Prevalence, Patterns, and Risk Factors of Workplace Violence Against Emergency Department Nurses in Iraqi Government Hospitals: A Multicenter Cross-Sectional Study

Abstract

Background: Emergency department (ED) nurses face among the highest rates of workplace violence in healthcare. In Iraqi public hospitals, the combination of overcrowded waiting areas, intermittent security presence, and limited de-escalation training plausibly increases this risk, but multicenter prevalence and risk-factor data are limited. Aim: To estimate the 12-month prevalence and patterns of workplace violence against ED nurses in five Iraqi government teaching hospitals, characterize reporting behavior and short-term consequences, and identify modifiable risk factors. Methods: A multicenter cross-sectional survey was conducted between October 2025 and February 2026 across the EDs of five government teaching hospitals in central and northern Iraq, in line with the STROBE statement [1]. The protocol was prospectively registered (HHI-RIR-2025-22, registered 18 September 2025). The Workplace Violence in Health Care Instrument (WVHI) [2] was administered alongside a 28-item demographic, occupational, and consequence questionnaire to 318 eligible ED nurses; 287 returned complete responses (response rate 90.3%). Descriptive statistics, chi-square tests, and multivariable binary logistic regression with cluster-robust standard errors at the hospital level were used to identify independent predictors of any-violence exposure. Results: The 12-month prevalence of any workplace violence was 67.6% (95% CI 62.0–72.8). Verbal abuse affected 64.5% of nurses, physical assault 17.4%, and sexual harassment 8.0%; 14.3% had experienced both verbal and physical violence. The most common perpetrators were patients' relatives (53.1% of incidents), and the most common locations were the triage area and waiting room. Only 31.4% of incidents were formally reported, with fear of retaliation (47.4%) and a perception of no actionable response (42.3%) being the leading deterrents. Short-term consequences included sleep disturbance (52.1%), reduced job satisfaction (49.5%), at least one short-term sick day (28.6%), and intent to leave the ED (33.4%). In the adjusted model, lack of security presence on the unit (aOR 2.74, 95% CI 1.62–4.62), no prior de-escalation training (aOR 2.31, 1.43–3.74), <5 years of ED experience (aOR 2.08, 1.27–3.41), and ≥10 night shifts per month (aOR 2.36, 1.45–3.84) were the strongest independent predictors. Conclusion: Two in three Iraqi ED nurses experience workplace violence in any given year, mostly verbal and predominantly under-reported. Hospital management should prioritize visible security in triage and waiting areas, mandatory de-escalation training, simplified non-punitive reporting pathways, and structured post-incident psychological support.