Application of Theory in Studies of Healthcare Built Environment Research

Abstract

We aimed to examine the nature and extent of theory application in studies of built environment attributes and impact on adults in healthcare facilities. Many varied theories are described when providing the rationale for research into built environments in healthcare. Uncertainty exists around the right theory to frame a research question, alignment with measurement tools, and whether healthcare setting makes a difference. This poses challenges to researchers seeking to build the evidence base for built environment design that benefits patients and staff. Our multidisciplinary review team scoped the literature to determine how theories are used to inform research investigating the impact of the built environment of healthcare on adults. When researchers recorded theory at development of the study question, in data collection, and in data analysis/interpretation, we called this explicitly theory-based application. Synthesis occurred using a narrative approach. Overall, we found 17 diverse theories named in studies. Explicitly theory-based use occurred with eight theories, comprising 47% of all theories used. Five theories were named more frequently in studies out of all theories identified. In 20% of studies, theory was not used explicitly during the research inquiry. We argue that researchers must continue to strive toward explicit use of theories, similar to development of other health interventions that employ multifactorial components.

Keywords

built environment health facilities psychosocial health research-informed design review theories

Application of Theory in Healthcare Built Environment Research

Research on how the built environment affects the health and care of people is increasing (Larsen et al., 2014; Watts et al., 2016). The design of the built environment can be linked to the health and safety of patients and staff (Hamilton, 2003; Joseph et al., 2014). Evidence-based design (EBD) means that conscientious design decisions are based on credible research and practice (Hamilton, 2003). This research field is still new, and the value of research guided by theories is underrecognized (Diaz Moore & Geboy, 2010; Iwarsson & Ståhl, 2009). However, using theories when postulating research questions is important because theories can influence which environmental attributes are studied and which relationships between these attributes and human responses are explored (Becker et al., 2011; Debajyoti & Barach, 2010). Theories can help to frame research questions, choose research methods, and interpret results (Lynch et al., 2018). Moreover, the role of research is not merely to apply theory but to advance theory, and this point is equally applicable to applied research. Several theories for supporting design decisions have been proposed (Shannon et al., 2017), but a summary of the application of these theories is lacking. A better understanding of the use of theory can provide a basis for discussion and guide theory application within EBD. Thus, we aimed to review the theories currently reported in built environment research in healthcare and to describe how these theories have been used to inform research.

A better understanding of the use of theory can provide a basis for discussion and guide theory application within EBD .

Literature Review

EBD

Efforts to develop credible evidence to support design decisions in health facilities have led to the introduction of many research methods (Becker et al., 2011; Peavey & Vander Wyst, 2017), and the value of rigorous study designs in the field has been highlighted (Rashid, 2013; Taylor & Hignett, 2014). New tools have opened more opportunities to measure relationships among the built environment, health, and human behavior. Interviewing users is a common approach to report how a healthcare environment is aligned with the original design objectives (Elf et al., 2017). However, reliance on user experience alone to understand the results of a design has been called into question (Brown, 2018).

Other methods that should be included in evaluations are measurement tools describing various aspects of the environments (Nordin et al., 2016; Parker et al., 2004). For example, structured observational instruments can measure how staff (Okcu et al., 2011) and patients (Anaker et al., 2017; Shannon et al., 2018) engage with healthcare environments. Tools to record sound pressure to determine the association between noise and staff work interruptions are being applied (Okcu et al., 2011). Despite new and innovative ways of measuring the impact on humans in healthcare facilities, the theoretical assumptions on which researchers are basing their research methods are still uncertain (Iwarsson & Ståhl, 2009). Without a strong theory of how built environmental designs are conceptualized to work, researchers risk not asking the right questions, measuring the right outcomes, or attributing findings correctly.

Theories, Models, and Frameworks

Theories, models, and frameworks are often used interchangeably. However, a common definition is that theories are detailed descriptions of factors and statements about the relationships between those factors, models overlap with theories by simplifying the phenomenon under study, and frameworks are the structure of how these factors are mapped into a set of categories that permit empirical evaluation (Lynch et al., 2018; Nilsen, 2015). Theories can also be divided into three abstraction levels. Grand theory is broad theory with wide fields of application and contains concepts that can be applied to a complete professional field. Middle-range theory focuses on limited phenomenon within an area (Merton, 1968), while contextual or praxis theory is limited to a specific situation. Empirical research within EBD will most certainly use middle-range theories and contextual theories. Davidoff et al. (2015) have described what constitutes a “good” working theory, that is, clearly understood factors and clear linking of measures to theoretical constructs (Table 1). A demand for clarity using theories has emerged in social sciences and public health interventions designed to produce human behavioral change (Davis et al., 2015). Davis et al. (2015) highlight how incomplete theory use when developing health interventions can result in not understanding why certain theories are used more frequently than others and whether theories share similar and overlapping constructs.

Table 1.

“Good” Theory Components.

1. Clear theoretical concepts?	Independent factors; theoretical ideas/assumptions?
2. Define relationships between factors?	Easily understood putative links between factors; can be clearly described?
3. Clear measurability?	Defined measures aligned to theoretical concepts, replicable, reliable?
4. Hypothesis testing?	Use of theory to test hypotheses?
5. Theory explanatory?	Can the theory be used to explain findings from a study or develop new theory?
6. Causality?	Can the theory be used to confirm or disconfirm links between factors?
7. Evidence base	Research support from others in the development and refinement of the theory?
8. Generalizability	Can use of the theory be translated into other contexts?

Note. Adapted from Michie et al. (2014).

To increase the rigor of studies of health interventions, the theory informing the research should be clearly stated (Liang et al., 2017; Michie & Abraham, 2004). The same practice should apply within built environment research. Once the relationships between factors are known, better predictions can be made about how the factors can interact to affect people (Eccles et al., 2005; Nilsen, 2015). Figure 1 shows a model of how theory can inform research and design practice.

Figure 1.

Theory, framework, and practice.

There is ongoing tension about what knowledge should influence health design practice in the development of EBD. Diaz Moore and Geboy (2010) point to the dilemma in merging knowledge acquired through traditional hypothesis-focused research with knowledge generated through inductive research (Figure 1). This position can be improved by providing more clarity about the conceptual knowledge underpinning the theories currently in use. If theory use is not clearly mapped onto an operational or data collection method, then it can be difficult to interpret how the chosen measures are a valid reflection of that theory. This limits the interpretation of study results and the possibility of combining results from similar studies to obtain an overall view of the likely success or failure of chosen built environment design solutions. Uncovering which theories are most used and how they are applied in research practice could enable us to identify which theories offer the greatest utility for researchers in the built environment domain.

Uncovering which theories are most used and how they are applied in research practice could enable us to identify which theories offer the greatest utility for researchers in the built environment domain .

Rationale of the Study

The aim of this scoping review was to provide a broad overview of theories applied to studies of the built environment in adult healthcare facilities. The following questions guided the review: (i)Which theories are explicitly used in studies of adult health facilities? (ii)What are the characteristics of studies that use such theories? (iii) How are the theories used in studies? (iv)What are the similarities and differences between the applied theories? and (v)What are the key strengths and weaknesses of the applied theories?

Given the lack of standard use of terms (e.g., theories, models, frameworks), a theory was identified as “a set of concepts and/or statements with specification of how phenomena relate to each other” (Davis et al., 2015, p. 327). We used “theory” as the main concept. We classified a study that identified a theory at any stage in a study as “using a theory.” This definition was based on the description by Davies et al. (2010) of the level of theory use within research, which could be either explicitly theory-based (theory is used as a direct test of one or more hypotheses) or having some conceptual basis (a theory is mentioned in the introduction and discussion but not used within any measures or analysis).

Method

A scoping review methodology was used (Arksey & O’Malley, 2005). The preferred reporting items for systematic reviews and meta-analyses criteria guided this review (Moher et al., 2015). In contrast to a systematic review, a scoping review summarizes all the relevant literature within a defined set, without a quality rating, to examine a broad range of existing studies (Arksey & O’Malley, 2005). The steps of the review were identifying the research question, identifying relevant studies, selecting studies, charting the data, and collating, summarizing, and reporting the results.

Study Identification

The search strategy was determined iteratively by applying key words and search terms for theories used by published researchers in the field, for instance, “enriched environments” (EEs) and “therapeutic landscapes” (TLs). Synonyms for these terms were also used, such as “Ulrich’s theory of supportive design” versus “stress-reduction theory” (Table 2).

Table 2.

Search Terms.

Term 1	Term 2	Term 3
Theories Models Theoretical frameworks Theoretical models	Health facility environment Physical healthcare environment Healthcare space Healthcare facility Healthcare architecture Healthcare building Healthcare design Evidence-based design Built environment Hospital design Hospital construction Hospital environment	Patient-/person-centered care Patient-/person-centered care International classification of functioning (ICF) Therapeutic environments Biophilia hypothesis Attention-restoration theory Salutogenics Sense of coherence Stress-reduction theory Ulrich’s theory of supportive design Person-environment fit Enriched environments Universal/inclusive design Hall’s theory of proxemics Gibson’s theory of proxemics Gibson’s theory of visual affordances Space syntax Integrated health design

Only empirical studies and reviews that sought to examine the “built environment” or “health facility environment” (and synonyms) and “conceptual frameworks” or “theoretical frameworks” (and synonyms) were included (Table 2). All adult health environments were considered, including residential care, ambulatory care, and acute hospital care. In addition, key authors (e.g., Ulrich, Iwarsson, Lawton) were searched, and key journals (e.g., Health Environments Research & Design Journal) were manually searched to locate additional material. Articles about nonadult or nonhealth facility or maternity settings were excluded. Records were included if published between January 1, 1950, and June 30, 2018.

The databases searched were OVID (Medline), ProQuest, PsycINFO, and CINAHL. Individual reviewers screened groups of theories by title and abstract and then screened articles by full text. We “snowballed” the reference lists of the selected full-text articles. A specialist librarian was consulted to confirm the correctness of the search terms used in the individual databases.

Study Selection

The screening of literature was conducted in a two-stage process.

Stage 1: Three reviewers (M.S., M.E., S.N.) conducted a preliminary scoping search during August 2016 to March 2017. A broad range of theories used in healthcare facility research were identified and collated, and this work has been published elsewhere (Shannon et al., 2017). This stage provided the review team with a list of theories to proceed to Stage 2 (Table 3). The research question and initial search strategy were developed by the main researcher (M.S.) and discussed with the review authors with backgrounds in EBD.

Table 3.

Range of Theories Used in Health Facilty Research studies.

Name of Theory	Theory Used in Stage 2	Year Developed	Developer’s Discipline	Healthcare Built Environment Context Studied
1. Hall’s Theory of Proxemics		1966	Environmental Psychology	Rehabilitation care
2. Ecological: Barker’s Model of Behavior Setting		1968	Ecological Psychology	Children, community settings
3. Evolutionary: Prospect-Refuge Theory		1975	Psychology	Healing garden spacesSimulated environments
4. Place Theory	✓	1977	Environmental Psychology	Environmental psychology
5. Visual Affordances Theory	✓	1979	Psychology	Acute hospitals
6. Ecological: Person–Environment Fit Theory	✓	1982	Environmental Psychology	Dementia careResidential settings
7. Space Syntax Theory	✓	1984	Linguistics	Architecture
8. Salutogenics	✓	1987	Psychology	Acute hospitals; mental healthcare; cancer care; dementia care
9. Evolutionary Theory: The Biophilia Hypothesis	✓	1980–1990	Psychology	Acute hospitals
10. Stress Reduction Theory or Ulrich’s Theory of Supportive Design	✓	1991	Psychology/Architecture	Acute hospitals: Surgical, ambulatory clinics; mental healthcare
11. Attention Restoration Theory	✓	1995	Environmental Psychology	Mental healthcare
12. Patient-Centered Care or Person-Centered Care	✓	1995–2006	Nursing/Psychology	Acute hospitals, medical-surgical care
13. Enriched Environments	✓	2002	Neuroscience—Animal and Human Study	Stroke rehabilitation
14. International Classification of Functioning, Disease and Health	✓	2002	WHO—Individual and Population Health	All health contexts
15. Therapeutic Landscapes	✓	2003	Health Geography/Environmental Psychology/Psychology	Acute hospital care
16. Inclusive Design or Universal Design	✓	2012	Architecture	Cancer care
17. Integrated Health Facilities Design Model		2013	Architecture	Dementia residential care

Note. WHO = World Health Organization.

Stage 2: This stage involved a detailed review search by M.S., M.E., and SN using the same search strategy as Stage 1. All reviewers independently screened the articles.

Charting and Collating the Data

The review group met several times to confirm the search consistency and to refine the data extraction form (Online Appendix 1). Data extracted during Stage 2 were collated in a single Excel spreadsheet tabulated for each reviewer’s extraction. Data were extracted from the articles independently, including name of theory and use of the theory in study phases, that is, development of the research question/study rationale, data collection, data analysis/results, discussion of findings, and strengths and limitations of the theory. The final form was developed following discussion (Online Appendix 1).

Data Summarization and Analysis

The data were first summarized descriptively to obtain the overall proportion of studies in which the same theory was mentioned. The characteristics of studies showing any use of theories were presented. Since there was no precedent of how to summarize theory application in built environment design research, we referred to the method of Davis et al. (2015) previously described. We summarized how the theory application occurred (Table 4), and whether the theories were applied to explain attributes of the built environment or to test the impact of built attributes on people. Finally, we narratively summarized and synthesized the similarities/differences of “explicitly theory-based” use and tabulated the strengths and weaknesses of the theories used in the final study cohort.

Table 4.

Synthesis of Scoping Review Findings.

Theory Name	Aim of Study	Study Sample	Theory Used to Develop Study Question	Theory Applied to Measures	Theory Used in Data Analysis Measures Used	Reviewer Comments
PCC (19/63)	To develop a PE measure; to explain how PE impacts on eating behavior, agitation, nurse–family interactions, level of education.	68.4% patientsDementia care, long-term care, acute hospital, neurological rehabilitation.	73.7%	68.4%	57.9%	Emerging consistent application in PE for acute hospital and dementia care: Where patient autonomy/agency, positive health behaviors, e.g., eating, are prioritized.PE is one factor of PCC.
P-E fit (9/63)	To examine relationships between performance, e.g., ADLS, physical activity, or perceived self-efficacy and PE.	89% older peopleOlder people, dementia care, residential care, Parkinson’s Disease.	100%	100%	88.8%	Consistent use of theory to investigate environmental, social, personal factors on individual living with progressive disease/aging.
TLs (15/63)	To explore factor of “place” on experience of healthcare.	100% either patients or staffCancer care, psychiatric care, older people.	93.3%	73.3%	73.3%	Emerging application in investigating sense of place/“geography of care” on people.
ICF (3/63)	To explore PE and impact on activity and participation of people in everyday life.	100% patientsStroke, disability, older people.	100%	66.7%	100%	Application in examination of how to support people with health conditions in accessing community.
Salutogenic	No studies	No studies	No studies	No studies	No studies	No studies
Hall’s Theory of Proxemics	No studies	No studies	No studies	No studies	No studies	No studies
Place Theory	No studies	No studies	No studies	No studies	No studies	No studies
EE (2/63)	To explore or measure effect of exposure to EE on people.	100% patientsStroke rehabilitation.	100%	100%	100%	Use in promoting activity and participation only in stroke health facilities to date.
Universal Design	No studies	No studies	No studies	No studies	No studies	No studies
Inclusive Design	No studies	No studies	No studies	No studies	No studies	No studies
Prospect-Refuge	No studies	No studies	No studies	No studies	No studies	No studies
BH (2/63)	To explore use of nature in health facilities.	100% patientsAcute hospital.	100%	0%	50%	Use developing in acute health facilities.
ART (2/63)	To synthesize studies examining effect of sound perception on human health in hospital.	100% patients, staffAcute, orthopedic; older residents.	100%	0%	100%	Inconsistent use of theory, overlapping use with another theory, e.g., SRT in two studies.
VAs (4/63)	To compare instruments to assess outdoor long-term care; to compare residential care units.	100% patientsResidential, dementia care.	75%	25%	50%	Emerging empirical use in long-term care settings.
SS (2/63)	To develop method to compare medical-surgical units according to social interconnectivity.	100%Architectural floor plans of acute hospital wards.	100%	100%	100%	Clear use to gather quantitative measures from floor plans, but not yet linked to patient or staff outcomes.
Inclusive and Integrated Health Facilities Design	No studies	No studies	No studies	No studies	No studies	No studies
SRT (1/63)	To compare light levels assumed to contribute to patient stress.	Ambulatory care patients.	100%	100%	100%	Emerging use in hospital settings.
Multiple Theories (4/63)	To investigate patient room design, gain insight into how architect students design, test effect of greenery on older residents.	100% patientsMixed settings.	100%	75%	75%	Incorrectly indexed in databases.

Note. n = 63 studies. PE = physical environment; ICF = International Classification of Functioning; PCC = Patient/Person-Centered Care; TLs = Therapeutic Environments; EE = Enriched Environment; BH = Biophilia Hypothesis; SRT = Stress Reduction Theory; ART = Attention Restoration Theory; SS = Space Syntax; VAs = Visual Affordances; P-E fit = Person–Environment Fit; ADLS = Activities of Daily Living.

Results

Study Selection

The research team reviewed 1,771 records against the inclusion criteria by title and abstract between November 14, 2016, and September 28, 2018. Of these, 212 articles were further screened by full text. Thirty-five articles were only about the organizational care environment, 21 records were nonempirical/nonreview studies, and 62 were not relevant to the study (pediatric, urban, schools). Finally, 32 records did not mention any use of theories. Thus, 63 articles were used for the final data extraction (Figure 2).

Figure 2.

Flow diagram of studies exploring or testing for impact of healthcare built environment on adults.

Theories Used

Overall, 17 theories were found in the first scoping review (Shannon et al., 2017), and of these, 5 theories appeared most frequently: patient-/person-centered care (PCC; 31.0%), TLs (24.1%), person–environment fit (P-E fit; 14.3%), Gibson’s theory of visual affordances (VAs; 6.3%), and international classification of functioning (ICF; 4.8%; Figure 3).

Figure 3.

Count of theories found in the review. ICF = international classification of functioning.

Characteristics of the Studies

The majority (70.1%) derived from a health-related discipline. Most of the studies were conducted in North American (39.7%) and European (37.0%) countries. The theories were employed mainly in studies of residential and acute hospital care (44.4% and 37.0%, respectively; Figure 4).

Figure 4.

Count of types of health settings studied using any theory.

Patients were studied in 37 of the studies (57.1%; e.g., Devlin et al., 2015; Pomeroy et al., 2011). The impact of the built environment on staff was examined in 15 studies (e.g., Rippin et al., 2015). The remainder explored the impact on both staff and patients (e.g., Wood et al., 2015).

Study Designs

A range of study designs was found, with cross-sectional (66.7%), comparative (17.5%), and review (15.9%) approaches employed. Qualitative study techniques were prominent (30.2%), often in the form of interviewing participants once to explore factors within a built environment that could influence people’s health. One third of these qualitative studies were informed by TL. For example, Moore et al. (2013) applied interviewing to explore the geography of hospice care.

When comparative methods were employed (one built design attribute compared to another attribute), multiple theories were featured, for example, PCC (18.1%), attention restoration theory (ART), and stress reduction theory (SRT; 18.1%). For example, Rippin et al. (2015) used PCC to explore the effect of a new intensive care unit design on nurse–family interactions and aimed to identify workplace challenges for staff.

Sixteen articles were incorrectly indexed in the databases or that multiple theories were used; for example, the study by Bergland et al. (2012) was indexed in the database search as using TL, whereas that study of a nursing home environment was based on PCC. Four researchers incorporated multiple theories in their studies (e.g., Annemans et al., 2014; Devlin et al., 2015).

Explicit Use of Theories

In 55.6% of all studies (35/63 studies), a theory was used explicitly throughout the study, from the development of the research question to informing the data collection methods, data analysis, and alignment of the results. It was much less common (13 studies, 20.6%) for a named theory to be used at only one stage. In one quarter of the studies (23.8%), the theory was applied in at least two stages, typically at research question development and data collection stages.

An explicitly theory-based approach was shown by alignment of the data collection methods and the theoretical construct and the continuation of this structure into the data analysis/interpretation study phases. We found eight theories for which such alignment occurred, albeit in small numbers of studies (PCC, P-E fit, ICF, EE, TL, SRT, ART, and space syntax [SS]; Table 4). For example, Hung and Chaudhury (2011) clearly described the use of PCC in the development of their research objective, in shaping their ethnography inquiry, and in reporting their results. Similarly, Park et al. (2017) explicitly based their study on P-E fit to explore how the built environment can compensate for impairments in older people in residential care.

The use of the theory for a conceptual basis was found mostly in the framing of the research question and in assisting with the interpretation of the study findings, such as in Chaudhury et al. (2013) and Topo et al. (2012). For example, Topo et al. (2012) described a new tool to assess a dementia care environment based on VA. However, there was a lack of clarity about the affordance descriptors chosen and of how raters would implement the measure in practice.

Overall, theories were used mainly to explore or to explain factors in the built environment that could act on people (76.1%). For example, the impact of the nursing home environment on residents’ eating behaviors was examined using P-E fit to identify individual coping responses based on the theoretical constructs (Evans et al., 2004). By contrast, some studies measured the efficacy of built design as an intervention (18%). For example, the impact of a newly designed neurological intensive care unit was measured using observations based on PCC (Rippin et al., 2015). Both exploratory and hypothesis testing approaches were applied in the remaining studies (23.9%; e.g. Devlin et al., 2015).

Similarities and Differences in Theory Use in Explicitly Theory-Based Studies

Five theories (PCC, P-E fit, TL, SRT, and ART) exploit factors arising from the built environment either to remove or to control stressors acting on people’s health and well-being (Online Appendix 2). Such theories suggest social and environmental factors (other than physiological factors) that could mediate good health promotion if harnessed correctly. Stressors could impact on patients when there is an absence of patient autonomy or when audiovisual distractions exist (PCC, SRT, and ART). P-E fit could be deleterious depending on the balance of an individual’s competency versus the environmental demands acting on the individual. Having a recognizable “sense of place” or “access to nature” in a health facility designed using TL and ART, respectively, could be viewed as supportive by providing more affinity for people remaining in that health setting. Finally, TL has a holistic approach comparable to PCC whereby both theories seek to invoke symbolism connected to “place” that might act on people.

Five theories (EE, P-E fit, PCC, SRT, and SS) describe relationships between factors and have explicit core constructs, for example, “patient autonomy” and “built environment,” with attempts to link the construct to the impact on people using an observer-rated tool, for example, the person-centered climate questionnaire (Bergland et al., 2012). The EE theory (Janssen et al., 2018), developed originally from animal models of brain injury, has helped to define what the content of an “enriched” social and cognitive built environment should be. Methods of observational mapping or interviewing have been used to link “EEs” to behavioral changes in people (cited in Janssen et al., 2018).

Finally, ICF, EE, ART, SRT, and P-E fit seek to frame the examination of an individual’s responses (cognitive, emotional, physical, and social) mediated by characteristics within the built environment itself. People’s responses to an EE are captured using behavioral mapping and interview data. The ability of an older person with a set of competencies (strengths) is measured against a set of attributes within a given built environment using P-E fit. Researchers using ICF argue that social participation can be enhanced by improved design options for people with stroke. Unfortunately, there is no easy tool to evaluate how this approach has made a difference to people with disability in practice.

Overall, there were fewer differences than similarities in how theories were used. We found that explicitly theory-based use varied according to health facility type in which the theories were most applied. For example, P-E fit was used primarily to investigate residential/long-term care environments, while researchers typically applied TL, EE, PCC, ART, or SRT to studies of hospital and rehabilitation settings.

Despite similarities in the theoretical constructs across many theories, different measures were selected. For example, exposure to EE involved both structured behavioral mapping (Janssen et al., 2014) and interviewing (White et al., 2015), while the impact of the audiovisual environment (in ART, SRT) was explored using patient perspectives (Devlin et al., 2015). Furthermore, we found a lack of clarity and consistency in how some theories were operationalized, with PCC having the most developed tools to measure built environment impact on adults (Edvardsson et al., 2008). Online Appendix 2 presents more details about the strengths and weaknesses of the theories.

Discussion

This study was conducted to understand whether and how theory has been used in studies on the healthcare built environment and its impact on the health of adults. In 34% of the screened studies, a theory was not mentioned at all. Theories were explicitly used in over 55% of the included studies, but we found only small numbers of studies where this occurred (between 1 and 9 studies). Our findings indicate the weak theoretical nature of the research field.

For example, among those who described a theory in their research, over 20% failed to apply this theory beyond mentioning it either to justify the research or to help interpret the findings. In studies that explicitly cited one of the eight dominant theories, few authors attempted to link the built environment attribute being investigated to a validated, reliable measure. Consequently, it is challenging to determine whether the study measures were adopted on an adequate theoretical basis and reliably mapped onto the theoretical constructs. Our findings echo those of others in the field of EBD who advocate for theory-based research (Becker et al., 2011; Trzpuc & Martin, 2010). For example, Becker et al. (2011) argue for matching research approaches to complex systems and using theory to guide research inquiry.

The included studies suffered from a lack of clarity about how to choose or interpret the measures used. Some theories (P-E fit, EE, SS, and ICF) have rules and processes that continue to be refined through research activity (Edvardsson et al., 2008; Iwarsson & Ståhl, 2009; McDonald et al., 2018). This ongoing refinement of theories is not uncommon in residential care research. For example, both staff and patient versions of the Person-Centered Climate Questionnaire have been developed to address differences in how older people (Edvardsson et al., 2008) and staff (Edvardsson et al., 2009) evaluate residential care environments. Future research should continue to address this lack of clarity by identifying which theories under what built environment contexts, for example, acute hospital versus rehabilitation, are most appropriate for specific adult populations, for example, adults with cancer versus stroke.

We aimed to identify whether similarities and differences exist with theory use, and we found that many theories appear to share common aspects. Overall, such theories place the person at the center of their experience of health and value individual personal factors and abilities, in conjunction with a responsive environment, to achieve optimal health and well-being. This holistic view of how the built environment intersects with adult health is shared between theories, such as patient decision-making using PCC, individual competency using P-E fit, and patient social engagement as a consequence of favorable interaction with the built environment using TL.

Overall, such theories place the person at the center of their experience of health and value individual personal factors and abilities, in conjunction with a responsive environment, to achieve optimal health and well-being .

Finally, we aimed to clarify the strengths and weaknesses in the application of theories in research. Theories were often used to help frame a research question, design research methods, and/or attempt to interpret findings. However, there is still inconsistency in how theories are operationalized. The field of EBD may benefit from information about theories and how to use them. To supply this information, research is needed to more firmly establish which theories and how many theories might be appropriately used to progress the field by, for example, developing use of “environment” beyond its current moderating/mediating role in the ICF. ICF use could be advanced beyond a classification to gather a more nuanced view of how built environment shapes adult responses in the context of a given disability status.

…research is needed to more firmly establish which theories and how many theories might be appropriately used to progress the field by .

Theories identified for this review act at what Merton (1968) describes as the middle-range theory level, without including overarching concepts at a wider societal context. More clarity in future research should specify which theory level is used according to the aim of the knowledge development (Gardner et al., 2010; Merton, 1968).

Limitations

During the study, we did not complete the full-text review simultaneously but did meet often to discuss and confirm consistency. Theories used to evaluate knowledge to action translation or to implement quality improvement cycles were not included as we did not seek to perform an exhaustive search of all types of theories existing across disciplines, nor did we aim to address quality evaluation of the healthcare built environment. We defined our own framework to indicate whether theories were applied explicitly. However, our aim was not to systematically categorize the robustness of theory usage, and there was very little available guidance of frameworks in the literature.

Conclusion

Numerous theories exist that influence the choice of how researchers study the built environment in health. However, a smaller number of these theories are used to explicitly frame research questions, to gather information about how the built environment impacts adults in a given context, and to report findings. In future, researchers should familiarize themselves with the existing theories that have been shown to have clear definitions of theoretical constructs and methods of data collection validly aligned with those constructs. Finally, any research outcomes should include confirmation or refutation of the applicability of the chosen theory in a study.

In future, researchers should familiarize themselves with the existing theories that have been shown to have clear definitions of theoretical constructs and methods of data collection validly aligned with those constructs .

Implications for Practice

Researchers should clearly define theory constructs, and relationships between physical design features according to these constructs, as well as linking them to health outcomes.

Use of theory exemplars, for example, PCC, P-E fit, and ICF, found in this review might inspire researchers to clearly formulate study designs aligned to well-defined theory constructs.

More research is needed to fully capture how built environments of hospital and rehabilitation facilities can impact on behaviors of adults beyond the reduction of stress, such as the shaping of physical, cognitive, and social activity for better health.

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Footnotes

Authors’ Note

M. Elf is not affiliated with Division of Building Design, Department of Architecture and Civil Engineering, Chalmers University of Technology, Gothenburg, Sweden and Department of Neurobiology, Care Sciences and Society, Karolinska Institute, Stockholm, Sweden now. This research was conducted as part of the first author’s PhD. M.M.S. and J.B. are affiliated with the National Health and Medical Research Council (NHMRC) Centre for Research Excellence in Stroke Rehabilitation and Recovery, Victoria, Australia (1077898).

Acknowledgments

The authors wish to acknowledge Anna Anaker for her contribution to the search, and Ruby Lipsom-Smith, and Dr Sharon Kramer for their comments on the manuscript. The Florey Institute of Neuroscience and Mental Health acknowledges the support received from the Victorian Government via the Operational Infrastructure Support Scheme.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: M.M.S. is supported by an Australian Government Research Training Program Scholarship. J.B. is funded by a National Health and Medical Research Council Fellowship (1058635). ME and SN are funded by Dalarna University.

ORCID iDs

Michelle M. Shannon, B.Physiotherapy, MSc

M. Elf, RN, PhD

Supplemental Material

Supplemental material for this article is available online.

References

Anaker

von Koch

Sjostrand

Bernhardt

Elf

(2017). A comparative study of patients’ activities and interactions in a stroke unit before and after reconstruction—The significance of the built environment. PLoS One, 12(7), e0177477. Retrieved from https://doi.org/10.1371/journal.pone.0177477

Annemans

Karanastasi

Heylighen

(2014). From designing for the patient to designing for a person. In Langdon

Lazar

Heylighen

Dong

(Eds.), Inclusive designing (pp. 189–200). Springer.

Arksey

O’Malley

(2005). Scoping studies: Towards a methodological framework. International Journal of Social Research Methodology, 8(1), 19–32.

Becker

Bonaiuto

Bilotta

Bonnes

(2011). Integrated healthscape strategies: An ecological approach to evidence-based design. Health Environments Research & Design Journal, 4(4), 114–129.

Bergland

Å.

Kirkevold

Edvardsson

(2012). Psychometric properties of the Norwegian Person-centred Climate Questionnaire from a nursing home context. Scandinavian Journal of Caring Sciences, 26(4), 820–828. Retrieved from https://doi.org/10.1111/j.1471-6712.2012.00979.x

Brown

T. L.

(2018). A critical assessment of the place of post-occupancy evaluation in the critique and creation of socially responsible architecture. Intelligent Buildings International, 1–12. Retrieved from https://doi.org/10.1080/17508975.2018.1437708

Chaudhury

Hung

Badger

(2013). The role of physical environment in supporting person-centered dining in long-term care: A review of the literature. American Journal of Alzheimer’s Disease & Other Dementias, 28(5), 491–500. Retrieved from https://doi.org/10.1177/1533317513488923

Davidoff

Dixon-Woods

Leviton

Michie

(2015). Demystifying theory and its use in improvement. BMJ Quality & Safety, 24(3), 228–238. Retrieved from https://doi.org/10.1136/bmjqs-2014-003627

Davies

Walker

A. E.

Grimshaw

J. M.

(2010). A systematic review of the use of theory in the design of guideline dissemination and implementation strategies and interpretation of the results of rigorous evaluations. Implementation Science, 5, 14.

10.

Davis

Campbell

Hildon

Hobbs

Michie

(2015). Theories of behaviour and behaviour change across the social and behavioural sciences: A scoping review. Health Psychology Review, 9(3), 323–344. Retrieved from https://doi.org/10.1080/17437199.2014.941722

11.

Debajyoti

Barach

(2010). Application of environmental psychology theories and frameworks to evidence-based healthcare design. In Valentin

Gamez

(Eds.), Environmental psychology: New developments (pp. 1–36). Nova Science.

12.

Devlin

A. S.

Andrade

C. C.

Carvalho

(2015). Qualities of inpatient hospital rooms: Patients perspectives. Health Environments Research & Design Journal 9(3)190–211. Retrieved from https://doi.org/10.1177/1937586715607052

13.

Diaz Moore

Geboy

(2010). The question of evidence: Current worldviews in environmental design research and practice. Architectural Research Quarterly, 14(2), 105–114.

14.

Eccles

Grimshaw

Walker

Johnston

Pitts

(2005). Changing the behavior of healthcare professionals: The use of theory in promoting the uptake of research findings. Journal of Clinical Epidemiology, 58(2), 107–112. Retrieved from https://doi.org/10.1016/j.jclinepi.2004.09.002

15.

Edvardsson

Sandman

P. Q.

Rasmussen

(2008). Swedish language Person-centred Climate Questionnaire—patient version: Construction and psychometric evaluation. Journal of Advanced Nursing, 63(3), 302–309. Retrieved from https://doi.org/10.1111/j.1365-2648.2008.04709.x

16.

Edvardsson

Sandman

P. O.

Rasmussen

(2009). Construction and psychometric evaluation of the Swedish language Person-centred Climate Questionnaire—staff version. Journal of Nursing Management, 17(7), 790–795. Retrieved from https://doi.org/10.1111/j.1365-2834.2009.01005.x

17.

Elf

Nordin

Wijk

McKee

K. J.

(2017). A systematic review of the psychometric properties of instruments for assessing the quality of the physical environment in healthcare. Journal of Advanced Nursing, 73, 2796–2816. Retrieved from https://doi.org/10.1111/jan.13281

18.

Evans

B. C.

Crogan

B. L.

Shultz

J. A.

(2004). Resident coping strategies in the nursing home: An indicator of the need for dietary services change. Applied Nursing Research, 17(2), 109–115.

19.

Gardner

Whittington

McAteer

Eccles

M. P.

Michie

(2010). Using theory to synthesise evidence from behaviour change interventions: The example of audit and feedback. Social Science Medicine, 70(10), 1618–1625. Retrieved from https://doi.org/10.1016/j.socscimed.2010.01.039

20.

Hamilton

D. K.

(2003, November 1). The four levels of evidence-based practice. Healthcare Design. Retrieved from http://www.aia.org/nwsltr_print.cfm?pagename=aiaj_a_20041201_fourlevels

21.

Hung

Chaudhury

(2011). Exploring personhood in dining experiences of residents with dementia in long-term care facilities. Journal of Aging Studies, 25(1), 1–12. Retrieved from https://doi.org/10.1016/j.jaging.2010.08.007

22.

Iwarsson

Ståhl

(2009). Accessibility, usability and universal design—Positioning and definition of concepts describing person-environment relationships. Disability & Rehabilitation, 25(2), 57–66. Retrieved from https://doi.org/10.1080/dre.25.2.57.66

23.

Janssen

Ada

Bernhardt

McElduff

Pollack

Nilsson

Spratt

N. J.

(2014). An enriched environment increases activity in stroke patients undergoing rehabilitation in a mixed rehabilitation unit: A pilot non-randomized controlled trial. Disability & Rehabilitation, 36(3), 255–262. Retrieved from https://doi.org/10.3109/09638288.2013.788218

24.

Janssen

Bernhardt

Walker

F. R.

Spratt

N. J.

Pollack

Hannan

Nilsson

(2018). Environmental enrichment: Neurophyisiological responses and consequences for health. In Bird

van den Bosch

M. A.

(Eds.), Nature and public health: The role of nature in improving the health of a population (pp. 71–78). Oxford University Press.

25.

Joseph

Quan

Keller

A. B.

Taylor

Nanda

Hua

(2014). Building a knowledge base for evidence-based healthcare facility design through a post-occupancy evaluation toolkit. Intelligent Buildings International, 6(3), 155–169. Retrieved from https://doi.org/10.1080/17508975.2014.903163

26.

Larsen

L. S.

Larsen

B. H.

Birkelund

(2014). A companionship between strangers—The hospital environment as a challenge in patient-patient interaction in oncology wards. Journal of Advanced Nursing, 70(2), 395–404. Retrieved from https://doi.org/10.1111/jan.12204

27.

Liang

Bernhardsson

Vernooij

R. W.

Armstrong

M. J.

Bussieres

Brouwers

M. C.

Gagliardi

A. R.,

& Members of the Guidelines International Network Implementation Working Group. (2017). Use of theory to plan or evaluate guideline implementation among physicians: A scoping review. Implementation Science, 12(1), 26. Retrieved from https://doi.org/10.1186/s13012-017-0557-0

28.

Lynch

E. A.

Mudge

Knowles

Kitson

A. L.

Hunter

S. C.

Harvey

(2018). “There is nothing so practical as a good theory”: A pragmatic guide for selecting theoretical approaches for implementation projects. BMC Health Services Research, 18(1), 857. Retrieved from https://doi.org/10.1186/s12913-018-3671-z

29.

McDonald

M. W.

Hayward

K. S.

Rosbergen

I. C. M.

Jeffers

M. S.

Corbett

(2018). Is environmental enrichment ready for clinical application in human post-stroke rehabilitation? Frontiers in Behavioral Neuroscience, 12, Article 135. Retrieved from https://doi.org/10.3389/fnbeh.2018.00135

30.

Merton

R. K.

(1968). Social theory and social structure ( Merton

R. K.

, Ed.). Free Press.

31.

Michie

Abraham

(2004). Interventions to change health behaviours: Evidence-based or evidence-inspired? Psychology & Health, 19(1), 29–49. Retrieved from https://doi.org/10.1080/0887044031000141199

32.

Michie

Brown

Gainforth

Campbell

West

. (2014). An ABC of behavior change theories. Silverback Publishing.

33.

Moher

Shamseer

Clarke

Ghersi

Liberati

Petticrew

Shekelle

Stewart

L. A.,

& PRISMA-P Group. (2015). Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Systematic Reviews, 4(1), 1. Retrieved from https://doi.org/10.1186/2046-4053-4-1

34.

Moore

Carter

Hunt

Sheikh

(2013). ‘I am closer to this place’—Space, place and notions of home in lived experiences of hospice day care. Health & Place, 19, 151–158.

35.

Nilsen

(2015). Making sense of implementation theories, models and frameworks. Implementation Science, 10(1), 53. Retrieved from https://doi.org/10.1186/s13012-015-0242-0

36.

Nordin

McKee

Wijk

Elf

(2016). Exploring environmental variation in residential care facilities for older people. Health Environments Research & Design Journal, 10, 49–65. Retrieved from https://doi.org/10.1177/1937586716648703

37.

Okcu

Ryherd

E. E.

Zimring

Samuels

(2011). Soundscape evaluations in two critical healthcare settings with different designs. Journal of Acoustic Society of America, 130(3), 1348–1358. Retrieved from https://doi.org/10.1121/1.3607418

38.

Park

Yoonsun

BoRin

Dunkle

R. E.

(2017). Aging in place of vulnerable older adults: Person-environment fit perspective. Journal of Applied Gerontology, 36(11), 1327–1350. Retrieved from https://doi.org/10.1177/0733464815617286

39.

Parker

Barnes

McKee

Morgan

Torrington

Tregenza

(2004). Quality of life and building design in residential and nursing homes for older people. Ageing and Society, 24(6), 941–962. Retrieved from https://doi.org/10.1017/S0144686X04002387

40.

Peavey

Vander Wyst

K. B.

(2017). Evidence-based design and research-informed design: What’s the difference? Conceptual definitions and comparative analysis. Health Environments Research & Design Journal, 10(5), 143–156. Retrieved from https://doi.org/10.1177/1937586717697683

41.

Pomeroy

S. H.

Scherer

Runkawatt

Iamsumang

Lindemann

Resnick

(2011). Person-environment fit and functioning among older adults in a long-term care setting. Geriatric Nursing, 32(5), 368–378. Retrieved from https://doi.org/10.1016/j.gerinurse.2011.07.002

42.

Rashid

(2013). The question of knowledge in evidence-based design for healthcare facilities: Limitations and suggestions. Health Environments Research & Design Journal, 6(4), 101–126.

43.

Rippin

A. S.

Zimring

Samuels

Denham

M. E.

(2015). Finding a middle ground: Exploring the impact of patient- and family-centered design on nurse-family interactions in the Neuro ICU. Health Environments Research & Design Journal, 9(1), 80–98. Retrieved from https://doi.org/10.1177/1937586715593551

44.

Shannon

M. M.

Elf

Churilov

Olver

Pert

Bernhardt

(2018). Can the physical environment itself influence neurological patient activity? Disability & Rehabilitation, 41, 1177–1189. Retrieved from https://doi.org/10.1080/09638288.2017.1423520

45.

Shannon

M. M.

Nordin

Anaker

Bernhardt

Elf

(2017). Theoretical frameworks in healthcare built environment research—A scoping review. Paper presented at the Arch17 3rd International Conference On Architecture, Research, Care and Health, Aarlborg University.

46.

Taylor

Hignett

(2014). Evaluating evidence: Defining levels and quality using critical appraisal mixed methods tools. Health Environements Research & Design Journal, 7(3), 144–151.

47.

Topo

Kotilainen

Eloniemi-Sulkava

(2012). Affordances of the care environment for people with dementia—An assessment study. Health Environments Research & Design Journal, 5, 118–138.

48.

Trzpuc

S. J.

Martin

C. S.

(2010). Application of space syntax theory in the study of medical-surgical nursing units in Urban hospitals. Health Environments Research & Design Journal, 4, 34–55.

49.

Watts

Khan

Pheasant

(2016). Influence of soundscape and interior design on anxiety and perceived tranquillity of patients in a healthcare setting. Applied Acoustics, 104, 135–141. Retrieved from https://doi.org/10.1016/j.apacoust.2015.11.007

50.

White

J. H.

Bartley

Janssen

Jordan

L. A.

Spratt

(2015). Exploring stroke survivor experience of participation in an enriched environment: A qualitative study. Disability & Rehabilitation, 37(7), 593–600. Retrieved from https://doi.org/10.3109/09638288.2014.935876

51.

Wood

V. J.

Gesler

Curtis

S. E.

Spencer

I. H.

H. J.

Mason

Reilly

J. G.

(2015). ‘Therapeutic landscapes’ and the importance of nostalgia, solastalgia, salvage and abandonment for psychiatric hospital design. Health & Place, 33, 83–89. Retrieved from https://doi.org/10.1016/j.healthplace.2015.02.010

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