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Life on the frontline

We're all familiar with A&E Departments, less so with what colours our perceptions and what could improve them. Becky Rowe, though, can provide some answers.

The topic of this year's winning Prosper Riley-Smith Research Effectiveness Award is an unusual one. Becky Rowe and her team at ESRO won a tender against nine other agencies to understand the precise nature and causes of incidents in A&E departments.

It's a big problem for the NHS: nearly 55,000 violent incidents are now being recorded in A&E each year. NHS staff are at risk, and it's costing the taxpayer. A Panorama investigation in 2007 put it at over £100m annually, equating to the salaries of 4,500 nurses.

Seeking design aid

The scale of the problem prompted the Department of Health to team up with the Design Council and launch a National Design Challenge, hoping that design might unearth innovative, cost-effective and easily implementable solutions. But first they needed to know the root causes of these incidents, and this is where Becky came in.

ESRO is no stranger to the public sector, 60% of its work stems from there, and as Becky pointed out, those in the company are passionate about complex issues. This, however, proved a stiff challenge. To respond to it, the company designed a detailed behavioural insight project focusing on two of the country's most "violent" A&Es.

It immersed itself in data from past incidents, but put these in context by complementing them with staff testimony, recognising the need to discover the behavioural triggers to aggression that CCTV footage and retrospective eye witness testimony couldn't give.

It also built in an ethnographic component, with the team staying in A&E for two unbroken five-day periods, including peak "Christmas Party Friday" and New Year's Eve, working 12-hour shifts night and day. The result was not just a wealth of material, says Becky, but the forging of friendships with staff who recognised the team's commitment to the project.

Throughout, the team systematically mapped patient and staff experiences of violence and aggression using a mix of structured and unstructured observation, thoroughly documenting and analysing the behavioural and emotional landscape. The work comprised:

  • 80 patient and 50 staff member interviews
  • Observing over 300 hours of hospital life
  • Studies of 30 past incidents
  • Documenting 60 new incidents

Using all of this (but without any film or photographic material featuring patients), they expressed the detailed behavioural observation in computer-generated 3D "behaviour maps". These overlaid the environmental triggers associated with aggressive behaviour on the realworld physical spaces where the fieldwork took place. The result? Insight into a complex phenomenon, and a platform from which to make informed decisions about which behaviours could most effectively be addressed through better design.

For instance, it became clear that certain "legendary" events had, over time, become inadvertently misremembered by staff. Immersive fieldwork, meanwhile, built up a picture of staff under pressure, not least because of the unpredictable nature of their workload. Patients found time in A&E equally fraught, experiencing pain, discomfort, fear and anxiety.

The team actually saw few acts of physical aggression overall, but did witness countless incidents of "low level hostility": rudeness, swearing, finger-pointing and shouting. It discovered how stress and anxiety, coupled with over 80 environmental and behavioural triggers, could make aggressors of otherwise peaceful patients.

This is where the 3D "behavioural maps" came into their own. They could depict areas familiar to staff, and map on to them triggers that had been identified. This, in turn, helped them to understand the root causes of some incidents that had previously foxed them. The maps thus facilitated far more constructive conversations, helping to park intractable issues and focus on those about which something could be done.

Top tips

So what, I asked Becky, were her three top tips for researchers that came out of this project? The response came as follows:

"Consider who you are communicating with when creating deliverables, there are always ways to make them punchy and get them to work even harder.

Always appreciate how hard people, particularly frontline staff, are really working. Appreciate, too, the effort they are putting into helping you research and what a sacrifice this can sometimes be. By investing your time and effort into understanding their experiences you can unlock more doors. In this project, it ultimately meant that the data was far more robust and more compelling. So devote time to building relationships.

Build in time for analysis, and be organised and ruthless about how you manage the data. There's a case for being as ruthless about what you include as what you exclude. The process of analysis is both an art and a science, and a really underrated skill.

Researchers don't just hang out with people, really good researchers understand the importance of robust and credible data, and are able to pull all that together and synthesise it in a clear and easily digestible way that will take clients and the target audience forwards to the next level. You have to go from the complexity and overwhelming nature of the real world and synthesise it down to a clear and actionable headlines that can help the client to move on."

The insights framework sat at the core of the ensuing year-long development process. It resulted in a suite of design solutions, including a toolkit, distributed to every NHS A&E department in the UK, and covering all aspects of improving the A&E experience.

The most significant innovation — and one which has been warmly welcomed by staff — has been a low cost new communication system informing patients what to expect and where they are in the process.

 

Louella Miles
Copyright © Association for Qualitative Research, 2013