Structural Factors and process factors in which care is provided
These refer to those factors that impact the structure in which care is provided. These include
all factors that are enshrined within the healthcare system such as the equipment, physical
facilities, human resource (HR), and organizational attributes, for example, staff training,
capabilities and payment strategies. They control how patients and providers in a health care
services framework act and the measures of the normal nature of care inside a framework or
system. Care for emergency mental health patients involves inherent structural differences
exhibited in the environment of care. Adequate resources ensure the provision of quality care
in stabilizing acute cases (Eric R. et al, 2010)
The healthcare system has much been on the timeline due to lack of enough human resources
for dispensing care to patients. It is even worrying that Emergency Physicians have little
training in behavioural emergency medicine. There are few physicians specialized in the
treatment and care of psychiatric patients (American Board of Emergency Medicine, 2015).
According to reports, there are 10.7 mental health workforces per 100000 population in
Africa. The deputy head of the mental health unit stated that in Kenya there are reported to be
88 psychiatrists with 427 trained psychiatric nurses spread across 14 mental health units
countrywide. The shortage of mental health workforce is compounding the problem of lack of
access to mental health care (Marangu et al, 2014). Psychiatrists and psychiatric nurses
should be equipped with adequate education, skills, knowledge, and experience in emergency
mental health care.
There are scarce resources allocated to psychological wellness in many Low and Middle-
Income Countries (LMICs) representing under 2% of the aggregate wellbeing spending plan
(Kwobah et al, 2017). The greater parts of the assets accessible are coordinated towards
treating and overseeing seriously sick mental health patients in major mental health facilities
(WHO, 2016). In many low to middle wage nations, HR for emotional well-being are
constrained. For instance, in Kenya, there are less than 100 mental health specialists. A large
portion of these is situated in Universities, National Referral Hospitals and a couple of local
health facilities (Ndetei et al, 2010). This is greatly affecting the quality of mental health care
provided at the mental health units with the already crippled healthcare system in the country.
Lack of sufficient education in the care of patients with mental disorders and a further
shortage of services to treat these kinds of patients is indeed affecting quality service delivery
(Stefan, 2010). Healthcare providers working in the mental health units perceive lack of
knowledge, skills, and expertise in handling patients presenting with emergency mental
health. There are reported problems with triage risk assessment, insufficient resources,
together with the ongoing patient and staff safety concerns, and perception of a crippled
mental health system (Manton, 2013). Their training should be in line with the current trends
and technology, covering core competencies in emergency mental health care, (Brasch J. et al
2004). Health care should be available and affordable to increase access to all. Availability of
health insurance coverage further increases the accessibility of health care, since this makes it
easier for patients to seek health care interventions as the need arises. (National Healthcare
Quality and Disparities Report, 2014)
Healthcare workers always have a feeling of helplessness and are frustrated with repeated
mental health patient visits and readmissions leading to increased workload due to
overcrowding of patients. This has affected the patient care processes and the perceived
output (Abraham, 2014). Working in such environments requires highly motivated
individuals. However, it is worsening that there are inadequate incentives to motivate and
boost the morale of those working in the public mental health hospitals (Ndetei et al, 2010).
There are inadequate medical equipment, drugs, and essential supplies which are necessary
for the provision of quality mental health care.
Presence of policy frameworks that are not up to standard pose a great challenge to the
delivery of care (Marangu E. et al, 2014).The White Paper (2013) recommended that clear
guidelines be formulated to guide on triaging of psychiatric patients, and for those patients
presenting with a history of attempted suicide or the intention to commit suicide. Moreover,
insufficient subsidizing and immature strategy systems add to the test of conveying a wide
populace based mental medicinal services. Lack of clear standard operating procedures
(SOPs) guidelines, policies, and treatment protocols are greatly affecting quality service
delivery during provision of emergency mental health care in the. Available information
shows very few studies on use and adherence to clinical practice guidelines. There is little
information on the use of clinical guidelines in mental health care (Barbui C. et al, 2014).
Process Factors
Based on the above literature, a number of processes factors have been revealed to greatly
affect the process of providing care to psychiatric patients in the ED including the provider-
client relationship, information provision, triage and staff motivation. However, there is
insufficient evidence of the other elements affecting the quality of care in the psychiatric ED
including the availability of standard operating procedures, early interventions, complications
of treatments among others.
Process factors are all those activities of changing health inputs into improving the health
status of those in need of mental health emergency care at mental hospitals. This involves the
interaction process between the healthcare providers and the patients seeking care (Martin et
al, 2013). People with mental health problems seeking emergency mental care evaluation,
face one of the most complicated processes for treatment and management in any given
healthcare systems across the world (Jeniffer et al, 2015). This may be mainly due to lack of
adequate knowledge diagnosis of emergency mental health and related problems and
increasing provider bias during service delivery which may compromise the quality of mental
care. Patients who are perceived to be cooperative are more likely to receive accurate
evaluation (P. Steven and Segal et al, 1995).
Abraham G, Tye-Din JA, Bhalala OG, Kowalczyk A, Zobel J, Inouye M (2014)
Accurate and Robust Genomic Prediction of Celiac Disease Using Statistical
Learning. PLoS Genet 10(2): e1004137.
https://doi.org/10.1371/journal.pgen.1004137
Agency for Healthcare Research and Quality, Center for Financing, Access, and Cost
Trends, Medical Expenditure Panel Survey, 2011.
Agency for Healthcare Research and Quality. 2015; Mental Disorders and/or
Substance Abuse Related to One of Every Eight Emergency Department
Cases: Research Activities.2015. Available
at:
http://archive.ahrq.gov/news/newsletters/researchactivities/sep10/0910 RA35.h
tml [Accessed February 14th, 2017].
A Ghazavi, G Mosayebi, H Salehi, H Abtahi (2010). Pakistan journal of biological
sciences: PJBS 12 (9), 690-69.
American Board of Emergency Medicine.2015; Qualifying Examination Description
and Content Specifications. 2015. Available
at: https://www.abem.org/public/emergency-medicine-(em)-
initial- certification/qualifying-examination/qualifying-examination-
description-and- content-specificiations [Accessed January 15th, 2017].
American College of Emergency Physicians. 2014. ACEP Member Testifies Before Congress
About “National Crisis” in Regard to America’s Mental Health Patients
Anderson, M.J., Diebel, C.E., Blom, W.M. & Landers, T.J. (2005). Consistency and
variation in kelp holdfast assemblages: spatial patterns of biodiversity for the
major phyla at different taxonomic resolutions. J. Exp. Mar. Biol. Ecol., 320,
35–56.
Atzema, L., Schull, J., Kurdyak, P., Menezes, N., Wilton, A., Vermuelen, M., Austin, P.
2012;Wait times in the emergency departments for patients with mental
illness. CMAJ. 2012;184, E969-976.
Barbui C, Girlanda F, Ay E, Cipriani A, Becker T, Koesters M. (2014) Department of
Public Health and Community Medicine, Section of Psychiatry, University of
Verona, Policlinico "GB Rossi", Piazzale L.A. Scuro, 10, Verona, Italy,
37134.
Betz ME, et al. Depress Anxiety. 2013. 2013 Oct; 30(10):1005-12. doi: 10.1002/da.22071.
Epub 2013 Feb 20.
Bird, P., et al., Increasing the priority of mental health in Africa: findings from
qualitative research in Ghana, South Africa, Uganda and Zambia. Health
Policy Plan, 2011. 26(5) p. 357-365
Bloom D. 2011;The global economic burden of non-communicable diseases.
Geneva, World Economic Forum.
Bostock, HC et al. (2004): Carbon isotope evidence for changes in Antarctic
Intermediate Water circulation and ocean ventilation in the southwest Pacific
during the last deglaciation. Paleoceanography, 19(4),
PA4013, https://doi.org/10.1029/2004PA001047
Bhugra D (2013), “We can cure the mental health crisis”. The Guardian. Available at:
http://www.theguardian.com/society/2013/sep/24/cure-mental-health-service-
crisis
Brasch J, Glick RL, Cobb TG, et al: Residency training in emergency psychiatry: a
model curriculum developed by the education committee of the American
Association for Emergency Psychiatry. Acad Psychiatry 28:95–103, 2004
Broadbent, M., Jarman, H., & Berk, M. (2002). Improving competence in emergency
mental health triage. Accident and Emergency Nursing, 10, 155-162.
Broadbent,M., Maxham, L., & Dawyer, T. (2007). The development and the use of
the mental Health triage scales in Australia. International Journal of Mental
Health Nursing, 16, 413-421.
Buriola W., Jernf J., Uert A., Guysten H. 2016;Nursing practice at a psychiatric
emergency service: evaluation using fourth generation assessment. Services on
demand journal. Scientific Online Library.
CDC. Health-related quality of life and activity limitations---eight states, 2013.
MMWR 2013; 47:134--40.
A study done in Australia revealed that clinicians were eager to learn more evidence-based
methods that will help them to provide better mental health care (Manton, 2013). A
therapeutic process can achieved when the care providers learn to create bonds with the users
of mental health care as the initial step . (Buriola et al., 2016). Development of linkage
between the family of the mental patient and the healthcare provider teams. It is considered
important as it aims at constructing care based on trust and bonding (Bessa and Waidman,
2015). This will help them in the provision of appropriate information and thus help in
initiating internalization and behavior change process among patients in the Emergency
Department. There should be a sufficient and effective relationship between the psychiatric
consultants, emergency caregivers, and the patient’s main care providers (PCP) through
communication.
The process of admitting psychiatric patients affects the perception of clients on the quality of
care given by clinicians. They face difficult challenges when evaluating acutely ill psychiatric
patients (Jeniffer et al, 2014). This relates to how they appropriately manage and further
assess agitated patients and the entire process of treating involuntarily admitted patients.
Early psychiatric interventions can help prevent the progression of such cases to critical ones.
In addition, there are no known standard operating procedures agreed regarding the
admission, management or discharge criteria for patients with psychiatric emergency
problems. They are not deliberated as part of actual emergency services and are considered as
problematic or nuisances by the care providers (Emergency Nurses Association, 2010).
(American College of Physicians Emergency (ACEP) 2014) recommends the use of protocols
when managing psychiatric patients. There should be evidence of the use of guidelines or
referral protocols.
For many reasons, caregivers don't feel good in giving consideration to mental health patients
who need immediate care. This brings about patients getting deficient care. This may
incorporate deficient instructive planning, mind supplier wellbeing concerns, swarming of
patients, the absence of trust in aptitudes and skill among caregivers, and absence of clear
rules (Egan et al., 2012). This can also be attributed to lower remuneration strategies as well
as poor working environments in which care is given. This greatly demotivates care
providers, thus perceived low quality of care discharged to clients. Poor staff attitudes such as
embracing a “no bother attitude’ which tends to create perceived stigma towards a patients
leads to delays in the advancement of norms of look after treating psychiatric
emergencies (Manton, 2013). Embracing positive attitude increases the ability of an
agitated or aggressive patient to cooperate and calm down hence improving the
effectiveness and efficiency of quality care. This is further complicated by lack of an
obvious concurrence on what constitutes a psychiatric crisis or diagram how
psychiatric evaluation ought to be directed during an emergency.
Triage has been a key component in managing psychiatric patients in the Emergency
Department. Assignment of triage priorities is based on the presentation of risky
symptoms of mental problems such as the risk of a physical problem, the risk of
suicide, distress, the risk of leaving among others (Agency for Healthcare Quality and
Research, 2011). Those patients expressing symptoms with riskier behaviors are
assigned the higher triage ratings. Relying on triage assignment is important since it
balances the utilization of available scarce resources thus minimizing the level of
deterioration in the patient's condition while holding up to be attended to by a physician
thus improving the quality of care provided. However, some other risk factors are
difficult to measure. For instance, there are no suicide appraisal criteria that has been
tried empirically for unwavering quality and legitimacy. Any faulty in the suicide
assessment procedure may adversely affect the patient’s treatment and safety
management procedures (Chang et al., 2011). Poor triaging priorities may lead to
overcrowding of patients in the emergency department leading to longer lengths of
stay in the hospitals thus affecting the quality of care. (American College of
Psychiatric Emergency (ACEP), 2014) recommends use off treatment protocols to
reduce patient waiting time when there is no psychiatrist available. Pulse report (2010)
indicated the average ED waiting time in the US in 2009 was about 4 hours. This
duration is contrary to the human right based approach, which requires that symptoms
are recognized early and treated to reduce progression to emergency states. (Peter et al,
2016). In Mathari hospital waiting time is up to one hour (Service Delivery Charter,
2015)
