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Annemans, M., Stam, L., Coenen, J., Heylighen A. (2017) How can research on patient experience
inform hospital design? A case study on improving wayfinding, Proceedings of Arch17 - 3rd
International Conference on Architecture, Research, Care, Health.
Please refer to the publisher’s final print version.
1
How can research on patient experience inform
hospital design? A case study on improving
wayfinding
Margo Annemans, Liesbeth Stam, Jorgos Coenen, Ann Heylighen
University of Leuven (KU Leuven), Department of Architecture, Research[x]De-
sign
firstname.lastname@kuleuven.be
Abstract
For patients a hospital visit is a profound experience influenced by their mental
and physical state in that moment. Various aspects of the hospital environment
play a role in their experience. For most patients communicating about this ex-
perience in all its complexity is a difficult task. This difficulty impedes designers’
and hospital professionals’ insight into patients’ perspective on the hospital en-
vironment.
For this reason we are investigating how research on patient experience can in-
form hospital design. In this paper, we explore more specifically (1) how insight
into patient experience can foster an empathic and motivated understanding
amongst healthcare professionals and designers, (2) what kind of information is
needed to achieve this, and (3) how their improved understanding impacts on
their problem solving ability. To this end, we report on a case study in collabora-
tion with a general hospital, with which we organised a series of workshops
about improving wayfinding.
Bringing together different profiles of designers and healthcare professionals
turned out to be an enrichment for all parties involved, even when working
within the same organisation. Depending on their profile, participants had differ-
ent expectations of the format and content of the information presented during
the workshop.
Although the workshop was generally evaluated positively, specific attention
should be paid to raising realistic expectations about information on patient ex-
perience. We found a discrepancy between what research can tell about real
patients’ experience, what healthcare professionals expect to learn, and what is
useful for designers to work with.
Keywords: Hospital design, Information Format, Patient experience, Wayfinding.
2
Introduction
For patients a hospital visit is an intense experience. Although familiarity with
the environment, anxiety, stress level, and physical state can differ significantly,
almost no one visits a hospital completely voluntarily. Staff experience the build-
ing from a professional angle: it is their daily work environment which they are
highly familiar with. These divergent perspectives impact on how both groups
consider and navigate the building. This became particularly clear when study-
ing the case of a general hospital where wayfinding appears to be a major is-
sue.
Prior research involving actual patients and volunteers exploring the hospital
building, showed that various aspects of the hospital environment play a role in
patients’ experience of wayfinding (De Valk, 2015; Weustenraad, 2015). For
staff it is not always easy to imagine or even be aware of patients’ difficulties in
navigating the hospital. Most patients find it hard to communicate about their ex-
perience in all its complexity (Annemans et al., 2012). This impedes designers’
and hospital professionals’ insight into patients’ perspective on the hospital en-
vironment.
The case study on wayfinding we report on in this paper is part of a larger pro-
ject in which we investigate how research on patient experience can inform hos-
pital design. In this paper, we explore more specifically (1) how insight into pa-
tient experience can foster an empathic and motivated understanding amongst
healthcare professionals and designers, (2) what kind of information is needed
to achieve this, and (3) how their improved understanding impacts on their prob-
lem solving ability. After sketching the background of the overarching project,
we explain the approach adopted in the case study. Subsequently, we present
insights in reply to the questions above. We then discuss to what extent the ap-
proach was successful and what lessons can be learned about informing hospi-
tal staff and designers on patients’ experience. We conclude that a discrepancy
exists between what research can tell about real patients’ experience, what
healthcare professionals expect to learn, and what is useful for designers to
work with.
Background
Various studies show that the environment – products, services, and spaces –
has a significant impact on patients’ wellbeing and as such can add to their
healing process (Ulrich et al., 2008; Huisman et al., 2012; Desmet & Pohlmeyer,
2013). Most designers and hospital staff are convinced of this impact but often
lack accessible information offering a nuanced insight into patients’ experi-
ences. Ideally this information is obtained through interaction with real users, al-
lowing the designer to develop a more thorough understanding of and empathy
with them (McGinley & Dong, 2011). However, since time and money re-
strictions in a typical design process often result in a minimal user engagement
(Cassim, 2010), designers are often unable to obtain this direct input from users
and become dependent upon indirect sources of human information (McGinley
& Dong, 2011).
3
As designers often do not have direct contact with the people they are design-
ing for, various techniques have been developed to bring them closer to these
people’s experience (Kouprie & Visser, 2009; McGinley & Dong, 2011; van Rijn
et al., 2011). These techniques vary from having direct contact with real people,
over consulting videotaped observations or interviews, to being presented with
profiles of imaginary persons. Most of these techniques aim to foster empathy.
In the case of vulnerable groups like hospital patients, practical and ethical re-
strictions make it hard for designers to actually engage with them.
Experiential user information like ethnographic data collected in various
(health)care settings, both hospitals and (residential) care facilities, could pro-
vide hospital staff and designers with much of the needed information to gain in-
sight into patients and residents’ experience and to empathize with them. Yet
the scientific articles this research is mostly presented in, are not the number
one source where designers look for information (Annemans et al., 2014). Pos-
sible explanations are that designers are rather motivated by visual communica-
tion and like information to be presented graphically (Lofthouse, 2006) or that
they often feel mistrust towards data that have already been interpreted (Re-
strepo, 2004). They claim to prefer raw data in a format that is condensed down
to be design-relevant (McGinley & Dong, 2011). On the other hand, architects
are often inspired by other architectural projects, whether consciously or not
(Heylighen & Neuckermans, 2002).
Approach
Context
The case study reported on here took place in a general Belgian hospital. The
hospital in its present form results from a fusion between two hospitals located
at the opposite sides of a street. With the fusion the distance between both
needed to be bridged, which was realised literally by building a covered bridge
over the street to connect the two buildings. This, in combination with the or-
ganic growth of both buildings over time, created a hard-to-understand building
layout, causing considerable wayfinding issues.
The current wayfinding system, overruling all previous ones, makes use of num-
bered streets, with numbers having no direct relationship with floors or corri-
dors. Scattered around the buildings are traces of former systems, like coloured
corridor crossings. Although the numbered street system is theoretically well
thought through, it is not always experienced as such by patients and visitors
who are unfamiliar with the building, and are often in an anxious or nervous
state of mind.
To prevent mistakes, reception staff are only allowed to give the route number
and an explanation on how to follow the arrows. Other staff often have a limited
understanding of the numbered routes, as they still think about the hospital in
terms of its former numbering with letters for different buildings and floor num-
bers in each building.
Study Design
The presented case study is part of a broader case study enquiry. A case study
is defined as the study of a case (person, place, event), selected for its particu-
4
larity, and 'bounded' by physical, temporal, social/cultural, and conceptual fea-
tures. Case studies are the preferred strategy to gain an in- depth understand-
ing of a contemporary phenomenon in a real-world context (Yin, 2012;
Flyvbjerg, 2006). In this case we studied a fusion hospital confronted with a par-
ticular wayfinding issue and aiming to obtain an in-depth understanding of the
problem as well as to take steps towards formulating possible strategies to
tackle the problems the hospital is facing.
The case study we report on consists of three workshop sessions in the hospital
with a variety of staff members. Each session took half a day and session 2 and
3 were organised in one day.
Session 1: Identifying problems
The first session focused on identifying problems with regard to wayfinding from
a patient perspective.
After participants expressed their personal issues with (the) wayfinding (sys-
tem), their attention was shifted towards the patient perspective. To this end, we
loosely applied the persona’s technique often used in product- and service de-
sign (Pruitt & Grudin, 2003; Nielsen, 2013). This technique allows designers to
base their decisions on fictional people’s goals and activity scenarios, thus tak-
ing into account a broader user groups than only those similar to themselves
(Pruitt & Grudin, 2003). The workshop started with a group session to identify
an example of a patient visiting the hospital, then participants were divided in
small team and each team was challenged to create its own patient profile.
Most important was the person behind the patient: pathologies or reasons for a
hospital visit were taken in consideration only after a person profile was created.
To diversify the routes through the hospital each group could pick a card with in-
formation on why this person visited the hospital.
To foster their empathy with patients and thus improve their insight into their
wayfinding experience, participants were asked to follow the assigned route
through the hospital, trying to perceive it from the perspective of the person they
had created and to document it through pictures. At the end of the session each
team was asked to present their route and to identify problems they encoun-
tered with regard to wayfinding.
Session 2: Offering insight into wayfinding based on experiential user information
In the second session participants were offered experiential patient information
through a website. The website encloses a combination of theoretical
knowledge and insights into (the experience of) wayfinding (fig. 1). This is
achieved by connecting data fragments from qualitative research on patients’
wayfinding experience with theoretical concepts on wayfinding.
The homepage of the website gives a short introduction on wayfinding. This the-
oretical part shows the reader that wayfinding is about more than just signage.
Also architecture and communication play an important role in guiding patients
to their destination. From the homepage the reader is directed towards four pro-
files of patients navigating a hospital. Each of these profiles is documented by
video-recordings of the patient’s route through the hospital and quotes from in-
terviews with the patient. When relevant, the profiles are complemented with
similar insights from other patients.
5
During the first part of the session participants were given the opportunity to ex-
plore the website. Thereafter, they were asked to pick at least three pictures
they had made in the first session and to re-evaluate them based on the new in-
sights they gained from the concepts and experiential information offered
through the platform.
Figure 1. Example of a profile on the website.
The assignment was structured following a step-by-step approach:
1. Identifying bottlenecks
2. Analysing bottlenecks through the application of theoretical concepts
3. Weighing possible solution strategies against one another
By following these steps, certain locations where multiple concepts were rele-
vant were identified. (Spatial) elements from which a wayfinding issue origi-
nated or which could serve as a trigger to improve the situation were then docu-
mented.
Session 3: Generating solutions
The third session was solution oriented. Based on the insights gained by the
analyses made in the previous sessions, participants, in dialogue with the re-
searchers, now explored possible solutions to the wayfinding problems that suit
the concrete context of the hospital.
Participants
Workshop participants were recruited by the hospital in consultation with the re-
searchers. We aimed at a broad variety of staff profiles dealing with wayfinding
or the wayfinding system from various angles. The first session was attended by
nine persons:
– facility manager
6
– head of the building department
– employee of the building department
– employee of the prevention service
– patient administration processes manager
– employee patient administration processes (= reception staff)
– employee patient transport
– employee logistics
– security staff
For the second and third session this group was complemented with two addi-
tional persons:
– reception volunteer
– nurse.
Although all participants work in the same organisation, this variety of people
had never before met to discuss the working of the hospital on an equal footing.
Data collection and analysis
The three sessions were led by two researchers (author 1 and 2) who alter-
nated in leading the discussion and observing. All group discussions were au-
dio-recorded. When participants were working in teams the researchers pro-
vided support and observed group dynamics and registered conversations. The
pictures taken by the participants in the first session were collected and used
both to analyse the outcome of the first session and to serve as a starting point
for the second session.
The analysis started right after each session with a first discussion between the
researchers about the issues at stake regarding (1) the desired and used con-
tent in relation to the format in which it was offered or generated, and (2) the ap-
proach of the workshop. Observations and evaluations were noted down and
taken into account for the next session.
Findings
This section discusses the workshop findings on the basis of the questions out-
lined above: (1) how insight into patient experience can create an empathic and
motivated understanding amongst healthcare professionals and designers, (2)
what kind of information is needed to achieve this, and (3) how their improved
understanding impacts on their problem solving ability.
Fostering an empathic, motivated understanding
Wayfinding is clearly a key issue in the hospital which most of the participants
are confronted with on a daily basis. Not only does staff’s experience differ sig-
nificantly from patients’, participants each had their own vision on the current
wayfinding system and according communication. The origin of the divergent
view on wayfinding can be found in how the building is approached by staff and
how this differs from how patients are expected to make use of the wayfinding
system. Staff are often familiar with multiple parts of the hospital, which offers
them an overview, whereas patients and visitors have a more fragmented expe-
rience as they come in contact with only parts of the hospital. Moreover, most
staff members still think about the hospital in terms of the former system of
buildings and building blocks, and not in terms of the present routing system.
7
This leaves them often unable to support patients in following the routing sys-
tem.
Staff members’ sensitivity towards the patient perspective differed depending on
their professional profile. Especially those who designed and implemented the
current routing system had difficulties understanding why wayfinding was so
problematic for patients and visitors. Given their overall understanding of both
the building and the system, they clearly saw the coherence and logic, and were
unable to zoom in on patients’ more fragmentary experience of the building.
This resulted in a mistrust towards patients’ ability to navigate the building. Fre-
quently heard comments include “People don’t take the time to understand the
logic behind the system” and “I don’t know whether you help patients by saying
the floor [they have to be on], because then they surely take the wrong eleva-
tor”. Reception staff were very well aware of the troubles patients were facing,
being unable to read the ranges of numbers and feeling lost when they could
not immediately spot the next sign. For them the enforced communication style,
telling them not to give more information than the route number, caused consid-
erable frustration.
When participants were asked to create a patient profile from whose perspec-
tive they would explore the building, all four groups opted for a vulnerable per-
son. Three teams created a refugee (probably due to moment of the case study,
at the height of the refugee crisis in Europe), unable to speak the language and
completely unfamiliar with the building and common procedures. The fourth
team opted for a confused older man. By following the route these people would
take when dealing with the health problems according to the corresponding sce-
narios, participants were confronted with issues they had formerly not consid-
ered:
– Patients are highly dependent on staff to get started with the routing system
especially when not following a standardized path, i.e. entering via the emer-
gency department or having missed a bus stop and approaching the building
from a different street.
– The current wayfinding system is designed from the perspective of a stand-
ard patient; one flaw -not understanding the language, not using the lift because
of claustrophobia, or just being too stressed to listen to the instructions- can re-
sult in getting lost.
By navigating the building from a patient’s perspective, participants experienced
the flaws in the routing system first-hand. The current wayfinding approach
strictly aims at guiding people to their destination completely based on signage,
without supporting them in understanding where they go. Once you miss a sign
or lose track of the numbers, there is no other option than returning to where
you came from. This is reflected by the pictures participants took while following
patients’ routes. A majority only showed signs and arrows, picturing nothing
more than the ceiling and the upper part of the walls (figure 2). Architectural ele-
ments were hardly ever recorded. Only when looking at the pictures participants
realised their limited focus. The few images showing people and views of the
environment were taken when they had lost track of the signage. Participants
stressed that at these moments they particularly appreciated encountering (per-
sonal) support and orientating elements.
8
Figure 2. Sequence of 9 consecutive pictures taken by participants only showing signs.
Concentrating on the upper part of the hallways limited the opportunity for par-
ticipants to actively use the built environment as support in navigating the build-
ing. Exploring the website helped participants realize that orientation is an im-
portant element in wayfinding. The website offered a whole section on how the
built environment could support orientation, based on both theoretical concepts
and visual material showing how people navigated another hospital.
Types of information and techniques
The technique offered in the first workshop to create patient profiles, supported
participants to think about the particularities of those experiencing wayfinding
problems. It seemed an excellent preparation for empathizing with vulnerable
hospital users and actually being open to perceive the building from their per-
spective. This change of mind-set –moving from being occupied with their own
view on, and frustrations with the wayfinding problems– appeared to be a nec-
essary step to be able to evaluate the building from a patient perspective.
The website offered various types of information, each holding its own value to
sensitize and motivate participants to obtain a better understanding of patients’
wayfinding experience. The introduction page explained certain theoretical con-
cepts which were then further developed on the next pages showing real pa-
tients dealing with wayfinding in a hospital. Links between the patients’ experi-
ences were also made based on these concepts.
When asked about the most relevant information type, participants pointed at
the video material. Especially appreciated were side-by-side videos of a hallway
respectively with and without people, complemented with an explanation of how
this was experienced differently by patients. Participants claimed that the theo-
retical framework was not that appealing and added little to motivate them or
enhance their empathetic understanding of wayfinding. Yet, in the following dis-
cussion and search for solutions, they often used the concepts offered through
the theory. Although not valued explicitly, offering these concepts apparently
9
seemed to provide the workshop participants with a common vocabulary to dis-
cuss certain issues that appeared during their exploration of the building and/or
while watching the patients’ video’s or reading their testimonies.
Understanding patients’ experience and empathizing with it is one thing, formu-
lating solutions to improve the situation is another. Connecting the offered theo-
retical concepts with concrete locations in the hospital was not sufficient to actu-
ally be able to formulate clear cut solutions. When asked what would support
them in coming up with these solutions, above all participants suggested exam-
ples of best practices.
Impact on problem solving ability
Generating solutions was not a natural next step after the evaluation of the hos-
pital building and its wayfinding system. Especially considering the familiar envi-
ronment with an open mind appeared to be challenging. The current system
was strongly defended and change encountered serious opposition by the em-
ployees of the building department. Yet, making use of the self-created patient
profiles seemed to be an eye opener. References to the wayfinding experience
from these patients’ perspective and the pictures taken along their route were
made: “I think there are pictures of the place where people go to [destination X]
that’s indeed a very difficult point, we saw that.” Also the experiential infor-
mation on wayfinding experience in a different hospital was used to think about
possible solutions. Participants referred for example to the use of a map to pro-
vide patients with something to hold on to and help reach their destination.
Before the workshop, participants each reflected on wayfinding from their own
perspective and did not seem to connect these perspectives to create a mutual
understanding. The shared vocabulary offered through the theoretical part of
the website and appropriated through the assignments appeared to be an im-
portant basis to start a dialogue. Whereas the strict instructions on how to com-
municate on the routing was a thorn in the side of the reception staff, for those
who designed and implemented the system it was unthinkable to change it. Of-
fering the participants insight into how signage, architecture and communication
work together to mediate patients’ wayfinding experience in combination with a
better understanding of the diversity of patient perspectives, seemed to open
their minds to rethink one-sided assumptions and see the value of extra inter-
ventions that may not exactly fit in with a wayfinding system based on num-
bered streets only.
Only during the discussion, guided by the researchers, participants seemed to
be able to connect the different types of information offered through the website.
At this point they combined theoretical concepts with the experience of following
the patient scenario’s. This resulted in the creation of a “spine” through the hos-
pital, i.e. the route from the entrance of one building to that of the other building.
The spine should not be used to actually follow the entire route but could func-
tion as a point of recognition to return to and depart from again. Also certain in-
tersections and vertical circulation could benefit from being more explicated.
Reflecting on the three workshops, participants concluded that when con-
sciously designed, signage and more implicit spatial interventions can comple-
ment and strengthen each other. Creating an integrated approach which com-
bines architecture that directs people while moving through the building with a
10
communication strategy that supports patients and visitors throughout their jour-
ney holds potential to enhance rather than endanger the functional system that
is now in use.
Discussion
Despite staff’s good intentions to be helpful and supportive towards patients and
visitors, many of them did not realise how far their use, understanding, and ex-
perience of the hospital building diverted from patients’. As some of the partici-
pants often come in close contact with patients and visitors experiencing way-
finding problems, think of reception staff or volunteers, this group could express
some of patients’ grief. Yet, none of them actually had ever followed these peo-
ple’s routes. Additionally, they were confronted with regulations imposed on
them regarding what they could tell patients and visitors and how far they could
go in offering support. Whereas these communication guidelines were formu-
lated with the best intentions with regard to the efficiency of the wayfinding sys-
tem, i.e. only following the signs, there was no common understanding on why
and how this conflicted with patients’ and visitors’ intuitive approach to and ex-
perience of navigating the building.
Fostering empathy with patients by making staff walk in their shoes, created a
first impression of patients’ perspective amongst the participants. They noticed
how dependent they were on staff members’ willingness to put them back on
track once lost. The (lack of) communication in various forms, be it spoken, writ-
ten, or through the building, even left them in despair regardless of their famili-
arity with the environment. The pictures they took of the followed route, only
showing signs, ceiling and the upper part of the walls, pointed at the depend-
ence on signage, and the lack of attention to additional (building) elements that
could support orientation and navigation. Being unable to literally open doors
they would normally use, provided them with a whole new perspective on the
(lack of) coherence of the built environment. Obtaining this embodied under-
standing seemed to motivate the group to further collaborate on solving the is-
sue, uniting each member’s previous personal concerns and perspective on pa-
tients’ and visitors’ experience.
In obtaining a better understanding of the wayfinding problems in the hospital,
participants felt especially supported by the video-recordings offered through
the website in the second session. In the third session, they frequently referred
to them connecting concrete situations from the videos with their own experi-
ence. An important advantage of the video’s (combined with a textual explana-
tion) seems the opportunity to offer nuanced insights in a compact way. Still,
when asked to analyse the pictures taken in the first session by connecting
them to theoretical concepts offered through the website, participants seemed
to hesitate. Only consulting the website was not considered sufficient to analyse
and identify bottlenecks in the hospital’s spatial organisation. To achieve this
participants demanded very concrete, and guided tasks.
The combination of embodied experience with fostering empathy seemed to
convince participants of the added value of integrating architecture, communica-
tion, and signage to improve wayfinding. The presented information, combining
theoretical concepts with visual material and narratives on patients’ and visitors’
wayfinding experience, raised their awareness of the problems patients were
facing and helped them to analyse the existing situation, but did not seem to
11
support them in finding solutions. To this end, participants suggested providing
best practices, i.e. examples of good solutions. This is in line with the outcome
of previous research pointing at architects’ case based design approach
(Heylighen & Neuckermans, 2002). Apart from the fact that providing this type
of information lay beyond the scope of the project, we are concerned that show-
ing these examples could also hamper participants’ out of the box thinking.
Conclusion
The case study shows how, apart from providing experiential patient infor-
mation, guidance and initiative by an external moderator provides an added
value to exploring the experiential by themselves. Although all participants were
working within the same organization, it took a third party to bring them together
to collectively discuss a common topic. Doing so turned out to be an enrichment
for all parties involved. This value was confirmed by the participants as they
planned to continue collective meetings to discuss this and other topics con-
cerning the hospital’s (spatial) organization.
Depending on their profile, participants had different expectations of the format
and content of the information presented during the workshop. For some empa-
thizing with patients was truly eye-opening, for others just a confirmation of what
they dealt with on daily basis. Letting go of the strict signage approach and ac-
cording communication was for some a relief, for others a heavy duty. Starting
from a shared understanding of the issues at stake, generated through the ses-
sion to foster empathy and the video-recordings and supported by a common
language provided through the theoretical concepts, created a basis for collabo-
ration between staff members with distinct profiles.
Although the workshop was generally evaluated positively, specific attention
should be paid to raising realistic expectations about information on patient ex-
perience. What research can offer, what hospital staff expect, and what is most
fruitful to support design does not always coincide. Particularly in the case study
presented here, we found a discrepancy between what research can tell us
about real patients’ experience, what healthcare professionals expect to learn,
and what is useful for designers to work with. In the overarching project the in-
sights gained through this case study will be combined with those from others to
add to our understanding of how research on patient experience can inform
hospital design.
Acknowledgements
This work was supported by Flanders Innovation and Entrepreneurship as a
Tetra-project under Grant number IWT 140570. The authors thank all workshop
participants for sharing their time and insights and the hospital boards for its
support.
12
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