Emergency psychiatric nursing: A concept analysis

Background: Individuals with Mental Disorders (ODGJ) are at risk of relapse, leading to emergencies. Untreated psychiatric emergencies can result in disability or even death. Emergency psychiatric care, if not promptly addressed, poses a crucial and complex topic. The aim of this research is to define and clarify these essential concepts, integrating them into mental health nursing care. Methods: Literature search employed keywords such as "emergency" AND "psychiatric" AND "nursing" in English databases (including PubMed, ScienceDirect, and CINAHL) without time restrictions. After extracting concept definitions and identifying characteristic features, psychiatric emergency nursing care was defined. Subsequently, case samples, antecedents, consequences, and empirical concept references were determined. Results: After reviewing four articles, psychiatric emergency nursing care was defined with the following attributes: "adequate response to psychiatric patients," "prompt care for patients with mental health issues should be simple and fast," and "stigma associated with those facing mental health problems." Conclusion: Mental health nursing care can utilize these findings for interventions, evaluating psychiatric emergency nursing care, and training high-quality nurses.


INTRODUCTION
Schizophrenia is a severe mental disorder affecting approximately 20 million people worldwide (World Health Organization, 2022).According to Riskesdas (2018), in 2017, the prevalence of schizophrenia in Indonesia reached 7 per thousand.This statistic implies that every 7 out of a thousand families in Indonesia have a member with schizophrenia, accounting for 450 thousand families with individuals facing mental health disorders.Furthermore, Riskesdas data indicates that in Central Java, the prevalence is higher at 8.7 per thousand, surpassing the national average (Kementrian Kesehatan RI Badan Penelitian, 2018).
Individuals with Mental Disorders (ODGJ) are at risk of relapse, leading to emergencies (Aju et al., 2017).Worldwide, mental health conditions, self-harm, behavioral disorders, and substance abuse pose significant challenges for healthcare professionals in assessing, treating, and referring patients with various mental health issues (Booker et al., 2015;Rees et al., 2014).Most patients requiring emergency care exhibit anxiety or manic/psychotic symptoms.Nurses' main concerns during such emergencies include stress, discomfort due to limited patient information, solitary interactions in confined spaces, and unpredictable situations (Daggenvoorde et al., 2021).Qualitative studies reveal nurses' concerns, affecting their care for psychiatric patients, such as worries about crowded emergency room environments and the impact on their beliefs, perceptions, knowledge, and confidence (Perrone McIntosh, 2021).
Compared to the general population, individuals with mental health disorders die, on average, twenty-five years earlier than those with treatable medical conditions (Perrone McIntosh, 2021).Statistics highlight a healthcare disparity for individuals with mental health disorders, with limited access to resources and treatment options (Pragholapati et al., 2023).Adequate care for these individuals depends on competent healthcare providers and a sufficient healthcare system (Pragholapati et al., 2024b).Nurses, being the largest healthcare professional group, are at the forefront and most affected by the surge of patients seeking mental health care in Emergency Departments (EDs) (Perrone McIntosh, 2021).Providing care for individuals with mental health disorders in the ED is a complex undertaking.
The Minister of Health of the Republic of Indonesia Decree No. 1627/MENKES/SK/XI/2010 on guidelines for psychiatric emergency services requires human resources, particularly nurses, with basic knowledge of general care, skills in observing vital signs abnormalities, experience in caring for patients with mental disorders in mental hospitals or other mental health facilities, and an interest in emergency care.Emergency psychiatric conditions that a mental health nurse may face include suicide attempts, panic attacks, catatonic fainting, hysterical attacks, temporary situational disturbances, grief reactions, rape, disasters, delirium tremens, acute drug-induced extrapyramidal syndrome, and drug toxicity (Jacob & Mathias, 2013;Pragholapati et al., 2024a).
Emergency psychiatric care is a crucial and complex topic (Kerrison & Chapman, 2007;Perrone McIntosh, 2021).Emergency nurses are well-trained to care for individuals with acute physical complaints and emergencies; however, they may lack training and confidence in caring for patients with mental disorders.Consequently, individuals presenting to the emergency department with mental health disorders receive care traditionally based on a medical model with different recovery beliefs (Perrone McIntosh, 2021).
As it is known, psychiatric nursing practices differ significantly from general or surgical nursing practices due to client characteristics, requiring different program standards (Yao, Shao, et al., 2021).Therefore, it is essential to implement specific programs for mental health nurses (Yao, Cheng, et al., 2021).However, a literature review reveals a lack of evidence for standardized training programs in psychiatric nursing (Suo & Xu, 2019).
The objective of analyzing the concept of psychiatric emergency nursing care is to clarify the meaning of the term "psychiatric emergency nursing care," develop operational definitions, and contribute to the enhancement of knowledge in psychiatric emergency nursing care.Developing knowledge about the concept of psychiatric emergency nursing care can serve as a research plan addressing interventions in mental health nursing care.
The "Emergency Psychiatric Nursing: A Concept Analysis" research has the potential to significantly impact mental healthcare practice, particularly in Indonesia.By providing a deeper understanding of the concept of emergency psychiatric nursing, including adequate response to psychiatric patients, prompt and straightforward care for individuals with mental health issues, and the stigma associated with mental health problems, the study addresses existing knowledge gaps in psychiatric emergency care.Moreover, it facilitates the development of targeted interventions to reduce the occurrence and negative consequences of psychiatric emergencies, contributes to stigma reduction efforts, and enhances nurse education and training programs.Consequently, the research has the potential to improve mental healthcare delivery, increase access to services, and enhance the quality of life for individuals facing mental health challenges in Indonesia.

Concept analysis approach
Concept analysis of psychiatric emergency nursing care is conducted using the Walker and Avant approach (Walker & Avant, 2005).This method aims to depict and clarify the phenomena occurring in psychiatric emergency nursing care.Concept analysis is a commonly used method to differentiate the attributes, properties, or dimensions of a concept.A concept is a label expressed as a word that encapsulates the essence of a phenomenon, and it may be relatively abstract.This approach involves eight distinct steps as follows (Walker & Avant, 2005): (1) selecting the concept; (2) determining the purpose of the analysis; (3) identifying all possible uses of the concept in nursing; (4) determining the defining attributes of the concept; (5) identifying model cases; (6) identifying borderline and contrary cases; (7) identifying antecedents and consequences of the concept; and (8) defining empirical references for the concept.

Data Sources:
A literature review was conducted by combining, using the Boolean term "AND," keywords such as "EMERGENCY," "PSYCHIATRIC," and "NURSING" in titles or abstracts.All fulltext articles published in scientific journals were included in the review.Journals in English databases (including PubMed, ScienceDirect, and CINAHL) were extracted without time limitations.
Emergency psychiatric nursing: A concept analysis Most review articles are published in English, and since 2007, there has been an increase in the number of publications.This indicates that interest in this research topic is relatively new and underexplored both nationally and internationally.The studies included in this review aim to assess nursing professionals' knowledge related to issues faced, skills, knowledge, attitudes, and perceptions encountered when approaching patients in psychiatric emergency care.According to the findings, care is often delivered in a fragmented manner, perceived as a set of techniques and procedures to be applied.Generally, nursing professionals may lack patience and fail to consider the reasons behind the behaviors of patients with mental disorders, occasionally displaying aggressive behaviors.
Research indicates that a therapeutic communication approach, paying attention to non-verbal expressions, can collaborate in reducing or eliminating aggressive patient behavior.Therefore, therapeutic communication can be configured, in psychiatric emergency situations, as one of the primary resources for humane care.Therapeutic communication helps nurses encourage patients to express facts, feelings, opinions, perceptions, pretenses, and expectations.
In emergency situations, therapeutic communication can protect patients from harm to themselves or others.For this, healthcare professionals should be direct, honest, calm, nonthreatening, convey a sense of control, act decisively, use empathy for intervention planning and evaluation.Difficulties in identifying urgent and emergency situations related to alcohol and/or other psychoactive substance use were revealed in some findings as a significant limitation for treatment planning.
It is noteworthy that societal changes related to the epidemic of alcohol dependence and other substance-related disorders significantly influence the increase in cases seeking emergency care.To address this growing demand, professionals must receive adequate preparation and training.A study conducted in Curitiba-PR aimed to understand the nursing team's conception of mental health emergency situations and analyze how the nursing team approaches users with mental disorders in emergencies, identifying that some participants did not recognize suicidal attempts and behavior changes caused by psychoactive substance use as emergency situations.According to the authors, misunderstanding these situations can lead to stigmatization regarding fundamental issues for the adequacy of approach and treatment for these clients.
One surveyed study identified an alternative to expanding information access, education, and training for specific mental health situations by inserting consultation and liaison activities with specialized mental health nursing teams.In this sense, including these activities can broaden the possibilities for facilitated access, early diagnosis of problems, initiation of appropriate and immediate person-centered interventions, besides creating a non-stigmatizing environment and promoting permanent education.
The obtained results also indicate that nursing professionals reported a lack of knowledge, as well as a lack of confidence and interaction skills in approaching patients in psychiatric emergency situations.Furthermore, the lack of knowledge among professionals highlights the need to improve undergraduate and postgraduate education.Some studies have identified that continuous education is needed for healthcare professionals working in psychiatric emergency sectors.Continuous education is understood as a process of ongoing education, personal and professional revitalization and improvement, covering individual and collective dimensions.
However, continuous education and adequate professional training, although essential, are not the only factors ensuring a solution to the identified problems.Professionals need to learn to work collaboratively, utilizing the possibility to enhance their knowledge from resource allocations developed by other professionals and teams interested in sharing similar experiences.Thus, professional training in this field should enable questioning and possibilities to overcome hospital-centered models, which create a disconnection between theory and practice, between basic and clinical training cycles, supporting the indiscriminate use of technology and promoting impersonal and decontextualized professional practices.These results reinforce research conducted on the same theme.A study in Brazil shows that nursing teams demonstrate interest in a broad educational process.Continuous education is needed and desired by mental health nursing teams, who have adopted some initiatives to promote it.On the other hand, it is crucial to clarify the identified gaps in the reviewed studies, as a prescription of continuous education for nursing teams may not be able to solve all the problems faced in psychiatric emergency situations.

Concept (Selecting the Concept):
Psychiatric emergency can be defined as any acute change originating from the mental realm where an individual's mental state alters, potentially implying an immediate and significant risk of death or serious injury to the patient or others, requiring immediate intervention and therapy.

Determining the Purpose or Goal of Analysis:
The specificity of nursing care in psychiatric emergency services reveals patterns of signs and symptoms that become the primary focus of nurses.It is crucial to highlight various patterns of issues and nursing needs that form the basis for formulating diagnoses in psychiatric emergency settings.This analysis emphasizes the need for common terminology and standards based on nursing diagnosis formulation to systematize healthcare.Further exploration in quantitative studies and qualitative research strategies with nurses in psychiatric emergency settings is recommended to aid in formulating nursing diagnoses and addressing challenges in this process.

Identifying All Possible Uses of the Concept in Nursing:
This study indicates a gap in psychiatric patient care in emergency rooms, reinforcing findings that emphasize the tension and pressure faced by professionals, patients, and families.Issues such as deficits in training, lack of professional development in mental health, and insufficient physical structures in emergency units were observed, making professionals position themselves impersonally and struggle to act in a humane manner.Challenges in the care of psychiatric crisis patients are prevalent, stemming from a lack of experience and knowledge about mental health, fear of being attacked, or disbelief in the patient's mental suffering.

Determining Concept Defining Attributes:
Based on related literature, the attributes of Emergency Psychiatric Nursing include: 1) appropriately responding to psychiatric patients (Nicholls et al., 2011), 2) providing immediate and simple mental health care (Agar, 2010), and 3) addressing stigma associated with mental health issues (Nicholls et al., 2011).

Identifying a Model Case:
The constructed case serves as an example to help clarify the concept, determining what it is, and, perhaps more importantly, what it is not.A model case is a constructed case that possesses all defining attributes of the concept.Borderline cases resemble the concept but lack one or more defining attributes.Cases are identified as a method to illustrate and support the analysis by providing examples of the concept's use.Cases can be real examples found in literature or can even be fabricated by researchers (Walker & Avant, 2005).
In the case of Mr. X, a 37-year-old individual admitted to the Provincial Mental Hospital of West Java after nights of screaming without apparent cause at home, accompanied by physically assaulting people he saw.This behavior followed an accident that occurred involving Mr. X and his deceased child.Upon assessment by a nurse, Mr. X is restrained, shouting loudly, "I want to die!! Don't disturb me!!" The data obtained indicates anomic suicide, destructive coping, intellectualization, rationalization, regression, disorientation, disorganization, tense body posture, impulsivity, aggression, agitation, withdrawal, catatonia, panic behavior, disturbed personal space, threatening gestures, expansive movements, staring eye contact, excessive rejection, and parental seduction influencing the client's trust and disturbed selfesteem.The nurse assesses the client using the RUFA scale, with a RUFA score of 5 and a SIRS score of 3.

Identifying a Borderline and a Negative Case:
The outline of the case helps clarify the concept and define attributes by explaining the model case and demonstrating consistency.
A 50-year-old male patient, a traffic accident victim, is brought to the emergency unit in an unconscious state.From the physical examination, the following data are obtained: open wounds on the forehead and face with bleeding from the nose and ears, visible bruising on the abdomen, abdominal distension (+), open fracture of the right half of the shin, cold extremities.Vital signs: Blood pressure 90/50 mmHg, respiratory rate 25 breaths/minute, pulse rate 120 beats/minute.
In this case, it lacks the attributes of immediate care for a patient with mental health issues, which should be simple and fast, and the stigma associated with those who have mental health problems.
Identifying Antecedents and Consequences: Antecedents: Antecedents are considered events or incidents that must occur or be in place before a certain concept takes place.Factors contributing to the occurrence of psychiatric nursing emergencies.In relevant literature, antecedents are identified as a variety of potential causes for psychiatric nursing emergencies, including crowding, boarding, and high patient complexity (such as old age, cognitive disorders, advanced imaging needs, or extensive blood tests).However, only one criterion is truly essential, and that is the definition of psychiatric nursing emergencies, such as the establishment of national, regional, or local time targets.Setting time limits to determine Expected Length of Stay (EDLOS) is crucial from both the patient's and organizational perspectives.When expecting psychiatric nursing emergencies within a specific timeframe, exceeding this limit allows us to consider psychiatric nursing emergencies beyond that duration.
Consequences: Consequences are considered as outcomes of antecedents and define the attributes.Our analysis reveals the potential consequences of the concept of psychiatric nursing emergencies, including decreased patient satisfaction and compromised patient safety.Factors contributing to and possibly causing psychiatric nursing emergencies include increased mortality, elevated risk of side effects, and poorer adherence to clinical guidelines.

Determining Empirical References:
The final step of the Walker and Avant concept analysis method is empirical reference, which presents how the concept is measured or the observation of the phenomenon occurring.Related terms have been used in the literature to describe psychiatric nursing emergencies.The analysis cannot identify a single superior time limit for psychiatric nursing emergencies over other time limits in any way.To identify such a time limit, one must consider at what point psychiatric nursing emergencies lead to decreased patient satisfaction and compromised patient safety.This point in time may vary in different settings and likely also for different subgroups of the psychiatric nursing emergency population.
Evaluating the concept of psychiatric nursing emergencies requires an instrument as an alternative to short-term inpatient units.The role of mental health nurse practitioners is explored for its potential to enhance mental health nursing practices in challenging clinical environments.This instrument needs to be developed to create a tool comprising all components related to the concept of psychiatric nursing emergencies.

Operational Definition:
Based on this concept analysis, psychiatric nursing emergencies highlight a scarcity of scholarly production in national and international journals on this topic, necessitating the development of further studies addressing this theme.The lack of specific knowledge about mental health and the manifestations of emotions such as frustration, fear, and sadness in emergency service nurses is emphasized.In this sense, the synthesis results indicate the importance of including actions such as continuing education and enhancing the qualifications of professionals working in emergency psychiatric care to provide better care and treatment for patients with mental disorders in emergency services.
However, for the implementation of this research, there are still some gaps to be filled, such as the need to mobilize health managers, motivate professionals, develop techniques to evaluate the steps to be implemented, and consolidate the human-centric healthcare service network.It is hoped that this study will serve as an incentive for the production of new research on the professional knowledge of nursing in approaching psychiatric nursing emergencies.Furthermore, it aids in implementing improvement and training measures for nursing professionals working in these situations.

CONCLUSIONS AND RECOMMENDATION
The concept analysis of psychiatric emergency nursing is developed around appropriately responding to psychiatric patients, providing immediate and straightforward mental health care, and addressing the stigma associated with individuals dealing with mental health issues.This concept analysis serves as a foundational basis for further research to delve deeper into psychiatric emergency nursing in Indonesia.This includes studies aimed at developing and implementing interventions to reduce the occurrence and negative consequences of psychiatric emergencies.By addressing the unique challenges and cultural factors, these interventions have the potential to improve the quality of mental healthcare delivery and mitigate the negative consequences of psychiatric emergencies in the Indonesian population.

DECLARATIONS
• Ethics approval and consent to participate Not applicable • Consent for publication Not applicable • Availability of Data and Material (ADM) The data and materials used in this research will be available for further examination or reproduction.All datasets generated during the study will be uploaded to the relevant data repository, and all experimental materials or instruments used will be described in detail in the methods section of the publication.This is aimed at supporting transparency and ensuring that this research can be verified by others.

Figure 1
Figure 1 Main reporting points for literature review flowchart