Reducing violence and aggression in A&E webinar: Insights from Design Council on Vimeo.
CHRIS HOWROYD
Hello and welcome. My name is Chris Howroyd, Programme Manager for Health here at the Design Council. This is the second of three webinars hosted by the Design Council today entitled Insights. All three webinars are centred around the design-led approach adopted to deliver reducing violence and aggression in the A&E programme of work, the outputs of which are public showcased this week. The aim of this mini series of webinars is to share learning from this programme, engage, provoke and hopefully inspire. We plan to be live for about an hour. Slides to show the presentation will last for about 40 minutes, leaving us 20 minutes for Q&A. We will be taking questions at specific intervals during the session, so if you would like to ask, clarify or query anything, please simply type a note into the text box on your webinar app screen. Without further ado, it’s my pleasure to introduce to you your speakers, Becky Rowe and Martin Bontoft.
BECKY ROWE
Thanks, Chris, and thank you, everyone, for joining us today on the Ethnography webinar. My name is Becky Rowe. I’m the Research Director from award-winning research agency ESRO and we were responsible for conducting research in two or our partner Trusts and I led that research.
MARTIN BONTOFT
And hello, my name is Martin Bontoft. I’m a design researcher and facilitator. I conducted the research at one of the Trusts.
BECKY ROWE
Martin and I are going to co-present the webinar today, so you’ll be hearing from us both as we progress through the presentation.
MARTIN BONTOFT
So, the aims of this webinar really are just to provide an overview of the work so that we understand exactly what the impact of ethnography can be, the benefits that arose from it and also to contextualise some of the briefs that we’ll hear a little bit later so you can understand how we got to the starting point following on the design work.
BECKY ROWE
Just to reiterate, Chris’s point earlier, we look forward to receiving any questions that you might have as we progress through the presentation and we’ll be answering questions at two points during the presentation, one point in the middle and one point at the end. So, please submit your questions and we’ll do our best to answer them as we go through. So, in terms of the presentation flow, we’re going to take you through five key sections. First we’re going to outline the need for the research. We’re going to talk briefly about why ethnography was selected over and above other research methods.
We’re going to talk you briefly through the field work that we did in the A&E context, including some of the challenges we encountered whilst we were there. We’re going to briefly take you through a selection of the key insights and findings. There are a huge number of insights, as we’ll go on to discuss and we don’t have time to do justice to the whole report here fully but all of the insights are available in the report that’s been produced by the Design Council and are on the website. And finally we’ll outline how those insights have led to the design briefs that went to the designers.
MARTIN BONTOFT
I think first is really just to understand the need for doing this research. There’s lots of data about aggression and violence in Accident & Emergency but, you know, a design process needs more than just data, it needs context, it needs intelligence, it needs the reasons why and that was really the focus of our work. We wanted to understand… We knew that the end result of our work was going to be a set of briefs that we can offer to the designers, so what we needed to do was go through the issue, provide some contextual information to that and also explore some of the determinants of aggression and violence in order that we could relate that to the designers.
BECKY ROWE
Just to add to Martin’s point there, there are more than 13,000 reported physical assaults of violence and aggression in A&E every year and I think most people would agree that that is totally unacceptable. To date current interventions have been focussed around reactive measures such as increasing security effort in hospitals, CCTV coverage and additional legislation looking at increasing the rights of staff to refuse treatment in A&E environments. Current sources of data focus around analysing incident reports and staff surveys, which is incredibly useful and provides enormous insight into the issue but doesn’t create a rounded pitch about the motivations and triggers and reasons why violence and aggression occurs in A&E. So, that leads us on to why ethnography was selected as a method for this research project.
MARTIN BONTOFT
What we did was we put a lot of people into the hospitals. 89 people spent a significant amount of time in A&E, simply with a notebook and a camera. That’s essentially, you know, the process that we followed. But ethnography is the study of behaviour in context. It’s tying into a system where from the outside it looks as if the behaviour is completely irrational and sitting within that system, you can understand why that behaviour is perfectly rational. And then it’s also about taking that understanding outside of the system and relating it to others so that they can do good work, so they can actually think of solutions, think of ways in which, you know, improvements can be made.
BECKY ROWE
And ultimately ethnography is the study of people and behaviour in context and in practice that involves naturalistic observation and interview and gathering a huge amount of… spending a huge amount of time in context, really gaining a holistic sense of what happens in the A&E environment. Ultimately ethnography goes beyond what people say they do and is the only way that you can reveal behavioural insights and triggers into the reality of people’s behaviour.
MARTIN BONTOFT
So, ethnography is just at one end of this spectrum of research. It’s working with non-verbalised, unarticulated information, really. You know, it doesn’t require people to be able to describe exactly why they do the things that they do. Because you’re sitting there with them, you can start using your empathy and your intuition and some of your… you know, there are some intellectual skills as well to really work out why it is that this behaviour is perfectly rational. It’s all about the real… you know, the actual, not the remembered or half-remembered, and it’s also not just about… I mean, in-depth interviews can get at a lot of that sort of information. So, in-depth interviews tend to be one-on-ones, you know, with a more limited number of people but with ethnography you can look at the processes of a group of individuals, not just each individual.
BECKY ROWE
It’s important to note that ethnography doesn’t… isn’t the kind of be-all and end-all. It doesn’t solve every single research question. It’s very much complimentary to other research methods. For example, ethnography is very much anchored in the specific context in which you’re conducting the research. It doesn’t provide the representative overview of all environmental, all opinions. However, as Martin correctly points out, it goes beyond articulated data and can reveal a different kind of data, going beyond what people are able or willing to say and reveal, the reality of life as it is lived.
MARTIN BONTOFT
So, it’s really good, you know, when you’ve got complexity, when the reality is… you know, when there’s a lot of systemic issues, when there’s a lot of interplay between all of those issues. It’s good at sort of… It provides you with time and the perspective to be able to identify all of those aspects of the complexity. It’s also really good because it relates… it gives you a flavour of the situational factors. I mean, within a design context the situation with the actual emotion, you know, evoking some of that within the design theme can be really useful and ethnography is great at producing rich pictures so that you understand what the impact might be of time of day, for example, or mood and also subtle things like the way in which the management system, for example, within A&E might have a direct bearing on the incidents of aggression and violence.
BECKY ROWE
Another factor when ethnography is a very valuable research method is when researching subjects that are incredibly complex or where the people involved would be considered as hard to reach, so for example individuals who may not be openly willing to identify themselves as perpetrators of violence or maybe difficult to identify as perpetrators of violence. So, where you are looking to study a population that would be difficult to recruit by other means, ethnography provides a tool that means that you can speak to and observe people without the need to find them in an external situation. And ethnography also yields a level of detail that’s not possible via other research methods. And by seeing the detail and the way that all of these different factors combine together and inter-relate, it can transform your understanding of a problem. So, as opposed to approaching an issue head-on, you can provide a kind of more nuanced and perhaps accurate picture of how the issue plays on the ground.
MARTIN BONTOFT
There’s an example of that in the Trust where I did my work. I discovered that there were six people managing the waiting space. The result of that was that in essence nobody was managing waiting space and there were some consequences from that which we’ll get into.
BECKY ROWE
So, on to the juicy bit, how did we actually do the field work in A&E? So, to provide a summary, the team visited six hospitals in total and the bulk of the research took place in three partner Trusts. In total over 300 hours of ethnographic research was completed and this included over 60 interviews with staff and patients.
MARTIN BONTOFT
So, this is how we spent Christmas and New Year last year, in A&E, watching people, you know, trying not to get in the way too much. You know, we ought to acknowledge at this point in actual fact, the contribution… the access that we were given by the Trusts that allowed us into the hospitals, we got the opportunity to sit with a wide range of individuals from senior clinicians, senior managers all the way through the organisation to include obviously security, porters, cleaners and indeed patients and carers who were waiting to be seen. In my Trust, and I think in Becky’s as well, we had the opportunity of watching security videos so that we could see significant incidents that happened outside the scope of this work. We also made sure that we were there at the right sort of times. So, I was in my Trust on one of the busiest days of the year and certainly over New Year as well.
BECKY ROWE
Absolutely. And over that period we collected a vast amount of data. As Martin alluded to, we collected numerous detailed descriptions of incidents which went into a level far beyond the level that’s commonly collated in incident reports. We also conducted extensive route cause analysis, looking at the reasons behind incidents, not just the detail of the actual incidents themselves. We looked at the way physical space was used in the department, the way people moved around the space and the way they interrelated and we also interviewed and tried to unpick the motivations and reasons why people became aggressive and violent in the A&E department.
MARTIN BONTOFT
So, some of the insights, some of the findings for this. You know, we saw 60 incidents of violence and aggression. There was a wide range of those, I mean an incredible diversity but I think the thing that I took away from this was although on the… you know, going into this work it was clear that we were going to see violence and aggression, when you see it it is still surprising, it is still affecting and it’s worth reflecting on how that affects clinicians when they’re faced with that over a long period of time during every shift. It becomes engrained. You know, their responses to aggression and violence becomes engrained. It becomes accommodated to and it’s worth acknowledging that. That colours every relationship that they have and many of the ways in which they deal with patients and carers.
BECKY ROWE
I mean, as Martin alluded to there, one of the important insights that we uncovered was that there was a huge difference between the sorts of incidents that were reported and the actual reality of incidents that occur in A&E environments and that’s partly because those staff members who are responsible for reporting incidents of violence and aggression have become so acclimatised to the level of hostility that they experience on a day-to-day basis that they don’t see it as important to… Or even notice the incidents as they’re happening.
So, by conducting ethnographic research we were able to approach the issue with a fresh pair of eyes and record incidents in a more accurate and realistic way and we documented both incidents that were documented by staff but also those that would have gone otherwise undocumented.
I think Martin also alluded to the fact that there was a huge range of incidents of violence and aggression and we’re not talking here simply acts of extreme physical violence which are very serious but in actual reality fairly rare but we witnessed all sorts of aggression and violence, ranging from moderate verbal hostility and using inappropriate language, for example countless incidents of people being frustrated and vaguely hostile or pointing, stamping, pacing around, verbally abusing staff right through to specific verbal attacks directed at individual staff members and even physical violence to property in the A&E environment.
So, we’re not talking simply physical assaults which are, of course, incredibly and need to be dealt with in the serious manner that they should be; however, we identified that there is a level of hostility in the A&E environment that creates a sense of A&E departments being a far more violent and aggressive places than they should be and often those lower level aggressive acts can lead to more serious physical and verbal assaults.
MARTIN BONTOFT
Yes. I mean, just to put some figures on it just from my Trust, the first rank of incidents is moderate verbal hostility. That was about half of the 36 incidents that I saw. I didn’t see any that I would rank five, where a weapon was used, where it was extreme physical violence but, on the other hand, I did see seven incidents where extreme physical violence resulting in injury did occur. The other thing that we should perhaps acknowledge is that, you know, in a couple of cases it was the staff that was being aggressive. I didn’t see any violence from staff – I mean, that would have been inappropriate – but, nevertheless, there was verbal hostility.
BECKY ROWE
And just to add to that, patients are not always the perpetrators, patients can also be the victims and visitors can be perpetrators of aggression and violence towards staff just as much as they also can be victims. So, it’s a really diverse range of incidents that we documented and possibly challenging some of the assumptions that could be associated with this issue that it’s people who have drunk too much or who are antisocial in their nature, actually there was a huge diversity of different incidents and that diversity presents a real challenge to this particular project because it’s a very complicated issue that affects many different people who have very different motivations for being aggressive or frustrated in this environment.
MARTIN BONTOFT
This slide really amplifies that fact, in actual fact, because what we wanted to try and do was explain that there was a range… that there was a whole series of different motivations for why violence and aggression might actually be perpetrated. I mean, at one end of the spectrum, we do have people who are just antisocial. They just come in with some evil intent in their mind and their intention is to disrupt. And of course that range extends all the way through to the young mum that’s got a baby that’s ill, who’s scared, anxious and deeply concerned about the welfare of somebody for which they have responsibility. Each of those people can in the right circumstances… or the wrong circumstances do something which might be considered inappropriate.
So, these people bring certain things into the space with them, of course, but they… we should also mention that they bring alcohol and drugs into the space in their bodies and that has significance as well and some of the incidents were definitely connected with intoxication. Others with loss of capacity from other reasons. There’s a significant number of the incidents that I saw had some mental health condition as an escalating factor, as a component of the mix. And then there were sort of situational factors as well that we talked about, the extreme tiredness of people. You know, people… We still do expect people to wait for four to six hours in a space that’s not particularly conducive to waiting from, say, midnight through to the early hours of the morning. Well, in some respects it’s not really surprising that, you know, they get a little bit antsy.
BECKY ROWE
I think it’s important to note that these perpetrator profiles were not created to stereotype or to put people into individual boxes. There’s a lot of crossover and overlap between the different profiles and they were really created to illustrate the diversity of different kinds of incidents and to help the design teams to challenge their own assumptions about who it was that was perpetrating the incidents. As Martin says, they could be anyone from, you know, a young family who are very concerned about their baby and maybe perceive that there’s inefficiency going on in the process and get very frustrated right through to people who are hell-bent on behaving antisocially and possibly would behave antisocially in other situations, including those who are clinically confused or simply just frustrated or confused about the process that they’re in.
MARTIN BONTOFT
So, we’re just giving you a sort of a headline view of some of the work that we did during the sort of analysis phase once we’d collected all the data. Another important tool was this mapping of patient journeys because one of the things that we wanted to capture and communicate was the incredible complexity of the journey. I mean, you know, from a naïve point of view, you might think you just rock up at A&E and that’s it, you know, you get seen to but in actual fact when you attend A&E, it may well be that you are exposed to five different waiting periods. You might have to wait for a ticket, you might have to wait for triage, you might have to wait for an X-ray, you might have to wait for treatment and you’ll probably have to wait to be discharged as well. Each of those waiting periods are not necessarily clear to people. It’s not… You know, they don’t feel in control of any of them. Their progression through this sort of process is not particularly clear and we wanted to make sure that that was really explicit.
BECKY ROWE
In addition to Martin’s point there, I think it’s worth mentioning that your experience at A&E is highly contingent on a number of factors – the seriousness of your injury, the method in which you arrive at the hospital, the urgency of your condition – and the differences in your experience aren’t always clear to an individual when you’re on that journey. So, you can see people receiving different kinds of treatment or different kinds of care than the kind of care that you’re experiencing and that can be incredibly frustrating and confusing and can lead to the individual feeling that they are being bypassed or forgotten or that they are not being taken seriously or, in fact, other people are taking advantages of weaknesses in the system. And that confusion and lack of clarity is one of the main point’s that’s been addressed in the design work of the team of PearsonLloyd through the better communication of different processes in A&E.
MARTIN BONTOFT
So, during the process of the work, what we tried to do was not only, you know, give clarity to all of the different findings but see if we could find ways in which we might cluster or group some of the things that we thought were important. We had a bit of a debate about the language. You know, even this morning Becky and I were still talking about the definition of a trigger.
BECKY ROWE
We’re always talking, us.
MARTIN BONTOFT
Yes, we’ll continue to do that but it was clear that there were quite a number of factors which seemed to escalate the situation and it seemed also that there were some of these factors that… You know, given the right sort of set of circumstances, the right kind of context, each of these escalating factors could become triggers, could actually tip people over the edge and make even the most reasonable people commit some violence or aggression. I mean, we’ve already kind of covered a few of them. This idea of lack of capacity, which might actually be because you don’t speak English, you know, you just don’t understand the process. It may be that there’s some underlying mental condition, it could be that drink, drugs, something like that that’s going on as well.
So, lack of capacity was a significant set of escalating factors. Another one was being required to do something without knowing or accepting that you had to do something. This would frequently in my analysis tip people over the edge. And, lastly, one of the significant triggers was when people were restrained, just the physical contact, which some… you know, in many cases was absolutely necessary for the protection of the person or the protection of the staff or the protection of other people within that waiting space.
CHRIS HOWROYD
[Inaudible from 00:24:42 to 00:25:07]. The first question relates very straightforward to your research in the hospitals and the relationship which you had and needed to develop with different line staff. How did they respond to you being there?
BECKY ROWE
That’s a really good question. Firstly, it took a great deal of preparation. Obviously the staff’s priority… All of the staff, either clinical staff or non-clinical staff, their priority is always in the treatment of patients and ensuring that they can do their jobs properly and it’s an incredibly busy environment and a very difficult environment to do research in. It took a lot of preparation to assure the staff of what we were going to do, what the research would entail and the staff were incredibly generous and supportive of the process but I think that is possibly because of how significant that they perceive the issue to be. So, the staff were very supportive. They allowed us access into all areas of A&E and overall we got to see kind of A&E through the perspective of the staff and I think without their help and support we wouldn’t have been able to do this process.
MARTIN BONTOFT
Yes, I mean, you know, to amplify that, we had incredible access to clinicians and to all areas of the Trust into which we… where we did the research. On the other hand, you know, the question was about the relationship with the staff. The staff were very positive in some respects. They wanted to see this issue being taken seriously but I think there was a… you know, an element of cynicism or scepticism about whether, in fact, anything could ever be done about this, partly reflecting, I think, some of their learned helplessness. You know, they’ve probably been around this cycle on a number of occasions and never… nothing has ever really happened significantly. And I think possibly also reflecting the fact that this is a systemic issue. There are many, many determinants of this and it’s complicated. It’s a social phenomenon as much as it’s a phenomenon of healthcare. The end result of that, I think, was that was a sense of accommodation to it. It was accepted that it was just part and parcel of being a modern clinician, which is sad but I guess it’s… you know, it’s a significant coping strategy for the clinicians.
CHRIS HOWROYD
And building on that, how much time did they have to invest in allowing you into the department in order to ensure that you collected the data which was necessary?
MARTIN BONTOFT
Certainly the way that… I suspect that we both ran the research in exactly the same way. We wanted to try and minimise the amount of impact that we would have, I mean, for obvious clinical reasons and we didn’t want people to be injured or treated any less well because we were there. So, you know, I mean, we were the proverbial flies on the wall.
BECKY ROWE
I would totally echo that. There was some time invested in the set-up and ensuring that staff were fully briefed. Not just the managers but also frontline staff knew who we were. Obviously you don’t want people wandering around the A&E department that are, you know, impostors or perceived as kind of evaluators. We weren’t there to evaluate the staff, we were there to try and understand their experiences and the patients’ experiences relating to a specific issue and I think time invested in briefing and ensuring we were identifiable was well worthwhile. It meant that the research could run smoothly and that we were able to get the sort of data that has led to these level of research findings.
CHRIS HOWROYD
Okay. We can take three other quick-fire questions. The next question is how does this research, if at all, relate to the provision of the QIPP agenda within the NHS at the moment?
MARTIN BONTOFT
That’s a really good question. I’m not sure I know enough about QIPP to be able to answer that, really. I mean, my understanding of… I mean, obviously the clinicians in the audience will have a much better understanding of what QIPP is all about. My understanding is it’s about effectiveness, it’s about bringing innovation to bear, you know, to smooth the passage of people through systems and to improve their experience as well. I mean, when we first started this work, QIPP wasn’t quite as… in the forefront of the clinicians’ minds as it is now.
So, I suspect that, you know, were we to do this work again, we could definitely provide input to QIPP processes much more effectively. I suspect that, although we haven’t covered it – PearsonLloyd’s design work will follow on from this at two o’clock – I suspect that an awful lot of their work is going to have… is going to provoke some innovations, is going to have some direct relevance for, you know, quicker processes and for reducing lull times, for improving the effectiveness of some aspects of the A&E system.
CHRIS HOWROYD
And the second question, what other forms of research did you draw upon to draw the design briefs together in addition to ethnography?
BECKY ROWE
That’s a very good question too. The ethnography built on a huge desk research project that was led by Catherine Pratt and Chris Howroyd of the Design Council. It was a really extensive piece of research that covered not just violence and aggression in the healthcare environment but also violence and aggression in related industries such as in Transport for London, in the prison sector and in many other industries. And that piece of work built on the work of academics, it built on the professional experiences of frontline staff, it was an incredibly thorough piece of research and that led to the way in which the ethnographic research was designed and formed a framework for the analysis process.
MARTIN BONTOFT
If the question is more about the analysis of the data, then, you know, that is a significant issue, I think. Very often when you’re doing ethnographic research within a design context it’s kind of considered that the data collection is by far and away, you know, the biggest task, if you like. In fact, in my experience, and I suspect Becky would agree, it is significant but it’s not the most significant. It’s really difficult sometimes to pull out the signal from all of the sometimes contradictory and conflicting information that you’re discovering when you’re doing ethnographic research.
So, you know, the process that we follow is kind of visible, it’s tangible, basically it’s writing everything down, usually on Post-Its. It’s finding an acre of white wall which the Design Council has in abundance and, you know, it’s getting that stuff up on the walls and it’s starting to work with it, starting to discuss it, to group it, to identify the themes, the patterns, whatever it is. It’s prototyping in a way. It’s prototyping, you know, kind of a consideration of the data and working out what it means. Extracting the signal from the noise.
CHRIS HOWROYD
Okay. And a much more practical question. How did you capture your observation? Did you use film, make notes, sound recorders? How did you enrich them?
MARTIN BONTOFT
I wasn’t allowed to use cameras, unfortunately, in my Trust but I would preferentially do that. You know, when… As a design researcher, using these sorts of techniques I find that perhaps these days my most important tool is my camera because it has video and still photography and will also record audio as well. So, you know, I would definitely want to use all of those sorts of things. I wasn’t able to in this particular context, no photography. So, for me it was just a notepad and a pencil.
BECKY ROWE
In the two Trusts that… where ESRO were doing the research, we used a huge variety of different data collection methods and we were allowed to take photos and we also had elements of both structured and unstructured data collection. One of the important things to note, that ethics is an incredibly important issue when doing any kind of research in a hospital environment or when you’re with more vulnerable people. So, the use of photographs and any video footage, we had to be very careful not to get any patients and to ensure that all…. any time we were taking photos that people were consenting, all of the people in the environment were consenting.
Research is a very big process and took quite a lot of time. Just to note, there was quite a significant element of structured data collection in this particular research project and all incidents were documented according to an incident data collection template so that we could have… so we can analyse the incidents consistently across all of the hospital sites and across different teams that were working on the project. So, there was… So, the short answer is, yes, we used sort of photos, a huge amount of notes but also very structured and unstructured data collection methods.
MARTIN BONTOFT
Okay. Brilliant. Well, some great questions there. I hope we’ll get some more towards the end of this. Just before we broke for questions, we were talking about these trigger clusters. We identified nine. There was one subsequently identified during the process of getting other feedback to this but let me just give you an example of what one of those clusters looks like. If we can produce the next slide... Here it is. So, here’s a trigger cluster. The theme is lack of progression and waiting times and if anybody has been to A&E in the UK, then you’ll kind of understand what this is. It’s really quite easy to empathise with.
Once you’re within the A&E system it can be very difficult to find out what’s happening and why. Decisions are clearly being taken that are going to have an effect on your experience and treatment but they’re rarely communicated. The sense of progression is not… you know, is… nobody seems to be really taking that into account. Nobody seems to be providing the information there. The wait seems longer because there is so little to do in these spaces and the facilities that are on offer in your average waiting space are meagre. Sometimes it’s difficult just to get a glass of water.
So, there’s all that going on, you know, waiting for long periods, but at the same time you have to stay awake, you have to stay aware of the system so that you don’t lose your place in it. So, this lack of progression is in a way compounded by the fact that you can’t relax and you have to stay on top of your game. There are also frequent disappointments. You know, other people will get called in front of you for good clinical reasons but sometimes that has an emotional impact, even though you can rationalise it for yourself. The major anxiety is that you’ve been forgotten or that you have made a mistake, you’re no longer in the queue somewhere, you’re going to look stupid and you’re going to feel stupid. That obviously compounds this. Bearing in mind also that, you know, you’re likely to be unwell or maybe anxious because you may be bleeding.
BECKY ROWE
So, I think, just to reinforce that point there, a few situations arise where you have to wait for such lengths of time without any sense of progression and that… and this trigger cluster has become particularly important when thinking about the design work. I think, when just taking one step back and thinking about the trigger clusters as a more macro set, it’s important to note that each of the individual escalating factors or triggers could affect different people differently. We’re not saying that each factor affects people in the same way. Different escalating factors have a different influence on different people and they work in a cumulative sense.
So, they can build up over time leading to a moment where your tolerance threshold or your ability to control your own behaviour is crossed and different people have different tolerance thresholds and alcohol and drugs can reduce your individual tolerance thresholds for violence and aggression. So, whilst the research strongly indicates that not all violence and aggression in A&E is conducted by people who have been drinking or under the influence of drugs, that is definitely a significant factor in reducing your threshold.
Possibly, just before we go into the detail of the other two trigger areas that we are going to discuss in more detail, it’s worth highlighting that there are actually nine trigger clusters of violence and aggression in total and we’re just going to… We don’t have time to talk through them all in detail today, so we’re just going to highlight some of the specific findings and some of the most influential findings on the design work. But in case you can’t read on your screen the tiny font that’s… of the posters there, I’m just going to read out the titles of the nine areas so you can get a sense of the breadth of the different triggers.
So, the first trigger is clash of people and that’s a reflection on the fact that many areas in A&E are crowded with a range of different sorts of people and they’re forced together by difficult circumstances. A&Es have people from all walks of life ranging from prisoners coming straight from prison right through to, you know, celebrities and VIPs who are in that environment. It’s incredibly stressful, the different mix of people, and throwing all of these different sorts of people can create a number of different stresses. As Martin highlighted, lack of progression is one of the escalating clusters that’s very important and has significant impact. We decided one of the areas is inhospitable environments and that’s the general feeling, that hospitals aren’t designed to be comfortable places. They’re full of sick people, they often aren’t pleasant to spend time in.
The fourth cluster is one we’ve called dehumanising environments and that’s reflecting that when people are in A&E they can feel out of sorts for a large number of reasons. Firstly they often may be suffering from an injury or an illness that is leading them to feel more stressed or anxious than normal and sometimes the way patients are managed can lead to a loss of perspective and they could behave in a way that they may not normally. Related to that, intense emotions is another trigger cluster and that’s the insight that A&E is a place where people may be experiencing all sorts of extreme life events, suffering pain or stress or having to witness how other people are coping or, indeed, not coping with their own stressful experiences. A&E really is a place of kind of life and death and there’s a… people undergo enormous stress in those environments and witnessing other people undergoing enormous stress and that can be contrasted in a way to the staff experience.
Martin, you might want to iterate this. The staff, they’re very used to this kind of intense working environment and the difference between how an individual who is perhaps in that environment, it’s the most serious thing that’s happened to them in their week, their month, their year, even their life and the staff, they deal with it on a day-to-day basis. So, there’s sometimes a mismatch between the way in which staff and patients behave.
Perceived inefficiency is another one of the trigger clusters and that’s relating to the sense that the space is disorganised or lacking focus. There’s also… One of the trigger is called inconsistent response to bad behaviour. That’s related to the way in which rules and regulations are applied or inconsistently applied, for example around smoking or use of mobile phones. And, finally, Martin’s spoken about this earlier on and that’s staff fatigue. It’s a real issue and working in an A&E department is highly demanding on staff. Many people work 12-hour shifts and fatigue can… [silence from 00:42:00 to 00:42:08] and, in fact, have the energy to deal with the constant flow of patients that are arriving through the A&E environment.
MARTIN BONTOFT
Yes. I mean, 12 hours is a long, long time and at busy times of the year, you know, it’s perhaps too long for many clinicians, given that they have not only… you know, they’ve got all their clinical work to do but they’ve also got significant management responsibilities for all the people that are coming through, that emotional management. So, there’s a lot for these people to do. I think we’ve covered most of the trigger clusters and maybe we’ll get some questions about those later.
BECKY ROWE
Martin, would you like to go through the detail of inhospitable environments or…?
MARTIN BONTOFT
Yes, let me try and do that then. So, one of the… I mean, one of the findings about A&E environments, the waiting area and indeed the clinical areas, is that most of the comments about them are quite negative. There are very few positive distractions in these sorts of places. There are very few, you know, positive ways in which you can actually use your time and consequently the waiting time seems much more… well, it just hangs heavy.
Becky mentioned about, you know, the complex and daunting nature of some of the processes that go on in the clinical spaces, you know, where there’s… there could be bodily fluids splashing around and there could be a significant number of activities going on which are completely outside of people’s normal experience but, on the other hand, of course, for staff it’s routine.
So, you know, one can get the sense of environments that are perhaps designed around a set of needs, clinical needs, perhaps not as much around the sort of experience of use. In other words, you know, for good reasons the clinical needs are first and foremost in the design of these spaces. Perhaps one of the things that we might suggest, and I think, you know, PearsonLloyd have picked this up in their work, is that actually there needs to be a slightly better balance between the experiential needs of people as well.
BECKY ROWE
So, the third trigger cluster that we wanted to take you through in a little bit more detail is about perceived inefficiency and actually perceived inefficiency is one of the areas that very rarely get brought u in incident report data. It’s a very good example of the sort of data that ethnographic research can yield and how that contrasts with other data sources and what we mean by perceived… What do we mean by perceived inefficiency? Well, we mean that from a patient’s perspective it can sometimes feel like staff in A&E environments are disorganised and lacking focus. I very much mean perceived here that patients often observe themselves and others seemingly waiting for others.
They can’t understand the causes of the wait. The causes of the wait are often not explained to them and while staff… And this is all while they perceive that staff are busying themselves with non-essential tasks such as answering the phone or filling in paperwork. When you start to understand the reasons why staff are answering the phone or filling in paperwork, you realise how important and integral they are to the care of patients. However, from… when you look through the patients’ eyes, those things can be perceived as inefficient. Why is the doctor or the consultant sitting there for seemingly hours on end filling in paperwork when I’m sitting here and I haven’t been seen as a patient and then often those kind of actions/behaviours aren’t explained to patients and can all lead to this sense of disorganisation and inefficiency.
MARTIN BONTOFT
The other thing to add to this is it’s not perceived inefficiency, I think there are inefficiencies within this system and, of course, people do spot them. I mean, I remember watching a nurse looking for 20 minutes to find a neck collar. I saw a senior consultant, a senior clinician, wandering across the hospital to try and find a ream of A4 paper. You know, I saw people trying to find important bits of kit on trolleys because they’ve been moved. I mean, on one level, of course, that’s simply an artefact of the complexity of everything that’s going on but it does mean that, you know, perhaps a focus on some of the components of the system would be… I mean, just things that would help people to get things together and keep them together, the right place for everything, might actually reduce some of these inefficiencies.
BECKY ROWE
It’s important to remember here that these triggers are cumulative and not necessarily triggers in their own right. For example, a staff member sharing a moment of humour with another member of staff, it might be their birthday, for example, or someone might just almost have picked up a very kind of natural and instinctive reaction to working well with your colleagues, could in itself be a trigger for a patient to feel more anxious or aggressive and that’s not to say that we’re not… we want staff to not work well together and to not enjoy their work, it’s more about thinking about the whole system of different escalating factors and how they might cause violence and aggression in patients.
MARTIN BONTOFT
Right. So, we want to make sure we’ve got plenty of time for questions at the end of this now, so I’ll just… I’ll go through this section a little bit more quickly. Basically what we’ve described is a whole series of activities, to collect data and then also to kind of pass that data and try and understand what it’s telling us. That’s not sufficient, however. What we also needed to do was contextualise that information, get other inputs from other stakeholders that we hadn’t had the time and the ability to do during the research phase. So, we had a whole tranche of work which is from this point on let’s try and understand what these other perspectives are, let’s use those in order to focus down on something that we call design briefs that we could then offer to the successful winner of a design competition, and you’ll be hearing from those a little bit later today.
So, this process then of getting to the design briefs was about researching, looking at the research evidence, challenging it and validating. We had two external groups of people that would help us to do that. The first was a group we called the expert reference group, academics, senior clinicians, people from other walks of life, architects, who came and gave their perspectives on what we’d done and really helped us to understand whether we were on the right sort of lines, whether this harmonised or, you know, kind of resonated with what they already knew, provided us with a kind of a check, did we cover everything. In fact, there was a slight omission from the research work that we covered and we actually developed a further cluster of escalating factors as a result of that.
Following on from the expert reference group then we had another group of people meet, an advisory board. Again, a whole series of, you know, significant people from lots of walks of life who looked at what we’d done. By this stage we’d collected… we’d created about 30 potential design briefs and what they helped us to do was scrunch down, group these, understand what… you know, how to prioritise them, which ones were more significant or, you know, in terms of the research evidence were strongly supportive of them or perhaps more significant in the sense that actually if you do this, you’re going to deal with a lot of the issue. It’s going to have a significantly leveraged effect. So, when we did that we went through the 31 design briefs and created… grouped them into six design challenges and these are the ones that have been published on the Design Council website. They were the focus of the design competition. We had… I think Chris had something like more than 40…
CHRIS HOWROYD
47.
MARTIN BONTOFT
…47 entrants to that design competition and, you know, some extremely good work in that. PearsonLloyd was the organisation that won that. We are going to be talking about their work at two o’clock. But that’s kind of the process that we follow. Should we ask for more questions, Chris?
CHRIS HOWROYD
By all means. We have a list here. I’m going to start off with one about evaluation. How do you evaluate the output of your work prior to and not relating the qualitative design solutions which the design team have developed?
BECKY ROWE
That’s a really good question. One of the ways that we evaluated our work was by working in partnership, firstly, with the Trusts. We involved them throughout and they validated and evaluated our research findings and ensured that they fitted with their experience. Separate to that we also took our research findings to a much wider audience from a range of different hospitals.
The ethnographic research was focussed in three specific partner Trusts who worked very closely with us. It was also important for us to get validation and challenge from other hospitals who weren’t involved in our research. It was very important to us from the outset that the research was not simply anchored in only the hospitals that took part in the research. It needed to be generalisable to a much wider group of hospitals and experience so the design solutions could be applied right across the estate.
CHRIS HOWROYD
Great. Two very specific stat-led questions. The first is related to the perpetrator profiles. Did you see one more frequently than the others?
MARTIN BONTOFT
Gosh, did we? No, I don’t think we did. I mean, bear in mind these profiles, we have to use them in a fairly sophisticated way. We can’t afford to assume that a particular person is one of the perpetrator profiles for anything other than a fleeting moment, really. What we were trying to do with these profiles was not stereotype individuals, you know, not characterise them as being this sort of person exclusively but really use them as a way of reminding ourselves that there was a variety of people involved, so they brought all kinds of stuff, you know, baggage/attitudes/expectations/beliefs into this sphere.
BECKY ROWE
Yes, I totally validate that, Martin. We should definitely see them as a tool to… and a set of different lenses from which to view violence and aggression rather than specific sets of different people.
CHRIS HOWROYD
A very similar question but in relation to the cluster or the trigger clusters which you developed. Was there a particular trigger cluster which drove more incidents?
MARTIN BONTOFT
You know, I kind of touched on this a little bit. Certainly this lack of capacity was an issue in the incidents that I recorded. There’s a whole series of things about that. I mean, people would come in on drink and drugs and sometimes with an underlying mental health condition. That rendered them not only in… you know, their better behaviour was inhibited but it also meant that it was extremely difficult to reason with them. So, that would exacerbate situations quite considerably. The other, I think, major effect was time of day. You know, it is not unreasonable to expect that when it gets to two in the morning, you’ve been waiting for four hours, there’s no end in sight to this wait period and you’ve just perceived that there actually seem to be fewer staff working, which is often the case, I guess, at two o’clock in the morning, it’s not surprising that people do sometimes kick up in a certain sense.
BECKY ROWE
And from my perspective, I think all of the trigger clusters are kind of interrelated and cumulative and they have a different impact on different sorts of people. So, one person… one trigger may be… or one escalator may be more important than another. I think the thing that compounds all of the different trigger clusters is waiting time and the experience of waiting. I think that’s one of the reasons why the design team very sensibly chose to focus on the waiting experience. That is a compounding factor and it underlines absolutely everything else in the A&E, partly because you’re just there for longer, so more things have a chance to impact on your experience. The longer you’re there, the more other escalators you’re likely to experience, the more… So, if I was to highlight one particular trigger cluster, I’d say waiting experience and quality of the waiting experience has been the most significant.
CHRIS HOWROYD
Okay. We have a question about how ethnographic research can help pursue an evidence-based design philosophy.
MARTIN BONTOFT
An evidence-based design philosophy.
CHRIS HOWROYD
Yes, that’s right. So, how can it help inform better design?
MARTIN BONTOFT
Well, I mean, the… I think it would be hard to conceive of a situation in which you could fail to do that, really. Do you know what I mean? It’s… I mean, the design… Well, I’m going to try hard not to get too philosophical about design here. Design for me is kind of a… is a necessary process, clearly, but it’s one where you go through two distinct phases, I think, of firstly divergent work where, you know, what you need to know is more about everything, connected with this area of endeavour.
Ethnography is a significant component in that. It’s not the only one. It’s not the only process of design or a design researcher would follow but it is in many circumstances the most productive. It also… I mean, it also helps you in that follow-on phase where once you’ve gone divergent you need to really kind of focus on… you know, focus down, be more convergent on a discreet set of opportunities that appear to offer the best response to the problems that you’ve identified and I think, you know, ethnography has a role to play in that as well.
I mean, taking all of that into account, I mean, in modern design it’s very much about stakeholder management. What I mean by that is that there will be many, many people who will have a role to play in the development of a successful outcome. Each of those people will have… will approach this design process with their own evidence, with their own information, their own hunches and attitudes and clearly a designer has to have evidence at his or her disposal to be able to, you know, make sure that their voice is heard and, you know, in complex situations clearly that’s going to be absolutely essential.
BECKY ROWE
I know we’re running out of time but just very briefly my perspective on that question would be that ethnography provides a really invaluable tool to see the world through the eyes of those you study. It enables you to pick up on the details that other research methods may miss and ultimately challenge some of the dominant orthodoxy and assumptions that may exist around a topic area. So, without doing this kind of ethnographic research, often the responses are… can address an issue very head-on, in a very kind of direct way. Ethnography enables you to see the other influencing factors and reasons for behaviour that are not possible via surveys or focus groups or analysing incident data, for example, and I hope the findings that we’ve outlined today and that are included in the report illustrate that.
CHRIS HOWROYD
Why do you think the NHS never seem to use research to understand the patient experience in different operational contexts?
MARTIN BONTOFT
Well, I don’t… I’m not sure I’d agree with that premise. I think they do. I think the issue is that it’s very, very complex. I mean, this is a systemic issue. There are, as our work has uncovered, many, many determinants of bad behaviour in A&E, just as there are in other areas of healthcare provision. So, I think it’s not that people fail to take notice of this, I think it’s sometimes that the projects need to be framed broadly enough, as this particular project is, that something can be achieved, that you can actually do the… you have enough of the system within your overview that you can make a significant difference and not just mess around around the edges.
CHRIS HOWROYD
But you believe that there is a trend that the NHS is taking more notice of ethnographic techniques.
MARTIN BONTOFT
Undeniably, I think. Certainly in my experience I think that’s absolutely the case but…
BECKY ROWE
And I would echo that in our experience as well.
MARTIN BONTOFT
Perhaps more importantly than that, they’re taking more regard of design and the design process of which ethnography is a component. I think they’re seeking to become much more innovative. They always were innovative but I think they’re seeking to become better managers of innovation and better implementors of innovation and obviously design, through prototyping… through research all the way through to prototyping has a role to play in that. As I say, I think sometimes what we fail to acknowledge as designers is that, you know, it is a very systemic area of work and one has to make sure that you’re doing this work with due regard to all of the different stakeholders who have a role to play in this work. In this particular project we were able to do that. It was configured in that way. Not all projects are completely… do quite as well.
CHRIS HOWROYD
Okay. And to round off a rather holistic question. Do you think this problem can be resolved through situational prevention and redesign of the physical environment?
BECKY ROWE
Well, I think it’s important to note that antisocial people will always be antisocial people and that’s a societal issue, that’s a policy issue, that’s a much wider issue than this particular project can tackle. If someone comes into A&E hell-bent on causing a fuss or assaulting a staff member, then there’s very little that design can do to solve that problem. However, there are many other… The research clearly indicates there are many other triggers of violence and aggression in A&E that design can absolutely have an impact on. Unfortunately there’s no one thing that will make… There’s no golden bullet in this sense.
There’s a lot of different practices that need to be taken into account and over time those… addressing all of those issues will definitely in my view make an impact on the issues of violence and aggression. So, for example, right through… a person’s experience could be influenced right through from the car park to their discharge experience and actually thinking right through all of those different issues is going to make an enormous difference. If you can’t find how to get into A&E when you first arrive, you’re going to arrive feeling quite frustrated and anxious already and the notion of… that one simple design solution will make all the differences is too simplistic in my view. It’s a holistic issue and it’s complex and a lot of work needs to be done on a lot of different practices in order to reduce the number of incidents that we’ve seen.
CHRIS HOWROYD
Thank you, Becky and Martin. Just a reminder that this webinar will be available to you again and you can listen again at the Design Council website. Please do join us for the remaining webinar session today at 2 p.m., the design solutions. Thank you for your time. I trust you found this session interesting and thought-provoking.