Reaffirming the needs
of the mentally ill in Emergency

Not every wound is gaping, not every injury visible, not every symptom perceptible. Yet, decisive action is just as necessary for Emergency patients with mental illness as for those with broken bones or a cardiac arrest. That’s why nurses in the JGH Emergency Department—some veteran, others novices—were looking to “extend the scope of their thinking about mental health patients,” says Melanie Sheridan, a Clinical Nurse Specialist. They found help close to home, from the hospital’s Mental Health team.

This past fall, the Psychiatry Department piloted a two-day workshop, customized for ED nurses intent on working more closely and effectively with mental health patients in the Emergency. Presentations were also developed, along with tours of the Psychiatry Unit. “We were approached by Emergency nurses who were open about needing more guidance, because training had always been one-to-one, ad hoc,” says Jo Zuckerman, a Psychiatry Nurse who began her career in the ED. “They wanted to be more engaged and more specialized in providing whole care, rather than tending to strictly ‘medical’ needs.”

Typically, hospital EDs mix psychiatric patients with medical patients (those having purely physical problems), who tend to be seen as needing more urgent and immediate care, says Vanessa McIntyre, who joined the JGH ED in 2008. “I enrolled to learn more about psychiatric patients, who often fall into a gray area where numbers, values and measurements are not as well defined. There isn’t often the same rush as we have with medical patients to provide urgent attention.”

Karen Finestone, a Clinical Nurse Specialist at the JGH Institute of Community and Family Psychiatry, places the dilemma into perspective: “If you miss a fracture and send a patient home, it’s a problem. If you miss a suicidal patient and send that person home, it’s no less of a problem. That’s why early intervention in the ER is especially important.”

Guy Lessard, the Head Nurse in Emergency Psychiatry and ICFP Psychiatry with 29 years’ experience, says that when patients come in, “they’re in crisis, it’s intense. They might be violent, belligerent or unstable. Once they’re on the unit, they’ll receive specialized care from the psychiatric team, but early and proper intervention in the ED is crucial in preventing escalation and getting them the urgent care they may need.” The workshops responded to this need, says Ms. Finestone, by addressing “how we can best help patients—and even families and staff—within those critical 48 hours.”

Once the new Emergency Department opens in Pavilion K in February 2014, psychiatric patients will get more thorough evaluations, says Ms. McIntyre, because the facility has a dedicated Psychiatry area. Currently, mental health patients are rarely placed in rooms, because their condition does not usually require the use of medical equipment. “They’re in no-man’s-land,” says Ms. Finestone. In such an environment, patients often experience a loss of dignity and autonomy, says Mr. Lessard. He expects the upgraded Emergency to “help them feel they are in a safe place that reduces stress or anxiety, and that lets them walk around or relax in a lounge.”

But even in a more welcoming environment, however, a prolonged stay in Emergency is not optimal. “We’re looking for ways to move people up from the ED more quickly,” says Ms. Sheridan, which is why the presentations to the ED nurses by the Psychiatry team included case studies of different psychiatric illnesses.

“Our workshop focused on how to assess mentally ill patients, to identify them early on, in the triage stage—for example, ‘This is what a depressed person looks like, this is what a psychotic patient looks like,’” explains Ms. Finestone. “They shouldn’t languish in the ED for long. It’s important not to get too caught up in the bloods, in the tests, in the technical details. We have to remember there’s a person there.”

To drive the point home, just such a person was invited to the workshop to describe her experiences in the many Montreal-area emergency departments that she’d visited as a patient. “That session resonated the most with me,” says Ms. McIntyre. “She reminded us that mental health patients are vulnerable and need reassurance or a kind gesture, just like any other patient. She said that merely ‘looking at us and saying hello’ would make a big difference. We don’t realize the full impact of our behaviour if we walk by them while avoiding eye contact or without acknowledging them.”

Her sentiment was echoed by Don Lucas, a student nurse in Psychiatry who also attended the presentations. “We learned that no matter how busy it can get in an ER, it’s so important for nurses to show they care.”

The benefits to additional specialized training are obvious, says Ms. Finestone. “The more sensitized you become to patients’ needs, the more you’ll see a positive outcome, and the more comfortable and competent you’ll feel.” Ms. Sheridan says she hopes future classes will be given not only to nurses, but to nursing assistants and orderlies as well, so that they can benefit from a team approach. The Associate Nursing Director for Mental Health, Valerie Frunchak, would also like to offer similar courses to the rest of the hospital. “We can learn from one another,” states Ms. Finestone.


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