Case Study: Workplace Violence Underreporting in a Hospital System

This case study investigates the underreporting of workplace violence (WPV) incidents within a hospital system by comparing self-reported experiences from a survey of 2010 healthcare workers with documented events in the hospital's electronic reporting system. The study reveals that a significant majority (88%) of employees who self-reported a violent incident did not formally document it, although many had reported it informally to supervisors. Factors such as injury severity and lost work time were associated with higher rates of formal reporting. The research highlights the importance of understanding the reasons behind underreporting to improve violence prevention efforts and tailor education programs for healthcare workers, ultimately aiming to create a safer work environment. Desklib provides access to a wealth of study resources, including similar case studies and solved assignments, to aid students in their academic pursuits.

Underreporting of Workplace Violence:
Comparison of Self-Report and Actual Documentation of Hospital Incidents
Judith E. Arnetz, PhD, MPH, PT1,2, Lydia Hamblin, MA1,3, Joel Ager, PhD1, Mark Luborsky,
PhD3,4, Mark J. Upfal, MD, MPH1,5, Jim Russell, BSN5, and Lynnette Essenmacher, MPH5
1Wayne State University School of Medicine
2Uppsala University
3Wayne State University
4Karolinska Institutet
5Detroit Medical Center
Abstract
This study examined differences between self-report and actual documentation of workplace
violence (WPV) incidents in a cohort of health care workers. The study was conducted in an
American hospital system with a central electronic database for reporting WPV events. In 2013,
employees ( n= 2010) were surveyed by mail about their experience of WPV in the previous year.
Survey responses were compared with actual events entered into the electronic system. Of
questionnaire respondents who self-reported a violent event in the past year, 88% had not
documented an incident in the electronic system. However, more than 45% had reported violence
informally, for example, to their supervisors. The researchers found that if employees were injured
or lost time from work, they were more likely to formally report a violent event. Understanding the
magnitude of underreporting and characteristics of health care workers who are less likely to
report may assist hospitals in determining where to focus violence education and prevention
efforts.
Keywords
workplace violence; health care workers; hospitals; underreporting
Accurate reporting of occupational illness and injury is the foundation of workplace-based
interventions to improve worker health and safety (Azaroff, Levenstein, & Wegman, 2002;
For reprints and permissions queries, please visit SAGE’s Web site at http://www.sagepub.com/journalsPermissions.nav.
Address correspondence to: Judith E. Arnetz, PhD, MPH, PT, Department of Family Medicine and Public Health Sciences, Division of
Occupational and Environmental Health, Wayne State University School of Medicine, 3939 Woodward Avenue, Detroit, MI 48201,
USA; [e-mail].
Authors’ Note
The content is solely the responsibility of the authors and does not necessarily represent the official views of Centers for Disease
Control and Prevention National Institute for Occupational Safety and Health (CDC–NIOSH).
Conflict of Interest
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
HHS Public Access
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Published in final edited form as:
Workplace Health Saf. 2015 May ; 63(5): 200–210. doi:10.1177/2165079915574684.
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Pransky, Snyder, Dembe, & Himmelstein, 1999). Incident reports documenting adverse
events can be used to calculate incidence and prevalence rates, identify risk factors, and
develop prevention efforts for specific occupational hazards (Stout, 2008). However,
underreporting of adverse workplace events is a significant barrier to injury prevention
generally (Pransky et al., 1999), and to the prevention of workplace violence (WPV)
specifically (Centers for Disease Control and Prevention–National Institute for Occupational
Safety and Health [CDC–NIOSH], 2006). In the health care industry, WPV poses one of the
most serious threats to worker health and safety (Gates, 2004; Janocha & Smith, 2010;
McPhaul & Lipscomb, 2004), but underreporting has long been a recognized barrier to
improvement (Arnetz 1998; Iennaco, Dixon, Whittemore, & Bowers, 2013; Lanza &
Campbell, 1991). This study documented the magnitude and nature of WPV underreporting
by examining differences between individual self-report and actual documentation of events
in a cohort of health care workers.
Underreporting of WPV
Underreporting of violent events has been defined as failure of victimized employees to
report these events to their employers, the police, or other officials (Findorff, McGovern,
Wall, & Gerberich, 2005). Underreporting hinders violence prevention efforts in two ways.
First, underreporting results in an underestimation of the true extent of the problem, thus
indicating less of a need for prevention of possible negative effects than may actually be
warranted (Bensley et al., 1997). Second, without knowledge of the full spectrum of violent
events to which workers are exposed, prevention efforts can only be designed to affect
limited aspects of the problem (Arnetz, 1998; Arnetz, Aranyos, Ager, & Upfal, 2011a). In
health care, various reasons for underreporting WPV have included lack of injury or time
lost, time-consuming incident reporting procedures (Arnetz, 1998; Gates, 2004; Lanza &
Campbell, 1991), lack of supervisory or coworker support, fear of reprisal or blame (Gates,
2004; Sato, Wakabayashi, Kiyoshi-Teo, & Fukahori, 2013), belief that reporting will not
lead to any positive changes (Gates, 2004; Kvas & Seljak 2014), and the common perception
among health care workers that violence is simply “part of the job” (Gates, 2004; Lanza &
Campbell, 1991; Lanza, Schmidt, McMillan, Demaio, & Forester, 2011). Varying definitions
of violence among employees and within organizations (Arnetz, 1998; Sato et al., 2013) can
also affect reporting behavior.
Physical assaults by patients, relatively common in emergency (Gacki-Smith et al., 2009;
Gates, Ross, & McQueen, 2006; Taylor & Rew, 2011), psychiatric (Lanza et al., 2011), and
geriatric (Leonard, Tinetti, Allore, & Drickamer, 2006; Zeller et al., 2009) departments, may
not be reported if staff perceive that the aggressive behavior was unintentional, that is,
related to the patient’s illness (Hesketh et al., 2003; Lanza & Campbell, 1991; Sato et al.,
2013). Health care workers may also be reluctant to report non-physical violence from
patients or co-workers because the behavior incurs no injury and may be organizationally
sensitive, especially when it concerns the misuse of power by the perpetrator, such as when
an employee is bullied by a supervisor (Ferns & Meerabeau, 2009; Findorff et al., 2005).
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Reporting Methods and the Magnitude of Underreporting
The magnitude of WPV underreporting among health care workers is difficult to quantify.
Questionnaires have been used to measure reporting behavior among workers (Ferns &
Meerabeau, 2009; Findorff et al., 2005; Sato et al., 2013). These studies have found a high
prevalence of underreporting of both physical and non-physical violence, with all results
based solely on employee self-report. Earlier research compared different forms of incident
reporting (Arnetz, 1998; Bensley et al., 1997; Grenade & Macdonald, 1995) and also found
high rates of underreporting. In a 12-month period, employees at 47 health care workplaces
recorded 684 violent events on incident reporting forms developed for the research study;
based on self-report, only 147 incidents (21%) were also filed as official work injury reports
(Arnetz, 1998). Bensley and colleagues (1997) compared assault injury rates among staff in
a psychiatric hospital using compensation claims, hospital incident reports, and
questionnaire data. Rates differed widely: 13.8, 35, and 415 injuries per 100 employees per
year were reported based on compensation claims, incident reports, and self-report,
respectively. That study used the hospital ward as the unit of analysis because questionnaires
were anonymous and it was not possible to link individual responses to individual workers’
compensation or work injury reports. Grenade and Macdonald (1995) found student nurses’
underreporting of physical assault using both documented incidents and a self-report
questionnaire. However, that study only compared results via the two methods without
linking the two data sets. To the researchers’ knowledge, no study to date has linked
individual questionnaire responses about WPV exposure and reporting behavior with actual
incident documentation. Using individual workers as the unit of analysis could quantify the
magnitude of violence underreporting and identify specific worker characteristics associated
with underreporting.
The current study compared individual questionnaire responses with actual documentation
of WPV events in a cohort of hospital employees. The aim of the study was to increase
understanding of underreporting by investigating differences between self-report and actual
documentation practices, and explore characteristics and reporting patterns of health care
workers who underreport. Based on previous research (Arnetz, 1998; Bensley et al., 1997;
Grenade & Macdonald, 1995), it was hypothesized that reports of violence via questionnaire
would exceed the number of actual documented incidents. Furthermore, it was expected that
reporting would be highest among hospital employees who were injured as a result of a
WPV incident (Findorff et al., 2005; Sato et al., 2013) and among those working on
psychiatric and emergency units (Arnetz, Hamblin, Ager, Aranyos, Upfal, et al., 2014).
Materials and Method
The study was conducted in an American hospital system comprised of seven hospitals and
approximately 15,000 employees. The hospital system maintains a centralized electronic
database of employee-reported occupational accidents and incidents, including needlestick
injuries, slips, trips and falls, and violent events. Incident reports are documented by
employees via any hospital system computer. The current study used a subset of the database
that included only WPV data. Hospital employees are encouraged to report all types of
WPV, both physical and non-physical, including incidents perpetrated by patients or visitors,
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known as Type II violence, and those perpetrated by other employees, Type III violence
(Injury Prevention Research Center [IPRC], 2001). The violence database was linked to the
human resource database that provides information on employee age, gender, job category,
date of hire, employment status, and paid productive hours (PPH). This linkage enabled the
calculation of standardized rates of violence per 100 full-time equivalents (FTEs) per year,
thus providing the hospital system with comparison rates of violence occurrence across
hospitals, work units, and over time. This population-based surveillance and reporting
system and WPV database have been described previously (Arnetz et al., 2011a; Arnetz,
Aranyos, Ager, & Upfal, 2011b). Hospital system policy required employees to document all
WPV incidents, both with and without resulting injury, via the electronic reporting system or
to a supervisor (Arnetz, Hamblin, Ager, Aranyos, Essenmacher, et al., 2014). The current
study was limited to employees on 42 hospital units ( N= 2,010) across the hospital system.
Based on analysis of rates of WPV from a 30-month period (January 2010-June 2012), these
units were identified as being at increased risk for violence (Arnetz, Hamblin, Ager,
Aranyos, Upfal, et al., 2014).
Instruments
The questionnaire developed for the study measured employees’ experience with violence
and aggression at work during the past year. Socio-demographic/backgrounditems included
age, gender, place (hospital) of employment, job category, supervisor status (yes/no), length
of employment in the health care field, and length of employment within the hospital
system. Violencewas defined as acts or threats of physical or verbal aggression. Employees
were asked whether they had been a target of violence or aggression at work during the past
year. Response alternatives were “No, never,” “Yes, once or twice,” and “Yes, several times”
(Arnetz & Arnetz, 2001). Violence-related injury: Employees were also asked whether they
had sustained any physical injury as a result of a violent incident (No, none; Yes, mild
injury; Yes, serious injury) and whether they had lost time from workas a result of a violent
event (No, Yes). Four items concerned reporting of violent incidentsand asked whether
employees were familiar with the centralized system for reporting incidents of WPV (No,
Yes); whether they had reported a violent incident via the system during the past year (No,
never; Yes, once or twice; Yes, several times); if employees had not reported a WPV incident
in the electronic system, they were asked to provide a reason for not doing so; and whether
they had reported WPV another way: to a supervisor, via the Compliance Hotline, a toll-free
number that an employee may call to report any type of work-related issue anonymously, or
by some other means.
Underreportingwas defined as the percentage of employees who self-reported experiencing
a WPV event but did not report any events into the electronic system. Current hospital
system policy mandates employees report any known incidents of violence through the
electronic system or to a supervisor. Supervisors must record all reported incidents through
the electronic system within 24 hours from the end of the shift. Thus, incidents reported by
employees to their supervisors are theoretically entered into the system, either by the
employee or the supervisor.
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Data Collection
In the spring of 2013, employees assigned to all 42 hospital units ( N= 2,010) were asked by
the researchers to participate in a questionnaire survey regarding their exposure to WPV and
knowledge of the WPV reporting system. Questionnaires were mailed home to employees
along with a postage-paid return envelope and a cover letter. The letter described the purpose
of the study and informed employees that participation was voluntary and questionnaire
responses were anonymous. Employees gave their consent to participate in the study by
completing and returning the questionnaire. Each employee responding to the questionnaire
received a US$10 gift card by mail. The cover letter explained that each questionnaire was
coded with an identification number that enabled the research team to identify respondents
from a master list. Once the questionnaires had been returned and the gift cards had been
mailed out, the list linking identification numbers with respondent names and addresses was
destroyed. Approximately 2 weeks after the first mailing, reminders and questionnaires were
re-sent to non-respondents. Approval for this study was granted by the Institutional Review
Board at the university and the Research Review Council of the hospital system.
Data Analysis
Using the pseudo identification numbers on the questionnaire survey, individual
questionnaire responses were compared with actual events entered into the electronic
reporting system in the previous 12 months. Questionnaire data were linked to the database
by a hospital system data analyst; the research team only had access to de-identified data
from the hospital system database.
Chi-square analysis was used to compare questionnaire respondents with non-respondents in
regard to gender, age group, employment status (full-time, part-time, and contingent), job
category, job tenure, and documentation of WPV incidents via the electronic system.
Underreporters, that is, employees who reported WPV through this study but did not
document any incidents in the electronic system, were compared with reporters, that is,
employees who both self-reported an incident through this study and documented incidents
in the system, using chi-square statistics. In a final step, forward stepwise logistic regression
was used to determine factors associated with reporting. The dependent variable, reporting
(yes/no), was calculated as having reported exposure to WPV on the questionnaire and also
reported an incident in the electronic system. An additional logistic regression was
conducted to assess factors associated with reporting a violent event to a supervisor.
Independent variables in both regressions included employee age, gender, type of work unit,
job tenure, employment status, violence-related injury, and lost work time due to a violent
event.
Results
A total of 446 employees responded to the questionnaire (response rate 22%). More than
80% of respondents ( n= 364) were female and 35% ( n= 157) were 50 years of age or older.
The majority of respondents ( n= 269, 60%) were nursing staff, part-time employees ( n=
194, 44%) and worked in either acute care nursing units ( n= 157, 35%) or emergency
departments ( n= 120, 27%). Respondents differed significantly from non-respondents with
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regard to age (60.1% respondents vs. 49.1% non-respondents ≥ 40 years, p< .001), job
tenure (17.5% respondents vs. 11.6% non-respondents worked ≥ 20 years in the hospital
system, p< .01), and job category (5.2% patient care associates among respondents vs.
12.6% among non-respondents, p< .001). Respondents did not differ significantly from non-
respondents with regard to documentation of a WPV incident in the electronic system in the
past year (8.3% respondents vs. 6.5% non-respondents, p= .19).
Self-Report Versus Documented Incidents of WPV
Figure 1 presents a flowchart summarizing survey responses and hospital system
documentation of violent workplace incidents. Of the 446 employees who responded to the
questionnaire, 275 (62%) reported experiencing at least one WPV event in the previous year;
of these, 243 did not document an incident in the database, representing an overall rate of
underreporting of 88%. Surprisingly, 63 of the 275 who self-reported violent events (23%)
also reported having documented at least one incident via the electronic reporting system,
but only 12 (4%) actually did so. Among the remaining 212 employees who stated in the
questionnaire that they did not document a violent incident electronically, 20 (9%) actually
did so. Thus, in reality, only 32 of the 275 employees (12%) who self-reported a violent
event had formally documented the incident via the electronic reporting system.
Characteristics of Reporters and Underreporters
Table 1 summarizes and compares characteristics of employees who documented violent
events in the electronic reporting system (“reporters,” n= 32) with employees who did not
(“underreporters,” n= 243). No significant differences were found between the two groups
with regard to gender, age, or length of employment. Reporters included a significantly
greater proportion of full-time employees than underreporters, and no contingent workers
were found among reporters ( p< .05). Fifty percent of reporters ( n= 16) had been injured as
a result of a WPV incident, compared with 11.5% ( n= 28) among underreporters ( p< .001);
25% of reporters ( n= 8) had lost time from work due to a WPV incident compared with
4.5% ( n= 11) among underreporters ( p< .001).
Of the 275 questionnaire respondents who said they had experienced a WPV incident, 45%
( n= 125) reported the violence using an alternative method (Table 2). Of the 32 who did
report via the electronic system, 14 (43.8%) also reported in some other way. Among the
243 underreporters, who did not report an incident via the electronic system, 111 (45.7%)
did report using an alternative method. Reporting to a supervisor was the most common
alternative method; slightly less than 80% of both reporters and underreporters reported
these incidents to their supervisors.
Table 3 summarizes the reasons for not reporting a WPV incident as described by the 212
questionnaire respondents who stated they had experienced a violent event, but had not
reported it. As indicated in Figure 1, 20 of the 212 individuals actually had documented an
incident in the electronic system; thus, Table 3 compares results by reporters and
underreporters. The most common reasons for not reporting were that the individual had not
been a target of/witness to a violent event (29.9%) and did not believe that reporting leads to
change (28.4%). The only significant difference between reporters and underreporters
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concerned being unsure of how to report; surprisingly, this was more common among
reporters (20%) than underreporters (5.4%) although only 14 respondents in total had
selected this alternative. Overall, 43 respondents had noted “other” reasons for not reporting
including fear of retaliation ( n= 13); the incident was reported by someone else ( n= 6); the
incident was patient-related (psychological or cognitive impairment) and was included in
either patient notes or discussed among the health care team ( n= 6).
Results of the logistic regression that examined factors associated with reporting incidents of
violence in the electronic system are summarized in Table 4. Employees had a higher
likelihood of reporting via the electronic system if they incurred a physical injury as the
result of the violent incident ( OR= 6.22) or if an incident resulted in time away from work
( OR= 3.56). No other demographic or work-related factors were significant.
Factors associated with reporting WPV to a supervisor are summarized in Table 5. Having
worked less than 5 years ( OR= 0.42) and working as security staff ( OR= 0.22) were both
significantly associated with lower likelihood of reporting WPV to a supervisor.
Discussion
The aims of this study were (a) to compare the self-report of WPV via the questionnaire
with actual documentation of violent incidents in a cohort of hospital employees, and (b) to
examine the individual and job characteristics and reporting patterns of “reporters” versus
“underreporters.” As hypothesized, a greater proportion of questionnaire respondents (62%)
self-reported an incident of WPV in the previous 12 months, compared with 12% who
actually documented the incident via the electronic reporting system. This finding is
consistent with previous research (Ferns & Meerabeau, 2009; Findorff et al., 2005; Sato et
al., 2013) based solely on self-report. Findorff and colleagues (2005) conducted a study in a
single health care organization and found that less than 60% reported physical violence and
less than 50% reported non-physical violence to their employers; most reports were oral and
not otherwise documented. Ferns and Meerabeau (2009) reported that 45% of nursing
students experienced verbal abuse during their clinical training and the majority (63%)
stated they had reported the incident. However, only four incidents were documented in
writing. Sato and colleagues (2013) found that more than 30% of nurses reported
experiencing patient aggressive behavior in the previous month, but 70% did not report the
incident.
The second hypothesis was that reporting would be highest among hospital employees who
were injured, and among those working on psychiatric or emergency units; this was partially
supported. A significantly greater proportion of reporters had been injured or lost time from
work as a result of a violent event, compared with underreporters; these two factors were
also significantly associated with a higher likelihood of reporting through the electronic
system. This finding may in part be explained by hospital system policy, which states that
employees who have been injured on the job and seek care at Occupational Health Services
must document the incident in the electronic system. These findings support previous
research that found a higher likelihood of reporting when the symptoms or impact of the
violence were more severe (Findorff et al., 2005; Sato et al., 2013). Both studies were based
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solely on self-report. Results of the current study did not support the hypothesis that
psychiatric and emergency department employees are more likely to report violence
compared with employees on other units. Comparisons by type of unit (Table 1) revealed
that a larger proportion of psychiatric employees were reporters (18.8%) than underreporters
(6.2%), but emergency department employees had a larger proportion of underreporters
(30.9%) than reporters (28.1%). However, the researchers did not find a higher likelihood of
reporting through the electronic system in any one type of work unit.
Only 32 of the 275 employees (12%) who self-reported violence in the workplace had
formally documented the incident via the electronic reporting system. This finding suggests
an overall underreporting rate of 88%. An earlier study of 47 health care workplaces based
entirely on worker self-report found a similar underreporting rate of 79% (Arnetz, 1998).
However, a closer look at the questionnaire data in the current study revealed that more than
45% of the 275 who self-reported violence in the past year ( n= 125) used other methods to
report the incident. Those individuals reported the incident verbally to their supervisors
(79.2%), via the Compliance Hotline (15.2%), or other means (18.4%). Although a small
number ( n= 14, 11.2%) of personnel had also reported through the electronic system, the
majority ( n= 111) had not. The only factors significantly associated with informal incident
reporting to a supervisor were short job tenure (< 5 years) and working as security staff; both
were associated with lower likelihood of reporting. Sato and colleagues (2013) found that
nurses with less work experience were less likely to report aggressive behavior. Combining
all of the alternative methods with electronic documentation, the rate of underreporting
dropped to 48%; 143 reporters (32 electronic reporters and 111reporters by other means)
leaves 132 of 275 exposed who did not report. Although this is an improvement over 88%,
almost half of the incidents were not reported.
No Data, No Problem!
This finding has implications for this and similar health care organizations. The hospital
system in this study has worked for the past decade to establish a centralized electronic
system for reporting WPV (Arnetz et al., 2011a, 2011b), and human resource policy
mandates reporting of known incidents of violence. Although employees who verbally
report incidents to their supervisors may be fulfilling their responsibility to report, these
informal reports may not always be available to upper management for policy decisions.
Much of the responsibility for entering incidents into the electronic system falls to unit
supervisors, who may not have time to file reports, may have other tasks that demand
priority, or may not be willing to admit that violence occurs on their units (Sato et al., 2013).
As a result, the population-based rates of violence, calculated annually and based on
documentation in the electronic system (Arnetz et al., 2011a, 2011b), may be substantially
underestimated. Underreporting is a critical barrier to appropriate allocation of resources for
WPV prevention. Accurate and complete surveillance of adverse events in the workplace,
including incidents of WPV and potential threat, is a prerequisite for effective intervention
(Azaroff et al., 2002; Bensley et al., 1997; Pransky et al., 1999), and the problem can be
summarized quite simply: Without accurate data, the true extent and nature of the problem
cannot be assessed.
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Strengths and Limitations
This is the first study to examine underreporting of WPV among health care workers by
linking and comparing individual questionnaire responses (self-report) regarding WPV
experiences with actual incident documentation. However, a number of limitations should be
considered. First, the study was conducted in a single hospital system in one geographic area
of the United States, and results may not be generalized to hospitals in other areas. Second,
the response rate on the questionnaire was low (22%). However, the researchers compared
characteristics of respondents with those of non-respondents and found few significant
differences. Moreover, all further analyses were limited to only the cohort of respondents
who self-reported WPV ( n= 275). Third, the questionnaire items related to experience of
violence were retrospective (past year), and recall bias may have affected the results. This
bias was especially evident in that 63 of the 275 who self-reported violent events (23%) also
self-reported having documented at least one incident via the electronic reporting system,
when, in fact, only 12 (4%) actually had done so. It may be that several of these individuals
had indeed reported incidents in the electronic system earlier, but not in the past year.
Conversely, of the 212 employees who self-reported that they did not record a violent
incident electronically, 20 (9%) actually had. Finally, the main aim of this study was to
better understand the magnitude of underreporting of WPV generally. Analyses did not
examine the type of violence experienced or reported. As suggested in earlier research
(Findorff et al., 2005), it is likely that underreporting of non-physical violence is greater than
that of physical violence.
Implications for Practice
The lack of agreement between employees’ survey responses and actual report practices may
be due to lack of injury, recall bias, or a lack of motivation to use the central electronic
reporting system to report violent events. Underreporting is a hindrance to determining the
actual extent of WPV toward health care workers. Understanding the magnitude of
underreporting and the characteristics of health care workers who are more likely to
underreport may provide hospitals with a more accurate estimate of WPV and determine
where to focus education, training, and prevention efforts.
Acknowledgments
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of
this article: This study was funded by Centers for Disease Control and Prevention National Institute for
Occupational Safety and Health (CDC–NIOSH), grant number R01OH009948.
Biography
Author Biographies
Judith E. Arnetz is a Professor in the Department of Family Medicine and Public Health
Sciences, Division of Occupational and Environmental Health, Wayne State University
School of Medicine. She has conducted research on workplace violence in the healthcare
sector for over 20 years.
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Lydia Hamblin is a research assistant in the Department of Family Medicine and Public
Health Sciences and a doctoral student in Industrial and Organizational Psychology at
Wayne State University.
Joel Ager is a Professor and Senior Statistician in the Department of Family Medicine and
Public Health Sciences, Wayne State University.
Mark Luborsky is a Professor in the Departments of Anthropology and Gerontology and
Director of Aging and Health Disparities Research at the Institute of Gerontology, Wayne
State University.
Mark J. Upfal serves as Corporate Medical Director at the Detroit Medical Center and is a
Clinical Associate Professor in the Department of Emergency Medicine, Wayne State
University School of Medicine. Dr. Upfal is an expert is occupational and environmental
medicine.
Jim Russell is Executive Director of Occupational Health Services at the Detroit Medical
Center.
Lynnette Essenmacher is Senior Data Analyst at Occupational Health Services, Detroit
Medical Center.
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Applying Research to Practice
Occupational health nurses should be aware of hospital workers’ attitudes toward
reporting violent events and work with hospital management on possible means to
develop a non-punitive culture that encourages reporting. Possible solutions to this
problem include education on underreporting, dissemination of hospital policies on
reporting, and holding employees and supervisors accountable for reporting violent
incidents that occur on their units.
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Figure 1.
Flowchart comparing self-report (questionnaire) and actual documentation (electronic
reporting system) of workplace violence (WPV) events among hospital employees ( N=
446).
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Table 1
Characteristics of Violence Reporters a( n= 32) and Underreporters b( n= 243)
Variable
Reporters Underreporters
pn (%) n (%)
Gender .31
Male 10 (31.3) 56 (23.0)
Female 22 (68.8) 187 (77.0)
Age (years) .22
<29 3 (9.4) 61 (25.1)
30-39 6 (18.8) 45 (18.5)
40-49 9 (28.1) 60 (24.7)
50+ 14 (43.8) 77 (31.7)
Length of employment at current workplace (years) .19
<5 11 (34.4) 118 (48.6)
5-9 10 (31.3) 46 (18.9)
10-19 9 (28.1) 45 (18.5)
20+ 2 (6.3) 34 (14.0)
Employment status .02
Full-time 18 (56.3) 91 (37.4)
Part-time 14 (43.8) 113 (46.5)
Contingent 0 (0.0) 39 (16.0)
Type of work unit .03
Acute care nursing 6 (18.8) 78 (32.1)
Emergency department 9 (28.1) 75 (30.9)
Intensive care unit 2 (6.3) 22 (9.1)
Surgery 1 (3.1) 22 (9.1)
Security 8 (25.0) 31 (12.8)
Psychiatry 6 (18.8) 15 (6.2)
Job category .02
Nursing 13 (40.6) 152 (62.6)
Security 6 (18.8) 28 (11.5)
Other technicians 6 (18.8) 11 (4.7)
Manager/administrative professional 2 (6.3) 19 (7.8)
Allied health professional 2 (6.3) 9 (3.7)
Mental health technician 2 (6.3) 5 (2.1)
Unit clerk 1 (3.1) 6 (2.5)
Clerical 0 (0.0) 3 (1.2)
Patient care associate/medical assistant 0 (0.0) 10 (4.1)
Injured as a result of a violent event <.001
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Variable
Reporters Underreporters
pn (%) n (%)
No 16 (50.0) 215 (88.5)
Yes, mild 13 (40.6) 25 (10.3)
Yes, serious 3 (9.4) 3 (1.2)
Lost time from work as a result of a violent event <.001
No 24 (75.0) 232 (95.5)
Yes 8 (25.0) 11 (4.5)
Note. WPV = workplace violence.
a
Reporters reported WPV via questionnaire and also documented the incident(s) via the electronic system.
b
Underreporters reported WPV via questionnaire, but did not document the incident(s) via the electronic system.
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Table 2
Alternative Methods of Reporting WPV: Comparison of Reportersa( n= 14) and Underreporters b( n= 111)
Total Reporters Underreporters
pVariable n (%) n (%)
Supervisor 99 (79.2) 11 (78.6) 88 (79.3) .84
Compliance hotline 19 (15.2) 4 (28.6) 15 (13.5) .25
Other 23 (18.4) 3 (21.4) 20 (18.0) .74
Total c 125 (100) 14 (100) 111 (100) .84
Note. WPV = workplace violence.
a
Reporters reported WPV via questionnaire and also documented the incident(s) via the electronic system.
b
Underreporters reported WPV via questionnaire but did not document the incident(s) via the electronic system.
c
Multiple response was possible; a total of 125 employees reported using an alternative method.
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Table 3
Reasons for Not Reporting Incidents of WPV Among the 212 Survey Respondents Who Stated That They
Experienced Violence but Did Not Report It. Comparison of Reportersa( n= 20) and Underreporters b( n= 184
Valid Responses)
Overall Reporters Underreporters
pVariable n (%) n (%) n (%)
Not a target or witness of violence .60
Yes 61 (29.9) 7 (35.0) 54 (29.3)
No 143 (70.1) 13 (65.0) 130 (70.7)
Not aware of reporting system 1.00
Yes 8 (3.9) 0 (0.0) 8 (4.3)
No 196 (96.1) 20 (100.0) 176 (75.7)
Did not have time .44
Yes 21 (10.3) 3 (15.0) 18 (9.8)
No 183 (89.7) 17 (85.0) 166 (90.2)
Not sure how to report .04
Yes 14 (6.9) 4 (20.0) 10 (5.4)
No 190 (93.1) 16 (80.0) 174 (94.6)
Not important to report 1.00
Yes 38 (18.6) 3 (15.0) 35 (19.0)
No 166 (81.4) 17 (85.0) 149 (81.0)
Reporting never leads to changes .38
Yes 58 (28.4) 4 (20.0) 54 (29.3)
No 146 (71.6) 16 (80.0) 130 (70.7)
Do not know/no particular reason 1.00
Yes 18 (8.8) 1 (5.0) 17 (9.2)
No 186 (91.2) 19 (95.0) 167 (90.8)
Other 1.00
Yes 43 (21.1) 4 (20.0) 39 (21.2)
No 161 (78.9) 16 (80.0) 145 (78.8)
Note. WPV = workplace violence.
a
Reporters reported WPV via questionnaire and also documented the incident(s) via the electronic system.
b
Underreporters reported WPV via questionnaire but did not document the incident(s) via the electronic system.
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Table 4
Logistic Regression Examining Factors Associated With Reporting WPV Incidents in the Electronic System a
( n= 275)
Variable β OR 95% CI
Physical injury (yes/no) 1.83 6.22 [2.64, 14.64]
Lost work time (yes/no) 1.27 3.56 [1.15, 11.00]
Note. WPV = workplace violence; OR= odds ratio; CI=confidence interval.
a
Adjusted for age, gender, type of work unit, job tenure, and employment status.
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Table 5
Logistic Regression Examining Factors Associated With Reporting WPV Incidents to a Supervisor a( n= 275)
Variable β OR 95% CI
Job tenure (reference 20+ years)
< 5 years −0.88 0.42 [0.19, 0.92]
5-9 years 0.26 1.30 [0.54, 3.13]
10-19 years −0.06 0.94 [0.39, 2.29]
Type of work unit (reference acute care nursing)
Emergency department −0.47 0.62 [0.32, 1.20]
Intensive care nursing −0.46 0.63 [0.24, 1.69]
Surgery 0.11 1.12 [0.43, 2.93]
Security −1.53 0.22 [0.08, 0.57]
Psychiatry −0.21 0.81 [0.30, 2.21]
Note. Significant factors in bold. WPV = workplace violence; OR = odds ratio; CI=confidence interval.
a
Adjusted for age, gender, employment status, physical injury, lost work time.
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