Looking beyond violence prevention climate – exploring line managers' violence preventive practices in two high-risk sectors

Abstract

Purpose

Work-related violence is a major occupational safety and health (OSH) issue. According to the concept of violence prevention climate, managers play a pivotal role in preventing the risk of violence at work. However, research on this is scarce. The objective of this study was, therefore, to examine line managers' use of violence preventive practices in high-risk sectors.

Design/methodology/approach

The authors employed three different sources of data (semi-structured interviews and field notes from both leadership seminars and coaching sessions) that were collected in the context of an intervention study in Denmark aimed at improving violence prevention. The authors conducted a thematic analysis of violence prevention experiences among 16 line managers – eight from the prison and probation services and eight from psychiatric hospitals.

Findings

Using an existing prevention framework, the authors categorized the descriptions into three types of violence preventive practices used by the line managers across the two sectors: “preventing violence”, “managing episodes of violence” and “promoting the positive”. Especially the category “promoting the positive” is often neglected in the intervention literature.

Originality/value

The study identified new aspects of managers' violence preventive practices than those included in the violence prevention climate concept. Such knowledge may help organizations devise improved systems for violence prevention in high-risk sectors.

Citation

Jaspers, S.Ø., Raaby Andersen, D., Karlsen, I.L., Sønderbo Andersen, L.P., Conway, P.M., Dyreborg, J. and Aust, B. (2022), "Looking beyond violence prevention climate – exploring line managers' violence preventive practices in two high-risk sectors", International Journal of Workplace Health Management, Vol. 15 No. 4, pp. 429-444. https://doi.org/10.1108/IJWHM-06-2021-0133

1. Introduction

Work-related violence is a major occupational safety and health (OSH) issue. Despite extensive preventive efforts over the years, violence and threats at work still represent a widespread risk, with consequences at individual, organizational and societal levels (Biering et al., 2018; Eurofound, 2017; Rudkjoebing et al., 2020; Xu et al., 2018a, b). Prevalence rates of violence vary greatly between sectors, but risk is particularly elevated in sectors with a high degree of client contact, such as hospitals and prisons (Gadegaard et al., 2018; Nyberg et al., 2020).

From both the theoretical and empirical points of view, it is well established that management practices can decrease the risk for violence and threats perpetrated by clients toward employees (Gadegaard et al., 2018; Spector et al., 2007, 2015). From a theoretical standpoint, management practices are assumed to play a key role in shaping safety and violence prevention climates, which in turn affect the risk of episodes of violence (Spector et al., 2007; Zohar, 1980). From the empirical point of view, a few prospective studies showed that the way employees experience how their manager prioritizes violence prevention, encourage registration of episodes and give support after occurrences of violence is associated with a lower risk of being exposed to violence and threats at work (Gadegaard et al., 2018; Spector et al., 2015). Previous studies also found that poor supervisor quality and low support from the closest supervisor are associated with a higher risk of exposure to violence and threats (Andersen et al., 2018; Gadegaard et al., 2018).

Employee-directed violence preventive practices are well described in the literature in, for instance, the de-escalation literature and in studies of coercion minimization in psychiatry such as “Safewards” (Bowers et al., 2015). On the other hand qualitative examinations of the role played by managers in violence prevention are – to the best of the authors' knowledge – rare. An exception is a recent study showing that line managers from a Swedish hospital perceived violence prevention as a twofold assignment where both employee and patient safety had to be assured, a goal that was difficult to achieve (Jakobsson et al., 2021). They also reported a mismatch as the most frequent type of violence occurring was represented by less severe episodes, whereas the organization's focus was on the management and prevention of severe episodes. The extant sparse research and the reported problems of practicing prevention poses a challenge for improving practice where the involvement of both employees and managers is recommended in workplace violence prevention (OSHA, 2004) and more generally in OSH interventions (Awa et al., 2010; Corbière et al., 2009). Violence prevention initiatives are complex and often jeopardized by low-resource environments [e.g. high levels of sickness absence and problems in recruiting (Byrne and Hummer, 2007; Cowman, 2009; McKeown et al., 2019)]. It is known from adjacent fields that managers, when attempting to enact practices to prevent accidents and mental health problems, face challenges in their work environment in terms of lack of time and support (Biron, 2018; Skakon et al., 2010; Tafvelin et al., 2019). This calls for more in-depth knowledge on how managers act in resource-scarce and complex environments characterized by a high prevalence of violence and threats. Such knowledge may help organizations devise improved systems for violence prevention in high-risk sectors.

The aim of this article is to examine how managers in prison and probation services and psychiatric hospitals describe the actions they undertake to reduce risk of violence and threats perpetrated by clients toward employees. To investigate such experiences, we used qualitative data collected in the context of an intervention study aimed at improving violence prevention in high-risk sectors (Jaspers et al., 2019). More details about the intervention are reported elsewhere; (Jaspers et al., 2019).

The overall question guiding this study is summarized as follows:

1. (1)

   What types of prevention practices do line managers use for preventing violence and threats of violence in two high-risk sectors?

2. Theoretical background

Theoretically, this study departs from the theory of safety climate. The main tenet of this theory is that shared perceptions of safety policies, practices and procedures in organizations affect the extent to which employees are motivated to enact, and actually enact, safety behaviors and consequently, the risk of accidents (Zohar, 1980). The assumption is that when safety becomes an integral part of how line managers perceive and define their role, interactions between management and employees about safety will increase, and, thereby, gradually contribute to a normative change in the employees' perception of how managers prioritize safety (Marín et al., 2017; Zohar, 2002b). If these norms can be maintained over time, it will strengthen the mutual expectations between management and employees that safety has a high priority, and changes in the safety climate will occur. This in turn will have positive effect on occupational safety (Kines et al., 2010; Zohar, 2002a). The safety climate theory is “facet specific” and has been adapted to specific areas of occupational health and safety, including violence prevention climate which is the focus of this study (Spector et al., 2007). In line with safety climate, violence prevention climate is conceptualized as the shared perceptions of practices and policies about violence prevention, and being able to resist the pressure for ignoring them. These three factors are operationalized as managements' communication about policies, managements' reinforcement of these policies and prioritization of violence prevention against other organizational priorities (Kessler et al., 2008). Violence prevention climate is, therefore, to a large extent a theory of managers' violence prevention in that it emphasizes specific focus areas and practices that managers need to use to reduce the risk of violence for their employees.

Research on the violence prevention climate has hitherto been focused on the violence prevention climate scale – a quantitative measure of violence prevention meant for assessing risk of violence (Kessler et al., 2008). Studies show that violence prevention climate does predict risk of violence, but findings are contradictory as to what dimensions are the strongest predictors of risk (Gadegaard et al., 2018; Yang et al., 2012). This indicates that current research does not capture the full span of practices that managers need to enact in order to prevent violence. For example, it remains unclear how to reduce the pressure for ignoring safety in a resource-scarce environment, or how to enforce safety procedures in relational work, which is less regulated than the technical/practical work the original safety climate concept was developed for. These are critical questions to answer in order to apply findings from studies of risk factors and protective factors of violence in intervention studies. To advance the concept of violence preventive climate, a deeper understanding of the mechanisms operating behind the development of an effective violence prevention climate is needed. In this study, we therefore conduct a qualitative analysis of line managers' violence preventive practices, with the goal of improving our understanding of the content and nature of line managers' violence preventive work.

3. Methods and materials

3.1 The integrated violence prevention intervention

The integrated violence prevention intervention is a theory-driven intervention to improve systematic violence prevention in workplaces. In the intervention set-up, a mapping of the workplace's existing violence preventive practices is carried out through interviews with employees and managers and a tailor-made questionnaire. Managers are then invited to participate in a leadership seminar and three coaching sessions. Employees are invited to participate in a seminar where they, together with their line managers, develop an “idea-bank” of possible actions to prevent violence at their workplace. Five steering group meetings are held wherein employees and the manager develop, carry out and evaluate action plans for violence prevention (see more details in Jaspers et al., 2019).

The effect evaluation of the intervention was performed using a stepped-wedged design, according to which participants entered the intervention in a stepwise fashion and acted as controls for each other before entering the intervention (Schelvis et al., 2015). Our study was conducted in four clusters of two to five workplaces over a period of two years (between September 2017 and September 2019). Seven work units (including two that dropped out during the study) were offered the intervention in cluster one and two. In cluster three and four, the number of meetings was reduced in order to better fit the available resources of the participating workplaces and the research team. As a result, only half of the workplaces were offered manager-directed activities (leadership seminar and coaching sessions). Overall, six line managers partook in these activities.

3.2 Recruitment procedure

To recruit workplaces for the intervention study, we contacted 24 public psychiatric wards from three different regions in Denmark; two agreed to participate, providing four work units each. In the prison and probation services (that is fully public in Denmark), a message was sent out centrally from the organization that encouraged all prisons and probations in Denmark to sign up for participation. The contact was most often made on the level right above line managers, but in some cases, the contact was established through another channel. This recruitment strategy combined with the stepped-wedge design, where the intervention starting point was randomized, resulted in a situation where some of the work units had to start up at a point in time that the line managers did not find convenient. A substantive effort was done afterwards to adjust the intervention activities to fit their respective situations.

3.3 Data sources and ethical considerations

All data were collected as part of the integrated violence prevention intervention study trial registration: ISRCTN86993466. Before data collection, the National Research Centre for the Working Environment approved the project on behalf of the Danish Data Protection Agency (Journal No. 2015-57-0074). No approval was required by the Danish National Committee on Biomedical Research Ethics, since the study included no collection of biological material.

Line managers were asked to participate in an intervention to prevent violence and threats and in an evaluation of the initiative through their immediate manager. Throughout the course of the intervention, the line managers had full confidentiality in interviews and coaching activities, and facilitators therefore shared none of the content with the line managers' own manager or their staff. In each interview, leadership seminar and coaching session, participants verbally consented that information collected in terms of field notes and audio recordings could be used for research purposes only and in an anonymized form. Line managers were given the possibility to withdraw any of their statements during the interviews or during the coaching sessions. Several of the line managers used this option. Table 1 provides an overview of the three different data sources.

For anonymization, all informants were given pseudonyms and all cases from each sector were given a number from 1 to 8.

3.3.1 Interviews

As part of the mapping of the workplaces' existing violence preventive practices within the Integrated Violence Prevention Intervention, we conducted 16 semi-structured interviews with line managers: eight from psychiatry and eight from the prison and probations services. The aim of these interviews was to understand what managers already did to prevent violence and threats, whether they envisioned possibilities for improvement and how they perceived their own role in violence prevention. Questions we asked them were, for instance, “What do you do in your work unit to avoid that violence and threats occur?”; “Do you have any meetings or occasions during the day where you discuss violence prevention?”; “Could you sum up the three most important focal points in your efforts to support the violence preventive work of your employees?”. Table 1 shows the characteristics of the line managers participating in the interviews. There is a clear difference in the distribution of sexes between the two sectors; all line managers in psychiatry are females, while the majority of line managers in the prison and probation services are males.

3.3.2 Field notes

Field notes were taken following every intervention activity (i.e. leader seminars and leader coaching sessions). Specific observation points for the field notes were contextual factors that could affect the implementation of the intervention [e.g. existing culture of participation and trust between manager and employees; (Jaspers et al., 2019)]. In addition to these specific observation points, the field notes chart also included a free text section that enabled to take note of other important aspects the facilitator noted after the coaching session.

3.3.2.1 Field notes from leader seminars

A total of three leader seminars in psychiatry and three leader seminars in the Prison and probation services were realized. The leader seminars were conducted by members of the research team. In the seminars, the line manager and his/her manager were present. In the psychiatric units, a nurse with special responsibilities for the improvement of patient care (called a practice development nurse) was also present. In the seminar, the mapping of existing violence preventive practices was presented, and the results were discussed with regard to challenges encountered when employing such practices. In psychiatry, the three leadership seminars were conducted with line managers from three units in the same hospital. As they shared the same head nurse, she partook in all the three seminars. The three leadership seminars in the prison and probation services were conducted with line managers from three different units, but within the same detention sharing the same section chief, who also participated in all seminars.

3.3.2.2 Field notes from leader coaching sessions

A total of 15 coaching sessions (nine in prisons and six in psychiatric units) were conducted. The coaching sessions were conducted by members of the research team. In the coaching sessions, managers were encouraged to identify an area that they wanted to improve in relation to their role in violence prevention as well as to develop a concrete action plan with steps to complete between the sessions. In this way, the coaching sessions provided insights into the leader's practical work and the challenges they face when preventing violence and threats. Participants were the line managers from the pre-intervention interviews. In the psychiatric units, the practice development nurse also participated.

3.4 Analytical approach

Data were analyzed using thematic analysis, as this approach is well suited for summarizing key features of large qualitative data sets and offers “thick descriptions” of the data (Braun and Clarke, 2006). The analysis was conducted in three steps. In step one, we used an inductive approach to code the full material (interview transcriptions and field notes) for passages where managers described their efforts of violence prevention and challenges in implementing such efforts. We coded the material for each of the two sectors separately. Each code was divided into a plus and minus sub-code, which indicated an expression of success or challenge faced in the use of a violence preventive practice, respectively. This coding resulted in an overview of what practices workplaces used successfully or experienced as challenging.

In step two, we searched for overall themes in the codes identified in step one and grouped them into types of prevention practices. Looking for frameworks that could be used to guide our categorization of prevention practices, we chose the “Integrated intervention approach for workplace mental health” (LaMontagne et al., 2014). Although this framework addresses the prevention of mental health, it builds on more general concepts of prevention stemming from public health, organizational psychology, positive psychology and medical science that can be applied to other health outcomes or risk factors in the psychosocial work environment, including risk of violence. The main tenet of the “Integrated intervention approach for workplace mental health” is that effective workplace intervention depends on the integration of three different approaches, which include: (1) prevent harm by reducing work-related risk factors (public health), (2) promote the positive aspects of the work to ameliorate mental health (positive psychology) and (3) manage mental health problems at the workplace when they arise (medical science) (LaMontagne et al., 2014). The public health approach consisting of primary, secondary and tertiary prevention levels has also been recommended as a way of conceptualizing violence prevention in the research literature and in official guidelines for practice in the area (American Association of Occupational Health Nurses, 2014; Paterson et al., 2005; WHO, 2008). This study used the three categories: prevent harm, promote the positive and manage illness in a deductive way, grouping the identified prevention practices in the three general intervention categories described in the framework. In the last analytical step, the three categories were tailored to violence prevention, by renaming them and providing summary descriptions based on the violence preventive practices included in each category.

4. Results

Line managers' violence preventive practices fell within the three identified categories: “promoting the positive”, “preventing violence” and “managing episodes of violence”. Promoting the positive involved the strengthening of group- and organization-level factors facilitating violence prevention, such as a good learning environment and the promotion of relational work with patients/inmates. In preventing violence, the focus was on changing the working conditions to minimize risk factors (primary prevention) and modify the employees' responses to risky situations and thereby preventing violent episodes (secondary prevention) (Paterson et al., 2005). Managing violent episodes entailed all the mitigating efforts surrounding episodes of violence. We provide an overview of all practices in Table 2. We found a substantial overlap in the practices used across the two sectors. For each of the three types of practices, we present the most common ones across the two sectors, providing examples from the data material as either quotes or plain text. Practices found in only one sector were listed in Table 2.

4.1 Practices for “promoting the positive”

Practices to promote the positive were described as early proactive preventive measures that managers enacted to enhance positive aspects in the workplace. The positive aspects included, for instance, trust or engagement and constituted the foundation for more specific preventive practices or practices for managing episodes of violence. While practices for promoting the positive can be beneficial for several purposes, line managers emphasized the specific benefit of these practices in the violence preventive work.

4.1.1 Creating a learning environment

Several managers in psychiatric units and prisons reported that they tried to create a learning culture that encouraged employees to recognize and disclose their knowledge gaps. The managers pointed out that this was crucial as learning new approaches to care and improving professional knowledge and skills had a substantial role in violence prevention. In one psychiatric unit, a manager reported that they had been working with their learning environment for a long time before participating in the intervention:

Interviewer: what I hear is that there can be a razor-sharp balance between learning and “you made a mistake” - that is, guilt and …

Line manager Catherine: Yes it must never be in that way [ …] I think we already at that time had a good culture, in that people never came to expose each other's weaknesses, to point fingers at each other, to find faults […] I think we try to hold on to having different forums in every day's life where we focus on learning.

(Interview, Psych 6)

In this example, the manager was working on creating a no-blame work environment, where the norm was to evaluate daily risky circumstances such as forced medication. By doing it frequently and in an appreciative way, they normalized these evaluative situations, which made employees more willing to engage in reflections on their own practice. Such reflexivity was a basis for improving the violence preventive work and engaging in learning from violent episodes.

4.1.2 Creating a good framework for relational work

All managers emphasized relational work with inmates and patients as the most important violence preventive measure. They reported that this was because relational work helped avoid conflicts, de-escalate conflicts and motivate inmates/patients to engage in less aggressive behavior; in prisons, good relations were also sometimes useful for getting insider knowledge about possible planned assaults between inmates or toward the personnel. Creating the best conditions for employees to engage in relation work was a way for the manager to support violence prevention. Creating a good frame could also include practical aspects such as securing that activities aimed at developing relations (e.g. resocializing/therapeutic sessions with inmates/patients such as sport) were easy to plan. In one leadership seminar and three coaching sessions from a detention center, participants highlighted how time pressure and sickness absence among staff represented severe challenges for arranging these activities.

4.2 Practices for “preventing violence”

These practices were aimed at modifying the working conditions that may increase the risk of violence/threats, often a conflict situation (primary prevention) and practices aimed at preventing the conflict situation from developing into violence and threats (secondary prevention). This preventive work was largely overlapping with the core task, as situations with conflict and violence were also incompatible with effective patient's care and containment and resocialization of inmates. Most of these practices could therefore also be seen as instrumental in the performance of the core tasks.

4.2.1 Facilitating a common and fit-for-purpose approach to relational work

Managers described how prevention of conflicts, and subsequent threats and violence, was related to the staff's ability to balance the need to abide by the rules and make individual exceptions in their relations with inmates and patients. By sticking to the rules, the room for patients/inmates to play the staff against each other was smaller, which prevented conflicts. On the other hand, having too strict a regime that leads to ignore the individuals could also create frustration and conflict. It could therefore turn out to be a violence preventive act to occasionally make an exception from the rules (e.g. if an inmate forgot to sign up for a bath and the prison officer knew that the girlfriend came visiting that day, the prison officer might let him take a bath). In an interview, one manager pointed out how facilitating this balance was the first out of three most important violence preventive tasks he performed:

Line manager Patrick: […] yes, it's crucial to make this balance work. That is, between the hard and the soft. It is so important that the officers also have the support of each other to make estimates in both directions. […] There has probably been a culture for many years where it has been the managers who have had to cut through and say, this is how we handle some situations, but it is really unsuitable to work that way […] So you can say that my […] [focus is] on enabling the employees to make choices that are balanced.

(Interview, prison and probation services 2)

With different types of inmates and patients, the balance needed to vary in order to best prevent conflicts. Some managers thought their employees struggled with striking this balance, either because the manager wanted to move the balance in a new direction or because there had been a substantial change in the staff or the type of inmates/patients they worked with. The steps managers described they take to facilitate a balanced approach were to engage in continuous discussions with the staff (e.g. in staff meetings) and to reflect upon the approach taken in specific situations in their daily work. At times, some managers from the prison and probation services also suggested employees that were too far from the desired balance to change department.

At a leadership seminar, a section chief reflected upon the challenge faced by line managers while engaging in this continuous work in an organization wherein staff meetings had been suspended due to cutbacks:

The section chief says: when you work with people, it may be that you decide on a set of rules, but when time goes by, someone pulls it in one direction, and someone pulls it in the other direction, and then this staff meeting once in a while, where you can just get it pulled back on the track, it's worth its weight in gold and we just do not have that.

(Field note supplemented with information from an audio file of the meeting, leadership seminar prison and probation services 1)

The section chief was here pointing to the importance of having all the employees gathered to pull them in the same direction. Other challenges described were mergers, where different departments had to reconcile different care cultures.

4.2.2 Sparring on difficult situations

Managers emphasized that being around physically in the unit was important to provide sparring in difficult situations and, as a result, prevent escalation of events and create a sense of security among employees. This also involved being a role model for relational work. A line manager in a psychiatric unit gave this description when asked about what she was doing to prevent violence as a manager:

Line manager Susan: […] I'm present, and I'm visible, and I'm appreciative in my approach and listening and available, and they know well that if they are in a situation, that they cannot solve here and now […] then they know that this - that is, my phone - it is not far away. Not even when I'm home.

(Interview, Psych 4)

What line manager Susan referred to was the management of risky situations. She explained that employees needed to be able to handle most of these situations by themselves, as she was not present two-thirds of the time in a three-shift system; her solution was, therefore, to have her phone open all the time. This manager emphasized how this practice created a sense of safety for employees, but it is obviously also important for improving, e.g. the ability to de-escalate.

4.2.3 Distributing emotional demands between employees

In both sectors, managers spoke about how they distributed the emotionally demanding tasks among the staff. This was typically done by distributing potentially aggressive patients or inmates between the staff within the unit (in psychiatry only) or between units or prisons to relieve the personnel for a while. Another task that could be emotionally demanding was running for alarm, and to distribute this task evenly among staff the manager had to make sure that all new employees had received physical de-escalation training. Managers assumed that these practices would be effective in preventing violence as they reduced those emotional demands that may deplete the psychological resources needed to de-escalate situations. This manager from a detention saw this effort as one of his primary violence preventive tasks:

Line manager Patrick: [ …] Then there is moving around the inmates, so that the different wards have a uniform distribution - yes, there is no wards that should be overloaded with violence, and on the other hand no ward should just sit around doing nothing.

(Interview, prison and probation services 2)

4.2.4 Analyzing episodes or near-episodes

In most workplaces, managers and work environment representatives met regularly (some every month, some four times a year) to analyze registered episodes of violence and threats and learn from them. Others also discussed episodes in staff meetings once a month or used yearly staff well-being surveys to determine patterns in the occurrence of violence or threats. Along these lines, several units had procedures for reflecting on incidents or near-incidents of coercion, either just after the incident or once a week/once a month. In the prison and probation services, one manager declared that he was planning to make an action plan during the coaching sessions to implement learning processes after incidents or near-incidents of violence; however, he had to abandon the idea because of insufficient staffing, high levels of sickness absence and two major episodes of violence.

4.3 Practices for “managing episodes of violence”

Practices to manage episodes of violence represented actions that were undertaken after an episode had occurred and were often described in the organizations' policies on how to handle episodes of violence and threats.

4.3.1 Providing support after an incident

Managers described different tasks related to providing adequate support, which included immediately moving the involved employees away from severe situations for a short defusing (unstructured talks to calm down and assess if there was further need for support), and arranging that colleagues from other departments covered for them. Managers were also involved in arranging longer and more structured debriefing sessions with a trained debriefer for employees involved (managers were at times trained debriefers themselves). In severe cases, sickness absence conversations were also part of the after-care. For less severe episodes (e.g. threats or emotionally demanding situations), managers emphasized the importance of “being around” as employees would not always take initiative to approach managers if they were not present. In one detention unit, managers formalized this procedure by having smaller meetings of 10 min throughout the day to get a feeling of the status of every employee:

Line manager Kent: […] Is there anyone you think she looks a bit down in the mouth, then the on-duty officer can just take her in and say “are you ok and ready to go home?” etc. in that way. Or he can give us a broad hint “just try to call”, or “just try to keep an eye on” when she is out next week, if she is completely ok. She did say she was, but I think her voice was just a little like. We do watch out for each other a little, and I think that's damn good this thing [referring to the meetings]. It has come to stay. That's also what the staff says.

(Interview, prison and probation services 6)

Line manager Susan from a psychiatric unit made the same point that it was sometimes necessary to make sure employees felt that it was legitimate to get help despite the resources that this entailed (e.g. time needed for providing help and colleagues that had to cover for those who were temporarily moved away from work).

4.3.2 Adjusting tasks after episodes of violence or threats

In the prisons, managers had the possibility to temporarily replace employees with staff from other low-risk departments to relieve pressure after experiences of violence. Sometimes they also had the possibility to move an inmate to another unit. This decision was taken during a shift or in the follow-up conversations after the registration of an episode. In psychiatric units, the adjustment of tasks occurred within the department. To make proper adjustments, during the interview line manager Susan highlighted the importance of having thorough knowledge of her employees. In one of the following coaching sessions, however, she reported that she was challenged in this endeavor by a too large span of control, as it was impossible to have frequent contact with all employees.

4.3.3 Practicing the workplace violence policies

Workplace violence policies typically contained a definition of violence and threats, guidelines for reporting episodes and guidelines for subsequent employee support. In addition, the policies often included guidelines for reporting episodes to the police for prosecution. Line manager Gitte explained how reporting to the police could be challenging in practice, despite being established in the policies:

Interviewer: And reporting to the police, whose responsibility is it? Is it you who has to step in and take the decision?

Line manager Gitte: Yes, it's a bit of a mess because sometimes it's almost said that you should not make police reports, and sometimes the department management wants to know it and sometimes they do not want to know it, and sometimes it is the line manager, but the thing is, that it is the employee who makes the police report if they feel that a police report must be made. […] Well, there is a guideline, there are guidelines on it. Yes there are!

(Interview, Psych 7)

Gitte described here that some employees did not want to report to the police because they were afraid of witnessing, and afterwards having to face the patient in the hospital. As the manager reports, the employees were also uncertain if the report would be made by the workplace in a way that their anonymity was protected.

5. Discussion

In this study, we aimed to investigate what types of practices line managers use for preventing violence in two high-risk sectors. We found that managers described a variety of practices, which were categorized in three types of practices: “promote the positive”, “prevent violence” and “manage episodes of violence”.

The practices that managers' report using in this study converge with the three violence prevention climate dimensions, namely policies, practices and pressure for ignoring violence prevention policies. Specifically, our results show that encouragement to register episodes, taking reports of violence seriously, adequate staffing and not ignoring violence prevention policies (e.g. providing support after incidents) because of time pressure are part of the practices that managers describe they use to prevent violence. These were all related to the categories “prevent violence” and “manage episodes of violence”. We also found that managers describe several other practices they perceive important for violence prevention. This suggests that, when shifting the use of the violence prevention climate concept from being a “diagnostic tool” to quantitatively measure the state of violence prevention in a given organization to being a concept to analyze actions in the area, more nuances appear. Some of the practices not captured by the violence prevention climate belonged to the category “promoting the positive”. Initiatives promoting the positive have been emphasized as a motivator for organizations to initiate action (LaMontagne et al., 2014) and as seen, in this study, to create a basis (in terms of, for instance, a safe learning environment) for some of the more specific actions needed in the management of violent episodes, such as the ability to analyze such episodes. This finding is also in line with a general approach in the psychosocial work environment research that places more emphasis on the need to promote positive factors such as, for example, psychological safety, social capital and relational coordination, as a primary way to reduce the risk of adverse working conditions (Bolton et al., 2021; Edmondson and Lei, 2014; Meng et al., 2019). This approach that focusses on how to create a work environment that promotes a continuous positive development of better strategies has been neglected in intervention research on violence prevention, which typically focuses on implementing a specific approach to conflict situations (Baby et al., 2018; Geoffrion et al., 2020; Tölli et al., 2017).

We found that “violence prevention climate” and “the integrated intervention approach for workplace mental health” allowed for a focus on preventive action and a more detailed vocabulary for these actions that can facilitate reflective practice and collegial support among managers. While some of the practices that managers described in the category of promoting the positive could have been captured as primary prevention effort as described in the public health approach (Paterson et al., 2005), or as a “before” effort in the Haddon matrix approach to injury prevention (Haddon, 1968), we believe that the chosen theoretical framework helped to identify “promote the positive” as a specific type of practice. This type of practice (e.g. creating a good learning environment) were clearly linked by the managers to violence prevention, but were also important areas to address to improve the broader psychosocial work environment and the quality of their core task.

Some of our findings concur with a similar study of line managers in the hospital sector that equally identify the categories “strive towards readiness to act” and “manage incidents” (Jakobsson et al., 2021). These categories overlap with our “prevent violence” and “manage episodes of violence” and are in line with the public health approach of primary, secondary and tertiary prevention that was applied in violence prevention already in 2005 (Paterson et al., 2005). This suggests that these are important and meaningful categories of action from the managerial perspective. However, there are also some differences, as Jakobsson and colleagues described the dilemma the hospital line managers had regarding the need to care for both employees' and patients' safety at the same time, which did not seem to be a concern for the managers examined in our study (Jakobsson et al., 2021). These differences probably reflect the different settings of the studies, ours being in high-risk sectors, where efforts to balance client safety and employee safety were more obviously part of their managerial tasks and a dilemma that they were used to handle. This points to the context-sensitivity of violence prevention and calls for more research in other settings to better capture different nuances in practice and theory that best guides intervention development.

There was a substantial overlap in the practices described in the two sectors. Although this overlap might seem surprising, the two sectors share a number of features. In Denmark, this is the case for organizational characteristics such as a three-shift system and high levels of sickness absence or turnover; in addition, both are public service organizations that are governed through political decisions. The core task and violence prevention are in both sectors dependent on the relational work between the staff and the patients/inmates. For the line managers, this means that the prioritization of violence prevention is intertwined with their approach to the core task. These similarities may result in line managers from the two sectors sharing comparable challenges and opportunities for prioritizing violence prevention, such as creating a common and fit-for-purpose approach to relational work.

The overlap between the two sectors suggests that the results from this study might be generalizable to other sectors in Scandinavian countries that share the same characteristics and have a high risk of violence, such as specialist schools, hospitals or care homes. However, it is unlikely that the practices found in this study would be useful in low-risk sectors, or in workplaces wherein client contact is brief, such as for example ticket inspectors.

We also found that line managers in both sectors described several challenges in their violence preventive efforts. It is known from workplace mental health management research that the managers' own work environment can influence their management practices and consequently the mental health of the employees (Biron, 2018; Skakon et al., 2010; Tafvelin et al., 2019). This is in line with findings of this study showing that time pressure, the use of three-shift system, leader’s span-of-control and sickness absence/turnover posed significant challenges for line managers' violence preventive efforts. It has to be noted that some of the challenges described by line managers need to be addressed on a higher management or political level. This includes aspects that were described by the line managers as creating high time pressure, such as documentation, overcrowding, understaffing and frequent organizational changes.

Future research is needed to test if the implementation of the described violence preventive practices can actually ameliorate violence prevention. Also, there is a need to conduct similar qualitative investigations of top-management's violence preventive practices, as they have a crucial role given their influence on the amount of resources allocated to violence prevention activities.

5.1 Practical implications

This study suggests that the inclusion of a strength-based approach in the design of workplace violence prevention programs could improve the success of such preventive efforts. The successful use of practices necessitates the development of a whole set of different skills in managers related to interpersonal relationships, appreciative/motivational communication, change management, de-escalation skills and knowledge on psychological reactions before, during and after potentially traumatic episodes. Interventions to improve these skills should be comprehensive in scope and account for the fact that line-managers’ work environment might prove at times to be an obstacle in developing and putting these skills into practice.

6. Conclusions

In this study, we found that line managers in psychiatry and the prison and probation services use a variety of violence prevention practices that can be categorized into three categories: “promoting the positive”, “preventing violence” and “managing episodes of violence”.

These practices converge with the three dimensions of the violence prevention climate, and with the public health approach to violence prevention, and thereby seem to be important and meaningful categories of action on a managerial level. However, the identified practices also go beyond these categories. Some of these practices belong to the category “promoting the positive”, which include factors such as managers attempting to create a learning environment that supports a continuous development of violence prevention. This study suggests that practices promoting the positive provide the basis for more specific practices, such as analyzing episodes of violence to identify patterns and therefore point at prevention needs. These practices are neglected in the current violence prevention intervention literature and may help organizations devise improved systems for violence prevention in high-risk sectors.

We also identified several challenges in connection to the managers' use of violence preventive practices. The main challenges mentioned were time pressure, the use of a three-shift system, span-of-control and sickness absence/turnover. The practices used and the challenges encountered largely overlapped in the two sectors, which suggest that they are generalizable to other sectors sharing similar conditions, such as special schools and institutions and care homes. Further studies should test interventions on violence prevention climate that implement the three types of violence preventive practices identified in this study.

Table 1

Data sources and participant information

Data source	Psychiatry	Prison and probation service
Interviews	8	8
Field notes from leadership seminars	3	3
Field notes from coaching sessions	6*	9*
Total number of sources	17	20
Participant information
Female	12	3
Male	0	9
0–5 years of experience as manager**	2	5
5–10 years of experience as manager**	1	3
10 + years of experience as manager**	5	1
Total number of participants across interviews, coaching sessions and leader seminars	12	12

Note(s): *Numbers differ because two out of four psychiatric units dropped out of the intervention, one after having participated in pre-intervention interview and one after having participated in the leadership seminar and the first coaching session. The three work units from the prison and probation services received the full intervention package; **This information was only collected for line managers in the pre-intervention interviews. Practice development nurses, section chiefs, head nurses and jail deputies are therefore not included in this count; Italics used as a marker of the total number of sources and participants

Table 2

Types of violence preventive practices described by line managers

	Promoting the positive	Preventing violence	Managing episodes of violence
Practices used in both sectors	Creating a learning environment	Facilitating a common approach to relational work	Providing support after an episode of violence or threats
	Create a good frame for relational work	Sparring with employees in situations involving difficult patients/inmates	Adjustment of tasks after episodes of violence or threats
		Distributing emotional demands between employees	Practice the workplace violence policies
		Analyze episodes or near-episodes
Practices used in just one of the sectors	Change management of new efforts beneficial to the violence preventive work (psychiatry)	Making good on-duty schedules (psychiatry)
	Create trust between manager and employees (prison and probation services)	Matching employees and employee experience/relations with patients (psychiatry)
	Create motivation and engagement in violence prevention activities (prison and probation service)	Correction of conflict-initiating behavior (prison and probation service)
		Protecting employees' mental resources (prison and probation service)