Patient Perspectives of Emergency Mental Health Care in a Rural State

Abstract

Increases in emergency department (ED) presentations for mental health conditions continue to challenge the national mental healthcare infrastructure, often resulting in ED boarding. However, limited prior studies capture the perspectives on mental healthcare of those experiencing prolonged boarding in the ED (≥ 24 hours stay) for mental health conditions. We aimed to assess patient perspectives on acute mental healthcare among individuals boarding in a general ED in a rural state. We performed semi-structured interviews of adults (≥18 years old) presenting with a primary mental health condition boarding in a general ED for at least 24 hours. An interview guide was developed a priori, and a trained study team performed the interviews. A thematic analysis was conducted by two independent coders. A coding tree was developed through an iterative process that included double-coding transcripts and monitoring of inter-rater reliability. Fifteen patients were interviewed to reach saturation. Ages ranged from 22 to 65. Analysis revealed several key themes including the environment of the ED, interactions with family members and staff, communication regarding the plan of care, patient perceptions of autonomy and respect, and mental healthcare services provided outside the ED. Our study revealed that adults encounter significant challenges to access timely acute mental healthcare in the ED in a rural state. Participant recommendations for improvement included increasing the availability of therapy while in the ED and providing a physical environment that is more welcoming. Community, hospital-based, and statewide quality improvement and public policy strategies should be considered to address the identified challenges.

Introduction

Addressing acute mental healthcare needs is a current challenge in the US and beyond (Roennfeldt et al., 2021). Large increases in the number of patients presenting to emergency departments (ED) for acute mental healthcare needs has put extreme strains on patients, families, and the limited mental health infrastructure that exists (Holland et al., 2021; Ruffo et al., 2022; Theriault et al., 2020). In addition to increased presentations, there are significant concerns with the care provided in the ED (Alakeson et al., 2010; Manton et al., 2013). Some of the central issues driving these concerns are a lack of access to psychiatric care in the ED while patients are boarding, an overall non-therapeutic environment, and high costs for health systems (Nordstrom et al., 2019). The limited infrastructure for acute mental health services often results in patients “boarding” in the ED for extended periods of time (Nordstrom et al., 2019). Boarding is defined by the Joint Commission (2012) as “the practice of holding patients in the ED or another temporary location after the decision to admit or transfer has been made.” The American College of Emergency Physicians has published policy solutions pertaining to Emergency Department boarding. Recommendations include financial incentives to increase mental health resources (e.g. workforce, psychiatric beds) in the ED, increased telehealth services, and investment in resources such as crisis hotlines that facilitate direction of patients to different levels of care, but these recommendations have not been widely adopted or supported.

Roennfeldt et al. (2021) conducted a systematic review of the qualitative literature focusing on patient experiences of ED mental healthcare with an overall goal to improve psychiatric care in the ED. Twenty-three qualitative studies were included and common themes included long wait times, physical space, the use of restrictive practices, wide variations in staff interactions, and a feeling that poor treatment was provided. Notably, these studies did not specifically address the subject of ED boarding. Of the seven conducted in the United States, five were published more than five years ago and none specifically focused on care provided in a general ED in a rural state (Allen et al., 2003; Carpenter et al., 2005; Cerel et al., 2006; Harris et al., 2015; Thomas et al., 2018; Wise-Harris et al., 2017; Wong et al., 2020).

Despite the known challenges of ED boarding, there are limited prior studies that capture the opinions and perspectives of patients with the highest level of acute mental health need in a general ED in a rural state. This project aims to characterize the patient experiences in this setting, focusing on both the challenges and opportunities for improvement.

Methods

Study Design and Setting

We conducted semi-structured interviews of patients boarding for mental health conditions in a general ED in a rural state from July 2022 to September 2022. The ED in which the study was conducted is an academic medical center with ~65,000 visits per year that serves a primarily rural population across three states. Boarding for both psychiatric and medical concerns is a frequent occurrence at the ED in which the study was conducted.

Our grounded-theory approach was based on related investigations with children and adolescents with mental health conditions and chronic conditions (Pulcini et al., 2021). Trained study team members performed the semi-structured in-person interviews in a private patient room within the ED. Training was provided by the senior author with expertise in qualitative methodology. The study team members and participants had no relationship prior to the interview. Participants were made aware that this study was intended to inform quality improvement efforts for those with prolonged boarding times for mental health conditions in the ED.

The interview guide was developed a priori and included a modified delphi process with a key stakeholder workgroup that included patients, psychiatrists, psychologists, social workers, patient and family advocates, and ED staff. The interview guide is included as supplementary online material. Study procedures were deemed not research by our Institutional Review Board as the overall focus of the study was to improve the quality of care of patients boarding for mental health conditions in the ED. We used the Consolidated Criteria for Reporting Qualitative Research to guide the collection, analysis, and reporting of data (Tong et al., 2007). (Appendix 1)

Study Protocol

Participants were deemed eligible for the study based on selective criteria and enrolled with consecutive sampling until saturation was reached. Only adult patients (≥18 years old) were eligible for participation in this study. Two study team members screened patients arriving to the emergency department using the electronic medical record. Chief complaints were reviewed to identify patients presenting to the ED with issues related to mental health (i.e. anxiety, panic attack, depression, suicidal ideation, suicide attempt) who had an ED length of stay ≥24 hours. The study team identified the Nurse, Advanced Practice Provider, and/or Physician caring for patients meeting these criteria. The study was then discussed with these care team members to determine whether they felt the patient was appropriate for interview. They were informed that the patient met inclusion criteria for the study and advised that exclusion criteria included patient history of violence and concern for the safety of study team members.

Following patient selection, trained members of the study team (obtained face-to-face verbal consent from patients to participate in the project. Six individuals declined participation, and 20 were deemed not appropriate to interview due to aggressive behavior or history of violence toward staff based on either chart review or provider discretion. Recruitment stopped when thematic analysis revealed that the study had reached saturation through an iterative study team review process.

Data Collection and Analysis

Interviews were digitally recorded and transcribed by a professional transcription service. Transcripts were not returned to participants for feedback. Relevant demographic information was also collected from each participant. Interviews varied in length based on participant responses (no time limit was set). No repeat interviews were performed, and field notes were not included in the final analysis as they were duplicative to the interview content.

A thematic analysis was conducted by two independent coders using NVivo coding software (version 1.6.1). Themes were not identified in advance. A coding tree was developed through an iterative process that included double-coding transcripts and monitoring of inter-rater reliability. Participants did not provide feedback on the findings. Quantitative data from the demographic survey were analyzed utilizing descriptive statistics.

Results

Characteristics of Study Subjects

Fifteen participants were interviewed to reach saturation. Participant ages ranged from 22 to 65 years old. Interviews lasted from 9 to 43 minutes. Most interviewees identified as white/Caucasian, with one participant identifying as American Indian/Alaska native (consistent with state demographics). Most participants (8) identified as female with 6 identifying as male and 2 identifying as transgender male. One participant chose not to disclose their gender identity. Seventy three percent of participants had public health insurance. The number of ED visits for mental health concerns among participants in the past year ranged from 1 to greater than 20. Table 1 provides the characteristics of the study subjects.

Table 1:

Demographics

Participants (n)	15
Participant age
Minimum	22
Maximum	65
Mean	37.8
Patient gender identity (N=15)
Female	8
Male	4
Transgender male	2
Chose not to disclose	1
Patient race (N=15)
White/Caucasian	93.3%
American Indian/Alaska native	6.7%
Type of patient’s primary health insurance (N=15)
Public health insurance	73.3%
Private health insurance	26.7%
ED visits in the past year for primary concern involving mental health
Minimum	1 (6 patients)
Maximum	>20 (1 patient)
Mean	4.9

Main Results

There was high inter-rater reliability (alpha > 80%) between the coders and five major themes were identified. These are included below, and additional data organized by themes is presented in Table 2.

Table 2:

Themes and representative quotations

Theme	Representative quotations
Environment	“I feel like there should be kind of a better place for people like me. Something like a block that you could at least walk around with your sitter […] It almost feels like I’m in prison in a way.” “I fixed my room up. I decorated. I used what I had for color and made some colorful things in here, and everybody loves it [laughs] – that has seen it.”
Interactions	“You’re alone probably 23 hours of the day for weeks, in this little room and it’s […] not healthy.” “I’ve had some great sitters. Some that I want to fill out [award nominations] for, because they’ve just been so helpful in kind of pulling me out of – not out of the darkness, necessarily, but just being able to distract me from it.”
Communication	“My nurse told me that she was going to try and find my care team […] to see if they have any updates, and it’s been hours. […] And I hate feeling like I don’t know what’s going on.” “I feel like I haven’t really been fully listened to in terms of what I’m open to and what my […] options are for what happens next. I’ve been completely left in the dark about the future.”
Autonomy and Respect	“I don’t like the approach of people being paternalistic and sort of like […] just change now or we’re going to drug you. Because everybody’s got a story.” “There are so many ways to hurt yourself everywhere no matter where you go. But I guess patients are not treated like we’re human.”
Community Mental Healthcare	“I have a team, I have a case manager, I have a therapist, I have a doctor, I have a person that works with me from the Howard Center. I have a lot of support, but just try making relationships with those people so you can trust them helps.” “In the community, in general, it feels like it’s—there’s no shame in mental health. There’s no shame in being mentally ill. And I think a lot of people think that there is. And that breaks my heart. If you need help, get help.”

Environment.

Participants described the environment of care of the ED within several minor themes: belongings, length of stay, noise, physical space, and visitor policy. One participant reflected, “It’s really cramped, like you can’t get out, and sometimes you’re here for days to weeks. So it’s really bad for your mental health. And you’re just isolated in a room, and you overhear stuff and it’s not – it’s not generally like a therapeutic environment.” Several mentioned the effect of being indoors: “Just breathing in fresh air would be nice, you know, while we’re waiting for something to happen.” Participants expressed consistent concern over their belongings being confiscated and lack of visitors allowed as well, with the overall concern that their mental health was worsened by the overall ED environment.

Interactions.

Participants often reflected on their interactions with family members and other patients. Most frequently, they commented on their interactions with staff members and perceptions of staff member attitudes. One reflected, “One time there was a social worker that really listened to my story and tried to genuinely help, but generally the [crisis evaluation] it’s just, do you want to kill yourself or someone else, yes/no, okay, great, thanks, bye. And that’s not human interaction. That’s like we’ve turned into machines. But mental health is a story, usually, and so people that don’t forget that is nice, whereas a lot of workers are just trained to assess – and you can feel that.” Several participants reflected on positive interactions with staff members: “this sitter just made me feel human. She made me feel like I wasn’t just some number on a list that was waiting for a room somewhere. And that felt good.” Participants consistently reflected that despite staff at times trying to connect and create a positive environment, their interactions were constrained by the resources, environment, and approach to mental health in the ED (therefore overlapping with other themes).

Communication.

Within the broader theme of communication, coders identified three subthemes: disposition, medication coordination, and patient awareness of plan. One participant noted the intersection between gender identity and mental health, commenting that he experienced dysphoria after having a pregnancy test conducted without his knowledge. Another participant expressed her willingness to advocate for herself and ask about the plan of care, and expressed concern for other patients who were not willing or able to do so. Some participants were not aware of their disposition until it was abruptly “sprung upon them”. Participants felt that consistent communication was vital to help improve the ED experience while boarding, and currently concrete strategies are lacking to make this possible.

Autonomy and Respect.

Participants discussed these values both directly and indirectly, additionally commenting on a feeling of paternalism. One participant reflected, “there are so many things I haven’t given my consent to that are major things to me.” Another hoped for “some sort of more compassionate approach besides just laying down the law because it’s turned into more of what feels like a police situation.” This also overlapped with the environment and communication themes, where belongings were often confiscated, visitors limited, and challenges in consistent communication made participants feel like “less than a person”.

Community Mental Health.

Several participants commented on their outpatient teams, and one participant suggested a potential for improvement by bringing the team approach to the ED: “Maybe they should have teams that come to you that get to know you and that you can have some say in your providers or examiners.” Overall participants encouraged a better bridge between the ED and community/outpatient mental health services, as they often felt disjointed while boarding in the ED.

Discussion

Through our study, we found that participants encountered significant challenges to access timely acute mental healthcare in the ED in a rural state. Participants proposed many short- and long-term suggestions for improvement. Five themes to describe challenges and proposed solutions emerged from the data collected: the environment of the ED, interactions with family members and staff, communication regarding the plan of care, perceptions of autonomy and respect, and mental healthcare services provided outside the ED.

Our study further affirms that the practice of boarding in the ED for mental health conditions is rarely therapeutic and often harmful. Though participants commented on the positive impacts that individual staff members had on their experiences, these were most often outweighed by the perception that boarding in the ED is “not healthy.” This is consistent with prior research regarding mental health care in the ED (Carstensen et al., 2017). The participants in our study also acknowledged the need for increased staffing and new facilities for psychiatric care but were acutely aware of the lack of funding currently available to enact these suggestions. The overall sentiment from the study participants, consistent with organizations such as the American College of Emergency Physicians (ACEP), is that the ED is not an appropriate setting for ongoing psychiatric treatment and healing. Despite the current mental health crisis and ongoing financial challenges, multi-tiered solutions should be considered to provide patient-centered emergency psychiatric care.

While more longitudinal solutions and alternatives to the ED setting are sought, our study suggests high value in engaging patients who are boarding in the ED for mental health conditions to craft improvement efforts. Our participants consistently provided concrete short and long-term suggestions for improvement. Although an alternative physical environment was discussed most frequently, many participants provided the feedback that they felt increased color, sunlight, and access to activities to pass time while boarding would be therapeutic. A participant reflected on a previous experience with the mental health system (outside the ED setting) and compared it to their current stay by saying, “[Our] minds were always doing a project or doing painting. Or we went outside for a walk. Just, I don’t know, we did stuff. And here I’m just laying here thinking how much more I wish I was dead.” Though environmental adaptations are costly, participants report that investments in this area would improve their experience during extended ED stays. Increased access to activities for patients may be a less expensive solution while more longitudinal solutions to ED boarding are put into place, with strong consideration given to emphasis on sleep hygiene and exercise outlets while boarding.

Others drew on their experiences in inpatient psychiatric facilities to discuss group therapy or more frequent interactions with the care team. One participant stated, “I think it’d be nice if they did have maybe a counselor or even a medical student, or anybody who could come around and maybe just lend an ear so you can maybe talk about things that are bothering you.” A potential concrete, inexpensive step that could be implemented safely is to improve interactions with care team members. EDs may consider collaborating with psychiatric providers to organize additional training for staff members who serve as one-to-one constant observers and thereby encouraging meaningful, therapeutic interactions with patients. Other creative solutions, as suggested by a study participant above, could involve members of the broader community such as medical students, peer support coaches, or volunteers from the community which have been successful in other settings with individuals with serious ongoing mental health concerns (Storm et al., 2020).

In addition to the improvements suggested above, communication between the healthcare team and those boarding in the ED for mental health conditions was the most urgent short-term need for improvement in our setting. It became clear through our analysis that improvements in communication both within the healthcare team and from the team to the patient are critical to improving the experience of ED boarders. In other studies, a similar theme has arisen in the form of patients feeling their symptoms were ignored (Carstensen et al., 2017). Though our participants did mention symptoms being ignored, they more often felt that their care plan was inadequately communicated. Moreover, they wished to be included in formulating the plan. These findings suggest that a standardized tool to facilitate communication may be helpful. Based on our analysis, a comprehensive and collaborative patient-centered communication approach rooted in mutual respect and empowerment could greatly assist patient experience and well-being while boarding in the ED for a mental health concern.

Limitations

The data collected only represents our single-center patient experience in a general ED in a rural state. Our study did not triangulate these findings with health care providers or other key stakeholders, whose perspectives are well represented elsewhere (American College of Emergency Physicians; Isbell et al., 2023). Lastly, we are unable to assess any differences between those individuals who were suitable to interview at the time of the study vs. those who were deemed not safe and/or suitable for an interview by care providers. In future studies it may be helpful to assess variations in patient perceptions based on social determinants of health as factors such as economic stability, homelessness, food insecurity, and other elements of the social context may affect patient interactions with the ED specifically and with the healthcare system at large.

Conclusions

In summary, we identified challenges and suggestions for improvement from adults boarding for a mental health condition in a general rural ED with the overall goal to inform future research and quality improvement efforts. Of note, quality improvement efforts, including many of those mentioned above, are currently ongoing in our ED based on the results of our study. We hope through dissemination of our findings we encourage others to identify and enact patient informed strategies to address the ED boarding crisis both inside and outside the ED, with a specific focus on rural emergency mental healthcare.

Public health significance statement:

This study identified gaps in mental health care that impact patients boarding (length of stay >24 hours) in an emergency department in a rural state. Gaps included communication, non-therapeutic physical environment, and preservation of patient autonomy. Community, hospital-based, and statewide quality improvement and public policy strategies should be considered to address these gaps, notably focused on rural populations seeking acute mental health care.

Appendix 1. Consolidated criteria for reporting qualitative studies (COREQ): 32-item checklist

No. Item	Guide questions/description	Reported on Page #
Domain 1: Research team and reflexivity
Personal Characteristics
1. Interviewer/facilitator	Which author/s conducted the interview or focus group?	4
2. Credentials	What were the researcher’s credentials? E.g. PhD, MD	Title page
3. Occupation	What was their occupation at the time of the study?	5
4. Gender	Was the researcher male or female?	4
5. Experience and training	What experience or training did the researcher have?	4
Relationship with participants
6. Relationship established	Was a relationship established prior to study commencement?	4
7. Participant knowledge of the interviewer	What did the participants know about the researcher? e.g. personal goals, reasons for doing the research	4
8. Interviewer characteristics	What characteristics were reported about the inter viewer/facilitator? e.g. Bias, assumptions, reasons and interests in the research topic	4
Domain 2: Study design
Theoretical framework
9. Methodological orientation and Theory	What methodological orientation was stated to underpin the study? e.g. grounded theory, discourse analysis, ethnography, phenomenology, content analysis	4, 5
Participant selection
10. Sampling	How were participants selected? e.g. purposive, convenience, consecutive, snowball	5
11. Method of approach	How were participants approached? e.g. face-to-face, telephone, mail, email	5, 6
12. Sample size	How many participants were in the study?	6
13. Non-participation	How many people refused to participate or dropped out? Reasons?	6
Setting
14. Setting of data collection	Where was the data collected? e.g. home, clinic, workplace	4
15. Presence of non-participants	Was anyone else present besides the participants and researchers?	4
16. Description of sample	What are the important characteristics of the sample? e.g. demographic data, date	6, 7, Table 1
Data collection
17. Interview guide	Were questions, prompts, guides provided by the authors? Was it pilot tested?	5, Supplementary Online Material
18. Repeat interviews	Were repeat inter views carried out? If yes, how many?	N/A
19. Audio/visual recording	Did the research use audio or visual recording to collect the data?	6
20. Field notes	Were field notes made during and/or after the interview or focus group?	6
21. Duration	What was the duration of the inter views or focus group?	6
22. Data saturation	Was data saturation discussed?	6
23. Transcripts returned	Were transcripts returned to participants for comment and/or correction?	6
Domain 3: analysis and findings
Data analysis
24. Number of data coders	How many data coders coded the data?	6
25. Description of the coding tree	Did authors provide a description of the coding tree?	6
26. Derivation of themes	Were themes identified in advance or derived from the data?	6
27. Software	What software, if applicable, was used to manage the data?	6
28. Participant checking	Did participants provide feedback on the findings?	6
Reporting
29. Quotations presented	Were participant quotations presented to illustrate the themes/findings? Was each quotation identified? e.g. participant number	7–9, Table 2
30. Data and findings consistent	Was there consistency between the data presented and the findings?	7–10, Table 2
31. Clarity of major themes	Were major themes clearly presented in the findings?	7–8, Table 2
32. Clarity of minor themes	Is there a description of diverse cases or discussion of minor themes?	7–8, Table 2

Developed from: Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. International Journal for Quality in Health Care. 2007. Volume 19, Number 6: pp. 349 – 357