Emergency primary care personnel's perception of professional-patient interaction in aggressive incidents -- a qualitative study.

BACKGROUND: Incidents of aggression and violence from patients and visitors occur in emergency primary care. Most previous studies have focused on risk factors such as characteristics of patient, health personnel or situation. This study aimed to explore professional-patient interaction in aggressive situations. METHODS: A focus group study with eight focus groups was performed, including a total of 37 nurses and physicians aged 25-69 years. The participants were invited to talk about their experiences of violence in emergency primary care. Analysis was conducted by systematic text condensation. Results were then illuminated by Honneth's theory The Struggle for Recognition. RESULTS: We identified three main themes regarding the interaction between health personnel and patients or visitors in aggressive situations: (1) unmet needs, (2) involuntary assessment, and (3) unsolicited touch. In all interactions the aggressive behaviour could be understood as a struggle for recognition. CONCLUSIONS: Aggression is more likely to arise in situations where the patients' needs or personal borders are invalidated. The struggle for personal recognition during the interaction between patient and health professionals should be addressed in health professionals' education. This knowledge might increase their awareness and help them to react in a more expedient manner.

Dealing with workplace violence in emergency primary health care: a focus group study.

BACKGROUND: Prevention and management of workplace violence among health workers has been described in different health care settings. However, little is known about which phenomena the emergency primary health care (EPC) organization should attend to in their strategies for preventing and managing it. In the current study, we therefore explored how EPC personnel have dealt with threats and violence from visitors or patients, focusing on how organizational factors affected the incidents. METHODS: A focus group study was performed with a sample of 37 nurses and physicians aged 25-69 years. Eight focus group interviews were conducted, and the participants were invited to talk about their experiences of violence in EPC. Analysis was conducted by systematic text condensation, searching for themes describing the participants' experiences. RESULTS: Four main themes emerged for anticipating or dealing with incidents of threats or violence within the system: (1) minimizing the risk of working alone, (2) being prepared, (3) resolving the mismatch between patient expectations and the service offered, and (4) supportive manager response. CONCLUSION: Our study shows a potential for development of better organizational strategies for protecting EPC personnel who are at risk from workplace violence.

Safety measures to prevent workplace violence in emergency primary care centres--a cross-sectional study.

BACKGROUND: Employees in emergency primary care centres (EPCC) have raised personal safety as an issue. Despite a high risk of experiencing workplace violence at EPCCs in Norway, knowledge regarding applied preventive measures is limited. The description of existing safety measures is an important prerequisite to evaluate and make guidelines for the improvement of preventive practices on a national level. The objective of this study was to investigate to which extent general practitioners work alone in EPCCs in Norway, and to estimate the prevalence of other preventive measures against workplace violence. METHODS: A survey was sent to the managers of all 210 registered EPCCs in Norway. The questionnaire included 22 items on safety measures, including available staff, architecture and outfitting of the reception and consulting rooms, and the availability of electronic safety systems and training or monitoring systems. The data were analysed using descriptive statistics. Differences between EPCCs staffed by one general practitioner alone and EPCCs with more health personnel on duty were explored. RESULTS: Sixty-one (30%) of the 203 participating EPCCs had more than one person on duty round-the-clock. These EPCCs reported the application of a significantly higher number of safety measures compared to the EPCCs with only one general practitioner on duty during some or part of the 24 hours. Examples of safety measures being more common in highly staffed EPCCs were automatic door locks (p < 0.001), arrangement of furniture in the consulting room ensuring that the patient is not seated between the clinician and the exit (p = 0.014), the possibility of bringing an extra person on emergency call-outs or home visits when needed for security reasons (p = 0.014), and having organised training regarding violence (p < 0.001). CONCLUSION: This study shows considerable differences between Norwegian EPCCs regarding applied preventive measures, and a higher prevalence of such measures in EPCCs staffed with several health personnel around-the-clock. More research is needed to understand the reasons for, and the effects of, these differences.

How Norwegian casualty clinics handle contacts related to mental illness: A prospective observational study.

BACKGROUND: Low-threshold and out-of-hours services play an important role in the emergency care for people with mental illness. In Norway casualty clinic doctors are responsible for a substantial share of acute referrals to psychiatric wards. This study's aim was to identify patients contacting the casualty clinic for mental illness related problems and study interventions and diagnoses. METHODS: At four Norwegian casualty clinics information on treatment, diagnoses and referral were retrieved from the medical records of patients judged by doctors to present problems related to mental illness including substance misuse. Also, routine information and relation to mental illness were gathered for all consecutive contacts to the casualty clinics. RESULTS: In the initial contacts to the casualty clinics (n = 28527) a relation to mental illness was reported in 2.5% of contacts, whereas the corresponding proportion in the doctor registered consultations, home-visits and emergency call-outs (n = 9487) was 9.3%. Compared to other contacts, mental illness contacts were relatively more urgent and more frequent during night time. Common interventions were advice from a nurse, laboratory testing, prescriptions and minor surgical treatment. A third of patients in contact with doctors were referred to in-patient treatment, mostly non-psychiatric wards. Many patients were not given diagnoses signalling mental problems. When police was involved, they often presented the patient for examination. CONCLUSIONS: Most mental illness related contacts are managed in Norwegian casualty clinics without referral to in-patient care. The patients benefit from a wide range of interventions, of which psychiatric admission is only one.

Admissions to a Norwegian emergency psychiatric ward: patient characteristics and referring agents. A prospective study.

BACKGROUND: In Norway, general practitioners serve as gatekeepers for specialist psychiatric care. Out-of-hours primary healthcare (i.e. casualty clinics) is responsible for the major part of acute psychiatric referrals. There are concerns regarding regular general practitioners' (rGPs') role in emergency psychiatric care of their enlisted patients. Also, the quality of casualty clinics' care and their gatekeeper function are questioned. AIMS: To investigate differences between acute admissions to a psychiatric hospital from casualty clinics, rGPs, specialist psychiatric services and other specialist services regarding characteristics of patients and circumstances of the referrals. METHODS: A prospective observational study. In the period of 1 May 2005 to 30 April 2008, anonymous information was recorded for all consecutive admissions (n = 5317) to the psychiatric acute unit (PAU) at a psychiatric hospital serving 400,000 inhabitants. The recorded information was: referring agent, circumstances of the referral, patient characteristics, and assessments by the receiving psychiatric resident and the therapist in charge of treatment at the PAU. RESULTS: There were only small differences between patients referred to PAU from casualty clinics, rGPs, specialist psychiatric services and other specialist services. The referrals from the different referring agents seemed equally well founded. However, the casualty clinics used more police assistance and coercion, and legal basis for admissions was more frequently converted than for other referring agents. CONCLUSION: Casualty clinics seem to function adequately as gatekeepers. The high proportion of casualty clinic referrals with converted legal basis might indicate unnecessary use of coercion.

Psychiatry out-of-hours: a focus group study of GPs' experiences in Norwegian casualty clinics.

BACKGROUND: For Norwegian general practitioners (GPs), acute treatment of mental illness and substance abuse are among the most commonly experienced emergency situations in out-of-hours primary healthcare. The largest share of acute referrals to emergency psychiatric wards occurs out-of-hours, and out-of-hours services are responsible for a disproportionately high share of compulsory referrals. Concerns exist regarding the quality of mental healthcare provided in the out-of-hours setting. The aim of this study was to explore which challenges GPs experience when providing emergency care out-of-hours to patients presenting problems related to mental illness or substance abuse. METHODS: We conducted a qualitative study based on two individual interviews and six focus groups with purposively sampled GPs (totally 45 participants). The interviews were analysed successively in an editing style, using a thematic approach based on methodological descriptions by Charmaz and Malterud. RESULTS: Safety and uncertainty were the dominating themes in the discussions. The threat to personal safety due to unpredictable patient behaviour was a central concern, and present security precautions in the out-of-hours services were questioned. The GPs expressed high levels of uncertainty in their work with patients presenting problems related to mental illness or substance abuse. The complexity of the problems presented, shortage of time, limited access to reliable information and limited range of interventions available during out-of-hours contributed to this uncertainty. Perceived access to second opinion seemed to have a major impact on subjectively experienced work stress. CONCLUSIONS: The GPs experienced out-of-hours psychiatry as a field with high levels of uncertainty and limited support to help them meet the experienced challenges. This might influence the quality of care provided. If the current organisation of emergency mental healthcare is to be kept, we need to provide GPs with a better support framework out-of-hours.

Contacts related to mental illness and substance abuse in primary health care: a cross-sectional study comparing patients' use of daytime versus out-of-hours primary care in Norway.

OBJECTIVE: To investigate prevalence, diagnostic patterns, and parallel use of daytime versus out-of-hours primary health care in a defined population (n = 23,607) in relation to mental illness including substance misuse. DESIGN: Cross-sectional observational study. SETTING: A Norwegian rural general practice cooperative providing out-of-hours care (i.e. casualty clinic) and regular general practitioners' daytime practices (i.e. rGP surgeries) in the same catchment area. SUBJECTS: Patients seeking medical care during daytime and out-of-hours in 2006. MAIN OUTCOME MEASURES: Patients' diagnoses, age, gender, time of contact, and parallel use of the two services. RESULTS: Diagnoses related to mental illness were given in 2.2% (n = 265) of encounters at the casualty clinic and in 8.9% (n = 5799) of encounters at rGP surgeries. Proportions of diagnoses related to suicidal behaviour, substance misuse, or psychosis were twice as large at the casualty clinic than at rGP surgeries. More visits to the casualty clinic occurred in months with fewer visits to rGP surgeries. Most patients with a diagnosis related to mental illness at the casualty clinic had been in contact with their rGP during the study period. CONCLUSION: Psychiatric illness and substance misuse have lower presentation rates at casualty clinics than at rGP surgeries. The distribution of psychiatric diagnoses differs between the services, and more serious mental illness is presented out-of-hours. The casualty clinic seems to be an important complement to other medical services for some patients with recognized mental problems.

Contacts related to psychiatry and substance abuse in Norwegian casualty clinics. A cross-sectional study.

OBJECTIVE: To provide quantitative measurement and analysis of the frequency with which patients contact emergency primary healthcare services in Norway for psychiatric illness, including substance misuse. Characteristics of the patient group and their contact times were also addressed. DESIGN: Cross-sectional observational study. SETTING: Data were collected from one district-based and one city-based casualty clinic in Norway. SUBJECTS: Patients seeking medical care during the whole of 2006. MAIN OUTCOME MEASURES: Patients' diagnoses, age, gender, and time of contact. RESULTS: Diagnoses related to psychiatric illness were found in 2.7% of all events at the casualty clinics, but were relatively more frequent at night (5.6%) and for home visits and out-of-office emergency responses combined (8.4%). Prevalence was almost doubled during the July holiday month. Prevalence remained relatively constant between ages 15 and 59. The most frequently diagnosed subgroups were depression/suicidal behaviour, anxiety, and substance abuse (21.3%) of which 76.8% was alcohol-related. Gender and age differences within diagnostic subgroups were identified. For example, substance abuse was more prevalent for men, while anxiety was more prevalent for women. CONCLUSION: Psychiatric illness and substance misuse have relatively low presentation rates at Norwegian casualty clinics, compared with established daytime attendance at general practitioners. However, the prevalence increases during periods with lowered availability of primary and specialist psychiatric healthcare. These data have implications for the allocation of resources to patient treatment and provide a foundation for future research into provision of emergency healthcare services for this group of patients.