Research paper| Volume 18, ISSUE 3, P138-148, August 2015

US emergency nurses’ perceptions of challenges and facilitators in the management of behavioural health patients in the emergency department: A mixed-methods study

Published:April 29, 2015DOI:



      Behavioural health patients often have longer lengths of stay in the emergency department compared with general medical patients, and their modalities of care are not well documented. This study's purpose is to describe US emergency nurses’ estimates of lengths of stay for behavioural health patients, explore factors affecting length of stay, and assess nurses’ perceptions of their skills, beliefs/attitudes, and confidence in caring for this population.


      Using a mixed-methods design with demographically-diverse samples of emergency nurses, survey data (N = 1229) were analysed using descriptive statistics, correlation coefficients, and linear regression. Focus group participant data (N = 20) were analysed for themes using constant comparison.


      Findings suggest that shorter lengths of stay are associated with higher levels of perceived nursing confidence/preparation to care for this population, along with the availability of appropriate resources and protocols/standards of care (p = 0.01). Longer lengths of stay are associated with an absence of dedicated inpatient space for managing the care of these patients.


      Participants note a lack of education, resources, and treatment options tailored to the delivery of safe, effective care for behavioural health patients. The use of trained specialists and additional guidelines/protocols may help move patients through the emergency department faster and with greater surety.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Australasian Emergency Care
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Centers for Medicare and Medicaid Services, and Substance Abuse and Mental Health Services Administration
        Behavioural health MITA, concept of operations document version 2.0.
        Author, Baltimore, MD2008 (Available from: [accessed 09.01.14])
        • Owens P.L.
        • Mutter R.
        • Stocks C.
        Mental health and substance abuse-related emergency department visits among adults, 2007.
        Agency for Healthcare Research and Quality, Rockville, MD2010 (HCUP statistical brief no. 92. Available from: [accessed 09.01.14])
        • Clarke D.E.
        • Hughes L.
        • Brown A.M.
        • Motluk L.
        Psychiatric emergency nurses in the emergency department: the success of the Winnipeg, Canada, experience.
        J Emerg Nurs. 2005; 31: 351-356
        • Gordon J.T.
        Emergency department junior medical staff's knowledge, skills and confidence with psychiatric patients: a survey.
        Psychiatrist. 2012; 36: 186-188
        • Kerrison S.A.
        • Chapman R.
        What general emergency nurses want to know about mental health patients presenting to their emergency department.
        Accid Emerg Nurs. 2007; 15: 8-55
        • McAllister M.
        • Creedy D.
        • Moyle W.
        • Farrugia C.
        Study of Queensland emergency department nurses’ actions and formal and informal procedures for clients who self-harm.
        Int J Nurs Pract. 2002; 8: 184-190
        • Purves D.
        • Sands N.
        Crisis and triage clinicians’ attitudes toward working with people with personality disorder.
        Perspect Psychiatr Care. 2009; 45: 208-215
        • Stuhlmiller C.M.
        • Tolchard B.
        • Thomas L.J.
        • Kalucy R.S.
        • King D.
        Increasing confidence of emergency department staff in responding to mental health issues: an educational initiative.
        Aust Emerg Nurs J. 2004; 7: 9-17
        • Valdez A.M.
        So much to learn, so little time: educational priorities for the future of emergency nursing.
        Adv Emerg Nurs J. 2009; 31: 337-353
        • Wand T.
        • Happell B.
        The mental health nurse: contributing to improved outcomes for patients in the emergency department.
        Accid Emerg Nurs. 2001; 9: 166-176
        • Stefan S.
        Emergency department treatment of the psychiatric patient: policy issues and legal requirements.
        Oxford Press, New York2006
        • Brinn F.
        Patients with mental illness: general nurses’ attitudes and expectations.
        Nurs Stand. 2000; 14: 32-36
        • Putman S.
        Mental illness: diagnostic title or derogatory term (attitudes toward mental illness). Developing a learning resource for use within a clinical call center. A systematic review on attitudes towards mental illness.
        J Psychiatr Mental Health Nurs. 2008; 15: 684-693
        • Reed F.
        • Fitzgerald L.
        The mixed attitudes of nurses to caring for people with mental illness in a rural general hospital.
        Int J Mental Health Nurs. 2005; 14: 249-257
        • Ross C.A.
        • Goldner E.M.
        Stigma, negative attitudes and discrimination towards mental illness within the nursing profession: a review of the literature.
        J Psychiatr Mental Health Nurs. 2009; 16: 558-567
        • Baraff L.J.
        • Janowicz N.
        • Asarnow J.R.
        Survey of California emergency departments about practices for management of suicidal patients and resources available for their care.
        Ann Emerg Med. 2006; 48: 452-458
        • American College of Emergency Physicians
        ACEP psychiatric and substance abuse survey 2008.
        Author, Dallas, TX2008 (Available from: [accessed 15.12.13])
        • Illinois Hospital Association
        • Behavioural Health Steering Committee Best Practices Task Force
        Final report: best practices for the treatment of patients with mental and substance use illnesses in the Emergency Department, 2007.
        Author, Naperville, IL2007 (Available from: [accessed 15.12.13])
        • Waseem M.
        • Prasankumar R.
        • Pagan K.
        • Leber M.
        A retrospective look at length of stay for paediatric psychiatric patients in an urban emergency department.
        Pediatr Emerg Care. 2011; 27: 170-173
        • Little D.R.
        • Clasen M.E.
        • Hendricks J.L.
        • Walker I.A.
        Impact of closure of mental health center: emergency department utilization and length of stay among patients with severe mental illness.
        J Health Care Poor Underserved. 2011; 22: 469-472
        • Nicks B.A.
        • Manthey D.M.
        The impact of psychiatric boarding in emergency departments.
        Emerg Med Int. 2012; (article ID 360308. Available from: [accessed 15.12.13]): 5pages
        • Slade E.B.
        • Dixon L.B.
        • Semmel S.
        Trends in the duration of emergency department visits, 2001–2006.
        Psychiatr Serv. 2010; 61: 878-884
        • Kropp S.
        • Andreis C.
        • te Wildt B.
        • Reulbach U.
        • Ohlmeier M.
        • Auffarth I.
        • et al.
        Psychiatric patient's turnaround times in the emergency department.
        Clin Pract Epidemiol Mental Health. 2005; 1 (5 pp. Available from: [accessed 15.12.13])
        • Park J.M.
        • Parl L.T.
        • Siefert C.J.
        • Abraham M.E.
        • Fry C.R.
        • Silvert M.S.
        Factors associated with extended length of stay for patients presenting to an urban psychiatric emergency service: a case–control study.
        J Behav Health Serv Res. 2009; 36: 300-308
        • Chang G.
        • Weiss A.P.
        • Orav E.J.
        • Jones J.A.
        • Finn C.T.
        • Gitlin D.F.
        • et al.
        Hospital variability in emergency department length of stay for adult patients receiving psychiatric consultation: a prospective study.
        Ann Emerg Med. 2011; 58: 127-136
        • Weiss A.P.
        • Chang G.
        • Rauch S.L.
        • Smallwood J.A.
        • Schechter M.
        • Kosowsky J.
        • et al.
        Patient- and practice-related determinants of emergency department length of stay for patients with psychiatric illness.
        Ann Emerg Med. 2012; 60 (e5): 162-171
        • Press Ganey
        2010 emergency department pulse report: patient perspectives on American Health Care.
        Author, South Bend, IN2010 (Available from: [accessed 15.12.13])
        • American College of Emergency Physicians
        Policy statement: definition of boarded patient.
        Author, Dallas, TX2011 (Available from: [accessed 20.11.14])
        • Schumacher Group
        Emergency department challenges and trends: 2010 survey of hospital emergency department administrators.
        Author, Lafayette, LA2010 (Available from: [accessed 20.11.14])
        • White B.A.
        • Biddinger P.D.
        • Chang Y.
        • Grabowski B.
        • Carignan S.
        • Brown D.F.
        Boarding inpatients in the emergency department increases discharged patient length of stay.
        J Emerg Med. 2013; 44: 230-235
        • Creswell J.
        • Plano Clark V.
        Designing and conducting mixed methods research.
        1st ed. Sage, Thousand Oaks2007
        • Emergency Nurses Association
        White paper care of the psychiatric patient in the emergency department.
        Author, Des Plaines, IL2013
        • Qualtrics
        Research suite [online software]. Version 52,327.
        Qualtrics, Provo, UT2014
        • IBM Corp
        IBM SPSS Statistics for Windows [Software]. Version 20.0.
        IBM Corp, Armonk, NY2012
      1. Crabtree B. Miller W. Doing qualitative research. 2nd ed. Sage, London1999
        • Chakravarthy B.
        • Tenny M.
        • Anderson C.L.
        • Rajeev S.
        • Instanbouli T.
        • Lotfipour S.
        Analysis of mental health substance abuse-related emergency department visits from 2002 to 2008.
        Subst Abus. 2013; 34: 292-297
        • Substance Abuse and Mental Health Services Administration
        • Center for Behavioral Health Statistics and Quality
        The DAWN report: monthly and seasonal variations in emergency department visits for drug-related suicide attempts: 2004 to 2008.
        Author, Rockville, MD2011 (Available from: [accessed 15.12.14])
        • Jones S.S.
        • Thomas A.
        • Evans R.S.
        • Welch S.J.
        • Haug P.J.
        • Snow G.L.
        Forecasting daily patient volumes in the emergency department.
        Acad Emerg Med. 2008; 15: 159-170
        • Creswell J.W.
        • Plano Clark V.L.
        • Gutmann M.L.
        • Hanson W.E.
        Advanced mixed methods research designs.
        in: Tashakkori A. Teddlie C. Handbook of mixed methods in social and behavioural research. Sage, Thousand Oaks, CA2003: 209-240
        • Bryman A.
        Integrating quantitative and qualitative research: how is it done?.
        Qual Res. 2006; 6: 97-113
        • Agency for Healthcare Research and Quality
        Emergency severity index (ESI): a triage tool for emergency department: DVDs and 2012 edition of the implementation handbook.
        Author, Rockville, MD2013 (Available from: [accessed 26.02.15])
        • Canadian Association of Emergency Physicians
        Canadian Triage Acuity Scale.
        Author, Ottawa, Canada2013 (Available from: [accessed 26.02.15])
        • McCallum Pardey T.G.
        The clinical practice of emergency department triage: application of the Australasian Triage Scale – an extended literature review part I: evolution of the ATS.
        Australas Emerg Nurs J. 2006; 9: 155-162
        • Bystrek D.J.
        Emergency department doctors’ and nurses’ knowledge and attitudes concerning substance use and users.
        J Trauma Nurs. 2010; 17: 119-120
        • Gordon J.T.
        Emergency department junior medical staff's knowledge, skills and confidence with psychiatric patients: a survey.
        Psychiatrist. 2012; 36: 186-218
        • Egan R.
        • Sarma K.M.
        • O’Neill M.
        Factors influencing perceived effectiveness in dealing with self-harming patients in a sample of emergency department staff.
        J Emerg Med. 2012; 43: 1084-1090
        • Kelleher S.
        • Cotter P.
        A descriptive study on emergency department doctors’ and nurses’ knowledge and attitudes concerning substance use and substance users.
        Int Emerg Nurs. 2009; 17: 3-14
        • Boudreaux E.D.
        • Allen M.H.
        • Claassen C.
        • Currier G.W.
        • Bertman L.
        • Glick R.
        • et al.
        The psychiatric emergency research collaboration-01 (PERC-01): methods and results.
        Gen Hosp Psychiatry. 2009; 31: 515-522
        • Douglass A.M.
        • Luo J.
        • Baraff L.J.
        Emergency medicine and psychiatry agreement on diagnosis and disposition of emergency department patients with behavioural emergencies.
        Acad Emerg Med. 2011; 18: 368-373
        • Boudreaux E.D.
        • Niro K.
        • Sullivan A.
        • Rosenbaum C.D.
        • Allen M.
        • Camargo Jr., C.A.
        Current practices for mental health follow-up after psychiatric emergency department/psychiatric emergency service visits: a national survey of academic emergency departments.
        Gen Hosp Psychiatry. 2011; 33: 631-663