Keperawatan Bencana Jurnal 3

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International Journal of Nursing Studies 95 (2019) 73–86
Contents lists available at ScienceDirect
International Journal of Nursing Studies

journal homepage: www.elsevier.com/ijns
Effectiveness and experiences of mental health nurses in cases of

medical emergency and severe physiological deterioration:
A systematic review
Geoffrey L. Dickensa, *, Lucie Ramjana,b , Gihane Endrawesb , Emily May Barlowc Bronwyn Everetta,b ,
aCentre for Applied Nursing Research (CANR), Ingham Institute for Applied Medical Research, Western Sydney University and South Western Sydney Local
Health District, Locked Bag 7103, Liverpool BC, NSW, 1871, Australia
b
School of Nursing and Midwifery, Western Sydney University, Building EB/LG Room 35, Parramatta South Campus, Locked Bag 1797, Penrith, NSW, 2751,
Australia
c
Division of Mental Health Nursing and Counselling, School of Social and Health Sciences, Abertay University, Bell Street, Dundee, DD1 1HG, United Kingdom
ARTICLEINFO ABSTRACT
Article history: Background: From a baseline of near zero, there has in recent years been a growing number of empirical
Received 6 August 2018 studies related to mental health nurses’ delivery of healthcare for severely physically deteriorating patients
Received in revised form 21 March 2019
or in medical emergency situations. To date, this evidence-base has not been systematically identified,
Accepted 19 April 2019
appraised, and integrated.
Objectives: To systematically identify, appraise and synthesise the available empirical evidence about
mental health nurses, medical emergencies, and the severely physiologically deteriorating patient.
Design: A systematic review in accordance with relevant points of the Preferred Reporting Items for
Systematic Reviews and Meta-Analyses guidelines.
Data sources: Multiple electronic databases (CINAHL; PubMed; MedLine; Scopus, ProQuest Dissertations
and Theses) were searched using comprehensive terms.
Review methods: Inclusion criteria: English language papers describing empirical studies (any design)
about i) the effectiveness of interventions to improve any outcome related to mental health nurses' delivery
of emergency medical care or care for the severely deteriorating patient; or ii) mental health nurses’
emergency medical care-related knowledge, skills, experience, attitudes, or training needs.
Further information was sought from study authors. Included studies were independently assessed for
quality. Effect sizes from intervention studies were extracted or calculated where there was sufficient
information. An integrative synthesis of study findings was conducted.
Results: A total of 22 studies, all but one published since 2011, met inclusion criteria. Ten were intervention
studies and twelve were cross-sectional observational or qualitative studies. Intervention studies were all
of weak quality overall and utilised pre- post designs mostly with limited post intervention follow-up time.
Observational and qualitative studies were generally of good quality but only parts of the evidence from
these studies were relevant to emergency physical care since most focused on mental health nurses and
their routine physical healthcare practice.
Conclusions: There are currently no validated instruments to investigate mental health nurses’ emergency
medical care-related attitudes. More rigorous controlled trials of interventions are needed to better establish
an evidence-base for educational interventions to improve this groups’ emergency care-related practice.
© 2019 Elsevier Ltd. All rights reserved.
Abbreviations: CJR, Clinical Judgement Rubric; ED, Emergency Department; GSES, Generalised Self Efficacy Scale; MEWS, Modified Early Warning Score; RRR, Rapid
Response Report.
* Corresponding author.
E-mail addresses: g.dickens@westernsydney.edu.au (G.L. Dickens), l.ramjan@westernsydney.edu.au (L. Ramjan), g.endrawes@westernsydney.edu.au (G. Endrawes),
e.barlow@abertay.ac.uk (E.M. Barlow), b.everett@westernsydney.edu.au (B. Everett).
https://doi.org/10.1016/j.ijnurstu.2019.04.014
0020-7489/© 2019 Elsevier Ltd. All rights reserved.
74 G.L. Dickens et al. / International Journal of Nursing Studies 95 (2019) 73–86
What is already known about the topic? Documentation of physical health assessments in mental health
settings has also been shown to be poor with one study finding more
People with mental illness have higher rates of all-cause mortality than half the case notes audited were missing details of appropriate
than those without mental illness. assessments; even basic observations such as record ing a blood
Until recently very little was known about the effectiveness of pressure on admission were only recorded in 57% of case notes
emergency medical care provided by mental health nurses for (Ward, 2005). Even with adequate documentation, failure to identify
their patients. deteriorating patients can occur because there is a lack of knowledge
A growing body of empirical literature has emerged in recent of signs and symptoms indicating physiologi cal deterioration, or
years. failure to recognise the significance of these findings (Australian
Commission on Safety and Quality in Health Care, 2008). Even in
spite of the advent of ‘track and trigger’ systems that assist with
What this paper adds early recognition of clinical deterioration, such as the medical
emergency team criteria in Australia and the modified early warning
There is some overlap between research into routine physical score in the UK, research has identified that the sensitivity of these
health care and emergency medical care. tools is low and their utility, validity and reliability have not been
Intervention studies for improving relevant skills of mental health adequately established (Australian Commission on Safety and
nurses are largely of low quality; more rigorous evaluation is Quality in Health Care, 2010).
required. Regardless, patient safety organisations and experts advocate their
The review found there are no validated instruments to investigate use for early identification and improved recording of observations
mental health nurses’ emergency medical care related attitudes. (National Institute for Health and Clinical Excellence, 2007; Australian
Commission on Safety and Quality in Health Care, 2010).
Also implicated as contributing factors to the failure to recognise

1. Background physiological deterioration in patients with mental illness are the
resistant or negative attitudes of clinicians who regard their role as
Peoplewithdiagnosesofmentaldisorder are atmore thandouble exclusively attending to patient’s mental well being: a number of
the risk of all-cause mortality than others in the population; most at studies have reported that mental health nurses lack confidence in
risk are those with psychoses, mood disorder and anxiety; mortality conducting physical health assessment, neurological observations,
rates are significantly higher in studies which include inpatients and emergency medical care including cardiopulmonary resuscitation
(John et al., 2018). Median years of life lost by this group is 10.1 (Ward, 2005). In one Australian study mental health nurses utilised
compared with population controls (Walker et al., 2015). While risk significantly fewer, typically half or less, core physical assessment
of unnatural causes of death is greatly increased, it is death from skills compared with surgical and medical nurses (Osborn et al.,
natural causes that remains responsible for the vast majority of 2015). While the number of core skills would be expected to differ
mortality among people with mental disorder. In people with based on the clinical work area, of note, measuring breathing rate,
schizophrenia, for example, cardiovascular disease accounts for pattern and related chest expansion were not skills regularly used
about one third of all deaths, cancer for one in six; other common by mental health nurses and, given changes in respiratory rate are
causes ofdeatharediabetesmellitus, chronicobstructivepulmonary one of the earliest signs of physiological deterioration (Mok et al.,
disease,influenza, and pneumonia (Olfson et al., 2015).Implicatedin 2015), could account for a proportion of adverse events in mental
increased mortality are high rates of smoking (Drope et al., 2018), health settings.
obesity (Annamalai et al., 2017), exposure to high levels of There has been a tangible and growing international response
antipsychotic pharmacotherapy (Tomiainen et al., 2016) and mental among mental health nursing academics and practitioners to this
disorder itself (Walker et al., 2015). While accounting for a small situation epitomised by a number of literature reviews covering a
number of deaths overall, patients with serious mental disorder are range of delineated areas including a decade of UK-only research
vulnerable to restraint-related death due, in part, to pre-existing on the role of mental health nurses in physical health care (Blythe
conditions that increase the risk of cardiac arrest and the fact that and White, 2012); consumers’ and professionals’ perceptions of
restraint can lead to positional asphyxia (Aiken et al., 2011). barriers to physical health care for people with serious mental illness
Failure to recognise and appropriately respond to significant (Happell et al., 2012); the focus and content of nurse provided
physiological deterioration in patients admitted to mental health units physical health care for mental health service users (Happell et al.,
has been highlighted as a factor in a number of fatal adverse events 2014); and the physical health of people with severe mental illness
in these settings (Findlay et al., 2012). While the reasons for this are (Collins et al., 2012). A relatively recently developed tool, the
multifactorial, it is likely related to the relative infrequency of acute Physical Healthcare Attitude Scale for mental health nurses (Robson
physiological deterioration in mental health settings and, hence, and Haddad, 2012), has demonstrated a range of attitudes towards
staff lacking experience in recognising and responding effectively, and involvement in physical healthcare interna tionally among mental
or underestimating the seriousness of a situation (Australian health nurses (Robson et al., 2013; Haddad et al., 2016; Ganiah et
Commission on Safety and Quality in Health Care, n.d.). al., 2017; Bressington et al., 2018). However, for the most part the
Further, in a scoping review on recognising and responding to scale does not address nurses’ attitudes to or involvement in
deterioration in mental state, Craze et al. (2014: p.21) have emergency medical care or care of the severely physiologically
suggested that the language used in medical records and verbal deteriorating patient. Further, to our knowledge no one has thus far
handovers in mental health settings reflects the superficial nature of systematically identified and reviewed the growing literature about
engagement with observation for signs of clinical deterioration of mental health nurses and the provision of emergency medical care
patients. Examples include: ‘patient appears settled’, ‘patient or care for the patient with clear signs of severe physiological
appears to be resting’ and ‘no change observed’. Further evidence deterioration. In the context of this review, emergency medical care
suggests management of physiological deterioration in mental health is defined as life-saving measures instituted in life-threatening
settings is often suboptimal due to poor communication between situations, such as a cardiac arrest (Hirshon et al., 2013); while care
multiple healthcare providers from more than one team, and across of the severely physiologically deteriorating patient is defined as the
different locations (Craze et al., 2014). ability to recognise and
G.L. Dickens et al. / International Journal of Nursing Studies 95 (2019) 73–86 75
respond to observable severe physiological abnormalities prior to an adverse emergency medical and/or physiological deterioration situations or simulations,
event (Australian Commission on Safety and Quality in Healthcare, 2017). and the outcomes using experiential, social, educational, cognitive, or
attitudinal terms (see Tables 1a and 1b). To ensure we captured studies
In this context we have conducted a systematic review to identify, relevant to the question of intervention effectiveness we used a Population
appraise, and synthesise existing evidence from empirical research literature Intervention Comparator Outcome structure (Population: mental health nurses;
about i) mental health nurses’ experience of providing emergency medical Intervention: any including education, policy or guideline change; Comparator:
health care and care for the severely physically deteriorating patient and their any or none; Outcome: any) (Munn et al., 2018). We searched five electronic
related knowledge, skills, educational preparation, and attitudes; ii) the databases: i) CINAHL, ii) PubMed, iii)
effectiveness of any interventions aimed at improving or changing mental
health nurses’ practice related to emergency medical care or care of the MedLine, iv) Scopus, and v) ProQuest Dissertations and Theses using text
physically deteriorating patient; and iii) to identify implications for the future words and MeSH terms. We also searched the reference list of all included
provision of relevant training and education, for policy, research, and practice. studies, plus those of relevant review studies.
The specific review question being addressed therefore is: what is known Searching was informed by the Australian Commission on Safety and Quality
from the international, English language, empirical literature about mental in Health Care (2011) standard on recognising and responding to clinical
health nurses’ skills, knowledge, attitudes, and experiences regarding deterioration in acute health care. The literature strategy was designed by
provision of emergency medical care and care for the severely physiologi GLD and conducted indepen dently by GLD and EMB.
cally deteriorating patient.
2.3. Inclusion and exclusion criteria
2. Methods Studies were included if they were an English language account of an

empirical study (any design) which examined exposure to real or simulated
2.1. Design medical emergencies. Studies were included if the participants were or
included mental health nurses defined as such by the study authors or were
Systematic review of the literature following the relevant points of the described in the study as registered nurses working in a psychiatric or mental
Preferred Reporting Items for Systematic Reviews and Meta Analyses (Moher health setting.
et al., 2009). No date or setting limiters were applied.
2.2. Search strategy 2.4. Data extraction
The review included both effectiveness and experiential questions. We The following information was extracted from included studies: title,
therefore devised a two-pronged literature search strategy. To capture studies author, publication year, data collection years, study location (country),
about related experience we used a Population Exposure Output format research objectives, aims or hypotheses, design, population, sample details
review question in which the population was defined as mental health nurses, and size, data sources, study variables (i.e., details of intervention) or other
the exposure as exposure, unit of analysis, and
Table 1a
Keywords used in the electronic database search (PEO format).
Population Exposure Outcome
((Mental health or AND (Medical Emergency OR Emergency Medicine OR Emergency AND (education OR preparation OR training OR knowledge OR
psychiatr* or Treatment OR Emergency Therapy OR Emergency Nursing OR experience OR belief OR opinion OR attitud* OR perception* OR values
mental) and Nurs*). Emergency Medical Services OR Emergency Care OR Emergency OR understanding OR knowledge OR skills)
Health Services OR Medical Emergency Services OR Clinical
Deterioration OR unexpected death or cardiopulmonary arrest or severe
clinical deterioration or escalating care or rapid response systems or core
physiological observations or emergency assistance or unplanned
transfer to higher level care or cardiac arrest or intensive care unit
readmission or repeat rapid response system calls OR simulation)
Table 1b
Keywords used in the electronic database search (PICO format).
Population Intervention Comparator Outcome
((Mental health AND (Medical Emergency OR Emergency Medicine OR AND Any or Waiting list AND (education OR preparation OR training OR knowledge
or psychiatr* or Emergency Treatment OR Emergency Therapy OR OR Placebo OR experience OR belief OR opinion OR attitud* OR
mental) and Emergency Nursing OR Emergency Medical Services OR Repeated perception* OR values OR understanding OR knowledge
Nurs*). OR Emergency Care OR Emergency Health Services OR Measures OR skills)
Medical Emergency Services OR Clinical Deterioration
OR unexpected death or cardiopulmonary arrest or severe
clinical deterioration or escalating care or rapid response
systems or core physiological observations or emergency
assistance or unplanned transfer to higher level care or
cardiac arrest or intensive care unit readmission or repeat
rapid response system call)
AND (Training or Education OR Preparation OR
Simulation OR Policy OR Guideline)
Table 2
Intervention evaluation study quality assessment.
Study Selection Bias Study Design Confounders Blinding Data collection Withdrawals Overall
Puskar et al. (2011) Strong Moderate Weak Weak Moderate Weak Weak
Hermann et al. (2011) Weak Weak Weak Weak Weak Moderate Weak
Wynn (2011) Moderate Moderate Weak Weak Strong Strong Weak
Unsworth et al. (2012) Weak Weak Weak Weak Moderate Weak Weak
Shaddel et al. (2014) Weak Moderate Weak Weak Strong Strong Weak
Chadwick and Withnell (2016) Weak Weak Weak Weak Strong Strong Weak
Haddad et al. (2016) Moderate Weak Weak Weak Moderate Strong Weak
Paulose et al. (2016) Weak Weak Weak Weak Weak Strong Weak
Fernando et al. (2017) Moderate Moderate Weak Weak Weak Strong Weak
Lavelle et al. (2017) Moderate Moderate Weak Weak Weak Strong Weak
Table 3
Cross-sectional, observational studies quality assessment (adapted from National Heart, Lung, and Blood Institute.
Tenkanen Robson Flood Herisco Manu Wynaden Ganiah Gebreegziabher Bressington

et al. et al. et al. et al. et al. et al. et al. Gebremedhn et al. et al. (2018)
(2012) (2013) (2014) (2015) (2015) (2016) (2017) (2017)
Research question or objective in this paper x x x x x x x x x
clearly stated
Study population clearly specified and defined x x x x x x x x x
Participation rate of eligible persons at least 50% x x No. x x x x x –
Subjects selected or recruited from the same or x x x x x x x x –
similar populations and in the same time

period
Sample size justification, power description, or No. x –
No. – – – –
x
variance and effect estimates provided

Inclusion and exclusion criteria for being in the x x x x x x x x x
study pre-specified and applied uniformly to

all
Outcome measures clearly defined, valid, x x x x x x x x x
reliable, and implemented consistently

Total (max 7) 6 7 5 6 6 6 6 6 5
x Condition achieved; - condition not achieved; NR = Not Reported.
study findings. Further, we categorised studies as interventional or conducted independently by authors GLD, LR, and GE. Where
non-interventional. Intervention studies aimed to describe the agreement was unanimous this was recorded; otherwise items
impact of an educational or real world (e.g., policy or practice) were discussed until consensus was reached.
change in terms of any mental health nurse- or nursing- related
outcome including patient-related variables arising from nursing 2.6. Study synthesis
actions (e.g., Medical Emergency Team referral). Non-intervention
studies were either descriptive of mental health nurse- or nursing Meta analysis was not possible due to the heterogeneous nature
related outcomes and/or utilised case control designs to compare of study designs and outcomes. We tabulated information about
them with those of other occupational or professional groups. We study findings and conducted an iterative process of grouping and
contacted corresponding authors of included studies regarding any theming results resulting in a descriptive synthesis. We carefully
issues where clarification or additional data could aid the review. considered study quality in the emphasis placed on individual
Where effect sizes were presented we extracted this information
or, where sufficient information was presented in the paper, or
following correspondence with the corresponding author, we Table 4
calculated the appropriate effect size statistic for the test used. Quality appraisal of qualitative studies.
Shanley Herisko et al.

2.5. Study quality appraisal
(2012) (2013)
Clear statement of research X X

Studies used a range of quantitative and qualitative methods aims
and no single appraisal tool was suitable for all studies. We Qualitative method appropriate X X
assessed the likelihood of bias in intervention studies with Design appropriate to address X –
research aims
reference to criteria described by Thomas et al. (2004) and
Recruitment strategy X –
involving assessment of the likelihood of selection bias in the

appropriate to study aims
obtained sample, study design, potential confounders, blinding, Data collected in a way that X –
potential for bias in data collection from invalid instrumentation, addressed the research issue
and participant retention (see Table 2). Relevant items from the US Researcher-participant X –
relationship adequately
Department of Health & Human Sciences NIH Quality Assessment
considered
Tool for Observational Cohort and Cross-Sectional Studies (NIH Ethical issues considered Data X –
National Heart, Lung & Blood Institute, 2018) were used to assess analysis rigorous Clear statement of X –
cross-sectional observational studies (see Table 3). Qualitative findings X How valuable is the research? X Total
–
(max 10) 10
descriptive studies were assessed using the Critical Appraisal Skills
–
2
Programme (n.d.) tool (see Table 4). Quality appraisal was
study findings in the results section and it underpinned our discussion mixed educational/policy and practice intervention). Of the seven
and recommendations. education-only intervention studies, k = 6 evaluated a simulation and k =
1 a paper-based self-instruction module. Of the interven tion studies, k =
3. Results 7 utilised longitudinal pre- post- intervention (AB) designs, k = 2
(Hermanns et al., 2011; Unsworth et al., 2012) were cross-sectional and
3.1. Study settings and participants evaluated quantitative outcomes only follow ing the change or intervention;
Unsworth et al.’s (2012) study used qualitative methods only and was
The search strategy resulted in the inclusion of 21 studies published also cross-sectional. All eleven non- intervention studies utilised cross-
in 22 papers (see Fig. 1 flowchart inclusion flowchart; Tables 5a and 5b) sectional designs. Of these, k = 4 were unmatched case control studies
involving a total of 2076 (M[SD] = 125.7[172.9], Mdn = 57, range 7–585) and k = 2 used qualitative methods only.
mental health nurses or mental health nursing students (n = 124; 5.6%).
In addition, one study (Puskar et al., 2011) provided no details of
participant numbers or characteristics, and a second (Flood et al., 2014) 3.3. Intervention/ exposure
reported N=393 participants in total but no details of profession. We
retained the study since a considerable proportion of the 280 ‘frontline’ The simulation(s) employed in intervention studies were generally
staff involved would be mental health nurses. Manu et al. (2015) examined described in some detail. Simulation training length was 30-minutes
Rapid Response Team calls made over a 10-month period in a US (Hermanns et al., 2011), half a day (Lavelle et al., 2017), and one day
psychiatric hospital and reported the proportion made by various (Herisko et al., 2015; Chadwick and Withnell, 2016). Information on
disciplinary groups including nurses. Studies were conducted in the UK simulation intervention length was not provided by Wynn (2011) or
(k = 8), US (k = 6), Australia, Ethiopia, Finland, India, Jordan, (all k = 1); Unsworth et al. (2012). Details of simulations can be seen in Table 5a; in
one international study was conducted across three nations, namely brief, they involved manikins or human person simulators of varying
Qatar, China (Hong Kong), and Japan. sophistication ranging from a manikin of realistic weight to more
sophisticated Human Person Simulators capable of producing physiological
Two papers (Robson and Haddad, 2012; Robson et al., 2013) described outputs or with the ability to ‘speak’ by researcher remote access.
different analyses from the same dataset and were treated as one study
for the purpose of this review. The simulation scenarios involved attempted suicide by hanging
(Hermanns et al., 2011), care provision for diabetic medical conditions
3.2. Study designs (Wynn, 2011); alcohol intoxication, drug induced psychosis, and chest
infection in a patient with Alzheimer’s Disease (Unsworth et al., 2012);
Of the included studies, ten examined an intervention (k = 7 an medical deterioration and prevention of medical emergencies (Fernando
educational intervention, k = 1 a policy intervention, and k = 2 a et al., 2018);
Fig. 1. PRISMA flowchart.

Table 5a
Included studies (Part 1: Interventional studies).
# Study Data Design. Data sources Sample Intervention Level of Main findings
Country Collection analysis
1 Puskar 1996 Case study Psychiatric clinic Mental Health Guidelines and annual mandatory training Service Rise in Condition As and decline in Condition
et al. -2005 and statistics [emergency Nurses. No details for Medical Emergency Cs. Reduction in adverse events (deaths,
(2011) US retrospective protocols activated, of N or Team access: two Medical seizures)
longitudinal adverse patient characteristics Emergency Team callout levels 1.
design outcomes] C (Crisis); 2. A (Arrest). C allows early
Medical Emergency Team referral.‘No
penalty’ clause for referring nurses 30-
min educational simulation of attempted
2 Hermann et al. not Cross 9-item self-report N = 10 student suicide by hanginginvolving a manikin. Class Understanding of metabolic and
reported sectional Suicide Clinical nurses physiological changes M(SD) = 1.4 (0.49)
(2011) US post Simulation Evaluation where 1 = ‘strongly agree’.
intervention. Tool.
Observation.
student
vocalization
3 Wynn not Longitudinal pre- Lasater (2007) N = 20 Mental Educational simulations of diabetic Significant improved pre- post test CJR
(2011) US reported post Clinical Judgment Health Nurses in a medical conditions using HPS. ‘Live’ scores. All students improved by Time
Rubric (CJR). Veterans Mental scenarios allow reaction to participants’ B. 80% participants satisfied. Number
Diabetes-related Health Hospital. decisions e.g., mistakes can result in of medical emergencies involving patients
medical transfer cardiac arrest with diabetes fell 55% in post-intervention
data. Satisfaction. month.
4 Unsworth et al. not Cross Focus group. N = 15 Mental Educational simulations (alcohol Student Bridging the gap: The
reported sectional Content analysis. Health Nurse intoxication, drug induced psychosis, cohort intervention facilitated skills learningin
(2012) UK post students in chest infection in a patient with Alzheimer’s context of the rarity of opportunity in vivo.
intervention training conducted disease): patient manikin capable of Raised awareness of possibility of patient
qualitative jointly with adult physiological outputs. physical deterioration.
evaluation
nurses. Instructors ‘speak’ for the Helped students recognise gaps in
mannequin from adjacent control knowledge. Learning inter professionally:
room.Response involves vital signs Working with adult students/ university
monitoring, recognition of medical professionals involved collective
emergency. assessment skills used.
Authenticity: the simulation was experienced

as authentic.
Reflection and learning: More likely to
take action M confidence pre- 3.73 post-
5 Shaddel et al. 2014 Longitudinal Two vignettes and a 1- N = 19 nursing Introduction of Modified early Warning Three 4.63 (P<.0001; r =0.871 ). Correct
AB item self confidence in staff in 2 forensic units Score (Wirral Community NHS Trust wards management decision made by 42.1% of
(2014) UK clinical judgement and 1 learning disability 2012) 15 minutes training on using nurses pre- and 92.1% post- training
rating. 10-item Modified unit. MEWS. 1-d educational simulation (P<.0001, w=.712 ).
Generalised Self involving Human Patient Simulators.
6 Chadwick and not Longitudinal Efficacy Scale (GSES; N = 95 Year 3 Student Proportion self-rating in top two GSES
reported AB Schwarzer and Mental Health cohort categories increa-sed on all 10-items Mdn
Withnell Jerusalem, 1995) [58]. Nurse students +36.0% (range +16.0% to +49.0%). Chi
(2016) UK completed x2 squaredanalyses of high/ moderate
questionnaires confidence vs. slight/no confidence all
significant <.01 (Cramer’s VM[SD] =
.37[.12], range .21-.52.)1 .
7 Haddad et al. not Longitudinal Physical Health N = 49 pre- post Introduction of personal health plan for Mental Cardiac ArrestM[SD] A 4.2(0.69) B 4.3(.67)
reported AB Attitudes Scale for questionnaires (81% patients, and aneducation session on Health P>.05 Hypoglycaemia: M[SD] A 3.8 (0.82)
(2016) UK Mental Health response) physical health assessment and manage Nurse B 3.85 (.89) P>.05 Hyperglycaemia M[SD]
Nurses (see Robson et Mental Health ment of patients with severe mental sample A 3.6 (1.1)
al., 2013) Nurses and health problems
nurses’ aides. B 3.8 (1.01) P<.05 Hedges' g = -0.2 (small)
8 Paul not Longitudinal AB Semi-structuredknowledge N = 30 psychi Education. Self-Instruction Modules Group. M(SD) AB scores Heart Attack 3.5(.77) v 6.3
et al. reported questionnaires regarding heart atric staff nurses. provided. (.66) 80 p <.0001)
(2016) attack respiratory arrest, convulsion, Mdn experience Hedges' g = 3.80; Respiratory arrest
India hypoglycaemia 6-12 months 3.3 (1.08) v 6.4 (.73) p <.0001 Hedges'
g = 3.28; Convulsion 2.9(1.24) v
5.8(.40) p <.0001, Hedges' g = 3.07);
Hypoglycaemia 2.8(.81) v 5.6 (.40) p
<.0001, Hedges' g 4.27) 2 Overall Max.
score 26 p<.05?
.
9 Lavelle et not Longitudinal Quantitative question n = 36 Mental 0.5-day educational Service Knowledge total(Cohen’s d = .7)
al. reported AB. Mixed naires: knowledge, Health Nurses simulation using high fidelity confidence total (d = .52) and
(2017) UK methods. confidence, and attitudes. and n = 17 others mannequin. Scenarios including attitudes (d = .34)3 all changed
attended sessions respiratory arrest, hanging, significantly pre-post intervention.
Mdn at each choking. Most items changed significantly.
session 7 (range
Incident reporting for 7 4-10) Incident reporting increased
months pre- post post training. For meds issues,
intervention.: medi illness and injury, suicide and self-
cation, illness & injury, harm.
self-harm & suicide. Qualitative: themes:
Qualitative survey. Focus confidence (up), team working
group at 3-months skills (improved), communications
skills (greater), reflective practice
(better), personal responsibility
(more).
10 Fernando not Longitudinal Self-evaluation form. 21- 63 nurses and Educational simulation. 1-d Regional Improvements in knowledge,
et al. reported AB item questionnaire examining junior doctors Simulation Workshop At the attitudes, and confidence (all
(2018) UK knowledge, attitudes, and (15 [24%] Mental Mental-Physical Interface large effect size eta squared (h2)
confidence. Health Nurses) (SWAMPI).Most scenarios about = 0.63, 0.25., 0.61 respectively).
psychiatric emergencies but one Satisfaction ratings 99%
about medical deterioration. Qualitative: Inter-professional
Course evaluation form yes/ no Learning Objectives were: Medical learning, leadership and teamwork,
answers plus open questions. deterioration in psychiatry – reflection, communication
Tools guided by the literature Prevention of medical emergencies
and piloted prior to use. – Inter professional working
between general and psychiatric
hospital
2
1 Cramer’s V 0.1 = Small Effect Size, 0.3 = Medium, 0.5 = Large (Cohen, 1988); Hedges' g 0.2 = Small Effect Size, 0.5 = Medium, 0.8 = Large. N.B. Hedges' g = 1 indicates the two
3
groups differ by 1 SD,Hedges' g = 2 indicates they differ by 2 SDs. and so on. Cohen’s d 0.2 = Small Effect Size, 0.5 = Medium, 0.8 = Large; h2 Small effect size = 0.01,
Medium = 0.06, Large = 0.14.
respiratory arrest, diabetic hypoglycaemia, hanging and choking asking respondents about their own relevant training. Several studies
(Lavelle et al., 2017). have surveyed mental health nurses working in practice about their
Non-simulation intervention studies aimed to evaluate the attitudes to physical health care including varying elements about
effect of the introduction of standardized guidelines and associat ed medical emergency and physiological deteriora tion (Robson and
mandatory training for nurses about Medical Emergency Team access Haddad, 2012; Robson et al., 2013; Haddad et al., 2016; Wynaden et
(Puskar et al., 2011), a self-instructional module (Paulose et al., 2016), al., 2016; Ganiah et al., 2017; Bressington et al., 2018).
introduction of a modified early warning score sheet and associated
training (Shaddel et al., 2014), and the introduction of personal health
plans for patients in a low secure forensic unit together with a single 3.4. Outcomes measurement
educational session on physical health care for nursing staff (Haddad
et al., 2016). The most frequently used outcomes measure was the Physical
Among the non-intervention studies, Herisko and colleagues Health Attitudes Scale for Mental Health Nurses (Robson and Haddad,
(Herisko et al., 2013) employed a qualitative design involving a group 2012) in k = 4 studies. While the tool has demonstrated validity and
interview to gather information about exposure to utilizing Medical reliability the outcomes of interest for this review were limited to three
Emergency Teams in a US psychiatric hospital. A second study by the items describing emergency/physiological deterioration related
team (Herisko et al., 2015) used an amended form of the structured scenarios: namely, confidence in dealing with cardiac arrest,
interview used in the previous study to gather quantitative data. In an hypoglycaemia and hyperglycaemia. The remaining Physical Health
unpublished PhD thesis, Shanley (2012) conducted qualitative interviews Attitudes Scale for Mental Health Nurses items relate to smoking
with mental health nurses with experience of exposure to suicide or intervention, confidence in delivering routine physical health screening
other sudden unexpected death of a patient. Of 15 participants, n = 6 and advice. No other two or more studies used the same outcomes
had direct experience of a fatal event including attempted resuscitation measure. Physical Health Attitudes Scale for Mental Health Nurses
and these accounts attracted additional analyses by the researcher. In was used in five non-intervention studies (Robson and Haddad, 2012;
Finland, Tenkanen et al. (2011) asked Registered Nurses (licensed pro Robson et al., 2013; Haddad et al., 2016; Ganiah et al., 2017;
fessionals with a 4-y university education) and Practical Mental Nurses Bressington et al., 2018); the remaining seven involved purpose-
(individuals with a 3-y vocational qualification) working in forensic designed interview or focus group schedules in qualitative studies
psychiatric settings about their own and their counterpart group’s (Shanley, 2012; Herisko et al., 2013), while the remaining studies used
mastery of 'Life support skills and safety in potential violent situations'. purpose-designed quantitative questionnaires Tenkanen et al., 2011;
Both groups were also rated by senior and managerial nursing staff. Flood et al., 2014; Herisko et al., 2015; Manu et al., 2015;
Flood et al. (2014) conducted a national cross-sectional survey to gather Gebreegziabher Gebremedhn et al., 2017). Physical Health Attitudes
information about respondents’ knowledge and awareness of Scale for Mental Health Nurses was used in one non-simulation interven
recommendations made in a Rapid Response Report about resuscitation tion study (Haddad et al., 2016); other non-simulation intervention
training and also attempted to gauge the likelihood of the studies outcomes included proxy measures of nurse behaviour including
recommendations being met by number of emergency protocols activated (Puskar et al.,
Table 5b
Included studies (Part 2: Non-interventional studies).
# Authors Data Study Data sources Sample Exposure Level of analysis Main findings
Collection design.
11 Shanley (2012) not Cross Interviews. Grounded theory. N = 6 Mental Health Nurses. with Previous Regional Emotional and psychological effects
UK reported sectional. experience of a suicide direct combined with managing an extremely
Qualitative exposure challenging clinical situation.
to on ward
suicide of a Challenges included
patient. immediate shock at finding dead/
dying patient and somatic anxiety.
Felt blame would be apportioned by
managers. Did not feel they had
made an error but found ‘closure’
difficult. 89% of Registered Nurses
report Registered Nurses to have
12 Tenkanen et al. not Cross 24-item questionnaire on core N = 260 Registered None/ National ‘extremely or fairly well’ mastery of
(2011) Finland reported sectional, interventions and mastery of specific Nurses/ Practical Mental routine related knowledge and skills but only
unmatched skills related to violence management Nursesa / Managers in practice 52% rated PMNs similarly; 74% of
case including 7 items (ÿ = .86) relating to forensic wards Managers rated Registered Nurses to
control. 'Life support skills and safety in potential have mastery but only 42% of PMNs.
violent situation' 72% of PMNs self-assess as having
mastery; 68% rate Registered Nurses
as having mastery.
Objectively, PMNs/ Registered Nurses

overrate their own mastery though
PMNs more
so.
13 Herisko et al. not Cross Group interview with 14 questions Mental Health Nurses. Medical Group Beliefs: Mental Health Nurses work
(2013) US reported sectional structured around a survey questionnaire N = 7 convenience Emergency with patients with complex medical
qualitative used in Jones et al. sample from aged, adult, Team problems; know Medical Emergency
and child & adole-scent utilization/ Team criteria; training is adequate;
care settings routine practice Medical Emergency Team is
preventative; aids patient management,
is educational; Attitudes: Glad Medical
Emergency Team exists, it is not over
used; confident would call Medical
Emergency Team if warranted;Perceived
barriers: Increased workload and
disruptive; lack of experience with and
participation in Medical Emergency
Team; unfamiliarity with patients;
unsure if symptoms meet criteria;
House Officer can transfer without
calling Medical Emergency Team so
call them first.
14 Robson and not Cross Physical Health Attitudes Scale for N = 585 Mental Health None/ NHS Mental ‘I am confident that I could resuscitate
Haddad (2012); reported sectional Mental Health Nurses (Robson and Nurses. 62.2% F; Mdn Age routine Health Trust a client who had a cardiac arrest'
Robson et al. survey. Haddad, 2012). 31-40; 55.8% White; Years practice 420/575 (73.0%) agreed. M (SD) 3.83
(2013) UK Items related to patient cardiac arrest qualified M 13.3 (9.9) yrs; (0.92).
and symptoms of hyperglycaemia. RGN qualification 24.3%.
‘I am confident in assessing signs
and symptoms of hypo glycaemia':
Hypoglycaemia: 390/578 (67.4%)
agreed. M (SD) 3.67(0.92).
Hyperglycaemia: 366/578 (63.3)

M(SD) 3.61(0.95)
15 Flood et al. not Cross Self-report ‘awareness of RRR’, N = 393 staff (280 Rapid National Aware of RRR: 21% of
(2014) UK reported sectional Resuscitation training and experience. ‘frontline’) from 19 of 58 Response community staff, 36% of frontline
survey, Compliance with RRR Standard 4: Units possible mental health care Report/ staff, 50% of senior/ managerial staff.
unmatched where rapid tranquilisation, physical providers routine Training: Basic Life Support 57%,
case intervention, or seclusion used to have practice 48%, 42% Any training reported: 61%,
control. access to staff trained in immediate life 82%, 83%; Immediate life support 2%,
support. Errors reported 25%, 31%; Experience: Yes: 26%,
27%,
Table 5b (Continued)
Collection design.
48% 67% compliance reported with

action 4. Qualitative feedback: Not
enough training around emergency
drug administration; skills and
knowledge around working with elderly
people lacking.Errors reported pre and
post- RRR. Pre- death 18, severe mod
8; Post 5, 8. (NB time periods not
equal)
16 Herisko et al. not Cross 17-item Mental Health Nurses’ Registered Nurses. Medical Hospital 4-‘Factors’: Patient focused
(2015) US reported sectional attitudes and perceived barriers N = 102 M age = 40. Emergency (complexity of patients); Positive
survey. about modified 76.5% F. 38.2%; MH Team forces for calling the Medical
Medical Emergency Team experience 9.3-years utilization. Emergency Team; Negative forces
Survey. One open-ended for calling the Medical Emergency
question.Descriptive statistics only. Team; Seeking assistance. Internal
reliability .78. Changes to training
made as a result of the results and a
problem solving algorithm. Describe
as being ‘liked’ but no numbers
presented. Negative forces for calling
a Medical Emergency Team statements
more
strongly agreed with (M 71) than

positive forces (M = 51).
Strong agreement that
physical healthcare for
psychiatric patients is complex
(M = 76% agree). 169 activations
17 Manu et al. Feb-Nov Cross Rapid Response Team N = 169 Rapid None/ Hospital made by 72.8% staff nurses,
(2015) US 2012 sectional activations from a 222-bed Response Team routine 5.9% nurse practitioners, 21.3%
survey psychiatric hospital. activations. 72.8% by practice others.
Mental Health Nurses. 64.5% Rapid Response Team calls
No details of N or made for acute change of condition,
characteristics 26.2% Abnormal physiological
parameter, 8.3% non-specific concern.
Resulted in: Rapid Response Team

transferred 127 (75.2%) to ED;ED
physicians decided n = 46 (27.2%]
required admission. ‘Appears to break
with traditional pattern of patient’s
psychiatrist calling a medical
consultant; nurses’ given more
authority allowing them to use
independent judgement’ Cardiac
Arrest 140/170 (82.3%) agreed
18 Wynaden et al. not Cross Physical Health Attitudes Scale for N = 170. 63.3% F; Mdn age None/ Site
(2016) Australians reported sectional Mental Health Nurses (see Robson and 31-44; routine
survey. Haddad, 2012) practice
19 Ganiah et al. 2017 Cross Physical Health Attitudes Scale for N = 225 Mental Health None/ National Cardiac Arrest A 136/225 (67.3)
(2017) Jordan sectional Mental Health Nurses (see Robson and Nurses M age 32.5 (7.22) routine 3.73 (1.04).11(0.79)
survey. Haddad, 2012). 59.9% M. practice Hypoglycaemia: 150/225 (74.3)
Arabic translation. 3.88 (0.97)
Hyperglycaemia: 144/225 (64.0%)
3.89 (0.94)
Also did top items re training needs
none of which are emergency stuff.
20 Gebreegziabher 2013 Cross Purpose-designed N = 461 (66.4% M) final year None/ Hospital Mental Health Nurses (M [SD]
Gebremedhn et al. sectional questionnaire: attitude (10- items) undergraduate students. 14 routine =7.3[1.8]) no different to other
(2017) survey, and skills (8-items) about Basic Life (3.0% Mental Health Nurse practice professions on attitude scores;
Ethiopia unmatched Support and students) significantly less skilled (M[SD} =
case Advanced Cardiovascular Life 1.7[1.8]) than anaesthetist
control. Support based on UK participants(3.9 [1.4]) but not others.
Resuscitation Council (2010) N.B. all professions mean skill scores
Guidelines and American Heart below adequate. Mental Health Nurses
Association (2005) least likely to believe that they were
accreditation criteria adequately equipped to
Table 5b (Continued)
Collection design.
perform CPR nut few other

substantial differences.
21 Bressington et al. 2016- Cross Physical Health Attitudes Scale for N = 481 Mental Health None/ National/ Cardiac Arrest: Qatar 119/136 (86)
(2018) 2017 sectional Mental Health Nurses (see Nurses (39% response routine International 4.18 (0.77); HK 124/143 (87) 4.09
Qatar, Hong survey, Robson and Haddad, 2012) and rate) practice (0.71); Japan 89/200 (45) 3.2 (0.99);
Kong, Japan unmatched Physical Health Attitudes Scale for Hypoglycaemia:Qatar 132/ 138 (96)
case control Mental Health Nurses translated into 4.34 (0.62); HK 125/ 143 (87) 4.11
Japanese (0.64); Japan 91/ 200 (46) 3.5 (0.87).
Hyperglycaemia:Qatar: 128/ 138

(93) 4.25 90.60); HK 113/ 143 (79)
3.92 (0.67); Japan 65/ 200 (33) 3.04
(0.86). Personal correspondence,
Bressington, April 2018.
a
Registered Nurses are licensed prof-essionals; Practical Mental Nurses have vocational training only.
2011), semi-structured knowledge questionnaire regarding man have been more favourably rated had theymerely aimed todescribe
agement of heart attack, respiratory arrest, convulsion, and related phenomena rather than evaluate an intervention. The quality of
hypoglycaemia (Paulose et al., 2016), and a 1-item clinical judgement the two qualitative studies varied widely: Shanley’s (2012) PhD thesis
self rating scale and two clinical vignette with dichotomous correct/ provided a rich detailed account of nurses’ experience of encountering
incorrect answers (Shaddel et al., 2014). suicide-type emergencies and is recommended.
The remaining simulation intervention studies used a re searcher-
completed observation rubric (Lasater, 2007), routinely collected
medical transfer data, and a participant satisfaction with training 3.6. Study findings
questionnaire (Wynn, 2011), and purpose-designed tools aimed at
capturing participants’ self-reported knowledge, confidence, and 3.6.1. Simulation intervention studies
attitudes to emergency scenarios (Herisko et al., 2013; Lavelle et al., In the study by Wynn (2011) participants underwent scenarios
2017). Lavelle et al. (2017) also collected qualitative data from a involving simulations of providing diabetes care and, during which,
structured survey questionnaire and from focus groups, while Fernando circumstances might change according to evolving conditions (e.g.,
et al. (2018) included a course evaluation form and open questions. wrong clinical decisions might lead to escalating crisis such as cardiac
Hermanns et al. (2011) collected data using a Self-Report Suicide arrest). There was a favourable statistically significant change from the
Clinical Simulation Evaluation Tool, a nine-item tool requiring pre- to the post intervention measurement of clinical judgment and
participants to self assess against content and process objectives on 80% of participants were satisfied with the training. Additionally, the
a 5-point Likert scale. The outcome in this study relevant to the current researcher reported a 55% fall in medical emergencies involving
review was level of agreement that the simulation had improved their patients with diabetes in the month following the training. Fernando et
understanding of relevant metabolic and physiological changes during al. (2018) reported statistically significant (large effect size [h2 ])
a simulation of finding a patient hanging from a door in an apparent improve ments in knowledge following intervention, while Lavelle et al.
suicide attempt. Unsworth et al.’s (2012) cross-sectional study utilised (2017) reported a similarly large effect size for knowledge and moderate
qualitative methods only to elicit accounts from participants of the value effect sizes (Cohen’s d) for positive changes in confidence and attitudes
of the simulation interventions investigated. Each simulation study also following simulated learning. Satisfac tion with the training in Fernando’s
described how, to varying extents, they encouraged participants to study (2018) was rated on four questions. Mean positive affirmation of
‘think aloud’ during exercised or video-recorded sessions. These data the questions was 99% (range 98–100%). rated positively by 99% of
were usually then incorporated into the analysis. attendees. Qualitative data reported in these studies comprised
exclusively positive comments about inter-professional learning,
leadership and teamwork, reflection, communication, confidence, and
personal responsibility. Chadwick and Withnell (2016) reported that
3.5. Study quality self efficacy self-ratings in relation to relevant statements about dealing
with emergency or physiological deterioration situations improved.
All ten intervention studies were rated as being of weak quality While they presented no inferential statistics, second ary analysis
overall (See Table 2). None included any sort of control condition and shows that change on all ten items was statistically significant in that
there was no concealment to intervention or evaluation. Of the participants were more likely to rate themselves moderately or highly
longitudinal studies, withdrawals were mostly non-existent though confident in each area following the simulation compared to the
probably largely because measures were taken before and immediately baseline assessment where they more commonly rated themselves as
after the training and longer term outcomes were only captured having no or only slight confidence (effect sizes [Cramer’s v] ranging
qualitatively. Haddad et al. (2016) conducted follow up data collection from small [.21] to large [.52]).
at 4-months retaining just over 80% of the original sample.
Quality of the cross-sectional studies was generally higher than

intervention studies (Mdn score = 6, range 5–7, maximum possible 7) Hermanns et al. (2011) cross-sectional study found that participants
and it should be noted that quality of interventional studies might reported a mean score of 1.4 on ‘understanding of
metabolic and physiological changes’ where 1=‘strongly agree’ and resuscitate a client who had a cardiac arrest was 67.3% (Ganiah et
5 ‘strongly disagree’. Unsworth et al. (2012) qualitative-only study al., 2017), 73.0% (Robson et al., 2013), 82.3% (Wynaden et al.,
found participants reporting that their simulation training had helped 2016), 86.0%, 87.0%, and 45.0% in Qatar, Hong Kong, and Japan
them to ‘bridge the gap’ in terms of providing an opportunity to respectively (Bressington et al., 2018) and 84.2% (Haddad et al.,
practice skills that may occur only rarely in the clinical setting. They 2016).
said that the training had raised their awareness of the possibility of Flood et al. (2014) found mixed levels of awareness among
patient physiological deterioration and had helped them recognise respondents to their national survey about recommendations about
gaps in their own knowledge. They appreciated having learnt resuscitation practice in mental health settings in the Rapid Response
alongside adult nursing students especially as this had given them Report. Only 36% of ‘frontline’ staff reported being aware of the
an additional perspective and they had found the simulation authentic. recommendations. However, 82% of these had received some level
Finally, they had expressed surprise and shock that events such as of resuscitation training in the past year. Only 27%, compared with
intoxication and substance misuse could escalate to emergency 26% of community staff and 48% of senior/managerial staff reported
levels and reported that, in future, they would be less likely to advise any actual experience of resuscitation. There was a reported
service users to ‘sleep it off’ given the importance of maintaining compliance rate of 67% with the report recommendation that units
physiological observations. where rapid tranquilisation or seclusion might be used should have
access to staff trained in immediate life support and relevant
equipment. Respondents’ qualitative feedback suggested a lack of
3.6.2. Non-simulation intervention studies knowledge around emergency drug administration and lack of
Haddad et al. (2016) found a statistically significant difference on confidence in working with elderly people.
the Physical Health Attitudes Scale for Mental Health Nurses’ total Tenkanen et al. (2011) study of nursing staff working in forensic
score at 4-month follow-up, but not on any of the four subscales. mental health settings in Finland explored differences between
Changes on one of three items specific to emergency or physiological groups of Registered and Practical Mental Health Nurses’ own and
deterioration situations was statistically significant (hyperglycaemia) reciprocal group ratings of overall mastery of various domains
and for two non-significant (cardiac arrest, hypoglycaemia) (Mark including life support skills. Both groups were also rated by senior
Haddad, Personal correspondence 24th April 2018). nurses/ managers. Results suggested that Practical Mental Health
Nurses overestimated their own group’s mastery of life skills relative
Paulose et al. (2016) reported that mean scores on individual to Registered Nurses and managers’ ratings while Registered
knowledge tests about managing heart attack, respiratory arrest, Nurses’ also overestimated their own mastery relative to other raters
convulsion, and hypoglycaemia all improved significantly follow ing but to a lesser magnitude. The authors conclude that, based on
provision of a self-instruction intervention; in addition the frequency broader information than this one topic area, Registered Nurses are
of those rated as having ‘very good’ knowledge in each area better equipped in the skills required to provide effective care in the
increased from 3% to 90%, 7%–87%, 0%–80%, and 0%–83% forensic environment.
respectively. Accordingly, effect size for each was uncommonly large Gebreegziabher Gebremedhn et al. (2017) compared self-report
with post-intervention Hedges' g scores indicating shifts of 3.07–4.27 attitude and skill ratings of different professional undergraduate
z-scores (i.e. SDs) from the pre-intervention level. A combined total groups in relation to performing cardiopulmonary resuscitation.
knowledge score also increased significantly (Mean [SD] 22.06 [1.92] Only a small proportion (3.0%) of N = 506 participants were mental
vs. 30.04 [2.82]; Hedges’g =3.31) (Bhattacharya Chanu, personal health nursing students. They did not differ significantly from any
correspondence 2nd May 2018). other group in terms of attitudes and rated themselves only as less
Puskar et al. (2011) study examined the number of Condition A skilled than anaesthetists.
(Arrest) and Condition C (Crisis) referrals made to a Medical Shanley (2012) found that physical presence during an inpatient
Emergency Team following introduction of protocols and associ ated sudden death or suicide added considerable qualitative complexity
training. They reported a rise in Condition C reporting, presumably to their experience and reaction than for nurses who were informed
reflecting increased confidence in nurses to report early, and a of the suicide or other sudden death (i.e., community mental health
decline in Condition A reports. Concurrently, there were falls in the nurses). Specifically, the former professed more concern about the
number of fatal outcomes following the protocol introduction. outcome of coroner’s inquest reports.
Shaddel et al. (2014) examined the effect on confidence and Herisko et al.’s (2013, 2015) studies of mental health nurse’s
knowledge of mental health and learning disability nurses of a brief experience of exposure to a Medical Emergency Team both found
teaching session and introduction of a Modified Early Warning Score that nurses’ reported both positive and negative forces impacting on
for physiologically deteriorating patients. Signifi cantly more nurses decisions to refer to Medical Emergency Team. However, in the
identified the correct course of action in two scenarios following the larger survey study (Herisko et al., 2015) more respondents agreed
intervention (w= .71) and nurses also reported more confidence in with ‘negative forces’ statements (M [SD] = 70.7[16.6]) than with
their clinical judgement following introduction of the Modified Early ‘positive forces’ statements (M[SD] = 51.1[21.2]). Qualitative data
Warning Score (r = .87). suggests difficulties include the increased workload from calling the
Medical Emergency Team, lack of experience, lack of participation in
3.6.3. Non-interventional descriptive studies the Medical Emergency Team, unfamiliarity with patients, uncertainty
Four non-intervention studies (Robson and Haddad, 2012; whether symptoms meet Medical Emergency Team criteria,
Wynaden et al., 2016; 2017; Bressington et al., 2018) used the interruptions, and preferring to call the House Officer first. There was
Physical Health Attitudes Scale for Mental Health Nurses to assess agreement from most participants with statements suggesting that
the attitudes of mental health nurses regarding physical health care. physical healthcare for psychiatric patients is complex (M[SD] =
In addition, we present baseline data from Haddad et al.’s (2016) 76.3[13.8]). Finally, Manu et al. (2015) reported that the majority of
intervention study as it also used the Physical Health Attitudes Scale 169 Rapid Response Team activations were made by staff nurses
for Mental Health Nurses; thus Physical Health Attitudes Scale for (72.8%). The authors concluded that the introduction of a Rapid
Mental Health Nurses data is available for N = 1523 individuals. Response Team empowered nurses to refer when the more traditional
Across studies the proportion of respondents agreeing that they were practice was for the patient’s psychiatrist to call a medical consultant.
confident they could
4. Discussion health and can further contribute to what is often referred to as diagnositic
overshadowing; where “physical and/or behavioural symptoms are
We conducted a systematic review of the empirical literature about inappropriately accredited to mental illness” (Geiss et al., 2018: p.327).
mental health nurses and emergency medical and clinical physiological Further the review also highlighted that factors such as the availability of
deterioration situations. We took a broad approach to searching the literature rapid response teams seemed to have a positive effect in empowering
due to a paucity of research on actual observations of care and included mental health nurses with the autonomy to independently ‘make the call’ to
studies involving real or simulated situations and included studies involving escalate a situation if concerned; potentially heightening clinical judgement
mental health nursing students and multidisciplinary professional groups in skills and perhaps should be used more widely in mental health practice
addition to those including only mental health nurses. Neverthe less, only 21 (Manu et al., 2015).
studies met our review inclusion criteria. Further, some of these papers were
only partially relevant since their main focus was on routine physical Next, what is the evidence about mental health nurses’ emergency-
healthcare (Robson and Haddad, 2012; Robson et al., 2013; Wynaden et related outcomes relative to those of other profession al groups? Again, we
al., 2016; Ganiah, 2017; Bressington et al., 2018). Nevertheless, we included are somewhat hampered by the quality of evidence since the only case
relevant results from these studies because they do represent some of the control studies were unmatched and we could not safely infer that differences
more contemporary sources of information. Nevertheless, we can state with were due to occupational as opposed to other variables. In terms of
confidence that there is a paucity of research in this important area of mental investigating attitudes, Physical Health Attitudes Scale for Mental Health
health nursing practice. Irrespective of the quantity of available research, Nurses is a welcome addition to the mental health nursing educational and
the risk of bias of included studies, in particular the intervention studies, was development toolkit. It is likely that attitudes about physical healthcare will
generally significant. impact on nursing practice, although this should be tested. Given Physical
Health Attitudes Scale for Mental Health Nurses’ psychometric properties it
should be used more widely and could be used as an outcomes measure in
a well-designed case control study. Others (Herisko et al., 2015; Lavelle et
al., 2017) have recognised the need to target outcomes related to education
4.1. Effectiveness specifically related to emergency situations rather than to physical healthcare
in general. While it is undoubtedly desirable that mental health nurses deliver
Of the evaluation studies, none employed a control group and none can routine screening, monitoring, and health promotion it may not be sufficient
truly support the conclusion that the intervention, usually a simulation, was to conflate these outcomes with those relevant to emergency care or severe
responsible for any subsequent improvement in practice. Nevertheless, as physiological deterioration.
far as what are largely routine evaluations conducted as part of routine
practice, they do suggest that the sessions are relevant, worthwhile,
challenging, enjoyed by participants, and feasible to implement. While there
may be substantial costs to simulated learning or training, the review tends
to support its use in mental health for more than ‘non-technical’ and 4.3. Limitations
interprofessional communication skill devel opment. Immersive experiences
that authentically replicate ‘real life’ physiological deterioration, may be
Any review is limited by the quality of included studies and those included
helpful in developing mental health nurses’ awareness, self-efficacy,
here were not methodologically strong. Given that mental health inpatient
confidence and critical thinking skills in medical emergencies whilst mitigating
services are common across the world it is possible that there may have
any risk or safety issues. The key educational benefits of simulation include
been studies published in non English languages that may have met the
opportunities to practice in a safe environ ment and receive feedback and
inclusion criteria. It is also possible that individual hospitals or services may
debriefing, being exposed to a variety of scenarios, in a controlled
have conducted audits of processes and outcomes in relation to, say,
enviornment and assessment of learning (Lateef, 2010). Further the review
resuscitation training.
supports the need for greater awareness and training among mental health
nurses of the policies and protocols within workplaces, which can increase
confidence levels in reporting early or escalating using ‘track and trigger’
systems. Regardless, there is clearly a need for more rigorous evaluations 4.4. Implications for research
conducted using valid and reliable instru mentation and using clear,
reproducible protocols. Clearly we also need to look to the evidence on the We cannot say with certainty how well prepared mental health nurses
effectiveness of various types of training, including simulation, for emergency are prepared for dealing with physical emergencies and severe physiological
situations in general and not just those involving mental health nursing. Of deterioration. Further research is needed to systematically assess nurses’
interest, meta-analysis has suggested that high fidelity manikins are attitudes, skills and knowledge and the translational impact of various
moderately better than low fidelity manikins in improving skills when follow- educational interventions on patients’ safety and health outcomes research.
up occurs immediately post training. However, when follow-up occurs at one
year then there is no accrual of benefit (Cheng et al., 2015).
5. Conclusion
Although there are considerable gaps in the literature examin ing mental
health nurses’ knowledge, skills and confidence in recognizing and managing
mental health consumers who are physiologically deteriorating. The current
review suggests that education alone does not guarantee change in attitudes
4.2. Experiences and nursing practice. This has implications for mangers and policy makers
who need to put in place relevant, effective strategies for their nursing staff
There were clearly ‘mixed’ experiences among the mental health nurses to support and adequately prepare them to manage such challenging
in terms of their knowledge levels, skills, attitudes, education and training situations, and develop monitoring and evaluative systems to ensure
needs. Uncertainty and apprehension often due to poor knowledge and lack compliance and measure consumers’ outcomes.
of awareness can contribute to a ‘blinkered’ approach to physiological
deterioration in mental
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International Journal of Nursing Studies 95 (2019) 73–86

Contents lists available at ScienceDirect

International Journal of Nursing Studies

Effectiveness and experiences of mental health nurses in cases of

© 2019 Elsevier Ltd. All rights reserved.

74 G.L. Dickens et al. / International Journal of Nursing Studies 95 (2019) 73–86

Also implicated as contributing factors to the failure to recognise

G.L. Dickens et al. / International Journal of Nursing Studies 95 (2019) 73–86 75

2.3. Inclusion and exclusion criteria

2. Methods Studies were included if they were an English language account of an

2.2. Search strategy 2.4. Data extraction

Population Exposure Outcome

Population Intervention Comparator Outcome

76 G.L. Dickens et al. / International Journal of Nursing Studies 95 (2019) 73–86

Intervention evaluation study quality assessment.

Wynn (2011) Moderate Moderate Weak Weak Strong Strong Weak

Tenkanen Robson Flood Herisco Manu Wynaden Ganiah Gebreegziabher Bressington

Research question or objective in this paper x x x x x x x x x

Participation rate of eligible persons at least 50% x x No. x x x x x –

Subjects selected or recruited from the same or x x x x x x x x –

similar populations and in the same time

variance and effect estimates provided

study pre-specified and applied uniformly to

Outcome measures clearly defined, valid, x x x x x x x x x

reliable, and implemented consistently

x Condition achieved; - condition not achieved; NR = Not Reported.

Shanley Herisko et al.

Clear statement of research X X

involving assessment of the likelihood of selection bias in the

G.L. Dickens et al. / International Journal of Nursing Studies 95 (2019) 73–86 77

Fig. 1. PRISMA flowchart.

78 G.L. Dickens et al. / International Journal of Nursing Studies 95 (2019) 73–86

Authenticity: the simulation was experienced

G.L. Dickens et al. / International Journal of Nursing Studies 95 (2019) 73–86 79

80 G.L. Dickens et al. / International Journal of Nursing Studies 95 (2019) 73–86

Objectively, PMNs/ Registered Nurses

Hyperglycaemia: 366/578 (63.3)

G.L. Dickens et al. / International Journal of Nursing Studies 95 (2019) 73–86 81

48% 67% compliance reported with

strongly agreed with (M 71) than

Resulted in: Rapid Response Team

82 G.L. Dickens et al. / International Journal of Nursing Studies 95 (2019) 73–86

perform CPR nut few other

Hyperglycaemia:Qatar: 128/ 138

Quality of the cross-sectional studies was generally higher than

G.L. Dickens et al. / International Journal of Nursing Studies 95 (2019) 73–86 83

84 G.L. Dickens et al. / International Journal of Nursing Studies 95 (2019) 73–86

G.L. Dickens et al. / International Journal of Nursing Studies 95 (2019) 73–86 85

86 G.L. Dickens et al. / International Journal of Nursing Studies 95 (2019) 73–86

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