Identifying elements of the health care environment that contribute to wayfinding.

Research

Identifying Elements of the Health Care Environment That Contribute to Wayfinding

Health Environments Research & Design Journal 2015, Vol. 8(3) 44-67 ª The Author(s) 2015 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1937586714568864 herd.sagepub.com

Debajyoti Pati, PhD, FIIA, IDEC, LEED AP1, Thomas E. Harvey Jr, FAIA, MPH, FACHA, LEED AP2, Douglas A. Willis, RN, MBA3, and Sipra Pati, MA4

Abstract Objectives: Identify aspects of the physical environment that inform wayfinding for visitors. Compare and contrast the identified elements in frequency of use. Gain an understanding of the role the different elements and attributes play in the wayfinding process. Background: Wayfinding by patients and visitors is a documented problem in healthcare facilities. The few studies that have been conducted have identified some of the environmental elements that influence wayfinding. Moreover, literatures comparing different design strategies are absent. Currently there is limited knowledge to inform prioritization of strategies to optimize wayfinding within capital budget. Methods: A multi-method, non-experimental, qualitative, exploratory study design was adopted. The study was conducted in a large, acute care facility in Texas. Ten healthy adults in five age groups, representing both sexes, participated in the study as simulated visitors. Data collection included (a) verbal protocols during navigation; (b) questionnaire; and (c) verbal directions from hospital employees. Data were collected during Fall 2013. Results: Physical design elements contributing to wayfinding include signs, architectural features, maps, interior elements (artwork, display boards, information counters, etc.), functional clusters, interior elements pairing, structural elements, and furniture. The information is used in different ways - some for primary navigational information, some for supporting navigational information, and some as familiarity markers. Conclusions: The physical environment has a critical role in aiding navigation in healthcare facilities. Architectural feature is the top contributor in the domain of architecture. Artwork (painting, sculpture, etc.) is the top contributor in the domain of interior design. Keywords wayfinding, hospital, health care design, interior design

Background Wayfinding is the ability to find one’s way without getting lost (Passini, Rainville, & Marchand, 1998). In itself a simple goal, this can be one of the most stressful tasks in a hospital. That wayfinding constitutes a chronic problem in health care facilities, and

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Department of Design, Texas Tech University, Lubbock, TX, USA 2 HKS Inc, Dallas, TX, USA 3 Texas Health Presbyterian Hospital Dallas, Dallas, TX, USA 4 Center for Advanced Design Research & Evaluation, Dallas, TX, USA To earn continuing education units on this article visit herd.sagepub.com/supplemental Corresponding Author: Debajyoti Pati, PhD, FIIA, IDEC, LEED AP, Department of Design, Texas Tech University, Lubbock, TX, USA. Email: [email protected]

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potentially affects staff time as well as the organization’s bottom line, is evidenced by multiple articles in professional and academic journals dating back to the 20th century (see for instance, Del Nord, 1999; O’Neill, 1991; Zimring, 1990). Wayfinding problems have been associated with high blood pressure, increased physical aggression, and fatigue in patients (Carpman & Grant, 2001). Furthermore, Rousek and Hallbeck (2011) argue that with an aging population, it is important to also consider patients with visual impairments when designing a wayfinding system. They identified several design elements involving signage, paths/target sites, lighting, and flooring that created navigation issues. The effects of the wayfinding issues on participants ranged from tripping to getting lost in the surrounding environment. The unique needs of the elderly population were further emphasized in a study by Lee and Kline (2011) who demonstrated that younger subjects performed better in wayfinding tasks than an elderly subject group. Although wayfinding has been acknowledged as a key concern in health care facilities, few comprehensive studies of the designed environment in health care facilities are available in published literature. Disparate studies have identified a few of the environmental attributes that influence navigation, including visual configuration of space, signage, landmarks, architectural differentiation, and symmetry of layout (Ahn, 2006; Baskaya, Wilson, & Ozcan, 2004; Carpman, Grant, & Simmons, 1985). More recently, a position paper published for the Center for Health Design argues that the building blocks of a wayfinding system for a hospital are put in place in the master plan, architecture, interior design, and finally the facility amenities, graphics, and signage. Based on earlier work (Passini & Arthur, 1992), the whitepaper suggests that a person in a hospital, looking for a destination, relies on five wayfinding factors (Huelat, 2007), that is, (1) knowing where he or she is, (2) knowing his or her destination, (3) knowing which route gets him or her to the destination, (4) knowing when he or she has reached the destination, and (5) knowing how to return. The aforementioned literature provided two pieces of key information, that is, (1) navigation inside buildings entails multiple questions, from comprehending where one is to knowing when

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one reaches the destination and (2) people seek information from multiple environmental sources during navigation inside buildings. In contemporary hospitals, designers hypothesize and implement multiple strategies to aid wayfinding (from personal experience of the authors). Since the implementation of any design strategy is associated with capital cost expenditure, the existing literature lacks information for design prioritization. All capital projects have an upper limit to available funds. It is typical across projects to prioritize and compromise among and between design strategies to complete a project within budget. What strategies, then, should designers accord more importance to? An associated issue important to capital optimization as well as developing strategies across capital projects is the way environmental cues are processed in the human cognitive system. It is conceivable that some cues are used for short-term cognitive processing whereas others are retained in long-term memory. Seminal studies on wayfinding in urban environments and complex navigation systems have suggested the concept of ‘‘mental maps’’ or ‘‘cognitive maps’’ (Lynch, 1960; Siegel & White, 1975). These theories suggest that people develop mental representations of the environment they encounter to better comprehend as well as navigate within it. These mental representations incorporate two types of information, that is, a survey-type information that constitute skeletal information at the global scale and route information that are context rich and incorporate environmental information at the local scale. Lynch (1960) suggested five types of information that get captured in cognitive maps as people attempt to make sense of their cities, namely, (1) path (streets, sidewalks, trails, and other channels in which people travel), (2) edge (perceived boundaries such as walls, buildings, and shorelines), (3) district (large sections of an urban area distinguished by some identity), (4) node (focal points, intersections, or loci), and (5) landmark (readily identifiable objects that serve as external reference points). Furthermore, Siegel and White (1975) asserted that the mental map is constructed of a series of mini-representations of a large and complex environment. People use such elements as paths to connect representations meaningfully.

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Health Environments Research & Design Journal 8(3)

Little is known regarding the types of environmental information used by people navigating inside buildings to populate and make sense of their cognitive maps. If data can be generated on (1) what types of environmental information people use while navigating inside buildings—which has already been examined to some extent in published literature, (2) which of the environmental cues are used more frequently—yet unknown, and (3) what roles do the different classes of information play in the development of mini-representations and cognitive maps, such data can serve as valuable design support information. Such information can enable optimization of wayfinding behavior, long-term organizational performance as well as first cost of health care facilities.

Objective The specific aim of this study was to examine the nature and extent of aid provided by various design elements in supporting wayfinding decisions by adult visitors in an acute care hospital.

Research Questions Considering the paucity of actionable knowledge available in the current scholarly literature, this study addresses three questions: 1. What aspects of the physical environment aid in wayfinding decision making for visitors? 2. How do the various wayfinding strategies compare in frequency of use? 3. What role do environmental cues in health care facilities, such as configuration, color, art, visible landmarks, maps, visual signage, and so on play win the wayfinding process?

Methodology A multi-method, nonexperimental, exploratory, qualitative design was adopted for the study. Wayfinding theories on urban environments were used as a starting point to code and classify data. The basic data types included verbal protocol, digital photography, and subjects’ response on a survey questionnaire. The protocol was approved by the institutional review board of the corporate

entity having administrative jurisdiction over the study hospital.

Study Setting The study was conducted in an 866-bed, tertiary care facility in Texas. In 2009, a large new addition of 512,000 square feet, coupled with 132,000 square feet renovation of existing buildings, was completed. Considerable attention was given to creating a building design and deliberate features that would assist wayfinding through this large health care complex. As a collection of interconnected buildings, this site offered a unique setting for undertaking this study. End users navigating to a destination may come across settings with different levels of environmental information in the same trip. In the new addition, several design elements and strategies were incorporated to enhance wayfinding. Internet-based research was conducted by the design team to develop hypotheses on the type of elements or strategies that help people navigate through a building. The initial framework identified a variety of environmental information that possibly supports wayfinding, including colors, numbers, landmarks, and orientation by direction or views. More specifically, the following strategies were incorporated: 1. Each floor has its own unique landmarks. For instance, artwork in the elevator lobbies are unique to each floor as shown in Figure 1a. 2. Each floor and each unit has its own unique numbering system. Rooms are identified by unique room numbers ‘‘AB54321’’ identifying the building (AB), the floor number (54), and then the room number (321). For example, a patient tower room numbers start with an H (first alphabet in the building name) followed by the floor number and then the specific room number (e.g., H03210). 3. Each floor has its own views to the outside to orient visitors and maintain a sense of direction. This is most prominent in the waiting areas at the elevator lobby and on the ends of the bed units. Figure 1b

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Figure 1. (a) Artwork in elevator lobbies. (b) Exposure from key public areas to exterior views.

illustrates exposure from key public areas to exterior views. 4. The art at the footwall of the patient rooms are selected from a series of six photographs so that not every adjacent room has the same footwall photograph (i.e., repetitions occur at a large interval of 80–90 feet).

Routes Three different and interconnected buildings were chosen for the study. The buildings included a main hospital, a professional (medical office) building, and a patient tower. A total of 11 sequential origin-destination routes were identified for the study, which covered exterior parking lots and spaces in the three buildings. The destinations covered four different levels, some of which can be reached via elevators, staircases, and an escalator. Exiting the building and approaching some of the destinations through exterior routes was also an option in some cases. The sequence of destination was designed such that a single one-way route to cover all destinations was not a possibility. The first origin point was approximately a mile away from the hospital, inside a mall. The last destination point was the hospital parking lot in which the subject was parked. The destinations

in the exact sequence used in the study are reproduced in Table 1.

Subjects, Sample, and Recruitment Two types of subjects were recruited for the study, namely, (1) volunteering healthy adults to simulate visitors and (2) volunteering hospital employees. In the case of simulated visitors, considering the exploratory nature of the study, a total sample size of 10 adults were targeted. Solicitation fliers were posted in churches, community halls, and grocery stores. In addition, general e-mail solicitation was sent to all employees and students at two professional institutions. There were three exclusion criteria for simulated visitors, namely, (1) the subject must not have visited or have been an employee at the hospital in the past; (2) the subject must not be a design professional or student, such as architect, interior designer, engineer, and so on; and (3) the subject must have normal eye sight for their age. A purposive quota sampling strategy was adopted for the study. Two types of quota were targeted. One was age-group. The study targeted two subjects in the age-groups of 20–29, 30–39, 40–49, 50–59, and 60 and above. Within each age-group, one subject was targeted to be male and the other female. Subjects were recruited on

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Table 1. Origins and Destinations Used in the Study. Route

Origin

Destination

Route 1

Suburban mall parking lot

Route Route Route Route Route Route Route Route Route Route

Hospital parking lot Main lobby Patient room H403 Cafeteria Imaging check-in desk Chapel Surgery waiting Admissions Professional building 1, elevator lobby Interventional center

Hospital parking lot (subject’s choice from multiple parking options) Main lobby Patient room H403 Cafeteria Imaging check-in desk Chapel Surgery waiting Admissions Professional building 1, elevator lobby Interventional center Subject’s parking lot

2 3 4 5 6 7 8 9 10 11

a first-come basis, until the quota in each subgroup was exhausted. There was no predetermined selection strategy for hospital employees. They were selected onsite at random by a research assistant. Other than visual identification of the employee by a hospital ID card or badge, there were no inclusion or exclusion criteria for recruitment of employees. One hospital employee was randomly approached at each origin point, only for those origins located inside the hospital. A total of eight hospital employees took part in the study.

Data Types and Instruments Simulated visitors. Three types of data were collected from simulated visitors. The first type of data involved verbal protocol. Subjects were given a destination at each sequential origin and asked to find their way. However, they were instructed to speak aloud (or think aloud) every thought occurring in their cognitive process. To prime the subjects, they were asked to imagine that one of their family members or relatives is currently a patient in the hospital and they need to perform certain tasks with the minimal expenditure of time. A research assistant accompanied the subject close by at all times, one of whose tasks was to continuously remind the subject to think aloud. The subjects were instructed to approach volunteers for help only if they feel that they are completely lost and only as a last resort. Their task was to navigate all the 11 routes by using

environmental cues alone. At no point in the process did the study staff offer or provide help to the subject. Two additional research assistants followed the subject. One assistant took photographs of physical elements that the subject pointed out during navigation as things aiding or hindering navigation. The third assistant captured the subject’s path on a set of pdf floor plans of the three buildings. At the conclusion of navigating the 11 routes, the subjects were administered a survey. The survey asked a short list of simple factual questions regarding their navigation experience in the hospital. The survey was expected to provide triangulation data for those generated through verbal protocol. Verbal protocol data were recorded using digital audio recorders. A digital camera was used for capturing photographs. Employees. Only one type of data was collected from the employees. At each origin point one employee was asked to provide verbal direction to the next destination (as outlined in Table 1). The verbal directions were captured using digital audio recorder.

Data Collection Simulated visitors. On the day of data collection, subjects’ simulating visitors were instructed to arrive at a predetermined time to a mall parking lot, about a mile from the hospital. On arrival they were given a description of the study, the task she or he was expected to perform and their rights as

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human subjects. Questions posed by the subjects, if any, were then responded to, and the informed consent form was administered. Subsequently, the subject was fitted with a digital audio recorder and then taken as a passenger to the site. She or he started giving verbal directions and thinking aloud (verbal protocol) from the mall parking lot. From that point onward, she or he was provided standardized oral instructions to proceed to the next predetermined destination, one at a time, until she or he reached the last destination. The last task involved filling out the survey. The subject was subsequently dropped back in the mall parking lot. The entire process took between 2 and 3 hrs. Employees. A study staff randomly selected an employee at each of the origin points located inside the hospital. The employee was provided with a verbal description of the study and was inquired regarding his or her interest in voluntary participation. On gaining approval, an informed consent form was administered. Subsequently, the employee was asked to provide verbal directions to the next destination on the list of routes. The total time with each employee was between 5 and 10 mins.

Data Preparation and Analysis Audio-recorded data from the 10 simulated visitors and 8 employees were transcribed verbatim by a professional transcriptionist. The transcripts were subsequently examined through content analysis. Microsoft Excel program was used for capturing data from the content analysis, in a series of separate worksheets. Coding the data involved two parallel strategies. In the first strategy, theories and frameworks from wayfinding in exterior environments were used as classifiers. The second strategy adopted a grounded theory approach, which included memoing and pattern identification. Memoing is a term used by qualitative research to describe the note taking done when first passing over considerable data to begin to look for patterns. The following questions constituted the primary drivers of the coding, memoing, and pattern identification tasks:

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1. Are subjects actively or passively seeking information from the physical environment? If so, what environmental elements or attributes are being used? 2. Are there evidences related to the five wayfinding factors articulated by Huelat (2007)? 3. Are there indications on the subjects’ use of environmental information in some form of cognitive map? Is meaningful route knowledge being created? Are subjects creating some form of survey knowledge? Are there meaningful counterparts of the five elements (Lynch, 1960)—path, edge, district, node, and landmark—in building interiors? 4. Do employees use environmental information while providing directions? The final sets of coding involved three clusters, namely, (1) those related to Huelat’s (2007) five factors, (2) those related to individual physical design attributes and elements, and (3) those related to cognitive maps. Chunks of data relevant to more than one coding cluster were coded and captured for each qualifying cluster separately (in duplication). The same type of coding was performed for audio recordings of employees’ verbal directions. The coding and data representation on Excel worksheets were done separately and individually for each subject and for each route. Time stamp from digital photographs and path/route maps was cross checked and individual images were linked to each subject’s verbal recording. Data from the paper survey were transferred to an Excel worksheet. The worksheets were subsequently rendered ready for quantitative analysis. The clusters and classification resulting from the coding phase, along with definitions, are listed in Table 2 (subclasses are not included but described in subsequent sections). This table also provides examples of subjects’ verbal exposition for each coding category. Since some of the coding classes entailed subjective judgments, coded data were reviewed by more than one member of the research team to ensure that expositions were classified meaningfully and accurately. Numerical frequency data were captured for each instance of occurrence, within each category, separately for each subject and each route.

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Table 2. Clusters and Coding Categories From Subject’s Verbal Protocol. Cluster

Coding Categories

Definition

Huelat’s (2007) five wayfinding factors

Where am I? Where to go? How to go? Did I reach? How to get back?

Environmental cues (elements and attributes)

Maps

Subjects’ comprehension of their current location Subjects’ comprehension of the location of destination Subjects’ comprehension of the route leading to destination Subjects’ comprehension of arrival at destination Subjects’ comprehension of route to previous origin point or other known location Diagrammatic, 2-dimensional representation of the global environment Alphanumeric and symbolic declarations of programmatic spaces, directions, and routes Logical clustering of programmatic spaces with mutually supportive functions Large movable equipment and associated accessories procured or designed by interior designers Logical pairing of elements of interior architecture (excluding furniture), with associated functions Physical elements designed by structural engineers Attributes of physical environment designed by architects Elements or attributes of physical environment procured or designed by interior designers used in a different way by subjects Spatial representations in the human brain Elements or attributes of the physical environment that are used as markers in cognitive maps

Signs Functional clusters Furniture Interior element pairing Structural elements Architectural features Other design elements

Cognitive mapping

Mental map Familiarity markers

The quantitative data were subsequently subjected to descriptive analysis. Data from employees and surveys were analyzed using similar descriptive statistics and compared with quantitative analyses of the audio transcripts of simulated visitors. Quantitative analyses were guided by the three research questions. The following questions were asked of the quantitative data: 1. What aspects of the physical environment aid in wayfinding decision making for visitors? This question was examined as part of the coding exercise. 2. How do the various wayfinding strategies compare in frequency of use for visitors? Examination of this question was conducted by calculating ‘‘percentage of total’’ for the frequency data in each individual category when compared to the total in each cluster. The cluster used was ‘‘environmental cues (elements and attributes).’’

3. What role do physical environment elements and attributes in health care facilities play in the wayfinding process? Examination of this question was conducted by calculating percentage of total for the frequency data in each individual category when compared to the total in each cluster. The clusters used here included ‘‘Huelat’s (2007) five wayfinding factors’’ and cognitive mapping.

Findings Aspects of the Physical Environment Contributing to Wayfinding A large variety of elements and attributes of the physical environment were identified in the data as contributing to wayfinding. The nature and frequency of support, however, vary considerably. Those include (1) maps, (2) signs, (3) logical clustering of functions, (4) furniture, (5) logical pairing of interior architecture elements, (6)

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structural elements (7) architectural features, and (8) other design elements. The ‘‘other design elements’’ include a large variety of things that interior designers procure or design and incorporate in building interiors. The specific elements found to be contributing to wayfinding, in this study, include (1) artwork, (2) fixed furniture and millwork, (3) display boards and information panels, (4) wall color, (5) vending machines, and (6) indoor plants. Following are brief descriptions of the elements and attributes identified. Maps. Maps, in this study, stand for diagrammatic, two-dimensional representation of the global environment. Maps on the study site primarily showed major departments, names of key program areas, hallways and corridors, and location of vertical circulation. Subjects frequently used maps for navigational information. Their most frequent focus was on hallways, vertical circulation nodes, and departmental boundaries. An observation worth noting was that subjects expected the exact name of their destination on the map. Furthermore, subjects expected a uniform pattern of map locations. For instance, if the first map they encounter was located in the elevator lobby, they expected a map every time they came across an elevator lobby. Figure 2 shows the two most common locations for maps when sought by the subjects—counter tops of the information desks in the lobbies of different hospital buildings and in the elevator lobbies. The following quote is an example of verbal protocol demonstrating the use of maps for navigational information: Here are what appear to be cashier stations and I saw those on the map so I thought that this long hallway here was near where the cafeteria would be and I see here now a sign that points me toward Cafeteria so I think I should go that way.

Signs. Signs, in this study, stand for alphanumeric and symbolic declarations of programmatic spaces, directions, and routes. Those include room or space names and labels, directional signs, and images, logos, or symbols suggesting programmatic use. Signs constituted one of the first types of information sought by subjects. Each minute aspect of labels, space names, numbers, and arrow

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directions (in directional signs) were intricately examined by the subjects in order to derive useful and logical navigational information. Data suggest some noteworthy observations. First, in sign boards showing multiple destinations, subjects expected the destinations to appear in the same order as shown on the sign board. Further, similar to maps, subjects expected some pattern in the location and orientation of signs, based on their first encounter with a type of sign. Figure 3 shows the different types of signs displayed in the hospital. The following verbal protocol exemplifies the use of signs for navigational aid: Well, I am looking for Patient Room H403 I believe you said, but I am not seeing something that says Patient Rooms.

Functional clusters. Functional clusters are defined as logical clustering of programmatic spaces with (sometimes) mutually supportive or complementary functions. Examples of such clusters include proximal location of cafeteria and lobby, main entrance and admissions, and adult waiting and children’s play area, among others. Figure 4a illustrates the proximity of a children’s play area to an adult waiting area. The actual waiting area (not visible here) is located on the other side of the escalator shaft. The following verbal protocol is the example of the way functional clusters were used as information sources: Everything is usually on the first floor Lobby area, food, you know, souvenirs or presents. The gift shop is usually on the same floor.

Furniture. Furniture is defined as large movable equipment and associated accessories procured or designed by interior designers. It includes tables, chairs, sofas, and so forth. Subjects drew logical conclusions from the type of furniture they encountered in their field of vision. For instance, they associated the presence of seats with waiting area, located far away in the visual field to be able to read signs and labels. Figure 4b is a view of a waiting area when walking toward the imaging department. The sight of the chairs, occupied or not, indicated that this was a waiting area. No signs were visible from here. The following verbal protocol exemplifies the use of information from furniture:

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Figure 2. (a) Maps on counter tops of information desk in lobby. (b) Map in elevator lobby.

Figure 3. Signs displayed in different parts of the hospital. Well I kind of see like something waiting down there . . . yes, I see like a lot of chairs and stuff . . . .

Interior element pairing. Element pairing refers to logical pairing of interior architecture elements (excluding furniture), with associated functions. For instance, interior windows (Figure 4c) with counters were associated with admissions. The following verbal protocol shows an

example of information derived from pairing (accurate or not): I am looking at that window over there. I don’t know what that is. I thought maybe it was something to do with Admissions.

Structural elements. Structural elements are defined as physical elements designed by structural engineers. Examples include structural

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Figure 4. (a) Children’s play area in an adult waiting area; (b) chairs, sofas, and couches, whether occupied or not, were indicative of a waiting area, even from a distance; (c) the ‘‘after hours’’ window of the pharmacy which a subject thought to be the admission area; (d) the columns that separated the working areas of medical records employees were mistaken from a distance to be elevator banks.

columns, beams, and so on. Subjects indulged in intelligent guesswork when they encountered with certain structure–function phenotypes. For instance, the presence of a series of deep columns was associated with elevator bank, although that was not the case, as illustrated in Figure 4d. The following verbal protocol provides an example:

That appears to be maybe a bank of elevators there . . . I thought it was but I see now that it does not appear to be.

Architectural features. Architectural features are defined as attributes of physical environment designed by architects or interior designers. Architectural features included two types of

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attributes. One pertained to view of exterior spaces from the interiors. The second pertained to multilevel interior views afforded by atriums. In addition, directional signs posted in exterior spaces were picked up by subjects as informational cues to help navigate in interior environments. The following verbal quote provides an example of the use of such information: Yes and there is Professional Building 3, which makes me think that this is Professional Building 1.

Other design elements. This category includes things in the physical environment procured or designed by interior designers but provided a different type of information to the subjects. Although many of the elements in this category will seem to have apparent overlap with other categories articulated earlier, the fundamental difference is that subjects used elements listed in this category purely as familiarity markers and not as active navigational aids. The subtle distinction between familiarity markers and navigational aid (albeit, perhaps, not less important in any manner) is articulated in detail in the discussion section. Interior elements identified in the data, belonging to this category, include (1) pieces of artwork, specifically paintings, sculptures, and piano; (2) fixed furniture and millwork, specifically information desk and cashier station; (3) display board and information panels, specifically, glass panel displaying names of donors, surgery information screen, electronic board with nonnavigational information, and a plaque with historical information; (4) wall color; and (5) vending machines. It is noteworthy that in case of paintings, the subjects did not capture the content of the artwork. They simply captured the existence of the artwork at a location. In addition, information desks were pointed out by subjects, whether occupied or not. Furthermore, display boards with information irrelevant to navigation were, nevertheless, found to be useful by the subjects. These other design elements are illustrated in Figure 5. Two other elements—indoor plants and fire extinguishers—were used only once as familiarity

markers and hence were excluded from the data analysis. The following verbal protocol data are examples of use of this type of environmental elements: The patient floor that we were on however was a completely different color, completely different tone. Everything about it was totally different. I would know that if I go there again. And I see Information desk so I know that (the destination) is not going to be it right there. I remember coming in from here because of the artwork which actually helps me stimulate my memory because it is different and it is an individual. That’s the hard part I have had with other hospitals is the fact that everything looks the same. My guess is it (the destination) is right there . . . by that television board that we just passed by that we were looking at.

Comparison of Frequency of Use How frequently did the subjects use the variety of environmental information identified in the previous section for active navigation or developing familiarity? Proportion and percentage data were calculated within the ‘‘environmental cues’’ cluster. Table 3 presents example text chunks within each type of coding category. It should be noted that environmental information in the ‘‘other design elements’’ category were used in a different way by the subjects (for familiarity development) in comparison to the remaining classifications (which were used as information for active navigation). Table 4 presents the percentage of times different types of environmental information were sought by the subjects. Table 5 presents the distribution in the other design elements category. A few notable observations can be made in Tables 3 and 4. Signs constitute the most frequent environmental information sought by subjects— substantially more than the other classes of information. Four classes of environmental information—signs, architectural features, maps, and other design elements—covered 95% of the occasions when environmental information were sought by subjects. Among other design elements, artworks were associated with the highest

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Figure 5. Other design elements. (a) artwork; (b) artwork; (c) electronic interactive panel; (d) glass panel displaying the names of donors; (e) wall color; and (f) desk.

frequency of environmental information use. Three types of other design elements—artwork, display boards and information panels, and fixed furniture and millwork—together accounted for 90% of the environmental information use.

Role of Physical Environment Elements and Attributes in the Wayfinding Phenomena What role do physical environment elements and attributes in health care facilities play in the

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Table 3. Examples of Text Chunks Coded in Different Categories of Environmental Information. Environmental Information Category

Subcategory

Example Quote

Maps

I will go look the first floor map again and see if it gives me any clues I was also checking to see how close we were to the next Information desk because there might be a map up there No I didn’t see a map set up similar to the one that is upstairs Signs I like having the sign on the side. If they just had the sign on the top I could cruise right past there and never notice that it was Admissions And right off the escalator I see a sign that says Chapel with an arrow straight ahead and I am going to follow that So this goes Cafeteria, Coffee Shop, Cashier, Chapel. So if there was any kind of justice in the world when we go down here we’d find them in that order Functional Everything is usually on the first floor Lobby area, food, you know, clusters souvenirs or presents. The gift shop is usually on the same floor Areas away from the Main building is more medical things. I don’t think there is coffee there Obviously here is Admissions and here is ATM, here is Restrooms. All of those things are normally in a kind of central location maybe near the lobby and an area where perhaps you would be headed toward patient rooms. Cashier’s Department. This appears to be the Cashier’s Department. That would lead me to believe I am near check-in Furniture I kind of see like something waiting down there but I am not sure if it is for the Surgery. I see like a lot of chairs and stuff Interior element I am looking at that window over there . . . I thought maybe it was pairing something to do with Admissions Structural That appears to be maybe a bank of elevators there elements . . . I thought it was but I see now that it does not appear to be Architectural Since I saw so many people waiting down there that’s what I kind of think features is the Surgery Lounge There is a wide space there that could be some sort of, or perhaps, it is still down another level because all those people were sitting down there that it is possible they were waiting for imaging Other design Artwork I remember the pictures on the wall now even though they didn’t mean elements anything to me I remember that pretty art at the end of the hallway too I remember coming in from here because of the artwork which actually helps me stimulate my memory because it is different and it is an individual. That’s . . . the hard part I have had with other hospitals is the fact that everything looks the same The walls are bland. The artwork helps. It is soothing, it is nice, and it is also a good reference point . . . it is a churchy door. Yes, it is real tall. It is taller than any of the other doors, interesting glasswork Fixed furniture And I see Information desk so I know that (the destination) is not going to and millwork be it right there I am just now seeing this electronic . . . Something that might look like an Display boards electronic board. Yes, maybe and it is. Oh no, this is just for donors. and information This is not helpful whatsoever panels (continued)

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Table 3. (continued) Environmental Information Category

Subcategory

Wall color

Vending machine

Example Quote My guess is it (the destination) is right there . . . by that television board that we just passed by that we were looking at We were here because this is the older part. So this is that same putty color of the old computers The patient floor that we were on however was a completely different color, completely different tone. Everything about it was totally different. I would know that if I go there again Everything is visually repetitive. You get that kind of Poltergeist feel like I am in a never ending hallway. I am not going to get where I am going because it just keeps looking the same. Nothing changes See now I am seeing people and I am seeing a coffee machine and that is what you see when you see a surgery waiting area

Table 4. Comparison of Environmental Information Types Sought by Subjects, From Most to Least Frequent. Environmental Cues Signs Architectural features Maps Other design elements Functional clusters Interior element pairing Structural elements Furniture

Frequency

Percentage of Total

825 139 76 63 29 13 12 10

70.70% 12.00% 6.50% 5.40% 2.50% 1.10% 1.00% 0.90%

Note. Frequencies may not represent importance; importance was not measured in this study. Percentage figures are rounded; total may not be exactly 100.

wayfinding process? This question was examined using two coding clusters. The first pertained to Huelat’s (2007) suggestion that the process involves five questions, namely (1) knowing where he or she is, (2) knowing his or her destination, (3) knowing which route gets him or her to the destination, (4) knowing when he or she has reached the destination, and (5) knowing how to return. Accordingly, the data coding exercise included each of the five themes to examine whether such thought processes exist and if so the comparative frequency of such thought processes. Data suggest that all five thought processes occurred among subjects. Examples of text chunks from audio transcripts that were used in

each thematic category are presented in Table 6. The comparative frequencies of each of these themes, as counted from audio transcript data, are presented in Table 7. Data suggest that almost two thirds of the time subjects were seeking environmental information associated with the wayfinding questions of the location of the destination and the way to navigate to the destination. Using environmental information for comprehension of current location was the third most frequent sought cue. Two new phenomena were observed during navigation. Although ‘‘where a person is’’ is typically associated with a person’s starting location, data suggest that subjects engaged in a ‘‘continuous assessment’’ of their then current situation during the entire process of navigation. According to study data, 66% of the thought process during navigation between sets of origin-destination were devoted to continuous assessment of ‘‘where am I?’’ Example of text chunk that articulates this phenomenon is provided subsequently. Implications of this phenomenon are addressed in the discussion section. I could see the sign (name deleted) at the top so I know that I am, I hope that I am going in the right direction. . . . .and if I am correct that H stands for (name deleted), which may not, hence I would think that maybe I am near patient rooms. We at least do appear to be in patient rooms now and there is 461.

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Table 5. Comparison of Elements Within ‘‘Other Design Elements’’ From Most to Least Frequent. Other Design Elements Artwork Display boards and information panels Fixed furniture and millwork Wall color Vending machine

Frequency

Percentage of Total of ‘‘Other Design Elements’’

Percentage of Total of All Elements

22 17 11 4 2

39.30% 30.40% 19.60% 7.10% 3.60%

1.89% 1.46% 0.94% 0.34% 0.17%

Note. Frequencies may not represent importance, and importance was not measured in this study. 2Percentage figures are rounded, and total may not be exactly 100.

Table 6. Examples of Text Chunks in Each Thematic Category. Thematic Category

Example Text Chunk

Where am I? Where to go?

I am just more towards the main part I am wondering if it may be that large area two floors down, so my proposal would be to go back After we get off the escalator I am going to go to my left That would probably lead me outside the hospital which is not what I want. So and then here so I see there is another exit-type looking thing so I don’t want to go that way How to go? I guess we can use the escalators So I am going to go up the escalators and then I am going to look at that sign that is up there Did I reach? And then this, that little sign, it is kind of small but it says, Welcome to the Family Surgery Waiting Lounge, so this is the waiting lounge So this sign on the pillar was the one I looked at when I was looking for the Surgical Center so that says the Interventional Center, so that confirms that it is here Returning back? I am going back down the putty-colored hallway . . . my thinking as I am going to some place I always want to know how to get back. So I like to point out things to find my way back I am going to go back the way I came just to be on the safe side. So I am going to turn to my right and I am just going to go back to the Main Lobby . . . We came this way and we came down the escalator so I am going to go back up the escalator

This elevator where we are standing maybe is this one although I don’t see . . . They are conference rooms and auditoriums, teaching areas, forum. So this is not what I am looking for.

A second phenomenon pertains to the subjects’ prediction regarding the probable visual appearance of the destination. Although it occurred explicitly in only 2.7% of the total occurrences of the five questions in the thematic category discussed in this section, it has potential implicit or indirect association with some of the classes of environmental information discussed in the other coding categories. This phenomenon will be further articulated

Table 7. Frequency Comparison of Huelat’s (2007) Questions During the Wayfinding Process, From Highest to Lowest. Thematic Category Where to go? How to go? Where am I? Returning back? Did I reach?

Frequency

Percent of Total Occurrences

377 332 162 115 78

35.40% 31.20% 15.20% 10.80% 7.30%

Note. 1 Frequencies may not represent importance, and importance was not measured in this study. Percentage figures are rounded, and total may not be exactly 100.

in the discussion section. Example of text chunk that articulates this phenomenon is provided subsequently.

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Table 8. Frequency Statistics and Example Text Chunks Pertaining to Cognitive Mapping. Wayfinding Phenomenon

Frequency

Percentage of Total Example Text Chunk

Mental map

109

62.40%

Familiarity marker 68

37.60%

(Name deleted). Okay, I remember seeing that when we were on the first floor I remember the Chapel is the very first thing on the left when we came in from the lobby so So I think that is kind, kind of far, not far, but I am going to go back down the same hallway because I remember it was not in the main area but it was a floor below with the escalators . . . .there should be a help desk here. Oh! Escalators, escalators. We should go to the escalators. . . . Yes, right above the escalators is the sign, surgery lounge

I would imagine that Surgery Waiting would be kind of big because I imagine this is where family is. But if it was like a waiting area or a reception area or that kind of thing there would be chairs against the window and it would be a dead giveaway—that’s a place where people wait. Most cafeterias are on the first floor.

The second coding cluster examined here is the one pertaining to cognitive mapping. Transcripts of audio data suggest evidence in support of two themes, namely, (1) creation of mental maps and (2) adoption of familiarity markers. Table 8 presents example text chunks as well as frequency statistics on the two concepts. Although prevailing theories provide evidence of people developing mental maps, the phenomenon of adopting familiarity markers in the process has not been discussed widely. A related phenomenon observed from the data is the use of ‘‘anchor points’’ by the subjects. The term anchor point is coined by the authors and was not used by the subjects. The concept relates to the adoption of a base location (like a mother ship in space) by the subjects, which served as interim point of familiarity and perceived safety as well as major nodes and orientation points in their mental maps. Subjects used such terms to refer to anchor points as ‘‘home base,’’ ‘‘where everything is,’’ ‘‘where I feel safe,’’ ‘‘that’s where I get help,’’ and ‘‘point of reference.’’ In total there are 32 instances of use of anchor points by subjects. On detailed examination of routes subjects followed, anchor points demonstrate some common

characteristics, including (1) close to an exterior entrance point (not necessarily the entrance used by the subject), (2) presence of vertical circulation, (3) presence of multiple activities, and (4) presence of maps and directional signs. Even if a specific anchor point had not been very effective in offering adequate help in locating their destinations, subjects still sought to return to these anchor points to orient themselves. A key concept from literature—landmarks— only rarely surfaced in the audio transcripts as a word. However, data suggest multiple uses of landmarks and varying elements serving as landmarks. Furthermore, landmarks were closely linked to the concept of familiarity markers. What are the implications of anchor points? What purpose do familiarity markers serve? What elements do people use to create familiarity markers? These issues are addressed in the discussion section.

Environmental Information Use in Employee Direction–Giving Behavior Most of the verbal directions provided by employees involved architectural features (hallways, lobby area) at 67.6% of total reference to environmental elements and attributes. It was followed by directional signs (8.8%) and space labels (2.4%) both falling under the ‘‘signs’’ classification. Following is an example quote of instances of use of physical design cues by employees. You come around our radiology front desk and head down the hallway to the orange chairs. You take a right at the orange chairs, okay?

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Table 9. Mean Ranking (Highest to Lowest) of Navigational Aid Self-Reported by Subjects in the Survey. Line Item

Table 10. Landmarks Self-Reported by Subjects as Helpful Information, in the Survey.

Mean Ranking

Following instinct Following signs and directions Following landmarks Asking people for help Using Facility Map

3.89 3.78 3.33 2.33 2.22

Follow that hallway to the elevator, which will be on your right. Take the elevator to the first floor and you should see the Chapel.

Results of Paper Survey Two findings from data analysis of the survey are of relevance. The first involved the response to a question ‘‘On a scale of 0–5, to what degree did the following help you in locating your destination today?’’ The line items included (1) ‘‘following signs and directions,’’ (2) asking people for help, (3) ‘‘following landmarks,’’ (4) ‘‘following instinct,’’ and (5) using a facility map. Table 9 presents the mean ranking obtained from data analysis. A second survey question of relevance is ‘‘along the route to your destination, are there any landmarks (distinctive features in the environment such as artwork, colors, stairs, elevators, and so forth) that you remembered particularly, which may help you find your way next time?’’ Table 10 lists the landmarks self-reported by subjects.

Discussion Environmental Information Sought by Subjects Study data suggest several useful information from practical as well as theoretical perspectives. The first issue of relevance is the kind of information sought by subjects during navigation. Data demonstrate that a wide range of environmental elements and attributes were used by subjects to navigate on the assigned routes, ranging from signs and architectural features to artwork. One key question of interest pertains to the elements

Landmark Architectural features (atrium, escalator, elevator, sky bridge, etc.) Artwork (painting, artwork around a column, etc.) Signs (including subway logo, bold signage, etc.) Other spaces (main lobby, lobby, patient tower lobby, etc.) Fixed furniture and millwork (desk, admission desk, etc.) Furniture (waiting area chairs, etc.) Functional clusters (coffee shop)

Frequency of Appearance in Survey Response 6 4 3 3 2 2 1

and attributes most frequently used by subjects. According to the study, data signs constitute the leader among all classes of environmental information, covering 71% of the number of times subjects sought information. Signs include space or room labels, numbers, directional signs, sign boards listing multiple destinations, and images and logos symbolizing certain functions. Based on study data, the environmental cues listed in Table 4 can be clubbed into three broader categories. The first broad category includes signs, architectural features, and maps. The authors would like to term this category ‘‘primary navigational information.’’ The second broad category includes functional clusters, interior element pairing, structural elements, and furniture. The authors would like to term this category ‘‘supporting navigational information.’’ The last broad category includes other design elements—which is itself an aggregate class including five subclasses of interior elements. The authors would like to term this category ‘‘mapping information.’’ Primary navigational information. Environmental elements and attributes in the primary navigational information category provided the global navigational information, as in ‘‘survey knowledge’’ suggested in literature. It creates the initial skeleton of the global environment in which the

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subjects navigated. It provided the basic, utilitarian, foundation of a cognitive map but lacking any rich contextual information. In terms of frequency of use the three elements or attributes, together, accounted for almost 90% of instances in which environmental information was sought by the subjects. This was corroborated in the subjects’ survey response, which after ‘‘following instinct’’ and following signs and directions obtained the highest mean rank to a question on the degree of help it provided in locating their destination. ‘‘Expanded visual access’’ was not part of the survey question. ‘‘Using facility map’’ showed up as the feature providing the least degree of help. The reason perhaps reflects on the quality of the maps as opposed to the frequency of use of maps (which was third highest). As noted earlier, subjects were expecting the exact name of their destination on the maps. It is possible that maps were not found to be helpful, despite the subjects’ frequent use of it for navigational information. It is noteworthy that none of the maps designed as navigation aid identified where the subject was (as in ‘‘You-AreHere’’). That may have contributed primarily to the low ratings of maps by subjects. These element or attribute types associated with primary navigational information are meaningful and intuitive. Signs and maps, by definition, provide the most vital information for navigation to a destination. Architectural features, in this study defined as visual access to exterior environments along with multilevel interior environments, in essence vastly expanded the visual field of subjects, thereby providing crucial information regarding horizontal and vertical circulation systems as well as external clues (via exterior signs) to possible internal routes to targeted destinations. Signs were the very first information sought by subjects. It was only preceded by a time window (sometime considerable) that involved the subjects’ critical assessment of whether the name of the destination provides any clue regarding the type of sign to look for. From that perspective, alphanumeric nomenclature for destinations also constitutes a type of sign. Thus, the subjects’ cognitive process is activated with the question pertaining to the meaning of the name of a destination and the

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appropriate sign type to seek to reach that destination. This iterative process of seeking meaning from a name or alphanumeric nomenclature, and subsequently seeking out appropriate signs, was repeated at each of the 11 origin points. Data point to cognitive processes that were involved in developing a global-level understanding of the three buildings and intra-/interbuilding circulation linkages. Supporting navigational information. Environmental elements and attributes in the supporting navigational information category played a different type of role in the cognitive process. Data suggest that subjects may be engaging in a process of developing a visual prediction of the destination and spaces along the destination. These may be originating from their long-term memory of similar spaces in other buildings. The authors would like to term this phenomenon as ‘‘destination features prediction’’ where destinations include the final as well as all interim destinations. As a result, subjects were continuously matching what they expect (images from memory) to what they see—although their prediction was not accurate all the time. When subjects expected the cafeteria to be collocated with the main lobby, or the admissions to be proximal to the main entrance, and they found it to be true, it acted as confirmatory supporting information—that they are probably at the right destination or following the right direction. Comparing expected visual features with actual ones constituted the initial cognitive process, which was invariably followed by final confirmation from signs and nomenclature. Similar other instances include expecting comfortable sofas in waiting areas, windows with pass-through counters at admissions (which was not true), and deep columns (or architectural wall elements) suggesting elevator bank (which was not true), among others. Functional clusters, interior element pairing, structural elements, and furniture are the four sources of information associated with supporting destination features prediction. The process of destination features prediction can also be viewed as a ‘‘continuous—where I am—assessment.’’ As subjects developed skeletal cognitive maps based on signs, architectural features, and maps, it appears from data that they also developed provisional (expected) mental

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images of interim and final destinations. As they navigated using the skeletal cognitive map, it appears that they were continuously assessing their location at any point in time (where am I) with the expected visual features, and further confirming with information from signs. As a result, it may be asserted (pending confirmation through further research) that initial cognitive maps are rarely purely skeletal in nature. People attach semirich contextual information to skeletal maps (based purely on initial information from signs, expanded visual field, and maps) with expected visual features from long-term memory. As people encounter actual environments during navigation, they perhaps replace their mental representations based on long-term memory with richer and truer contextual information from the immediate environment. When a mismatch between expected and actual environmental features occurs, those locations, interestingly, served as landmarks for subjects. But, what are landmarks? That warrants discussion on the third type of broad environmental cue category—mapping information. Mapping information. What roles do other interior design elements play in wayfinding? Shouldn’t the primary and supporting navigational information be sufficient for people to navigate in building interiors? Are there any justifications for capital expenditure on the other interior elements? Data suggest that subjects meaningfully and frequently used information offered by elements in the other design elements category of environmental cues. This study identified five classes of other design elements that provided useful information—artwork, display boards and information panels, fixed furniture and millwork, wall color, and vending machines. Discussions on other design elements should ideally occur within the concept of anchor points introduced previously. To comprehend the concept of anchor points, it is best to imagine oneself in the woods or in the outer space. While navigating in such environments, it is common for people to create safe spots to which that they can return. In outer space, it is the mother ship. In the woods, it is often a clearing or perhaps a base camp.


It must be noted that all subjects were totally unfamiliar with the hospital where the study was conducted and had never visited the facility in the past. They were in unfamiliar territory. As subjects begun developing skeletal maps using information from signs, visual field, and maps, and populating those maps with provisional expected visual features of yet unseen and unknown destinations (interim and final), perhaps, the first instinct was to locate a safe spot (a base camp or a series of base camps or mother ships). Study data strongly suggest the phenomena of identifying anchor points. Anchor points, as previously articulated, had several common attributes— close to an external entrance point (not necessarily the entrance used by the subject), proximal location of vertical circulation, multiple activities, presence of people, and presence of maps and signs. As subjects navigated beyond these anchor points, they tended to select and pick elements in the visual environment as familiarity markers. The process is akin to leaving pebbles on one’s path in the woods or rather using any element that sticks to one’s memory like bread crumbs along the path. This phenomenon is pertinent to the concept of landmarks. While, traditionally, landmarks are considered as visually dominating objects, study data show that a wide variety of elements (including those visually dominating) being used as landmarks or familiarity markers. This phenomenon is corroborated in the survey data. Data show that familiarity markers were actively used by subjects whenever they traversed the same path more than 1 time. This phenomenon can also be viewed as a part of the continuous assessment of ‘‘where I am.’’ Moreover, familiarity markers perhaps constitute the contextual information, which were added continuously to the skeletal survey map to develop rich route map information described in the introduction. Elements in the other design elements category of environmental cues were the ones used as familiarity markers or landmarks by the subjects of this study. The importance of this class of information is reflected in the frequency of information seeking (Table 4) where it ranks immediately after the broad category of primary

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navigational information. It is corroborated in the survey data (Table 9) where following landmarks was rated immediately after ‘‘following signs and directions’’ as the information source that afforded the highest degree of help to the subjects. Among the other design elements group of elements, artwork (paintings, sculptures, and a piano) constituted the most frequent information source to be used as familiarity markers or as landmarks. Finally, in comparison to studies in other settings, wayfinding studies in hospitals should be viewed as a special case. It is because, unlike other settings, people do not visit hospitals regularly and when they do they are generally at a high level of stress and anxiety.

Study Limitations Five areas of limitations are evident. First, the subjects were generally from an educated middle-class background. That leaves a considerable proportion of patient or visitor population out of the analysis. The second area of limitation pertains to using simulated visitors as opposed to actual visitors. It may be asserted that real visitors would experience higher levels of acute stress and anxiety and may behave somewhat differently from the observed behavior in this study. This is despite the investigators’ attempt to induce some level of stress by creating a hypothetical scenario (priming) for the subjects. The third limitation pertains to obtaining the subject’s review of the audio transcript. Since the transcripts contained verbal protocol as opposed to interviews, which were transcribed verbatim, there was no reason to believe that the subjects would disagree with the transcription. The subject, however, could have provided some insight into what they were truly thinking at some point in time. It may be argued that since the transcripts captured their ongoing thought processes, the subjects themselves may offer interpretations that are different from what they were thinking at that point in time, if they do actually manage to remember. The cross checking of interpretations primarily occurred among the investigators.

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Fourth, although the sample size for simulated patients and visitors was appropriate for a qualitative, exploratory study, the sample size for employees could have been larger. That may have provided some additional confidence into the kinds of environmental information employee’s use while providing direction. Finally, the study was conducted in one hospital. Multisite studies would have provided greater credence to study findings by virtue of a larger sampling under a more broad set of circumstances.

Future Efforts This research opens up a series of questions for examination in future studies. The first pertains to subjects. The subject profile could be expanded to include people with other levels of education and income, people not proficient in English as well as using actual patients and visitors as opposed to simulated ones. Furthermore, repetition of the study in multiple health care facilities will enable identification of common themes and provide greater credibility to the findings. An associated issue not examined pertains to wayfinding challenges encountered by the staff. Perhaps, typically, it is assumed that health care staffs do not encounter wayfinding challenges since unfamiliarity with the facility should not be an issue for them (other than the initial few days for a new employee). However, in the context of health care in the United States, in both the public and private sector, it is customary to hire short-term rotating or float nurses (sometimes called agency nurses). These nurses may not be familiar with the physical facility and may experience the same level of disorientation as visitors and family members of patients. Improper wayfinding could affect staff response time in getting special medications, getting equipment, and similar issues as a result affecting efficiency, safety, or both, depending on the nature of staff trip. The type of information sought by staff for wayfinding may or may not be different from those sought by patients’ family members and visitors; which is impossible to ascertain without empirical data. Furthermore, several concepts and phenomenon of theoretical and practical importance

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emerged in this study that warrant further examination include (1) continuous where I am evaluation by subjects, (2) destination feature prediction, (3) creation and use of anchor points, and (4) familiarity markers as landmarks and the expanded definition of landmark for wayfinding in building interiors. Finally, a crucial question pertains to ‘‘importance.’’ There are conceptual differences between ‘‘frequency of use,’’ ‘‘usefulness,’’ and importance among the various sources of environmental information. The present study question did not include examination of importance—for instance, identifying the ‘‘aha’’ moments leading to leaps in clarity pertaining to navigation. Future studies need to extend the current study to examine this vital question. Ideally importance should drive capital investment, for which this study creates the necessary foundation.

A. Data show that the very first cognitive process, where subjects spent substantial amount of time, is in attempting to find meaning in the label itself. Since labeling systems fall beyond the purview of the design profession, it is imperative that professionals be engaged in developing and testing labeling and numbering system for buildings, floors, rooms, and other program areas. B. Labeling systems get distorted over time as new buildings are added to an existing hospital. While developing a labeling and numbering plan, focus on devising systems that will retain its meaning over the long run, as the facility expands and new buildings are added. C. Data suggest that incorporating building name or number, floor name or number, and room name or number in a labeling system provides useful clue to subjects. D. These findings are only those observed in this one study. Consultants must survey published literature on designing labeling systems for developing a comprehensive plan. 2. Signs. A. Signs constitute the most frequently sought environmental information. Since signs are typically not within the purview of the design profession, it is imperative to engage specialist consultants for developing signage system. B. In some instances, subjects got confused with directional signs that ended up with another directional sign to the same destination but in the opposite direction. Test the signage system to ensure that directional signs do not lead to dead ends and accurately point to the destination. C. Be careful with up/down arrows. Those could be interpreted differently as forward/backward or upward/downward, depending on the subject. D. Subjects interpret left and right side placement of arrows on a single board differently. Ensure that placement of

Conclusion A wide range of environmental elements and attributes provide information during navigation. Those include signs, architectural features expanding visual fields, maps, interior elements (artwork, display boards, information counters, and so forth), predictable functional clusters, predictable pairing of interior elements, structural elements, and furniture, among others. The information is used in different ways. Signs, architectural features, and maps are used as primary navigational information. Functional clusters, interior element pairing, structural elements, and furniture are used as supporting navigational information. Other interior design elements play the vital role of familiarity markers. Signs, architectural features that expand visual fields, maps, predictable functional clusters, and artwork constitute the five most frequently used environmental elements for information during navigation, in that order. Architectural feature is the top contributor in the domain of architecture. Artwork (painting, sculpture, piano, and so forth) is the top contributor in the domain of interior design, according to study data.

Implications for Practice 1. Alphanumeric labeling system.

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directional arrows on a single sign are meaningful, clear, and not likely to be misinterpreted. E. Subjects expect a pattern in signage location. Be consistent in where signs are located. F. Be aware of the wayfinding implication associated with a series of laterally deep column wraps or architectural features. Such architectural elements block line of sight to signs that are meant to be viewed at a distance. G. These findings are only those observed in this one study. Consultants must survey published literature on designing signage systems for developing a comprehensive plan. 3. Sign or information boards. Sign or information boards are boards or electronic screens that show directions to multiple destinations. Subjects assume that the order of progression of destinations shown on the boards is reflected in actual placement of destinations. Ensure a match between the order of progression on sign boards and the actual sequential appearance of destinations. 4. Maps. A. Subjects expect to see the actual name of their destination on the map. While including all destinations on a single map may not be feasible be as inclusive as possible. B. Ensure that all maps show the location of the person viewing it. C. Subjects expect some pattern in map locations. For instance, if their first encounter with a map occurs in an elevator lobby, they expect all elevator lobbies to have maps. Develop a consistent and predictable plan for map locations. D. There is a large body of literature on you-are-here maps. Consultants should refer to those in addition to these findings. 5. Space programming and planning. A. Proximity, adjacencies, visual, and physical access are typical considerations in

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6.

7.

8.

9.

space planning. In addition to these, program areas with mutually supporting functions or complementary functions may be collocated. Subjects predict destinations based on logical clustering of functions. B. Initiate this procedure, from a patient or visitor perspective, starting with the major entrances and subsequently follow through to the rest of the public areas or public–clinical space interface locations. Movable furniture. A. Subjects develop expectations regarding furniture type based on the destination. Choose or design movable furniture that reinforces the phenotype of a destination. Interior architecture and structural elements. A. Subjects engage in predicting and matching elements of interior architecture and subtle implications of structural patterns with program areas or subfunctions. Make the optimal use of such cognitive matching. Architectural feature—visual field. A. Subjects make optimum use of expanded visual field for obtaining primary navigational information. The frequency of such use in this study is only second to the use of signs. B. Optimize size and location of exterior windows to expand visual field beyond the typical limits in building interiors. C. Locate exterior signs and directions strategically to afford visibility from interiors and inform interior wayfinding. D. When multilevel atrium spaces are included in a project, design and locate such spaces to maximize visual fields from the expected starting points of visitors and patients. Enhance such expanded visual field with proximal location of major signs, maps, and vertical circulation. Create direct lines of sight to important destinations and major hallways and vertical circulation cores on all levels. Anchor points.

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A. Depending on the size of a facility, design multiple anchor points where appropriate. B. Make optimal use of atrium spaces to create anchor points—there are strong synergetic relationships between the two. C. ‘‘Nodes’’ or the crossing of major public hallways offers ideal locations for creating anchor points. Whenever feasible, use such nodes for designing cognitive anchors. D. Locate anchor points close to major entrances and vertical circulation for best performance. Incorporate multiple activities and logical clustering of program areas—anchor points and logical clustering of program areas bear a synergetic relationship. Ensure large number of people presences—especially uniformed staff. Strategically locate maps and signs for best identification from a distance. E. In case of multiple anchor points, locate anchor points within reasonable proximities. Maintaining direct line of sight between anchor points is optimal. If that is not feasible, reduce cognitive confusion by maintaining relatively orthogonal hallway configurations and reducing intersection of major hallways between anchor points. F. Create unique perceptual characteristics (visual, auditory, tactile, and olfactory) for each anchor points. 10. Familiarity markers. A. Familiarity markers play a crucial role in navigation, including creation of anchor points. Be strategic in the use of artwork, fixed furniture, and millwork such as information or reception counters, display boards and information panels, and colors. Ideally, these can be used to provide perceptual differentiations between major public hallways. B. Environments with higher complexity (familiarity markers, people, and

activities) tend to aid more in developing familiarity. 11. Budget optimization. Pending further studies to develop greater level of corroboration of study findings, budgetary allocation may be ordered according to the frequency of use of environmental elements and attributes found in this study. The top five elements and attributes are (1) signs, (2) architectural features that expand visual field, (3) maps, (4) predictable functional clusters, and (5) artwork, in that order. Architectural feature is the top consideration in the domain of architecture. Artwork (painting, sculpture, piano, etc.) is the top consideration in the domain of interior design, according to study data. Authors’ Note This study was conducted as part of a contract with the US Department of Defense (W912DY-10-D0002-0005). Adeleh Nejati, Shireen Kanakri, and Buu Le provided data gathering support to this study. Amaya Labrador contributed to the literature review. Dr. Upali Nanda, contributed to the study methodology. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was conducted as part of a contract with the US Department of Defense (W912DY-10-D-0002-0005). References Ahn, J. (2006). Wayfinding at the East Campus of Cayuga Medical Center in Ithaca, NY. DEA 453 Project 2. Ithaca, NY: Cornell University. Baskaya, A., Wilson, C., & Ozcan, Y. (2004). Wayfinding in an unfamiliar environment. Different spatial settings of two polyclinics. Environment and Behavior, 36, 839–867. Carpman, J., & Grant, M. A. (2001). Design that cares. San Francisco, CA: Jossey-Bass.

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Carpman, J., Grant, M. A., & Simmons, D. A. (1985). Hospital design and wayfinding: A video simulation study. Environment & Behavior, 17, 296–314. Del Nord, R. (1999). Wayfinding: A quality factor in human design approach to healthcare facilities. World Hospital Health Services, 35, 28–30. Huelat, B. J. (2007). Wayfinding: Design for understanding. A position paper for the environmental standards council of the center for health design. Concord, CA: The Center for Health Design. Lee, S., & Kline, R. (2011). Wayfinding study in virtual environments: The elderly vs. the youngeraged groups. International Journal of Architectural Research, 5, 63–76. Lynch, K. (1960). The image of the city. Cambridge: MIT Press. O’Neill, M. J. (1991). Evaluation of a conceptual model of architectural legibility. Environment and Behavior, 23, 259–284.

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Passini, R., & Arthur, P. (1992). Wayfinding: People, signs and architecture. New York, NY: McGrawHill. Passini, R., Rainville, C., & Marchand, N. (1998). Wayfinding and dementia: Some research findings and a new look at design. Journal of Architectural and Planning Research, 15, 133–151. Rousek, J. B., & Hallbeck, M. S. (2011). The use of simulated visual impairment to identify hospital design elements that contribute to wayfinding difficulties. International Journal of Industrial Ergonomics, 41, 447–458. Siegel, A. W., & White, S. H. (1975). The development of spatial representations of large-scale environments. Advances in Child Development and Behavior, 10, 9–55. Zimring, C. (1990). The cost of confusion: Nonmonetary and monetary cost of the Emory University hospital wayfinding system. Atlanta: Georgia Institute of Technology.

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The untold story: how the health care systems in developing countries contribute to maternal mortality.

Identifying the common elements of treatment engagement interventions in children's mental health services.

Intensifying the Focus on the Contribution of the Inanimate Environment to Health Care-Associated Infections.

Health care workers and AIDS. HIV transmission in the health care environment.

The Environment and Children's Health Care in Northwest China.

Encouraging 5-year olds to attend to landmarks: a way to improve children's wayfinding strategies in a virtual environment.

Reflections on the holding environment in health-care counseling.