Lessons from Emergency Psychiatry

Lessons from Emergency Psychiatry: Reflections from a Medical Student Elective at Queensway Carleton Hospital

Author: Shelly Palchik

Prolonged stays in the Emergency Department can quietly erode a patient’s sense of feeling seen. While healthcare providers know that patients continue to receive active care even as labs, imaging, specialty consultations, or reassessments are pending, the interim period can make patients feel as though their care has stalled. This sense of invisibility and vulnerability is especially pronounced among those presenting with mental health concerns.

As a fourth-year medical student rotating through the Queensway Carleton Hospital, I witnessed something unique in their Emergency Department, an added layer of personnel reminding patients that they are not forgotten. This came in the form of the Mental Health Crisis Nurses, a vital bridge in the graded chain of care. Crisis nurses are registered nurses specifically trained in the urgent assessment of mental health crises. Working directly with emergency department team members and psychiatric staff, they ensure efficient assessment and appropriately triage referrals of patients presenting with psychiatric emergencies. They assist in mitigating efficient discharge, sometimes meaning that a patient does not have to be assessed by a staff Psychiatrist. Alternatively, they can streamline the admission process while providing compassionate care concurrently.

During my elective in outpatient and emergency psychiatry, I was consulted by the crisis nurse about a woman presenting with suicidal ideation in the context of multiple life stressors and prior psychiatric history. Prior to my assessment, she was seen by the crisis nurse and expressed immense gratitude to be able to simply to speak with someone. She noted that this was her first encounter with a crisis nurse, a marked improvement over her prior experiences. The crisis nurse had already reviewed the patient’s previous mental health-related history and even which resources she had already engaged with. This allowed me to focus my assessment and plan, as much of the preliminary history had already been collected. The graded emergency assessment approach was crucial in building rapport, validating the patient’s experiences, and collaborating on a safe discharge plan.

Evidence supports the integration of speciality nurses to ease caseload burden in emergency settings [1]. Benefits include improving time to treatment and predicting better outcomes and mortality for patients [2]. Notably, these nurses also improve patient satisfaction. Although not specifically explored in the context of mental health, there was evidence that nurses specifically excelled in health teaching and education, addressing questions, and active listening, all key components in psychiatry [2].

In acute mental health presentations, early intervention and de-escalation are critical [3]. Building rapport and demonstrating robust communication is particularly crucial for patients presenting with severe emotional stress. Dignity-related distress is linked with higher intensity of suicidal ideation and is also associated with greater depressive symptoms and mental health comorbidities [4]. Crisis nurses, trained in these delicate interactions, provide an additional point of contact and reassurance, preserving humanity in moments of extreme emotional vulnerability.

When I returned to the Queensway Carleton for my emergency medicine elective, I gained even deeper appreciation for this model. As the first point of contact for patients in the emergency department, I observed how early rapport and a therapeutic alliance shape patient trust. I met a gentleman experiencing his first episode of hypomania, distressed by feeling like he was losing control of his life. He

shared that this was his first time in the emergency department for a mental health crisis, and he appreciated the non-judgmental and validating nature of our encounter. After our discussion, he met with a crisis nurse to explore resources and next steps; their conversation further bolstered his sense of support and safety.

That evening, every member of his care team played an essential role in shaping his impression of psychiatric services, an area already burdened by social and systemic stigma. Through these experiences, I developed an appreciation for how powerful first impressions are in shaping patient-provider trust, engagement in care, and even clinical outcomes. Mental health crisis nurses help to uphold the integrity of both emergency and psychiatry services, and can foster patient trust in moments when first impressions matter most.

In my training as a medical student, I have seen various emergency psychiatry healthcare models. In some large academic centers that have not adopted crisis nurses, resident physicians often manage multiple concurrent consults independently, making timely assessments more difficult. Other hospitals have integrated mental health and addictions triage services in the emergency room, where addictions care navigators and nurses collaborate in facilitating individualized care. I have also witnessed how broad integration of crisis nurses enhanced triage, streamlined discharges, and improved patient satisfaction. Most importantly, they promote dignity through evidence-based crisis intervention grounded in empathy and human connection.

My time spent at Queensway Carleton Hospital remains deeply formative. It reinforced my approach to clinical practice and shaped my understanding of collaborative interdisciplinary care. With a goal to work in emergency psychiatry, I aim to carry forward these values in my training and instill humanity in each clinical encounter, further reminding patients that they are not forgotten.

References:

1. Horvath, S., & Carter, N. (2024). Closing gaps in emergency care: The vital role of Advanced Practice Nurses in serving vulnerable populations. Canadian Journal of Emergency Nursing, 47(2), 138–143. https://doi.org/10.29173/cjen229

2. Woo, B. F. Y., Lee, J. X. Y., & Tam, W. W. S. (2017). The impact of the advanced practice nursing role on quality of care, clinical outcomes, patient satisfaction, and cost in the emergency and critical care settings: A systematic review. Human Resources for Health, 15(1), 63. https://doi.org/10.1186/s12960-017-0237-9

3. Shaikh, U., Qamar, I., Jafry, F., Hassan, M., Shagufta, S., Odhejo, Y. I., & Ahmed, S. (2017). Patients with borderline personality disorder in emergency departments. Frontiers in Psychiatry, 8. https://doi.org/10.3389/fpsyt.2017.00136

4. Buchok, M., Chochinov, H. M., Kowall, S., Bolton, S.-L., El-Gabalawy, R., Hensel, J. M., & Bolton, J. M. (2025). Self-Reported Dignity among People Admitted to Psychiatric Wards and Its Association with Suicidal Behaviour: Perte de dignité auto-évaluée chez les personnes admises dans des services psychiatriques et son association avec les comportements suicidaires. The Canadian Journal of Psychiatry, 70(9), 681–689. https://doi.org/10.1177/07067437251355644