Table 2.

Illustrative quotations from staff

Knowledge and skills necessary for the job	Interactions with patients and colleagues	Effects on staff
Education and training: ‘I think the emphasis in certain subjects is out of proportion. The notion that every junior doctor has to do four months surgery, I'm not quite sure what the value of that is. The fact that everyone has to do four months medicine, I can see the value of that, because whatever specialty you go into, there's a certain amount of medicine. Psychiatry, psychology, delirium, dementia is a fairly important part of what a lot of people will end up doing or dealing with. I don't know how much people have sat down and said, “Well, what are we training people to be and therefore what are the core competencies that our doctors need?”’ (Interview 58, Consultant)	Initial assessment, clerking:  ‘If you had a sort of pro forma or something like that which you could work your way through, then it would guide what you do in a more structured way. And it would standardise your care a bit better because every single person, when they're confronted by an agitated patient will do something different. Or they would deal with that situation in a different manner.’ (Interview 60, Consultant)	Emotional responses and psychological well-being:  ‘For any health professional involved with a patient who is either being aggressive or very vocal and agitated, I think it's distressing. I think in a general busy medical ward, they are high maintenance, high input patients that actually generate a lot of angst.’ (Interview 40, Consultant)
Job expectations:  ‘There is a stigma isn't there? When I said to people “I used to work on the neurosurgical ward”, it was like, “Oh wow”. I don't get that reaction now when I say I work with the elderly, no: “Oh right”.’ (Interview 30, Nurse)	Handling aggression and violence:  ‘If you don't have that life experience and the awareness of your own body language and how you may be perceived by somebody else you can get yourself in a tricky situation, or not be aware that something's going to happen, because you can't see the triggers.’ (Interview 51, Occupational Therapist)	Behavioural responses:  ‘I think sometimes, it's to ignore them, sometimes it's to do the bare minimum, sometimes you do see people losing their temper, getting short with patients. So it can be quite negative. I think neglect sometimes happens.’ (Interview 59, Consultant)
Experience outside formal settings:  ‘I think people who haven't had personal experience like I've had struggle, like, I know friends who struggle. Because it's difficult to know how to deal with patients, especially aggression and things like that’ (Interview 4, Health-care Assistant)	Communication with patients:  ‘Sometimes you're more veterinary in your approach. And then you perhaps may not be treating them in the same way as someone else that you can talk to. Are the patients given the same respect and dignity, because they can't talk to you and converse with you in the same way?’ (Interview 37, Consultant)	Job satisfaction:  ‘If you're doing it, and because you're not properly trained, and there is no satisfaction because the patient isn't responding because they, you're not speaking the same language and it becomes frustrating. And then, it just ended up worse and you just sort of resent those patients because you cannot deal with it.’ (Interview 16, Nurse)
	Teamwork:  ‘You have to make a real effort to say “Let's have an MDT about that person”. And it does happen, but if they were on a ward where the MDT met twice a week, and you know, they were all specialists in that area, I think those people would probably do a lot better. That's often what's lacking on a non-geriatric ward is you don't have that MDT.’ (Interview 40, Consultant)	Confidence in competence:  ‘It should be mandatory that you have some form of training, not just what the illness is about, but ways of actually being able to nurse properly and to talk to the patient, ways of dealing with patients that you might find difficult. I think if more nurses were confident about dealing with it, they wouldn't shy away from it so much.’ (Interview 16, Nurse)
	Specialist support:  ‘Quite often, senior doctors don't really know how to manage these patients either, and so you end up just having to refer, making a phone call to the psycho-geriatricians. When you get it, it's helpful but it's quite difficult to get. If you had a more specialist team coming in, then they might be able to get on top of things quicker and recognise the needs that this patient might have.’ (Interview 26, Junior Doctor)