Hospitals and psychiatric institutions XX  Central registers for recording measures that restrict freedom should be enshrined in the law as an effective and systematic prevention strategy as quickly as possible. XX  A comprehensive preventive concept is required in order to avoid sexual assault in medical facilities. XX  Medication-based restrictions of freedom can also be applied in psychiatric hospitals and must be reported pursuant to the Hospitalisation of Mentally Ill Persons Act (). XX  Staff-related, organisational and patient-related strategies must be intertwined in violence protection. Security services should never be deployed in the borderline area to nursing and care. Preference should be given to alternative measures (e.g. crisis teams) in as far possible. 2.2.2 Hidden violence in the day-to-day routine of psychiatric hospitals Coercive measures are a component of psychiatric treatment that can be vital in acute situations with aggressive patients. Proximal restrictions such as restraint for the benefit of the patients can be necessary during the nursing process. One of the main tasks of the NPM in this area is to monitor the general conditions and point out non-compliance where appropriate. This is often caused by the insufficient exploitation of preventive measures for avoiding restrictions of freedom. Corresponding observations are highlighted in this report. A distinction must be made for aspects of a structural nature and the nonphysical use of force, which can have a negative impact on the care situation. Structural violence These include insufficient human resources. Staff shortages are a problem in many institutions and facilities, in particular during the night, when a lot of staff are on sick leave and at the weekends. This causes stress for the staff and overload in acute situations. From the view of the NPM, it is thus necessary to create a more flexible system. This would guarantee being able to react faster to existing demands and ensure that sufficient capacity is available. Otherwise, it is to be feared that staff will be unable to cope with the tasks and end up suffering themselves from mental illness such as burn-out. Psychological violence Difficult underlying conditions can also result in some forms of psychological violence which manifest as threats, insults and abusive language for example. Cognitive or emotional, affective or mental damage can be the consequence. An appreciative approach and careful choice of words are of great importance, especially when dealing with persons with mental illnesses, some of whom are in a psychiatric facility against their will and often feel at the mercy of others and helpless. 46