Subtrama sentimental (1) Ángel y Ana Vásquez

These featured in all participants’ interviews, but in different ways. Some participants drew on psychosocial and emotional constructions of challenging behaviours and the impact that it has on them, whilst others drew on them by dismissing or overlooking them. Here, “psychosocial” relates to wider

psychological and social influences contributing to the aetiology of mental health and recovery, including intra- and inter-personal process (Kinderman, 2005). Participants also drew on systemic discourses to talk about challenging behaviour and justify their own actions as a group. Here, systemic discourses related to the wider systemic and political context of the NHS. Systemic theories construct problems as within the relationships of this wider context, rather than within individuals (Vetere & Dallos, 2003). It is of particular note that this research took place within the NHS during a political period of

“austerity”. The psychosocial and emotional constructions were considered to be marginalised by the more dominant biomedical and systemic discourses. The absence of environmental discourse, such as noise, crowding and facilities, in the interviews of this study is interesting.

Toni demonstrates this by immediately defending her argument in a

rehearsed discourse indicating that she is used to confrontative disagreement when she presents a non-dominant approach: “We’re not saying aggressive is acceptable but we are saying we can understand why it happened…” (Toni, p.10; 46-47).Equally, Toni demonstrates that she is also rehearsed in

questioning the utility of the construct of challenging behaviour: “Is this really challenging behaviour (.) or somebody upset because (.) they’ve been

neglected or … shoved aside continuously?” (Toni, p.13; 23-25).

This highlights how the introduction of the term challenging behaviour to highlight its social construction and the social context has not been successful and has instead become synonymous with the terms it had aimed to replace.

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The marginalisation of the alternative discourses is further is demonstrated in the following quotation: “We’ve got this new system at the moment called DASA Scoring. So you try and erm deescalate the situations before it gets to the point where we have to now, it’s an immi-imminent risk” (Samira, p.12; 33- 39). Here Samira refers to the Dynamic Appraisal of Situational Aggression (DASA: Ogloff & Daffern, 2006) which is a checklist tool developed to assess the likelihood of a service-user becoming aggressive based on observable characteristics, such as “irritability” and “easily angered when requests are denied”. Opportunities for reflection and learning are replaced with a checklist. The DASA’s clinical utility has been critiqued for having potential to

overestimate the likelihood of aggression (Griffith, Daffern, & Godber, 2013). The checklist items, as with the biomedical model, overlook contextual and environmental influences on behaviour and make no attempt to understand or remedy triggers for it. Lantta, Konto, Daffern, Adams & Valimaki (2016) found that not only was the DASA time consuming and perceived as upsetting and disrespectful by service-users, there were also concerns that negative

attitudes towards a service-user were likely to influence scores. This approach is in contrast to behavioural monitoring charts that aim to understand the function of the behaviour would be used in a psychosocial approach such as PBS.

Such risk assessment tools have been criticised more broadly as being unthinking tick-box exercises (Reid, 2003). This is interpreted as an example of biomedical dominance undermining the potential for useful non-biomedical approaches. Further, a checklist to recognise aggression echoes other

participants’ discourses of excessive paperwork drawn on in the construction of challenging behaviour: “there’s just (1.5) too many screening tools, too many (3) too, too much ((laughs)) paperwork .hh to actually engage with the patient as much as (1) as would be beneficial for them… to actually talk to the person that the paperwork’s about” (James, p.17; 14-22).

Participants constructed their work environment as one that is of high risk for staff stress and burnout. They highlighted experiences and risk of assault, verbal aggression, loss of autonomy, reduced opportunities for a sense of

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personal accomplishment through the lack of a poorly defined primary task; a lack of resources, including staff shortages; and too much paperwork (Bowers & Flood, 2008; Farrell & Doves, 1999; Flannery et al., 2007; Kindy et al., 2005; Menzies-Lyth, 1988; Sullivan, 1998).

3.4 Reflections

The process of analysis was particularly hard. I was very aware of my emotional response when reading the transcriptions. I had expected to feel angry on behalf of service-users. However, I found myself also feeling angry at the system on behalf of staff. Narratives, that echoed literature on domestic violence, were particularly pertinent to me and I felt that nurses too were subject to social injustice. During the interviews, it felt as though participants had little opportunity to talk about the behaviours they face on the wards and the personal impact that this has on them. One participant contacted me following the interview, to inform me that she had found it helpful to talk about these things and had made contact with the Trust Occupational Health service for support. She informed me that from this she has received a diagnosis of PTSD following a serious incident that had been aimed at her. Although not a part of the research, I felt that this epitomised the military metaphor of the mental health ward as constructed by participants.

I managed these emotions by taking regular breaks during the process of analysis. For example, going for walks to calm down and actively looking at data from a different perspective. I also asked my supervisor to look over my comments on analysed transcripts to encourage me to think about things from other perspectives and ensure my interpretations were rational rather than emotional.

Despite the small number of interviews, the amount of data felt overwhelming and progress was slow. I constantly felt uncertain as to whether I had

approached analysis in the right way, as there is no definitive text or guidance on how to conduct discourse analysis. I managed these difficulties by

ensuring that this research met the criteria outlined on the QARI (JBI, 2014) and being mindful of the common pitfalls of discourse analysis outlined by Antaki, Billig, Edwards and Potter (2003).

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My emotional reactions to some transcripts were significantly different to my reactions during the interview. For example, I struggled to feel empathy for James during his interview and found myself feeling irritated by some of his comments. However, I found myself more drawn to his sense of feeling burnt out and that the system had taken from him the job that he “used to love”, with his chance to witness recovery lost in the systemic pressures. I wondered if this difference was perhaps because he was an hour late for the interview and I had struggled to put this annoyance aside. I also wondered if perhaps

mannerism or intonation, that were not picked up on in transcription, may have led me to focus on different parts of his narrative in the interview. However, I also wondered if perhaps this was a strength of working from transcripts, in that I was able to attune to things that I may have otherwise missed.

This was similar for Samira. I really enjoyed the interview with her. I noted that she was smiley and engaging, and came across as kind and compassionate. However, during the analysis I found myself drawn to aspects of her transcript that left me feeling annoyed and judgemental. For example, it was more noticeable in the transcript that she frequently referred to pressing charges, or wanting to press charges, against service-users in the absence of motivation to understand why incidents had occurred. This is not to say that I disagree with pressing charges following assault, more that it felt her talk about this in the transcript came across to me as cold. I managed this by looking for examples of warmth in her transcript to contrast this.

The process of making amendments to these findings was a challenge. Although theory was drawn on to inform the analysis, it was difficult to respond to these mostly positivist theories through the findings in a way that remained true to the discourse analysis methodology which does not attempt to draw conclusions on cognitive or individualistic processes (Parker, 1992).

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