Discussion 3 paragraphs

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Children and Youth Services Review

journal homepage: www.elsevier.com/locate/childyouth

Visits to an emergency department by children and adolescents with substance-related disorders and the perceptions of nursing professionals

Maraiza Mitie de Macedoa, Jacqueline de Souzab,⁎, Leticia Yamawaka de Almeidab, Kelly Graziani Giacchero Vedanab, Manoel Antônio dos Santosc, Adriana Inocenti Miassob

a Emergency Unit Adult, Hospital de Clínicas de Marília, Marília, SP, Brazil. bUniversity of São Paulo, Ribeirão Preto College of Nursing, Avenida dos Bandeirantes, 3900, Campus Universitário - Monte Alegre, Ribeirão Preto, SP CEP: 14040-902, Brazil cUniversity of São Paulo, Faculty of Philosophy, Sciences and Literature of Ribeirão Preto, Ribeirão Preto, SP, Brazil.

A R T I C L E I N F O

Keywords: Pediatrics Adolescents Psychiatric emergency department Substance-related disorder Nursing team

A B S T R A C T

The aim of this study was to describe the prevalence of visits to the emergency department (ED) by children and adolescents with substance-related disorders, between 2009 and 2011, to compare them to adults and to analyze how the nursing team perceived the health care for this population. A cross-sectional study was conducted based on qualitative and quantitative data collected in a Brazilian ED. The quantitative data were obtained from records of a hospital's information system, and the qualitative data were collected through semi-structured in- terviews with nursing professionals from the ED. During the period analyzed, 7.3% of visits to the ED by patients with substance-related disorders corresponded to children or adolescents. Summarily, we found that, from the participants' perspectives, the nursing care provided in the ED to patients with substance-related disorders was strongly framed on the primary role of this setting (i.e., to stabilize acute symptoms and provide security for patients); however the particularities related to the development stages were not emphasized by the participants. Improving clinical knowledge and understanding the emotional dimension of emergency psychiatric care could enhance the capacity of the nursing teams working in this context. Issues related to structure and the politics that framed teaching and assessing mental health are important considerations to further improve the assistance given to patients with substance-related disorders, especially children and adolescents.

1. Introduction

Studies carried out in Ireland, Spain, the United Kingdom (UK), and the United States (US) have shown an increase in the number of ado- lescents with substance-related disorders receiving assistance from emergency services (Bolton, 2009; Chun, Duffy, & Linakis, 2013; Costa et al., 2012; Kelleher & Cotter, 2009; Lacruz & Lacruz, 2010; Matsu et al., 2013; Muroff, Edelsohn, Joe, & Ford, 2008). Treating adolescents can be challenging, especially in emergency departments (EDs) (Pon, Asan, Anandan, & Toledo, 2015).

The chronic nature of substance-related disorders and psychiatric illness means that there is a need for an effective referral process to ensure that patients with such disorders are seen by specialized services able to offer follow-up health and psychosocial care (Bukstein, 2005; Clarke, Hughes, Brown, & Motluk, 2005; Manton et al., 2013; World Health Organization [WHO], 2008). The roles of EDs are to evaluate

and treat acute diseases and injuries, including drug intoxication and overdose. Although these departments are not suitable for the follow-up of patients with substance-related disorders, the professionals' attitudes play a key role in early detection, giving guidance and referral to continuity of treatment (Bolton, 2009; Kelleher & Cotter, 2009).

In addition to the specific challenges related to the immediate health situations typical of EDs, the health team in these services is also responsible for the administration of the resources available to quickly attend the demands. It is also expected that these teams manage the inherent difficulties regarding substance-related disorders that are an expressive cause of visits in these settings (Conlon & O'Tuathail, 2012; Nicholls, Gaynor, Shafiei, Bosanac, & Farrell, 2011).

Previous studies about children and adolescents and emergency assistance have investigated how the characteristics of medical teams in EDs influence decisions about the management of these patients (Muroff et al., 2008), the effects of assistance to them (Sheridan et al.,

https://doi.org/10.1016/j.childyouth.2018.08.018 Received 6 March 2018; Received in revised form 17 August 2018; Accepted 17 August 2018

⁎ Corresponding author. E-mail addresses: [email protected] (J.d. Souza), [email protected] (K.G.G. Vedana), [email protected] (M.A.d. Santos),

[email protected] (A.I. Miasso).

Children and Youth Services Review 93 (2018) 492–500

Available online 21 August 2018 0190-7409/ © 2018 Elsevier Ltd. All rights reserved.

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2016), the sociodemographic and clinical profiles of pediatric and adolescents that visited emergence departments (Chun et al., 2013; Costa et al., 2012; Dolan & Fein, 2011), and parameters for the treat- ment of psychiatric or substance-related disorders (Bukstein, 2005; Dolan & Fein, 2011; WHO, 2008). Nevertheless, studies about the ac- tions, skills, and attitudes of nursing teams to emergency assistance for patients with psychiatric disorders (Elias, Tavares, & Cortez, 2013; Manton et al., 2013; Nicholls et al., 2011; Shafiei, Gaynor, & Farrell, 2011) or with substance-related disorders (Kelleher & Cotter, 2009) have focused mostly on the adult population.

Issues of alcohol and drug use are more pronounced during ado- lescence than at any other period of the lifespan and represent a sig- nificant public health concern (Brown, D'Errico, & Morrell, 2015). Be- sides, children and adolescents with substance-related disorders are part of the population attended in EDs, and over the years, increasing numbers of children and adolescents with these disorders and other acute psychiatric problems have been attended in health services, but the assistance for them is heterogeneous in different settings and countries (Janssens, Hayen, Walraven, Leys, & Deboutte, 2013). These are complex cases, and caring for them requires a structured approach, because children and adolescents have particularities related to the development stages, manifestation of symptoms, communication, risks, and demands of care, among other aspects that need to be addressed in nursing assistance (McCaskill & Durheim, 2016). Additionally, emer- gency care is an important moment for performing differential diag- nosis and analysis about possibilities of rehabilitation that, in the case of children and young people, can strongly contribute to a better prognosis (Scivoletto, Boarati, & Turkiewicz, 2010). Thus, it is im- portant to explore how nursing professionals perceive the health care delivered to these patients in emergency settings to help analyze the framing of nursing care provided by them and to discuss strategies to improve the quality of such assistance (Catrib & dos Santos Oliveira, 2012; Chun et al., 2013; McDonald, 2012).

The aim of this study was therefore to describe the prevalence of visits to the emergency department (ED) by children and adolescents with substance-related disorders, between 2009 and 2011, to compare them to adults and to analyze how the nursing team perceived the health care for this population.

2. Methods

This was an exploratory descriptive, cross-sectional study conducted in the ED of an inner city area of São Paulo, Brazil, based on qualitative and quantitative data. The Research Ethics Committee (protocol 694/ 12) approved all research for this project. Participants signed written consent forms, and identification numbers were used for data collection tools and interview transcripts to maintain the confidentiality of par- ticipants.

2.1. Sample

The ED studied has 49 nursing professionals, of whom nine are as- sistance nurses (ANs) and 40 are nursing technicians (TNs). ANs are professionals who concluded a nursing undergraduate course of four or five years and who work in the health assistance at hospitals or primary healthcare services. They are able to execute management, training, and supervision of the TNs as well as more complex nursing procedures (e.g. large dressings and invasive procedures). TNs are professionals with at least a high school-level education and who concluded a two- year nursing course and are able to work at hospitals or primary healthcare services performing less complex nursing procedures (e.g. hygiene and comfort of the patient, administration of medication) under supervision of ANs.

The criteria for eligibility to participate of this study were having worked in the ED for at least six months and having cared for some children or adolescents with substance-related disorders while in this

department. All professionals met these criteria and were invited to participate in the study.

A specialized nurse trained in data collection recruited the partici- pants, and this recruitment was done in three steps. Firstly, a poster with an invitation, the aim of the study, and the phone numbers and email addresses of the researchers was posted at the entrance of the nurses' room. Secondly, a date was scheduled with the manager of the unit to negotiate two meetings with the nursing team from both shifts (daytime and night-time). Finally, a face-to-face invitation was given during the meetings that occur one hour before the shift change. The professionals who agreed to participate gave their phone number and were contacted to negotiate an appropriate schedule to interview. Thus, 31 health professionals (6 ANs and 25 TNs) voluntarily accepted the invitation to participate.

2.2. Data collection

2.2.1. Quantitative data Firstly, the quantitative data were collected. In 2012, a specialized

nurse and an information analyst collected retrospective and secondary data on administrative records from the hospital's information system of visits to the ED by children and adolescents with substance-related disorders, between 2009 and 2011. They collected data on socio- demographic variables, year of attendance, outcome (discharge, hos- pitalization, referral, and return to consultation), and diagnosis (ac- cording to codes from the International Classification of Diseases, 10th Revision [ICD-10]). It is important to highlight that the diagnosis re- gistered in the hospital's information system was based on diagnostic hypotheses attributed by medical professionals during their first eva- luation of the patients or based on medical records from other depart- ments or health services that share relevant information within the same system.

2.2.2. Qualitative data Secondly, between 2013 and 2014, the qualitative data collection

was developed. We presented the prevalence data obtained from quantitative data collection and the characteristics of children and adolescents attending the ED, in previous years, to each nurse partici- pant in the qualitative phase, prior to the face-to-face interviews, which revealed to them a previous idea about the prevalence of this demand in the hospital.

Semi-structured interviews were conducted individually and were based on an open-ended, investigator-developed protocol, consisting of three trigger questions concerning the nursing care offered in the psy- chiatric ED to children and adolescents (i.e., those under the ae of 19) with substance-related disorders. The questions were as follows: (1) What is it like taking care of patients in this department? (2) How is nursing care provided to adults with substance-related disorders in this department? (3) How is nursing care provided to children and adoles- cents with substance-related disorders in this department? The research team considered that proposing to participants a reflection on two different stages of life could promote deeper answers on the subject. We used these questions as a trigger for interviews. Other questions were added during the interview process, according to the flow of the con- versation with each participant.

A specialized nurse with training and experience in qualitative data collection conducted the interviews. All interviews were conducted in a private room in the department and audiotaped. They lasted 35 to 50min.

Regarding the age stages considered in this study, it is important to highlight that the United Nations Organization considers adolescents to be between 15 and 24 years old and the WHO between 10 and 19 years old, but Brazilian legislation establishes as adults people above 18 years (Eisenstein, 2005). In this study, we consider as adolescence the age group described by the WHO, aiming for future comparison with stu- dies from other countries.

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2.3. Data analysis

2.3.1. Quantitative data The quantitative data were organized into tables, showing the

number of visits to the ED by patients with substance-related disorders between 2009 and 2011, the outcome of these visits, and the main characteristics of the patients involved. In the hospital's information system, from which the data collection was performed, 82 registrations of visits from that period (between 2009 and 2011) did not have the age information; therefore, those cases were considered as missing data.

We also used the chi-squared test to analyze the associations be- tween age and outcomes, and the odds ratios for such associations were calculated from the contingency tables generated. All analyses were done using SPSS software, version 17.0.

2.3.2. Qualitative data The taped interviews were transcribed in a text editor program, and

two nursing researchers (one with a doctorate and the other a master's degree student) conducted content analysis according to Graneheim and Lundman (2004).

This analysis was performed based on a framework of practice parameters for the assessment and treatment of children and adoles- cents with substance-related disorders (Bukstein, 2005) and the roles of the nurses in EDs (Clarke et al., 2005; Manton et al., 2013; WHO, 2008).

Regarding the qualitative codification, it was processed by both analysts individually, according to the manifest content of the textual data. The codes were clustered into categories based on similarities between words and codified fragments of the text. Secondly, the cate- gories were organized into two themes by considering the latent con- tent of the analysis units previously categorized. Both researchers compared their interpretations to ensure accuracy and reliability. In all cases, the agreement between both analysts was> 80%. Another team member, who had experience with nursing psychiatric assistance in the ED, immersed herself in the data and the categorization to help confirm and interrogate the findings processed by both analysts. We then col- laboratively discussed and reconceptualized the final categories and relationships.

3. Results

We identified that, in 2009, there were 2,304 (93.24%) visits by adults and 167 (6.76%) visits for substance-related disorders by chil- dren and adolescents. In 2010, there were 2,039 (92.46%) visits by adults and 166 (7.53%) visits by children and adolescents. In 2011, there were 2,247 (92.28%) visits by adults and 188 (7.72%) visits by children and adolescents. The findings correspond to around 174 visits by children and adolescent with substance-related disorders per year.

According to the registers in the hospital's information system, the ED received, during this period, about 381 visits per year by children and adolescents for mental health problems. Then, visits by children and adolescents with substance-related disorders corresponded to around 45% of those mental health problems.

The main drugs used by these patients were alcohol, marijuana, and cocaine.

The age of the adolescents ranged from 8 to 19 years old (mean=17; SD 1.8), and in the adult group the age ranged from 20 to 90 years old (mean= 38; SD 11.8). These visits predominantly con- cerned male patients, both for adults (87.4%) and children and ado- lescents (77.4%).

The diagnoses for children and adolescents were mainly F19 — mental and behavioral disorders due to use of multiple drugs (61.6%) — and F14 — mental and behavioral disorders because of cocaine (23.4%). Among adults, the main diagnoses were F10 — mental and behavioral disorders due to the use of alcohol (50%) — and F19 — mental and behavioral disorders due to use of multiple drugs (36.7%).

Table 1 shows that children and adolescents were significantly more

likely to be hospitalized (odds ratio= 2.058, p=0.002) and referred to another department or service (odds ratio= 2.965, p=0.000) than adults; however, adults were significantly more likely to appointment scheduling to other departments in the same hospital than children and adolescents (odds ratio= 0.661, p=0.038). Discharge did not show a significant association with youth, adolescence, or adulthood (p=0.222).

Concerning the qualitative results, the demographic characteristics of the nursing professionals who assisted these patients are summarized in Table 2.

The Table 3 shows the main qualitative results obtained from the interview data and respective categories.

3.1. Nursing interventions and emotional dimension of caring for patients with substance-related disorders

The participants described interventions and emotional dimensions of assistance to patients with substance-related disorders, such as adults, children, and adolescents. They emphasized procedures, such as making physical restraints, assisting the physician during assessment, collecting data, and administering psychotropic medication. These as- pects are illustrated in the following quotes:

“During the admission of these patients in the ED, we physically restrain the patient, notify the psychiatrist, and wait for prescription of medication and for instructions from a psychiatrist about what to do with this patient.” (Interviewed IS, female, 39 years old, married, without children, working in ED as NT for eight years).

“If the patient does not present agitation, we conduct him or her to the medication room and give the psychotropic medication prescribed” (Interviewed RP, male, 40 years old, married, one children, working in ED as NT for one year).

Only a few participants (i.e., two from all AN, and three from all NT) mentioned providing orientation to family and patients as a nursing intervention. The common personal characteristics among these pro- fessionals were not observed. According to these nursing professionals, the content of this provision consisted of information about hospitali- zation, the importance of drug abstinence, and medical instructions. Others mentioned information concerning outpatient mental health services, religious institutions, and other treatment options. As they put it:

“We instruct patients to stop drug consumption” (Interviewed JS, male, 43 years old, married, two children, working in ED as NT for 27 years).

“We try to explain to these patients that there are outpatient treatments for this disorder. We give information about specialized clinics and churches that work in this field” (Interviewed LS, female, 39 years old, single, without children, working in ED as NT for 19 years).

The majority of participants said there were no differences in nur- sing interventions for adults or children and adolescents. Furthermore, they mentioned that adolescents have the same characteristics as adults. This can be illustrated as follows:

“There aren't differences between the assistance for the two groups of patients (adults and paediatric); all are assisted equally” (Interviewed DS, male, 28 years old, married, without children, working in ED as NT for one year, and works also in other health services).

“I think treatment is indifferent in assisting adults or pediatric pa- tients with these problems… I think that we have tried to take care of all of them in the same way” (Interviewed CA, female, 23 years old, single, without children, working in ED as NT for six months, and works also in other health services).

The few professionals who identified some differences in the assis- tance provided to adults and children and adolescents. These differ- ences were limited to their feelings of compassion that only children evoked.

“I feel so much compassion for children with substance-related

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disorders. They are so innocent and anyone can ‘change their mind’ (influence them to use drugs)” (Interviewed LP, female, 42 years old, married, one children, working in ED as NT for eight years).

“It is so hard to see a child in this situation (with substance-related disorders); I feel compassion for the parents who deal with this difficult situation” (Interviewed RP, male, 40 years old, married, one children, working in ED as NT for one year, and works also in other health ser- vices).

Among professionals that mentioned no differences in nursing in- terventions for adults or for children and adolescents, seven had less than three years of experience working in the ED. Among those that mentioned differences, just three had less than three years of experience working in the ED. The median of years worked at ED were similar for both groups (respectively, seven and eight years). In these two groups, we had professionals with and without children, in the same propor- tion. The common personal characteristics among these professionals were not observed. Some nurses said that, if they could choose, they would not care for drug users. For instance:

[I would work with] neither [a] child nor adult drug users, because the recovery rate for this type of problem is so low. It is frustrating and I do not like it. (Interviewed SG, female, 34 years old, married, two children, working in ED as AN for two years, and works also in other

health services).

3.2. Challenges and skills required in caring for children and adolescents with substance-related disorders

Nurses mentioned some skills needed to take care of these patients. General nursing knowledge, patience, sensitivity and discretion, capa- city for dialogue, discernment, respect, and compassion for patients were some of the skills referred to by participants. They also indicated that agility, assertiveness, and good observational skills are important:

“Comprehensive care is the first step. You need to establish a dia- logue with the patient and respect the patient based on an integral perspective, taking into account social, psychological, and physical aspects” (Interviewed LS, female, 39 years old, single, without children, working in ED as NT for 19 years).

“We have to try to be very attentive and agile, to be assertive and to do what is necessary. We cannot give too much importance when a patient cries or complains; we cannot allow them to manipulate us” (Interviewed VF, female, 47 years old, single, one children, working in ED as NT for 25 years).

The structural challenges mentioned included a lack of a private

Table 1 Visit outcomes during the period between 2009 and 2011, according to age group.

Outcome Children and adolescents n (%) Adults n (%) Odds ratio Confidence interval (95%) p-Value

Discharge 449 (87) 5783 (89) 0.848 (0.649–1.109) 0.228 aAppointment scheduling 28 (5.4) 520 (8.0) 0.661 (0.447–0.978) 0.038 Hospitalization 22 (4.3) 138 (2.1) 2.058 (1.300–3.257) 0.002 Referral 17 (3.3) 74 (1.1) 2.965 (1.737–5.063) 0.000 Totalb 516 (100) 6.515 (100)

a Appointment scheduling corresponds to the cases that some professionals from the ED scheduled consultations with patients in other departments from the same hospital.

b Missing data corresponding to 163 subjects.

Table 2 Characteristics of nursing professionals.

Characteristics N (%)

Gender Male 13 (41.9) Female 18 (58.0)

Age (years) 23–32 8 (25.8) 33–42 14 (45.2) 43–51 9 (29.0)

Marital Status Single 6 (19.3) Married/Stable union 20 (64.5) Divorced 5 (16.1)

Children None 12 (38.7) 1 or 2 16 (51.6) 3 or 4 3 (9.7)

Degree of nursing Assistance nurse 6 (19.3) Technician nurse 25 (80.6)

Years worked at emergency department < 1 7 (22.5) 1–5 5 (16.2) 6–10 10 (32.2) 11–20 3 (9.7) > 20 6 (19.3)

Job in another institution Yes 11 (35.5) No 20 (64.5)

Table 3 Thematic analysis of qualitative data.

Categories Sub-categories Codes

Nursing interventions and emotional dimensions of caring for patients with substance- related disorders

Informational support

Orientation concerning:

- interventions,hospitalization,and drug withdrawal

- specialized services for drug treatment

- religious institutions Physical support Physical and chemical restraint

Medications to control symptoms Physician–nurse collaboration Discharge Referral to specialized hospital

Differences between adult and pediatric patients

Pediatric and adult patients receive the same treatment Preference for working with adults

Feelings Compassion, frustration, psychological identification

Challenges and skills required to care for children and adolescents with substance- related disorders

Knowledge General nursing knowledge Communication techniques Professional ethics code

Skills Capacities for observation and discernment Agility, strong stance, and humanized care Capacity to be affective and discreet

Structural aspects

Lack of privacy in attendance Few professionals Need for training and capacity- building courses

Organization aspects

Team communication Support of psychiatrists

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place to care for pediatric patients with substance-related disorders, the limited number of nurses, and a lack of training in specific skills. They commented:

“Sometimes the only place to put these patients is the corridor, in restraint on a stretcher or on a mattress on the floor” (Interviewed CA, female, 23 years old, single, without children, working in ED as NT for six months, and works also in other health services).

“The number of team professionals isn't enough to provide adequate nursing assistance to both children and adults” (Interviewed IS, female, 39 years old, married, without children, working in ED as NT for eight years).

Participants explained that better communication between team professionals and greater support from psychiatrists are the main im- provements they would like to see in the organization of work pro- cesses. One participant said:

“Patients are not admitted according to the proper procedure be- cause there are not enough physicians and we do not have proper support from psychiatrists” (Interviewed CS, male, 38 years old, mar- ried, four children, working in ED as NT for seven years).

Another mentioned: “We do not have much contact with psychiatrists. In general, they

only come to talk to us when it is necessary to transfer a patient; a little bit more communication is necessary between psychiatrists and us to improve this assistance” (Interviewed ML, female, 35 years old, di- vorced, one children, working in ED as AN for six months).

4. Discussion

This study provides important new data on the provision of emer- gency nursing care for children and adolescents with substance-related disorders, as most studies in this field only concern adults. Summarily, we found that, from the perspective of participants, the nursing care provided in the ED to patients with substance-related disorders was strongly framed on the primary role of this setting (i.e. to stabilize acute symptoms and provide security for patients); however, the particula- rities related to the development stages were not emphasized by the participants.

Despite this, the participants stated some important aspects related to continuity of patient care and humanized practice. The nurses we interviewed highlighted the emotions evoked by the patients, and some of nurses noted that there are particular challenges in providing nurse care for them. Hence, specific skills are needed.

A slight increase was observed in the proportion visits in the ED by of children and adolescents with substance-related disorders during the period analyzed, and this result corroborate previous studies (Costa et al., 2012; Lacruz & Lacruz, 2010; Scivoletto et al., 2010).

This study found around 174 visits to the ED by children and ado- lescents with substance-related disorders, which is 45% of the total 381 visits related to mental health problems by this population. This pro- portion is high compared to a previous study undertaken in Hawaii (Matsu et al., 2013), which showed that about 28% of visits by youth with mental health problems to an ED were related to substance-related disorders.

These results may reflect differences related to the specificities of the health systems of these countries. Furthermore, this may indicate a lack of access to or inefficiency in community health services in terms of treatment. It can also indicate early initiation in substance use by youth and poor public policies and strategies related to prevention. However, considering the scope of our study, it is not possible to con- firm these theories, and additional studies are needed to identify the real causes of this phenomenon.

Some previous studies on the use of emergency services by children and adolescents with mental health problems have found that they can be the first and sometimes the only source of care for patients with substance-related disorders (Cronholm et al., 2010; Matsu et al., 2013). However, our study indicated that the most common outcomes of visits

by children and adolescents with substance-related disorders during the period analyzed were hospitalization and referral to specialized ser- vices, unlike for adults. This result suggests that teams such as those investigated are an important gateway to the health system, and they are probably worried about the continuity of treatment of child and adolescent patients. In this regard, it is important to highlight that the nurses mentioned the provision of patients and their families with or- ientation concerning hospitalization and other services from the health system, corroborating the idea of continuity of patient care. We un- derstand that visits outcomes to children and adolescents can be in- fluenced by other factors, such as specifics actions from other team professionals or issues related to availability and access to this specific population.

In addition, these professionals mentioned certain emotions that children and adolescent patients evoked differently from adults, sug- gesting some influence of age on the outcomes of visits by different groups. Based on the qualitative data, it is apparent that children and adolescents evoke compassion in nursing professionals, perhaps re- flecting the hope that younger patients have more chance than adults to engage in treatment, even though some studies have indicated that younger age is a risk factor for non-engagement in treatment (Brorson, Arnevik, Rand-Hendriksen, & Duckert, 2013; McHugh et al., 2013).

According to the majority of the professionals we interviewed, providing nursing care for children and adolescents with substance- related disorders in the psychiatric ED is no different from providing care for adults with similar problems. The average age of adolescents attending the psychiatric ED was 17 years old, and individuals of this age, in general, have many of the same physical characteristics as adults. This may explain the attitudes and emotions reported by the nursing team; however, other issues related to health professional education and national mental health policies have certainly influenced these attitudes. We had a previous idea that personal attributes, such as having children or more experience in the ED, could influence per- ceptions, but our data could not confirm it.

It was identified that the competencies required in caring for chil- dren and adolescents with substance-related disorders, from the parti- cipants' perspective, were similar to the competencies needed for psy- chiatric patients in general. No specific skills or knowledge were mentioned for the care of people related to the use of substances and for the care of children and adolescents. However, substance-use disorders require specific assessment and interventions regarding intoxication or withdrawal and associated clinical physiological, mental, and social demands (Amaral, Malbergier, & Andrade, 2010).

Additionally, patterns of communication adequate to different stages of development, knowledge about manifestation of symptoms, and understanding of the relationship between substance use and adolescent development are crucial competences to provide quality care to adolescents with substance-related disorders independently of the healthcare setting (Center for Substance Abuse Treatment, 1999; Scivoletto et al., 2010; United Nations Children's Fund [UNICEF], 2011). These are complex cases; therefore, caring for them requires a structured approach (McCaskill & Durheim, 2016) and well-trained nursing professionals, an aspect mentioned by participants as an im- portant need in those settings.

Although the participants identified important interventions, knowledge, and skills related to nursing assistance for children and adolescents, other skills important for the successful development of the nursing role in this department were not mentioned. These include screening for consumption patterns of drug use, examining patients' mental state, verifying vital signs, testing the cause of agitation (if re- lated to a medical condition or exacerbation of a psychiatric disorder), verbal de-escalation, and therapeutic relationship techniques (Bukstein, 2005; Clarke et al., 2005; Manton et al., 2013).

Indeed, basic and immediate emergency nursing care was described as a fast assessment, taking action to stabilize acute symptoms and providing security for patients through verbal, pharmacological, or

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physical de-escalation or restraint. However, pediatric patients have specific characteristics that must be considered, such as the risk of developmental disorders, vulnerability to abuse and violence, human rights violations, and educational, legal, and family problems (Dolan & Fein, 2011; Marynowski-Traczyk & Broadbent, 2011; Shafiei et al., 2011; WHO, 2008). It is also necessary to consider the impact that the hospital environment and some of the interventions used may have on young people's development. Our nurse participants highlighted three interventions: physical restraint, chemical restraint, and physi- cian–nurse collaboration. Nursing care should not be limited to these three domains.

Physical restraint was the intervention most commonly used to control aggressive behavior according to the nurses we interviewed. Use of physical restraint should be reduced and questioned; it should not be regarded as part of standard care. Use of physical restraint is a controversial practice, subject to ethical debate, which has no ther- apeutic benefits and is associated with deleterious effects. It is per- mitted in some countries when justified by significant risks and once less restrictive treatments have failed. Evidence-based guidelines re- commend the use of less coercive methods to control aggressive beha- vior, such as early recognition of aggression, attitudinal management, environmental control, continuing education, establishment of proto- cols and routines, and a cohesive and organized approach to patient management (Duxbury & Wright, 2010; Knutzen et al., 2014; National Institute for Health and Care Excellence [NICE], 2005; Rocca, Villari, & Bogetto, 2006). Additionally, a previous Brazilian study identified that TN were more likely to use restraint, when compared to AN (Vedana et al., 2017). However, we did not observe such in our study; that is, nursing professionals with different education levels mentioned the use of restraint.

Administering medication to pediatric patients requires specific knowledge to avoid exposing them to risks, but the nurses who parti- cipated in this study told us they were not trained specifically to care for such patients. Nurses are partly responsible for ensuring that med- ication is administered safely and maximizing the benefit to the patient (Choi et al., 2016). Thus, they need to be sufficiently prepared before assuming this role.

Only a few professionals mentioned providing orientation to pa- tients and family members, even though the encouragement of families to support their loved ones in continuing treatment is one activity that must be implemented in the case of pediatric clients with substance- related disorders in the case of a psychiatric emergency (Dolan & Fein, 2011). The operational aspects mentioned by participants, such as theoretical cognizance, communication skills, ethics, and humanized practice, are consistent with the recommendations of previous studies, highlighting that strategies for child and adolescent assistance are di- rectly related to professional experience and mostly emphasize inter- action, empathy, reassurance, support, and solidarity (Catrib & dos Santos Oliveira, 2012; Sivakumar, Weiland, Gerdtz, Knott, & Jelinek, 2011).

Some participants stated differences in the emotions evoked by children and adults. According to a previous study concerning assis- tance for children in emergency settings, it is easier for nursing pro- fessionals who work with children to adjust to assisting adults, rather than the reverse. Thus, institutional efforts are necessary to develop skills aiding medical professionals in dealing with children in this context, because psychological and mental health knowledge is essen- tial to approach this specific patient group, independently of diagnosis or health condition (Grant & Crouch, 2011).

Drug use is a behavior that also evokes different emotions in nursing teams (Dolan & Fein, 2011; Rocha, de Vargas, de Oliveira, & Nolli Bittencourt, 2013) because it involves complex factors, such as in- dividual choice, autonomy, and self-harm. Nursing teams need to de- velop a good interpersonal relationship with this type of patient and practice without judgment. This is certainly a major challenge for health professionals (Entwistle, Carter, Cribb, & McCaffery, 2010).

In this sense, it is important to discuss that nursing care can be comprised from two intrinsic skills: both technical and emotional skills. With regard to emotional skills, it is emphasized that providing sym- pathy and emotional support is essential for effective engagement in therapeutic relationships and contributes to improve the patient's re- sponse to treatment (Ehlers, 2008; Leonard, 2017).

In the counterpoint of this discussion, there are highlighted aspects, such as anxiety generated in nursing professionals facing the strong emotions, the possibility of these experiences raising unresolved pre- vious emotions, and the fear of confusing emotion and rationality (Leonard, 2017; Pisaniello, Winefield, & Delfabbro, 2012).

Thus, several authors have emphasized the importance of profes- sionals becoming aware of their own emotions because they have po- tential effects on both providers and those who receive the care (Cecil & Glass, 2015; Leonard, 2017; Papadopoulos & Ali, 2016; Pisaniello et al., 2012).

These effects are related to the quality of care, provision of emo- tional support, qualified identification of the patient's needs, estab- lishment of significant relationships with them, and self-awareness about individual difficulties in interacting with patients (Cecil & Glass, 2015; Leonard, 2017; Papadopoulos & Ali, 2016; Pisaniello et al., 2012).

Performing tasks faster to spend less time with patients and focus only on the technical aspects of the work are often attempts by pro- fessionals to mask or hide emotions emanating from contact with the patient. In addition, the management inappropriate of negative emo- tions can culminate in aggressive, hostile, distancing, and even ne- glecting patient needs (Pisaniello et al., 2012).

In this way, it is recommended that nursing and other health pro- fessionals be open to both their own feelings and those of others, and that institutions should establish mechanisms to assist these profes- sionals in the adaptive management of the emotions they experience, mainly in case of units that attend to pediatric, public, and complex healthcare demands. This will certainly result in more satisfied patients, safer care, more cost-effective and time-based care, and happier and more resilient professionals (Leonard, 2017; Papadopoulos & Ali, 2016; Youngson, 2014).

Also, it is very important to consider the role of parents or care- givers to support the assistance and motivate the treatment of children and adolescents, mainly in cases of emergency health. However, in general, the problem of drug use by children and adolescents reflects other previous problems regarding their family and social environment; for example, issues related to negligence, violence, and other psycho- social problems (Mirza & Mirza, 2008). Thus, there are additional challenges to health teams and to the success of treatment.

The challenges mentioned by participants in this study accord with previous studies that have highlighted a lack of physician support, lack of privacy for patients during health assistance, and inappropriate hospital and outpatient facilities (Marynowski-Traczyk & Broadbent, 2011; Shafiei et al., 2011; Sivakumar et al., 2011).

The emergency environment is characterized by high stimulus and is focused on fast assessment; however, psychiatric patients, especially children or adolescents, have specific needs, such as guidance, trustful and supportive interpersonal relationships, and, in the emergency context, a sense of stability and safety from the part of professionals. It is important to have a calm and safe environment, low stimulus, and appropriateness for both patients and their families (Dolan & Fein, 2011; Marynowski-Traczyk & Broadbent, 2011; Nicholls et al., 2011).

Furthermore, the nurses pointed out that they had not received specific training to assist children and adolescents, or patients with substance-related disorders, corroborating previous studies with doc- tors and nurses from EDs (Kelleher & Cotter, 2009; Morris et al., 2011). These professionals are selected to work in a Brazilian public ED through an exam based on general nursing knowledge and skills. After this selection, these professionals usually do not receive specific training, support, or specialized supervision for the assistance related to

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psychiatric or substance-related disorders, or about the specific needs related to the different life stages. Thus, public health efforts are urgent to sufficiently prepare these teams and support them in the assistance of this specific and complex challenge of providing health assistance to pediatric patients, including those with substance-related disorders.

4.1. Implications for practice

All professionals who have contact with pediatric patients with substance-related disorders, especially nursing professionals, need to consider the specific needs of patients' developmental phase and to know about health and social providers and support programs that can contribute to reducing the vulnerable situation of this group. Nursing teams could be more actively involved in caring for children and ado- lescents with substance-related disorders. Introducing evidence-based, systematic protocols governing the provision of nursing care should be a priority. Another factor that could contribute to improving nursing assistance for pediatric patients with substance-related disorders is the development of knowledge and skills in identifying and managing overdose and intoxication symptoms, as well as providing orientation and managing the psychosocial implications of these problems as well as the emotions that these demands evoked (Bolton, 2009; Chun et al., 2013; Costa et al., 2012).

It is also very important that nursing teams reflect on the use of physical restraint and discuss the use of less coercive strategies. Hospitals should provide nurses with training in the safe administration of medicines to pediatric patients and offer teams in EDs access to emotional support.

In short, we strongly recommend that mental health nurses, psy- chiatrists, and pediatricians collaborate to develop evidence-based guidance on care of emergency cases, with specific guidance for the various health professionals involved in providing emergency care. This should include guidelines on screening for suicidal risk, violence, the risk of self- and peer-directed aggression, ethical aspects, safe physical restraint, and establishing the feasibility of treatment via community health services (Bolton, 2009; Chun et al., 2013; Costa et al., 2012; Dolan & Fein, 2011; Nicholls et al., 2011; WHO, 2008). It would be important to make this guidance available to nursing professionals around the world, mainly in countries of medium and low income that have few specialized professionals to deal with these demands. Fur- thermore, nursing professionals need better working conditions in EDs. Nursing associations could provide support for this claim, aiming to help nursing teams promote comprehensive, proper, and safe care for these patients.

4.2. Contextualizing this discussion in the current Brazilian Context

It is important to highlight that the main legal basis of current Brazilian Mental Health Policies is Federal Law n. 10.216, which or- dains the protection and rights of people with psychiatric disorders in Brazil. Specifically, in regard to substance-related problems, some Ministry of Health regulations give guidance on drug demand control, prevention, and assistance to people with such problems. In these regulations, children and adolescents are highlighted much more in relation to preventing the use of these substances than to the specific needs of treatment or social protection.

Summarily, these policies are stronger in terms of their ethical bases than their technical and operational aspects (Souza, Fioratti, Macedo, & de Macedo, 2018). This characteristic has also influenced the re- formulations of education for health professionals (Fernandes et al., 2009), and it certainly reflects in professional practices.

Specifically, in regard to children and adolescents' mental health, it is recently recognized as a public health issue in terms of Brazilian Health System, and it is considered as one of the main challenges to National Mental Health Policies (Delfini & Reis, 2012).

Despite this, it is important to highlight that some initiatives in

public policy have been undertaken in Brazil. In 1990, a legal frame- work was established to protect and guarantee the rights of Brazilian children and adolescents, the Child and Adolescent Statute (Lei n. 8.069, 1990). More recently, an ordinance from the Brazilian Ministry of Health created Psychosocial Care Centers specifically for children and adolescents (Centro de Atenção Psicossocial Infantil) (Portaria n. 336, 2002). Nevertheless, more efforts are necessary to enforce these laws and to provide adequate healthcare to children and adolescents. Hospitals and EDs in Brazil are generally structured to provide care to adults and to children and adolescents in the same environment, without consideration of the needs related to these development stages.

Despite such initiatives, it should be noted that policy and assistance evaluation programs are also incipient in Brazil and require more spe- cific indicators for both mental health and the specificities of the dif- ferent stages of the life-cycle assessment.

It is worth mentioning that, in the guidelines of the last national health service evaluation program, the pediatric public is mentioned only in the item of guarantee of accompanying parents during hospi- talization and specific structure for cancer treatment (Brazil, 2015; Lei n. 10.216, 2001; Souza et al., 2018).

It is important to highlight that all the results from our study are embedded in these structural and political contexts of Brazil.

4.3. Limitations

It is important to highlight that the use of secondary data in the quantitative phase is a limitation of this study. It is possible that some patients with substance-related disorders have not been detected or identified by professionals as the main reason for visiting the ED. to reduce this bias, we consider the number of visits where the main problem presented by patients, according to medical records, was re- lated to these diagnoses

Other limitation is the lack of other qualitative data, beyond inter- views, for triangulation. Observation of professionals in the emergency setting would allow a better understanding of the processes and re- lationships in the context of these subjects, enabling data validation and making the outcomes more representative. Second, only nursing teams were chosen to participate in the study. Using the same approach with other professionals could complement the information obtained by maximizing the study's scope

In regard to the sample, we intended work with all the nurses and technician nurses from the ED, but considering the voluntary char- acteristic of the participation, we lost 18 participants. It can constitute bias in the analysis of perception from this group, mainly because we do not know the cause of these recuses; on the other hand, it has to be considered as one of the aspects from ethical compromise.

The specific limitations of qualitative methods do not permit gen- eralization of the findings. To the best of our knowledge, however, this is the first study to investigate nursing interventions, nursing skills, and the emotional and structural issues related to care of pediatric patients with substance-related disorders in Brazilian EDs.

4.4. Recommendations for further research

Beyond the limitations highlighted above, another important re- commendation for further research is to undertake systematic or in- tegrative revisions of basic guidelines and protocols, as well as to conduct clinical studies evaluating the implementation of educational strategies. Moreover, internal protocols are needed to sustain the practice of nursing teams in assisting children and adolescents with problems related to substance use in emergency services. This would provide an important advance in this field of clinical practice and re- search.

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5. Conclusion

The ED studied receives an average of 174 (SD 9.8) visits by ado- lescents with substance-related disorders per year, and during the period analyzed (2009–2011) the prevalence of visits by this population was 7.2% of all visits related to such disorders.

Substance-related disorders among children and adolescents seen in EDs generate complex demands on nursing teams. These demands in- clude needs related to the development stage, such as physiological and emotional changes, behavior strongly influenced by peers, conflictive attitudes and higher risks related to accident involvement, human rights violations, sexual health, and other needs related to substance- related disorders, such as symptoms, the substance's effects, co- morbidities, challenging behavior, higher risks of injuries, criminal involvements, and unhealthy lifestyles.

Therefore, these professionals perceive many challenges and feel- ings that require special attention from the institution's managers. Psychological aspects, as well as clinical knowledge, must be con- sidered in enhancing the capacity of such teams, particularly bearing in mind the important factors of ethics, humanization, and human rights related to pediatric patients and substance use.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Declarations of interest

None.

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