Theory Manuscript

Health Environments Research

& Design Journal
1-16
Space Syntax Analysis: Tools for ª The Author(s) 2016
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DOI: 10.1177/1937586715624225

Healthcare Facility Spatial Analysis herd.sagepub.com

Ahmed Hassem Sadek, M.Arch1,3, and

Mardelle McCuskey Shepley, FAIA, EDAC, FACHA, LEED AP BDþC2

Abstract
Aim: This article reviews and addresses various spatial measures that provide and facilitate accurate
descriptions of different layout typologies with particular focus on healthcare facilities. Background:
Evidence-based design is a field of study that emphasizes the importance of using credible data in order to
influence the design process. It addresses whether/how the design and operation of buildings support
positive health outcomes through a growing collection of solutions informed by research and practical
knowledge. In order to acquire this knowledge, we must consider the environment in a very precise and
measurable way, which can then be investigated quantitatively with regard to various human behaviors
and cognitive processes. Topical Headings: Space Syntax theory and methods are concerned with
understanding how spaces are arranged and connected to one another. It provides quantitative measures
of individual spaces and of the entire layout, thereby achieving great accuracy. Space Syntax researchers
have used graph theory to define spatial measures and have produced computer tools to quantify the
relational properties of spaces and to provide numerical and display values for each. Moreover, they have
developed more precise tools that can be embedded within basic Space Syntax concepts in order to
augment the credibility of the acquired data. Conclusion: The study elaborates on the effectiveness of
Space Syntax and its newly developed measures for the field of healthcare facility design and research. We
present a comprehensive model that brings together these measures with their correlated behavioral and
perceptual consequences, thereby providing a point of departure for further investigation and exploration.

Keywords
evidence-based design, Space Syntax, healthcare, behavior, spatial analysis

A growing body of research demonstrates the sig-
nificant impact of the healthcare physical envi-
ronment on a variety of health-related outcomes
such as length of stay, pain, medication, stress,
mood, and environmental appraisal (Huisman,
Morales, van Hoof, & Kort, 2012; Ulrich, Berry,
Quan, & Parish, 2010; Ulrich, Zimring, Quan,
Joseph, & Choudhary, 2004). This places the built
environment as a key factor in defining physi-
cal and psychological health for patients and
1
Department of Architecture, Faculty of Engineering, Assiut
University, Assiut, Egypt
2
Department of Design and Environmental Analysis, Cornell
University, Ithaca, NY, USA
3
Faculty of Architecture, Building and Planning, Melbourne
School of Design, University of Melbourne, Victoria, Australia
Corresponding Author:
Ahmed Hassem Sadek, MArch, Department of Architecture,
Faculty of Engineering, Assiut University, 71516 Assiut, Egypt.
Emails: ahmed-sadek@hotmail.com; sadeka@student.unimelb.
edu.au
2 Health Environments Research & Design Journal
their families as well as for healthcare staff.
Evidence-based design (EBD) is a field of study
that addresses whether/how the design and
operation of buildings positively support health
outcomes through a growing collection of solu-
tions informed by research and practical
knowledge. The approach has become popular
in healthcare architectural design in an effort
to improve patient and staff well-being, aid the
patient healing process, reduce stress, and con-
tribute to safety (Fouts & Gabay, 2008; Shepley,
Harris, & White, 2008).
The built environment has to be considered
precisely to accurately predict its influence on
people’s mental-health, behavioral interaction,
and engagement with the environment. Conse-
quently, researchers have adopted Space Syntax,
along with other tools and methods, to facilitate
fulfilling this aim. The concept of Space Syntax,
which was originally introduced by Hillier, con-
centrates on revealing the underlying social logic
of spaces by developing strategies to describe
their configurations and their effects on various
social and cultural attributes (Bafna, 2003). It
provides rich and diverse quantitative descrip-
tions of the built environment configurations,
particularly buildings and urban street networks,
with a main focus on their arrangement and inter-
connections. This rigorous description allows for
potential explanations of a variety of physical and
psychological responses such as user movement,
experiences, and cognitive knowledge of place
(Montello, 2007).
The built environment has to be
considered precisely to accurately predict
its influence on people’s mental-health,
behavioral interaction, and engagement
with the environment.
Accordingly, this article focuses on basic and
newly refined Space Syntax tools used in health-
care facility research, including those that were
developed with the aim of augmenting the preci-
sion of spatial analysis. We provide a literature
review of the studies that currently involve, or
potentially involve, implications for healthcare
environments.
Little research has focused on addressing the
application of Space Syntax and its newly devel-
oped tools for healthcare research. Haq and Luo
(2012) summarized studies that applied Space
Syntax measures in healthcare settings until
2011; however, the focus was not on recently
developed tools. Turner (2007a) addressed the
technical description of a number of the programs
written to perform Space Syntax analysis but did
not focus on the newly developed measurements
that underlie the precision of spatial analysis.
According to the authors’ knowledge, no previ-
ous studies have thoroughly demonstrated and
reviewed the existing and developed tools of
Space Syntax in order to provide a comprehen-
sive overview for further investigation and explo-
ration within the field of healthcare design. We
note that the spatial tools and constructs men-
tioned in this article are not exclusive applica-
tions to hospital layouts and fit the analysis of
several building typologies. However, they have
been addressed here in a way that serves the con-
temporary trends in the field of healthcare facility
design and research. We also note that the new
developments included in this study are not
stand-alone methods that contradict the basic
concept of Space Syntax. However, they are con-
tinuous and sequential improvements that have
been introduced over time through ongoing
research with the purpose of refining the basic
analytical methods of Space Syntax.
Method
For the purpose of this study, electronic databases
including PubMed, EBSCO, and SAGE and the
websites of the Space Syntax biannual symposia
were examined in order to define studies that
carry robust implications and contribution to the
research in healthcare environments between the
years 1990 and 2014. Previous reviews in health-
care research addressing Space Syntax and devel-
opments in Space Syntax analysis were identified
and their reference lists were inspected. The
search was expanded by using a combination of
the following terms: EBD, hospital design,
healthcare design, quantitative representation of
the space, spatial analysis, spatial configuration,
Sadek and Shepley
and behavior. In total, 112 papers were selected.
The content of 29 of them was further reviewed
and analyzed. The inclusion criteria were based
on studies that are relevant to healthcare facilities
and introduced refined syntactical analysis meth-
ods or empirical examinations.
The following sections of this article briefly
introduce the development of Space Syntax basic
measures and constructs, followed by studies that
have applied them to healthcare contexts. The
article goes further by reviewing the attempts to
introduce newly refined syntactical representa-
tions and measures that have the potential to
increase the accuracy of spatial description. The
developed tools were divided into discrete and
combined measures with careful elaboration on
the usefulness of each tool in addressing specific
issues in healthcare design. The authors conclude
by providing a comprehensive model that brings
together the basic and newly developed spatial
analysis tools in conjunction with their correlated
behavioral and perceptual consequences with the
intention of building a platform that allows for
future research.
Basic Space Syntax Measures
Convex and axial maps are the most popular tech-
niques for describing spatial configuration in
Space Syntax. Convex maps, which are primarily
used to analyze arrangement of programmatic
spaces, are generated by partitioning a given spa-
tial setting into a set of fewest and fattest convex
spaces; each convex space then is defined with a
node and its possible connections are defined
with an edge, generating a justified graph that
represents the spatial relations between adjacent
spaces (Hillier & Hanson, 1984). When the focus
is to capture behavioral characteristics such as
movement, axial maps are more appropriate mea-
sures. They are defined as ‘‘the longest sets of
lines of sight that pass through all the open spaces
in a study area’’ (Hillier & Hanson, 1984, p. 91).
The number of direct connections to other lines or
spaces is called connectivity. The level of con-
nection, in term of the number of turns along a
path, is defined as the step depth, which describes
the mutual relationship between all lines or
spaces. Through this process, integration values
3
can be assigned to each place in the layout. This
indicates how well one space is connected to all
other spaces in a system. For instance, a corridor
with high integration means that it is closely con-
nected (with fewer topological steps) to all other
corridors in a given layout and vice versa. When
integration is calculated for all spaces in a system,
it is named global integration or integration-n.
We can also calibrate integration based on con-
nections at two-step depths which are named
local integration or integration-3. The correlation
between connectivity and integration values is
used to define the intelligibility of the entire sys-
tem. It identifies how far a person, in a local posi-
tion, is able to build up a picture of the global
structure based on its parts (the number of local
connections). For more exploration of its com-
plex nature and mathematical expressions, please
refer to ‘‘Space is the machine’’ by Hillier (1996)
and Hillier, Burdett, Peponis, and Penn (1987).
Convex and axial maps are the most
popular techniques for describing spatial
configuration in Space Syntax.
In order to increase resolution, Iida (2001)
implemented a segmentation algorithm into a
software program named Segmen (Turner,
2007b). The analysis was based on breaking con-
tinuous axial lines into segments according to
their intersection with other lines. This approach
facilitated finer scales of spatial analysis and
helped differentiate systems that are character-
ized by uniform structures from those with more
organic geometrical patterns (Al-Sayed, Turner,
Hillier, Iida, & Penn, 2014).
Segmented analysis appeared to have signifi-
cant drawbacks when basing the analysis on
topological configurations (fewest turns). The
problem occurs as previously well-integrated
axial line turns into more segregated shorter lines
due to the calculated turns/steps associated with
the adjacent segments on the same line. This, in
fact, contradicts the logical structure of a space,
as it treats steps to straight segments similarly
to those crossing orthogonal lines (Turner,
2004). Additionally, the concept of topological
step depth does not distinguish between different
turn angles as it treats a slight shift of 15 as equal
4 Health Environments Research & Design Journal
to a right angle of 90 even though it is not a sub-
stantive turn (Turner, 2001a). Therefore, Turner
(2001a) introduced a new syntactic model, named
angular segment analysis (ASA) as a refined
method to overcome these problems. The refined
method still utilizes the concept of segmenting
axial lines but bases the measures on the amount
of angular change a long a path, by assigning
angular weights to each connection in the system
ranging from ‘‘0’’ when passing in a straight line
to ‘‘2’’ when turns reach +180 (Turner, 2004).
The concept of ASA shifted the segment rep-
resentation to be a fundamental construct when
performing spatial analysis. Its analytical power
has been established in many studies within the
Space Syntax research community including the
seminal study by Hillier and Iida (2005). They
investigated the strength of three types of analy-
sis: topological (fewest turns), geometrical (least
angle), and metric (shortest distance) in four
urban areas in London. Movement patterns were
most highly correlated with geometrical followed
by topological configuration of spaces. Metric
distance was far less correlated with both vehicu-
lar and pedestrian movements within the studied
areas. The reason for that was attributed to the
nature of metric distance analysis which does not
take into consideration route complexities.
Hillier, Turner, Yang, and Park (2007) pro-
posed a different way to benefit from metric
analysis rather than assigning direct metric
weightings to Space Syntax measures. They
argued that the best way to implement metric
analysis is by using radius distance for these mea-
sures. This radius identifies how far calculations
are allowed to reach within a certain distance.
By selecting a subset of the system and process-
ing the values accordingly, Hillier et al. (2007)
were able to capture different local spatial phe-
nomenon including formal and functional proper-
ties of the network (spatial differentiation of areas
at the neighboring scale). ASA with a defined
metric distance turned out to be one of the most
recommended spatial representations within
Space Syntax software (Al-Sayed et al., 2014).
Isovist is another fundamental type of spatial
representations that deals with the visual proper-
ties of the built environment. It is defined as ‘‘the
set of all points visible from a given vantage
point in space’’ (Benedikt, 1979, p. 49). The iso-
vist area is the area of the visible field, usually
assumed as having a 360 field of vision. Turner
(2001b) developed a software program named
UCL Depthmap basically to perform isovist anal-
ysis similar to what had been previously applied
to axial lines and convex spaces. The utilized unit
of analysis in this approach is the ‘‘tile,’’ which is
a set of square tiles with a convenient dimension
that can be laid on any floor plan. Consequently,
the connectivity and integration values for each
tile can be calculated. Two structures of the lay-
out can be constructed, the first is the visibility
structure (Visibility Graph Analysis [VGA])
which is developed when the tiles are placed at
eye-level and only walls break up their interrela-
tionships. However, when the tiles are placed at
knee-level with the presence of furniture, then the
accessibility structure can be constructed (Turner,
Doxa, O’Sullivan, & Penn, 2001).
Space Syntax researchers have combined
these measures and produced several computer
software programs that provide tables with
numerical syntax values in addition to color-
coded diagrams to display the distribution of
those values on the plan layouts (Figure 1). With
these software programs and constructs of Space
Syntax, architectural plans and individual spaces
within them can be quantitatively measured and
described in rigorous ways, allowing them to be
used as independent variables in various research
projects and their consequent statistical analyses.
Applications in Healthcare Facility Research
Despite being relatively new in the field of
healthcare facility research, a growing body of
research has applied Space Syntax analysis in
healthcare settings. Basic Space Syntax measures
have been used to study wayfinding, privacy pre-
ferences, perceived quality of care, user cost,
nurses’ movement, and evacuation patterns in
hospital buildings (Haq & Luo, 2012). Wayfind-
ing, which has received reasonable attention in
the application of Space Syntax, was also investi-
gated by Khan (2013b) to understand patients’
satisfaction and travel experience. Different asso-
ciations were reported between satisfaction,
travel behavior, and layout syntactic properties
Sadek and Shepley
Figure 1. Example of visual graph (left) and axial map (right) analysis (Cai & Zimring, 2013).
according to gender, age, frequency, and number
of visits.
Basic Space Syntax measures have been
used to study wayfinding, privacy
preferences, perceived quality of care,
user cost, nurses’ movement, and
evacuation patterns in hospital buildings
(Haq & Luo, 2012).
In addition to the studies represented in Haq
and Luo (2012), Zadeh, Shepley, and Waggener
(2012) addressed the role of design in promoting
efficiency and reducing redundancies in nursing
units. Justified permeability diagram method was
applied to quantitatively and qualitatively analyze
the spatial ordering and space flow in five acute
care settings and determine their potential effects
on care quality. Setola, Borgianni, Martinez, and
Tobari (2013) studied patterns of interaction
among patient and medical staff. They analyzed
the integration core (the top 10% of integrated
lines) of both public and staff spaces in three hos-
pitals. They demonstrated that interaction was
occurring mostly in overlapping spaces when the
two cores overlapped, while it was occurring in
transition spaces between the two cores when
they were not overlapping. Pachilova and Sailer
(2013) and Sailer et al. (2013) also studied
interaction between patients and caregivers by
5
comparing spatial layouts of two different outpa-
tient clinics using the analysis of axial step depth.
They suggested that shared facilities for care-
givers along with clear spatial separation of staff
and patient areas may help in facilitating good
and frequent communication among them.
Cai and Zimring (2013) employed Space Syn-
tax analysis to understand cultural differences
between Chinese and U.S. designs of nursing
units. The study revealed interesting culture dif-
ferences regarding encounter, communication,
territoriality, hierarchy, and privacy. From a
similar perspective, Khan (2013a) investigated
hospital design in Bangladesh. The study repre-
sented a reflection of the designer’s cultural val-
ues and norms on the spatial organization of
Bangladeshi hospitals. Space Syntax analysis was
further combined with discrete event simulation
in the process of designing a new emergency
department in order to analyze the potential influ-
ence of spatial configuration on the effectiveness
of visual surveillance, movement, and communi-
cation (Morgareidge, Cai, & Jia, 2014). The study
demonstrated the importance of these tools for
facilitating decision making, improving organi-
zational performance, and reducing capital and
operational costs. These studies, accordingly,
represent promising evidence of the significance
of Space Syntax theory in the field of healthcare
facility design and research.
6 Health Environments Research & Design Journal

Figure 2. General visual connectivity (left) and target visual connectivity (right; Lu & Zimring, 2012). The pictures
show the ability of target visibility analysis to better and more accurately discriminate between layout locations
that have higher target visibility of patient beds compared to general visibility of all parts of the layout.

Newly Refined Spatial
Representations and Measures
Scholars have also sought, in complementary
ways, to increase the precision of spatial config-
uration measures. They have developed and
improved additional measures and techniques in
order to increase the accuracy of representing
spatial characteristics. These attempts include the
following:
Target Visibility Analysis
Previous research has demonstrated the impor-
tance of visibility for patient and staff out-
comes. Better observation and faster response
to patients, which contributes to reducing patient
falls and mortality rates, are among the benefits
of improved visibility. Additionally, it is associ-
ated with less travel time for nurses and increased
communication (Lu & Zimring, 2012). Despite this
importance, former attempts to develop methods
depicting and analyzing visibility patterns in build-
ings focus mainly on generic visibility of all open
spaces and omit foci on critical targets. Accord-
ingly, Lu, Peponis, and Zimring (2009) developed
a computational tool named target visibility analy-
sis to quantify and graphically represent visibility to
patients locations. The tool works by superposing a
grid of tiles with even spacing on the original layout
and defining targeted objects in order to calculate
the mutual visibility (lines of sight) between them,
thus allowing for the targeted visual connectivity
value to be calculated (Figure 2). The proposed tool
is a refinement to the standard analysis of visual
fields as it enables the visibility measurement of a
specific number of targets from definable observa-
tion locations. This allows the researcher to assign
particular locations with more weight than others.
In the calculation process, partially or fully visible
targets will be considered visible. However, there
are number of ways where targets can be redefined
if specific parts of them are more important. Addi-
tionally, a distance radius can be applied in the anal-
ysis according to the user’s interest.
. . . former attempts to develop methods
depicting and analyzing visibility patterns
in buildings focus mainly on generic
visibility of all open spaces and omit foci
on critical targets.
The authors introduced the Targeted Visibility
index (TVi) which is defined as ‘‘the ratio of the
average targeted visibility value of all locations in
the setting, and number of pre-selected targets’’
(Lu, 2010, p. 55). This provides a way to compare
the degree of targeted visibility between various
nursing layouts that have different numbers of
patient beds.
In order to demonstrate the importance of Tar-
get Visibility analysis as a tool that has capabilities
Sadek and Shepley
in assessing healthcare design proposals, Lu
(2010) reanalyzed three typologies of nursing
units—radial, double, and single corridor lay-
outs—which were investigated in a previous
study by Trites, Galbraith, Leckwart, and Sturda-
vant (1969). The results of the TVi corresponded
completely with the Trites et al.’s original empiri-
cal findings. Additionally, Lu and Zimring (2012)
investigated distribution and behavior of nurses
and physician in an intensive care unit (ICU)
based on the visibility pattern of the setting.
Staff positions were highly correlated with the
target visibility measures compared to general
visibility, which suggests targeted visibility as a
particularly appropriate tool when investigating
patterns of spatial use and behavioral conse-
quences of medical staff in nursing units. In a
later study, Lu, Ossmann, Leaf, and Factor
(2014) replicated a study of Leaf, Homel, and
Factor (2010) in an ICU with the aim of enhan-
cing the methodology and complementing the
original findings. They used target visibility
analysis to calculate various visibility measures
of patient rooms including patient head visibi-
lity and patient room visibility in addition to
measuring field of view and the shortest walk-
ing distance from the nurse station to patient rooms.
High ICU mortality rates were significantly associ-
ated with severely ill patients assigned to rooms
with low visibility. This was aligned with the orig-
inal outcomes of Leaf and colleagues.
Spatial Positioning Tool (SPOT)
Similar to the idea of target visibility is the con-
cept of spatial positioning which was adopted
by Markhede and Carranza (2007) to analyze
face-to-face interaction in buildings that are
strongly influenced by organizational and cultural
features. They proposed the implementation of
this tool to examine the relationships between
occupied spaces as a supplement to regular Space
Syntax analysis that create graphs and measures
of all occupied spaces, ignoring the special status
of specific occupied parts. Unlike the target visi-
bility analysis, which bases its calculation on the
tile as the unit of analysis, the SPOT adopts iso-
vists to represent and analyze spaces. The posi-
tion of the isovist can be determined according
7
to subjects/objects spatial distribution, allowing
for the visual situation to be illustrated on the
generated graphs. SPOT produces two kinds of
graphs: intervisibility, which shows overlapping
isovist fields that become darker when many
overlapping layers are superimposed, and net-
work graphs which show the relative asymmetry
integration (Figure 3).
Unlike the target visibility analysis, which
bases its calculation on the tile as the unit
of analysis, the SPOT adopts isovists to
represent and analyze spaces.
Markhede, Miranda, and Koch (2010) demon-
strated in their studies the power of SPOT by ana-
lyzing 600 workstations distributed on three floor
plans in an office building located at Posten
Headquarters, Sweden. In addition to intervisibil-
ity graph analysis, snapshot observations and a
series of surveys asking questions about face-to-
face interactions were carried out. Face-to-face
interactions were 50% higher at the workstations
located in the more intervisible areas compared to
those placed in the less intervisible places. This is
also supported by other researchers in the field of
Space Syntax such as Sailer (2007), who believes
that organizational relations is needed as com-
plement to the regular Space Syntax analysis.
The concept of SPOT is implemented via an inde-
pendent software written in Java which allows it
to run in Windows, Mac, and Unix machines
(Turner, 2007a). Furthermore, Carranza, Koch,
and Izaki (2013) proposed a further development
for SPOT by integrating it as a design tool in
addition to its primary analytical role. The
researchers developed algorithms to calculate iso-
vists in real time and apply them to a new hospital
ward in order to refine the design and visualize its
effects simultaneously on issues significant to
healthcare effectiveness like visibility, accessibil-
ity, and contact between caregivers and patients.
The use of spatial positioning analysis main-
tains the incorporation of organizational aspects
into the analysis of layouts, which allows the
focus to shift to investigating interaction and
knowledge sharing. Furthermore, spatial posi-
tioning has the potential to be applied in the field
of healthcare design and research. For instance,
8 Health Environments Research & Design Journal
Figure 3. Intervisibility graph (top) and network integration graph (bottom) (Markhede et al., 2010). Darker areas
indicate the zones that are visible from the largest number of the pre-identified positions (locations of interest).
patients’ occupation of place can be tested in rela-
tion to different functions such as ICUs and infu-
sion suites, where visibility along with privacy
and communication are crucial for safety and
other positive health outcomes. Additionally, the
impact of different nurse station typologies, such
as centralized and decentralized nurse stations,
can be investigated. This might open the way to
create representations for social relationships
such as interactions, awareness of peers’ work,
and knowledge exchange, allowing for testing
and evaluating different combinations and solu-
tions for existing and new layouts.
Weighted Isovist Area
With regard to critical functional areas in hospi-
tals, where proximity to an observer is crucial for
patient safety, Kim and Jung (2014) proposed a
mathematical model to control the existing lim-
itation in the classical measures of the isovist.
As mentioned before, the isovist field represents
the range and the area of the space that can be
seen from a vantage point. However, the conven-
tional measure does not discriminate between
concentrated and dispersed spaces. Therefore, the
authors developed the concept of weighted isovist
area. The associated tool uses distance as a
weighting factor to develop the isovist area, thus
discriminating between different shapes and
sizes. Distance, as a factor, can represent the
information at the investigated points regarding
quality of surveillance, privacy, and security. The
model enables researchers to define the specific
weighting functions according to their context.
The weighted isovist is implemented by substitut-
ing the distance between the isovist origin and a
point on the isovist boundary. It reveals areas
that constitute large visible regions based on the
needed information (weighting distance) from the
observation point (Figure 4). The developed
model is also implemented into Syntax2D, one
of the spatial analysis software programs, to pro-
vide a ready-to-use tool that considers the differ-
ences between nearer and farther regions.
Distance, as a factor, can represent the
information at the investigated points
regarding quality of surveillance, privacy,
and security.
The software Syntax2D also provides path-
based measures that generate isovists from a
Sadek and Shepley
Figure 4. General isovist area (left) and distance-weighted area (right) (Kim & Jung, 2014).
series of observation points. The cumulative iso-
vist of the path can be shown and the data from
each of these points can be analyzed according
to several measures. For instance, colored circles
along the path are used to display the area value
of each isovist (Turner, 2007a). The importance
of the available information through a specific
path is emphasized and illustrated by Lu and Seo
(2012). They suggest quantifying route properties
rather than the overall unit shape in order to pre-
dict nurse behavior and movement patterns.
Multi-Layered Network
Visibility may also play a significant role in con-
ditions such as wayfinding and intelligibility of
spaces, where the presence of a visibility link can
reduce the degree of segregation of a desired des-
tination. However, Space Syntax, when con-
structing the axial representation of a building,
does not take this issue into consideration, caus-
ing what is called the visibility–accessibility
problem which occurs when spaces have accessi-
bility barriers that do not hinder visibility. In
order to overcome this problem, Dalton and Dal-
ton (2009) developed the multi-layered tool,
where elements of the building that can be seen,
but not directly accessed, are taken into consider-
ation through a formula implemented into the
software WebmapAthome (version 0.91.1). This
process assigns a degree to these particular situa-
tions. Thus, a new type of integration is created,
which incorporates visibility and accessibility
into the syntactical representation.
9
Beck and Turkienicz (2009) also address the
influence of visual information on space intellig-
ibility, where the layout of Pinacoteca Art
Museum was analyzed in term of the intelligibil-
ity of three defined routes taking into consider-
ation the visibility and permeability relations.
The analysis depicted how visual information and
connections may add more structure and levels of
prediction to the visitors’ route, which is crucial
for wayfinding situations and spatial cognition.
In a recent study dealt with the same issue, Var-
oudis and Psarra (2014) developed and applied
a new approach that takes into consideration 3-
D visual relationships, extending the original
VGA to a 3-D VGA model. The tool managed
to precisely represent and discriminate locations
that have highly visibility links and are, at the
same time, not directly accessible (e.g., atrium
and crossing bridges).
The concept of multi-layered network can be
applied to another issue when describing the
space—the signage system (Dalton & Dalton,
2009). The presence of signage can raise the intel-
ligibility of a building as it aids in enhancing
clarity of the route in the built environment. The
concept can represent the presence of signage
when analyzing a floor plan, thus altering the
description of spaces and allowing for an inte-
grated understanding of the built environment.
By taking signage and visual information into
account, a wide range of conditions can be repre-
sented. This can ultimately enhance the predic-
tion of wayfinding difficulties in complex
healthcare settings, which is a key factor in
10
frustrating patients and families, causing stress,
and diverting staff time to giving directions
(Ulrich et al., 2010).
By taking signage and visual information
into account, a wide range of conditions
can be represented. This can ultimately
enhance the prediction of wayfinding
difficulties in complex healthcare settings,
Place Syntax
Place attractiveness is one of the determinants of
accessibility research, where ‘‘place’’ determines
a geographically specific space or location that
has a particular content. On the other hand, Space
Syntax deals only with ‘‘spaces’’ that have no
specified content and therefore no measurable
attractions. Noting these differences between
space and place, Jiang and Claramunt (2002)
have distinguished between geographic and geo-
metric accessibility. They define geographic
accessibility as the proximity of places, while
geometric accessibility is defined as the proxim-
ity of spaces. In order to overcome this issue and
to deal with the full concept of accessibility,
Ståhle, Marcus, and Karlström (2005) developed
a tool named Place Syntax which brings the
Space Syntax description of the cognitive envi-
ronment into a combined accessibility analysis
model with the conventional descriptions of
attraction. This suggests the possibility of loading
geographical data and qualitative factors for
improved predictions of pedestrian movement
within Space Syntax.
Space Syntax deals only with ‘‘spaces’’
that have no specified content and
therefore no measurable attractions.
Despite being developed mainly for urban
planning and design, Place Syntax may lead to
better understanding and prediction of patient
movement and crowding within hospital layouts
characterized by uneven distributions content
attractions that might contradict the configurative
descriptions of the space.
Health Environments Research & Design Journal
Team-Base and Peer Distances
Traditional classification of nurse station ty-
pologies such as centralized, decentralized, and
hybrid layout doesn’t provide an accurate reading
for the fairly different spatial relationships that
might exist in real practice where infinite combi-
nations of those components exist (Cai & Zimr-
ing, 2012). Based on the concept of step depth,
this study proposed a more systematic approach
to quantify and categorize the spatial configura-
tion of nursing units. They proposed team-base
distance, which represents the visual proximity
to team work, and peer distance (PD), which rep-
resents the visual proximity to peer alcoves, as
fine-grained spatial metrics to evaluate beha-
vioral differences between nurses such as fre-
quency of interaction and awareness of peers’
work. Behavior mapping and co-awareness net-
work analyses were also conducted beside the
spatial analysis as a multi-layered approach to
test the validity of the proposed spatial metrics.
The results of the two ICU wings demonstrated
a strong correlation between the proposed spatial
metrics and nurse behavior and co-awareness. In
particular, nurses assigned to lower PD alcoves
had significant higher interaction ratios. Addi-
tionally, their awareness of other patients’ condi-
tions was significantly higher than nurses in other
alcoves. Overall, this research provided in-depth
descriptions of nurse station typologies and their
relation to nurses’ communication and learning.
Combined Methods
Alongside the efforts to develop advanced tools
and construct measures for spatial analysis,
researchers proposed and integrated new methods
using Space Syntax in order to enhance the depic-
tion of spatial properties and facilitate the inves-
tigation of specific situations.
Nurse Assignment
In a time and motion study conducted by Hen-
drich et al. (2009), the analysis of the collected
data discerned that no statistically significant
relationships existed between unit layout type
(racetrack, radial, corridor, etc.) and time nurses
Sadek and Shepley
spent in patient rooms. However, noticeable dif-
ferences between individual nurses in the same
unit were observed. Therefore, the authors pro-
posed investigating a sub-area of the unit layout
within which individual nurses are assigned in
order to understand the influence of spatial con-
tent on nurses’ movement. This was named
nurse’s assignment. Axial integration measures
were calculated for the total number of patient
rooms in each assignment allowing spatial prop-
erties to be assigned for each nurse. Parameters
of movement patterns, such as number of entries
to patient rooms and nurse stations, were consid-
ered as the dependent variables in the study. This
generalized linear model demonstrated the ability
to predict the impact of spatial properties of a
nurse’s assignment on the frequency of trips
made to patient rooms. For instance, higher inte-
gration values for nurse assignment were associ-
ated with higher number of entries to patient
rooms and the nurse station. Average time per
visit was negatively associated with number of
entries to patient rooms, however, the total num-
ber of entries was positively associated with the
total time spent in patient rooms.
. . . higher integration values for nurse
assignment were associated with higher
number of entries to patient rooms and the
nurse station.
The syntactical spatial analysis was further
developed by Choudhary, Bafna, Heo, Hendrich,
and Chow (2010) to include visual connectivity
of the corridors outside the rooms and visual step
depth of the rooms from the nearest nurse station.
The final developed model represented a signifi-
cant tool that can be utilized to inform the assign-
ment process in existing hospitals or investigate
the potential influence of different assignment
sets.
Medication Administration
In order to reveal additional rigorous information
about the effect of hospital layout on nurse beha-
vior and walking distances, Seo, Choi, and Zimr-
ing (2011) conducted a study in two different
11
ICUs, one with a radial and smaller layout and the
other with a larger racetrack layout. They deter-
mined that the overall shape and type of the unit,
as studied in previous research, might be insuffi-
cient to accurately explain and predict nurses’
walking behavior. Instead the route characteristics
which connect different unit components, such as
patient room and medication area, contribute more
to nurse behavior and walking distances. Therefore,
they introduced a new method to observe nurses
while performing a specific work process, namely,
medication administration. Observing one task
helps minimize the influence of other work pro-
cesses on nurse behavior. Additionally, it allows for
a more precise investigation of the effects of the
physical spatial properties on the observed behavior.
Visibility analysis for the shortest medication
path was calculated in order to determine the per-
centage of the visible area of the unit that nurses
could see while performing their tasks. Moreover,
general target visibility analysis was performed to
define differences in visibility of patient beds
from both nurse stations. They found that walking
distances were not less in the smaller unit as was
expected, rather it was higher. Furthermore, the
calculated number of extra stops was associated
significantly with path visibility, which may play
a role in increasing walking distance and task per-
formance time. The study plays a role as well in
demonstrating the applicability of the developed
tool ‘‘target visibility analysis.’’
The findings of this study were supported by
Lu and Seo (2012), where nurses did walk more
in the smaller unit compared with the larger one.
This result reinforced the assumption that specific
spatial characteristics in a unit have greater
effects on nurse behavior rather than whole spa-
tial properties. Additionally, they hypothesized
two measurements of route properties. The first
one is the closeness value, which focuses on
assessing whether the routes pass through the
central nurse station and the second variable,
named the path visibility index, is linked with
quantifying the visibility from the path to the
nurses’ work areas including the central nurse sta-
tion and alcoves. This allows for better investiga-
tion of spatial properties and their contribution to
behavioral differences.
12 Health Environments Research & Design Journal

Conclusion elements of the built environments such as sig-

nage. Additionally, target visibility analysis,
The effect of hospital layouts on patient, visitor, and
SPOT, and weighted isovist area allowed the
staff behavior has been the focus of many rigorous
analysis to shift from general visibility to critical
research studies during the last decade using Space
targets and representing information availability.
Syntax. The development of refined tools that
However, several issues remain to be explored
precisely measure layout configurations allows
including the impact of the vertical dimension,
researchers to better investigate occupant behavioral
such as ceiling height and its proper representa-
and perceptual consequences related to the built envi-
tion, along with non-spatial characteristics of the
ronment, thus, enhancing the credibility and quality
environment such as surface colors, textures, and
of EBD. Moreover, these tools allow designers and
patterns. It is also beneficial accounting for indi-
clients to consider alternatives and assess proposals
vidual group differences in responds to layouts.
before complex buildings are constructed.
One of the contemporary research applications in
This article adds to the existing knowledge of
hospitals is the performance analysis based on
the use of Space Syntax in the field of healthcare
agent simulation. It was also introduced earlier
facility research. It enhances the understanding of
into the Depthmap 7 software (Turner, 2007b),
the effects of the built environment on occupants
where the agent decision is based on the visibility
through the illustration of Space Syntax measures
graph. Integrating other parameters from the queu-
that depict these impacts. A summary of basic and
ing theory such as capacity, waiting times, queue
newly developed measures and their correlated
lengths, and cycle time into the agent decision-
behavioral and social relationships is provided
making process constitutes a promising direction
in Figure 5. This comprehensive model includes
for future investigations as well.
major research and design themes accompanied
The continuous improvements in rigorous mea-
by related analytical tools and measures, in addi-
sures for quantifying the spatial properties of the
tion to the prospective outcomes of these applica-
built environment contribute to the effectiveness
tions. These rubrics are broken into a variety of
of the theory of Space Syntax. These develop-
categories in three clusters based on basic, newly,
ments are imperative to maintaining Space Syntax
and combined Space Syntax methods. Direct links
as a strong and unique discipline and enhancing its
are provided to represent the relationship among
contribution to the field of environmental psychol-
the tools and their measurable consequences, cre-
ogy as a comprehensive theory.
ating a platform for future studies that aim to
enhance outcomes for both patients and caregivers.
It provides a design and research road map to facil- Implications for Practice
itate researchers and designers’ selection of the
Space Syntax analysis, including traditional and
appropriate measures.
newly developed measures, ameliorates the
This review illuminates several attempts to
description of spaces. Using this method, we can
refine and overcome some of the shortcomings
assess and validate healthcare facilities by com-
in Space Syntax theory and its related measures
paring layouts in term of:
as identified by Ratti (2004), Montello (2007),
and others. Segmenting axial lines, incorporating  supporting wayfinding and intelligibility,
metric information in the form of radius analysis,  facilitating supervision and security,
combining information on land use, and imple-  enhancing workflow and reducing
menting multi-layered network allowed research- redundancies,
ers to overcome several of these limitations.  minimizing staff and clients walking dis-
Respectively these attempts helped highlighting tances, and
phenomenon related to discriminating different  promoting privacy within treatment areas.
types of spatial configuration, edge effect and
local phenomenon, place attractiveness, and Specific design attributes can be also provided
representing visibility–accessibility issues and based on the analysis of tools such as target
Sadek and Shepley 13

Examinable research & design themes

Spatial analysis tools Outcomes highlight
Behavioral and and measures issues related to:
Design level
perceptual level

Flow Convex maps & justified

Spatial ordering permeability diagram (JPD) Efficiency
Quality of care delivery
Accessibility
Territoriality & Axial & segment analysis Orientation quality
hierarchy through: Wayfinding
Movement pattern - Step depth Cultural influences
Communication - Least angle Social relationship
Spatial knowledge - Metric distance Privacy

Visual surveillance Isovist & visual graph

Observation
Response time
Falls rates
Pattern of spatial use Target Visibility analysis Nurses travel time
Knowledge sharing
Face to face interaction Spatial Positioning Tool Mortality rates

Available Weighted Isovist Area Security

information

Spatial cognition Multi-Layered Network Frustration & stress

Staff time to give
Place Syntax directions

Frequency of interaction Learning

Team-base distance & Peer
Awareness of peers’ work distance Knowledge exchange
Critical support

Frequency of trips to Time spent in patient rooms

Nurse
patient rooms &
assignment Basic Space Assignment process
movement patterns
Syntax
Medication measures Fatigue
Walking distances &
tasks’ performing time administration Job satisfaction

Figure 5. Summary of basic and newly developed spatial measures and their correlated behavioral and social
relationships.

visibility or spatial positioning, which provides  medication administration (walking distances

predictions of patterns of spatial use.
In the field of healthcare facility research, Space
Syntax can be adopted to compare design trends, like
nurse station typologies, and investigate their effects
on social and organizational relationships such as:
 interactions,
 knowledge exchange,
 awareness of peers’ work,
 time spent with patient, and
and task performing time).
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of
interest with respect to the research, authorship,
and/or publication of this article.
Funding
The author(s) disclosed receipt of the following
financial support for the research, authorship,
14
and/or publication of this article: This article was
developed while the first author was a visiting
scholar at the Center for Health Systems and
Design at Texas A&M University. The author
would like to express his sincere appreciation to
the Egyptian Ministry of Higher Education that
funded his stay there.
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