The Social Side of Under-Reporting in Healthcare
Under-reporting workplace violence in healthcare isn’t driven by one issue– it’s built from layers.
Earlier this week, The Reality of Under-Reporting Workplace Violence in Healthcare examined the infrastructure failures that make reporting difficult. Then, The Hidden System Failures Behind Under-Reporting explores the technical barriers created when systems are unreliable.
This third piece looks at the most complex layer: the social and culturally based pressures that shape whether reporting feels safe, acceptable, or even possible. Infrastructure determines whether reporting can happen.
Culture determines whether reporting should happen– but social pressures determine whether reporting will happen. While infrastructure can change quickly, social and cultural barriers require time, consistency, and trust to repair.
This is the piece of the puzzle that determines whether change sticks.
Defining “Social” and “Cultural” Barriers
Under-reporting doesn’t happen only because workflows break down; it also happens because people bring their own identities, expectations, and lived experiences into every shift. Two forces shape this: social drivers and cultural drivers—related, but distinct.
Social Drivers
These are interpersonal pressures that influence behavior at the individual level, such as:
- peer expectations,
- team dynamics,
- identity-based pressures related to gender, age, or professional role,
- concern about how colleagues will interpret one’s actions.
These forces shape how a person wants to be seen— and whether reporting feels aligned with that identity.
Cultural Drivers
These are organization- or unit-wide norms that define what is “normal,” “expected,” or “acceptable,” including:
- whether violence is viewed as an unavoidable part of care,
- how leaders respond to incidents,
- the value placed on safety vs. speed,
- whether reporting is treated as meaningful or as a burden.
Cultural drivers create the environment; social drivers determine how people behave within it. Importantly, cultural barriers are usually more responsive to organizational change because policies, workflows, communication, and leadership behavior can be directly adjusted to shift them.
Social pressures run deeper– they require shifts in mindset and identity, often influenced by improved culture but not changed by policy alone.
The Social and Cultural Pressures That Influence Reporting
Once the definitions are clear, it’s easier to see how both cultural and social pressures shape real-world decisions about reporting–even before a caregiver ever opens a reporting form.
Cultural Pressures: What the Environment Teaches Staff
Cultural pressures come from the workplace itself: the norms, expectations, and systems that signal what matters.
“Violence is just part of the job.”
- As noted in The Reality of Under-Reporting Workplace Violence in Healthcare, 64% of ED staff report believing violence is expected. When aggression is normalized, reporting feels unnecessary–or even like complaining.
“We don’t make a big deal out of this.”
- If previous reports disappeared or didn’t lead to action, staff quickly learn the silent lesson: it’s easier not to bother.
“Don’t disrupt the team.”
- In fast-paced units, reporting can be perceived as slowing things down or triggering administrative work that strains the group.
These pressures aren’t about individual identity– they’re about the environment. Because they stem from culture, leaders can influence them more directly by improving response consistency, normalizing reporting conversations, and making follow-up visible.
Social Pressures: What Individuals Feel They’re Expected to Be
Social pressures are personal. They reflect how individuals believe they’re supposed to show up in their role or identity.
“I should be able to handle this.”
- Male healthcare workers under 30 are disproportionately less likely to report–often due to pressure to appear strong, in control, or unfazed.
“I don’t want my capability questioned.”
- While some caregivers fear being seen as overly sensitive, others worry reporting will signal they aren’t fully prepared for the demands of high-acuity care– even when the situation was objectively unsafe.
“I don’t want to get a patient in trouble.”
- Compassion-driven hesitation is common when the aggressor is confused, experiencing dementia, or in crisis– even if the risk was real.
These pressures tend to be more deeply rooted and take longer to change.
Meaningful cultural improvements– consistent responses, psychological safety, reliable systems–help reduce them over time, but they ultimately require shifts in personal beliefs and team-level interactions.
Together, These Pressures Make Silence Feel Easier
Cultural norms set the tone. Social expectations shape individual choices. Both influence whether reporting feels:
- safe,
- worthwhile,
- supported,
- or risky.
Understanding the difference helps leaders target interventions more precisely– and change both the environment and the interpersonal dynamics that sustain under-reporting.
Infrastructure Shapes Culture (For Better or Worse)
When reporting systems are slow, inconsistent, or fragmented, they unintentionally teach staff that reporting is burdensome or unproductive. That weak infrastructure then reinforces negative cultural values, like normalizing violence or discouraging “bothering” the team.
This is why fixing infrastructure is step one– it creates the foundation for cultural and social change to take root.
Why These Pressures Matter
When socially driven under-reporting becomes the norm, the impact reaches far beyond incident counts.
- Leaders can’t see where risks are increasing.
- Training and staffing decisions become misaligned.
- Aggression becomes expected instead of addressed.
- Teams lose trust in the organization’s support.
Over time, these gaps compound into broader organizational strain: increased turnover, higher workers’ comp and post-incident costs, disrupted staffing models, and ultimately, pressures that can affect the quality of care.
When staff don’t feel safe reporting small incidents, they’re even less likely to report the ones that are escalating– leaving hospitals blind to the very patterns that drive financial and operational instability.
How Leaders Can Break the Silence
Fixing under-reporting isn’t about telling staff to “speak up more.” It’s about reshaping the environment so reporting feels normal, supported, and uncomplicated.
Normalize the conversation.
Violence shouldn’t only come up after something serious happens. Frequent, low-stakes conversations in huddles, rounding, debriefs, and elsewhere help staff understand that every incident counts.
Redefine what strength looks like.
Leaders should actively reinforce that reporting is not a weakness; it’s professionalism. It’s how teams protect each other, identify patterns, and advocate for safer environments.
Validate experiences.
A threat, a shove, a verbal outburst– none of it is “too small” to report. When leaders consistently acknowledge every concern, staff stop worrying that their incidents will be dismissed.
Make reporting collaborative.
Instead of sending staff off to submit reports alone, encourage teammates to do it together. “Let’s log this,” goes a long way toward reducing the emotional weight.
Clarify that reporting isn’t about blame.
Many caregivers fear that reporting will feel punitive to the patient in their time of need. Leaders should communicate, repeatedly, that reporting is about documenting patterns– not punishing individuals.
Remove friction from the process.
Even the strongest culture can’t overcome a complicated workflow. Reporting should be fast, intuitive, and accessible.
What Changes When Culture and Infrastructure Move Together
When organizations address infrastructure, culture, and social pressures simultaneously, meaningful improvements become possible:
- More complete, higher-quality reporting.
- Earlier identification of violent patterns.
- Faster interventions and fewer escalations.
- Reduced burnout and turnover.
- Improved physical and psychological safety.
- Stronger trust between leadership and frontline teams.
This is how reporting evolves from an optional task to a shared habit.
Building an Environment Where Speaking Up Feels Safe
This trilogy of articles has shown one thing clearly: under-reporting isn’t a single problem– it’s a layered one.
Infrastructure creates the foundation. Culture shapes the environment. Social pressures determine behavior.
When all three move together, environments shift. When they don’t, silence persists.
A safer healthcare system depends on leaders addressing every layer: building reliable infrastructure, modeling healthy culture, and supporting caregivers through the deeply human pressures that influence their decisions. Real change happens when reporting becomes something everyone sees, hears, and practices– long before a crisis ever reaches its peak.
