Addressing Workplace Violence: Developing a Collaborative Intervention with a Participatory Action Research Approach

Safety & Health Assessment & Research for Prevention (SHARP) — Research for Safe Work


The growing field of Occupational Health Psychology (OHP) is focusing research efforts toward better understanding and control of organizational level factors such as work-life and safety cultures, which may function towards primary prevention of occupational illness and injury. Through examining the managerial and supervisory practices, processes, and policies of work organization and their influence on employee work and health, the knowledge gained from research can be used to advocate for and develop interventions for healthy work environments and safe workplaces (Sauter & Hurrell, 1990). SHARP researchers are collaborating on this project with two Washington psychiatric care facilities.

Our research goal is to identify and prioritize key organizational influences such as supervisor support on patient aggression and coworker disruptive behavior. In addition, we seek to increase understanding of how direct care provider high stress, high aggression working conditions influence health, family, and work outcomes. Finally, this research seeks to advance innovative approaches to engage interdisciplinary hospital care provider, labor, and management stakeholders in the research process of developing a collaborative organizational intervention to address workplace violence prevention.


Recent research in Europe and the United States has focused on healthcare workers’ experience of workplace violence in the form of patient aggression and coworker interpersonal conflict or psychological aggression on the job. The research has examined not only patient assaults but also coworker overt and covert disruptive behaviors such as social isolation, work sabotage, withholding information needed to complete work, and verbal threats. A number of terms describe the problem such as interpersonal conflict, incivility, workplace bullying, and psychological aggression (see Hershcovis, 2011). These behaviors are costly to organizations and employees and have been linked to lowered productivity, work stress, poor health, and loss of talent as targeted individuals often choose to leave the organization in search of work in a healthier environment (Rosenstein & O’Daniel, 2008). Coworker disruptive behavior has also been linked to poor patient safety outcomes (Rosenstein & O’Daniel, 2008; The Joint Commission Sentinel Event Alert, 40, 2008).

This project assessed the relationships of workplace context resources important to care provider health, family health, and organizational health outcomes in a public psychiatric hospital. We conducted a cross-sectional survey study of current practices, outcomes and experiences and integrated these data findings with qualitative data findings from focus groups and interviews with hospital direct care providers.

A key finding suggested that family supportive supervisor behaviors (see Hammer et al., 2009) were a key support mechanism for employees. In our analyses, family supportive supervision serves to replenish some of the resources depleted by the strain of experiencing psychological aggression (Yragui, Hammer, Demsky & van Dyck, 2013). With this replenishment, direct care providers’ ability to manage psychological aggression demands in both work and family domains is increased, potentially resulting in better health, safety, and work outcomes. These findings highlight the critical role of supervisors in psychiatric care settings – to promote safer workplaces and to support care providers as they manage the strains of workplace aggression that impact them at work and at home.

This knowledge has informed the development of a supervisor training intervention with multi-disciplinary hospital stakeholders designed to reduce workplace violence by increasing supervisor work-life support and violence prevention support for their employees.

Participatory Action Research (PAR)

Participatory Action Research (PAR) is an interactive research approach which incorporates a value and purpose of promoting change through research, in part by taking place in and being developed by those in the community of study. PAR is used within a range of settings and has advanced with a primary focus of linking theory, research, practice and action (Reason & Bradbury, 2008). The PAR process is that of systematic inquiry in which those who are experiencing the work-related issues team up with researchers to make decisions guiding the study, such as, what information to collect and how to collect it (Rosskam, 2009). For this research, we met with union representatives and care providers at risk for workplace violence, as well as upper-level management and mid-level supervisors to work collaboratively with SHARP researchers to design the study, implement the research activities, and design the supervisor training intervention.

PAR Methods

Our community-based participatory research partnership engaged in intervention research at a public psychiatric facility in Washington State. Specifically, the Intervention Development Team (IDT) consisted of a multi-disciplinary group of union representatives, direct care staff and supervisors, and upper-level management who met regularly over the course of more than a year, from March, 2012 to June, 2013. The meetings were guided by the researchers by training topic, and were free and open to discussion by any member. These discussions were critical for designing the content of the supervisory training as well as the training method of delivery which included a computer-based training for knowledge content and a face-to-face interactive training component for skill development.

The steps of the research towards a final intervention product were to (1) conduct a baseline survey on workplace violence, safety, work schedule flexibility, work-family conflict, and employee health, family and work outcomes and individual interviews and focus groups with hospital direct-care providers, (2) review and discuss the existing occupational health psychology research literature with the intervention development team on topics related to the training, (3) discuss results of the qualitative and quantitative data analyses from the hospital survey and the individual interviews and focus groups with the team through reports and presentations, (4) design and develop training topics focusing on priorities from the report data-based recommendations and intervention team’s discussions, (5) create training materials, (6) pilot the training computer-based and interactive components, (7) and revise and finalize the intervention.

Study Data

In designing and administering our survey, we gathered data on a wide variety of validated survey instruments and open-ended qualitative questions. In addition, we conducted focus groups with care providers and individual interviews with supervisors on the topics of work-life management, workplace violence prevention, safety behaviors, and coworker disruptive behaviors. The topics were also introduced to our Intervention Development Team and extensive minutes from our group discussions comprise an additional data source.

Qualitative Data

Qualitative data in the form of focus groups with direct care providers and individual interviews with supervisors and managers were conducted at two time points in the study. In the first year they were conducted as formative research to mirror the key topics of the survey and add depth to the survey baseline findings. In the second year, as the Intervention Development Team was discussing the training topics, a second series of focus groups and interviews was conducted to learn about successful ward teams and identify specific behaviors that teams and their supervisors use toward supporting schedule flexibility and work-life integration for employees in high stress work conditions and for supervisor support for team violence prevention and safety and handling disruptive behavior. These interview data were analyzed and along with the data source of extensive meeting minutes from the Intervention Development Team meetings we had rich data findings to draw on to develop an intervention that was relevant for the hospital.

Intervention Development Model

The Job Demands-Resources Model (JD-R) guided the research and development process. The JD-R model proposes that job resources such as social support from supervisors may bufferthe impact of job demands on stress reactions, including burnout (Bakker, Demerouti, & Euwema, 2005; Bakker, Demerouti, Taris, Schaufeli, & Schreurs, 2003). In addition, Cohen and Wills (1985)stress buffering hypothesis states that social support protects employees from the negative effects of stressful experiences. We proposed that those employees with higher levels of patient aggression and coworker disruptive behavior have a greater psychological need for support, especially support that addresses the employee’s ability to integrate work and family demands while contending with the psychological and physical demands of patient aggression and injury at work. In addition to protecting employees from the negative impact of patient aggression, the resource of supervisor support affords direct care providers a means to replenish depleted energy related to recovering from patient assault and injury or handling coworker disruptive behavior (Bakker, Demerouti, & Euwema, 2005).

Intervention Topics

The training topics that emerged from the qualitative and quantitative data collection and analysis and discussions with the Intervention Development Team  were Work-life Culture and Safety Culture. Work-life culture generally refers to the shared beliefs and expectations around employees’ non-work lives while safety culture refers to shared beliefs and expectations around safety and violence prevention. A work-life and safety culture that is supportive of employees positively impacts the health, safety and work experience of employees through reducing work stress. The specific content underlying both topics was developed by the Intervention Development Team and informed by the survey data, interviews and focus groups. For example, the idea of ‘team situational awareness’ for maintaining safety on the hospital ward was something that was initially remarked upon in  ward focus groups, presented to and discussed with the Intervention Development Team, and then added to the training while incorporating further feedback from the IDT group as a positive behavior for supervisors to support. Creating and maintaining ‘team situational awareness’ is crucial to both staff and patient safety, and is improved by a high functioning, communicative  team where a supervisor and staff provide emotional and instrumental support to their coworkers.

Throughout the participatory process the IDT group engaged in substantive discussions on the qualitative and quantitative findings from the organization prior to and during the project. This research process produced a strong intervention through drawing on multiple perspectives and places of organizational knowledge – leading to a more authentic training content specific to the organization.

Conclusions and Future Work

The current study's innovative contribution is the iterative integration of quantitative and qualitative data with the participatory action research process in the development of an organizational training. Combining both qualitative and quantitative methods allowed for depth and breadth of understanding that cannot come from a single method alone. Mixed methods and the PAR approach are complementary and potentially lead to stronger, focused interventions that effectively address some of the most relevant issues confronting the organization. Fundamental to participatory action research is the promotion of employee participation in decision making toward addressing workplace issues. We are encouraged that the knowledge produced from this participatory action research project has provided additional training resources for the improvement of work-life management, violence prevention, and work stress-related health for care providers at the hospital.

Future work will center on a formal evaluation study using a quasi-experimental design with control and experimental groups to test the effectiveness of the training intervention. We hope to expand this evaluation to include employees in similar work-environments in the medical and social services. The eventual goal of this research is to have an evidence-based intervention that is applicable to all supervisors and their teams.

Contact Nan Yragui at if you have questions about this study.

This report was made possible by Grant Number 1R21OH009983-01 (N. Yragui, PI) from the Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health (CDC/NIOSH), and the Washington State Department of Labor & Industries. The contents of this presentation are solely the responsibility of the author and do not necessarily represent the official views of these institutes or departments.

Recommended References

Bakker, A. B., Demerouti, E., & Euwema, M. C. (2005). Job resources buffer the impact of job demands on burnout. Journal of Occupational Health Psychology, 10(2), 170-180. doi: 10.1037/1076-8998.10.2.170

Bakker, A. B., Demerouti, E., Taris, T. W., Schaufeli, W. B., & Schreurs, P. J. G. (2003). A multigroup analysis of the Job Demands-Resources Model in four home care organizations. International Journal of Stress Management, 10(1), 16-38. doi: 10.1037/1072-5245.10.1.16
Cohen, S., & Wills, T. A. (1985). Stress, social support and the buffering hypothesis. Psychological Bulletin, 98(2), 310-357. doi: 10.1037/0033-2909.98.2.310

Hammer, L. B., Kossek, E. E., Yragui, N. L., Hanson, G. C., & Bodner, T. E. (2009). The development and validation of a measure of family supportive supervisory behaviors (FSSB). Journal of Management, 35(4), 837-856.
Hershcovis, M. S. (2011). "Incivility, social undermining, bullying...oh my!": A call to reconcile constructs within workplace aggression research. Journal of Organizational Behavior, 32(3), 499-519. doi: 10.1002/job.689
Reason, P., & Bradbury, H. (2008). The SAGE handbook of action research: Participative inquiry and practice. London: SAGE Publications.

Rosenstein, A. H. & O'Daniel M. (2008). A survey of the impact of disruptive behaviors and communication defects on patient safety. Joint Commission Journal of Quality and Patient Safety, 34, 464-471.

Rosskam, E. (2009). Using participatory action research methodology to improve worker health. In P. L. Schnall, M. Dobson & E. Rosskam (Eds.), Unhealthy work: Causes, consequences, and cures (pp. 211-228). Baywood, NY: Baywood.

Sauter, S. L., & Hurrell, J. J. (1999). Occupational Health Psychology: Origins, content, and direction. Professional Psychology: Research and Practice, 30, 117-122.

The Joint Commission [TJC]. (July 9, 2008). Behaviors that undermine a culture of safety. Sentinel Event Alert, 40, 1-3. Retrieved from [accessed 10/29/12].

Yragui, N. L., Hammer, L, B., Demsky, C. A., & Van Dyck, S. (May, 2013). Linking Workplace Psychological Aggression to Employee Work, Safety & Health: The Moderating Role of Family-Supportive Supervisory Behaviors (FSSB). Paper presented at the biannual conference of Work, Stress, and Health, Los Angeles, CA.

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