 5-13 years) than the population of local service users (<.001). Seventy percent were White British and most were without a psychiatric diagnosis (55%-82% across sites). The emergency department provided the largest single source of referrals to the unit (42%), followed by the Crisis and Home Treatment Team (20%). The use of most mental health services, including all types of admission and community mental health services was increased post discharge. Social-distancing measures due to the COVID-19 pandemic were in place for slightly over 50% of the follow-up period. Comparison to a pre-COVID cohort of 934 individuals suggested that the pandemic had no effect on the majority of service use variables.

CONCLUSIONS

Short-stay crisis units are typically accessed by a young population, including those who previously were unknown to mental health services, who proceed to access a broader range of mental health services following discharge.

Effecting change and improving practice in a regional Emergency Department: A Mental Health Nurse Practitioner's perspective

Providing appropriate, timely intervention and care to people who present with mental health issues to an Emergency Department presents unique ongoing challenges, often affecting patient experiences and outcomes. To address such concerns, a Mental Health Liaison Nurse role, led by a Mental Health Nurse Practitioner, was introduced to a regional Emergency Department. This role provided integrated emergency-based mental health clinical practice, with positive findings reported in a recently published multi-site translational research project. With sound quantitative and qualitative evidence detailing the benefits of this role, the experiential perspective from a clinician working in this frontline space further confirms the importance of having access to such a position in leading cultural and systemic change. This discussion article identifies key processes that align current research with the clinical perspective. Such processes recognize the challenges of implementing a new role and moving forward from these to embed consistent clinical practices. The need to build sound internal and external stakeholder partnerships, effect change implementation, and assign recommendations to ensure sustainability of improved practice and processes are highlighted in this paper. This article is, therefore, designed to assist other advanced practice nurses, who may be embarking on a similar journey and want to influence organizational policy and practice.

Short-stay crisis units for mental health patients on crisis care pathways: systematic review and meta-analysis

BACKGROUND

Internationally, an increasing proportion of emergency department visits are mental health related. Concurrently, psychiatric wards are often occupied above capacity. Healthcare providers have introduced short-stay, hospital-based crisis units offering a therapeutic space for stabilisation, assessment and appropriate referral. Research lags behind roll-out, and a review of the evidence is urgently needed to inform policy and further introduction of similar units.

AIMS

This systematic review aims to evaluate the effectiveness of short-stay, hospital-based mental health crisis units.

METHOD

We searched EMBASE, Medline, CINAHL and PsycINFO up to March 2021. All designs incorporating a control or comparison group were eligible for inclusion, and all effect estimates with a comparison group were extracted and combined meta-analytically where appropriate. We assessed study risk of bias with Risk of Bias in Non-Randomized Studies - of Interventions and Risk of Bias in Randomized Trials.

RESULTS

Data from twelve studies across six countries (Australia, Belgium, Canada, The Netherlands, UK and USA) and 67 505 participants were included. Data indicated that units delivered benefits on many outcomes. Units could reduce psychiatric holds (42% after intervention compared with 49.8% before intervention; difference = 7.8%; P < 0.0001) and increase out-patient follow-up care (χ² = 37.42, d.f. = 1; P < 0.001). Meta-analysis indicated a significant reduction in length of emergency department stay (by 164.24 min; 95% CI -261.24 to -67.23 min; P < 0.001) and number of in-patient admissions (odds ratio 0.55, 95% CI 0.43-0.68; P < 0.001).

CONCLUSIONS

Short-stay mental health crisis units are effective for reducing emergency department wait times and in-patient admissions. Further research should investigate the impact of units on patient experience, and clinical and social outcomes.

Patient and Provider Perspectives on Emergency Department Care Experiences among People with Mental Health Concerns

Emergency departments (EDs) are an important source of care for people with mental health (MH) concerns. It can be challenging to treat MH in EDs, and there is little research capturing both patient and provider perspectives of these experiences. We sought to summarize the evidence on ED care experiences for people with MH concerns in North America, from both patient and provider perspectives. Medline and EMBASE were searched using PRISMA guidelines to identify primary studies. Two reviewers conducted a qualitative assessment of included papers and inductive thematic analysis to identify common emerging themes from patient and provider perspectives. Seventeen papers were included. Thematic analysis revealed barriers and facilitators to optimal ED care, which were organized into three themes each with sub-themes: (1) interpersonal factors, including communication, patient–staff interactions, and attitudes and behaviours; (2) environmental factors, including accommodations, wait times, and restraint use; and (3) system-level factors, including discharge planning, resources and policies, and knowledge and expertise. People with MH concerns and ED healthcare providers (HCPs) share converging perspectives on improving ED connections with community resources and diverging perspectives on the interplay between system-level and interpersonal factors. Examining both perspectives simultaneously can inform improvements in ED care for people with MH concerns.

Mental Health and Addiction Related Emergency Department Visits: A Systematic Review of Qualitative Studies

Mental health and addiction (MHA) related Emergency Department (ED) visits have increased significantly in recent years. Studies identified that a small subgroup of patients constitutes a disproportionally large number of visits. However, there is limited qualitative research exploring the phenomenon from the perspectives of patients who visited ED frequently for MHA reasons, and healthcare providers who provide care to the patients since the overwhelming majority of studies were quantitative based on clinical records. Without input from patients and healthcare providers, policymakers have inadequate information for designing and implementing programs. The purpose of this study was to systematically review the literature of qualitative research on frequent MHA related ED visits. The findings of the review revealed that a lack of community resources and existing community resources not meeting the needs of patients were critical contributing factors for frequent MHA related ED visits.

Emergency department use for mental and substance use disorders: descriptive analysis of population-based, linked administrative data in British Columbia, Canada

OBJECTIVES

Information on emergency department (ED) visits for mental and substance use disorders (MSUDs) is important for planning services but has not been explored in British Columbia (BC), Canada. We describe all MSUD ED visits for people ages 15 and older in the province of BC in 2017/2018 and document trends in MSUD ED visits between 2007/2008 and 2017/2018 by disorder group.

DESIGN

Population-based linked administrative data comprised of ED records and physician billings capturing all MSUD ED visits in BC.

SETTING

BC is Canada's westernmost province with a population of approximately 5 million. Permanent residents receive first-dollar coverage for all medically necessary services provided by licensed physicians or in hospitals, including ED services.

POPULATION

All people age >15 with MSUD ED visits during the study period.

MEASURES

All claims with a service location in the ED or corresponding to fee items billed only in the ED were examined alongside ED visits reported through a national reporting system. Patient characteristics (sex/gender, age, location of residence, income, treated disorders and comorbidities) and previous outpatient service use for all ED visits by visit diagnosis are also described.

RESULTS

A total of 72 363 people made 134 063 visits to the ED in 2017/2018 for needs related to MSUD. MSUD ED visits have increased since 2010, particularly visits for substance use and anxiety disorders. People with more frequent visits were more likely to be male, on public prescription drug plans for income assistance, prescribed psychiatric medications, and living in lower-income neighbourhoods. They used more community-based primary care and psychiatry services and had lower continuity of primary care.

CONCLUSIONS

MSUD ED visits are substantial and growing in BC. Findings underscore a need to strengthen and target community healthcare services and adequately resource and support EDs to manage growing patient populations.

Mental Health Nurses' Experiences of Working in the Emergency Department of Two Rural Australian Settings

Providing effective mental health care in Emergency Departments (ED) is a fundamental expectation, as EDs increasingly become the first point of contact with health services for people in mental distress. As part of a larger multi-site translational research project this study explored the experiences, perspectives and recommendations of mental health liaison nurses (MHLN) employed in the EDs of two rural hospitals in New South Wales, Australia. Participants identified numerous benefits associated with embedding the MHLNs within the ED team. Some challenges associated with changing thinking and practice were recognised and recommendations for improving ED mental health care provided.

The psychiatric decision unit as an emerging model in mental health crisis care: a national survey in England

Psychiatric decision units have been developed in many countries internationally to address the pressure on inpatient services and dissatisfactory, long waits people in mental health crisis can experience in emergency departments. Research into these units lags behind their development, as they are implemented by healthcare providers to address these problems. This is the first-ever national survey to identify their prevalence, structure, activities, and contextual setting within health services, in order to provide a robust basis for future research. The response rate was high (94%), and six PDUs in England were identified. The results indicated that PDUs open 24/7, accept only voluntary patients, provide recliner chairs for sleeping rather than beds, and limit stays to 12-72 hours. PDUs are predominantly staffed by senior, qualified mental health nurses and healthcare assistants, with psychiatry input. Staff:patient ratios are high (1:2.1 during the day shift). Differences in PDU structure and activities (including referral pathway, length of stay, and staff:patient ratios) were identified, suggesting the optimal configuration for PDUs has not yet been established. Further research into the efficacy of this innovation is needed; PDUs potentially have a role in an integrated crisis care pathway which provides a variety of care options to service users.

Patient and staff experience with a new model of emergency department based mental health nursing care implemented in two rural settings

BACKGROUND

As part of a larger multi-site translational research project this study explored patient and staff experiences, perspectives and recommendations in relation to a mental health liaison nursing (MHLN) service implemented in the emergency department (ED) of two rural hospitals in New South Wales, Australia.

METHODS

Semi-structured interviews were conducted across the two sites with a sample of ED patients (n = 32), ED nurses (n = 14), ED medical officers (n = 11) and psychiatrists (n = 3). Data were analysed thematically.

FINDINGS

Patients highlighted the therapeutic benefits of the MHLNs, particularly being listened to and understood. Patients appreciated being seen promptly and having effective follow-up. Some negative experiences were encountered. Staff recognized that embedding the new model of care in the ED impacted positively on ED culture and practice. A nurse practitioner position as clinical lead instituted at one site made the most substantial contribution to integrating mental health care within the ED. Room for improvement was also noted.

CONCLUSIONS

Findings from this study indicate that an ED-based model of MHLN care developed in a metropolitan setting was successfully translated to two rural EDs. While translating a model of care from one context to another is not without its challenges, adherence to the key principles of this model of MHLN care was associated with the most positive outcome.

Strategies to Care for Patients Being Treated in the Emergency Department After Self-harm: Perspectives of Frontline Staff

INTRODUCTION

Every year, approximately 500 000 patients in the United States present to emergency departments for treatment after an episode of self-harm. Evidence-based practices such as designing safer ED environments, safety planning, and discharge planning are effective for improving the care of these patients but are not always implemented with fidelity because of resource constraints. The aim of this study was to provide insight into how ED staff innovate processes of care and services by leveraging what is available on-site or in their communities.

METHODS

A total of 34 semi-structured qualitative phone interviews were conducted with 12 nursing directors, 11 medical directors, and 11 social workers from 17 emergency departments. Respondents comprised a purposive stratified sample recruited from a large national survey in the US. Interview transcripts were coded and analyzed using a directed content analysis approach to identify categories of strategies used by ED staff to care for patients being treated after self-harm.

RESULTS

Although respondents characterized the emergency department as an environment that was not well-suited to meet patient mental health needs, they nevertheless described 4 categories of strategies to improve the care of patients seen in the emergency department after an episode of self-harm. These included: adapting the ED environment, improving efficiencies to provide mental health care, supporting the staff who provide direct care for patients, and leveraging community resources to improve access to mental health resources postdischarge.

DISCUSSION

Despite significant challenges in meeting the mental health needs of patients treated in the emergency department after self-harm, the staff identified opportunities to provide mental health care and services within the emergency department and leverage community resources to support patients after discharge.

Patient and clinician experiences with an emergency department-based mental health liaison nurse service in a metropolitan setting

As part of a larger multi-site translational research project this study explored patient and staff experiences, perspectives, and recommendations in relation to a mental health liaison nursing (MHLN) team established in the emergency department (ED) of a metropolitan hospital in New South Wales, Australia. Semi-structured interviews were conducted with a sample of ED patients (n = 26), ED nurses (n = 10), ED consultants (n = 9), and members of the consultation-liaison psychiatry team (n = 5). Data were analysed thematically. Patients emphasized the numerous therapeutic qualities of the MHLN role, the promptness with which they were seen and the value of follow-up. Privacy was identified as important, and some negative experiences were reported. Staff identified that the MHLN team are able to respond to a variety of ED presentations in a timely manner. There was recognition that the MHLN team needs to be integrated within the ED as a specialist resource that builds ED capacity. Consistent staffing of the MHLN team with designated clinicians was also considered essential. Integrating a nurse practitioner-led MHLN team within the ED has demonstrated multiple benefits for patients, ED staff, and overall service provision. Incorporating a specialist mental health nursing service within the ED builds confidence in ED clinicians. Members of the psychiatry team also acknowledge the value of aligning the clinical governance of the MHLN team within the ED and the reduced workload this model of care has on their service provision to ED, freeing them up to concentrate on their broader general hospital role.

A poststructural analysis: Current practices for suicide prevention by nurses in the emergency department and areas of improvement

AIMS AND OBJECTIVES

To use a poststructuralist framework to critique historical, social and institutional constructions of emergency nursing and examine conflicting discourses surrounding suicide prevention. The aim is to also demonstrate practical guidance for enhancing emergency nursing practice and research with regard to suicide prevention.

BACKGROUND

Emergency departments have been historically constructed as places for treating life-threatening physical crises, thereby constructing other "nonurgent" health needs as less of a priority. Physical needs take priority over psychological needs, such as suicide-related thoughts and behaviours, negatively impacting the quality of care that certain groups of patients receive.

DESIGN

A theoretical analysis of the published literature on the topic of emergency nursing and suicide prevention was conducted and analysed using a poststructuralist framework.

METHODS

Relevant literature on the topic of emergency nursing related to suicide prevention was analysed for a poststructuralist construct of power, language, subjectivity and discourse. Implications to practice and research were identified, as well as expanding emergency nursing using a poststructuralist framework. SQUIRE guidelines were used (see Supporting Information).

DISCUSSION

The emergency department is a critical point of intervention for patients with urgent and life-threatening needs. However, the biomedical model and historical, social, and institutional expectations that influence emergency nurses' beliefs and values do not effectively respond to the needs of suicidal patients. One step to address this issue is to deconstruct the current understanding of emergency nursing as a treatment for only life-threatening physical crises in order to become inclusive of psychological crises such as suicide-related thoughts and behaviours.

RELEVANCE TO CLINICAL PRACTICE

How a poststructural framework can be used to expand emergency care is discussed. Examples include empowering nurses to challenge the "taken-for-granted" emergency nursing and recognizing the health needs that fall outside of the dominant discourse of emergency care.

Stigmatisation of those with mental health conditions in the acute general hospital setting. A qualitative framework synthesis

RATIONALE

Patients with long-term mental health conditions often have complex physical, mental, and social needs. They are frequent users of the acute general healthcare system, but can experience stigmatising attitudes and behaviours, and structural discrimination. We wished to improve understanding of stigmatisation in the acute healthcare setting, to target areas for future intervention.

OBJECTIVE

A synthesis of qualitative literature was undertaken in order to understand how patients with long-term mental health conditions are stigmatised, or otherwise treated, within the acute healthcare system.

METHOD

A theory-driven framework approach was implemented. Existing stigma theory was used to outline a framework for categorizing stigmatising and non-stigmatising phenomena within the acute healthcare system.

RESULTS

A systematic literature search of qualitative studies identified a sample of 51 studies that would inform the framework. Using data in these studies, a final theoretical 'best fit' framework was developed. In this framework there is an overarching pattern of labelling and stereotyping, plus five ways in which patients with mental health conditions are stigmatised in the acute healthcare system: devaluation, social control, avoidance, rejection, and failure to act. In addition, the framework outlines positive attitudes and behaviours - valuing, adjustment, responding, legitimising, and positive action - which contrast with the stigmatisation patterns.

CONCLUSIONS

The study offers a framework for identifying stigmatisation and positive treatment of those with mental health conditions in an acute health setting. This framework is of potential value in targeting areas for improved quality of care and may have utility beyond this setting and stigmatised group.