Investigating the Impact of Healthcare Environmental Design on Staff Security: A Systematic Review

HERD. 2021 Jan;14(1):251-272. doi: 10.1177/1937586720921407. Epub 2020 Jul 20.


Objective: To systematically review the literature regarding the role of the physical environment in preventing or mitigating aggressive behavior toward healthcare professionals in acute care, outpatient, and psychiatric/behavioral health facilities.

Background: Globally, the incidence of violence against healthcare professionals is alarming. Poor environmental design has been identified as a risk factor of violence toward employees. The design of the physical setting in which healthcare is provided may moderate the incidence and severity of violence against healthcare workers.

Methods: We conducted electronic database searches of PubMed and CINAHL through November 2018.

Result: Findings were organized according to four categories identified in the literature regarding crime prevention through environmental design (CPTED) including natural surveillance, access control, territoriality, and other CPTED elements. Fifteen studies (published between 1991 and 2017) met the inclusion criteria. Of the 15 studies, 4 incorporated environmental interventions. In the 11 remaining studies, physical environment attributes (i.e., layout, location, ambient conditions, equipment) were among the factors affecting violent incidents and staff security. Most study settings were hospital-based (11, with 10 of those specifically focused on emergency departments), followed by behavioral health facilities (4 studies). Design-focused recommendations, such as providing a second door in a triage room and a sub-waiting area inside the treatment zone, were summarized according to CPTED categories.

Conclusion: This review suggests that the physical environment in healthcare facilities may affect the incidence of violence by patients or visitors against staff. Further research is needed to identify environmental design strategies that may protect the safety of healthcare professionals.

Keywords: emergency department design; environmental design; security; staff well-being; violence.

Publication types

  • Systematic Review

MeSH terms

  • Delivery of Health Care
  • Emergency Service, Hospital*
  • Health Personnel*
  • Hospitals
  • Humans
  • Violence / prevention & control