On: October 6, 2022

This paper provides an overview of the author’s beliefs on the value of having nurses providing expert opinions about adverse events and clinical negligence claims in mental health facilities.

Traditionally, the voice of nurses has been largely excluded in the investigation of medico-legal cases occurring in mental health facilities in favour of medical professionals. In part, this might be due to the over-medicalisation of the patient’s thoughts, emotions, and behaviours as symptoms of their psychiatric diagnosis (Aho, 2008). There is also a fallacy that nurses are lacking in clinical expertise when compared to other health professionals, due to their historical image as handmaidens with limited power to influence clinical decisions (Arora & Gulia, 2020).

Today, nurses working in mental health facilities are no longer handmaidens to the physician and play a vital role in shaping safe and high-quality care in the healthcare system (Sahakyan, Akopyan, & Petrosyan, 2020; Trueland. 2020). Most nurses are highly regarded by their colleagues in the clinical environment as clinical experts by evidence of their education levels, experience, and ability to effectively make critical and complex clinical decisions (McHugh & Lake, 2010). Moreover, many nurses lead and contribute to the advancement of clinical education and research to improve healthcare structures, processes, and outcomes (Sahakyan, Akopyan, & Petrosyan, 2020). For example, the prevention and management of patient aggression which is the most common problem faced by health professionals with adverse consequences in mental health facilities (Bulgari, Ferrari, Pagnini, de Girolamo, & Iozzino, 2018). To facilitate the discussion, patient aggression is used to highlight the value of having expert nurses providing opinions about adverse events and clinical negligence claims in mental health facilities.

Patient aggression is generally recognised as the display of verbal or physical assault with the potential of causing physical, psychological, or emotional harm to the person encountering it (Lim, Wynaden, & Heslop, 2017). Patient aggression is the major reason patients have prolonged hospital stays and experience restrictive practices such as restraints, seclusion, and high doses of sedative medications (Pompili, Carlone, Silverstrini, & Nicolo, 2017). The consequences of patient aggression can significantly contribute to adverse events and medical negligence claims in mental health facilities, for example, medication errors, falls, injuries, and unexpected death in mental health facilities (Mills, Watts, Shiner, & Hemphill, 2017).

Nurses spend the most amount of time with patients clinically when compared to other health professionals such as doctors, psychologists, and social workers. As such, nurses hone their knowledge and skills to perform an accurate comprehensive risk assessment and recognise early warning signs (Koukia, Madianos, & Katostaras, 2009). Reasons for aggression are complex but can be broadly grouped into three categories of origin:

  1. internal (the consumer’s illness-related factors, personality traits, substance abuse);
  2. external (aspects of the ward environment); or
  3. situational (interpersonal conflict, relationship, or communication breakdown) (Duxbury, 2015).

The clinical expertise that nurses possess to ascertain the patients’ reasons for aggression and then plan and implement care to de-escalate the identified risks is important to prevent and reduce patient aggression from occurring (Lim et al., 2017). This same clinical knowledge and skills nurses have may also be used to provide expert opinions to fulfil the Bolam Test (1957), which is critical in the medico-legal field to establish what most clinicians would consider as a reasonable standard of care (Brown, 2022). Having the nurses’ expert opinion may be important to avoid over-medicalising patient aggression in mental health facilities and downplay the responsibility of the organisation, clinicians, and the individual patient. Consequently, the defendant and claimant may have comprehensive and specific information about the issues such as the communications in the multidisciplinary team, the system for assessing and managing risks, and the level of quality care and treatment that may have contributed to the adverse event occurring (Mills, Watts, Shiner, & Hemphill, 2017).

Additionally, the occurrence of patient aggression in mental health facilities is also a major reason for the high rates of workers’ compensation claims (Itzhaki, Bluvstein, Bortz, et al., 2018). As such, legal professionals are likely to represent clients seeking financial compensation for the physical and psychological harm experienced after being exposed to patient aggression. This highlights the relevance and appropriateness of engaging nurses to examine the contributing factors of the adverse event, and to provide their expert opinions on whether there has been a breach of duty for the patient and staff to support a fairer assessment and compensation for the victim. Correspondingly, knowledge of the contributing factors may also enable the nurse to offer recommendations for mitigating and reducing the risk of the adverse event reoccurring.

Patient aggression, a common problem in mental health facilities, is just one context that highlights the value of having nurses provide expert opinions about adverse events and clinical negligence claims. Compared to other health professionals, nurses have more responsibility in mental health facilities to provide safe and therapeutic care, and are likely to have a superior understanding of the contributing factors to adverse events.

By Dr Eric Lim

Registered Nurse


Aho, K. (2008). Medicalizing mental health: A phenomenological alternative. Journal of Medical Humanities, 29, 249-259. Doi: 10.1007/s10912-008-9065-1

Arora, S. & Gulia, S. (2020). Nurses, becoming a voice to lead in 2020. International Journal of Nursing Science Practice and Research, 6(2), 42-46.

Brown, A. (2022). Clinical negligence claims for pressure injuries from the perspective of a tissue viability medico-legal nurse expert. Community Wound Care, S14-S20

Bulgari, V., Ferrari, C., Pagnini, F., de Girolamo, G., Iozzino, L. (2018). Aggression in mental health residential facilities: A systematic review and meta-analysis. Aggression and Violent Behavior, 41, 119-127. https://doi.org/10.1016/j.avb.2018.06.002

Duxbury, J. (2015). Minimizing the use of coercive practices in mental health: The perfect storm. Journal of Psychiatric and Mental Health Nursing, 22(2), 89-91. doi:10.1111/jpm.12206

Itzhaki, M., Bluvstein, I., Bortz, A. P., Kostistky, H., Noy, D. B., Filshtinsky, V., & Theilla, M. (2018). Mental health nurse’s exposure to workplace violence leads to job stress, which leads to reduced professional quality of life. Frontier in Psychiatry, 27(9), 1-6. https://doi.org/10.3389/fpsyt.2018.00059

McHugh, M. & Lake, E. T. (2010). Understanding clinical expertise: Nurse education, experience, and the hospital context. Research in Nursing and Health, 33(4), 276-287. Doi:10.1002/nur.20388

Mills, P., Watts, B. V., Shiner, B., & Hemphill, R. R. (2017). Adverse events occurring in mental health units. General Hospital Psychiatry, 50, 63-68. http://dx.doi.org/10.1016/j.genhosppsych.2017.09.001

Koukia, E., Madianos, M. G., & Katostaras, T. (2009). “On the spot” interventions by mental health nurses in inpatient psychiatric wards in Greece. Issues of Mental Health Nursing, 30(5), 327-336. Doi:10.1080/01612840902754586

Lim, E., Wynaden, D., & Heslop, K. (2017). Recovery-focussed care: How it can be utilized to reduce aggression in the acute mental health setting. international Journal of Mental Health Nursing, 26(5), 445-460. doi:10.1111/inm.12378

Sahakyan, S., Akopyan, K., & Petrosyan, V. (2020). Nurses role, importance and status in Armenia: A mixed method study. Journal of Nursing Management, 28(7), 1561-1569. DOI: 10.1111/jonm.13109

Trueland, J. (2022). Have you ever described yourself as ‘just a nurse’? Nurse Standard, 35(2), 37-39