adfa, p. 1, 2011.
© Springer-Verlag Berlin Heidelberg 2011
Wayfinding in Hospital: a case study
Laura Bezerra Martins
Federal University of Pernambuco (UFPE) – Brazil
Hugo F. Vasconcelos de Melo
Federal University of Pernambuco (UFPE) – Brazil
Abstract: The purpose of this study is to understand how the human displacement in
large buildings takes place and suggest solutions to improve its flow. The type of in-
stallation to be focused on is the hospital environment. For case study, we took as ex-
ample a hospital based in Recife, capital of Pernambuco - Brazil. The importance of
this research lies in the fact that it opened new horizons for the study of accessibility,
bringing together areas of management and design, which are often treated in an iso-
lated manner, but actually complement each other in order to reach an overall result for
the various users of this type of system.
Keywords: Wayfinding, Design, Ergonomics and Usability, Healthcare
Space is essential for the survival of human beings and it is through it that man creates
environments to fulfill ones tasks. In order to carry out activities there will always be a
space built with specific functions. One of man’s main tasksis the act of moving be-
tween spaces, which consists of moving from one point of origin to a destination. This
act of displacement is considered the basic unit to perform almost all human activities,
that is, the functional basis of a built environment is to facilitate orientation and mobil-
ity between sectors. Clear access to built environments is a basic requirement of every
architectural design .
The influence of the environment in the way people carry out their activities, shows the
importance of evaluating the quality of built environments that are increasingly ineffi-
cient for user performance . We live today in a more complex and saturated world.
Therefore, we are forced to live in areas where boundaries are difficult to be discerned.
To detect the specific characteristics and nature of the environment allows for the cre-
ation of communication systems that improve human interactions .
According to modernity with its new technologies has brought about profound changes
in the way of conceiving space. The built environment should now be thought to ac-
commodate a greater diversity of people and perform different activities . In light of
such developments, people start to travel longer distances in shorter periods. However,
their spatial skills are insufficient for locomotion in spaces of high complexity without
support from systems thought to adapt the environment for everyday activities.
It is understood that the act of signaling is a multidisciplinary study, that plans the space
globally, i.e., it goes beyond the use of graphic language in built environments and is
above all the act of planning space with dynamism, to facilitate the flow of people in a
safe, natural and orientated way . An example of a complex space with high variety
of services and movement of people is the hospital, where it isof complex nature and
presupposes certain urgency in the flow of patients and staff. It is this background that
the current study focuses on, analyzing specifically a hospital based in Recife, capital
of Pernambuco - Brazil. This hospital is a nonprofit organization designed to provide
eye care services to the population using public health system. Its current building is
used in a disorderly manner. It consists of adaptations and extensions of several houses
in the region, forming an improper complex for the activity that is proposed.
To conduct the case study, this work is based on complementary theoretical references
that represent a series of recommendations that will bring to the environment not only
agility in moving and task performance, but will also give the environment larger per-
sonality. It is known, however, that the use of wayfinding as main reference is the best
way to minimize weaknesses and find solutions forhigh complexity and great popula-
tion flow locations.
The use of señalética of Costa , as a theoretical reference, comes after the flow issues
and spatial organization are well studied and will serve as an additional signaling sys-
tem. According to O'Neil cited in Ribeiro , in installations with wayfinding issues,
the use of graphics system serves to compensate the complexity of the design and those
who perform the route gain speed. Finally, informational ergonomics is used assupport
both for wayfinding studies and for studies of graphic signage.
The aim of this study is, in addition to point out the major flaws of flows and sectori-
zation in hospitals, to generate unified method recommendations based on principles of
Wayfinding, Señalética and Informational Ergonomics, in order to minimize disruption
caused by environments without architectural planning and make them able to facilitate
the tasks that each user will have to find their own destiny within a building.
2. Methods and techniques
The theoretical basis for the unification of methods aimed at improving the spatial or-
ganization and the flow of users within built environments is wayfinding that has as its
object of study the dynamic relationship of human behavior with the space, resulting in
drawing up a plan of action in which three processes are involved: decision making,
implementation of the decision and information processing . The process of way-
finding is a dynamic relationship which involves the individual, one’s personal skills
and the environment in which one is inserted. Thus, wayfinding is a process of behav-
ior, design and operation.
Behavior is the external manifestation of the processes of perception and cognition re-
lated to the skills and experience of each person, ie, involves the individual and the
person’s ability to interpret space and from that take decisions based on the information
gathered in the environment. Spatial navigation requires capacity of perception, inter-
pretation, memorization and spatial skills from the user, thus the subject is capable of
building the mental map of the given environment .
Design involves the elements and organization of the built environment such as the
system of architectural information that studies the morphology of the building. In order
to facilitate the morphological definition of a building, Arthur and Passini cited in Ri-
beiro  distinguish three phases to define wayfinding layout: identification of spatial
units; grouping of these units in zones; and, finally, sectorization no these areas and the
connection between them.
Another aspect of design concerns the way the room is decorated, ie, the information
system of objects, which are the spatial elements that reveal the identity of the environ-
ment and the function of each sector . The information system of objects consists of
geometry, colors, lighting and finishing, as well as the furnishings and equipment that
make up the space . The purpose of implementation of object information system
goes beyond the generation of comfort and enhances the informational matter in the
A final aspect of the design is the information system that, according to , is every-
thing that complements the environments in which previous systems do not address the
issues of wayfinding. These systems can be graphic in nature (use of signaling signs,
displays, maps and brochures), sonorous (whistles or sirens), verbal (interpersonal com-
munication) or tactile (signaling through textures on floors and walls and Braille used
on maps, signs and brochures).
The transaction relates to administrative decisions that managers tend to make in the
built environment, which will affect the way space is considered and, consequently,
affect positively or negatively the behavior of users in the system. They are: the choices
of terminology in graphic signage, the way employees are trained to receive and inform
users, the deployment of anticipated information when there are changes in the sectors
and maintenance of the imaging signal system.
Señalética is a discipline that collaborates with engineering, architecture, environment
and ergonomics, under the graphic design vector, responding to the needs of infor-
mation and orientation caused by the contemporary phenomenon of mobility, which is
the movement of different groups of people able to generate new situations and diffi-
culties in environment navigation .
The concept of señalética is divided into three systems of language (linguistic, iconic
and chromatic) which, although they relate to form the graphical signaling system, con-
tain expressions that should be studied in detail for the creation of a cohesive system,
integrated with the identity of the studied area and always taking into account the stud-
ies of informational ergonomics.
2.3 Informational Ergonomics
The discipline is interested in improving the human interface of workspaces and its
objects, taking into account how the environment acts in the performance of people in
their workplace and during the work break .
In this study, fundamental concepts will be used of what is known as Informational
Ergonomics, based on studies of legibility and comprehensibility of texts and images,
however, regarding the signaling of constructed environments, informational ergonom-
ics can cover not only what relates to graphic design issues, but also the layout issues
of the environment and the types of flows they generate, in addition to studying human
behavior when connected to these factors .
In terms of environmental design in wayfinding, the main contribution of informational
ergonomics is to add surveys concerning zoning and recording the movements of users
in the location to define dislocation problems, thus indicating possible solutions in im-
proving the flow of people in the building.
3. Results and discussion
3.1 Mapping of the system
The system user
Through institution database research and on-site observations, information from users
of this health system was obtained. Because this is a charity hospital, it can be said that
the majority of the patients are public health system users, so those without financial
means to pay a private health insurance or treatment and who already attend the hospital
long enough need to develop a cognitive map of the environment.
Given the previous matter, it was noted that the attendance regarding age varies be-
tween children, adults and seniors; however, with a slight advantage for the elderly,
since the main vision problems in need of surgery occur at this stage of life. The in-
creased demand from children occurs due to the existence of a program focused on the
rehabilitation of this public. It was also found a great demand for routine and urgent
medical appointments, both with patients varying in terms of age and physical condi-
tion. With regard to education, we observed a lot of people with problems of functional
illiteracy and again, in this matter, the elderly are the ones with the most difficulties. In
terms of physical impairment, motor and visual were the most noticeable types. Again,
it was found that the elderly public accounts for most cases of disabled people seeking
Based on this survey, it is necessary to think of a wayfinding system focused on com-
fort, with simple morphology for users to be able, during the visits, to create a cognitive
map of the location. In terms of graphical signaling, one must think about panels that
favor the elderly, children and disabled users, i.e. panels with effective printing and
contrasts, besides the use of good graphic resources, since the location is used by chil-
dren and persons with low reading proficiency.
The architectural information system
The layout of a facility shall be defined by identifying the spatial units so they can be
grouped by zones, and these shall be organized and close to each other according to the
similarities in needs and demand from users . The environments are grouped by areas
having common characteristics and, in turn, the zones should be differentiated from
The areas should be grouped according to the homogeneity of services, facilities, func-
tions and even types of users. The zoning of an installation should always be done by
taking as basis the main areas, i.e., the most important and most sought after, followed
by their sub-areas and so on, always following a hierarchy of importance or demand
Evaluating the layout of the hospital blueprint (Figure 1), it is possible to identify that
the sectorization of its current headquarters is made in an arbitrary manner and that
even if an environment that grew without planning, zoning could be done correctly,
taking into account space limitations.
Fig. 1. layout of the hospital blueprint – sectorization arbitrary
Even without solving the chronic wayfinding problems of the current headquarters the
institution first because it is a structure that was not born to house a hospital, second
because the demand for services has surpassed all limits of the physical space, it is
possible to indicate a simple sectorization and more integrated into the environment, as
long as there are changes in the layout of the building, which should be held in a mul-
tidisciplinary way between architects, decorators, designers, ergonomists and adminis-
After mapping the environment sectors, it is necessary to trace the flow of user move-
ment because this movement record will identify the dilemmas of environment areas,
i.e., the places where bifurcations in the flow of movement occur. Based on the infor-
mations of the movement registration on the floor plan, it is also possible to set the
existing activity flowcharts in the hospital, and its type of morphology.
As can be seen in the representation of the movement flow below (Figure 2), in order
to navigate between sectors, users and hospital staff are required to perform unneces-
sary tasks to go from a given starting point to a destination. People with different needs
within the facility stumble confusedly, without knowing where to go and therefore de-
pend, for the most part, on the verbal assistance of staff and volunteers.
Fig. 2. representation of the movement flow below - unnecessary tasks
In view of the flow movement analysis it is possible to say that all dilemma points and
sectors of the institution can be linked together, creating an interconnected system. This
does not follow any organized route and the circulation paths are sinuous and defined
on the basis of pre-existing barriers in areas that were annexed as the headquarters ex-
panded. In this type of movement organizational pattern is random, there is no structural
order and its information structure can only be performed using reference points and
anchor points at intersections, because hierarchical order among the sectors is nonex-
The information system of objects
Environmental aesthetics is one of the strongest subjective components within a health
institution and directly influences staff, patients and visitors . The correct combina-
tion of hospital sectors, associated with the right choice of color, lighting and texture,
makes the healthcare environment less stressful, and serves to reinforce the cognitive
map of each visitor at the facility .
The health institution studied flees from all aesthetic rules applied to hospitals, but not
in a positive way. While healthcare environments have mostly white walls as the main
color and blinding lighting, the hospital analyzed has as main tone gray color followed
by blue, considered the standard color of the institution, and brown, present in much of
the furniture. The lighting, especially in the corridors, is precarious (see Figure 3). Not
being enough the fact of it being a narrow place with dim lighting, to further aggravate
the difficulties of movement, the sectors consist of cool colors poorly differentiated
from each other and that, instead of increasing the lighting and giving the idea of ex-
pansion, they retract and absorb the little lighting existing in the building. Being a mo-
notonous environment, the psychological result of misuse of colors are boredom, fa-
tigue, drowsiness, unwillingness, decreased attention and, consequently, the disorien-
Fig. 3. The lighting is precarious in the corridors
The system of additional information
The main system of additional information to the institution is the verbal system, i.e.,
personal communication of staff and volunteers with patients and visitors. Through
field studies, it could be noted that this is the only system that really works, especially
among users who visit the institution for the first time and older people who have the
greatest difficulties to build cognitive maps. The institution users are approached by
volunteers at the entrance, which is the beginning of the process. Instead of people
seeking the reception, they are welcomed because the physical structure of the current
building no longer absorbs the daily demand of patients, i.e., to prevent that a patient
spend a lot of time in the wrong line or waiting for a service that will not work that day,
volunteers are ready to reportavailability for treatment and directing people entering
the wrong traffic flows.
Despite being an institution with a focus on visual impairment, there is no tactile sign-
age to minimize possible embarrassment to the blind and visually impaired. There is a
notorious lack of use of graphical signs, starting by the visual identity which is reduced
to a logo without manual standardization, implementation and use restrictions. The ex-
istent graphical signs are facades and location plaques (Figure 4), placed without the
slightest concern for the image of the hospital, so important in the study of señalética
approached by Costa (1992).
Fig. 4. The existent graphical signs are facades and location plaques
The operational system
Based on field research and interviews with hospital workers, it was possible to find
the following administrative restrictions which can lead to problems in the implemen-
tation of a future wayfinding system : lack of knowledge or interest in the technical
standards dealing with organization quality management; lack of understanding the re-
lationship between ease of navigation in the environment and quality of the services;
ignorance of real importance for a designer to work with architects during the new
building development, which is already in planning progress. Another limitation arising
from administration is that they think that a signaling system is reduced only to the
creation of direction and location support.
However, a wayfinding system covers issues that deal even with how an institution
manages its spaces and services. For example, always looking to improve the infra-
structure system and make a regular maintenance of the environment, and seek greater
efficiency in service flow. The control over decisions on layout and ambiance of the
facilities is in the hands of management and without the involvement of a multidisci-
plinary team. The result is poor sector division, many employees are unaware of the
environments subjacent to their workplaces, and do not understand how the process of
care within the hospital works. As a result, workers are unprepared to provide adequate
information to system users, the forms for scheduling of appointments, exams or sur-
geries do not provide sufficient information for patients to find their destinations on
days when attendances are marked.
As one can see from the moment the administration restrictions for each wayfinding
subsystem are understood, and thereupon adjusted, the professionals involved in de-
signing a new wayfinding system have greater dominance in applying the new project,
which according to Carpman and Grant  should solve the existing problems and pre-
vent new ones. For a project focused on studies of wayfinding to have wide success, it
is necessary that the administration understands its physical environment as dynamic,
that is, able to avoid further issues arising from possible structural changes or exten-
Bearing in mind that the analyzed institution is to plan a new building, it is necessary
to suggest, before the design of the new building, a type of movement system that takes
into account the most sought after areas for their users. With respect to morphology and
zoning, the most appropriate thing for the types of services offered by the institution
would be a system of hierarchical central circulation, where the pattern of organization
is through a network. In this case, users of the system come into contact first with the
most popular environments, and these determine the next steps to reach the most im-
portant sectors of the building. The two most sought after areas within the hospital
would be the general reception area, which does not exist in the current circulation
system, and the emergency.
There is also need for a circulation system for employees that connects the restricted
areas adequately to public areas, focused on the mobility of patients. In this case, it is
necessary to understand how worker sand health professionals should flow within the
system. Only a multidisciplinary study involving architects, designers and administra-
tors of the hospital is able to reach a circulation system that is born already predicting
future extensions and modifications, since an architectural system such as the system
of hospitals, is dynamic and should be expanded over time, according to the birth of
new specialties, sectors and technologies. From a well resolved circulation system, it is
possible to start the design of the floor plan having in mind a structural pattern that
takes into account the priority needs of users, so that they reach their destinations in a
safe and more agile way.
Regarding the information system of objects, it is necessary to bear in mind the their
aesthetic integration to harmonize and thereby help the users in designing the cognitive
map of the building. In the hospital environment there should be two kinds of lighting,
natural and artificial . Some studies, according to Hood and Brink , show that the
use of natural lighting benefits the health of people who spend many hours of the day
indoors, and brings economy to the institution. The natural lighting is crucial tool for
connecting the hospital building with nature, assisting in the circadian system. How-
ever, in the case of this institution that is focused on eye care, there has to be caution
with the excess of natural light in the environment so no problems are cause to patients
with serious ocular sensitivity.
On the use of color and knowing that most of the guidelines for its use in design is
based on pre-established cultural beliefs and that there are no universal guidelines for
such use in hospital environments, due to the complexity of groups that use this type of
environment, especially those focused on public health, Young cited in Hood and Brink
, conclude that the definition of color for environments is subject to a number of
approaches that should work jointly and they will always vary according to installation
type and work carried out in the area. The choice of colors to compose the environments
of a hospital building must conform to the design principles that take into account the
best degree of reflection, culture, local behavior and representative visual identity of
the institution. These aspects should be arranged so that they make the best composition
of lighting, surroundings and graphic signage chromaticism.
Regarding the proper use of the furniture when they are well selected, they can enhance
spatial orientation of those inserted into the system as well as improve the populational
flow, providing support, comfort, safety and promoting the correct interaction between
visitors and employees . In terms of the current case study, it is suggested that fur-
niture use be considered so that it is appropriate in terms of comfort to the types of users
in the institution. The color coordination should follow the principles of color research
that should be used in the environment, ie, in addition to providing comfort, furniture
should work on strengthening user’s cognitive map.
For the additional information system, the main suggestion is around the use of appro-
priate informational graphics systems in the new layout and objects aesthetic to be ap-
plied to the analyzed hospital environment. The system of graphic signs must respect
principles of hierarchy and suggested information in the work of Joan Costa  Direc-
tional signs should have three to four information and messages neatly listed according
to the degree of importance or demand for each sector, giving particular emphasis to
primary information, ie, the name of the entry sector. The planning for the sub-sectors
should be given following the order of distance of each destination. On the use of color
in panels, one should always seek the contrast, ie the colors for each of the main sectors
of the hospital should be quite different from each other so there is no orientation con-
fusion among users of the system. Another important question regarding the use of
colors is to avoid a large number of shades, answering only to the key sectors, because
a large number of chromatic signs disruptthe recognition of sectors, especially for peo-
ple with visual impairments.
Regarding the use of pictograms, as this study analyzes a big hospital with public health
insurance, the propositionis to work the historically accepted style, the silhouettes tech-
nique produced by AIGA and applied in the research of the program "Hablamos Juntos"
in partnership with the SEGD . Regarding the use of maps, it would be interesting
to workwith them like infographics. Infographics combines images and words harmo-
niously, making the information in the panels contain a story for the user with begin-
ning, middle and end . The proposal to use Infographics refers to the journalistic
work, since the current study goes further, suggesting that this type of approach be used
not only in so-called general location maps or part of a signaling system, but also in
newsletters that should be printed to educate users, causing them to become accustomed
to the system of pictograms and to the movement flow logic of the institution being
Regarding other systems of additional information, it is required the use of a tactile
system on floors for the visually impaired, where the textures on floors should be able
to guide passersby not only to the maps with Braille communication, as well as to the
main destinations within the facility. About the additional verbal system, it is necessary,
in accordance with the operating system, proper training on the flow dynamics of the
hospital for all staff and volunteers, so that they become part of the system helping to
guide patients and visitors. This training can be done from the process flow diagram,
which shows all steps of the users in the search for appropriate services within the
With the current research it can be concluded that to effectively work a signaling system
is to go beyond the graphics system. One must work together with other disciplines
beyond the ambit of graphic design. This set of disciplines addressed in harmony is
called Wayfinding, which means to know where you are, know your destination and
walk up to it, always having in mind evidence that the route taken is correct, without
going through unnecessary procedures, Environments where the architecture favors
navigation cause people to improve their cognitive skills.
An environmental project focusing on wayfinding promotes not only physical and men-
tal health of users, but also the financial health of the institution, because it is implicit
that employee productivity problems are associated with navigation issues, since
theyoften waste time guiding patients instead of performing their tasks.
Finally, it is concluded that this case study is a rich example of how not to use health
environments, as they contain errors ranging from the use of space to employee train-
ing, encompassing flaws in all subsystems of wayfinding. Therefore, it is important to
demonstrate that healthcare environments should be designed by multidisciplinary
teams in order to minimize future errors.
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