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Behav. Sci. 2014, 4, 423–436; doi:10.3390/bs4040423

behavioral sciences

ISSN 2076-328X www.mdpi.com/journal/behavsci

Review

Wayfinding in Healthcare Facilities: Contributions from Environmental Psychology

Ann Sloan Devlin

Department of Psychology, Connecticut College, 270 Mohegan Avenue, New London, CT 06320, USA; E-Mail: asdev@conncoll.edu; Tel.: +1-860-439-2333; Fax: +1-860-439-5300

External Editor: Jack L. Nasar

Received: 1 September 2014; in revised form: 13 October 2014 / Accepted: 20 October 2014 / Published: 31 October 2014

Abstract: The ability to successfully navigate in healthcare facilities is an important goal for patients, visitors, and staff. Despite the fundamental nature of such behavior, it is not infrequent for planners to consider wayfinding only after the fact, once the building or building complex is complete. This review argues that more recognition is needed for the pivotal role of wayfinding in healthcare facilities. First, to provide context, the review presents a brief overview of the relationship between environmental psychology and healthcare facility design. Then, the core of the article covers advances in wayfinding research with an emphasis on healthcare environments, including the roles of plan configuration and manifest cues, technology, and user characteristics. Plan configuration and manifest cues, which appeared early on in wayfinding research, continue to play a role in wayfinding success and should inform design decisions. Such considerations are joined by emerging technologies (e.g., mobile applications, virtual reality, and computational models of wayfinding) as a way to both enhance our theoretical knowledge of wayfinding and advance its applications for users. Among the users discussed here are those with cognitive and/or visual challenges (e.g., Down syndrome, age-related decrements such as dementia, and limitations of vision). In addition, research on the role of cross-cultural comprehension and the effort to develop a system of universal healthcare symbols is included. The article concludes with a summary of the status of these advances and directions for future research.

Keywords: wayfinding; healthcare; technology; user characteristics

OPEN ACCESS

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1. Introduction: Environmental Psychology and Healthcare Facility Design

Research from environmental psychology has the chance to improve our lives; this claim is nowhere more evident than at the intersection of environmental psychology and healthcare facility design. In addition, this intersection reflects one of the primary characteristics of environmental psychology: its interdisciplinary quality. Much of the research on healthcare facility design involves collaborations between environmental researchers and those in other professions (e.g., architecture, computer science). Some of the contributions are applications to existing topics (e.g., wayfinding) in the context of healthcare; other findings are specific to healthcare (e.g., the effects of same-handed vs. mirror-image inpatient rooms). Reflecting the interdisciplinary nature of the discipline, literature about these issues is not only found in the mainstays of the discipline (i.e., Environment and Behavior and the Journal of Environmental Psychology), but also in journals specifically developed for this subject matter (e.g., Health Environments Research and Design Journal). Beyond this inner core, research integrating environmental psychology and healthcare facility design is found in a wide array of journals indirectly related to the physical environment including nursing, critical care, pain, ergonomics, emergency medicine, comparative effectiveness research, intensive care, infectious diseases, and public health, among others. Research on wayfinding, the particular focus of this article, is also summarized in compendiums covering wayfinding in health care [1–3].

2. Wayfinding

Despite its fundamental role, wayfinding is often overlooked in the evidence-based design research, although Ulrich, Berry, Quan, and Parish [4] include it as one of their dimensions in a nine-faceted framework for evidence-based design. Reinforcing this assessment of wayfinding as an underappreciated aspect of the designed environment, a map designer quoted in Devlin’s [5] book about doctors’ offices points to the attitude of architects that wayfinding systems are often an afterthought and overlay. This map designer notes that wayfinding systems are infrequently part of the planning process at the programming stages. Facility planners are encouraged to use the master planning process to create effective wayfinding systems [6], but this advice is seldom heeded, despite the fact that wayfinding is one of the variables beyond clinical service that affect patients and staff [7,8]. This lack of recognition about the critical role of wayfinding systems has unfortunate outcomes because an environment that fosters independent wayfinding will reduce costs; people who are unsure where they are and how to reach a destination will interrupt staff engaged in other activities. For example, Nelson-Shulman [9] showed that patients exposed to posted signs in an admitting area made fewer demands on staff and were more knowledgeable about admitting procedures and amenities available, in contrast to patients without this posted information. A cost-estimate by Zimring [10], which is often cited, is that problems in wayfinding at Emory University Hospital cost the institution $220,000 annually. Most of the research using evidence-based design focuses on patients’ interactions with the clinical areas of the hospital, rather than on the more public spaces where wayfinding typically begins, despite the role of such spaces in the experience of patients and visitors.

An early application of wayfinding to the healthcare arena came from the work of Carpman, Grant, and Simmons [11], whose book Design that Cares: Planning Health Facilities for Patients and Visitors

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is a landmark volume that integrates environmental research and healthcare design. The authors argue that a “coordinated wayfinding system” is needed in healthcare facilities and that the ease of wayfinding will affect stress [11] (p. 19). Research from that book points to a number of themes that have received continued attention, including the importance of nomenclature (i.e., how destinations are named), density (i.e., the number of signs), context, placement, and visibility. Studies conducted for the University of Michigan Patient and Visitor Participation Project (PVP), part of the Replacement Hospital Program, generated much of the research for Design that Cares (both published papers and unpublished research reports) [12,13]. These documents look at such issues as the power of environmental affordance (what the environment “says” to us through its structure) vs. that of manifest cues (the effectiveness of the actual signage posted in the environment) [13].

A good deal of the research on wayfinding taps into the capacity of human cognition, including how much information we can hold in short term memory, for example the seminal article by Miller [14]; difficulties in multitasking [15]; and the schemas we have for the relationship between signage and the physical environment (e.g., that movement forward in space is up on a map) [16,17]. Research with applications for wayfinding in healthcare environments has often come from other institutional settings such as housing for the elderly or long-term care facilities [18,19] and libraries [20], although beyond Carpman et al. [11–13] there is some early work on healthcare environments [21–23]. From the standpoint of plan configuration and signage, wayfinding research on any large building or complex of buildings is applicable to healthcare environments.

2.1. Plan Configuration and Manifest Cues

Wayfinding is a particular challenge in large healthcare complexes with numerous buildings [7], often lacking distinctive appearance, which are linked to one another as the complex grows over time. Early on in the research on wayfinding, plan configuration was shown to be a correlate of wayfinding performance [24,25]. More recent research substantiates that finding. Using architecture students as newcomers to polyclinics that differed in their symmetry, Baskaya, Wilson, and Özcan [26] used reactions to a tour and a sketch map task to show the benefits of a regular but asymmetrical setting over a regular and symmetrical setting. Strikingly, 63.2% of the participants in the regular, symmetrical building felt “completely lost” during a tour in contrast to only 6.5% of those in the regular, asymmetrical setting [26] (p. 851). Baskaya et al. [26] showed that symmetry and repetition of similar elements could be a drawback to wayfinding, pointing again to layout as an element to be considered in the initial plan. The authors remark that landmarks to create distinctiveness may be particularly important in a building with symmetry. At the neural level, researchers are developing more sophisticated explanations of how landmarks may be coded, and the spatial layout itself has been described as a kind of landmark [27].

As the comment by Baskaya et al. [26] shows, wayfinding includes both attention to the floor plan (the building structure) and environmental cues (e.g., landmarks, signage) overlaid on that floor plan [28]. These distinctions are also reminiscent of the idea introduced by Carpman et al. [13] that we have the environmental affordance (what the structure suggests can occur) and the manifest cues (e.g., signage) that are used to elucidate the floor plan configuration. Some research [29] has placed environmental affordances (i.e., corridor width, brightness) in direction competition with manifest cues (i.e.,…