INTRODUCTION: THE URGENCY OF THE PROBLEM
There is growing concern with the problem of 'challenging behaviour' (CB) in nursing and other clinical professions (Farrell, Bobrowski, & Bobrowski, 2006; Moniz-Cook, Woods, & Gardiner, 2000). A wide range of behaviours are encompassed by this term, ranging from violence to eccentric habits. It is not the severity of behaviours per se that determines whether it is challenging. Rather, it is whether nurses feel that they have the ability to manage the situation; that is, whether they have the necessary environmental resources (e.g. patient facilities) and personal resources (e.g. communication skills) (Kay, 1995).
Staff working with patients whose behaviour is labelled as CB are more anxious and less satisfied with their jobs than are others, feel less supported, and are more emotionally exhausted (Jenkins, Rose, & Lovell, 1997), more fearful about workrelated violence and less safe at work (Rose & Cleary, 2007). Other reported effects of patient aggression on staff include anger, guilt, selfblame and feelings of powerlessness (Needham, Abderhalden, Halfens, Fischer, & Dassen, 2005). In recognition of this problem, a plethora of state and national guidelines and requirements is falling on employers' desks (Department of Human Services, 2007; International Labour Organization, International Council of Nurses, World Health Organization, & Public Services International, 2002; Worksafe, 2008).
Our aim here is to provide a coherent framework for services to meet this new responsibility. We describe a training model based on sound educational principles, which acknowledges the importance of nurses' values, emotions and skills, their knowledge of the factors affecting clients' behaviour, and their knowledge of the ways in which the cultural and physical situation can influence behaviour. Program evaluation, in terms of learner outcomes and cost-effectiveness, are also discussed.
CHALLENGING BEHAVIOUR IS A PROBLEM OF INTERACTION
Attempts to understand CB fall into two broad types. The predominant approach emphasises properties of the patient and illness; for example, CB is related to gender, age, or intellectual disability (Emerson et al., 2001; Holden & Gitlesen, 2006; McClintock, Hall, & Oliver, 2003). Taking this approach objectifies CB, leading to an emphasis on policies and procedures for risk aversion and containment (Holmes, 2006). The second approach is 'interactional', whereby CB is recognised to be a product of both the patient and external factors - specifically the environment and staff behaviour (Secker et al., 2004).
The most obvious way in which staff are involved in the problem of CB is in labelling behaviour as 'challenging'. For example, consider a man raising his voice in the Emergency Department to complain about his spouse's care. The growing concern with CB and the increasing vigilance for 'violence hazard identification and risk assessment' that is emphasised in policies (Worksafe, 2008) may sensitise the nurse to perceive this as aggressive, and therefore as a 'risk factor' for escalation to physical violence. By contrast, a nursing response, based on assessment of individuals' needs, might be to regard such behaviour as evidence of intense anxiety. Taking an interactional perspective would then lead the nurse on to identify possible sources of the anxiety and to consider how staff might exacerbate or mitigate it. This reasoning therefore leads to the second level at which staff are involved in the problem of CB: they can inadvertently behave in ways that promote or reinforce CB. For example, the nurse who interpreted the man's raised voice as aggressive might become defensive or assertive in response. This might well, however, provoke an aggressive response from someone who is intensely frightened and needs reassurance. By contrast, the nurse who was sensitive to the man's underlying needs would try to calm him through a reassuring response. …