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Purpose: The purpose of this research is to (1) investigate the impact of nursing unit design on nursing staff communication patterns and, ultimately, on patient falls in acute care nursing units; and (2) evaluate whether differences in fall rates, if found, were associated with the nursing unit physical structure (shape) or size.Background: Nursing staff communication and nursing unit design are frequently linked to patient safety outcomes, yet little is known about the impact of specific nursing unit designs on nursing communication patterns that might affect patient falls.Method: An exploratory longitudinal correlational design was used to measure nursing unit communication structures using social network analysis techniques. Data were collected 4 times over a 7-month period. Floor plans were used to determine nursing unit design. Fall rates were provided by hospital coordinators.Results: An analysis of covariance controlling for hospitals resulted in a statistically significant interaction of unit shape and size (number of beds). The interaction occurred when medium- and large-sized racetrack-shaped units intersected with medium- and large-sized cross-shaped units.Conclusion: The results suggest that nursing unit design shape impacts nursing communication patterns, and the interaction of shape and size may impact patient falls. How those communication patterns affect patient falls should be considered when planning hospital construction of nursing care units.