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Assisting emergency nurses to offer the best care to those with mental health problems: Nurses in emergency departments face many pressures, including how to give those who present with mental health issues the best possible care. There are some developments aimed at helping ED nurses achieve this goal.

Emergency departments (EDs) in New Zealand have been used for the assessment of people with mental health problems since the move towards deinstitutionalised care. (1) Some ED nurses say they lack confidence in their knowledge and skills to care for these patients. This article discusses the challenges in providing mental health education to nurses in EDs and some of the ways ED nurses are being supported to give care to patients with mental health problems.

I am interested in this area because of my former roles as an ED clinician and an educator who helped facilitate national emergency nursing education. I have had many conversations with ED colleagues about their opportunities for mental health education. They describe a range of mental health undergraduate and postgraduate experience prior to emergency nursing. Courses are available for some ED specialty work such as trauma and triage. However, it can be difficult for ED nurses to access relevant and ongoing mental health education. These factors contribute to feelings of ambivalence, frustration and lack of confidence. This may result in an inconsistent standard of care for the person with a mental health problem. It is this inconsistency I wish to emphasise, as I have seen many examples of confident and excellent care being delivered to this group of people. The ED provides unique challenges as a working environment. It is periodically characterised by the lack of control over the influx of patients, frequent interruptions, rapid interventions, and a focus on physical illness and injury. (2, 3) Those working in EDs have a range of education needs, and ongoing mental health education competes with these other demands.

Trends in emergency care can also affect education. Greater use of technology has occurred, which creates training challenges. (4) The increasing complexity of those who present with a drug and alcohol component as well as a mental health issue, has been recognised as a challenge for EDs internationally. (5) ED health professionals also deal with hospital overcrowding, which is the most significant problem facing their speciality over the past decade. (6)

Such factors create pressure on dedicated education time and may distract from building a mental health education strategy for staff. It may also lead to an over reliance on busy mental health emergency teams and senior ED medical staff to provide mental health education. Studies indicate similar problems for generalist nurses working in emergency and other non-mental health environments. (7, 8, 9) One of the solutions identified in the literature is the mental health consultation/liaison nursing role. I have been hearing about the development of this role in some hospitals including their EDs. This is in addition to the model of a mental health crisis or emergency team, which is well established. I have heard of this role developing within New Zealand but there is no published evidence of this.

Mental health consultation/liaison nursing

A broad definition of the consultation/liaison role is "a specialist mental health nurse who consults to nurses and other healthcare professionals within a non-psychiatric general hospital, department or unit." (10) But the rote can vary in different workplaces.

In Australia, two researchers investigated the consultation/liaison role in two EDs. They found it involved networking and mediating between ED medical and nursing staff and the various mental health services. (11) Administrative activities included the development of treatment policies and resource folders. Clinical activities included triage assessment and debriefing. Feedback from the ED nurses identified an improved relationship between mental health and ED services, and decreased waiting times for people with mental health problems. Interestingly, project participants related its success to the fact the role was not part of the ED staff establishment. This degree of independence, in the view of the participants, made it easier for the person in this position to challenge entrenched attitudes. (11)

Additional benefits of the consultation/ liaison role, such as the rote modelling that occurred informally, have been outlined. As a result, ED staff were more interested in working with patients with mental health problems as their confidence improved. (12)

Potential tensions

The introduction of new roles such as the consultation/liaison role can potentially create tensions between ED and mental health staff philosophies. One researcher described the experiences of mental health nurses working in various triage roles, including those based in EDs. Mental health nurses who worked in ED perceived that undue pressure was placed on them by ED staff "to assist in relieving the burden of psychiatric clients on the emergency department". (13)

Misunderstandings occur between health professional groups and frequently "another person's agenda is assumed rather than made explicit, so that barriers between professionals build without any attempt to explore the issues behind them." (14) Planning to effectively embed newly created roles, such as the consultation-liaison role, is very important. (15)

These themes of support for professional learning fit with objectives outlined in the Report of the Safe Staffing/Healthy Workplaces Committee of Inquiry. This report states that the work environment is "the principal place of learning and education, and future efforts should maximise opportunities for knowledge and skill acquisition at the point of care". (16)

The consultation/liaison role has the potential to assist staff at the point of care. The same report outlines the importance of collaboration between education and health providers to ensure relevance of training to the workplace. (15) This theme of collaboration links to another example of learning support for ED nurses.

In 2005, the New Zealand Guidelines Group (NZGG) launched a project entitled Self harm and suicide prevention collaborative: A project for emergency departments, Maori health and mental health services. (17) This developed from one of the objectives of the New Zealand Health Strategy to reduce suicide rates and suicide attempts. The project is aimed at implementing the recommendations of the Ministry of Health's guideline on improving the care of people in EDs at risk of suicide. (17) Modelled on a quality improvement programme used in Australia, it involves collaboration between the various stakeholders to create sustainable change. Currently 17 EDs are taking part. As part of the project, emergency and mental health professionals are reviewing their focal processes to address barriers to quicker assessment of those at risk of suicide. Teleconferences are held regularly to allow each service to share its progress. There is also a website which has progress reports as well as international links to useful websites.

This project is a work in progress but it provides staff with networking opportunities and the ability to exchange ideas and resources. This type of model is described by the Health Workforce Advisory Committee as an example of ongoing development and evolution of health professionals' education. The committee states that "forums to discuss focal research and evaluation projects should be used to publicise and share information, and to promote safety, quality, service and workforce improvement". (18)

This article has looked briefly at two developments within the New Zealand emergency setting which address ongoing education needs. Demonstrating ongoing competency is critically important for registered nurses under the Health Practitioners' Competence Assurance Act 2003. Achieving ongoing relevant education for nurses in clinical and support roles can be challenging but the role and project described here have the potential to achieve this. Learning support does not necessarily lead to best clinical practice but it can assist health professionals "to articulate their discomforts and uncertainties, admit to their lack of knowledge without fear of being seen as weak or helpless, and devise ways of overcoming the constraints on acquiring a sense of confidence and self-esteem, which so often seem to characterise the pressures on health care staff". (14)

It is too early to establish outcomes related to the self harm and suicide prevention collaborative project but published evaluation of the mental health consultation/liaison role in New Zealand is recommended.

Ultimately, the aim of the consultation/liaison role, of the guideline project and of all efforts to support ED nurses in their job, is to achieve positive outcomes for those who present with a mental health problem to an ED.


1) Ministry of Health. (2003) New Zealand Health Strategy. DHB Toolkit. Mental Health. Retrieved 04/04/2005.

2) Wears, R.L., Croskerry, P., Shapiro, M., Beach, C., & Perry, S.J. (2002 Center for safety in emergency care: A developing center for evaluation and research in patient safety. Topics in Health Information Management; 23: 2, 1-12.

3) McArthur, M. & Montgomery, P. (2004) The experience of gatekeeping: A psychiatric nurse in an emergency department. Issues in Mental Health Nursing; 25, 487-501.

4) Knaggs, M. (2003) Balancing the art of nursing with technical expertise ... an emergency nurse's perspective. Unpublished research paper in nursing. Wellington: Victoria University.

5) Spain, D. (2004) Distinguishing medical from psychiatric causes of mental disorder presentations. In P. Cameron., G. Jelinek., A.M. Kelly., L. Murray., A.F.T. Brown & J. Heyworth (Eds) Textbook of Adult Emergency Medicine. Edinburgh: Churchill Livingstone.

6) Ardagh, M. and Richardsons, S. (2004) Emergency department overcrowding--can we fix it? The New Zealand Medical Journal; 117: 1189, 1-6.

7) Crowley, J. (2000). A clash of cultures: A & E and mental health. Accident and Emergency Nursing; 8, 2-8.

8) O'Brien, A.J., Hughes, F., & Kidd, J.D. (2006) Mental health nursing in New Zealand primary health care. Contemporary Nursel; 21, 142-152.

9) Royal College of Psychiatrists & British Association for Accident and Emergency Medicine. (2004) Psychiatric services to accident and emergency departments, Retrieved06/03/2005.

10) Sharrock, J., Grigg, M., Happell, B., Keeble-Devlin, B., & Jennings, S. (2006) The mental health nurse: A valuable addition to the consultation-liaison team. International Journal of Mental Health Nursing; 15, 35-43.

11) Gillette, J., & Bueknell, M. (1996) Transforming emergency department culture: The impact of the psychiatric nurse consultant. Proceedings of the Australian and New Zealand College of Mental Health Nurses Inc 22nd annual conference, New Zealand.

12) McDonough, S., Wynaden, D., Finn, M., McGowan, S., Chapman, R., $ Hood, S. (2004) Emergency department mental health triage consultancy service ... an evaluation of the first year of the service. Accident and Emergency Nursing; 12, 33-38.

13) Sands, N. (2004) Mental health triage nursing: An Australian perspective. Journal of Psychiatric and Mental Health Nursing; 11, 150-155.

14) Morton-Cooper, A. and Palmer, A. (2000) Mentoring, preceptorship and clinical supervision: o guide to professional support roles in clinical practice. (2nd Ed.) Oxford: Blackwell Science.

15) Lee, S. (2006) The advanced practitioner's guide to integrating physical and mental health: introducing the role of the mental health consultant liaison nurse. Unpublished research paper in nursing. Wellington: Victoria University.

16) Safe Staffing/Healthy Workplaces Committee of Inquiry. (2006) Report of the Safe Staffing/Healthy Workplaces Committee of Inquiry. Wellington: Author.

17) New Zealand Guidelines Group. (2006) Self harm and suicide prevention collaborative: a project for emergency departments, Moori health and mental health services. Retrieved 01/08/2006.

18) Health Workforce Advisory Committee. (2003) The New Zealand Health Workforce Future Directions--Recommendations to the Minister of Health. Wellington: Author.

Charlotte Thompson, RN,MA (Applied) Nursing, is a professional nursing adviser with NZNO. She has previous clinical nurse educator experience in emergency departments at MidCentral and Capital and Coast District Health Boards. This article was developed from her masters thesis Caring for people with mental health problems who present at the ED: A nurse educator's journey.
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Title Annotation:Enrolled Nurses
Author:Thompson, Charlotte
Publication:Kai Tiaki: Nursing New Zealand
Geographic Code:8NEWZ
Date:Sep 1, 2006
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