A User-Centered Approach to Evaluating Wayfinding Systems in Healthcare

Abstract

Objective:

The purpose of this methodology is to provide the designers of wayfinding systems in healthcare facilities a process for evaluating and optimizing a design prior to implementation. The use of this methodology can improve patient experience in hospitals by preventing the installation of confusing, incomplete, and/or frustrating wayfinding systems.

Background:

Despite known wayfinding and information design principles, wayfinding continues to be a challenge in healthcare environments. One reason is that the design of wayfinding systems is rarely evaluated with end users prior to implementation. The methodology outlined in this article is an application of usability testing that involves end users navigating a space using prototyped signage and other elements of a wayfinding system to determine the effectiveness of the system and identify improvement opportunities. This methodology was developed for use in an emergency department that had outdated signage and required a new wayfinding system.

Conclusion:

This methodology provides a structured process for testing and improving the design of a hospital wayfinding system prior to implementation.

Keywords

wayfinding usability testing human factors information design evaluation

A User-Centered Approach to Evaluating a Hospital’s Wayfinding System

Visiting a hospital can be a stressful experience; visitors are usually not there by choice and are often in a state of discomfort, pain, and/or anxiety, whether they require care themselves or are visiting someone who is ill or injured (Berger, 2009; Carpman & Grant, 2016; Mollerup, 2009). In an effort to reduce these feelings of unease and improve the visitor experience, hospitals need to allocate resources to optimize and simplify navigation within their facilities. The utilization of an effective wayfinding system allows visitors to efficiently locate their destination and ensures that required care is received in a timely manner, whether navigating the emergency department or attending an appointment (Cooper, 2010; Rodrigues et al., 2020).

The utilization of an effective wayfinding system allows visitors to efficiently locate their destination and ensures that required care is received in a timely manner, whether navigating the emergency department or attending an appointment .

Wayfinding can be a challenge in healthcare facilities for a number of reasons. Hospitals are large, complex, unfamiliar environments that may or may not have taken wayfinding into consideration during early design (Devlin, 2014; Mollerup, 2009). Furthermore, spatial issues often develop and/or are exacerbated over time as hospitals are renovated and additions are built (Cheng & Pérez-Kriz, 2014; Mollerup, 2009; Rousek & Hallbeck, 2011). In addition to the inherent complexity of the physical design of healthcare facilities, the population demographic typically includes a large number of first-time and infrequent visitors. Consequently, the majority of individuals using these wayfinding systems are unfamiliar with the space, which can increase feelings of stress and anxiety (Chang, 2013; Huelat, 2004; Mollerup, 2009). Compounding these challenges is the fact that hospital visitors often have reduced visual, cognitive, and/or physical capabilities (Davis & Ohman, 2016; Jamshidi & Pati, 2020; Mollerup, 2009; Rousek & Hallbeck, 2011).

Wayfinding systems are often constrained to a single language, which can be problematic for visitors whose first language is not English (Cooper, 2010; Cowgill et al., 2003). Additionally, naming conventions used in hospitals often contain medical jargon, are long and complex, and may result in similarities between distinct destinations (Campbell & Scott, 2014; Mollerup, 2009; Rodrigues et al., 2020). This fact may be particularly problematic for individuals who lack knowledge and experience with the healthcare system or the facility, and those with impairments, as mentioned previously.

There is a large body of existing literature that attempts to provide guidance on how to develop an effective wayfinding system (Apelt et al., 2007; Calori & Vanden-Eynden, 2015; Gibson, 2009; Rodrigues et al., 2019). However, wayfinding continues to be a problem in healthcare environments. One reason for this disconnect may be that design teams do not typically conduct an in situ evaluation of a planned wayfinding system prior to implementation to ensure that end users are able to navigate effectively. Wayfinding systems are developed by skilled designers using well-established principles and technical expertise. However, designers need to consider end users and ensure that they are able to successfully interpret and utilize the design, given their level of knowledge. Prototyping of signage is a strategy that has been used to improve wayfinding systems in healthcare and other environments; however, the evaluation of these prototypes does not always follow a structured format involving anticipated end users (Luca & Narayan, 2016; Short et al., 2019).

Usability testing is a method in which representative users are observed completing tasks using an interface, product, tool, or system in order to identify and mitigate potential areas of error and/or frustration (Barnum, 2020; Nielsen, 1994). Usability testing is an effective way to validate a design and identify opportunities for improvement prior to implementation but may seem daunting or impractical for evaluating wayfinding systems, given their scale.

This article describes a methodology that can be used to evaluate a proposed wayfinding system by engaging end users (i.e., patients and visitors) to determine how easily they can navigate a space using the proposed system. The outlined approach was developed by applying the traditional method of usability testing to a physical environment, using high-resolution paper prototypes of elements within the wayfinding system. This methodology was developed for use in existing spaces (e.g., a renovation of a department) but can also be modified for use in new construction.

Evaluation Methodology for a Proposed Wayfinding System

Planning Stage

Identify evaluation questions

The first step in planning an evaluation of a wayfinding system is to identify and clearly articulate the questions that the evaluation aims to answer. Evaluation questions will likely be a mix of generic items that would apply to any wayfinding system and objectives that are specific to the space being evaluated. Generic questions may include items such as “Are the proposed signs visible in terms of contrast, text size, and placement?” and “Is the terminology used clear and easily understood?” Specific evaluation questions may include items such as “Is the placement of the department map by the nursing desk appropriate?” and “Should the term ‘X-ray’ or ‘diagnostic imaging’ be used?” Ensure that evaluation questions reflect the goals of the project and aim to answer any outstanding questions.

Identify key routes

Once the evaluation questions have been identified, the next step is to determine which wayfinding routes to include in the evaluation. It likely will not be possible to test every possible route, sign, and element of the wayfinding system, so it is important to prioritize effectively. In order to determine the appropriate routes to be included in the evaluation, consider where patients and/or visitors will be required to travel independently, without assistance from staff members, as these are the areas in which they are most likely to face challenges. Include high traffic, high priority, and complex routes, including those that require users to travel a long distance and/or navigate a large number of intersections. Also include complex intersections such as those that require a large number of signs and those that include multiple hallways (i.e., four or more) or have an intersection shape other than a typical linear cross. Routes selected may also include areas where there is less confidence in the proposed wayfinding solution or there are outstanding questions. Ensure that all evaluation questions are covered by the routes selected. In some evaluations, staff routes may also be included.

It likely will not be possible to test every possible route, sign, and element of the wayfinding system, so it is important to prioritize effectively .

The most effective way to identify key routes will differ depending on whether the wayfinding initiative relates to an existing space or new construction. In an existing space, identify routes to evaluate by observing patient movement throughout the space, noting high traffic areas and areas where people get lost or express confusion. Staff who work in the area will also be able to identify areas where visitors frequently require assistance. For new construction, routes can be mapped on a floor plan by a group of clinical experts who are familiar with the design and intended use of the space. In this case, look for key wayfinding points (e.g., complex intersections, areas with a high density of signage) and high traffic routes, as described previously. Note that this method can also be used for existing spaces in combination with usage patterns.

Develop scenarios

After the routes have been identified, they need to be converted into scenarios that can be used to guide participants during the evaluation. Write simple scenarios that are worded as an instruction for the participant to locate a specific destination. Ensure that scenarios include a starting and an end point and match the language and terminology used by staff. In an existing space, ask staff what directions they would give to a visitor including what specific words they would use. For example, “Imagine that you are coming to the emergency department to visit a friend. The triage nurse tells you that your friend is located in the ‘intake’ area. Use the signs to go to this area.”

Develop debrief questions and additional measures

Develop questions to be asked during a debrief interview at the end of the session in order to capture the participant’s thoughts and suggestions. Ask questions that are open ended and relate to the project’s evaluation questions. Debrief questions may ask about challenges experienced with each route (i.e., areas the participant got lost/confused), how easy it was to follow the signs, how appropriate the location of the signs were, legibility (e.g., contrast, text size), language and terminology, and specific elements of the wayfinding system (e.g., How easy is the map to understand?). At the end, ask whether there is anything else they would like to comment on.

In addition to the qualitative interview, there is an opportunity to include quantitative measures that can be used to compare routes. Some examples of measures to include for each route evaluated are the number of times help was required to complete the route, subjective rating of task difficulty using a Likert-type scale, and time to complete the route.

Recruit and schedule participants

Another key part of planning a wayfinding evaluation is to identify and recruit participants. Typically, when evaluating the wayfinding system in a hospital, the end users are patients and visitors, as opposed to staff. It is important to ensure that the sample of participants includes a range of demographics but is reflective of the population that uses the facility. It is important to include populations that may have challenges with wayfinding, such as elderly individuals, visually and/or physically impaired individuals, and people who speak English as a second language. Involve participants who are not familiar with the area being tested (i.e., have not been to the site/department before).

Facility staff may also be included in the wayfinding evaluation in order to consider the experience of new staff, students, and individuals who need to navigate between departments (e.g., laboratory staff, allied health, porters). While there will likely be some overlap, the routes that are evaluated for staff may differ from the routes that are tested with patients and visitors, so consider these two types of participants independently during scenario development.

The number of participants included in the evaluation will depend on the time and resources available. Ideally, recruit 15 participants, which should result in the identification of all major usability challenges with the system. If it is not possible to test 15 participants, ensure that at least five to seven are included, which will capture approximately 80% of usability challenges with the system (Nielsen & Landauer, 1993).

If it is not possible to test 15 participants, ensure that at least five to seven are included, which will capture approximately 80% of usability challenges with the system .

When scheduling sessions, ensure that there is adequate time to complete introductions, provide instructions, run through all scenarios, and debrief. It is recommended that the sessions are 1:1, with one participant and one evaluator working through each scenario together. This approach will foster a test environment in which participants can openly share their ideas and opinions by limiting the observer effect as well as groupthink (Horwitz & McCaffery, 2008; Janis, 2008). As a result, the maximum number of improvement opportunities and potential solutions can be identified.

Print signs and other materials

The final piece of the planning stage is to ensure that the designs are complete and ready for print. Develop signs, maps, and other materials that are high resolution, to scale, and printed in color on a durable material such as thick matte laser or inkjet paper (Figure 1). Note that it may not be practical or feasible to print and post all signage for an entire department or facility; however, include coverage in all areas within the selected routes. Try to incorporate as many aspects of the wayfinding system as possible. For example, if the wayfinding system will use colored walls as landmarks, post colored paper on the walls to imitate this.

Figure 1.

Examples of signage prototypes used for a wayfinding evaluation. Note. Signs are printed high resolution, to scale, and in color. Existing signs are masked with white paper (circled, right image).

Setup

Mount the proposed signage in the exact locations planned for installation. Posting of signs will involve attaching signs to walls and ceilings using mounting materials that are appropriate for the space (e.g., string and tape). It is important that participants only see the signage that is being evaluated rather than a mix of existing and proposed signage. Cover existing signage (e.g., with blank paper) to limit confusion and ensure the validity of the evaluation findings (Figure 1).

Running the Session

Introductions and expectation setting

Start the session with clear introductions including who the evaluator is, the purpose of the evaluation, and what the participant will be asked to do. Explain to the participant that they will be asked to complete X number of routes in the space using proposed signage and other wayfinding strategies, with the goal of identifying improvement opportunities. It is important to stress that the evaluation is testing the wayfinding system, not the participant’s skill or knowledge, and that any challenges experienced are reflective of the design and will help to inform improvement decisions. Encourage the participant to be critical and honest during the session and address any questions or concerns they have before starting.

Talk aloud method

Instruct participants to verbalize their thoughts, questions, challenges, and so on, as they complete each scenario. This strategy will allow the evaluator to gain insight into areas that are confusing and/or need improvement. Participants may need to be reminded throughout the session to verbalize their thoughts; however, it is important to limit interruptions and distractions throughout the activity.

Instruct participants to verbalize their thoughts, questions, challenges, and so on, as they complete each scenario .

Scenarios and data collection

After the overview is complete, walk with the participant to the starting point for the first scenario. Read the scenario to the participant and then follow them as they attempt to complete the route. As the participant completes each route, take detailed notes on what is observed, such as where the participant goes, where they look, what tools they use and do not use, and so on. Record all comments made about likes and dislikes, what is confusing, suggestions for improvements, and so on. If quantitative measures were developed in the planning stage, capture these data for each scenario. Refrain from providing assistance unless absolutely necessary.

Debrief

After each route, complete a short verbal debrief with the participant about their experience while it is still fresh in their mind. This may include asking questions such as “What was challenging about that route?” “What would make it easier?” and “What would you change?” This is also a good opportunity to ask clarifying questions about any comments that the participant made during the task or anything that was observed. At the end of the evaluation, once all routes have been completed, conduct a formal debrief in a quiet location. During this conversation, ask the questions that were developed during the planning stage. In addition, ask clarifying questions and revisit areas where challenges were observed.

New Construction

The methodology described in this article is most applicable to existing spaces requiring new or updated signage but can also be used for new construction with some modifications. To evaluate a proposed wayfinding system for a new hospital or department, follow the steps as outlined above. In this case, temporary signage can be mounted and evaluated within the empty space prior to the facility opening. The evaluation can take place during various phases of the build but ideally would occur once walls and all key infrastructure are in place (i.e., the facility looks similar to how it will look when open). However, testing must occur early enough so that there is time to revise, manufacture, and install all elements of the wayfinding system prior to opening.

The main difference with new construction compared to a renovation is how routes are identified and prioritized, as usage patterns (e.g., bottlenecks, common points of confusion) are unavailable. Rather, routes can be mapped out on a floor plan by a group of clinical experts who are familiar with the design and how the space will be used. In order to do this effectively, develop scenarios that represent how patients and visitors would use the space and draw the routes out on the floor plan. The outcome of this exercise is the identification of key decision points, complex routes and intersections, and high traffic routes to be tested during usability testing.

Application of Methodology in an Emergency Department

This methodology was used to evaluate a wayfinding system consisting primarily of signage and posted maps in a small (45-bed/recliner) emergency department in Edmonton, Alberta, Canada. In this case, an existing department required updated signage due to ongoing wayfinding challenges. A package of signs and maps was developed by a designer using information design and wayfinding principles. The evaluation methodology was followed as described above for a sample of nine “patient/visitor” participants. In this evaluation, three routes were tested that were identified by hospital staff as being particularly problematic: (1) triage to intake, (2) intake to the washroom, and (3) washroom to the exit (Figure 2). Signs were posted in approximately half of the department to test these routes, and existing signage was covered with white paper (Figures 1 and 2). Table 1 provides details of the evaluation, including specific scenario language and debrief questions. Table 1 can be used as a template for future evaluations. This research study was approved by the Research Ethics Board of the University of Alberta.

Table 1.

Evaluation Template Including Emergency Department Evaluation Content.

Step	Emergency Department Evaluation Content
Identify evaluation questions	Are the signs legible and visible in the space (color, font size, placement)? Is the department map useful and if so, located in the appropriate location? Is the icon that is used for the washroom intuitive and visible? Are there any terms that are not clear?
Identify key routes	By speaking with the department staff, the following routes were determined to be most challenging due to route length, number of signs, language, and so on: Triage to intake Locating a washroom Locating the department exit
Develop scenarios	Start at triage: “Imagine that you are coming to the emergency department to see a friend. We will start at triage to find out where they are. The triage nurse tells you that your friend is located in the intake area and to go through rapid assessment zone to get there. Use the signs to go to this area.” Once get to intake: “For the second task, we will have you locate the washroom in the emergency department using the signs provided.” Once get to washroom: “We will now look for a way out of the department. Try to use a door other than where you first came in.”
Develop debrief questions and additional measures	Example debrief questions: Describe any challenges you had with each route. Are the signs positioned in appropriate locations where the information is needed? If not, where did you need more information? Describe any areas where you got lost. Were the signs easy to read (i.e., legible)? If not, what would you change? What words or icons you did not understand? How did the signage affect your experience in the space? Did you notice the map of the emergency department when you first entered? If not, where would be a better location for it? Is the department map useful? Explain. What would you change about the signs? Is there anything else you would like to add? Measures: Number of times the participant asked for help Was the participant able to find the destination without assistance? “How easy was it to find the destination using the signs?”: very easy, easy, difficult, very difficult
Recruit and schedule participants	An 8.5 × 11” poster was developed asking for volunteers to participate in the study. The poster stated that participants should not be familiar with the department and explained what they would be asked to do. The poster was posted in public spaces near the hospital (e.g., library, coffee shops). Participants were also recruited through the healthcare organization’s volunteer and patient/family advisor groups.
Print signs and other materials	Signs and the department map were printed high resolution, to scale, and in color, on large pieces of thick white paper.
Mount signs	The signs and department map were mounted using tape, string, and paper clips in the locations they were intended to be installed. White paper was taped over existing signs.
Introductions and expectation setting	Script, paraphrased: Thank you for participating in this evaluation (Evaluator to introduce self). Purpose of the session is to evaluate new signage in the emergency department. You will be asked to find your way to specific locations in the emergency department using paper versions of the proposed signs. Please say out loud what you are thinking so that we can understand your experience. For example, what questions you have, what signs you notice, and so on. At the end of the task, we will discuss your experience and any suggestions. Any challenges you experience with this task are due to the design and placement of the signs, not you. Any difficulty you have is likely to be experienced by others and will help us understand where things need to be improved. Your participation is voluntary and you may stop or take a break at any time. Do you have any questions before we begin?
Scenarios and data collection	The evaluator and participant walked to the triage desk and the evaluator read Scenario 1. As the participant navigated to the intake area, the evaluator followed them and recorded what they said and observations of where they looked. The evaluator provided hints about where to look only if the participant got lost. The quantitative measures were recorded at the end of each scenario. At the end of each scenario, the evaluator asked the participant what challenges they had with the task, as well as specific questions depending on what occurred. For example: ○ “I noticed you did not see this sign, what would make it more obvious?” ○ “I noticed you looking around in this area, what were you expecting to find?”
Conduct debrief interview	The debrief questions were asked to the participant. Challenges and suggestions recorded during the session were discussed further.

Figure 2.

Floorplan of emergency department evaluated.

The value of evaluating the proposed wayfinding system was readily apparent. A number of constraints were identified, which the designers were not originally aware of, including the position of security cameras, curtains, bulkheads, and posted materials (i.e., pamphlets) on the walls. Some of these limitations could be addressed (e.g., removing posted materials), but others required a change to the placement of the signs (e.g., security cameras, curtains). A large number of changes to the placement of the signs were made, highlighting the challenges with using a floor plan and the designers’ memory of the space to specify placement. The placement of items such as security cameras and curtains is not something that is typically included in department floor plans, so would not have been identified without visiting the space.

A number of other changes were made to the signs following the evaluation, including increasing the font size, changing the position of icons, changing the color of some of the signs to make them more salient, and combining and simplifying signs where relevant. The evaluation also raised a number of questions about the terminology used by the department for certain areas, which were brought to the site and design team for resolution. For example, one area in the emergency department was called “intake,” which is a term used throughout sites in the province, but caused confusion for most participants, as they expected this to be a reception area, not a care area. Finally, the department map had to be moved due to only one participant noticing it during the evaluation. Emergency medical service stretchers are often parked in the area where it was posted, which was discovered during the sessions. Overall, there were a number of improvements made to the wayfinding system based on the evaluation that would not have been identified prior to installation of the actual signs had the evaluation not occurred. A summary of key findings can be seen in Table 2.

Overall, there were a number of improvements made to the wayfinding system based on the evaluation that would not have been identified prior to installation of the actual signs had the evaluation not occurred .

Table 2.

Key Findings From Emergency Department Wayfinding Evaluation.

Theme	Example(s)
Placement of signs and map	Signage was placed at inconsistent heights due to environmental constraints. Participants reported that they look for signage at eye level rather than near ceiling height. Existing bulkheads, security cameras, and curtains constrained the placement of signs, so they could not be positioned in the optimal location. Modifications were made to the signs to accommodate the new placement. Certain areas presented unique problems for the participants. Signage located above a door frame was not noticed. Signage mounted too closely to one another created clutter and information overload. Misleading directional arrows. The intake area was not clearly defined, which caused most participants to be unsure whether they had arrived at the location. Finding a location to mount the map proved unsuccessful as the only wall space available was hardly ever free of clutter such as carts, stretchers, and emergency medical service personnel.
Language and/or wording on the signs	Several terms used on the signs were not clear to users: Intake Rapid assessment zone Diagnostic imaging “Washroom” was represented using an icon only, which was missed by nearly all participants.
Hierarchy of information	The majority of participants did not notice the washroom icon, as it was placed in the sign header rather than listed as a destination. Too small. Placement at the top of the sign in the black bar wasn’t expected. They were looking for the word “washroom” beside the icon.
Legibility of signs	Font size needed to be increased to be legible from a distance. The color scheme of the signage was modified in order to increase contrast between signs and the surrounding department.

Key Learnings From Emergency Department Evaluation

Due to significant distance between planning and test sites, there was no opportunity to pilot test the scenarios prior to the evaluation. Ideally, the test protocol should have been piloted with at least one person outside of the planning team in order to identify improvements and ensure that the evaluation objectives are met. Had a pilot been conducted, it would have been recognized that the third scenario did not address the evaluation objectives as the route was too short and overlapped with the other scenarios, meaning that no new signage was encountered. Consequently, Scenario 3 was modified after the first few participants so that the remaining participants would start in a different location, which exposed them to new routes and signs.

Another key learning from the emergency department evaluation was that the staff who worked in the department had valuable feedback regarding challenges with the existing signage. Although staff were not included in the evaluation itself, informal conversations were held with several staff members, and their feedback was incorporated in the post evaluation design revisions. Based on this experience, it is suggested that as part of the evaluation, staff be interviewed at minimum, as their experience may lend valuable insights to address challenges observed.

The data collection method was modified slightly after the first participant, as the evaluators realized that it would be useful to bring a map of the department with them as they worked through the scenarios. This allowed the evaluators to quickly and clearly note findings related to specific locations on the map, which would have been otherwise difficult to describe.

When evaluating new signage in a functioning unit, there are a number of considerations and logistical challenges to be aware of. It is important to keep hallways clear, so the evaluators must ensure they do not get in the way of patient movement or care when installing signs and when running participants through the space. In addition, noise and patient privacy must be considered and respected. The evaluators also must be careful not to cover any important signage that may introduce a safety risk. This was apparent during the emergency department evaluation as the department was quite busy, so the evaluators had to be strategic and aware of their surroundings when posting the signs.

Limitations

While the methodology outlined in this article has been shown to be useful in identifying improvement opportunities for proposed wayfinding systems, a number of limitations exist. This methodology is best suited to evaluate signage for a single unit or department. Due to the time and cost required to plan, recruit, install, and test, it would be very challenging to evaluate all routes and signage for an entire facility. For this reason, in the emergency department evaluation, only a subset of routes was evaluated, although an effort was made to include as many signs as possible. The learnings from the evaluated routes were applied to areas that were not included.

Another constraint with this methodology is the financial costs associated with developing high fidelity prototypes and participant compensation. Although paper prototypes are fairly inexpensive, the printing costs increase as the scope of the evaluation expands. Another limitation of using paper prototypes is that they may draw more or less attention compared to the final product due to differences in material, reflectiveness, and so on, which may alter findings related to visibility.

Finally, it can be challenging to recruit a representative sample of participants. Often, the people who volunteer for these evaluations are individuals who are familiar with the healthcare system, such as hospital volunteers, patient/family advisors, and students. These participants may have less difficulty navigating the system than individuals who are elderly or speak English as a second language. The sample of participants used in the emergency department evaluation was less diverse than desired due to a low number of volunteers from the community. As a result, the majority of participants were students and patient/family advisors. These participants were primarily women, aged 20–50, all fluent in English, with good vision, and some knowledge or experience in healthcare systems. Ideally, the sample population should contain a wide range of characteristics in order to ensure that all perspectives are considered.

Conclusion

Despite the wealth of existing information on how to design signage and other wayfinding strategies effectively, hospital wayfinding systems are often not intuitive. Involving patient/family representatives in the evaluation of these systems can identify improvement opportunities that may not be otherwise recognized during the design phase. This article provides a structured methodology that can be used to evaluate a proposed wayfinding system prior to implementation in order to optimize its effectiveness and improve the patient/visitor experience in the hospital setting.

Implications for Practice

Provides a tangible method that can be directly applied to projects involving evaluation or development of wayfinding systems and signage.

Validation and optimization of the design of a proposed wayfinding system prior to implementation can prevent the need for costly changes after it is installed.

Optimization of wayfinding systems can improve the patient experience in healthcare settings by making the space easier to navigate, which can reduce anxiety and ensure people get to their destination on time.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Katherine Bubric, MSc

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