Wold Perham Health Ward Clerk

Protecting the pillars of our communities: How to keep frontline workers safe from threats

As staff recruitment and retention remain major challenges in the healthcare industry, how do you ensure staff members feel safe in their work environments? This question has been a driving force behind design conversations in recent years, especially after the pandemic and its lingering effects.

The Bureau of Labor Statics reports that the rate of injuries from violent attacks against medical professionals grew by 63 percent from 2011 to 2018, and hospital safety directors say aggression against staff escalated as the COVID-19 pandemic intensified in 2020. In a 2022 survey by National Nurses United, the nation's largest union of registered nurses, 48 percent of the more than 2,000 responding nurses reported an increase in workplace violence — more than double the percentage from a year earlier.

Safety considerations were previously limited in large part to behavioral health units, but these considerations are now a pressing need in all areas of hospitals and clinics. In an effort to prepare for and shield healthcare staff against agitated or aggravated patients and visitors, the following design elements should be essential components of healthcare campus designs.

Considerations to protect staff from agitated patients

According to the World Health Organization, the COVID-19 pandemic triggered a 25 percent increase in the prevalence of anxiety and depression worldwide. There are many proactive safety design features that can be implemented to address patients who become increasingly anxious and cause hospital staff to feel uncomfortable or unsafe.

Exam room design should always mindfully establish the position of the patient and staff to the doorway. There should be a clear exit path for staff, and patients should never be able to block the staff’s path to the door. Staff members should also have access to charts or computers without turning their backs to their patients. This helps reduce surprises and allows staff members to remain aware of their surroundings. In some cases, a second exit point from the exam room may be considered for additional safety.

When designing emergency departments, any area where staff has first contact with patients needs enhanced safety considerations until the patient’s safety risk can be assessed. The registration desk should be in a location where other emergency room (ER) staff can see it to provide backup if needed and should have a second exit path to allow for quick escape. The same applies to the nurses’ station, which should be in an area with visibility to patients and visitors. The design should avoid placing any staff workspaces in isolated areas, and the campus security desk should be strategically located, particularly for evening and nighttime hours. Security cameras should be placed in deliberate locations, along with an accessible duress button to use if circumstances escalate and a patient becomes aggravated. Triage rooms are first-contact areas where adrenaline can be elevated and should also have a second exit way, if possible.

The patient services and consultation rooms should be placed in open, visible areas. These rooms need to allow for some privacy for confidential conversations but should also be transparent with interior windows or glass panels to areas where other staff is present. To keep safety top of mind, other staff nearby must have the ability to observe staff-patient interactions and provide backup if needed. Similar to other areas, computers should be viewable by staff without having their backs to patients, and there should be a clear exit path along with a duress button in case of emergency.

Tammy Nevala, emergency department director at Perham Health, a critical access hospital located in central Minnesota, has seen a large increase in patients with mental health and chronic behavioral health issues - such as drug and alcohol addiction - over the past three years. She shared that these patients challenge the safety of the staff and need to be monitored closely. If they have violent tendencies, it may require two or more staff members to de-escalate the situation, keeping everyone safe. Emergency departments need to be designed with more flexible exam rooms that can easily convert to safe or step-down rooms by utilizing roll-down shutters to conceal equipment or systems that allow equipment to be demounted and quickly removed from the room.

Considerations to protect staff from aggravated visitors

According to the Occupational Safety and Health Administration (OSHA), possible sources of violence in hospitals, nursing homes, and other healthcare settings include verbal threats or physical attacks by patients, distraught family members who may be abusive or even become active aggressors, gang violence, domestic disputes that spill over into the workplace, and coworker bullying.

There are many design considerations to protect the healthcare clinical area from the lobby so the area stays secure if there is an active shooter or aggressor in the event of an escalated attack. The front entrance sequence, including the registration area and primary entry points, needs to be protected against unwanted intruders. The front reception desk should be strategically placed so it is not easy to access if a patient is upset. Additionally, visitors and patients shouldn’t have the ability to walk behind the reception desk or in any part of the facility that gives them a direct link to the back of the house or the clinical area. It’s imperative to have the ability to lock down the back of house and provide staff workers in the lobby a safe way to get out if the rest of the building is locked down.

Additional technological enhancements are being made to emergency department entrances and registration areas to provide an added level of security, including metal detectors and cameras in lobbies and behind the reception desk to allow for better awareness of surroundings. Lockdown buttons are now a necessity to secure the front entrance if an aggressor is known to be coming or if there are additional aggravated visitors. Code green buttons provide additional support by alerting security of issues. Security can quickly go to the cameras to see where help is needed and get people in or out.

Keeping healthcare staff safe as they serve the most vulnerable in our communities is of utmost importance. Preparing for situations with agitated or aggravated patients and visitors is essential to creating proactive buffers against active and potential threats. Design considerations such as multiple exit paths, duress buttons, and lockdown capabilities are just a few of the many ways Wold strategically approaches healthcare campus safety planning. For additional insights on Wold’s healthcare design expertise, please visit our insights page.

Sara Malin, AIA, is a healthcare architect and principal at Wold Architects & Engineers and can be reached at smalin@woldae.com. Andrew Jordan, AIA, ASHE, is a healthcare planner and principal at Wold Architects & Engineers and can be reached at ajordan@woldae.com.

This piece was originally published in Healthcare Design Magazine on January 22, 2024 and can be viewed here, and was republished in Campus Safety on February 14, 2024 and can be viewed here.

More Insights