Nurses’ discourses of challenging behaviour in inpatient mental-health services
| Pages | 253-268 |
| DOI | https://doi.org/10.1108/MHRJ-02-2018-0006 |
| Date | 10 December 2018 |
| Published date | 10 December 2018 |
| Author | Amy Mellow,Anna Tickle,David M. Gresswell,Hanne Jakobsen |
| Subject Matter | Health & social care,Mental health |
Nurses’discourses of challenging
behaviour in inpatient
mental-health services
Amy Mellow, Anna Tickle, David M. Gresswell and Hanne Jakobsen
Abstract
Purpose –Nurses working in acute mental-health services are vulnerable to occupational stress. One
stressor identified is the challenging behaviour of some service users (Jenkins and Elliott, 2004). The purpose
of this paper is to discuss the discourses drawn on by nurses to understand challenging behaviour and talk
about its management.
Design/methodology/approach –Nurses working on acute and psychiatric intensive care unit (PICU)
wards were interviewed, and data were analysed using discourse analysis.
Findings –Biomedical and systemic discourses were found to be dominant. Alternative psychosocial and
emotional discourses were drawn on by some participants but marginalised by the dominant biomedical
construction of challenging behaviour.
Originality/value –Existing studies have not considered how discourses socially construct challenging
behaviour and its management in inpatient mental-health services.
Keywords Qualitative research, Challenging behaviour, Discourse analysis, Inpatient
Paper type Research paper
Background
Nurses working in acute mental-health services are a group of health care professionals
particularly vulnerable to occupational stress and burnout, with key stressors identified as a lack
of adequate staffing levels and “physically threatening, difficult or demeaning patients”(Jenkins
and Elliott, 2004, p. 627). The risk of assault to mental-health nurses is high (National Institute for
Clinical Excellence (NICE, 2015a; Robinson and Grant, 2017) and they also face a wide range of
behaviours that pose a challenge from service users, such as “noncompliance”and attempts to
abscond (Stewart et al., 2009). While it is recognised such behaviour may be a response
to confinement or disagreement with proposed treatment, the term “challenging behaviour”
(borrowed from learning disabilities literature) has been used as common parlance in acute
mental-health settings, and has been identified as the most commonly cited reason for the use of
restrictive interventions on incident forms (Ryan and Bowers, 2006). This study adopts
Emerson’s (2001) broad definition of “challenging behaviour”, which incorporates behaviour
other than violence and aggression:
Culturally abnormal behaviour(s) of such an intensity, frequency or duration that the physical safety of
the person or others is likely to be placed in serious jeopardy, or behaviour which is likely to seriously
limit use of, or result in the person being denied access to ordinary community facilities. (Emerson,
1995; cited in Emerson, 2001)
Challenging behaviour affects the health and safety of staff, service users and carers alike, and is
associated with a negative experience of care (Beech and Leather, 2005; NICE, 2015a).
There are disparate theories that claim to account for challenging behaviour by individuals with
mental-healthdifficulties. A biomedical view wouldpropose that such behaviours in mental-health
Received 25 February 2018
Revised 5 August 2018
Accepted 31 August 2018
Amy Mellow is based at the
CAMHS North Team,
Nottinghamshire Healthcare
NHS Trust, Nottingham, UK.
Anna Tickle is based at the
Institute of Health,
Work and Organisations,
Nottinghamshire Healthcare
NHS Trust, Nottingham,
UK and Department of
Psychology, University of
Nottingham, Nottingham, UK.
David M. Gresswell is based at
the Department of Psychology,
University of Lincoln,
Lincoln, UK.
Hanne Jakobsen is based at
the South London and
Maudsley NHS Foundation
Trust, London, UK.
DOI 10.1108/MHRJ-02-2018-0006 VOL. 23 NO. 4 2018, pp. 253-268, © Emerald Publishing Limited, ISSN 1361-9322
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settings have a physiological basis and requiremedication (Double, 2002). In contrast,behavioural
theories propose that the environment, including other people, is key to understanding of
challenging behaviour, as behaviours are functional and maintained by their consequences
(Skinner, 1974). Challenging behaviours are likely a complex manifestation of a combination of
factors. Theseare not limited to the aggressor’sdisposition but include attitudes of staffmembers,
and the physical environment, particularly environments that limit the service user’sfreedom,like
the inpatientward (Farrell et al., 2010; NICE, 2015a). The experienceor threat of aggression is likely
to influence nurses’attitudes towards serviceusers and has negative effectson staff wellbeing and
the quality of care delivered (Arnetz and Arnetz, 2001; Stanko, 2002).
Attributions of aggressive behaviour can influence a team’s subsequent response to it (Collins,
1994; Whittington and Higgins, 2002). Weiner’s (1972) theory of attributions proposes that our
attitude towards a behaviour depends on how much control we believe the person to have over
their behaviour and its outcome, and whether we believe they are capable of changing. Nurses’
attributions of behaviour have been found to differ depending on the diagnostic label the person
has been given, with those labelled with personality disorders considered to be more in control of
their behaviour than others (Markham and Trower, 2003).
Staff and service users also hold different views on the precursors of incidents of violent or
aggressive behaviour, e.g. service users perceive the main precursors to be poor communication
and environmental conditions whilst staff name the main reason to be the service user’s mental
illness (Duxbury and Whittington, 2005). It has also been found that a large proportion of staff see
a person’s behaviour to be intentional and controllable, increasing the likeliness of inappropriate
responses (Hastings et al., 1997).
Training regarding appropriate prevention, de-escalation and management of challenging
behaviour is now mandatory for all NHS staff working in inpatient mental-health settings (NHS
Security Management Service, 2005). However, the evidence-base for the effectiveness of such
training is questionable (Rogers et al., 2006). Guidelines stipulate training must emphasise
prevention and that non-physical interventions, such as verbal de-escalation, as a first response
and that restrictive interventions, including physical interventions such as restraint and seclusion,
must only be used as a last resort (NHS Security Management Service, 2005).
Service users have reported that they believe restrictive interventions are not only used as a last
resort (Fish and Culshaw, 2005) and research with staff supports this: Fewer than half of staff
working on psychiatric intensive care units (PICUs) across England and Wales rated verbal
de-escalation as one of their three most used interventions for challenging behaviour (Lee et al.,
2001; Wright et al., 2005). A review by Stewart et al. (2009) found that more robust studies point
to a range of behaviours, including attempts to abscond and noncompliance, as identified
reasons for the use of restrictive interventions. Decisions to use restrictive interventions are
reported to be influenced by contextual demands, a reported lack of alternatives, perceptions of
risk and the escalatory effects of restrictive interventions themselves (Perkins et al., 2012).
Menzies Lyth (1960) proposed that health care institutions organise themselves to defend against
staff anxiety, triggered by caring for people in distress, and that this could lead to practices that
are contrary to guidelines. Conflict arises in the competing demands of delivering care and
needing to remain in control, where there are high levels of distress and crisis, and with aspects of
care involving containment to manage risks (Mind, 2013; Vassilev and Pilgrim, 2007). Challenging
behaviour and the use of restrictive interventions arguably represent a struggle for control
between staff and service users in inpatient mental-health services (Breeze and Repper, 1998),
which may escalate both challenging behaviour and restrictive practice.
The psychologicaland physical risks of restrictiveinterventions areserious and include distress and
injury for both staff and service users (Lancaster et al., 2008; Bonner et al., 2002), and have been
linked to a number of service user deaths( Mind, 2013; Paterson etal., 2003). Psychologically, for
service users,the experience of being restrainedis distressing, disempoweringand retraumatising,
leading to feelings of fear, frustration and anger, thus increasing the risk of further aggression
(Bonner et al., 2002; Fish and Culshaw, 2005; Mind, 2013; Sequiera and Halstead, 2004).
Likewise, the experience of seclusion has been found to have the potential for iatrogenic
harm (Mellow et al., 2017). Such risks undermine the aim of supporting people to recover from
mental-health difficulties.
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