Maintaining a safe environment in emergency department waiting rooms
Intended for healthcare professionals

Maintaining a safe environment in emergency department waiting rooms

Suzanne Robinson Lecturer adult nursing, clinical skills and simulation lead, School of Nursing and Midwifery, Faculty of Health, University of Plymouth, Plymouth, England

Why you should read this article:
  • To recognise factors that can result in communication breakdown between staff and patients, leading to potential confrontation in the emergency department (ED)

  • To enhance your ability to assess and manage patients safely in ED waiting rooms

  • To contribute towards revalidation as part of your 35 hours of CPD (UK readers)

  • To contribute towards your professional development and local registration renewal requirements (non-UK readers)

Increasing demand, overcrowding and insufficient resources have led to situations where patient care is delivered in emergency department (ED) waiting rooms. For nurses undertaking triage in the ED waiting room, overcrowding is challenging, particularly in terms of assessing patients in a timely fashion, monitoring patients for clinical deterioration and ordering investigations. Additionally, long waiting times and a lack of information can lead to communication breakdowns with patients and, at times, patient confrontations with ED staff.

This article explores the effects of the busy environment in ED waiting rooms on patients and staff such as triage nurses and waiting room nurses.

Emergency Nurse. doi: 10.7748/en.2023.e2189

Peer review

This article has been subject to external double-blind peer review and checked for plagiarism using automated software


Conflict of interest

None declared

Robinson S (2023) Maintaining a safe environment in emergency department waiting rooms. Emergency Nurse. doi: 10.7748/en.2023.e2189

Published online: 19 December 2023

Aims and intended learning outcomes

The aim of this article is to support triage nurses and other emergency department (ED) staff to assess and manage patients safely in ED waiting rooms, especially when demand for services is high. After reading this article and completing the time out activities you should be able to:

  • Anticipate factors that are likely to contribute to confrontation in ED waiting rooms.

  • Identify strategies to alleviate patients’ discomfort and anxiety and make extended waiting times more tolerable.

  • Understand how to communicate with patients and their relatives in the ED waiting room to manage their expectations.

  • Contribute to maintaining the safety and well-being of healthcare professionals, including yourself, in the ED.


Emergency care continues to be a focus of political and healthcare leadership, with the ED perceived as the ‘front door’ to the NHS and images of ambulances queuing outside overwhelmed EDs regularly featuring in health service media reports (Pickover 2023). ED overcrowding is a major issue worldwide, with the UK experiencing an unprecedented increase in demand for emergency care in recent years (Spechbach et al 2019, Stone et al 2020, Innes et al 2021). Recent data released by NHS England (2023) demonstrated that 11% of all patients attending ED waited more than 12 hours from the point of arrival until they were either admitted or discharged.

The literature regarding ED overcrowding is concerned predominantly with causative factors such as peaks in demand for emergency care. A report from the Royal College of Emergency Medicine (RCEM) focused on improving the input, throughput and output in EDs when demand for emergency care overwhelms capacity (RCEM 2023). Suggestions included the involvement of senior doctors of all specialties in the rapid assessment and treatment of patients, together with front-loading patient investigations to reduce delays in decision-making. In a report on ED overcrowding, Javidan et al (2021) acknowledged that the issue is complex and multifactorial, varying not only between hospitals but also at different times in the same hospital. The report suggested strategies to aid patient flow, which focused on timely discharge or transfer of patients from the ED (Javidan et al 2021). However, while such interventions increase patient flow they often place a significant burden on already overstretched nurses who have to manage complaints from patients and their carers (McConnell et al 2016).

Key points

  • Overcrowding, long wait times and environmental factors can have an adverse effect on nurse-patient communication in the emergency department (ED), potentially resulting in conflict

  • Triage nurses must maintain an open dialogue and share information with patients to help manage their expectations

  • Nurses can use various strategies to make patients’ wait in the ED more tolerable

  • To ensure that ED nurses feel valued requires an environment that promotes their health and well-being

Triage and waiting times

While this article does not focus on the process of triage itself, which in simple terms involves the initial assessment of patients to gauge the urgency of their need for treatment, it is important to recognise that the triage nurse is often working in a busy environment, with little or no privacy, and is subject to constant interruptions from colleagues and patients and their carers (Sedgman et al 2022). Furthermore, triage nurses often work alone in an open public space, meaning they are more exposed to risk of assault than other staff (Timmins et al 2023).

The primary aim of triage in the ED is to promote clinical safety by risk-managing undiagnosed patients as they present. While ED staff view triage as vital to the provision of quality care, patients may take a different view (Phiri et al 2020, Mackway-Jones et al 2023). For example, patients identified by triage as having a lower-acuity illness or injury can often become frustrated while enduring longer waiting times while people who are critically ill are managed first. Such patient perceptions often arise from a sense of injustice that they have been ‘under triaged’, resulting in an unreasonably long wait to be treated (Spechbach et al 2019). If triage nurses do not explain the reasons for prolonged waits, these patients may become anxious and frustrated due to a feeling that others have been prioritised (Phiri et al 2020).

One of the main reasons for patients’ feelings of neglect and abandonment in the ED is a lack of information, particularly about waiting times and triage categories, as well as suboptimal communication with healthcare staff in the ED waiting room (Spechbach et al 2019). Waiting times are considered an important determinant of patient satisfaction and represent a quality indicator that is receiving significant attention in an increasingly service-oriented NHS (Spechbach et al 2019). In itself, waiting can be frustrating, not only because it obstructs an individual’s goal attainment, but also because there is a sense of time wasted, which can be an additional source of stress (Efrat-Treister et al 2020). Consequently, managing patients’ expectations about waiting times is critical, especially since perceived waiting times are a more significant determinant of patient experience of care than actual waiting times (Bull et al 2022).

Role of the triage nurse

Triage is designed to be a brief process, but when undertaken multiple times a day, incremental increases in the time spent with each patient can result in significant treatment delays. The triage nurse role has evolved from one concerned primarily with assessment to include provision of immediate first aid and analgesia, recording vital signs and ordering further investigations. These ‘secondary triage’ tasks are essential to the systematic monitoring of patients in the ED waiting room and to maintaining patient safety (Innes et al 2021). However, high volumes of patients and constant interruptions can interfere with the triage workflow, overstretching the triage nurses’ capabilities and resulting in longer queues in ED waiting rooms (Sedgman et al 2022, Mackway-Jones et al 2023). This places patients at risk of undetected deterioration while waiting to be seen, which can increase their stress levels, potentially culminating in aggression and violence (Innes et al 2015).

Effectively, over time emergency nursing care has been extended into the ED waiting room and many EDs have been forced to increase the number of triage nurses or to develop a designated waiting room nurse role to undertake secondary triage tasks, enabling triage nurses to focus on primary triage (Innes et al 2021, Sedgman et al 2022).

Time Out 1

Consider a time when you were working in triage. Was the ED overcrowded? Was there evidence of conflict between staff and patients? Were you at any point concerned for your safety or the safety of others? If the answer to any of these questions is ‘yes’, note the factors that might have contributed to this situation

Environmental factors

In addition to long waiting times, the ED waiting room can be a distressing and uncomfortable environment for patients and staff. For example, harsh lighting, excessive noise and lack of privacy, together with a lack of immediate assistance, can increase patients’ stress levels and potentially trigger feelings of panic, particularly for those experiencing mental health issues (Innes et al 2015, Molloy et al 2020). However, evidence suggests that where patients’ surroundings are comfortable, and adequate staffing and resources are available, their perceptions of the quality of care they received during their wait are improved (Phiri et al 2020).

Spechbach et al (2019) suggested that the design of an ED waiting room can be a significant factor in improving patient satisfaction, particularly through the use of ‘fillers’ such as repeated information about waiting times and distraction in the form of television, music and reading material. Similarly, the provision of mobile phone chargers can be invaluable. Physical comfort in the ED waiting room is also important and can involve providing blankets for patients if it becomes cold through the constant opening of doors, and providing refreshments. These seemingly small measures can make the difference between a patient feeling neglected and abandoned or feeling valued (Bull et al 2022).

Research has been undertaken to investigate innovative ways to engage and educate patients while they wait in the ED. Mohammed and Lockey (2023) proposed a model whereby a digital platform was personalised for each patient based on their presenting condition, which would also contribute to patient education and shared decision-making with staff. Further research is required to establish the viability of such a model; however, as an established entry point to healthcare the ED is a prime setting for health promotion initiatives. For example, one Canadian study surveyed patients’ (n=151) attitudes towards the introduction of an influenza vaccination programme in the ED waiting room, which would take advantage of a ‘captive audience’ to improve the health of the wider population (Ozog et al 2020). The results showed that patients who were classified as low acuity were supportive of an influenza vaccination while waiting in the ED.

Supporting patients to be actively involved in their care is at the core of person-centred care, which focuses on the individual rather than the task and considers social factors such as housing, employment status and caring responsibilities (Bull et al 2022). Implementing person-centred triage in EDs could increase patient satisfaction, improve care delivery and increase job satisfaction (Phiri et al 2020).

Pain management

Pain is the primary reason for most patients attending ED, so timely identification of pain and provision of analgesia are vital skills for ED nurses. However, due to the high workload in EDs, patients often wait for long periods to receive analgesia (Hamalainen et al 2021). Integrating pain management into the assessment process, for example by incorporating nurse-initiated analgesia at triage, has been shown to streamline the process of pain management in the ED, thus increasing patient comfort and resulting in a more positive patient experience (Sampson et al 2020).

Medicines that can be administered in the ED waiting room to patients with pain include opioids and non-opioids and medicines with alternative routes of administration including inhaled and nasal preparations (Hamalainen et al 2021). However, not all EDs have patient group directives in place for nurse-initiated analgesia at triage. Additionally, challenges such as patient behaviour, lack of knowledge about pain management among staff and heavy workloads can delay pain management in EDs (Hamalainen et al 2021).

Therefore, it is important that ED nurses consider non-pharmacological pain management interventions at triage. These include the application of splints and repositioning of limbs, the application of heat and cold packs, and distraction methods, all of which can help to alleviate patients’ pain while they wait to be seen. An intervention as simple as application of a broad arm sling can reduce a patient’s pain and anxiety (Bull et al 2022). However, it is important to explain to the patient that the intention of non-pharmacological interventions is to alleviate pain and reduce anxiety, otherwise they may perceive that their pain has not been properly addressed with medicines, leading to potential complaints (Taylor et al 2021).

Time Out 2

Think back to Time Out 1 and an occasion when you were providing triage in an ED. Did you witness any conflict during your shift? On reflection, were there any predisposing factors to this conflict? Could these have been identified and managed earlier or differently to prevent the incident?


It is crucial that triage nurses maintain an open dialogue and share information with patients to help alleviate any anxiety, confusion or isolation that they may be experiencing (Bull et al 2022). In the author’s clinical experience, suboptimal communication and a lack of information from staff in the ED waiting room can increase the potential for conflict and violent incidents. Box 1 demonstrates some potential sources of conflict between staff and patients in the ED waiting room.

Box 1.

Potential sources of conflict between staff and patients in the emergency department waiting room

  • Suboptimal communication

  • Prolonged waiting times

  • Lack of information about triage processes and waiting times

  • Patients’ physical discomfort

  • Environmental factors – inadequate signage and layout of the waiting room

  • Friction between people in a crowded space

  • Clinical deterioration, including in people with mental health issues

  • Perceptions of long wait times and inefficient care provision

  • Staff fatigue

Communication is a crucial element of the nurse-patient relationship. However, in an environment such as the ED waiting room, effective communication can be challenging. As the number of patient and staff interactions increases, so too does the risk of miscommunication, while the limited private space in many EDs further hinders communication (Stone et al 2020, Molloy et al 2020).

When communicating with patients in the ED, nurses should be aware of their own facial expressions, gestures, eye contact and body language to avoid any perceptions of rudeness or dismissiveness (Spechbach et al 2019, Al-Kalaldeh et al 2020). For example, what a nurse considers to be a confident and assertive manner could be perceived by patients as authoritative and judgemental. Therefore, it is essential that triage nurses consider their tone of voice and, where possible, try not to rush interactions and interventions. Relatives in particular will be sensitive to non-verbal behaviours and may use them to gauge how well the patient is being cared for (McConnell et al 2016, Bull et al 2022).

It is also important to ensure that information shared with patients is accurate, as providing information that generates false expectations can increase patients’ frustration – more so than if no information had been given (Efrat-Treister et al 2020). Similarly, comments such as ‘It won’t be long now’ or ‘You’re next to be seen’ may be well-meaning but can be counterproductive as they can falsely raise patients’ expectations. It is therefore crucial that triage nurses are honest with patients about wait times.

At times, it may be necessary for triage nurses to prioritise an immediate medical intervention and this can lead to the inadvertent neglect of other aspects of a patient’s health, such as their emotional and psychological well-being and social issues (Phiri et al 2020, Anderson et al 2021). This can result in patients feeling dehumanised; therefore, using a person-centred collaborative approach to communication will enable triage nurses to support patients’ confidence in the care provided (Phiri et al 2020, Bull et al 2022).

Time Out 3

Consider the following scenario:

At 9pm, a 68-year-old woman self-presents to the ED after tripping over a paving slab and sustaining a ‘fall onto an outstretched hand’ (FOOSH) injury

She has an obviously deformed right wrist but is stoical about how much pain she is in and has managed to find a seat in the waiting room

There is a one-hour wait for triage and a seven-hour wait to see a doctor

How might you make the patient’s wait more tolerable? What techniques would you use to assess and manage her pain, for example?

Violence and aggression

ED nurses are more likely to experience violence than those working in other areas of healthcare, since they are constantly in close contact with patients in stressful and painful circumstances (Timmins et al 2023). Triage nurses are particularly at risk while engaging with patients and relatives during the initial assessment and when managing complaints about waiting times and care that has not met expectations. People naturally tend to focus on their own needs, therefore frustration about waiting increases any sense of injustice patients and relatives may feel and which, if not resolved early, can lead to anger and even aggression (Efrat-Treister et al 2020, Timmins et al 2023). Violence and aggression are often perceived as an occupational hazard among ED nurses, and the incidence of such attacks has risen despite the introduction of the Assaults on Emergency Workers Act (Offences) 2018, which makes provision for more severe sentencing for those who injure or threaten emergency workers (Timmins 2023).

The exact causes of violence and aggression against nurses in EDs are largely unresolved. There is no single reason why a person may become violent or aggressive in the ED, but the most frequently reported causes are mental health issues, followed by drug and alcohol use (Carver and Beard 2021, Timmins et al 2023). Patients who present under the influence of illicit substances or alcohol often display unpredictable behaviour, leading to them being perceived as disruptive (Molloy et al 2020). This can make communication with these patients difficult, and some ED staff will avoid interaction with patients they consider to be challenging or potentially dangerous (Al-Kalaldeh et al 2020). This avoidance can be due to ED staffs’ knowledge that managing such patients is time-consuming and potentially labour intensive and diverts care from other patients (Manning 2020).

A lack of experience and training and negative past experiences can also act as barriers to staff engaging with patients who exhibit challenging behaviour, as can sociocultural influences. For example, social class, occupational status and religious beliefs can influence the attitudes of nurses and patients, leading to preconceived ideas and judgements that can adversely affect communication (Al-Kalaldeh et al 2020).

Furthermore, patients who present to an ED with an existing cognitive impairment such as dementia or a learning disability are at risk of diagnostic overshadowing, where a change in the person’s behaviour is attributed to their existing diagnosis rather than alternatives being considered (Manning 2020, Ainsworth et al 2021). Therefore, it is important that triage nurses quickly ascertain whether an individual’s aggressive or unpredictable behaviour is due to an underlying physiological cause such as hypoxia, brain injury or delirium, or external factors such as the environment (Carver and Beard 2021). For example, the noisy and bright environment of ED waiting rooms can be intimidating for people experiencing mental health issues, leading to an exacerbation of their symptoms, increased stress and hostility towards staff (Pascoe et al 2022).

Pascoe et al (2022) outlined how patients with mental health issues, despite being some of the most vulnerable patients, are often subjected to longer waits for treatment, resulting in deterioration of their symptoms. The researchers suggested that increasing early access to mental health practitioners who are embedded in the ED team may alleviate this issue. Many EDs have incorporated a mental health liaison nurse into the staff team, but often they are not available for 24 hours a day. Additionally, with up to 10% of ED presentations involving mental health issues occurring overnight, time-pressured ED staff are often unable to devote the required level of support to these patients (Molloy et al 2020). It is important that triage nurses establish early therapeutic engagement with patients with mental health issues, preferably in a calm environment and alongside an experienced mental health professional, to alleviate the person’s agitation and de-escalate any potentially volatile situations (Molloy et al 2020).

Risk assessment

Triage nurses must possess a suitable level of experience alongside high-level assessment skills to enable them to detect signs of aggression and deploy effective de-escalation techniques to maintain a safe environment; for example, using active listening skills and establishing a rapport to evaluate patients’ pain and unmet needs (Innes et al 2021, Manning 2020).

There are several risk assessment tools available, which may be used to recognise concerning patient behaviour. One simple tool is the acronym STAMP (staring, tone and volume of voice, anxiety, mumbling, pacing), which identifies five components of observable behaviour and cues that may influence or exacerbate violence in the ED (Luck et al 2007) (Box 2).

Box 2.

STAMP framework

STAMP can be used to identify five components of observable behaviour and cues that may influence or exacerbate violence in the emergency department (ED):

  • Staring – prolonged glaring by the patient or an absence of eye contact

  • Tone and volume of voice – such as sarcasm and raising the voice

  • Anxiety – the patient appearing flushed, demonstrating rapid speech, showing expressions of pain such as grimacing or clutching at their body, confusion and a lack of understanding about processes in the ED

  • Mumbling – talking ‘under their breath’, criticising staff but in a voice loud enough to hear, repetition of requests and slurring or incoherent speech

  • Pacing – walking around a confined space such as a waiting room or bed space, repeatedly returning to the nurse’s area, ‘flailing’ in bed and resisting interventions

(Luck et al 2007)

The STAMP framework can support early recognition of volatile situations, enabling timely application of de-escalation techniques (Luck et al 2007, Carver and Beard 2021).

Improving the environment

Improvements to the ED environment such as clear signage and an effective means of providing important information to patients, for example a public address system, can contribute to a reduction of incidences of aggression. Security measures, such as security guards, CCTV and panic buttons, can expedite responses to violent incidents (Carver and Beard 2021).

At an organisational level, system-wide interventions should include measures such as improved bed management to improve patient flow in chronically overcrowded EDs. At ED management level, prioritising staff training, particularly in conflict resolution and de-escalation techniques, can promote safe and effective care delivery in the ED waiting room; such training will also improve staffs’ confidence and reduce the likelihood of them becoming victims of aggression or abuse (Anderson et al 2021, Carver and Beard 2021, Kirk and Edgley 2020, Power et al 2022).

Time Out 4

Imagine that the patient in Time Out 3 was accompanied by her daughter and consider this alternative scenario:

It is a busy Friday night and most staff have been pulled into a major trauma, resulting in increased waiting times

At 11pm the patient’s daughter approaches you and demands to know, in a raised voice, what is happening because her mother is in a lot of pain, still has not been seen by anyone and other patients have been seen before her

She glares at you and shouts: ‘At least have the decency to do something about the pain!’

How would you manage this confrontation? What interventions could have been employed to avoid this escalation?

Staff support and resilience

Many nurses are drawn to work in EDs because of unpredictability and a lack of routine, although these elements can also become a source of stress, particularly when balancing work pressures with a busy family life, for example (Briggs 2022, Power et al 2022). Staff such as triage nurses can feel considerable pride at being part of an ED team, with the team dynamic often described as similar to that of a family. A supportive atmosphere contributes to ED staffs’ well-being, enabling them to speak out about clinical issues without being concerned about punishment (Anderson et al 2021, Power et al 2022).

ED nurses have to be resilient because they deal with daily exposure to suffering, high-stakes decision-making, violence and distress (Anderson et al 2021). They will often tolerate aggressive behaviour that would not normally be acceptable because they recognise that patients are frightened and stressed (Kirk and Edgley 2020). However, suppressing their own emotions to manage such an unpredictable environment can take its toll on ED nurses’ well-being, so effective support is required from trust management (Anderson et al 2021).

ED nurses’ continued exposure to stress can manifest as, for example, sleep disturbance, anxiety and low mood. If not addressed, these factors can affect nurses’ care delivery and even lead to them avoiding challenging patients or situations (McConnell et al 2016). Ongoing issues such as sleep disturbance will eventually increase ED nurses’ stress levels, contributing to emotional exhaustion and burnout. Adverse incidents occurring as a result of this may lead to disciplinary procedures (Briggs 2022). Decreased job satisfaction due to factors such as burnout can also result in nurses leaving the profession, creating a vicious cycle of staff shortages in areas such as the ED and placing additional pressure on remaining staff (McConnell et al 2016, Al-Kalaldeh et al 2020).

There is also a significant mismatch between the expectations of the public and trust managers of the level of service that should be provided in EDs and what staff believe to be reasonable, which can lead to a degree of demoralisation among ED staff (Power et al 2022).

To ensure that ED nurses feel valued in their role, an environment that promotes their health and well-being is required, which will in turn positively influence staff retention. A supportive environment will enable ED nurses to seek early help with work-related issues, rather than trying to manage on their own through concerns about being labelled ‘weak’. Innes et al (2021) suggested that mandatory resilience training should be provided for all ED nurses, incorporating coping strategies, relaxation techniques, stress management and mindfulness. However, while there are various ways in which individuals can seek help, it is vital that managers also have a role, including (Anderson et al 2021):

  • Encouraging inclusive team behaviours, such as improving access to group learning opportunities.

  • Taking action against violence and abuse towards ED staff by supporting them to report offences.

  • Ensuring that ED staff have the resources to provide high-quality, person-centred care.

  • Prioritising ED nurses’ learning and development opportunities to invest in their well-being.

Time Out 5

Think about an incident involving anger or aggression in the ED waiting room you have recently experienced or witnessed. Were you anxious or fearful, or calm, confident and in control? Consider the support you received – what improvements could be made that could have prioritised your well-being?

Collaboration between waiting room nurses and triage nurses

The waiting room nurse role, which was introduced in response to overcrowding in EDs, is designed to work in collaboration with the triage nurse (Innes et al 2021). Waiting room nurses are allocated to the ED waiting room to make it easier for patients and their families to identify someone responsible for supporting them during the wait for treatment following triage and to release the triage nurse to focus on initial assessments (Innes et al 2015). In addition to sharing the workload, this collaborative approach promotes a safer environment in the ED by delivering person-focused care and by providing nurses in both roles with time to detect clinical deterioration, improve patient satisfaction and reduce the potential for aggression.

To promote collaborative working with the wider ED team, the waiting room nurse can use a safety checklist to ensure patients’ clinical deterioration is detected early and that their ongoing care needs are met while they wait for medical treatment (Stone et al 2020).

Figure 1 shows an example waiting room nurse checklist.

Figure 1.

Example waiting room nurse checklist



Increasing demands are being placed on ED staff, particularly triage nurses and waiting room nurses in public-facing roles. Overcrowding, long waiting times and environmental factors culminate in a busy and unpredictable environment, which can have an adverse effect on nurse-patient communication and result in conflict and potential aggression towards nurses.

Waiting room nurses should adopt measures such as safety checklists to detect patients’ clinical deterioration and meet their care needs while they wait for medical treatment.

Time Out 6

Identify how maintaining a safe environment in ED waiting rooms applies to your practice and the requirements of your regulatory body

Time Out 7

Now that you have completed the article you might like to write a reflective account as part of your revalidation. See:


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Aim The aim of this study was to explore the cultural...

Adherence to oral chemotherapy: a review of the evidence
Oncology is rapidly changing. Over the past few years there...