HERD: Health Environments Research & Design Journal

This study explored the perspectives of healthcare designers to identify key design strategies that are adopted to optimize wayfinding in complex healthcare environments, addressing a notable gap in academic literature.

Wayfinding in healthcare facilities is often challenging for patients, visitors, and staff due to complex layouts and stressful conditions. While academic research has examined specific environmental features, little is known about key strategies formulated and adopted by design practitioners to enhance wayfinding in complex healthcare environments, and how general wayfinding considerations are incorporated in the design process.

We conducted semi-structured focus group sessions (n = 34 participants) with experienced healthcare design practitioners. Participants met stringent inclusion criteria, including a minimum of five years of experience and involvement in at least three relevant healthcare projects. Transcripts were analyzed using reflexive thematic analysis.

We put forward a novel framework linking four key design considerations to seven design variables which were mapped to embedded and applied approaches across chronological and spatial dimensions of the design process. Six core wayfinding strategies were identified: simplicity, consistency, spatial hierarchy, orienting cues, ambient cues, and landmarks. We also elucidate divergences between industry perspectives and existing literature, particularly regarding the role of signage and the potential of biophilic design.

The importance of prioritizing embedded wayfinding strategies early in the design process is highlighted, integrating cultural and contextual relevance, and fostering collaboration between industry and academia to steer research efforts toward more pressing issues.

Current lighting recommendations rely on Western laboratory studies, leaving the real-world mechanisms linking light exposure to sleep in Asian older adults unclear. This study aims to systematically analyze the complex relationships among daily light exposure, activity patterns, and sleep health in older adults living in residential environments.

Existing lighting guidance for sleep and circadian health is predominantly based on Western laboratory research, with no clear elucidation of the real-world associative mechanisms between light exposure and sleep among Asian older adults. This study targets this research gap by exploring the relevant correlations in real residential settings, to lay a foundation for targeted lighting improvement for the elderly population.

We employed a field investigation combining subjective and objective measurements in the living spaces of 116 elderly participants in Shanghai, China. Individual ocular light exposure and activity patterns were collected via luxmeters and interviews. Sleep quality and chronotype were assessed using the Pittsburgh Sleep Quality Index (PSQI) and Munich Chronotype Questionnaire (MCTQ). Hierarchical multiple linear regression was employed to examine associations, controlling for age and gender.

Field measurements confirmed that participants' indoor environments were pervasively light-deficient, lacking sufficient daytime stimulus for robust circadian entrainment. Age was the strongest negative predictor of sleep efficiency (β= -0.419, p < 0.001). After controlling for age, the light environment explained a significant 9.3% of additional variance (p = 0.012). Notably, higher maximum daytime ocular illuminance (Ev) was associated with lower sleep efficiency (β = -0.413, p = 0.015), while higher maximum evening ocular illuminance (Ev) was associated with higher sleep efficiency (β = 0.279, p = 0.008).

These findings challenge simplistic guidelines: high daytime light peaks likely represent uncomfortable glare rather than effective circadian stimulus, while evening light proxies for beneficial social activity. This underscores the urgent need for context-aware, glare-free residential lighting strategies to promote healthy aging among older adults.

This study aimed to develop a cost-benefit analysis (CBA) process to guide the evidence-based selection of healthcare flooring materials that balance safety, environmental sustainability, and economic viability.

Flooring selection in healthcare environments significantly influences patient safety and well-being, operational costs, maintainability, and environmental performance. However, tools that support material choices aligned with both sustainability goals and long-term cost efficiency remain limited, especially in the predesign and specification stages.

A CBA approach was applied, integrating discounted cost analysis for economic assessment, sustainability key performance indicators for environmental and maintenance evaluation, and a benefit-cost ratio model for final decision-making. This quantitative approach compared flooring materials’ “first costs” to long-term benefits concerning safety, environmental sustainability, and maintainability, supporting trade-off analysis in healthcare design.

Based on the data used for this research, common flooring materials such as rubber and linoleum demonstrated a high balance of durability, safety, and sustainability performance. Conversely, vinyl-based options scored lower on composite criteria for long-term performance and sustainable value proposition. This examination culminated in a generalizable cost-benefit model for healthcare material decisions.

This study introduces a design decision-support approach that complements choice management during the environment of care predesign stage for practitioners and healthcare facility operations specialists. The parameters used in this study offer the potential to better inform environmental planning lifecycle choices by considering healthcare flooring material safety and sustainability as equally weighted criteria, without compromising operational fiscal prudence.

The aim of this study was to explore meanings embedded in corridors and how these relate to older adults’ experiences of physical movement and their living environment within a residential care facility.

Residential care facilities should serve as both care environments and homes. Nevertheless, many facilities are designed like hospitals, prioritizing care over a homelike environment. Corridors are a common feature in residential care facilities’ communal areas, yet little is known about older adults’ experiences of these spaces.

The study had an explorative qualitative design, adopting a phenomenological hermeneutic method. Three men and three women between 81 and 96 years of age were interviewed when moving through residential care facility corridors. Two men and two women participated one follow-up interview each.

The interpretation led to the overarching theme Corridors’ multifaceted role in shaping lived spaces. This theme comprises seven sub-themes which portray meanings ranging from physical aspects through to emotional impact, incentives, integrity, habituation, symbolic meanings of institutions and power, and how corridors may lack in meeting personal needs. Themes were further interpreted in relation to theories on sociomateriality, place/placelessness, and affordances.

The findings highlight corridors as material and symbolic spaces that influence older adults’ well-being. However, there is also a risk of existential placelessness when personal connection with the environment is lacking. Incorporating personal and homelike elements that address older adults’ aesthetic, social, and existential needs can soften clinical atmospheres, transforming corridors into meaningful parts of the living environment.

To compare the perspectives of two stakeholder groups, adult day care center (ADCC) managers and family members of older adults with disabilities or dementia, regarding ADCC site and building design features.

The ADCCs provide community-based services for older adults with disabilities or dementia and support family caregivers. Different stakeholder groups, including managers and family caregivers, may have varying views on the planning and design of health facilities. However, little is known about how managers and family members differ in their views on ADCC planning and design.

We adopted a cross-sectional exploratory design across Taiwan. Ten site selection factors and eight building design factors were used to construct an analytic hierarchy process questionnaire. A total of 81 managers and 59 family members were included, and the data were collected using one-on-one interviews. Pairwise comparisons between factors were conducted to obtain the eigenvectors (priority weights), and weight differences between the managers and family members were calculated using t-tests.

Managers placed higher importance on community attitudes and governmental support, while family members emphasized access to health services, transportation, and public safety. In building design, family members valued clearer spatial visibility, whereas managers placed relatively greater emphasis on temperature control.

Managers and family members of service users weighed site and building design factors differently, especially in the domains related to “support and attitudes” and “services, systems, and policies.” These findings highlight important differences between these two stakeholder groups and provide critical insights for the planning and design of ADCCs.

This study was conducted to investigate the effect of light brightness on stress, anxiety, and psychological well-being during non-stress test (NST) measurements.

Emotional and environmental factors that may cause stress and anxiety in pregnant women should be carefully evaluated and the necessary measures should be taken before and during the applications to pregnant women.

This research was conducted with 100 pregnant women as a randomized controlled experimental study. Data were collected using a personal information form, the psychological well-being questionnaire (PWQ), the perceived stress scale (PSS), and the state-trait anxiety inventory (STAI), which were administered before and after the NST measurement.

There were significant intra-group differences between the mean pre-test (before NST) and post-test (after NST) scores of the pregnant women in the intervention group on the scales used in the study [PWQ pre-test (33.90 ± 9.18) and post-test (36.24 ± 7.83); PSS pre-test (32.26 ± 6.74) and post-test (27.0 ± 4.13); STAI pre-test (48.88 ± 4.04) and post-test (46.26 ± 3.97)] (p < 0.05). The difference between the mean pre-test (33.98 ± 9.11) and post-test (33.86 ± 9.04) PWQ scores of the pregnant women in the control group was insignificant. But there was a significant difference between the mean pre-test (32.08 ± 6.64) and post-test (33.0 ± 6.77) PSS scores of this group (p < 0.05).

The results of the study indicated that reducing ambient light brightness levels during NST measurements increased pregnant women's psychological well-being and reduced their stress and anxiety.

This study examines how the rural physical environment—including spatial environment and leisure facilities—relates to the mental health of rural older adults in China, and explores group differences.

Evidence on the impact of rural environments on elderly mental health is limited, despite growing attention to this issue.

Using 2020 CLASS data, structural equation modeling in Mplus analyzed the pathways linking rural space and recreational facilities to mental health and compared group differences.

Both the rural spatial environment and recreational facilities are positively associated with the mental health of rural older adults, with differences in magnitude and mechanism. Recreational facilities show a stronger association than the spatial environment. The spatial environment is mainly related to mental health through a direct pathway, whereas the association between recreational facilities and mental health is partially mediated by physical exercise, with the direct effect remaining dominant. Group analyses indicate that physical exercise plays a greater mediating role among older adults aged 60–74, while among those aged ≥75, the association is primarily direct and more pronounced. Partial mediation through physical exercise is observed only in northern and more developed rural areas.

The study underscores the vital role of rural leisure facilities in enhancing elderly mental health, particularly those aged ≥75. Improving rural spatial design and developing diverse, age-friendly leisure facilities can promote well-being and provide evidence-based guidance for policies supporting rural revitalization and elderly quality of life.

This study examines how flexible design attributes in staff-only communal spaces influence healthcare workers’ perceived social support during high-stress periods such as the COVID-19 pandemic.

Communal staff spaces offer essential opportunities for relaxation, rejuvenation, and social interaction. Indeed, for some, these spaces can become third places supporting individual needs and fostering a sense of belonging. The pandemic, however, imposed severe restrictions on the use of such spaces, often exacerbating staff stress levels. Lessons from the recent pandemic highlighted the need to reassess these dedicated spaces in terms of their design and functionality.

A survey of healthcare staff (n = 233) who had worked in the field during the pandemic was conducted. The survey was informed by prior research that included a scoping review and expert interviews. Participants evaluated three illustrated design scenarios using Likert-scale measures of social support.

Nonparametric tests revealed statistically significant differences in staff preferences across three design scenarios emphasizing different flexibility attributes (p < .001). Post hoc analyses showed a strong preference for versatile spaces, particularly those that provided both indoor and outdoor options. Flexibility attributes directly support core third-place qualities by enabling spaces to remain accessible, comfortable, and socially supportive even as conditions change.

Findings emphasize the importance of investing in intentionally designed staff spaces that can operate as supportive third places. Flexible environments that can adjust to evolving needs play a crucial role in helping communal spaces function as effective third places that support connection, social interaction, and staff well-being.

This study explores how individuals form first impressions when encountering a hospital lobby in the United States. It examines the roles of emotional responses and decision-making during brief environmental exposure, focusing on how sensory cues and emotional reactions shape visitor judgments.

As part of a larger mixed-methods project, this paper presents findings from the quantitative phase. Data were collected between June 2023 and February 2024 from participants visiting a hospital lobby in West Texas. Participants were randomly assigned to either a 5-min or unlimited exposure condition. Three newly developed self-report scales measured environmental perceptions, emotional responses, and first impression judgments. Due to non-normal data distribution, nonparametric analyses (Spearman's rho, Mann-Whitney U) were conducted. Age and gender were also analyzed.

Participants formed first impressions rapidly, often within 5 min. Emotional responses significantly influenced the relationship between environmental perceptions and judgments. Negative emotions, such as nervousness, fear, and distress, had a stronger influence on first impressions than positive emotions. No significant differences were found between exposure durations or across age and gender. Sensory and visual cues were critical in shaping emotional reactions and first impressions.

First impressions in hospital lobbies are formed quickly and are strongly shaped by the physical environment and emotional responses. Reducing negative emotional triggers such as confusion, poor signage, or unwelcoming interactions is more effective than incorporating positive features. Visitors rely on brief, “thin-slice” cues to evaluate and emotionally respond to a space, making initial moments of experience crucial for forming first impressions.

This study investigates the relationship between universal design (UD) attributes, autonomy, and the psychological wellbeing of older adults with disabilities. The goal is to provide evidence-based design guide for aging-in-place, prioritizing UD elements that promote autonomy and psychological wellbeing.

A total of 165 older adults participated in the online survey. Using structural equation modeling, the latent factors of UD were identified for the kitchen, bathroom, and general areas within home environments.

Results revealed that bathroom UD features, including walk-in bathtubs, curb-less showers, shower seats, and grab bars, significantly predicted autonomy, whereas kitchen and general UD features did not. Additionally, autonomy was positively associated with psychological wellbeing and fully mediated the relationship between UD features and wellbeing.

Implications for aging-in-place design are provided, emphasizing the importance of prioritizing functionally essential design factors in residential planning and remodeling for older adults with disabilities.

Recognizing the limited research and design guidelines for these essential health care settings, this study gathered pilot data on the design of outpatient rehabilitation therapy (RT) facilities as a foundation for future research.

Providing RT is core to addressing health conditions that might otherwise lead to higher and more costly levels of medical intervention. The World Health Organization estimates that 2.4 billion people worldwide would benefit from RT; however, only half receive care. As a result, more space may be sought for ambulatory clinics and hospital-based settings that cater to both inpatients and outpatients.

Interviews (n = 21) and questionnaires (n = 43) involving RT patients and staff and RT facility designers were conducted with overlap between the interview and questionnaire participants. Both methods explored amenities and features of RT environments.

Among the findings, there were several significant differences regarding the importance and effectiveness (presence) of specific environmental elements. Additionally, there were some significant differences among patients, staff, and designers in terms of their perceptions of importance and effectiveness.

Eight potential design guidelines are suggested, rather than recommended, as of yet. They are topics for future research and include the provision of an appropriate balance of private and shared spaces, acoustical treatment of open therapy areas, efficient and restorative staff areas, outdoor spaces, window views and daylight, flexible lighting, and appropriate furniture and wall coverings.

The physical design of outpatient clinics plays a critical role in shaping staff satisfaction, workflow efficiency, and perceived performance. While evidence-based design is increasingly emphasized, limited research has systematically examined how spatial layout, environmental quality, and zoning influence staff experience and behavior across diverse clinical contexts.

This study examines the impact of outpatient clinic layout and environmental attributes on staff satisfaction, stress, task performance, and communication. The goal is to identify high-impact zones and design factors that improve staff outcomes and operational resilience.

A mixed-methods design was used across four outpatient clinics within a unified health system. Data collection included behavioral mapping, Gemba walk-throughs, staff surveys, and multiple regression analyses. Quantitative and qualitative data were triangulated to evaluate spatial use patterns and environmental predictors of staff experience.

Key operational areas—nurse stations, exam rooms, and team rooms—were identified as multifunctional hubs. Their effectiveness was shaped by adjacency, workspace size, visual access, and acoustic privacy. Regression analysis showed that travel distance, spatial clarity, and wayfinding were significant predictors of satisfaction, performance, and reduced stress. Qualitative data reinforced the importance of ergonomic furnishings, access to restorative areas, and flexibility in reconfiguring underutilized spaces.

Outpatient environments that integrate spatial clarity, environmental comfort, and intuitive flow are essential for supporting staff experience and performance. These findings offer practical guidance for designing adaptable, high-functioning ambulatory care settings.

An established publication type in medicine, case reports allow clinicians to share novel or unusual observations. Their strengths include the ability to identify new phenomena, facilitate communication between practice and research, generate hypotheses, and provide insights into conditions that it may be unethical or impractical to study directly. Architecture and environmental design lack an equivalent method for systematically sharing practice-based insights.

This paper establishes clear, structured guidelines for documenting and preparing case reports in architecture and environmental design.

Using a comparative and conceptual approach, this study adapts the CARE Guidelines—developed for case reporting in medicine—to the context of design practice. The study draws conceptual parallels between stages of clinical care (e.g., diagnosis, treatment, outcomes) and those of the design process (e.g., problem identification, interventions, post-occupancy evaluations). Building on this comparison, it introduces a new set of guidelines for architectural case reports.

The resulting framework, the SCALE Guidelines (Standardized Case reports for Architecture and the buiLt Environment), consists of 12 components that provide a standardized structure for writing design case reports. The guidelines will help practitioners share real-world insights in a format suitable for scholarly dissemination that promotes consistency, completeness, and rigor in reporting.

Although evidence-based design aims to inform design decisions in practice through research, case reports serve the opposite function: informing research decisions through insights from practice. The formal recognition of case reports in design as a distinct publication type can help bridge the gap between design practice and research.

This paper presents an integrated framework combining perspectives from nursing, environmental psychology, and critical space theory. The framework is intended to support the study of materiality in ICUs and to inform future research on stakeholders’ needs and guiding design interventions for more supportive, healing care environments.

Intensive care units (ICUs) are paradoxical spaces designed to save lives yet often experienced by patients as environments of dependency, disorientation, and loss of control. Materiality of the ICU environments can exacerbate stress and compromise recovery. While interventions addressing the material environment show promise in improving care experiences, existing approaches remain limited by single-theory perspectives that fail to capture the complexity of ICU materiality.

The integrated conceptual framework was developed through theory-informed synthesis guided by relevance to ICU settings and theoretical complementarity. Three established theories were synthesized—Roy's Adaptation Model, Ulrich's Theory of Supportive Design, and Lefebvre's Critical Theory on Space Production—using conceptual mapping across ontological, interactional, and interventional levels.

The analysis revealed convergent points and complementary relationships across the three theories. The integrated framework synthesizes these perspectives across three interconnected dimensions: environmental stimuli and adaptive response, spatial production and power relations, and evidence-based supportive design.

The integrated framework demonstrates that healing ICU environments require interdisciplinary approaches addressing interconnected biological, psychological, social, and material dimensions simultaneously. Effective interventions must target adaptive physiological needs, reduce psychological stress through supportive design, and challenge spatial power relations that marginalize patients and families. This framework provides a foundation for research and practice that empowers all care-related stakeholders to actively shape healing ICU environments.