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Decentralized nurse stations can put nurses closer to patient rooms, but the available evidence does not show that this arrangement is automatically better for care. A post-occupancy evaluation of an orthopedic unit at SSM St. Mary’s Hospital in Jefferson City, Missouri, found that facility ratings rose after a 2014 renovation while most patient-care quality scores stayed similar and the score for nurses’ responses to patient calls slipped slightly. The researchers suggested that distance and visual disconnection between staff might help explain that result, but this was a hypothesis—not proof that decentralized design caused slower responses or worse care.
For hospital owners, architects, and construction teams, the practical lesson is to treat station layout as a set of trade-offs to evaluate in context. Patient proximity is only one consideration; communication, support-space access, visibility, workflow, and patient privacy also matter.
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1Repair Windows errors before they cause bigger problems2Fix the driver behind crashes, sound loss and screen glitches3Clear out junk files and repair common Windows errorsWhat did the Missouri evaluation find?
The evaluation examined a 2014 remodeling of the orthopedic unit at SSM St. Mary’s Hospital in Jefferson City, Missouri. Building Design + Construction reported the findings on January 19, 2017. Lawrence Group retained the Institute for Health + Wellness Design at the University of Kansas to conduct a third-party post-occupancy evaluation, with findings intended to inform planning for a later expansion at another SSM hospital. The Building Design + Construction report and the University of Kansas account describe a mixed picture rather than a simple verdict for or against decentralized stations.
Facility scores increased significantly after renovation. Most scores related to patient-care quality remained similar, while the rating for nurses’ responses to patient calls declined slightly. That distinction matters: the reported result was a change in a survey score, not a measurement demonstrating that nurses actually took longer to answer calls, and not evidence that the renovation caused poorer clinical outcomes.
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The Institute hypothesized that decentralization might contribute to the call-response perception. If nurses are distributed among small work areas rather than sharing a central station, they may have fewer opportunities to consult one another, and visual separation may make coordination or awareness of a call more difficult. Those are plausible design questions for a project team to investigate, but the evaluation did not establish them as causes. Other details needed to interpret the change fully—including the initial Missouri evaluation’s sample size and complete survey instrument—are not provided in the available reporting.
The evaluation also used a checklist developed by the Center for Health Design and a space-syntax analysis that produced a heat map of visual connection through the unit. The University of Kansas account says patient-satisfaction surveys were used as well. These methods offer different kinds of evidence: surveys record respondents’ perceptions, while spatial analysis can help describe visual relationships in a plan. Neither, by itself, demonstrates why a rating changed or proves a clinical effect.
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What does “decentralized” mean in a nursing unit?
In a decentralized arrangement, work areas are distributed closer to patient rooms rather than concentrated in one central nurse station. The intended design logic is straightforward: reduce the separation between staff and patients, and potentially make it easier for nurses to observe or reach rooms. A centralized arrangement groups staff at a shared station, which can make face-to-face communication and access to some shared functions more convenient. Actual layouts vary, and labels alone do not tell a project team how a particular unit will work.
These arrangements should not be treated as a binary choice between “near patients” and “able to communicate.” A unit can have distributed work points and shared team areas, or a central hub with additional support locations. The relevant question is how the entire plan supports the work that takes place: where nurses chart, find supplies, consult colleagues, receive calls, and move between patients and support spaces. The Missouri evaluation raises concerns worth testing in a design process; it does not establish one universal configuration.
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Why can patient proximity and teamwork pull in different directions?
Moving work areas nearer to patient rooms may improve proximity, but proximity is not the same as continuous observation or faster response. Sightlines can be interrupted by doors, corners, partitions, equipment, or the orientation of a room. A heat map of visual connection can help identify where visibility is stronger or weaker, but it cannot alone establish what staff notice during a shift or how quickly they respond.
At the same time, spreading staff locations can affect how easily nurses encounter one another and use shared support spaces. Informal conversations can be important for exchanging information, mentoring, or asking for help. If a plan makes those interactions less convenient, any potential benefit of being closer to patient rooms may come with a coordination cost. The Missouri report’s suggested link between visual disconnection, team consultation, and call response is a hypothesis about this tension, not a causal finding.
Neither dimension should be reduced to a single proxy. A centrally located station does not guarantee effective teamwork, and a work point near a room does not guarantee meaningful surveillance. The design must be assessed against the unit’s actual processes, including where staff need to collaborate and which patient needs are most relevant to the project.
What does later research add?
A separate peer-reviewed before-and-after study provides a more detailed comparison of patient and nurse perceptions. Its findings, indexed by PubMed, should not be confused with the Missouri evaluation: it involved different units and different survey samples. In that later study, patients reported preferences for decentralized units in relation to larger single-occupancy rooms, privacy and confidentiality, and overall design satisfaction.
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Nurses’ responses were more mixed. They approved of patient rooms, the unit environment, and noise levels, but reported reduced access to support spaces, lower levels of team and mentoring communication, and lower design satisfaction than in centralized units. This contrast helps explain why a layout may be received differently by patients and staff: room privacy and the overall patient environment can improve in respondents’ eyes even as staff perceive communication or work support less favorably.
The later study reported 26 nurses surveyed in centralized units before the move and 51 in decentralized units afterward. Patient survey counts were 62 before and 49 afterward. These figures describe that separate study, not the initial Missouri evaluation. The before-and-after design and survey findings are useful evidence about reported perceptions, but they should not be stretched into a claim that decentralization alone caused each difference or that all hospitals will see the same results.
In 2017, Health Facilities Management described follow-up work at St. Mary’s and the University Medical Center of Princeton at Plainsboro. The University of Kansas account says that work included observation, behavior mapping, tracking, focus groups, and surveys. Health Facilities Management reported a 30-question, three-part nurse survey in the follow-up work, covering respondent information, perceptions of unit design and nurse stations, and perceptions of teamwork and job satisfaction. These follow-up methods and the 30-question instrument belong to the later work described in those reports; they are not the sample size or full questionnaire for the initial Missouri evaluation.
Which design trade-offs should a project team examine?
The evidence points to several questions that can be addressed during planning and post-occupancy evaluation. The aim is not to select a station model based on one survey result, but to identify which outcomes matter for a particular unit and how the plan supports them.
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| Design question | What to examine | Why it matters |
|---|---|---|
| Patient proximity and visibility | Distance from work points to rooms; sightlines and visual connections through the unit | A nearby work point may support proximity, but the plan must still be assessed for actual visibility and access. |
| Staff movement and support spaces | Routes between rooms, work areas, supplies, and support spaces | Distributed locations can change walking patterns and the convenience of reaching shared functions. |
| Nurse-to-nurse communication | Where staff can consult, exchange information, and mentor colleagues | The Missouri researchers raised communication as a possible explanation for the response-to-call rating; later nurses reported lower team and mentoring communication in decentralized units. |
| Patient perception | Room privacy, confidentiality, room size, and overall design satisfaction | Patients in the later peer-reviewed study favored decentralized units on these reported dimensions. |
| Staff perception of the environment | Noise, room quality, unit environment, support access, and design satisfaction | The later study found both positive nurse views and concerns, showing why staff outcomes should be examined separately. |
A team can turn these axes into a project-specific evaluation plan. Before construction, define which outcomes the design is meant to improve and how they will be assessed. During design, use plan review and spatial analysis to identify likely visibility and movement issues, while recognizing that those tools do not substitute for observing work. After occupancy, collect staff and patient feedback and examine behaviors relevant to the project’s questions. Where feasible, use consistent measures before and after a change so that the comparison is interpretable. Even then, a post-occupancy comparison can identify associations and raise explanations to investigate; it does not automatically isolate the design as the cause.
Independent reader supportYour contribution helps us test, update, and keep practical guides available for everyone.How should hospitals interpret the evidence?
Read the Missouri findings narrowly and the later study as context. The Missouri result is that facility scores rose significantly, most patient-care quality scores stayed similar, and one call-response score dipped slightly after the renovation. The proposed explanation involving distance and visual disconnection was a hypothesis. It is inaccurate to describe the evaluation as proving that decentralized stations slow care, reduce patient satisfaction overall, or make communication worse in every hospital.
The later peer-reviewed study adds evidence that patients and nurses may value different features of a unit. It does not erase uncertainty about why perceptions differ, nor does it settle how a specific hospital should build. Differences in unit layouts, staffing, workflows, patient populations, and operational practices can matter; the evidence here does not establish a universal outcome across those contexts.
Hui Cai, identified in the 2017 article as an assistant professor at the University of Kansas, cautioned: “This design trend needs to be further investigated before it is accepted as standard for every hospital.” That warning is best understood as a call for evidence-led design decisions, not as a recommendation to reject decentralization.
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What should be carried into the next renovation?
For owners and construction teams, the practical response is to make assumptions explicit. If a design is intended to improve patient proximity, specify what proximity means for that unit and how the team will know whether it improved. If shared communication is a concern, examine whether the plan provides convenient places and routines for staff to coordinate. If privacy is a priority, assess the patient-room experience without assuming that staff workflows will automatically improve alongside it.
Then evaluate more than one outcome. Patient perceptions, staff perceptions, spatial relationships, and observed work patterns answer different questions. Keeping those measures distinct helps prevent a favorable facility rating from being mistaken for proof of better care—or a single lower survey score from being treated as proof that an entire design approach failed. The available findings support careful comparison and local evaluation, not a blanket standard for every hospital.
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Does a lower nurse call-response rating mean patients waited longer?
Not necessarily. The Missouri report describes a slight decline in a survey score about nurses’ responses to calls; it does not provide a measured response-time result establishing that actual waits increased.
Were the Missouri evaluation and the later peer-reviewed study the same project?
No. The peer-reviewed study is separate and reports its own before-and-after samples. Its counts of nurses and patients should not be assigned to the initial SSM St. Mary’s evaluation.
Can a space-syntax heat map show whether nurses will respond promptly?
No. It can represent visual connection through a plan, but response depends on more than sightlines. It is one input to design evaluation rather than a direct measure of care or response time.
Why might patients and nurses rate the same unit differently?
They experience different aspects of the environment. Patients may focus on room size, privacy, and overall design, while nurses also depend on support-space access and opportunities for team communication and mentoring.
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