A recent study found a surprising answer. In an ideal world, a nurse could turn around 360 degrees in one location and see all his or her assigned patients. That was true to an extent in the Nightingale ward layout, which is still prevalent in many countries around the world. In other western countries, the ward concept has long been replaced by patient rooms that are occupied by one, two, or four patients. In the United States, single-patient rooms have become the industry norm. As the occupants of the patient room have decreased, the issue of patient visibility has grown.

Single-patient room versus ward design

In single-patient room units, it is theoretically impossible to provide immediate visibility of all assigned patients from one physical location, other than in intensive care units of 10 beds or less. Larger footprints of contemporary bed units compound these challenges. Keeping the number of beds constant, a Nightingale ward would demand a considerably smaller footprint compared to units with single-patient rooms.

The impossibility of ward-style visibility of assigned patients has led to several alternative, objective interpretations of visibility, specifically in acute care settings. Those range from being able to see the patient's head from the room door, to being able to see any view of the patient from the room door, to being able to see the room doors of assigned patients from the nurses' principal work zones.

The term “visibility” becomes more complex with the need of an audibility dimension. The ability to hear alarms and calls for help from the patient rooms is an increasing need. That's because, with an aging population, their frailties are leading to increasing potential for accidents and the risk of falls.

Inboard or outboard room configuration

What is the most appropriate strategy to maximize patient visibility? The patient room configuration could play a significant role, especially the bathroom location. In inboard configurations, bathrooms are located on the corridor wall of the patient room. In outboard configurations, the bathrooms are located on the window wall. There are less-frequent instances of clustered (also known as nested or mid-board) configurations, where bathrooms of two adjoining patient rooms cluster together to share the length of one common wall.

Variants of the outboard configurations typically offer better patient visibility. Since the bathroom is located on the exterior wall, the configuration enables a clear line of sight between the patient room door and the patient. The degree of visibility (patient's head compared with any view of the patient) can also be easily manipulated through design in an outboard configuration.

Further, without the bathroom as a barrier between the patient and the corridor, it offers a better auditory link with the patient room. In contrast, achieving the same in variants of inboard configurations is challenging, owing to the location of the bathroom between the corridor and the patient.

All of which made the findings of a recent study conducted on this quite surprising.

The IBMC study

When researchers from HKS's Clinical Solutions & Research team and INTEGRIS Baptist Medical Center (IBMC), located in Oklahoma City, conducted a study to compare inboard and outboard configurations, they expected outboard configuration to perform better regarding patient visibility. The study was designed as a preliminary investigation to develop a more elaborate and comprehensive comparative study of the two configurations. The newly renovated bed tower at INTEGRIS offered a true natural experiment opportunity to study the topic, since it contains units that have rooms with both inboard and outboard configurations, with the staff and patient population remaining the same.

The preliminary study was conducted in an old unit-the first row of rooms with inboard configuration, and the second with outboard configuration, around a racetrack configuration. However, the two sets of rooms were not identical in size; the outboard rooms were originally designed as semiprivate rooms. Four of the outboard rooms were being used as single-occupancy rooms, offering the opportunity to conduct a preliminary study while taking into account the key variations.
A plan of the sixth floor at INTEGRIS Baptist Medical Center, in Oklahoma City, Okla., where the patient visibility study was conducted. Courtesy of HKS, Inc.

A plan of the sixth floor at INTEGRIS Baptist Medical Center, in Oklahoma City, Okla., where the patient visibility study was conducted. Courtesy of HKS, Inc.

Layouts of inboard and outboard rooms used in the study. Courtesy of HKS, Inc.

Layouts of inboard and outboard rooms used in the study. Courtesy of HKS, Inc.

Patient rooms in proximal location to nurse documentation stations, supplies, and medication rooms at INTEGRIS Baptist Medical Center help enhance perceived patient visibility even when line of sight to patient may be obstructed. Photography by Blake Marvin/HKS, Inc.

Patient rooms in proximal location to nurse documentation stations, supplies, and medication rooms at INTEGRIS Baptist Medical Center help enhance perceived patient visibility even when line of sight to patient may be obstructed. Photography by Blake Marvin/HKS, Inc.

Rooms closer to the nurse station at INTEGRIS Baptist Medical Center may be perceived as offering greater patient visibility; the bathroom location in the room appears to be a secondary issue. Photography by Blake Marvin/HKS, Inc.

Rooms closer to the nurse station at INTEGRIS Baptist Medical Center may be perceived as offering greater patient visibility; the bathroom location in the room appears to be a secondary issue. Photography by Blake Marvin/HKS, Inc.

Data from 20 volunteering nurses were collected over a period of seven days in November 2007. During that timeframe, nurses were randomly assigned to either all inboard rooms or all outboard rooms with single occupancy. Data were collected on 16 dimensions pertaining to nursing care. The questionnaire was designed in a way to allow the subjects to rate the suitability of the physical environment for specific activities on a seven-point Likert-like scale.

Surprise findings

In contrast to expectations, data analysis suggested that the inboard patient rooms were rated more suitable than the outboard rooms in the nurses' ability to observe patients from the corridor (5 versus 4 on the suitability scale). The suitability scale ranged from 1 to 7 points, with 7 points being the highest suitability rating. Further, the inboard rooms were rated more suitable in the ability to hear patients' calls for help or alarms while the caregiver is outside the patient room (again, 5 versus 4 on the suitability scale).

What could explain these unexpected findings? A closer look at the room locations reveals that the four outboard rooms were located further away from the nurses' station and support spaces, as compared to inboard rooms. More inboard rooms were located in the vicinity of the central nurse station and support rooms, which were physically located at the center of the unit. In terms of distance, the mean and median distance between the inboard rooms and the central support spaces was 54 feet, as compared to 99 feet for the outboard rooms included in the study-almost twice the distance. As a result, it was possibly easier for the nurses assigned to inboard rooms to strike a balance between patient monitoring, direct patient care, and accessing the nurses' station and support rooms, as well as engaging in socialization, mentoring, and consulting. That may have led to a perception of better patient visibility, even though the patients in the inboard rooms were not in direct line of sight from the corridor or room entrance.
The outboard location of the patient bathroom offers unobstructed line of sight from the corridor. However, perceived visibility appears to be affected more by distance of the room from documentation and support spaces at INTEGRIS Baptist Medical Center

Photography by Blake Marvin/HKS, Inc.

The outboard location of the patient bathroom offers unobstructed line of sight from the corridor. However, perceived visibility appears to be affected more by distance of the room from documentation and support spaces at INTEGRIS Baptist Medical Center

Larger contemporary bed unit footprints created greater separation between patient and support spaces

Photography by Blake Marvin/HKS, Inc.

Larger contemporary bed unit footprints created greater separation between patient and support spaces

The key suggestion originating from this finding is that attributes of the unit (patient room clustering in relation to nurse work zones and support rooms) is more important than room attributes (inboard, outboard, or other configurations) for patient visibility.

This implication is crucial in contemporary nursing practice, particularly from the viewpoint of patient safety. Larger building footprints have created greater separation between the patient and support spaces. As a result, hunting and gathering tasks pertaining to patient documentation, supplies, and medication have increasingly consumed staff time.

For instance, in a recent study conducted by Ascension Health, Kaiser Permanente, and Purdue University, involving 767 nurses from 36 medical surgical units, it was found that nurses spend only 19.3% of their time in patient care activities, and only 7.2% on patient assessment and checking vital signs. Time spent on hunting and gathering tasks is essentially time away from the patients, thus significantly impacting patient visibility and monitoring.

Beside inappropriate use of clinical resources, reduction of patient visibility could have significant patient safety implications. In a recent study involving a representative sample of 20 hospitals across the United States, a team of researchers from Stanford University Center for Health Policy and Harvard Business School focused on operational and physical design factors affecting patient safety in healthcare settings. Facility failure (or physical design-related factors) was the top factor affecting patient safety (sharing the top slot with equipment and supply failure). One of the key factors related to facility failure was the difficulty in observing patients.

Implications for planners, designers, and administrators

What does this mean for healthcare planners, designers, and administrators? From a patient visibility and safety viewpoint, outboard rooms perhaps work better than inboard rooms, but the advantages of one room configuration type over the other could be neutralized by certain unit attributes.

Optimizing bed-unit design for patient safety would necessitate either creating smaller units or distributing documentation, supplies, and medication in larger units. Distributed supplies and medication, of course, have their own challenges, such as inventory management, control, rotation, and charge capture, as well as restocking responsibility.

Such challenges, however, need to be weighed against patient safety issues in inpatient unit design. More research is needed to possibly demonstrate that the higher operational costs typically associated with decentralized placement of all patient care resources immediately within the patient room might be justified with improved patient outcomes and satisfaction, or with reduction in injury incidents or medical errors. HD

Debajyoti Pati, PhD, FIIA, is director of research and Tom E. Harvey, Jr., AIA, MPH, FACHA, is director of the Clinical Solutions & Research Group, HKS, Inc., Dallas, Texas. Kay Shields Ragan, RN, is Clinical Director, Orthopedic and Neurology Services, INTEGRIS Baptist Medical Center, Oklahoma City, Oklahoma.

For further information, contact Dr. Pati at 214.969.5599 or dpati@hksinc.com.

Healthcare Design 2009 November;9(11):84-90