Violence in healthcare settings, especially within hospital emergency departments (EDs), has reached alarming levels worldwide, contributing to physical harm, psychological distress, increased staff turnover, and ballooning organisational costs. While aggression in EDs is often framed as a behavioural or cultural issue, growing evidence suggests that the built environment may play a decisive role in either exacerbating or mitigating risks.

A scoping review by (Jacob et al., 2025), published in the Health Environments Research & Design Journal, investigates the effectiveness of physical design interventions in reducing patient and bystander violence in EDs. The authors argue that environmental design has been underexplored compared to behavioural and training-based solutions, which are lower-ranked on the “Hierarchy of Risk Controls.”

As the review points out, interventions commonly rely on staff training and incident management—administrative controls which leave frontline workers to navigate risky environments. In contrast, engineering and elimination-based controls, such as strategic building layout and spatial orientation, may offer more proactive, structural solutions. Yet, despite widespread staff perceptions linking design to safety, empirical evidence supporting the efficacy of these interventions remains scant.

Methodology

A scoping review methodology, guided by the Joanna Briggs Institute framework and reported via PRISMA-ScR guidelines, was selected to map the existing literature rather than critically appraise study quality. The team sought to clarify key concepts, catalog physical design strategies used to address workplace violence (WPV), and identify gaps in research.

Search Strategy

• Databases searched: CINAHL, Medline, Scopus, PsycINFO
• Keywords included: aggression, violence, emergency department, physical design, built environment
• Boolean operators and subject headings were used for precision
• Only intervention studies were considered; mental health, paediatric EDs, and non-research papers were excluded

Over 21,000 articles were screened using ASreview, an AI tool that filtered papers by relevance. After manual review and de-duplication via Covidence, ten studies met the inclusion criteria. These came from a variety of contexts, including Australia, Germany, Egypt, Italy, Taiwan, Iran, and the United States.

Data Extraction and Analysis

Extracted variables included year, country, study aim, methodology, participants, and physical design elements. Content analysis was performed using a three-stage process: extraction, thematic categorisation, and synthesis. Themes were developed inductively and refined through multiple readings and team discussion.

Results

The evidence base for physical design interventions in EDs is limited. Only ten studies were identified, with most relying on staff perceptions rather than quantifiable outcomes. Of the ten studies, only one directly measured reductions in aggression following design modifications, and even that lacked statistical significance due to limited scope and sample size.

Four core themes emerged from the synthesis:

1. Preventing Harm from Weapons

Design features that prevent weapon use were frequently cited:

• Weapon screening stations at entry points
• Secured furniture and equipment to prevent use as makeshift weapons
• Bulletproof glass or enclosed reception desks
• Metal detectors, though staff opinions on their effectiveness were mixed. Some felt they promoted false security unless contextually appropriate

These interventions were seen as important, particularly when combined with environmental controls that minimise opportunities for weapon concealment or access.

2. Controlling Physical Access

Natural access control was considered essential to reduce unauthorised or aggressive entry:

• Locked doors using electronic, biometric, or coded systems
• Separate entrances for staff, patients, and visitors
• Clearly defined property lines via floor markings, reception barriers, and gatekeeping zones
• Isolated escape routes and de-escalation rooms designed with secure exits
• One-way patient flow strategies to avoid congestion and frustration

Design features that constrained movement without compromising care were highlighted as more effective than training alone in managing violence.

3. Observation and Awareness

Visibility and staff awareness were linked to early identification of escalating behaviour:

• Open layouts enabling line-of-sight between staff and patients
• Glass panelling, mirrors, and decentralised nurse stations for monitoring blind spots
• CCTV surveillance—perceived as both a deterrent and investigatory tool, particularly when signposted
• Lighting design—debated across studies, with some advocating increased brightness for safety and others suggesting dimmed lighting for patient comfort
• Security staff proximity—stations positioned near entries and nurse desks were thought to boost deterrence and response capability

Duress alarms and panic buttons were frequently mentioned as critical emergency safeguards, with some linked directly to police stations.

4. Patient Comfort

Environmental factors influencing stress and agitation were identified as key violence triggers:

• Quiet rooms and de-escalation zones for high-risk patients
• Calming interior colours, low-stimulus environments, and single-room designs
• Accessible toilets, food, and drink stations to reduce frustration during long waits
• Distraction features such as chalkboard walls, puzzles, and reading materials in waiting areas
• Flow design—for instance, patients not re-entering the same waiting room to reduce agitation

Overcrowding emerged as a consistent risk factor across multiple studies, often compounding wait times, decreasing privacy, and elevating emotional volatility.

Discussion

Despite high staff consensus around the importance of design in managing WPV, the evidence remains largely perceptual and anecdotal. Physical environments are not neutral spaces; they shape workflow, interactions, and emotional responses. As such, design interventions may offer low-burden, systemic alternatives to person-dependent strategies.

Several design principles align with Crime Prevention Through Environmental Design (CPTED) frameworks, suggesting potential crossover between healthcare safety and urban planning. However, the authors note that many hospital renovations or new builds lack an evidence-informed rationale, relying instead on legacy assumptions or budget constraints.

Staff reported a “need to act” in the face of increasing WPV, often prompting ad hoc design solutions in the absence of robust research. This urgency underscores the cost, both human and organisational, of violence in EDs, ranging from physical harm and psychological trauma to absenteeism, turnover, and insurance liabilities.

Limitations

Several caveats apply:

• Study scope was narrow, focusing solely on general hospital EDs, excluding paediatric and mental health settings
• All studies relied on staff perceptions, introducing possible recall bias, selection bias, and limited generalisability
• Only one study measured WPV rates quantitatively, and even that was constrained by sample and time frame
• Grey literature was excluded, potentially overlooking valuable organisational reports or unpublished interventions

As a scoping review, the study did not assess the methodological quality of included papers, nor did it attempt to aggregate effect sizes.

Practical Takeaways

While conclusive evidence is lacking, the review offers several practice-informed recommendations:

Design for Weapon Risk Reduction

• Secure loose items
• Include discrete weapon screening zones
• Avoid false reassurance when implementing metal detectors

Control Access Thoughtfully

• Incorporate differentiated access zones for staff and patients
• Use smart locks or keypads
• Map egress routes for staff safety

Amplify Visibility and Early Warning

• Use open layouts and transparent walls
• Install properly placed CCTV with clear signage
• Position security personnel strategically
• Ensure panic alarms are accessible and responsive

Elevate Patient Comfort

• Include quiet rooms and calming design palettes
• Provide access to basic needs (toilets, food, hydration)
• Reduce overcrowding and implement patient flow design
• Use visual distractions to alleviate wait-time stress

Call for Evidence-Based Design

• Embed empirical metrics like WPV incident tracking in future design evaluations
• Collaborate with human factors experts and simulation modellers
• Assess design impacts on staff compensation, morale, and safety outcomes

This review suggests that physical design is a critical—but underutilised—lever for mitigating workplace violence in emergency departments. Moving forward, there’s a compelling case for interdisciplinary collaborations and rigorous outcome evaluations to transform intuitive solutions into evidence-based policy.

Citation

Jacob, D., Jacob, B., Jacob, E., & Jacob, A. (2025). Effectiveness of Environmental Design Interventions to Reduce Aggression and Violence in Emergency Departments: A Scoping Review. HERD: Health Environments Research & Design Journal. https://doi.org/10.1177/19375867251351027