Hospital outpatient perceptions of the physical environment of waiting areas: the role of patient characteristics on atmospherics in one academic medical center

This study explores how outpatients perceive the physical environments of the waiting areas in a medical center. All the 15 analyzed items were ranked as relatively high with a range of 3.362 to 4.010; environmental cleanliness was the most satisfactory whereas noise level was the least satisfactory.

We also analyzed the relationship between patients' demographics and perceptions of the physical environments of waiting areas, applying the summated indices of patient satisfaction with physical environments in the waiting areas. What was determined is that women were less satisfied with the cleanliness of the physical environments, measured in terms of the holistic and restrooms' surroundings. Traditionally, women take more responsibility for environmental cleanliness at home, which might account for and translate into their having higher expectations of cleanliness than men. Furthermore, in terms of restroom environment, trash tends to accumulate much faster in women's restrooms than in men's restrooms; curiously, both are cleaned at equal intervals in the studied medical center. We suggest that the hospital housekeeping staff check and clean the restrooms more frequently to sustain higher comfort levels for female patient use.

In this study, we determined that older patients were more satisfied with several dimensions of the physical environment, including visual and body contact conditions, than the younger patients. Previous studies on patient satisfaction have shown that patients' age, in an upward direction, is positively related to patient satisfaction [30–32, 38–42]. In addition, we found that first-time outpatients registered less favorable perceptions than returning outpatients in body contact environment; these were measured as common components of chair sufficiency and comfort, air freshness, and room temperature. This finding may exist because this medical center has the largest volume of outpatients in central Taiwan. The crowded conditions might surprise first-time visitors, especially those who are used to visiting other healthcare facilities with lower service volumes, leading to uncomfortable feelings in the surroundings, including possible chair insufficiency, odorous air quality, and uncomfortable temperature (i.e. too hot or cold).

Patients' perceptions of the visual environment and cleanliness differed significantly amongst outpatients who arrived in the morning and outpatients who arrived in the afternoon. In this medical center, more physician offices were open, and there was higher outpatient volume in the mornings than in the afternoons (31.67 visits per office in the morning vs. 22.37 visits per office in the afternoon). The researchers noticed that overall lighting was brighter in the morning and slightly reduced in the afternoon, as several physicians' offices were not open and several lighting systems were deactivated. These visual conditions might indirectly influence patients' perceptions of the visual feelings as a whole. We suggest that the hospital continuously maintain the lighting systems in the waiting areas or centralize the waiting areas when some offices are closed and patient volume is lower; these actions may render patients less lonely or afraid. Moreover, cleanliness was perceived as being better in the morning and worse in the afternoon. People perceived the cleanliness (holistic and restrooms' surroundings) based on various factors and even users' customs. Therefore, we suggest that the housekeepers check the holistic environment and the specific areas (i.e., restrooms) more often to better recognize the special needs of afternoon patients.

Certain limitations of this study should also be pointed out. First, all the assessments measured were very standardized so that they could be compared easily across overall patient characteristics; yet, we also provided an open item for the respondents free to respond. A more dynamic and customized evaluation would have been more effective for evaluating patients' demands. For example, our respondents expected the providers to enhance the volume of readings, wall-mounted televisions, health education brochures, water, access to wheel chairs, and no-interrupted space for the minority populations.

A second limitation to this study is that we did not record and ask how long the respondents waited before receiving the questionnaire. It is indeed an important point whether the respondents had sufficient time to appraise the waiting areas. One method we used to overcome this possible pitfall was adding "not applicable" for all individual question items, in case the respondent had no experience with the individual items. In addition, the issue of social desirability bias needs to be mentioned, because some evidence has indicated that patients completing patient satisfaction questionnaires via face-to-face have higher levels of satisfaction as compared to those who receive questionnaires via post [30].

Moreover, another limitation is that our data were collected from only one medical center. A larger sample size comprised of outpatients from different medical centers should be examined to validate the findings from this study. In future research studies involving this context, patient expectations should be examined to provide more information for healthcare managers, a method by which the managers can better design healing environments. In addition, patient health status [43, 44] and personality [45] should also be considered to decrease their possible confounding effects in the study of patients' perceptions.