Occupational Violence and Aggression (OVA) in residential aged care represents a persistent and complex sociotechnical challenge.
Despite increasing deployment of policies, training and technologies, OVA continues to cause harm to workers, residents, and organisations.
This presentation explores OVA through a human factors and ergonomics lens, asking what “the perfect fit” between people, tasks and intelligent systems looks like in practice and what happens when that fit isn't imperfect.

Situated within a national residential aged care provider, this work aimed to move beyond reactive, person focused interventions and conduct a tactical systems review of OVA.

The goal was to understand how work and care practices, workers, management, organisational decisions, technologies, and environmental conditions interact to shape risk, and to identify opportunities for prevention and control across the broader system.

A structured systems thinking methodology was applied. This included utilising Systems Theoretic Process Analysis (STPA) to model the OVA control system, clarifying safety constraints, feedback loops and control gaps between frontline staff, technology (e.g. duress systems), management and governance. AcciMap analysis was then undertaken to identify multi level contributing factors spanning government, regulatory, organisational, team and resident interfaces. PreventiMaps translated these insights into preventative controls. Finally, AcciMap was applied to aggregated OVA incident data, enabling pattern recognition beyond single event investigations.

Key principles included a non blaming stance, privileging work as done over work as imagined, and explicit consideration of human system fit — particularly where intelligent or procedural controls amplify or constrain human performance.

Findings reveal that the “perfect fit” is rarely achieved through isolated controls.
Instead, safety emerges when intelligent systems, care models and organisational decisions are coherently aligned with human capabilities and limitations.
The presentation shares practical lessons for ergonomists, safety professionals and system designers seeking to improve OVA prevention through system level redesign rather than individual resilience.