Bedroom Design

References in this paper are based on a confidence rating scale.
A confidence rating of 1 is considered to

be evidence based and will be followed by . A confidence rating of 2 is based on expert opinion and
will be followed by . A confidence rating of 3 will not be followed by number symbol.
Primary Author: Margaret P. Calkins
Bedroom Design
Decisions about bedroom design are a significant consideration when
designing a care community. The largest concern relates to the proportion of shared
rooms versus private rooms. We will discuss benefits for residents, staff issues,
family satisfaction, and clinical outcomes. This paper will then address design
considerations not related to private versus shared configuration.
Private Room vs. Shared Room

The literature is clear that private rooms benefit the resident in both
psychosocial and physical/clinical ways. Private rooms are associated with increased
mobility and range of motion(1). They also lead to improved sleep with fewer
interventions for promotion of sleep(2). It has been suggested that a larger size (12
x 24) private room can help residents feel less claustrophobic, move about more
safely, and demonstrate fewer behavioral problems(3). Regardless of size, however,
numerous sources found that private rooms resulted in a major reduction in
irritability and conflict between residents(4). It is also easier to personalize private
rooms, providing familiarity and continuity with the past, and supporting a sense of
identity(5).
Baugh replicated earlier results by showing a 20 to 1 preference for private
rooms for the reasons of privacy for self and others(6). Residents who felt they had
more privacy expressed greater satisfaction with their current experience(7).
Residents had the most trouble with a roommate when they felt they had lost
their autonomy(8). This relates to the lack of control over environment-based
stimulation, such as television or radio control, access to and control over the
window, or having to pass through someone elses territory to use the toilet or leave
the room(9).
On the less positive side, private rooms are also associated with decreased
incidences of interpersonal interactions and less self-maintenance behavior(10).
Calkins and Cassella conducted an exhaustive literature review and found one
research project where 22% of residents in shared bedrooms indicated a strong
emotional bond with their roommates(11). This means 78% did not have a strong
emotional tie with their roommates. Interestingly, even people with strong emotional
ties to their roommates indicated a preference not to do activities with, or confide in,
their roommate. This suggests that some residents may make the best of a bad
situation, particularly when having a private room is not an option.
Although many people may argue that a care provider should provide all
private rooms, there are times when some residents may want to share a room, such
as with spouses, siblings, or friends(12). Furthermore, privacy in bedrooms is not
necessarily an either-or proposition: it can be viewed along a continuum. At one end
are multi-bedded open wards (no longer permitted by code) or rooms with two
people separated only by a piece of fabric (we refuse to call this a privacy curtain!).
This provides visual privacy (if someone remembers to close the curtain) but not
auditory or olfactory privacy. The location of the curtain does not guarantee separate
territories for each individual. At the other end of the privacy continuum is a private
room with a private toilet room with bathing/showering available, which provides
privacy at all levels.
In the middle are a variety of room layouts that give each
individual a certain level of privacy, but also compromise privacy in some manner.
The plans below illustrate two-person shared rooms that range from less privacy to
more privacy. Each can be considered in terms of: (1) different types of privacy, (2)
defensibleness of the space (territoriality), and (3) access to resources (such as
windows).
Traditional Shared Room

The traditional shared room (often referred to as a hospital
layout), where beds are separated by a cubicle curtain.
Privacy - low. Because the only separation between the beds is typically a cubicle
curtain, there is virtually no acoustic, olfactory, or thermal privacy. Not only are
conversations with visitors and television programs overheard, but conversations
between caregivers and the resident, and noises related to the provision of care are
overheard, seriously compromising HIPPA privacy regulations.
Defensible Space low. Because the individual living by the window must cross
the space of the person who lives on the hallway side, there are frequent and
uncontrolled intrusions into each others space by the resident, staff, and visitors.
Further, because these rooms often have minimal square footage, residents
belongings often make the room highly cluttered and difficult to move around in. A
common complaint is that one persons belongings impinge on the territory of the
roommate.
Access to resources unequal. The person on the hallway side has no control of,
or visibility to, the window if the cubicle curtain is closed. The resident further away
from the window does not get the benefit of the bright, outside light which is shown
to reduce agitation(13). Depending on the layout of the room, sometimes wardrobes
and dressers are built in, but may be located only on one side of the room, which
necessitates repeated trespassing behavior on the part of the roommate or staff to
get clothes. The resident with dementia who cannot see the toilet from his or her bed
is more likely to have incidences of incontinence (see paper on toilet rooms for
further reference)(14).
Enhanced Shared Rooms

Toe-to-Toe Layout
This type of toe-to-toe layout (and similar L-shaped plans)
are referred to as enhanced shared rooms(15). An enhanced
shared room is defined as giving each resident a well-defined
and generally exclusive territory within the room or provide
essentially private bedrooms with a shared bathroom
(16)
These rooms would have to be larger than the traditional layout, but have additional
benefits of allowing the resident to move around more safely and allowing more
room for visiting with more than one person(17). An option that takes up the least
amount of floor space is the toe-to-toe arrangement of residents beds(18). Diagrams
of this arrangement can be found in Calkins (2001). However, this arrangement
reduces the ability of the staff to see the resident from the hallway. Although this
creates more privacy, it makes monitoring residents more difficult for the staff.
Privacy- low. The dotted line represents a cubicle curtain, so there is still no
acoustic privacy in this version. However, perceived levels of privacy are increased.
Residents no longer have to pass through anothers territory to get to their space
and belongings. Staff considers this arrangement to eliminate issues or problems
between residents by 75-80%(18).
Defensible space- high. Each resident has equally defensible space, which means
that there is no need for a resident to trespass into the other residents space to get
to his or her space. Each resident has a window and equal access to the toilet.
Access to resources equal. Each resident has his/her own window and closet in
his/her own personal space.
L Shaped Room
With this layout, referred to a super-enhanced or privacyenhanced shared room, each resident has his/her own
bedroom with a door, providing visual and acoustic privacy, as
well as defensible space. There is still a door to the hallway, so
the vestibule provides discrete access to the shared toilet. Note
that each sleeping area has a sink for toiletries (plan courtesy
of Nelson-Tremain Architects).
Privacy- high. Each person has the ability to close the door for acoustic, olfactory,
or thermal privacy. Residents clearly have the ability to be as social or private as
their mood dictates.
Defensible space- high. There are few intrusions into the residents space. Staff
enters the room for necessary caregiving. A resident could allow access for visitors
by leaving the door ajar, or deny access by closing the door.
Access to resources equal. Each resident has equal access to the toilet room
and windows. By having his/her own sink, a resident does not need to wait for a
roommate to vacate the toilet room to perform grooming activities of daily living
(ADLs). Residents can use any form of stimulation, such as a television or radio,
without having to use another persons belongings, or be forced to listen to anothers
program choices.
An alternative way to provide both privacy and an option for sharing a room is
to create companion suites, in which a door can be either placed or removed
between two rooms (similar to adjoining rooms in hotels). There is no solid evidence
as to current trends, but some experts suggest that roughly 15-20% of the rooms
should be able to be shared if residents desire.
Shared Room Issues

One of the hardest aspects of the job for staff is constantly dealing with
roommate conflicts. There is clear evidence that staff, including nursing assistants,
social workers, and even housekeeping staff, spend time each week dealing with
roommate conflicts. Some estimate this to be as low as 2 hours up to 25 hours, but
may be much higher at times (or be perceived as much higher because nursing
assistants in particular, multitask and cope with roommate conflicts while providing
care)(19). Having two residents in one place may allow the staff to be more efficient
with care as they can take care of two residents at once(20). However, small shared
rooms make this care difficult as the staff cannot move around to do their work.
Also, as mentioned previously, conversations related to care should be private, which
is virtually impossible in a shared room where residents are separated by only a
curtain. Cleaning shared rooms takes longer. It is also easier for staff to intervene in
resident conflicts when there is a private location to discuss matters without being
overheard(21).
Another challenge of the traditional shared room design is that it can be more
difficult for residents with dementia to orient themselves to their personal space
because the room looks the same on both sides (22). Efforts to personalize each
residents space using display shelves, personal items, personal furniture and
artwork(23). Issues relating to visiting can hamper the relationship between
roommates. This can be especially true during the dying process when family
members want to be close to their relative, and the roommate feels as though
he/she is intruding on a private time(24). For these reasons and more, the
traditional hospital style bedroom should be avoided.
Cost of Private Versus Shared Bedrooms

Calkins and Cassella conducted a detailed cost analysis of private versus
shared bedrooms(25). A copy of this paper, published in The Gerontologist is available
for download free at www.IDEASInstitute.org. Go to the publications tab.
Room Layout and Doors

The type and style of doors used in the bedroom can impact the residents
day-to-day life. Research conducted in the 1980s found an 8-fold increase in the
independent use of toilets that were directly visible to the residents, as opposed to
being located behind a curtain or door(26). The location of the toilet, and the style and
positioning of the door, need to be carefully considered. Some suggest that the door
should swing outward into the bedroom(27). Others argue that the door should be
designed so that it can remain in an open position, maximizing visibility to the toilet.
This can be accomplished either by having the door open into the bathroom against a
solid wall (it must be a double hinged door for safety reasons), or by using a pocket
or surface mounted-sliding door(28). To the greatest extent possible, there should be
a direct visual relationship between the bed and toilet to maximize independent
continence.
Window size is an important consideration. Large windows (4 x 6) provide
visual access to the stimulation outside, an issue considered important by staff (29).
The windows should be hung low enough (maximum 24 inches above finished floor)
so that a resident in a wheelchair or reclining in bed can easily see out (30).
Flexibility of Furniture Layout

Once the decision has been made regarding the layout of the bedrooms in
terms of private versus shared and access to the toilet, one must consider the
furniture layout in the room. Ideally, every bedroom has options for arrangement of
furniture. In general, larger bedrooms allow for more flexible furniture positioning.
One care community found that a 12 x 12 module, exclusive of the toilet room,
provided maximal flexibility for a private room. The bed can be placed on different
walls to the residents liking. This would mean that multiple locations for a call
system be created, or a wireless system be installed (image on next page courtesy of
Evergreen Retirement Community).
If the care community is a high-acuity home, there must be specific locations

for medical gasses and suction. Although this may limit the bed placement in the
room, it does not mean that flexibility of other furniture cannot exist, giving the
resident a level of autonomy and personalization. The length of a call button cord
must be considered. If the resident cannot reach it from the bed, safety issues are
created and in turn, the placement of the bed will be limited (31).
Resident Room
Layout Options
State building codes vary, but many indicate that there must be 3 feet of
clear space on three sides of the bed (Delaware requires 4 feet between beds).
Although subject to interpretation by the authority having jurisdiction, this does not
mean that the head of the bed must be placed against the wall. Designing the
bedrooms so the long side of the bed can be against the wall permits the greatest
flexibility.
The ability to bring in favorite pieces of furniture promotes residents
memories of the past and helps them to create a sense of ownership in their
room(32).
Also,
bedrooms
are
nicer
aesthetically
with
residents
personal
belongings(33). The 2009 Life Safety Code has been adjusted to allow for any style of
furniture as long as there is a sprinkler system or smoke detector in the bedroom.
Allowing residents to decorate their rooms in a similar style to their past homes
eases the transition to the long-term care facility, and helps to increase the comfort
level of the residents(34).
Resident Personalization
Residents are coming to the care community to live. They should be able to
decorate their space with some personal possessions to assist in the transition to the
care community and create a more homelike environment in their living space. The
design can assist with personalization. We have previously discussed personal
furniture, so this discussion will entertain other forms of room personalization.
A resident may choose to bring items to hang on the walls. Staff feels that the
hanging of pictures is tremendously important (35). Some administrators express
concerns over on-going maintenance (e.g., spackling and repainting to cover nail
holes) required as residents change rooms. One way to solve this problem is to
install plate rails and picture hanging systems that do not involve nailing directly into
the wall surface(36). Plate rails also allow the personal items to be kept out of the way
of wandering residents(37).
Another trend is incorporating display cases in the hallway by the bedroom
(38)
door
. Display cases with personally meaningful items outside rooms allow better
orientation for residents with dementia. Zeisel found that personal items at a
bedrooms entrance were associated with fewer inappropriate behaviors(39). Other
ways to identify ones room include highly visible room numbers and distinguishing
colors for bedroom doors(40).
Storage
Studies are showing how the design of the residents bedroom can assist with
the residents ADLs. Such design features include modified wardrobes, staff storage
space in bedrooms, and location of light switches. Wardrobes or closets designed to
make it easier to find and access clothing is one adaptation (41). In one research
project, clothing that was to be worn the next day was chosen the night before and
hung in sequential order on one side of the closet, increasing dressing independence
by 19%(42). Some have found that locking access to part of the closet can minimize
rummaging, while others feel that residents should not be denied access to their
clothing. The wardrobe should also be at least 36 inches wide and be wide enough to
hold a coat, otherwise the implication is that one is unable to go anywhere (43).
If a small amount of space is designated for staff supplies in the bedroom, the
staff can be more efficient by not having to return to a central location between each
resident visit(44).
Lighting
Residents can begin their morning ADLs if they can have enough light to
ambulate safely. There should be a light switch and call button close to the bed,
easily reachable while still sitting on the bed(45). The ability to adjust lighting from
more than one location also increases autonomy and safety(46). Be cautious when
choosing tables with anchored lamps. These can improve safety, but will compromise
the residents ability to choose where the lighting is placed (47).
Other
options
for
lighting
can
make
the
resident
bedroom
less
institutionalized. For example, residents and staff indicate that lamps create a more
pleasant aesthetic than just having ceiling fixtures(48). Lighting coming from various
light sources offers the resident more autonomy in controlling the amount and type
of light in the room(49). By allowing the resident access to easily adjusted window
curtains or sheers, the amount of natural light can also be adjusted(50).
Visual and Auditory Stimulation

Although wallpaper can be more homelike than painted walls, some patterns
can be disorienting to the resident with dementia(51). Avoid patterns that have high
contrast and appear busy. Carpeting in the bedroom can reduce ambient noise and
provide texture to the room(52). Heating and cooling units should be as quiet as
possible to avoid overpowering background noise, which makes conversation more
difficult to interpret, especially with hearing aids(53). Ideally, each room will have
individual control over heat and air conditioning, and controls should be easily
adjustable by the resident. Call bells can be noisy, creating negative or unwanted
stimulation(54). Televisions should be placed at eye-level, as higher placement can
be negative(55).
10
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15
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17

Bedroom Design

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Bedroom Design

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References in this paper are based on a confidence rating scale.

A confidence rating of 1 is considered to

Primary Author: Margaret P. Calkins

Private Room vs. Shared Room

In the middle are a variety of room layouts that give each

Traditional Shared Room

Enhanced Shared Rooms

Shared Room Issues

Cost of Private Versus Shared Bedrooms

Room Layout and Doors

Flexibility of Furniture Layout

If the care community is a high-acuity home, there must be specific locations

Visual and Auditory Stimulation

Namazi, K.H. (1990). Effect of personalized cues at bedrooms on wayfinding among

Design Lexicon: Project description and outcomes. Unpublished manuscript.

Cluff, P. (1990). Alzheimer's disease in the institution: Issues in environmental design.

Baltimore MD: Health Professions Press.

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