Workplace’s Development of Activities and Action Plans to Prevent Violence From Clients in High-Risk Sectors

Abstract

Introduction

Interventions trying to prevent violence from clients towards employees tend to show limited effect on the risk or the frequencies of violent episodes, possibly due to a too-narrow focus on only one or a few preventive strategies. This study aimed to show what employees and line managers identify as key intervention areas for preventing violence and threats.

Methods

The study is based on data collected during a participatory intervention study aiming to improve violence prevention in Danish psychiatric units and prison and detention centers. In the intervention study, employees and line managers from 13 work units developed 293 suggestions and 92 action plans to prevent workplace violence. Through qualitative thematic analysis of the suggestions and action plans, we identified the main categories that work units viewed as important and realistic to work with to improve violence prevention.

Results

We identified 12 topics of violence prevention that work units considered relevant. Action plan topics used by more than half of the work units included: specific approaches to violence prevention (e.g., de-escalating techniques), communication between employees to transfer knowledge between shifts, and introduction to new employees and temporary workers. Topics used by three to five work units were: interdisciplinary corporation, communication and relational work, uniform approaches, organization of work, and staffing. Topics used rarely were: definition of violence and threats, policy and guidelines, support from colleagues and management, and engagement in violence prevention. For nine of the 12 topics, action plans were developed in both high-risk sectors.

Conclusions

The violence prevention action plans developed by work units from two high-risk sectors indicate that workplaces estimate the prevention of client-induced workplace violence to require activities on many levels and cannot be solved by a single focused approach. This variety of preventive activities needs to be considered when designing violence prevention interventions.

Keywords

workplace violence mental health and violence violence exposure

Introduction

Violence and threats of violence in the workplace are particularly prevalent in sectors with a high degree of client contact (Hogh & Viitasara, 2005; Liu et al., 2019; Mento et al., 2020). Especially employees in psychiatric wards (Spector et al., 2014) and prisons (Konda et al., 2012, 2013; Rasmussen et al., 2013) have been found to be highly exposed to violence and threats from patients or inmates. Exposure to violence or threats of violence at work has been associated with several health consequences, such as symptoms of anxiety and depression and post-traumatic stress disorder (PTSD) (Andersen et al., 2019; Madsen et al., 2021; Pihl-Thingvad et al., 2019; Rudkjoebing et al., 2020). Furthermore, violence and threats of violence have been found to be associated with physical health issues such as the increased risk of diabetes (Xu, Hanson, et al., 2018) and cardiovascular disease (Xu, Magnusson Hanson, et al., 2018). Additionally, studies have found an increased risk of long-term sickness absence (Clausen et al., 2012; Aagestad et al., 2014), and that exposure to violence predicted health-related absence from work several years after having been exposed (Friis et al., 2018).

In this study, we focus on type II violence where the perpetrator is the client, and the victim is the employee (Wassell, 2009). It differs from other types of workplace violence, for example, robbery (type I), where the perpetrator has no legitimate relationship with the business or its employees. Type II violence has a relational aspect as the victim and the perpetrator encounter due to common legitimate access to the workplace, for example, patients at a hospital. Therefore, type II violence is also referred to as client-on-worker violence (NIOSH, 2021). In the present study, we follow the definition of violence and threats used by the Danish work environment authorities that state that violence can occur as both physical and mental violence. Physical violence involves actively inflicted violence such as blows, kicks, or stab wounds. Psychological violence is an episode in which employees are exposed to threats of violence, humiliation, suspicion, insult, or discriminatory statements, or can be expressed without words such as clenched fists. Psychological violence can also be perpetrated electronically via, for example, text messages, Email and websites (Arbejdstilsynet, 2011). The episodes may occur both in the workplace and outside the workplace but are related to one’s work or function. The reason for client-on-worker violence are often complex and can be influences by a multitude of individual, situational, and organizational causes (Arnetz et al., 2015; di Giacomo et al., 2020; Nowrouzi-Kia et al., 2019; Papadopoulos et al., 2012; Pompeii et al., 2013; J. T. Wassell, 2009). In psychiatry and prisons, employees interact with inmates and patients in challenging life situations. Inmates and patients live at the institutions around the clock during a difficult period of their lives while dealing with their situation, feelings, and for some, their illness. At the same time, they are subject to certain requirements and rules at the institutions. In this context of personal crisis, various situations (internally, externally, and situational (Pelto-Piri et al., 2020)) such as changes in health conditions, changes in personalized medicine, incomprehensible waiting time (e.g., with contact to lawyers), or restrictions (e.g., regarding smoking, visits) may cause frustration, aggregation, fear, feeling of powerlessness or anger which can lead to violence or threats of violence against the employees that they encounter daily.

Despite this multitude of reasons, most violence prevention research studies tend to be focused on a single component such as education and training, and the intervention approach often is to test a specific concept and evaluate its effects on, for example, the frequency of violence (Baby et al., 2018; Geoffrion et al., 2020; Tölli et al., 2017). Although some of these interventions have shown an effect, the incidence of violence and threats remains high and continues to be a serious work environment problem. Therefore, some researchers are arguing for the importance of multi-stranded efforts that address the complexity of violence prevention (Anderson et al., 2010; Brooks et al., 2010; Somani et al., 2021). Studies testing multi-component interventions typically work with different types of initiatives simultaneously, often targeting several organizational levels to create more fundamental and lasting changes at the workplace (Arnetz et al., 2017; Bowers et al., 2015; Burack et al., 2012; Gillespie et al., 2014; van de Sande et al., 2011). For example, Arnetz and colleagues conducted a participatory multi-component intervention study with seven hospitals, which tailored the intervention activities to the specific needs for better violence prevention. The intervention included the development of a data report system providing timely and accessible unit-level violence data to facilitate the development of concrete action plans for violence prevention, which led to a lower risk for violence-related injury in intervention units compared to control units (Arnetz et al., 2017). Bowers and colleagues' “SafeWards” intervention consisted of 10 initiatives to improve team collaboration and patient relationships in 31 psychiatric workplaces. The result showed a statistically significant decrease in conflicts between employees and patients (Bowers et al., 2015). Despite these encouraging examples, there is still sparse knowledge about what works in relation to dealing with the multi-stranded problem of violence prevention (Spelten et al., 2020). Our study will help providing some more knowledge in this area.

This study builds on data from a multicomponent intervention study that was tailored to address the specific challenges at the participating workplaces (Jaspers et al., 2019). While the results of the intervention study will be published elsewhere, in this study we will focus on the perspective of employees and their line managers when developing their violence prevention activities. Independently of the effect evaluation of the intervention, we assess it relevant to unfold the specific actions taken to prevent violence during the intervention course. We chose to take a closer look at the decisions made by employees and line managers as we consider them to be experts of the potential conflict-filled encounters between the clients and the institutions: they have knowledge about the potential stressors for their clients (inmates and patients) and they know what is lacking to create flow, support, and mental surplus for themselves and their colleagues to effectively prevent violence and threats. Based on this knowledge we might be able to point at aspects for violence prevention that need more attention.

The aim of this study was to show what employees and their leaders consider important and possible to work with to improve violence prevention at their workplaces.

To achieve that we formulated the following three research questions:

1) Which topics, that is, which specific actions and types of actions do employees and line managers in two high-risk sectors suggest as central to their violence prevention work?

2) Which topics of violence prevention do workplaces from two high-risk sectors decide to work with and are there differences between the two sectors?

3) What characterizes the topics that employees and line managers find important in violence prevention?

Method

Description of the setting and demographic

This study is based on data from employees and line-managers in psychiatric units and prison and detention centers in Denmark. In both sectors the risk for exposure to violence and threats from clients are high (The National Research Center for the Working Environment, 2019). The prison system in Denmark is public and is administrated by the Danish Ministry of Justice, which is the only body that has the authority to run prison and detention centers in Denmark. We conducted the study in high-risk units, which were detention centers and special secured wards for, for example, gang members. All inmates were over 15 years old and the majority are men. The vast majority of the inmates in the Danish prisons are Danish citizens, however in the detention centers and secured prisons, 50% are Danish citizens, about 20% immigrants, about 15% descendants of immigrants, and about 15% citizens of other countries (The Directorate of Correctional Services, 2020). All the included psychiatric units are also public and are all associated with large hospitals that also treat somatic diseases. All patients in these units were 18 years or over, but otherwise there were no unique patterns concerning gender, background, and type of psychiatric disease among patients in the different units. Patients forcibly admitted were part of the patient groups; however, none of the units included in the study treated forensic psychiatric patients.

The aim of our study was to include high-risk workplaces that were motivated to improve their violence prevention work but other than that, no special recruitment strategies in terms of diversity were made. The aim was high external validity to generalize our findings across settings (Bent-Goodley, 2021) (see Jaspers et al., 2019 for more details about the recruitment process).

Description of the intervention set-up

This study is based on data collected from an intervention study called “Integrated Violence Prevention Intervention” to improve violence prevention in two high-risk sectors (Jaspers et al., 2019). Sixteen high-risk workplaces were recruited to participate in the study: eight psychiatric units and eight prison and detention centers. Thirteen work units completed the full intervention program, seven psychiatric units, and six units from the prions and detention centers. Inspired by DeJoys’ (DeJoy, 2005) integrated accident prevention framework, we developed an intervention concept where employees and line managers were encouraged to systematically work together to improve violence prevention at their workplaces.

The intervention consisted of four phases conducted during a period of 6-months: (1) A preparation phase. (2) A phase where we mapped the existing practice of violence prevention through questionnaires and interviews. (3) A problem-solving phase consisting of the following intervention activities: (a) A three-hour workplace seminar where employees and line managers identified problems, generated ideas and prioritized the most relevant and urgent activities for violence prevention at their workplace. (b) This was followed by meetings of a steering group consisting of the line manager and three-four employee representatives that during 5–6 meetings developed the suggestions into action plans, which were implemented, evaluated, and altered if needed. Depending on the resources at the workplaces, one or more action plans were worked with between each steering group meeting. 4) An assimilation phase, where the changes were integrated into the everyday practices at the workplaces (see Jaspers et al., 2019 for further details about the intervention). The main results of the intervention study will be published elsewhere.

Description of the data used in this study

This study is based on data gathered in the interventions’ Phase 3: the problem-solving phase. Findings from this phase are relevant beyond the intervention itself. These data provide insight into what employees and line managers across 13 high-risk workplaces find relevant to work with to create good violence prevention. This knowledge provides insight into what themes other workplaces can benefit from addressing in their preventive work. In the following, we describe the data collection process more thoroughly.

An important aspect during the problem-solving phase was to motivate the participants to generate ideas for how violence and threats at work could be prevented. To initiate the idea generation process, the researchers who facilitated the intervention presented seven categories of violence prevention at the seminar and asked the participants to discuss if activities within these categories would be relevant for violence prevention at their workplace. The seven categories were: 1. Specific approaches to violence prevention, 2. Education and training, 3. Introduction of new employees, 4. Definition of violence and threat, 5. Policy and guidelines of violence prevention at the workplace, 6. Support from colleagues and management, and 7. Engagement in violence prevention. Furthermore, we included a category called “other” to be open to ideas that could not be contained in the seven categories. The seven categories were developed by the research group and were based on the research literature on violence prevention, that is, the concept of violence prevention climate, the literature on psychosocial intervention more broadly, and on official violence prevention guidelines (see appendix A for an overview of the seven categories and the related references).

The presentation of the seven categories was followed by a process where the employees and line managers were divided into groups and asked to discuss the relevance of the seven categories in their daily work and develop specific ideas for violence prevention tailored to their needs. Employees and line managers discussed the tailored ideas, elaborated on the ideas, and prioritized them. Each seminar resulted in a list of ideas (between 16-72 ideas pr. seminar). Across all 13 workplaces a total of 293 ideas for violence prevention were developed.

These lists of ideas, called the “idea banks,” for preventing workplace violence and threats were the basis of the steering groups’ work. The steering group at each workplace decided which idea to develop into an action plan. Each action plan described the preventive violence activity that was decided to be implemented, who was responsible for implementing this activity, and a deadline for the implementation. In total 92 action plans were developed by the 13 participating work places (between 1-12 action plans pr. workplace).

The analytical process

The first and the second author (ILK and DRA) coded the 293 ideas from the 13 workplace seminars. In the first attempt to find a fitting coding strategy, our approach was deductive (Bernard, 2017; Goetz & LeCompte, 1981), as we tried to code the ideas according to the seven predefined categories of violence prevention. During the coding process, it became clear that the seven categories of violence prevention identified in the literature prior to the study did not entirely reflect the ideas generated at the seminars by employees and line managers. Therefore, an inductive analytical process (Bernard, 2017; Nowell et al., 2017) was chosen to identify categories that better fitted the empirical data. Thematic analysis was used (Nowell et al., 2017) to identify cross-cutting topics of violence prevention. Two rounds of coding were conducted, between which the first and the second author met to discuss the categorization. To achieve consensus, we systematically went through the content of the categories in question. We tried to find a categorization that was the most common denominator that was still informative for the content. For example, risk assessments and self-defense courses were categorized as specific approaches to violence prevention, as they were both about giving employees tools for violence prevention. On the contrary, the categories dealing with communication remained divided into two groups after our discussions. One concerned the internal communication between employees and the transfer of information, making sure important knowledge were passed on that could help episodes from escalating. In contrast, the other category concerned employees' communication with the inmates/patients and was about creating a mutual relationship and building trust. These two were fundamentally different regarding required action plans and the mechanisms that affected violence prevention. The process resulted in both mergers and splits of the initial codes to better fit the empirical data. The 92 action plans were coded according to the same identified topics for violence prevention as the action plans were developed based on ideas from the “idea banks.” We examined how many workplaces had developed action plans for each of the topics for violence prevention and documented which sector the workplaces belonged to.

Results

The analysis of the 293 ideas developed by the 13 workplaces resulted into the identification of 12 topics of violence prevention.

Violence prevention topics

Table 1 shows the original seven categories that we asked the participants to discuss and the additional six categories that were developed by the participants.

Table 1.

Topics of violence prevention identified in the literature and by line managers and employees.

Seven Categories Identified in the Literature as Important Aspects for Violence Prevention	12 Topics that the Work Units Identified as Important Aspects for Violence Prevention during the Workplace Seminars
1. Specific methods	1. Specific methods to violence prevention
2. Education and training	1. Specific methods to violence prevention
	2. Communication between employees and written/oral reports
3. Introduction of new employees to the workplace	3. Introduction of new employees and temporary workers to the workplace
	4. Interdisciplinary cooperation
	5. Communication and relational work with patients/inmate
	6. Uniform approaches to patients/inmates
	7. The organization of work
	8. Staffing and the constellation of the staff group
4. Definition of violence and threats	9. Definition of violence and threats
5. Policy and guidelines of violence prevention	10. Policy and guidelines of violence prevention at the workplace
6. Support from colleagues and management	11. Support from colleagues and management
7. Engagement in violence prevention	12. Engagement in violence prevention

Table 2 gives a detailed description of the 12 topics that the work units identified as important for violence prevention during the intervention.

Table 2.

Description of the 12 topics identified as important for violence prevention.

12 Topics that the Work Units Identified as Important Aspects of Violence Prevention during the Workplace Seminars	Description of the Topic
1. Specific methods to violence prevention	The topic includes risk assessment, education and training, and physical and practical solutions, such as having video surveillance or where to place the furniture to get out of a room most easily and quickly in dangerous situations
2. Communication between employees and written/oral reports	This topic covers activities that are done to communicate knowledge about the clients between employees sharing the work tasks but who work in different shifts, so that it is possible to plan work tasks and to make sure that everyone has knowledge about what is going to happen during the day (e.g., a visit) This makes it possible to be aware of and prepare for situations that can lead to conflicts or frustrations among clients
3. Introduction of new employees and temporary workers to the workplace	This topic covers having a mentor to go to; to make sure that the new employee knows who he/she can go to when working in day-evening- or night shift; that the new employee knows what kind of task he/she can do as a temporary worker, and be aware of the rules and requirements to do the job in a satisfactorily and safe way
4. Interdisciplinary cooperation	This topic covers internal and external interdisciplinary cooperation, for example, internal collaboration at the department between different disciplines or between work units at the same workplace (e.g., a collaboration with another work unit to react to each other’s alarms), and collaboration with external partners (e.g., between correctional officers and the police). It is about securing that all relevant parties have the necessary knowledge about a client, that internal and external parties apply to the same rules and align their approaches
5. Communication and relational work with patients/inmate	This topic is about getting to know the client to be able to understand and “read” them. This can be gained through time spent together certain activities or how the work is organized. It also concerns a stable group of staff that supports the development of good relations with clients
6. Uniform approaches to patients/inmates	This topic is about using uniform approaches and rules and to agree on the degrees of flexibility in enforcing them. Too much flexibility can increase divisiveness between employees and clients, and in between employees. Uniform approaches are relevant both within a ward/department and between different departments at a hospital or prison
7. The organization of work	The organization of work covers how the day is structured, so that everyone knows what to do and when to do it; to allocate resources in the best possible way during the day and to try to be ahead of events and be prepared for them. A well-organized workday creates less waiting time and more predictability for clients, which in turn can contribute to fewer potential conflict situations. When the work tasks are well distributed and efficiently organized, it creates more time and energy to meet clients in a de-escalating way. It gives time for building relationships between employees and clients
8. Staffing and the constellation of the staff group	In both sectors, there are periodic challenges, for example, overcrowding/low staffing, high sickness absence, high job turnover, and challenges in recruiting new staff. This topic is about working with these issues. It is about using the available resources in the best way and ensuring a stable team of employees in the department. This covers how and where replacements are used; recruiting new employees; and improving work environment issues that cause sick leave etc.
9. Definition of violence and threats	This topic is about being aware of the individual employees’ and the colleagues' understandings of what is considered as violence and threats. Discussing individual definitions and understandings makes it possible to find out about different limits for assessing what kind of behavior can be tolerated and what not. Being aware of these differences, helps to avoid, that individual experiences of exposures to threats and violence are overlooked
10. Policy and guidelines of violence prevention at the workplace	In both sectors, it is mandatory to have a violence prevention policy. Therefore, working on this topic was not a matter of formulating a policy but examining how the policy worked in practice. The topic covers making sure that everyone knows the policy and that it clearly describes what to do in cases of violence. In both sectors, the employees were concerned about how the procedure was concerning violence and threats outside the workplace and how to handle police reporting and witness protection
11. Support from colleagues and management	Collegial and managerial support is critical in dealing with an incident. The participating workplaces described how the need for this type of support could vary a lot between individuals. Therefore, there is an additional need for the staff group and the manager to know each other well to capture any dissatisfaction among employees involved in major or minor episodes of violence and threats. The topic covers how to follow up on an episode with violence or threats, which interventions are needed and provided, and initiating a dialog where individual concerns can be expressed
12. Engagement in violence prevention	This topic covers that both employees and managers take an active part in the prevention of violence and threats at work and therefore contribute to making the workplace as safe as possible for everyone

Action plans

Table 3 gives an overview of how many work units developed an action plan related to a specific topic of violence prevention. We divided the degree of application into three levels: “High degree of application” applies to action plans that were developed by more than half of the work units (7-13 work units developed actions plans related to this topic); “medium degree of application” applies to action plans that were developed by three-five of the work units, and “low degree of application” applies to action plans only developed by one or two of the work units. In addition, Table 3 displays if the topics were worked with in psychiatric units and/or prison and detention centers, the number of work units with action plans related to the topic and the amount of action plans related to the topic. For the last two columns, the table also gives more details with regard to the two sectors. In the column “Number of work units with action plans related to the topic” we show the percentage of workplaces from psychiatric units or prison and detention centers with the topic. For example, for the first category “Specific approaches to violence prevention” it is shown that 100% of the psychiatric units, that is, all six psychiatric units, worked with this topic, while only 86% of the prison and detention centers, six of the seven work units, worked with this topic. In the column “Number of action plans related to the topic” we show the percentage of action plans made by the work units for each of the two sectors, that is, in total, 30 action plans were developed for the topic “Specific approaches to violence prevention,” and 15 of these action plans, or 50%, were developed by psychiatric work units and 15 action plans (50%) were developed by prison and detention centers.

Table 3.

Overview of Which Topics the Work Units chose to Work with During the Intervention.

Topic	Psychiatric Units	Prison and Detention Centers	Degree of Applica-Tion	Number of Work Units with Action Plans Related to the Topic (Percent of Workplaces from Psych./Prison Working with the topic^a)	Number of Action Plans Related to the Topic (Percentage of Action Plans Made by psych./Prison^b)
1. Specific Approaches to Violence Prevention (See Appendix B for Clarification of Subgroups on This Topic)	√	√	High	12	30
				100% psych	50% psych
				86% prison	50% prison
2. Communication between employees and written/oral reports	√	√	High	7	15
				33% psych	33% psych
				71% prison	67% prison
3. Introduction of new employees and temporary workers	√	√	High	7	13
				50% psych	46% psych
				57% prison	54% prison
4. Interdisciplinary cooperation	√	√	Medium	5	6
				33% psych	50% psych
				43% prison	50% prison
5. Communication and relational work with patients/inmate	√	√	Medium	3	3
				17% psych	33% psych
				29% prison	67% prison
6. Uniform approaches to patients/inmates	√	√	Medium	4	6
				17% psych	17% psych
				43% prison	83% prison
7. The organization of work	√	√	Medium	4	5
				17% psych	20% psych
				43% prison	80% prison
8. Staffing and the constellation of the staff group	√	√	Medium	3	9
				17% psych	11% psych
				33% prison	89% prison
9. Definition of violence and threats	√	√	Low	1	3
9. Definition of violence and threats	√	√	Low	17% psych	100% psych
10. Policy and guidelines of violence prevention at the workplace	√	-	Low	1
	√	-	Low	17% psych	100% psych
11. Support from colleagues and management	-	√	Low	1
11. Support from colleagues and management	-	√	Low	14% prison	100% prison
12. Engagement in violence prevention	-	-	Low^c	0	0

^aSix psychiatric units correspond to 100%, for prison and detention centers seven work units correspond to 100%.

^bThe percentage refers to how many action plans each work unit developed out of the total number for the topic. If 30 action plans were developed for specific methods and psychiatric units developed 15, this is stated as “50% psych”.

^cEngagement was a topic that the employees talked about at the seminars, and it was represented in the list of ideas at some work units, but no action plans directly focusing on this topic was developed.

As can be seen in Table 3, most action plans were developed related to the following three topics 1) “Specific approaches to violence prevention,” 2) “Communication between employees and written/oral reports,” and 3) “Introduction of new employees and temporary workers.” As there could be several action plans related to the same topic, the total number of action plans related to these three topics was 58. For the most part the two sectors were similar with regard to working with these three topics; however, there was a difference with regard to the topic about communication. More prison and detention centers worked with the topic “Communication” (71% compared to 33% of the psychiatric units) and also prison and detention centers developed more action plans about improving communication (67% compared to 33% of the psychiatric units). The five topics with a medium degree of application were: “Interdisciplinary corporation,” “Communication and relational work with patients/inmates,” “Uniform approaches to patients/inmates,” “The organization of work,” and “Staffing and the constellation of the staff group.” Altogether 29 action plans were developed that were related to these five topics. More prison and detention centers worked with these five topics and also developed more action plans than the psychiatric units, except for the topic “Interdisciplinary cooperation” where the same amount of action plans was developed in both sectors (three action plans in each sector). The four topics with a low degree of application were: “Definition of violence and threats,” “Policy, and guidelines of violence prevention at the workplace,” “Support from colleagues and management,” and “Engagement in violence prevention.” A total of five action plans related to these four topics were developed. For three topics, action plans were only developed in one of the two sectors. For the topics “Definition of violence and threats” and “Policy and guidelines of violence prevention at the workplace,” only a psychiatric unit developed an action plan related to this topic. For the topic “Support from colleagues and management,” only one workplace from the prison and detention centers developed an action plan related to this topic. For the topic “Engagement in violence prevention,” no action plans were developed, but one of the psychiatric units included the focus on another action plan on specific approaches. The specific action plan was about identifying new ways of de-escalating, thereby bringing new techniques into play and at the same time getting more employees engaged in the violence prevention work.

All 12 topics were identified as important for violence prevention at both psychiatric wards and prison and detention centers, and both sectors made action plans for nine of the 12 topics. Appendix C provides an example of an action plan on each of the 12 topics, one from each of the two sectors.

Discussion

Our first research question was, which topics do employees and line managers in two high-risk sectors suggest as central to their violence prevention work? We identified 12 topics of violence prevention across the 13 participating work units. The 12 topics address different organizational levels: the individual level, for example, the specific approaches to violence prevention; the group level, for example, interdisciplinary collaboration, uniform approach, and communication between employees; and the organizational and leadership level, for example, the politics at workplaces, staffing, and the organization of work. Most of the topics are in some way interlinked in the everyday work and affect the preventive violence work, for example, not having enough employees at work during a shift (staffing) affect the organization of work, and the time and resources that can be spent on relationship work between employees and clients. The topics might affect violence prevention on their own or in combination with each other.

The participants discussed all of the seven categories that we—based on existing knowledge—identified beforehand, and ideas for these topics were developed. In these cases, our findings support the existing knowledge in the field. For example, a focus of the employees and line managers is training and education, which we have identified as part of the topic “Specific approaches to violence prevention.” Action plans within this topic were developed in both sectors and the degree of application was high, meaning that more than half of the workplaces decided to implement activities related to this topic. This is also in line with new studies that confirm the importance of training and education in violence prevention work (Baby et al., 2018; Geoffrion et al., 2020; Tölli et al., 2017).

However, a number of topics for violence prevention identified by the employees and line managers in our study are to a lesser extent or not at all addressed in intervention studies about improving violence prevention. These topics are: “Communication between employees and written/oral reports,” “Interdisciplinary corporation,” “Communication and relational work with patients/inmate,” “Uniform approaches to patients/inmates,” “The organization of work,” and “Staffing and the constellation of the staff group.” Some of these topics concern the direct interaction (communication) among employees and between employees and their clients, while other topics address the conditions and the organization under which the work is conducted (resources and organization of work).

While some topics are highlighted in official violence prevention guidelines, for example, high worker turnover and working when understaffed is described as a risk factor in hospitals—especially during mealtimes and visiting hours (Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers. Act, 2016: p4), we were not able to identify intervention studies that address three of the topics identified by participants (i.e., the constellation of the staff group, interdisciplinary collaboration, communication between employees). There can be various reasons for this; the topics can be difficult to influence as they are closely related to other factors in the organization such as finances, professional boundaries, and IT/communication tools. Or it may be because these conditions may primarily have been considered contextual matters and not primary inventory focus areas.

Our second research question was which topics of violence prevention do workplaces from two high-risk sectors decide to work with and are there differences between the two sectors? Three topics were worked with “to a high degree” by the workplaces (between 12 and seven workplaces developed action plans for these topics); these topics were: “Specific approaches to violence prevention,” “Communication between employees and written/oral report,” and “Introduction of new employees and temporary workers.”

In the research literature, specific approaches to violence prevention, such as risk assessment and education and training, are known elements of violence prevention that have been assessed in a large number of workplace interventions (Almvik et al., 2000; Baby et al., 2018; Bowers et al., 2015; Somani et al., 2021; Tölli et al., 2017; Wassell, 2009). However, the other two topics that workplaces themselves identified as important to work with are not often studied in intervention studies. At the participating workplaces, the introduction of new employees was found to be important as new employees and temporary workers were often perceived as the most vulnerable to experiencing violence and threats. It was referred to that new employees and temporary workers, among other things, did not yet know the clients and thus had less opportunity to be aware of, for example, changes in behavior that might lead to a conflict or to violence. In addition, many new employees are also recent graduates and may therefore feel insecure about their competencies and lack experience in dealing with conflicts. For the inmates or patients, new faces might also lead to insecurities and unrest and thus might increase the potential for violence or threats. Therefore, a good introduction is crucial to create security for the new employees, the clients, and the rest of the employees who depend on the corporation with the new employees. Studies also show that younger employees are at higher risk to be exposed to violence and threats (Hahn et al., 2013; Wei et al., 2016). Nonetheless, we do not know of any studies that specifically focus on educating younger employees to prevent them from being exposed to violence at work. The same is true for the topic concerning communication between employees, which mainly involved how best to pass on knowledge between employees who worked in day-, evening-, and night shifts and who very rarely meet for joint staff meetings. The workplaces described this topic as crucial as exchanging important knowledge about clients might affect how employees approach clients. Knowledge exchange was also seen as important for planning work tasks and for optimizing or re-organizing work. Our study, therefore points at some important aspects that seem to have the potential for violence prevention and that should be tested in well-designed intervention studies.

Although the ideas underlying the topics were developed in response to specific challenges in each workplace, all 12 topics were found in both sectors, and both sectors made action plans for nine of the 12 identified topics. This suggests that the topics are relevant in psychiatric units and prison and detention centers.

The overlap in topics addressed might be due to characteristics that the two sectors share in relation to fundamental challenges and work conditions. These are, among other things, that the employees work in day-, evening-, and nightshift, are dependent on oral/written reports to exchange crucial information about clients, and dependent on a well-functioning interdisciplinary corporation. This indicates that other comparable workplaces could also benefit from working with the 12 topics of violence prevention, especially with the three topics used by most workplaces in this study.

Our third research question was: What characterizes the topics that employees and line managers find important in violence prevention? There is not one specific aspect that characterizes the topics. The amount and variations of topics confirm that violence prevention is a multifaceted effort as violence occurs in a complex interplay of several factors (Anderson et al., 2010; Viitasara & Menckel, 2002). We argue that the variety and complexity of the topics is as important a finding as the content of the 12 specific topics of violence prevention. Thus, a comprehensive range of approaches at different organizational levels is what employees and line managers in two high-risk sectors point to when aiming to improve their violence prevention effort. This finding is consistent with a recent review by Somani and colleagues (Somani et al., 2021), assessing training and education for de-escalating and violence prevention in nursing. They find that standalone training and structured education programs have limited impact whereas several of the multicomponent interventions (however, only five of 26 identified studies fall into the category of multicomponent interventions) demonstrate an actual decrease in rates of workplace violence. This finding points in the same direction as the overall result of this study, where employees and line managers identify a variety of aspects at different organizational levels that they find relevant in their violence prevention work. This suggests that in future studies we should not only examine a single component for violence preventive interventions but design and test multi-component interventions.

Strengths and Limitations

The main strength of this study is that we identified what actions employees and line managers find relevant for preventing violence in practice when they can develop their action plans tailored to their needs. The variety of identified topics shows that workplaces assess that violence prevention requires many different activities and that the focus on only one aspect probably does not solve the problem.

Another strength is that the data collected for this study was based on a participatory intervention study, which means that the content of the intervention was developed by the participants during the intervention study. This approach allowed the workplaces to freely choose the topics they themselves assessed as most important to work with. Although we suggested to consider some topics identified as important for violence prevention in the scientific literature (the seven categories) it was up to the workplaces to develop action plans that they felt fit best to their needs. This approach therefore allowed us to get insight into workplaces’ own assessment of what is needed to improve their violence prevention.

Furthermore, a strength is that we gathered the data used in this article from two high-risk sectors regarding employee exposure to client-induced violence and threats of violence and were able to identify a cross-cutting pattern in what employees and line managers find important to work with to prevent violence. This overlap may be due to the shared characteristics of the two sectors (such as employees working in day-, evening-, and nightshifts, dependent on a well-functioning interdisciplinary corporation, a high degree of contact with clients (inmates/patients)). It may indicate that other workplaces sharing the same characteristics, such as other hospital units than psychiatry, care homes for people with dementia, or other residential institutions caring for people with special needs, may benefit from working with the identified topics of violence prevention.

A limitation and important context for these findings is that the study did not include financial resources to provide the work units for their work with the violence preventive action plans. The workplaces contributed to the study by prioritizing violence prevention, for example, allocating the necessary time for employee seminars, steering group meetings, etc. The two sectors included in the study are publicly financed and characterized by scarce resources (see Jaspers et al., 2021). When employees and line managers in the steering groups had to prioritize the topics for their violence prevention efforts, they had to consider what was possible within the limits of the existing resources. This affected the proposed actions, and there is, for example, a lack of environmental proposals as for example changing the architecture is usually expensive. A general point that was highlighted as important across the workplaces, but which was only dealt with occasionally, was staffing. All workplaces emphasized that being well staffed was central for violence prevention. However, due to limited resources and recruitment challenges it was often not possible to hire more employees. Therefore, the workplaces worked with the topic in other ways, for example, by ensuring that new interns became interested in applying for a job in the work unit., Hence, the action plans developed by the workplaces show that workplaces assess that a number of activities are possible to conduct within the given limits and thus can encourage other workplaces to improve their violence prevention despite sparse resources.

Another limitation of this study is that we can only point at what workplaces assessed to be important to work with and therefore decided to develop and implement action plans for. The effects of the intervention study will be published later in a separate article, and the effects studied there will focus on if the intervention leads to better cooperation between employees and line managers in their activities for violence prevention. Therefore, with this study, we cannot prove if interventions focusing on a variety of topics at the same time will lead to better effects than interventions only focusing on one specific aspect, as this would require another research design. Nevertheless, this study contributes to the increasing understanding that more complex interventions are needed to deal with complex workplace risks, including violence prevention (Anderson et al., 2010; Brooks et al., 2010; Somani et al., 2021).

Conclusion

Using data from a participatory, workplace-tailored intervention to prevent violence and threats of violence from patients or inmates towards employees in psychiatric units and prisons and detention centers, we identified 12 topics of violence prevention. The 12 topics of violence prevention provide insights into what line managers and employees across 13 different work units find important and assess as possible to work with when aiming to improve violence prevention in high-risk workplaces. Our results illustrate that workplaces assess violence prevention as a complex tasks that requires a variety of approaches at different organizational levels and not just activities focusing on a single aspect. Intervention studies testing the effectivity of multi-faceted interventions are needed to confirm the assessment by the workplaces.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was Funded by The Working Environment Research Fund, project number: 24-2016-03-2016510163.

ORCID iDs

Iben Louise Karlsen, PhD

Dorte Raaby Andersen, PhD

Birgit Aust

Sofie Østergaard Jaspers

Lars Peter Sønderbo Andersen

Appendix A

Appendix B

Appendix C

Author Biographies

Iben Louise Karlsen, PhD, is a researcher at The National Research Centre for the Working Environment in Copenhagen, Denmark, with a PhD from The Department of Anthropology, University of Copenhagen. Her research focuses on social relations and interactions at work. She has done research on occupational accident prevention, sustainable work environment, and workplace violence prevention in high-risk sectors.

Dorte Andersen sociologist, PhD and researcher at the Department of Occupational Medicine – University Research Clinic, Regional Hospital West Jutland, Herning, Denmark. Her research focuses on interactions in the workplace and how workers perceive and manage physical and emotional aspects of their work. As a sociologist, her interests are the social relations, normative codes, and organizational structures at the workplace that influence the behavior, and identities of the workers.

Sofie Ø. Jaspers, PhD, is a post doc in the department of psychosocial work environment at the National Research Center for the Working environment in Denmark. She received her PhD from the same research center and has a background in psychology. Her main areas of research covers workplace violence prevention, intervention research and process evaluation.

Lars Peter Sønderbo Andersen is a psychologist and has a PhD in work and organizational psychology. He graduated from Aarhus University in 2001. He got his PhD from Aarhus University in 2006. He worked as a clinical psychologist and researcher at the Department of Occupational Medicine in Herning, Denmark since 2004.

Birgit Aust MSc, PhD has been a senior researcher at the National Research Centre for the Working Environment in Copenhagen, Denmark since 2002. Her main research interests are the development, implementation and evaluation of workplace interventions aimed at improving the psychosocial work environment including interventions to reduce violence at work and interventions to create mentally healthy workplaces.

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