Exploring Mental health Barriers in Emergency Rooms (EMBER)
Authors: Hilton Emily , Smith Jacqueline , Szeto Andrew , Knaak Stephanie , Chan Eric , Grimminck Rachel , Smith Jennifer , Horn Sarah , Mustapha Wafa 
Published: May 2023

Background: Mental illness stigma is a complex public health issue that creates barriers for clients seeking services. For many clients, an ED visit may be their first point of contact with the health-care system for a mental illness/addiction crisis – but it often results in poor outcomes and negative experiences due to discriminatory and structural inequities. Calgary Health Foundation has funded a five-year multiphase study (EMBER) to explore stigma holistically through patients, families, physicians, psychiatrists, nurses, and protective services in FMC ED. The goal is to explore, address, understand, and evaluate interventions that mitigate stigma at both the individual and organizational levels.

Methods: The EMBER research team is working collaboratively with AHS Policy Services team to examine mental health and addiction-related policies that may be connected to institutional stigma and practices that create barriers to access, help-seeking and the provision of mental health and addiction services. The ORBIT model is being used as a conceptual framework to support the cross-disciplinary approaches used by the research team to explore clinical and public health policy needs (phases 1 & 2); multiple intervention strategies (phase 3); targeted changes in health behaviors related to mental health stigma; and the potential of behavioral treatments to affect health outcomes (phases 4 & 5).
Intervention implementation considerations include: (1) the perceived fit between proposed training and identified learning needs; (2) the suitability of intervention content for different learner groups; (3) intervention length; (4) format of delivery; (5) size of training groups; (6) mix of professionals within groups; (7) incentives for participation; (8) sustainability; (9) support for reinforcement of training over time; (10) anticipated implementation challenges and how to address them; and (11) expected or desired outcomes.

Evaluation Methods: Addressing structural and resource inequities in the delivery of mental health/addiction care is a focal point of our study and an evidenced based pathway to ensure improved health outcomes for all Albertans. We are employing a mixed-method approach to capture quantitative and qualitative findings related to the experiences of patients/families, health care providers, and protective services as well as the policies that inform the delivery of care in ED settings.

Evaluation throughout Phases 1/2 included thematic analysis of interview and focus group transcripts. In Phase 1, baseline surveys were used to collect demographics of participants and current levels of stigma amongst ED staff. Phase 2a, includes policy review through a human rights lens. In Phase 3, quantitative and qualitative surveys will be used pre- and post-intervention, and at follow up points (TBD). In Phases 4/5, the intervention data will be synthesized and used to inform recommendations for scale and spread.

Results: Based on in-depth 60–90-minute focus groups or interviews with patients/families, health care providers, and protective services in phase one, the following results were captured using thematic analysis.

Structural Stigma

· Mental health rooms in the ED feel like “jail cells”
· Staffing and other resource inequities for mental health care
· Lack of training and role confusion

Interpersonal Stigma

· Patients/families: perceived lack of mental health training and resources, leading to unsatisfactory experiences, including in many cases, experiences of harm
· Staff: inadequate mental illness training and occupational distress contribute to staff burnout and compassion fatigue

Intrapersonal Stigma

· Patients/families: lack of communication and dehumanizing interactions with staff contributing to feelings of isolation, shame, and hopelessness
· Staff: vulnerability in disclosing personal mental health struggles

Advice and Lessons Learned:

Including a patient research partner in this study ensures that the voices of patients/families are heard, respected, and represented, and that a focus on patient-identified priorities and outcomes is maintained. Our PRP is an active and important member of our research team who acts as a liaison and role model during focus group discussions with patients and families. She assists with stigma reduction by using her lived experience and voice to educate others.

More recently, we have identified professional silos within the healthcare system that have become the catalyst for promoting collaboration between EMBER researchers, AHS AMH clinical and operational leaders, and the Calgary Health Foundation (funder). Prioritizing the engagement of multiple stakeholders who have a direct interest in the process and outcomes of this study and how it is translated back into structural, policy and practice changes, is an important pathway to achieving sustained positive impact.