The Emergency Department (ED) is a dynamic environment that challenges nurses to manage critical situations such as patients with psychological distress [1]. Nurses at EDs are confronted with patients complaining of physical signs connected to psychological distress which may influence the abilities of nurses to make an appropriate diagnosis and management [2]. Nurses at EDs are assumed to have the knowledge and skills to differentiate psychologically-based symptoms from physical-based ones [3]. However, such an issue hypothesizes that nurses are trained and educated during their academic preparation to manage patients with psychological distress. This hypothesis is confronted with reports that there is a significant increment in the number of patients with psychological problems reported to EDs. Previous reports showed that psychological distress is present in 84% of patients who had frequent attendance to EDs [4, 5]. This has raised the attention toward the need to address the knowledge and skills of nursesat the emergency departments where specialized psychiatric personnel are present to provide appropriate psychological intervention once needed. While nurses give priority to manage physical complaints rather than psychological ones [5], further harm to the patients is expected due to the mismanagement or delayed management of psychological needs [5]. The harm could be temporary or permanent in the form of self-harm or committing suicide [5]. Thus, acquiring knowledge and skills to identify and signify psychological distress associated with psychological problems is a priority issue to be investigated among nurses in EDs.

Interestingly, while nurses in EDs possess knowledge about psychological distress and its psychotherapeutic approaches, they still lack the skills to appropriately manage it [6]. Among the issues that interfere with the performance of nurses is lack of agreement on defining patients with psychological distress which may contribute to mismanagement at EDs [6]. While some proposed that psychological distress is a psychological symptomatic condition, others indicated that psychological distress has physical and psychological signs and symptoms [4, 6-8]. This requires that nurses need to be more attentive to both psychological and physical symptoms equally. Once nurses are well-equipped with knowledge and skills to assess and manage psychological distress, this would reflect positively on nursing care outcomes. Appropriate management of patients with psychological distress was found to improve quality of life, decrease recurrent visits for non-cardiac chest pain, and to lower depressive and anxiety symptoms [9]. Moreover, previous studies reported that management of psychological distress in EDs is associated with decreased workload, length of stay, and financial burden of health care services [9, 10]. Such reports enhanced the reciprocal benefits of appropriate management of psychological distress between nurses and their patients at EDs. Further, nurses are also vulnerable to secondary traumatic stress due to working in emergency settings and that nurses are unable to detect psychological symptoms associated with physical deteriorations [11-14]. This indicates that nurses and other health care professionals also become stressed and suffer from psychological distress while caring for patients who attend emergency units and may be in need of psychological management and care [15]. Nevertheless, the literature emphasized the need to further investigate and ensure that nurses in emergency settings have adequate knowledge and skills and are sufficiently competent to manage psychological distress [6]. In Jordan, psychological distress among emergency topics is not covered in nursing curricula, and that nurses in EDs rely heavily on their employer in order to get trained and educated to improve their skills to identify and manage psychological distress [16]. Therefore, the purpose of this study was to identify the knowledge and skills of nurses related to the management of psychological distress in emergency departments.

The research questions were: what is the level of nurses' knowledge related to the management of psychological distress in emergency departments? 2) what is the level of nurses' skills related to the management of psychological distress in emergency departments? and 3) are there differences in knowledge and skills related to the management of psychological distress in relation to nurses' socio-demographic characteristics?.

Connecting knowledge to practice, in general, is one cornerstone of the quality of nursing care and improving nursing care outcomes. It has been observed that nurses lack theoretical and clinical training in managing psychological distress in emergency units during their undergraduate education [16]. This may have questioned sources of education at the clinical area and emphasized the significant role of staff development courses and training. We have found that nurses in EDs had a low level of knowledge to detect signs and symptoms of psychological distress, and lack skills to manage such problems if they were able to detect it. However, nurses had the ability to detect psychological signs and symptoms much better than physical signs inferring that nurses encounter difficulty in detecting and differentiating psychological-based symptoms from physical-based ones. In other words, nurses are more sensitive to physical complaints than psychological ones. The results support previous findings that nurses do emphasize and focus on physical symptoms rather than psychological ones in emergency departments [6, 10]. However, the question remains whether nurses lack the knowledge to manage or confused about the way to manage psychological distress while assessing physical ones. Probably nurses prioritize the management of physical signs and symptoms assuming urgency of physical signs and symptoms. The literature supported these findings where almost two-thirds of nurses in EDs have difficulty in detecting and managing patients with psychological complaints [22]. The shared signs and symptoms between physical and psychological complaints have also been reported as one factor that confuses emergency nurses at triage and emergency room while caring for patients with psychological distress [6, 22]. Recently, there is an agreement that nurses in emergency units similar to other health professionals need the skills to manage traumatic stress to improve their care outcomes [23].

On the other hand, nurses in this study had a high level of knowledge regarding the management of psychological distress. The highest three reported areas indicated nurses' awareness about the significance of appropriate triage and the harmful effect of psychological distress on patients' health and well-being. These findings are congruent with the international guidelines and studies that triage is critical to understand patients’ needs and minimize the harmful effects and consequences of psychological distress [1, 6, 24]. However, nurses did not indicate other areas such as assessment, interventions and evaluation despite being importunate [19]. The results showed various areas of nurses' knowledge deficits and lack of awareness related to appropriate care for psychological distress at EDs.

One interesting finding in this study is that nurses reported a high level of knowledge in managing psychological distress, while had moderate skills to manage it. Nurses showed that they have knowledge about psychological distress which is supposed to enable them to manage psychological distress; however, their skills and practice to manage psychological distress did not correspond with their level of knowledge. This discrepancy may contribute to variation in the quality of care provided. One possible explanation is that nurses have probably been exposed to information packages that discussed psychological distress while they have not been adequately exposed to the clinical application or have not actually managed such scenarios. The findings agree with previous international ones who found that nurses have good knowledge about psychological distress; however, they lack skills to appropriately manage it [6, 22]. The literature had proposed some inclusion for this discrepancy where nurses are probably lacking the confidence to manage patients with psychological distress in EDs due to their inadequate knowledge and training to manage such complaints [6, 22].

This study also found that nurses' years of experience and previous experience in psychiatry had no significant correlation with their knowledge and skills in managing psychological distress. While nurses who had received special courses or training in managing psychological distress had higher levels of knowledge to manage psychological distress than those who did not. The result of the study emphasized that courses or training about psychological distress enabled nurses to have the required knowledge to manage patients with psychological distress. In the previous report, high fidelity simulation has been found to be a significant contributor to knowledge, skills and motivation among nurses [27-29]. This experience can be emphasized at academic institutions and clinical areas while implementing staff development courses and training. Health care professionals, including nurses, need to be exposed to psychological distress scenarios, health policy programs and live cases to acquire the knowledge and skills to appropriately manage psychological distress in Eds [6, 21, 28]. The study signifies the importance of clinical courses on psychological distress and its positive outcomes on the abilities of nurses to manage psychological distress at EDs. In addition, many studies have also emphasized the importance of training and its positive impact on nurses' knowledge and quality of nursing care [29]. In Jordan, emergency care has different kinds of concepts, in general, emergency care has minor non-acute and severe acute kind of cases and is not specialized as a trauma center. Nurses in ER rooms are managing cases from minor non-acute to severe acute traumatized cases.

One limitation of this study could be related to the fact that none of the emergency departments in Jordan is considered a specialized trauma center which may widen the variation between emergency nurses working in these units.

The results have implications for emergency nursing practices and for continuing nursing education at EDs. The study highlighted the need to pay more attention and improve awareness regarding psychological distress at EDs among nurses and emphasized on the need of training and preparing emergency nurses and other health care professionals for the proper management of patients with psychological distress at EDs so that health care professionals as well as policy decision-makers could pay attention towards it. The study highlights the lack of knowledge and skills of nurses in identifying and dealing with patients with psychological distress at ED. Nurses need to improve their knowledge to identify the psychological and the physical signs and symptoms of psychological distress as well as the skills to provide proper care at the EDs. Finally, proper management for psychological distress requires improving nurses' knowledge and skills to identify and manage patients with psychological distress at EDs.