Journal of Building Engineering 44 (2021) 102931

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Journal of Building Engineering

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Impact of circulation complexity on hospital wayfinding behavior (Case

study: Milad 1000-bed hospital, Tehran, Iran)
Amir Ehsan Pouyan a, *, Abdulhamid Ghanbaran a, Amir Shakibamanesh b
a
School of Architecture and Urban Design, Shahid Rajaee Teacher Training University, Tehran, Iran
b
Department of Urban Planning and Design, School of Architecture and Urban Studies, Art University, Tehran, Iran

A R T I C L E I N F O A B S T R A C T

Keywords: The character of large-scale healthcare facilities may tie into wayfinding difficulties and this oppression will yield
Wayfinding performance in first-time users. Hence, the circulation of a building is the key factor in organizing its layout. Five circulation
Spatial route complexity patterns have been found in hospitals based on route geometry, and each of them has its own complexities
Individual differences
affecting wayfinding behavior. The present study focused on these complexities in circulation patterns in Milad
Circulation patterns
Healthcare space
1000-bed mega-hospital and investigated the results related to wayfinding performance, people’s chosen strat­
Space syntax egy, and individual capabilities in wayfinding. Then, it detailed the users’ views and performance regarding the
existing circulation layouts in order to improve the design and implementation of the delivery system. To design
wayfinding tasks, first, the space syntax technique was conducted to anticipate the wayfinding flow and intel­
ligibility of the space to define the origin and destination of every task. Then, 10 different scenarios were defined
as a result of a detailed qualitative investigation of the hospital environment and interviews with stakeholders.
Next, the “wayfinding performance” was assessed while participants were completing the assigned tasks. Finally,
the obtained wayfinding strategies from the users during the process were evaluated. As a result, circulation
patterns of the hospital significantly rely on the rate of distance trajectories, deviations from the main path and
sign usage of wayfinders. Further, among all types of circulation patterns, the ease of wayfinding in radial, and
deep corridor wards were higher among other patterns. The results indicate that circulation patterns should be
assessed due to functional ward demands and the referred community needs.

1. Introduction
Hospitals are considered as a complex mini-cities in which logical
relationships among various departments formed in accordance with
signs and cues inside them. However, their multi-functionality may add
difficulty level in wayfinding to some extent. Due to the sketchy
knowledge of its environment, as well as a sense of disorientation,
especially for (at-risk) patients [1,2]. In addition, healthcare complexes
undergo more changes and developmental plans, so that one may
experience uncertainty in finding his/her destination even after a long
time visit [3,4]. Besides, architects and designers face challenges such as
stress, anxiety and fatigue caused by complicated and long corridors as a
result of afterthought in design process [5]. Thus, to design healthcare
spaces with more demand-built approach, architects must provide
legible space due to overcrowded situation in some hospital
departments.
Apart from above issues, differences between individuals, their level
of sensorial arousals, and similar hospital ward names can influence
wayfinding behaviors [6–8]. For instance, a multiplex building with
aesthetic attractiveness can confuse wayfinders with high or low spatial
capabilities [9–11].
To this end, it is evident that in an unfamiliar environment, the level
of environmental complexity for a user would become a serious draw­
back at first. Although, this issue can be compensated to some extent. As
the familiarity proliferates, the wayfinding performance and spatial
navigation would improve in both accuracy and latency [12,50]). As a
result, the complexity of the configuration would be considered less
important. In this regard, [13]; stated that plan configuration impact
wayfinding behavior the most among other building features. In fact, a
visit to an unfamiliar environment, people rely on plan layout properties
such as centrality or vertical components of the building, and salient
spatial landmarks to fulfill their incomplete cognitive maps, that might
contain any aspect of the setting [12]. Also, Karimi [14] and Rodrigues
[15] claimed that navigation is mostly affect from building layout and

* Corresponding author.
E-mail address: pouyanehsan@gmail.com (A.E. Pouyan).

https://doi.org/10.1016/j.jobe.2021.102931
Received 21 November 2020; Received in revised form 24 June 2021; Accepted 26 June 2021
Available online 6 July 2021
2352-7102/© 2021 Elsevier Ltd. All rights reserved.
A.E. Pouyan et al.
Fig. 1. Wayfinding complexities Evaluation Correlation.
Fig. 2. Wayfinding process.
efficient signage. According to Dilani [16]; about 49% of human traffic
in a hospital is related to corridors, which is considered significant,
compared to the time spent in nursing stations (16%), patients’ room
(19%), and other spaces (16%). Therefore, the plan configuration (CFG)
and path formations in hospitals are the great contributors to overall
legibility and the ease of connections between departments [17].
As maintained by Baskaya et al. [12]; a regular but asymmetrical
floor plan is easier to comprehend and traverse than regular and
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Journal of Building Engineering 44 (2021) 102931
symmetrical layout in healthcare complexes. Namely a department with
deep corridor shape system allow easy orientation, so that environ­
mental learning and travel plan execution would become easier for
them. Despite the fact that the lack of differentiation in a particular
environment affects novice and expert wayfinding behavior [10], ar­
chitects should be equipped with the knowledge of every uniformity in
both the design of plan layout and spatial elements. In this respect,
“symmetrical forms that might be thought less complex are seriously
deficient when used uniformly with more repetitive units”.
As shown in Baskaya et al. [12]; various design configurations shown
to have significant effect on people’s wayfinding behavior that has not
been empirically tested to any great extent yet. In this regard, the per­
formance of a wayfinder in each layout type of hospital departments is
considered as the initial point. In order to define a better bond between
wayfinding behavior and configuration types of a healthcare setting, the
framework of the study adopted from “wayfinding complexity model” as
an interaction between the individual and the building characteristics
[9], which users’ have to deal with three steps of users’ mental repre­
sentation (cognitive map), building physics (spatial syntax of the space),
and spatial capabilities (applied strategies) [18–20] (Figure 1).
There is a growing body of research in measuring wayfinding
complexity that investigates the most effective building physics and cues
for facilitating behavioral dynamics and finding a destination [13,
21–26]. However, empirical research that focuses specifically on
healthcare settings is limited; it might be due to logistical factors [132].
Thus, the current study Aim was to evaluate the complexity of way­
finding in a real-built Milad 1000-bed hospital design in Tehran. This
was accomplished by the use of stalking observation, which allowed the
study of participant behavioral responses during wayfinding tasks under
different design conditions. In this context, although the process faced
some technical issues, but these deficits act as an advantage. For
example, the operational noise of the environment was not controlled
during the service hours-time, in which, this added realism to the test.
1.1. The framework for assessing wayfinding complexity
As stated, wayfinding consists of individual’s direction in space
(origin selection), path identification, programming for and continuous
A.E. Pouyan et al.
monitoring during traveling the path, and destination recognition while
approaching (out-of-access and out-of-sight) [6] (Figure 2). Accord­
ingly, many factors, such as the building features, and spatial skills of the
users, or a combination of both, determine how wayfinding would be
performed.
All of the wayfinding process parts (some of them can happen
simultaneously) are interrelated and egocentrically affected by previous
knowledge of the individuals. However, in the process of wayfinding
people would need critical environmental information [27]. In fact,
Scotland’s National Health Service [28] knows four factor that involved
in wayfinding: 1) people’s perception of the environment, 2) the way­
finding data from environment, 3) people’s ability to orient themselves
spatially, and 4) the cognitive and decision-making process they expe­
rience. To elaborate, People’s perception of the environment may affect
wayfinding because each user can experience the environment differ­
ently. But environmental factors that wayfinding information come from
include complexity of the layout, level of visual accessibility, and sa­
liency of the landmarks [13]. Also, position of the information, legibility
of the environment (architectural differentiation), and wayfinding per­
formance would affect the process of every individual. In this essence,
subjective and objective dimensions of the wayfinding will be presented
in the next section.
1.1.1. Subjective dimension of wayfinding behavior
1.1.1.1. Mental spatial transformations. In cognitive map studies, there
are two reference frames that represent spatial locations, and their re­
lations. The reference frames of the environment are based on a 2D
conception of the space, in which has distance measures and direction
quantities [29–32]. This knowledge enables people’s mind to grasp
spatial imagery of the environmental features or implying to
geographical coordinate references during wayfinding. Places and
spatial relations based on system coordination is allocentric represen­
tation. In which, one would reason about the logical relations of a group
of spaces. So, the allocentric reference frame argue about the
object-to-object knowledge. In its essence, “Spatial perspective taking”
is significantly related to allocentric representation. As it is visualizing
an environment in its entirety from a different position. In contrast,
there is an egocentric knowledge [33] comes from working memory of
experienced navigated environments. According to this account, the
mental representation is based on directional relations between the self
and target locations in the environment. Distances and turns (environ­
mental features) during wayfinding process is represented relative to the
user’s self (e.g., Ref. [31]. It has been described as self-to-object re­
lations: “The individual can essentially view or access distant locations
in the environment along a straight line of sight, through intervening
points” [34]; p. 564). For example, spatial perspective-taking ability is a
significant predictor for the correction of misalignment for turning de­
cisions along a route. The self-to-object spatial knowledge reflects the
core meaning of “sense of direction”, and moving or transforming
mental representations of previously seen objects in space. It is often
measured by asking people to recognize the same shape in different axis
or axes (it is generally measured by Mental Rotation test of Vandenberg
and Kuse [31,35,36].
1.1.1.2. Spatial preferences. Several types of wayfinding strategies exist
as people learn the environment [6,37,38]. For example, some way­
finders might first head toward center of an area and then look for their
destination, whereas others might use salient cues in an environment for
reference [22]. It is also likely that wayfinders follow intrinsic heuristics,
such as using long sightlines [39]. The ability and/or tendency to
employ different wayfinding strategies depends on individual differ­
ences [40–42]. In this study, as Siegel and White [43] proposed way­
finding strategies, the measured spatial preferences are based on LRS
model: (a) Landmark knowledge (the spatial relations among salient
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Journal of Building Engineering 44 (2021) 102931
objects); (b) Route knowledge (previously experienced routes) and (c)
Survey knowledge (reasoning the integration of configurational spatial
information). These spatial preferences interact with building charac­
teristics and the information that they afford, thereby influencing which
properties would be highlighted on the cognitive map.
Also, it should be taken into consideration that decision-making
process which is undertaken along a path contributes to survey knowl­
edge [44]. Further, Kuliga et al. [19] proved that preferences for survey
information in high complexity layout facilities are indirectly repre­
sented in wayfinding performance. They proposed that the particular
advantage/disadvantage of any preferences would vary with the specific
type of wayfinding task the participants are utilizing.
1.1.1.3. Direction perception. Methods in human navigation have iden­
tified as landmark, route or survey knowledge integrated with the
feedback from locomotion, in line with mental estimates of the distance
and direction of objects from one another. An individual’s sense of di­
rection could be important to all of the wayfinding methods. For
example, a person with a well-defined sense of direction can decide
better in maze-like perplex situations or intersections on route, by
looking for relative landmark knowledges. Besides, they can rely more
confidently on mental references when registering the degree of a turn.
Lastly, individuals with strong direction senses would swiftly match a
scene they encountering with egocentric mental representations [36].
The sense of direction charge on mental perspective-taking feature, and
it has been shown to be a reliable predictor of navigational performance
in large scale buildings than small-scale ones (e.g. Refs. [36,45,46].
Furthermore, it is positively related to various survey knowledge mea­
sures (direction-pointing, map-drawing, and estimates of distance) [36,
38].
1.1.1.4. Spatial anxiety. It is widely accepted that higher “Spatial anx­
iety” would impair spatial preferences, and memories in recalling visited
environments. This would lead to disorientation during navigation, as
well as wayfinding performance when in doubt decision making in
spatial nodes will be difficult [47]. Researchers have suggested that
spatial anxiety has strong correlation with deviation from the main route
and people with high levels of spatial anxiety are slower than people
suffering less anxiety due to physical features of a building [48]. In order
to be more specific, individuals facing more spatial anxiety, hold their
attention to the more detailed feature in built environment to conquer
more information from relevant landmarks on route [49].
1.1.2. Objective dimension of wayfinding behavior
In order to, investigate objective dimension of wayfinding in space,
one has held the ability to decompose every aspect of the built envi­
ronment. So, the plan layout is the first and foremost reference of in­
formation about the built environment. The very related concept
working aside plan configuration in wayfinding literature is the “Inter­
connection density” (ICD) [50], which is “the average number of con­
nected decision points for each decision point in a particular
environment” [2]. Generally, higher ICD is correlated with more prob­
lems in wayfinding performance. That is, two environments might share
the same ICD value, but vary in their floor plans. Werner and Schindler
[51] varied two issues in ICD discourse: (1) alignment approximate to
the regions near the elevator in multi-floor buildings, and (2) type of
junctions in functional nodes of the plan layout. Results indicated that
slower wayfinding performance occurs when the region around the
elevator is misaligned to the rest of the building. ICD is very related to
the concept of space syntax in behavioral studies-an approach that an­
alyzes social relations and spatial cognition of users in 2D layout of space
by mathematical approach [52], based on graph theory [53]; [71]). One
of the basic techniques in which, it consists of nodes and edges [53].
Every individual space specified as a node, and the immediate connec­
tion of two spaces form the edges. This method begins with the
A.E. Pouyan et al. Journal of Building Engineering 44 (2021) 102931

Fig. 3. Example of an intelligible spatial layout (left), and an unintelligible spatial layout (right) [124].

simplification of the plan in the form of a 2D joint convex forms called

Fig. 4. SAM Visual Questionnaire.
convex maps [54]. A convex map is a map in which any point in space
can be seen from each point in that space. Connections between convex
spaces exist when a person can move from one of these spaces to another
without trespassing the intermediate spaces. A popular example in
determining the convexity of a space is to make sure that the line drawn
from any vertex of the space to other vertices does not intersect the
border of the space. Some researchers have used this notion by the
approach of node proximity degree and have argued that navigators are
sensitive to centrality of nodes in the network. They have established

Fig. 5. Overview of Milad One thousand Bed Hospital.

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Fig. 6. Overview of 1000-bed milad hospital.

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A.E. Pouyan et al.
Fig. 7. Space syntax analysis of Milad Hospital.
understanding of the way a person explores a building or a survey a
route as the integration level of its space to the others [55–57].
Major trends in space syntax measures utilized by wayfinding studies
are “Axiality of sight lines”- as the fewest and longest lines of sight/
movement covering the whole 2D floor in regards to topological prop­
erties of the space [22,58–69], and “Visibility Graph Analysis”- the vi­
sual features of the built environment is defined as the set of all of the
points visible with 360⁰ field of vision from a given vantage point in
space [57,70,71].
The concept of layout complexity is the idea of built environment
configuration, understood as a network of interconnected units. This
definition meets with the Axial line analysis in space syntax, it can be
conceptualized that the flow of axial lines, their connection positions,
and the depth they traverse through the specified space is the repre­
sentation of complexity in the aforementioned space [69]. Axial line
analysis has various measure as follows:
Axial Line (Connectivity)- Which focuses on capturing movement
dynamics and wayfinding behaviors, and applies axial maps as the best
tools [53,57]. The subspaces of network (convex maps) consist of the
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Journal of Building Engineering 44 (2021) 102931
lines of sight and movement, which represent the navigable structure of
a building combining into a network [53,55,72]. In fact, it demonstrates
the relation of wayfinding to the spatial layout of a building, and each
difference mostly has an association with inexplicable variance [73].
Axial Line (Integration)- As “Global Accessibility” or “Integration-n”
(the number of spatial connections to a place from the rest of the
building), is a description of the accessibility of one place from the other
entire places in a building [72];[8]; [57]. In a pioneering and influential
work by Peponis et al. [56]; researcher examined people’s walking
routes with two tasks in a hospital. They assessed all the trajectories they
traversed (coined as “Redundant Path”), and came up into a conclusion
of every individual space with a high integrated value gravitate high
percentage of human movement in healthcare departments. These
absorbent spaces can structure in the most accessible and central loca­
tion of a building [74]. Moreover, wayfinder’s formulate a set of major
destinations in a stacked 2D floor subjectively better than detailed
spaces in a ward. The major paths can be assessed by the topological
properties relations between all paths. Thus, the integration measure of
space syntax can identify and measure a set of major paths. Space syntax
A.E. Pouyan et al.
Fig. 8. Milad hospital floor AxialLine-Intelligibility scatter plots.
has been used to describe healthcare settings, such as forecasting the
nurse’s travel path in wards or between departments in healthcare fa­
cilities [17], however, there is a growing trend in predicting patient’s
behavior due to the construction developments in healthcare industry
and the quality of care [75]. Sadek and Shepley [57] provided a
comprehensive review of spaces syntax technique in healthcare, noting
that the largest number of articles reporting the use of this technique
involve in “patients privacy preferences in quality of care, user’s cost,
nurse bases in ward layouts, and evacuations”. Understanding patient’s
behavior and movement dynamics are involved in relation with age,
gender, wayfinding errors or frequency of reconciliation from the main
path, which showed that when uncertain about destination, people
gravitate to spaces with higher central integration [76].
In the local integration measure, a primary set of starts/destinations
can be developed with accessible and central, or segregated distant
sections of a building. The “Local Accessibility” (i.e., the number of
spatial associations to a place from an adjoining and subgroup of the
more extensive network), can be measured by the use of “Axial Line,
Integration Radius three” (excluding the entire spaces outside three al­
terations of direction) [72,77].
In addition, spatial intelligibility as accounts for a space syntax tool
to assess building legibility. The simplicity and forecast of wayfinding in
a location is represented by this benchmark [52,55,56,72,73,78–81].
Further, the intelligibility of space is measured via an association be­
tween the total building space and its local specifications [82], which is
related to the relationship between the connectivity of space (measured
locally) and its global integration (Fig. 3).
Isovist Analysis (Visibility Graph Analysis)- Based on Gibson’s
Ecological approach (1979) the visual perception begins by reflected
light rays from outer world. In this regard, the space user will face
changes in the visual properties during wayfinding, because the data he/
she receives when changing his/her position in space through the pro­
cess. In this regard, Benedikt [70] introduced his concept as “Isovist” in
order to combine Gibson’s approach and architecture. He defined
isovists as the set of all points visible from a vantage point in space. So as
to, allow the size and the shape of the space geometry quantified. Hillier
et al. [52] had shown previously that relationship between Axial lines
through the space does correspond with movement patterns. Thus, by
combining isovist fields a trend of how well integrated isovists began to
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Journal of Building Engineering 44 (2021) 102931
develop [83]. The methodology was later acknowledged simply as
“Visibility Graph Analysis” (indicates visual accessibility) [77].
For a set of origin-destination pairs, the extra forecasts of difficult
tasks can also be facilitated by the notion of integration in VGA. Kuliga
et al. [19] used this logic to develop a task classifying system. Their
strategy comprised the assumption that wayfinding could be simple
from and to an integrated and visually accessible place due to High
(visual) accessibility, and navigation between any two separated places
could make a challenge due to Low (visual) accessibility.
1.2. Research aims and hypotheses
This study has based its initial aim on carrying out the level of
complexity in every ward layout design in hospitals. It is proved that by
measuring newcomer’s wayfinding performance indirectly [19] through
the relationship of people’s wayfinding strategies and individual dif­
ferences. In connection with this point, Milad 1000-bed hospital in
Tehran (Iran) selected due to its various environmental differentiation.
The process began with the spatial analysis of the hospital and way­
finding challenges one would experience when surveying a route in a
hospital [84]. In order to address floor navigation (Ward layouts in one
individual floor) with a manipulation of low or high accessibility. The
data were statistically compared between all tasks designed based on
out-patient or companions needs to test the following hypotheses:
Hypothesis.1. Wayfinding performance for different ward types will
be related to spatial analysis of accessibility in the following ways:
H.1a. Performance will be better in routes with high visual accessible
destinations that in routes with segregated destinations.
H.1b. Performance will be better in routes passing through one
department than routes traverse through several departments.
H.1c. Performance will be better when there is one salient way to
travel than patterns with similar routes.
Hypothesis.2. Wayfinding performance for different ward layouts
will be related to individual differences in spatial perceptions and
preferences in the following ways:
H.2a. Spatial anxiety will be lower in visually available routes.
A.E. Pouyan et al. Journal of Building Engineering 44 (2021) 102931

Table 1
Design approaches of internal horizontal routes of hospitals.
Sample of a Ward Ward Circulations Hospital Wards

The Corridor configuration or Nightingale (Long nave ward)

Type of hospital section, which contained one large room without subdivisions for patient
occupancy. Sample plan: C, T, L

Nuffield or Duplex Configuration

A combination of two Corridor configuration, each including its own nurse station, but sharing
support spaces that is located between the two.

Racetrack Configuration
Support spaces and nursing stations located in the center of the ward.

Cluster Configuration
Sections of the hospital are formed by the formation of oblique and orthogonal axes.

Radial configuration
Nursing stations are located in the center of the section and the rest are around.

Circulation Space.
Staff Space.

H.2b. Sense of direction and mental spatial transformation will be
higher in visual accessible destinations.
H.2c. Performance will be different in men and women figures in each
type of ward, based on their preferences.
Such questions would lead to the optimization of users’ wayfinding
behavior, long-term efficiency of healthcare buildings, and reduction of
service cost in the healthcare industry.
2. Method
2.1. Individual differences and strategies in spatial reasoning
Spatial capability is distinct from general intelligence. Some of the
capabilities such as mental rotation skill (mental rotation test is the
ability for rotating the mental representations of 2D and 3D objects
because of relating to the visual presentation of object rotation in the
human mind [85]). However, they possess low explanatory power for
the data of wayfinding behavior in larger spaces [45]. Additionally,
wayfinder needs less stored spatial knowledge when visual accessibility
to salient features and more connectivity in the environment, such as
vertical circulations [55,80]. Thus, wayfinding can be expected to have
more difficulty with the limitation of visual accessibility to noticeable
landmarks. In a building, these parts can be named as “central” and, via
repetitive usage, can turn into anchors for consumers [55,56,86,87].
Accordingly, wayfinding performance may be predicted to be superior
when the start and destination places are central inside a floor. Simul­
taneously, the spatial capabilities of individuals in space are different.
An individual may carefully perform a paper-and-pencil mental rotation
test while he/she is weak in finding a destination. The diversity of ca­
pabilities is observed in different spatial tests, which indicates that tests
may involve various cognitive processes. In the field of spatial cognition
studies, evaluating individuals’ spatial capabilities should be evaluate
for controlling whether their wayfinding efficiency reflects work de­
mands or their abilities [88].
The users were categorized as spatial relationship reasoning, direc­
tion sense, strategy preferences, and spatial anxiety by considering
mental capabilities. In this regard, the standard questionnaires were
employed including mental rotation [35], spatial perspective-taking
[89], Santa Barbara sense of direction [36], spatial representation
[42], and spatial anxiety scales [40]. The questionnaires rank partici­
pant’s and describe their strategies for wayfinding briefly in each task
based on the instructions [35,36,40,55,89,90].

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A.E. Pouyan et al. Journal of Building Engineering 44 (2021) 102931

Table 2
Wayfinding Tasks.

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A.E. Pouyan et al.
Moreover, the emotional response model of PAD [91] with three
subsets of pleasure, arousal, and dominance is utilized to measure the
level of perceptions and emotions in individuals. After each wayfinding
task, and perceiving the full spatial relations of the space, individuals
assess stimuli based on their emotional mode [92]. In the present study,
each stimulus was rated as 1–9 by using the self-assessment manikin
(SAM) test (unpleasant: 1–4, neutral: 5, pleasant: 6–9) (Fig. 4).
2.2. Wayfinding performance
Wayfinding performance is assumed to be an indirect criterion for
the quality of the individual’s cognitive map, and the individual way­
finding strategies utilized by humans [9]. According to Ref. [93] way­
finding performance can be measured by various variables such as,
travel duration (Time), travel trajectory, doubts during the process (stop
frequencies), deviation excess from conventional path to the destina­
tion, looking for environmental cues as a result of getting lost. Thus,
previous studies [19,22,50,93] assumed that spending less time to reach
destinations, traveling shorter distances, deviating less from the correct
path, applying lower signs, and pausing fewer during travel reflect
wayfinding performance better, which are measured with the dependent
variables of time (s), distance (m), deviation from the main path
(percent), sign usage (frequency), and pauses during travel (frequency)
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[19].
To elaborate deviation from the main path, the shortest path to the
destination is considered, in which, it is calculated by using the ratio of
deviation to optimal shortest path (PAO = (traveled distance - shortest
path)/shortest path). The ratio of PAO to deviation represents the
additional traveled distance [19,56,94–96].
Also, sign usage reflects the strategy utilized by the wayfinder, which
confirms that the user is still on the correct path. The component is
considered as an individual looking at a sign during a travel, as well as
stopping to read a sign (pause + sign usage). Pauses, doubts, and un­
certainty are representing the individual’s need for information during
wayfinding.
2.3. Case study
After assessing components such as the objective, functionality, main
mission and assignments, bed number, and architecture of hospitals, as
well as their urban service range, 12 mega-scale hospitals having almost
identical characteristics were selected, among which, Milad hospital was
considered as final choice because of possessing more complex CFG.
(Based on the unofficial hospital reports, 6000 people visit the hospital
every day, except for COVID-19 cases).
Milad hospital was built in 2001 with 12 floor stories. The hospital
A.E. Pouyan et al.
Fig. 9. Demographic Characteristics of the experiment.
has 1000 licensed beds, 24 surgery rooms, 20 pre-surgery and 20 post-
surgery care beds. Also, the hospital host patients in Pediatric Inten­
sive Care Unit, Neonatal intensive care unit, CCU, dentistry, and various
diagnosis labs. As well as, sections for visitors, including 430 seats. In
Administrative division, there is a conference center (with 190 seats),
and two classrooms. The hospital Inpatient section consists of three
wings, and a central tower, in which situated near the outpatient tower
with 8 floors (Figs. 5 and 6).
2.4. Analyzing building to classify wayfinding tasks
Based on the healthcare design guidelines, spatial circulation forms
up to 40% of total public functional spaces in hospitals [133]. Accord­
ingly, Space circulations can be independently accessible by all of the
individuals, including entry, the main lobby, receptions, corridors,
vertical connections, and waiting rooms [97]. In order to define tasks
and ensure the visibility of origins and destinations directly [8,19], the
space syntax analysis method was conducted in spaces with outpatient
access [57,98,99], based on reasons for visitors to the hospital [84];
reported the main reasons in outpatient departments are medical con­
sultations, emergencies, and visiting a patient (Figs. 7 and 8).
2.5. Final classification of wayfinding tasks based on spatial analysis
In order to design and determine the origin and destination of tests,
spatial component analysis is performed on hospital maps, and the
classification patterns of spatial circulations were limited to horizontal
circulations (although combining vertical and horizontal routes results
in various classifications and other results, which is out of the scope of
this study) [19,62]. Thus, the layout of the study was formed based on
the access system classified by Nazarian et al. [17]; in which it is
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Journal of Building Engineering 44 (2021) 102931
structured from the geometric arrangement of healthcare spatial circu­
lation sections (Table 1).
These five types of horizontal circulations were founded in the
selected hospital. Considering the above-mentioned space syntax anal­
ysis, tests were designed to measure wayfinding behavior of its users
(patients and their attendants) in spatial circulation CFGs of healthcare
environment, in line with evaluating access levels (low and high) (2*5).
As a result, ten core trials were spread throughout the building. This
sequence of tasks was made based on the scenario in each functional
group of spaces related to each other by their therapeutic relevance,
deep scanning of the wards, and blind-participation of wayfinders in
each space for cognition and recall, and there is a link between the
destination of one task to the origin of the next. Which begins from
Corridor CFG1, Racetrack CFG1, Corridor CFG2, Radial CFG1, Cluster
CFG1, Cluster CFG2, in the general ward (ground floor), continues by
Racetrack and Radial CFG2 respectively in the emergency department
(first Floor, central tower), and inpatient surgery Ward (4th, 5th and 6th
floors, central tower), and ends by Duplex CFG1 and CFG2 chosen in the
clinical floors (floors no. 2, 3, and 4; out-patient ward) (Table 2).
Several paths with dissimilar distances to the destinations were
accessible for each task. In order to, explore different interpretations of
the individual’s regarding each types of spatial circulation, tasks probed
affiliated specific challenge as follows (This established system formed
with advices by environmental psychologists during several consulta­
tions) [8,13,50,100,101]:
First task (Corridor CFG)- since the task aims at linking the accessible
start and destination of a deep corridor-shaped circulation, pattern
passes through functional nodes. This issue leads to the visual concen­
tration of individuals in population absorbent places during wayfinding
(High spatial abilities are needed to travel successfully in this task).
Second task (Racetrack CFG)- The first Racetrack task sought to assess
A.E. Pouyan et al.
Table 3
Task descriptions.
Circulation Hospital Section Wayfinding Scenario and
Pattern Task Type Procedures
Visual Accessibility (Origin
to Destination)
1. Corridor - Ground floor, central “Imagine you have to take a
Configuration- corridor medical diognosis for a serious
1 - Easy; wayfinding task health condition, try your best
- High to complete the task. Please
complete the task with a
nimble manner”.
Start at the main entrance of
the building, then after
experinecing Radiology, CT
Scan, Out-patient, Admin.
sections, lastly stop at the
Medical Diagnostic Laboratory
entry and its nursing station.
2. Racetrack - Ground Floor, Medical “Then, you need to discuss your
Configuration- Diagnostic Laboratory test results with Dermitologist
1 - Easy, wayfinding task at the back part of the
- Medium Diognostic Laboratory. Please
complete the task with a
nimble manner”.
Go from entry door to the “Exit
Stair case” at the other end of
the space circuit in this section,
and find the specialist office
next to it.
3. Corridor - Ground floor, left central “Imagine one of your friends
Configuration- corridor suffering from a heart disease,
2 - Hard; wayfinding task and he/she have to do treamill
- High test. You are accompanying
him/her from “Movement
therapy ward” to “Angiography
ward” in order to monitor his/
her medical results by the
expert. Please complete the
task with a nimble manner”.
It begins at the initial point of
hospital’s left central corridor,
moving towards end of the
corridor to the right, finishes
by the Clock (near the
angiography nursing station).
4. Radial - Ground Floor, “Imagine you are invited to a
Configuration- Administrative Division scientific congress in the
1 - Easy, wayfinding task hospital. You are late, and the
- Medium session has been started. Also,
every person invited has a
receipt for a seat. Please find
your seat as quickly as
possible”.
This section is surrounded by
central building shaft at the
back, below the main entry and
located at the top of Out-
patient section. The path starts
at the intersection between
central shaft and Admin. area
filter. Then, turn right at the
lobby, enter conference hall,
find seat no.15 in line 9.
5. Cluster - Ground Floor, Out-Patient “Imagine you are feeling ill,
Configuration- area and Accounting and you need to see an Internal
2 section medicine specialist at the
- Hard, wayfinding task outpatient area by your self,
- Medium but before that you have to pay
the bills for the hospital
admission. Please complete the
task with a nimble manner”.
By starting from the Outpatient
entry, first look for
Administrative section sign and
then go through the supportive
space corridor, enter
12
Journal of Building Engineering 44 (2021) 102931
Table 3 (continued )
Circulation Hospital Section Wayfinding Scenario and
Pattern Task Type Procedures
Visual Accessibility (Origin
to Destination)
accounting area, look for the
first junction on your right.
6. Cluster - Ground Floor, “Suppose that a friend of yours
Configuration- Orthopedic, and Speech- injured his/her hand and got a
1 Language Pathology ward bone fraction. So, you are
- Easy, wayfinding task accompanying him/her to the
- Medium Orthopedic ward to cast, and
stabilize the broken bone.
Please complete the task with a
nimble manner”.
First keep in mind the global
spatial configuration of the
Speech-Language Pathology
department, go straight ahead,
at the end of the corridor turn
left and use nursing station sign
as a salient landmark to arrive
at the destination.
7. Racetrack - First Floor, Emergency “Assume you are experiencing
Configuration- Department a respiratory problem. You
2 - Hard, wayfinding task have to first take care of the
- High pain in the emergency area.
Please complete the task with a
nimble manner”.
Go through emergency dept.
hall, pass nursing station and
treatment beds find your way
from entrance gate to the
outside corridor, your
destination is the second exit.
8. Radial - Fourth Floor, Inpatient “Picture an emergency
Configuration- surgery ward situation in which you have to
2 - Hard, wayfinding task escape from the building with
- Medium urgency, and the elevators are
out of service”.
Your starting point is from the
emerg-ency exit (Fourth Floor)
from west ward wing, follow
corridors into elevator lobby,
then go south, deep into the
ward. The destination point is
in the end of the corridor.
9. Duplex - Third floor, Clinic “After paying the entailed
Configuration- Department receipts for clinical admissions
1 - Easy; wayfinding task in ground floor. You are
- Medium directed to see the Internal
medicine specialist in clinical
floors. Please complete the task
with a nimble manner”.
After arriving at the third floor
the first origin is the beginning
of the clininc area and you need
to seek for the support space at
the back, between the two
functional corridors. The
destination point that you have
visit is the last door across the
bended corridor.
10. Duplex - Third floor, Clinic “Imagine that after you’ve
Configuration- Department visited by the specialist, you
2 - Hard; wayfinding task need some medical treatments
- Low from the nursery. Please
complete the task with a
nimble manner”.
This task begins with task 9
destination point, and you have
to reasone about the
relationship between support
area space and the main
corridor, in order to find the
destination on the other wing
of the clinics, in contrast with
task 9 destination (last door at
the back corridor).
A.E. Pouyan et al. Journal of Building Engineering 44 (2021) 102931

Table 4
Individual differences among groups.
Spatial Abilities in tasks F (7, 48) = 1.11; Wilks’s Λ = 0.69; η2p =
Spatial perspective-taking (absolute 0.18; p = 0.38
directional errors)

Mental Rotation (score out of 40)

Space Perceptions in tasks

Sense of Direction (Score out of 100)

Spatial Anxiety (Score out of 50)

Spatial Strategy taking in tasks

LANDMARK-BASED

ROUTE-BASED

SURVEY-BASED
(continued on next page)

13
A.E. Pouyan et al.
Table 4 (continued )
user in an accessible origin and destination. In a small-scale section of
the hospital (This task needs a high survey strategy).
Third Task (Corridor CFG)- This pattern is based on a complex and
challenging spatial task, where the trajectory is traversed towards a
segregated destination (High spatial skills are required to navigate the
environment).
Fourth Task (Radial CFG)- The test is considered as an easy pattern; in
which user may have to apply his/her logic for making decisions from
origin to destination. Although the pattern is slightly challenging due to
its symmetry, it encourages individuals to traverse its radials swiftly (It
needs high mental spatial abilities and reasoning).
Fifth Task (Cluster CFG)- The test is designed as a difficult wayfinding
performance, in which one would arrive at the destination effortlessly, if
the individual’s spatial ability is strong (This pattern entails people to
have high-resolution spatial abilities).
Sixth Task (Cluster CFG)- This route is considered as a simple per­
formance with a focus on which the relationships of inner ward which
needs more spatial attention from the user (The spatial abilities are more
used in this task).
Seventh Task (Racetrack CFG)- A simple wayfinding task and slightly
ambiguous destination was designed, which demands high spatial
analysis from participants. One should form spatial relations in his/her
cognitive map and seeks to choose and search for the correct destination.
Eighth Task (Radial CFG)- A difficult wayfinding task is considered as
it begins from a segregated start (eastern inpatient surgery ward) to a
segregated destination. The test is slightly challenging due to the need
for silence in inpatient ward and high similarity between ward sections
(This pattern requires high mental spatial ability and reasoning for
successful wayfinding).
Ninth Task (Duplex CFG)- It is duplex with simple wayfinding, in
which destination cannot be observed while following the route. How­
ever, two matching paths are considered including main corridor and its
supporting space corridor which provides high spatial similarities for the
participants (The task needs high mental rotation ability).
Tenth Task (Duplex CFG)- The test has been anticipated as a difficult
degree performance, and the destination is out of sight (This pattern
requires high mental rotation ability).
2.6. Research community
Wayfinders were selected based on the matter no previous experi­
ence or familiarity with the hospital environment. In addition, partici­
pants mostly belonged to the academic community due to the possibility
of access and cooperation. All of whom were healthy, without move­
ment disabilities and corrected vision. The number was determined 45
persons, which was consistent with similar studies [19,102–105,129].
Each of the participants performed wayfinding tests individually. Even
they were warned not to ask any questions from staff, and other people
in order to survey the effect of spatial circulation alone.
The self-reports indicated that the building had never been seen or
visited previously by the participants. In order to assure the accurateness
of these reports, participants completed a questionnaire and responded
to whether they were already familiar with the hospital after wayfinding
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Journal of Building Engineering 44 (2021) 102931
tests are completed so that familiar ones were excluded from the study.
Thus, 16 women (MAGE = 21.5; SD = 0.875; 18–35 years old) and 23
men (MAGE = 22.5; SD = 0.9383; 18–35 years old) participation
considered for the calculation and analysis (the records related to 6
peoples were set aside due to the suspicion of familiarity) (Fig. 9). The
analyzed data indicated that demographic records were not significantly
different.
2.7. Test instructions
After arriving at the hospital, each individual was first welcomed by
the research team and invited to a quiet room near the main entrance of
the hospital. Then, each participant was guided by researchers to the
starting point after signing consent forms. Further, researcher provided
each wayfinder with the written instructions related to each task
(Table 3), and made sure that they understood the instructions in finding
the shortest way. The participants were informed that an experimenter
would follow them during the process, in case they needed any technical
help (The effect of experimenter act and speech was nullified by an
anonymous person for recording participants’ behavior). Researchers
asked those who wrongly express reaching the destination to continue
searching. Negative semantic load words (e.g., “error” or “incorrect”)
were avoided during the process. Then, the researchers guided the
participants to the next starting point by using a predefined path or
elevator to limit the level of additional route information which could be
obtained by the individual. The team cautioned the participants that
they were not allowed to ask others for directions through their training
in identifying the shortest path. Participants were notified by the team
that the maximal time was 10 min for every task completion. After
performing 10 wayfinding tasks, participants filled out a set of ques­
tionnaires. The whole duration of the process, as well as the time
required for disciplinary coordination in each ward lasted around 120
min. Each participant received a compensation of 4U$D per hour for
their participation.
3. Findings
3.1. Individual differences in statistics
The spatial abilities measured in all tasks consisted of spatial
perspective taking and mental rotation scores. Results show that almost
all men made fewer errors in wayfinding decision makings with a mean
score of 137 (Standard Deviation (SD) = 15.8); However, women ach­
ieved a roughly better score in the mental rotation test with a mean of 35
out of 50 (SD = 6.91). In addition, this trend was repeated in sense of
direction for men 74 (SD = 13.7) and women 59 (SD = 16.2), while the
spatial anxiety of women was significantly higher than that of men.
Furthermore, the spatial strategies of participant in men and women
stats were almost similar in landmark selections and path reasoning, as it
is 8 and 7 for men and 6 in both groups for women respectively, but
women’s survey strategy was more superior, their mean band score was
8 out of 10 (with a max. concession of 9) (Table 4).
A.E. Pouyan et al. Journal of Building Engineering 44 (2021) 102931

Table 5
Dependent Variables calculated for participants.
Dependent Variables Wayfinding Tasks Task Comparison
Impact/Influence

Distance Traveled (Meters) F (4, 35) = 4.94; Wilks’s Λ = 0.129; η2p = 0.712; sig = 0.00

Wayfinding Time* (Seconds) F (4, 37) = 1.892; Wilks’s Λ = 0.291; η2p = 0.486; sig =
0.003

Pauses* (Frequency) F (4, 33) = 4.535; Wilks’s Λ = 0.633; η2p = 0.819; sig =
0.001

Sign Usage (Frequency) F (4, 31) = 0.535; Wilks’s Λ = 0.015; η2p = 0.211; sig =
0.206

Deviation/PAO (Percentage) F (4, 33) = 0.985; Wilks’s Λ = 0.129; η2p = 0.985; sig =
0.00
(continued on next page)

15
A.E. Pouyan et al. Journal of Building Engineering 44 (2021) 102931

Table 5 (continued )
Dependent Variables Wayfinding Tasks Task Comparison
Impact/Influence

Ranked Task Difficulty (Out of F (4, 29) = 1.107; Wilks’s Λ = 0.735; η2p = 0.554; sig =
5) 0.00

The asterisks indicate two different groups among the wayfinding variables.

Table 6
Correlation between performance variables wayfinding process.
Task.1 Task.2 Task.3 Task.4 Task.5 Task.6 Task.7 Task.8 Task.9 Task. 10

Parametric correlation (Pearson correlation coefficient) between groups measuring path efficiency in each pattern
Distance* R = 0.46 - R = 0.09 R = 0.13 - - R = 0.32 R = 0.75 - -
Pauses Sig = 0.03 Sig = 0.02 Sig = 0.05 Sig = 0.02 Sig = 0.03
Distance* R = 0.39 - R = 0.07 R = 0.09 - - R = 0.26 R = 0.51 - -
Sign Usage Sig = 0.02 Sig = 0.02 Sig = 0.05 Sig = 0.02 Sig = 0.03
Distance* R = 0.63 R = 0.89 - - R = 0.74 R = 0.61 R = 0.59 R = 0.82 - -
Deviation/PAO Sig = 0.02 Sig = 0.03 Sig = 0.01 Sig = 0.03 Sig = 0.01 Sig = 0.01
Pauses* R = 0.34 R = 0.19 R = 0.06 R = 0.008 R = 0.33 R = 0.38 R = 0.17 R = 0.43 R = − 0.25 R = − 0.32
Sign Usage Sig = 0.01 Sig = 0.05 Sig = 0.02 Sig = 0.05 Sig = 0.05 Sig = 0.03 Sig = 0.02 Sig = 0.01 Sig = 0.05 Sig = 0.03
Pauses* - R = − 0.28 - - R = 0.45 R = 0.37 - - - -
Deviation/PAO Sig = 0.03 Sig = 0.01 Sig = 0.01
Sign Usage* Deviation/PAO R = − 0.34 - R = − 0.07 R = − 0.03 R = 0.52 R = 0.54 - - R = − 0.39 R = − 0.48
Sig = 0.02 Sig = 0.02 Sig = 0.05 Sig = 0.05 Sig = 0.05 Sig = 0.03 Sig = 0.03
Parametric correlation (Pearson correlation coefficient) between groups of individual differences with path efficiency
Spatial Ability* Pauses R = − 0.12 R = − 0.145 R = − 0.38 - - - R=− 0.09 - R=− 0.29 R = − 0.13
Sig = 0.03 Sig = 0.01 Sig = 0.09 Sig = 0.03 Sig = 0.03 Sig = 0.04
Spatial Ability* Sign Usage R = − 0.5 R = − 0.44 R = − 0.53 - - - R=− 0.53 - R=− 0.42 R = − 0.57
Sig = 0.03 Sig = 0.01 Sig = 0.03 Sig = 0.01 Sig = 0.03 Sig = 0.03
Spatial Ability* Deviation/PAO R = − 0.07 R = − 0.081 R = − 0.21 R = − 0.29 - - - - R=− 0.22 R = − 0.18
Sig = 0.04 Sig = 0.03 Sig = 0.01 Sig = 0.03 Sig = 0.01 Sig = 0.03
Landmark Strategy* R = 0.78 R = 0.81 - - - - R = 0.51 R = 0.68 - -
Sign Usage Sig = 0.03 Sig = 0.05 Sig = 0.05 Sig = 0.05
Route Strategy* Deviation/PAO R = − 0.63 R = − 0.48 R = − 0.55 R = − 0.68 - - R = − 0.54 R = − 0.55 - -
Sig = 0.05 Sig = 0.03 Sig = 0.03 Sig = 0.01 Sig = 0.03 Sig = 0.05
Survey Strategy* R = 0.68 R = 0.56 R = 0.64 R = 0.84 - - R = 0.56 R = 0.72 R = 0.51 R = 0.4
Sign Usage Sig = 0.01 Sig = 0.03 Sig = 0.03 Sig = 0.03 Sig = 0.03 Sig = 0.04 Sig = 0.03 Sig = 0.03
Survey Strategy* Deviation/ R = 0.24 R = 0.16 R = 0.195 R = 0.19 - - R = 0.28 R = 0.22 - -
PAO Sig = 0.05 Sig = 0.05 Sig = 0.04 Sig = 0.05 Sig = 0.05 Sig = 0.04

3.2. Evaluation of circulation pattern
MANOVA was conducted among men and women stats to assess the
integrability of the two groups in order to increase result reliability, if
the test results were significant. In this regard, the statistical tests were
performed on individual variables, space perceptual characteristics, and
individual strategies, represent no significant difference between men
and women. Additionally, the results of MANOVA on six dependent
variables indicated that samples were slightly different in some vari­
ables. Wayfinding duration and pause frequency along the path were
different in Task.3 (deep corridor-Hard), Task.7 (Racetrack-difficult),
Task.8 (Radial-difficult), and Task.10 (Duplex-difficult). Accordingly,
they were excluded from the continuation of statistical processes.
Different routes, duration, and movement pauses can be analyzed using

16
A.E. Pouyan et al.
non-parametric tests (the performance of women’s wayfinding was
greater compared to that of men only in Task.4). Therefore, women and
men’s groups were merged, and statistical analyses were only continued
in the fixed variables of some tasks (Table 5).
All of the tasks designed in this study were based on the dual rela­
tionship of circulation and access type. According to the anticipations
made by the researchers, tasks 1 and 8 were respectively predicted as the
easiest and the most difficult tasks. The order of the tasks from easy to
difficult was as follows: 1, 2, 4, 6, 7, 9, 5, 3, 10, and 8. To assess the
hypothesis, the wayfinding process of individuals was measured in 5
circulation patterns by implementing MANOVA on the fixed variables,
including path difficulty, deviation amount, traveled distance, as well as
the frequency of signs. The results were slightly different from the order
anticipated related to access difficulty by researchers’ tests. As pre­
dicted, task.1 was introduced as the easiest circulation experienced in
the path, which can be related to the depth of sight, as well as desti­
nation accessibility. Further, the path of Racetrack circulation (Task.8)
was ranked as the most difficult one. The final order was provided by
participants from simple to difficult as 1, 6, 4, 3, 5, 9, 7, 2, 10, and 8
(Table 6).
Regarding the results obtained from the classification of traveled
distance, sign usage, and deviation amount from the main path, way­
finding in task.7 was more difficult due to the ups and downs of the task,
as well as its experienced difficulty by individuals in spite of traveling
shorter distance, However, they had a longer travel duration. Further­
more, the frequency of pauses along the path was determined as 0.073
(men) and 0.126 (women), that of sign usage was obtained as 0.204
(men) and 0.334 (women), and the deviation was 24.07% (men) and
11.11% (women).
The shortest travel ratio was achieved in the first deep corridor task,
where the destination was fully visible from the starting point. Thus,
wayfinding efficiency increases if the start and destinations are more
visible (although proving the issue needs to study among a bigger
community with different cultural individuals) by considering their
dominant strategy applied on the path.
Assessing, attention to signage; indicated that task.6 possessed
higher frequency (0.679 and 0.563 for men and women, respectively)
with lower deviation from the path (7.272% and 3.636% respectively),
by reflecting that, individuals turn to landmark strategy more and look
for a specific and purposeful cue (signage) during wayfinding when
knowing the destination and seeing signs on the path. The minimum
frequency of sign usage in the environment was determined in task.10
(men: 0.065, women: 0.078), which does not indicate itself in path
difficulty and deviation from the main path. The regular and organized
shape of the clinics is considered as one of the main reasons to this issue.
In summary, the contrast in the dual relationship between circulation
patterns and access type demonstrates the lack of complete adherence in
the hospitals from circulation patterns. The performance may be mostly
related to decision-making and strategy selection by participants.
Accordingly, the correlation between tasks and circulation patterns
were analyzed to survey wayfinding performance. First, the relation­
ships between different dependent variable pairs measuring wayfinding
efficiency were separately assessed in each test. As shown in Table .6,
the number of pauses in tasks 3, 5, and 6 increased, and the participants
traveled longer distances because of utilizing spatial signs, and logical
reasoning. In addition, the dual relationship of distance and sign usage
was significant, which was interesting in the Racetrack pattern and
represented that an increase in sign usage due to path complexity results
in decreasing the wayfinding efficiency of individuals. Examining travel
length and deviation from the main path in task 1, 2, and 5 to 8, reflected
a well-appointed relationship (R ≥ 0.5, sig<0.05) so that an increase in
distance, enlarged the chances of deviation from a specified path.
Further, no relationship was found between these variables in other
tasks. The deviation can be considered as a reason for time-longevity by
individuals, which can be studied better in evaluating spatial symbols
and signs further (see more e.g., Refs. [15,84].
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Journal of Building Engineering 44 (2021) 102931
In every task, longer pause resulted in increasing sign usage (sig≤
0.05), which demonstrates the level of individual confusion during
user’s pauses on-route in hospital circulation patterns. Furthermore,
utilizing more sign usage leads to less deviation, apart from tasks 5 and 6
(the travel distance was too short).
Second, correlation among individual performances in every path
was examined to assess whether the individual differences (including
spatial capabilities, self-conceptualizing, and spatial preferences) were
related to wayfinding efficiency of patterns or interacted with the type of
tasks. However, it turns out that the latter is significant.
Sign usage was consistent with the spatial capabilities of individuals
so that those utilizing more survey strategy looked for signs more opti­
mally in almost all of the circulation patterns [84,106]. Further, the
correlation of destination visibility and sign usage by users can be
evaluated.
Additionally, the Landmark strategy was much considered in task.3,
which could lead researchers toward the issue that individuals updated
their direction during the wayfinding process in corridor circulation
without the destination being seen. Regarding the preference of the
Route strategy, the better wayfinding performance of individuals was
obtained in all tasks except for 2 and 7. Apart from these, when a
participant used more survey strategy, they would prefer sign usage
more as data confirms (R > 0.4; sig≤0.04).
Based on the assessed correlations, results of the components related
to the spatial capabilities of individuals, as well as their dominant
strategy in each circulation-type, were attributed to the pattern and
cannot be generalized to others. The necessity of this issue was due to
the succession of the experienced spaces and the number of the partic­
ipants who utilized a special approach, as the distance along two routes
might have statistical similarity, even when participants crossed dis­
similar routes.
4. Discussion
Based on the results, circulation patterns with irregular forms and
lopsided deep corridors acted as the structural aspects affecting way­
finding experience and sense of direction negatively [107,108]. Never­
theless, regular linear CFG made positive impacts on movement
dynamics, and a further connection to functional nodes compared to the
other circulation patterns which leads to more legible spaces. Also, an
increase in visual degree for the straight view to destination facilitates
movement dynamics [9,20], Further, problems in real-world can be
more and appropriately studied by utilizing diverse building assessment
methods with diverse space users [109–112].
Radial and Racetrack circulation patterns lead to the environmental
guidance of the participant if hospital interior spaces load as a whole on
their mental map and its organizational structure. Even in the Duplex
circulation pattern, movement disorientation usually happens due to the
lack of recognition about supporting spaces and its logical relations.
After passing through different wards and long paths with similar
characteristics in consecutive floors, and tolerating the excessive visual
load caused by incongruent information, individuals may not distin­
guish destination. Thus, the pattern-related problems can be solved if
environmental capabilities are extended in each interior [107].
No spatial design alternative such as an opening in intersection or
curvature points in corners was predicted for helping individuals’
movement dynamics in the functional nodes existing on the path of deep
circulation pattern in the hospital. Therefore, integrating building
assessment methods may be valuable. Such functional node design leads
to the unnecessary gatherings of individuals due to the disorientation
doubts in decision-making. Furthermore, the alternatives of view to
healing gardens and urban environment (spatial signs), as well as central
atrium, were not applied for better structuring and wayfinding perfor­
mance [113–120]. These problems can reduce by considering the results
obtained by Allison [1]; which propose nature visibility through corri­
dors and circulation spaces in hospitals.
A.E. Pouyan et al.
The results should be interpreted by considering the limitations. The
participants groups did not represent the total population reaching out
to the hospital (according to the reports made by the administrative
division) or the two sexes presented at the hospital, as no data were
accessible on the number of visitors and family members, hence the
sample size was calculated by a review of other analogous studies, which
led to the absence of comparing performances of patients, families, and
visitors.
Due to the purposive intents of the study, its participants are limited
to healthy young people in which future studies should conduct the ef­
fects of users’ behavioral and individual capabilities. As Rousek and
Hallbeck [121] pointed out, the absent of interest concerning people
with disabilities such as visually impaired, handicapped, and cognitively
disordered in many healthcare facilities, so that they experience an
arduous and tiring wayfinding. Therefore, probing health status of the
end-user can be extended as an initial and viable fact in healthcare
facilities.
Moreover, low wayfinding performance due to anxiety, stress, cul­
tural differences, pre-emotional effects, crowding, and literacy level in
hospital environments (as in today’s healthcare-tourism globally flour­
ishes) results in lowering the level of therapeutic services for all users.
These issues would make patients wander around, anxious, tired, and
represent bad behavior towards hospital staff [103,107,122]. Any of the
aforementioned deficits above can be extended in future studies and
would complement results, and findings that presented in this study
(due to the limited budget, time, and administrative restrictions of the
hospitals).
What’s more, aging reduces a range of cognitive capabilities to a
varying degree in an analogy to the younger society, and wayfinding is
an initial one. The effect of age on the ability to switch from following a
known route to using a novel shortcut to take the optimal route to a
destination is well-documented [123]. This confirms that the age-related
deficits do affect the performance of those under the examination. Thus,
studies can address these issues in a broader view.
5. Conclusion
The present study applied a well-defined framework of wayfinding
complexity to evaluate wayfinding performance under various health­
care layout design conditions based on the quality of individuals’
movement dynamics. Various data sources were gathered and evalu­
ated, including behavioral metrics, space syntax measurements, and
self-reported responses. In general, 10 different scenarios were designed
based on the access level (low/high) implemented in four various ward
sections of the hospital, including corridor configuration (CFG), race­
track CFG, radial CFG, cluster CFG, and duplex CFG. The tasks were
defined with the destination of one connected to the other until expe­
riencing the last one. Participants were included in this study using a
convenience sample (all of whom were academics), and every one of
them had to travel each 10 tasks. The findings revealed that there is no
significant difference between the wayfinding records of men and
women, although their strategy selection was dissimilar. Moreover, the
participants generally considered deep corridor circulation as the
simplest experienced path because of its visual depth of functional
spaces, and the racetrack ward circulation as the most difficult one to
travel due to space resemblance for each of the wings. Accordingly, each
participant can adopt a dominant strategy in facing various environ­
ments and represent particular efficiencies. The issue guides the de­
signers, builders, and decision-makers of the healthcare industry to
consider cases in the built environment for each individual’s need with
each type of behavioral and movement pattern while not supposing a
comprehensive prescription for all users is a failed decision.
Authors’ note
The authors declare that they have conformed with the ethical
18
Journal of Building Engineering 44 (2021) 102931
regulations of the studied hospital and that the contributor’s personal
information were and will be anonymous.
CRediT authorship contribution statement
Amir Ehsan Pouyan: Conceptualization, Methodology, Investiga­
tion, Analysis, Visualization, Writing, Review, Editing. Abdulhamid
Ghanbaran and Amir Shakibamanesh: Conceptualization, Method­
ology, Review, Editing, and Supervision.
Funding
This article is based on the doctoral thesis of the first author, which is
being conducted by Dr. Abdul Hamid Ghanbaran and consultant Dr.
Amir Shakibamanesh in Dept. of Architecture and Urban Planning,
Shahid Rajaee Teacher Training University, Iran.
Declaration of competing interest
The authors declare that they have no known competing financial
interests or personal relationships that could have appeared to influence
the work reported in this paper.
References
[1] D. Allison, Hospital as city: employing urban design strategies for effective
wayfinding, Health Facil. Manag. 20 (6) (2007) 61.
[2] A.S. Devlin, Wayfinding in healthcare facilities: contributions from
environmental psychology, Behav. Sci. 4 (4) (2014) 423–436, https://doi.org/
10.3390/bs4040423.
[3] D.S. Kim, Specialized Knowledge Roles and the Professional Status of Healthcare
Architects, Doctoral dissertation, Texas A & M University, 2001.
[4] Z. Sevinç, E. Bozkurt, Wayfinding behaviors in a healthcare environment: a case
study analysis of individual differences, Gazi University Journal of Science Part B:
Art, Humanities, Design and Planning 3 (3) (2015) 37–45. Retrieved from, https
://dergipark.org.tr/en/pub/gujsb/issue/7457/98199.
[5] S. Lee, S.S. Dazkir, H.S. Paik, A. Coskun, Comprehensibility of universal
healthcare symbols for wayfinding in healthcare facilities, Appl. Ergon. 45 (4)
(2014) 878–885, https://doi.org/10.1016/j.apergo.2013.11.003.
[6] R.G. Golledge, Human wayfinding and cognitive maps, Wayfinding behavior:
Cognitive mapping and other spatial processes (1999) 5–45.
[7] P. Mollerup, Wayshowing in hospital, Australas. Med. J. (10) (2009) 112.
[8] D.R. Montello, Navigation, Cambridge University Press, 2005. https://psycnet.
apa.org/doi/10.1017/CBO9780511610448.008.
[9] L.A. Carlson, C. Hölscher, T.F. Shipley, R.C. Dalton, Getting lost in buildings,
Curr. Dir. Psychol. Sci. 19 (5) (2010) 284–289, https://doi.org/10.1177/
0963721410383243.
[10] R. Li, A. Klippel, Wayfinding behaviors in complex buildings: the impact of
environmental legibility and familiarity, Environ. Behav. 48 (3) (2016) 482–510,
https://doi.org/10.1177/0013916514550243.
[11] R. Passini, Wayfinding; a conceptual framework, Man Environ. Syst. 10 (1980)
22–30.
[12] A. Baskaya, C. Wilson, Y.Z. Özcan, Wayfinding in an unfamiliar environment:
different spatial settings of two polyclinics, Environ. Behav. 36 (6) (2004)
839–867, https://doi.org/10.1177/0013916504265445.
[13] J. Weisman, Evaluating architectural legibility: way-finding in the built
environment, Environ. Behav. 13 (2) (1981) 189–204, https://doi.org/10.1177/
0013916581132004.
[14] H.A. Karimi, Indoor Wayfinding and Navigation, CRC Press, Boca Raton, FL,
2015. Retrieved from, https://scholar.google.com/scholar?
cluster=8578386509025666979&hl=en&as_sdt=0,5.
[15] R. Rodrigues, R. Coelho, J.M.R.S. Tavares, Healthcare signage design: a review on
recommendations for effective signing systems, HERD: Health Environments
Research & Design Journal 12 (3) (2019) 45–65, https://doi.org/10.1177/
1937586718814822.
[16] A. Dilani, Presentation, Patient Environments by Design Programme, 2010
(London, UK).
[17] M. Nazarian, A.D. Price, P. Demian, A review of different approaches to access
and people circulation within health-care facilities and the application of
modelling, simulation and visualisation. CIB-W096 Architectural Management In
the Digital Arena, 2011.
[18] K. Fisher, M. Saxton, P.M. Edwards, Seattle central library as place:
reconceptualizing space, community, and information at the central library, in:
Take One Building: Interdisciplinary Research Perspectives of the Seattle Central
Library, Routledge, 2016, pp. 129–150.
[19] S.F. Kuliga, B. Nelligan, R.C. Dalton, S. Marchette, A.L. Shelton, L. Carlson,
C. Hölscher, Exploring individual differences and building complexity in
A.E. Pouyan et al.
wayfinding: the case of the seattle central library, Environ. Behav. 51 (5) (2019)
622–665, https://doi.org/10.1177/0013916519836149.
[20] K. Murakami, Too Many People Getting Lost in New Downtown Library, 2006
(Seattle Post Intelligencer).
[21] C. Calori, D. Vanden-Eynden, Signage and Wayfinding Design: a Complete Guide
to Creating Environmental Graphic Design Systems, John Wiley & Sons, 2015,
https://doi.org/10.1002/9781119174615.
[22] C. Hölscher, T. Meilinger, G. Vrachliotis, M. Brösamle, M. Knauff, Up the down
staircase: wayfinding strategies in multi-level buildings, J. Environ. Psychol. 26
(4) (2006) 284–299, https://doi.org/10.1016/j.jenvp.2006.09.002.
[23] H. Li, N.A. Giudice, Assessment of between-floor structural and topological
properties on cognitive map development in multilevel built environments,
Spatial Cognit. Comput. 18 (3) (2018) 138–172, https://doi.org/10.1080/
13875868.2017.1384829.
[24] H. Li, T. Thrash, C. Hölscher, V.R. Schinazi, The effect of crowdedness on human
wayfinding and locomotion in a multi-level virtual shopping mall, J. Environ.
Psychol. 65 (2019) 101320, https://doi.org/10.1016/j.jenvp.2019.101320.
[25] G. Sharma, Y. Kaushal, S. Chandra, V. Singh, A.P. Mittal, V. Dutt, Influence of
landmarks on wayfinding and brain connectivity in immersive virtual reality
environment, Front. Psychol. 8 (JUL) (2017) 1–12, https://doi.org/10.3389/
fpsyg.2017.01220.
[26] J. Van der Zwart, T.J. van der Voordt, Pre-occupancy evaluation of patient
satisfaction in hospitals, HERD: Health Environments Research & Design Journal
9 (1) (2015) 110–124, https://doi.org/10.1177/1937586715595506.
[27] A. Mondschein, E. Blumenberg, Brian D. Taylor, Going Mental: Everyday Travel
and the Cognitive Map, University of California Transportation Center, 2013.
[28] National Health Service (Nhs), Wayfinding: Effective Wayfinding and Signing
Systems Guidance for Healthcare Facilities, Health Facilities Scotland, a Division of
NHS National Services Scotland, Scotland, 2007.
[29] G.W. Evans, Environmental cognition, Psychol. Bull. 88 (1980) 259–287, https://
doi.org/10.1006/jevp.1998.0089.
[30] T. Ishikawa, D.R. Montello, Spatial knowledge acquisition from direct experience
in the environment: individual differences in the development of metric
knowledge and the integration of separately learned places, Cognit. Psychol. 52
(2) (2006) 93–129, https://doi.org/10.1016/j.cogpsych.2005.08.003.
[31] S. Münzer, L. Lörch, J. Frankenstein, Wayfinding and acquisition of spatial
knowledge with navigation assistance, J. Exp. Psychol. Appl. 26 (1) (2020)
73–88, https://doi.org/10.1037/xap0000237.
[32] J. O’Keefe, N. Burgess, Geometric determinants of the place fields of hippocampal
neurons, Nature 381 (6581) (1996) 425–428, https://doi.org/10.1038/
381425a0.
[33] R.F. Wang, E.S. Spelke, Human spatial representation: insights from animals,
Trends Cognit. Sci. 6 (9) (2002) 376–382, https://doi.org/10.1016/S1364-6613
(02)01961-7.
[34] P.W. Thorndyke, B. Hayes-Roth, Differences in spatial knowledge acquired from
maps and navigation, Cognit. Psychol. 14 (4) (1982) 560–589, https://doi.org/
10.1016/0010-0285(82)90019-6.
[35] S.G. Vandenberg, A.R. Kuse, Mental rotations, a group test of three-dimensional
spatial visualization, Percept. Mot. Skills 47 (2) (1978) 599–604, https://doi.org/
10.2466/pms.1978.47.2.599.
[36] M. Hegarty, A.E. Richardson, D.R. Montello, K. Lovelace, I. Subbiah,
Development of a self-report measure of environmental spatial ability,
Intelligence 30 (2002) 425–447, https://doi.org/10.1016/S0160-2896(02)
00116-2.
[37] A. Afrooz, D. White, B. Parolin, Effects of active and passive exploration of the
built environment on memory during wayfinding, Appl. Geogr. 101 (2018)
68–74, https://doi.org/10.1016/j.apgeog.2018.10.009.
[38] G.L. Allen, Spatial abilities, cognitive maps, and wayfinding, in: R.G. Golledge
(Ed.), Wayfinding Behavior: Cognitive Mapping and Other Spatial Processes,
Johns Hopkins University Press, Baltimore, MD, 1999, pp. 46–80.
[39] J. Frankenstein, Human Spatial Representations and Spatial Memory Retrieval
(Doctoral Dissertation, Diss. ETH No. 22980), ETH Zurich, Switzerland, 2015,
https://doi.org/10.3929/ethz-a-010608257.
[40] C.A. Lawton, Gender differences in way-finding strategies: relationship to spatial
ability and spatial anxiety, Sex. Roles 30 (11–12) (1994) 765–779, https://doi.
org/10.1007/BF01544230.
[41] C. Meneghetti, F. Pazzaglia, R. De Beni, Spatial mental representations derived
from survey and route descriptions: when individuals prefer extrinsic frame of
reference, Learn. Indiv Differ 21 (2011) 150–157, https://doi.org/10.1016/j.
lindif.2010.12.003.
[42] F. Pazzaglia, R. De Beni, Strategies of processing spatial information in survey and
landmark-centred individuals, Eur. J. Cognit. Psychol. 13 (4) (2001) 493–508,
https://doi.org/10.1080/09541440125778.
[43] A.W. Siegel, S. White, The development of spatial representations of large-scale
environments, in: H.W. Reese (Ed.), Advances in Child Development and
Behaviour, Academic Press, New York, 1975.
[44] A. Afrooz, The Influence of Active versus Passive Exploration of the Built
Environment on Way-Finding and Visual Memory, 2016 (PhD, New South Walse).
[45] M. Kozhevnikov, M.A. Motes, B. Rasch, O. Blajenkova, Perspective-taking vs.
mental rotation transformations and how they predict spatial navigation
performance, Appl. Cognit. Psychol.: The Official Journal of the Society for
Applied Research in Memory and Cognition 20 (3) (2006) 397–417, https://doi.
org/10.1002/acp.1192.
[46] M. Malanchini, K. Rimfeld, N.G. Shakeshaft, A. McMillan, K.L. Schofield,
M. Rodic, R. Plomin, Evidence for a unitary structure of spatial cognition beyond
19
Journal of Building Engineering 44 (2021) 102931
general intelligence, npj Science of Learning 5 (1) (2020) 1–13, https://doi.org/
10.1038/s41539-020-0067-8.
[47] A.M. Hund, J.L. Minarik, Getting from here to there: spatial anxiety, wayfinding
strategies, direction type, and wayfinding efficiency, Spatial Cognit. Comput. 6
(2006) 179–201, https://doi.org/10.1207/s15427633scc0603_1.
[48] G. Ramirez, E.A. Gunderson, S.C. Levine, S.L. Beilock, Spatial anxiety relates to
spatial abilities as a function of working memory in children, Q. J. Exp. Psychol.
65 (3) (2012) 474–487, https://doi.org/10.1080/17470218.2011.616214.
[49] P.J. Clarke, C. MacLeod, A.J. Guastella, Assessing the role of spatial engagement
and disengagement of attention in anxiety-linked attentional bias: a critique of
current paradigms and suggestions for future research directions, Hist. Philos.
Logic 26 (1) (2013) 1–19, https://doi.org/10.1080/10615806.2011.638054.
[50] M.J. O’Neill, Effects of signage and floor plan configuration on wayfinding
accuracy, Environ. Behav. 23 (5) (1991) 553–574, https://doi.org/10.1177/
0013916591235002.
[51] S. Werner, L.E. Schindler, The role of spatial reference frames in architecture:
misalignment impairs way-finding performance, Environ. Behav. 36 (4) (2004)
461–482, https://doi.org/10.1177/0013916503254829.
[52] B. Hillier, R. Burdett, J. Peponis, A. Penn, Creating life: or, does architecture
determine anything? Architecture and Behaviour 3 (1987) 233–250. https://disc
overy.ucl.ac.uk/id/eprint/101.
[53] B. Hillier, J. Hanson, J. Peponis, What Do We Mean by Building Function? E & FN
Spon Ltd, 1984. Retrieved from, https://discovery.ucl.ac.uk/id/eprint/15007/.
[54] S. Alitajer, M. Hajian, Evaluating graph theory approaches, convex space and
intersection to architectural spatial analysis, case study: jahanbani,Neshastehpour
and azadmanesh houses, kashan, Naqshejahan-Basic studies and New
Technologies of Architecture and Planning 7 (2) (2017) 33–48. Retrieved from:
http://bsnt.modares.ac.ir/article-2-529-en.html.
[55] S. Haq, C. Zimring, Just down the road a piece: the development of topological
knowledge of building layouts, Environ. Behav. 35 (2003) 132–160, https://doi.
org/10.1177/0013916502238868.
[56] J. Peponis, C. Zimring, Y.K. Choi, Finding the building in wayfinding, Environ.
Behav. 22 (1990) 555–590, https://doi.org/10.1177/0013916590225001.
[57] A.H. Sadek, M.M. Shepley, Space syntax analysis: tools for augmenting the
precision of healthcare facility spatial analysis, HERD: Health Environments
Research & Design Journal 10 (1) (2016) 114–129, https://doi.org/10.1177/
1937586715624225.
[58] M.S. Batty, The automatic definition and generation of axial lines and axial maps,
The automatic definition and generation of axial lines and axial maps 31 (4)
(2004) 615–640.
[59] D. Chang, A. Penn, Integrated multilevel circulation in dense urban areas: the
effect of multiple interacting constraints on the use of complex urban areas,
Environ. Plann. Plann. Des. 25 (4) (1998) 507–538.
[60] B. Emo, Seeing the axial line: evidence from wayfinding experiments, Behav. Sci.
4 (3) (2014) 167–180.
[61] C. Hölscher, T. Tenbrink, J. Wiener, Would you follow your own route
description? Cognitive strategies in urban route planning, Cognition 12 (2)
(2011) 228–247.
[62] C. Hölscher, M. Brösamle, G. Vrachliotis, Challenges in multilevel wayfinding: a
case study with the space syntax technique, Environ. Plann. Plann. Des. 39 (1)
(2012) 63–82, https://doi.org/10.1068/b34050t.
[63] B. Jiang, C. Claramunt, Integration of space syntax into GIS: new perspectives for
urban morphology, Trans. GIS 6 (3) (2002) 295–309.
[64] E. Pafka, K. Dovey, G. Aschwanden, Limits of Space Syntax for Urban Design:
Axiality, Scale and Sinuosity, Environment and Planning B: Urban Analytics and
City Science, 2018, pp. 1–15.
[65] C. Ratti, Space syntax: some inconsistencies, Environ. Plann. Plann. Des. 31 (4)
(2004) 487–499.
[66] M. Salheen, L. Forsyth, Addressing distance in the space syntax syntactical model,
Urban Des. Int. 6 (2) (2001) 93–110.
[67] P. Steadman, Developments in space syntax, Environ. Plann. Plann. Des. 31 (4)
(2004) 483–486.
[68] A. Turner, A. Penn, B. Hillier, An algorithmic definition of the axial map, Environ.
Plann. Plann. Des. 32 (3) (2005) 425–444.
[69] L. Zhang, A.J. Chiaradia, Urban Volumetrics: Spatial Complexity and Wayfinding,
Extending Space Syntax to Three-Dimensional Space, 2020 arXiv preprint arXiv:
2012.14419.
[70] M.L. Benedikt, To take hold of space: isovists and isovist fields, Environ. Plann.
Plann. Des. 6 (1) (1979) 47–65.
[71] A. Turner, M. Doxa, D. O’sullivan, A. Penn, From isovists to visibility graphs: a
methodology for the analysis of architectural space, Environ. Plann. Plann. Des.
28 (1) (2001) 103–121, https://doi.org/10.1068/b2684.
[72] S. Bafna, Space syntax: a brief introduction to its logic and analytical techniques,
Environ. Behav. 35 (2003) 17–29, https://doi.org/10.1177/0013916502238863.
[73] A. Penn, Space syntax and spatial cognition: or why the axial line? Environ.
Behav. 35 (2003) 30–65, https://doi.org/10.1177/0013916502238864.
[74] S. Haq, Where we walk is what we see: foundational concepts and analytical
techniques of space syntax, HERD: Health Environments Research & Design
Journal 12 (1) (2019) 11–25, https://doi.org/10.1177/1937586718812436.
[75] H. Cai, Y. Lu, H. Sheward, A historical study of Chinese nursing unit design
evolution since 1989, HERD: Health Environments Research & Design Journal 12
(4) (2019) 53–66, https://doi.org/10.1177/1937586718820682.
[76] S. Haq, Y. Luo, Space syntax in healthcare facilities research: a review, HERD:
Health Environments Research & Design Journal 5 (4) (2012) 98–117, https://
doi.org/10.1177/193758671200500409.
A.E. Pouyan et al.
[77] A. Turner, Depthmap 4: A Researcher’s Handbook, Bartlett School of Built
Environment, University College London, London, 2004. Retrieved from, http
://discovery.ucl.ac.uk/id/eprint/2651.
[78] D. Dara-Abrams, Ground truthing space syntax, in: K.F. Richter, U.J. Rüetschi
(Eds.), The Cognitive Approach to Modeling Environments (Report Series of the
Transregional Collaborative Research Center SFB/TR 8 “Spatial Cognition”
Report No. 009-08/2006, Universität Bremen, Bremen, Germany, 2006,
pp. 23–28.
[79] D. De Leeuw, P. De Maeyer, L. De Cock, A gamification-based approach on indoor
wayfinding research, ISPRS Int. J. Geo-Inf. 9 (7) (2020) 423, https://doi.org/
10.3390/ijgi9070423.
[80] R. Li, A. Klippel, Wayfinding in libraries: can problems be predicted? J. Map
Geogr. Libr. 8 (2012) 21–38, https://doi.org/10.1080/15420353.2011.622456.
[81] D.R. Montello, Spatial cognition and architectural space: research perspectives,
Architect. Des 84 (5) (2014) 74–79, https://doi.org/10.1002/ad.1811.
[82] A. Afghantoloee, M.A. Mostafavi, G. Edwards, A. Gharebaghi, Personalized
legibility of an indoor environment for people with motor disabilities: a new
framework, ISPRS Int. J. Geo-Inf. 9 (11) (2020) 649, https://doi.org/10.3390/
ijgi9110649.
[83] A. Turner, A. Penn, Making isovists syntactic: isovist integration analysis. 2nd
International Symposium On Space Syntax, 1999 (Brasilia).
[84] R. Rodrigues, R. Coelho, J.M.R.S. Tavares, Users’ perceptions of signage systems
at three Portuguese hospitals, HERD: Health Environments Research & Design
Journal 13 (3) (2020) 36–53, https://doi.org/10.1177/1937586720924761.
[85] R.N. Shepard, J. Metzler, Mental rotation of three-dimensional objects, Science
171 (3972) (1971) 701–703, https://doi.org/10.1126/science.171.3972.701.
[86] M. Batty, Space Syntax and Spatial Interaction: Comparisons, Integrations,
Applications, 2017. Retrieved from, https://scholar.google.com/scholar?
cluster=3226532686864688789&hl=en&as_sdt=0,5.
[87] B. Kuipers, D.G. Tecuci, B.J. Stankiewicz, The skeleton in the cognitive map: a
computational and empirical exploration, Environ. Behav. 35 (1) (2003) 81–106,
https://doi.org/10.1177/0013916502238866.
[88] P. Mavros, Measuring The Emotional Experience of Pedestrian Navigation: the
Development of a Research Approach for Mobile Psychophysiological Experiments
(Doctoral Dissertation, UCL (University College London), 2019. https://discovery
.ucl.ac.uk/id/eprint/10071602.
[89] M. Kozhevnikov, M. Hegarty, A dissociation between object manipulation spatial
ability and spatial orientation ability, Mem. Cognit. 29 (5) (2001) 745–756,
https://doi.org/10.3758/BF03200477.
[90] M. Hegarty, D. Waller, A dissociation between mental rotation and perspective-
taking spatial abilities, Intelligence 32 (2) (2004) 175–191, https://doi.org/
10.1016/j.intell.2003.12.001.
[91] J.A. Russell, A. Mehrabian, Evidence for a three-factor theory of emotions, J. Res.
Pers. 11 (3) (1977) 273–294, https://doi.org/10.1016/0092-6566(77)90037-X.
[92] M.A. Nazari, C.G. Nabizadeh, S. Vahedi, M. Rostami, Validity and Reliability of
Self-Assessment Manikin, 2012.
[93] C. Hölscher, G. Vrachliotis, T. Meilinger, June). The floor strategy: wayfinding
cognition in a multi-level building, in: 5th International Space Syntax
Symposium, Techne Press, 2005, pp. 823–829. Retrieved from: http://hdl.handle.
net/11858/00-001M-0000-0013-D563-B.
[94] S.J. Büchner, Environmental Structure, Mental Representations and Path Choice
Heuristics: Information Processing in Wayfinding, Doctoral dissertation, Verlag
nicht ermittelbar), 2010.
[95] R.A. Ruddle, S.J. Payne, D.M. Jones, Navigating buildings in" desk-top" virtual
environments: experimental investigations using extended navigational
experience, J. Exp. Psychol. Appl. 3 (2) (1997) 143. https://psycnet.apa.org/doi/
10.1037/1076-898X.3.2.143.
[96] J.M. Wiener, A. Schnee, H.A. Mallot, Use and interaction of navigation strategies
in regionalized environments, J. Environ. Psychol. 24 (4) (2004) 475–493,
https://doi.org/10.1016/j.jenvp.2004.09.006.
[97] N. Setola, S. Borgianni, Designing Public Spaces in Hospitals, Routledge, 2016,
https://doi.org/10.4324/9781315718842.
[98] B. Klarqvist, A space syntax glossary, NA 6 (2) (2015).
[99] Y. Zhang, X. Chen, J. Jiang, Wayfinding-oriented design for passenger guidance
signs in large-scale transit center in China, Transport. Res. Rec. 2144 (1) (2010)
150–160, https://doi.org/10.3141/2144-17.
[100] A. Natapov, S. Kuliga, R.C. Dalton, C. Hölscher, Linking building-circulation
typology and wayfinding: design, spatial analysis, and anticipated wayfinding
difficulty of circulation types, Architect. Sci. Rev. 63 (1) (2020) 34–46, https://
doi.org/10.1080/00038628.2019.1675041.
[101] P. Steadman, Building Types and Built Forms, Troubador Publishing Ltd, 2014.
[102] D. Wingler, H. Machry, S. Bayramzadeh, A. Joseph, D. Allison, Comparing the
effectiveness of four different design media in communicating desired
performance outcomes with clinical end users, HERD: Health Environments
Research & Design Journal 12 (2) (2019) 87–99, https://doi.org/10.1177/
1937586718796626.
[103] Z. Zamani, Effects of emergency department physical design elements on security,
wayfinding, visibility, privacy, and efficiency and its implications on staff
satisfaction and performance, HERD: Health Environments Research & Design
Journal 12 (3) (2018) 72–88, https://doi.org/10.1177/1937586718800482.
20
Journal of Building Engineering 44 (2021) 102931
[104] D. Wingler, A. Joseph, S. Bayramzadeh, A. Robb, Using virtual reality to compare
design alternatives using subjective and objective evaluation methods, HERD:
Health Environments Research & Design Journal 13 (1) (2020) 129–144, https://
doi.org/10.1177/1937586719851266.
[105] E. Vilar, F. Rebelo, P. Noriega, E. Duarte, C.B. Mayhorn, Effects of competing
environmental variables and signage on route-choices in simulated everyday and
emergency wayfinding situations, Ergonomics 57 (4) (2014) 511–524, https://
doi.org/10.1080/00140139.2014.895054.
[106] C. Calori, Signage and Wayfinding Design: A Complete Guide to Creating
Environmental Graphic Design Systems, Wiley, 2007.
[107] S. Jiang, S. Verderber, On the planning and design of hospital circulation zones: a
review of the evidence-based literature, HERD: Health Environments Research &
Design Journal 10 (2) (2017) 124–146, https://doi.org/10.1177/
1937586716672041.
[108] G. Marquardt, Wayfinding for people with dementia: a review of the role of
architectural design, HERD: Health Environments Research & Design Journal 4
(2) (2011) 75–90, https://doi.org/10.1177/193758671100400207.
[109] M. Broadbent, L. Moxham, T. Dwyer, Implications of the emergency department
triage environment on triage practice for clients with a mental illness at triage in
an Australian context, Australas. Emerg. Nurs. J. 17 (1) (2014) 23–29, https://
doi.org/10.1016/j.aenj.2013.11.002.
[110] A. Gharaveis, D.K. Hamilton, D. Pati, M. Shepley, The impact of visibility on
teamwork, collaborative communication, and security in emergency departments:
an exploratory study, HERD: Health Environments Research & Design Journal 11
(4) (2018) 37–49, https://doi.org/10.1177/1937586717735290.
[111] Y. Lu, M.M. Ossmann, D.E. Leaf, P.H. Factor, Patient visibility and ICU mortality:
a conceptual replication, HERD: Health Environments Research & Design Journal
7 (2) (2014) 92–103, https://doi.org/10.1177/193758671400700206.
[112] D. Pati, S. Pati, T.E. Harvey Jr., Security implications of physical design attributes
in the emergency department, HERD: Health Environments Research & Design
Journal 9 (4) (2016) 50–63, https://doi.org/10.1177/1937586715626549.
[113] D. An, J. Ye, W. Ding, Spatial features and elements affecting indoor
wayfinding—a case study in a transit hub. International Conference on Human-
Computer Interaction, Springer, Cham, 2019, pp. 357–367, https://doi.org/
10.1007/978-3-030-22666-4_26.
[114] T.L. Buchanan, K.N. Barker, J.T. Gibson, B.C. Jiang, R.E. Pearson, Illumination
and errors in dispensing, Am. J. Hosp. Pharm. 48 (10) (1991) 2137–2145,
https://doi.org/10.1093/ajhp/48.10.2137.
[115] C.C. Marcus, Healing gardens in hospitals, Interdisciplinary Design and Research
e-Journal 1 (1) (2007) 1–27. Retrieved from, https://scholar.google.com/sch
olar?cluster=17704381303747405621&hl=en&as_sdt=0,5.
[116] K. Dijkstra, M.E. Pieterse, A. Pruyn, Stress-reducing effects of indoor plants in the
built healthcare environment: the mediating role of perceived attractiveness,
Prev. Med. 47 (3) (2008) 279–283, https://doi.org/10.1016/j.
ypmed.2008.01.013.
[117] S. Jiang, Encouraging Engagement with Therapeutic Landscapes: Using
Transparent Spaces to Optimize Stress Reduction in Urban Health Facilities, 2015.
https://tigerprints.clemson.edu/all_dissertations/1495/.
[118] D. Pati, T.E. Harvey Jr., P. Barach, Relationships between exterior views and
nurse stress: an exploratory examination, HERD: Health Environments Research
& Design Journal 1 (2) (2008) 27–38, https://doi.org/10.1177/
193758670800100204.
[119] R.S. Ulrich, et al., A conceptual framework for the domain of evidence-based
design, HERD: Health Environments Research & Design Journal 4 (1) (2010)
95–114, https://doi.org/10.1177/193758671000400107.
[120] E. Vincent, Therapeutic Benefits of Nature Images on Health, 2009.
[121] J.B. Rousek, M.S. Hallbeck, The use of simulated visual impairment to identify
hospital design elements that contribute to wayfinding difficulties, Int. J. Ind.
Ergon. 41 (5) (2011) 447–458, https://doi.org/10.1016/j.ergon.2011.05.002.
[122] D. Pati, T.E. Harvey Jr., S. Pati, Physical design correlates of efficiency and safety
in emergency departments: a qualitative examination, Crit. Care Nurs. Q. 37 (3)
(2014) 299–316, https://doi.org/10.1097/cnq.0000000000000032.
[123] M.A. Harris, T. Wolbers, How age-related strategy switching deficits affect
wayfinding in complex environments, Neurobiol. Aging 35 (5) (2014)
1095–1102, https://doi.org/10.1016/j.neurobiolaging.2013.10.086.
[124] Y.O. Kim, Spatial Configuration, Spatial Cognition and Spatial Behaviour: the
Role of Architectural Intelligibility in Shaping Spatial Experience, Doctoral
dissertation, University of London, 1999. Retrieved From, https://discovery.ucl.
ac.uk/id/eprint/1317973.
[129] S. Jiang, M. Powers, D. Allison, E. Vincent, Informing healthcare waiting area
design using transparency attributes: a comparative preference study, HERD:
Health Environments Research & Design Journal 10 (4) (2017) 49–63, https://
doi.org/10.1177/1937586716675581.
[132] R.S. Ulrich, C. Zimring, X. Zhu, J. DuBose, H.-B. Seo, Y.-S. Choi, X. Quan,
A. Joseph, A review of the research literature on evidence-based healthcare
design, HERD: Health Environ. Res. Des. J. 1 (3) (2008) 61–125, https://doi.org/
10.1177/2F193758670800100306.
[133] J. Carthey, Reinterpreting the hospital corridor: “Wasted Space” or essential for
quality multidisciplinary clinical care? HERD: Health Environ. Res. Des. J. 2 (1)
(2008) 17–29, https://doi.org/10.1177/193758670800200103.