Stigma Toward Mental Illness Poses Safety Risks for ED Patients

By Stacey Kusterbeck

Stigma toward patients with mental illness is common among ED nurses, a recent study found.¹ This concerning finding is unsurprising to many ED providers familiar with the challenges of caring for psychiatric patients. “There is no ‘silver bullet’ that will fix this issue,” says Adam Hennessey, DO, director of the National Travel Physician Program at Progressive Emergency Physicians/Emergency Care Partners.

EDs must use a variety of approaches to combat mental health stigma, including providing direct feedback and training to employees, recommends Hennessey.

ED providers may have difficulty completing assessments because of the patient’s altered mental status, or the patient may be agitated, combative, or intoxicated, says Edwin D. Boudreaux, PhD, a professor in the Departments of Emergency Medicine, Psychiatry, and Population and Quantitative Health Sciences at University of Massachusetts Chan Medical School. “As a result, ED clinicians may sometimes develop certain negative attitudes, especially if the patient is very well-known to the ED. Patients who are sometimes called high-utilizers if they have psychiatric conditions, are particularly vulnerable to being stigmatized,” says Boudreaux. A previous study showed that emergency nurses were more likely to negatively describe patients with irritable (vs. calm) behavior and to exclude specific clinical information during handoffs.²

“It’s understandable why busy, stressed clinicians might develop negative reactions to patients presenting with challenging behaviors. That’s where the stigmatization can occur — and can lead to from mild to severe adverse consequences,” says Boudreaux.

Compassion fatigue is what happens most frequently. Some ED providers struggle to put themselves in the position of the patient. “They may find it difficult to really bring their best selves to managing the patient. Instead, they inadvertently behave in a dehumanizing way toward the patient. That can affect the person’s emotional well-being,” says Boudreaux.

Even well-intentioned ED protocols can have unintended consequences for psychiatric patients. For example, for patients kept on involuntary psychiatric holds, protocols may require that personal belongings are removed and that patients are placed in rooms without their cell phones or even a TV. “They are put in what we call safe rooms, which is important to preserve their safety. But to the patient, it can seem austere, cold, inhospitable, and like they are being punished,” explains Boudreaux.

To mitigate the possibility a patient could be emotionally harmed, Boudreaux suggests that ED clinicians take the time to explain the purpose of the involuntary hold in a respectful manner.

Stigma also can harm patients medically. “The most severe example is if ED clinicians miss something important medically because the providers think the patient is ‘just a psychiatric patient.’ Adverse medical events can happen because of that,” says Boudreaux. ED providers might assume the patient is behaving erratically because of a psychiatric condition when it is actually due to a brain trauma or some other neurological condition. A classic example is a patient experiencing homelessness who frequently presents with psychotic symptoms being discharged, only to die shortly thereafter of a brain bleed due to head trauma that was missed because the treatment team did not conduct a thorough medical exam. This kind of issue is reflected in the scant documentation in some ED charts of psychiatric patients who present frequently. “If they present with the same type of behavior they’ve presented with in the past, EDs may be less likely to do a thorough workup. Documentation of medical decision-making is important and may help mitigate risk,” says Boudreaux. ED providers could wrongly assume the patient is again having a psychiatric crisis. On the other hand, if the patient has undergone recent diagnostic testing with normal findings, there might be no need to repeat those tests. “There’s a tension between providing adequate medical clearance and not overtesting. That is a conundrum in the ED, for sure,” says Boudreaux.

It is probably impossible to eliminate ED clinicians’ stigma against psychiatric patients. “But you can train them to identify when they have an emotional reaction to a patient. And you can implement protocols and guidelines to set providers up to behave in ways that are compassionate, and to not ignore the due diligence of a complete medical workup,” says Boudreaux.

For example, ED providers must search the patient’s belongings to be sure there is nothing that the patient could use to hurt themselves or others and remove items such as shoelaces or belts. However, protocols can stipulate that ED providers explain why it is necessary and allow the patient to wear their own clothes afterward rather than a paper gown.

“There are ways to follow safety precautions while, at the same time, acting respectfully to the person,” says Boudreaux.

REFERENCES

1. McIntosh JT, Jacobowitz W. Attitudes of emergency nurses toward clients with mental illness: A descriptive correlational study in a nationwide U.S. sample. Issues Ment Health Nurs 2024;45:105-113.
2. Huff NR, Chimowitz H, DelPico MA, et al. The consequences of emotionally evocative patient behaviors on emergency nurses’ patient assessments and handoffs: An experimental study using simulated patient cases. Int J Nurs Stud 2023;143:104507.