Abstract
Purpose:
The aim of the study was to examine literature on first impressions and how physical design factors influence users’ first impressions.
Background:
Engineering a first impression through physical design has been successfully used in the context of US federal buildings and retail. A patient’s first impression is important as it affects their downstream behaviors and experiences. However, little is known about it in the context of healthcare design.
Method:
This study is part of a broader literature review that searched for studies on the first impression phenomenon, which were examined in a cross-disciplinary literature review, along with trade/professional journals/magazines. Three databases were in-depth searched—Scopus, Web of Science, and HaPI along with Google Scholar search and hand searching. A total of 187 satisfied articles and three books were reviewed through three phases to obtain an understanding of the first impressions and the factors affecting it.
Results:
After the in-depth review of the theories behind the first impression, the authors proposed a conceptual framework explaining the concept of the first impression and engineering it through physical design. The findings from published articles suggest five conceptual steps between early information pickup and early impression formation: (1) exposure time, (2) information pickup, (3) cognition, (4) emotion, and (5) judgment.
Conclusions:
The findings show a causal association between one’s initial information pickup during the first 5 min of exposure to a target and the formation of a first impression. It suggests a crucial role of physical design of the environment, including in healthcare facilities.
Keywords
How does the physical environment influence first impression? Hospitals spend considerable resources for an instantaneous positive emotional response from patient, family, and visitors (Healthcare Facilities Today, 2013). Ulrich et al. (2008) indicates that the design of healthcare environments can significantly influence patient satisfaction and well-being. Factors such as appropriate lighting, noise reduction, comfortable furniture, and aesthetically pleasing surroundings have been shown to have positive impacts. Typically, the resources are spent in the main entrance lobby (HMC Architects, 2021), which means that a hospital’s ability to engineer a positive patient experience can start the moment the patient walks in the door. Many healthcare facilities have made environmental improvements to soften their bland, institutional feel by incorporating colors, artwork, plants, and comfortable furniture. Hospital lobbies contain a variety of features that can influence a patient’s experience. Several studies have suggested that people’s initial reactions to a subject are shaped by the first 5 min of their exposure (space in the content), a phenomenon commonly referred to as a “first impression” (Carney et al., 2007; Grenier, 2016). Therefore, many hospitals provide extra spaces in their lobby to give patients a choice as to what to do before seeing their doctor, which might be viewed as helping to build a positive experience.
A first impression can be understood as the early moment of interaction between an individual and a target (which can be another person or a space) and is affected by initially perceived features from which individuals form a positive or negative judgment (Gronier, 2016). The phenomenon was originally discussed in social psychology in 1946 by Asch described it as a process that socio-cognitive in nature and is characterized by subjective complexity. (Table 1) Thus, the interaction that occurs between the individual and target can also be understood as a form of cognitive interpretation. It is an active process that depends on the information available about the target (Hamilton et al., 1980). First impression is an important phenomenon that, if engineered properly, enhances an individuals’ experience (Brown, 2015; Harris et al., 2002), improves satisfaction (Brown, 2015; GSA, 2017), and reduces stress (Diamond, 2020). In healthcare settings, this phenomenon is essential as a part of patients’ overall experience and can contribute to or alleviate stress and anxiety (Clark, 2019). It can affect patients’ emotional reactions and feelings toward the facility. It may not be erroneous to assert that having a positive initial feeling is very important, especially in hospitals, since it impacts patients’ experiences and behaviors downstream. A first impression also contributes to lasting impressions (Cucinotta, 2017; Digirolamo & Hintzman, 1997; Miller et al., 2004; Okten, 2018); even though a hospital visit may seem short in duration, it can still significantly impact a patient’s emotional experience (Harris et al., 2002).
The Characteristics of the Included Studies.
Despite the importance of first impression, in healthcare settings or otherwise, there is very little documented evidence that first impression phenomenon has been systematically and proactively used as a guiding principle in the design field. Two exceptions are retail environments and the First Impression Program (General Services Administration [GSA], 2017), a guideline introduced by the US GSA in an effort to improve the public’s perception and experience inside federal buildings. According to assessment research by the GSA, visitors are often highly stressed when visiting federal buildings. The study demonstrated the importance of well-designed lobbies to help reduce visitors’ negative emotions, ensure safety, and create welcoming and accessible spaces. As a result, the first impressions program guide was implemented to assist designers in creating transitional spaces in federal lobbies that address various psychological factors influencing first impression identified by researchers and scholars in fields like social psychology, psychology, medicine, neurobiology, and marketing. Similarly, in the retail environment, Turley and Milliman (2000) have emphasized the importance of creating a positive and inviting atmosphere o to attract and retain customers. The lighting, music, visual stimuli, and even the scent of a retail store can all influence how customers perceive the store and the products it sells (Turley & Milliman, 2000). Retailers are thus cognizant these factors and often allocate significant resources creating a welcoming and visually appealing environment for their customers.
It may be argued that first impression strategies are not one-size-fit-all. Desired and targeted emotions may not be the same for different organizations and building types—what is desirable for federal buildings may be different from hospitals, malls, entertainment parks, airports, or correctional facilities. To engineer the appropriate first impression, a theoretical understanding of the underlying phenomena could considerably support design decision making. Furthermore, the phenomenon of first impression is yet unexplored in healthcare settings and building design, in general, with a few exceptions. Based on available literature, it could be argued that a positive first impression may contribute in more than one way to healthcare organizations: (a) Positive first impressions could contribute to better patient outcomes, downstream; (b) higher perceived quality of care, and hence, perhaps, better patient satisfaction, more repeat visits, and higher referrals; and (c) better hospital ratings. For instance, a review by the Health Leaders Media Intelligence Unit revealed that 41% of patients indicated their intention to change their hospital to find a better patient experience (Nicoloff, 2012). The study demonstrated a need for healthcare organizations to focus more on improving patients’ experiences overall, in which their first impression of the hospital may play a crucial role.
This literature review paper aims to posit a preliminary knowledge foundation that provides a conceptual framework from theoretical perspective on first impression, and the way individuals arrive at an early impression with limited information, specifically within a healthcare setting. To this end, this paper addresses two questions: (1) What is the theoretical pathway between a perceiver’s first exposure to an environment and the resultant formation of a first impression; (2a) What factors affect or play a role in this theoretical pathway; and (2b) Are any of these factors physical environment factors?
Method
The literature review for this study is part of a broader literature review that was divided into three phases (Figure 1). The first and third phases involved a title, abstract, and in-depth review of scholarly publications and books from various fields. Meanwhile, the second phase involved a title and in-depth review of the full text of both peer-review and gray literature. The first two phases each addressed the research questions. The third phase was added subsequently to address missing information in the data collected. The study analyzed a total of 185 articles, two chapter books, three books, and gray literature that were published in 33 scientific journals, and on six government websites. This literate included 62 from the analyzed data used in the broader study. The data were collected and analyzed between August 2020 and February 2022 by two researchers in the field of environmental design.
Flow diagram of screening and study selection.
The first research question and part of the second question were addressed in the first phase: (1) What is the theoretical pathway between a perceiver’s first exposure to an environment and the resultant formation of a first impression and (2a) What factors affect or play a role in this theoretical pathway? The researchers were exploring the first impression phenomenon across disciplines; therefore, the researchers used to search key words: “first impressions” and “first impressions phenomenon.” The researchers targeted review articles from HaPI, Scopus, and Web of Science databases in addition to a search engine (Google Scholar; Figure 1). The disciplines included “sociology,” “psychology,” “web design,” “hospitality management,” “information systems,” “neuroscience,” and “science and technology.” In addition to gathering general information on the first impression phenomenon, this phase also collected data on the types of impressions, “positive” and “negative,” and factors that influence first impression formation. By exploring the phenomenon in this way sheds light on how it has been addressed from different perspectives. The initial search harvested 1,613 studies between 1940 and 2020 (the oldest and most recent papers found). Title review was performed to filter relevant studies that addressed the core of first impression. The researchers found several terms to be used in the second phase including thin slice, emotion, judgment, initial impression, and positive and negative impressions. An abstract review was performed for 305 articles to filter out the articles not aligned with the main purpose of the study. This filter resulted in 117 studies and one book. Subsequently, the researchers performed in-depth reviews, and the extracted data were organized in an Excel worksheet for further review. The excluding criteria included (1) article that was difficult to access, (2) technology that was tested, (3) studies in neurosciences that focus more on the technical process in the brain, (4) study that did not focus on first impression, and (5) stopping data collection when enough information regarding the scope was gathered. The broader literature review included 117 peer review and one book, whereas this part of the literature review included 21 peer review. In this phase, included studies are all written in English and follow these criteria: (1) peer-reviewed literature that examined first impressions, and/or (2) conceptual studies that used relationships and theoretical propositions to provide in-depth explanations.
During the second phase, the researchers queried various phrases key words using general search engines to identify other scientific journals, magazine articles, conference proceedings, websites, and books that might provide more insight into question: (2b) Are any of these factors physical environment factors? These sources were then hand-searched for relevant information from 2000 to 2001. This approach was adopted when initial searches using the method from the first phase failed to yield substantive results regarding the importance of the phenomenon and the environmental attributes that influence an individual’s first impression. Key words included “first impression,” “initial impression,” “impression,” “indoor impression,” “patient impression,” “thin-slice,” “satisfaction,” “emotion of space,” “patient judgment,” “people response indoor,” and “atmosphere.” Title review was performed to filter for 83 articles to filter out those that did not addressed the main purpose of the study. The exclusion criteria included (1) articles that did not focus on first impressions, (2) were not relevant, (3) were marketing-related, or (4) stopped when collecting enough information regarding the scope. This filter resulted in 52 articles that were subjected to in-depth reviews, and the extracted data were organized in an Excel worksheet for further review. The exclusion criteria during this phase included (1) repetitive information and (2) information outside the scope of the research. All the included studies in this phase were written in English and followed these criteria: (1) gray literature on interior environments, including experts’ opinions regarding first impressions in hospital settings and the first impression program used in U.S. federal lobby. In this phase, in-depth reading was used to filter out sources that did not meet the purpose of the study. The researchers added 52 articles to the initial harvest, for analysis. In this study, the researcher included 33 articles (nine were peer review and 24 gray literature), and one book chapter from the second phase.
After the two phases, data analysis involved two main tasks: (1) identify any theoretical pathway between early information pickup and formation of an early impression, and (2) any evidence in published literature regarding factors that contribute to this phenomenon at any point on the theoretical pathway. After collecting and reviewing the data from the two searches, the researchers used in-depth analysis of the phenomena, structures, associations, and empirical findings and subsequently illustrated the extracted information in a logical and comprehensible representation. During this process, the researchers found missing information in the data; therefore, the third phase of data collection was conducted to address the gaps. This was performed using Google Scholar and included the key words included “cognition,” “cognitive and affordance,” perceived affordance,” and “perceived design.” These sources were then hand-searched for relevant information from 1977 to 2001. Title review was performed for 42 articles and excluded those that (1) were not relevant, (2) subject were children, or (3) study did not focus on the indoor environment. This filter resulted in 18 articles and were in-depth review. The exclusion criteria were (1) not accessible articles, (2) information outside the scope of the research, and (3) stopped when collecting enough information regarding the scope. The researcher harvested an additional 18 articles and two books in the broader literature review and included one book, one chapter book, and four articles (two peer reviews and two gray reviews) in this study. Information from this search was extracted, reviewed, and represented in a similar manner as described above.
Results
Information in published literature suggest five steps between early information pickup and early impression formation: (1) exposure time, (2) information pickup, (3) cognition, (4) emotion, and (5) judgment. Together, these five phenomena offer a conceptual pathway explaining the concept of first impression. The following subsections articulate each step in the plausible pathway in details, including influential factors in each step.
Exposure Time, Personal Factors, and Information Pickup
The first step in the formation of a first impression begins as soon as the perceiver is exposed to the target (a space, person, etc.) for a short period of time (Kim, 2019; Figure 2). These exposure times were labeled in previous research as thin slicing (Screen Cloud, 2016). Thin slicing is a psychological term that explains how people make their decisions based on a thin slice or a moment of information (Ambady & Rosenthal, 1992). Thin slicing relates to individuals’ unconscious mind’s capacity to detect trends in circumstances and actions based on very small slices of experience. Humanity is characterized in large part by thin slicing, wherein they thin slice every time when they interact with things (Hedges, 2014). This thin slicing was found to affect and influence people even if they never engage in verbal communication (Hedges, 2014).
When individuals enter a space, they are subjected to a host of verbal and nonverbal information (Kuzmanovic, 2012) through all their senses: hearing, smell, taste, touch, and sight (Böhme, 2006, pp. 399–403). Consequently, when patients enter hospital lobbies, they can become overwhelmed by many sensory stimuli and pieces of information, a lot of which individuals filter out consciously (Valenti & Gold, 1991). Which means, what patients consciously or subconsciously pick up as they enter a space, whether loud screaming or the sound of waterfall, for instance, may influence their first impression. This is true with other senses, such as the difference between smelling dirt or blood versus the smell of clean spaces or hospitality environments. Research indicate that what patients see (visual stimuli) are much more influential and effective (Ayers Saint Gross, 2011; Lester, 2006). Visual stimulus is the main source of nonverbal communication and has been found to be more powerful than verbal communication (Ayers Saint Gross, 2011; Kuzmanovic et al., 2012). A key distinguishing factor for hospitals is the fact that patients and family members are generally in a high state of acute stress, anxiety, and/or pain, which may determine a different filtering mechanism for information. What is not known are the varieties of specific information, consciously or subconsciously sought by patients in hospitals on initial engagement, which may determine the nature of first impression formed.
While scientific evidence is not forthcoming in this domain, expert opinions incorporated in design solutions may provide an initial foundation on possible factors affecting initial information pick up in hospitals. Bylines in healthcare design magazines underscore the importance of clear indoor spaces (DiNardo, 2013), creating warmer (Eronen, 2019; Peri Bader, 2015) and welcoming spaces (GSA, 2017; Stanford Children’s Health, 2012), accessible spaces with clear wayfinding (GSA, 2017; Marquard, 2015), ensuring safety (GSA, 2017; Robinson & Foell, 2005), appropriate signages (Diamond, 2020; DiNardo, 2013; GSA, 2017; Robinson & Foell, 2005), and aesthetics (DiNardo, 2013; Lindgaard, 2007; Naqshbandi & Munir, 2011; Robinson & Foell, 2005; Wood, 2014). These include visual connections to the outdoors via glass, and clear connected indoor spaces with easy-to-use wayfinding (Dinardo, 2013). Desired solutions include paths that provide visual information and direct people in their direction and opening up the environment to ensure safety (GSA, 2017). It is asserted that when patients enter visually connected spaces, they may feel safer than in enclosed spaces. In the context of federal buildings, the U.S. General Services Administration GSA argues that lobbies offering clear sightlines to help the security office monitor the space is important to ensure safety. Visible and legible signage is also considered important in federal buildings (GSA, 2017), wherein clear, well-designed, and well-located signage are expected to assist in reducing visitors’ anxiety as they walk through security. These recommendations provide some clues regarding expert opinions on the type of information sought at initial exposure, including informational, navigational, orientational, and personal safety. In retail environment study by Christodoulides et al. (2016), the researchers indicated that a customer’s first impression of a retail store can have a significant impact on their overall perception of the store and its products. They discussed various factors influencing first impressions, including store layout, lighting, music, and scent, which can all be used to create a positive and inviting environment. Additionally, the authors noted that staff appearance and behavior can also impact customers’ first impressions, as well as the use of digital technology in retail settings.
Personal factors
Studies have also indicated that individuals pick up information from a target differently depending on their personal factors in addition to the exposure time (Figure 2). Perceivers engage with their senses differently (Heil, 1983, p. 2016), have different genders (which can impact overall first impressions; Carney et al., 2007; Chan et al., 2011; Humă, 2010; Soltanian & Sadeghi, 2021), and can be influenced by mood (Ambady & Gray, 2002; Boone & Buck, 2003), age (Hess et al., 1998), and personal value and preferences (Schiller et al., 2009). These differences affect the type of information picked up during thin slicing.
A model positing a causal pathway between an individual and their first impression. The association among personal factors of perceivers, exposure time, information pickup from a target, perceived affordances in an environment, individuals’ emotions, and judgment.
Individuals judge differently, and they experience the space differently which affect how they form their first impression. Perceivers’ personal preferences affect the value they perceive in others, which affects their first impression (Schiller et al., 2009). Age is also found to influence first impression. For instance, in healthcare setting, the elderly constitute the majority of users, who need more time to experience a space (unfamiliar spaces). A person’s physical abilities, including their functional, cognitive, and functional abilities, can change as they age. They perceive and experience indoors differently as a result of these changes (Schambureck & Parkinson, 2018). Also, they need more time to adapt to changes in illumination between indoors and outdoors and vice versa (Schambureck & Parkinson, 2018). Moreover, their memory and speed of perceiving the surrounding information are lower than younger adults (Hess et al., 1998).
Exposure time
Numerous studies have looked at different exposure times needed to form first impression. The length of exposure time may affect the information perceived as individuals are exposed to a target. The retail environment can have a significant impact on forming first impressions and has shown that the first few seconds of a customer’s interaction with a store can have a lasting impact on their overall shopping experience and likelihood to return in the future (Turley & Milliman, 2000). Carney et al. (2007) investigated how individuals form judgments with varying exposure times of 5, 20, 45, 60, and 300s and found that five min (300 s) gave the most appropriate results. Grenier (2016) investigated the first impression of a webpage by comparing two conditions: 5s versus unlimited exposure time. The data indicated that participants in the unlimited exposure group formed their first impression in less than 5 min, and their results were more accurate than the other group. Moreover, the accuracy of the perceivers’ first impressions would be lowest in the first minute and highest in the 3rd or 5th minute (Carney et al., 2007).
Information Pickup and Perceived Affordance
When individuals pick up information from a target, they create internal perceptual and cognitive representations of the information (Figure 2). These representations were discussed by Hamilton et al. (1980), who viewed first impression as a perceiver’s cognitive interpretation of a target. Thus, cognition is “the perceiver’s accumulated knowledge about the target…” (including both acquired information and inferences drawn from it) (p. 1051). During this process, the perceiver collects and organizes available information about the target to develop a coherent internal representation in memory (cognitive structure; Hamilton et al., 1980).
Ecological theories of perception and cognition suggest that these internal representations include perceived affordances in the context of built environments, a concept posited by Gibson (1977). Norman (1999) describes perceived affordance as a design characteristic of an element that indicates how this element can be used. Initially, the term affordance referred to the apparent and genuine properties of a thing, basically those principal properties that decide exactly the way in which the thing might be utilized. Perceived affordances are important stimuli information picked up during exposure to an environment (Valenti & Gold, 1991). When individuals enter a space, they perceive information from the surrounding environment (Zumthor, 2006), which is the result of the total attributes of the environment that influence the individuals’ perceptual system. Then, they create internal perceptual and cognitive representations of the information based on the affordances, which influence how they experience the space. In addition, the affordances provided by a space can vary depending on the mobility of the user. Elderly patients, for example, may experience declining vision, which requires them to compensate by increasing their attentiveness and carefully examining the area (Schambureck & Parkinson, 2018).
Although the concept of affordance was first posited in the domain of physical design, other disciplines have adopted and applied it in their own contexts, including organizational affordance (Klecum et al., 2016) and social affordance (Rietveld et al., 2013; Valenti & Gold, 1991). Crucially, all these affordances are perceived as a whole as patients enter a hospital lobby, and the response to a specific affordance versus another depends on the person’s situation and current needs (Rietveld et al., 2016). These affordances are not visible but have an impact on how patients experience the hospital environment.
Organizational affordance
An organizational affordance is described as a potential for facilitated activity by a group of actors, such as teams or business units (Klecun et al., 2016). These groups may create affordances to achieve organizational goals. The organizational affordance relies on “expertise, organizational processes and procedure, controls, boundary-spanning approaches, and another social capacity present in the organization” (p. 5). The organization may afford with the goal of achieving hierarchical objectives. These may reflect in the environment, people, and processes, patients are exposed to during initial exposure to a hospital organization. The organization may align its affordances with hierarchical goals, which can be seen in the environment, people, and processes that patients interact with during their initial encounters.
Social affordance
Social affordance refers to the properties of an environment that allow for social interactions including an individual’s response in everyday life (Rietveld et al., 2013). There are many factors influencing how individuals respond to social affordance including gender (Rietveld et al., 2016), age, and culture (Valenti & Gold, 1991). Social affordance has impacted users as they pick up stimuli information (Valenti & Gold, 1991). Klecun et al. (2016) indicated that affordance that involves cultural system is recognized directly rather than perceived. Valenti and Gold (1991) discussed the correlation between the perception of social affordance and interaction and found that it was achieved as greetings, farewells, and assistance. What is socially “afforded” could be perceived as a stimulus during formation of first impression.
Perceived Affordance and Emotion
The Lazarus (1991) cognitive theory of emotion stated human cognition as the main determinant that influence individuals’ emotions, which has an influence on the association between appraisal and behavior. Perceived affordances constitute conveyed messages that affect users’ emotions and elicit a response to it (Figure 2). Thus, individuals’ feelings are influenced by their perceptions of the surrounding environment, which depends on nonverbal communication most of the time (Zumthor, 2006). Schreuder et al. (2016) define emotion as a momentary expression that is straightforwardly connected with environmental stimuli. This response can be observed consciously (feeling aroused, feeling pleasant in a specific environment) or unconsciously processed. The unconscious emotional experience is utilized to oversee the allocation of processing resources that influence cognition, decision, and behavior.
Dahal (2011) indicated that first impressions can be understood as an emotional state or the feeling individuals have about things. As for spatial impressions, design influences people on an emotional level long before they consciously understand it (Middelkamp, 2016). According to Zumthor (2006), individuals perceive their surrounding atmosphere through their emotions based on various types of perceptions that form rapidly. Thus, when people enter spaces, they perceive information from the environment via affordances that leads them to experience the space in a certain way.
Emotion and Judgment
Emotion plays an essential role in individuals’ decision making (Schreuder et al., 2016). According to Lazarus’s (1991) cognition of emotion theory, individuals’ emotions lead to decisions on whether they can deal with the external incident or circumstance, which results in an emotional reaction. According to Lerner et al. (2015), decision making is seen as a response to emotional processes from the internal point of view. Therefore, individuals make quick decisions depending on their emotional responses (Figure 2). Individuals form strong opinions based on their feelings, and these opinions are inherently biased, which, in turn, affects the judgment of subsequent information. Thus, individuals’ emotions in the hospital lobby regarding their surrounding environment affect their quickly formed first impressions, which influence how they direct their own behavior. Several studies on first impressions measure individuals’ judgment through their emotional responses to the target (Satterthwaite et al., 2009). They form strong opinions easily based on very limited information (Lim et al., 2000; Okten, 2018).
Biased strong opinions
Studies show that individuals form a strong opinion based on their first impression and that these opinions are inherently biased, which, in turn, affects their judgment of subsequent information (Lim et al., 2000). Impression bias is “a limitation of human information processing in which people are strongly influenced by the first piece of information that they are exposed to, and (that) they are biased in evaluating subsequent information in the direction of the initial influence” (p. 115). Individuals get strong impressions from the surrounding environment and its familiarity (Screen Cloud, 2016) and apply their existing beliefs to new information (Casad, 2019). It is important to consider the level of consciousness that can influence individuals’ first impressions (Boone and Buck, 2003). For example, if individuals are familiar with the characteristics of healthy indoor environments and find those same characteristics in a space, it can help create a positive first impression. Similarly, attractive indoor spaces can also lead to a positive first impression (Wargo, 2006). When people are familiar with the characteristics of a healthy environment, they may perceive a space as healthy. Staczek discussed the positive impact of a well-designed lobby and waiting area, along with access to daylight, which can be a positive distraction and help create a calming and healing environment for patients.
Judgment and First Impression
Schiller et al. (2009) indicated that impression contains effective judgment. A first impression is part of the first moment of interaction and is affected by initially perceived features from which individuals form a positive or negative judgment (Gronier, 2016). Okten’s (2018) definition of first impression includes any information about the target from their physical properties, their nonverbal and verbal behaviors, and even the surrounding environment, all of which influences people’s impression and judgment about others. The process begins when perceivers are exposed to a target. They establish nonverbal communication through the interaction with the target; during this communication, they pick up information from the target and perceived affordance in the environment (Figure 2). Depending on the perceiver’s physical characteristics and their feelings (emotions), they will start to judge the target with limited information available in a short time, which forms the basis for their first impression. The amount of time it takes to make the initial judgment will vary from individual to individual, which is discussed under personal factors.
Discussion
In an effort to better understand how first impression is formed in a patient’s experience within a hospital, this study addressed the following research questions: (1) What is the theoretical pathway between a perceiver’s first exposure to an environment and the resultant formation of a first impression; (2a) What factors affect or play a role in this theoretical pathway; and (2b) Are any of these factors physical environment factors? Toward these objectives, this study reviewed literature from various disciplines to understand how individuals perceive their surrounding environments and articulate any theoretical association between exposure to the environment at the point of entry and individuals forming their first impressions. The finding from published literature showed that there are five conceptual stages that occur between the initial gathering of information and the formation of early impressions: (1) exposure time, (2) information pickup, (3) cognition, (4) emotion, and (5) judgment. Together, these five phenomena provide a viable theoretical framework for understanding the concept of first impressions.
The findings show that several factors affect the process of forming users’ first impressions. (1) Exposure time and (2) personal factors are considered the initial two factors in this process, which refer to the time that people spend in a space and their personal characteristics (Figure 2). As people pick up information from their surroundings, (3) perceived affordance becomes another factor that can impact first impressions. Due to the rapid formation of first impressions with limited information, people often create (4) rapid perceptions that may (5) bias their opinions of the space. This, in turn, affects their judgment when forming their initial impressions. The following subsections will discuss the physical design implications of factors that the researchers identified from the key ones for forming first impressions, namely, (1) exposure time and (2) personal factors, (3) perceived affordance, (4) rapid forming perceptions, and (5) biased strong opinions.
While numerous questions remain to be answered, two things are known from existing literature regarding exposure time and personal factors. First, the first impression is formed based on information sought and received in the first 5 min (Carney et al., 2007; Gronier, 2016; Wood, 2014). It means that what patients, family members, and visitors experience in the first 5 min are critical to hospital administrators and designers. The more important question pertains to the specific stimuli that needs to be engineered during those first 5 min. In this context, it is also known that generally people arriving at hospitals are highly stressed, irrespective of their age and sex. High stress impairs perceiving (Paul et al., 2016). Thus, unlike other public buildings and spaces, hospital designers and owners have a much more difficult task in designing the stimulus intended during ones first engagement at the entrance points. One pertinent question to be examined is whether expert opinions on this, where current focus has been on informational, navigational, orientational, and personal safety stimuli, are indeed accurate, and if so, in what order and magnitude. Other types of stimuli sought by people, if any, need to be determined to help optimize first impression in hospitals. The most important information is the way these stimuli are associated with the physical design of the entrance areas.
A related question is one of designing affordances, since it is what forms the end result of the initial information pickup. This question cannot be answered without examining the questions raised in the previous section. However, one understanding gained from the literature is that affordances are not purely in the domain of physical design. Organizational instruments is also vital in conjunction with the physical design of entry areas. Assuming the most patient-centered and people-focused policies in place, the key question is what affordances need to be incorporated in the physical design of hospital entry areas. Yet another important consideration for hospital design originates from the fact that a sizable proportion of patients enter a hospital, at least in the United States, through the emergency department. Thus, physical design considerations need to focus on the emergency department entrance as well. Moreover, patients entering the main lobby may be in a different emotional state and acuity level compared to those entering the emergency department, which may warrant more granularity in one’s inquiry.
Study Limitations
The study searched for relevant articles in only three databases. There might be additional relevant articles in other databases that were not harvested or examined. The study focused on retail environments and federal lobbies to investigate how they address the first impression phenomenon. The study routes to experts’ opinions on first impression of hospital lobby and scientific evidence is lacking as a result, an evidence-based and systematic approach to understanding the first impressions of engineering in healthcare design has not been explored. It is crucial to develop guidelines for healthcare design, and further studies are needed to examine this conceptual framework specifically in the context of hospital lobbies.
Conclusion
First impression has been posited as an important factor influencing downstream experiences of building users. Published literature suggests a causal link between the information individuals gather in the first 5 min of exposure to a target and the formation of their initial impression. This suggests the crucial role that physical design plays in building environments, including healthcare facilities. Based on the literature, a conceptual framework has been developed to assist designers in making design decisions that will create compelling first impressions.
Implications for Practice
First impression is a complex phenomenon involving exposure time and personal factors, perceived affordance, rapid forming perceptions, and biased strong opinions. Simply designing visually attractive environments may not suffice.
Organizational environments influence perceived affordances and hence first impressions. Physical design of hospital entrances needs to be considered.
Designing for positive first impressions may warrant a multidisciplinary approach, with active participation of hospital stakeholders.
Robust scientific evidence in this domain of inquiry is not widely available. Most of the evidence currently available are expert opinions. Hospital administrators and healthcare design firms may consider adopting their projects as design-research opportunities for developing a scientifically robust evidence base. The causal framework presented in this article, in conjunction with expert opinions, may be used as a tool for generating robust hypothesis for examination.
Footnotes
Acknowledgment
The author(s) would like to express their appreciation to the Deanship of Scientific Research at Taif University, Taif, Saudi Arabia, for funding this research through a scholarship. The author would also like to acknowledge the Saudi Ministry of Higher Education and sincerely appreciate their funding support during her stay there.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
