Understanding the social context of violent and aggressive incidents on an inpatient unit.

The English National Service Framework for Mental Health stipulates that the highest quality of health care should be provided for mental health service users. Incidents of aggression and violence militate against achieving that goal, yet such incidents are frequently reported in inpatient settings. Much research in this area reflects a dualistic, perpetrator/victim conceptualization of incidents. This study aimed to take a more systemic approach by treating violent and aggressive incidents as social interactions and by seeking to understand the social contexts in which they took place. In this paper we describe and discuss the main themes to emerge from 15 staff accounts of 11 incidents on one ward. A striking theme reflected throughout the interview data was the lack of staff engagement with clients, and particularly an inability to look at the world through clients' eyes in interpreting their behaviour. We conclude that the 'zero tolerance' campaigns currently being conducted in the UK in relation to aggression towards NHS staff are unlikely to succeed without attention to understanding why aggressive behaviour arises and identifying features of the caring environment that may contribute to it. Rather than adopting a position of 'zero tolerance', we argue that three steps are required following an aggressive incident: emotional support; critical reflection and learning; and the pursuit of accountability.