Assessing the knowledge of emergency medical care practitioners in the Free State, South Africa, on aspects of pre-hospital management of psychiatric emergencies

Introduction Studies have reported that emergency medical care practitioners (EMCPs) encounter challenges when attending to psychiatric emergencies. The EMC provider's ability to understand, assess and manage psychiatric emergencies has been reported to be poor due to limited knowledge and insufficient training. In South Africa (SA), little is known about the knowledge of EMCPs on pre-hospital management of psychiatric emergencies. The objective of this study was to assess the knowledge of EMCPs working in the Free State province on aspects of pre-hospital management of psychiatric emergencies. Methods This descriptive study used a questionnaire survey to obtain data on the knowledge of EMCPs on aspects of pre-hospital management of psychiatric emergencies. Results Only 159 of the initial 192 questionnaires distributed were returned, giving a response rate of 82.8%. The majority (87.4%) of the participants reported inadequate knowledge of pre-hospital management of psychiatric emergencies. More than a third of the participants reported that they are not knowledgeable on how to assess a psychiatric patient (P < 0.01), 64.2% and 73.6% (P < 0.001 in both cases) could not perform mental status examination and lack the knowledge of crisis intervention skills for managing a psychiatric emergencies. The majority (76.7%; P < 0.001) of the participants are not conversant with the Mental Health Care Act 2002 (Act no. 17 of 2002). Finally, participants (94.3% and 86.8%, respectively; P < 0.001) agree that teaching and prior exposure to a psychiatric facility, as in work integrated learning, will empower EMC graduates with skills required to effectively manage psychiatric emergencies. Conclusion EMC practitioners are often the first healthcare professionals arriving at any scene of medical emergencies including psychiatric emergencies. To avoid malpractices, which could be detrimental to patient's health, it is of utmost importance that EMCPs are well trained and equipped to manage any form of medical emergency including those involving psychiatric patients.


Introduction
Globally, the burden of mental disorders continues to rise with significant impact on health, social, economic and human rights sectors [1]. Psychiatric emergencies (PEs) are acute onset of disturbance of behaviour, thought or mood of an individual which if untreated may lead to harm, either to the individual or to others [2].
Psychiatric emergency is a broad concept that consists of various disorders grouped into two major categories namely; acute excitement with psychomotor agitation and self-destructive or suicidal behaviour [3]. Psychiatric emergencies are often, but not always, caused by mental illness and about 60% of cases needing medical attention occur in non-psychiatric facilities [3]. According to Calzada and colleagues, acute agitation accounts for almost half of the total psychiatric emergencies in the pre-hospital setting [4]. Immediate treatment directed against these acute manifestations is needed, both to improve the patient's subjective symptoms and to prevent behaviour that could harm the patient or others [5].
In SA, the Life Esidimeni tragedy, that led to the death of 144 mental health care users and the torture of 1418 others [6], has raised important ethical and clinical issues [7]. This requires that healthcare professionals, including EMCPs are well trained on the ethical and clinical principles of managing psychiatric patients. EMC practitioners (EMCPs) are often the first healthcare professionals arriving at any scene of medical emergencies. An EMCP will routinely encounter patients with acute psychiatric disturbances in practice [8,9].
However, studies have reported that EMCPs encounter challenges when it comes to providing high-quality, safe and effective healthcare for the mentally ill [10,11]. It has been advocated that EMC personnel require mental health skills that will allow them recognise and manage mental illness in ways that will collaboratively add value to overall patient care [12]. At present, little is known about the knowledge of EMCPs in SA on pre-hospital management of psychiatric emergencies.
Using a questionnaire survey, this study assessed the knowledge of EMCPs, working in the Free State province of SA, on aspects of prehospital management of psychiatric emergencies.

Methods
This research was designed as a descriptive study that made use of a questionnaire survey.
Questionnaire survey: the structured questionnaire used in this study was self-administered and was distributed manually (in hard copy) to the participants of this study. The questionnaire was compiled using factors identified during the literature review, which had been used by previous studies. Questions were adapted so that they were applicable to the context of the pre-hospital EMC environment. The questionnaire collected data in the following three sections; section A: biographical data; age, gender, qualification, district of operation, level of experience, EMC certification, and sector of practice, section B: knowledge survey questions; assessed participants knowledge on aspects of pre-hospital management of psychiatric emergencies. In this section, participants were asked to choose between "yes", "no" or "unsure" in response to subjectspecific, closed ended questions relating to the management of psychiatric emergencies in the pre-hospital setting. The open-ended questions requested that participants' supply a motivation for their response to the closed-ended question. The levels of knowledge assessed include; level 1: remember (K1) (The ability of the participants to recognise, remember and recall terms or concepts); and level 2: understand (K2) (The ability of the participants to be able to explain ideas or concepts) [13]. Section C: obtained participants' perceptions on the inclusion of teaching on pre-hospital management of psychiatric emergencies in the EMC curriculum in SA. Participants were requested to return completed questionnaire to the nearest emergency medical service (EMS) station in a box labelled for such purpose. Data collection and analysis: data collection was aided by EMS station managers and the drivers of the planned patient transport (PPT) system in the different regions, who assisted in both the dissemination and collection of the questionnaires. Quantitative data collated from the structured questionnaire was analysed quantitatively and results presented as frequencies and percentages.

Results
Only 159 of the initial 192 questionnaires that was distributed were returned, giving a response rate of 82.8%. Of the participants, 78.0% Duration of service as pre-hospital EMC provider: the number of years that participants had been working as pre-hospital emergency medical care personnel is presented in Figure 2. The majority, that is, 42.8% (n = 68) of participants, indicated that they had been in service for between five and ten years. A further 22.0% (n = 35) had worked for 10-15 years, while only 3.1% (n = 5) and 3.8% (n = 6) had less than two years and greater than twenty years of service, respectively ( Figure 2). Location of workplace: more than half (51.6%; n = 82) of the participants worked in urban settings (metropolitan/city); 28.3% "anxiety disorder; personality disorders; violent disorder; substance abuse", #2 "delirium/dementia; psychosis; attempted suicide or deliberate self-harm; alcohol or drug overdose; withdrawal symptoms of drug dependence; panic, violence or excitement", #3 "suicide attempts, violent behaviour, psychosis, personality disorders, substance abuse and intoxication".
Knowledge on how to approach an individual with psychiatric emergency: only 33.3 % (n = 53) of the participants indicated that they are knowledgeable on how to approach an individual with psychiatric emergency (cf. quotes #4 and #5), 38.3% (n = 61) indicated that they are not knowledgeable (cf. quotes #6 and #7), and 27.7% (n = 44) are unsure of how to approach such case (cf. quote #8). #4 "approach patient in a calm manner to gain their trust and see if the patient is willing to work with you after gaining their trust", #5 "try to calm and reassure patient. Take the family member with when talking with the patient", #6 "I did not receive any structured formal/informal training, nor any exposure during any training period", #7 "no I have zero skills to handle them so am even scared to approach. They might harm me", #8 "every psychiatric pt is different, so I would say it differs".
Knowledge on how to assess an individual with psychiatric emergency: the majority (46.5%, n = 74) of the participants indicated that they are not knowledgeable on how to assess an individual with psychiatric emergency (P < 0.01) (cf. quotes #9-#11), only 19.5% (n = 31) indicated that they know how to assess such patient (cf. quotes #12 and #13), while 34.0% (n = 54) indicated that they are unsure (cf. quote #14). #9 "usually we contact SAPS for assistance", #10 "no education on psychiatric patient", #11 "no proper guide lines, how to assess specifically psychiatric patient like other cases/emergencies", #12 "obtain hx. Talk to the pt ask relevant questions", #13 "assess mental status; patient behaviour ", #14 "I don't know the exact signs of a compute psychiatric patient".

curriculum.
Participants were asked to indicate the extent to which they "Agree" or "Disagree" with the statement in Table 1.

Discussion
According to the World Health Organization (WHO) report on mental disorders, around 450 million people worldwide currently suffer from mental disorders and one in four people in the world will be affected by mental or neurological disorders at some point in their lives [14].
Accompanying this high prevalence are reports confirming the increase in the frequency of psychiatric emergencies presenting to emergency departments and emergency medical services globally [15][16][17][18][19]. Pre-hospital emergency care is an essential part of the continuum of emergency health care provided by emergency medical services (EMS) responders [20]. EMCPs are the initial health care providers at the scene of any medical emergency and are often the first to evaluate the nature of the emergency, determine the need for medical resources, initiate management and provide medical transport for the sick and injured [20,21]. However, it has been reported that the EMC provider's ability to understand, assess and manage psychiatric emergencies remains poor [22] [27,28]. Findings presented by this study suggest that EMCPs within the Free State province are relatively young (median age group 36-40 years) with majority having between 5 and 10 years of working experience in the EMC sector ( Figure 2). This corroborates similar findings by Butler (2015) [31]. Despite 64.2% of the participants indicating that they have attended to a psychiatric emergency case before, the majority (87.4%) of the participants across the cadres reported that they are not confident of their knowledge on pre-hospital management of psychiatric emergencies. Thus, suggesting that majority of the patients attended to by these 102 (64.2%) EMCPs were poorly managed. While the EMCP is not expected to diagnose patients with psychiatric emergencies, it is vital that the practitioner has a thorough understanding of the presentation and management of such patients in order to provide safe and expedient transport to definitive care [8].
In this presented study, the majority (47.8%) of the participants indicated that they are not knowledgeable on the different types of psychiatric emergencies. In cases involving suicidal ideations, the EMCP is expected to approach the individual with a degree of understanding of their turmoil and speak in a calm, supportive manner [22]. Findings by this study reveal that more than a third of the participants indicated that they are not knowledgeable on how to approach an individual with psychiatric emergency. This was attributed to lack of training or exposure (cf. quotes #6 and #7).  [36]. Studies have reported that early crisis intervention, with immediate reduction of psychotic symptoms is beneficial for the longterm prognosis of this illness [37,38]. In this present study, the majority (73.6%) of the participants indicated that they are not knowledgeable on crisis intervention skill for managing a psychiatric patient (cf. quotes #17 and #18). This could lead to poorer long-term prognosis and poor patient outcome.
In SA, like in many other parts of the world, patient care takes place within a legal framework consisting of legislations, Acts, policies and laws to protect patient's rights.    ***, P < 0.001