The 30-bed orthopedic unit on Florida Hospital Waterman’s fifth floor was laid out as a radial nursing unit with clear sight lines from the nurse’s station to the head of each patient’s bed. When the hospital decided to relocate the unit to a sixth floor shell space, what began as the replication of the existing layout quickly evolved into a rigorous study of how decreasing staff-to-patient visibility affects the patient experience.

The basic architecture for the new sixth-floor location was determined years before during initial construction, so options for altering the floorplan were limited. As the project began, however, Gresham Smith and hospital administrators questioned whether the high visibility of patient beds from outside the rooms was negatively impacting patient satisfaction scores. HCAHPS surveys indicated that noise levels sometimes disrupted patients’ sleep, and hospital leadership wondered whether the ability to monitor patients from outside the room resulted in less in-room engagement. Due to the lack of a continuous leaning edge between the bed and the toilet room, questions were also raised about the impact on patient fall rates.

After an exhaustive review of existing research, Gresham Smith suggested that flipping the beds to the opposite wall might alleviate each of the concerns that had been raised. Because many of the studies and whitepapers reviewed were inconclusive, however, the team also proposed a study to determine how the change would affect the acoustics of patient rooms, the amount of time staff spent in the rooms, and patient behavior, satisfaction and fall rates.

Observations and measurements were taken for nine months in the fifth floor space prior to the move and again for nine months in the new sixth floor space after the build-out and relocation. At the end of the study, researchers found that noise levels in the new layout were lower, hospital staff were observed in patient rooms more frequently, and patient ratings of the hospital overall had increased. Although not statistically significant, the study also found a slight increase in fall rates.

The study was peer-reviewed and published by The Journal of Environmental Psychology in September 2016 and also received a Certificate of Research Excellence from the Environmental Design Research Association. While not a silver bullet, it reveals a natural tension between staff’s ability keep a constant watch on each patient and the patient’s ability to rest and recuperate in privacy. Creating a safe and comfortable healing environment requires designers and facility operators to strike a balance between privacy and visibility.


Florida Hospital Waterman


Tavares, FL

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Lesa Lorusso, Ph.D., MBA, MSArch, Allied AIA, ASID, RID, NCIDQ
Lesa Lorusso, Ph.D., MBA, MSArch, Allied AIA, ASID, RID, NCIDQ
Healthcare Director of Research & Insights