Care experiences of older people with mental health needs and their families in emergency medical services settings

Abstract Background There are challenges to person‐centred care provision in Emergency Medical Services (EMS) settings. The environment is often busy and noisy which can influence the experience of older people and their carer/partners when they attend emergency departments. Older people with mental health needs are a vulnerable group of people who are at risk of not having their needs met in acute care settings. This is due to complex presentations and increased pressures on the EMS system. Aim The aim of the paper was to explore the care experience of older people with mental health needs and their carer/partners in pre‐hospital and in‐hospital Emergency Medical Services settings. Method This study used an interpretive qualitative approach incorporating in‐depth, individual interviews to gather information on the experience of the older person with mental health needs and carers/partners. Data were analysed using Braun and Clarke's (2006) thematic analysis. Results Fifteen individual interviews were carried out with older people with mental health needs (n = 10) and with carers/partners (n = 5). Six themes on ‘Getting there, getting in and getting out’, ‘Seeing the person’, ‘Perceptions and experiences of the pre‐hospital and Emergency Department (ED)’, ‘The effects of the experience on personal well‐being’, ‘Older person/carer/partner perceptions and experiences of the EMS staff’ and ‘Making it better’ emerged from the data. Conclusions The results suggest that previous experiences with the emergency care system influence the way older people with mental health needs and their carers make decisions on current and future care needs. Negative experiences can be influenced by the layout and organisation of the ED. Participants remain reluctant to discuss or disclose their diagnosis in the Emergency Medical Services setting due to a perceived stigma. Health and social care systems and services need to undergo transformations to ensure that all people who access services are treated fairly and effectively.


| INTRODUC TI ON
Emergency medical services (EMS) is the term used to refer to pre-hospital emergency and emergency department (ED) care.
Using these services can be a frightening and distressing experience for older people and their carers/partners as the environment is often noisy and busy. These issues can be exacerbated by longer waiting times in ED, as they often require more complex assessments and admission to hospital for further care (Goode et al., 2021). Vulnerable older people with mental health needs are at risk of not having their care needs met in acute care settings due to these complex presentations, ageism, lack of education and increased pressures within the EMS (Dewing & Dijk, 2016;Goldberg et al., 2012). The way the health and social care system has responded to rising numbers of attendances has presented a challenge to person-centred care provision in ED (McConnell et al., 2016). An exploration of how the acute healthcare system meets the needs of older people with mental health problems, their carers/partners and the healthcare team is therefore beneficial in both education and healthcare planning.

| Background
The World Health Organisation's definitions of the terms 'older person' and 'mental health' are used in this study. According to the WHO (2015), most Western societies consider the age of 65 and over to apply to an 'older person'. Mental health is '… a state of well-being in which an individual realises his or her own abilities, can cope with the normal stresses of life, can work productively and is able to make a contribution to his or her community' (WHO, 2004, p38). The WHO (2017) report that worldwide, approximately 15% of people over sixty live with a mental health disorder. Consequently, as the numbers of people in society are getting older, the number of older people attending emergency departments across the world is increasing. The context of caring for older people with mental health needs in the pre-hospital and acute care areas, such as ED, has been a source of question and concern worldwide. Traditionally, the focus in EMS is on the Triage process and treating life-threatening physical presentations; consequently, mental health needs are not seen as high importance. A key factor to providing effective care in emergency medical settings is early assessment. To be able to holistically assess and treat this patient group within a brief period of time requires an elevated level of competence in both physical and mental health conditions (Mental Health Foundation, 2009). The primary focus of EMS staff is the culture of 'fixing problems' that are usually physically orientated and that mental health assessment and care are of a secondary priority. The RCEM (2021, p2) emphasise that: 'A patient presenting to ED with either a physical or mental health need should have access to ED staff that understand and can address their condition, and access to appropriate specialist services, regardless of their postcode, GP or time of arrival.'

What does this research add to existing knowledge in gerontology?
• There is a dearth of evidence reporting on the experience of older people with mental health needs and their carer/partners in Emergency Medical Services (EMS) settings. This study is the first of its kind to report the experiences of older people with mental health needs and their carer/partners in the pre-hospital and inhospital emergency department settings.
• Older people with mental health needs report feelings of stigmatisation and these perceptions affect their well-being and the judgements they make. Stigma influences their decisions to seek help and makes them hesitant to reveal their mental health needs to EMS staff.
They delay seeking support for their physical and mental health needs, often making their condition/s worsen.
What are the implications of this new knowledge for nursing care with older people?
• We suggest that a priority triage category with a longer assessment time for older people with mental health needs is adopted. This would enable triage staff to assess and schedule treatment options, thus reducing waiting times. Older people with mental health needs may present with a complex history, comorbidity, and sensory or cognitive impairment. Increasing the time available to triage the older person would be beneficial for the staff to action a more detailed assessment.
• The creation of a standard assessment framework to assist in the assessment of mental health would assist in pre-hospital and ED departments. Access to electronic care records, including the medical history and current medication, would assist triage nurses and paramedics in a triage decision for the attending complaint. How could the findings be used to influence policy or practice or research, or education?
• The role of gerontological experts within EMS is vital in providing a person-centred experience for older people (with and without mental health needs) and in education Despite the widely reported rising numbers of older people in society, this age group are not the most frequent users of EMS.
According to NHS data (2020a), in the decade from 2010-2020, those aged 65 years and over have presented in smaller percentages (19.2%-22%) than the 15-34 (26.8%-30.1%) or 35-64 (30.4%-31.3%) age groups. However, these figures are not representative of outcomes, as older people account for between 51% (Hakenewerth et al., 2015) and 85% (Goode et al., 2021) of the admissions to acute areas, and between 20% and 72% of older people being transported by ambulance (Goode et al., 2021;Melby & Ryan, 2005). Older people with mental health needs have poorer outcomes of care when compared to the same age group who do not have any mental health issues (Mather et al., 2014;Sampson et al., 2009Sampson et al., , 2013Schnitker et al., 2011). Older adults, in general, spend a long time waiting in EDs (5 h) and those who also have a mental health issue wait 44 min longer (Goode et al., 2021). In other quality indicators, the care is unequal in terms of a longer length of stay, increased reattending, increased risk of falling, reduction in activities of daily living (ADL) and in the way they are perceived and treated by some healthcare staff. The rates of readmission and hospitalisation are also high which require appropriate care planning, discharge and continuity of care as they are more likely to be discharged to a long-term care facility (Bradshaw et al., 2013). Increased functional decline in both physical and mental realms are evident as well as a marked increase in mortality, both whilst in hospital and following discharge (Adams et al., 2015). Despite the parity in the statistical estimates and projections, there has been little research and planning undertaken to establish the nature and extent of service that will be required in the future.
There is a dearth of evidence reporting on the experience of older people with mental health needs and their carer/partners in Emergency Medical Services (EMS) settings. Statistical estimates and projections have indicated an increased prevalence of mental health conditions and increased life expectancy (WHO, 2022).
However, related research and planning into strategies for the most effective ways to develop health and social care services for older people is limited. This is necessary to proactively establish the nature and extent of EMS that will be required. An important part of this planning is to consider how the older person with mental health issues and their carer/partner experience EMS when attending for physical needs. The need to strategically plan for future personcentred care delivery led to the research question; what are the experiences of older people with mental health needs and their carer/ partners in EMS settings? This study was the first of its kind to examine this question. This paper reports on stage two of a larger study.
Stage one data examined 74,766 ED attendance records of adults aged 65 years or over. Older people with mental health needs made up a sub-sample of 1818. When compared to older people without mental health needs, the sub-sample waited longer, were admitted to hospital in higher numbers and relied heavily on the ambulance service (Goode et al., 2021).

| Participants and recruitment
The given an information letter asking for consent to be contacted by the researcher. Three days after attending the ED, the clinical team ensured the person was discharged home using the hospital database. Following confirmation, the researcher telephoned to ensure that they were willing to participate and arranged a suitable time and location for the interview to take place. Written informed consent was obtained by the researcher using participant information sheets (PIS) and consent forms. The researcher did not know of selection of potential participants until they gave permission to be contacted.
The aim of qualitative interviews was to gain insight into their individual experiences, and therefore, the numbers of participants became less relevant. Older people had a variety of mental health needs, including living with dementia, anxiety, depression and alcohol dependency. All the older people attended ED because of a physical illness (Tables 2 and 3). Data saturation was reached at a sample size of 15 service users (10 older people with mental health needs and 5 carers/ partners).

| Data collection
One-to-one semi-structured interviews were used to explore the experience of the EMS system from the service user and carer/partner perspective. The interviews ranged from 20 to 100 min in length.
At participants' request, interviews took place in the older person's or carer's home as that was more comfortable for them. Design of the semi-structured interviews was guided from the literature, the objectives of the study and questions that arose from stage one (Goode et al., 2021

| Data analysis
Thematic analysis of the data followed Braun and Clarke's (2006) six phase method. This allows for identification, analysis, and reporting of the data in patterns and themes within a data set, with the researcher taking an active role in the identification/selection of patterns and themes and the reporting of the same. The interviews were recorded on a digital voice recorder and transcribed on a wordfor-word basis. Following the transcription process, pseudonyms were used instead of real names to ensure the source of the data was unidentifiable to anyone other than the researcher. NVivo 10 (2014) data management system was used to organise and manage the data (Braun and Clarke Phase 1). During analysis, the researcher made notes in the transcriptions as both a memory aid and to assist in the coding process. Braun and Clarke's (2006) 15-point checklist was completed within the research team and the six phases of thematic analysis achieved (Table 5).

| Ethics
Ethical approval was obtained from Ulster University and Office

| Ethical conduct
2.5.1 | Rigour and trustworthiness Lincoln and Guba (1985) describe four areas that can assure that the findings of a qualitative study have rigour and trustworthiness as credibility, transferability, dependability and confirmability. How these areas were addressed in the study is shown in Table 6.

| RE SULTS
Six themes emerged from the data. The voice of the participants shaped the themes and subthemes that are presented in Table 7.
Each theme is reported using direct quotations from the participants.
Theme 1. Getting there, getting in and getting out.
Independence and remaining in control of their day-to-day lives was essential and decisions about how to get to the ED emphasised this point. Decisions related to how quickly they would be attended in their home and on arrival to ED. EMS staff were viewed as being able to sort out immediate problems, thus reducing the worry and the wait to be attended. In the ED, needs were met instantly whilst seeking help via the General Practitioner (GP) usually involved waiting for an appointment. There was a perception that 'ambulance patients' were prioritised over those who could walk into the department. This affected on decision-making on what was the best way to attend the ED.
'…when we were in an ambulance…he was seen straight away…If you go in an ambulance, obviously you get into one of those rooms and you're seen straightaway…' (Joan, Partner).
Many of the participants wanted to find out immediately what was wrong with them. However, once the older person was in the ED and they had some idea of how they were feeling and what was wrong, the priority changed to wanting to get out of the ED and go home.
'…let's go there, let's get the problem fixed and be discharged' Participants discussed treatment that they had received at one or more of the nine Emergency Departments throughout the region.
The physical layout of the ED caused concern because of the lack of ability of the older people with mental health needs and their carer TA B L E 4 Interview Schedule for Older person and carer/family member Step 1 • Introduce self to participant and explain about nature of the interview.
• Inform participant that interview will be recorded for transcription and anonymity will be assured. • Check informed consent has been signed and that they are happy to continue.
• Probing questions such as 'can you tell me more about that?' and 'what did you mean by?' will be used to elicit clear and in-depth information. • Ask participant to introduce self with first name for the tape.
Step 2 Prerequisites/attributes 1. Was this your (or your relative's) first visit to an emergency department? Probe for detail. 2. What made you (or your relative) attend the emergency department? 3. How did you know something was wrong? 4. How did you decide which ED to attend? Probe for influencing factors. 5. How did you (or your relative) get to the emergency department? What factors influenced this decision? 6. Did you travel alone or accompanied? If accompanied by whom? 7. What happened when you arrived at the department? 8. Can you tell me about how you/your family member was assessed when you arrived in the emergency department? Did you inform the staff of MH history? Did they ask and record?
Context and Delivery of Care (Environment and Care Processes) 9. Would you tell me about your experience of being in the pre-hospital and emergency department? 10. What is it like to be a patient/carer or partner in the pre-hospital and emergency department? 11. What aspect of care in the pre-hospital and emergency department was most important to you? 12. How would you describe your experience of the environment of the pre-hospital and ED for the delivery of your (or your relative's) care needs? 13. Did you inform the staff about your mental health history when they were doing their initial assessment; what was the response? Did they assess for your MH care needs? 14. How do you feel that the MH care needs were provided for in pre-hospital and ED? 15. What would you say were/are your main concerns about being in ED? 16. Can you tell me about your experience of waiting in the ED? Probe for length of time, reason for waiting (referral, etc.). 17. To what extent, if at all, did your ED experience impact your mental health…probe for increased anxiety, etc 18. What happened after you (or your relative) were treated at the emergency department? (Admission/discharge).

Results (person-centred outcomes)
19. How did you feel about the staff who delivered the care to you or your partner? Probe for competency, caring, communication especially in relation to MH needs assessment (listening). 20. Did you feel like you (or your relative) had personalised treatment? 21. Were you involved in any of the decision-making relating to your (or your relative's) care? 22. Did you feel satisfied with the care you (or your relative) received? 23. Is there any other comment you would like to make about your experiences or views on your experience of the pre-hospital and emergency department?
Step 3 Ensure participant has had opportunity to give opinions and thank them for their help in the study. Close interview.

TA B L E 5 Ways in which Braun and Clarke (2006) 6 Phases of Thematic Analysis was achieved in this study
Step Phase Description of the process Ways in which this was achieved in this study

1.
Familiarising yourself with your data Transcribing data (if necessary), reading and rereading the data, noting down initial ideas.
All interview transcripts were read and reread whilst listening to the interview recording for correction to ensure accuracy of transcription.

Generating initial codes
Coding interesting features of the data in a systematic fashion across the entire data set, collating data relevant to each code.
Paper copies of the transcriptions were viewed and initial codes highlighted using Saldaña's suggested questions on why they were chosen (2016) 3. Searching for themes Collating codes into potential themes, gathering all data relevant to each potential theme.

Reviewing themes
Checking in the themes work in relation to the coded extracts (Level 1) and the entire data set (Level 2), generating a thematic map of the analysis.
Word frequency and tag clouds generated in NVivo 10 (2014). Mind/code maps generated.

5.
Defining and naming themes Ongoing analysis to refine the specifics of each theme, and the overall story the analysis tells; generating clear definitions and names for each theme.
Narrative exemplars for generation of each subtheme produced. Development of themes from subthemes and narrative exemplars. Consultation with supervisory team in peer review process

6.
Producing the report The final opportunity for analysis.

Selection of vivid, compelling extract examples, final
analysis of selected extracts, relating back of the analysis to the research question and literature, producing a scholarly report of the analysis.

Credibility
Credibility was maintained through the use of using an ethically approved semi-structured interview schedule to guide the discussion and the use of word for word transcriptions. A sample of these were also co-analysed by a member of the research team. The principal investigator kept a research journal and memos on NVivo 10 (2014), with notes and reflections on issues as the study progressed.

Transferability
Transferability is demonstrated through the description of sampling factors including the geographical location of the study, the number of participants, the pseudonym of participants and their reason for attending ED (Tables 2 and 3), and the timeframe of data collection and analysis.

Dependability
Dependability is assured through the detailed information provided on the research method including inclusion and exclusion criteria (Table 1), participant information (Tables 2 and 3), interview schedule (Table 4) and process of thematic analysis (Table 5).

Confirmability
Confirmability of the results are demonstrated though peer review during thematic analysis and data reporting. Themes and discussions also include direct quotations from the participant and are confirmable through the process of coding into themes and the production of coding exemplars and theme maps (Lincoln & Guba, 1985). Braun and Clarke's (2006) phases of thematic analysis produced coding mind maps and narrative exemplars. Theme diagrams were created, and a joint review and analysis of themes was completed by the interview team. Noise is only one part of the sensory stimulation for the older person and carer, with the multi-sensory stimulation of the whole ED having a detrimental effect on the mental health of the older person and carer/partner.

TA B L E 6 Rigour and Trustworthiness
Theme 5. Older person/carer/partner perceptions and experiences of the EMS staff.
Views on interacting with the staff were polarised. Participants either thought the staff were amazing or terrible, angels or demons.
Praise was extended to pre-hospital staff who were viewed in incredibly positive terms, including an emphasis on how their presence whilst waiting to be dealt with in the ED made them feel safe. They were also viewed as providing significant support to the older people with mental health needs by being there for them, being friendly and helpful and providing a good standard of personalised care in a professional and knowledgeable manner. They could assess the problem and get it sorted, even though the ED was often busy. EMS staff tried to establish caring relationships showing understanding and compassion for the older person and family. (Karen, Carer) described good experiences with staff who were caring and compassionate.
'…you could see them trying to establish a rapport and they certainly displayed empathy and sympathy for her plight… They were very kind'. At times, participants reported care from EMS staff as task orientated and lacking understanding of those with mental health needs.
They felt they were 'just one of the crowd' and 'boxes were being ticked' as opposed to having individualised care.
Theme 6. Making it better.

Participants offered suggestions for physical and structural
change in the department, with the proximity of other people and the lack of privacy as the key priorities. The waiting area caused most concern to many of the participants, and many participants suggested the provision of a quiet room that older people with mental health needs could use whilst waiting. Involvement of the users of the service was vital to making a strategic change when planning care structures for the older person.
The older people with mental health needs watched the care that was delivered in the ED, and they had a genuine understanding of the pressure the EMS staff were under. One older person put this into the context of how the lack of staff meant he felt very alone and could not speak to anyone of his concerns. They reiterated the need for training and education on how to recognise and care for older people with mental health needs several times throughout the interviews.
The system that allows unrestricted access to the ED is particularly important for the older people with mental health needs.
However, the 'availability' of care 24/7 was mentioned as an area that concerned them because it added pressure to the ED system.
Participants discussed the problems associated with waiting when the older person had mental health needs. All these participants had a physical need that was treated in the ED; however, one carer suggested that the system should be reviewed to allow the development of a special ED that catered for mental health needs including the need to streamline the bureaucracy and administration involved in the ED as it also contributes to the wait.

| DISCUSS ION
This study adds to existing evidence by reporting the emergency care experiences of service users and subsequent suggestions on how to improve EMS care. Two main overarching findings were elicited: firstly, the EMS environment and physical and mental wellbeing and secondly, ongoing interdisciplinary education.

| The ED environment
There is a need for change in the physical environment and a structural change in the system, including how people use EMS. Older people reported they want professional, competent care that includes information about what is happening and how long they will have to wait. Our respondents affirmed that attending the ED is a stressful experience that often causes fear and anxiety, which supports findings by Moss et al. (2015) and McConnell et al. (2016).
They have concerns about the design of the ED and its impact on care and their experience. The noisy, busy, crowded environment influenced their ability to cope with the situation, which supports findings from Watson et al. (1999), Bridges (2008)  This would be a welcome development.

| LI M ITATI O N S
The voice of older people with mental health needs have been missing in much of the literature, partly because it is a difficult population to recruit This was also the experience of the research team in this study who had to rely on gatekeepers to assist in recruitment.
The study was undertaken in one geographical region in the UK.
Also, the number of participants was relatively small. Both of these factors may limit the transferability of the findings to other EMS settings.

| Education
There is an urgent need for training for all MDT members on effective communication with the older person with mental health needs, including the effect the physical environment (including sensory stimulation) can have on the older person with mental health needs (especially someone living with dementia). This training should include the impact this has on the family and how they can be involved in care.

| Research
Further investigation into the causes of the inequality in outcome for the older person with mental health needs in acute care settings is recommended. Stigma would merit further exploration, examining why the older people with mental health needs still feel stigmatised. Examination is needed into the impact stigma has on their well-being.

| Practice
Consideration should be given to the e impact of the built environment on the older person with mental health needs. This includes the access to the ED, including the ambulance, the physical environment and the sensory stimulation within the ED. The lack of privacy and confidentiality in the ED should also be considered. Older people with mental health needs and their carers/partners should be involved in this process.
Care pathways based on up-to-date evidence are needed to provide the highest possible care for older people with mental health needs and their families. Suggestions to include in the care pathway would include a combination of early senior doctor review, comprehensive assessment, a conducive and comfortable environment and early geriatrician and multidisciplinary team involvement (Wright et al., 2014). These should be monitored and developed alongside existing key performance indicators.

| Policy
The inequality of care that the older person with mental health needs experience should be recognised as a health and social care priority, with clear standards of improvement outlined for all health and social care providers. Co-ordination of primary and secondary healthcare provision should consider the inequality of care and develop innovative ways of working to improve current provision to provide 'joined-up-care' for older people with mental health needs.
The development and implementation of national guidelines and staff education and training in the assessment and treatment of older people with mental health needs in EMS settings could ensure that the care experience is a positive one.

ACK N OWLED G EM ENTS
We would like to acknowledge the help and guidance provided by Northern Ireland (DHSSPSNI). We are responsible for the interpretation of the data, and any views or opinions presented are solely ours and do not necessarily represent those of the BSO.

CO N FLI C T O F I NTE R E S T
The authors declare no conflicts of interest.

DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings will be available in Ulster