Impact of Mental Health Boarding on Clinicians at a Children’s Hospital: A Qualitative Analysis

Abstract

Background:

The child and adolescent mental health boarding crisis (i.e., prolonged stays in acute care hospitals for patients awaiting mental health treatment) continues to challenge acute care hospital staff and resources. We sought to understand clinician’s experiences while caring for patients experiencing mental health boarding.

Methods:

We conducted semi-structured qualitative interviews with clinicians who care for patients experiencing mental health boarding in an acute care freestanding children’s hospital with no inpatient psychiatric unit. We used an inductive approach to determine interview themes and major findings.

Results:

The study included 48 clinician participants from diverse specialties, including 13 social workers, 11 nurses, 5 psychiatric technicians, 6 pediatric residents, 4 attending pediatric hospitalists, 4 attending psychiatrists, 1 psychologist, and 4 other mental health specialists. We identified emergent themes in 5 domains: 1) Frustrations with the mental health care system 2) Lack of training in mental healthcare skills, 3) Feelings of helplessness, 4) Ineffectiveness of medical model of care during mental health boarding, and 5) Resilience and support factors.

Conclusions:

Caring for patients with mental health boarding has negative effects on clinicians, and health system efforts to prevent boarding could improve workforce retention and reduce burnout.

Background

Around 20% of children and adolescents in the United States (US) have a mental or behavioral health diagnosis.¹ In recent years, community mental health resources have not kept pace with the need for services, and young people have increasingly sought mental health care in emergency departments and acute care medical hospitals.^2–3 As a result of the influx of these patients, pediatric mental health boarding,⁴ i.e., the practice of holding patients in an emergency or inpatient setting until the transfer location has been determined,⁵ is increasingly receiving attention from health systems and the general public.^6–9 Shortages of inpatient psychiatric facilities, community mental health resources, and mental health care providers have led to an increase in the number of days young people spend in EDs and medical units awaiting the next step in their mental health care.

This crisis has created challenges for clinicians providing care in ED and inpatient settings.^10–12 Patients seeking emergency care often present with high-acuity symptoms, including high risk of suicide, self-harm, and aggression. When caring for patients with these complex needs in general medical EDs and inpatient units, clinicians experience secondhand trauma, moral injury, and job dissatisfaction.^13–15 In particular, clinicians who self-report having inadequate training in mental health care skills experience elevated stress levels when there is a lack of psychiatric hospital beds for mental health boarding patients.^16–18

In order to inform acute care hospital ED and inpatient medical unit leaders and clinical educators about workforce stressors associated with caring for patients experiencing mental health boarding, and to generate ideas for how to promote psychological safety and job satisfaction, we interviewed clinicians caring for patients experiencing mental health boarding. The study’s primary objectives were to understand how clinicians experience their role in providing care for young people during mental health boarding, including inquiry into specific stressors and supports.

Methods

We conducted semi-structured interviews in person and over the phone with clinicians working in direct patient-facing roles caring for patients experiencing mental health boarding in the emergency department and inpatient medical units at the Children’s Hospital of Philadelphia (CHOP) Main campus, a 603-bed acute care freestanding children’s hospital in an urban setting with no psychiatric unit at the time of this study. Patients presenting to the emergency department with a mental health chief complaint receive a mental health assessment from a social worker and a psychiatrist. If the psychiatrist recommends inpatient psychiatric care and no inpatient psychiatric unit bed is immediately available, the patient is typically admitted either to an emergency department observation unit or to an inpatient medical unit to board while awaiting availability of a psychiatric unit bed. During mental health boarding, patients are cared for by a multidisciplinary medical and behavioral health team. They receive a 1:1 safety observer, environmental safety measures including a room with minimal access to objects that can be used for self-harm, and a daily re-assessment by a psychiatrist. Median length of stay for patients with mental health boarding at CHOP is 3.9 days. Clinicians were invited to participate via e-mail by a member of the study team.

The interview guide was created collaboratively by researchers trained in pediatric medicine, social work, and public health to understand experiences of clinicians caring for this population. The main focus of the interview guide was each participant’s experience with caring for children and adolescents experiencing mental health boarding. Specific domains of the interview guide included: description of the interviewee’s clinical role and the interviewee’s descriptions of and reflections on clinical experiences; clinical professional relationships; coping strategies; stressors; and, positive aspects of working with children and adolescents with mental health concerns. Interviews took place in August 2019-March 2020.

Participants provided consent prior to the interview and were compensated $25 for their time and participation. Interviews lasted between 45 minutes and 1 hour. Interviews were audio recorded and transcribed verbatim with identifying information redacted from the transcript. Participants were provided a copy of their interview transcript upon request.

Using an inductive approach, a codebook was created based on both a priori from previous work and emerging themes.^19–20 Interviews were coded by two master’s level researchers (DW & CB). Coders met frequently to resolve discrepancies and come to a shared understanding of code definitions and applications. Codes were then organized into larger themes which were agreed upon by all authors. Researchers used NVivo 12 to facilitate data analysis.²¹

The study was reviewed by the Children’s Hospital of Philadelphia institutional review board and deemed exempt.

Results

We interviewed 48 clinicians about their experiences caring for patients experiencing mental health boarding. Among those interviewed, we spoke with 13 social workers, 11 nurses, 5 psychiatric technicians, 6 pediatric residents, 4 attending pediatric hospitalists, 4 attending psychiatrists, 1 psychologist, and 4 other mental health specialists (see Table 1). Most participants self-identified as female (82%). Years of experience in their current position ranged from less than 1 year to greater than 20 years.

Table 1 –

Interview Participant Characteristics in a Study of Clinicians Caring for Patients with Mental Health Boarding at a Freestanding Children’s Hospital

	n	%
Total	48	100
Role
Social Worker	13	27
Nurse	11	23
Pediatric Resident Physician	6	13
Psychiatric Technician	5	11
Pediatric Hospital Medicine Attending Physician	4	8
Attending Psychiatrist	4	8
Psychologist	1	2
Other Mental Health Specialist*	4	8
Gender identity
Male	9	18
Female	39	82
Years in current role
<1	8	16
1–2	18	38
3–5	15	31
6+	7	15

Average number of years in role = 25

^*Note: Other mental health specialists included: 1 child life specialist and 3 board certified behavior analysts

From these interviews, five major themes emerged: 1) Frustrations with the mental health care system, 2) Lack of training in mental healthcare skills, 3) Feeling of helplessness, 4) Ineffectiveness of medical model of care during mental health boarding, and 5) Resilience and support factors. Selected quotes illustrating these themes can be found in Table 2.

Table 2 –

Quotes from Clinicians Caring for Patients with Mental Health Boarding at a Freestanding Children’s Hospital

Theme	Quotes
Frustrations with the mental healthcare system	“Hearing stories from some of these patients about trauma and stuff that they’ve had is very disturbing, that can be emotional in terms of hearing that this child was abused, that can emotionally affect me.” (C12)
	“It’s discouraging to see the same kids coming back over and over again. It stinks that you know, even when you’re sending these kids out, you know what you’re sending them to, and you wanna give them hope. But, at the same time, it doesn’t feel like there’s a lot of hope out there.” (C17)
	“I think unfortunately as somebody who works in public health and looking at that, I think that the bottom line is that everything is driven by money. Unfortunately, preventative care has never been the source of getting a lot of attention. It’s not jazzy. It’s hard to make predictions on cost over time. That’s pediatrics, right? But pediatrics is paid the least, yet we’re the ones that are trying to uphold our kids and those are the people that are going to be the future. I know that sounds cheesy, but at the same time that’s just the example, that’s just how our society works.” (C44)
Lack of training in mental healthcare skills	“It’s difficult when it comes to caring for suicidal patients and boarding patients because as a pediatric resident, I don’t think we’re necessarily trained to be able to care for them in a way that’s actually therapeutic for them. So a lot of times it’s just keeping them here until we can find a place that’s better for them. And that isn’t necessarily therapeutic for them or us.” (C30)
	“I feel like I can’t do anything to make these kids feel better. I’m not trained in therapeutic communication. I don’t know what to say to them or do other than let them know when they get a bed.” (C33)
Ineffectiveness of medical model of care during mental health boarding	“There’s been times where I’ve had a patient that needed inpatient placement that’s just been waiting for so long, has had no behavioral issues here. I’ve had to be the one to be like, hey, guys, why are we still recommending this?“ (C17)
	“I don’t know what the inpatient psychiatric hospitals are like. I hear multiple different stories from families, from social workers that used to work there, or any other staff that have just had exposure to those places. I never really honestly hear any good things. All of it is negative, scary stories.” (C32)
Feelings of helplessness	“Our team and our unit leadership has expressed that to the administration at large multiple times and their response is often, well, there’s nowhere else for them to go and you guys are the best suited because you have the safer unit.” (C14)
	“Most days I don’t feel impactful. I felt like I was having very little impact. Often, I felt that patients need to find a good therapist that we weren’t able to provide while they were here. So, it just felt mostly like waiting for moments to pass and keeping them safe in the moment while they weren’t safe and just waiting for those moments to pass. I felt helpless a lot of the time.” (C28)
Resilience and support factors	“I think that just helping [has a positive impact], when you believe something is good trying to help it achieve its potential and achieve the mission and vision that it was meant to serve is pretty rewarding.” (C45)
	“My colleagues tell me about this patient they had. Sometimes it kind of comes off nonchalantly, but it’s their way of venting or processing it. Then at that time, I might say, I or someone else had a similar situation. These are how we approach it and we talk through it.” (C34)

Frustrations with Mental Health Care System

Participants commented on the cyclical nature of mental health treatment and hospital processes. Many participants attributed this cycle to failures of the mental health care system, calling it “broken” and under-resourced, especially in the context of young people’s increasing mental health needs. Many participants expressed frustration with the mental healthcare system and found it discouraging that treatment options often ended with patients returning for care. One physician said: “I think the system, in general, is just so frustrating. And the way we deal with mental health in this country is just ridiculous and it doesn’t work. And so, I think just trying to care for these children within the context of this system is the most frustrating thing.” (C17)

Specific problems participants discussed with the mental and medical health systems included: insurance barriers, lack of time to care for patients, low bed availability, few community resources, and no available step-down or care coordination approaches. Some participants expressed frustration about the care provided at inpatient psychiatric facilities and felt that private inpatient psychiatric hospitals contributed to the “revolving door” of patients. When asked about the perceived effectiveness of inpatient psychiatric treatment, one physician noted: “I think that the pushback is that we have been so convinced that inpatient psych is the solution and I feel like that’s become the jerk response in their effort to put behavioral health as something we need to be mindful of and I think it’s a backfiring. I think that the numbers kind of show that.” (C19)

Lack of Training in Mental Health Care Skills

Pediatric hospital medicine attending physicians, pediatric resident physicians, and general medical acute care nurses were unique in that these groups mentioned a lack of training in mental healthcare which made caring for patients with mental health boarding difficult. The other groups we interviewed did not bring up this topic during the interviews. Pediatric attending and resident physicians and nurses felt they lacked an understanding of how to best provide medical care for patients with mental health boarding. They also shared that they had little training in how to emotionally care for themselves after a difficult experience. One provider said “During orientation we get training on ordering restraints and ordering the medications that we need. I think that I didn’t get any preparation about the emotional consequences. I knew what I had to do in terms of putting in the orders. But I don’t think that I was prepared emotionally for how I would feel in the moment and how to handle those feelings while I was in the room while the patient was actively saying the things they were saying.” (C28)

Feelings of helplessness

Participants discussed feelings of helplessness when caring for patients with mental health concerns and secondary trauma when exposed to difficult stories reported by patients.

One physician said “I feel helpless and useless. I feel like I understand the system pretty well. But, on a larger scale, the system is baffling to me and there’s so much I don’t understand about it. So, I feel very useless in my ability to help them navigate it or help to make things happen.” (C17)

Clinicians with general medical training also felt ineffective in caring for patients with mental health concerns, since these patients often do not have medical needs. However, the same clinicians noted that they did feel effective in keeping patients safe until the patients reach a place where they can receive intensive mental healthcare. Not being able to assist in the mental healthcare of these patients was discouraging, especially to non-mental health focused roles. As one emergency medicine clinician noted: “I think that adds to the difficulty of caring for those patients, is that there is nothing I’m doing for them, and then they leave. And I have no idea what happened. Where is any sense of reward from that, other than maybe the few interactions I had with them while they were in the hospital?” (C30)

Many participants felt that patients were transferred to inpatient psychiatric units for the sake of placement, under the guise of ensuring safety, because other appropriate treatment options such as partial hospital programs, dialectical behavior therapy, or intensive outpatient or in-home services did not exist. Conversely, many participants felt powerless when discharging patients to a volatile home environment knowing that their space would not be conducive to mental and physical well-being. One social worker said: “They’ll go back home with the alleged perpetrator who sexually abused them, that kind of thing, or they’re going to grandma’s house who lives a block down from the alleged perpetrator’s house. You feel powerless.” (C27)

Ineffectiveness of medical model of care during mental health boarding

Feelings of helplessness were often coupled with the feeling of not being able to provide effective care to patients experiencing mental health boarding in the context of a medical model. Physicians specifically endorsed frustration that boarding is often associated with days-long delays in initiating mental health care focused on a patient’s specific concerns during a time of severe mental health crisis.

Across disciplines, participants pointed out systems failures, and noted that many patients do not receive treatment that aids in long term success. “I would love to work in a psych facility if I thought I was actually helping. The fact that so many kids are coming back to us from them doesn’t make it very promising.” (C35). Nurses and physicians reported that they often felt that they were not truly able to help a patient; in part they expressed this feeling in response to patients’ high rates of return visits. Clinicians from other specialties did not express this sentiment.

Whereas most professionals we interviewed felt insignificant in patients’ care experience during mental health boarding, social workers were unique in that they felt that they could contribute to a patient’s wellbeing in non-traditional ways outside the medical model. They mentioned activities such as conversation, video games, arts, crafts, and other games. One clinician that felt these activities had a positive effect on their patients said: “They’re essentially just sitting here. I try to engage with them socially, so I play videogames with them. One patient’s teaching me how to crochet. Just try to normalize their experience. It’s a tough situation to be here”. (C18)

Resilience and support factors

Across all disciplines, clinicians emphasized that support from others was important for their resilience from the emotional and physical work of providing care during mental health boarding. Peer support was integral to participants’ occupational wellbeing. Their coworkers’ knowledge and expertise about the difficulty of the job provided comfort and understanding during and after emotionally stressful situations. When asked why peer support was a major contributor to workplace wellness, one participant said: “You never worry alone. If you ever have a difficult case, there’s always someone to talk to or kind of vent with or process with, which is really nice.”(C43) Clinicians also mentioned interdisciplinary collaboration as a support in helping children and families to receive integrated care.

Participants also mentioned other self-care practices and factors that helped them maintain resilience in the context of limited resources and challenging care situations (Table 3).

Table 3 –

Clinician reported Self-Care Activities and Resilience Supports

Self-care or Resilience Activity
1. Spending time with loved ones, family, children, etc. 2. Spending quality time with pets 3. Physical fitness 4. Formal and informal peer support 5. Therapy/other professional mental health support 6. Meditation and mindfulness 7. Time spent alone 8. Clear boundaries of work and home life

When asked about the positive aspects of working with patients experiencing mental health boarding, some participants said they enjoyed making an improving on the lives of children and families. One clinician said: “I enjoy the most when I interact with the kids and I see them laughing and smiling during their stay at the hospital, make a joke because it makes their time better here. Makes my time better here. And I like to just be able to make a difference.”(C2)

Unlike other groups, social workers and psychologists explained that they promoted and received supportive messages reminding coworkers to practice self-care. Social workers and psychologists discussed self-care as a component of their practice for themselves and a way to support colleagues. Participants in these disciplines recognized the emotional burden that all members of their team faced when providing care for patients during mental health boarding. Many members on the team worked to cultivate an environment that supports and promotes self-care.

Discussion

In this qualitative investigation of clinician experiences while caring for children and adolescents experiencing mental health boarding in an acute care hospital and emergency department, we identified key themes related to: frustration with the mental healthcare system, lack of training in mental healthcare skills, feelings of helplessness, ineffectiveness of the medical model for mental health boarding care, clinician’s resilience and support factors. Clinician participants shared that they felt scared, unable to provide adequate care for their patients, and unable to meet the needs of their patients due to lack of training, resources available, and overwhelming number of boarding patients at their hospital. Clinicians reported that they are not adequately prepared, resourced, and supported to meet the needs of patients currently presenting to pediatric hospitals with mental health concerns, despite being well-trained and otherwise well suited to care for patients with physical medical needs. Our findings are consistent with literature exploring physician burnout and the effect of increased mental health patient volumes on the workforce.^22–24

As many participants noted in this study, continued education, training, and exposure to evidence-based mental healthcare skills and practices would greatly benefit the members of the workforce, particularly those with general medical training backgrounds.

Ensuring that clinicians are mentally and physically well in their workplace is a key priority for health systems. Workplace burnout has become so prevalent that in 2019, the World Health Organization (WHO) added “burnout” to the ICD-11 as an occupational phenomenon, not classified as a medical condition. They defined burnout as a “syndrome conceptualized resulting from chronic workplace stress that has not been successfully managed” and characterized the symptoms as feelings of energy depletion or exhaustion, increased mental distance from one’s job or feelings of negative cynicism related to one’s job, and reduced professional efficacy.²⁵ Given this context, healthcare systems are developing efforts to combat this phenomenon deliberately and adopting practices like monitoring work schedules to ensure “work-life balance” and proactive messaging towards destigmatizing negative physical and mental health effects of burnout.²⁶ Studies have shown that providing leave away from work, information on how to prevent and recognize the signs of burnout, structured meditation, and teaching resilience are all effective interventions in decreasing burnout among health care workers.²⁷

As our study and others have reported,^28–29 camaraderie, and connection are key supports and resilience factors among clinicians working in mental health related fields. Most clinical teams benefit from opportunities to connect in formal and informal spaces outside of direct patient care.³⁰ Hospitals should consider including opportunities for clinician-to-clinician connection in efforts to promote wellness, reduce clinician burnout, and retain a healthy workforce. Hospital operational, administrative, and financial support is paramount in ensuring that wellness programs identify and prioritize employees’ mental health needs, and that employees have the psychological safety within their job roles to be able to participate in formal wellness programs and to serve as informal supporters for their peers. It was widely reported by our sample that peer support was a protective factor in reducing burnout which could be a key element of future hospital-wide wellness support efforts and trainings.

Clinicians working with patients experiencing mental health crises are at risk of suffering from vicarious or secondary trauma from mental health patients.^29–31 Many participants in our study noted that the home lives of their patients are not conducive to healing and could be traumatizing, resulting in repeat admissions. Additionally, triggering life events reported by patients were particularly upsetting to those we interviewed. This trauma can have long lasting effects on the mental health of the pediatric mental health workforce and warrants further research and intervention.

Several study limitations warrant consideration. We did not capture the perspectives of clinicians who do not regularly encounter patients experiencing mental health boarding and purposely sampled from units that frequently work with patients who are boarding. Clinicians with other work experiences may have other perspectives on the current mental health crisis that were not captured in this study. In addition, we completed this study at a large, urban children’s hospital with no inpatient psychiatric unit that sees higher volumes of boarding patients. Clinicians working in general emergency departments, pediatric units in general hospitals, or smaller children’s hospitals may have different experiences than clinicians included in this study. Nevertheless, our findings are consistent with other studies that were conducted in different settings.^{6,8, 17}

Future research to understand the detailed training and wellness programs that would best serve clinicians who care for hospitalized patients with mental health concerns is needed. Though each discipline shared sentiments throughout the study, it is clear that “a one size fits all approach” would not be appropriate for all clinicians and programs should be tailored based on experience and role. Understanding the needs of clinicians in the midst of the current mental health crisis is paramount in preserving the mental and physical wellness of the pediatric mental health workforce.

Conclusions

The mental health crisis has led to an influx of pediatric patients with mental health needs seeking care and boarding in EDs and acute care hospitals, and health systems are not well resourced to care for this patient population. Clinician education, professional development, and wellness programs can consider incorporating formal mental supports for these clinicians in order to prevent staff turnover and burnout in a workforce that experiences substantial workplace stress.

Abbreviations:

US

United States

CHOP

Children’s Hospital of Philadelphia