A Comparative Analysis of the Spatial Design Perspective of Wayfinding: The Emergency Room as a Case Study

Abstract

Medical buildings, particularly emergency rooms, can be challenging to navigate, leading to stress and time loss for users if spatial layouts are poorly organized. This study focused on the concept of wayfinding, particularly on oral and visual communication, which has been identified as a human factor influencing the wayfinding process. This study aimed to examine the spatial design phase of emergency rooms in terms of wayfinding. The study approach used quantitative and qualitative methods. A literature review and observations during field visits were carried out. During the field visits, the researchers considered the numbers of human factors in the emergency rooms. Space syntax software was used to analyze the architectural plans from the perspectives of (1) visibility and (2) connectivity, examining the location of human factors in the architectural layouts. A comparative study of three cases in the United Arab Emirates was performed. The following human factors were identified: receptions and two categories of nurse stations, namely, first-look nurse stations (FLNSs) and observation nurse stations (ONSs). The results demonstrate the need for a developmental phase regarding the spatial arrangements of human components, guided by a space syntax analysis, to enhance the wayfinding process in the three emergency room cases. This study provides various recommendations for the repositioning of the human factors in the three case studies: for case study “A”, one of the three human elements should be modified; for case study “B”, only one of the two human elements should be altered; and, for case study “C”, all three human components should be moved to an advantageous position based on the spatial data. The conclusion illustrates the feasibility of adopting a spatial analysis approach for emergency rooms in the early design stages.

1. Introduction

Hospitals are regarded as intricate buildings. Their complexity arises from the numerous functions and services that they provide to society [1]. In the book “Hospital: A Design Manual”, the author characterizes hospital building designs as consisting of multiple functional zones interconnected by internal logistics and traffic patterns. The author asserts that establishing organization is among the most arduous stages in hospital planning [2]. This complexity underscores the importance of the concept of wayfinding in hospitals [3]. Wayfinding refers to an individual’s purposeful and coordinated movements while navigating their environment [4]. It is the capacity to navigate to a specific destination and to identify the goal upon approaching it [5].

Individuals who encounter issues with disorientation in hospitals experience adverse psychological effects. According to prior studies regarding hospital visits and wayfinding issues, the psychological dimension of hospital visits poses challenges; regardless of whether visitors are present for personal reasons or due to illness or injury, they are often not there voluntarily and often experience distress, discomfort, and/or anxiety [6,7,8]. The cost of unsuccessful wayfinding when patients and visitors are disoriented is the requirement of additional time to navigate, resulting in tardiness for appointments. Disorientation is detrimental and induces stress. This tension leads to emotions of helplessness, elevated pressure, headaches, pain, heightened physical exertion, and exhaustion [7]. According to Gulrajani, a medical facility where patients face stress due to wayfinding problems can be described as a “disabling environment” [9]. This research indicates that negative outcomes significantly adversely affect a patient’s health status and recovery process [10]. Conversely, successful wayfinding systems significantly improve the behaviors and perceptions of staff, patients, and visitors, eventually influencing patient satisfaction, staff morale, and the financial performance of an organization. Effective navigation in healthcare institutions reduces patient stress and anxiety, hence improving patient outcomes, profitability, safety, and staff efficiency [11].

This study considers the emergency room (ER) as a case study due to its substantial societal function in healthcare. The majority of patients admitted to this department are typically transferred to other hospital departments. Thus, the operations of the emergency department significantly influence the activities of other departments and patient satisfaction [12]. Previous studies have indicated that the primary function of the emergency room (ER) is to address emergency and urgent cases requiring immediate intervention via a swift diagnosis and the provision of medical or surgical care within a brief timeframe [13,14]. In addition, research has indicated that the significance of emergency room utilization will increase, and maneuvering through these chaotic, high-pressure circumstances is likely to become increasingly vital [15].

Wayfinding is influenced by a variety of inputs and variables. One study indicated that the visual configuration of a space and architectural uniqueness are variables that influence the navigation process [16]. The environmental psychologist Gerald Weisman (1979, 1981) examined the factors that influence wayfinding in medical buildings and found that plan configuration was the most influential, followed by spatial landmarks, spatial differentiation, and, finally, signage and room numbers [17]. Research in other fields found that, when reinforcing the wayfinding system, a series of elements will affect the process, such as the building layout, sensory cues (smells and noises) signs, maps, and verbal direction [18].

Researchers have delineated and synthesized the factors affecting the wayfinding process into three principal axes. Rooke et al. [19] determined the following as the three main interacting axes in a wayfinding system: (A) physical properties: entrances, pathways, etc.; (B) coded information: signage graphic systems; (C) social practices: staff and volunteers. Another researcher introduced the same axes but with synonymous terms, namely, (A) the architectural environment, (B) graphic data, and (C) human factors that provide oral and verbal information for the navigation process [20].

For several reasons, this study is limited to human factors; they frequently attend and provide significant knowledge of the facilities. Personnel can disseminate their knowledge of the facility to service users and visitors and, through their comprehension of expected traffic patterns, identify when individuals are disoriented or want assistance [21]. Research conducted by Broadbent [22] and Evans [23] substantiates that patients experience stress in hospital settings, which can hinder their capacity to receive environmental information, either coded information, such as graphic maps and signs, or architectural information, such as the physical appearance of the environment [9].

This study primarily focused on the spatial organization of human factors. The spatial locations of human factors were examined by using space syntax software, that is, the open-source software “DepthmapX” version 0.80., which was used to obtain spatial data from the perspectives of visibility and connectivity [24]. The reason for emphasizing the visibility and connectivity of human factors is grounded in the U.S. Department of Veterans Affairs Design Guide for Emergency Units, which asserts that a clear delineation of staff areas facilitates navigation, thereby alleviating stress and enhancing operational efficiency [25]. Moreover, the configuration of medical departments must be designed to enable workers to see the maximum number of patients effectively. This guarantees secure administration and upholds the need to care for a greater number of patients [9].

Few studies have explored wayfinding in the emergency room in the United Arab Emirates (UAE). No studies in the UAE have addressed the need for wayfinding guidelines or parameters to adhere to while designing the spatial organization of the ER. Therefore, the objective of this study was to enhance the consideration of wayfinding factors during spatial design phases of emergency rooms in the UAE. This study highlighted the significance of considering the locations of human factors in the ER architectural layout. These locations are where oral and verbal information regarding wayfinding is provided.

The researchers collected the architectural layouts from the construction companies in both PDF and AutoCAD version 2021formats. Field visits for the three case studies were carried out to determine the number of human factors and categorize them. Moreover, the researchers observed the locations of the human factors in each case study. According to the field visits and literature review, the researchers identified the following human factors in the emergency rooms: receptions and two categories of nurse stations, namely, first-look nurse stations (FLNSs) and observation nurse stations (ONSs). The DepthmapX version 0.80 software tool was used to analyze the three layouts from two perspectives: visibility and connectivity. The spatial data—obtained from the software—were analyzed and discussed in terms of the focus of the study: human factor locations for wayfinding. This research posits that the spatial organization of emergency rooms neglects the placement of human factors in areas of high visibility and connectivity. Consequently, these departments require development approaches that incorporate the concept of wayfinding. The spatial data of the three case studies were compared, and recommendations are made for improving the locations of human factors in these case studies. The results can aid architects, interior designers, and hospital administrators in optimizing the spatial design of ERs for wayfinding purposes.

2. Literature Review

2.1. Wayfinding and Spatial Design

The notion of wayfinding has been explored in various studies in the field of medical buildings [26,27,28]. However, the perspective of spatial design requires further exploration. Wayfinding entails resolving spatial challenges when traversing from one location to another. It includes three cognitive processes: information processing, decision making, and decision implementation [29]. According to Chen et al. [5], wayfinding is the capacity to navigate to a specific destination and to identify the target upon arrival. Passini and Arthur asserted that wayfinding can be succinctly defined as spatial problem solving. Therefore, individuals should employ their cognitive and behavioral skills to address problems. Moreover, they characterized it as a cognitive map, representing a comprehensive mental image or depiction of an environment’s spatial arrangement and structure. In other words, cognitive mapping, or imageability [30], pertains to the spatial comprehension of end-users inside an environment, encompassing both the mental representation of spatial design elements and the capacity to navigate within that place. Wayfinding encompasses not only cognitive mapping but also the perceptual processes involved in spatial information processing, spatial decision-making plan formulation, and plan implementation [31].

Recent research has demonstrated that the design of buildings and the configuration of spatial regions directly influence human cognitive maps.Studies have indicated that architectural designs and spatial arrangements are influenced by human sensory perception and cognition, resulting in increased user confidence in wayfinding and reduced instances of disorientation [32,33]. The architectural context and rationale behind a building’s design are essential for effective wayfinding. This is linked to the notion that the logical components of architectural designs significantly influence users’ capacity to comprehend and retain information [34].

As stated in the Introduction, various factors can influence the wayfinding process in the medical setting. This research examines human oral and visual communication, which can serve as a means of providing secure and direct information to users in high-stress environments. Human practice highlights the significance of staff, volunteers, and other visitors in the environment through spoken instructions [3]. Regarding spatial components, the spatial layout and circulation systems are design elements that must be evaluated when addressing potential challenges faced by end-users in intricate surroundings. This is due to the need for end-users to understand both the spatial configuration of a complex environment and its circulation systems [31]. Lynch [35] categorized these components into five design features: pathways, edges, districts, nodes, and landmarks. In this study, “paths” denote internal passageways, whereas “landmarks” signify observable environmental characteristics, such as nurse stations and reception areas.

2.2. Emergency Room

Hospital-based emergency rooms (ERs) are among the most critical and complicated areas of any healthcare facility because a poorly run ER can negatively impact the operation of the entire hospital system, which could make it more difficult to provide healthcare services to the general public [36]. The ER is typically regarded as one of the most critical departments in a hospital, where patients frequently arrive in severe distress, experiencing pain and requiring prompt medical intervention [37,38,39].

ER space designers initially create efficient areas for normal care, expecting daily, weekly, and seasonal fluctuations in patient arrivals with diverse critical, emergent, and urgent treatment requirements. ERs offer specialist care in designated spaces equipped with appropriate tools, enabling staff to swiftly adhere to procedures for the treatment of pediatric, cardiac, trauma, geriatric, and stroke patients [39]. It is recommended that the ER ergonomics design considers staff opinion, creates a favorable patient experience, optimizes provider efficiency and workflow, and increases both patient and organizational outcomes [40].

The ER can be accessed through multiple paths, including the main hospital reception area, the ambulance door, and a direct pathway. It contains three or four triage rooms for expedited diagnostic and treatment protocols. Patients with non-life-threatening conditions may experience extended wait times to consult a general practitioner. If the condition is serious but not life-threatening, the emergency room may refer the patient to a fast-track diagnostic facility. All treatment protocols are linked to the arrival of ambulance patients, who frequently require urgent medical attention. Acute medical units (AMUs) serve as a link between emergency departments and inpatient wards for patients with acute diseases [2].

Previous studies investigating emergency rooms and highlighting the wayfinding concept presented an ER physical design that positively impacted ergonomics, which increased staff satisfaction and performance [41]. Other research considered “color coding” to improve wayfinding in the ER, finding that the color-coding system positively influenced wayfinding [15]. However, Welch enumerated various factors that could enhance the quality of ER services, with architectural design issues constituting one of them [42]. The significance of examining the spatial design of the ER, as highlighted by researchers, is underscored by the ER’s vital function in delivering prompt care. The configuration of the internal space is important for enabling immediate, efficient, and effective patient care [37,38,39].

As previously stated, wayfinding conditions in the ER can influence the efficiency of the healing process [43]. This research examines architectural plans in terms of the visibility and connectivity of human factors, receptions, and nurse stations, which influence the wayfinding process. Visibility is a criterion for the effectiveness of any ER, as care staff needs to be aware of patients’ conditions [44,45]. The wayfinding guidelines for healthcare in 2023 demonstrate the role of human factors in reinforcing navigation; they increase the frequency of attendance, improve ergonomics, and provide great familiarity with the facility. The staff must disseminate their knowledge of the facility to service users and visitors and, through their comprehension of the intended traffic pattern, identify when individuals are disoriented or require assistance [21].

The reception is situated in the public area and serves as the public-facing component of the emergency room. The first staff member interacts with the patient upon their arrival at the entrance in the public section of the ER. This is an administrative assistant who collects the patient’s name and information for registration but does not assess their medical status [46].

According to prior research, nurses are essential to patient care in the ER, dedicating a significant portion of their time to engaging with and attending to patients [47]. Nurse stations can be sorted into two categories: first-look nurse stations (FLNSs) and observational nurse stations (ONSs). A first-look nurse station is positioned at an open desk that monitors the walk-in entrance and the waiting area. The nurse performs a swift visual evaluation of each incoming patient and determines whether the patient requires immediate transfer to the ER for life-saving measures or should be directed to an alternative pathway for potentially contaminated pandemic cases. The first-look nurse guides the patient to a suitable place for further assessment (triage) or treatment (direct bedding) according to the established flow of the emergency department [46]. The observational nurse station must be located in the short-stay unit, which is a separate unit for the observation and assessment of patients over a long period. Patients suitable for the short-stay unit require observation, diagnostic services, therapy, or follow-up, which may take up to 24 h [25].

2.3. Space Syntax

In terms of space syntax, Bill Hillier (1937–2019) was the pioneer. His contribution to understanding the built environment through an operational methodology for analyzing spatial relationships among constructed entities facilitated an improved understanding of the relationship between space and society. Currently, space syntax is utilized globally in both study and practice. Space syntax offers accuracy regarding spatial concepts and many analytical methods that enable the characterization of the spatial attributes of cities, buildings, and their interiors. The principles and analytical techniques are well established. The present issue is how to implement these techniques in planning practice to enhance sustainable built environments [48,49,50]. The space syntax methodology is based on graph theory from discrete mathematics, and it is used to calculate spatial links between streets or corridors in the constructed environment. Space syntax encompasses a collection of approaches that can be utilized independently or in various combinations [51,52,53].

The international success of space syntax is founded on four key aspects: Firstly, space syntax provides a succinct explanation of space and the spatial elements utilized in analyses [54]. Secondly, space syntax comprises a collection of analytical methods for assessing spatial interrelationships in the constructed world. Through the application of mathematics to the spatial relationships in the built environment, novel phenomena emerged that necessitated the refinement of concepts and the introduction of new terminologies.

Thirdly, space syntax provides a methodology to correlate outcomes from spatial analyses with diverse socioeconomic variables. Fourthly, through rigorous research, space syntax comprises a collection of theories regarding the interconnections between space, spatial relationships, and society [53].

This research employs the space syntax analytical tool DepthmapX to assess spatial design in terms of visibility and connectivity. The DepthmapX software tool can be used to analyze syntactic values and understand spatial relationships. It is a powerful tool for understanding the relationships between spatial arrangement and human behavior in the built environment [24].

In space syntax, spatial configurations are delineated using geometric entities such as points, axial lines, segments, convex spaces, and isovists [55]. In a space syntax graph, visibility is represented by an isovist [56]. An isovist field represents the whole visual perspective of an observer from a specific location inside the constructed environment [57]. It is a field of vision [43]. An isovist field is defined as a visual representation of the observable area inside a 360-degree or 180-degree perspective from a certain location [58]. Conversely, connectivity is represented by an axial map [59]. An axial map of a built environment is the set of the longest and fewest axial lines (pp. 17, 91, 97, [60]) [61].

2.4. Space Syntax and Wayfinding

Space syntax theoretical terms, comprising a collection of analytical methods for quantifying spatial interrelationships, have been extensively employed in wayfinding research to enhance the understanding of spatial performance. A space syntax analysis enables a quantitative measurement of certain spatial attributes, including visibility and connectedness [51], as well as facilitating an understanding of the correlation between societies and spatial dynamics [60]. Ford et al. delineate that the notion of space syntax focuses on establishing the principles that govern user movement and characterizing spatial configurations about social and cultural features. From the perspective of a comprehensive investigation of building spaces, user behavioral patterns are critical factors in delineating the wayfinding issue [62]. The correlation between wayfinding and spatial configuration was examined through space syntax, focusing on the characteristics utilized by pedestrians to navigate new urban settings [63] and the wayfinding challenges in intricate multilevel structures [64].

Empirical research utilizing space syntax demonstrates that wayfinding efficacy and human navigational choices are significantly influenced by the intelligibility of building designs and urban configurations [65]. Prior research has indicated that the spatial arrangement influences spatial cognition [66]. Space syntax provides a means to quantitatively assess the spatial arrangement, linking it to spatial cognition, which influences the decision-making processes of navigators [67].

This study is not the first to associate visibility and connectedness with wayfinding. Troffa [16] conducted a study with the objective of ascertaining whether individuals choose the shortest paths, the most conspicuous ones, or those with minimal angular deviations. The findings indicated that individuals prefer the longest path, distinguished by maximum visibility. Furthermore, a study on emergency departments indicated that achieving high-quality results relies on increased visibility and enhanced circulation connectivity, both of which improve wayfinding and environmental performance [41].

Carpman et al. [18] determined that visibility significantly influenced the navigation behavior of individuals entering a hospital. Furthermore, a study on navigation in libraries examined the correlation between visibility and connectivity by evaluating spatial design from a wayfinding standpoint, revealing a positive relationship between the two variables [59]. Axial map and isovist analyses were employed to forecast user pathways and examine the correlations between the spatial arrangement of hospital spaces and patients’ wayfinding behavior [68].

The Literature Review section explores the intersections of wayfinding, spatial design, and space syntax analyses and addresses emergency room settings. Wayfinding encompasses cognitive processes related to information processing, decision making, and execution, facilitating effective navigation between sites. Research has indicated that architectural design and spatial arrangement significantly affect human cognitive mapping and navigation skills, particularly in healthcare settings. The emergency room, as a vital hospital department, needs an effective spatial design to enable prompt treatment delivery. The research underscores the need for visibility and connectedness in emergency room design, especially for human considerations such as greeting spaces and nursing stations. Space syntax, developed by Bill Hillier, facilitates a quantitative assessment of spatial relationships using technologies such as DepthmapX. Prior research has indicated that wayfinding efficiency is favorably associated with the intelligibility of building design, with visibility identified as a critical element in hospital navigation behavior and overall environmental efficacy.

3. Materials and Methods

3.1. Research Design

This study employed a mixed-methods approach. An investigation was performed with space syntax software, notably the open-source software tool DepthmapX version 0.80. This software tool was used to analyze the architectural drawings of emergency rooms in three case studies. The visual produced by the DepthmapX was qualitatively and quantitatively interpreted. It was used to examine the locations of human aspects in terms of visibility and connectivity. This is a type of mathematics that attempts to describe the most important parts of spaces and rate them using certain traits that are based on topological information instead of metric properties [69]. The qualitative approach was also based on a literature review and field visits that provided photographs of the human factors. The research determined the human factors—reception, first-look nurse stations (FLNSs), and observation nurse stations (ONSs)—in the ERs. Observations were conducted through field visits to determine the number of human factors in each of the cases.

3.2. Case Study

This research considered the emergency room as a case study due to its important societal role, and it aimed to enhance the wayfinding process by shedding light on spatial performance. The spatial designs of three case studies across the United Arab Emirates were investigated. The drawings were gathered from the construction companies that built the medical buildings. The following points provide general information of the three case studies:

• Case study “A”: The ER area is 400 m², and the hospital is located in Sharjah (UAE). Figure 1 shows the ER layout.
• Case study “B”: The ER area is 465 m², and the hospital is located in Dubai (UAE). Figure 2 shows the ER layout.
• Case study “C”: The ER area is 352 m², and the hospital is located in Dubai (UAE). Figure 3 shows the ER layout.

A field visit was conducted to observe the human factors. Case study “A” had three human factors, namely, one reception, one first-look nurse station (FLNS), and one observation nurse station (ONS), as shown in Figure 4. Case study “B” had two human factors, namely, one reception and one observation nurse station (ONS), as shown in Figure 5. Finally, case study “C” had three human factors, namely, one reception, one first-look nurse station (FLNS), and one observation nurse station (ONS), as shown in Figure 6.

3.3. Material

The research material depends on visibility and connectivity. A visibility graph analysis (VGA), also known as an isovist analysis, can be useful in determining the visibility of a building focal point [70]. An isovist field represents a person’s perspective from a specific point in an enclosed space. It is mostly used for direction and wayfinding [71]. The isovist field is one of the fundamental geometrical components in a space syntax analysis [72].

Connectivity, shown on axial maps, was utilized to represent building networks more simply. On an axial map, the last set of lines that passes through each convex space forms all axial links. These lines, which can be viewed as paths (or possibly as routes), are called axial lines. Moreover, an axial line is the longest line representing the highest possible axial extension of any point in a straight line [59]. Hillier [73] and Turner [74] defined an all-line axial map as “a set of lines made up of all lines drawn tangent to vertices that can see each other”. In this study, the zoning plan included the locations of the human factor components, namely, the reception and nurse stations, as the focal points. Axial maps were used to represent the spatial design in lines, and a VGA was used to examine isovists, with the scale of colors shown in Figure 7 [75]. Furthermore, the DepthmapX tool provides a numerical value for each space’s visibility and connectivity [76].

3.4. Results and Recommendations

The research findings indicate the necessity of a developmental phase for the spatial arrangements of human factors, informed by the space syntax analysis, to improve the wayfinding process in the three emergency room cases. The spatially analyzed data generated by the space syntax software (VAG and axial maps) demonstrated that certain locations exhibit greater visibility and connectivity. This study recommends new locations for the human factors to facilitate the efficiency of oral and verbal communication for wayfinding objectives.

A comparative analysis of the three case studies indicated that, in all scenarios, adjustments should be made to the positioning of the human factors inside the emergency room layout to significantly enhance the wayfinding process. Based on the results of the spatial analysis of case study “A”, this study suggests that the location of only one of the three human factors should be changed: the reception desk should be moved to a more visible and connected spot; the two nurse stations can remain in their locations. Case study “B” has two human factors, and only the location of the nurse station (ONS) should be changed; the second human factor, “the reception desk”, can remain in the same location. In the third scenario—case study “C”—the locations of all three human factors require adjustment: the reception desk, ONS, and FLNS.

The following points highlight the results and recommendations, and Figure 8, Figure 9 and Figure 10 display the suggested new zoning plans and the data obtained from the space syntax software:

• Case study “A”: The reception desk should be moved closer to the main pathway, next to the waiting area, as this new location can improve its visibility and connectivity. The FLNS is already in the best location in the layout in terms of visibility and connectivity. The ONS should remain in the observation room—as per ER design standards—and it is in the best location in terms of visibility and connectivity in the observation room. Based on the results from the numerical values, the new recommended location can enhance visibility and connectivity by 17%.
• Case study “B”: This case includes two human factors: a reception and an ONS. The ONS should be moved opposite to the entrance of the observation room, as this location may enhance its visibility and connectivity. The reception desk can remain in the same location, closer to the main ER entrance adjacent to the main pathway. The main pathway appears to be in the best location in terms of visibility and connectivity. Improvements of 41% were recorded for the nurse station’s (ONS) new location in terms of the values for visibility and connectivity.
• Case study “C”: Three new locations are recommended for the three human factors. However, the new locations are in the same zones, and the three human factors will keep serving the same areas. The reception desk, FLNS, and ONS should be moved closer to the main pathway. The main pathway is in the best location in terms of visibility and connectivity. The numerical values exhibit higher values while moving toward the main pathway. The new recommended locations can enhance the visibility and connectivity values for the reception desk (by 55%), FLNS (by 34%), and ONS (by 58%), as discussed in the findings section.

4. Findings and Discussion

Visibility and Connectivity

• Case study “A”

The spatial data of the ER in case study “A” are presented in Figure 11. There are a total of three human factors in this case: a reception, an FLNS, and an ONS. The layout includes three pathways, which are indicated as having high visibility, marked in yellow and green. Furthermore, the interaction between two of the pathways presents the highest number of points in the layout, marked in orange and red. The first nurse station (FLNS), which is near the ambulance entrance (A. Entrance), is marked in a combination of orange, yellow, and green, whereas the second nurse station (ONS), which is in the observation room, is marked in yellow, indicating its high visibility. However, the reception, as the second human factor, comes in at a lower level than the nurse stations, as it is marked with green and blue tones. The areas with the lowest levels are the treatment and service rooms, which are private zones, marked with blue and dark blue tones.

The axial maps in the first case study exhibit a greater number of lines in red, orange, and yellow across the three paths. The triage room is in an advantageous location, being located in a densely connected region with two opposing doors. A spatial analysis of case study “A” indicates that areas with high visibility correspondingly have strong connectivity compared to other areas.

In this research context, wayfinding is considered to be influenced by human factors: the reception and the two nurse desks [3]. This research argues that the reception location can be justified. The pathways in both analyses, where the two nurse stations are located, rank first in terms of visibility and connectivity. The reception desk can be relocated to the opposite wall, which is marked in yellow only. However, the nurse stations are in suitable locations in terms of visibility, connection, and emergency room standards [25,47].

On the other hand, the new yellow location has a numerical value of 1198 in terms of visibility compared to the previous location with a value of 899, and a value of 11 in terms of connectivity compared to the previous location (value of 9). The new recommended location for the reception can improve visibility and connectivity by 17%, considering the red color as the highest point with 100%, with numerical numbers of 1755 in VAG and 12 in axial maps.

• Case Study “B”

The data of the ER in the second case study “B” are presented in Figure 12. There are a total of two human factors in this case: one reception and one nurse station (ONS). The VGA illustrates the high visibility of the vital space in red, orange, and yellow. The vital space is the main path that runs through the entire department. The reception area, as a human factor that improves wayfinding, is located in front of the only entrance from outside, and it is marked in green to blue, indicating poor visibility. However, the main pathway, which has high visibility, crosses its zone. On the left side of the layout is the observation room where the nurse station (ONS) is located, and the visibility is indicated by yellow and light green; however, the observation room is in a location with higher visibility, marked with an orange tone. The other paths that link the ER to the other hospital departments are marked with a light blue color, indicating less visibility, and the closed treatment and service rooms have the lowest visibility, marked with dark blue. The axial maps show that the middle of the main pathway, where the reception desk, triage rooms, and waiting areas are located, has the most connected axials, marked in red, orange, and yellow; however, when moving to the left toward the observation room and to the right side of the layout toward the treatment room, the analysis presents fewer connections.

The path is the main connected part in the layout and has the highest visibility. The analysis demonstrates that this pathway interacts with the whole ER and that it is the main way or circulation line. In this case, this study recommends relocating the nurse desk (ONS) in the observation room [25] toward the area marked with an orange tone. The reception, as per the standards [25,47], should face the entrance, so this study suggests leaving it in the same location.

The new recommended location for the nurse station (ONS) indicated a numerical value of 2905 in terms of VGA and 21 in terms of axial maps compared to the results from the previous location (1541 in terms of VGA, and 7 in terms of axial maps). An improvement of 41% was recorded after considering the highest location (red color): 3296 for visibility, and 34 for connectivity as 100%.

• Case Study “C”

A graph analysis of case study “C” is presented in Figure 13. The human factors are one reception and two nurse stations: an FLNS and an ONS. The VGA presents the major pathways in the whole ER plan in red, orange, and yellow. However, the reception and the two nurse stations are in locations with poor visibility. These locations, where oral and visual information is provided, are hidden in less visible areas, marked with blue tones. Moreover, the closed spaces for service and treatment rooms are marked in blue and dark blue, indicators of low visibility.

The case study “C” layout is divided into two sections in terms of connectivity. It is found that the first section, where the treatment, doctor duty, and observation rooms are located, has highly connected areas; however, the second section, where the reception, waiting area, main door, and triage rooms are located, has poor and fewer connections in the layout. The first section shows that the pathway is well connected compared to the closed private rooms with blue axils; even the observation room, where the nurse station is located, has fewer connections.

Here, it is also clear that the main movement area in the architectural plan has the highest visibility and the highest number of contact points. Despite their importance in navigation and orientation, the placement of human elements at points of high visibility or contact has been neglected. The reception and nursing station locations are weak in terms of connectivity and visibility.

This study recommends relocating the three human elements. The locations of the three elements should be moved toward the main pathway (which has the highest in visibility and connectivity) while considering the ER design standards [25], meaning that they should remain in the same zone performing the same function. For example, the reception should be moved toward the pathway but still face the entrance, the nurse station (FLNS) should remain in the triage room but move toward the pathway boarders, and the other nurse station (ONS) should be relocated within the observational room at the end of the pathway that crosses the area.

On the other hand, the numerical values for the highest location (the main pathway) in visibility and connectivity indicate 2050 for VGA and 57 for axial maps. The following percentages are mentioned after considering these results as 100% in terms of visibility and connectivity. The reception desk in the new recommended location exhibits the following values: 1942 for VGA, compared to the previous location value of 835; 38 for axial maps, with the previous value being 6. That presents a 55% improvement. The nurse station (FLNS) results in terms of VGA were 1084 for the new location and 363 for the previous location, with a 34% improvement. The nurse station (ONS) indicates 2020 for the recommended place in VGA and 814 for the previous location; axial maps present values of 50 for the new place and 17 for the previous location, which is a 58% improvement in terms of visibility and connectivity.

5. Limitations and Future Research

As with the majority of previous studies, the design of this study is subject to limitations, therefore providing opportunities for further research. This study is confined to three cases of emergency rooms in the United Arab Emirates; subsequent research may explore the emergency rooms and their connectivity to other departments. Furthermore, future studies may broaden this inquiry to many healthcare contexts in multiple countries and cultural situations in order to formulate more extensive design principles.

This study aimed to explore wayfinding in emergency department layouts using space syntax in a case study; however, more comparative studies are needed to expand our understanding of the topic. Future studies are needed to explore other buildings and variables. Nevertheless, the methodology presented herein shows promising results, making its application to other cases possible. Wayfinding is a complex human behavior that is influenced by a variety of inputs and variables. This study primarily focused on the configurational structure of the layouts in terms of human factors; nevertheless, future studies are needed to include more complex variables such as human experience, measured via interviews and surveys, to improve the understanding intrinsic to human wayfinding. Subsequent research may employ a more comprehensive methodology to investigate other significant aspects that could affect navigation efficiency, such as signage systems and physical properties.

The findings of this study must be considered in light of these limitations. These limitations facilitate the acquisition of specific findings and support the formulation of recommendations that improve or advance the circumstances of each case study in the context of the United Arab Emirates.

6. Conclusions

This research attempted to enhance the understanding of the concept of wayfinding in healthcare facilities. The stages of producing architectural designs for all departments must consider effective solutions for navigation. This study emphasized the human factors associated with various locations (zones) in emergency rooms. The mixed-methods approach used in this study has the benefit of facilitating a better understanding of the emergency department arrangements within the medical building. This study’s evaluation scale was the visibility and connectivity of the spatial locations of human factors in emergency rooms related to wayfinding requirements.

The space syntax tool yielded reliable data for subsequent study endeavors, as these data can encourage architectural designers to use space syntax tools in the initial phase to examine the locations of human factors. Furthermore, the parameters can be considered before the designs are implemented in the United Arab Emirates or globally, for example, the relocation of human factors—the reception desk, the first-look nurse station, and the observation nurse station—to high-connectivity and -visibility locations. Therefore, the efficiency of oral and verbal communication can be enhanced for wayfinding processes in the examined layouts.

The subsequent conclusions can improve spatial designs for navigation in emergency rooms:

• Architectural plans can be evaluated before implementation from the perspectives of connectivity and visibility for wayfinding solutions.
• Architects and interior designers should consider the wayfinding requirements in the initial phase of medical building designs.
• Hospital administrators can carry out post-occupancy assessments to ensure that the visibility and connectivity of human factor elements are properly addressed and optimized.
• Pathways are the main components of ER architecture drawings, and, to enhance the effects of human factors in wayfinding, they should be located in visible and highly connected areas.
• Treatment rooms should always have less connectivity and visibility due to their privacy norms.

This study was limited to emergency departments. Future studies could investigate various departments to enhance the understanding of the role of spatial design analysis in promoting wayfinding in the medical environment. Moreover, the other two factors that affect wayfinding—physical properties and graphic design—could also be investigated.