Perceived Differences in the Management of Mental Health Patients in Remote and Rural Australia and Strategies for Improvement: Findings from a National Qualitative Study of Emergency Clinicians

Introduction. We aimed to describe perceptions of Australian emergency clinicians of differences in management of mental health patients in rural and remote Australia compared with metropolitan hospitals, and what could be improved. Methods. Descriptive exploratory study using semi-structured telephone interviews of doctors and nurses in Australian emergency departments (EDs), stratified to represent states and territories and rural or metropolitan location. Content analysis of responses developed themes and sub-themes. Results. Of 39 doctors and 32 nurses responding to email invitation, 20 doctors and 16 nurses were interviewed. Major themes were resources/environment, staff and patient issues. Clinicians noted lack of access in rural areas to psychiatric support services, especially alcohol and drug services, limited referral options, and a lack of knowledge, understanding and acceptance of mental health issues. The clinicians suggested resource, education and guideline improvements, wanting better access to mental health experts in rural areas, better support networks and visiting specialist coverage, and educational courses tailored to the needs of rural clinicians. Conclusion. Clinicians managing mental health patients in rural and remote Australian EDs lack resources, support services and referral capacity, and access to appropriate education and training. Improvements would better enable access to support and referral services, and educational opportunities.


Introduction
Despite rural and remote Australians having higher rates of mental illness, they lack specialist mental health services [1]. This is of concern to policy makers and practitioners, and to patients who report poor quality mental health services and prejudicial attitudes from staff in rural emergency departments (EDs). EDs are often the only places where acute mental health care is available 24 hours a day in rural centres. In Australia, these EDs are mostly staffed by general practitioners or career medical officers. Clinicians in these environments, both doctors and nurses, often have extensive generalist skills that their counterparts in urban practice do not have. However, there are often deficiencies in their confidence and skills in managing common mental health emergencies, and there have been calls for them to be better trained in this area [1].
There is limited availability of education and training for ED staff in the management of acute mental health conditions, particularly in rural areas. Despite recommendations for increased education to improve awareness of mental health among ED clinicians in general [2], structured education for ED clinicians is lacking, apart from specialised postgraduate courses, as is a clear identification of their learning needs. A learning needs analysis of Australian emergency physicians was conducted in 2006 via survey [3], but there were no data related to the issues around the mental health-related learning needs of doctors in rural and remote areas, and there has to date been no comparable study for nurses.

Emergency Medicine International
As part of a national study into the learning needs of emergency doctors and nurses across Australia, this study aimed to describe these emergency clinicians' perceptions of whether there were differences in assessment and management of mental health patients in rural and remote areas in comparison to metropolitan hospitals and ways of improving the management of these patients in rural EDs.

Study Design and Ethics Approval.
A descriptive exploratory study was undertaken, based on semistructured telephone interviews. This study was approved by the Human Research and Ethics Committees at La Trobe University's Faculty of Health Sciences.

Interview Schedule Design and Development.
A national learning needs analysis of ED clinicians was undertaken, overseen by a research team at St Vincent's Hospital Melbourne with responsibility for questionnaire design, data collection, and data analysis. The interview schedule was developed through an iterative process by this team of two emergency physicians, a researcher/emergency nurse, a research psychologist, and a research officer.
The final interview schedule (Table 1) included one closed question eliciting yes/no/undecided responses to a series of potential learning areas and 16 open-ended questions on various aspects of the learning needs of ED clinicians in managing mental health patients in the ED, including confidence, attitudes, differences between city and rural settings, the effect of resources and comorbidities on assessment, mental health triage, and areas to prioritise for learning.
The current study reports those data from ED clinicians related to direct questioning (yes/no/unsure) eliciting responses to the question of whether the clinicians perceived differences in the assessment and management of mental health patients in rural and remote areas in comparison to metropolitan hospitals, and what they were. Australia's population is concentrated in the major capital cities, and most other towns are relatively small. Clinicians in remote and rural areas in this study were mostly working in smaller rural hospitals. The clinicians were also asked for ideas for improving the management of these patients in rural EDs that may not have access to ED-based clinicians specialising in mental health. While some of the other openended questions also elicited qualitative responses related to subthemes within the broad themes discussed under these questions, they were not specifically related to differences between rural and urban settings and so were not further analysed.
We felt that both clinicians working in remote and rural work contexts and those in city hospital environments could provide useful and potentially contrasting views in response to these research questions and so incorporated data from both groups in this study.

Participants.
In August 2009, doctors who were members of the Australasian College for Emergency Medicine (ACEM) and nurses who were members of the College for Emergency Nursing Australasia (CENA) were invited to be interviewed. Staff in these groups were considered for inclusion if they were working clinically in Australian EDs at the time of the study. Participants were selected from those responding in accordance with attempted proportional distribution across regional and metropolitan settings and across Australian states and territories where possible.

Recruitment and Data
Collection. ACEM and CENA distributed an email invitation to their members on behalf of the investigators to participate in this study. Interested members were invited to email the research officer to express their interest. The research officer then scheduled a time for telephone interview. The Plain Language Statement and interview questions were emailed to the participant prior to the scheduled interview, and all participants provided written informed consent. Interview responses were audiorecorded to permit later verbatim transcription. Transcriptions were provided to participants for validation. Interviews were concluded in February 2010.

Data Analysis.
After transcription and validation, content analysis of qualitative data was undertaken by two research officers using the Framework Method by Ritchie and Spencer [4]. Themes and subthemes were determined independently by two members of the research team, and consensus reached before apportioning responses. Themes and subthemes were analysed according to clinical role (doctor or nurse).

Participant Characteristics.
In total, 39 ACEM members and 32 CENA members responded to the invitation, from which a sample of 20 ED doctors (51% of those responding) and 16 ED nurses (50% of those responding) was selected for participation based on clinical role and jurisdiction. The sample was stratified according to metropolitan and rural EDs, Australian states and territories and seniority of position held in the ED. Table 2 demonstrates the participant's' characteristics.

Differences in Management of Mental Health Patients in
Rural and Remote EDs. In response to direct questioning about whether the clinicians perceived differences in the assessment and management of mental health patients in rural and remote areas in comparison to metropolitan hospitals, and what they were, responses from the 36 clinicians fell into 3 broad themes, resources/environment, staff, and patient issues.
Under resources/environment, 14 doctors and 10 nurses offered responses. Both groups of clinicians noted limited access in rural areas to psychiatric support services (8 doctors, 9 nurses); alcohol and other drug services (7 doctors, 2 nurses); limited options for referral (3 doctors, 2 nurses). Doctors only reported that the logistics of referral  presented challenges (1 doctor) and nurses only commented specifically on limited resources generally (6 nurses). Under the theme of staff issues, comments came from 11 doctors and 7 nurses, under the following subthemes. Both groups of clinicians noted a lack of knowledge and understanding of mental health issues in rural areas (6 doctors, 5 nurses); differences in the assessment and management of rural mental health patients (8 doctors, 1 nurse); a lack of acceptance of mental health conditions in rural areas (3 doctors, 1 nurse); a lack of understanding about dual (physical and mental health) diagnosis (1 doctor, 1 nurse). Doctors noted that staff are more resilient (5 doctors) and flexible (1 doctor) in rural EDs.
Under patient issues, 3 doctors and 2 nurses made comments. They noted a better understanding of social issues contributing to mental health problems for rural patients from local communities (3 doctors, 1 nurse); similarly better community and family support (1 doctor, 1 nurse), although 1 doctor felt there was actually less of this support.
Three doctors and 1 nurse provided responses indicating they were not sure if there were differences or that the question was not applicable as they had not worked in the country.
Qualitative responses below are listed with remote and rural practitioner responses first, followed by relevant responses from city practitioners.

Suggested Improvements in the Management of Mental
Health Patients in Rural EDs. In response to direct questioning asking for ideas for improving the management of these patients in rural EDs that may not have access to ED-based clinicians specializing in mental health, 1 doctor and 3 nurses stated they had no rural experience and did not offer other responses. Otherwise, responses from the 36 practitioners fell into three broad themes of resources, education, and guidelines.
Under the theme of resources, 17 doctors and 10 nurses offered specific responses, with the following subthemes. Medical and nursing clinicians suggested improvements in access to mental health experts for consultation (8 doctors, 4 nurses); improving access to specific mental health services in rural areas (4 doctors, 5 nurses); establishing support service networks (4 doctors, 1 nurse); implementing specific mental health services in rural areas (2 doctors, 3 nurses).
Only doctors offered suggestions about ensuring access to mental health teams/experts (7 doctors); increasing resources to assist in the management of aggressive patients (1 doctor); enhancing visiting psychiatric provider coverage (1 doctor); enhancing existing mental health services in rural areas. Only nurses offered suggestions about improving links between ED staff and mental health staff (2 nurses); implementing case management approaches (1 nurse).
Under the theme of education, 10 doctors and 5 nurses made a range of specific suggestions, grouped into these subthemes. Both groups of clinicians made suggestions about training local clinicians to improve MH knowledge and access to local expertise (6 doctors, 2 nurses); education about patient assessment and management (6 doctors, 1 nurse). Doctors only had ideas about risk assessment training (3 doctors); acute sedation and psychiatric medication training for GPs working in ED settings (2 doctors Under the theme of guidelines, 3 doctors and 4 nurses offered specific suggestions, with the following subthemes. Medical and nursing clinicians suggested utilising best practice guidelines (1 doctors, 3 nurses); developing supporting information and best practice resources (2 doctors, 1 nurse).
Qualitative responses below are listed with remote and rural practitioner responses first, followed by relevant responses from city practitioners.

Doctors' Responses.
In terms of differences between rural and metropolitan management, rural and metropolitan doctors agreed that a common theme was lack of access to support services in rural EDs; doctors acknowledged the difficulty of practising in this environment:  3.5. Nurses' Responses. Again, resource issues dominated the discussion of differences between the country and city, both by rural and city clinicians: ". . . they don't have the same resources . . . and that tends to be a major stumbling block for them because they often have to transfer patients out that maybe didn't need to be transferred out because they don't have someone local or even close by . . . to . . . service the patients' needs." (metropolitan) "Lack of resources; lack of clinicians for sure; lack of education for ED staff to manage these people." (metropolitan)

Discussion
Respondents in this study nominated constraints in resources, lack of psychiatric support services, particularly alcohol and other drug services, and limited options for referral as major differences in the rural and remote environment. Further, there was an acknowledgment of deficiencies in skills and knowledge, to some extent balanced by the resilience and flexibility of clinicians in these settings. A number of respondents reported concerns about attitudes towards patients with mental health problems amongst clinicians in rural EDs.
Despite some advantages in having local knowledge of the social and family circumstances of patients presenting with mental health problems in rural and remote areas, our study showed that ED clinicians face very significant barriers to the delivery of effective mental health care because of lack of resources, lack of training, and lack of easy access to specialist support. Many related anecdotes of particularly difficult cases, mostly centred around acutely agitated patients requiring chemical restraint and transfer and the associated logistic difficulties. Responses from both metropolitan clinician groups indicated significant concern and sympathy for their rural colleagues' predicament, delivering mental health care in an underresourced isolated environment, often with inadequate training.
In suggesting ways to improve the situation, a range of responses was provided; most were realistic in suggesting innovative ways of accessing specialist support, rather than hoping for increased government expenditure for local resources and infrastructure, and optimizing training and skills for local rural clinicians. A number of participants suggested a dedicated mental health line with easy access to senior specialist psychiatric opinion, and this would appear to be an option worthy of further investigation and research. Others noted the potential of internet-based conferencing and training packages, and material on clinical guidelines, referral pathways, and appropriate forms for patient detention and transfer.
There were suggestions that a weekend course for emergency management of mental health presentations could be developed and delivered in rural locations, similar to the Emergency Life Support Course offered by the Australasian Society for Emergency Medicine, or the Early Management of Severe Trauma Course offered by the Royal Australasian College of Surgeons. A number of organizations, such as the Discipline of Emergency Medicine at the University of Western Australia, in conjunction with Rural Health West, now conduct rural weekend courses in cardiac and respiratory care, orthopaedic emergencies, toxicological emergencies, and others [5]. These locally delivered courses have been extremely well received by practitioners in rural and remote locations, and a mental health emergencies course could be modeled along similar lines.
A mental health care course specifically designed for rural and remote practitioners has been evaluated in Western Australia [1]. The Managing Mental Health Emergencies course improved confidence, skills, and attitudes, enabling participants to better differentiate between substance intoxication and psychosis, and dementia and delirium, themes identified in our research. Thematic analysis in followup interviews revealed that participants recognised their prejudicial attitudes, developed new skills they were putting into practice, and communicated better. Our study clearly identifies a need for such courses to be rolled out to rural and remote practitioners; these may address some of the concerns Emergency Medicine International 7 we identified about the need for attitudinal change in rural EDs towards patients seeking mental health care.
Online programs appear to offer some advantages. The Mental Health Emergency Care (MHEC) online learning program was recently trialed in several rural New South Wales health service locations [6]. Modeling collaborative practice in emergency mental health care, this program was shown to improve confidence and perceived effectiveness in managing acute mental health problems. There is clearly great scope here for innovative and effective delivery of emergency mental health care education to rural and remote areas, as suggested by many participants in our study.
There is limited research on the benefits of bolstering acute mental health services in rural Australia. A regional/rural crisis assessment and treatment service (CAT) was trialed in rural Western Australia in a before and after study measuring its impact on inpatient admissions to an acute adult psychiatric facility [7]. While there was a nonsignificant trend in this study towards fewer and more appropriate admissions, policy makers and state governments have historically been unwilling to commit significant resources to these areas despite the clear need. Enhancing training opportunities is likely to be seen as more practical and costeffective.

Limitations.
Despite around a third of the respondents in this study who provided demographic data are working in rural and remote areas, our data may have been somewhat biased towards metropolitan attitudes to mental health care in rural areas. Many of the metropolitan respondents, however, indicated that they had worked in rural environments previously. The sample was broadly representative across jurisdictions, region, and grade of medical staff, but unfortunately there were no nurses from New South Wales or clinicians from the Australian Capital Territory in the study. This limits the generalisability of the results.

Conclusion
Australian clinicians working in rural and remote EDs face significant hurdles in delivering acute mental health care in comparison with their city counterparts, particularly in lack of resources, support services and referral capacity, but also in access to appropriate education and training opportunities. There is a compelling case for improving ease of access to support and referral services, and providing appropriate educational opportunities, either with locally delivered and tailored courses or via online learning.