Nursing Inquiry 2015; 22(4): 296–305
Feature
Discourses of aggression in forensic mental health: a critical discourse analysis of mental health nursing staff records aPsychiatric
Lene L Berring,a Liselotte Pedersena and Niels Buusb Research Unit, Region Zealand, Roskilde, Denmark, bInstitute of Public Health, University of Southern Denmark, Odense, Denmark Accepted for publication 27 May 2015 DOI: 10.1111/nin.12113
BERRING LL, PEDERSEN L and BUUS N. Nursing Inquiry 2015; 22: 296–305 Discourses of aggression in forensic mental health: a critical discourse analysis of mental health nursing staff records Managing aggression in mental health hospitals is an important and challenging task for clinical nursing staff. A majority of studies focus on the perspective of clinicians, and research mainly depicts aggression by referring to patient-related factors. This qualitative study investigates how aggression is communicated in forensic mental health nursing records. The aim of the study was to gain insight into the discursive practices used by forensic mental health nursing staff when they record observed aggressive incidents. Textual accounts were extracted from the Staff Observation Aggression ScaleRevised (SOAS-R), and Fairclough’s critical discourse analysis was used to identify short narrative entries depicting patients and staffs in typical ways. The narratives contained descriptions of complex interactions between patient and staff that were linked to specific circumstances surrounding the patient. These antecedents, combined with the aggression incident itself, created stereotyping representations of forensic psychiatric patients as deviant, unpredictable and dangerous. Patient and staff identities were continually (re)produced by an automatic response from the staff that was solely focused on the patient’s behavior. Such response might impede implementation of new strategies for managing aggression. Key words: aggression, critical theory, discourse analysis, forensic nursing, hospitals, language, nursing records, psychiatric, qualitative studies.
Managing aggression and violence in a mental health setting is an important and challenging task as it can result in staff and patient injuries (Anderson and West 2011; Bowers et al. 2011). Aggression can be expressed differently ranging from a patient raising their voice to a direct provoked or unprovoked attack (Foster, Bowers and Nijman 2007), but there is a broad consensus that aggression includes ‘nonverbal, verbal and physical behavior that are threatening or harmful to others or property’ (Morrison 1992, 422). Aggression can be Correspondence: Lene L Berring, Psychiatric Research Unit, Toftebakken 9, 4000, Roskilde, Denmark. E-mail:
defined and studied in several ways, such as a normal part of life, a symptom of illness or as a socially constructed phenomenon (Liu 2004). In this article, we adopt a social constructionist perspective (Gergen 2001) on aggression as we explore the ways in which aggression is constructed in clinical language use. These constructions of aggression influence on, and are influenced by, the concrete management of aggression. Understanding healthcare professionals’ ways of constructing aggression is an important supplement to the existing research on aggression as it gives insight into the social contexts of aggression and aggression management.
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BACKGROUND Aggression Most research in psychiatry account for aggressive episodes by referring to the following themes: the incident, its antecedent, its consequences, the time and place, the patient and staff perspectives, and the social and clinical profile of the patient (Cornaggia et al. 2011; Papadopoulos et al. 2012; Dack et al. 2013). Based on a systematic review, Dack et al. (2013) describe the profile of the typical aggressive patient as male, involuntarily admitted and with a diagnosis of schizophrenia; he is most likely young, single and from an ethnic minority. Besides this, the risk of aggression is increased by previous episodes of aggression, the presence of impulsiveness and hostility, and long periods of hospitalization (Cornaggia et al. 2011). However, Dack et al. (2013) suggest that factors other than patient characteristics may help predict aggression. Most studies of aggression and violence in clinical psychiatry have focused on the patient characteristics; however, Papadopoulos et al. (2012) found that aggressive situations could also be triggered by a problematic relationship between staff and patients. Only a few studies have included the patient’s perspective or sought explanations beyond the level of the immediate hospital context, such as the dynamic environment within which health-care is provided (Papadopoulos et al. 2012). Duxbury (2002) included the patient perspective and found a distinction between the way staff and patients viewed both the problem of aggression and the responses to aggression. Staff members point to internal patient factors and external factors as a reason for aggressive behavior, whereas patients view staff responses (e.g., a controlling style among staff) as a factor provoking aggression. A subsequent study (Duxbury and Whittington 2005) confirmed that both patients and staff were clearly dissatisfied with the way aggression was managed and that they drew on different discourses to construct specific notions of the reasons for aggression. Moreover, Benson et al. (2003) found that clients and staff use the same discourses of mental illness to explain aggressive and violent incidences. Issues of blame were a dominant construct in everyday accounts, with patients blaming staff and staff blaming patients. A central finding in Secker et al. (2004) thematic analysis of the social context of aggressive incidents was that staff did not engage much with patients and were not capable of relating to the patients’ perspectives. The above studies illustrate that patients are predominantly represented as those who were responsible for causing aggression but, also, that the constructions of © 2015 John Wiley & Sons Ltd
aggression differ according to the position and perspective of those who are interviewed. Little is known about the social contexts of aggressive incidents and the interpretative frames and discourses people draw on when they construct explanations of aggression, and how they position themselves when doing so.
Discourses in nursing records When it comes to discourses in mental health nursing, written records play a central part in how aggression and nursing is represented, as such records produce a textually mediated reality (Cheek and Rudge 1994). A discourse is a particular way of constructing some part of the world, such as identity, social relationships and social reality (Fairclough 2003), which can be identified in all kinds of language use (Gee 2013). Nursing documentation takes place within a dynamic social context involving many actors and agendas (Buus and Hamilton In press). In keeping with this, documentation has widespread social consequences. As some studies suggest, written text can perpetuate certain unspoken assumptions about patients and staff. Recording establishes nurses as professionals as their use of language externalizes their professional consciousness and decisionmaking (Buus 2009). Furthermore, the language used creates representations of nurses and patients (Heartfield 1996; Irving et al. 2006; Perron and Holmes 2011; Schofield, Tolson and Fleming 2012). Conventions and habits of language are maintained in social routines and traditions, such as in day-to-day records and oral shift reports (Ekman and Segesten 1995). Records and shift reports are regarded as crucial for the continuity of care, and nursing record systems are expected to have a significant influence on nurses’ practice. Millar and Sands (2013) pointed out incompleteness in documentation practice; they found that in mental health settings, shift handovers involving information on risk were unstructured and based on a ‘need-to-know’ attitude. That ‘need-to-know’ attitude might create inappropriate constructs of patients. Buus (2006) also found that handover information was provided in an ad hoc manner based on the outgoing nurses’ own opinions of the incoming nurses’ need for information. He described how nurses acquire a significant part of the clinical knowledge about their patients through interactions with other staff members, rather than through direct interaction with their patients. The findings indicated that nurses, through their recordings, produced stereotyped representations of the patients (Buus 2006). Hamilton and Manias (2006) investigated spoken and written language in nursing, and based on a critical analysis 297
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of nurses’ oral and written language, they demonstrated the way in which discourses were expressed in acute inpatient psychiatric units. They identified how a management discourse was expressed in the language used. Generally speaking, a management discourse monitors, reports and controls products and productivity, and they argued that the management discourse was influenced by the pressure for throughputs, in the form of high patient turnover. This was seen in how patients were objectified and were ‘tracked as risk-laden objects through the process of a hospital stay’ (Hamilton and Manias 2006, 91). What this seems to suggest is that documentation plays a central role in how patient subjectivities are represented, which was also reported in Perron and Holmes’ (2011) study about constructing mentally ill inmates in a forensic setting. Based on progress notes and observations, they identified how patient subjectivities were produced. Patients were portrayed as five stereotypes: the (in)visible patient, the patient at risk, the deviant patient, the disturbed patient and the disciplined patient. They also revealed how nurses monitor patients. The practice of surveillance was made compulsory by a climate of persistent focus on risk and security (Perron and Holmes 2011). The authors suggest that even though there was a discourse of care in the unit, the progress notes illustrated complex discursive practices of correction, and the way in which subjects were represented became authoritative and difficult to challenge. In addition to formal medical discourses also informal discourses exist in nurses’ records (Irving et al. 2006; Buus 2009), which is reflected in nurses using everyday language with more or less specific clinical meanings (Buus 2009). Mohr’s (1999) study pointed out this use of everyday language in chart entries. She found that a large part of the language in chart entries consisted of professional jargon, and she argued that this jargon-laden language was the primary tool of communication among nurses and other professionals. Mohr argued that jargon can be efficient, but jargon can also hide the shortcomings of inadequately prepared staff members. Furthermore, Mohr argued that the charts positioned the patients as deviant others. The studies above exemplify how nurses and patients are represented in nursing records. Nurses are represented as authoritative and difficult to challenge and care is represented as corrections. This custodial approach is enrolled in a risk management discourse, and patients are represented as risk-laden objects, described with metaphors depicting the deviant other and the disturbed
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patient. The literature concerning aggression within inpatient settings is extensive and indicative of the level of concern surrounding the topic. Taken together, previous research of discourses in documentation practices indicates that records produce a textually mediated reality constructing stereotyped representations of the patients, based on the nurses’ own interpretation of the incident. Thus, the context of aggression is complex. In this study, we will explore the discursive practices of nurses when they write reports of aggressive incidents in a forensic mental health setting.
Theoretical framework Discourses display how social events are represented and encompass the use of spoken and written language (Gee 2013). Fairclough defined discourse as a practice not just of representing the world, but also of signifying, constituting and constructing the world in meaning (Fairclough 1992). Thus, discourses in healthcare records shape and maintain certain representations of patients, by allowing what is included and what is excluded. Discourses are different ways of representing some part of the world. This can be social practice, such as processes, relations and the structures of the mental and the material world, as well as the social world (Fairclough 2003). Language represents codes, conventions and habits of language that are produced in the context and have culturally and historically located meanings (Fairclough 1992). This study was informed by a constructionist view (Gergen 2001) and designed to focus on how nurses describe and textually mediate aggression in a forensic context. If we understand how the language used creates social effects, we may be able to question underlying, taken-forgranted assumptions about aggression. Awareness of these discursive mechanisms may help expand and develop new strategies for aggression management.
AIM The aim of the study was to analyze the discursive practices used when forensic mental health staff record observed aggressive incidents. The following study questions are addressed: 1 How are patients and mental health staff represented in mental health staff’s first-hand accounts of aggressive episodes? 2 Which discourses can be identified in the clinical texts?
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METHODS
Procedure
Setting
The data forming the corpus of the study were the written records made by mental health staff recording observed aggressive incidents. The data were free text accounts extracted from a register of descriptions of aggressive episodes from 2008 to 2012 based on the SOAS-R. SOAS-R registrations are recorded as first-hand records and are kept separate from the day-to-day documentation, but they still form part of the biographical file of the individual patient. The corpus of texts analyzed consisted of 270 accounts concerning 181 male and 3 female patients. These accounts were systematically extracted as every 10th of a total corpus of 2700 recorded aggressive episodes. For the purpose of this study, the 270 accounts were copied and pasted into a text document and analyzed.
The study setting was a forensic psychiatric institution having the Capital Region of Denmark as its catchment area. The vast majority of the patients were admitted under court orders for psychiatric treatment because they were considered unfit to serve a prison sentence due to severe psychopathology. To achieve the aim of the study, we chose a critical discourse analysis (CDA) approach to examine how the mental health staff construct accounts of aggression when recording incidents. Critical discourse analysis is an interdisciplinary approach to the study of discourse which views language as a form of social practice and focuses on the ways social and political domination is reproduced in text and talk (Fairclough 2003). There are different approaches to CDA, but the assumption shared by all CDA practitioners is that language effects social change and that language constitutes power (Fairclough 1992). The CDA framework conceived by Fairclough (1992) was originally three-dimensional and involved analysis of text, discursive practice and social practice. As our dataset includes written records only, the approach we chose in this study focuses on the written text —linguistics and semiosis. Critical discourse analysis draws on several disciplines in the social sciences, such as critical linguistics, to examine the ideologies and power relations involved in discourse (Fairclough 1992).
The SOAS-R The Staff Observation Aggression Scale (SOAS-R) (Palmstierna and Wistedt 1987; Nijman et al. 1999) is a tool for recording aggression, ensuring that information about aggression is adequately recorded. The SOAS-R is to be filled out by mental health staff when an aggressive incident has been observed. The form is a structured template incorporating information on any provocation leading up to the incident, the means used by the patient, the target of aggression, the consequences for the victims and the measures used to stop the aggression. Furthermore, there is a space where the nurse can describe the situation in free text. The SOAS-R has been used as a measurement tool in a number of descriptive studies (Abderhalden et al. 2002; De Niet, Hutschemaekers and Lendemeijer 2005; Bj€ orkdahl et al. 2007) and a review based on fifteen years of findings published in 2005 concluded that the SOAS-R makes it possible to obtain data in a highly comparable way (Nijman et al. 2005). © 2015 John Wiley & Sons Ltd
Ethics The project was reported to the Regional Ethics Committee of Region Zealand and fully complies with Danish legislation. The Danish Data Protection Agency was notified of the study and found it to comply with the standards for storing and processing data. The project was carried out in accordance with the Declaration of Helsinki II Principles. There were not risks, disadvantages or discomfort associated with the project for any of the participants involved. The hospital management gave access to the already anonymized data extractions (that is, no names or personal identification numbers). Private details in the data extracts presented below have been altered to ensure that participants cannot be recognized.
Data analysis The text analysis in our study investigates which discourses the nurses drew upon by examining the linguistic properties of the texts. After reading the texts and making some initial analyses, a basic pattern of clauses stood out as central to us and we decided that the analysis should include a detailed examination of the following textual features: textual organization, grammar and vocabulary (Fairclough 1992). First, we analyzed the textual organization, such as text cohesion and intertextuality. Our focus was on how genres and recording styles were incorporated in the texts (Fairclough 2003), and we were able to identify a typical text structure. Second, we analyzed the grammar. The examination of this feature gave insight into how nurses interpreted their world and how they identified themselves as nurses. Grammar addresses the micro-aspects of a text, 299
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De Niet GJ, GJM Hutschemaekers and BHHG Lendemeijer. 2005. Is the reducing effect of the staff observation aggression scale owing to a learning effect? An explorative study. Journal of Psychiatric and Mental Health Nursing 12(6): 687–94. Duxbury J. 2002. An evaluation of staff and patient views of and strategies employed to manage inpatient aggression and violence on one mental health unit: A pluralistic design. Journal of Psychiatric and Mental Health Nursing 9 (3): 325–37. Duxbury J and R Whittington. 2005. Causes and management of patient aggression and violence: Staff and patient perspectives. Journal of Advanced Nursing 50(5): 469–78. Ekman I and K Segesten. 1995. Deputed power of medical control: The hidden message in the ritual of oral shift reports. Journal of Advanced Nursing 22(5): 1006–11. Fairclough N. 1992. Discourse and social change. Cambridge, UK; Cambridge, MA: Polity Press. Fairclough N. 2003. Analysing discourse: Textual analysis for social research. New York: Routledge. Foster C, L Bowers and H Nijman. 2007. Aggressive behaviour on acute psychiatric wards: Prevalence, severity and management. Journal of Advanced Nursing 58(2): 140–9. Gee JP. 2013. An introduction to discourse analysis: Theory and method. New York: Routledge. Gergen KJ. 2001. Psychological science in a postmodern context. The American Psychologist 56(10): 803–13. Goffman E. 1963. Stigma: Notes on the management of spoiled identity. Englewood Cliffs, NJ: Prentice-Hall. Hamilton B and E Manias. 2006. ‘She’s manipulative and he’s right off’: A critical analysis of psychiatric nurses’ oral and written language in the acute inpatient setting. International Journal of Mental Health Nursing 15(2): 84–92. Heartfield M. 1996. Nursing documentation and nursing practice: A discourse analysis. Journal of Advanced Nursing 24(1): 98–103. Irving K, M Treacy, A Scott, A Hyde, M Butler and P MacNeela. 2006. Discursive practices in the documentation of patient assessments. Journal of Advanced Nursing 53(2): 151–9.
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Liu J. 2004. Concept analysis: Aggression. Issues in Mental Health Nursing 25(7): 693–714. Miles M, BAM Huberman and J Saldan ˜ a. 2014. Qualitative data analysis: A methods sourcebook. Thousand Oaks, CA: Sage. Millar R and N Sands. 2013. ‘He did what? Well, that wasn’t handed over!’ Communicating risk in mental health. Journal of Psychiatric and Mental Health Nursing 20(4): 345– 54. Mohr WK. 1999. Deconstructing the language of psychiatric hospitalization. Journal of Advanced Nursing 29(5): 1052– 9. Morrison EF. 1992. A coercive interactional style as an antecedent to aggression in psychiatric patients. Research in Nursing & Health 15(6): 421–31. Nijman HLI, P Muris, HLG Merckelbach, T Palmstierna, B Wistedt, AM Vos et al. 1999. The Staff Observation Aggression Scale–revised (SOAS-R). Aggressive Behavior 25 (3): 197–209. Nijman HLI, T Palmstierna, R Almvik and JJ Stolker. 2005. Fifteen years of research with the Staff Observation Aggression Scale: A review. Acta Psychiatrica Scandinavica 111(1): 12–21. Palmstierna T and B Wistedt. 1987. Staff Observation Aggression Scale, SOAS: Presentation and evaluation. Acta Psychiatrica Scandinavica 76(6): 657–63. Papadopoulos C, J Ross, D Stewart, C Dack, K James and L Bowers. 2012. The antecedents of violence and aggression within psychiatric in-patient settings. Acta Psychiatrica Scandinavica 125(6): 425–39. Perron A and D Holmes. 2011. Constructing mentally ill inmates: Nurses’ discursive practices in corrections. Nursing Inquiry 18(3): 191–204. Schofield I, D Tolson and V Fleming. 2012. How nurses understand and care for older people with delirium in the acute hospital: A critical discourse analysis. Nursing Inquiry 19(2): 165–76. Secker J, A Benson, E Balfe, M Lipsedge, S Robinson and J Walker. 2004. Understanding the social context of violent and aggressive incidents on an inpatient unit. Journal of Psychiatric and Mental Health Nursing 11(2): 172–8.
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TRIGGER (T)
The trigger presents the part of the narrative that describes the events leading to the aggression. The trigger intensifies the unpredictability highlighted in the Context. The trigger often describes a restriction, a kind of limit-setting statement, a certain rule or treatment regime. Triggers are described by the nurses and represent their interpretation of the trigger: for example, ‘the patient got upset because he was prevented from smoking’ (see Extract 1). In many entries, the trigger includes the word ‘denied’, for example: ‘. . . Pt. was denied smoking two cigarettes in a row. . .’ (no. 546). The structured SOAS-R template uses the word denied, which might have influenced the records.
rationale makes use of local, specialized language, and it legitimizes the interventions chosen by reference to authorities or various treatment regimes. Sometimes the narrative includes more than one rationale, and sometimes there is no apparent rationale at all. These rationales can be seen as explanations and legitimization of the interventions used in Phasing Out, or as further deliberations on the aggressive incident. The rationale contains various types of implicit presumptions and dilemmas, for instance, that the patient does not know what is best for him. The rationale shows how staff members try to achieve a balance between, on the one hand, what the patient says and, on the other hand, staff observations when they interpret and articulate patients’ intentions.
AGGRESSION (A)
This part presents the plot at the core of the narrative. The aggression part displays various recording styles and includes a number of words referring to aggression in different ways. Furthermore, we found a mix of specialized language and direct quotations used to characterize the patient using dramatic metaphors or homemade words. In the vocabulary, nurses draw on terminology from other contexts, among others a military or prison context (‘the patient was marching down the corridor’ (no. 70). RATIONALE (R)
The rationale is the part of the entries used to explain the circumstances in which the aggression occurred and to clarify the actions of the staff and the patient. The
Table 2 Data Extract 2 divided into parts Context Trigger
Aggression
Rationale
Phasing out
Pt. talked to his brother on the phone. Was allegedly told that the police had kicked in the door to his apartment and let out his two parrots and that they now lay dead in his apartment. Pt. became very angry, agitated and shouted loudly, both on the phone and afterwards when retelling it to the staff. Pt said, for example, ‘You’ve treated me like a pig, but just you wait I’ll kill you all, it will be a bloodbath, you’re torturing me’. In the situation, pt. was hardly able to distinguish between the staff members present and outside persons, who he believes has committed the above. Pt. was, with some difficulty, calmed down (account no. 1785)
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PHASING OUT (P)
Phasing out describes the culmination of the event. Nurses describe either how the patient withdraws or how the staff manages the patient successfully. Phasing out often includes intervening, either in terms of close observation or controlling or restraining the patient. In this part, nurses tend to depict themselves—explicitly or implicitly— as problem solvers, or as somebody who cannot be blamed in the situation. Data Extract 1 is an example of a short narrative entry consisting of the following combination of parts: C+R+T+A+P. It places the events in a sequence differing from the chronological order. The genre is standard reported speech, and the text is declarative. This extract is a knowledge-oriented statement of facts produced by the mental health staff. It is noticeable in Extract 1 how the staff tries to achieve a balance between care and restrictions when helping the patient calm down by upgrading restrictive interventions from ‘at obs.lev. 1’ to ‘restrained and further sedated’. The parts of text are linked together, and C+R+T establish the circumstances leading up to the aggression. Phasing Out legitimizes the intervention by referring to authorities (mentioning the doctor) and notes the assumption: ‘to calm down pt.’. The semantic relations between the sentences and clauses in the narrative create an image of a successful staff intervention, which constructs the identity of the nurses as problem solvers. In this way, nursing intervention is legitimized.
Representing actors This section describes how the nurses typically represent the patients and themselves.
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REPRESENTING PATIENTS AS UNTRUSTWORTHY
The analysis revealed a systematic way of representing patients as discursive elements of aggression. In particular, this is seen in the way in which nurses construct the patient’s perspective using quotes, and in their use of modality markers when describing the patient’s perspective. Data Extract 2 (table 2) is an example of how nurses represented the patient through their recording practices. Lower affinity markers are used in the descriptions of the patient’s opinion. Thereby, the nurse weakens the patient’s perspective on the events. The entry constructs the patient position as a person who is unable to provide an accurate description of the trigger. The nurse underscores the factuality of the observation by quoting the patient’s direct speech: ‘You’ve treated me like a pig, but just you wait I’ll kill you all, it will be a bloodbath, you’re torturing me’. By including direct speech, the writer employs markers indicating the severity of the situation, thereby depicting the patient as dangerous and unpredictable. The quote emphasizes the patient’s anger, expressed earlier in the nurse’s words: ‘angry, agitated and shouting loudly’. Using the modality markers ‘hardly able to’ and ‘he believes’, the nurse minimizes the credibility of the patient’s point of view. Phrases like ‘was allegedly told’ indicate a probability that the patient might be wrong. Extract 2 also shows how the rationale expresses assumptions about the patients: ‘. . .in the situation pt. was hardly able to distinguish. . .’. This way of phrasing seems to contradict the patient’s experience and indicates that patient is not trustworthy. REPRESENTING STAFF AS FREE OF BLAME
Representing staff illustrates how nurses depict themselves, identified on the basis of an analysis of grammar. Throughout the texts, the active and passive voice is used in specific ways. The main social actors, patients, are represented as active participants in the quotes. They are the doers of things and are therefore to be held responsible for the aggression. Healthcare staff members are represented impersonally and by means of the passive voice, which places the staff in the background of the incidents and as not directly responsible, for instance: ‘was therefore prevented from smoking’ (Extract 1). The nurses’ way of presenting the text can also be seen in terms of the way they implicitly describe their commitment. This is an important part of how they identify themselves. The texts revealed a technique aimed at giving an impression that coping with aggression is difficult. Thereby, professionals construct themselves as having a challenging
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job, which is illustrated in Extract 2: ‘Pt. was, with some difficulty, calmed down’. In describing the patients in this way, nurses convey a specific representation of themselves as the carers of their patients, positioning themselves as key players. In their presentation, mental health staff members are the objects of the aggression, but at the same time, they are implicitly using physical or verbal power to manage the patients, as in Extract 1 when the patient was mechanically restrained, or in Extract 2 when the patient was verbally calmed down. By choosing what to highlight from the event, the nurses justify their actions. In this way, they create an identity of themselves as responsible problem solvers, free of blame for any mismanagement of the aggressive incident.
Discourses of aggression The final section demonstrates how specific discourses on aggression are present in the texts. This was identified in the textual cohesion, and in particular, the vocabulary used to describe aggression. Recording aggressive incidents forces the mental health staff to translate their experience into an objective, formal reporting language. When transforming their experiences into an aggression record, they draw on a repertoire of textual features. This can be seen in the choice of phrasing and use of metaphors. Examples of metaphors we found in the data were as follows: ‘double time march’ (no. 2150), ‘will butcher them’ (no. 190), ‘witches who should be burnt’ (no. 745), ‘says he will shoot the undersigned’ (no. 1339), ‘stab him in the back’ (no. 241). The phrases and metaphors are often patient quotes, used by the nurses to describe the event. The metaphors create social imaginations belonging to different contexts, which will be interpreted by a reader on the basis of his or her understanding of the context. The metaphors we found are common to representations of aggression in a battlefield. A specific theme in the records is how care is constructed. Nurses seem to describe care in terms of regimes such as ‘seclusion regime’ (no. 996) or surveillance: ‘obs.lev. 1’ (no. 757). These regimes were identifiable in the analysis in various forms, but were commonly constructed as influenced by the patient’s behavior. Nurses are presented as solving the problems, by intervening to reverse the situation, for instance, in Extract 1 when the patient ‘was unable to control himself’ and the nurses helped him to become able to control him by medical and mechanical restraint. And in Extract 2 when the patient is ‘agitated and shouting loudly’,
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the nurse is able to calm him down verbally. Thereby, the nurses choose corrections to manage the patient that mirror the behavior of the patient, as a ritual response made by the nurses and solely guided by the patient’s behavior.
DISCUSSION The aim of the study was to gain insight into forensic nurses’ discursive practices of recording observed aggressive incidents. Viewed through the lens of a Fairclough CDA, the records illustrate how the nurses represented patient characteristics through the way they interpreted and linked complex social interactions. Papadopoulos et al. (2012) correctly emphasized that the SOAS-R only captures the nurses’ construction of aggression, which leaves the complete nature of the antecedents of aggression uncertain. In this sense, we were only able to show a partial and reconstructed glimpse of the social context in which an aggression took place. The free text accounts revealed how staff included and combined a collection of words when referring to aggression. The texts illustrated a particular set of circumstances that might never occur again in exactly the same way, ‘photographic slices of life’ as described by Appleton and King (2002) (with reference to Guba and Lincoln). The records gave insight into the ways in which staff members ascribe meaning to their experiences of aggression. When describing aggression, the authors of the records interact with their own world, and such descriptions can be viewed as a constructed reality shaped by the authors. The records gave access to events that were only known firsthand by the actors involved in the unique situation but had been recalled and reconstructed by the authors of the records. However, the stories can create social imaginaries interpreted by a reader on the basis of his or her understanding of the context. This could lead to situations where treatment decisions are heavily influenced by the nurses’ practices of recording and reporting (cf. Buus 2009). Nurses’ reporting practices can have widespread social consequences, such as assigning responsibility to patients for causing aggression. Mental health nurses frequently construct the cause and responsibility for aggression with the patient (Duxbury 2002; Duxbury and Whittington 2005). One such assumption was identified in the detailed reporting practice. The main actors, the patients, are represented as the aggressors. They are the doers of things and are therefore to be held responsible for the aggression. Assigning responsibility to patients for causing aggression was emphasized in how staff constructs the patients as untrustworthy. Staff members weaken the patient’s perspective, even though they try to construct a balance between what the © 2015 John Wiley & Sons Ltd
patient says and staff observations. Patient characteristics were demonstrated in the choice of phrasing when patients were quoted directly. That discursive technique constructed scenarios of deviant and dangerous patients who do not know what is best for them. When nurses emphasize patients as risk object, this potentially takes precedence over other concerns, ignoring that patients in mental health settings are acutely ill and have complex nursing needs, (cf. Schofield et al. 2012). The staff members’ representation of themselves as somebody who manages difficult patients successfully and without blame may also have social consequences. The use of the passive voice places the staff in the background of the incidents and as not responsible for the aggression. We found that the SOAS-R incidents were stated as matters of fact. In the short narrative entries, nurses produced successful staff interventions which depicted the episodes as unavoidable, and consequently, no staff members could be blamed. Furthermore, nurses legitimized intervention with reference to authorities, and they renamed restrictions as treatment. Such discursive framing of situations relived staff from responsibility and depicted them as acting correctly, in accordance with rules and regulations. Furthermore, they also represented themselves as the objects of aggression, which framed the mentally ill persons as violent and aggressive and reinforced the stigma associated with mental illness (Goffman 1963). Mental health workers implicitly used physical or verbal power to manage the patient solely guided by the patients’ behavior. Such techniques may be reinforced within a culture which assumes professionals always know best. In our inquiry, this was echoed in the documentation practice that emphasized nursing interventions as containment and corrections that fit into a battlefield metaphor. Perron and Holmes (2011) identified a similar containment discourse, named ‘corrections’. In their study, medication constituted a central strategy by which nurses took over and managed a situation. Our study only captured the correctional role based on aggression records; however, we suggest that the identification of a dominating correctional discourse may be linked to the particular genre of textual recording. Nurses in our study seemed to describe care in terms of regimes such as ‘seclusion regime’ or surveillance. These regimes were identifiable in the analysis in various forms. Nurses were presented as solving the problems, by intervening to reverse the situation. Thereby, the nurses chose corrections to manage the patient that mirror the behavior of the patient, as a ritual response made by the nurses, and solely guided by the patient’s behavior. We acknowledge that defusing anger may take precedence over other concerns; 303
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however, it is necessary to fundamentally rethink how power is shared with people and, as Campbell and Lindow (1997) pointed out, whether the mental health workers are working ‘with’, ‘doing to, ‘for’ or ‘with’ the individual patient.
language use in stressful situations and in the subsequent oral and written reporting.
Limitations
Abderhalden C, I Needham, TK Friedli, J Poelmans and T Dassen. 2002. Perception of aggression among psychiatric nurses in Switzerland. Acta Psychiatrica Scandinavica 106: 110–7. Anderson A and SG West. 2011. Violence against mental health professionals: When the treater becomes the victim. Innovations in Clinical Neuroscience 8(3): 34–9. Appleton JV and L King. 2002. Journeying from the philosophical contemplation of constructivism to the methodological pragmatics of health services research. Journal of Advanced Nursing 40(6): 641–8. Benson A, J Secker, E Balfe, M Lipsedge, S Robinson and J Walker. 2003. Discourses of blame: Accounting for aggression and violence on an acute mental health inpatient unit. Social Science & Medicine 57(5): 917–26. Bj€ orkdahl A, M Heilig, T Palmstierna and G Hansebo. 2007. Changes in the occurrences of coercive interventions and staff injuries on a psychiatric intensive care unit. Archives of Psychiatric Nursing 21(5): 270–7. Bowers L, H Nijman, A Simpson and J Jones. 2011. The relationship between leadership, teamworking, structure, burnout and attitude to patients on acute psychiatric wards. Social Psychiatry and Psychiatric Epidemiology 46(2): 143–8. Buus N. 2006. Conventionalized knowledge: Mental health nurses producing clinical knowledge at intershift handovers. Issues in Mental Health Nursing 27(10): 1079–96. Buus N. 2009. How writing records reduces clinical knowledge: A field study of psychiatric hospital wards. Archives of Psychiatric Nursing 23(2): 95–103. Buus N and BE Hamilton. In press. Social science and linguistic text analyses of nurses’ records: A systematic review and critique. Nursing Inquiry DOI: 10.1111/nin. 12106. Campbell P and V Lindow. 1997. Changing practice: Mentalhealth nursing and user empowerment. London: MIND. Cheek J and T Rudge. 1994. Nursing as textually mediated reality. Nursing Inquiry 1(1): 15–22. Cornaggia CM, M Beghi, F Pavone and F Barale. 2011. Aggression in psychiatry wards: A systematic review. Psychiatry Research 189(1): 10–20. Dack C, J Ross, C Papadopoulos, D Stewart and L Bowers. 2013. A review and meta-analysis of the patient factors associated with psychiatric in-patient aggression. Acta Psychiatrica Scandinavica 127(4): 255–68.
The texts were analyzed in accordance with Fairclough’s (1992) approach to CDA. This approach ensured a systematic and comprehensive exploration of the linguistic properties of the texts. The corpus of texts was relatively large (2700), and the systematic selection of a sample of 270 extracts ensured that the writing styles of several nurses were present in the dataset. Furthermore, the number of extracts ensured records of a variety of aggressive incidents as the sample concerned 184 unique patients. Co-researchers took part in quality checks and in discussions of interpretations. During the coding process, we analyzed different sequences of text together with a forum of peers to challenge our reading of the texts, and the specific patterns in the short narrative entries were checked for their representativeness against the total text corpus (Miles, Huberman and Salda~ na 2014). Our study captured the textual perspective of aggression from the mental health staff’s perspective, and we regard our set of findings as one representation among several possible representations of aggression.
CONCLUSION This study gained insight into nurses’ discursive practices when they record observed aggressive incidents in a forensic setting. The analysis indicated that the nurses articulated their clinical experiences in narrative forms that stereotyped forensic psychiatric patients as being deviant, unpredictable and dangerous and, simultaneously, legitimized their own actions and interventions. Nurses need to become more aware of the constitutive power of their language and, in particular, the ways in which it might harm patients. Language use has social functions that are rarely evident to the actual language users and we regard the study as an important contribution to nurses’ reflections on the inevitable constructive nature of their clinical discourse. Conventionalized language use, such as described in the present study, might impede the implementation of new strategies for managing aggression and we hope that the present study can motivate policy-makers, leaders, service-users and nurses to collaborate in developing and implementing new strategies for aggression management. Finally, we suggest that relevant nursing bodies develop training curricula to promote greater reflection on 304
REFERENCES
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Discourse of aggression in Mental Health
De Niet GJ, GJM Hutschemaekers and BHHG Lendemeijer. 2005. Is the reducing effect of the staff observation aggression scale owing to a learning effect? An explorative study. Journal of Psychiatric and Mental Health Nursing 12(6): 687–94. Duxbury J. 2002. An evaluation of staff and patient views of and strategies employed to manage inpatient aggression and violence on one mental health unit: A pluralistic design. Journal of Psychiatric and Mental Health Nursing 9 (3): 325–37. Duxbury J and R Whittington. 2005. Causes and management of patient aggression and violence: Staff and patient perspectives. Journal of Advanced Nursing 50(5): 469–78. Ekman I and K Segesten. 1995. Deputed power of medical control: The hidden message in the ritual of oral shift reports. Journal of Advanced Nursing 22(5): 1006–11. Fairclough N. 1992. Discourse and social change. Cambridge, UK; Cambridge, MA: Polity Press. Fairclough N. 2003. Analysing discourse: Textual analysis for social research. New York: Routledge. Foster C, L Bowers and H Nijman. 2007. Aggressive behaviour on acute psychiatric wards: Prevalence, severity and management. Journal of Advanced Nursing 58(2): 140–9. Gee JP. 2013. An introduction to discourse analysis: Theory and method. New York: Routledge. Gergen KJ. 2001. Psychological science in a postmodern context. The American Psychologist 56(10): 803–13. Goffman E. 1963. Stigma: Notes on the management of spoiled identity. Englewood Cliffs, NJ: Prentice-Hall. Hamilton B and E Manias. 2006. ‘She’s manipulative and he’s right off’: A critical analysis of psychiatric nurses’ oral and written language in the acute inpatient setting. International Journal of Mental Health Nursing 15(2): 84–92. Heartfield M. 1996. Nursing documentation and nursing practice: A discourse analysis. Journal of Advanced Nursing 24(1): 98–103. Irving K, M Treacy, A Scott, A Hyde, M Butler and P MacNeela. 2006. Discursive practices in the documentation of patient assessments. Journal of Advanced Nursing 53(2): 151–9.
© 2015 John Wiley & Sons Ltd
Liu J. 2004. Concept analysis: Aggression. Issues in Mental Health Nursing 25(7): 693–714. Miles M, BAM Huberman and J Saldan ˜ a. 2014. Qualitative data analysis: A methods sourcebook. Thousand Oaks, CA: Sage. Millar R and N Sands. 2013. ‘He did what? Well, that wasn’t handed over!’ Communicating risk in mental health. Journal of Psychiatric and Mental Health Nursing 20(4): 345– 54. Mohr WK. 1999. Deconstructing the language of psychiatric hospitalization. Journal of Advanced Nursing 29(5): 1052– 9. Morrison EF. 1992. A coercive interactional style as an antecedent to aggression in psychiatric patients. Research in Nursing & Health 15(6): 421–31. Nijman HLI, P Muris, HLG Merckelbach, T Palmstierna, B Wistedt, AM Vos et al. 1999. The Staff Observation Aggression Scale–revised (SOAS-R). Aggressive Behavior 25 (3): 197–209. Nijman HLI, T Palmstierna, R Almvik and JJ Stolker. 2005. Fifteen years of research with the Staff Observation Aggression Scale: A review. Acta Psychiatrica Scandinavica 111(1): 12–21. Palmstierna T and B Wistedt. 1987. Staff Observation Aggression Scale, SOAS: Presentation and evaluation. Acta Psychiatrica Scandinavica 76(6): 657–63. Papadopoulos C, J Ross, D Stewart, C Dack, K James and L Bowers. 2012. The antecedents of violence and aggression within psychiatric in-patient settings. Acta Psychiatrica Scandinavica 125(6): 425–39. Perron A and D Holmes. 2011. Constructing mentally ill inmates: Nurses’ discursive practices in corrections. Nursing Inquiry 18(3): 191–204. Schofield I, D Tolson and V Fleming. 2012. How nurses understand and care for older people with delirium in the acute hospital: A critical discourse analysis. Nursing Inquiry 19(2): 165–76. Secker J, A Benson, E Balfe, M Lipsedge, S Robinson and J Walker. 2004. Understanding the social context of violent and aggressive incidents on an inpatient unit. Journal of Psychiatric and Mental Health Nursing 11(2): 172–8.
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Discourses of aggression in forensic mental health: a critical discourse analysis of mental health nursing staff records aPsychiatric
Lene L Berring,a Liselotte Pedersena and Niels Buusb Research Unit, Region Zealand, Roskilde, Denmark, bInstitute of Public Health, University of Southern Denmark, Odense, Denmark Accepted for publication 27 May 2015 DOI: 10.1111/nin.12113
BERRING LL, PEDERSEN L and BUUS N. Nursing Inquiry 2015; 22: 296–305 Discourses of aggression in forensic mental health: a critical discourse analysis of mental health nursing staff records Managing aggression in mental health hospitals is an important and challenging task for clinical nursing staff. A majority of studies focus on the perspective of clinicians, and research mainly depicts aggression by referring to patient-related factors. This qualitative study investigates how aggression is communicated in forensic mental health nursing records. The aim of the study was to gain insight into the discursive practices used by forensic mental health nursing staff when they record observed aggressive incidents. Textual accounts were extracted from the Staff Observation Aggression ScaleRevised (SOAS-R), and Fairclough’s critical discourse analysis was used to identify short narrative entries depicting patients and staffs in typical ways. The narratives contained descriptions of complex interactions between patient and staff that were linked to specific circumstances surrounding the patient. These antecedents, combined with the aggression incident itself, created stereotyping representations of forensic psychiatric patients as deviant, unpredictable and dangerous. Patient and staff identities were continually (re)produced by an automatic response from the staff that was solely focused on the patient’s behavior. Such response might impede implementation of new strategies for managing aggression. Key words: aggression, critical theory, discourse analysis, forensic nursing, hospitals, language, nursing records, psychiatric, qualitative studies.
Managing aggression and violence in a mental health setting is an important and challenging task as it can result in staff and patient injuries (Anderson and West 2011; Bowers et al. 2011). Aggression can be expressed differently ranging from a patient raising their voice to a direct provoked or unprovoked attack (Foster, Bowers and Nijman 2007), but there is a broad consensus that aggression includes ‘nonverbal, verbal and physical behavior that are threatening or harmful to others or property’ (Morrison 1992, 422). Aggression can be Correspondence: Lene L Berring, Psychiatric Research Unit, Toftebakken 9, 4000, Roskilde, Denmark. E-mail:
defined and studied in several ways, such as a normal part of life, a symptom of illness or as a socially constructed phenomenon (Liu 2004). In this article, we adopt a social constructionist perspective (Gergen 2001) on aggression as we explore the ways in which aggression is constructed in clinical language use. These constructions of aggression influence on, and are influenced by, the concrete management of aggression. Understanding healthcare professionals’ ways of constructing aggression is an important supplement to the existing research on aggression as it gives insight into the social contexts of aggression and aggression management.
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Discourse of aggression in Mental Health
BACKGROUND Aggression Most research in psychiatry account for aggressive episodes by referring to the following themes: the incident, its antecedent, its consequences, the time and place, the patient and staff perspectives, and the social and clinical profile of the patient (Cornaggia et al. 2011; Papadopoulos et al. 2012; Dack et al. 2013). Based on a systematic review, Dack et al. (2013) describe the profile of the typical aggressive patient as male, involuntarily admitted and with a diagnosis of schizophrenia; he is most likely young, single and from an ethnic minority. Besides this, the risk of aggression is increased by previous episodes of aggression, the presence of impulsiveness and hostility, and long periods of hospitalization (Cornaggia et al. 2011). However, Dack et al. (2013) suggest that factors other than patient characteristics may help predict aggression. Most studies of aggression and violence in clinical psychiatry have focused on the patient characteristics; however, Papadopoulos et al. (2012) found that aggressive situations could also be triggered by a problematic relationship between staff and patients. Only a few studies have included the patient’s perspective or sought explanations beyond the level of the immediate hospital context, such as the dynamic environment within which health-care is provided (Papadopoulos et al. 2012). Duxbury (2002) included the patient perspective and found a distinction between the way staff and patients viewed both the problem of aggression and the responses to aggression. Staff members point to internal patient factors and external factors as a reason for aggressive behavior, whereas patients view staff responses (e.g., a controlling style among staff) as a factor provoking aggression. A subsequent study (Duxbury and Whittington 2005) confirmed that both patients and staff were clearly dissatisfied with the way aggression was managed and that they drew on different discourses to construct specific notions of the reasons for aggression. Moreover, Benson et al. (2003) found that clients and staff use the same discourses of mental illness to explain aggressive and violent incidences. Issues of blame were a dominant construct in everyday accounts, with patients blaming staff and staff blaming patients. A central finding in Secker et al. (2004) thematic analysis of the social context of aggressive incidents was that staff did not engage much with patients and were not capable of relating to the patients’ perspectives. The above studies illustrate that patients are predominantly represented as those who were responsible for causing aggression but, also, that the constructions of © 2015 John Wiley & Sons Ltd
aggression differ according to the position and perspective of those who are interviewed. Little is known about the social contexts of aggressive incidents and the interpretative frames and discourses people draw on when they construct explanations of aggression, and how they position themselves when doing so.
Discourses in nursing records When it comes to discourses in mental health nursing, written records play a central part in how aggression and nursing is represented, as such records produce a textually mediated reality (Cheek and Rudge 1994). A discourse is a particular way of constructing some part of the world, such as identity, social relationships and social reality (Fairclough 2003), which can be identified in all kinds of language use (Gee 2013). Nursing documentation takes place within a dynamic social context involving many actors and agendas (Buus and Hamilton In press). In keeping with this, documentation has widespread social consequences. As some studies suggest, written text can perpetuate certain unspoken assumptions about patients and staff. Recording establishes nurses as professionals as their use of language externalizes their professional consciousness and decisionmaking (Buus 2009). Furthermore, the language used creates representations of nurses and patients (Heartfield 1996; Irving et al. 2006; Perron and Holmes 2011; Schofield, Tolson and Fleming 2012). Conventions and habits of language are maintained in social routines and traditions, such as in day-to-day records and oral shift reports (Ekman and Segesten 1995). Records and shift reports are regarded as crucial for the continuity of care, and nursing record systems are expected to have a significant influence on nurses’ practice. Millar and Sands (2013) pointed out incompleteness in documentation practice; they found that in mental health settings, shift handovers involving information on risk were unstructured and based on a ‘need-to-know’ attitude. That ‘need-to-know’ attitude might create inappropriate constructs of patients. Buus (2006) also found that handover information was provided in an ad hoc manner based on the outgoing nurses’ own opinions of the incoming nurses’ need for information. He described how nurses acquire a significant part of the clinical knowledge about their patients through interactions with other staff members, rather than through direct interaction with their patients. The findings indicated that nurses, through their recordings, produced stereotyped representations of the patients (Buus 2006). Hamilton and Manias (2006) investigated spoken and written language in nursing, and based on a critical analysis 297
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of nurses’ oral and written language, they demonstrated the way in which discourses were expressed in acute inpatient psychiatric units. They identified how a management discourse was expressed in the language used. Generally speaking, a management discourse monitors, reports and controls products and productivity, and they argued that the management discourse was influenced by the pressure for throughputs, in the form of high patient turnover. This was seen in how patients were objectified and were ‘tracked as risk-laden objects through the process of a hospital stay’ (Hamilton and Manias 2006, 91). What this seems to suggest is that documentation plays a central role in how patient subjectivities are represented, which was also reported in Perron and Holmes’ (2011) study about constructing mentally ill inmates in a forensic setting. Based on progress notes and observations, they identified how patient subjectivities were produced. Patients were portrayed as five stereotypes: the (in)visible patient, the patient at risk, the deviant patient, the disturbed patient and the disciplined patient. They also revealed how nurses monitor patients. The practice of surveillance was made compulsory by a climate of persistent focus on risk and security (Perron and Holmes 2011). The authors suggest that even though there was a discourse of care in the unit, the progress notes illustrated complex discursive practices of correction, and the way in which subjects were represented became authoritative and difficult to challenge. In addition to formal medical discourses also informal discourses exist in nurses’ records (Irving et al. 2006; Buus 2009), which is reflected in nurses using everyday language with more or less specific clinical meanings (Buus 2009). Mohr’s (1999) study pointed out this use of everyday language in chart entries. She found that a large part of the language in chart entries consisted of professional jargon, and she argued that this jargon-laden language was the primary tool of communication among nurses and other professionals. Mohr argued that jargon can be efficient, but jargon can also hide the shortcomings of inadequately prepared staff members. Furthermore, Mohr argued that the charts positioned the patients as deviant others. The studies above exemplify how nurses and patients are represented in nursing records. Nurses are represented as authoritative and difficult to challenge and care is represented as corrections. This custodial approach is enrolled in a risk management discourse, and patients are represented as risk-laden objects, described with metaphors depicting the deviant other and the disturbed
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patient. The literature concerning aggression within inpatient settings is extensive and indicative of the level of concern surrounding the topic. Taken together, previous research of discourses in documentation practices indicates that records produce a textually mediated reality constructing stereotyped representations of the patients, based on the nurses’ own interpretation of the incident. Thus, the context of aggression is complex. In this study, we will explore the discursive practices of nurses when they write reports of aggressive incidents in a forensic mental health setting.
Theoretical framework Discourses display how social events are represented and encompass the use of spoken and written language (Gee 2013). Fairclough defined discourse as a practice not just of representing the world, but also of signifying, constituting and constructing the world in meaning (Fairclough 1992). Thus, discourses in healthcare records shape and maintain certain representations of patients, by allowing what is included and what is excluded. Discourses are different ways of representing some part of the world. This can be social practice, such as processes, relations and the structures of the mental and the material world, as well as the social world (Fairclough 2003). Language represents codes, conventions and habits of language that are produced in the context and have culturally and historically located meanings (Fairclough 1992). This study was informed by a constructionist view (Gergen 2001) and designed to focus on how nurses describe and textually mediate aggression in a forensic context. If we understand how the language used creates social effects, we may be able to question underlying, taken-forgranted assumptions about aggression. Awareness of these discursive mechanisms may help expand and develop new strategies for aggression management.
AIM The aim of the study was to analyze the discursive practices used when forensic mental health staff record observed aggressive incidents. The following study questions are addressed: 1 How are patients and mental health staff represented in mental health staff’s first-hand accounts of aggressive episodes? 2 Which discourses can be identified in the clinical texts?
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Discourse of aggression in Mental Health
METHODS
Procedure
Setting
The data forming the corpus of the study were the written records made by mental health staff recording observed aggressive incidents. The data were free text accounts extracted from a register of descriptions of aggressive episodes from 2008 to 2012 based on the SOAS-R. SOAS-R registrations are recorded as first-hand records and are kept separate from the day-to-day documentation, but they still form part of the biographical file of the individual patient. The corpus of texts analyzed consisted of 270 accounts concerning 181 male and 3 female patients. These accounts were systematically extracted as every 10th of a total corpus of 2700 recorded aggressive episodes. For the purpose of this study, the 270 accounts were copied and pasted into a text document and analyzed.
The study setting was a forensic psychiatric institution having the Capital Region of Denmark as its catchment area. The vast majority of the patients were admitted under court orders for psychiatric treatment because they were considered unfit to serve a prison sentence due to severe psychopathology. To achieve the aim of the study, we chose a critical discourse analysis (CDA) approach to examine how the mental health staff construct accounts of aggression when recording incidents. Critical discourse analysis is an interdisciplinary approach to the study of discourse which views language as a form of social practice and focuses on the ways social and political domination is reproduced in text and talk (Fairclough 2003). There are different approaches to CDA, but the assumption shared by all CDA practitioners is that language effects social change and that language constitutes power (Fairclough 1992). The CDA framework conceived by Fairclough (1992) was originally three-dimensional and involved analysis of text, discursive practice and social practice. As our dataset includes written records only, the approach we chose in this study focuses on the written text —linguistics and semiosis. Critical discourse analysis draws on several disciplines in the social sciences, such as critical linguistics, to examine the ideologies and power relations involved in discourse (Fairclough 1992).
The SOAS-R The Staff Observation Aggression Scale (SOAS-R) (Palmstierna and Wistedt 1987; Nijman et al. 1999) is a tool for recording aggression, ensuring that information about aggression is adequately recorded. The SOAS-R is to be filled out by mental health staff when an aggressive incident has been observed. The form is a structured template incorporating information on any provocation leading up to the incident, the means used by the patient, the target of aggression, the consequences for the victims and the measures used to stop the aggression. Furthermore, there is a space where the nurse can describe the situation in free text. The SOAS-R has been used as a measurement tool in a number of descriptive studies (Abderhalden et al. 2002; De Niet, Hutschemaekers and Lendemeijer 2005; Bj€ orkdahl et al. 2007) and a review based on fifteen years of findings published in 2005 concluded that the SOAS-R makes it possible to obtain data in a highly comparable way (Nijman et al. 2005). © 2015 John Wiley & Sons Ltd
Ethics The project was reported to the Regional Ethics Committee of Region Zealand and fully complies with Danish legislation. The Danish Data Protection Agency was notified of the study and found it to comply with the standards for storing and processing data. The project was carried out in accordance with the Declaration of Helsinki II Principles. There were not risks, disadvantages or discomfort associated with the project for any of the participants involved. The hospital management gave access to the already anonymized data extractions (that is, no names or personal identification numbers). Private details in the data extracts presented below have been altered to ensure that participants cannot be recognized.
Data analysis The text analysis in our study investigates which discourses the nurses drew upon by examining the linguistic properties of the texts. After reading the texts and making some initial analyses, a basic pattern of clauses stood out as central to us and we decided that the analysis should include a detailed examination of the following textual features: textual organization, grammar and vocabulary (Fairclough 1992). First, we analyzed the textual organization, such as text cohesion and intertextuality. Our focus was on how genres and recording styles were incorporated in the texts (Fairclough 2003), and we were able to identify a typical text structure. Second, we analyzed the grammar. The examination of this feature gave insight into how nurses interpreted their world and how they identified themselves as nurses. Grammar addresses the micro-aspects of a text, 299
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De Niet GJ, GJM Hutschemaekers and BHHG Lendemeijer. 2005. Is the reducing effect of the staff observation aggression scale owing to a learning effect? An explorative study. Journal of Psychiatric and Mental Health Nursing 12(6): 687–94. Duxbury J. 2002. An evaluation of staff and patient views of and strategies employed to manage inpatient aggression and violence on one mental health unit: A pluralistic design. Journal of Psychiatric and Mental Health Nursing 9 (3): 325–37. Duxbury J and R Whittington. 2005. Causes and management of patient aggression and violence: Staff and patient perspectives. Journal of Advanced Nursing 50(5): 469–78. Ekman I and K Segesten. 1995. Deputed power of medical control: The hidden message in the ritual of oral shift reports. Journal of Advanced Nursing 22(5): 1006–11. Fairclough N. 1992. Discourse and social change. Cambridge, UK; Cambridge, MA: Polity Press. Fairclough N. 2003. Analysing discourse: Textual analysis for social research. New York: Routledge. Foster C, L Bowers and H Nijman. 2007. Aggressive behaviour on acute psychiatric wards: Prevalence, severity and management. Journal of Advanced Nursing 58(2): 140–9. Gee JP. 2013. An introduction to discourse analysis: Theory and method. New York: Routledge. Gergen KJ. 2001. Psychological science in a postmodern context. The American Psychologist 56(10): 803–13. Goffman E. 1963. Stigma: Notes on the management of spoiled identity. Englewood Cliffs, NJ: Prentice-Hall. Hamilton B and E Manias. 2006. ‘She’s manipulative and he’s right off’: A critical analysis of psychiatric nurses’ oral and written language in the acute inpatient setting. International Journal of Mental Health Nursing 15(2): 84–92. Heartfield M. 1996. Nursing documentation and nursing practice: A discourse analysis. Journal of Advanced Nursing 24(1): 98–103. Irving K, M Treacy, A Scott, A Hyde, M Butler and P MacNeela. 2006. Discursive practices in the documentation of patient assessments. Journal of Advanced Nursing 53(2): 151–9.
© 2015 John Wiley & Sons Ltd
Liu J. 2004. Concept analysis: Aggression. Issues in Mental Health Nursing 25(7): 693–714. Miles M, BAM Huberman and J Saldan ˜ a. 2014. Qualitative data analysis: A methods sourcebook. Thousand Oaks, CA: Sage. Millar R and N Sands. 2013. ‘He did what? Well, that wasn’t handed over!’ Communicating risk in mental health. Journal of Psychiatric and Mental Health Nursing 20(4): 345– 54. Mohr WK. 1999. Deconstructing the language of psychiatric hospitalization. Journal of Advanced Nursing 29(5): 1052– 9. Morrison EF. 1992. A coercive interactional style as an antecedent to aggression in psychiatric patients. Research in Nursing & Health 15(6): 421–31. Nijman HLI, P Muris, HLG Merckelbach, T Palmstierna, B Wistedt, AM Vos et al. 1999. The Staff Observation Aggression Scale–revised (SOAS-R). Aggressive Behavior 25 (3): 197–209. Nijman HLI, T Palmstierna, R Almvik and JJ Stolker. 2005. Fifteen years of research with the Staff Observation Aggression Scale: A review. Acta Psychiatrica Scandinavica 111(1): 12–21. Palmstierna T and B Wistedt. 1987. Staff Observation Aggression Scale, SOAS: Presentation and evaluation. Acta Psychiatrica Scandinavica 76(6): 657–63. Papadopoulos C, J Ross, D Stewart, C Dack, K James and L Bowers. 2012. The antecedents of violence and aggression within psychiatric in-patient settings. Acta Psychiatrica Scandinavica 125(6): 425–39. Perron A and D Holmes. 2011. Constructing mentally ill inmates: Nurses’ discursive practices in corrections. Nursing Inquiry 18(3): 191–204. Schofield I, D Tolson and V Fleming. 2012. How nurses understand and care for older people with delirium in the acute hospital: A critical discourse analysis. Nursing Inquiry 19(2): 165–76. Secker J, A Benson, E Balfe, M Lipsedge, S Robinson and J Walker. 2004. Understanding the social context of violent and aggressive incidents on an inpatient unit. Journal of Psychiatric and Mental Health Nursing 11(2): 172–8.
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TRIGGER (T)
The trigger presents the part of the narrative that describes the events leading to the aggression. The trigger intensifies the unpredictability highlighted in the Context. The trigger often describes a restriction, a kind of limit-setting statement, a certain rule or treatment regime. Triggers are described by the nurses and represent their interpretation of the trigger: for example, ‘the patient got upset because he was prevented from smoking’ (see Extract 1). In many entries, the trigger includes the word ‘denied’, for example: ‘. . . Pt. was denied smoking two cigarettes in a row. . .’ (no. 546). The structured SOAS-R template uses the word denied, which might have influenced the records.
rationale makes use of local, specialized language, and it legitimizes the interventions chosen by reference to authorities or various treatment regimes. Sometimes the narrative includes more than one rationale, and sometimes there is no apparent rationale at all. These rationales can be seen as explanations and legitimization of the interventions used in Phasing Out, or as further deliberations on the aggressive incident. The rationale contains various types of implicit presumptions and dilemmas, for instance, that the patient does not know what is best for him. The rationale shows how staff members try to achieve a balance between, on the one hand, what the patient says and, on the other hand, staff observations when they interpret and articulate patients’ intentions.
AGGRESSION (A)
This part presents the plot at the core of the narrative. The aggression part displays various recording styles and includes a number of words referring to aggression in different ways. Furthermore, we found a mix of specialized language and direct quotations used to characterize the patient using dramatic metaphors or homemade words. In the vocabulary, nurses draw on terminology from other contexts, among others a military or prison context (‘the patient was marching down the corridor’ (no. 70). RATIONALE (R)
The rationale is the part of the entries used to explain the circumstances in which the aggression occurred and to clarify the actions of the staff and the patient. The
Table 2 Data Extract 2 divided into parts Context Trigger
Aggression
Rationale
Phasing out
Pt. talked to his brother on the phone. Was allegedly told that the police had kicked in the door to his apartment and let out his two parrots and that they now lay dead in his apartment. Pt. became very angry, agitated and shouted loudly, both on the phone and afterwards when retelling it to the staff. Pt said, for example, ‘You’ve treated me like a pig, but just you wait I’ll kill you all, it will be a bloodbath, you’re torturing me’. In the situation, pt. was hardly able to distinguish between the staff members present and outside persons, who he believes has committed the above. Pt. was, with some difficulty, calmed down (account no. 1785)
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PHASING OUT (P)
Phasing out describes the culmination of the event. Nurses describe either how the patient withdraws or how the staff manages the patient successfully. Phasing out often includes intervening, either in terms of close observation or controlling or restraining the patient. In this part, nurses tend to depict themselves—explicitly or implicitly— as problem solvers, or as somebody who cannot be blamed in the situation. Data Extract 1 is an example of a short narrative entry consisting of the following combination of parts: C+R+T+A+P. It places the events in a sequence differing from the chronological order. The genre is standard reported speech, and the text is declarative. This extract is a knowledge-oriented statement of facts produced by the mental health staff. It is noticeable in Extract 1 how the staff tries to achieve a balance between care and restrictions when helping the patient calm down by upgrading restrictive interventions from ‘at obs.lev. 1’ to ‘restrained and further sedated’. The parts of text are linked together, and C+R+T establish the circumstances leading up to the aggression. Phasing Out legitimizes the intervention by referring to authorities (mentioning the doctor) and notes the assumption: ‘to calm down pt.’. The semantic relations between the sentences and clauses in the narrative create an image of a successful staff intervention, which constructs the identity of the nurses as problem solvers. In this way, nursing intervention is legitimized.
Representing actors This section describes how the nurses typically represent the patients and themselves.
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REPRESENTING PATIENTS AS UNTRUSTWORTHY
The analysis revealed a systematic way of representing patients as discursive elements of aggression. In particular, this is seen in the way in which nurses construct the patient’s perspective using quotes, and in their use of modality markers when describing the patient’s perspective. Data Extract 2 (table 2) is an example of how nurses represented the patient through their recording practices. Lower affinity markers are used in the descriptions of the patient’s opinion. Thereby, the nurse weakens the patient’s perspective on the events. The entry constructs the patient position as a person who is unable to provide an accurate description of the trigger. The nurse underscores the factuality of the observation by quoting the patient’s direct speech: ‘You’ve treated me like a pig, but just you wait I’ll kill you all, it will be a bloodbath, you’re torturing me’. By including direct speech, the writer employs markers indicating the severity of the situation, thereby depicting the patient as dangerous and unpredictable. The quote emphasizes the patient’s anger, expressed earlier in the nurse’s words: ‘angry, agitated and shouting loudly’. Using the modality markers ‘hardly able to’ and ‘he believes’, the nurse minimizes the credibility of the patient’s point of view. Phrases like ‘was allegedly told’ indicate a probability that the patient might be wrong. Extract 2 also shows how the rationale expresses assumptions about the patients: ‘. . .in the situation pt. was hardly able to distinguish. . .’. This way of phrasing seems to contradict the patient’s experience and indicates that patient is not trustworthy. REPRESENTING STAFF AS FREE OF BLAME
Representing staff illustrates how nurses depict themselves, identified on the basis of an analysis of grammar. Throughout the texts, the active and passive voice is used in specific ways. The main social actors, patients, are represented as active participants in the quotes. They are the doers of things and are therefore to be held responsible for the aggression. Healthcare staff members are represented impersonally and by means of the passive voice, which places the staff in the background of the incidents and as not directly responsible, for instance: ‘was therefore prevented from smoking’ (Extract 1). The nurses’ way of presenting the text can also be seen in terms of the way they implicitly describe their commitment. This is an important part of how they identify themselves. The texts revealed a technique aimed at giving an impression that coping with aggression is difficult. Thereby, professionals construct themselves as having a challenging
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job, which is illustrated in Extract 2: ‘Pt. was, with some difficulty, calmed down’. In describing the patients in this way, nurses convey a specific representation of themselves as the carers of their patients, positioning themselves as key players. In their presentation, mental health staff members are the objects of the aggression, but at the same time, they are implicitly using physical or verbal power to manage the patients, as in Extract 1 when the patient was mechanically restrained, or in Extract 2 when the patient was verbally calmed down. By choosing what to highlight from the event, the nurses justify their actions. In this way, they create an identity of themselves as responsible problem solvers, free of blame for any mismanagement of the aggressive incident.
Discourses of aggression The final section demonstrates how specific discourses on aggression are present in the texts. This was identified in the textual cohesion, and in particular, the vocabulary used to describe aggression. Recording aggressive incidents forces the mental health staff to translate their experience into an objective, formal reporting language. When transforming their experiences into an aggression record, they draw on a repertoire of textual features. This can be seen in the choice of phrasing and use of metaphors. Examples of metaphors we found in the data were as follows: ‘double time march’ (no. 2150), ‘will butcher them’ (no. 190), ‘witches who should be burnt’ (no. 745), ‘says he will shoot the undersigned’ (no. 1339), ‘stab him in the back’ (no. 241). The phrases and metaphors are often patient quotes, used by the nurses to describe the event. The metaphors create social imaginations belonging to different contexts, which will be interpreted by a reader on the basis of his or her understanding of the context. The metaphors we found are common to representations of aggression in a battlefield. A specific theme in the records is how care is constructed. Nurses seem to describe care in terms of regimes such as ‘seclusion regime’ (no. 996) or surveillance: ‘obs.lev. 1’ (no. 757). These regimes were identifiable in the analysis in various forms, but were commonly constructed as influenced by the patient’s behavior. Nurses are presented as solving the problems, by intervening to reverse the situation, for instance, in Extract 1 when the patient ‘was unable to control himself’ and the nurses helped him to become able to control him by medical and mechanical restraint. And in Extract 2 when the patient is ‘agitated and shouting loudly’,
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Discourse of aggression in Mental Health
the nurse is able to calm him down verbally. Thereby, the nurses choose corrections to manage the patient that mirror the behavior of the patient, as a ritual response made by the nurses and solely guided by the patient’s behavior.
DISCUSSION The aim of the study was to gain insight into forensic nurses’ discursive practices of recording observed aggressive incidents. Viewed through the lens of a Fairclough CDA, the records illustrate how the nurses represented patient characteristics through the way they interpreted and linked complex social interactions. Papadopoulos et al. (2012) correctly emphasized that the SOAS-R only captures the nurses’ construction of aggression, which leaves the complete nature of the antecedents of aggression uncertain. In this sense, we were only able to show a partial and reconstructed glimpse of the social context in which an aggression took place. The free text accounts revealed how staff included and combined a collection of words when referring to aggression. The texts illustrated a particular set of circumstances that might never occur again in exactly the same way, ‘photographic slices of life’ as described by Appleton and King (2002) (with reference to Guba and Lincoln). The records gave insight into the ways in which staff members ascribe meaning to their experiences of aggression. When describing aggression, the authors of the records interact with their own world, and such descriptions can be viewed as a constructed reality shaped by the authors. The records gave access to events that were only known firsthand by the actors involved in the unique situation but had been recalled and reconstructed by the authors of the records. However, the stories can create social imaginaries interpreted by a reader on the basis of his or her understanding of the context. This could lead to situations where treatment decisions are heavily influenced by the nurses’ practices of recording and reporting (cf. Buus 2009). Nurses’ reporting practices can have widespread social consequences, such as assigning responsibility to patients for causing aggression. Mental health nurses frequently construct the cause and responsibility for aggression with the patient (Duxbury 2002; Duxbury and Whittington 2005). One such assumption was identified in the detailed reporting practice. The main actors, the patients, are represented as the aggressors. They are the doers of things and are therefore to be held responsible for the aggression. Assigning responsibility to patients for causing aggression was emphasized in how staff constructs the patients as untrustworthy. Staff members weaken the patient’s perspective, even though they try to construct a balance between what the © 2015 John Wiley & Sons Ltd
patient says and staff observations. Patient characteristics were demonstrated in the choice of phrasing when patients were quoted directly. That discursive technique constructed scenarios of deviant and dangerous patients who do not know what is best for them. When nurses emphasize patients as risk object, this potentially takes precedence over other concerns, ignoring that patients in mental health settings are acutely ill and have complex nursing needs, (cf. Schofield et al. 2012). The staff members’ representation of themselves as somebody who manages difficult patients successfully and without blame may also have social consequences. The use of the passive voice places the staff in the background of the incidents and as not responsible for the aggression. We found that the SOAS-R incidents were stated as matters of fact. In the short narrative entries, nurses produced successful staff interventions which depicted the episodes as unavoidable, and consequently, no staff members could be blamed. Furthermore, nurses legitimized intervention with reference to authorities, and they renamed restrictions as treatment. Such discursive framing of situations relived staff from responsibility and depicted them as acting correctly, in accordance with rules and regulations. Furthermore, they also represented themselves as the objects of aggression, which framed the mentally ill persons as violent and aggressive and reinforced the stigma associated with mental illness (Goffman 1963). Mental health workers implicitly used physical or verbal power to manage the patient solely guided by the patients’ behavior. Such techniques may be reinforced within a culture which assumes professionals always know best. In our inquiry, this was echoed in the documentation practice that emphasized nursing interventions as containment and corrections that fit into a battlefield metaphor. Perron and Holmes (2011) identified a similar containment discourse, named ‘corrections’. In their study, medication constituted a central strategy by which nurses took over and managed a situation. Our study only captured the correctional role based on aggression records; however, we suggest that the identification of a dominating correctional discourse may be linked to the particular genre of textual recording. Nurses in our study seemed to describe care in terms of regimes such as ‘seclusion regime’ or surveillance. These regimes were identifiable in the analysis in various forms. Nurses were presented as solving the problems, by intervening to reverse the situation. Thereby, the nurses chose corrections to manage the patient that mirror the behavior of the patient, as a ritual response made by the nurses, and solely guided by the patient’s behavior. We acknowledge that defusing anger may take precedence over other concerns; 303
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however, it is necessary to fundamentally rethink how power is shared with people and, as Campbell and Lindow (1997) pointed out, whether the mental health workers are working ‘with’, ‘doing to, ‘for’ or ‘with’ the individual patient.
language use in stressful situations and in the subsequent oral and written reporting.
Limitations
Abderhalden C, I Needham, TK Friedli, J Poelmans and T Dassen. 2002. Perception of aggression among psychiatric nurses in Switzerland. Acta Psychiatrica Scandinavica 106: 110–7. Anderson A and SG West. 2011. Violence against mental health professionals: When the treater becomes the victim. Innovations in Clinical Neuroscience 8(3): 34–9. Appleton JV and L King. 2002. Journeying from the philosophical contemplation of constructivism to the methodological pragmatics of health services research. Journal of Advanced Nursing 40(6): 641–8. Benson A, J Secker, E Balfe, M Lipsedge, S Robinson and J Walker. 2003. Discourses of blame: Accounting for aggression and violence on an acute mental health inpatient unit. Social Science & Medicine 57(5): 917–26. Bj€ orkdahl A, M Heilig, T Palmstierna and G Hansebo. 2007. Changes in the occurrences of coercive interventions and staff injuries on a psychiatric intensive care unit. Archives of Psychiatric Nursing 21(5): 270–7. Bowers L, H Nijman, A Simpson and J Jones. 2011. The relationship between leadership, teamworking, structure, burnout and attitude to patients on acute psychiatric wards. Social Psychiatry and Psychiatric Epidemiology 46(2): 143–8. Buus N. 2006. Conventionalized knowledge: Mental health nurses producing clinical knowledge at intershift handovers. Issues in Mental Health Nursing 27(10): 1079–96. Buus N. 2009. How writing records reduces clinical knowledge: A field study of psychiatric hospital wards. Archives of Psychiatric Nursing 23(2): 95–103. Buus N and BE Hamilton. In press. Social science and linguistic text analyses of nurses’ records: A systematic review and critique. Nursing Inquiry DOI: 10.1111/nin. 12106. Campbell P and V Lindow. 1997. Changing practice: Mentalhealth nursing and user empowerment. London: MIND. Cheek J and T Rudge. 1994. Nursing as textually mediated reality. Nursing Inquiry 1(1): 15–22. Cornaggia CM, M Beghi, F Pavone and F Barale. 2011. Aggression in psychiatry wards: A systematic review. Psychiatry Research 189(1): 10–20. Dack C, J Ross, C Papadopoulos, D Stewart and L Bowers. 2013. A review and meta-analysis of the patient factors associated with psychiatric in-patient aggression. Acta Psychiatrica Scandinavica 127(4): 255–68.
The texts were analyzed in accordance with Fairclough’s (1992) approach to CDA. This approach ensured a systematic and comprehensive exploration of the linguistic properties of the texts. The corpus of texts was relatively large (2700), and the systematic selection of a sample of 270 extracts ensured that the writing styles of several nurses were present in the dataset. Furthermore, the number of extracts ensured records of a variety of aggressive incidents as the sample concerned 184 unique patients. Co-researchers took part in quality checks and in discussions of interpretations. During the coding process, we analyzed different sequences of text together with a forum of peers to challenge our reading of the texts, and the specific patterns in the short narrative entries were checked for their representativeness against the total text corpus (Miles, Huberman and Salda~ na 2014). Our study captured the textual perspective of aggression from the mental health staff’s perspective, and we regard our set of findings as one representation among several possible representations of aggression.
CONCLUSION This study gained insight into nurses’ discursive practices when they record observed aggressive incidents in a forensic setting. The analysis indicated that the nurses articulated their clinical experiences in narrative forms that stereotyped forensic psychiatric patients as being deviant, unpredictable and dangerous and, simultaneously, legitimized their own actions and interventions. Nurses need to become more aware of the constitutive power of their language and, in particular, the ways in which it might harm patients. Language use has social functions that are rarely evident to the actual language users and we regard the study as an important contribution to nurses’ reflections on the inevitable constructive nature of their clinical discourse. Conventionalized language use, such as described in the present study, might impede the implementation of new strategies for managing aggression and we hope that the present study can motivate policy-makers, leaders, service-users and nurses to collaborate in developing and implementing new strategies for aggression management. Finally, we suggest that relevant nursing bodies develop training curricula to promote greater reflection on 304
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