Life on the frontline

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:

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.