Psychiatry out-of-hours: a focus group study of GPs' experiences in Norwegian casualty clinics

Abstract

BackgroundFor Norwegian general practitioners (GPs), acute treatment of mental illness and substance abuse are among the most commonly experienced emergency situations in out-of-hours primary healthcare. The largest share of acute referrals to emergency psychiatric wards occurs out-of-hours, and out-of-hours services are responsible for a disproportionately high share of compulsory referrals. Concerns exist regarding the quality of mental healthcare provided in the out-of-hours setting. The aim of this study was to explore which challenges GPs experience when providing emergency care out-of-hours to patients presenting problems related to mental illness or substance abuse.MethodsWe conducted a qualitative study based on two individual interviews and six focus groups with purposively sampled GPs (totally 45 participants). The interviews were analysed successively in an editing style, using a thematic approach based on methodological descriptions by Charmaz and Malterud.ResultsSafety and uncertainty were the dominating themes in the discussions. The threat to personal safety due to unpredictable patient behaviour was a central concern, and present security precautions in the out-of-hours services were questioned. The GPs expressed high levels of uncertainty in their work with patients presenting problems related to mental illness or substance abuse. The complexity of the problems presented, shortage of time, limited access to reliable information and limited range of interventions available during out-of-hours contributed to this uncertainty. Perceived access to second opinion seemed to have a major impact on subjectively experienced work stress.ConclusionsThe GPs experienced out-of-hours psychiatry as a field with high levels of uncertainty and limited support to help them meet the experienced challenges. This might influence the quality of care provided. If the current organisation of emergency mental healthcare is to be kept, we need to provide GPs with a better support framework out-of-hours.

Primary Care Physician Perceptions on Caring for Complex Patients with Medical and Mental Illness

“…This distress was also noted in a qualitative study of Norwegian primary care physicians who reported frustration with limited mental health resources after-hours. 41 The lack of integration of mental and medical health care both financially and structurally has been implicated as a factor in the poor health outcomes and increased costs of care in complex patients with cooccurring illness. 42,43 For this reason, the Institute of Medicine has recommended increased integration of services as fundamental to improving the quality of care for patients with co-occurring mental and medical illness.…”

For en bedre akuttmedisinsk tjeneste i Norge

“…I en studie som prospektivt hentet inn informasjon om legevaktkontakter relatert til rus og psykiske lidelser, ble truende atferd spontant beskrevet i 32 av 853 journalnotat (4 pst.). Noen leger er bekymret for egen sikkerhet, spesielt i møte med pasienter som er så ruspåvirket eller psykisk syke at deres atferd oppleves uforutsigbar (Johansen, Carlsen & Hunskaar, 2011). Internasjonal forskning tyder på at bekymring for egen sikkerhet reduserer legenes villighet til å delta i vakt (Magin, Adams & Ireland, 2005;Magin, Adams & Sibbritt, 2008;Hobbs, 1994).…”

“…Noen av pasientene med rusproblemer eller dårlig psykisk helse er krevende å behandle på legevakt, og vanskelige å henvise videre på grunn av få alternativer til døgninnleg-gelse (Johansen, Carlsen & Hunskaar, 2011). I en 25 år gammel norsk studie ble det observert at legevaktleger kom i klem mellom lekfolk og spesialisthelsetjenesten i psykisk helsevern ved problemstillinger relatert til psykisk sykdom (Måseide, 1991).…”

“…Det var den gang ulike oppfatninger om hva psykisk helsevern skal vaere behjelpelig med og hva spesialisthelsetjenesten mener at de kan og skal bidra med. Dette gjelder mange steder også i dag, og legevaktleger rapporterer om uttalte samarbeidsproblemer med spesialisthelsetjenesten, som oppleves som lite tilgjengelig (Johansen, Carlsen & Hunskaar, 2011). Dette preger legevaktlegene i møtet med pasientene og kan føre til at de kvier seg for å kontakte spesialisthelsetjenesten ved behov for rådgivning eller assistanse og for logistikken som er involvert ved innleggelse.…”

“…Legevaktleger har gitt uttrykk for at legevakttjenesten noen steder er organisert slik at forholdene ikke ligger til rette for å gi gode tjenester til denne pasientgruppen (Johansen, Carlsen & Hunskaar, 2011). Eksempler på slike forhold er tidspress, stor pasienttilstrømning, dårlig tilgang til komparentopplysninger og annen nødvendig informasjon, samtidighetsproblematikk, stykkprisfinansiering i avlønning av leger og lite egnede lokaler.…”