Point of View
Why do Patients keep on
Getting Lost in Hospitals?
Mollerup (2008) identified 5 causes why people have problems finding their way in hospitals:
Complex architectural changes:
Initially, hospitals may have a straightforward design, but subsequent additions and modifications can confuse the original, clear planning, making navigation for patients and visitors challenging.Unfamiliarity or altered layouts:
Many patients and visitors struggle with hospital navigation either due to their unfamiliarity as first-time visitors or because of modifications and relocations within the hospital since their last visit.Confusing unit names:
The names of hospital units on signs often possess long, challenging, and similar wording, which can mislead visitors—such as a person seeking the gastroenterologic clinic may mistake it for another unit starting with "gastro."Visitors with limited capacities:
Wayfinding issues also arise when patients and visitors have limitations, such as visual impairments, reduced mobility, or diminished mental capacities, which inhibit their ability to navigate effectively.Anxiety-induced navigation issues:
Anxiety, commonly experienced by patients and visitors in hospitals, can notably impair wayfinding abilities, making navigation through the facility even more difficult.
“Anxiety, commonly experienced by patients and visitors in hospitals, can notably impair wayfinding abilities, making navigation through the facility even more difficult”
But there seems more to it…
In general, signs provide clear cues about turns and decisions without requiring significant study time or imposing a high memory load (Butler et al., 1993). However, when there is an excess of directional information, it can lead to problems. Passini (1984, 1990) recommends the following guidelines for signs: they must attract attention, be graphically similar to other signs in the environment, be consistently located, and contain only 4-5 bits of information.
Over recent years, hospitals have increasingly turned their attention to the so-called Patient Experience. Patients are progressively expecting a retailer-like experience with effective, personalized, and empathetic communication. Hospitals aim to burden the patient as little as possible with unnecessary visits and, for efficiency reasons and customer friendliness, attempt to consolidate appointments for medical treatments. This means that patients have multiple appointments in one day or can have immediate follow-up examinations. This not only necessitates patients to navigate from an entrance to the correct outpatient clinic but also to find their way between different clinics.
If a hospital houses 100 indoor destinations and has only one entrance, then there are 100 routes there and 100 routes back, totaling 200 routes. Now, suppose that every physical location must also be findable from every other physical location, this would immediately lead to an increase of 100*99 = 9900 additional routes.
In brief, the modern patient approach can cause the number of routes to exponentially increase, and therefore also the number of references on wayfinding choice points to be able to follow the respective routes. And as result exceeding the recommended amount of information according Passini (1984, 1990)
The question arises as to how many references to a physical location on a single sign a wayfinder in a hospital can process without the number of wayfinding errors and cognitive load increasing excessively?
Therefor, another hypothesis is that suboptimal tools contribute to the problem, given the lack of consensus on spatial information design for effective wayfinding, as evidenced by the numerous information design strategies for signage, employed in the hospital market.
The 3 main information design concepts that are utilized in hospitals
The information design approach closely aligns with the way indoor spaces in hospitals settings are labeled.
In general, three main concepts are employed:
Textual labelling of indoor locations
Numerical labelling of indoor locations
Alpha-numerical labeling of indoor locations
Textual labeling
Hospitals are notorious for using medical terms which are difficult to pronounce, to understand, to spell and to remember (Miller 2000). Patients often find these medical terms confusing according Mollerup (2008). In the United States, very long names of the financial donors are sometimes used as well to identify medical units.
In the case of a large hospital with 100 indoor locations that patients need to find, this would necessitate the placement of 100 references at each wayfinding decision point. While this approach might be feasible in very small hospitals, it is not recommended for larger hospitals due to the reduced efficacy of the system.
Passini (1984) argues that signs should not use not more than 3-4 bits of information, although with some graphical enhancement this could go up a little.
Moreover, the proliferation of signage would result in astronomical costs.
Textual labeling
Numerical labeling
Textual labeling of indoor locations thus seems not to work well in large hospitals. Small hospitals appear to be able to manage with it, although further research is needed to confirm this.
Over the years, alternative methods have been designed to prevent the problem of information overload and to avoid having to fill the building with signs, which can be quite costly.
Around 1990, this method emerged in the Netherlands to encode indoor locations with a unique number instead of a piece of text. This provides the advantage of logically grouping destinations in numerical sequences for reference at wayfinding decision points. Assigning these numbers is not a trivial task. It is not a random process to assign numbers to indoor locations, as the way they are interconnected through hallways determines where to assign numbers in order not to end up with many broken arrays, and thus too many directional signs at wayfinding choice points.
It involves an approach with heuristics, which can be a complex, very time-consuming manual process and, as a result, will be very costly.
And, because of the complexity, you will end up with a solution that is acceptable, but not optimal. But mostly it is done incorrectly, accommodating only inbound wayfinding and not cross-departmental wayfinding through a path with the least energy expenditure. So, it often leads to flawed information design solutions that either provide too little or too much information at wayfinding choice points
Numerical labeling
Alpha-Numerical labeling
Numerical coding of indoor locations has the potential to resolve the problem of information overload for patients, thereby leading to better wayfinding performance (accurate and quick) and a more pleasant wayfinding experience (easy, stress-free). The only issue is that wayfinding designers often struggle to resolve this and end up either implementing it incorrectly or not using it at all.
When the designer aims to code effectively while respecting the design requirement that every endpoint must be findable from each choice point, the alphanumeric labeling method is often chosen. This method has become a commonly used concept in information design because it offers an easy way out for the designer, but the question is how easy the design is for the patient?
Within this concept, a typical method is to distinguish between building sections (like Building A, Building B, or Hall A, Hall B, Square A, Square B, etc.), and sometimes floors, as well as the specific location of a patient's appointment.
For instance, if a patient is directed to B.2.23, they are expected to first locate building section B, then find and use an elevator to reach the second floor, and finally find room 23. This approach is sometimes referred to as 'progressive disclosure'.
However, the question remains whether this is a suitable solution for patients. Patients often struggle to understand this method, particularly when it's not clear to them as they transition between different zones or floors, especially if entrances are not at the ground level. This lack of clarity regarding floor levels can result in a high number of errors, particularly when there are no additional indicators for up and down directions. It has also been noted that it's not always obvious to everyone that the first digit represents the floor number (Butler et al., 1993).
Moreover, patients struggle to determine whether, when moving from B.2.20 to C.2.30, they should initially go down to the ground floor before proceeding to zone C or if they can stay on the second floor to move from section B to section C. Typically, patients are redirected to the starting point, which leads to unnecessary walking, consuming unwanted energy (Butler et al., 1993), and results in routes with more twists and turns, increasing cognitive load and the likelihood of errors (Best, 1970).
Alpha-numerical labeling
What Hospitals Need:
“Evidence Based Wayfinding Design”
Due to the absence of a unanimous agreement on the design of spatial information for efficient wayfinding, as indicated by the numerous signage design strategies employed in the hospital industry, it appears reasonable to preliminary conclude that insufficient tools contribute to the issue. Wayfinding Design is based on the opinion of the designer instead of being evidence based.
We hebben nooit empirisch vastgesteld welke methode van de bovengenomende 3 information designs, leiden tot de beste wayginding performance en beste wayfinding experience.
Is the term 'Ophthalmology' cognitively easier to process than 'B30'? Does it also lead to fewer errors? Moreover, does 'B30' differ cognitively from 'B.1.04' Utilizing numbers imposes a modest memory load because individuals navigating via signage need only remember a single task: follow the signs that feature the number within the indicated range (Butler et al., 1993). The number of ranges in this experiment were limited to just two. The question is, how would the cognitive load increase when the number of directional information would increase?
Another point of consideration is the volume of information that the wayfinder must process upon approaching a wayfinding choice point. Ideally, no more than 4-5 references should be displayed on a sign, and potentially 6 or 7 with adjustments in the user interface domain (Arthur & Passini, 1992). This has never been empirically investigated and may have significant implications for highly branched wayfinding choice points.
When a wayfinder approaches a wayfinding decision point (image 4) where there exist n=3 physical directional options to select from (proceeding straight, veering right, or turning left), the objective becomes to optimize the number of references towards n at this decision point, irrespective of the originating branch.
Image 4
When employing the numerical method of labeling, it is essential that the numbers are distributed in such a way that the number of references at wayfinding choice points is optimized to the value n. Doing this manually is impractical, making the task not only incredibly time-consuming but also far from optimal in terms of results.
It is expected that the numerical method will perform best in terms of wayfinding performance (error-proneness, speed) and wayfinding experience (ease, stress). However, solving this manually is not feasible, leading designers to often opt for solutions that are easier for them but more complex for users.
To address this, we utilize Mathematical Optimization and elements from Space Syntax Theory. These algorithms enable the distribution of labels in a manner that optimizes all routes towards the shortest path, minimizes the number of references at each wayfinding choice point, maintains performance below the cognitive and performance threshold, and ensures that any endpoint can be referenced at any wayfinding decision point.
Would you like to know what this method can do for you? Read more here.