Over the past decade, the NHS has sought to become a more patient-centred healthcare provider. Implementing this cultural change is an ongoing process. First-time visitors to A&E still encounter a complex system – and human contact remains the best way to guide, help and reassure them. This human contact provides the interface between service users and the healthcare system, and can be considered to be the ‘customer service’ that they experience.
However, the frontline staff providing this service may be subject to many systemic factors which impede their ability to deliver a patient- or service user-focused service, such as understaffing or time constraints. This may also be exacerbated by continuous negative feedback and abuse from those using the A&E service.
Opportunity
The NHS Constitution cites compassion, dignity and respect among its core values. The realities of working 12-hour shifts in a pressured and stressful environment, however, will inevitably have an impact upon the ability of staff to uphold these values. Indeed, ethnographic research conducted as part of this project identified staff fatigue as one of the key triggers for patient and service user aggression. Staff fatigue is inevitable, so there is an opportunity to explore how the system can mitigate its effects. The proposed design solutions should provide the necessary support to ensure that good ‘customer service’ is delivered throughout, and be able to withstand the stresses and strains of working in an A&E department.
Approach
The design team recognised that staff, patients and other service users are typically well meaning and emotionally tolerant, but that emotions commonly experienced in A&E, such as frustration, anxiety, fear, pain and loss, can all reduce these tolerance thresholds for both staff and patients.
This design output centred on a programme to engage staff and work with them to ensure the departmental culture is one of dignity and respect. The designers focused on how to attend to the relationships and interactions among and between every person involved in A&E.
The People project aims to promote staff engagement, boost morale and reduce staff absenteeism to enable staff to become advocates of change. The goal is to help individuals and the department as a whole to understand, learn and improve ways of handling aggression and violence, while maintaining levels of compassion and empathy, and sustaining this into the future.
Design solutions
A two-pronged solution was proposed. The first was an induction pack for staff new to A&E, and the other was a system for more established staff members to promote reflection on managing violence and aggression.
Induction pack
The induction pack was designed to help individuals joining the department understand the culture of the hospital they are entering. This pack would need be developed with the A&E department to tailor it to their needs and dovetail it into their existing induction processes. It could contain information on patient types likely to become aggressive or violent, guidance on how best to respond, and indicate ‘flashpoint’ times when aggression is most likely to occur.
Current working patterns within A&E also support the concept of an induction pack. While all staff working in an A&E department should receive training to develop the necessary skills, there are many staff who may regularly work within the department but do not qualify for training. At university hospitals, for example, there are also many trainee nurses and junior medics in the department who may be there for only a few months at a time and therefore miss out on training. The induction pack therefore helps to resolve this problem, so that all staff have the requisite knowledge.
Reflective programme
For long-term staff a reflective programme was proposed that encourages staff to notice incident levels, discuss and reflect on their experiences, and give feedback to management on their recommendations for improvement. The design team proposed an 8-week programme, consisting of 8–10 people and conducted twice a year. During the programme, they recommend that participants – representing a vertical cross-section of staff across the A&E department – meet once a week for an hour.
1. Observation
Noticing incident levels is important in helping staff understand the potential perpetrators of violence and aggression and to reflect on the reasons for this behaviour. This enables tools and procedures to be developed to proactively respond, and help prevent or mitigate against violence and aggression.
The design team have developed a ‘noticing pack’, which is a series of posters for staff to customise. Each week, a poster would be put up in the staff room to establish where the aggression and violence lies within a set of parameters. Staff would then make a mark in the appropriate place every time they experience aggression or violence – and a isual map would gradually develop of the spread of incidents. Each week, these parameters would be changed and different variables noticed. This information would help to shine a spotlight on the issue of violence and aggression within the department, so that staff can become aware of where, when and from whom it is occurring.
2. Discussion
This observation work then feeds into a weekly discussion forum, where staff can reflect upon their experiences, and deal with the day-to-day problems of working in this environment, as well as how to respond to the findings they have collected. It would need to be conducted by an external facilitator who is able to question and confront the issues at hand.
Discussing these problems as a group is important as it facilitates learning from other people’s experiences and then enables everyone to proactively deal with the issues as a group, as well as feeling less isolated in dealing with these experiences. A similar initiative in the USA found that staff were able to better respond to patients’ social and emotional needs and improve their interactions with patients and other staff, while feeling less stressed and isolated. Initially, the discussion forum would focus on the results from the noticing pack. Staff could then move on to explore how these findings can be used proactively to prevent violence and aggression occurring in future.
The design team felt that it was essential for the findings from these observations and discussions to be reported back to senior management, with any recommendations for changes that can be implemented. This way, positive changes can occur within the department and the group will feel that there is a purpose to the work. These insights can also be fed back into the induction pack, creating a positive feedback loop and ensuring that any new learnings are passed on to other members of staff.