Nurses’ Rationale for Underreporting of Patient and Visitor Perpetrated Workplace Violence: A Systematic Review

doi:10.21203/rs.3.rs-1751244/v1

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Nurses’ Rationale for Underreporting of Patient and Visitor Perpetrated Workplace Violence: A Systematic Review

https://doi.org/10.21203/rs.3.rs-1751244/v1

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published 23 Apr, 2023

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Background: Patient and visitor perpetrated workplace violence is a problem within healthcare and is known to be underreported by nurses and other healthcare workers. However, it is unclear why nurses choose not to report these violent events. This systematic review aimed to investigate nurses’ reasons and rationale related to underreporting of violence that occurs in the workplace and to summarize recommendations to solve this problem.

Methods: Following PRISMA guidelines for systematic review reporting, studies conducted between 2011 and early 2022 were identified from MEDLINE, CINAHL, APA PsychInfo, and Psychological and Behavioral Sciences Collection via EBSCOHost. Quantitative studies related to patient and visitor perpetrated violence containing explanations, reasons, or rationale related to underreporting were included.

Results: After quality appraisals, 19 studies representing 16 countries were included. The resulting themes identified nursing, management, and organizational factors. The most prominent nursing factors included nurses’ fear of consequences after reporting, nurses’ perceptions, and lack of knowledge about the reporting process. Common management factors which contributed to nursing underreporting included lack of visible changes after reporting, non-supportive culture in which to report, and lack of penalties for perpetrators. Organizational factors included the lack of policies/procedures/training for WPV and the reporting of it as well as a lack of an efficient and user-friendly reporting system. Supportive interventions from management, organizations, and community sources were summarized to provide insight to improve nurse reporting of workplace violence events.

Conclusion: Underreporting of workplace violence is a complex and multi-faceted problem. An investigation into the rationale for underreporting a workplace violent event illustrates nurses, management, and organizations contribute to the problem. Clear and actionable recommendations such as the development of a clear and concise reporting process and educational support are addressed to encourage staff reporting. Comprehensive reporting processes are needed to help address workplace violence in healthcare.

Underreporting

Reporting

Workplace Violence

Nursing

Patient Perpetrated

Visitor Perpetrated

Aggression

Workplace violence (WPV) is a ubiquitous global problem within healthcare (1, 2). As defined by the United States Occupational Safety and Health Administration (OSHA), WPV is “any act or threat of physical violence, harassment, intimidation, or other threatening disruptive behavior that occurs at the worksite … and includes threats, verbal abuse, physical assaults, and even homicide…” (3). Patients and visitors are the main perpetrators of WPV regardless if the event was verbal, psychological, physical, or sexual in nature (4).

Nurses are at the highest risk of WPV due to direct contact with patients and visitors compared to other professional roles in healthcare (5). One out of five nurses experience a physically violent event each year (5). Considering the World Health Organization estimates there are 27.9 million nurses across the globe, this equates to more than five and a half million nurses experiencing a physically violent event while providing patient care each year (6).

However, this staggering number of events may not be an accurate representation of the magnitude of the problem due to underreporting. Underreporting is defined as a failure of the victimized employee to report events to employers, police, or other officials (7). OSHA estimates that two-thirds of all workplace-related injuries and illnesses go unreported (8). However, Arnetz et al. (9) found only 12% of workplace violence events were formally reported while other sources state reporting of WPV events was as low as 3% (10). This variability of underreporting is irrefutably related to the concept of underreporting itself. Not only is WPV underreported, but it is possible that underreporting is also underreported.

Moreover, different forms of WPV are not reported equally or proportionately. Physically violent events are more likely to be reported, especially if there was an injury or lost time from work (11). However, Schablon et al. (12) found that each year, 94% of nurse’s experience verbal aggression. As often as verbal violence occurs, it is likely to be underreported (13). Verbal violence, “near-misses”, and other events perceived to not be sufficiently serious enough to warrant a report, are (13, 14).

Underreporting is considered a significant barrier to addressing WPV. Simply stated, “what goes unreported, goes unfixed” (13). Not only does underreporting underestimate the magnitude of the problem, but prevention and interventions may address only what is known. Without a full understanding of WPV, efforts and interventions may miss the full spectrum of the problem (11).

Objective

A comprehensive review to understand the causes of underreporting of WPV events may assist healthcare leaders to address the problem. As a multi-faceted and global concern for nursing, WPV in healthcare needs clear identification of nurses’ perspectives of underreporting of patient and visitor perpetrated violence to ensure mitigating interventions can be initiated. Therefore, the purpose of this systematic review was to investigate nurses’ reasons or rationale for underreporting patient or visitor perpetrated WPV in healthcare. Once identified, an analysis of the selected studies included an outline of interventions and recommendations.

Study design

This systematic review addressed the reasons and rationale for underreporting by nurses after WPV events and was designed and based upon the international guideline of The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) (15).

Eligibility criteria

Searches and studies were limited by several factors. Inclusion criteria incorporated studies written in English, peer-reviewed articles that were published between January 1, 2011, and March 24, 2022, and studies with clearly defined designs and methods. The included studies focused on patient or visitor perpetrated violence (OSHA Type II WPV), the subjects or participants needed to be inclusive of nurses and provided reasons or rationale for the underreporting of WPV in a healthcare setting. Studies were excluded if sexually violent events were the primary focus of the project, if the subjects or investigators were students and if the study only presented prevalence rates of underreporting without additional information related to underreporting rationale. Additionally, qualitative studies, editorials, commentaries, and conference abstracts were excluded.

Search strategy and data sources

A comprehensive literature search was performed by a medical librarian on September 3, 2021, and updated again on March 24, 2022, for additional recent studies. Databases were searched using a combination of keywords and database-specific indexing terms (when applicable) representing the concepts of type II workplace violence, i.e., patient and visitor perpetrated WPV, healthcare personnel, and underreporting. See Fig. 1 for the Ovid MEDLINE® search strategy.

The following electronic databases were searched for eligible studies: MEDLINE (via Ovid MEDLINE® ALL), CINAHL (Cumulative Index to Nursing and Allied Health Literature, via EBSCOhost), APA PsycInfo (via Ovid), and Psychology and Behavioral Sciences Collection (via EBSCOHost). In addition to the databases, a search of Google Scholar was conducted on March 24, 2022, to identify any additional relevant publications. All database search results were exported to and de-duplicated in EndNote™ 20 (Clarivate Analytics, Philadelphia, PA). After removing duplicates, 86 articles remained, 64 of which were excluded based on title and abstract. Twenty-two articles were assessed in full text and 3 were excluded due to qualitative study methodology, leaving 19 studies included in the analysis. See Fig. 2 for the PRISMA Flow Diagram of the literature searching processes.

Quality appraisal

Quality appraisals of the selected literature were conducted by two authors using the Scottish Intercollegiate Guidelines Network (SIGN) checklists (16). SIGN utilizes different checklists applicable to the methodology used in the study being assessed. Thus, the appropriate checklist was used based on each study appraised. These quality appraisal tools evaluated the study design to assess for significant risk of bias in the results or conclusions drawn within the study. Scoring of each study used “high quality, acceptable, or unacceptable”. Any discordance between the first two assessments was resolved by a third author.

Description of included studies

Of the 19 included studies, 16 countries were represented: China (n = 2), Indonesia (n = 1), Italy (n = 1), Japan (n = 1), Jordan (n = 2), Nigeria (n = 1), Palestine (n = 1), Saudi Arabia (n = 3), Serbia (n = 1), Slovenia (n = 1), United States (n = 3), and multinational (n = 2). The multinational studies included Poland, Czech Republic, Slovak Republic, Turkey, and Spain. Most were cross-sectional survey studies (79%) and nursing was represented in the collective or identified as the independent profession being studied. Quality assessments revealed that 15 studies scored as high quality and four as acceptable. None of the studies were eliminated due to unacceptable scoring. See Table 1 for a summary of study characteristics.

Table 1 Summary of study characteristics included

Underreporting factors

Content analysis illuminated three factors contributory to underreporting: nursing, management, and the organization. Subthemes were identified for each factor; eight for nursing, three for leadership, and four for the organization. Results of the factors and subthemes are outlined in Table 2.

Table 2

Rationale for underreporting of workplace violence
Rationale for Underreporting Workplace Violence
Nursing Factors
Personal Characteristics 25,30,31	• Female • Younger in age • Newer nurse, less work experience • Working alone • Caring or empathetic personality • Working in a specialty care area • More violent experiences, the less likely to report • Desensitized to violent patients • Personal bias against reporting
Fear 9,10,11,18,19,20,21,22,24,25, 26,27,28,29,30,31	• Losing job • Serious consequences • Legal consequences • Poor job performance evaluation • Reprisals from management • Revenge or retaliation • Not being believed • Blaming victim • Lack of support from colleagues • Low patient satisfaction scores • Causing harm to the patient by reporting
Lack of Knowledge About Reporting Workplace Violence 9,10,11,21,22,23,25,27	• How to report • What to report (ambiguous) • Who to report to • Never instructed on the reporting process • Unsure what is considered “reporting” – Does documenting in the patient chart or verbally reporting to coworkers /supervisor count?
Time Constraints 9,10,11,24,25,30	• Too time-consuming • Too busy • Inconvenient • Forget
The perception that Violence is Unavoidable 9,10,11,17,18,19,25,30,31	• “Part of the job” • Expected to “handle it” • Common to their patient care area • Not important
Perception of the Patient 11,25,30,31	• Some patients cannot control their behavior • Violence not intentional • Patient apologized
Perception of the Level of Severity 9,10,11,18,19,22,23,25,29,30, 31	• Physical violence is more often reported than verbal violence • Physical injury more likely to be reported • Verbal violence is not considered violence or not severe enough to report • More likely to report if a weapon was used • Increased severity of an event, increased reporting • Mitigation of the violent incident is considered when deciding to report
Other Negative Perceptions 10,11,18,21,22,23,25,26,27,28,31	• Feelings of guilt or shame • Viewed as occurring due to the nurse’s actions • Pressure from colleagues not to report • Considered a bureaucratic task • Viewed as a preventable event • Previously reported and had a negative experience
Management Factors
Unsatisfied with Outcome 9,10,11,17,19,20,21,22,23,24, 25,26,27,28,30,31	• Lack of adequate response from management following a report • Causes or event itself not investigated • No positive changes as a result of reporting; useless • No consequences for the perpetrator • Dissatisfied with the resolution of events
Lack of Support to Report 2,10,11,21,25,26,29,31	• No incentive to report • Discouraged from reporting • Not mandatory to report • Lack of manager support to report
Culture 10,11,25,31	• Lack of willingness to defend nurses • Paying greater attention to patients rather than nursing staff • Not taken seriously • Reporting is not the norm; others do not report
Organizational Factors
Lack of Policies and Procedures 25,26	• Lack of clear and detailed policies and procedures that address workplace violence
Lack of a Reporting System 2,11,25,26,29	• Lack of a functioning and user-friendly reporting system for workplace violence
Unstandardized Reporting Process 25	• The current reporting process is too difficult and lengthy • Complicated process • Unclear reporting process • Not suitable for visitor aggression • Paper reporting forms are not available
Lack of Training Programs 25,26,29	• Lack of mandatory organizational training on workplace violence • Lack of violence prevention training programs

This systematic review investigated quantitative studies which outlined reasons and rationale for nurses to underreport WPV events. As a global phenomenon, WPV underreporting is internationally pervasive. The 19 studies published between 2011 to early 2022 were relatively homogenous in respect to methodology and surveyed nurses about their experiences with underreporting. Investigation into underreporting revealed three contributing factors to underreporting: nurses, leaders, and organizations.

Nurse factors that impact underreporting Nurses’ characteristics impact underreporting of WPV. Studies suggest that younger female nurses, less experienced nurses, and nurses who experience a higher frequency of violence are less likely to report it. Sato et al. (31) suggested nurses with less experience may perceive themselves as less valued while developing their nursing competency and therefore feel their voice has less significance compared to their leaders. These characteristics appear to mirror nurses who are most often targets of WPV. Although other studies contain varying results, younger female nurses with less experience are most often the victims of WPV events (32). Additionally, nurses who work alone, in specialty areas, or are highly empathetic are also less likely to report WPV. As noted by Hanson et al. (33), home care nurses, who largely work alone, find themselves reliant upon their knowledge and skills to keep them safe against WPV. This independence and self-reliance may also translate into underreporting.

Most often, nurses underreport due to the perception that violence is “part of the job” which leads them to minimize the event (14, 19, 31, 34). Although five of the 19 studies used the term “part of the job”, other studies describe this synonymously as “common to their care area” (10) or “de-sensitized to violent patients” (23). Additionally, the nurse was found to underreport if the event was not viewed as severe enough, the behavior was perceived to be unintentional, no injury was incurred, or the patient apologized. This is noted to be particularly true for verbal aggression, which has become so commonplace that it is accepted as part of the nature of the workplace (14). These attitudes normalize violence, promote complacency towards WPV events, and appear to contribute to underreporting.

Emotions and feelings such as guilt and shame can also contribute to nursing underreporting and are noted in five studies. Emotions can affect reporting if the nurse perceived themselves, in any way, culpable for the event, anticipated the event, or feel they should have had knowledge or skills to combat or deescalate the situation (26). Alas, these emotions may be misplaced as some violent episodes are unforeseeable and therefore unable to be thwarted (35).

Fear, a stronger emotion, was a significant reason for nurses to underreport as noted in 15 out of 19 studies. Fear can manifest from multiple sources. Not only can the nurse be fearful of perpetrator retaliation or revenge, but there can also be fear from colleagues or management. The nurse may fear a lack of collegial support, judgment from peers, feel pressure to not report if peers do not, or fear being blamed for the event. Fears related to management include the fear of losing their job, managerial reprisal, poor job performance appraisals, or legal consequences if the nurse reports. The nurse may also be fearful of poor patient satisfaction scores or negative consequences to the perpetrator as a result of the nurse reporting the event.

Fear is a known issue with WPV and seems to parallel issues related to underreporting. Female nurses are more fearful of WPV compared to men (36). This may be due to women typically being smaller in stature and lacking the large physical presence men possess to confront WPV events. Women are also noted to be psychologically more sensitive after events which can translate into compounding fear (36). Additionally, nurses fear management reprisals. This may be related to leaders making decisions that reduce the negative impact on the hospital after a WPV event but these decisions may be at the expense of nursing interests (30, 37).

Time constraints can also play a significant part in reporting WPV events. If nurses perceive reporting as too time-consuming, inconvenient, or do not have the time to step away from patient care, reporting may be hindered. This is similar to underreporting of all errors or incidents within nursing. Hamed and Konstantinidis (38) found that lack of time, reporting processes that are too laborious, and work pressures present barriers to reporting incidents within nursing. Thus, the barrier of time to report events is not specific to WPV.

Other contributing aspects of WPV underreporting are in the realm of knowledge or lack of education. Nurses underreport when there is a lack of clear definition of what constitutes WPV, don’t know who, where, or how to report an event, or if there is a cumbersome reporting system. This is similar to other incident reporting for nurses who state they have a lack of skills, knowledge, and training to file a report, and state they are uncertain as to what constitutes an error (38). This lack of information may leave nurses vulnerable and uncertain as to the appropriate steps to take when an incident occurs, regardless of whether the event is related to WPV or another type of incident.

Management factors that impact underreporting

Management is noted to be the most impactful factor in nurse underreporting of WPV events. As mentioned in 17 of the 19 studies, nurses underreport due to a lack of positive changes after filing a report and thus perceive reporting as “useless”. This may make victims hesitant to report again. However, Arnetz (9) found nearly half of all healthcare workers provide only a verbal report to a colleague or supervisor. Although a staff member may believe the event was reported, formal documentation of the event may not have been provided to upper management who can initiate changes in policies, procedures, and endow resources to address WPV (9). Thus, the staff member, who verbally reported the WPV event to their supervisor, is left with the perception that no positive changes occurred from reporting and therefore, reporting is useless. In essence, ineffective reporting by nurses leads to further underreporting.

Moreover, nurses underreport due to dissatisfaction with the follow-through after a WPV event. This appears similar to other error/incident underreporting issues and a lack of managerial investigation into the cause of an incident (38). A noted difference between WPV events and other forms of incident reporting is the lack of consequences for the perpetrator of WPV by management. However, both error/incident reporting and WPV underreporting may stem from the nurse's perception that they will be blamed for the event (38).

Organization

For healthcare organizations, WPV is an evolving problem and requires infrastructure to support WPV safety and reporting. For organizations without established infrastructure such as WPV policies and procedures outlining reporting processes, efficient reporting systems, and resources to address WPV, underreporting persists unabated. Moreover, nurses underreport WPV events if the organization has not provided the training on WPV as well as the reporting processes in a supportive environment.

Interventions

As a result of the systematic review on WPV underreporting, the authors discovered, summarized, and categorized potential WPV interventions into three themes: organizational, management, and community. Whereas the organization develops the infrastructure to combat WPV, such as with policies and procedures, management ensures these are carried out and creates a culture of non-judgmental approachability supporting the concept that WPV is never "part of the job". Community leaders, such as those from professional organizations, law enforcement, government, and academic institutions, may join collaboratively beyond the walls of healthcare, to solve this complex and multidimensional problem.

Reporting and WPV prevention infrastructure have a significant mediating effect on the negative consequences after an event. Policies, procedures, reporting systems, and staff education are necessary to ensure pre-established processes provide protection for the staff and foster organizational trust (40). Recommended interventions for healthcare leaders are summarized in Table 3.

Table 3

Interventions to mitigate underreporting
Organizational Interventions
Policy 2,9,10,11,17, 19,20,21,22, 24,25,26,27, 28,29,30,31	• Develop a clear and detailed WPV policy that includes definitions of WPV and mandates formal reporting without retribution • Put into place prevention, reporting, and resolution processes that include actions for staff to take when a violent event takes place • Identify structure/process for immediate response and follow up • Consider a zero-tolerance WPV policy/campaign which enacts a mechanism of penalizing and suspending care of violent patients • Develop and display signage about behavior expectations and consequences for violent acts. Be prepared to enforce this policy
Reporting System 11,21,22,25, 26,30	• Ensure that the reporting system is clear, effective, user-friendly, and not time-consuming • The reporting system should have oversight by stakeholders and be routinely evaluated for effectiveness and usability. Consider surveying victims about their perceptions of the reporting system once a report is filed
Education and Training 1,2,7,9,10,11, 17,18,19,20, 21,22,24,25, 27,28,29,30, 31	• Educate staff about the phenomenon of WPV in healthcare and its implications • Discuss that everyone has the right to freedom from harm • Reinforce that WPV is not “part of the job” • Institutional training should include the detailed WPV policy. The definition of WPV, its seriousness, the importance of reporting, what to report, and as well as the reporting process should be discussed • Training to include the reporting system for WPV • Educate that reporting is mandatory • Educate that WPV reporting will be non-punitive and that it will not affect their annual job performance evaluation • Educate about the magnitude of underreporting • Educate that reporting is essential for upper management to allocate resources and make the necessary changes to address WPV • Educate that reporting is a pre-requisite for effective intervention • Discuss that the lack of reporting can minimize the problem and can put nurses at risk in the future • Discuss that all WPV reporting will be investigated • Institutional training to include mandatory, annual WPV training review • All institutional orientation programs to include WPV training for new employees • Prevention programs should include risk factors, de-escalation techniques, teamwork training, therapeutic communication skills, and conflict management skills • Teach collaborative patient care to decrease unmet patient needs • Provide routine training in situational awareness • Provide scripted simulations of WPV • Provide training to managers on conflict resolution, early recognition of problems, and coaching skills
Staffing 2,10,17,19, 20,21,25	• Always ensure the presence and availability of security officers • Maintain adequate staffing • Provide police officers
Security Measures 10,17,19,20	• Perform risk assessments routinely • Review and address workflow and overcrowding issues to decrease wait times • Communicate behavior expectations to patients and family • High-risk patients/families should be communicated to all staff/departments • Consider redesigning patient care areas to include physical barriers and other acceptable security measures • Enforce security and visitor policies
Collaboration 11,19,22,25, 30	• Collaborate with leaders in other hospitals and institutions to share data, find solutions and implement improvements • Develop a high organizational WPV response team • Manage this interprofessional team to collaborate and review each report of WPV and provide a satisfactory response • Ensure that all leaders are engaged
Support-Resources 20,22,26	• Provide resources for staff that are affected by WPV-physical, emotional, psychological, and legal • Offer interventions to reduce occupational stress • Offer resources that help to teach coping skills
Management Interventions
Create a Positive Unit Culture 11,21,22,25	• Display a caring, engaged, supportive, approachable, and non-judgmental attitude • Create an environment of valuing nurses’ input • Create and maintain a culture of recognizing, addressing, reporting, and preventing violence • Develop and enforce an open and blame-free culture around WPV and the reporting of it • Maintain good communication with staff
Follow up 11,19,20,21, 22,25,28	• Investigate and address all reports of WPV promptly and consistently • Debrief with staff after a violent event • Provide positive feedback and follow up promptly after a WPV event is reported • Follow up routinely for all WPV reports • Enforce WPV policies
Collaboration 19	• Collaborate with interprofessional team and top management
Support 2,9,10,11,22	• Listen to staff and genuinely offer support • Provide time for staff to formally report WPV • Guide avenues for seeking help • Message intolerance of WPV
Community Interventions
Collaboration 11,21,22,24, 26,28,29,	• Collaborate with external stakeholders to share data, find solutions, and implement improvements – professional organizations, law enforcement, educational institutions, NGOs, lawmakers, etc. • Collaborate with community leaders to develop and implement a national program for tracking and preventing WPV • Collaborate with law enforcement to enforce laws that deter assaults on healthcare workers • Collaborate with academia to promote early education for nursing and medical students • Collaborate with community leaders to develop a campaign on WPV in healthcare
Legislation 22	• Promote and sponsor legislation that protects healthcare workers from WPV
WPV = Workplace Violence NGO = Non-Government Organization

Limitations

Workplace violence is a complex problem and article retrieval was limited to keyword identification and may have excluded common synonyms for workplace violence. Accumulation of additional articles via snowball methods is not replicable and may not be complete due to the dynamic topic of WPV. Moreover, only articles published in English were included and may not reflect a complete global understanding of WPV underreporting.

Content related to the interventions was not initially part of the underreporting systematic review process. Many studies included in the underreporting systematic review contained content about interventions within their study and therefore it was included within the discussion section. A full review of interventions to address underreporting of WPV may be warranted.

Underreporting is a complex and multi-faceted problem. This systematic review and investigation into the rationale for nurses to not report a WPV event illustrate nurses, management, and organizations contribute to the problem. Without consistent and comprehensive reporting, improvements toward workplace violence solutions within healthcare will continue to be unresolved. Recommendations to address underreporting for each of the themes highlight the importance of clear and actionable reporting procedures, resources, and staff support for reporting.

RN: Registered Nurse; WPV: workplace violence; OSHA: Occupational Safety and Health Administration; PRISMA: Preferred Reporting Items for Systematic Review and Meta-Analysis; CINAHL: Cumulative Index to Nursing and Allied Health Literature; SIGN: Scottish Intercollegiate Guidelines Network; HCW: healthcare worker; NGO: non-government organization

Ethics approval and consent of publication-Not applicable.

Consent for Publication-Not applicable.

Competing interests-The authors have no conflicts of interest to declare.

Availability of data and materials-The dataset and review materials used during the systematic review are available upon request of the corresponding author.

Funding-There was no source of funding for this systematic review.

Authors’ contributions-All the authors contributed to the main manuscript. KD and CS determined study selection and literature acquisition. JS, JF, and CS were responsible for data extraction and interpretation of results. All authors read and approved the final manuscript.

Acknowledgements-Not applicable.

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No competing interests reported.

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published 23 Apr, 2023

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Nurses’ Rationale for Underreporting of Patient and Visitor Perpetrated Workplace Violence: A Systematic Review

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Abstract

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Background

Methods

Study design

Eligibility criteria

Search strategy and data sources

Quality appraisal

Results

Description of included studies

Underreporting factors

Discussion

Management factors that impact underreporting

Organization

Interventions

Limitations

Conclusion

Abbreviations

Declarations

References

Additional Declarations

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Journal Publication

Version 1