An interdisciplinary mixed-methods systematic review of multidimensional factors shaping the outpatient waiting experience

Abstract

Background

Patient satisfaction is a central indicator of healthcare quality and a key outcome in outpatient care. The waiting room, as the first point of contact, strongly shapes patients’ comfort, expectations, and perceptions of service quality. Yet most existing studies remain confined within single disciplinary domains rather than integrated relationships among them. This lack of cross-disciplinary synthesis limits theoretical understanding and practical guidance. A systematic review is therefore needed to develop a comprehensive framework for improving outpatient experiences and supporting evidence-based design.

Methods

A mixed-methods systematic review was conducted following PRISMA 2020 guidelines to identify major research themes and determinants of patient satisfaction in outpatient waiting rooms. Literature was retrieved from Scopus (2010–2024) using a modified PICO framework adapted for environmental and experiential variables. Quantitative bibliometric mapping analyzed keyword co-occurrence and thematic evolution across three periods, complemented by qualitative coding and thematic synthesis to interpret mechanisms and integrate findings.

Results

This review included 125 studies, 113 research articles and 12 reviews (9.6%), with most appearing in medical/clinical outlets (n = 71; 56.8%), alongside contributions from the social sciences, nursing, engineering, psychology, and management. Across 2010–2014, 2015–2019, and 2020–2024, thematic emphasis shifted from service-quality–focused work toward broader patient-experience and built-environment perspectives, reflecting increasing cross-disciplinary integration. Quantitative mapping and the qualitative synthesis consistently organized determinants into five dimensions: physical environment, healthcare service experience, patient characteristics, perceptual environment, and mediating pathways. These results collectively informed the development of an integrated conceptual framework that structures the field around these five dimensions and their dynamic interactions.

Conclusions

This review consolidates dispersed findings into a multidimensional framework explaining how environmental, psychological, and service-related factors interact to shape patient satisfaction. The proposed framework offers a comprehensive basis for future empirical work and provides practical guidance for the holistic design and management of outpatient environments across disciplines.

Background

The concept of “atmospherics” introduced by Kotler [1] refers to the influence of physical and controllable components of an environment on experience and behavior. Initially applied to marketing, it highlights how environmental factors can significantly impact purchasing decisions and has, over time, expanded to service environments such as healthcare. In healthcare, atmospherics encompasses not only the design and construction of physical spaces but also the cognitive, emotional, and physiological responses these environments elicit from patients [2]. The impact of the physical environment on patient experiences and satisfaction has been widely studied, with several researchers emphasizing its role in shaping patients’ perceptions of care quality. For example, Gotlieb et al. highlighted that patients’ perceptions of their hospital rooms were directly related to their overall view of the hospital’s quality, with cleanliness being a key factor valued by patients in several U.S. cities [3]. Similarly, Shen et al. [4] demonstrated that the indoor environmental quality of hospitals played a crucial role in patient health outcomes, further reinforcing the significant influence of environmental factors on patient satisfaction.

This emphasis on environmental factors is particularly relevant to outpatient waiting rooms, where patients spend considerable time before receiving care. The outpatient waiting experience encompasses a range of factors that influence patient perception, including the physical environment, service quality, and emotional responses [5–7]. The importance of studying the waiting experience is underscored by its significant impact on patient satisfaction, healthcare behaviors, and health outcomes [8]. Negative waiting experiences, often marked by discomfort, anxiety, and frustration, have been shown to reduce patient satisfaction and affect long-term relationships with healthcare providers [9, 10]. Notably, the waiting room experience plays a pivotal role in shaping patients’ overall perception of care quality, affecting their emotional well-being and influencing their compliance with treatment plans [11, 12].

A large body of research has been devoted to investigating how physical design elements in outpatient waiting rooms—such as seating comfort, cleanliness, noise levels, and lighting—affect the waiting experience [13–15]. Likewise, research indicates that overcrowding and uncomfortable seating are linked to heightened patient stress and dissatisfaction, whereas a comfortable, quiet environment tends to foster more positive waiting experiences [16, 17]. Additionally, the quality of interactions with healthcare personnel—including the clarity of communication, the emotional support provided, and the timely provision of information—plays a significant role in patient satisfaction [18]. Furthermore, psychological factors, particularly anxiety and uncertainty related to medical care, are central to the waiting experience. Prolonged wait times, especially when coupled with a lack of information about the medical process, have been shown to exacerbate patient anxiety, making this a critical determinant of overall patient satisfaction [19, 20]. Meanwhile, existing literature has conducted comprehensive reviews on factors influencing outpatient waiting experiences. For instance, Juliá-Nehme et al. utilized the Spatial User Experience model to examine how waiting room environments impact patients [21]. Xuan et al. critiqued the Western-centric focus of prior research, offering a comparative perspective to broaden the scope of patient satisfaction studies [6]. Additionally, Beukeboom et al. and Qi et al. integrated previous studies to explore the stress-reducing effects of nature and the holistic design of pediatric clinic waiting rooms, respectively, highlighting the importance of environmental factors in enhancing patient comfort and satisfaction [22, 23].

However, despite the growing body of research on factors influencing outpatient satisfaction, comprehensive reviews specifically focused on the outpatient waiting room remain scarce. While substantial progress has been made in examining both the physical environment and patients’ psychological and emotional experiences, existing literature tends to adopt a fragmented perspective, limiting the understanding of how these factors co-occur and jointly shape patient outcomes [24]. While factors such as waiting time, environmental comfort, and service quality in waiting rooms are widely acknowledged as key determinants of patient satisfaction, a comprehensive, multidisciplinary systematic review integrating all relevant factors, evaluating their interactions, and comparing their relative importance remains lacking in the literature. Additionally, the dynamic nature of waiting room environments has not been thoroughly explored, particularly regarding how these contextual changes impact patient satisfaction. Many studies rely on cross-sectional data, which limits the understanding of the dynamic mechanisms through which waiting room environments affect patient satisfaction [25]. Thus, investigating the interrelations among these factors is essential for providing a more comprehensive framework to enhance the outpatient healthcare experience.

In response to the identified gap—that existing studies on outpatient waiting room satisfaction are fragmented across disciplines and lack an overarching structure—this review aims to integrate these dispersed perspectives through a mixed-methods synthesis. Accordingly, it addresses two research questions: (1) How has patient satisfaction in outpatient waiting rooms been investigated across different disciplinary domains? (2) Can these diverse findings be synthesized into a multidimensional framework that systematically explains the key factors influencing satisfaction? By answering these questions, the review not only consolidates fragmented evidence into an interdisciplinary perspective but also introduces a structured framework that can guide both future research and practical efforts to improve outpatient waiting environments.

Research methods

This study employed a mixed‑methods systematic review to map central research themes and identify key determinants of patient satisfaction in outpatient waiting rooms. This review was conducted in accordance with the PRISMA 2020 guidelines for systematic reviews to ensure transparency and reproducibility. Quantitative and qualitative techniques were integrated to synthesize evidence from studies published over the past 15 years. As shown in Fig. 1, the workflow comprised three sequential phases: data collection, quantitative analysis, and critical review.

Fig. 1.

Overview of research methodology

In the first phase, a comprehensive literature search was conducted in the Scopus database using a PICO (Population, Intervention, Comparison, Outcome) framework, which laid the foundation for the study [26]. Scopus was selected due to its broad interdisciplinary coverage, high citation indexing, and inclusion of key fields such as environmental design, medicine, and psychology [27, 28]. To ensure transparency and reproducibility, a modified version of the PICO framework was employed. Originally designed for clinical evidence synthesis, PICO is widely used in systematic reviews to formulate structured and answerable research questions [29]. In this study, the “Intervention” and “Comparison” elements were replaced with “Issue” and “Context” to better reflect the complex environmental and experiential variables relevant to outpatient waiting environments. This adaptation enabled the inclusion of diverse studies spanning environmental design, healthcare service delivery, and psychological patient experience, thereby capturing the full range of factors shaping the outpatient waiting experience.

Subsequently, the quantitative analysis employed keyword co‑occurrence techniques to identify and trace the evolution of thematic structures in the literature. Bibliographic records—including titles, abstracts, author keywords, and citation information—were retrieved from Scopus and processed using VOSviewer, a standard bibliometric platform for network clustering, link‑strength assessment, and overlay visualization [30]. Author-provided keywords were used as the unit of analysis because they concisely capture each study’s core themes. To reduce semantic redundancy, a synonym dictionary was developed, consolidating terms such as “customer satisfaction” and “patient satisfaction,” and standardizing variations such as “healthcare facility” and “health care facilities” [31, 32]. A minimum occurrence threshold of two was applied to exclude infrequent terms unlikely to represent meaningful research themes [33]. Clusters were then generated using VOSviewer’s modularity optimization algorithm, grouping keywords into coherent thematic domains that reflected shared topical foci. Although this approach does not establish causality, it provides an empirical overview of the dominant thematic areas and maps the conceptual landscape of patient satisfaction research [34].

To further explore temporal dynamics, a Sankey diagram was constructed to trace the flow of standardized keywords across three publication periods (2010–2014, 2015–2019, and 2020–2024). The five-year cut-offs were chosen to obtain roughly equal sample sizes while keeping the sequence intuitive for readers, thereby facilitating comparison with patient-satisfaction trend analyses and reflecting common longitudinal segmentation practices in healthcare research.

Informed by the distribution and evolution of research themes revealed in the bibliometric analysis, the final phase entailed a critical qualitative review to interpret these patterns. This integrative synthesis yielded a multidimensional analytical framework for organizing the diverse determinants of patient satisfaction. Each study was coded according to this framework through a multi-stage iterative process involving independent coding and group discussion to resolve discrepancies. This procedure enhanced reliability and ensured that the qualitative synthesis was aligned with the bibliometric findings. By cross‑validating findings from the quantitative and qualitative analyses, the study established a robust, evidence‑based foundation for a comprehensive, multidisciplinary understanding of the interactions among environmental, experiential, and organizational determinants of patient satisfaction in outpatient waiting rooms.

Co‑occurrence mapping and thematic structure

The search identified 477 records. After title/abstract screening, 312 were excluded. We sought and retrieved 165 full texts (reports not retrieved: 0). At full-text assessment, 76 reports were excluded: non-waiting settings (n = 67), special contexts/scope mismatch (e.g., COVID-19; n = 6), and no patient satisfaction/experience outcomes reported (n = 3), preprints (n = 2). Studies conducted during the COVID-19 pandemic were excluded because they represent non-routine healthcare conditions that may introduce context-specific bias in patient satisfaction evaluation. The database search therefore contributed 87 studies. Citation searching identified 38 additional records; after assessment (reports not retrieved: 0), no further exclusions were made, yielding 38 additional studies. In total, 125 studies were included (Fig. 2).

Fig. 2.

Flowchart of literature selection process

Analysis of 125 studies shows that research on patient satisfaction has been dominated by medicine (75 papers), while also involving social sciences, nursing, engineering, psychology, and management, as shown in Table 1. This multidisciplinary presence suggests that patient satisfaction is not only a topic of healthcare service quality but is also linked to social structures, environmental design, and technological applications. Over time, both the disciplinary weight and the thematic focus have shifted, a trend that is particularly visible in the thematic evolution illustrated in Fig. 3. In this visualization, node size represents keyword frequency, and the width of links between periods reflects the strength of co-occurrence, clearly demonstrating how research themes have persisted or transformed over time. Changes in disciplinary leadership and associated research themes reflect the dynamic evolution of the field, with each period shaped by dominant disciplines that directed the extension and deepening of research themes.

Table 1.

Cross-disciplinary analysis of patient satisfaction research

Subject category	Count
Medicine	75
Social Science	9
Nursing	8
Pharmacology, Toxicology and Pharmaceutics	8
Business, Management and Accounting	6
Psychology	5
Multidisciplinary	4
Engineering	3
Arts and Humanities	2
Computer Science	1
Decision Sciences	1
Dentistry	1
Health Professions	1
Technology	1

Fig. 3.

Thematic evolution map of patient satisfaction

Period 1 (2010–2014). Research was primarily shaped by medicine and nursing, with an emphasis on healthcare service quality and basic accessibility. Frequent keywords such as service quality, healthcare, hospital, and patient-centered care indicate that the focus remained on healthcare systems and the quality of care [35–37]. Most studies in this period were published in medical journals and highlighted improvements in service processes as a means to enhance patient satisfaction.

Period 2 (2015–2019). Perspectives and methods from public health and the social sciences were increasingly incorporated into patient satisfaction research, leading to a broader thematic scope. Keywords such as waiting room, patient experience, and determinants began to appear, reflecting this expansion. Researchers shifted attention beyond the medical supply side toward patient perceptions, waiting experiences, and sociodemographic differences [25, 38, 39]. In addition, some studies compared healthcare systems across regions, highlighting how institutional and policy environments influence patient satisfaction.

Period 3 (2020–2024). Psychology, environmental science, and information science became more prominent, and research themes extended to psychological mechanisms and digital technologies. Keywords such as trust, anxiety, indoor air quality, machine learning, and social media appeared frequently, indicating that mental health, environmental design (e.g., air quality and spatial atmosphere), and digital tools were increasingly incorporated into the analytical framework of patient experience [40–42]. The growing number of studies in architecture and computer science further illustrates the strengthening trend of interdisciplinary integration.

After examining the temporal evolution of themes, it is also important to consider the overall connections and interrelations among research topics. As shown in Fig. 4, the knowledge structure of patient satisfaction research reveals clusters that reflect how topics have gradually differentiated and intertwined over time. The density and strength of connections between nodes indicate that core concepts such as patient satisfaction, service quality, and quality of care occupy pivotal positions across disciplines and provide the foundation of the research framework. Figure 5 illustrates the temporal characteristics of thematic development. Traditional topics such as service quality and hospital established the early foundation of the field, whereas the subsequent emergence of psychological and technology-related topics, including anxiety, machine learning, and social media, demonstrates a shift from single-dimensional quality assessment toward environmental perception and digital transformation. Table 2 provides statistical evidence for this trend by presenting the distribution of high-frequency keywords: patient satisfaction consistently shows the highest frequency and strongest connections, while newer topics such as patient experience and waiting room indicate the extension of research boundaries. Overall, patient satisfaction research now demonstrates a comprehensive, interdisciplinary, and multi-dimensional pattern, with key factors distributed across different clusters. Building on this structure, the following section will focus on five thematic clusters and examine the research priorities and methodological orientations within each.

Fig. 4.

Author keyword co-occurrence network

Fig. 5.

Visualization of the average age of keywords

Table 2.

Top keywords in patient satisfaction literature

Cluster	Keyword	Frequency	Average Year	Total Link Strength
1	machine learning	2	2022	7
	patient experience	9	2020.4	22
	patient stress	3	2019.7	5
2	social media	2	2021.5	7
	China	6	2020.5	12
	outpatient satisfaction	8	2019	16
3	patient satisfaction	69	2019.3	131
	quality of care	15	2018.4	35
	service quality	18	2018.4	43
4	physical environment	5	2018.6	14
	waiting room	7	2018.7	4
	patient loyalty	6	2018.8	11
5	communication	2	2021	7
	determinants	4	2019	11
6	patient-centered care	3	2019	8
	continuity of care	2	2018.5	2

Cluster 1 mainly examines the influence of the waiting room environment on “patient stress” (Avg. pub. year = 2019.7) and “patient experience” (Avg. pub. year = 2020.4). Research in this cluster is primarily led by medicine and nursing, with additional contributions from psychology and engineering. Common methods include questionnaire surveys, on-site monitoring, and experimental designs, which are used to reveal how waiting rooms shape anxiety and satisfaction from different perspectives. In medicine and nursing, some studies have applied approaches such as “machine learning” (Avg. pub. year = 2022) to identify key determinants of patient experience through techniques like random forests or multi-dimensional models. For example, Almaazmi et al. reported that facility conditions, waiting processes, and service response speed significantly affect anxiety and satisfaction [43]. In psychology and engineering, environmental exposure and experimental paradigms are often employed to examine the mechanisms through which environmental elements influence patient outcomes. For instance, studies have introduced real and artificial plants into waiting rooms to compare psychological responses under different natural settings, aiming to test the regulatory effect of biophilic design on anxiety levels [22]. Other work has combined questionnaires with situational presentations to analyze how natural elements alter patients’ subjective perception of waiting time and thereby influence their medical experience [7]. Overall, this cluster highlights the waiting room as a key context for psychological adjustment and underscores the role of emotional experience in shaping patient satisfaction.

Cluster 2 is centered on the keyword “outpatient satisfaction” (Avg. pub. year = 2019). Most related studies were published in the medical field, with additional contributions from nursing, psychology, pharmacology, and the social sciences. Research in this cluster focuses on measuring and interpreting patients’ overall evaluation of outpatient medical experiences. The majority of studies employ questionnaires and statistical modeling to examine perceptions of service quality, waiting experiences, and the degree of expectation fulfillment. Sociodemographic variables are commonly incorporated into these models to reveal differences in satisfaction across groups. Studies conducted in countries such as “China” (Avg. pub. year = 2020.5), India, and Ethiopia have widely adopted demographic variables, underscoring the importance of these variables as analytical dimensions in outpatient satisfaction research [14, 44]. In recent years, the introduction of “social media” (Avg. pub. year = 2021.5) has broadened research methods. Nursing studies have also begun to emphasize the role of institutional and cultural contexts in shaping patient experience [25]. In psychology and engineering-related work, patient feedback on waiting spaces, cleanliness, and facility conditions has been extracted from social media comments to complement traditional questionnaire-based approaches [40]. Taken together, this cluster shows that outpatient satisfaction functions not only as a comprehensive outcome measure but also as a convergence point for exploring service quality, environmental perception, and expectation management.

Cluster 3 focuses on how medical services and care quality shape “patient satisfaction” (Avg. pub. year = 2019.3). Research in this cluster spans medicine, nursing, management, and the social sciences, though medicine and nursing remain dominant. Discussions of “service quality” (Avg. pub. year = 2018.4) are most extensive, with about 26 of the 125 studies addressing this topic. By contrast, “quality of care” (Avg. pub. year = 2018.4) is concentrated in medicine and nursing, with greater emphasis on evaluating professional nursing and clinical services. In medicine and nursing, studies commonly employ questionnaires and cross-sectional surveys to assess the influence of factors such as nursing professionalism, service timeliness, and communication transparency on satisfaction [44, 45]. In management and social sciences, the focus is on measuring service experience, with methods such as factor analysis and structural equation modeling used to demonstrate the significance of waiting time management, customer orientation, and organizational process optimization [46]. Research in technology and decision sciences has introduced machine learning and neural networks to analyze large-scale data and identify key drivers of satisfaction [41]. Different disciplines thus contribute distinct perspectives: medicine and nursing emphasize professionalism and processes; management highlights experience and institutional differences; and technical fields advance methodological innovation. Collectively, these approaches underscore the stable core position of service quality in shaping patient satisfaction.

Cluster 4 focuses on the influence of the “physical environment” (Avg. pub. year = 2018.6) of the “waiting room” (Avg. pub. year = 2018.7) on patient satisfaction. Relevant studies generally use questionnaire surveys, environmental monitoring, and cross-sectional designs to examine how elements such as spatial layout, lighting, air quality, noise, and cleanliness affect patient comfort, and in particular, “patient loyalty” (Avg. pub. year = 2018.8). In public health, environmental health, and occupational health research within the medical field, greater attention has been given to how physical conditions in waiting rooms can enhance comfort, satisfaction, and willingness to return for follow-up visits. For example, on-site monitoring of waiting areas combined with patient surveys has revealed the significance of factors such as illuminance, air circulation, and temperature and humidity in shaping satisfaction [40]. Engineering studies incorporate environmental variables into quantitative analyses to explore dose-response relationships between environmental quality and satisfaction [47]. In the social sciences, research links the waiting room environment with patients’ overall perception of medical institutions, highlighting how cleanliness and spatial comfort can influence social identity and loyalty [48]. Overall, this cluster indicates that the physical environment of the waiting room plays a fundamental role in patient satisfaction, influencing not only short-term medical experiences but also long-term loyalty through comfort and security.

Cluster 5 mainly addresses “continuity of care” (Avg. pub. year = 2018.5) and “patient-centered care” (Avg. pub. year = 2019), with research concentrated in medicine and nursing. Scholars commonly use cross-sectional or longitudinal surveys to examine continuity of care across different stages of patient visits, emphasizing the role of informational, managerial, and relational continuity in shaping satisfaction and trust [39]. Based on the patient-centered care framework, some studies further highlight the importance of patient participation and personalized care in improving satisfaction and loyalty, particularly in nursing services and primary care [49]. In essence, this cluster reflects a shift from single-visit experiences toward continuous care and patient-centered long-term relationship building, demonstrating the deepening of satisfaction research along the temporal dimension.

Informed by the thematic evolution, keyword co‑occurrence statistics, and cluster analysis presented above, it is evident that research on patient satisfaction—though dispersed across disciplines and approaches—exhibits an underlying, interconnected logic. Building on these insights, this study proposes a multidimensional analytical framework that integrates the core determinants and explicates the mechanisms and interrelationships through which they shape the outpatient waiting experience.

Multidimensional factors of patient experience

Following the thematic evolution and cluster analysis, it is evident that patient satisfaction in outpatient waiting rooms is influenced by multiple factors spanning various disciplines. As depicted in Fig. 6, these findings (i.e., the factors influencing the outpatient waiting experience) can be examined using the multidimensional framework proposed in this review. This framework comprises five domains: physical environment, service quality, psychological states, sociodemographic characteristics, and indirect variables. This framework aligns with the multidisciplinary nature of patient satisfaction research; the five domains operate interdependently, with some exerting direct influences on satisfaction outcomes and others shaping patient perceptions through more subtle or mediated pathways. Recognizing this multidimensional structure provides a clearer perspective on how patients evaluate their waiting experiences. The following section unpacks each of these five dimensions in turn, examining both their individual contributions and the mechanisms through which they intersect to shape satisfaction in outpatient settings.

Fig. 6.

Multidimensional factors of patient satisfaction

Physical environmental

The physical environment of waiting areas plays an important role in the patient journey and has been shown to influence satisfaction, experiential evaluations, perceived waiting time, and behavioral responses [6]. Furthermore, patients’ perceptual assessments of environmental conditions have been shown to directly mediate their comprehensive appraisals of hospital service quality [50]. Key elements such as spatial layout, equipment, and cleanliness jointly shape patient satisfaction. The following sections detail their respective roles in outpatient settings.

Spatial layout

Spatial layout refers to the organization and arrangement of spaces within healthcare settings, such as waiting areas, consultation rooms, and corridors. An effective spatial layout supports easy wayfinding and reduces confusion, thereby lowering patient anxiety and enhancing comfort during the visit, especially for first-time visitors [51].

In particular, the spatial characteristics of waiting areas, such as openness and size, have a direct impact on patient experiences. Spacious, well-organized waiting rooms have been consistently linked to greater patient comfort and higher satisfaction levels [21]. A survey of 219 outpatients in Chinese hospital clinics found a significant positive correlation between patients’ overall waiting experience and the spatial dimensions of waiting areas [6]. In contrast, cramped or overcrowded spaces often lead to lower satisfaction, especially during long waits, by exposing patients to crowded, uncomfortable conditions [19].

In addition to these direct effects, spatial layout also influences patient satisfaction through indoor environmental quality—especially indoor air quality (IAQ). Narrow corridors or tightly packed rooms tend to have poor air circulation, resulting in air stagnation and elevated pollutant levels [52]. High occupant density further restricts airflow and increases contaminant concentrations, worsening patients’ perceptions of the environment [53].

Consequently, optimizing spatial layout can enhance immediate psychological comfort while simultaneously addressing crucial indirect factors such as ventilation and IAQ, ultimately leading to higher overall patient satisfaction.

Facilities and equipment

As a fundamental component of the outpatient experience, facilities and equipment encompass not only the physical layout and comfort of the waiting area but also the accessibility of amenities and the availability of modern medical and digital infrastructure. These tangible elements serve as the first point of contact between patients and the healthcare environment, shaping their initial impressions and overall satisfaction.

The spatial configuration and ergonomic design of seating in waiting areas significantly influence patients’ waiting experiences [21]. An empirical study by Sui et al. has demonstrated that rigid or non-ergonomic seating designs are frequently associated with heightened patient dissatisfaction, underscoring the importance of ergonomic considerations in furniture selection [54]. Specifically, seating that incorporates ergonomic principles has been shown to reduce physical discomfort and enhance overall patient satisfaction metrics. In a quantitative study employing patient surveys, researchers established that the comfort of hospital environments and diagnostic facilities directly impact experiential outcomes, with optimal facility design being particularly critical in specialized settings such as orthopedic outpatient clinics [55].

Beyond hardware infrastructure, the modernization of digital infrastructure is equally pivotal [44, 56]. Studies have demonstrated that providing real-time appointment updates via digital displays or other platforms enables patients to better track their visit progress, thereby improving holistic satisfaction [39, 57]. Furthermore, granting patients autonomy in selecting seating or accessing amenities within waiting areas has been empirically linked to enhanced holistic care experiences [58]. These findings collectively emphasize that facilities and equipment are pivotal in optimizing patient-centered healthcare environments.

Hygiene and cleanliness

Within healthcare settings, cleanliness constitutes a critical determinant of patient satisfaction and trust. Patients often consider cleanliness as a top priority, with visible dirt or neglect causing immediate concern and negative impressions. A clean waiting room—including one with spotless floors, tidy seating, and well-maintained restrooms—plays a pivotal role for shaping patients’ holistic care experiences. While Desta et al. did not specifically study the impact of waiting room cleanliness on patient satisfaction, their findings highlighted that a clean healthcare environment is an essential component of quality healthcare. They found that cleanliness and proper maintenance of the healthcare setting are factors that can positively influence patients’ perceptions and satisfaction levels [14]. As Chandra et al. revealed in their survey [45], there is a significant positive correlation between patients’ evaluations of environmental hygiene and their overall satisfaction metrics, a finding that is corroborated by the results of Ke et al. [44]. Consequently, healthcare institutions must prioritize rigorous sanitation management protocols to ensure the provision of a comfortable and safe healthcare environment, ultimately enhancing patient satisfaction and institutional trustworthiness.

Healthcare service experience

Beyond the physical environment, patient satisfaction is strongly influenced by the healthcare service experience, which is shaped by healthcare processes and human interaction and encompasses three critical dimensions: service attitude, service quality, and social support systems. The clinical competence of healthcare providers, quality of information delivery, and emotional support play pivotal roles in enhancing patient satisfaction [59]. Furthermore, robust social support networks and patient-centered care initiatives significantly alleviate patient anxiety and reinforce trust in healthcare services [42].

Service quality

Service quality, which emphasizes the professionalism, efficiency, and outcomes of healthcare delivery, serves as a critical metric for evaluating healthcare delivery standards [14]. This paper, however, focuses specifically on the professionalism of nurses and response efficiency in the waiting room. Mohebbifar et al., through cross-sectional survey analysis, revealed that during the waiting period, healthcare personnel’s professional competence and the quality of information communication are critical determinants of patient satisfaction [19]. Even in scenarios of prolonged waiting times, patients’ satisfaction levels may remain elevated when healthcare providers deliver timely and effective communication [60]. Consequently, this underscores the importance of prioritizing healthcare professionals’ communication proficiency and professional competencies to align with patient expectations throughout care delivery.

Furthermore, fostering a health-literate environment is essential for optimizing satisfaction metrics. This involves providing accessible, clear, and comprehensible medical information through patient education initiatives, thereby empowering patients to better understand their health status and therapeutic regimens [61]. These initiatives strengthen patient autonomy while optimizing healthcare experiences. By integrating clinical expertise with communication efficiency and health literacy initiatives, healthcare institutions can significantly enhance overall patient satisfaction and trust.

Service attitude

Service attitude, defined as the emotional expression, behavioral conduct, and communication styles of healthcare providers during patient interactions, directly shapes patients’ subjective perceptions and overall healthcare experiences [41]. Empirical evidence consistently underscores the critical role of healthcare providers’ emotional support, approachability, and patience in enhancing patient satisfaction [24, 25, 57]. Specifically, when healthcare professionals respond to patients’ concerns with patience and treat them with respect, satisfaction with healthcare services increases significantly [20]. Based on more than 130 h of semi-structured interviews, Chu et al. demonstrated that explicit and heartfelt apologies from medical staff substantially mitigate the negative emotional responses patients experience due to a long waiting period [39]. For elderly patients, effective and high-quality communication is especially crucial in promoting better health outcomes [62]. These findings underscore the growing recognition that patient-centered care—characterized by respectful, empathetic, and individualized provider-patient interactions—is essential to improving both patient satisfaction and clinical outcomes, making it a core priority in healthcare research and practice [49].

Social support system

The social support system refers to the support resources available to patients through healthcare facilities or within the community, which help them manage the emotional and practical challenges of care [63]. In the context of outpatient waiting experiences, social support also plays an important role in shaping how patients perceive and cope with delays in service. As demonstrated by Wang et al., perceived social support not only alleviates anxiety during healthcare encounters but also directly modulates satisfaction with medical services [42]. One important form of such support comes from interpersonal interactions among patients in waiting areas, which have been empirically shown to boost emotional well-being and improve patients’ overall evaluations of hospital services [46]. Equally important is the involvement of family and friends during the treatment process, as their support helps reduce emotional stress and reinforces adherence to medical guidance, thereby further elevating satisfaction outcomes [42, 64]. When patients feel emotionally supported by those around them, they are also more likely to develop a sense of trust in the care process.

Consequently, healthcare institutions should prioritize initiatives to foster patients’ social support networks, which can be achieved by designing environments that encourage interpersonal engagement and communication. Such initiatives not only ameliorate patients’ emotional experiences but also strengthen their trust in healthcare systems and satisfaction outcomes.

Patient demographic characteristics

Outpatient satisfaction is not determined solely by environmental or service-related factors; it is also deeply influenced by patients’ own characteristics and perceptions. Individual differences shape how care is experienced, interpreted, and evaluated. Specifically, research highlights the roles of sociodemographic attributes, expectations, psychological or emotional states in shaping satisfaction outcomes. Exploring these dimensions provides insight into the patient side of the care experience, and helps inform more personalized strategies for service improvement.

Sociodemographic characteristics

Patients’ sociodemographic characteristics, such as age, gender, education level, income, and place of residence, are closely associated with differences in their perception of care [65, 66]. These attributes often correspond to distinct patterns of care-seeking behavior and service priorities. For instance, Ren et al. found that older adults are more attentive to the comprehensiveness and reliability of medical services, whereas younger patients are more sensitive to issues like waiting times, indicating generational divergence in care preferences [57]. Socioeconomic status also matters [67, 68]. Individuals with higher income and education levels are typically more concerned with the efficiency and professionalism of care [67, 69], while older or lower-income patients may place greater value on environmental comfort and provider attentiveness [70]. Additionally, other demographic factors such as gender and urban-rural residency have been linked to variations in how patients rate their care experiences [65, 71]. In light of these findings, it is imperative for healthcare institutions to implement personalized care protocols that account for demographic-specific expectations to optimize satisfaction outcomes in outpatient settings.

Patient expectations

Patient expectations refer to individuals’ preconceived beliefs or assumptions about the nature, quality, and timeliness of medical services they are about to receive. These expectations serve as a dual function: they can either mitigate the psychological discomfort associated with waiting or exacerbate negative emotional responses [69]. It is noteworthy that the level of expectation regarding outpatient waiting times varies significantly across patient groups, which directly influences their satisfaction with healthcare services [66]. Ma et al. found that providing patients with unfavorable information about potential delays effectively lowered their expected waiting time, which in turn reduced dissatisfaction when actual waits were prolonged [60]. This suggests that expectation management through early communication can buffer negative emotional responses during outpatient waiting. Failure to meet patient expectations, especially in terms of service quality, may lead to negative evaluations of the overall service [41].

Moreover, in the age of digital communication, social media has become a prominent space for patients to share their healthcare encounters. These user-generated narratives do more than reflect personal experiences; they also shape the expectations of future patients by influencing perceptions of what constitutes acceptable waiting conditions and service quality [40]. Given these evolving dynamics, it is essential for hospitals to actively manage and align patient expectations within the outpatient waiting context. By doing so, they can enhance patient satisfaction, mitigate the negative emotional effects of waiting, and ultimately contribute to a more constructive doctor-patient relationship.

Psychological and emotional states

Patients’ psychological and emotional states, including mental and affective conditions, influence the way they interpret and react to healthcare experiences. Almaazmi et al. have established that psychological stressors—such as anxiety, frustration, and perceived stress—exert a significant adverse impact on patients’ experiences within the outpatient waiting environment [43]. These negative emotional states are often triggered by extended waiting times, uncertainty regarding diagnosis or treatment outcomes, and perceived inadequacies in service quality. Within this context, patients’ emotional conditions, particularly their levels of anxiety and psychological stress, function as crucial mediating variables in the formation of their evaluations of healthcare services [7]. Specifically, patients with lower anxiety levels and greater emotional resilience are more likely to provide favorable assessments of outpatient services, as they are better equipped to cope with waiting-related stress and uncertainty. Conversely, when anxiety is heightened, patients tend to interpret care experiences more negatively, often perceiving lower service quality and less satisfactory interactions [41].

These findings underscore the importance of addressing the emotional dimension of the outpatient waiting experience. Accordingly, by enhancing patients’ emotional well-being during the waiting process, healthcare providers can improve overall satisfaction and foster more favorable evaluations of the healthcare encounter [64].

Perceptual environment

In addition to structural and spatial design, patients’ satisfaction with outpatient care is directly shaped by the human perceptual environment, which refers to individuals’ subjective experiences in sensing and interpreting ambient conditions [7]. This domain encompasses key perceptual dimensions such as visual comfort (affected by illumination), thermal comfort (influenced by temperature and humidity), olfactory comfort (related to environmental odors), and acoustic comfort (related to background sound). Although these environmental stimuli can be objectively measured, their effects on patient satisfaction primarily emerge through patients’ sensory perceptions and emotional responses. Recognizing and optimizing these perceptual dimensions is therefore essential for designing outpatient environments that are both psychologically supportive and conducive to higher patient satisfaction.

Thermal comfort

Thermal comfort, which reflects individuals’ subjective perceptions of ambient temperature and humidity, constitutes a critical dimension of the perceptual environment that directly influences patients’ physical well-being and emotional regulation during the outpatient waiting process. As interrelated perceptual factors, temperature and humidity jointly shape thermal comfort through their combined impact on thermoregulatory and sensory systems. Shao et al. demonstrated through experimental research that fluctuations in ambient temperature significantly affect patients’ psychophysiological states, particularly in psychiatric populations, where thermal variations may either exacerbate or alleviate clinical symptoms [72]. Similarly, relative humidity levels within the perceived comfort range—generally around 40% to 60%—are associated with enhanced subjective comfort, while extreme deviations (e.g., below 30% or above 70%) often lead to discomfort, irritability, and heightened stress responses [52].

Maintaining stable and optimal thermal comfort in outpatient waiting areas is therefore essential for minimizing environment-induced anxiety and fostering a more supportive patient experience.

Visual comfort

Visual comfort, reflecting patients’ subjective evaluations of illumination conditions, plays a critical role in shaping emotional regulation and satisfaction within outpatient waiting environments. This dimension encompasses both artificial lighting and natural daylight, with variations in intensity, distribution, and quality directly influencing patients’ perceptual and emotional responses [13]. Thoughtfully designed illumination contributes to a calming spatial atmosphere, which in turn supports emotional regulation and improves the overall waiting experience [48]. Empirical research by Juliá et al. demonstrated that both excessively dim and overly bright lighting conditions can provoke negative emotional reactions, leading to increased discomfort during waiting periods [21]. In contrast, Morales and Navarrete highlighted the restorative benefits of natural daylight, noting its positive association with psychological well-being and emotional stability in enclosed healthcare spaces [73]. By optimizing visual comfort, outpatient facilities can create psychologically supportive environments and enhance patient satisfaction.

Olfactory comfort

Olfactory comfort, referring to patients’ subjective evaluations of ambient odors, represents a subtle yet influential component of the perceptual environment in outpatient waiting areas. In healthcare settings, olfactory stimuli arise from diverse sources such as cleaning agents, medical supplies, and the ambient surroundings. Although often overlooked, these odors have been shown to influence patients’ psychological states and emotional well-being [13]. Empirical studies have demonstrated that pleasant and fresh-smelling environments can significantly enhance emotional responses and positively shape perceptions of the waiting experience. Notably, patients’ evaluations of the olfactory environment are strongly correlated with self-reported comfort levels and situational anxiety [74]. Furthermore, research suggests that scent-based interventions, such as therapeutic aromatherapy, may serve as effective non-pharmacological strategies for alleviating anxiety during prolonged waiting periods [75]. As such, strategic optimization of olfactory comfort holds potential not only for improving immediate emotional well-being but also for enhancing overall satisfaction with outpatient healthcare services.

Acoustic comfort

Patients’ experiences within outpatient waiting areas are also strongly shaped by the acoustic environment, which serves as a fundamental component of the broader perceptual context. The acoustic environment encompasses various auditory elements, including background noise, conversational sounds, and intentionally introduced features such as ambient music. Variations in acoustic conditions have been directly linked to differences in patients’ satisfaction with care services. Empirical studies have indicated that elevated noise levels are associated with lower patient satisfaction ratings and more negative evaluations of the care environment [13]. In particular, qualitative studies in psychiatric outpatient clinics have reported that disruptive noise may lead to unfavorable perceptions of service quality and comfort [54].

In contrast, appropriately designed auditory interventions—such as carefully controlled background music—have been found to improve patients’ evaluations of the waiting experience and contribute positively to satisfaction outcomes [76]. However, the effectiveness of such interventions depends on specific parameters, including volume, exposure duration, and frequency, as poorly managed auditory stimulation may compromise perceived quality [77].

Accordingly, enhancing acoustic comfort represents a practical and effective means of promoting higher patient satisfaction in outpatient settings.

Indirect variables

Building on the direct influences, recent studies highlight that in outpatient waiting environments, patient anxiety can be effectively alleviated through targeted environmental design, primarily by regulating emotions and redirecting attention [7]. Interventions incorporating low-saturation color schemes, natural elements (e.g., greenery, biophilic walls), and visual media (e.g., art displays, health education videos) have shown promise in reshaping patients’ emotional responses and perceptions of waiting. Rather than functioning in isolation, these elements interact with physical settings, service quality, and patient characteristics, collectively forming an integrated “environment–emotion–behavior” framework for optimizing the outpatient care experience.

Color design

Color design refers to the intentional use of color schemes within physical environments to influence individuals’ emotional and psychological responses. A growing body of empirical research underscores the calming potential of color design in outpatient settings. For instance, studies have shown that warm hues such as yellow and orange are consistently associated with comfort and optimism, making them effective in reducing emotional distress [78]. These effects have been observed not only in pediatric populations but also among adults, suggesting the cross-age applicability of color-based interventions in clinical environments [79]. Building on this evidence, research by Huber and Bailey—who collected responses from 1,114 women shown various waiting room photographs—further demonstrated that while cultural background influences specific color preferences, the underlying psychological benefits of thoughtful chromatic strategies remain robust across diverse demographic groups. Strategically selected color schemes have been shown to alleviate anxiety and enhance patients’ subjective evaluations of the waiting experience, regardless of age or cultural background [80].

These findings collectively emphasize the value of evidence-based color interventions as a key component in outpatient spatial design, with meaningful implications for both emotional well-being and perceived service quality [81, 82].

Natural environment design

Natural element design refers to the deliberate incorporation of biophilic features such as live indoor plants and nature-themed images into built environments to evoke the calming and restorative effects of nature. Empirical studies consistently show that these natural elements can reduce patient anxiety and shorten perceived waiting time, which indirectly improves overall satisfaction with healthcare services [7]. For example, the presence of wooden textures enhances feelings of warmth and relaxation, leading to more positive evaluations of the care environment [83]. Notably, research has shown that there appears to be an optimal visual density of natural elements in interior spaces, typically ranging from 13% to 24%, that yields the most significant psychological and stress-reducing benefits, avoiding overstimulation while maximizing restorative potential [84].

Controlled experiments by Beukeboom et al. revealed that exposure to genuine natural elements (e.g., live plants) produces stronger therapeutic effects compared to artificial substitutes like plastic greenery. However, when live plants are not feasible, simulated nature still effectively alleviates stress and promotes environmental comfort [22].

Grounded in biophilic design principles, the presence of vegetation and nature-inspired aesthetics has been widely validated as beneficial to patients’ emotional regulation, psychological recovery, and spatial satisfaction [4, 13, 48]. Consequently, strategic integration of biophilic elements should be prioritized in the design of outpatient facilities to optimize patient-centered care and improve spatial experiences.

Artistic and media elements

Artistic and media elements refer to the incorporation of visual art, digital media, and interactive installations into physical spaces, aiming to enrich the sensory environment through diverse forms of perceptual stimulation. By engaging visual and auditory channels, such strategies help mitigate anxiety, particularly during extended waiting periods. For example, the incorporation of television content in pediatric outpatient zones has been shown to not only ease children’s anticipatory distress but also lessen caregiver anxiety, thus reinforcing a positive care dynamic for families [85].

In parallel, the presence of curated visual art—such as paintings or sculptural displays—has been empirically associated with improved emotional balance and psychological comfort in adult patient cohorts [86]. Beyond static visual enhancements, interactive artistic installations provide immersive experiences that help divert attention, reduce perceived waiting time, and counteract feelings of isolation within the waiting environment [38].

These approaches illustrate the utility of integrating multisensory artistic and media elements into outpatient spatial planning. By aligning aesthetic stimulation with psychoeducational engagement, healthcare facilities can construct more responsive and psychologically attuned environments that promote patient-centered care and experiential quality.

Discussion and future directions

This review consolidates recent empirical studies on how outpatient waiting environments influence patient satisfaction and reveals a consistent pattern: satisfaction is not determined by a single factor but emerges from the multifaceted interaction of environmental, psychological, service-related, and sociodemographic dimensions [6, 65]. Among these, perceptual environmental attributes—such as ambient temperature, lighting, humidity, odors, and acoustic comfort—consistently shape patients’ subjective evaluations of care quality. These perceptions are further moderated by patients’ psychological predispositions and demographic characteristics, underscoring the importance of contextualized and patient-centered design approaches [67, 71].

Despite the increasing recognition of this multidimensional structure, current research still exhibits several critical limitations. Most studies continue to examine environmental factors in isolation, overlooking the complex interdependencies among environmental features and patient-specific attributes. This fragmented approach limits the development of integrative design strategies that account for synergistic or conflicting effects between variables. Although promising interventions—such as the incorporation of natural elements, color and lighting adjustments, acoustic improvements, and digital media integration—have been identified, they are typically tested independently rather than within a unified framework [7, 38, 39, 75, 79]. Consequently, it remains unclear how different environmental and psychological factors interact to shape overall satisfaction. For instance, biophilic design can alleviate anxiety, but its effect varies across patients with different aesthetic preferences or health literacy levels [61]. Likewise, digital information systems and intelligent queuing interfaces can help manage perceived waiting time and enhance service transparency, yet their effectiveness depends heavily on patients’ technological adaptability and trust in such systems [87].

Furthermore, factors such as patient density, family involvement, and urban-rural disparities in healthcare access—particularly in developing countries—remain insufficiently explored [44, 71]. Current studies also seldom simulate patients’ emotional states or cognitive processing during the waiting experience, which restricts the understanding of how design interventions can optimize both perceptual and behavioral outcomes. Moreover, cross-sectional research designs struggle to capture the evolving expectations and emotional dynamics of patients in increasingly digital and data-driven healthcare environments [45].

A note on the COVID-19 pandemic. The pandemic may have temporarily heightened patient sensitivity to certain environmental attributes (e.g., crowding, layout, air quality) [88, 89]. However, because this review focuses on identifying the categories of factors influencing outpatient satisfaction rather than estimating effect sizes, this shift does not alter the qualitative structure of our findings. The proposed multidimensional framework remains applicable to routine outpatient settings.

The synthesis of these findings highlights the need for a paradigm shift from reductionist environmental analysis toward integrative, dynamic, and patient-centered models. By situating patient satisfaction at the intersection of environmental psychology, health services research, and design science, future frameworks can better inform the evidence-based design of outpatient spaces. This perspective supports a transition toward “responsive environments” that not only meet functional needs but also enhance psychological well-being through adaptive environmental cues.

To address these gaps, future research can be advanced through three interrelated directions.

First, future studies should move beyond single-factor analysis to establish holistic frameworks synthesizing environmental, psychological, technological, and cultural variables. This includes integrating environmental factors (color, lighting, soundscape, biophilic elements, olfactory and thermal comfort) with psychological dispositions (anxiety sensitivity, aesthetic preference) and service dimensions (digital media integration, family involvement, real-time information systems). Such frameworks should promote adaptable, patient-centered environments capable of dynamically responding to diverse user profiles.

Second, patient satisfaction evolves with sociocultural change, healthcare reform, and technological diffusion. Longitudinal and comparative studies are needed to track these shifts and to examine how variables such as urban–rural disparities, cultural norms around family participation, and digital literacy mediate satisfaction outcomes—particularly in developing regions where healthcare access and resources differ substantially.

Third, realizing these multidimensional and evolving frameworks requires methodological innovation. The complex, non-linear interactions among environmental, psychological, and service-related variables—and their evolution over time—pose challenges that traditional empirical approaches struggle to capture. To address this, future research can leverage data-driven and computational modeling techniques, such as machine learning, to analyze large-scale behavioral and perceptual data and to identify latent determinants of satisfaction. In addition, emerging generative and simulation-based design tools can assist researchers and practitioners in visualizing and testing how specific design configurations influence patients’ emotions, expectations, and behaviors before real-world implementation. Rather than representing a separate line of inquiry, these approaches extend and operationalize the proposed multidimensional framework, enabling healthcare environments that are more adaptive, evidence-based, and patient-centered.

Collectively, these insights reaffirm that improving patient satisfaction in outpatient waiting rooms demands an interdisciplinary and dynamic perspective—one that integrates environmental quality, service experience, psychological well-being, and contextual diversity into a coherent framework for future research and practice.

Conclusion

This review synthesized fragmented evidence on outpatient waiting-room satisfaction across disciplinary domains and integrated these findings into a cohesive, multidimensional framework. While this conceptual framework clarifies how environmental, psychological, and service-related dimensions interact to shape patient experiences, it is important to contextualize its contributions within the study’s limitations. These include the reliance on a single database and English-language literature, the inherent constraints of bibliometric keyword analysis, and the field’s predominant use of cross-sectional data, which collectively necessitate cautious interpretation and empirical validation of the proposed interactions.

Precisely these limitations, however, serve to define the critical research gaps and underscore the necessity for a forward-looking agenda. To this end, the review advances a research framework with three priorities: (1) developing integrated, multidimensional design models; (2) promoting longitudinal and cross-cultural studies to capture dynamic and contextualized patient journeys; and (3) leveraging adaptive, data-informed optimization through continuous feedback. By charting these pathways, this review provides a foundational conceptual tool for interdisciplinary collaboration. Future research building upon this foundation is poised to support the development of more targeted, flexible, and patient-centered outpatient environments, ultimately enhancing patient experiences and advancing the overall quality of healthcare services.

Author contributions

The first draft of the manuscript was prepared by Fanyu Yang和Yuxuan Zhang, Chendi Wang and Jingfeng Yuan reviewed and edited the manuscript. All authors read and approved the final version of the manuscript submitted for publication.

Funding

The study was supported by the National Natural Science Foundation of China (Grant No. 72401131), the Natural Science Foundation of Jiangsu Province (Grant No. BK20241398), and the Ministry of Education’s Humanities and Social Science Fund (Grant No. 23YJCZH311).

Data availability

All data generated or analysed during this study are included in this published article.

Declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.