Care institutions struggle to standardize violence reporting in southern Germany

A qualitative study of elderly and special needs care institutions in southern Germany found that violence-prevention programs are in place but incident documentation remains fragmented, heavily dependent on paper records and subjective judgments. Researchers conducted 18 semi-structured interviews with violence-protection officers, institution managers, de-escalation trainers and other specialists from 16 organizations between June and August 2025. The participants described training, reporting channels and formal response plans, but no shared system for defining when an event must be recorded, determining its severity or aggregating incidents for review.

The study focused on residential and group homes for people with disabilities as well as inpatient elderly care in southern Germany. Seven participants worked in elderly care and 10 in special needs care. One further participant represented a large association with approximately 80,000 clients and was counted in the special needs care group because most of that person’s operational experience was in that sector. The organizations covered a wide range of sizes, including an elderly-care home with 34 employees and 30 clients and an association headquarters with 37,000 employees. All interviews were conducted virtually in German, lasted between 37 minutes and 1 hour 8 minutes, and were transcribed manually with identifying details removed.

Every participating organization had at least some violence-prevention arrangements, although responsibility for these arrangements varied considerably. Eleven of the 16 institutions had a violence-prevention concept, and 11 participants also reported internal guidelines for handling violent incidents. In larger organizations, prevention concepts might be managed by a support unit responsible for organizational development or equality, while smaller facilities often assigned the work to management. Violence-protection officers, pastoral-care staff, project employees, consultants and de-escalation trainers were also involved. Special needs care providers generally described more detailed strategies, whereas measures in elderly care were less consistent, a contrast the authors related partly to a German obligation introduced in 2021 for special needs care providers but not yet reflected in elderly care.

Training was among the most common measures. Topics included de-escalation, non-violent communication, self-defense, sexual violence, cultural and awareness work, participation, self-determined decision-making and dealing with specific medical conditions. Six institutions said they had dedicated employees trained in de-escalation programs, while two mentioned external offices for consultation or reporting. Risk analysis, staff self-reflection and pagers used to alert nearby colleagues quickly were also raised by participants as prevention-related practices. These measures formed the foundation of the organizations’ responses, but the interviews showed that they were not consistently connected to a shared process for recording, reviewing and comparing incidents.

Documentation was often dispersed across paper forms, client files, care reports, handwritten notes, quality-management systems and internal communication channels. Some facilities provided forms as printable PDFs or word-processing documents, but specialized information technology was uncommon. One participant described keeping notes in a calendar linked to an email account that only the participant could access because a secure shared area was unavailable. Another described an electronic quality manual alongside printed forms and Outlook channels. Information about an incident might therefore be divided among several records, making it difficult for managers to provide concise estimates of how often violence occurred or in what contexts.

The interviews also exposed uncertainty about which events counted as violence and which required formal documentation. Participants described client-related aggression, challenging behavior, verbal abuse, kicking, biting, hitting and sexual advances as possible categories. One participant said an organization had searched for a long time for fixed criteria defining a “serious incident” but had been unable to establish them. Another participant described only documenting client incidents that went beyond behaviors such as pinching or spitting. The study deliberately used violence broadly and independently of malicious intent, particularly because criminal responsibility may be limited among people with dementia or multiple disabilities; determining guilt or criminal liability was explicitly outside the research.

Severity assessment was also individualized. All 18 participants identified the affected person’s assessment as a major influence, and 10 said their institution used only subjective judgments. Some reporting forms listed types of violence without a measure of intensity, while others used traffic-light or three-level escalation systems. Incidents categorized as minor “green” cases or escalation level one were generally resolved directly by employees and left undocumented. The boundary between moderate “yellow” and serious “red” incidents was much less clear. Staff considered visible injury, perceived consequences, the reaction of the affected person and external risk, but the interviews did not reveal consistent operational thresholds connecting those factors to documentation, management involvement or external reporting.

Organizational culture could influence where staff placed that threshold. Employees accustomed to frequent aggression might regard lower-level behavior as normal or insufficiently reportable, even though colleagues in another institution could classify the same conduct differently. The authors said repeated exposure can produce habituation and normalization, making violence less visible at the individual, organizational and societal levels. Interviews also identified a role conflict: employees who are attacked are expected to move quickly from caregiver to a person requiring assistance, potentially generating hesitation or feelings of guilt. Financial constraints were a recurring concern, with one participant describing violence protection as a “nice-to-have” rather than a service adequately financed by the organizations’ cost bearers.

Despite these obstacles, interviewees said incident records served several purposes. They supported statutory and legal documentation duties, reporting serious cases to supervisory authorities, and notification of employers’ liability insurance associations when employees were clearly injured. Internally, records helped emergency-response teams communicate, allowed staff to review cases, supported follow-up with affected employees and provided evidence that risks had been identified and countermeasures taken. Anonymized information was also passed to occupational safety personnel and used for reflection and prevention planning. One participant stressed the value of writing down facts quickly, saying that memories become less clear as time passes and that the resulting notes can later be used to examine frequencies and improve reporting chains.

The findings do not quantify the prevalence of violence, establish trends over time or demonstrate that any intervention prevents incidents. The sample was deliberately selected, geographically limited and based on self-reported expert perspectives, creating a risk of social-desirability bias. Frontline employees, clients and other people who directly experience or report incidents were not interviewed, and one researcher conducted the interviews and analysis. The results therefore identify an organizational gap rather than measuring its size: institutions can recognize violence and train staff while lacking the definitions and infrastructure needed to compare incidents, identify recurring patterns, evaluate workloads or assess whether corrective measures are working.

Based on the interviews, the authors call for institutions to clarify what they mean by violence, supplement subjective experience with objective criteria, redesign existing reporting forms and establish structured, centralized procedures for documentation and follow-up. They argue that uniform digital reporting could make incidents more visible, support rapid assistance after an event, clarify when escalation is needed and create a reliable basis for risk analysis and targeted prevention. The study did not test an application or measure the effects of such a system. Its contribution is a set of practical requirements: consistent event definitions, clearer severity thresholds, accessible reporting, managerial support, systematic review and aggregation of data. Further research should include frontline workers and clients, whose experiences were missing from the present sample.

Subject of Research: Workplace violence prevention and incident documentation in southern German elderly and special needs care institutions

Article Title: Violence prevention and incident documentation in elderly and special needs care institutions in southern Germany: results from semi-structured interviews

Article References: Kappe, M., & Schobel, J. (2026). Violence prevention and incident documentation in elderly and special needs care institutions in southern Germany: results from semi-structured interviews. Frontiers in Psychiatry, 17, Article 1838036. https://doi.org/10.3389/fpsyt.2026.1838036

Image Credits: AI Generated

DOI: 10.3389/fpsyt.2026.1838036

Keywords: workplace violence, elderly care, special needs care, incident documentation, violence prevention, de-escalation training, qualitative interviews, digital reporting, healthcare safety, organizational culture, Violence, prevention