The overall method was to synthesize theories and evidence of relevance to the design and content of garden environments in healthcare settings. This is in accordance with theory triangulation, which was described by Patton (2002) as the use of multiple theoretical perspectives to examine and interpret data. Thus, in the present study, theory triangulation was used to begin the development of an evidence-based tool that we henceforth call the quality evaluation tool (QET).
The procedure comprised two steps: (1) developing the theoretical principles of the QET and (2) beginning the development of the practical construction of the QET. To increase validity, each step was carried out using a process in which the two authors discussed the principles, construction and content of the QET until consensus was reached.
Developing the theoretical principles of the QET
The theoretical principles are intended to illustrate how the QET is related to basic theories of restorative environments and to clarify the theoretical evidence-based nature of the QET. Theories and models were selected that have implications either for general design or for constituents of outdoor environments in healthcare settings. One theory was used as the foundation, and other theories and concepts were then related to this theory using a set of models. These models formed the basis for developing the practical structure of the QET.
Developing the practical construction of the QET
This article takes a first step toward the practical construction of the QET, to present an outline for future expansion. This first step mainly regards the development of environmental qualities. As the QET is intended to be used in EBD processes in healthcare settings, the environmental qualities are based on evidence-based research. Evidence that is useful in design processes is based on both quantitative and qualitative research (Viets, 2009). To increase the validity further, all evidence (i.e., environmental qualities) included in the present study is confirmed by multiple sources and originates either from international peer reviewed journals or from reputable scientific anthologies. However, credible evidence-based explanations are achieved only when they are based on good theoretical models (Giacomini, 2009). Hence, our aim is to integrate evidence based on field research (interventions, POEs, questionnaires, interviews, observations) with theories in health and design.
The basic ambition has been to encompass a wide range of needs: from basic human needs to the general needs of individuals in healthcare settings. Thus, the QET aims to include needs due to poor general health in connection to impaired physical and/or cognitive functions as well as emotional disabilities and fatigue. The following works have had particular influence on the overall set-up of the QET and on the environmental qualities in particular:
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Grahn et al.’s (2010) eight main dimensions of experience that constitute the fundamental building blocks of parks and gardens and that has been evaluated in a Swedish healthcare garden.
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Cooper Marcus’ (2007) ten design guidelines for hospital outdoor space, for the garden to be used and reach its full potential.
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Bengtsson and Carlsson, 2006 and Bengtsson and Carlsson, 2013 descriptions of 10 respective 12 themes describing nursing home residents’ needs and sensitivities in their contact with the outdoor environment.
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Rodiek's (2008) tool for evaluating senior living environments; a tool that consists of seven environmental principles with nine to ten assessable items in each.
In addition, research focusing on other groups with specific needs with regard to the outdoors has been added from particular POE studies, as well as from Cooper Marcus and Barnes, 1999a and Cooper Marcus and Barnes, 1999b anthology.
The collected data were processed to allow description of coherent environmental qualities that are intended to be useful in design processes. The number of qualities and their descriptions were carefully considered so as to achieve a diverse but still workable tool. The theoretical principles were used as a guide to place the environmental qualities in a larger context, the aim being to achieve design solutions of a general character that facilitate healing processes, as advocated by Cooper Marcus and Barnes (1999b) and Tenngart Ivarsson (2011). The theoretical principles were also used to determine the basic order of qualities listed in the QET. In addition to this, empirical studies reported by Grahn et al. (2010) determined the order of certain qualities (i.e., the earlier-mentioned nature dimensions). Each quality was labeled with one umbrella term, sometimes originating from different sources. The qualities are presented with references to their sources. Each quality is exemplified with at least one photo. The next step of the practical construction of the QET will be to clarify the disposition of the environmental qualities in relation to the different steps in the design process. A first preliminary outline describing the overall principles of this disposition is presented
The overall method was to synthesize theories and evidence of relevance to the design and content of garden environments in healthcare settings. This is in accordance with theory triangulation, which was described by Patton (2002) as the use of multiple theoretical perspectives to examine and interpret data. Thus, in the present study, theory triangulation was used to begin the development of an evidence-based tool that we henceforth call the quality evaluation tool (QET).The procedure comprised two steps: (1) developing the theoretical principles of the QET and (2) beginning the development of the practical construction of the QET. To increase validity, each step was carried out using a process in which the two authors discussed the principles, construction and content of the QET until consensus was reached.Developing the theoretical principles of the QETThe theoretical principles are intended to illustrate how the QET is related to basic theories of restorative environments and to clarify the theoretical evidence-based nature of the QET. Theories and models were selected that have implications either for general design or for constituents of outdoor environments in healthcare settings. One theory was used as the foundation, and other theories and concepts were then related to this theory using a set of models. These models formed the basis for developing the practical structure of the QET.Developing the practical construction of the QETThis article takes a first step toward the practical construction of the QET, to present an outline for future expansion. This first step mainly regards the development of environmental qualities. As the QET is intended to be used in EBD processes in healthcare settings, the environmental qualities are based on evidence-based research. Evidence that is useful in design processes is based on both quantitative and qualitative research (Viets, 2009). To increase the validity further, all evidence (i.e., environmental qualities) included in the present study is confirmed by multiple sources and originates either from international peer reviewed journals or from reputable scientific anthologies. However, credible evidence-based explanations are achieved only when they are based on good theoretical models (Giacomini, 2009). Hence, our aim is to integrate evidence based on field research (interventions, POEs, questionnaires, interviews, observations) with theories in health and design.The basic ambition has been to encompass a wide range of needs: from basic human needs to the general needs of individuals in healthcare settings. Thus, the QET aims to include needs due to poor general health in connection to impaired physical and/or cognitive functions as well as emotional disabilities and fatigue. The following works have had particular influence on the overall set-up of the QET and on the environmental qualities in particular:•Grahn et al.’s (2010) eight main dimensions of experience that constitute the fundamental building blocks of parks and gardens and that has been evaluated in a Swedish healthcare garden.•Cooper Marcus’ (2007) ten design guidelines for hospital outdoor space, for the garden to be used and reach its full potential.•Bengtsson and Carlsson, 2006 and Bengtsson and Carlsson, 2013 descriptions of 10 respective 12 themes describing nursing home residents’ needs and sensitivities in their contact with the outdoor environment.•Rodiek's (2008) tool for evaluating senior living environments; a tool that consists of seven environmental principles with nine to ten assessable items in each.In addition, research focusing on other groups with specific needs with regard to the outdoors has been added from particular POE studies, as well as from Cooper Marcus and Barnes, 1999a and Cooper Marcus and Barnes, 1999b anthology.The collected data were processed to allow description of coherent environmental qualities that are intended to be useful in design processes. The number of qualities and their descriptions were carefully considered so as to achieve a diverse but still workable tool. The theoretical principles were used as a guide to place the environmental qualities in a larger context, the aim being to achieve design solutions of a general character that facilitate healing processes, as advocated by Cooper Marcus and Barnes (1999b) and Tenngart Ivarsson (2011). The theoretical principles were also used to determine the basic order of qualities listed in the QET. In addition to this, empirical studies reported by Grahn et al. (2010) determined the order of certain qualities (i.e., the earlier-mentioned nature dimensions). Each quality was labeled with one umbrella term, sometimes originating from different sources. The qualities are presented with references to their sources. Each quality is exemplified with at least one photo. The next step of the practical construction of the QET will be to clarify the disposition of the environmental qualities in relation to the different steps in the design process. A first preliminary outline describing the overall principles of this disposition is presented
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