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On the Planning and Design of Hospital Circulation Zones: A

Review of the Evidence-Based Literature

Article  in  HERD · October 2016

DOI: 10.1177/1937586716672041

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Literature Review
Health Environments Research
& Design Journal
1-23
On the Planning and Design ª The Author(s) 2016
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DOI: 10.1177/1937586716672041

A Review of the Evidence-Based herd.sagepub.com

Literature

Shan Jiang, PhD1, and Stephen Verderber, ArchD2

Abstract
Objective: This present literature review explores current issues and research inconsistencies
regarding the design of hospital circulation zones and the associated health-related outcomes.
Background: Large general hospitals are immense, highly sophisticated institutions. Empirical studies
have indicated excessively institutional environments in large medical centers are a cause of negative effects
to occupants, including stress, anxiety, wayfinding difficulties and spatial disorientation, lack of cognitional
control, and stress associated with inadequate access to nature. The rise of patient-centered and evidence-
based movements in healthcare planning and design has resulted in a general rise in the quality of hospital
physical environments. However, as a core component of any healthcare delivery system, hospital cir-
culation zones have tended to remain neglected within the comparatively broad palette of research
conducted and reported to date. Method: A systematic literature review was conducted based upon
combinations of key words developed vis-à-vis a literature search in 11 major databases in the realm of the
health sciences and the planning and design of built environments for healthcare. Results: Eleven peer-
reviewed articles were included in the analysis. Six research themes were identified according to
associated health-related outcomes, including wayfinding difficulties and spatial disorientation, commu-
nication and socialization patterns, measures and control of excessive noise, patient fall incidents, and
occupants’ stress and satisfaction levels. Conclusions: Several knowledge gaps as well as commonalities
in the pertinent research literature were identified. Perhaps the overriding finding is that occupants’
meaningful exposure to views of nature from within hospital circulation zones can potentially enhance
wayfinding and spatial navigation. Future research priories on this subject are discussed.

Keywords
hospitals, circulation zones, health outcomes, systematic literature review, evidence-based design,
patient-centered care

1
School of Design and Community Development, West Virginia University, Morgantown, WV, USA
2
John H. Daniels Faculty of Architecture, Landscape and Design, Dalla Lana School of Public Health, University of Toronto,
Toronto, Canada

Corresponding Author:
Shan Jiang, PhD, School of Design and Community Development, West Virginia University, 4320 Agricultural Science Building,
PO Box 6108, Morgantown, WV 26506, USA.
Email: [email protected]
2 Health Environments Research & Design Journal

Hospitals are large, complex institutions that con- Empirical studies have shown that excessively
tinually evolve (Latimer, Gutknecht, & Hardesty, institutional environments of large medical cen-
2008). In many cases, these care settings are built ters have caused various adverse outcomes in
and expanded in phases across a period of their inhabitants, among which hospital wayfind-
decades in a manner that inadvertently isolates ing, usually defined as a spatial-solving process
their occupants from experiencing sustained based on cognitive map (Passini & Arthur, 1992),
visual-spatial sensory contact with the external becomes the biggest challenge (Allison, 2007).
world. This condition, in the extreme, is tanta- Other adverse outcomes include heightened stress
mount to occupants’ exposure to environmentally and anxiety levels, a lack of perceived personal
induced sensory deprivation, as in exposure to control, lack of accessibility to positive distrac-
perceptually underwindowed or entirely window- tions, and, more specifically, inadequate mean-
less conditions (Verderber, 1986). In addition, ingful contact with nature (Ulrich, Zimring,
large healthcare institutions are highly compart- Quan, Joseph, & Choudhary, 2004; Verderber,
mentalized entities, with numerous layers of 2005, 2010, 2015). Circulation zones in health-
functional requirements governing their planning care facilities, typically defined as spaces
processes and spatial attributes. This phenom- expressly dedicated for the movement of people,
enon has its roots in the Middle Ages, whose large equipment, and supplies between myriad interna-
monastic hospital campuses expressed a clear lized departments, are essential components of
functional separation between sacred and secular any care delivery system (Carthey, 2008). Circula-
structures, with the open chapel-ward possessing tion zones belong to hospitals’ public spaces, those
a superordinate role apart from all other spatial spaces that the public who use the hospital can
zones on the campus, circulation or otherwise reach independently, including such as the area
(Goldin, 1994; Thompson & Goldin, 1975). Var- in front of the entrance, the entrance hall, reception
ious support functions were interconnected via a areas, corridors, vertical connections, and waiting
network of internal and external circulation rooms (Setola & Borgianni, 2016). The planning
paths. As these places evolved through the cen- and design of circulation zones may in fact signif-
turies, they were shaped in time by more advanced icantly impact users’ perceptions and experiences
medical practices as well as by advanced build- from the perspective of multiple stakeholders. In
ing technologies. fact, these spatial zones contribute greatly to one’s
By the 19th century, when germs were first impressions of any care setting, and for this
revealed as the primary cause of most illness, reason alone warrant a thoughtful examination of
the contagious patients were isolated from other their broad planning and design potentialities.
types of patients, which resulted in an unprece-
dented wave of spatial compartmentalization in The planning and design of circulation
hospitals (Pangrazio, 2013; Verderber, 2010). zones may in fact significantly impact
Certain types of spatial separation/isolation took users’ perceptions and experiences from
on extreme high priority, and this was attributa- the perspective of multiple stakeholders.
ble to evolving best safety and treatment prac-
tices. Concurrently, this, together with greater
emphasis on patients’ rights and desires for Essential Components of a Healthcare
self-actualization, greater personal control, fam-
ily inclusiveness, and overall participation in
Delivery System
caregiving and healing, has more recently gov- Hospital circulation zones can occupy a signifi-
erned the landscape of spatial compartmentali- cant percentage of a facility’s overall physical
zation in hospitals and other types of healthcare footprint. According to the Australasian Health
facilities, with significant consequences for the Facility Guidelines, healthcare circulation spaces
planning and design of hospital circulation may constitute up to 40% of total functional floor
zones. areas in general hospitals (Carthey, 2008). This
Jiang and Verderber 3

estimate is comparable in the United States in 12-hr period, with an assignment of four patients;
similar institutions. For instance, in a typical this traveling distance increases significantly
32-bed adult inpatient care unit, the departmental when more patients are assigned (Welton,
grossing factor can reach up to 1.6 in current Decker, Adam, & Zone-Smith, 2006). Nurses and
healthcare programming best practices (Latimer other support personnel also spend a significant
et al., 2008), which signifies that circulation amount of time from the nurse station viewing
zones may occupy up to around 30% of the adjacent corridor environs and associated spaces,
department gross area.1 Such spaces are essential which is both inevitable and essential. Ample
in terms of the services and functions they afford empirical evidence has shown the physical work
on a 24/7 basis, as they link interdepartmental environment (including circulation zones) can
transportation and communication. Additionally, affect one’s overall job performance, job satisfac-
they serve a medicinal function, because patients tion, interpersonal communication patterns,
with certain levels of ambulation capabilities use employee fatigue, error rates, and physical and
corridors and adjacent public spaces for rehabi- psychological stress (Hendrich, Chow, Skierc-
litation activities. For instance, to facilitate reha- zynski, & Lu, 2008; Pati, Harvey, & Barach,
bilitation therapies, patients are encouraged to 2008; Stichler, 2009; Ulrich et al., 2004, 2008;
participate in the ‘‘walking for wellness’’ pro- Vischer, 2008). Therefore, hospital circulation
grams (Callen, Mahoney, Grieves, Wells, & zones, as part of the major physical work envi-
Enloe, 2004).2 They are usually accompanied ronment for nurses and other caregivers, may sig-
by trained escorts and walk throughout hospital nificantly impact job performance, satisfaction,
corridors several times per day. In addition, hos- and well-being.
pital circulation zones serve as a ‘‘backstage’’ or
‘‘neutral space’’ for interpersonal communica- Essential Transitional Linkages Connecting
tions. These exchanges among medical team
members, and others, as well as the various
Interior Spaces With Nature
informal learning activities these spaces facili- Significant empirical evidence indicates views of
tate, render them essential amenities (Carthey, nature from within a hospital possess therapeutic
2008). benefits (Ulrich, 1984; Verderber, 1986). The
thoughtful integration of nature into a healthcare
physical environment has been demonstrated to
Essential Components of the Total
reduce people’s stress (Dijkstra, Pieterse, &
Healthcare Experience Pruyn, 2008; Ulrich, 1999), reduce people’s per-
Hospital circulation zones occupy a vital role in ceived pain (Vincent, 2009), improve one’s mood
the experience of the total environment for all status (Cooper Marcus, 2007; Jiang, 2015),
types of users. Bitner (1992) and, more recently, enhance staff’s alertness, and contribute to a
Fottler, Ford, Roberts, Ford, and Spears (2000) reduction of medical errors (Pati et al., 2008;
concluded that public spaces in healthcare facili- Buchanan, Barker, Gibson, Jiang, & Pearson,
ties were closely related to patients’ overall satis- 1991). As for space expressly devoted to nature
faction levels and may also impact their mood content, many ‘‘healing gardens’’ in hospitals
and physical behaviors. Pangrazio (2013) also remain disconnected from their adjoining inter-
pointed out that healthcare public zones can cre- iors. Four major barriers to their usage persist in
ate a memorable and positive experience by pro- most hospitals have been identified, among which
viding orientation, enhancing self-actualization, two limitations are (1) inadequate knowledge of
building self-confidence, and therefore furthering the existence of the hospital garden and (2) low
the overall healing process. This especially per- visibility and difficulty in physically accessing
tains to hospital staff, specifically, who spend this space (Whitehouse et al., 2001). Pasha
most of their time traveling the corridors provid- (2013) has observed that therapeutic nature and
ing care and retrieving supplies. A nurse on shift gardens located directly off highly trafficked
can travel upward of 5 miles during an average zones (e.g., a corridor intersection, lobbies, or
4 Health Environments Research & Design Journal

main circulation arteries) are more likely to be literature search included Academic Search Com-
discovered and inhabited by users. In a broader plete, Avery Index to Architectural Periodicals,
sense, having a view to nature from a patient room, Applied Science and Technology Source, Scien-
waiting area, staff office, and corridor can greatly ceDirect, EBSCOhost Online Research Data-
increase the probability of knowing about the exis- bases (EBSCO), Medical Literature Analysis
tence of a hospital garden, hence encourage and Retrieval System Online (MEDLINE), The
engagement with nature (Cooper Marcus, 2007). Cumulative Index to Nursing and Allied Health
Therefore, as a transitional link connected the Literature Database (CINAHL), Scopus Data-
patient’s room to the outdoor environment, hospi- base, PsycINFO – American Psychological Asso-
tal circulation zones justify their being examined ciation Database, SAGE Journals, and Journal
in order for them to be planned and designed to Storage Database (JSTOR).
maximize their nature-transparency quotient. Cir- However, relatively few studies were identified
culation zones, therefore, warrant them becoming that fulfilled the database search criteria. Next, the
more central in the overall planning and design of literature search was extended to reports of
healthcare settings, as these spaces can promote research studies on healthcare public spaces/com-
positive distractions and cognitive respite from the mon spaces and the general physical environments
rigors of one’s daily routine and simultaneously of healthcare facilities. After scrutinizing the
serve an essential role as transport of equipment search results, 11 peer-reviewed publications
and supplies. Yet, to date, there have not been an identified as relevant; these sources were further
adequate number of studies on the design of hos- sorted into two categories according to their level
pital circulation zones, neither a comprehensive of relevance to the overall research topic: Level
review of the empirical research conducted on this 1—primary resources, included five articles per-
topic. The primary aim of the analysis is therefore taining to healthcare circulation zones as the major
to examine the existing literature on the relation- focus (see Appendix Table A1). Level 2—second-
ship between the planning and design of hospital ary resources included six articles with general
circulation zones and associated health-related healthcare public spaces as their principal research
outcomes for human well-being. focus with hospital circulation zones mentioned as
a component (see Appendix Table B1). Finally,
Therefore, as a transitional link connected based on a careful perusal of each source identi-
the patient’s room to the outdoor fied, seven research themes were identified based
environment, hospital circulation zones on health-related outcomes discussed in each
justify their being examined in order for inclusive article. These associated outcomes
them to be planned and designed to included (1) wayfinding difficulties and spatial
maximize their nature-transparency disorientation, (2) communication and socializa-
quotient. tion patterns, (3) measures and control of exces-
sive noise, (4) patient fall incidents, (5) occupants’
stress level, and (6) occupants’ satisfaction level.
These results are reported in Figure 1.
Method
A systematic literature review on this subject was
conducted by means of a three-step procedure.
Results
First, a key word search was conducted to identify Appendix Tables A1 and B1 present the set of pub-
all relevant studies published in the English lan- lications chosen for inclusion in the literature
guage from the year of 2000 to present. The key review, with key background information and find-
word combinations included two groups: (1) hos- ings presented. These consist of a description of the
pital, healthcare facility, healthcare environment, topic and scope of the study, key research theme(s),
assisted living facility, care unit, patient ward and the type of healthcare facility studied, the research
(2) corridor, hall/hallway, circulation zone/space, design and sample, key measures of health out-
mover space, transfer area. Database used for the come, the impact of healthcare circulation spaces
Jiang and Verderber 5

Figure 1. Principal themes/health outcomes identified in the literature/precedent analysis. Courtesy of the
authors.

on well-being, and design recommendations, if complexity, Allison (2007) concluded that urban
applicable. This analytical framework was adapted planning and design principles were in fact rele-
from a literature review conducted on evidence- vant and applicable to the design of such facili-
based environment and aging research in Japan ties. Carthey (2008) supported Allison’s findings,
(Verderber & Song, 2005). Below, a description concluding that every corridor should ‘‘be con-
of these various research themes is reported. sidered a part of the larger circulatory system of a
hospital, in much the same way urban streets are
part of a hierarchy of connecting routes within a
Wayfinding Difficulties and Spatial
city’’ (p. 24).
Disorientation As a means to improve hospital internal way-
Two articles included in the literature analysis finding behaviors, the findings from Lynch’s
addressed hospital corridor design and wayfind- (1960) seminal study, The Image of the City,
ing (Allison, 2007; Carthey, 2008). Multiple provide insight by clearly identifying five phys-
renovations/expansions of a hospital’s physical ical elements of the physical setting that possess
envelope often yield labyrinthine-like configura- a significant role in helping develop one’s men-
tions of internal corridors, which make wayfind- tal map of a place: paths, nodes, landmarks,
ing a challenge at the very least, and a source of edges, and districts. ‘‘Hospitals, like cities,
significant environmental stress, in the extreme. should have landmarks, public places and green
Since a general hospital is in many ways rather spaces for both therapeutic and navigational pur-
analogous to a small city regarding its functional poses’’ (Allison, 2007, p. 61). Because of this,
6 Health Environments Research & Design Journal

circulation zones should be designed in a hier- users’ perceptions of a redesigned corridor

archical manner like the hierarchy of circulation environment in a psychiatric hospital. One pri-
pathways within a city: boulevards, secondary mary corridor in this hospital was redesigned
streets, and service street or back alleys (Allison, by (1) replacing its largely ‘‘institutional’’
2007). In healthcare settings, ‘‘boulevards’’ or physical attributes to bring about a sense of
internal ‘‘streets’’ can be planned and designed greater connectivity with nature; (2) breaking
as central spines, which also connect the consti- up the perceptually vast, undifferentiated
tuent parts of larger healthcare complexes. If expanse of the corridor space itself through the
thoughtfully planned and built, these spaces can introduction of multiple informal seating areas;
simultaneously afford natural daylight, internal and (3) blocking unpleasant views to the out-
and external landmark cues, and provide related doors while enhancing visual and physical
spatial orientation amenity. Similarly, secondary access connectivity to an adjacent courtyard
arteries or ‘‘streets’’ can function as corridors garden (Edgerton, Ritchie, & McKechnie,
between hospital diagnostic, treatment, and 2010). Observational studies and a survey of the
ambulatory care zones, similar to a series of patients and staff were conducted before and
‘‘storefronts.’’ Accordingly, so-called service after these design interventions. Results indicated
and equipment-only ‘‘back alleys’’ in hospitals a significant increase in the number of patients
can be principally for back-of-house functions conversing with other people in the corridor after
yet this is not an excuse to design these zones the design interventions. Patients, furthermore,
devoid of meaningful contact with the outside were more likely to be accompanied by a staff
world (Allison, 2007). member or a visitor, and more patient–nurse
communications occurred in the redesigned cor-
ridor environment.
Communication and Socialization Patterns Andersson, Ryd, and Malmqvist (2014)
Three published research articles addressed the explored the function and use of common
theme of communication and socialization pat- spaces in 14 assisted living facilities dedicated
terns among the various users. Carthey (2008) for older residents in Sweden. Common spaces
stated that hospital corridors often serve as an studied in each facility included shared spaces
ancillary setting for clinical care interactions adjacent to the apartments, the dining room,
among multidisciplinary care team members. the sitting dayroom, the kitchen, the corridor,
Literature examined by Carthey pointed out the adjoining staff spaces, and outdoor balconies
value of ‘‘backstage’’ spaces or ‘‘neutral and open spaces. They concluded that residents
zones,’’ such as corridors, that foster conversa- and employees have differing objectives and
tions and cross-disciplinary communication, and goals for space use, and this in turn influenced
which break down traditional hierarchical bar- space use. Common spaces were deemed
riers and specializations that otherwise exist important for social interactions among resi-
within a medical caregiver team. A significant dents and between the residents and staff. The
amount of informal learning can also occur due design recommendations that resulted from this
to the frequency of casual encounters and con- study centered on improvements in lighting
versations among scientists, physicians, nurses, conditions in facility corridors (Andersson,
administration, internists, and allied Ryd, & Malmqvist, 2014).
professionals-in-training and that these spaces
are particularly invaluable in teaching institu-
tions (Carthey, 2008).
Measures and Control of Excessive Noise
The built environment has been shown to be Three articles explored noise-related aspects
a relevant support modality for patients with within hospital circulation zones. Xie and Deng
dementia and related psychological disorders. (2014) identified characteristics of primary
Edgerton, Ritchie, and McKechnie (2010) stud- noise sources in hospital corridors, by focusing
ied the impacts on patients’ behaviors and on a long, undifferentiated corridor within a
Jiang and Verderber 7

cardiology department in a hospital in Mainland Patient Fall Incidents

China. By using sound level meter monitoring
Wood-Nartker, Guerin, and Beuschel (2014)
devices, the acoustic levels in the corridor were
examined the environmental cues and associated
measured across a 24-hr period. An on-site
impacts on patient falls at 140 assisted living
observational study was conducted simultane-
facilities located in the lower peninsula of Michi-
ously in the same period. Types of noise sources
gan in the United States. This study utilized a
were identified and ranked according to the
checklist instrument consisting of 110 environ-
occurrence of frequency. The top 10 noise
mental sensory cues to classify and document the
sources included doors closing and squeaking,
presence/nonpresence of such cues in the public
footsteps, coughing, loud conversations, general
spaces at each facility. Public spaces studied
movement activities, thumping and banging of
included 41 types of rooms. Five specific room
carts and the like, housekeeping services, tele-
types were found where patient falls occurred
phone ringing, cabinet doors closing loudly, and
most frequently, including living room/lounges,
equipment cart/trolleys (Xie & Deng, 2014).
dining rooms, corridors, public restrooms, and
Using a somewhat similar research method,
circulation foyers. A correlational analysis
Lau and Roy (2014) compared different design
between the level of presence of sensory cues and
materials used in the hospital corridor environ-
the incidence of patient falls was then examined.
ment, and their impact on noise control at Palo-
Results showed that overall facility size mattered
mar Medical Center, in San Diego in the United
in patient fall occurrence rates. With respect to
States. Materials compared in this study
the circulation zones in medium-large facilities, a
included (1) carpeting versus hard flooring/vinyl
converse relationship existed between the number
tile surfaces and (2) standard acoustical ceilings
of environmental cues present and the number of
versus high-performance acoustical ceiling sys-
patient falls. Design suggestions for the injection
tems. The results indicated that corridors with either
of effective fall-reducing environmental cues in
carpeting or high-performance acoustical ceiling
these public spaces included (1) incorporating
grid systems were associated with lower noise lev-
high-contrast conditions between wall and floor
els as well as a significant decrease in theses spaces
surfaces and furnishings; (2) the use of matte
cited as a source of annoyance and distraction to
finishes; (3) the use of color, artwork, photos, and
patients and medical professionals (Lau & Roy,
various memorabilia on wall surfaces to enhance
2014).
wayfinding; (4) clear, well-placed signage in all
Wang et al. (2013) explored the role of a dedi-
circulation spaces; (5) use of visual and auditory
cated service corridor adjoining an older Inten-
alarms; (6) use of graphic images on walls; and
sive Care Unit (ICU) setting in relation to the
(7) the nonuse (removal) of distracting graphic
incidence of excessive noise levels, staff stress,
images and colors on floor surfaces (Wood-
and a decrease in overall staff satisfaction in an
Nartker, Guerin, & Beuschel, 2014).
academic medical center located in Central Illi-
nois. A comparative before–after analysis was
conducted in an adult cardiac ICU that had
recently been relocated from an older, traditional
Occupants’ Stress Levels
hospital to a new addition with its own dedicated Two published investigations examined occu-
service corridor. A survey regarding pre- and pants’ stress levels and one study focused on
postmove perceptions of environmental comfort, patients’ fears and anxiety levels (albeit not as a
stress levels, and staff satisfaction was conducted primary research theme in the case of the latter).
with the nursing staff. Acoustical measures of As previously mentioned, Edgerton et al. (2010)
noise sources were also compared. Results indi- concluded, in part, that patients felt more relaxed
cated the new, dedicated service corridor reduced when traversing a corridor environment with
noise levels and staff stress while improving staff natural features such as natural daylight and
satisfaction levels (Wang et al., 2013). views to exterior gardens, and particularly when
8 Health Environments Research & Design Journal

associated with a noninstitutional interior design assessment tool including (1) building configura-
palette. Wang et al. (2014) concluded that having tion, (2) fixed/attached objects, (3) nonfixed/
a dedicated service corridor in the ICU reduced movable objects, (4) malleable materials, (5)
staff’s perceived stress and improved their job opportunities for socialization and personal pri-
satisfaction. Foureur et al. (2010) found that long, vacy, and (6) the auditory/sensory environment
windowless, undifferentiated corridors in a birth- (Topo, Kotilainen, & Eloniemi-Sulkava, 2012).
ing/maternity unit setting can be frightening and a Specific physical qualities found to be closely
cause of anxiety, even contributing to the status of related with hospital circulation zones included
a patient’s labor. (a) hallways, corridors, and vestibules with elec-
tronic surveillance devices and abundant lighting
and (b) direct physical access to the outdoor envi-
Occupants’ Satisfaction Levels ronment and exterior gardens. Similarly, postoc-
Pangrazio (2013) discussed the general public’s cupancy evaluations were subsequently carried
circulation zones in healthcare settings and the out in 10 residential dementia care facilities in
positive impacts on users’ perceptions and Finland, using the same RCEA tool. The results,
experiences (Pangrazio, 2013). Five types of with regard to corridor spaces, indicated that
public spaces were identified, including collec- corridors with windows on their end points
tor spaces (i.e., arrival and orientation spaces invited the user to venture, engage, look outside,
such as entry lobby and reception zones), intro- and rest (when seating was provided). Second,
spective spaces (i.e., arrival zones and other facility conditions featuring abundant natural
spaces perceived as of calming effect such as a daylight in circulation spaces supported way-
chapel and support spaces such as cafes and din- finding and provided an inviting ambiance.
ing areas), movement spaces (i.e., corridors), Conversely, facilities characterized by under-
and transition zones (i.e., spaces situated windowed or windowless and undifferentiated
between departments and most general public corridors were found to be less preferred (Topo
areas such as elevator lobbies). It was concluded et al., 2012).
this typology of public circulation spaces could Foureur et al. (2010) developed a ‘‘Birth Unit
impact patients’ positive perceptions of the qual- Design Spatial Evaluation Tool’’ for the assess-
ity of care dispensed and one’s overall satis- ment of hospital birthing units in Australia. Cor-
faction with the healthcare facility. From a ridor spaces, as previously mentioned, were
cost-to-benefit perspective, a rethinking of considered in their research. Four dimensions
healthcare facility planning best practices of each unit were measured including (1) char-
should more directly address these public space acteristics affecting what the researchers
design opportunities (Pangrazio, 2013). described as the ‘‘fear cascade,’’ (2) the unit’s
physical attributes, (3) aesthetic aspects of the
unit, and (4) the presence (absence) of adequate
Other Patient-Centered Care Issues essential support provisions for women and their
Most investigations to date have examined this families while on the unit. It was concluded that
subject area from a patient-centered perspective. the facilitation of effective navigational beha-
Among them, two articles developed postoccu- viors and the presence of a welcoming care envi-
pancy evaluation tools for healthcare facilities ronment reduced patient anxiety. ‘‘Long
where circulation zones were carefully consid- corridors can be frightening and cause anxiety
ered. Topo, Kotilainen, and Eloniemi-Sulkava for first-time arrivals, especially those who are
(2012) developed the ‘‘Residential Care Environ- not sure how far it might be and whether help is
ment Assessment’’ (RCEA) tool for the assess- nearby’’ (Foureur et al., 2010, p. 49). Other fear-
ment of dementia care units. This method was inducing features related to counter therapeutic
used to examine the impact of the quality of the corridor zones included poor lighting conditions
setting and its affordances relative to patient well- and the absence of windows and views to the
being. Six specific attributes comprised this outdoors. One additional key element of
Jiang and Verderber 9

Figure 2. Site plan of the monastery of Turmanin, Syria, about 475 AD. Adapted from Thompson and Goldin
(1975).

therapeutic health facility design in this regard the entire inner side length of the adapted stoa-
was having a connection with nature and easy patient wards surrounding a large open-air central
access to gardens and courtyards, ‘‘Moving to courtyard. Later, the Bimaristans of the ancient
another environment, especially a garden or out- Middle East in Baghdad, Cairo, and Damascus
door setting, can reduce fear and restore the pro- featured large open-air courtyards and adjoining
duction of oxytocin (i.e., the hormone patient wards with corridors that ran continuously
responsible for initiating labor) to support strong at the perimeter (Montague, 1984). Later, the
contractions’’ (Foureur et al., 2010, p. 49). Roman valetudinarium was a military hospital,
featuring a racetrack circulation system, with the
first double-loaded corridors in Western hospi-
Discussion tals. After the fall of Rome in the 4th century, the
Circulation zones and adjacent public spaces massive monastic medical complexes of the Mid-
have been a fundamental and essential spatial dle Ages across Europe were operated by reli-
feature of healthcare environments since the gious orders (Thompson & Goldin, 1975;
Asclepiad of Ancient Greece, with their open Verderber, 2003). These places featured large
spaces and interior side corridors that ran along chapel-wards surrounded by an array of secular
10 Health Environments Research & Design Journal

Figure 3. Interior of the Hotel Dieu of St. Jean in Angers, France (founded 1153) as depicted in the 19th century.
Adapted from Thompson and Goldin (1975).

support structures. The circulation arteries link- United States, dating from the agency’s founding
ing these various out-building secular support in 1930, were still using this same ward footprint
structures with the sacred space of the chapel- well into the 1970s, a footprint developed more
ward were outdoors, typically, although far from than a century earlier (Verderber & Fine, 2000).
randomly configured (Figure 2). By contrast, the After 1945, in the era of the modernist megahos-
generous circulation aisles of the chapel-ward pital, the size of the building envelope increased
infirmary were the principal means of interior exponentially in size and its sheer complexity.
circulation for everything, as they were shared This resulted in myriad interior—undifferentiated
by people, equipment, and supplies (Goldin, interior circulation zones linking dozens of spe-
1994). There was no distinction between public cialized units and departments—departments
(direct caregiver and patient use) and back-of- dedicated to the advancement of medical science
house circulation arteries in this regard (Thomp- by means of highly sophisticated medical tech-
son & Goldin, 1975; Verderber, 2010). The nologies for the diagnosis and treatment of illness
massive chapel-ward infirmaries that dominated and disease.
the European healthcare landscape in the 12th By the 1990s, in the most progressive
through 15th centuries were characterized by instances, the pendulum had begun to swing
immense ceilings, wide circulation zones, and away from these excessively oppressive building
spatial undifferentiation, since in times of plague envelopes and their attendant Spartan circulation
even these spaces became filled with patient zones, toward a facility planning and design
beds (Figure 3). strategy that sought a greater connectivity with
In the classic Nightingale nursing ward, 16 nature and greater sense of visual/sensory trans-
beds were arrayed on each side of a central cir- parency with the outdoor milieu. One early out-
culation zone, connecting all portions of the ward. come of this contemporary trend was the rise of
Each ward, in turn, was connected to a central the ‘‘healing garden’’ and more recently, thera-
circulation artery linking multiple open wards peutic gardens. Most recently, in a very positive
on the hospital campus. Many of the earliest hos- development internationally, many other mani-
pitals built by the Veterans’ Administration in the festations of this movement toward the blurring
Jiang and Verderber 11

Figure 4. Evidence-based knowledge gaps identified with respect to hospital circulation zones and health-related
outcomes. Courtesy of the authors.
12 Health Environments Research & Design Journal

Figure 5. The inpatient unit and corridors at Helsingor Psychiatric Hospital in Denmark (2006). Courtesy of JDS/
Julien DeSmedt Architects.

of the lines between architecture and landscape cognitive spatial orientation. It has been
architecture are occurring in hospitals and allied hypothesized that single-loaded corridors with
healthcare settings including the injection of windows views looking onto nature were inher-
landscape architecture from the earliest phases ently more legible than double-loaded corridors
of site/facility planning and design (Jiang & with monotonous, institutional interior condi-
Verderber, 2016). tions. As Allison stated, ‘‘locating pathways
Best practices in the planning and design of along the edges of courtyards can also help-
healthcare circulation zones and their relation- even small courtyards placed along public cor-
ship to their users’ well-being and health status ridors can assist in wayfinding’’ (p. 64). A
must continually evolve to reflect the state of greater degree of transparency between the inte-
the art. Somewhat surprisingly, a paucity of rior and exterior realms of a healing setting can
systematic research exists on this topic com- break down barriers that have persisted in hos-
pared to the large volume of research that has pitals in the West for hundreds of years (Jiang &
been conducted and published on many other Verderber, 2016). The concept of theraseriali-
facets of the healthcare environment relative to zation is apropos, defined by the interior and
occupants’ safety, well-being, and health sta- exterior realms of a healthcare setting, in effect,
tus. In this regard, current research gaps on this being consciously planned and designed to
facet of the total built environment are discern- dematerialize many of the myriad walls and bar-
able as are environmental interventions to riers that tend to overcompartmentalize, segre-
enhance the efficacy of these zones and their gate, and otherwise excessively wall off internal
positive impact on health outcomes (Ulrich elements within the typical hospital. In so doing,
et al., 2008). As such, and as depicted in Figure alternatively, they are able to become ‘‘layered’’
4, the knowledge gaps cited in the previous dis- with one another, where interior-to-exterior spa-
cussion warrant further exploration using tial sequences are more interconnected and
evidence-based methodologies. internal functionality expressed more transpar-
One particular research finding in the preced- ently—interwoven—in a completely new way.
ing analysis is natural views in hospital circula- This strategy is promising at this time, as it can
tion zones afford potential therapeutic benefits yield positive outcomes for building inhabitants
in relation to hospital spatial navigation beha- from a therapeutic standpoint (Jiang, 2015;
vior. As discussed by Allison (2007), views to Jiang & Verderber, 2016; Verderber, 2010). The
the outside world can provide a vista to various Helsingor Psychiatric Hospital, in Denmark
external landmarks, enhancing internal (2006), by JDS/Julien DeSmedt Architects,
Jiang and Verderber 13

inventively uses a corridor intersection node to planning, facility planning, and architectural
activate a powerful view into an adjacent out- design strategies.
door garden (Figure 5). Thoughtful facility plan-
ning and design strategies such as this warrant
further investigation beyond the scope of the Implications for Practice
present discussion. This study will inform healthcare design profes-
The internal circulation zones within hospitals sionals and administrators on these points:
warrant reappraisal as arteries not unlike coral
reefs—containing continuous interesting natural  Hospital circulation zones are critical,
views, with multivalent atrium gardens, seating essential components of a healthcare deliv-
nodes, and light wells and vegetated-wall aper- ery system and significantly impact users’
tures—places judiciously situated along primary perceptions and experiences from the per-
and secondary corridors and between various spective of multiple stakeholders.
departmental units. This affords connectivity  Hospital circulation zones are associated
with nature and the outdoor milieu. Correspond- with various essential health-related out-
ingly, seating areas and water elements should be comes including wayfinding and spatial
integrated, hierarchically, providing a vibrant orientation, interpersonal communications
palette of discrete viewing places (e.g., perches and socialization, the effects of excessive
and outlooks). This interwoven vocabulary of cir- noise, incidents of patient fall, and occu-
culation arteries, windows, views, and seating pants’ stress and level of satisfaction.
nodes function collectively as ‘‘landmarking  It is recommend that circulation zones in
devices,’’ as essential aids in the spatial and sen- healthcare facilities be viewed as integral ele-
sory navigation of otherwise uninspiring, and ments in campus and building planning pro-
cognitively, if not physically challenging circula- cesses from both a functional and
tion realms. Collectively, these amenities can sig- psychological standpoint. They hold the
nificantly aid the occupant in constructing a power to foster a sense of psychological
sustainable, flexile cognitive map of a healthcare respite and positive distraction from the rigors
setting. These and related hypotheses/concepts of one’s daily routine while simultaneously
call for further exploration using evidence-based providing essential functional support on a
research as a basis for articulating campus master 24/7 basis.
14
Appendix A

Table A1. Summary of Primary Resources in the Design of Hospital Circulation Zones.

Impacts of Healthcare
Measures of Health Circulation Spaces on
Authors (Year) Type of Facility/Site Research Design; Sample Outcome Well-Being Conclusions/Design Suggestions

Allison (2007) General hospitals in Theoretical assumptions N/A A clear hierarchy of In healthcare design, systematic consideration of
the United States circulation spaces (e.g., paths, nodes, landmarks, edges, and districts
major thoroughfares, contribute to effective wayfinding and enhance
secondary stress, and users’ overall experience
back alleys) promotes Urban planning and design principles are applicable
exceptional wayfinding to medical planning and hospital design, e.g.,
behavior Lynch’s five elements on the image of the city
(1960)
Carthey (2008) General healthcare Literature review; N/A Hospital corridors Hospital corridors are important to the
facilities in Theoretical assumptions (1) serve as ‘‘neutral functioning of multidisciplinary clinical teams and
Australia zones’’ in healthcare quality of care delivery. Inflexibly reducing
facilities for clinical care corridor spaces may be a false economy. A
and interaction by ‘‘nook’’ in a corridor for benches or ledges is
multidisciplinary care preferred, as shown in the diagram:
teams, (2) provide
spaces for informal
interpersonal
behaviors, and
(3) facilitate wayfinding

Edgerton, A psychiatric hospital Comparison of a corridor Behavioral mapping; Certain positive design Findings support the value of variability in
Ritchie, and in Scotland before-and-after design Questionnaire on interventions to the architectural arrangement of circulation spaces
interventions 10 aspects of the hospital corridor and in ‘‘breaking-up’’ long corridors. Findings

(continued)
 Table A1. (continued)

Impacts of Healthcare
Measures of Health Circulation Spaces on
Authors (Year) Type of Facility/Site Research Design; Sample Outcome Well-Being Conclusions/Design Suggestions

McKechnie Observational study: corridor (1) positively impact also support, for dementia patients,
(2010) behavioral mapping environment and patients’ behaviors, architectural edge spaces/exterior walls with
Survey: dementia patients users’ perceptions (2) make patients feel windows/views of nature and as settings for
(n ¼ 100; more relaxed, and social interaction
preintervention ¼ 53, (3) improve patient– Positive design interventions in hospital corridors
postintervention ¼ nurse communications include (1) removing obtrusive ‘‘institutional’’
47), and staff (n ¼ 55; features and instead introducing views of
preintervention ¼ 30; gardens and landscape features; (2) using opaque
postintervention ¼ 25) glass to accentuate the daylight while blocking
out unsatisfactory external views; (3) changing
the color/pattern of the ceiling, wall, and floor
coverings to interject representations of nature;
(4) reducing the width of corridors to a less
institutional, more welcoming scale; (5)
introducing ergonomically designed timber
beams to act as informal seating elements;
(6) planting trees outside, adjacent to the
circulation artery and viewable from within; and
(7) installing site-specific artworks at key
intervals
Wang et al. Adult-cardiac ICU Survey: nursing staff Acoustical measures of A dedicated service The addition of a dedicated service corridor in a
(2013) in an academic (n ¼ 118) noise; Assessment of corridor can (1) reduce new ICU improved noise control, reduced staff
medical center in On-site observation staff stress and overall and daytime stress, and improved staff satisfaction. The
the United States Quasi-experimental, satisfaction noise levels in the unit, dimension of the measured service corridor is
before-and-after (2) reduce service 80 600 (approximately 2.6 m) in ceiling height and
comparison of noise traffic and amount of 60 (approximately 1.8 m) in width
levels in two ICUs crash cart activity in the
patient corridors, (3)
improve the usage of
patient corridors for
patients walking/

(continued)

15
16
Table A1. (continued)

Impacts of Healthcare
Measures of Health Circulation Spaces on
Authors (Year) Type of Facility/Site Research Design; Sample Outcome Well-Being Conclusions/Design Suggestions

ambulation, (4) reduce

staff stress, and (5)
improve staff
satisfaction
Lau and Roy Palomar Pomerado Comparison of noise Acoustical measures of Carpeting and high- Replacement of excessively hard surface flooring
(2014) Health (PPH) in levels: two corridors noise; assessment of performance acoustical materials, i.e., carpets and high-performance
the United States and adjacent public users’ perception of ceiling in the hospital acoustical ceiling, reduces ‘‘corridor activity
spaces noise (various corridor and the noise’’ and enhances users’ overall experience
Survey to patients and sources) adjacent spaces (1)
staff (sample size not reduce overall noise
known) levels and (2) reduce
users’ perceptions of
annoyance and
distraction caused by
excessive noise
Note. Courtesy of the authors.
 Appendix B

Table B1. Summary of Secondary Resources in the Design of Hospital Circulation Zones.

Impacts of Healthcare
Type of Facility/ Measures of Health Circulation Spaces on Conclusions/Design
Authors (Year) Site Research Design; Sample Outcome Well-Being Suggestions

Foureur et al. (2010) Birthing/Labor Literature review; interviews Development of the Birth Certain conditions for To facilitate and support the
and Delivery with key informants (10 Unit Design Spatial corridors in birth units can physiology of natural
Room (LDR) midwife clinicians and Evaluation Tool (BUDSET) be frightening and cause childbirth, BUDSET
birth units in researchers and 3 healthcare anxiety, including (1) identified four fundamental
Australia architects); expert panel excessively long corridor design principles, including
(experts from midwifery and arteries, (2) corridors with (1) characteristics affecting
architecture) insufficient natural lighting, the Fear Cascade, (2) facility
(3) and windowless characteristics, (3) aesthetic
corridors that lack visual aspects of the unit, and
connectivity with the world (4) essential support elements
beyond preferred by women and
family members. For corridor
arteries, it is fear reducing to
provide connectivity with
nature in a manner that allows
patients, family, and visitors to
circulate with relative ease
into gardens and courtyards
on-site
Topo, Kotilainen, and Special Care Units Randomized controlled Residential Care The presence of windows in Five environmental/spatial
Eloniemi-Sulkava for patients intervention using a Environment Assessment spatially dead-end corridors affordances were identified
(2012) with dementia qualitative assessment tool; (RCEA) tool developed by invited residents to obtain vis-à-vis the RCEA diagnostic
in Finland (N ¼ On-site observation research team sensory respite. Excessively tool. These corridor-related
10) narrow corridors, corridor items influence overall
arteries bisecting or environmental quality:
traversing dinning or living (1) Layout and Building
areas, or an absence of Configuration: spatial
landmarks coupled with a movement patterns and
monotonous or excessively direct accessibility to natural

(continued)

17
18
Table B1. (continued)

Impacts of Healthcare
Type of Facility/ Measures of Health Circulation Spaces on Conclusions/Design
Authors (Year) Site Research Design; Sample Outcome Well-Being Suggestions

long corridor configuration daylight sources, views to

were perceived as the immediate outdoor
perceptually and spatially environment vis-à-vis
restrictive. Sufficient lighting windows, balconies, and
in circulation arteries and gardens and (2) Attached
adjacent public spaces was Objects: corridor arteries
found to support spatial and/or vestibular spaces
orientation, and establishes a sufficiently spacious enough
quasi-residential ambience and equipped with electronic
surveillance amenities, and
sufficient natural and artificial
lighting.
Suggestions for the
improvement of corridor
and associated circulation
arteries in special care units
include the interjection of
(1) furnishings, color
palettes, and works of art
such as paintings to visually
demarcate the end points of
corridors; (2) removal of
extraneous equipment and
furnishings from corridors
to enhance fire safety
preparedness, wayfinding,
and spatial amenity;
(3) incorporate furnishing at
the end points of corridors,
where feasible, to double
function their use as nodes

(continued)
 Table B1. (continued)

Impacts of Healthcare
Type of Facility/ Measures of Health Circulation Spaces on Conclusions/Design
Authors (Year) Site Research Design; Sample Outcome Well-Being Suggestions

for social interaction; and

(4) provide effective lighting
yet in a manner that controls
for excessive glare at the end
points of corridor arteries
Pangrazio (2013) General hospitals Theoretical assumptions N/A Public spaces (e.g., circulationPublic spaces in hospitals can
in the United systems, identified as one of promote memorable,
States the five typologies) enhance positive experiences,
patients’ overall experience. contributing to the healing
Six attributes should be process through the
considered when designing provision of well-designed
supportive healthcare public spatial orientation cues.
spaces including Second, from a cost/benefit
(1) environmental factors, perspective, rethinking the
(2) user characteristics, functions of occupant-
(3) public and private attuned design in public
interpersonal relationships, spaces in hospitals enhances
(4) patients’ physical health the overall patient, visitor
status and functional and staff experience
capabilities, (5) the function
of time, and (6) patients’
emotional disposition
Wood-Nartker, Assisted living On-site interviews with 3-Point scale/presence of An inverse relationship Environmental sensory cue
Guerin, and facilities in the sensory cue checklist sensory cueing devices occurred between the recommendations for
Beuschel (2014) United States incidence of patient falls and common spaces in assisted
(N ¼ 140) the presence of sensory cues living facilities included
in corridor arteries: the (1) provide high contrast
greater the number of between surface finishes and
environmental cues, the furnishings; (2) employ
lower the number of falls. aesthetically attractive
Facility size and room type finishes; (3) use color,

(continued)

19
 Table B1. (continued)

20
Impacts of Healthcare
Type of Facility/ Measures of Health Circulation Spaces on Conclusions/Design
Authors (Year) Site Research Design; Sample Outcome Well-Being Suggestions

predicted fall behavior. artwork, photos, and related

Effective design resulting in memorabilia on walls to
adequate environmental enhance wayfinding;
sensory cues reduces patient (4) provide clear, well-placed
fall rates signage; (5) effective visual/
auditory alarm devices;
(6) incorporate clearly
discernible graphic images
on wall surfaces; and
(7) avoid distracting or
confusing colors and graphic
images on floor surfaces
Andersson, Ryd, and Assisted living Observation: residents and unit Assessment of space Residents, staff, and related Lighting use routines within
Malmqvist (2014) facilities in staff (n ¼ 302); group utilization patterns and stakeholders hold different common spaces varied
Sweden interviews: unit staff perceptions of facilities by views about the demarcation considerably; existing
(N ¼ 14) (n ¼ 24); individual multiple users and of home and work place and lighting conditions in a
interviews: residents stakeholders the role of common spaces subset of public circulation
(n ¼ 10), relatives (n ¼ 4), as venues for social arteries were assessed as
and planers and architects interaction. The physical inadequate
(n ¼ 7); Questionnaire: unit environment of common
staff (n ¼ 177) and unit heads spaces within assisted living
(n ¼ 16) facilities, corridors included,
have an impact on patient
socialization patterns
Xie and Deng (2014) Cardiology Observational study: behavior Acoustical measurements: Noise levels in cardiology N/A
department at a patterns of noise sources noise levels corridor arteries were found
general hospital and the recording of noise to greatly exceed World
in China levels Health Organization
guidelines. Four typical noise
sources were identified:
obtrusive talking, loud door
closings, coughing, and
footsteps
Note. Courtesy of the authors.
Jiang and Verderber 21

Declaration of Conflicting Interests several times a day and educating patients and
The author(s) declared no potential conflicts of families about the importance of staying mobi-
interest with respect to the research, authorship, lity (Callen et al., 2004).
and/or publication of this article.
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