Emergency department nurses’ care of psychiatric patients: A scoping review

International Emergency Nursing 54 (2021) 100929

Contents lists available at ScienceDirect

International Emergency Nursing journal homepage: www.elsevier.com/locate/aaen

Review

Emergency department nurses’ care of psychiatric patients: A scoping review Jennifer T. Perrone McIntosh a b

a,b,⁎

T

Adelphi University, Garden City, NY 11531, United States Farmingdale State College, Farmingdale, NY 11735, United States

ARTICLE INFO

ABSTRACT

Keywords: Emergency Department Nurses’ role Psychiatric patients Emergency nursing Mental illness

The emergency department (ED) is a difficult place for psychiatric patients. However, individuals with mental illness often use the Emergency Department as a primary source of healthcare. This study was conducted to identify and examine published literature related to ED nurses’ care of individuals with mental illness and to identify associated research gaps. A scoping review within the Arksey and O’Malley [11] framework was un­ dertaken to answer, “what factors influence ED nurses’ care of individuals with mental illness?” Sixteen studies met the inclusion criteria. The PRISMA method [16] was used to illustrate the flow of studies. The review resulted in three main themes influencing ED nurses’ care for psychiatric patients. These were concerns related to environment; beliefs and perceptions; and knowledge and confidence. The results are described and framed within Biddle's role theory [33], and the gaps in the literature related to research and recommendations for specific investigations are presented.

1. Introduction Emergency department (ED) nurses are well-trained to care for in­ dividuals presenting with acute physical complaints and emergencies; However, they lack training and confidence in caring for psychiatric patients [1]. Consequently, individuals presenting to the emergency department with mental illness receive care that is traditionally based on a medical model which also holds a different belief of recovery [2]. Due to the healthcare disparities, poor health outcomes, and high ED utilization, ED nurses have a significant role in effecting change. Therefore, it is critical to understand the factors that influence the ED nurses’ care of psychiatric patients. In comparison to the general population, individuals with mental illness die on average twenty-five years sooner from treatable medical conditions [3]. The mortality rate is higher among mentally ill patients with medical comorbidities when compared to those without medical comorbidities [4]. Serious mental illness costs America nearly $193.2 billion in lost earnings per year [5]. The Agency for Healthcare Re­ search and Quality [AHRQ] [6] reported that one in eight patients present to the emergency departments because of mental health and substance abuse complaints; this is nearly 12 million visits per year. There has been a 55% increase of individuals visiting the ED with mental illness since 2008 and an increase of 415% of patients pre­ senting to the ED with suicidal ideation, often attributed to limited care options [6]. Despite these statistics, emergency department nurses

⁎

report feeling unprepared to identify and meet the needs of individuals presenting to the ED with mental illness [7–9]. The statistics suggest that individuals with mental illness experience healthcare disparities, and have limited access to resources and care options [6,10]. Adequate care for individuals with mental illness is dependent on competent providers as well as adequate healthcare systems. Nurses, as the largest group of healthcare professionals, are at the frontline and the most impacted by the surge of patients seeking care for mental illness in the ED. The nursing care of individuals with mental illness in the ED is complex. A scoping review is undertaken to contextualize knowledge on the nursing care of psychiatric patients in the ED, determine the current understanding, and identify gaps in the literature. A scoping review is a study that allows for the mapping of key concepts and relevant litera­ ture in a field of interest [11]. The purpose of this review is to 1) de­ termine what is known about the nursing care of psychiatric patients in the ED and 2) discover the factors that impact the quality of nursing care of psychiatric patients in the ED. This is significant because an understanding of the barriers that ED nurses face in caring for psy­ chiatric patients can enhance the experience and quality of care pro­ vided which will lead to better patient outcomes, decreased recidivism, and decreased mortality. Hospital administrators could allocate efforts to design training and competencies tailored to the care of individuals with mental illness in the ED setting. By doing so, ED nurses will be better equipped to recognize their potential biases, and provide safe,

Address: 2350 NY-110, Farmingdale, NY 11735, United States. E-mail address: [email protected].

https://doi.org/10.1016/j.ienj.2020.100929 Received 2 April 2020; Received in revised form 6 August 2020; Accepted 8 September 2020 1755-599X/ © 2020 Elsevier Ltd. All rights reserved.

International Emergency Nursing 54 (2021) 100929

J.T. Perrone McIntosh

quality, respectful and dignified care to psychiatric patients. Lastly, findings from this review can also inform policy makers to create ap­ propriate resources and assistance for individuals with mental illness.

[14]. Including grey literature in a scoping review allows for a com­ prehensive data selection relevant to the topic of interest [15]. There­ fore, websites, such as the Emergency Nurses Association and the American Psychiatric Nurses Association were searched. A reference list of all of the full text publications from the databases and websites searched were reviewed until saturation was achieved. ProQuest RefWorks, a web-based commercial reference management software, was used to facilitate storage, screening and management of the search results.

2. Methodology A scoping methodology was used to explore the breadth of literature on ED nurses’ care of psychiatric patients. A scoping review differs from a systematic review in that a scoping review allows for the mapping of relevant literature in a field of interest [11]. Scoping studies “aim to map rapidly the key concepts underpinning a research area and the main sources and types of evidence available, and can be undertaken as stand-alone projects in their own right, especially where an area is complex or has not been reviewed comprehensively before” [11]. Scoping reviews lead to recommendations for future research, and aim to provide contextual knowledge and the identification of existing lit­ erature gaps [12,13]. The scoping review allows for analytic frame­ works or thematic development [11]. The Arksey and O’Malley [11] framework uses five stages for con­ ducting a scoping review: 1) identifying the research question; 2) identifying the relevant studies; 3) study selection; 4) charting the data; and 5) collating, summarizing and reporting the results.

2.3. Stage three: study selection Arksey and O’Malley [11] describe the study selection process as a systematic process of sorting through the literature from the review. The PRISMA [16] methodology is used to illustrate the flow of studies (shown in Fig. 1). To answer the research question, publications which included the following criteria were used:

• Emergency department nurses caring for psychiatric patients or in­ dividuals presenting with mental illness symptoms were included • Studies that included mental health nurses caring for psychiatric patients in the ED were excluded • The setting was limited to the emergency department

2.1. Stage one: the research question

The review process was completed by one reviewer. All titles from the list of 389 publications were reviewed. 188 records were removed due to duplication. The titles which were ambiguous were maintained for further evaluation. Following the review of titles, the abstracts of the remaining 193 publications were screened for relevance to the re­ search question and inclusion criteria. Records not related to the nur­ sing care of psychiatric patients in the ED, and those on substance use disorders and nursing students were excluded. Editorials were also excluded from this review. The remaining 88 full-text articles were further assessed for eligibility. Articles were excluded if they focused on the patient experience; general ED staff (doctors, nurse practitioners, physician assistants and support staff); psychiatric mental health nurses; inpatient psychiatric setting; inpatient medical setting; com­ munity setting; substance uses; general ED nurse experience that ex­ cludes the psychiatric patient. Sixteen studies were selected for this scoping review.

The first stage of the Arksey and O’Malley [11] framework requires the identification of an area of interest, and to explore concepts, such as the target population. The research question aims to guide the em­ ployed search strategy. The research question for this review was: What factors influence ED nurses’ care of psychiatric patients? 2.2. Stage two: identifying the relevant studies According to Arksey and O’Malley [11], to identify relevant studies that will answer the research question, a comprehensive search of various sources must be performed. Electronic databases were searched for peer-reviewed publications and grey literature sources that were deemed relevant to answer the research question. The keywords used for the search with Boolean phrases included: mental illness, psychiatric symptoms, psychiatric patients, emergency de­ partment, emergency room, behavioral health, nurse, mental health. Boolean operators used were ‘AND’ and ‘OR’ and ‘NOT’. Excluded terms ‘NOT’ in the search included psychiatric behavioral health nurses and psychiatric units This search was undertaken in relevant EBSCOhost databases: CINAHL Complete, Health Source: Nursing/Academic Edition and Medline; OneSearch; Cochrane Database of Systematic Reviews; Google Scholar; PubMed; ProQuest Dissertations and Theses Global and the Joanna Briggs Institute. These databases were searched as they were relevant to the topic of interest and research question. The search was limited to publications in the English language, including published dissertations. In order to capture a wide range of studies, publications over a 15-year period (2005–2020) were included; the final search was conducted in March 2020. Studies were excluded if they did not discuss nursing care of patients with mental illness in the ED; focused on the patient experience, substance use, nursing students caring for psychiatric patients, non-nursing healthcare professionals, and letters to the editor. Grey literature is referred to any document not published by com­ mercial publishers, such as dissertations, theses and government reports

2.4. Stage four: charting the data This stage of the Arksey and O’Malley [11] framework requires the synthesis and interpretation of the data to assist in answering the re­ search question. The studies included in this review were charted and classified according to author, purpose, setting, sample description and size, study design, data collection method, key points from the studies, and their associated themes (Table 1). 2.5. Stage five: collate, summarize and report results This final stage of the Arksey and O’Malley [11] framework requires a qualitative description to summarize and synthesize the data. A final discussion that applies the meaning of the identified results is required. Coding and categorization of concepts within the literature, known as qualitative thematic analysis as described by Levac et al. [32], is used as a method of analysis for this review.

2

International Emergency Nursing 54 (2021) 100929

J.T. Perrone McIntosh

Fig. 1. PRISMA 2009 Flow Diagram.

nurse” would constitute a social position with specific characteristic patterns and predictable behaviors. Furthermore, the ED nurse as a social position has sets of expectations to exhibit characteristic roles. Biddle [33] also posits that role expectations occur through socializa­ tion or learned behavior enforced by others. Role Theory can also be viewed as a theatrical performance where actors are constrained to perform their assigned parts and scripts [34]. As such, ED nurses’ role is shaped by socialization, experiences, reinforced behaviors, and “per­ formance” expectations. Biddle [33] also posits that roles can be problematic, at times. Roles can be difficult to perform if they are challenging. Roles can take a long time to learn. When a person is not able to meet their role expectation, role conflict can arise [33]. This can occur primarily when a person has two or more obligations competing for their attention. In the context of the ED nurse, role conflict can arise when a nurse is competing to care for patients with physical complaints and for psychiatric patients. When formal positions in an organization are not explained, the person does not understand what specific skills and responsibilities are expected, thus role ambiguity arises [33]. For example, if the ED nurse does not understand or possess specific skills, knowledge and attitudes that are needed to effectively care for psychiatric patients, they may have to rely on trial and error to meet the patients’ and the standard of care ex­ pectations. Lastly, role overload can occur when the role demands are high [33]. This can lead to the person having their quality of work compromised due to time pressures and heavy workload [35]. The use

3. Results The Table of Evidence Summarizing the Articles Reviewed for ED Nurses Care for Psychiatric Patients appears in Table 1. This scoping review includes sixteen studies (see Table 1). The majority of the stu­ dies were qualitative (n = 10), including dissertations (n = 2) as part of the grey literature; quantitative studies (n = 3), and mixed-method studies (n = 3). The studies were mostly international originating from Australia (n = 8); U.S. (n = 5); Canada (n = 2); and Brazil (n = 1). All the studies included ED nurses as participants. The data collection methods included interviews, focus groups and surveys. Publication years ranged from 2006 to 2018. The numerical analysis of the results provides a better understanding of the breadth and nature of the lit­ erature. Biddle’s [33] role theory assisted in organizing the emerging themes from the literature. 3.1. Theoretical framework Biddle [33] defines role theory as a “science concerned with the study of behaviors that are characteristic of persons within contexts and with various processes that presumably produce, explain, or are af­ fected by those behaviors” (p.4). Role theory includes essential features of social life and characteristic patterns of behavior known as roles [34]. Human beings behave in ways that are different, but predictable based on their social identity and position [34]. Therefore, the “ED 3

4

To explore issues around clinician’s knowledge and confidence in this area of emergency medicine.

Jelinek et al. [22]

Jackson [21]

To identify issues from the ED clinicians’ viewpoint with the management of patients presenting to the ED with mental illness To explore the lived experiences of the emergency department nurses who have suffered patientinitiated violence in Eastern Tennessee

Innes et al. [20]

To explore how triage nurses in general emergency departments make clinical decisions for patients who present with mental illnessrelated conditions.

Clarke et al. [18]

To evaluate the effectiveness of a tailored TIC education package for ED nursing staff and to describe subsequent clinical practice that was trauma informed after TIC education

To explore the experience of rural nurses in managing acute mental health presentations within an emergency context.

Beks et al. [17]

Hall, et al. [19]

Study Purpose

Author/Date

Australia

16 ED nurses and 20 ED doctors

24 Eastern Tennessee ED nurses with at least 6 months experience

N = 61 (survey); n = 48 (focus groups)

Australia ED

U.S.

N = 34 ED nurses participated in TIC education; n = 14 ED nurses participated in focus groups

N = 11 ED nurses with triage experience

N = 13 rural generalist nurses

Sample description, size (n)

Australia 1 Urban and 1 rural ED

Manitoba, Canada ED

Australia rural ED and rural urgent care centers

Setting

Table 1 Table of Evidence Summarizing the Articles Reviewed for ED Nurses Care of Psychiatric Patients.

Qualitative

Descriptive phenomenology

Mixed method

Mixed method

“Think Aloud” qualitative methodology

Qualitative

Study design

Semi-structured telephone interviews

Focus group interviews

Survey and focus groups

Pre and post-education questionnaire Two one-off focus groups

Participants received 5 paperbased scenarios and asked to talk into voice recorder about reasoning process for triage using the CTAS e-triage computer software

Semi-structured face to face interview

Data collection method

Physical Environment of the ED Time Constraint Knowledge and Confidence

Perceptions and Experiences of Aggression

Physical Environment of the ED Time Constraints

Physical Environment of the ED Time Constraints Perceptions and Experiences of Aggression Knowledge and Confidence

Time Constraint Triage and Assessment Uncertainties Perceptions and Experiences of Aggression Knowledge and Confidence Time Constraint Resource Scarcity Triage and Assessment Uncertainties Perceptions and Experiences of Aggression Knowledge and Confidence

Subthemes

(continued on next page)

Themes: 1) managing the scores; 2) managing the current ED environment; 3) managing uncertainty and risk, and 4) managing own distress and confidence in communicating with patients in distress. Increased comfort in situations where police waited with patients in the ED; Triage score manipulated to increased nurses comfort gambling/paying/ overriding the system. Willingness to adjust communication approach to elicit information for better decisionmaking. Lack of confidence in eliciting information and lack of confidence in communication skills; limited time for triage. ED environment complexity and pressures posed some challenges in applying the Trauma-Informed Care (TIC) framework as a means of reducing restrictive interventions. Time constraints related to rapid turnover and complex presentations. 4 RNs had previous work experience in mental health setting. General understanding that TIC can reduce re-traumatization. Major themes: human resources, educational preparation, communication, environmental factors, restraint of patients and the treatment of relatives/carers Lack of leadership support. Feelings of helplessness and powerlessness by nurses. Nurses were more understanding of violent acts if the patient had mental illness Nurses identified risk assessment; differentiating psychiatric disorders; behavior management as knowledge gap

Nurses reported lack of preparation for assessing and managing individuals with mental illness

Key points

J.T. Perrone McIntosh

International Emergency Nursing 54 (2021) 100929

To gain an understanding of the experiences of ED nurses caring for clients with a mental illness in the ED.

To understand how RNs working in the ED conceptualize recovery for people experiencing mental illness. Primary question: “What is your understanding of recovery as it applies to consumers with a mental illness in the Emergency Department?”

To assess A&E nurses’ attitudes towards patients who engage in deliberate self-harm, and in particular the influence of age, length of clinical experience, or previous in-service education on those attitudes. To define the specialized skill and knowledge of emergency nurses by examining the frequency with which recommended psychiatric nursing competencies are performed in the ED setting. 2) To assess emergency nurses’ rankings of importance and self-efficacy related to recommended psychiatric nursing competencies in order to explore their relevance to emergency nursing To explore and describe ED nurses’ experiences, and feelings caring for patients with mental illness

MarynowskiTraczyk & Broadbent [23]

MarynowskiTraczyk, Moxham & Broadbent [2]

McCann et al. [24]

5

Plant & White [26]

Mello et al. [25]

Study Purpose

Author/Date

Table 1 (continued)

Medium-sized community hospital in northeastern U.S.

N = 10 ED RNs (all females)

N = 75 ED nurses

N = 43 ED nurses

Australia ED

U.S.

N = 14 ED nurses

ED nurses (n = 6) Purposive sampling;

Sample description, size (n)

Australian EDs

Australia

Setting

Qualitative- focus group format

Quantitative. Crosssectional design

Pre-posttest design

Qualitative. Phenomenological approach

Hermeneutic phenomenology

Study design

Interviews Data collection using Krueger and Casey’s method

Surveys to rank frequency, importance and self-efficacy of 15 psychiatric nursing competencies

Questionnaire

Structured interviews

Semi-structured interviews

Data collection method

Physical Environment of the ED Time Constraints General Beliefs Recovery does not Occur Knowledge and Confidence

Knowledge and Confidence

General Beliefs

Recovery does not Occur Stigma and Diagnostic Overshadowing Knowledge and Confidence

Time Constraints Physical Environment of the ED

Subthemes

(continued on next page)

Main theme: powerlessness captured the overarching and substantive experience of the participants. Facing the challenge; Struggling with the challenge; Unmovable barriers;

1. Time as a causative factor; 2. environment and the influence of surroundings and 3. understanding the client’s personal journey. Nurses experienced stress due to time constraints and workflow challenges imposed by individuals with mental illness 1. Recovery does not occur; 2. Seeking help from the ED; 3. Getting through the acute mental health crisis; 4. Referral to other areas of mental health care; 5. Implementing strategies for ongoing care; 6. Living in the community ED RNs have limited awareness of what recovery means to individuals with mental illness. Their conceptualization of recovery is based on the medical notion of recovery Increasing age, greater accident and emergency experience and attendance at specific deliberate self-harm education were factors that contributed to positive attitudes towards individuals who engage in deliberate self-harm Nurses ranked key assessment competencies that a required for the care of patients with psychiatric illness as important (mean 1.81, SD = 129 to 3.46, SD = 0.76), but consistently ranked the frequency of their performance (mean 0.64, SD = 1.06 to 3.01, SD = 0.92) and self-efficacy lower (3.13, SD = 0.78 to 3.49, SD = 0.74)

Key points

J.T. Perrone McIntosh

International Emergency Nursing 54 (2021) 100929

Vedana et al. [29]

To understand emergency nursing experiences in assisting people with suicidal behavior

To examine the impact of Mental Health Emergency Care-Rural Access Program (MHEC-RAP) on providing access to specialist care through the experience of local providers. (MHEC-RAP is a telepsychiatry service established in 2008 to provide access to specialist emergency mental care care). The interviews were also used to understand the ED providers’ experience of managing emergency mental health patients. To articulate the experience of ED nurses caring for individuals with mental health issues in the ED

Saurman et al. [27]

Tyerman [28]

Study Purpose

Author/Date

Table 1 (continued)

ED & pre-hospital services in Sao Paulo Brazil

Canada Urgent care Centers & ED nurses

Rural & remote EDs in Sydney, Australia

Setting

N = 19 who had cared for a patient either at risk for suicide or suicide attempt; 16% had mental health training; 21% had experience in mental health; 11% had suicide training.

Purposive & snowballing N = 10

N = 12 (managers and nurses and 1 GP)

Sample description, size (n)

Grounded Theory (Straus & Corbin)

Descriptive phenomenology

Qualitative methodHermeneutic phenomenology

Study design

Interviews

Interviews

Interview

Data collection method

6

Physical Environment of the ED Time Constraints Triage and Assessment Uncertainties Suicidality and Care Dissonance Perception and Beliefs of Aggression Stigma and Diagnostic Overshadowing Knowledge and Confidence Suicidality and Care Dissonance Stigma and Diagnostic overshadowing Knowledge and Confidence

Resource Scarcity Perceptions and Beliefs of Aggression Stigma and Diagnostic Overshadowing

Subthemes

(continued on next page)

Categories: Critical, challenging and complex situation; Judgments about unjustifiable act; Felt moved; Need to provide healthcare Of the sample size of 19, only 2 were nurses, the remainder were nursing assistants or nursing techs. Barriers to therapeutic care included lack of time, overburden of activities and brief contact; nonempathic reflection about suicide; unacceptable, intolerable & increased demands from professionals; Nurses experienced feelings of dissatisfaction, discrimination, negativity, compassion, altruism, discomfort. Lack of preparation for assisting this group linked to negative reactions.

Generally, providers had negative experiences about dealing with patients who were abusive, sedated and involuntarily admitted, absconding or threatening with no one to help. Mental health presentations were viewed to be difficult and challenging causing stress and disruption to the milieu. Guided by a modified Penchansky and Thomas’ theory of access to include accessibility, availability, acceptability, affordability, adequacy & awareness. Inadequate assessment & management of MH patient in the EDs; Lack of knowledge; ethical concerns related to restrictive interventions; stigma; environmental constraints; limited time; and role ambiguity. Fear of aggression and potential for harm to self and others contributed to the decision to implement control interventions that were often ethically distressing to the nurse

Key points

J.T. Perrone McIntosh

International Emergency Nursing 54 (2021) 100929

International Emergency Nursing 54 (2021) 100929

Time Constraints Resource Scarcity Triage and Assessment Uncertainties General Beliefs Perceptions and Beliefs of Aggression Stigma and Diagnostic Overshadowing

of Biddle’s [33] role theory can inform nurses and researchers about the role of ED nurses in caring for psychiatric patients. Three major themes and their sub themes emerged from this scoping review related to the nurse’s role in caring for psychiatric patients in the ED. The identified themes were: the environment and the role it plays; the influence of nurses’ perceptions and beliefs about psychiatric patients, psy­ chiatric diagnoses and patient behaviors; and the ED nurses’ knowledge and confidence and their impact on care. Throughout the following theme descriptions are quotes from the literature reviewed to further support and illuminate the findings and final themes.

Survey and focus group interviews

3.2. Theme 1 3.2.1. The ED environment and the nurse’s role Within the theme of environment and the nurse’s role, four related sub-themes were identified: the physical environment, related time constraints, resources and the overall impact on the process of triage within their role. 3.2.2. Physical environment of the ED The ED environment impacts the role of the ED nurse in their caring for psychiatric patients. Several studies found that the chaotic, fastpaced and overcrowding of the ED make “caring” difficult and cause ED nurses to experience burnout and trauma [1,19,28]. Participants in a study by Innes et al. [20] identified that the busy and noisy ED en­ vironment affected the care of psychiatric patients who can require a calm and quiet, low-stimulus environment. In addition to the chaotic ED environment, Plant and White [26] found in their study that the lack of privacy and the flow and function of the ED milieu as challenging for nurses to adequately care for psychiatric patients. Furthermore, safety and security features of the ED, lack of resources, and various levels of staff experiences also influenced ED nurses’ care of psychiatric patients [22]. 3.2.3. Time constraint as a barrier to caring In addition to the physical environment of the ED, time constraints were identified as impeding ED nurses’ abilities to providing quality care to psychiatric patients [28]. Feelings of guilt were expressed by nurses related to time [26]. Time constraints were related to rapid turnover and caused challenges for caring for complex presentations in the ED, such as psychiatric presentations [19,23]. Developing and maintaining therapeutic relationships with individuals with mental illness were difficult because of the brief contact and time constraints [17,20,29]. A participant in a study by Beks et al. [17] described “… Non-physical symptoms take more time too…you need to build a rap­ port and it’s hard to make someone feel like you care about them when you’ve only got a couple of minutes” (p. 6). In another study, a parti­ cipant reported “…Our biggest constraint in psychiatric issues is …very time consuming to that nurse…” [31], p.144). System delays such as access to timely care, waiting for medical clearance and waiting for mental health consults were reported as barriers to quality of care in the ED [18,20]. This coupled with the physical ED environment constraints negatively impacted the nursing care of psychiatric patients in the ED. In addition to its impact on care delivery, time also affected nurses’ confidence in caring for psychiatric patients, “…everyone is time poor and the aim is to use whatever length of time in the most effective way” [22] p.5).

N = 1229 (survey). N = 20 (focus group) U.S. To describe US emergency nurses’ perceptions of the current state of emergency care for behavioural health patients and the report identified facilitators and challenges. Wolf et al. [31]

Exploratory mixedmethod design

Knowledge and Confidence

ED nurses reported having moderately average competency in caring for behavioral health patients. Results not generalizable since study included ED nurses, non-ED nurses and other allied health personnel. Competencies were self-reported. Participants reported lack of education, resources, and treatment options. Longer lengths of stay associated with the absence of dedicated space for behavioural health patients Survey 102 participants (72% ED nurses, 20% non-ED nurses, 8% allied health personnel) U.S. To determine the effects of a 7hour concentrated education experience on perceived competency of nurses and other allied health professionals to care for behavioral health patients Winokur et al. [30]

Pre-post study

Subthemes Key points Data collection method Study design Sample description, size (n) Setting Study Purpose Author/Date

Table 1 (continued)

J.T. Perrone McIntosh

3.2.4. Resource scarcity The lack of resources, especially related to psychiatric care resulted in feelings of discomfort by ED nurses generating thoughts such as, “we can’t deal with this… why do you come here? …wrong hospital, honest, we don’t have psychiatry in this area” [18], p. 500). The limited availability of mental health professionals and police/law enforcement assistance were identified as potential limitations to managing mental 7

International Emergency Nursing 54 (2021) 100929

J.T. Perrone McIntosh

health emergencies in the ED [27]. “…they aren’t getting the treatment here- they need to be in a facility that can manage them better…” [31] p. 144). The pressures and complexities of the ED environment make it difficult for nurses to implement non-restrictive interventions [19].

standard of care was identified as “stabilize and transfer” or to obtain medical clearance by obtaining “pee in a cup” [31]. Physical and che­ mical restraints were viewed as being an important safety measure to protect the patients from self-harm and from harming others [20]. “…Getting rid of them…often means sedating them and putting them down…” [31] p.144). Contrary to the majority of literature, a study by McCann et al. [24] found that older and more experienced nurses had more positive attitudes toward patients who self-harm as compared to younger and less experienced nurses.

3.2.5. Triage and assessment uncertainties The triaging process was also described as a constraint to caring for psychiatric patients in the ED. During assessments, ED nurses found that the lack of, or limited information from patients, collateral sources, and objective observations led to uncertainty about the patients’ pre­ sentation [18] and thus influenced their interaction with patients. Participants in a study by Beks et al. [17] reported that their un­ certainty in assessing psychiatric patients “…am I asking the right question, am I going to say something to trigger them?” (p.6). Prioritization of patient care was also challenging for ED nurses when interacting with psychiatric patients. Physical symptoms were triaged as having greater priority than mental illness [28]. “When you look after a multiple number patients, it’s the individual who presents the most critically ill with visible symptoms would be a priority over someone presenting with mental health issues. Unless they have a lifethreatening injury they rate very low” [28] p. 84). Similarly, a parti­ cipant from a study by Beks [17] reported “one hand you’re thinking ‘this is self-inflicted’…And then you’ve got someone who is really sick from a medical issue and you think ‘they can’t help it’” (p.8). Another participant described “…When someone comes in physically its easy [because] you just have the steps, but when it’s a behavioural thing, you’ve got to navigate that whole, that unknown territory…” (p. 7, [17]). Nurses labeled psychiatric patients who presented frequently to the ED as “frequent flyers” who even misrepresented their symptoms in order to receive treatment and necessities [28]. “With mental health patients, it’s not like…get the medication going, it’s like, ‘oh boy, he’s here again, that is the perception” [28]. In another study by Wolf et al. [31], concerns were raised about inexperienced and poorly trained staff who, during triage, did not accurately assess for the risk of violence to self or others. “…we didn’t even know he was suicidal. No one took the time in triage to ask the right questions” (p. 144). Interactions with individuals presenting with mental illness help to shape ED nurses’ mental images and expectations. These images and expectations are also influenced by nurses’ knowledge of societal views of mental illness, such as stigma.

3.3.3. Suicidality and care dissonance One subtheme that emerged from the review was the nurses’ ex­ perience when caring for individuals who presented to the ED with suicidality and the conflict that subsequently arose. Vedana et al. [29] posited that nurses perceived discrepancies and conflicts in caring for individuals who were suicidal because patients wanted to die, did not collaborate and hid their symptoms. Caring for suicidal individuals was referred to as caring “against their wishes”. Their findings were that nurses saw suicide as an “unjustifiable act” that was incomprehensible and unacceptable. Nurses displayed negative and discriminatory atti­ tudes towards them: “this kind of patient is not my favorite. I do not have the skills to assist them. I never wanted to work at any psychiatric service. I am afraid of these patients and I don’t know how to deal with them” [29]. In further support of suicidality’s impact on ED nurses, a participant in another study voiced “suicidal patients aren't taken ser­ iously because I think that people have had those experiences where people say that and not mean it, so that patient may come in three weeks later and say it again, and mean it, and they may not be be­ lieved“ [28]. ED nurses also reported that caring for suicidal patients leads to a nurse-patient relationship that can include opposition, re­ sistance and conflict [29]. 3.3.4. Perceptions and experiences of aggression Experiences of verbal and physical aggression in the ED can impact ED nurses’ caring for psychiatric patients. Mental illness is viewed as a contributing factor to violence. A participant reported in a study by Wolf et al. [31] that individuals with mental illness can be “violent and manipulative”. However, it could also be understood that the behavior is influenced by the illness. “Sometimes they’re not very pleasant but they’re sick.” [17]. Nurses believed they were at risk for harm when caring for in­ dividuals presenting to the ED with acute aggressive and violent be­ haviors [19]. Fear of the unknown and fear of potential aggression and violence impacted nursing care of individuals who presented to the ED with mental illness [28]. Lack of comfort in caring for psychiatric pa­ tients also surfaced in a study by Jelinek et al. [22], “Aggression and anger is probably something I don’t deal with very well” (p. 5). Avoidance of caring for psychiatric patients could further exacerbate the perceived patterns of aggression or violence. Nurses reported … [some staff] ignore problems and things will escalate and then all of a sudden you’ve got a violent patient on your hands…” [22]. The fear of possible aggression impacted ED nurses’ ability to pro­ vide quality care to psychiatric patients, and often led to the im­ plementation of restrictive interventions which caused ethical distress to nurses [28]. Perceiving that aggression was experienced more when no one is available to provide assistance was also described by Saurman et al. [27]. Clarke et al. [18] supported this finding with reports that the presence of police /law enforcement members in the ED made the en­ vironment safer and enhanced the management of the ED. Unavoidability, as a finding, emerged from a qualitative study ex­ ploring the perception of patient-initiated violence in the ED. A parti­ cipant verbalized that: “whether that violence is intentional makes the difference in how I want that treated and how I react. If the patient has pathology either mental health or a disease process, they get a pass and are excused in my book for any violent outburst…” [21]. In the same

3.3. Theme 2 3.3.1. ED nurses’ perceptions and beliefs about psychiatric patients Within this theme, the nurses’ beliefs and perceptions influenced conflict within their role. In the reviewed literature, they described suicidality, aggression and their views of recovery as processes with which they grappled. According to Biddle [33], when a person has role expectations that are incompatible, role conflict arises. As such, when nurses are expected to do two or more things that cannot both be completed, they can experience role conflict. Suicidality and aggression were found to cause role conflict in ED nurses as they were often in­ congruent with the nurses’ personal beliefs. 3.3.2. General beliefs Caring for individuals with mental health needs was believed to conflict with the ED culture, and found to be a challenge [26]. In some instances, nurses avoided caring for psychiatric patients, “some nurses [with] 20–30 years [of service], they will avoid psych at all costs…” [31]. In other cases, the nurse interaction with psychiatric patients is minimal, “…Nobody takes care of them. You may have one or two nurses that may go in and check on them every two hours and make sure they have got food, but that’s about it…” [31]. Care beliefs were also different for psychiatric patients. The 8

International Emergency Nursing 54 (2021) 100929

J.T. Perrone McIntosh

study, participants also expressed helplessness and powerlessness be­ cause of the police dropping off patients with mental illness to the ED [21]. Nurses’ perceptions or beliefs of potential for aggression also im­ pacted the quality of their communication with psychiatric patients, “… If they’re aggressive, I’m not going to ask them a lot of questions only because I’m worried about if I ask them something they don’t like, are they going to lunge at me, are they going to get cranker, so I don’t have a lot of confidence with psych patients at all…” [22]

comorbid conditions. For example, an elevated heart rate was often assumed to be related to anxiety or agitation; presentations of delirium were also overshadowed as psychiatric symptoms. It is evident in the literature that psychiatric patients are at increased risk for diagnostic overshadowing due to negative beliefs and behaviors displayed toward them. Despite some of the negative beliefs and attitudes toward psychia­ tric patients, ED nurses viewed the need to provide healthcare as a requirement for their role [2,29].

3.3.5. Recovery does not occur ED nurses viewed recovery as being different for psychiatric pa­ tients. A study by Marynowski-Traczyk et al. [2] found that ED nurses’ understanding of recovery for individuals with mental illness is that recovery does not happen. Recovery was believed to: equate to either improvement of, or resolution of presenting symptoms; be an outcome, not a process; be the return to baseline, and overcoming of an acute crisis [2]. Nurses did not perceive that individuals with mental illness could recover, one saying “It’s difficult for people with a chronic mental illness to be viewed as recovered in the ED” (p.78). Plant and White [26] also posited that nurses viewed patients with mental illness as not easy to “fix”, especially because nurses were not able to see the outcome of the care provided. In this study, nurses believed that the care pro­ vided to the patients had no impact as “they keep coming back”.

3.4.3. Knowledge and confidence Lack of knowledge and confidence were repeated themes affecting ED nurses’ views of caring for psychiatric patients. Knowledge took the form of lacking in preparation for example, in assessments. Contrary to a finding by Plant and White [26], that nurses with more years of ex­ perience were less likely avoidant or dissatisfied with the care inter­ actions with individuals with mental illness, Wolf et al., [31] found that the more experienced nurses were more likely to avoid caring for psychiatric patients in the ED. In a cross-sectional study evaluating psychiatric nursing competencies applied to emergency settings, parti­ cipants ranked key assessment competencies that are required for the care of patients with psychiatric illness as important, but consistently ranked the frequency of their performance and self-efficacy lower [25]. Winokur and colleagues [30] reported that emergency department nurses had moderately average perceived competency in caring for patients with mental illness. ED nurses expressed that the lack of edu­ cation and skills in caring for patients with mental illness impacted their care delivery, and hindered the delivery of optimal care [2,26,29,28]. Mental health was viewed as a specialty requiring dif­ ferent skills than those needed for the general ED population “mental health is so different…” [17]. A participant in a qualitative study by Tyerman [28] shared the following: “I think that it's very hard to treat a psychiatric patient when you don't have the skill set or the background knowledge. I find it very hard to treat psychiatric patients because I don't have a background in it. So, I'm going in, blindsided per se, and trying to help the situation, that I am not confident that I can help, so I don't know sometimes how to approach a patient appropriately” (p. 56). ED nurses have identified knowledge gaps in the assessment and management of psychiatric patients [22,31]; and psychotherapeutic and communication skills [31]. Confidence was viewed in several studies as closely linked to knowledge or the lack of knowledge. Nurses expressed a lack of con­ fidence in eliciting information at triage, and in delivering optimal care to individuals with mental illness [18]. ED nurses reported that lack of knowledge and preparation about mental health, and perception of professional inability caused discomfort in caring for suicidal in­ dividuals. ED nurses were unsure of how to respond to past trauma despite recognizing this as being a component of their role [19]. Lack of preparation was often linked to negative reactions, judgement, dis­ crimination and challenges to engaging in empathic relationships and providing care [29]. Despite the lack of knowledge and confidence, ED nurses in a study by Clarke et al. [18] revealed that when aware of the phenomenon of “diagnostic overshadowing” which occurs when mental illness presentation overrides the physical needs of an individual, nurses were motivated to establish certainty of “what is going on”. Nurses compensated for the lack of knowledge and confidence by using personal experiences, beliefs and common sense [29].

3.4. Theme 3 3.4.1. ED nurses’ knowledge and confidence in caring for psychiatric patients Within this theme, the literature described ED nurses’ lack of knowledge and related lack of confidence and what authors have identified as “diagnostic overshadowing”, closely related to stigma, and influencing role confusion. 3.4.2. Stigma and Diagnostic Overshadowing Stigma was identified as a contributing factor to the quality of care delivery [28]. Wolf et al. [31] found that clinicians displayed dis­ criminatory attitudes and practices, such as “patient profiling” and “subjective judgement calls” toward psychiatric patients. “We’re just so focused on people that are bleeding and coughing and everything else… there’s just not a lot of training [for mental health]…If mental health is not managed well, it can be devastating for the whole department and other patients and whole lot of other things’ cause they do tend to disrupt the whole department…” [27]). In another study, nurses avoided caring for psychiatric patients as they were viewed as less important than other patients [31]. “People sort of don’t want to take care of them…they say, ‘Oh they’re not that important. This other pa­ tient over here is more important…[so] they don’t get that the same attention” [31] p. 144). Psychiatric patients were viewed as “time wasters…problematic group” who required “a lot of attention [17]. Nurses also revealed that role and responsibility confusion affect their ability to provide quality care to individuals with mental illness [28]. In one study, participants reported that they were unsure whether the patients with mental illness presented to the ED because of acute ex­ acerbation of their mental illness symptoms or were “just attention seeking”. Nurses expressed that psychiatric patients were manipulative and believed they were taking advantage of the staff and the “system.” This decreased the nurses’ motivation to care for the patients’ inter­ personal needs. Another finding was that psychiatric patients were communicated with and approached differently than the general ED population. “I know I approach them completely different to you know another patient that’s not mental health. You’re just a bit more wary of the potential for risk I guess” (Beks et al, p. 6). Originating in 1982 by Ress et al. [36], psychiatric overshadowing occurs when physical and/or behavioral symptoms are inaccurately correlated to mental illness [37]. This leads to under or misdiagnosis of

4. Discussion This scoping review revealed the complexities of the nursing care of psychiatric patients in the ED framed within the role theory [33]. Ac­ cording to Biddle [33], human beings behave in ways that are pre­ dictable based on their social identity and position. The literature re­ viewed confirmed that in many instances the ED nurses’ behaviors were predictable when caring for psychiatric patients as these were repeating 9

International Emergency Nursing 54 (2021) 100929

J.T. Perrone McIntosh

themes. Nurses expressed fear, frustration, lack of knowledge and confidence when caring for psychiatric patients. Biddle [33] posited that expectations occur through socialization or learned behavior enforced by others. ED nurses’ expectations can be assumed to be influenced through learned behavior as supported by the literature. Expectations of violence, aggression, and expectations that psychiatric patients required less care were echoed themes in the lit­ erature [22,31]. However, just as these expectations are influenced through socialization or learned behavior, these can be renewed through education focused on caring for psychiatric patients, and re­ inforced in practice. Biddle [33] posited that roles can be problematic. For example, those that are difficult to perform can be challenging. ED nurses faced challenges in performing their role when caring for psychiatric patients. The physical environment of the ED, time constraints, lack of resources, and the triage and assessment process have been found to impact ED nurses’ ability to effectively care for psychiatric patients. The fastpaced, loud and busy nature of the ED makes it a nontherapeutic setting for psychiatric patients thereby affecting the ED nurses’ ability to per­ form their role. Biddle [33] posited that persons can experience role conflict when two or more obligations compete for their attention. This review re­ vealed that ED nurses have many obligations competing for their at­ tention. The review revealed the separation between the needs of the general ED patient population and those of the psychiatric patients. While both groups compete for the ED nurses’ attention, the studies revealed that the nurses viewed the physical needs of their patients as more important and requiring more urgent attention than the psy­ chiatric needs of patients. This was apparent in the subthemes of triage and assessment, general beliefs, and stigma. Other competing “things” that emerged in the study included the fear for aggression and violence and the need for additional education. ED nurses also experienced role ambiguity. According to Biddle [33], role ambiguity occurs when persons do not understand what specific skills and responsibility are expected of them. Throughout the review, findings from studies revealed that ED nurses did not under­ stand what skills or responsibility were expected of them when caring for psychiatric patients. This was evident in the triage and assessment of patients, and also in the theme of knowledge and confidence when caring for psychiatric patients. The literature revealed a lack of edu­ cational preparation and a knowledge deficit in the nursing care of psychiatric patients. Lastly, when role demands are high, role overload ensues [33]. This can compromise the quality of work [38]. In many instances, ED nurses have identified the overall demands of caring for psychiatric patients in the ED as being high, and leading to time pressures and heavy work­ load. These can ultimately negatively impact the already vulnerable and underserved psychiatric patients, and can lead to poor health outcomes.

their effect on beliefs and attitudes need to be undertaken. Specific studies could then focus on how programs on increasing knowledge about caring for patients with suicidality and aggression might affect beliefs, knowledge and confidence Influencing much of the findings in this scoping review on caring were the actual limitations that may be experienced by ED nurses in general in their environment. These in fact may emerge if studies are undertaken on overall environmental influences s compared with caring for all patients in an ED. It may in fact be that it is easier to conclude that these resources, or lack of, can erroneously be attributed to patients deemed not suitable for what EDs can provide. Closely related to the need for investigations on environment are those that would address the impact of Psychiatric Emergency Programs within the ED on the overall ED nurses’ role. Many EDs have incorporated spaces, beds, and specialists for such programs across the country. The impact of these on nurses has not been studied. For ex­ ample, do these programs decrease or increase stigma in an ED. Are such programs effective with respect to resource use, patient satisfac­ tion and nurses’ confidence? 6. Scoping review limitations Having a one-person reviewer was a limitation of this review. More than half of the studies occurred outside of the US (n = 11). This is a limitation because of the variations in culture, processes, and en­ vironments across international settings. 7. Conclusion This scoping review synthesized and summarized the existing lit­ erature on the nursing care of psychiatric patients in the ED framed within Biddle’s [33] role theory. ED nurses’ care of psychiatric patients is an important and complicated topic. Understanding the factors that impact the care is essential as it will provide greater insight for the basis of the ED nurses’ role and behaviors. Additionally, findings for this review can be used to design and implement meaningful educational resources to improve ED nurses’ knowledge, confidence and attitudes in caring for psychiatric patients. These findings can raise awareness on the need for policy development to support psychiatric patients. Lastly, future qualitative and quantitative studies are warranted to address the gaps that emerged from this review. Declaration of Competing Interest The author declare that they have no known competing financial interests or personal relationships that could have appeared to influ­ ence the work reported in this paper. Acknowledgement

5. Implications and recommendations

The author wishes to acknowledge Jane H. White, PhD, PMH-CNS, BC, FAAN, Vera E. Bender Professor of Nursing, Adelphi University College of Nursing and Public Health for her invaluable support, mentoring, and editing of multiple iterations of this article.

Based on this review of the limited number of published research studies, it is not possible to develop practice recommendations. The majority of the studies in this review were undertaken in international EDs which may have different culture, workflow and beliefs than those in the U.S. Many of the studies were also qualitative in methodology and used focus groups for data collection. Therefore, future qualitative research studies are warranted to explore the experiences and process of ED nurses caring for individuals with mental illness in the U.S. This would add an increased understanding of the lived experience of ED nurses. Studies are also needed to measure outcomes of interventions such as educational changes to increase ED nurses’ knowledge and con­ fidence for caring for individuals with mental illness. For example, educational programs on caring for patients with mental illness and

Ethical statement The author has met all ethical standards related to the research and writing of this manuscript. Funding Source The author denies receiving any financial support for this manu­ script 10

International Emergency Nursing 54 (2021) 100929

J.T. Perrone McIntosh

References [20]

[1] Emergency Nurses Association (2014). Care of behavioral health patients in the emergency department. Retrieved from: https://www.ena.org/practice-resources/ behavioral-health. [2] Marynowski-Traczyk D, Moxham L, Broadbent M. Emergency department registered nurses’ conceptualization of recovery for people experiencing mental illness. Austr Emerg Nurs J 2017;20:75–81. [3] Centers for Disease Control and Prevention; 2018. [Accessed 15 March 2020]. [4] Kongable GL, Tarko M. Psychosocial aspects of medically compromised persons. Psychiatric Nursing for Canadian Practice. Philadelphia: Lippincott Williams & Wilkins; 2006. [5] National Alliance on Mental Illness- Mental Health by the Numbers; 2019. [Accessed 15 March 2020]. [6] Agency for Healthcare Research and Quality (2017). Overview of the nationwide emergency department sample (NEDS). Healthcare cost and Utilization Project (HCUP). Retrieved from: www.hcup-us.ahrq.gov/nedsoverview.jsp. [7] Clarke DE, Hughes L, Brown AM, Motluk L. Psychiatric emergency nurses in the emergency department: the success of the Winnipeg, Canada, experience. J Emerg Nurs 2005;31(4):351–6. [8] Gordon JT. Emergency department junior medical staff's knowledge, skills and confidence with psychiatric patients: A survey. Psychiatrist 2012;36:186–218. [9] Kerrison SA, Chapman R. What general emergency nurses want to know about mental health patients presenting to their emergency department. Accid Emerg Nurs 2007;15(1):48–55. [10] Corrigan PW, Druss BG, Perlick DA. The impact of mental illness stigma on seeking and participating in mental health care. Psychol Sci Public Interest 2014;15(20):37–70. [11] Arksey H, O’Malley L. Scoping studies: Towards a methodological framework. Int J Soc Res Method 2005;8(1):19–32. [12] Anderson S, Allen P, Peckham S, Goodwin N. Asking the right questions: Scoping studies in the commissioning of research on the organisation and delivery of health services. Health Res Policy Syst 2008;6(7). [13] Davis K, Drey N, Gould D. What are scoping studies? A review of the nursing lit­ erature. Int J Nurs Stud 2009;46:1386–400. [14] National Institutes of Health. (2019). Literature search: Databases and gray litera­ ture. Office of Research Services. https://www.nihlibrary.nih.gov/services/sys­ tematic-review-service/literature-search-databases-and-gray-literature. [15] Peterson J, Pearce PF, Ferguson LA, Langford CA. Understanding scoping reviews: Definition, purpose, and process. J Am Assoc Nurse Practition 2016;29(1):12–6. [16] Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: The PRISMA Statement. Ann Intern Med 2009;151:264–9. [17] Beks H, Healey C, Schlicht KG. ‘When you’re it’: A qualitative study exploring the rural nurses experience of managing acute mental health presentations. Rural Remote Health 2018;18(3):1–12. [18] Clarke DE, Boyce-Gaudreau K, Sanderson A, Baker JA. ED triage decision-making with mental health presentations: A “think Aloud” study. J Emerg Nurs 2015;41(6):496–502. [19] Hall A, McKenna B, Dearie V, Maguire T, Charleston R, Furness T. Educating

[21] [22]

[23] [24] [25] [26] [27] [28] [29] [30] [31] [32] [33] [34] [35] [36] [37] [38]

11

emergency department nurses about trauma informed care for people presenting with mental health crisis: a pilot study. BMC Nurs 2016;14(21):1–8. Innes K, Morphet J, O’Brien AP, Munro I. Caring for the mental illness patient in emergency departments- an exploration of the issues from a healthcare provider perspective. J Clin Nurs 2013;23:2003–11. Jackson, K. (2017). Qualitative study exploring emergency nurses’ perception of patient-initiated violence. [Doctoral dissertation, University of Phoenix]. Pro-Quest Dissertation Databases. Jelinek GA, Weiland TJ, Mackinlay C, Gerdtz M, Hill N. Knowledge and confidence of Australian emergency department clinicians in managing patients with mental health-related presetnations: Findings from a national qualitative study. Int J Emerg Med 2013;6(2):1–7. Marynowski-Traczyk D, Broadbent M. What are the experiences of Emergency Department nurses in caring for clients with a mental illness in the Emergency Department? Austr Emerg Nurs J 2011;14:172–9. McCann T, Clark E, McConnachie S, Harvey I. Accident and emergency nurses’ attitudes towards patients who self-harm. Accid Emerg Nurs 2006;14:4–10. Mello JJ, Bell JF, Siegel EO, Ward DH. Evaluating psychiatric nursing competencies applied to emergency settings: A pilot role delineation study. Int Emerg Nurs 2016;25:37–42. Plant L, White J. Emergency room psychiatric services: A qualitative study of nurses' experiences. Issues Mental Health Nurs 2013;34(4):240–8. Saurman E, Kirby SE, Lyle D. No longer ‘flying blind’: how access has changed emergency mental health care in rural and remove emergency departments, a qualitative study. BMC Health Services Res 2015;15(156):1–11. Tyerman, J (2014). Emergency nurses’ experiences of care for individuals with mental health issues in the emergency department. [Doctoral Dissertation, Queen’s University]. Retrieved from Pro-Quest Dissertation Databases. Vedana KGG, Magrini DF, Miasso AI, Zanetti ACG, deSouza J, Borges TL. Emergency nursing experiences in assisting people with suicidal behavior: A grounded theory study. Arch Psychiatr Nurs 2017;21:345–51. Winokur EJ, Loucks J, Rutledge DN. Effect of concentrated psychiatric education on perceived competence to care for behavioral health patients. J Emergency Nurses Online 2017;43(5):419–25. Wolf LA, Perhats C, Delao AM. US emergency nurses’ perceptions of challenges and facilitators in the management of behavioural health patients in the emergency department: A mixed-methods study. Austr Emerg Nurs J 2015;18:138–48. Levac D, Colquhoun H, O’Brien KK. Scoping studies: Advancing the methodology. Implementation Sci 2010;5(69):1–9. Biddle BJ. Role theory: expectations, identities, and behaviors. New York, NY: Academic Press; 1979. Biddle BJ. Recent development in role theory. Ann Rev Sociolo 1986:67–92. Kahn AJ. Social work and policy studies. Policy Studies J 1973;2(1):8–12. Reiss S, Grant WL, Szysko J. Emotional disturbance and mental retardation: Diagnostic overshadowing. Am J Mental Deficiency 1982;86:567–74. Jones S, Howard L, Thornicroft G. “Diagnostic overshadowing”: Worse physical health care for people with mental illness. Acta Psychiatr Scand 2008;118:169–71. Brown SP, Jones E, Leigh TW. The attenuating effect of role overload on relation­ ships linking self-efficacy and goal level to work performance. J Appl Psychol 2015;90(5):972–9.