Nurses' Workplace Violence Reporting Behaviours and Reasons for Not Formally Reporting: A Cross‐Sectional Secondary Analysis

ABSTRACT

Aim

To investigate predictors of nurses' reporting behaviours and their reasons for not formally reporting.

Background

Underreporting of workplace violence (WPV) among nurses contributes to gaps in WPV prevention measures, as it cannot be fully understood. WPV is classified according to its source (Type II: patients and visitors, Type III: coworkers) and forms (physical assault, threat of assault, emotional abuse, verbal sexual harassment and sexual assault).

Design

This is a secondary analysis of cross‐sectional survey data collected in 2019 from British Columbia (BC), Canada.

Methods

This study had a sample of 4109 BC nurses. Multinomial logistic regression was used to analyse predictors of reporting behaviours. Reasons for not reporting were analysed descriptively.

Results

Informal reporting to management or through a patient safety incident report was less likely when nurses experienced threat of assault, emotional abuse and verbal sexual harassment from both Type II and III sources and physical assault from Type III sources. Higher perceptions of WPV prevention efforts increased odds of informal and formal reporting through employee incident procedures. Believing that nothing would change after reporting remained among the top three reasons for not formally reporting across all WPV sources and forms. Nurses also commonly selected not knowing the formal process, lack of leadership support and other reasons stated in an open‐text response.

Conclusion

Findings indicate that nurses in BC, Canada, perceive many barriers to formal WPV reporting. Formal reporting systems should address these barriers so that healthcare organisations can effectively track WPV and have data to inform WPV prevention measures.

Implications

To promote WPV reporting, healthcare organisations need multifaceted interventions including confidential and simplified reporting systems, leadership support to follow‐up with nurses and education and training on reporting systems.

Reporting Method

The authors of this manuscript have adhered to the relevant EQUATOR guidelines based on the STROBE cross‐sectional reporting method.

Patient or Public Contribution

No patient or public contribution.

Summary.

• What does this paper contribute to the wider global clinical community?

  • ○
    This secondary analysis offers an overview of reasons why nurses do not formally report, with the belief that nothing will change as a common theme for all WPV sources and forms.
  • ○
    Higher perceptions of WPV prevention efforts encourage informal and formal reporting among nurses. However, WPV form and source also influence reasons why nurses do not formally report WPV.
  • ○
    Based on the reasons for and predictors of reporting, multifaceted interventions are needed to close gaps in WPV reporting and prevention, including leadership support in enacting changes, simplified and confidential reporting systems and education on formal reporting systems and management of workplace violence.

1. Introduction

Workplace violence (WPV) is a persistent issue among national and international healthcare settings with impacts on nurses, patients and organisations. Nurses are one of the highest‐risk groups for exposure to WPV because of their direct contact with other people (Stahl‐Gugger and Hämmig ²⁰²²). WPV can be characterised by its source and form. The source or perpetrator of WPV in healthcare settings includes patients, families or visitors and other healthcare workers (HCWs), while the WPV form describes the negative physical or nonphysical behaviours committed by the source (Hesketh et al. 2003; Huang et al. ²⁰²²). Typically, WPV incidents are reported less than 50% of the time (Huang et al. 2022). However, the severity of WPV cannot be fully understood with incomplete reporting data, compromising the effectiveness of WPV prevention efforts (Oğuz, Sayın, and Gürses ²⁰²⁰). Furthermore, research on underreporting among Canadian nurses was conducted over 20 years ago and did not study reasons for not reporting (Hesketh et al. 2003). Therefore, there is a gap in understanding whether WPV prevention efforts impact reporting and the reasons for not formally reporting in Canadian healthcare settings. The purpose of this study was to assess predictors of reporting WPV and the reasons for not formally reporting based on the source and form of WPV that nurses in Canada experienced.

2. Background

WPV is broadly defined as ‘any act in which a person is abused, threatened, intimidated or assaulted in his or her employment’, which includes threatening behaviour, verbal or written threats, verbal abuse and physical attacks (Canadian Centre for Occupational Health and Safety [CCOHS] ²⁰²³). WPV categorised by source includes four types: Type I is by individuals not connected to the organisational employees (e.g., a criminal); Type II is by patients and visitors or families; Type III is by other organisational employees (i.e., colleagues); and Type IV is by someone related to the organisational employees (e.g., relative) (Lanctôt and Guay 2014). Research consistently identifies Type II and III WPV as the most common sources of WPV in healthcare and therefore, these types are the focus of this study (Huang et al. 2022). Based on a systematic review by Spector, Zhou, and Che. (2014), patients are the main source of physical assault (64.3%) and nonphysical WPV (53.9%) followed by Type III WPV from nurses, physicians and other colleagues (10% to 39.2% depending on WPV form).

Previous Canadian research by Hesketh et al. (2003) classified WPV forms into physical assault, threat of assault, emotional abuse, verbal sexual harassment and sexual assault. In this study, physical assault was defined as the use of force against another person and included behaviours such as spitting, throwing objects, pushing, hitting and biting; threat of assault included verbal or written notes that communicated the intent to harm; emotional abuse involved insults, coercion and gestures that caused humiliation; verbal sexual harassment was any unwanted remarks of a sexual nature that caused humiliation and made the person feel threatened; and sexual assault involved forced sexual contact. Among HCWs, a meta‐analysis of 158 international studies found that nonphysical WPV such as emotional abuse was more common (42.5%) than physical assault (24.5%) (Liu et al. 2019).

An integrative review of 21 international studies found that consequences of WPV included reduced psychological, emotional and physical well‐being as well as declines in work performance and work commitment (Tuominen, Tölli, and Häggman‐Laitila ²⁰²³). Stress, burnout, depression, anger, fear, disappointment, chronic headaches, sleep difficulties and injuries can affect work performance through negative attitudes towards work, reduced interactions with patients and other staff and reduced work commitment leading to absences and staff turnover (Tuominen, Tölli, and Häggman‐Laitila ²⁰²³).

Nurses have options to not report and informally or formally report WPV. Informal reporting involves communication with management about the incident either verbally or through electronic means or the creation of a patient safety incident report, which does not state the nurse's experience (Havaei, MacPhee, McLeod, et al. ²⁰²⁰). Alternatively, formal reporting typically involves the nurse detailing their WPV experience and consequences through a designated channel to ensure follow‐up of the incident (Huang et al. 2022). In British Columbia (BC), a province in Canada, 2024 data indicated over half of nurses did not report WPV even though 81% experienced verbal or emotional abuse and 39% were exposed to weapons (British Columbia Nurses' Union [BCNU] ²⁰²⁴). Currently, in BC, formal reports are made by calling the Provincial Workplace Health Contact Centre (PWHCC) or using another designated Employee Incident Report (EIR) procedure (BCNU ²⁰²³). The PWHCC incident report takes 10 minutes or more to complete and may involve leaving messages (PWHCC n.d.), which complicates communication and can contribute to underreporting (Huang et al. 2022). Based on the limitations of this reporting system and trends in nurses' experience of WPV, there is a gap in understanding whether BC nurses report depending on who perpetrated the incident, the appropriateness of WPV prevention efforts or other reasons and beliefs regarding reporting. An improved understanding of the predictors of reporting behaviours and reasons for not reporting can be a starting point for improving current WPV prevention strategies and promoting safe work environments.

2.1. Aims

The aim of this study was to evaluate predictors of nurses' reporting behaviours and the reasons for not formally reporting based on the source and form of WPV that nurses in Canada experienced. The key research questions were as follows:

1. Does nurse exposure to Type II and III WPV and nurses' perceptions of WPV prevention efforts predict their reporting behaviours across the five WPV forms after accounting for nurses' demographic and workplace characteristics?

2. Do nurses' reasons for not formally reporting WPV vary across those exposed to Type II versus Type III WPV?

3. Do nurses' reasons for not formally reporting WPV vary across those exposed to the five WPV forms?

3. Methods

3.1. Study Design

This study is a secondary analysis of cross‐sectional survey data from a larger project focused on nursing workplace psychological health and safety, conducted in a collaboration between the University of British Columbia (UBC) research team and BCNU (Havaei, MacPhee, McLeod, et al. ²⁰²⁰). The STROBE checklist for cross‐sectional studies was used to report the study (von Elm et al. ²⁰⁰⁷).

Ethics approval for this secondary analysis was obtained from the UBC Behavioural Research Ethics Board prior to the study being conducted (approval number: H23‐03010).

3.2. Setting

The data from the larger study were collected in the fall of 2019, when BCNU invited their 47,000 nursing members to complete a voluntary 25‐min online survey. Strategies to encourage participation in the larger study included having a 2‐month data collection period; weekly reminders via union emails, social media and print advertisement; and a random raffle draw for two Apple watches. Overall, a total of 5512 nurses from BC across a variety of nursing roles, geographical regions and healthcare sectors responded to the larger survey, resulting in a response rate of approximately 12% (Havaei, MacPhee, McLeod, et al. ²⁰²⁰).

3.3. Sample

Inclusion criteria for this secondary study were actively working regulated nurses including Registered Nurses (RNs), Registered Psychiatric Nurses (RPNs), dual RN and Psychiatric Nurses (RN/RPN) and Licensed Practical Nurses (LPNs) who experienced Type II and/or III WPV within the last year in BC. Nurses on maternity or disability leave and nurses who experienced WPV from ‘other’ individuals who were not identifiable as Type II or Type III sources were excluded from the analysis because they may have referred to Type I or IV WPV. Applying these exclusion criteria yielded a sample size of 4109 for inclusion in this secondary analysis. To be conservative, an a priori power calculation was conducted with G*Power version 3.1 for a small effect size of 0.02 based on Cohen's (1988) criteria with 80% power for nine predictor variables (seven control variables and two variables of interest), yielding a sample of 791. Research that investigated the relationship between exposure to WPV forms from Type II sources and reporting found moderate to large effect sizes using Cohen's (1988) criteria with a sample size of 147 (Copeland and Henry 2017). Therefore, this study's sample size of 4109 was sufficiently large.

3.4. Measures

Subject matter experts from the BCNU and UBC nursing academic research team used nursing literature (Hesketh et al. 2003) to develop a series of questions on WPV and reporting behaviours used in the larger study and included for this secondary analysis. The questions were reviewed and revised by subject matter experts before final administration (Havaei, MacPhee, and Ma ²⁰²⁰).

3.4.1. Outcome Variables

Outcome variables included reporting behaviours and reasons for not formally reporting WPV. Reporting behaviours were measured by asking participants how they typically responded to each form of WPV they experienced over the last year. The options included 1 = did not report the incident(s); 2 = informally reported the incident(s); and 3 = formally reported the incident(s) (Havaei ^2019a).

Reasons for not formally reporting WPV were measured if participants indicated that they either did not report or informally reported WPV. These participants were asked a follow‐up check‐all‐that‐apply question on reasons for not formally reporting WPV. Each reason was coded as 1 if they were selected, which included ‘violence is part of my job’, ‘fear of retaliation’, ‘fear of being seen as weak or incompetent’, ‘lack of leadership support’, ‘nothing will change after reporting incident(s)’, ‘feelings of sympathy with the perpetrator’, ‘I did not know this was the formal process’, ‘this is not the formal process at my workplace’ or an option to specify other reasons (Havaei ^2019b).

3.4.2. Predictor Variables

Predictor variables included two key variables (WPV source and perceptions of the extent of WPV prevention efforts) and seven control variables (education, nursing role, professional designation, employment status, years of nursing experience, location and sector).

3.4.2.1. Key Predictor Variables

First, exposure to each WPV form (physical assault, threat of assault, emotional abuse, verbal sexual harassment and sexual assault) was determined by the question, ‘Over the last year, how frequently have you experienced each of the following types of violence in your primary workplace?’ (Havaei ^2019a). Response options were rated on a 7‐point scale ranging from 0 = never to 6 = every day (Havaei ^2019a). Each WPV form variable was transformed into a dichotomous variable, where 0 = the participant did not experience the WPV form and 1 = the participant did experience the WPV form. If participants indicated that they experienced any of the five WPV forms, they were asked a check‐all‐that‐apply question asking to indicate the source as patients, family members or visitors, physicians, nursing coworkers, allied health professionals, management or other (Havaei ^2019a). Participants could have experienced only Type II WPV, only Type III WPV or both Type II and III WPV. Therefore, WPV source was coded as 1 = Type II (patients, family members or visitors), 2 = Type III (physicians, nursing coworkers, allied health professionals and management) and 3 = both Type II and III.

Perception of WPV prevention efforts was measured with one question, ‘To what extent do you think your employer has taken appropriate measures to prevent violence in your primary workplace?’ Response options were rated on a 5‐point scale ranging from 1 = not at all to 5 = a great deal (Havaei ^2019a).

3.4.3. Control Variables

3.4.3.1. Demographic Variables

Demographic variables accounted for in this study included education (1 = diploma or certificate, 2 = undergraduate degree and 3 = graduate degree), nursing role (1 = direct care provider, 2 = nurse leader and 3 = educator), professional designation (1 = LPN and 2 = RN and/or RPN), employment status (1 = full‐time, 2 = part‐time and 3 = casual) and years of nursing experience (1 = 5 years or less, 2 = 6 to 10 years, 3 = 11 to 15 years, 4 = 16 to 20 years and 5 = 21 years or more) (Havaei ^2019a). The education and nursing role variables included an ‘other’ option to allow participants to provide an answer that was not listed in the survey. Those who selected ‘other’ were recoded into existing categories based on their responses to other survey questions. RNs, RPNs and RN/RPNs were collapsed into one category, 'RN and/or RPN'.

3.4.3.2. Workplace Variables

The two workplace variables were location (1 = urban, 2 = suburban and 3 = rural) and sector (1 = acute care, 2 = community care and 3 = long‐term care) (Havaei ^2019a).

3.5. Data Analysis

Data were analysed using IBM SPSS v29.0. Descriptive statistics were used to describe the characteristics of the sample, predictor and outcomes variables and reasons for not formally reporting WPV across source and form. Missing data were handled by pairwise deletion, which only excluded participants if they were missing data for the analyses (Pallant 2020).

The first research question on predictors of WPV reporting behaviours was examined using multinomial logistic regression (MLR) because this method of data analysis predicted classification for a dependent variable with more than two categories (Field 2009). MLR assumptions such as multicollinearity, linearity, outliers and independence of errors were checked and met through SPSS analyses. The seven control variables and two key predictor variables were entered together (i.e., forced entry) into the MLR models. Odds ratios (ORs) and confidence intervals (CIs) were used to determine the impact of findings and estimate the likelihood of an event occurring between two conditions (Field 2009). To aid in interpretation, ORs of < 1 were inverted by dividing the OR by 1 (Pallant 2020).

The second and third research questions on reasons for not formally reporting across WPV sources and forms were analysed descriptively. There were 23 possible combinations of two to four WPV forms that participants could have experienced, and these combinations were grouped together for analysis. Reasons for not formally reporting across WPV forms were analysed depending on whether participants experienced only physical assault, only threat of assault, only emotional abuse, only verbal sexual harassment, only sexual assault, a combination of two to four WPV forms or all WPV forms. Participants also had the option of specifying additional reasons for not formally reporting. These open‐text responses were analysed thematically.

4. Results

4.1. Characteristics of the Sample

Table 1 shows descriptive statistics for the demographic and workplace characteristics of the sample. The vast majority of the sample was female (91.2%) and direct care providers (89.5%). RNs made up 82.8% of the sample (RNs: 76.5%, RPNs: 5.9% and RN/RPN: 0.4%). The mean age of the sample was 40.4 years (SD = 11.5). Of the sample, 63.3% worked full time, 48.2% had an undergraduate degree and 52.1% had less than 10 years of nursing experience. Over half of participants worked in acute care (74.9%) and in urban locations (62.3%).

TABLE 1.

Demographic and workplace characteristics of participants (n = 4109).

Characteristics	M (SD)	f	%
Age
Under 25	40.4 (11.5)	176	4.3
25–34		1384	33.9
35–44		1040	25.5
45–54		872	21.3
55 and above		614	15.0
Gender
Female	—	3745	91.2
Male		352	8.6
Prefer to describe		9	0.2
Professional designation
RN and/or RPN	—	3403	82.8
LPN		706	17.2
Employment status
Full time	—	2599	63.3
Part time		1090	26.6
Casual		415	10.1
Nursing role
Direct care provider	—	3671	89.5
Nurse leader		346	8.4
Educator		85	2.1
Highest level of education
Diploma/certificate	—	1296	31.6
Undergraduate degree		1979	48.2
Graduate degree		830	20.2
Years of experience
5 years or less	—	1222	29.8
6–10 years		914	22.3
11–15 years		730	17.8
16–20 years		325	7.9
21 years or more		907	22.1
Nursing sector
Acute care	—	3074	74.9
Community care		648	15.8
Long‐term care		382	9.3
Location
Urban	—	2549	62.3
Rural		822	20.1
Suburban		719	17.6

Abbreviation: SD, standard deviation.

4.2. Descriptive Statistics of Key Predictor and Outcome Variables

Table 2 displays frequencies and percentages for the experience of WPV by source and form and ratings of WPV prevention efforts from the preceding year. Of note, the majority of participants thought that their employer took slightly to moderately appropriate measures to prevent WPV (70.2%).

TABLE 2.

Descriptive statistics for WPV source and form and perception of WPV efforts (n = 4109).

Variable	f	%
WPV source
Only Type II	2055	50.0
Only Type III	176	4.3
Both Type II and III	1878	45.7
WPV form
Physical assault	2986	72.7
Threat of assault	3520	85.7
Emotional abuse	3730	90.8
Verbal sexual harassment	2465	60.0
Sexual assault	506	12.3
Perception of WPV prevention efforts
Not at all	409	10.0
Slightly	1475	36.2
Moderately	1386	34.0
Considerably	621	15.2
A great deal	183	4.5

Abbreviation: WPV, workplace violence.

Figure 1 shows reporting behaviours across WPV forms. Over half of participants exposed to physical assault (56.4%) and threat of assault (53.3%) informally reported, while over half of participants exposed to emotional abuse (60.2%) and verbal sexual harassment (55.0%) did not report. Slightly less than half of participants who were exposed to sexual assault (47.9%) informally reported incidents. Physical assault was most often formally reported at 25.5%, while emotional abuse was the least formally reported at 6.4%.

FIGURE 1.

Percentage of reporting behaviours by WPV form (n = 4109). WPV, workplace violence. [Colour figure can be viewed at wileyonlinelibrary.com]

4.3. Research Question 1: Predictors of Reporting Behaviours Across WPV Forms

4.3.1. WPV Prevention Efforts and Reporting

The MLR results for predictors of reporting WPV forms are shown in Table 3. Participants' perception of the appropriateness of their employer's WPV prevention efforts significantly predicted their informal and formal reporting behaviours for all five WPV forms after accounting for participants' demographic and workplace characteristics. Comparing informal and not reporting, for every unit increase in participants' perceptions of the appropriateness of WPV prevention efforts, nurses were 1.28 times more likely to report physical assault (OR = 1.28, 95% CI = [1.15, 1.43]), 1.27 times more likely to report threat of assault (OR = 1.27, 95% CI = [1.18, 1.38]), 1.25 times more likely to report sexual assault (OR = 1.25, 95% CI = [1.00, 1.56]), 1.23 times more likely to report verbal sexual harassment (OR = 1.23, 95% CI = [1.12, 1.35]) and 1.18 times more likely to report emotional abuse (OR = 1.18, 95% CI = [1.09, 1.27]).

TABLE 3.

Multinomial logistic regression results for predictors of reporting WPV forms (n = 4109).

	Physical assault	Threat of assault	Emotional abuse	Verbal sexual harassment	Sexual assault
	OR (95% CI)	OR (95% CI)	OR (95% CI)	OR (95% CI)	OR (95% CI)
Informal Reporting
Prevention	1.28*** (1.15, 1.43)	1.27*** (1.18, 1.38)	1.18*** (1.09, 1.27)	1.23*** (1.12, 1.35)	1.25* (1.00, 1.56)
Source a
Type III	0.21* (0.06, 0.80)	0.63 (0.27, 1.43)	1.12 (0.78, 1.60)	0.50 (0.19, 1.36)	—
Both II/III	0.90 (0.73, 1.10)	0.85* (0.73, 0.98)	0.65*** (0.56, 0.76)	0.67*** (0.56, 0.80)	0.70 (0.46, 1.05)
Formal Reporting
Prevention	1.31*** (1.16, 1.48)	1.43*** (1.26, 1.61)	1.18* (1.03, 1.36)	1.41*** (1.19, 1.66)	1.51** (1.13, 2.03)
Source a
Type III	0.21 (0.04, 1.09)	1.21 (0.45, 3.28)	1.46 (0.81, 2.63)	0.34 (0.04, 2.69)	—
Both II/III	1.12 (0.89, 1.41)	0.96 (0.75, 1.23)	0.77 (0.58, 1.03)	0.79 (0.57, 1.09)	0.61 (0.35, 1.07)

Note: The models adjusted for control variables (i.e., education, nursing role, professional designation, employment status, years of nursing experience, location and sector).

^a Reference category was Type II WPV.

^* p < 0.05.

^** p < 0.01.

^*** p < 0.001.

Comparing formal versus not reporting, for every unit increase in participants' perceptions of the appropriateness of WPV prevention efforts, they were about 1.51 times more likely to report sexual assault (OR = 1.51, 95% CI = [1.13, 2.03]), 1.43 times more likely to report threat of assault (OR = 1.43, 95% CI = [1.26, 1.61]), 1.41 times more likely to report verbal sexual harassment (OR = 1.41, 95% CI = [1.19, 1.66]), 1.31 times more likely to report physical assault (OR = 1.31, 95% CI = [1.16, 1.48]) and 1.18 times more likely to report emotional abuse (OR = 1.18, 95% CI = [1.03, 1.36]).

4.3.2. WPV Source and Reporting

WPV source predicted participants' informal reporting behaviours for all WPV forms except sexual assault after accounting for participants' demographic and workplace characteristics. Compared to participants who experienced Type II physical assault, exposure to Type III physical assault was associated with a lower likelihood of informally reporting. Experiencing physical assault from a Type III source over the last year was associated with 0.21 times the odds of informally reporting (OR = 0.21, 95% CI = [0.06, 0.80]). In other words, participants who experienced only Type II physical assault were approximately 4.76 times more likely to informally report compared to those who only experienced Type III physical assault (1/0.21).

In comparison to those who only experienced Type II WPV, participants who encountered both Type II and III WPV had 0.65, 0.67 and 0.85 times the odds of informally reporting emotional abuse (OR = 0.65, 95% CI = [0.56, 0.76]), verbal sexual harassment (OR = 0.67, 95% CI = [0.56, 0.80]) and threat of assault (OR = 0.85, 95% CI = [0.73, 0.98]) respectively. These findings mean that those who had exposure to only a Type II WPV source were 1.54 (1/0.65), 1.49 (1/0.67) and 1.18 (1/0.85) times more likely to informally report emotional abuse, verbal sexual harassment and threat of assault, respectively, compared to participants who were exposed to both Type II and III sources. On the contrary, WPV source did not significantly predict participants' formal reporting behaviours across WPV form.

4.4. Research Question 2: Reasons for Not Formally Reporting Type II and III WPV

Of the sample, 3884 participants did not report or informally reported WPV. Table 4 shows the reasons participants did not formally report across Type II, Type III and both Type II and III WPV in the last year. The belief that nothing would change after reporting incidents was the top reason for not formally reporting among participants who experienced Type II WPV (60.8%), Type III WPV (62.8%) and both Type II and III WPV (74.6%). Participants who only experienced Type II WPV also did not know the formal process (32.2%) and indicated other reasons for not reporting (26.5%). In the Type III WPV category, other frequently selected reasons included lack of leadership support (46.8%) and fear of retaliation (45.5%). Participants who experienced both Type II and III WPV also selected lack of leadership support (51.8%) and had a fear of being seen as weak or incompetent (34.8%).

TABLE 4.

Reasons for not formally reporting WPV sources (n = 3884).

Reasons	Only type II (n = 1916)	Only type III (n = 156)	Both type II/III (n = 1812)
	f (%)	f (%)	f (%)
Nothing will change after reporting incident(s)	1164 (60.8%)	98 (62.8%)	1352 (74.6%)
I didn't know this was the formal process	616 (32.2%)	32 (20.5%)	416 (23.0%)
Other	508 (26.5%)	43 (27.6%)	397 (21.9%)
Violence is part of my job	467 (24.4%)	3 (1.9%)	470 (25.9%)
Lack of leadership support	457 (23.9%)	73 (46.8%)	939 (51.8%)
Feelings of sympathy with the perpetrator	324 (16.9%)	12 (7.7%)	257 (14.2%)
Fear of being seen as weak or incompetent	291 (15.2%)	40 (25.6%)	631 (34.8%)
Fear of retaliation	137 (7.2%)	71 (45.5%)	589 (32.5%)
This is not the formal process at my workplace	101 (5.3%)	8 (5.1%)	108 (6.0%)

4.5. Research Question 3: Reasons for Not Formally Reporting the Five Forms of WPV

Table 5 displays the reasons participants did not formally report according to the form or combination of forms they experienced over the last year. Most participants experienced a combination of WPV forms (n = 3011), and there were no participants who only experienced sexual assault. Believing that nothing would change after reporting remained the top reason why participants did not formally report for those who only experienced emotional abuse (57.4%), any combination of two to four WPV forms (68.3%) and all five WPV forms (80.1%). Other reasons were the most common for not formally reporting physical assault (51.2%) and verbal sexual harassment (50.0%). Other reasons specified by participants included lack of time to report due to workload or having no paid time to report; rationalising behaviours from perpetrators due to their diagnosis, chronological age or influence of medications; lack of knowledge or accessibility of the reporting system; and WPV characteristics, such as its impact, severity and frequency. Not knowing the formal process was the most common reason for not formally reporting threat of assault (49.3%). Perceived lack of leadership support was another top three reason for participants who experienced emotional abuse (37.5%), a combination of WPV forms (37.8%) or all WPV forms (46.2%).

TABLE 5.

Reasons for not formally reporting WPV forms (n = 3884).

Reasons	Physical assault a (n = 43)	Threat of assault a (n = 75)	Emotional abuse a (n = 272)	Verbal sexual harassment a (n = 26)	Combinations b (n = 3011)	All c (n = 457)
	f (%)	f (%)	f (%)	f (%)	f (%)	f (%)
Other	22 (51.2%)	23 (30.7%)	63 (23.2%)	13 (50.0%)	687 (22.8%)	140 (30.6%)
I didn't know this was the formal process	16 (37.2%)	37 (49.3%)	77 (28.3%)	9 (34.6%)	833 (27.7%)	92 (20.1%)
Nothing will change after reporting incident(s)	11 (25.6%)	20 (26.7%)	156 (57.4%)	5 (19.2%)	2056 (68.3%)	366 (80.1%)
Lack of leadership support	5 (11.6%)	12 (16.0%)	102 (37.5%)	0 (0%)	1139 (37.8%)	211 (46.2%)
Feelings of sympathy with the perpetrator	5 (11.6%)	8 (10.7%)	32 (11.8%)	0 (0%)	464 (15.4%)	84 (18.4%)
Violence is part of my job	3 (7.0%)	6 (8.0%)	9 (3.3%)	0 (0%)	757 (25.1%)	165 (36.1%)
This is not the formal process at my workplace	3 (7.0%)	4 (5.3%)	12 (4.4%)	1 (3.8%)	171 (5.7%)	26 (5.7%)
Fear of retaliation	2 (4.7%)	3 (4.0%)	88 (32.4%)	1 (3.8%)	585 (19.4%)	118 (25.8%)
Fear of being seen as weak or incompetent	0 (0%)	2 (2.7%)	78 (28.7%)	0 (0%)	740 (24.6%)	142 (31.1%)

^a The groups only include participants who experienced a single WPV form, including physical assault, threat of assault, emotional abuse or verbal sexual harassment.

^b ‘Combinations’ refer to the experience of two to four workplace violence forms.

^c ‘All’ refers to the experience of all five forms of workplace violence.

5. Discussion

This study had several key findings. First, emotional abuse and verbal sexual harassment were the least reported WPV forms. Second, WPV source was not related to formal reporting behaviours, but it was a significant predictor of nurses' informal reporting behaviours. More specifically, nurses who experienced both Type II and III WPV were less likely to informally report threat of assault, emotional abuse and verbal sexual harassment compared to nurses who experienced these forms from only Type II sources. Also, even though nurses reported physical assault more often than other forms, if it was perpetrated by Type III sources, they were less likely to informally report it compared to physical assault from Type II sources. Third, over half of nurses perceived WPV prevention efforts as slightly to moderately appropriate, and higher perceptions of prevention efforts were consistently related to a higher likelihood of both informal and formal reporting of all WPV forms. Fourth, nurses' reasons for not formally reporting showed some similarities and nuanced differences across various forms and sources of WPV. For instance, the belief that nothing would change after reporting incidents was a consistent top three reason for not formally reporting among all WPV sources and forms. Additional frequently selected reasons were not knowing the formal process, lack of leadership support and other reasons indicated in an open‐text response. Fear of retaliation was also the third most common reason for not formally reporting emotional abuse and Type III WPV.

Emotional abuse and verbal sexual harassment were the least reported WPV forms among nurses in this study, which may be attributed to gender‐based factors and perceptions of severity. The vast majority of the sample in this study was female, and previous qualitative research found that the language of emotional or verbal abuse often involved gendered and sexualised insults that degraded women's character (Jackson et al. 2013). Additionally, nonphysical WPV (e.g., emotional abuse and verbal sexual harassment) might be viewed as not severe enough to report because no physical injury was sustained, the behaviour was viewed as unintentional, there was an apology from the perpetrator or the behaviours were normalised as part of the workplace (Spencer et al. 2023). Similarly, Jackson et al. (2013) discussed how women might underreport sexual harassment because it has been normalised to the point where they do not recognise it as a distinct action that should be reported or feel shame associated with sexualised violence.

Nurses with cumulative exposure to both Type II and III WPV versus only Type II WPV may be less likely to informally report due to the trivialisation of WPV, which occurs when there is normalisation of WPV and avoidance of discussing WPV due to fear of negative peer judgements (Geoffrion et al. 2015). Geoffrion et al. (2015) found that the more HCWs and law enforcers were exposed to severe violent acts, the less likely they were to complain about WPV, and this normalisation contributed to perceiving discussion on WPV as taboo. However, colleague support was also associated with less fear about discussing WPV (Geoffrion et al. 2015). Therefore, increasing support for nurses who experienced WPV might reduce the taboo associated with WPV discussion and facilitate incident reporting.

Nurses may also be less likely to informally report Type III physical assault over Type II physical assault due to the lack of recognition for bullying behaviours and fear of retaliation from colleagues after reporting (Taylor 2016). Qualitative research suggests that nurses are unsure of what behaviours can be reported, tolerate bullying from colleagues or are afraid of reporting, especially against their colleagues (Type III WPV) due to being labelled as a ‘complainer’ (Taylor 2016). Consequently, nurses may prefer the option to confidentially report because they may be afraid of retaliation from the perpetrating co‐worker or worsening of the situation, even more so if there is a lack of leadership support and protection following a report (Huang et al. 2022). Among BC healthcare organisations, reporting procedures do not always ensure confidentiality, which is barrier to formal reporting (Huang et al. 2022). For example, some healthcare organisations may have an online confidential system for reporting incidents related to bullying, sexual harassment or physical assault, whereas reports through the PWHCC are not anonymous and are followed by a Human Resources investigation (Providence Health Care [PHC] ²⁰²²; Vancouver Coastal Health, n.d.). Although the investigation and follow‐up interventions may require the identification of the reporting nurse, the lack of anonymous and confidential reporting may continue to deter nurses from disclosing WPV incidents perpetrated by Type III sources.

In contrast to informal reporting, WPV source was not a significant predictor for nurses' formal reporting of any WPV forms. This finding may be explained in the context of nurses' reasons for not formally reporting WPV according to source. Regardless of the WPV source, the majority of nurses in each category identified ‘nothing will change after reporting incidents’ as the number one reason for not formally reporting. This finding aligns with other studies, which found that barriers to formal reporting included slow or lack of follow‐up from the organisation (Huang et al. 2022; Spencer et al. ²⁰²³). Changes within healthcare organisations may occur over a period of time, and nurses may not report because they perceive a lack of immediate resolution (Huang et al. 2022). WPV reporting systems must prompt leaders to complete follow‐up actions shortly after incidents occur. This recommendation aligns with the Registered Nurses' Association of Ontario (RNAO) (2019) best practice guidelines for preventing WPV against HCWs where healthcare leaders who are actively involved in reinforcing prevention measures promote positive work environments.

Over half of the nurses perceived their primary employer's WPV prevention efforts as slightly to moderately adequate, but higher perceptions of these efforts were related to increased odds of informal and formal reporting across WPV forms. Nurses' safety relies on adequate WPV prevention measures, including policies, reporting systems and education (Spencer et al. 2023). For example, a code white as part of emergency security measures is activated by anyone who witnesses or experiences violent and aggressive behaviour (Health Emergency Management BC [HEMBC] n.d.). Previous research in BC reported deficiencies in medical‐surgical and mental health nurses' access to enough properly trained code white responders (47%–70%), code white drills (50%–66%), employers listening to staff suggestions about WPV prevention (29%–38%) and fixed alarms (24%–39%) or personal alarms (19%–90%) (Havaei, MacPhee, and Lee ²⁰¹⁹). These multicomponent safety measures are recommended to support HCWs, which have been found to reduce staff injuries and increase feelings of safety (RNAO ²⁰¹⁹). Additionally, with quick, confidential and accessible reporting systems and education on reporting, nurses may more frequently report their experiences of WPV regardless of its source or form (RNAO ²⁰¹⁹; Scallan et al. ²⁰²⁴). Having accessible reporting systems along with other WPV prevention measures may facilitate increased reporting rates and further inform the effectiveness of prevention interventions.

Nurses' reasons for not formally reporting across WPV forms and sources demonstrated some similarities and nuanced differences. Frequently selected reasons were the belief that nothing would change after reporting, lack of leadership support, lack of knowledge about the formal process for reporting and other reasons nurses listed in the survey responses. There was variation in the top three reasons for not formally reporting WPV sources and forms, such as fear of retaliation being an important reason for Type III WPV and emotional abuse. These factors have been consistently identified in previous reviews of international studies as barriers to reporting (Huang et al. 2022; Spencer et al. ²⁰²³). These findings suggest that nurses need leadership support to facilitate positive changes in WPV prevention and reduce its prevalence. Although nurses may lack knowledge about reporting procedures, these systems and policies must also be accessible and sensitive to the time it takes to complete a report (Spencer et al. 2023).

Furthermore, themes from the open‐text reasons for not formally reporting were lack of time and rationalising behaviours from perpetrators due to their diagnosis, chronological age or influence of medications. Reduced staffing levels and patient care are factors that affect nurses' ability to report WPV (Huang et al. 2022), but can be facilitated if healthcare leaders provide dedicated reporting time by finding coverage for their workload (Spencer et al. 2023). Nurses may also rationalise WPV as unintentional due to various factors such as patients' diagnosis and age (children vs. older adults) or effects of medications (e.g., anaesthesia), which reduces control over their behaviours (Phillips 2016). Alternatively, Gillespie and Tamsukhin (2023) discuss how universal violence precautions should be implemented to assume that all individuals who interact with the healthcare system may be at risk for committing WPV due to diagnosis, emotions in crisis situations or environmental factors. Universal violence precautions include healthcare leadership's commitment to safety and follow‐up, worksite analysis, hazard prevention and control, safety and health training and recordkeeping and programme evaluation (Gillespie and Tamsukhin 2023). This approach can help protect nurses regardless of who they interact with during care.

5.1. Limitations

This secondary analysis has some limitations. First, the low response rate to the original study (12% of 47,000 BCNU members) may impact external validity when generalising findings to other samples and contexts (Havaei, MacPhee, and Ma ²⁰²⁰). Despite this limitation, the analysis was still conducted using a relatively large sample of over 4100 nurses. Furthermore, the data from this study were collected before the COVID‐19 pandemic and may not reflect nurses' experiences with exposure to WPV and reporting behaviours in a postpandemic era. Second, survey questions asked participants to refer back to events of the last year, which may increase recall bias (Havaei, MacPhee, and Ma ²⁰²⁰). Third, the reasons for not formally reporting may be influenced by both WPV form and source, but these influences were not considered in this study. Finally, no cause‐and‐effect relationships regarding the factors impacting WPV reporting can be concluded due to the cross‐sectional nature of the data (Havaei, MacPhee, and Ma ²⁰²⁰).

5.2. Relevance to Clinical Practice

Nurses may feel less comfortable reporting colleagues over patients and their visitors, work in environments where WPV is trivialised, be under time pressures to complete patient care or misunderstand the nature of WPV incidents that can and should be reported. Given the negative impacts of WPV on nurses, patients and organisations, it is essential to redevelop reporting systems with options for confidentiality or anonymity in addition to making them time efficient. Educating nurses on definitions for various WPV forms and sources that can be reported and specifying follow‐up actions by healthcare leadership for every level of WPV severity can reduce underreporting. Ultimately, addressing WPV reporting requires multifaceted interventions instead of standalone strategies involving the input of subject matter experts (e.g., nurses and other HCWs, leadership, security personnel, occupational health and safety, violence prevention advisors, patient and family partners) on addressing deficits in current reporting procedures and educational initiatives on violence prevention and management.

6. Conclusion

WPV is a widespread issue in BC, Canada healthcare settings, and understanding its origins through reporting informs WPV prevention strategies. The findings from this study emphasise the importance of creating a culture of safety among nurses to report WPV and ensure that every source and form of WPV is addressed by appropriate policies and follow‐up interventions. WPV source and prevention efforts are associated with reporting, and nurses have multiple reasons for not reporting WPV. Therefore, actions to increase formal reporting will need to include multifaceted measures, such as fostering psychologically safe workplaces so nurses feel comfortable reporting WPV, understanding nurses' needs, receiving feedback on creating confidential and simplified reporting systems, providing education and training on reporting and utilising universal violence precautions to reduce risk of WPV. Facilitating WPV reporting among nurses, regardless of its form and source, will enable more effective efforts focused on preventing WPV.

Conflicts of Interest

The authors declare no conflicts of interest.

Data Availability Statement

Research data are not shared.