Support and control of psychosocial OSH demands in psychiatric care

Psychosocial occupational safety and health (OSH) risks pose significant challenges in Swedish psychiatric inpatient care. This study seeks to explore demand, control, and support factors within this context. Utilizing a multi-methodological approach, the researchers analyzed data from the Synergi deviation system (The 736 measure reports that include actions and preventive activities, 463 risk reports) alongside focus-group interviews featuring 67 participants, including 24 registered nurses, 25 psychiatric aides, 9 managers, and 9 physicians. Data were deductively analyzed using the Job Demand-Control-Support (JDCS) model. Synergi Data results included quantitative demands, emotional demands, deficiency demands, emotional support, safety support, organizational support, and conversational strategies to enhance control. Focus-group participants reported experiences of emotional and quantitative demands, organization-based stigmatization, control factors (e.g., participation in decisions, mirroring, therapeutic meetings about aggression [TERMA] training), and emotional support to manage emotional demands. The increased digitalization has led to new forms of emotional demands, such as patient stalking on social media platforms and smartphone filming of employees. The results also indicate that improvements in patient safety, group dynamics, and collaborative efforts have positively influenced well-being among the employees. This study highlights identified JDCS factors of importance for practical implications to manage psychosocial OSH in psychiatric inpatient settings, and advocates for further multi-methodological studies to enhance control in psychiatric care.


Introduction
An extensive body of international research has shown elevated risks of negative health outcomes among people who are exposed to chronic stressors at work (Siegrist, 2017;Levi, 2016).Psychosocial occupational safety and health (OSH) risks are related to an increased risk of depressive symptoms (Karasek & Theorell, 1990;Bonde, 2008;Gatchel & Schults, 2012;Siegrist, 2017).Depression is a leading cause of psychiatric illness (Bonde, 2008).Previous studies have clarified a need for more research on psychosocial risks (Leka et al., 2011;Aas et al., 2011;Schnall et al., 2017;Bergh et al., 2018) and a lack of knowledge about psychosocial OSH in psychiatric care (Hylén et al., 2018).Psychosocial risks can be defined as "the likelihood that work-related psychosocial hazards will harm employees' health and safety through their perceptions and experience" (Leka et al., 2017, p.1).
There is a notable relationship between occupational stress and high staff turnover among healthcare employees (Mosadeghrad, et al., 2011;Basu et al., 2017).In addition, from a patient safety perspective, stress increases the risk of errors, in this case, failures made in the process of care that may result in severe harm to patients (The Swedish National Board of Health and Welfare, 2023).Further, psychosocial risks such as heavy workload contribute to stress and thereby affect patient safety (The Swedish National Board of Health and Welfare, 2023; Källberg et al., 2017) and increase the likelihood of in-hospital patient mortality (Aiken et al., 2014).Furthermore, psychosocial OSH risks may include violence at work, consisting of physical threats, verbal threats, assaults, sexual harassment, and bullying (Beech and Leather, 2006).Research shows that violent incidents are common in psychiatric workplaces (Beech and Leather, 2006;Privitera, 2010) and continue to cause financial, organizational, and personal costs, despite awareness of the issue in regulatory and governmental organizations.Identifying psychosocial risks is essential for addressing this concern in healthcare organizations (Yassi & Hancock, 2005) and psychiatric clinics (Hylén et al., 2018), and there is a need for further understanding of the root causes (Privitera, 2010).
Previous psychosocial OSH research has sought to understand the psychosocial work environment and stress through various models, including the job demands-resources (JD-R) model (Demerouti and Bakker, 2011), effort-reward imbalance (ERI) model (Siegrist, 2002), and job demand-control-support (JDCS) model (Karasek et al., 1981).The JD-R model places particular focus on motivation (Demerouti and Bakker, 2011), and the ERI model on rewards and effort (Siegrist, 2002).However, the JDCS model exhibits a substantial inclination toward the evaluation of task-level control, an aspect notably marginalized in the ERI model (Ostry et al., 2003).There is a need for further research related to the JDCS model (The Swedish Agency for Health Technology Assessment and Assessment of Social Services (SBU), 2018), and a stated importance of understanding demand, control, and support in the workplace (Karasek et al., 1998;Fransson et al., 2012;Stress Research Institute, 2015;Gauche et al., 2017;Basu et al., 2017).
Research about demands, control, and support has a basis in the work demand and control model (Karasek et al., 1981).The model was expanded into the JDCS model shown in Fig. 1 (Johnson & Hall, 1988;Karasek et al., 1998).The model is based on the assumption that high levels of demand with low perceived control and support increase the degree of stress.
Earlier research in different work contexts concerning the JDCS model (see Fig. 1) has shown quantitative, cognitive, and emotional work demands (Kristensen et al., 2002;Fransson et al., 2012;Stress Research Institute, 2015;Trousselard et al., 2016).Over the past years, work life has changed and research has demonstrated additional demands, such as IT demands, changing management, and different worklife balance demands (see Karasek et al., 1998;Kristensen et al., 2004;Vegchel et al., 2004;Tsaparlis, 2014;Kalakoski, 2016;Gauche et al., 2017;EU-OSHA, 2017;Chungkham et al., 2013).Table 1 shows a theoretical overview model of different demands, control, and support factors in various workplaces.Not all of these necessarily form part of the present study results, but they provide a theoretical basis for the identified support, demand, and control factors.

Research aim and objectives
The current consensus is that high levels of demand, a low degree of control, and a lack of support at work can increase the risk of cardiovascular disease and exhaustion (Stress Research Institute, 2015, Fransson et al., 2012, Trousselard et al., 2016).However, there is a lack of knowledge about employees within inpatient psychiatric care regarding their perceptions of psychosocial OSH (Hylén et al., 2018).Most studies about psychosocial OSH in psychiatric care to date have been quantitative.Further qualitative research is required to fill this gap and achieve a deeper understanding of the complex psychosocial OSH in psychiatric care, as it differs from other care settings.In psychiatric care, the work environment is characterized by psychosocial challenges, including patients with complex psychiatric conditions such as depression, anxiety, bipolar disorder, and psychotic illnesses (Mariano et al., 2021).This creates a challenging environment for the healthcare staff and the need for support and resources to manage it, and a need to explore the experience of psychosocial OSH demands among the employees.The JDCS model is used because it makes it possible to examine the relationship between complex work environment factors and the individual's psychological response.The JDCS model offers a welldefined analytical framework that enables a structured and systematic analysis of the various dimensions of the work environment and the management of the employee's psychosocial OSH.The study contributes by using a multi-methodological approach that combines data from content analysis of registry data including reported deviations, incidents, and improvement suggestions in the deviation system Synergi Life, in parallel to focus-group interviews with registered nurses, psychiatric aides, physicians, and unit managers.The aim of this study is to describe demand, control, and support factors experienced by staff in psychiatric inpatient care from further research questions.
Q1 What types of work demands are described in inpatient psychiatry among registered nurses, psychiatric aides, physicians, and unit managers?Q 2 What types of support factors are described in inpatient psychiatry by registered nurses, psychiatric aides, physicians, and unit managers?Q 3 What types of control factors are described in inpatient psychiatry by registered nurses, psychiatric aides, physicians, and unit managers?
The objective of this study is to demonstrate the experiences about how the psychosocial OSH can be improved in inpatient psychiatry.The objective is also to theoretically explore and qualitatively apply the JDCS model within the context of inpatient psychiatry.

Study design
This study has a qualitative descriptive design with a multimethodological research approach.The multi-method research methodology, in which multiple forms of qualitative data are used (Mik-Meyer, 2020), was selected as it increases the possibility of obtaining varied and extensive research findings (Kasirye, 2021).Hence, the multi-method approach has been described as qualitative data gathering from more than one source, comprising, for instance, interviews, analysis of documents, and observations (Mik-Meyer, 2020).This multimethod study included 1) register data from the deviation system Synergi [Synergi Life 15.3.0.6,DNVGL] and 2) focus-group interviews with registered nurses, psychiatric aides, physicians, and unit managers in psychiatric inpatient care (DNV, 2023).Synergi is a data system where deviations are reported by employees and managers within psychiatric healthcare (see 3.2.1 and Appendix E).The Synergi Life data analysis included employee experiences related to health, safety, environment, and quality (DNV, 2023).Focus-group interviews were chosen as data from these have previously been used in qualitative research to understand behaviors (Stewart & Shamdasani, 2014).The participants in the focus-group interviews were divided and segmented according to work  (Johnson & Hall, 1988, p. 1336) [developed further from Karasek (1979)].
The researchers reviewed the study process using the validation template for qualitative methods from the state's preparation for medical and social evaluation (SBU, 2023).The study researchers also considered the consolidated criteria for reporting qualitative studies (COREQ) (Tong et al., 2007).The COREQ domains embrace (1) research team and reflexivity (see 3.2, 3.2.2,author credentials), (2) study design ( see 3.1, 3.2, 3.2.1, 3.2.2, Appendix C), and (3) analysis and findings  (see 3.3 and 4).For further descriptions of the COREQ and SUB validation template see Appendices A and B.
To increase study credibility, the researchers used member checks (data set twofocus-group interviews) and triangulation (data sets one and twofocus-group interviews and reports from Synergi Life).Mertens (2019) described member checks as getting verification from participants about the data, after the interview.The researchers summarized the qualitative data after the interviews and asked the respondents whether the empirical data had been understood correctly.The respondents had the opportunity to add or remove data.Using triangulation, the researchers were able to include different sources of data and a theoretical model (Synergi data, interview data, and the JDCS model).Triangulation was, in the present study defined as a process whereby several sources of data are used or several perspectives added by, for example, a theoretical framework, for a more objective analysis of the result (Lichtman, 2023).The researchers in this study used both theoretical and data triangulation.The triangulation included: a.The initial phase, where data collection, analysis, and validation were conducted for Data Set 1 (Reports from Synergi Life).b.Data collection, analysis, and validation procedures were carried out for Data Set 2 (focus-group interviews).
c.Both types of data were subjected to deductive coding and analysis based on a pre-established theoretical framework (JDCS model).d.The data underwent various specific described processes in accordance with Sections 3.2 and 3.3.

Synergi Life data
The deviation system Synergi Life was used to report perceived risks,  negative events (errors and adverse events), and proposed improvements in the work environment.Deviations were understood as incident reports with information and proposals reported by employees to prevent negative events, share lessons learned, manage actions, and show employee experiences related to health, safety, environment, and quality (HSE & Q; DNV, 2023).According to the Swedish Patient Safety Act (SFS 2010:659), it was mandatory for all healthcare employees in Sweden to report risks and errors using local reporting systems.All participants in the studyregistered nurses, psychiatric aides, physicians, and unit managerscould submit incident reports.The employees used the Synergi Life software at work to report incidents, such as violent or offensive occurrences.These reports formed the basis for the present study's data analysis.Employees also had the opportunity to report improvement proposals or measures.Categories in the flowchart in Fig. 2 were developed by the Synergi Life software, and these categories of data were selected by the Synergi coordinator, who assessed and described the psychosocial deviations.For a more detailed explanation of synergy data, see Appendix D.

Focus-group interviews
The researchers used purposive sampling when selecting participants (Denscombe, 2017).Purposive sampling was used to include the people most suited to answer the research questions and aim.Purposive sampling was additionally applied to achieve variation in clinical experience among participants.The reason for including the four professional areas was to get a comprehensive perspective of the psychosocial work demand, control, and support factors.Two researchers conducted face-toface focus-group interviews.An interview template was developed based on the need to gain an objective and descriptive indication and understanding of psychosocial OSH, and it was consequently more general rather than directed toward specific factors (see Appendix C).To deal with social desirability bias and confidentiality, the researchers explained to the respondents that their interviews would be pseudonymized so that individuals would not be distinguishable within the groups.Eighty-one employees were asked to participate, of which agreed.Of these, 24 were registered nurses, 25 were psychiatric aides, were unit managers, and 9 were physicians.Two researchers performed 18 focus-group interviews.All interviews were conducted in two conference rooms at the psychiatric clinic.The researchers recorded the interviews, took field notes, and compiled these after the interviews.After the interviews, each file was transcribed.
The interviews were 60-80 min long.The interview template was piloted and read before the interviews by (1) the research group, (2) researchers outside healthcare, (3) a researcher within OSH research, (4) a case manager outside healthcare, (5) an RN within healthcare, (6) two independent researchers in healthcare, as well as (7) a reference group (four individuals with psychiatric care experience).

Data analysis
The researchers analyzed the data deductively.The content analysis was based on Graneheim and Lundman (2004).The deductive analysis process is described in Fig. 3.
The motivation for using content analysis was its usefulness for systematically handling large volumes of data and for examining trends and patterns in documented texts (Stemler, 2000).The analytical process for both Synergi Life incident reports and focus-group transcriptions using the program NVIVO included the steps laid out in Fig. 3.

Table 2
The description of identified demands, support, and control factors from the Synergi Life data.

Demands Support Control
Quantitative

Organization-based support:
Organization-based support means the strategic and organizational-based support factors, such as organizational routines.For managers, it is essential to have an employee coordinator.The employees emphasize that safety routines regarding inexperienced substitutes or a safety coordinator can be effective.The safe distribution of employees is mentioned as important.It includes the distribution of women with men as they may have physical differences, and of experienced employees with less experienced employees.

Control by information and discussion:
The managers and employees mark the importance of discussion and information regarding decisions in work groups, which can increase their control over demands.It is essential to have discussions and information about safety, patient health, and organization in the workgroup.

Overcrowding of patients:
The employees perceive that overcrowding can lead to stress, difficulty sleeping, fatigue, and feelings of ethical stress among employees.Further, overcrowding of patients reduces patient safety.

Threats:
The employees describe various forms of destructive interactions, of which threats, death threats, and threats together with violence are commonly directed at the employees by patients.

Deficient patient safety:
The employees expressed that it is demanding to have insufficient patient safety.That includes deficiencies regarding work routines, guidelines, medical tests, and weekly compliance talks with patients.
Safety support for a perceived good atmosphere: Safety support is an effort or action aimed at increasing safety.The employees and managers expressed safety support as central to preventing or handling emotional demands, threats, violence, and conflicts, by using isolation rooms and medical routines such as injections for violent patients or safety tools such as alarm systems. 1 The employees are reported at the group level and include doctors, nurses, and aides.The manager and employee groups are described separately in the table.

Synergi Life content analysis
Three researchers analyzed the qualitative coding data with the content analyses from the Synergi Life text reports; statements referring to demands, control, or support were condensed, coded, subcategorized, and thematized.The various steps below were undertaken to address potential coding disagreements, especially steps three and seven, during which discussions took place within the research team to reach a consensus.The researchers distinguished 463 unique reports concerning risks, negative events, and improvement proposals (Fig. 2), and 736 measure reports.A qualitative content analysis was performed on the pseudonymized Synergi Life incident reports (see processes 1-5 and appendix D) and reported at the group level to avoid individual employees being singled out, in accordance with the ethics application.
1.A discussion was carried out by the research group regarding a first extraction of demands, control, and support with a focus on the demands.2. The researchers identified individual statements in accordance with the data analysis (see 3.3), to identify and understand the demands in each report (Graneheim & Lundman, 2004).3. A research group discussion was carried out to ensure and together validate the data analysis of demands.4. One researcher performed an analysis of support and control in the measure reports. 5.A research group discussion was carried out to ensure and validate the data analysis of the Synergi Life incident reports and focus-group interviews.

Interview content analysis
The interview data were analyzed in (QDA) NVIVO (Fig. 4), the qualitative data analysis program [QSR international, Release 1.6.1,1137].The research content analysis process was carried out as shown in Fig. 3.For increased practical implementation and common knowledge, the data were read by three researchers before analysis was carried out by Researcher 1.Then, a final validation was performed in which the research group together validated the analysis from Researcher 1 based on their initial reading of the transcribed data and the data from member checking, summarized by Researcher 2. At this stage, the researchers actively engaged in discussions to resolve any disagreements, striving to achieve a consensus.The researchers discussed and concentrated data from repeated statements in the interviews.The sentences were condensed into more concise forms.

Research ethics
The transcribed material and Synergi Life data were pseudoanonymized, compiled, and reported at a group level so that no sensitive personal data could be made available to unauthorized persons.All researchers involved had a duty of confidentiality and followed the data protection regulation (GDPR).The data and recorded material were encrypted.A prepared encrypted code key was locked separately from the coded material.Only the researchers were authorized to access the material and the code key.The Swedish Ethical Review Authority (Ref.No. 202100-6925) approved the research plan and project.The organizational management of the psychiatric clinics approved and permitted to carrying out all focus-group interviews and analysis of the reports from Synergi Life.A reference group containing a chief physician, operation managers, and human resources (HR) employees from Dalarna County was also included; they assisted the researchers by answering any questions that arose during this research project, validating data from Synergi Life reports commenting on the study and providing organizational knowledge.

Analysis of Synergi data
The results were coded deductively to identify demand, control, and support factors.From this, patterns could be discerned based on the experiences as demanding and what provides control or support, according to the definition from Karasek et al. (1998).Subcategories were termed as shown in Fig. 3.The categories of demands are shown in Table 2.The employees and managers provided statements about work overload experiences that were categorized as quantitative demands.Emotional demands were described as experiences from meetings between humans and inadequacy demands were categorized and defined as the demanding feeling experienced when an error occurs, such as a disruption or the discovery that something is missing, insufficient, or defective.

Interview data
The results indicate the complexity of control, support, and demands that exist at several levels within the organization.There is also a clear interaction between demand, control, and support factors.For instance, insufficient control can increase the different quantitative demands, whether directly or indirectly, and they can affect and trigger each other and have indirect impacts on emotional demands.For example, insufficient control of the schedule becomes especially demanding according to the perceptions of registered nurses and psychiatric aides.Every work group demonstrated the quantitative demands of heavy workload, overcrowding of patients, and staff shortages.In addition, all workgroups expressed a lack of inclusion and influence within the organization, emphasizing the importance of knowledge to enhance the sense of control.They also articulated that increased patient health after treatment is empowering and has a positive effect on the employees' sense of well-being.Registered nurses and psychiatric aides stated that an increased salary increases the attractiveness of the workplace.Fig. 4 demonstrates the interview results.There are descriptions at the beginning of each thematic subsection regarding workgroup perceptions of each support, control, and demand factor.

Emotional demands
4.2.1.1.1.The demands related to patients, increased digitalization, new employees, and behavior.Registered nurses, psychiatric aides, and physicians primarily describe emotional demands.Emotional demands arise when patients violate, harass, manipulate, or use master suppression techniques against employees.Master suppression techniques can include social manipulation to exert control or gain power in social interactions, for example by instigating conflicts among coworkers.The respondents described that increased digitalization contributes to new forms of demands, as it is easier for employees to be stalked via social media and recorded or filmed with a smartphone.
"The patients can also look for sore spots among the employees.For instance, a few weeks ago a patient said he would send people and kill a coworker's family… and we have many addiction patients with us.I feel they are the most threatening, they are the most attentive, regarding provoking us."(Registered nurse) Emotional demands predominantly encompass instances of violence and threats.The violence and threats constituted a larger proportion of the emotional demands, approximately 40 statements, in contrast to the 10-20 statements observed in the other categories.It is noteworthy that the majority of statements about violence and threats originate from psychiatric aides and registered nurses.Patients with substance abuse issues can be particularly demanding.Employees without training concerning addict patients are especially vulnerable.When violence and threats occur, there is an increased risk that new employees become afraid to return to work.
"There are many employees who are stalked by patients; it's quite frequent… we have a colleague who has been involved in this on Instagram, Facebook, it is problematic… a colleague has been recorded by a patient on the phone.You have to be prepared for the fact that you can be recorded during a conversation… we were also filmed a while ago."(Psychiatric aide) Respondents also described how demanding emotional situations may arise from conflicts between employees, insufficient competence, and newly hired employees that affect group constellations and different employee personalities.

Organizational and management demands
4.2.1.2.1.Organizationally based violation.Registered nurses, psychiatric aides, and unit managers described violations or negative comments by employees from other healthcare professions.In addition, they described how the psychiatric organization is deprioritized and has low status.For instance, violating statements are made suggesting a lack of competence compared with other healthcare employees.Respondents describe a perceived low status and stigmatization of psychiatric work, even among students.This can be demanding and offensive to employees today and makes recruitment into psychiatry more difficult.
"Other employees in healthcare say that psychiatric employees can't do anything.When we admit other patients to psychiatry, they say that we are totally incompetent, yes, but that's the way it is, and that's how everyone in healthcare describes it, yes, that's how you get many comments, for instance, you are not a real nurse.(Registered nurse)

Insufficient organizational change or general management.
Insufficient organizational change is a central organizational and management demand, according to the registered nurses, psychiatric aides, and physicians.It includes ineffective implementation of organizational change by insufficient inclusion and inadequate information dissemination to employees which causes anxiety and stress.According to the respondents, insufficient information, inclusion, and listening to employees are in general demanding.
"Yes, and you did not get any really clear messages or information, so it has led to anxiety among employees… the employees were worried, and then they looked for other jobs… many employees have been worried… about organizational change.There has been poor information from managers and several levels in the organization, and we are the ones who are affected."(Registered nurse) The data also show generally insufficient management from inadequately present operations managers and unit managers, or through manager competence.The employees have also experienced managers talking negatively about employees.On their side, the employees distanced themselves from the manager, and feelings of anxiety and fear toward the manager arose.
4.2.1.2.3.The manager's situation.The registered nurses, psychiatric aides, and unit managers describe that the manager's job is demanding.Managers were involved in statements across all subcategories related to managerial situation demands.There are difficulties concerning recruitment and little time for management work, as they sometimes need to work as nurses because of employee shortages.Unit managers have furthermore been without operations managers for long periods, and they may feel that higher management controls them too much, which can cause them to quit the job according to the interviews.The respondents describe that the unit managers do not have time to work with leadership or with their ideas.
"The managerial role becomes problematic when you have to work so much clinically; we have a manager who has to take all the nursing parts and the management work."(Psychiatric aide) 4.2.1.2.4.Insufficient control of the schedule becomes demanding.The registered nurses and psychiatric aides described insufficient control over the schedule as a demanding factor.The employees described that schedule-based demands include having insufficient control of the schedule, working at night, working long shifts, and needing to adapt to colleagues' schedules.They also felt that a demanding schedule can cause employees to quit and can create a bad psychosocial work environment.
"The biggest problem is the schedule, and the scheduling annoys us all… I feel that I cannot control my working hours that much; I feel that I get more of these demanding extensive shifts than the others; you could maybe control the schedule more if you have more employees… I cannot control my time or set my schedule because I have to adapt to the other nurses on the wards."(Registered nurse) 4. 2.1.3. Quantitative demands 4.2.1.3.1.Heavy workload and overcrowding of patients.The registered nurses, psychiatric aides, unit managers, and physicians described heavy workload as related to lack of time.When psychiatrists receive satellite patients, the employees may lack the skills or materials necessary to treat those patients.In addition, patient diagnosis, employee personality, responsibility for several departments, and administrative work are all factors that increase the experienced workload.Furthermore, overcrowding of patients increases anxiety and ethical stress since it is not possible to provide adequate care because of the lack of inhospital beds.Further consequences related to heavy workload are sleep-initiation or sleep-maintenance disorders among employees and reduced patient safety.
"You have had too much to do; you have to take care of too many patients and the kitchen at the same time; there are so many tasks that you have not written down and then you have a feeling of inadequacy."(Registered nurse) 4.2.1.3.2.Staff shortages.Staff shortages are demanding, according to the registered nurses, psychiatric aides, unit managers, and physicians in the study.The interviews also show that heavy workloads and staff shortages are interrelated.Consequences related to staff shortages are stress, reduced patient safety, fatigue, ethical stress, overtime, and fear of turning down work.Inexperienced substitute employees also need extra support and the interviews showed a lack of trust in substitutes on the part of employees.Staff shortages may also increase the probability that employees quit.Consequently, experience is lost in the organization.Staff shortages were experienced by the majority of registered nurses and psychiatrists.

Control by inclusion and influence.
The registered nurses, psychiatric aides, unit managers, and physicians all emphasized a lack of control by insufficient inclusion and influence.Especially lack of including and listening to employees and providing clear and continuous information regarding the workplace or work duties.Proposals for the managers at every level included creating a dialogue, demonstrating an understanding of the employees' health and well-being, and appreciating the employees.One example of a solution by a unit manager was a structured plan for recovery.
"I work strategically and practically so that my employees can recover, for example, compensation vacation days after overtime work; I talk to my employees about how we should plan for them to have recovery, so it will work for them."(Unit manager) The managers and employees reported that they have influence over the job tasks or the form of employment by, for example, being a manager, protection officer, care coordinator, or union representative.Control by inclusion and influence can be increased by strategically adapting work tasks in the schedule together with other employees or managers.Employees could adjust their schedules and exchange work shifts with each other to get more time off for recovery, variety, reflection, socializing with colleagues, and patient care.
"Yes, we want to have managers who talk to us, communicate in a normal way, discuss things you want to change, and get feedback, so you can come to a consensus before you as a manager just give a decision."(Physician) 4.2.2.0.2.Control by increased knowledge and skill.The registered nurses, psychiatric aides, unit managers, and physicians all described knowledge and skill as being important to experiencing a sense of control.Increased knowledge and skills reduce stress, provide selfconfidence, increase self-assurance, help to prevent unfavorable thoughts during leisure time, and control emotional demands such as violence and threats, especially toward new employees.The ability to handle threatening situations contributes to increased control over emotional demands.The participants described therapeutic meeting with aggression [TERMA]) training, conversation methodology, and interactive or cooperative learning by knowledge and experience exchange with another individual or a few others as important to increase knowledge and skill.TERMA training is a concept and an educational methodology provided by the organization.The data showed a knowledge increase by the occurrence of mirroring, supportive guidance from guiding representatives (GR), and mentoring.Mirroring is a recounted reflection of a situation, work shift, or instance of employee well-being.GRs guide small groups or individuals, depending on the GR's experience or knowledge.This method increases knowledge and independence for employees and provides training to the GR through the process of guiding, according to the respondents.Similarly, the interviews show that guidance from employees to students can be strengthening for both the student and the employee.Mirroring and GR guidance are perceived to stimulate and increase support for the employee, beyond just augmenting the sense of control.The managers mentioned that it is essential to obtain support from a deputy manager or recruitment coordinator, such as HR support.The managers described that organizational planning days or support forums with other managers are also important sources of support.In addition, the registered nurses and physicians noted that it is essential to get support for the managers from higher management.
"A deputy manager who can help, so that some routine tasks and more can be assigned to that manager… I think that Human Resources could do more, also be able to support us as a management team or supervise and give instructions… recruitment is demanding for us and hugely timeconsuming.I think that Human Resources could help us much more with recruitment.It should be a situation and conditions where we talk to them about who we need and they organize recruitment."(Unit manager) 4.2.3.1.2.Emotional support for employees.Emotional support is essential, according to the interviewed registered nurses, psychiatric aides, unit managers, and physicians.Individual emotional support includes conversations about OSH and therapeutic and incident-related support.Employee well-being must be followed up on directly after an incident and again later.New employees may need extra supervision and support after an incident.Respondents' proposals for managers are that they should listen to and understand employees, give employees recognition, and create an environment where employees dare to ask questions and are respected, and where there is transparency.Nurturing a feeling of trust among colleagues is also fundamental, particularly in incident situations.
"Yes, the manager still has ultimate responsibility over the work environment and must then also listen to the employees and be observant… If an incident has occurred, it is important before you leave that day to follow up on the well-being of the employee… that you really follow up and see how they are; sometimes the employees feel really bad a while later after an incident."(Psychiatric aide) 4.2.3.1.3.Group and challenge-based support for employees.The registered nurses, psychiatric aides, unit managers, and physicians all specified that support from their work group is a central support factor at their workplace.Several respondents highlighted that facing tough challenges together at work strengthens the workgroup.The workgroup camaraderie, and group activities in general, improve psychosocial OSH.This includes group meetings with attendants from other departments, group support after an incident, and group OSH theme days.Through such meetings, the group can reach a consensus and address perceived OSH challenges and improvement factors.
"The workgroup is good enough to make you cope with the fact that it's been hard… it makes you able to control the tough times.If it is demanding, if my work group hadn't existed maybe I wouldn't have stayed.We support each other… Why do we think that the bond has become so strong in the workgroup?Because we confront difficult things together, you don't have room to turn your back on each other; if it becomes a serious situation, we all need each other."(Psychiatric aide) 4.2.3.2.Support from a good atmosphere 4.2.3.2.1.Strengthen employees through feelings of contribution and patient health.The interviews showed the essentiality of employees participating in development projects, contributing to the workplace, and having familiarity with performing a good job.Perceptions of patient well-being or safety contribute to the well-being of the employees, according to the registered nurses, psychiatric aides, unit managers, and physicians.According to the registered nurses and psychiatric aides, getting an increased salary improves the employees' perceptions of workplace attractiveness and reduces stress symptoms.Additionally, the respondents described the importance of continuous organizational work to attractiveness, status, and marketing of psychiatric care.Consecutively, the majority of respondents described being proud of their work and mentioned that they do work with a social benefit, which is rewarding for them.
"I think it feels meaningful every day, I think it feels like you have a job useful to society.I get a lot of appreciation from the patients on a daily basis.Things have gone badly for many patients before they come to us, and when they, after they have been here, are healthy, it is rewarding for us employees."(Registered nurse) K. Gummesson et al.

Discussion
The aim of the present study was to identify psychosocial demand, control, and support factors in psychiatric inpatient care.The data showed support demands and control factors at both the organizational and employee level.The analysis demonstrated emotional and quantitative demands in both the reporting system and focus-group interview data.Organizational change, including moving, merging, or closing departments, and organizational-based stigmatization and violations, are central challenging demands.Previous studies on demands in psychiatry have largely included emotional demands such as violence and threats or interpersonal contact with patients who have social problems (Vegchel et al., 2004;Beech and Leather, 2006;Lu et al., 2019;Andersen et al., 2019;Odes et al., 2021).As working life has changed, new demands have arisen and there has been some OSH research conducted concerning IT demands, mostly focused on errors and shortcomings in IT systems (Gauche et al., 2017).However, the current study demonstrates additional emotional demands, where digitalization has led to employees being more easily persecuted on social media by patients.Furthermore, the respondents described a need for opportunities to participate in decisions, for increased transparency of relevant organizational information, and consequently for a sense of inclusion and increased control in the organization in accordance with the JDCS model (Karasek et al., 1998).

Demands
Organizational-based stigmatization and violation of psychosocial OSH control and support need further research.Employees and organizations perceive and treat psychiatry as being less prioritized and less important compared with other healthcare fields.Psychiatric employees feel that other healthcare work groups and students do not value their competence because they work in psychiatric care.Those demanding statements and behaviors appear at universities and in healthcare organizations, according to the respondents.This may occur as the organizational stigma that arises at an organizational level (Slewa & Sörbye, 2021), and spreads to the employee level and contributes to perceived violations among employees.
Organizational demand from increased digitalization in society also needs further research, such as the stalking of employees on social media or the filming of employees with a smartphone.The present study indicates that violations, threats, and violence are common, a finding that confirms earlier studies in psychiatric care (Beech and Leather, 2006;Privitera, 2010).These situations occur despite the availability of support and control routines.One reason might be that quantitative demands, such as heavy workloads, reduce the possibility of providing support and control.It is also evident that the quantitative demandsincreased overcrowding, heavy workload, and staff shortagesaffect each other in a destructive cycle, compounding and developing into a difficult trend to manage.In future studies, it would be of interest to use the JD-R (Demerouti and Bakker, 2011) or ERI models (Siegrist, 2002), to realize additional perspectives on these demands in psychiatric inpatient care or apply these theories to the present study findings.

Control
The data highlights a need for improved implementation of organizational changes and demonstrates a need for control in terms of employee information and dialogue.As the results indicate, there are several methods of workplace learning such as learning from each other about work situations.In the current study, this type of workplace learning the researches conceptualize as Socially Based Learning (SBL).Socially Based Learning (SBL) refers to workplace learning characterized by individuals learning from one another in the context of work situations it is acknowledged that its level of regulation can vary.This spectrum ranges from entirely unregulated instances of spontaneous knowledge exchange to more structured forms that include organized guidance, such as mentoring and coaching.Previous studies have considered this to be informal learning (Olofsson, 2017).The data showed that SBL can promote control and support through the strategies of mirroring and supportive guidance from guiding representatives; both increase control and are used to avoid emotional demands such as conflicts, especially for new employees.Another form of learning stated to be effective is TERMA (therapeutic meeting with aggression) (Skåne County, 2018).The method exists for employees to prevent and respond to threats and violence, creating the best possible environment for staff and patients in care units.The unique quality of TERMA is that it works preventively with a low-affective treatment and approach.It may also be important for increasing control by enhancing competence among managers of employees who are exposed to emotional demands such as violence.This form of educational intervention can be important in avoiding PTSD among employees (Andersen et al., 2019).There is, however, a need to problematize TERMA and SBL actions at additional levels of the organization.Quantitative demands and lack of support from the organization illustrates the importance of carrying out the measures to handle the OSH on several levels in the organization, something that supports the findings of previous research (Egan et al., 2007).The complexity and on some occasions the discrepancy between support and control efforts at different levels in relation to certain demands calls for increased transparency and collaborative efforts between these levels, a point which the interviews also validate.Increased competence, and hence control among employees, might provide increased colleague support in threatening situations and can stimulate a sense of control.Increasing competence might also make it easier for employees when work situations require excessive concentration and attention or when employees are faced with unexpected interruptions (Karasek et al., 1998;Kalakoski et al., 2012).Earlier healthcare research has shown that interruptions affect patient safety, cause delays in care (assessment and treatment), and are associated with medical errors (Danesh et al., 2022).

Support
Identified support factors are both long-and short-term, and occur at the group, organizational, and individual levels.The support factors include strengthening at an individual level through experiencing increased patient well-being.The respondents also reported that mutual challenges, such as violent situations, may have a group-strengthening effect because the group is forced to cooperate.Emotional support is also critical and commonly occurs at the group and individual levels.It can be preventive or may come after an incident, such as exposure to violence and threats.It seems important to create conditions in which managers can provide support to employees and get support.Accordingly, the respondents described the need for extra support in the recruitment process for managers and actual time for leadership work, for example by having a deputy manager.This can be particularly relevant as the OSH and the manager's health are important principles for good leadership (Lundqvist et al., 2018).

Research strengths and limitations
There is a need for qualitative research in the realm of psychosocial OSH, particularly with a focus on factors related to control and support.This is essential due to the intricate nature of the issue, and the majority of previous studies have predominantly concentrated on risks.Fernemark et al. (2020) have underscored the demand for qualitative research K. Gummesson et al. in the field of psychosocial OSH, emphasizing its importance in advancing our understanding of these complex dynamics.However, it should be noted that in qualitative studies, caution should be exercised when reading or interpreting results suggesting causal inferences between psychosocial risks, job-related factors, and psychosocial outcomes at the individual or organizational level.The psychiatric inpatient care organizations have in recent years been included in one or more organizational changes, which may have affected the results of the study.
Several demands continually recurred in the incident reporting system, leading to questions about the value of the deviation management systems if documentation and follow-up do not lead to improved control or support.Further, the actual number of errors and adverse events is unknown but assumed to be large because these occurrences are not always reported.The reasons for insufficient reporting among employees are time constraints, fear of reprisal, and lack of feedback.It is worth questioning how this reporting is done and how confidential the employees' reports are.It may be of value to improve the confidentiality of this process so that employees dare to describe events thoroughly.This is a complex issue from an OSH point of view because while there are extensive systems for catching OSH-related demands, organizations are implementing changes that induce feelings of frustration, anger, resignation, and stress, as conveyed in the interviews.There is, accordingly, a demand for further studies measuring the effectiveness of various Synergi measure types, processes of reporting, deviation causes, and specific labor roles, as this is beyond the focus of this study.

Conclusion, contributions, and further research
In conclusion, this study inquired into the long-term work necessary to increase support and control to handle recent demands because of organizational stigmatization, violations, increased digitalization, and increased workload and demands on employees and managers due to under-resourcing.Increased support and perceived control are central factors in continued OSH endeavors to handle these demands in the studied inpatient psychiatric care.This calls for increased dialogue between managers and employees, greater employee inclusion, qualitycertified SBL (see 5.2), conversation methodology, and feelings of being able to contribute.Consequently, the study contributes to an increased knowledge of experiences about psychosocial demand, control, and support in the studied psychiatric care institutions with further implications for practice, supported by recommendations.

Demands
• The study demonstrates a perceived stigmatization, demanding workload, and violations towards employees and managers in psychiatric inpatient care, as well as a need for extended OSH research to deal with these demands.• Increased societal digitalization and smartphones are resulting in new demands, such as stalking on social media and recording on smartphones by patients, and calls for further OSH research to understand this issue.

Control
• SBL and conversation methodology are described as enhancing the control of emotional demands such as threatening situations, and hence increasing knowledge among employees.It may therefore be important to continuously implement and follow up the process.In addition, these findings indicate it may be useful to establish causal or contributing relationships between SBL interventions and job control outcomes.• Dominant control factors are inclusion in decisions, dialogue-based management, and a clear and continuous flow of information between employees and managers.The study reveals a special need for consideration of these factors when implementing organizational changes.This is also notable, as control of the schedule by strategically adapting duties and changing schedules in collaboration with colleagues increases opportunities for leadership, recovery, and carebased work.This is particularly essential, as the employees mention that a lack of control over scheduling is demanding.

Support
• The employees who experienced feelings of contribution and a sense of increased patient health, patient recovery, and positive feedback from the patients, found it to be supportive and strengthening.• Threatening group situations or challenges may strengthen workgroup cohesion because the situation forces workers to cooperate.Notably, the lack of experience among substitutes or trust within the work group may create conflicts or anxiety among employees.

Fig. 3 .
Fig. 3.An example of the analysis process and the coding of the interview and Synergi Life data.

Fig. 4 .
Fig. 4. The NVIVO mapping of themes and subcategories in data based on the JDCS model [D=demands, C=control, S=support, in interview data]. 1.
"If you are alone with three newly hired employees or substitutes, you as an employee can experience stress and increased workload.Knowledge and experience are very important… We should have more mirroring (what has worked well, what has worked less well, what does the next shift need to include) after each work shift when new employees arrive… more supportive guidance would also be good."(Psychiatric aide)