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.
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.
These are interpersonal pressures that influence behavior at the individual level, such as:
These forces shape how a person wants to be seen— and whether reporting feels aligned with that identity.
These are organization- or unit-wide norms that define what is “normal,” “expected,” or “acceptable,” including:
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.
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 come from the workplace itself: the norms, expectations, and systems that signal what matters.
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 are personal. They reflect how individuals believe they’re supposed to show up in their role or identity.
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.
Cultural norms set the tone. Social expectations shape individual choices. Both influence whether reporting feels:
Understanding the difference helps leaders target interventions more precisely– and change both the environment and the interpersonal dynamics that sustain under-reporting.
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.
When socially driven under-reporting becomes the norm, the impact reaches far beyond incident counts.
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.
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.
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.
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.
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.
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.
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.
Even the strongest culture can’t overcome a complicated workflow. Reporting should be fast, intuitive, and accessible.
When organizations address infrastructure, culture, and social pressures simultaneously, meaningful improvements become possible:
This is how reporting evolves from an optional task to a shared habit.
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.