Analysis

A new approach to de-escalating mental health service users’ violent behaviour in ED settings

Researchers in Australia believe they may have come up with a new role for nursing students in helping to tackle the rising number of violent service users in emergency departments.

Researchers in Australia believe they may have come up with a new role for nursing students in helping to tackle the rising number of violent service users in emergency departments

Security guards are routinely placed within emergency departments (EDs) to respond when mental health service users become aggressive.

However, a team of researchers from Australia believes there is a case for replacing some of these guards with assistants in nursing (AINs), who are often second or third-year nursing students.

The researchers’ views are based on a study of AINs who tested the role in Lyell McEwin Hospital’s ED in Adelaide, Australia. The study also considered the views of other ED team members.

Boost patient outcomes

The researchers anticipated that service users would view security guards as heavy-handed enforcement officers or police, rather than people who could improve their well-being.

‘Security guards focused on risk and safety, but engaged minimally with patients because of their limited scope of patience and lack of health training’

Lead researcher Eimear Muir-Cochrane, who is the chair of mental health nursing at Flinders University in Adelaide and visiting professor of mental health at City University of London, wanted to explore what AINs thought about supervising service users and whether this role could boost patient outcomes.

Professor Muir-Cochrane speculated that if AINs could adopt this role, they then could help tackle ongoing rises in the numbers of service users with mental health problems attending EDs in Australia.


Assistants in nursing keep patients occupied with structured
or creative activities such as playing cards. Picture: iStock

The researchers were entering new territory. During a pre-study literature search they did not come across a single paper on AINs working in this way.

‘I try to tell patients’ families that my role is as an intermediary – it’s not direct care and it’s not too distant’

Eight AINs took part, alongside eight registered or enrolled nurses, three mental health nurses and five nurse managers. Service users were risk-assessed by mental health clinicians and then assigned to a security guard if considered a high risk to themselves or others. If they were a lower risk they were allocated to an AIN or a nurse. The level of supervision was reassessed regularly according to changes in the service user’s condition.

Registered nurse supervision

Working under the supervision of a registered nurse, students recorded a service user’s behaviour every 15 minutes, and this was signed off by a registered nurse every hour. The students, given personal alarms for their safety, also carried out routine observations of blood pressure, temperature and blood glucose level monitoring. After the six-month study the 24 participants in the project were interviewed.

Professor Muir-Cochrane says: 'The overarching theme was that AINs occupy a unique space between direct nursing care and the limited interaction that may be characteristic of the guard’s role.

‘The overarching theme was that AINs occupy a unique space between direct nursing care and the limited interaction that may be characteristic of the guard’s role’

‘Security guards focused on risk and safety, but engaged minimally with patients because of their limited scope of practice and lack of health training.

‘AINs had more opportunity to engage and gave patients undivided time – unlike nursing staff, who were focused on key tasks such as encouraging a patient to have a shower, de-escalating behaviour or providing information to other staff. Chatting and listening was seen as an important part of the AIN role.’

The nurses said this was a bonus because they themselves did not have much time to chat with service users, even though this is a core mental health nursing role.

Intermediary role

As one AIN explains: ‘I try to tell patients’ families that my role is as an intermediary; it’s not direct care and it’s not too distant.’

Professor Muir-Cochrane says the AINs kept patients occupied through structured or creative activities.

‘Some encouraged patients to have breakfast, while others provided magazines, paper to write on or playing cards.’

‘AINs had more opportunity to engage and gave patients undivided time’ 

Some AINs did not view their interactions with patients as a therapeutic relationship, because they did not have the skills that a nurse possesses.

AINs considered themselves better at de-escalating conflicts than security guards. However, one AIN revealed that it was handy to have security guards around if a patient was ‘yelling or throwing things at people’.

One registered nurse said that security guards tended to be short-tempered rather than understanding if a patient wanted to leave a cubicle. Some managers questioned the wisdom of assigning inexperienced, mostly young, nursing students to a group of patients who may be unpredictable or confused.

Ethical issues

Professor Muir-Cochrane admits the study has its limitations. The views of patients were not included, partly because of ethical issues in recruiting them while they were still receiving care. Neither were guards’ views sought because their managers refused permission. The AIN sample was also small.

Lyell McEwin Hospital is now using AINs permanently in its EDs and it is cost-effective, although Professor Muir-Cochrane was not able to say by how much.

‘While AINs can provide opportunities for nursing staff to engage in other tasks, adequate ratios of qualified nursing staff to AINs are essential to ensure patient and staff safety’

She believes that ED/AIN schemes can work provided certain criteria are met. These would include regular refresher training on de-escalation and aggression management, as well as training for guards to enhance their awareness of patient distress.

‘Patients should help evaluate the role of AINs, perhaps through short, simple questions on discharge, or a nurse could phone them subsequently as part of aftercare.’

‘While AINs can provide opportunities for nursing staff to engage in other tasks, adequate ratios of qualified nursing staff to AINs are essential to enable necessary supervision and delegation of tasks to ensure patient and staff safety.’

Professor Muir-Cochrane does, however, caution against using AINs to plug nursing shortages. She hopes to publish the research next year.

What does the assistant in nursing role entail?

Researchers in Australia suggest that nursing students, working as assistants in nursing, could replace some security guards in emergency departments to care for service users.

  • There is speculation that nursing students are better at communicating with service users and offering a supportive environment.
  • Nursing students would work under nurses’ supervision.
  • Security guards would still be on hand to deal with violent service users.
  • Nursing students should not be used to plug nursing shortages, the researchers argue.

Tell us what you think

Could a similar system work in the UK? Let us know what you think by emailing Mental Health Practice journal editor Colin Parish at colin.parish@rcni.com 

Christian Duffin is a freelance journalist

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