Violence in hospitals is an endemic problem affecting nurses in all settings, and those working in emergency departments are particularly vulnerable to attacks. In a 2009 survey by the Emergency Nurses Association, one-quarter of 3,465 ED nurses surveyed reported more than 20 physical assaults and 200 verbal assaults during a three-year period. A 2012 follow-up survey found that 55 percent of the 6,500 nurses surveyed had been the target of physical or verbal abuse in the previous week alone.

However, it’s not just nurses who are potentially in danger—EDs are among the highest risk areas for other staff as well as for patients and visitors. In an era of skyrocketing healthcare costs, overcrowded jails, and a historic shortage of available mental health beds, EDs are often the only viable option for ill people in desperate situations who may at times be aggressive and/or under the influence of alcohol or drugs. Add to that long wait times, stressful situations, and unrestricted 24-hour access, and EDs become a hotbed of unrest that can boil over into violence.

Although a host of public-policy and operational factors contribute, there is a lot design can do to prevent ED violence and make responses more effective when events do occur.

Conducting an assessment
The first step toward mitigating ED violence is to conduct an assessment. The ASIS International Workplace Violence Prevention and Intervention Standard provides guidance to ensure that best practices are considered and integrated into each facility.

The risk assessment is an investigative and analytical process used to determine the nature of threats and levels of risk, and steps to be taken to mitigate risks. This should happen early during the predesign stage, so that space planning, work flows, and special adjacencies or other functional parameters can be understood and considered in the final schematic design.

Translating the assessment into design solutions is a collaborative process that should involve those in charge of
operational decision-making, as well as security, law enforcement, and clinical staff. Designs should also be developed alongside prevention policies.

The following tips will look at key areas of the ED, with the understanding that every project is different, and assuming an assessment has first been done.

If nothing else, EDs should be designed in such a way that security staff can cordon off the entrance and access to the rest of the facility, create safe spaces for staff, and provide opportunities for rapid egress from secured spaces, with camera surveillance and intrusion alarms as standard features for all healthcare facilities.

Entry zone
The first step in keeping everyone safe upon entry to the ED is to clearly delineate waiting and treatment areas and control access between them. This allows staff to remove themselves from a threat occurring in a waiting area while security addresses the situation.

Duress alarms should be placed at the central workstation and in strategic locations throughout the department for easy access. These silent alarms alert on-site security personnel of disruptions and can be set up to contact police, as well. Lockdown activation buttons should also be placed at registration, triage, central desks, and throughout treatment areas, allowing staff to lock entrances to the unit discreetly.

Designers should also pay careful attention to how sight lines are arranged in waiting rooms, giving visual access to the entrance from registration, triage, and security. Electronic systems for monitoring walk-ups and patient drop-offs and security alert systems in the lobby help prepare staff for the unexpected.

Security personnel posted at the ED entrance can serve as a calming presence, leading to early detection of threats and a greater overall sense of safety. Depending on need, the design could range from a desk with security glass to an office filled with security monitors.

Waiting areas should be shielded from outside view to reduce threats like gang retaliation, with seating arranged to allow free movement of people in the case of an evacuation and to avoid potential entrapment or blocked egress.

Designers can influence safety in how they lay out, separate, and sequence patient throughput. Triage rooms should be arranged in an onstage/offstage layout with a “front door” to the public waiting room and a controlled-access “back door” for the staff. This allows staff to remove themselves easily from a hostile situation.

One major source of stress for patients is known as “negative progression,” the feeling of neglect and discrimination that occurs when a patient is sent back to the lobby after registration and triage, only to wait a second time. This emotional trigger, which may result in violence against staff, can be avoided by designing waiting areas post-triage with distinct areas for fast-track, pediatric, and low- and high-acuity. These second-stage waiting areas avoid the need for patients to return to a previous location, reducing stress and the potential for angry outbursts, and can be located away from the main waiting area in a small alcove near triage but just outside of the main ED treatment areas.

Care zones and room clusters
Isolation of staff within care delivery spaces leaves them physically vulnerable. To keep nurses safe, these areas should enable visibility within and between different zones.

Although larger EDs often warrant decentralized clinical workstations, pod configurations may result in many doorways, corridors, entrances, and exits that increase transportation time and create obstructions to travel during violent events. To mitigate this, nurses’ stations and patient rooms should be placed to enable line-of-sight monitoring. Out-of-sight back rooms and dead-end corridors should also be avoided, while hallways with curved mirrors can be used to provide visibility around corners.

Safe rooms that can be locked from the inside should be considered as a place of retreat for patients, staff, and visitors in the case of violent events. These should be equipped with a duress button, telephone, reinforced door, peephole, and external lock-and-key access.

Safety and aesthetics
Because stress affects both staff safety and patient outcomes, every design solution should be considered within the context of evidence-based design principles and calibrated to reduce stress while improving the patient experience.
Designers should employ any means at their disposal to mitigate the stress of long waits, such as providing access to natural light, respite areas, TVs, and children’s play areas. Lighting, furniture, and finishes should provide a feeling of security, with color schemes in calming hues such as blues and greens.

Physical security barriers, which have the potential to generate negative feelings about a patient’s access to staff, should be implemented discreetly while giving the appearance of openness. Non-full-height walls, for example, can be used to separate the ED check-in station and triage area, creating the impression that it is part of the waiting room, while also controlling access.

By properly balancing safety and aesthetic considerations, designers can create more secure spaces for staff while also helping patients feel safer, calmer, and more cared for.

Steven Henrich, BA, AIA, is senior architect at Leo A Daly Los Angeles. He can be reached at Nicole Cirrincione, RN, BSN, MIA, is job captain at Leo A Daly Los Angeles. She can be reached at