Nurse Perceptions of Pediatric Mental Health Emergency Care: A Qualitative Study

Abstract

The key goal of the mental health nurse practicing in emergency mental health care services is ensuring that their patients have access to best practice mental health care. The aim of this study was to examine mental health nurses’ perceptions of their role in and preparation for providing mental health care services for pediatric emergency department patients. A qualitative constructivist method was employed. Inductive data were gathered using a focus group discussion model employing open-ended questions as probes. The participants were nine experienced practicing mental health nurses. Discussion was facilitated through detailed probing of the nurses’ experiences in providing care for clients in emergency departments. Four principal themes emerged from the data about mental health nurses’ experiences during the provision of emergency care: (i) barriers to adequate care provision; (ii) problems among populations; (iii) pediatric special needs; and (iv) the general need for improvements to mental health care. Each participant in this study asserted that they endorse the introduction of care by specialized mental health nurses in emergency care departments to better serve this population in Saudi Arabia. Inclusion and acceptance of psychiatric mental health nurses as full members of the multidisciplinary emergency department team, improved education and training opportunities, standards-based evaluation by collegial supervisors, availability of tools for assessment, and recognition of the role of pediatric psychiatric mental health nurses in emergency department care were goals expressed by the focus group members.

Plain language summary

Nurse perceptions of pediatric mental health emergency care

The MHNP emergency service need improve the standard of care for pediatric patients presenting in the ED by removing the typical stages between assessment, referral, and subsequent therapeutic program.

Accessible Summary

What is known on the subject?

The MHNP emergency service needs to improve the standard of care for pediatric patients presenting in the ED by removing the typical stages between assessment, referral, and subsequent therapeutic program.

What does this paper add to existing knowledge?

Additional research is required to investigate the service to improve access to in-progress care via enhanced bonds and channels with general practitioners and specific discipline services.

What are the implications for practice?

Establishing and assessing this broadened MHNP role will also help to highlight the advantages of advanced nursing practice in modern healthcare in Saudi Arabia. By providing efficient access to mental health expertise and more simplified synchronization of care, the ED can increase awareness about mental health and positively affect patient outcomes.

Keywords

emergency care mental health nurse clinical pediatric psychiatric

In the Saudi Arabian healthcare system, the role of the psychiatric-mental health nurse (PMHN) has emerged in recent times as a progressive and dynamic component of nursing. However, the role of the PMHN specialist continues to evolve and adapt to local needs. Emergency departments (EDs) with embedded mental health nurses in the UK, USA, Canada, and Australia serve as leaders in this practice. However, the practice of employing PMHNs in Saudi Arabia is more limited in ED settings. Emergency mental health (MH) care services aim to ensure that pediatric and adult patients are provided with holistic and effective support and access to mental health care (MHC) rooted in evidence-based research (EBR; Sharrock & Happell, 2002).

The World Health Organization (WHO, 2021) has stated that 1 in 7 of the world’s children aged 10 to 19 years experiences a mental disorder, accounting for 13% of the burden of disease for that age group. Children at times need access to MHC during ED care due to suicidality, substance abuse, addiction, anxiety, panic attacks, depression, reactions to injuries or physical abuse, and behavioral crises (Keles et al., 2020). Among additional concerns in ED care requiring PMHN specialist care is pediatric medical traumatic stress. This is defined as “a set of psychological and physiological responses of children and their families to pain, injury, serious illness, medical procedures and invasive or frightening treatment experiences” (Hoysted et al., 2018). It has been identified worldwide, but may be more common in nations where traumatic living conditions or war are present, for example, Afghanistan, Bosnia, Cambodia, India, Kuwait, Lebanon, Palestine, and Rwanda (Hoysted et al., 2018).

In the Saudi Arabian context, the comparatively new specialized PMHN role is well recognized as a field of practice, although PMHNs constitute only 5% of the total nursing workforce, which is comprised of 38% Saudi Arabian nationals, of whom 75% are generalist diplomate nurses (Alluhidan et al., 2020). The remainder of the nursing workforce consists of foreign contracted nurses. According to the World Health Organization Regional Office for the Eastern Mediterranean (2019), as of 2017, there were 1.3 psychiatrists and 10.7 MH nurses per 100,000 people in Saudi Arabia. Moreover, 78% of all MH spending is utilized by inpatient psychiatric units and hospitals. Outpatient MHC facilities per 100,000 population number 0.08, compared with the European Union rate of 0.42 (Alhafi, 2020; World Health Organization Regional Office for the Eastern Mediterranean, 2019).

Emergency Pediatric Mental Health Care

Pediatric ED patients often present for care with MH problems, which is an opportunity to identify and provide timely care to them through screening (Chun et al., 2013). Parents and children who participated in pediatric MH screening as an adjunct to ED care reported it to be acceptable 82% and 75% of the time, respectively, and 99% and 97% of the physicians and nurses respectively, reported that the screening did not make caring for patients difficult (Williams et al., 2011). In another study this screening step assisted in the identification of children with mood disorders and psychosis and could deliver benefits in mediating return visits to the ED. Those children diagnosed with mood disorder and psychotic-related illness who returned to the ED, 6.1% and 8.7%, respectively, returned within 72 hr, and 28.5% and 36.6%, respectively, returned in the long term (Newton et al., 2010). Hackfeld (2020) found that prior to training, 30% of the ED nursing staff in a large urban pediatric hospital were not confident in their ability to use a screening.

MH care is often required Many occasions require MH care in the ED setting, and PMHNs are equipped to provide holistic care to parents of children cared for by the ED due to threatened suicide. Montreuil et al. (2015) provided four main inductive themes describing helpful interventions provided by MH nurses: caring for the child as special, caring for the parents, managing the child’s illness, and creating a therapeutic environment. These themes perceptions were echoed by parents of traumatic brain injury victims who were cared for by PMHNs in EDs and acute care units using the Swanson Caring Theory, which included culturally competent involvement of parents in care of their injured child, upholding parents in advocacy for their child, providing information to the family in ways adjusting to their traumatic situation, and enabling families to address cultural, psychological, and environmental needs (Roscigno, 2016).

Emergency Pediatric Mental Health Care in Saudi Arabia

Any model for delivering best practice care should be tailored to meet local needs. Consideration of environmental, social, and cultural aspects, service structures, and regulatory factors is key to the successful utilization of PMHNs to best meet healthcare needs (Delaney, Naegle et al., 2017). The Saudi National Mental Health Survey, the first large-scale assessment of MH and MHC in Saudi Arabia, relied on the Global Burden of Disease Initiative report and small cross-sectional studies conducted in Saudi Arabia to inform the research. This work reported that there was insufficient information regarding MH or mental illness to make evidence-based conclusions regarding the dimensions and needs of MHC in Saudi Arabia (Al-Subaie et al., 2020).

Healthcare and educational policymakers and planners are currently intensely focused on pediatric mental healthcare. These efforts may yield EBR that could be employed to establish structured, specialized pediatric MH care in the healthcare system. Important examples of this trend are the establishment of the Child and Adolescent Psychiatry Fellowship Program, which was instituted in 2016 (Saudi Commission for Health Specialities, 2016), and the initiation of a dedicated child and adolescent psychiatry unit and residency hosted by King Saud University College of Medicine (2023).

Theoretical Considerations

Meleis (2011) classified theory in nursing into needs, interaction, and outcome theories. She classified the Conservation Theory of Nursing proposed by Levine (1969) as an outcome theory of nursing. This theory discusses two types of conservation in nursing practice—personal and social integrity. Personal integrity means that nurses assist clients in working toward self-determination, self-awareness, self-advocacy, and recognition. Social integrity emphasizes the recognition of clients as members of multiple groups and the promotion of sound health behavior through adaptive change, which is nurtured by the nurse. PMHM nurses placed in EDs as members of the multidisciplinary care team complement emergency medical care for children and their families by applying their specialized MH care skills.

Purnell’s (2002) 12 domains of cultural competence describe cultural sources of variation in societies, cultures, communities, and individuals that influence the acceptance and appropriateness of medical care in all settings. PMHNs may fulfill the role of promoting awareness and application of culturally competent caring activities by the multidisciplinary team, employing holistic caring practices that include enhancing communication between children, parents, and healthcare providers, and therapeutically counseling and advocating for patients and their families as they navigate the medical environment seeking care.

Goal of the Study

The present study represents an effort to conduct EBR that presents the perceptions and needs of PMHNs during the delivery of pediatric MH care in EDs as members of the multidisciplinary care team.

Method

To best approach the research question, a qualitative constructivist investigation was employed, focusing on input from practicing PMHNs to provide first-hand insights into clinical experience in the ED (Frechette et al., 2020). The basis of constructivism is the assertion that reality is driven by research findings and shared experiences based on individual constructions of meaning (Gash, 2014).

Participants and Setting

The sample for this study included nine participants, six of whom were female and three of whom were male. The participants were aged between 30 and 40 years and were enrolled in graduate nursing MH studies in Fall 2021. A poster in the graduate school commons area requested participants with a minimum of 3 years of patient contact experience in ED settings to contact the researchers via telephone. Any volunteer without the required experience in ED care was excluded. The participants worked in a variety of settings. Table 1 displays a profile of their experience.

Table 1.

Participants’ Mental Health Care Experience.

Location of experience	Participants (n)	Length of time
Public primary care facility	4	3–5 years
Public tertiary care facility	2	7–8 years
Privately funded facility	1	3–5 years
Mixed (private + publicly funded)	2	6–7 years

Data Collection

According to Sim and Waterfield (2019), focus groups enable the sharing of experiences, opinions, perceptions, and ideas. Focus groups have several other advantages, such as exploiting problem-solving skills via group discussion and strategic approaches, underscoring the value of sharing experiences and knowledge (Ramani et al., 2018). Krueger and Casey (2009) recommend 8 to 10 participants plus a moderator as the ideal size for a focus group.

The researcher who served as the moderator was known to the students during their undergraduate education and initiated the discussion, including a brief explanation of the purpose of the research and the procedure for group meetings, including the use of digital recording.

Semi-structured discussion employed the probes listed in Table 2. These open-ended questions were designed to facilitate a candid discussion of the participants’ concerns and experiences (Creswell & Poth, 2016).

Table 2.

Probes Used to Initiate Focus Group Discussions.

• Please share your thoughts on how your expertise as a PMHN is pertinent to the delivery of pediatric emergency care.

• How do you feel pediatric patients who have psychiatric or behavioral care needs can best be cared for in the emergency department setting?

• What do you see as barriers to providing best practice care for children in the ED?

• Do you recommend any changes in policy, procedures, facilities, or staffing in an ED that serves children?

As the focus group sessions progressed, the moderator employed theoretical sampling to structure the questions based on the preceding answers supplied by the participants. This process enhanced the opportunity for the participants to offer their thoughts and provide more detailed information about their experiences and related feelings. Each group session was approximately 1 hr in duration. Saturation was marked by the cessation of the emergence of new inductive data, which was achieved during the second meeting. At the final meeting, the moderator engaged the participants in member checking to confirm that the data were complete and appropriately represented.

Data Analysis

The data were reviewed, and the inductive data were grouped by the investigators based on emerging themes. The thematic analysis software NVivo 10.1 (QSR International, Doncaster, Victoria, Australia) assisted in the analysis of the inductive data. The resulting codes were reviewed by the principal investigators and induced to form axial codes, which resulted in the formation of themes.

Rigor

The researchers endeavored to consider the interviewees’ views and avoid any predetermined notions, using member checking at the conclusion of each meeting to confirm the participants’ conceptual positions. The participants’ experience, professional qualifications, and member checking enhanced credibility. The digital record contributed to confirmability. The use of verbatim data and thematic classifications was reflectively evaluated by two peers to assist in conferring further rigor. Transferability depends upon common features of study participants to a population of interest and is enhanced by careful description of the initial group (Rodon & Sesa, 2008).

Ethical Considerations

The study was approved by an institutional review board. Informed consent (both written and oral) was obtained from the participants. All the group discussions were recorded digitally and subsequently transcribed into a Word document, and both formats were stored in a secure storage unit. Anonymization of the data during the transcription conferred confidentiality to the participants, who were informed that they were free to withdraw from the focus group at any time and for any reason. All the statements made by the participants were considered. The researcher ensured that the sessions were planned to provide the participants with adequate time for thinking and reflection.

Findings

The focus groups facilitated open communication and the exploration of perceptions and opinions on the primary themes. The following themes emerged: barriers to adequate care provision, problems among populations, pediatric special needs, and the general need for improvements to MHC. These themes are discussed in detail in the following sections, including verbatim quotes from individual participants, for the purpose of further elucidation.

Theme One: Barriers to Adequate Care Provision

The focus group participants provided insights into the barriers to the provision of adequate MHC and services for pediatric patients in the ED. They emphasized the need to prioritize training to gain skills in the identification and management of pediatric patients who have MH aspects to their presenting problems.

Subtheme One: Education and Training Requirements

The participants considered that specialized education and training is necessary for ED nursing staff to effectively identify and manage MH concerns among pediatric and adult patients. As one participant said, “It is critical that education is provided about the causes, indicators, symptoms, and best management practices of pediatric and adult mental illness” (Participant 7).

Tools have been developed for the assessment of mental status but are not taught or provided, as one participant mentioned: “This education needs to cover how to use tools for mental health screening, instructions for patient discharge, and mental health aftercare for patients with depression, suicidal ideation, or previous suicide attempts” (Participant 1).

The participants viewed organizational structures and policies related to administration, advanced training opportunities, and promotion as barriers to PMHN utilization in EDs, as illustrated by the following quote:

There are limitations in [the] departmental structure and administration within the emergency department that impact efficient and effective assessment. Education and training opportunities for [psychiatric mental health nurses] posted to [the] emergency department require improved identification and management of pediatric and adult psychiatric illnesses. (Participant 7)

A desire for more theoretical knowledge related to the early detection of maladaptive behavior was mentioned by several participants: “We were working without a good theoretical background—especially in medications” (Participant 2), and “It is also important to understand the importance of oversight and comprehension of aspects associated with self-harm or suicide in children and adolescents” (Participant 4).

The profile of pediatric ED visits was increasingly becoming identified as having an MH component that needed to be met by nurses with MH training and experience, as exemplified by the following:

A comparatively large proportion of pediatric emergency visits were due to psychiatric or violence-associated issues; therefore, it is vital that we become more knowledgeable about pediatric psychiatric patients and ensure that the care provided is psychological as well as physical. (Participant 3)

Subtheme Two: Lack of Information

The participants felt that best practice based on EBR was not being implemented. One comment made during the focus group was as follows: “An issue is that information about children and adolescents is most frequently garnered through supposition or conjecture” (Participant 9).

In addition, record-keeping of MH data for patient care was not practiced, as one participant stated: “When these databases were developed, pediatric psychiatric issues were essentially unacknowledged” (Participant 4).

The participants felt that there was a gap in awareness and recognition of the need for MHC to be available as a component of comprehensive care. One participant stated, “Fundamentally, the cause of these barriers is a lack of information about adolescents, and more specifically, pediatric psychiatric illness” (Participant 6).

Subtheme Three: Mental Health Services

The participants acknowledged the benefits of offering public MHC that focuses on clients who are seen in the ED who would otherwise not be seen by MH services. The participants further asserted that health promotion and primary prevention needs could be met by posting a PMHN in the ED. They also recognized the importance of not just reacting to a crisis when an individual visits the ED, but also implementing ongoing interventions to decrease the risk of long-term issues and repeat visits. One ED nurse offered the following opinion: “I believe that interventions prior to reaching that [emergency intervention] point could be very helpful. Our approach has always been reactive rather than proactive, and I think this should change” (Participant 9).

When discussing the advantages of having PMHNs posted to the ED, one participant commented that their services should be encompassed within the overall ED structure, rather than being limited by the inflexible bounds of psychiatric services. The focus group used this opinion as an opportunity to discuss the needs of patients that the current system does not effectively address. One participant commented at this stage as follows:

This approach enables you to address the group of patients who may not typically receive services from mainstream psychiatric and mental health departments and the population who generally do not look for aid, as they have presented with physical health and general medical problems. As that therapeutic bond is not forged in the preliminary stages, it is perhaps a lost opportunity. (Participant 3)

The participants noted that, at times, any type of specialized MH care was unavailable. One participant said, “It is sometimes difficult to access both inpatient and outpatient mental health services, and their effectiveness [is] called into question.” (Participant 3)

Theme Two: Problems Among Populations

The participants emphasized their views of problems among people with MH issues. They focused especially on pediatric MH issues and discussed the available services and cultural aspects in their communities. Two participants commented: “Pediatric patients with mental illnesses have less access to mental health services and have a lower probability [than adults] of receiving the care they require” (Participants 4 and 1).

The participants pointed to a lack of organizational and cultural acceptance of MHC, as follows:

There are problems around obtaining information and following through with mental health referrals, probably due to the stigma and negative feelings about psychiatric illnesses and the lack of adequate aid when [it] is required. (Participant 5)

Cultural aspects are significant, especially concerning the stigma surrounding mental illness. (Participant 9)

Diverse minority groups were observed to have lower levels of access to MH care, as the following statement shows: “It is also the case that patients in treatment who are from minority populations are underrepresented and are frequently provided with a lower standard of mental health care” (Participant 3).

The participants felt that specialized MH care for the treatment of children was difficult to access, stating the following: “Children with mental health issues have a higher risk of receiving inadequate or no care” (Participant 6) and “This finding is especially disturbing, considering the raised rates of suicidal ideation, anxiety, depression, and school dropouts” (Participant 8).

Theme Three: Pediatric Special Needs

Children with special healthcare needs often have a coexisting psychiatric morbidity (Steinhausen et al., 2006). Some of the participants’ comments on this topic are as follows: “Children with asthma and allergies seem to have higher rates of anxiety disorders” (Participant 1) and “Learning and congenital handicaps, as well as obesity, are associated with other issues, such as depression and anxiety, particularly in primary schools” (Participant 5).

Theme Four: General Need for Improvements to Mental Health Care

The participants discussed MH service delivery systems and made several suggestions that they felt would be helpful in caring for adults and children with emotional disturbances, including the following: “Changes in access to mental health care for children could enable them to live and participate to a far greater extent in their communities” (Participant 5).

The general need new sources of information to be available was sensed by the participants, as demonstrated by the following statement: “There needs to be increased awareness, recognition of disparities, early screening processes, technological interventions, and additional research on this topic” (Participant 7).

Inclusion in the multidisciplinary team and the availability of evaluative screening tools were seen as essential for providing high-quality care, as one participant mentioned:

In order to determine the optimum means of screening for undiagnosed psychiatric illness, psychiatric assessments in the emergency department and engagement with community care are necessary […] Priority must be given to [the] inclusion of psychiatric nurse specialists in the multidisciplinary team management of pediatric mental health emergencies. (Participant 9)

An improved knowledge base through collaboration between professionals was seen as a constructive way to improve competencies:

Formation of a pediatric emergency care applied research network, which would be a mental health interest group, offers a perfect opportunity to carry out extensive studies that explain, assess, identify, and engage with treatment approaches within an emergency setting. (Participant 6)

Discussion

The focus group proceedings resulted in themes associated with experiences and views about caring for pediatric patients with MH diagnoses in the ED. These themes may generate comprehension that might otherwise be difficult to quantify or identify. The results of this study suggest that nurses are important in providing an experiential account of occurrences that are likely to be seen in the ED and in illuminating perspectives related to skills or information that may be missing from the care provided (Cochran, 2019). The lead role that nurses play in helping ED patients with MH issues means that they are well placed to identify and offer support to these patients.

The participants discussed the current and growing concern with pediatric MH emergencies within the context of pediatric ED care. Pediatric psychiatric emergencies comprise a considerable portion of pediatric emergency medical care, in addition to patients who need MHC as adjunct care for other concerns when they attend an ED (Carubia et al., 2016; Gullick et al., 2019; Hoge et al., 2022).

A range of problems identified by the participants concerning pediatric MH care provision in EDs agree with the findings of other studies in this subject area. These included insufficient or nonexistent screening and evaluation for MH issues, inadequate training and knowledge, low confidence levels among healthcare professionals caring for pediatric MH patients, deficient built environment ED settings for patients experiencing an MH crisis, extended wait times in EDs for patients requiring MH care, and admission problems due to a dearth of psychiatric inpatient resources (Dombagolla et al., 2019; Granek et al., 2019).

Barriers to Pediatric Emergency Department Care Settings

Training

The participants in this study highlighted the need for PMHNs to have numerous multidisciplinary elements in education and training. They believe that they are not well integrated with other professionals within the overall healthcare system and require more opportunities to gain further theoretical and practical education. PMHNs, as reflected in the present data, believe that they require additional skills to deliver advanced MH services (Kilbourne et al., 2018). It is critical that the contributions of PMHNs be integrated into diverse areas of training and practice, such as interprofessional continuing education and training programs, symptom management methods, medication adherence, and other support tools (Al-Subaie et al., 2020; Settipani et al., 2019).

Secondary traumatic stress is the personal cost of caring for victims of traumatic events (Bahari et al., 2022; Bock et al., 2020; Osofsky et al., 2008). Nurses in Scotland, Ireland, Poland, and Jordan employed in EDs or palliative care units experienced this phenomenon 75%, 64%, 39%, and 52.3% of the time, respectively (Ogińska-Bulik et al., 2021). To address the propensity of experiencing secondary posttraumatic stress and compassion fatigue as the result of caring activities, including in emergency care, PMHNs require training at all educational levels in skills to address and prevent the effects of these stressors.

Further steps to improve training practices may be accomplished through the participation of PMHNs in interprofessional education involving nursing, medical, dental, and pharmacy students in unified curricular experiences. This approach has been found to be well accepted by participants in various global locales (Shakhman et al., 2020; Sunderji et al., 2015; Zechariah et al., 2019) and may be instrumental in improving communication and collaboration among members of the care team.

Nursing Role

MHC in Saudi Arabia is aimed predominately at inpatient psychiatric care. Thus, an important first step in integrating PMHNs into the ED team is to change perceptions of the range of MH care in a modern healthcare system (Dvoskin et al., 2020).

The roles of nurses in the recent past have been poorly defined. Policymakers need to redefine the roles of nursing emergency care personnel with regard to utilizing the PMHN as an important member of the ED team. Providing collegial clinical supervision, a clear role definition, and opportunities to improve professional skills may assist PMHNs in integration into EDs of all types (Alyahya et al., 2021; Delaney, 2017; Marynowski-Traczyk et al., 2017).

Problems With Populations

Culturally competent nursing practice is highly important in all settings. The MHC of pediatric patients everywhere is of special concern, but it is complicated by particular features in Saudi Arabia. MH and MHC are highly stigmatized in Saudi Arabia and in the surrounding North Africa and Middle East region (Merhej, 2019). Public knowledge that a patient has received MHC is stigmatizing to the extent that care may be avoided altogether by those who need it (Alyahya et al., 2021). Thus, social and cultural awareness is an important priority in the eradication of impediments to the establishment of ED care for pediatric cases (Patel et al., 2018).

As noted previously, most healthcare professionals working in Saudi Arabia are foreign contractors, who may not be attuned to the nuances that govern clients’ choices for their care. Thus, care decisions made by MH care professionals in psychiatric settings may not comply with local norms or be well understood or accepted by local consumers—to the extent that they may affect the delivery of appropriate care (Alhafi, 2020; Halabi et al., 2021).

However, Saudi nationals who are healthcare providers are not immune to disrupted relations between themselves and consumers. Alshehry (2022) studied nurse communication and conflict through the lens of patient safety. The highest patient safety, as self-perceived by nurses, was positively associated with communicating effectively. Perceived conflicts between nurses and their patients or relatives have been negatively associated with nurses’ perceptions of patient safety, and Saudi nurses have reported higher nurse–patient or nurse–family conflict than Filipino or Indian nurses (Alquwez, 2020). These data suggest that Saudi nurses may have culturally mediated communication styles and expectations from personal interactions that differ from those of foreign nurses. This may indicate a need for training and orientation aimed at self-awareness and professional and ethical practices among the Saudi workforce, in addition to the orientation of foreign staff.

Pediatric Special Needs

Pediatric mental health emergency care differs from adult MH emergency care. Pediatric patients need an environment and care team that is specific to them. These needs include specialized care providers trained in pediatric care and particular equipment sized and suited to children’s needs (Remick et al., 2018).

Assessment

A vital phase in providing appropriate and timely care in any setting is assessment. The American College of Emergency Physicians published a position paper advocating for increased pediatric MH tools for employment in the ED, promotion of education and research to prepare for MH emergencies, and acknowledgment of the importance of children’s ethnic and social backgrounds during the assessment process to enhance the delivery of MHC in EDs (Mace, 2006). The use of the HEADS-ED test at the screening stage for adolescent MH care in EDs has proved very effective. This instrument provided 82% and 87% sensitivity and specificity, respectively, in predicting the need for psychiatric consultation and referral for admission to inpatient MH care when used to evaluate children receiving care in an ED (Cappelli et al., 2012).

Additionally, the HEARTSMAP psychosocial assessment and management tools used in caring for children in EDs have also received attention. HEARTSMAP is employed to identify patients for ED psychiatry assessment, inpatient admission, and referral to community follow-up (Lee et al., 2019). Its sensitivity and specificity findings are similar to the results of HEADS-ED testing, making these two instruments useful in the assessment, planning, and implementation of treatment plans for MHC care in EDs.

Setting

The built environment of EDs creates difficulty in accessing age-appropriate emergency services for pediatric patients. Triage and care facilities require specialized design for pediatric cases to accommodate the patient and their family in an environment that provides privacy, is safe from hazardous materials and furnishings, and insulates pediatric patients from the milieu of a general ED (Delaney, 2017; Hoge et al., 2022; Sunderji et al., 2015).

General Need for Improvement

The introduction of a holistic approach to MHC may also be instrumental in the inclusion of PMHNs in the professional ED team. The present orientation is based on the medical model of treatment, which emphasizes addressing the physical care of patients with the prescription of drugs and referrals to inpatient care or discharge. This approach may not provide comprehensive assessment and planning for pediatric MHC patients (Marynowski-Traczyk et al., 2017; Settipani et al., 2019).

Among the concerns voiced by Saudi nurses as a group in addition to pay and workload are barriers related to inadequate support from supervisors, limited prospects for promotion, lack of access to educational opportunities, and tenuousness of membership in the multidisciplinary team (Aldhafeeri et al., 2022). These findings were expressed by the participants in this study and by previous inquiries. Fleury et al. (2018) and Alhafi (2020) found that higher job satisfaction among MH professionals was positively related to the absence of team conflict, stronger team support, better team collaboration, greater involvement in the decision-making process, and good working relationships with the team, whereas stressors were identified as poor working relationships between healthcare personnel, difficult relationships with patients and their families, high workloads, understaffing, and lack of positive feedback from clinical supervisors. These findings are in close agreement with those of the current study.

The participants perceived the need for qualified nurse manager supervision that might relate to them collegially, offering guidance and feedback. This concern agrees closely with Alluhidan et al. (2020), who suggested the importance of training focused on practical needs and the use of uniform tools by supervisory staff to evaluate performance.

Study Limitations

This study has certain limitations. One limitation is that the study may not represent the views of all PMHNs in Saudi Arabia. Only nine participants who were selected based on their work experience were involved in the study. Nevertheless, the participants varied in their experience (Table 1), which may make the results applicable to a broader audience while providing practical and experiential data related to PMHN care in ED services. The transferability of these data and findings needs to be tempered by analysis of the population of interest.

Recommendations

The participants in this study confirmed that they supported the introduction of PMHNs for the delivery of care in pediatric EDs. They illuminated concerns about barriers that they have faced in their practice, their desire to fill an active role and to have access to advanced training in this area of practice, to have greater acceptance as a member of the multidisciplinary team, enhanced guidance by a collegial supervisor and administration, standards-based evaluation by supervisors, and recognition of their role by policymakers and administrators.

The development of a comprehensive system of care for pediatric MH concerns in all settings needs to be tailored to the physical and psychosocial needs of children who have unique anatomic, physiologic, developmental, and medical needs that differ from those of adults (Remick et al., 2018). The Saudi Vision 2030 mandate for modernization of all aspects of care for Saudi citizens and residents is a top priority for adoption of change and improvement in healthcare standards and delivery (Alghaith et al., 2021; Al-Subaie et al., 2020). Official recognition in Saudi Arabia of specialized care for MH disorders is relatively new, beginning with the adoption of the Mental Health Act in 2006. The establishment of this recognition provides a platform for initiatives to develop and improve MH care within the healthcare system (Carlisle, 2018). This codification of MH practice may provide opportunities to augment the traditional medical treatment model in addressing emergent psychiatric and mental health conditions with holistic care in EDs (Creamer & Austin, 2017) staffed by a multidisciplinary team including PMHN specialists.

Footnotes

Acknowledgements

The author thanks the Deanship of Scientific Research, College of Nursing Research Centre at King Saud University for funding this research.

Author Contributions

SAH Conceived the study and collected the data. SAY determined the methodology and wrote the background section, SAH wrote the discussion. Both authors reviewed and amended the manuscript before submitting for publication.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Ethical Considerations

The research and interview process commenced after the ethics committee of the University approved (Institutional Review Board - King Saud University – Kingdom of Saudi Arabia) with log No.KSU-HE-20-65.

ORCID iDs

Sami Abdulrahman Alhamidi

Seham Mansour Alyousef

Data Availability Statement

Data sharing not applicable to this article as no datasets were generated or analyzed during the current study.

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