The analysis resulted in six qualitatively different, yet logically interrelated, hierarchical categories of description. Comparing the interviews, we found a modest conceptual development among the participants. The categories of description varied particularly with regard to what emphasis was placed on the different parties in the helping relationship and whose agency was favored in the prevention and management of staff-directed aggression. In this section, we confer our results. The categories are presented in Table 1. Each category is represented by the use of illustrative quotations, intended to convey important experiential dimensions of each conception, or particular way of seeing.
Observation, alertness and awareness
Most participants described practice in encounters with staff-directed aggression in terms of ‘observation, alertness and awareness’. Their workplace was conceived as involving considerable risk with highly unpredictable, unique situations involving aggression from primarily psychotic and unstable tenants. Considerable energy was invested by staff in keeping themselves and their colleagues alert and vigilant in observing the movements of the tenants. Attention by staff was revealed as highly situationally dependent, vulnerable and fickle, and was reported to decrease in the wake of aggressive encounters. Some stated that this was due to the staff’s need to rest and regroup following alarming incidents. Routine practices also appeared to make staff become negligent and unresponsive to observable signs of aggression in clients. Especially when staff were uncertain of the risk of aggression from tenants, the need for being alert and attentive was described as particularly important:
“It wasn’t a pleasant atmosphere in the facility. Not at all. When you went to work, and you were working, your shoulders never dropped. You had your guard up, all the time. We [the staff] agreed that ‘we don’t drop our shoulders until we’re done for the day’. Because suddenly [snaps his fingers] something happens, out of the blue.” (M3, second interview).
Becoming habituated to staff-directed aggression, through regular exposure at work, was yet another threat to beneficial prevention and management practices that participants cautioned. The antidote to inattentive habituation was vesting mental energy in promoting awareness.
Participants mentioned preparation and rehearsal as helping to manage aggressive encounters with tenants when their observation and “reading” of tenants’ behaviors seemed to have failed. Several participants stated that the locally based education and training activities had helped to maintain their focus on staff-directed aggression at work.
Participants often expressed disempowerment regarding staff-directed aggression, due to lack of influence on the composition of tenants in the facility, inadequate tools to address resistance and challenges presented by uncooperative tenants, and poor job alternatives for staff intending to leave. Service user autonomy was seen as potentially impairing staff interaction with tenants perceived in need of help to prevent deterioration and subsequent increased risk of violence. A perceived reluctance to interact with staff is seen in a rather typical statement from one participant regarding an ‘uncooperative’ tenant:
“I don’t know if he actually has the necessary insight into his own limitations to understand that if he’d been more receptive towards receiving assistance or accepted guidance and counseling from us, he might have become more self-reliant. Because he really wants to manage most things by himself.” (F10, first interview).
Exponents of this view held confidence in external interventions to solve situations of staff-directed aggression. This entailed involving managers to provide authority, treatment and sometimes including physical restraint, or the police in grave situations. Ultimately, when all possibilities to establish a helping relationship seemed exhausted, or a serious violent incident had transpired, the only available solution in this view was eviction, or forcing the tenant to move to other accommodations. This was something several of the participants endorsed.
Established understanding and knowledge of service users
In conceptualizing prevention and management practice in line with the descriptive category of ‘Established understanding and knowledge of service users’, participants’ focus shifted toward the staff’s professional and experiential knowledge of tenants, and the staff as the primary originator of preventive and managerial strategies. Knowledge of individual triggering and response patterns was typically established over time, primarily by staff spending time with tenants and witnessing their behavior in various contexts. The staff’s assessments of risk were from this conception based on more or less formal diagnostic criteria and hearsay from colleagues or others. When familiar with a service user’s identifiable signs of aggression, the staff could better implement interventions and calm aggressive tenants.
“I know this tenant a bit already. I think that’s a factor, because then you can see when he’s grumpy and avoid placing the two in the same room, you see? Try to avoid it, but you can’t be everywhere, can you?” (F1, first interview).
In this view, the root causes of staff-directed aggression are found primarily in service user deficiencies, such as poor coping resources, communication or cognitive difficulties and psychotic traits. Staff-directed aggression is seen as a form of communication, related to service users’ frustrations reaching a threshold. Aggressive behavior is usually considered as rooted in tenants’ traumatic childhood experiences. Medication is the preferred intervention and violence is often perceived as associated with medication non-compliance. This approach advocates staff control and the establishment of safe boundaries between staff and tenants.
In this view, limit setting is a valued and frequently mentioned intervention, albeit fraught with risk, as some tenants strongly oppose it. Accordingly, this necessitates particular caution when approaching such tenants.
Some participants reported that the competence-development activities and ensuing reflections on practice had signaled an implementation of redefined and more controlling practices toward particular service users during home visits.
Perceived as being more proficient in communication, staff were perceived as obliged to provide simpler communication settings for tenants and match their own communication with tenants’ level of activation and the particular situation. Tenants were considered highly dependent on staff, both in social interaction and in avoiding escalation of situations. When asked about the place for service user involvement in establishing measures to prevent staff-directed aggression, the participants envisioned mainly a conditioned form of involvement, usually based on tenants’ compliance with regulations, realization of their ‘wrongdoings’, and their perceived cognitive ability to acquire such insights, thus positioning staff as ‘gatekeepers’ of service user involvement.
Finally, from this conception participants valued distancing and detachment from service users to avoid being manipulated or harmed by their aggressive behavior; they described emotional and interpersonal closeness as increasing the risk involved in service provision.
Team-based risk management and deliberation
In the category of ‘Team-based risk management and deliberation’, practice is described according to dimensions of the workplace collective. A common agreement on practice and assessment of tenant behavior was idealized in this conception. However, this agreement was often described as lacking and divisive practice was repeatedly depicted as the untoward norm at the workplace.
“We’re different, we do our work differently, and some of us disapprove of this and that, and then the manager does something that others disapprove of. And the outcome is a big mess in the team, which isn’t very helpful”. (M3, second interview).
Several participants cautioned against splitting and manipulative behaviors from tenants posing an additional threat to the team’s integrity and collegial collaboration.
However, several participants found dissimilar viewpoints to be valuable in analyzing episodes from different angles and enhancing staff understanding of tenants, as well as in finding good strategies for prevention and management of aggression. Collegial sharing of experiential knowledge was appreciated in this view, and was also depicted as important in evaluating incidents at work, necessitating openness and tolerance between colleagues. By observing colleagues’ strategies or modelling their practice to colleagues, participants valued mutual learning as a route for improving safety at work.
In this conception, the team provided support and care in periods of tenant aggression or following aggressive encounters. Several participants mentioned that violent incidents often make teams focus excessively on the perpetrating tenant, leading to fatigue in the staff and neglect of other tenants. Several also stated that the education and training helped the team maintain focus, even in more stable and uneventful periods.
Lone work was reported to involve greater risk, and participants regularly advocated working with colleagues when faced with challenging service users. This required mutual knowledge and understanding of the particular situations, as well as having congruous insight and skills in preventive and management practices in general.
Adaption of own dispositions and behaviors
When participants conceptualized practice in prevention and management of staff-directed aggression in terms of ‘adaption of own dispositions and behaviors’, they did so with a clear recognition of the impact staff themselves can have on the development and manifestation of aggression. Participants spoke of the need to adapt their practice, behavior and bodily awareness according to tenant needs in aggressive encounters.
Strategies for preventing and managing service user aggression often mentioned in this approach are ‘containing’ tenants and being attentive of service user communication. Tenants being listened to and ‘seen’ by staff is presumed to make staff-directed aggression perceived unwarranted and thus de-escalate situations.
Staff behavior was considered particularly important in ensuring a safe working environment less likely to provoke clients. Staff should not respond to aggression in a confrontational, agitated, reproachful or vociferous manner. Participants valued considerate strategies, being respectful, inviting and “being sort of determined, but not too determined. So they feel they’re somewhat in charge of the situation themselves, without you overly controlling them” (F1, second interview). In this view, predictable and amicable staff and the ability to build trust installs in tenants a sense of security and confidence that they will receive consistent and unconditional care.
The focus in this conception is on staff characteristics such as experience-based insight into one’s personal boundaries and tolerance limits and the ability to uphold these in interaction with tenants. Some participants found that the education and training enhanced their ability to lower the threshold for threatening behavior and initiate preventive and management strategies at an earlier stage. Embodied sensitivity (or ‘gut feeling’) and a sense of own safety in situations were decisive for discerning risk in this view. Providing service users with descriptions or assertions about the situation or behavior could increase insight and prevent unmediated aggression.
“What I think characterizes staff that are good at prevention, is that they dare to say something about what they see. Their prevention is sort of, ‘Now I can see it’s like this. What do you think about that? Am I seeing this in the wrong way, or do you think I’ve gotten it wrong now?” Because often thinking aloud can calm the client. So trying to acquire some reflection with the tenant, then…” (F7, second interview).
Finally, time is an important factor in this conception. Staff must be patient and tolerant toward service users to improve their relationship and minimize aggression.
Reflexivity, sensitivity and care
In the fifth category, ‘Reflexivity, sensitivity and care’, the prevention and management, and the explanations, of staff-directed aggression were portrayed as highly complex. In this conception, there was greater awareness of tenants and the interconnectedness between service users and staff. Staff were seen as responsible for monitoring their own attitudes and emotional reactions to the service users and for maintaining conscious reflection on their practice.
“You have to be reflective. If you don’t reflect, things can quickly go wrong. Because you have to become aware of the things that happen here. We can’t always understand situations, or why someone reacts like this or that in a certain situation. In here, we’re talking about very disturbed people. They can have psychotic outbursts or whatever. But reflecting on our own behavior… That’s something we ought to be good at”. (F2, second interview).
Prevention and management strategies were portrayed as based on a sensitive and active adaptation of staff members’ own reactions, behavior and attitudes to meet service user needs. What staff seemed to dread in this view was unreflective practice; the ideal was a reflective practitioner. Some called for reflection to be included more systematically in work routines. By extension, the ability to learn adaptively from situations distinguished skilled staff in this view.
Using sensitivity and empathy with tenants’ situation, and showing respect for their choices and considering them accountable, were considered prerequisites for implementing low conflict practices.
With the acknowledgment of service users’ right to privacy at home and autonomy in making own choices, respect appeared as a key value in this view: “I think that to establish a good working alliance with another person—and this goes for every human being —we need to be treated with respect” (F2, first interview). Empathic attention to the other’s perspective enabled staff to be understanding and compassionate in their interaction with tenants. It also provided another avenue for gaining insight into how their practices affected tenants, perceived as fundamental to adapting staff practices.
Some participants described violent tenants as relationally damaged. By deliberately showing that they cared about them as valuable human beings, staff imagined they could alleviate such relational damage and non-violent, trusting staff-service user relations could ensue. Some participants who subscribed to this view advocated close relationships between staff and tenants as a way to prevent aggressive escalation.
In line with an acknowledgment of phenomenal complexity and unlike the previous conceptions, some participants holding the fifth conception asserted staff-directed aggression in more positive terms as non-compliance and resistance from service users. Aggression was interpreted as service users still having enough spite in them to fight back and reject limitations imposed on them by both their own illnesses and repressive features of mental health services.
Involvement and dialogue
In the sixth and final category, ‘Involvement and dialogue’, participants viewed staff and tenants as coequals in developing strategies for preventing and managing staff-directed aggression. Staff was urged to explore incidents in collaboration with tenants, and to help them express their experiences with and opinions on practice, thus mitigating the power imbalance in the service relationship, in a non-directive and caring atmosphere. Tenants’ reasoning behind their aggression should be included to enhance practice, and staff should prompt tenants to identify suitable strategies to cope with aggression, either alone or in collaboration with staff. Being mindful of how bodily activation impacts the ability to reflect and communicate for both parties, participants maintained that such dialogue ought to take place once the tenant’s level of activation had sufficiently decreased and stabilized.
Opportunities for learning for both parties present themselves by involving service users and reflecting with them on the causes and consequences of the aggression according to this conception. Through this, staff could increase their understanding of the tenant’s tolerance limits, triggers and preferred staff interventions, while tenants, in the other hand, could gain insight into their symptoms of aggressive escalation and develop individual management strategies. Improved insight into the consequences of their behavior would according to participants, enable clients to take greater responsibility for their actions. It was also mentioned that tenants could learn from gaining greater understanding of the reasons for staff safety procedures, thus making staff reactions to aggression more predictable and perceived as less threatening.
Dialogue following an incident was also described by some participants as having therapeutic and restorative potential. “I usually say there are always three sides to a story. You have your own experience, then you have the other’s experience and then you have the truth” (F10, second interview). By reflecting on a situation and allowing for both sides’ accounts of it, staff and tenants could potentially achieve closure and move on together.
In this view, participants valued being perceived as genuine in their care for tenants by promoting interpersonal knowledge and a forthcoming atmosphere, thusly aiding prevention of staff-directed aggression.
“You should kind of play on their side. Not that ‘play’ implies that you’re at all fake. But show that you care. That you really want the best for them. You don’t want them to suffer. ‘I’m here if you need anything’, kind of. ‘I understand that you’re hurting right now’. Because you get a different kind of knowledge and get to know them in another way. And I think the service users here see that. I think they see far more than we think they do. If you genuinely care, that’s very important for cooperation between you and the tenants.” (F1, second interview).
Participants suggested that if staff was being perceived as humble, open about own failings and having the ability to ask forgiveness if they in some way had treated a client wrongly or misunderstood a client, then tenants would show a more tolerant and equitable attitude toward them. Participants conceived this as promoting trusting relations between tenants and staff, enabling staff to communicate hope, promote change and persevere in providing care and support to help tenants move on in their lives.
Conceptual changes identified in the data
When asked about their perceptions of the impact from attending the education and training sessions in the second interview, several participants mentioned increased awareness and reflection on the topic of staff-directed aggression in the workplace, both personally and collectively. Others were more negative toward the notion of change, often because of ostensibly vast differences in opinions on appropriate practice, inattention and even age-related inflexibility toward staff-directed aggression among colleagues. However, as can be seen in Table 2, only four participants eventually made statements in the second interview salient enough to be considered as advanced conceptions. The advancement in ways of seeing occurred as a one-step movement between the fifth category and the sixth. Interestingly enough, by the time of the second interview, two participants voiced previously unmentioned aspects of the phenomenon in line with the first conception. This implied they actually had experienced a downward movement in the hierarchical outcome space. One of these participants additionally experienced an upward development in her way of seeing, reaching the sixth conception by the second interview.
As previously mentioned, the first and second interviews differed substantially in both length and content.