Good designers spend time with the end-users of the products and services they create and involve them in the process of designing and making. They will often conduct ethnographic research to understand what it is that people actually need and want, rather than make assumptions. Through this process, designers often uncover latent as well as known needs. This ensures the products and services that are eventually created are useful, useable and desirable.
There is good data available from a number of sources about the number of reported incidents of violence and aggression that occur in A&E departments. However, through desk research conducted by the Design Council for the Reducing violence and aggression in A&E programme, a need was highlighted for primary research to provide detailed evidence relating to the specific triggers and drivers of violence and aggression, and the detail of incidents in A&E.
Ethnographic research was conducted in three core hospital Trusts: Guy’s and St Thomas’ NHS Foundation Trust, Chesterfield Royal Hospital NHS Foundation Trust and Southampton University Hospitals NHS Trust. Cumulatively, over 300 hours of observation were conducted during some of the busiest times for the departments, when violence and aggression are most prevalent, including the Friday and Saturday nights leading up to Christmas and New Year’s Eve.
Across the research sites, a huge amount of data was collected:
- 300 hours of observational data
- Over 60 staff and patient interviews
- Over 80 documented incidents of violence and aggression
Conventional research techniques such as focus groups or questionnaires can tell you what people think they do. But ethnographic research techniques provide evidence of what people really think and do. Observation, listening to people's stories in group discussions, contextual and behavioural analysis provide detailed portraits of real people’s experiences which explain the cultural factors that influence and shape their behaviours.
Ethnographic research is a qualitative research method that allows researchers to investigate an issue in context. Rooted firmly in behavioural science, ethnography allows researchers to gain insight into complex issues: moving beyond what people say they do to what they really do.
Key research findings
For the Reducing violence and aggression in A&E programme, an ethnographic research team of ESRO and Martin Bontoft Ltd conducted several hundred hours of interviews with a wide range of NHS staff, as well as patients and their friends and family, the police, mental health experts and A&E design experts. They produced this film of interviews with staff about the issue of violence and aggression in A&E.
Reducing violence and aggression in A&E by design from Design Council on Vimeo.
Accident and Emergency departments are immensely complex, defined by unpredictable workloads and diverse clientele. Patient journeys vary across different A&E departments, and within a given site patient experience can be extremely variable – dependent upon arrival method e.g. ambulance or ‘walk-in’ and the severity of the
But while the people and conditions seen by A&E staff are inherently diverse, most patients are united by the belief that their condition is both urgent and important. This is often accompanied by feelings of anxiety, stress and discomfort – and compounded by the fact that attendance is, for the patient at least, likely to coincide with an unusual life-occurrence and deviation from routine. It should not be forgotten that, for some patients and visitors, a trip to A&E could be associated with a serious event which could change their life forever.
Violence and aggression in A&E is typically reported in the media as being related to alcohol or drugs. While the ethnographic research teams did observe many incidents where these factors were implicated, the reality is far more complex and the findings of this project highlight the diversity of incidents – ranging from relatively infrequent assaults and serious injury to daily occurrences of verbal abuse, confrontation and hostility. It is important to note that many of the lower-level incidents observed went unreported, with staff seemingly acclimatised to what they considered fairly commonplace, disrespectful and rude behaviour.
Violence and aggression in A&E is affected by a number of different variables including:-
- Individual characteristics (e.g. intoxication, mental health, propensity to violence, propensity to anger or antisocial behaviour etc.)
- Needs and motivations (both medical and non-medical needs)
- Triggers and escalators of violence and aggression (including environmental, procedural, social and emotional factors)
- Emotional state and individual tolerance thresholds
Violence and aggression in A&E is more commonplace than is represented in the official figures due to low levels of staff reporting, especially for less serious incidents. Staff regularly put up with hostility, verbal abuse and confrontation – and less frequently, but no less importantly, are subjected to assault and physical abuse.
Few would disagree with the importance of protecting staff working in Accident and Emergency departments from violence and aggression. However, the complexity of the issue means that solutions may not be straightforward. Perpetrators of violence and aggression exhibit a diverse range of behaviours, although it is worth reiterating that almost all attenders to A&E are united by the dual goals of wanting appropriate care and attention and to be seen as quickly as possible.
Triggers and escalators of violence and aggression are numerous and found throughout the patient journey and the physical environment. Individual triggers rarely provoke violence and aggression in isolation; instead they work together, building up to a crescendo of emotion which can tip an individual over their own threshold of acceptable conduct.
In order to make any significant impact on the number of incidents, designers will need to think about A&E both in a holistic way, including a consideration of A&E’s place within the wider healthcare context, and by paying attention to specific and local details.
All research findings were presented to a group of experts with experience in A&E, healthcare design or violence and aggression in other sectors who processed, validated and refined the research findings and insights into a set of design briefs which identify opportunities for designers to help develop solutions to issues in different emergency departments.