Anger management: reducing violence in A&E

Violence and aggression present serious problems for the NHS. Hospital staff experience more than 150 incidents a day, approximately 20% of them in accident and emergency (A&E), and the estimated annual bill exceeds £69 million, though this does not account for the impact of such behaviour on staff. Turnover is high, money spent on training often goes to waste and sickness rates are costly.

In 2011, the Design Council, working in partnership with the Department of Health, ran a UK-wide open innovation competition to produce design-led improvements to A&E environments, systems and services, so that the likelihood of violence and aggression occurring is reduced.

Understanding the issue

There is a lack of official data detailing levels of violence specifically within A&E departments, but it is clear that such abuse occurs frequently. Violence and aggression is particularly prevalent in A&E departments because they are especially complex, high-pressured and unpredictable environments. It is common to hear staff say that "no day in A&E is ever the same".

In order to understand the issue, the Design Council commissioned two ethnographic research companies to spend more than 300 hours in NHS Trust A&E departments, looking at how they worked from a user's perspective. By working with experts, including managers and staff at three trusts, emergency care specialists and organisational consultants, researchers developed a clear picture of the issues faced by front-line staff.

This research led to the identification of six perpetrator characteristics pertaining to individuals who commit acts of aggression or violence: clinically confused, frustrated, intoxicated, antisocial/angry, distressed/frightened and socially isolated.

Beyond individual characteristics that may make an individual more or less likely to be violent or aggressive, the research agencies documented a huge number of escalators of violence and aggression. These were grouped into nine separate triggers, but are typically experienced in tandem:

• clash of people
• waiting times/lack of progression
• inhospitable environments
• dehumanising environments
• intense emotions in a busy space
• unsafe environments
• perceived inefficiency
• inconsistent response to 'undesirable' behaviour
• staff fatigue.

While it is widely known that some individuals, such as those with mental health problems, or under the influence of alcohol or other substances, are more likely to behave aggressively and violently than others, the research also suggested that nearly 50% of all incidents come from patients who are sober and that flare-ups were as likely to occur from visitors accompanying the patient as the patients themselves.

A&E patients are often in pain and the visitors that accompany them are understandably worried about their condition. This mix of pain and worry can alter people's behaviour, perhaps reducing their tolerance levels and making them more likely to behave aggressively.

The ethnographic and desk research highlighted the significant potential for designers to improve the experience of A&E and make departments safer.

National design challenge

Insights and findings from this research alongside workshops with staff and patients led to the identification of design briefs, which were issued to the UK design community through a national competition, allowing teams to propose innovative yet practical approaches to help reduce violence and aggression in A&E departments. Their responses could include new systems, processes, interior layouts, furniture, equipment, communications and/or services.

The winning team was a UK-based multidisciplinary consortium led by design studio PearsonLloyd, comprising some of the country's most respected designers, researchers, evaluation consultants, senior clinicians and social scientists. They were awarded a modest research and development grant to develop practical, cost-effective solutions that could be easily retrofitted into existing NHS A&E departments.

Over a four-month period, the team was supported by an independent advisory board made up of senior health, industry and education stakeholders, who were convened by the Design Council to offer the team strategic guidance. In addition, the team worked closely with three partner NHS Trusts to research, develop and refine their concepts.

The ideal patient experience

By breaking down the different key stages of a typical patient journey through A&E, the team was able to create an ideal patient experience, which would help to inform eventual solutions.

For the team, this period of discovery resulted in them taking a holistic approach to the issue of violence and aggression in A&E. This led them to distil the challenge ahead into four overarching themes:

• the arrival experience - creating positive first impressions and managing expectations for patients and other service-users
• the waiting experience - how to successfully intervene before frustrations accumulate
• guidance - providing information to patients and other service-users to alleviate the stress of the unknown
• people - building a healthy mutual relationship between the user and the system.

The team investigated each of these themes in greater detail to understand how they currently work in A&E departments. This enabled them to identify every possible opportunity for their design solutions to help reduce violence and aggression, and also helped them to understand that the solutions would have to work under certain constraints. Specifically, the solutions would need to be implementable, non-trust specific, retrofittable, flexible and affordable.

The team's solutions distilled the four theme areas into three distinct outputs: guidance, people and toolkit.
Computer models, mock-ups and initial prototypes were used to test ideas in real A&E departments and get feedback from staff and patients. This helped in developing the concepts further and establishing criteria for evaluating the success of their final solutions.

The solutions

Solution 1: Guidance

Many people become frustrated with the A&E service because of a lack of clear, effective information and guidance. This increases their anxiety and has the potential to develop into aggressive or violent episodes.

The primary design output therefore focused on a guidance package that communicates essential information to the patients and other service-users arriving at A&E, containing generic information relating to the process for receiving treatment, and live information relating to the status of the department and waiting times.

The recognition that static, fixed information presented the best opportunity for conveying basic information to patients and other service-users in A&E led to the design team developing the concept of the 'slice'. A narrow vertical slice in each space would be modified to contain all the information relevant to the user at that stage in the treatment process, and become the recognised communication point for patients throughout the department. This meant that rather than redesigning the whole department, or refitting each and every room, a 'slice' could be inserted, which would gently guide the patient or other service-user along their journey through A&E.

The 'slices' themselves were envisaged as starting outside the building in the car park, and then continuing inside throughout the department. A handful of standard-sized wall panels were designed which could be used anywhere within A&E; a ceiling panel was also incorporated for patients arriving on stretchers.

To accompany the 'slices', a process map was developed, which became the core of the communication language. This illustrated the patient journey as a series of steps moving towards the goal of treatment, with a pause (or wait) before moving onto each step. The steps were categorised into the four larger stages of check-in, assessment, treatment and outcome (or further treatment).

The process map is intended to be displayed on a wall in the waiting room, but the information should also be available in a portable format as a patient leaflet.

Print information is ideal for communicating the basic static information about the department, but a digital information stream is also necessary to communicate live information. The digital content builds on the visual language established in the print information.

Using the existing data stored in software systems already used by A&E departments enables the updating to
be done automatically and regularly; it can also provide more accurate and relevant information. As a solution that could be immediately implemented (subject to the A&E department having the right software), this was developed for the project.

In addition to the live information screen, the design team also identified the potential benefits of installing a touchscreen facility. In particular, a barcode-enabled touchscreen can enable patients to access their own records and view the waiting times particular to their own personal treatment. The touchscreens could also display information in multiple languages, and provide an audio channel for those with impaired vision.

Solution 2: People

Over the past decade, the NHS has sought to become a more patient-centric 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.

The front-line staff providing this service, however, may be subject to many systemic factors that 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.

A two-pronged solution was proposed. The first was an induction pack for staff new to A&E, designed to help individuals joining the department to understand the culture of the hospital they are entering. The other proposal took the form of a system for more established staff members to promote reflection on managing problems when they arise.

For long-term staff, a reflective programme was put forward that encourages staff to notice incident levels, discuss and reflect on their experiences, and provide management with feedback on their recommendations for improvement. The design team proposed an eight-week programme, consisting of eight to ten people and conducted twice a year.

Solution 3: Design toolkit

Instead of redesigning just one specific waiting room or department, the designers worked on producing guidance to inspire and enable NHS Trusts to implement these changes and improve safety within their A&E departments.

The toolkit is a guidance document that compiles all the high-level design recommendations that can help to reduce aggression and violence in A&E. These are not design solutions in themselves, but may be specifications or service changes.

The toolkit breaks the patient journey down into its different stages of the A&E process and presents case studies of best practice that are in place at other NHS Trusts. It is intended to be used by all NHS staff, while also providing a reference source for architects or interior designers working on newbuild projects.

Where next?

A new facility at Barts Health NHS Trust at Newham University Hospital in London opened to the public on 18 May 2013, and is the first in the UK with PearsonLloyd's new 'guidance system' in place.

The same innovations will be implemented at University Hospital Southampton NHS Foundation Trust and St George's Healthcare NHS Trust in London later this year, and will be evaluated in full, with impact results expected in early 2014.