Focus

“Why are you wasting our time?”

Shunned in the emergency room

By Avril Roberts

“Get that schizo out of my emergency department! If you want to admit her, admit her to your ward, but get her out of here – and tell her to take care of her diabetes!”

This is the reception Michele Misurelli got four years ago, on arriving at an emergency department with skyrocketing blood glucose levels and fears that she might go into a diabetic coma. “My psychiatrist managed to get me a space on his psych ward and had me admitted for my diabetes,” says Misurelli. “I should have been on a medical ward, but they didn’t think I qualified. They thought I was playing games with them.”

“The attitude is that we are a nuisance, that we are faking it, that we don’t have any grounds to be there,” says Misurelli. “We get told, ‘This is an emergency department. We’re dealing with gunshot wounds, knifings and heart attacks. Why are you wasting our time when there are people who are sick? If you just give yourself a good kick, you wouldn’t be here.’”

It’s an attitude that plays out in emergency rooms across the country. People with mental illness and addiction say they experience stigma and discrimination by ER staff, from reception to medical personnel, regardless of whether they are seeking medical or psychiatric care. This can lead to delays in receiving services and increased wait times. In the ER, because they are in contact with health care providers at a time of crisis or vulnerability, this stigma can be particularly devastating.

Consumers tell us about the many forms that stigma and discrimination in the ER can take:

Disrespectful words. Calling people “frequent flyers,” “problem patients,” and “heavy users.” Joking about people’s physical or mental health conditions.

Dehumanizing body language. Rolling eyes and knowing glances. “You go up to the desk and the nurses immediately put their heads down and ignore you like you’re invisible.”

Judgmental attitudes. “Oh, you’re here again?” Viewing addiction as a lifestyle choice, not as an illness. When one addiction agency in Ontario approached the head of a local ER with an offer to have an addiction worker on hand, gratis, the offer was declined with the comment, “Well, it’s their choice, isn’t it?”

Exclusion or refusal of care. Misdiagnosing or ignoring a medical problem because someone has a history of mental illness or addiction.

Harsh interventions. “Raising your voice can get you sedated.” Excessive use of force by security.

Discriminatory policies and procedures. Mandatory undressing for psychiatric patients. Segregation of people in locked rooms regardless of legal status, behaviour or elopement risk.

Posted signs indicating expected behaviours. “You are required to behave as if you don’t have a problem because staff are not trained in mental health matters and can’t deal with you at the level of your emotional distress.”

Lack of privacy. “There’s no such thing as being discreet. You have to go up in front of everybody else. It’s everybody’s business.”

Inappropriate triage and long waits. “You can wait eight to 10 hours while they take everybody else.” “It’s like apartheid. There are the mental disorders and the physical disorders. The physical disorders get preference and they’re legitimate, but the mental disorders are considered a pain in the butt.” In a study published in the Canadian Journal of Emergency Medicine in 2008, all of the 27 men with a history of suicidal behaviour and substance use who were surveyed had negative expectations about the visit. “The hospital is always my last resort,” said one man. “I end up feeling worse, and the waiting …”

Yet despite the fact that emergency departments are seeing more and more people with mental health and addiction issues – either for those issues or for unrelated physical complaints – progress in combating stigma and discrimination has been slow.

As part of Alberta’s participation in an emergency room pilot project of the World Psychiatric Association’s (WPA) Open the Doors global anti-stigma campaign in the late 1990s, recommendations for emergency room standards were presented to the Canadian Council on Health Services Accreditation (now Accreditation Canada). These recommendations, concerning privacy, security, safety, patient and family rights, training and patient satisfaction were not incorporated into national hospital accreditation standards until 2008, so their impact has yet to be seen.

In the meantime, Misurelli, who sat on the WPA committee, is pinning her hopes on the Mental Health Commission of Canada’s (MHCC) 10-year anti-stigma / anti-discrimination campaign, Opening Minds, which is currently targeting stigma among health care providers: “It takes a national effort and it takes consumers to speak for themselves and turn to the service providers and say, this is what’s wrong, this is what’s needed and this is how it’s going to go,” says Misurelli.

Emergency rooms are a good starting point because they represent the front line where stigma and discrimination are likely and where professional disciplines work together. These three pilot projects of Opening Minds are leading the way.

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In Nova Scotia, the Cape Breton District Health Authority has initiated a project where front-line staff from local emergency departments will each spend a day at the Crossroads Clubhouse community-based recovery program in Sydney. “Emergency department staff see people with mental illness at their worst,” says Dr. Linda Courey, director of mental health and addiction services for the health authority. “We need to humanize people with mental illness and see them when they’re well and functioning. ER nurses need to see people with mental illness as regular people who get ill from time to time, not as troublesome diagnoses.”

The goal is to have all ER nurses at the Cape Breton Regional Hospital complete the training. The two nurses who have attended so far have told Courey that it was a powerful experience. The next step will be a meeting between the Family Working Group and emergency department staff and management to share experiences and ideas for improvement.

In related initiatives, the health authority is educating mental health and addiction clients about emergency department functions and processes because, Courey says, “some of the difficulties arise out of unrealistic expectations.” One of the meetings was about the changes in the triage scale and why some people wait longer than others.

The emergency department at the Cape Breton Regional Hospital recently added a private room for people who are agitated or feel overwhelmed. The hospital is thinking about creating compliment cards (as opposed to complaint cards) as a strategy for providing positive feedback to ER staff, in order to encourage behavioural change.

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Between January and March 2009, Ontario’s Central Local Health Integration Network (LHIN) held 13 one-hour anti-stigma workshops with 208 emergency room staff at five area hospitals. The curriculum was designed with input from the Central LHIN Consumer/Survivor Network members. These Understanding the Impact of Stigma workshops involved hearing consumers’ stories, challenging myths about mental illness and addiction and engaging in small group discussions. Each participant was asked to make a personal commitment to eliminate stigmatizing behaviours in the workplace and in daily life.

“We thought that an experiential approach would help participants recognize their own stigmatized views and start to break that down,” says Arla Hamer, who was chair of the Central LHIN Mental Health and Addiction Education Work Group at the time. “Hearing consumers’ stories of the impact of stigma in their lives and what made a difference in their recovery is intended to raise understanding and awareness of stigma.”

For current chair Lori Kerr, two things stood out when she observed several of the sessions: “The surprise of participants in realizing that they project stigma, and their realization that even within an organization one person can effect change.”

Constantin Nastic, a consumer, offers an example. “A hospital worker bent down to eye level and put her hand on my arm. Her kindness and words of caring gave me hope. The way she looked in my eyes. The tone of her voice. She could have done the same thing a 100 times before and it wouldn’t have made a difference, but at that moment, it did.”

The project has also instilled hope that attitudes and behaviour can change. Before- and after- measures of participants’ knowledge, attitudes and intention to change behaviour showed significant improvements. One of the biggest shifts was in the perception of recovery, which Hamer attributes to hearing consumers’ stories: “Consumers were able to demonstrate that recovery is possible and that it is an active process.”

One participant commented, “We have a lot of repeat patients. I will treat these patients as if it’s the first time I’ve met them. I will not judge them based on past visits.” Ninety-two per cent of participants expressed a strong desire to learn more about mental health and addiction. To facilitate that learning, a resource manual has been sent to each participating location.

The workshops yielded an added bonus. “They helped consumers appreciate the challenges of the ER nurses, so there was learning on both sides, which was a benefit we didn’t foresee,” says Hamer.

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In Castlegar, British Columbia, an emergency team leader and a mental health and addiction services team leader are collaborating on a program that will highlight triage, in addition to exploring stigma, mental health and addiction issues. The training will be delivered to all emergency department nurses and physicians in the health service area.

“We noticed that we were not triaging patients with mental health complaints in a timely manner, and physicians were not accepting them in their order of triage,” says Cheryl Whittleton, emergency team leader at Castlegar Health Centre. “They would look at other patients who were quick, perhaps a sore throat or sore foot, before mental health clients with a higher acuity level. One of our goals is to educate emergency staff and physicians on the importance of seeing mental health and addiction patients based on the triage level they were assigned.”

This focus on triage dovetails with recent revisions to the Canadian Triage and Acuity Scale (CTAS), which is the recognized standard for emergency department triage in Canada. As of January 2009, CTAS educational materials contain clearer definitions of mental health complaints. For example, depression and suicidal or deliberate self-harm are divided into sub-categories, each with a recommended level of triage.

Jim Fenning, team leader with Arrow and Slocan Lakes and Castlegar Mental Health and Addiction Services, welcomes these changes. “We’re trying to be more specific about how these situations are handled,” he says.