Overtime and emergency department setting tracked with frequent violence against nurses
Workplace violence reached a strikingly high level among emergency department nurses in a multisite health system in the southeastern US, where nearly nine in 10 respondents reported some form of violence in the prior month. The burden was not confined to one source or one type of incident. Patients and visitors accounted for almost all episodes, while coworkers also contributed a meaningful share, making the problem both a bedside safety issue and an organizational one.
The study linked nurse survey responses with administrative and electronic medical record data from 11 emergency departments in 2023, allowing investigators to move beyond simple frequency counts and examine work-system conditions at multiple levels. In adjusted models, overtime stood out as the clearest occupational factor associated with violence. Night shift and freestanding emergency department status, by contrast, were associated with lower odds of reported workplace violence.
Nearly universal exposure to violence in a high-pressure setting
Among 337 emergency department nurses, 296 reported workplace violence in the prior month, a prevalence of 87.8%. The sample was relatively young, with a mean age of 34.9 years, and most participants were female and white. Mean nursing experience was 9.0 years. Those baseline characteristics matter because they frame the reality of a workforce already operating in a high-turnover, high-acuity environment where repeated exposure can quickly become normalized.
The incident mix was heavily weighted toward patient- and visitor-driven events. Of the nurses who reported violence, 292 of 296, or 98.6%, identified patients or visitors as involved. Coworker-related violence was also present, affecting 60 of 296 nurses, or 20.3%. The findings point to a familiar but often underappreciated clinical truth: emergency department violence is not a single phenomenon. It arises from crowding, distress, intoxication, psychiatric crisis, long waits, and interpersonal strain inside teams under pressure.
One sentence captures the gravity of the data: violence was the norm, not the exception.
Overtime emerged as the strongest work-hour signal
In the adjusted mixed-effects analysis of 299 nurses, overtime was associated with substantially higher odds of workplace violence, with an odds ratio of 3.21 and a 95% confidence interval of 1.30 to 7.93. The magnitude of that association is clinically important because overtime is not merely a scheduling artifact. Extra hours can erode situational awareness, slow de-escalation, and leave nurses less able to absorb the emotional and physical demands that accompany aggressive encounters.
Fatigue also changes the interactional terrain. A nurse working beyond a standard shift may have less reserve for conflict management, shorter attention spans for escalating cues, and less opportunity to reset after a difficult patient interaction. In an emergency department, where agitation can intensify in minutes, those differences can shape whether a tense exchange stays verbal or becomes physical.
The study design does not prove causation, yet the association between overtime and violence is hard to dismiss. Work-hour policy and staffing design can influence both the likelihood of exposure and the ability to respond safely once an encounter turns hostile.
Night shift and freestanding emergency departments showed lower odds
Night shift was associated with lower odds of workplace violence, with an odds ratio of 0.28 and a 95% confidence interval of 0.10 to 0.78. Employment in a freestanding emergency department was also linked to lower odds, with an odds ratio of 0.25 and a 95% confidence interval of 0.09 to 0.76. Those findings likely reflect differences in patient flow, crowd density, visitor volume, staffing patterns, and the overall intensity of the clinical environment, although the analysis was not designed to isolate a single mechanism.
Freestanding emergency departments often operate with a different operational profile than in-hospital sites. Fewer admitted inpatients, altered visitor traffic, and different case mix may reduce some of the interpersonal friction that can accompany a busier hospital-based department. Night shift is harder to interpret. Lower odds could reflect reduced visitor presence, a different mix of patients, or under-recognition of certain events during overnight work. The data support association, not certainty about why the association exists.
Prevention needs to be built into work design, not left to individual resilience
The clinical implications extend beyond security policy and into staffing strategy. If overtime amplifies risk, then violence prevention cannot rely solely on training nurses to de-escalate conflict after it begins. Staffing practices, fatigue management, surge planning, and environmental design all become part of the prevention strategy. Emergency departments are built for immediacy, but violence prevention depends on anticipating strain before it peaks.
Because the analysis combined survey information with administrative and electronic health record data, it captures a more complete picture of the work system than a questionnaire alone. Even so, the findings remain tied to one health system in one region, and the cross-sectional design limits any statement about directionality. Nurses who experience more violence may also be more likely to work overtime, or the same conditions that drive overtime may increase violence exposure. Both pathways are plausible.
The most actionable message is plain: emergency department nurses are encountering violence at a rate that should be treated as a core patient-safety and workforce-safety problem, not an unavoidable feature of the job. The strongest association in this study centered on overtime, and the setting itself mattered as well. Any serious prevention effort will have to address how emergency departments are staffed, how long nurses stay on shift, and how different site types shape risk in daily practice.