A pilot evaluation of a prehospital emergency psychiatric unit: The experiences of patients, psychiatric and mental health nurses, and significant others

Abstract

Purpose

To explore the significance of the alliance with the Prehospital Emergency Psychiatric Unit for patients, psychiatric and mental health nurses, and significant others, and to evaluate their experiences of treatment and care.

Design and Methods

A qualitative inductive interview study with 11 participants: four patients, six nurses, and one significant other. The interviews were analyzed with content analysis.

Findings

The analysis resulted in four subcategories: To be met with respect, presence and time, knowledge and experience, and feeling of support, and one category: A psychiatric team with knowledge and experience creating stability and a sense of self‐worth.

Practice Implication

The Prehospital Emergency Psychiatric Unit enables a safe, person‐centered service.

1. INTRODUCTION

Mental illness is a growing problem in Sweden, and for young people the trend is increasing (Swedish National Board of Health and Welfare, 2019). People with mental illness are vulnerable and need professional care to maintain trust. Many people who commit suicide have had contact with the healthcare system (Laanani et al., 2020). This has become a great challenge for the healthcare, and also for the police. In 2018, the Swedish Police Authority attended an increasing number of incidents relating to mental illness, such as suicide or suicide attempts, as a big part of the everyday work of the police (Swedish National Board of Health and Welfare, 2019). The fact that the police are the first line of response can be very stigmatizing for the suicidal individual as well as for significant others (Lindström et al., 2020). An alternative to police intervention is prehospital acute services, for example, an ambulance, but, according to Todorova et al. (2020), the ambulance personnel lack knowledge about the care of people with mental illness. Lindström et al. (2020) emphasize that patients in need of acute prehospital psychiatric care are particularly vulnerable and tend to become stressed when meeting with the police or ambulance personnel. Nurses specializing in psychiatric care are trained in psychiatric and mental health nursing. According to Gabrielsson et al. (2020), psychiatric and mental health nursing in Sweden is a caring, reflective, recovery‐oriented, health‐promoting, and therapeutic practice that makes a difference.

1.1. The prehospital emergency psychiatric unit

The Prehospital Emergency Psychiatric Unit is a 3‐year project in the southern part of Sweden and the overall aim of the project is to reduce the stigmatization of mental illness and to prevent suicide by building alliances with patients, significant others, and personnel. The aim is also to offer support to ambulance personnel from specialist nurses in psychiatric care and to develop collaboration between ambulance and a psychiatric clinic. A specialist trained nurse from the ambulance service and a specialist nurse in psychiatric care are working together in a purpose‐built vehicle with two seats instead of a stretcher. The project includes seven ambulance nurses, and four specialist nurses which are rotated in the project. The Prehospital Emergency Psychiatric Unit is dispatched by emergency call operators when they identify a mental health‐related crisis every day from 3 pm to 01.00 am. The reason is to increase the ambulance personnel's knowledge of suicide assessments, triage, and psychiatric and mental health nursing care, as well as guiding patients to the right level of care. This was evaluated by Todorova et al. (2020) to determine the current perceptions of ambulance nurses’ knowledge and competence regarding mental illness in the Prehospital Emergency Psychiatric Unit. They found that there is an urgent need for ambulance nurses to learn more about the appropriate approach to patients with mental illness. Önnheim et al. (2021) have recently made a 1‐year evaluation and The Prehospital Emergency Psychiatric Unit, had 1425 dispatched from 2019 to 2020. According to their evaluation, 51% were about serious mental illness and 18% suicide assessment. The Prehospital Emergency Psychiatric Unit conducted 52% care intervention at home and 48% were dispatched to care facility.

Similar projects have started in Stockholm (the Psychiatric Emergency Mobility) and in Gothenburg (the Prehospital Psychiatric Resource). The evaluation after 1 year in Stockholm showed positive results and a third of all service users did not contact the ambulance again but were satisfied with the emergency intervention. The most common causes of the emergency intervention in Stockholm were suicidal ideation, severe mental illness, and substance abuse (Bouveng et al., 2017). In Gothenburg, it was found that anxiety, suicide assessment, and substance abuse were the most common causes of emergency care (Alfredsson & Andersson, 2016).

As mental illness increases in Sweden, there are demands for competence, interpersonal skills, and collaboration between professionals in prehospital emergency settings. The project of The Prehospital Emergency Psychiatric Unit is also important for reducing the stigma of mental illness and for suicide prevention, but also for maintaining trust and building alliances with patients, significant others, and personnel. Therefore, the aim of this pilot evaluation is to explore the significance of the alliance with the Prehospital Emergency Psychiatric Unit for patients, psychiatric and mental health nurses, and significant others, and to explore their experiences of the treatment and care provided.

2. METHOD

2.1. Design

To explore patients’, nurses’, and significant others’ experiences of the Prehospital Emergency Psychiatric Unit, individual interviews, and a focus group were conducted. Interviews were conducted with patients, a significant other, and nurses. The focus group, consisting of three nurses, was formed to promote interaction and discussion. All interviews were transcribed verbatim and analyzed with content analysis according to Burnard (1996). The interviews were conducted by students (the second to fifth author) from the one‐year Master's Program for Specialist Nurses in Psychiatric Care, and the last author. All students were given tutorials by the first and last authors during the whole procedure.

2.2. Participants and data collection

The interviews included 11 participants. All managers of inpatient units at Malmö psychiatric clinic were given written information, sent by e‐mail, about the study. The second and fourth authors contacted the Prehospital Emergency Psychiatric Unit by e‐mail and telephone, providing written and oral information. They also got a gatekeeper who gave the patients written information about the study and about informed consent, as well as a pre‐paid envelope with the address to Malmö University where they could send the informed consent if they wanted to participate in the study. For the interviews with the nurses, the third and fifth author contacted the managers of the adult as well as the child and adolescent psychiatric emergency room, and of the psychiatric emergency room for addiction, by telephone, to get the nurses’ e‐mail addresses. They then sent written information and informed consent forms by e‐mail. For the significant others, a Facebook page was produced during February 2021, with information about the study and with e‐mail addresses to the first and last author for those who were interested in participating. Both the individual interviews and the focus group were conducted during spring 2021, the interviews with four patients, three nurses, and one significant other, and the focus group with three nurses. All nurses were specialist nurses in psychiatric care (studying at the one‐year Master's program). They worked at a psychiatric emergency room, for adults, and three of them also worked part‐time at the Prehospital Emergency Psychiatric Unit (Table 1). Three interviews with the patients were performed face to face at Malmö University and one by telephone because of the Covid‐19 pandemic. The patients had been admitted to the Prehospital Emergency Psychiatric Unit on at least one occasion. The contact reasons were addiction problems, symptoms of depressive disorder, suicide thoughts, and manic disorder. The interviews with the patients varied from 16 to 60 min. The significant other was interviewed digitally, by the last author. The focus group and the interviews with the nurses were conducted by digital conference, Zoom, due to Covid‐19 and, in the case of the focus group, also due to difficulties for the nurses to find the time to attend individually. The interviews were recorded via mobile phone or dictaphone and lasted from 37 to 102 min. Before the start of each interview, all participants were given oral information and it was checked that the informed consent was in order. An open‐ended interview guide was used during all interviews, also for the focus group, and the introductory question was “How did you experience the Prehospital Emergency Psychiatric Unit?”. The open‐ended interview guide varied according to which informant was interviewed.

Table 1.

Demographics of the participant (N = 11)

Nurses n = 6
Sex	4 Women
	2 Men
	39−67
Age
Educational level	6 Specialist Nurses in Psychiatric Care (1‐year Master's program)
Workplace	3 working at Psychiatric Emergency Room
	3 working at Psychiatric Emergency Room and the Prehospital Emergency Psychiatric Unit
Experiences from the PEPU	7 months to more than 1 year

Patients n = 4
Sex	3 Men
	1 Women
Age	39–67 years

Significant others n = 1
Sex	1 Woman
Age	19 Years

2.3. Data analysis

All interviews were transcribed verbatim by the second to last author and analyzed with content analysis (Burnard, 1996). The interviews were read and reread by all authors to capture the informants’ experiences of the Prehospital Emergency Psychiatric Unit. The analysis was done in four steps. First, the text was coded with single words, and second, the words were grouped together into subcategories. Third, the text was color‐coded, and in the last step, the categories emerged and captured the sense of the whole. See Table 2, presenting quotations in relation to main category and subcategories. Throughout the process, all the authors of the study participated in the analysis.

Table 2.

Main category, subcategories, and quotations

Main category
A psychiatric team with knowledge and experience creating stability and self‐worthiness
That they talked to me … like an ordinary human being… […] (Patient 1)
Well, I thought it felt very, well, very different, as if it was, yes, as if it felt serious because I'd never had the experience of the psychiatric ambulance being called. But I still think that they treated us very well. (Significant other)

Subcategories with quotations
To meet with respect	Presence and time	Knowledge and experience	Feeling of support
So, if it hadn't been for him, I would probably still have sat in my apartment, refusing to leave. Then there would perhaps have been a police escort.	They really spent time … getting me to understand that I had to accompany them of my own free will […]. So, they spent time … calming me down and well […] they took the time to do that, instead of just dragging me along.)	We usually come indoors to the patient, asking them for a short talk and sitting down where the patient themselves feel safe, it can be in the kitchen, on the edge of the bed, or on the sofa. Then we talk for a while and take some vital parameters, and a colleague also makes a medical assessment to see if there's anything in that area.	Phoning and talking to them is no trouble, sort of, now I have this … may I talk to a doctor and discuss how to proceed here or what do you feel, this patient, how do you usually do then before …well… you can communicate with them.
			Well, there's a possibility to get care in the home which hasn't existed earlier, so that's a change, and when you come home you have access to a medical record, which you haven't had before.
	And then he psychiatry he the nurse said … that… that “right now there's nothing more important than being here.” He didn't at all make me feel that I… that I wasted society's resources and such.
		Many patients who were actually helped at home, who didn't come to the psychiatric emergency, and those we came with are actually in need of a medical assessment and hospitalization and many of these patients who usually drive in with anxiety or who live at LSS housing [special service housing] who don't really have to be driven in, they, they haven't seen as much of them since the start of the PEPU [the Psychiatric Emergency Prehospital Unit].
			… it's nice, because you bring in your own personal views and values [when you are] with him, which can make me sad. In such situations you have to be quite square and I suppose that's what the Prehospital Emergency Psychiatric Unit is good at. They make demands. An ultimatum, that this is the way it is.
		[…] they are specialized within this and, well, an ordinary ambulance nurse may not have the same broad knowledge and be able to deal with these individuals, so therefore it's great that it exists.
		They are after all experts on other things and they ask other types of questions. Questions that were more relevant for me and my situation. (Patient 4)

2.4. Rigor

To ensure rigor in the findings, we aimed for trustworthiness in accordance with standard criteria for qualitative research (Graneheim & Lundman, 2017). A clear presentation of the result and significant quotations, as well as the fact that the experiences of nurses, patients, and a significant other were included, strengthen the credibility of the study. We aimed for transferability by a clear description of the participants and of the design and method. To achieve dependability, we used interview guides and the process of analysis was discussed continually among the authors.

2.5. Ethical considerations

This study was approved by the Swedish Ethical Review Authority (Reg. no. 2019‐06468). All informants got both written and oral information about the study before the interviews and informed consent forms were signed. All interviews were voluntary, and the participants were informed that they could withdraw without explanation and that the data were treated confidentially by the authors.

3. RESULTS

The analyzed material resulted in four subcategories and one main category. The subcategories were: To be met with respect, presence and time, knowledge and experience, and feeling of support. The main category was: A psychiatric team with knowledge and experience creating stability and a sense of self‐worth (Table 2). The Prehospital Emergency Psychiatric Unit involves both a psychiatric and mental health nurse and a specialist trained nurse from the ambulance service. In the text, the words “nurse” and “psychiatric and mental health nurse” are used to describe the staff conducting psychiatric nursing care at the ambulance service and at the psychiatric clinic, respectively.

3.1. A psychiatric team with knowledge and experience creating stability and a sense of self‐worth

Being part of a team created a sense of belonging and a sense of support among the nurses in the Prehospital Emergency Psychiatric Unit. Furthermore, it enabled an alliance between the Prehospital Emergency Psychiatric Unit, staff in the adult psychiatric emergency department, and other professions, which contributed to better emergency care for people with mental illness. The patients described a professional encounter, where the nurse made time to talk and evaluated the patient's condition as well as adjusting their body language to confirm the patient.

That they talked to me … like an ordinary human being… […] (Patient 1)

Feelings of safety and calm, knowing that the Prehospital Emergency Psychiatric Unit was available, were experienced by a significant other.

Well, I thought it felt very, well, very different, as if it was, yes, as if it felt serious because I'd never had the experience of the psychiatric ambulance being called. But I still think that they treated us very well. (Significant other)

3.2. To be met with respect

All patients had previous experience of the regular ambulance for transport to the psychiatric emergency clinic. One of the informants had first received care from the regular ambulance at home, and described how crucial it can be to feel safe and to trust the ambulance staff. The ambulance staff had been standing, looking down at the patient during the conversation, urging them to go to the hospital and pointing out that there were no alternatives. This had resulted in the patient feeling reluctant to seek care. The psychiatric and mental health nurse in the Prehospital Emergency Psychiatric Unit, on the other hand, sat down next to the patient, talking calmly and respectfully, which created a trustful alliance and, for the patient, a sense of being safe.

So, if it hadn't been for him, I would probably still have sat in my apartment, refusing to leave. Then there would perhaps have been a police escort. (Patient 3)

3.3. Presence and time

The patients felt that the psychiatric and mental health nurse was talking respectfully to them as well as being present in the moment. The psychiatric and mental health nurse was perceived to be patient and calm, taking the time to explain the situation to the patient, which was appreciated.

They really spent time … getting me to understand that I had to accompany them of my own free will […]. So, they spent time … calming me down and well […] they took the time to do that, instead of just dragging me along. (Patient 1)

In contrast, some patients expressed negative experiences from previous meetings with the regular ambulance. Instead of feeling that the staff were present, some of the informants had had the feeling of being in their way and taking up the staff's time.

And then he psychiatry he the nurse said … that… that “right now there's nothing more important than being here.” He didn't at all make me feel that I… that I wasted society's resources and such. (Patient 1)

Hearing this made it easier for the informant, who could let go of the thought of taking up someone's time or being in the way and stop feeling awkward.

3.4. Knowledge and experience

The psychiatric and mental health nurses agreed that they had the specialist competence to offer people with mental illness the right assessment and care at home. This competence was reflected in how they used their knowledge in different nursing care situations.

We usually come indoors to the patient, asking them for a short talk and sitting down where the patient themselves feel safe, it can be in the kitchen, on the edge of the bed, or on the sofa. Then we talk for a while and take some vital parameters, and a colleague also makes a medical assessment to see if there's anything in that area. (Nurse 6)

These situations also included possessing the competence to assess the patients’ need for medication, conducting therapeutic conversations with patients and relatives, and providing clear information regarding the course of events in complex care contexts. Furthermore, several participants believed that this resulted in a reduced risk of vulnerability in patients and relatives, and thus in improved care. Another benefit was that patients no longer had to seek psychiatric emergency care to receive help, due to the possibility to receive adequate psychiatric care at home.

Many patients who were actually helped at home, who didn't come to the psychiatric emergency, and those we came with are actually in need of a medical assessment and hospitalization and many of these patients who usually drive in with anxiety or who live at LSS housing [special service housing] who don't really have to be driven in, they, they haven't seen as much of them since the start of the PEPU [the Psychiatric Emergency Prehospital Unit]. (Nurse 6)

As the Prehospital Emergency Psychiatric Unit team consisted of an ambulance nurse and a psychiatric and mental health nurse who worked in parallel, the Prehospital Emergency Psychiatric Unit was perceived to have the competence to exclude both somatic and psychiatric diseases. This enabled an assessment of different conditions in individuals in the home. The significant other interviewed in this study also described how the psychiatric and mental health nurse had the required knowledge and expertise to talk to patients with mental illness.

[…] they are specialized within this and, well, an ordinary ambulance nurse may not have the same broad knowledge and be able to deal with these individuals, so therefore it's great that it exists. (Significant other)

Moreover, the patients pointed out that it was noticeable that the psychiatric and mental health nurses had knowledge and experience of psychiatric illnesses and problems and knew what they were talking about, something that for some patients could imply a feeling of being understood.

They are after all experts on other things and they ask other types of questions. Questions that were more relevant for me and my situation. (Patient 4)

3.5. Feeling of support

The psychiatric and mental health nurses working in the Prehospital Emergency Psychiatric Unit felt that they received various forms of support from care staff and other authorities, such as the police and rescue services. Overall, the experience of the staff in the Prehospital Emergency Psychiatric Unit team was that they received help and support when they felt vulnerable and alone in their work situation.

Phoning and talking to them is no trouble, sort of, now I have this … may I talk to a doctor and discuss how to proceed here or what do you feel, this patient, how do you usually do then before …well… you can communicate with them. (Nurse 1)

Moreover, the nurses who worked at the adult psychiatric emergency department said that the Prehospital Emergency Psychiatric Unit functioned as an extra support in telephone counseling for persons whose relatives were in need of emergency psychiatric help. Information about the possibility of getting an emergency psychiatric assessment at home, could thereby lead to better care of patients.

Well, there's a possibility to get care in the home which hasn't existed earlier, so that's a change, and when you come home you have access to a medical record, which you haven't had before. (Nurse 6)

Furthermore, some nurses at the emergency unit also experienced support in the telephone triage, where the knowledge that the psychiatric and mental health nurse in the Prehospital Emergency Psychiatric Unit had recently made a psychiatric assessment of the patient, facilitated the counseling.

Finally, nurses in the Prehospital Emergency Psychiatric Unit team prioritized giving the patients an opportunity to talk about their ill health. Thereby, the patients gained insight into their illness and the need to seek care. Some of the informants thought that was the reason why they themselves decided to seek voluntary care in the psychiatric emergency department.

The significant other expressed a sense of relief at not being responsible for transportation or for persuading their next of kin to seek psychiatric care. However, the significant other also expressed frustration when the SOS Alarm operator was reluctant to send the team to the patient's home, due to making a different interpretation than the relative regarding the patient's need for contact with the Prehospital Emergency Psychiatric Unit. Nonetheless, feelings of safety and calm, knowing that the Prehospital Emergency Psychiatric Unit was available for transport to the psychiatric emergency clinic, were evident.

… it's nice, because you bring in your own personal views and values [when you are] with him, which can make me sad. In such situations you have to be quite square and I suppose that's what the Prehospital Emergency Psychiatric Unit is good at. They make demands. An ultimatum, that this is the way it is. (Significant other)

4. DISCUSSION

The Prehospital Emergency Psychiatric Unit is a project in the southern part of Sweden where a specialist trained nurse from the ambulance service works together with a specialist nurse in psychiatric care. This pilot evaluation described how a psychiatric team with knowledge and experience created stability and a sense of self‐worth for the patient. Both the patients and the significant other in this study expressed their gratitude for the alliance with the Prehospital Emergency Psychiatric Unit, which made them feel safe. Furthermore, they expressed that the professional encounter where nurses made time for the patient, created a significant sense of self‐worth. This is in line with the study of Lindström et al. (2020), who interviewed patients in Stockholm based on a similar concept. They found that the patient appreciated the team's profound knowledge and the fact that they saw the patient's vulnerability but still created a person‐centered care. In this study, this led to patients who previously did not voluntarily want to come along in the ambulance changing their attitudes and coming along without coercion. This study focuses on the personnel from psychiatric emergency care, the patient, and the significant other, and not on specialist trained nurses from the ambulance service.

Our result showed the importance of creating a team spirit among the nurses in the Prehospital Emergency Psychiatric Unit. Such a team spirit is beneficial, according to research where the interpersonal relationships in a working group led to an improved commitment to nursing work (Amukugo et al., 2020) and increased patient safety (Fatahi, 2019; Lee & Doran, 2017).

Another benefit, according to the result of this study, was that two nurses with specialist competencies worked together, which improved the care for people with mental illness, as well as favoring the exchange of knowledge. Several studies have emphasized both the need to modify the acute care of people with mental illness and the importance of increased knowledge in prehospital care (Morgan et al., 2018).

We found that being present and having time were crucial factors for the alliance between the patient and the Prehospital Emergency Psychiatric Unit. Attentive personnel who listen and take the patient's mood seriously create a calm and secure alliance in an acute psychiatric situation. We also emphasized the importance of having specialist nurses in psychiatric care, because of their knowledge and experiences in psychiatric and mental health nursing. Both the patients and the significant other felt supported and treated with respect and nonjudgmentally. Todorova et al. (2020) pointed out the importance of an emergency team with combined psychiatric and ambulance specialist expertise to improve patient safety. Suicidal persons are very vulnerable and Quinlivan et al. (2020) argued for the importance of staff in the health service working together to reduce suicide rates. Two of the ultimate and specific aims of the collaborative project described in this study are to reduce the stigmatization of mental illness and to prevent suicide. We have not yet evaluated this, but a feeling of support is undoubtedly very important for suicidal individuals. To create a feeling of support you need a therapeutic and empowering alliance with both patient and significant other (Gabrielsson et al., 2020; Sellin et al., 2017, 2018), which could enable mental health care to reduce suicide rates (Bolton et al., 2015; While et al., 2012). According to Creed et al. (2018), prehospital transport by emergency medical services for persons with mental illness crises can lower the utilization and costs of emergency departments. Therefore, it would be interesting to evaluate the satisfaction of patients treated by the Prehospital Emergency Psychiatric Unit, without transport to the psychiatric emergency clinic.

4.1. Study limitations

A sample of eleven participants may be seen as small. Every individual narrative was considered relevant for the study aim, however, providing different perspectives. The result highlights the narratives of patients, a significant other, staff at the Prehospital Emergency Psychiatric Unit, and psychiatric and mental health nurses at the psychiatric emergency clinic. The fact that only one significant other participated is the main limitation of the study. However, the experiences of the participants are similar and indicate that the Prehospital Emergency Psychiatric Unit is beneficial for individuals in need of care and support due to mental illness.

4.2. Implications for psychiatric nursing practice

Seeking psychiatric care can be a traumatic experience for patients as well as for significant others. The Prehospital Emergency Psychiatric Unit enables a safe person‐centered environment and for patients to stay in their homes, avoiding transportation to the psychiatric emergency clinic. Creating a safe environment is a cornerstone in psychiatric nursing care and enables a therapeutic relationship. In addition, the Prehospital Emergency Psychiatric Unit eases the pressure on the psychiatric emergency clinic, due to the possibility to evaluate and care for persons with mental illness in their homes.

Therefore, we think that a Prehospital Emergency Psychiatric Unit with knowledge and experience enabling them to create stability and a sense of self‐worth for the patients, should be self‐evident in the initial crucial evaluation of a person's mental health and need of psychiatric care. It also seems plausible that the Prehospital Emergency Psychiatric Unit has an important role both in reducing the stigma of mental illness and in suicide prevention.

CONFLICT OF INTEREST

The authors declare no conflict of interest.

Sunnqvist, C. , Berngarn, A. , Ezinne Ekezie, P. , Lundgren, E. , Nilsson, E. , & Örmon, K. A pilot evaluation of a prehospital emergency psychiatric unit: The experiences of patients, psychiatric and mental health nurses, and significant others. Perspect Psychiatr Care, 2022;58:2255–2262. 10.1111/ppc.13055

DATA AVAILABILITY STATEMENT

Data available on request from the authors The data that support the findings of this study are available from the corresponding author upon reasonable request.