How visibility may reduce security issues in community hospitals’ emergency departments

Why does this study matter?

• The safety and security of ED staff is perilous due to changing societal dynamics and staff can experience both verbal and physical violence.
• When staff can maintain an awareness of unit activities, security and safety issues might be prevented, controlled, or at least minimized.
• Visibility as a design factor, an operational factor, and a layout characteristic can potentially be leveraged to improve both ED safety and care efficiency.

With these elements in mind, this study investigated the nature of the relationship between staff perceptions of safety and security and the extent to which different ED layouts influenced staff visibility of unit activities.

How was the study done?
Data collection consisted of both staff interviews and on-site observations in five different ED facilities. After testing the interview questions and observation procedures at one site, researchers branched out to include four other facilities from the same health system. The 17 staff interviewed had a minimum of 3 years’ experience in the ED setting and had been employed at their current facility for at least one year. Interviews from all five sites were included in the final analysis. The limited number of observations from the pilot ED were not included in the final observation analysis, but the included facilities represented a variety of layouts including a linear layout with three staff workstations; two EDs with different pod arrangements; and an ED with one main area, a nurse station at each end and separate trauma and fast-track areas.     

So what do we learn from the study?
Interview and observational data were categorized into two main themes with seven overlapping subthemes. The first theme, visibility, highlighted the benefits of visibility in mitigating risk and responding to emergencies. Subtheme topics included the challenge of differing visibility levels across locations; different types of visibility; different visibility priorities, and visibility related to security and security staff. The second theme was specific to security and included subthemes regarding –again- the presence of security officer(s), risks associated with psychiatric patients, psychiatric patient room location, and issues with staff being able to locate one another.  

Can we say the results are definitive?
Noted limitations include the lag between data collection in 2016 and article publication in 2023, the need to include a wider variety of ED settings and layouts, the potential to include perceptions of different staff groups, and the need to explore post-pandemic care routines of psychiatric patients due to changing dynamics. Other limitations include the lack of differentiation between perceptions of physicians, nurses, and other ED personnel since 17 medical staff members in five different facilities were interviewed but only two RNs and one physician were noted.

What’s the takeaway?
Design recommendations related to facility design that were identified from this study include:

• Maximizing visual connectivity to all locations within EDs can prevent, control or minimize security issues.
• ED environments can influence perceptions of safe and efficient care such that nurses prefer visual connectivity with colleagues to facilitate care delivery, and staff generally prefer layouts that facilitate awareness of unit activities.
• Departments with centralized layouts demonstrated better visibility, whereas distributed layouts demonstrated lower levels of visibility and staff were less likely to help one another during high-risk events.
• To maximize staff perceptions of safety, priority should be to ensure security personnel can see and be seen and that staff can visualize the ED entrance, waiting room, triage area, and areas in which psychiatric patients receive care.
• Incorporating these strategies can help design professionals and healthcare leaders improve ED efficiency, reduce security risks, and potentially contribute to greater job satisfaction resulting in healthier work environments.

Summary of:
Gharaveis, A., Hamilton, D. K., Pati, D., Shepley, M. M., Rodiek, S., McCall, D., (2023) How Visibility May Reduce Security Issues in Community Hospitals’ Emergency Departments, HERD: Health Environments Research & Design Journal, Pages in press https://doi.org/10.1177/19375867231188985

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