Reducing workplace violence by creating healthy workplace environments

Invited paper

Reducing workplace violence by creatinghealthy workplace environments

Bob Bowen, Michael R. Privitera and Vaughan Bowie

Abstract

Purpose – The purpose for writing this paper is to help develop and apply integrated models and

methods of best practice that can prevent and manage workplace incivility (WPI) and workplace

violence (WPV).

Design/methodology/approach – This approach uses the framework of the public health model to

integrate neurobiological, behavioural, organisational, mental health, and educational theory into a

holistic framework for the primary, secondary, and tertiary prevention of WPV. The key concepts built into

this model are those of organisational violence (OV), trauma-informed services, and positive behaviour

support (PBS). This approach is further illustrated by case studies from organisations that have

successfully implemented safety protocols that demonstrate the effectiveness of such an integrated

approach. This method is derived primarily from qualitative data based on the expertise and experience

of the authors in the areas of psychiatry, social work research, and instructional implementation as well

as reviews of the current literature.

Findings – This model suggests that understanding WPI and violence as reactions to a combination of

internal and external stressors is key to interrupting these violent responses. Responding to WPV

requires that organisations first take responsibility for their own role in generating WPV and recognize the

impact of organisationally generated trauma on staff and services users. In this behavioural model, WPV

and WPI have functions which require the teaching of replacement behaviours that help individuals to

escape from these stresses in ways that do not cause harm to themselves and/or others. Thus,

management must instruct staff how to teach and reinforce appropriate social and communicative

behaviours in order to replace those behaviours leading to WPV and WPI.

Practical implications – The practical implications of this paper are that it provides human service

practitioners with: an understanding of the functions of reactive violence at work; a methodology to

identify different types WPI and WPV; a framework to proactively teach violence replacement

behaviours, empowering people to address the causative factors in ways that do not cause harm to self

and/or others; skills that can be taught to management and staff individually or in group settings, as well

as to service users; and implementation models from various organisations that have achieved

significant reductions in WPV. Another important outcome demonstrated through the case studies is that

significant financial savings can be achieved through reduction of WPI and WPV which may in turn lead

to a related improvement in the quality of life for staff and service users through changes in workplace

practices. This outcome has implications for organisational practice and theory as well as human

services education and training.

Social implications – One key social implication of the model, if integrated into the company’s social

responsibility policies and practices, is the potential for improving the quality of life for staff and patients

in health care settings as well as employees, customers, and service users in other settings.

Originality/value – The originality shown in this paper is the way the three key concepts of OV,

trauma-informed services, and PBS are built into a public health model to prevent and mitigate WPV. This

paper is of particular value to boards of management, organisational directors, supervisors, HR and

training departments as well as direct care staff, service providers, and regulatory bodies.

Keywords Workplace, Violence, Workplace incivility, Positive behaviour support

Paper type Research paper

DOI 10.1108/17596591111187710 VOL. 3 NO. 4 2011, pp. 185-198,Q Emerald Group Publishing Limited, ISSN 1759-6599 j JOURNAL OFAGGRESSION, CONFLICTAND PEACERESEARCH j PAGE185

Bob Bowen is the CEO of

The Mandt System, Inc.,

Richardson, Texas, USA.

Michael R. Privitera is an

Associate Professor of

Psychiatry at the University

of Rochester Medical

Center, Rochester,

New York, USA.

Vaughan Bowie is an

Adjunct Fellow at the

University of Western

Sydney, Sydney, Australia.

Introduction

Workplace violence (WPV) between staff in organisations is estimated to cost organisations

in the US$4.2 billion per year in lost time and productivity (Tunajek, 2007). By understanding

the cumulative effect of workplace incivility (WPI), a low level form of WPV that could be

non-physical or physically deviant behaviour violating norms of mutual respect (Andersson

and Pearson, 1999), a behavioural model emerges. This model suggests that simply

educating staff about WPV and WPI is insufficient, and that understanding incivility and

violence as responses to a combination of internal and external stressors is key to

interrupting these violent responses. In this behavioural model, WPVandWPI have functions

which require the teaching of replacement behaviours that help individuals to escape from

these stresses in ways that do not cause harm to themselves and/or others. This requires that

organisations first take responsibility for their own role in generating WPV and then instruct

management staff how to teach and reinforce appropriate social and communicative

behaviours in order to replace those behaviours leading to WPV and WPI. Case examples

from organisations that have successfully implemented safety protocols will be presented

with specific training and leadership actions that can be replicated in other workplaces.

Violence in the workplace continues to escalate in the human service industry. According to

the US Bureau of Labor Statistics:

[. . .] a worker in health care and social assistance is nearly five timesmore likely to be the victim of

a nonfatal assault or violent act by person than the average worker in all industries combined.

At the same time that non-fatal declined in private industries, they increased slightly in

human services, according to this same report. Hospitals in the USA have 29.5 percent of

the employees in human services, but account for 40.1 percent of all non-fatal injuries

(Janocha and Smith, 2010). Whilst injuries to workers were decreasing in all other work

settings, health care workers risk of injury increased in the last ten years in the USA. Data in

the UKmirrors this trend, with 15.3 percent of life science and health professionals subjected

to WPV and 15.2 percent of health and social work employees reporting they have

experienced WPV (Paterson et al., 2008). As pervasive as these measurements of violence

are, most experts agree that the prevalence, intensity and effects of WPVare under-reported

(Privitera and Arnetz, 2011). The authors will focus on the presence of those positive aspects

of healthy organisational structures that give hope to the wounded persons who come to

health care settings in search of healing.

The International Labour Organisation has developed the following definition of WPV:

Any action, incident or behaviour that departs from reasonable conduct in which a person is

assaulted, threatened, harmed, injured in the course of, or as a direct result of, his or her work.

Internal workplace violence is that which takes place between workers, including managers and

supervisors. External workplace violence is that which takes place between workers (and

managers and supervisors) and any other person present at the workplace.

Whilst we go through the process of identifying violent behaviour, we must not lose sight of

the fact that some violence is a reaction to the culture of the organisation itself. What would

be a dysfunctional behaviour in a healthy and functional organisational climate can be seen

as a coping mechanism in an unhealthy, dysfunctional environment. It is not just ‘‘bad

apples’’ that must concern us, we must also focus on the possibility of a ‘‘bad barrel’’ (Bowie,

2010). When focusing on individuals (patients or staff in the health care system), such an

approach operates on a ‘‘bad apple’’ response to managing and preventing violence in the

workplace. However, there has been growing awareness of the role organisations may play

in creating oppressive and violent climates within their workplace, that may in turn trigger

violence by staff, patients, or others. This latter approach is the ‘‘bad barrel’’ approach to

managing WPV (Bowie, 2006).

Bowie (2011) expanded on this definition by adding the concept of organisational violence

(OV) in which ‘‘organizations knowingly and unnecessarily place their workers or clients in

dangerous or violent situations or allow a climate of abuse, bullying, or harassment to thrive

in the workplace’’. It is a relatively new construct to understand that the context of staff

PAGE 186 j JOURNAL OF AGGRESSION, CONFLICT AND PEACE RESEARCHj VOL. 3 NO. 4 2011

behaviour includes the policies and procedures of an organisation, as well as their practices,

which constitute unwritten policies and procedures (Sims and Keon, 1999). OV can be a

causative factor in both staff to staff violence and client to staff violence, as well as other

types of WPV (Bowie, 2011).

WPV can be present at various levels of intensity, and at its’ lower spectrum is known as WPI.

At all levels, these behaviours are used by staff in response to perceived stressors in their

work environments. WPI is defined as:

[. . .] low-intensity deviant behaviour with ambiguous intent to harm the target, in violation of

workplace norms for mutual respect. Uncivil behaviours are characteristically rude and

discourteous, displaying a lack of regard for others (Andersson and Pearson, 1999, p. 457).

WPI is calculated to cost $11,581 per nurse per year in lost productivity in the USA (Lewis

and Malecha, 2011).

Although causal factors for aggression range in the biological, psychological, and social

spectra of human experience (Ferns, 2007), often described collectively as biopsychosocial

causes, the two general types of aggression that more rapidly differentiate on basis of

motive are instrumental (sometimes referred to as predatory) and reactive (affective)

(Cornell et al., 1996; McElliskem, 2004). Instrumental aggression is goal directed and

planned aggression whereas reactive includes arousal such as hostility.

The authors understand that some models of violence postulate combinations of the two

types, and differentiate various causal factors mentioned here. However, the dichotomous

model provides staff with an ability to more easily understand in the moment that the violence

is not directed at them personally. By de-personalizing the behavioural interactions, staff is

empowered to analyze the behaviour instead of reacting to it, and consequently decreasing

the likelihood the interaction will escalate.

Table I, taken from the Society for Research in Child Development (2007), provides a

framework for assessing the two types of violence and in teaching staff how not to engage in

aggression, but to use other behaviours to achieve the same goals of violence.

Most episodes of WPV begin as reactive rather than instrumental forms of aggression

(Keashly, 2005) and hence are the focus of this paper. The effect of reactive aggression can

be lessened by teaching people who want to ‘‘get back’’ at the people or person who

harmed them in some way to respond using their cognitive analytical skills rather than to

react using primarily emotionally based behaviours. To do this, however, people must

de-escalate. An increase of 20 percent in pulse significantly decreases the ability of people

to use cognitive skills and as a result interactions, between people when they have

escalated, are often aggressive and conflictual (Gottman and Levenson, 1988).

After staff experience WPI and WPV, the natural human response may be to escalate into

reactive violence. In order to de-escalate in a healthy manner, one must affirm their feelings

after experiencingWPI and/orWPV, and then choose abehaviour that addresses the issues in

away that leads to resolutionof the conflict (Mandtet al., 2008). This approachalso empowers

staff to identify their feelings after a real or perceived event and affirm those feelings

Table I Understanding aggression to assist with responding

Feature Instrumental aggression Reactive aggression

Cue source/type Internal ExternalMotive Personal gain (acquisition) Harm the stimulus/antecedent (escape)Premeditation Yes NoImpulsivity Low HighEmotion Calm AngryMoral cognition Actions morally discounted Actions justified or deserved

Source: Society for Research in Child Development (2007)

VOL. 3 NO. 4 2011 jJOURNAL OF AGGRESSION, CONFLICT AND PEACE RESEARCHj PAGE 187

in themselves. Choosing behaviours to address the issues in a way that leads to a positive

resolution of the conflict is the goal of programmes that address all forms of violence.

Separating the two types of violence in order to craft responses that are preventative and

incorporating the models described above allows us to view reactive aggression as an

attempt to escape from a perceived dysfunctional situation. Aggression can then be seen as

a coping mechanism to help people to escape from people or situations that cause them

stress (Ursin and Olff, 1995).

The public health model of behaviour change has been adapted for use in residential child

care and by extension in human service systems (Paterson et al., 2006). Themodel theorizes

that primary prevention is more cost effective than treating symptoms of illness (secondary

prevention) or by intensive hospitalization services (tertiary prevention). It is usually

presented in a pyramid format to demonstrate the importance of allocating more resources

to primary and secondary levels of prevention and intervention. It is the recommendation of

the authors that for every hour of time spent in teaching people how to intervene in a situation

that there be at least two hours focused on de-escalation and three hours on prevention. This

will provide for the resources necessary to de-escalate and, more importantly, prevent WPV

and WPI. As applied to WPI and WPV, the authors have organised primary, secondary, and

tertiary interventions below, in Figure 1.

Figure 1 Primary, secondary, and tertiary interventions into WPI and WPV

Create hospitable andengaging environments

which are trauma informedand move away from

coercion using PositiveBehaviour Support. ReviewPolicies and Procedures to

ensure they incorporatepositive practice models. QA

incorporates employeeinput/surveys

Teach people to "affirm theiremotions and choose their

behaviours" integratingneurological processing

information into behaviouralchoicemaking. Supervisors

taught to proactively addressWPI

HR Involvement, conflictmanagement strategies,

respond to WPI and WPVimmediately. Use restorativejustice model if employment

is to continue, and iftermination is warranted,always used dignity and

respect

• Tertiary prevention (deal with the apples, debriefing to clean the barrel if needed)• INTERVENTION

• Secondary prevention (keep the barrel clean)• DE- ESCALATION

• Primary prevention (create a good barrel!)• PREVENTION


Primary prevention

Instead of focusing just on the ‘‘bad apples’’ (Rhodes et al., 2010) who are often blamed for

WPI and WPV, our focus is also on the barrel holding the apples. All behaviour occurs within

a social context and within organisations that context is the culture of the organisation. The

goal of intervention is to help organisations move from a toxic to a beneficial culture in which

staff can do their work more effectively (Bowie, 2010).

As WPV and WPI occur within complex workplace systems, Figure 1 shows how they can

associate with each other. Prevention of WPVandWPI must have systemic components, and

focus on all four of the major areas, not just one. For instance, organisation with ‘‘state of the

art’’ policies and procedures, trauma-informed leadership (having basic understanding of

how trauma affects the life of the individual-seeking services), and a non-coercive climate,

can still experience WPV and WPI because of situational stresses interacting with personal

traits. An important and often overlooked concept in understanding organisational cultures

and climates is the perceptions of employees within the organisation (Griffin et al., 2000). An

organisation that believes it has ‘‘state of the art’’ policies and procedures and Human

Resource functions that support employees only has them if the perception of employees

validates them. Figure 2, which shows a great deal of research, links together the concepts

of WPV/WPI, organisational wellbeing and organisational performance using an

organisational health model (Cotton and Hart, 2003). Previously, the stressors and strain

model, which dominated occupational stress research over 30 years, failed to link the stress

process with organisational performance. As such, occupational stress had been formerly

marginalised into the broader management and organisational behaviour literature, and had

been relegated to lower hierarchy of concern to organisational administration (Wright and

Cropanzano, 2000; Hart and Cooper, 2001).

In human service and health care settings, morale is suffering as a result of the increase in

WPI and WPV, reflected in the data from the US Bureau of Labor Statistics. Roger Fallott has

written extensively on the concept of ‘‘Trauma-informed Services,’’ (Fallot, 2011). By being

aware of the trauma histories of people, patients and staff alike, organisations can create a

service structure that is, in Fallott’s words, ‘‘hospitable and engaging’’. The process of

engaging staff is seen in the many examples of success in organisations that use a variety of

staff surveys to assess and address issues of OV and the cultures which inadvertently

support it (Cotton and Hart, 2003; Possibilities, 2008).

Hospitable environments are those which invite other people into the environment through an

admissions process with the promise of emotional, psychological, and physical safety.

These three levels of safety are seen in statutes on abuse, which prohibit physical abuse,

emotional abuse, and psychological abuse (CMS, 2006). Many organisations do a credible

job of providing this level of hospitality to individuals served, but less so to the staff who serve

them. Reducing WPI and WPV toward staff needs to be re-assessed as a quality of care

variable of interest to regulatory agencies, as mounting evidence show that WPV toward staff

ultimately affects quality of care provided to patients (Arnetz and Arnetz, 2001; Privitera and

Arnetz, 2011).

Engaging environments empower individuals served to direct the process of their own

recovery, habilitation or rehabilitation. This requires a shift from traditional behaviour

management models which focus on reinforcement and punishment to change behaviour to

the model of positive behaviour support (PBS). This shift in philosophy and belief has been

made in many health and social service settings as behaviour change theories are applied to

client behaviour. However, behaviour change efforts in addressing how staff interacts with

one other continue to use punishment-based models.

There is a common concept which states, ‘‘you can only give what you have in abundance’’.

Human service andhealth care environments are stressful andprovide services to apopulation

whose acuity needs are increasing. At the same time, the concept of ‘‘display rules’’

(Cropanzanoet al., 2004) states that when employees cannot display the emotionswithin them,

their stress level will increase. Supervisory and managerial staff must recognise this process

andoffer support to their staff inorder toprovide themwithenvironmentswhichmeet their needs


for safety so they can provide safety to others. To offer physical, psychological, and emotional

safety to others, staff must have this safety in abundance. Another way to state this is ‘‘you can’t

give what you don’t have’’. If staff barely or do not have enough safety for themselves, so to

speak, they cannot give safety to others. This preventative aspect of supervision will help to

structure a positive workplace environment in which low level violence can be monitored with

mediated discussion (Lewis and Malecha, 2011).

Positive behaviour support (PBS) as a preventative tool

All behaviour can be thought of as having a purpose or function of escape or acquisition.

At times, behaviour can have both functions. A simple example is choosing a menu item in a

restaurant. A person will choose a food which helps that person escape from hunger and at

the same time acquire a specific taste or texture. The functions of the behavioural patterns

that are described with the word ‘‘violence’’ are presented in Table I. In reactive aggression,

which is the most common form of WPV, the functions are described as wanting to in some

way harm a person who has caused harm and to escape from the immediate situation which

may cause harm.

Figure 2

Source: Figure constructed with data taken from Cotton and Hart (2003)

Oppressive Organisational Climate* (Type IV Organisational Violence):• Reflected in policies, procedures, practices of supervisors and managers• Pressure for and allowing unsafe practices.

Adverseemploymentexperiences: acts ofviolence, threats,assaults, coercivepractices, bullying

IndividualDistress:anxiousness,anger, guilt,sadness etc.

Core TaskPerformance

Contextual/DiscretionaryPerformance

Individual morale.Positive affectivedimension:Pleasurable emotionalstate, energy,enthusiasm, pride.

WPV previouslymarginalized to broadermanagement andorganizational behaviorliterature, via Stressorsand Strain Model.

EmployeePerformance

Mediated bypersonality(emotionality,extroversion)

Mediated bypersonality(emotionality,extroversion)

- -

- -

- -

+

+

Organizationalperformanceoutcomes

+

+

+

+

KEY:

+ or - - : direction of correlation to relationship

Stronger relationship

Weaker relationship

Bold Underline: targets for intervention to improve leadership by managersand administration for better results.

WPV: Workplace violence WPI: Workplace incivility

*Climate of the organisation is the sum of the processes and activities within theorganisation as they are perceived by staff (Griffin and Hart, 2000). In otherwords it consists of managerial and leadership practices as well as organizationalprocesses and structures (Cotton and Hart, 2003).

Occupational Wellbeing, Organisational Performance and WPI/WPV(Organisational Health Model)


The concept of ‘‘escaping to safety’’ (Lindsay, 2000) rather than attacking the threat is a very

helpful construct in the prevention of WPI and WPV. In animal research, prey animals are not

stressed by the presence of a predator, but rather by an inability to detect their presence

(reduced predictability) and having escape routes to safety blocked. Using PBS to structure

personnel policies, teach supervisory and managerial skill and focus on creating an

organisational culture which teaches staff what to do (known as positive practice) can

provide a predictable environment in which emotional, psychological, and physical safety

can be established for staff and service users.

PBS can be described as a way to help people acquire the goals of their behaviour (the

antecedent) in ways that do not cause harm to themselves and/or others. By identifying the

antecedent events and using a structural analysis of the antecedent (Stichter et al., 2004),

prevention can be accomplished in a way that also teaches the individual to use different

behaviours the next time they encounter the same or similar event(s). Rather than focusing

on consequences to teach behaviour change, a structural analysis identifies the component

elements of the antecedent – ‘‘what do you really want – and then rearranges the antecedal

conditions’’. Using this approach to identify the variety of events that precede violent

behaviour will help individuals and organisations move from a reactive to a proactive

methodology of violence prevention.

Central to PBS is the understanding that staff who use PBS, ‘‘continually move away from

coercion’’ in all forms (NAU, 2005). Rather than seek compliance, PBS models invite people

to cooperate by building a relationship based on dignity and respect, and finding ways to

motivate people to change their behaviour through an invitational and collaborative process

rather than an externally imposed process of compliance (Bowen, 2009).

In the workplace, what this means is that the focus of the organisation must be one of taking

the lead in creating safe environments – physical, emotional, psychological. When people

feel safe they are free to focus on relationships, which in many cases are the foundation for

achievement. This approach is highlighted in the work of Maslow (1954), in which he

postulated that after the need for basic human sustenance, human beings needed safety.

The physical, psychological, and emotional safety of human beings is a pre-requisite

for healthy neurological development in children (Perry, 2000a) and to the continuing

development of those social structures that bind us together in human communities.

Thus, the leadership of the organisation must commit to this process of ‘‘continually moving

away from coercion’’ and restructure relationships at a level far deeper than simply reframing

the organisational chart. One example is the flexible matrix of relationships at the Treasure

Coast Forensic Treatment Center in the USA (Vanderberg and Bowen, 2011) which

incorporates security guards, psychiatric aides, nurses, therapists, psychologists and

psychiatrists into a holistic treatment team. Each member of the team is able to share their

perceptions of patient behaviour and be informed by the perceptions of other team

members. These relationships of equality of worth with a difference of roles (Bowen, 2006)

has led to the virtual elimination of seclusion and restraint with only two staff injuries resulting

in time lost from work at that organisation in 2010.

Personnel policies and procedures generally approach the question of changing employee

performance through punitive rather than positivemeasures, the ‘‘bad apple’’ approach. The

use of punitive responses such as unpaid suspension, letters of reprimand, employment

reviews, etc. are generally speaking, ineffective at changingbehaviour in the long-term (Mohr

andBowen, 2009). Theworddiscipline at its rootmeaning is supposed tobe teach, but no one

has ever looked forward to their next employee discipline meeting (Bowen, 2011). In the

creation of cultures that support instead of abuse employees, personnel policies must be

changed to reflect a continual move away from coercive practices in changing the behaviour

of people.

Secondary prevention – de-escalation

In their studies of organisational health in Australia, Cotton and Hart (2003) were concerned

with the relationship between occupational wellbeing and organisational performance. They


posited that for occupational wellbeing to be meaningful to the organisation, it must be tied

to organisational performance (Cotton and Hart, 2003). Distress on the job is a separate

concept from morale and makes independent contributions to overall employee wellbeing.

Organisational climate is a broader concept relating to how employees perceive the way in

which their workplace functions (Griffin et al., 2000), consisting of perceptions-concerning

leadership and managerial practices, as well as organisational structures and processes.

These organisational structures and processes consist of appraisal and recognition

processes, decision-making styles, clarity of roles and alignment of goals of the organisation,

etc. (James and McIntyre, 1996; Hart and Cooper, 2001). The emotional impact of these

organisational factorsonmoralearemore influential thanadverseemployment experiencesof

stress (Hart et al., 1997). This is true across different types of professions, regardless of the

adverse employment experiences (i.e. true for police and true for teachers, etc.). In other

words, positive practice models in which employees are directed towards ‘‘what to do’’

instead of ‘‘what not to do’’ will provide the individual and organisational morale needed to

overcome the effects of WPI and WPV.

Leaders who understand the power of participation through feedback systems such as

employee surveys and then utilise them, can mitigate much of the stress which is part of all

work environments. Leadership is the most critical factor in moving away from coercion and

towards creating hospitable and engaging organisations (Huckshorn, 2004). When leaders

create a vision and empower others to not only share it but also build on it, WPV has been

reduced dramatically. Examples include Pennsylvania’s psychiatric hospitals (Smith et al.,

2005) and reductions of violence in an adolescent unit in a psychiatric hospital in

Massachusetts (LeBel and Goldstein, 2005).

When de-escalation is necessary, it is often because the preventative steps were ineffective.

Organisations sometimes look at escalation into WPI andWPVas symptomatic only of issues

amongst staff. It is critical, however, that the organisational culturebeassessed todetermine if

there was a causative factor, or setting event within policies and procedures, supervisory

practices, etc.

Teaching people to ‘‘affirm their emotions and choose their behaviours’’ (Mandt et al., 2008)

empowers them to affirm the validity of their emotions, whilst at the same time choosing

behavioural responses that are not violent. This approach can decrease impulsivity and

move people away from reactive violence and towards a cognitively driven model in which

we choose to act in a rational and not emotive manner. By affirming the underlying emotions,

we do not denigrate or deny emotion; rather we validate the feeling and choose the

behaviour that helps us achieve our goals.

However, in order toprevent violence fromoccurring, the antecedent events, including setting

events, must be identified (Crone and Horner, 2003). When people respond to a behaviour

without any clear understanding of its preceding events, they will most likely form part of a

power struggle with the individual because they do not know what the individual wanted to

accomplish through their behaviour. The first step of prevention in cases of client on staff and

staff on staff violence must, therefore, be the identification of the antecedent events.

Neurosensory input-output behavioural model in secondary prevention

Research has demonstrated that when a person’s pulse increases by 20 percent over their

baseline they can no longer process in the cognitive centers of their brain, but rather in the

limbic system. Neurological research has confirmed this process of people shifting from

cognitive toaffectiveprocessingof incomingstimuli under stress (LeDoux, 1989;Perry, 2000a).

Under the stress of WPI and WPV, people will react from their own fear, frustration, anxiety or

tension. It is critically important that managers and supervisors understand this process,

so they can prevent and, if necessary, de-escalate situations such that stress processing at a

cognitive level can occur.

Efforts to de-escalate that rely on an explanation of consequences will be doomed to failure,

as consequences are perceived as punishment when people process incoming information


at an emotional level (Foa and Kozak, 1985; Bowen, 2010). When people experience any

stimuli, the incoming information is carried by the nervous system into the brain, where it is

‘‘perceived, processed, interpreted, and acted on’’ (Perry, 2009). Stress can act as a barrier

to this neurosensory process and the more stress a person experiences, the less they are

able to cognitively process the information. Instead of processing cognitively, the person is

now more likely to react to a situation emotionally rather than respond cognitively (Perry,

2000b; Gillece, 2008). This model is shown in Figure 3.

Personal traits that develop as a result of an individual’s exposure to trauma, especially

during childhood, alter the neurosensory process shown in Figure 3. At times of high stress,

or when there has been a strong history of childhood trauma, the incoming sensory stimuli is

processed first in the limbic system, and then in the neocortex seconds, minutes, hours or

even days later. It is for this reason people sometimes react emotionally and later apologise

for their behaviour (LeDoux, 1989; Bowen, 2009). Therefore, the process of de-escalation

must recognize the importance of emotion, as escalation is an emotional and not a cognitive

process (Mandt and Hines, 2008). This can be accomplished by a combination of skill

teaching and supervisory monitoring and reinforcement when people practice the skills

during an incident that has successfully been de-escalated.

Examples include:

B Teaching people to use conflict resolution tools such as ‘‘I language,’’ and ‘‘carefronting’’

(Augsburger, 1981) instead of typical confrontational skills.

B Understanding how violence and threats of violence are neurologically processed as

incoming stimuli and outgoing behaviour (input-output loop) (Perry, 2000a).

B Focusing on changing future behaviour rather than punishing past behaviour through a

restorative justice model (MacRae and Zehr, 2004). Restorative (reparative) justice

involves needs of victims whilst encouraging accountability of and often help for the

offenders.

Tertiary prevention – intervention

When prevention is not possible, or is ineffective, intervention is needed in order to prevent

escalation frombecoming violence. This requires a level of external intervention that still gives

people choice and a measure of power and control over their lives. It can be thought of as

‘‘offering options’’ to the individual when they cannot select the options themselves. These

Figure 3 Neurosensory input-output behavioural model

• Emotional behaviour, motivation, memory, pain and pleasure sensations

• Directs sensory impulses through the body, smell, taste, vision equilibrium

• Core life functions such as breathing, heartbeat temperature, sleep

• Concrete and abstract thought processing

Neocortex

Limbic System

Diencephalon

Brain Stem

Sensory input goes up through all the systems to thecortex, and out again through the spinal cord


external controls can be systemic in nature, such as policies and procedures identifying

specificmeasures to take in case of violence, or they can be protective responses to address

specific threats on a case by case basis.

It is at thepoint of intervention that organisations often resort to punitivepractices that become

part of the oppressive culture. It is important to hold true to the valueswe hold especially aswe

intervene. The models of Restorative Justice and PBS (Ross, 2009) also work during the

intervention process. At the University of Rochester Medical Center (Farley-Toombs, 2011),

administrators demonstrated their belief in a multidisciplinary process by clarifying roles and

staff procedures allowed with violent patients. As a result, there was a marked reduction in

patient to staff assaults and patient on patient assaults. These same principles have been

shown to work in reducing WPV between staff as an intervention protocol (International

Institute for Restorative Practices, 2011).

In the opinion of the authors, the path towards reduction in WPI andWPV involves continually

moving away from coercion and applying the same principles of non-coercive behaviour

change used with service recipients to the service providers, and thus changing

organisational cultures. This systems level approach has resulted in significant savings in

many organisations, including:

1. Grafton (Sanders and Gaynor, 2010) which was able, over a 4 year period, to:

B Reduce physical restraint by 99.7 percent.

B Reduce client-related injuries to staff by 41.2 percent.

B Reduce lost time expenses from client-related injuries by 94 percent.

B Save $5,785,437 in costs over a five-year period.

2. Community Memorial Hospital in Menominee Falls, Wisconsin was able to work with all

stakeholders to eliminate workers compensation costs due to patient aggression, and

has continued to focus on reducing all types of violence within the hospital.

3. Developmental Services of Nebraska, a provider of residential services for people

affected by intellectual and developmental disabilities, worked with their staff to virtually

eliminate restraint, and is now moving towards a system of ‘‘coercion free services’’

(Possibilities, 2008).

Conclusion

The authors started this paper with data on increases in injuries in human service and health

care settings. Despite prevention efforts over the last several decades, and individual

instances of significant reduction in the use of restraint, WPI andWPVare increasing. A study

presented at the 7th European Congress on Violence in Clinical Psychiatry (Putkonen et al.,

2011) showed that in a randomized study, the use of restraint and seclusion was dramatically

reduced during the study, but after the study ended, seclusion and restraint rates returned to

their previous levels. Rather than focus on the causative factors of what causes OV, WPI and

WPV, the authors focused on those positive aspects of organisational structures that give

hope to the wounded persons who come to health care settings in search of healing. This

hope is reflected in stories of success from Australia, the UK, the USA and elsewhere.

Because WPV and WPI occur within the context of large systems of care, a systems theory

model focusing on prevention, de-escalation, and intervention is needed upon which to base

other necessary programmes. Integrating a behavioural model to understand WPV and WPI

with a neurosensory model to conceptualize a dichotomous understanding of WPV and WPI

will greatly reduce WPV and its lower spectrum WPI, leading to more positive healing

environments and more positive work environments for staff. Further research is needed to

more fully integrate the models presented in this paper and increase the safety of all

stakeholders in human service settings.


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Corresponding author

Bob Bowen can be contacted at: [email protected]

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Reducing workplace violence by creating healthy workplace environments