Recent Research - Arts in Healthcare
March 2010
Introduction
Arts in healthcare has been a growing sector in the UK for more than 20 years. However it is only in the last 10 years that significant robust research has been carried out to provide evidence of the claimed benefits of incorporating art in healthcare settings. The main impacts are held to be:
- Well designed healthcare environments feel less institutional and improve the well being of patients, staff and visitors
- The arts in hospitals improve patient health, recovery and wellbeing including clinical outcomes
- The arts can help the healthcare environment function more effectively
- Participation in the arts is beneficial to patient health and wellbeing
- The arts contribute to a quality work environment for staff and support staff recruitment and retention
Roger Ulrich gave a presentation during Architecture Week in 2003 in which he gave the background to arts in healthcare research which he and others carried out in the late 1980s and 1990s. It provides the context for the selection of research studies in this roundup which all date from the first decade of 2000.
Resources for further research are given at the end of the article.
Arts in health: a review of the medical literature (2004)
Rosalie Lelchuk Staricoff
Published by Arts Council England
This review of medical literature published between 1990 and 2004 explores the relationship of arts and humanities with healthcare, and the influence and effects of the arts on health. It covers 385 references from medical literature. The aim of the study was to strength existing anecdotal and qualitative information demonstrating the impact that the arts can have on health. It did not seek to be the definitive evidence base for arts in healthcare interventions, and indeed, it points to many areas where further research is needed.
The research explored the contribution of the arts towards:
- Achieving clinical outcomes for the benefit of patients
- Raising staff morale and job satisfaction
- Widening the skills of nurses and doctors
- Providing better quality of healthcare
- Enhancing the quality of life of mental health users
- Helping mental health providers manage the service
Key findings include:
- Medical areas in which research shows clear, reliable evidence of clinical outcomes achieved through the intervention of the arts including reduction in blood pressure, heart rate, length of hospital stay and perception of pain;
- The positive impact of the arts on the effectiveness of health practitioners, including concentration, stereo vision and 3D thinking, and patient awareness and care in student nurses;
- The value of the arts in mental healthcare including improving patients’ communication skills, enabling them to express themselves, enhancing self esteem, and bringing about positive behavioural changes;
- The different impact of different art forms on mental health service users;
- Information on the mechanisms underlying the perception and processing of the arts, including the association between the mental and physical state of artists and their work.
The report finishes with recommendations for future research where current knowledge and evidence are inadequate.
A Study of the Effects of Visual and Performing Arts in Health Care (2005)
Rosalie Lelchuk Staricoff, Jane P Duncan, Melissa Wright
Commissioned by Chelsea and Westminster Hospital Arts
The research for this study was carried out at Chelsea and Westminster Hospital from 1999 to 2002. A unique approach was designed to evaluate scientifically the effect of visual and performing arts in healthcare, and to explore whether they could have an effect on psychological, physiological and biological outcomes of clinical significance.
The objectives were:
- To produce a quantitative evaluation of the effects of the visual and performing arts on patients, staff and visitors;
- To answer whether the integration of the arts in healthcare can induce physiological and psychological changes of clinical value;
- To find out whether the visual and performing arts can induce changes in physiological responses;
- To establish staff attitudes towards the particular environment and the potential effect that it could have on job satisfaction, recruitment and retention.
A research protocol was designed after extensive consultation with medical, nursing and managerial staff at the eight clinical units taking part in the study. This enabled a range of measurements to be identified which might indicate outcomes of clinical significance. It was important that the collection of data did not interfere with the running of clinics, add to staff workload or impose changes of procedure that might influence findings. All the research was done as controlled, blind or double blind studies to avoid bias which might affect the validity of the evidence, and as far as possible in the circumstances, participating groups were randomised.
Psychological changes were evaluated using the Hospital Anxiety and Depression scale completed by patients before and after the intervention of visual arts and/or live music. Physiological and biological changes were measured in the presence or absence of visual art and/or live music. The impact of visual arts and/or live music was also measured by indicators such as length of labour, length of hospital stay, requirement for anaesthesia, and staff evaluation.
The findings provide evidence that the integration of visual and performing arts into the healthcare environment has a range of outcomes which could have clinical significance.
Designing for Health: Architecture, Art and Design at the James Cook University Hospital (2005)
Dr Jane Macnaughton, Mike White, Dr Peter Collins, Prof. Simon Coleman, Geoffrey Purves, Dr Peter Kellett, Anu Suokas, Karen Taylor
Published by Universities of Durham and Newcastle
This research was carried out over two years at two hospitals, Middlesbrough General Hospital and the James Cooke University Hospital (JCUH). It compared hospital accommodation before and after the move into a new £120m PFI building (JCUH) and the work was carried out by a multidisciplinary team using a mixture of qualitative and quantitative methodologies. The three study questions were:
- How was the design brief for JCUH developed and what were its main principles;
- Were these principles noticed and valued by users and did they produce a better environment for patient care;
- What was the impact on users of the new commissioned artwork in JCUH.
The mainly qualitative approach allowed additional themes to be revealed and researched. Methodologies for the three questions differed and included questionnaire survey, interviews, photographic survey, direct observation and examination of documentation. The post-build research took place only 6 months after the move to the new accommodation which may have adversely affected some results.
Key findings included:
The three key design philosophies in the brief – patient centred care, the Institute concept (hospital within a hospital) and the Mall or village street idea – were successfully retained in the building. Clinical staff were involved in meetings throughout the design process. However the perception was that there was little involvement of patients or local people in decisions about the building.
The quality of the patient environment was improved including privacy and décor. Key patient benefits were rooms with natural light, control over their immediate environment and feeling at home. Staff were less satisfied that their needs had been accommodated, especially in staff offices, changing and recreation areas. The Institute concept had reduced travel distances for patients and staff, and the Mall, and the presence of artworks in it, contributed to the impression that JCUH was a quality hospital.
The artworks included a series of historical murals which were praised by patients and staff. The choice of a Captain James Cook theme had less impact than these murals in creating a sense of community ownership. The commissioned artworks were explicitly intended to have functions in addition to creating a sense of quality health care and providing a therapeutic environment. These included creating community links and assisting with wayfinding. Artworks were largely valued for providing colour, distraction and a sense of calm in the public areas, and for some patients they made the place less institutional. The works were put in place too late for their value as waymarks to be assessed.
Evaluation of Enhancing the Healing Environment Programme (2006)
Karin Lowson, Sophie Beale, York Health Economics Consortium; John Kelly, Mark Hadfield, RKW Healthcare Consultants
Commissioned by the Department of Health (NHS Estates)
Published by York Health Economics Consortium, University of York
The King’s Fund launched the Enhancing the Healing Environment (EHE) programme in 2000 to address the fact that although the NHS has the largest building programme in its history and there is increasing awareness of the impact of environment on health and wellbeing, yet many patients, visitors and staff see the hospital environment as drab and depressing. EHE aimed to encourage and support nurse-led teams, working in multi-disciplinary partnerships with service users, arts co-ordinators, estates staff and managers, to improve the hospital environment. The evaluation focused on nine of the 23 projects in the England-wide second phase of the project. It looked at four areas: Personal development; Improvement to the environment; Therapeutic benefit; and Economic benefit.
Key findings included:
EHE teams indicated positive personal experiences of the programme whilst acknowledging that working in multi-disciplinary teams was hard but satisfying work. Team members developed individual and team working skills and gained experience of the impact of design and colour on people’s mood, project management and negotiating funding and resources. They gained from working in partnership with people they would not normally work with.
The evaluation tested two tools for a consistent approach to environmental review developed by NHS Estates, AEDET and ASPECT. It found that ASPECT was more suited to the smaller schemes realised under EHE, although using the two tools together captured dimensions that neither alone would have reflected. All participating environments demonstrated a much higher score following completion of the new schemes.
The evaluation of therapeutic benefit focused on three aspects: staff and patient satisfaction and general well being; patient/user behaviour and clinical outcome; and the process of managing patients. Insufficient time between the end of the scheme and the evaluation limited the collection of quantitative data, but extensive anecdotal and informal evidence indicated the schemes had been effective.
Economic benefit was evaluated by gathering costs attributable to artworks, design, decoration and furniture. A cost effectiveness analysis could not be attempted because robust evidence of the effects of the scheme was not available. Conclusions were that imaginative designs do not need to cost a great deal, small sums from a central grant can leverage funding from other sources, and raising funds is useful in generating good publicity. The evaluation concludes with lessons learned and a good practice checklist.
The impact of visual arts and design on the health and wellbeing of patients and staff in mental health care: A systematic review of the literature (2006)
Norma Daykin, Ellie Byrne.
Funded by Estates and Facilities Division, Department of Health
Published by Centre for Public Health Research, University of the West of England
The report describes a systematic review of research literature on arts in mental healthcare. Over 600 papers published between 1985 and 2005 were identified. 23 reports of empirical studies met the researchers’ criteria, and were subject to critical appraisal. The study was carried out to ascertain the current level of knowledge of the impact of arts in mental healthcare environments. It was a precursor to undertaking a rigorous qualitative research study of the Moving On project within the Avon and Wiltshire Mental Health Partnership.
The 23 relevant studies covered the range of arts and health activities: art in design and environmental enhancement, commissioned works in health care settings and participatory and therapeutic patient arts. Research topics included the impact of art interventions on patients and staff, the impact of design and environment of health care facilities, the impact of participatory arts, and patient and staff perceptions of healthcare environments.
Findings derived from the various studies were that:
- Research on design and environment issues is further developed than that on arts. There is little research into the impact of arts on mental health;
- Evidence from the 23 studies suggests that arts can affect a range of clinical outcomes in patients, including physiological and psychological indicators;
- There are diverse and sometimes conflicting views on arts between patients and staff.
- Staff and patients can have difficulty in adapting to changes in the environment. Consultation and ownership are important elements in successful transition processes;
- The arts can contribute to uplifting environments, promote well-being and reduced stress;
- The arts can reinforce way-finding and information provision helping patients to feel more in control within healthcare environments;
- The small number of studies of participatory arts identified benefits for participants including personal achievement and transformation, enhanced communication and relationships, improved atmosphere in health care settings and enhanced coping with hospitalisation;
- Arts are seen as contributing to sustainable, supportive and healing environments.
Based on the findings of this review, seven key themes were identified for the Moving On evaluation, as set out in the Building on the Evidence report below, to which this report is an appendix.
Building on the Evidence: Qualitative Research on the Impact of Arts in Mental Health Care (2008)
Norma Daykin, Ellie Byrne, Tony Soteriou, Susan O’Connor.
Funded by Estates and Facilities Division, Department of Health
Published by Centre for Public Health Research, University of the West of England
Moving On was a three year programme of integrated public art commissions in mental healthcare. The study examined the impact of arts in a range of contexts and upon a broad range of service users and staff across four sites within a large NHS mental healthcare Trust.
The evaluation explored diverse experiences rather than clinical outcomes and therefore a mixture of qualitative approaches were used. It included a systematic Literature Review, discourse analysis of 400 project documents, and qualitative research including interviews and focus groups with services users, staff, artists, carer and other stakeholders.
The Literature Review (above) defined seven key themes for the evaluation:
- Key impacts and outcomes of arts in healthcare
- The contribution of arts to health care environments
- The benefits of patient participation in arts
- Appropriate and inappropriate art
- Tension between ‘art’, ‘participation’ and ‘health’
- The importance of participatory processes and the role of consultation and control in mediating complex responses to the arts
- The need for robust research, including qualitative research, based on appropriate models of arts processes
The research identified four levels at which the arts can enhance perceptions of internal and external healthcare environments: by creating a sense of being modern and fit for purpose, by enhancing aspects of the environment which are valued by staff and users, by diminishing negative aspects of the environment, and by reinforcing the qualities that different rooms and spaces offer. The role of artwork may be constrained by four conditions: by being perceived mainly as aesthetic rather than improving functioning of the hospital environment, by day-today management practices affecting access to particular spaces, by changing the visual environment but not affecting other qualities seen as important such aural quality, and by creating new challenges such as maintenance issues.
Responses to the arts are often framed through the notion of ‘value for money’ including utility and patient benefit, aesthetic considerations such as locality and nature, and political considerations such as participation and ownership. Where artworks were rated positively across these dimensions they were perceived to represent ‘a good investment’.
Service user participation was a key theme. Participation was both at strategic level of decision making and taking part in creative activities. ‘In mental health settings where the notion of participation is strongly embedded, the introduction of arts projects can be contentious’, with a tension between long-term capital investment and quality, and a service user led arts strategy.
The report includes a Best Practice Framework and indicates a number of areas for further research.
Invest to Save: Arts in Health Evaluation (2008)
Amanda Kilroy, Charlotte Garner, Clive Parkinson, Carolyn Kagan, Peter Senior
Published by Arts for Health at Manchester Metropolitan University
This 3-year HM Treasury funded project aimed to strengthen the capacity of the North West Regions’ Arts and Health community through networking and training opportunities and building the evidence base for the effectiveness of creativity, culture and the arts on health and economic outcomes. Set in the context of an increased national emphasis on partnership working and a shift towards individual responsibility for healthy living, the project aimed to encourage the development of participatory arts based practices in a range of settings and to understand their benefits more fully.
The design of the evaluation process supported collaboration between the six participating projects, with the aim of exploring practice and learning, building capacity and a shared language, identifying meaningful measurement tools and developing more imaginative and informative data collection methods. Appreciative Inquiry workshops at the outset brought together the diverse partners to explore the definition of good practice and optimum perceived outcomes. The agreed key areas for measurement were well being, general health, depression and job satisfaction, to be measured by recording pre and post intervention responses. The research team also conducted semi structured interviews with project participants, teams, artists and stakeholders.
The findings covered five areas: The criteria and qualities of successful arts and health projects; the optimum qualities of the physical and cultural environment for successful health and wellbeing outcomes; the profile of participants taking part in the projects; the benefits in terms of personal development and empowerment perceived by participants; and well being outcomes in the short and longer term. The evaluation also explored the concept of transformational change through the arts and the conditions needed to provide sustained opportunities for engagement in the arts beyond short term projects. The report includes recommendations for the future development of arts and health in the North West.
Hospital Arts Co-ordinators: an accidental profession? (2009)
Josie Aston, Wellcome Trust Fellow, Clore Leadership Programme 2008/09
An arts and health specialist herself, Josie Aston carried out a research project into the role, challenges, training and support needs of hospital arts co-ordinators in the UK as part of her Clore Leadership Development programme. There are over 100 hospital arts co-ordinators in the UK but no recognised entry route, career path or training courses.
The research was confined to arts co-ordinators working in hospitals as opposed to those working in the broader healthcare sector. The main focus was on those working in the UK, but to draw out generic features common to all arts and health programmes, rather than those defined by the UK’s NHS context, 28% of contributors were working in the USA or Canada and experience amongst the interviewees included working in Australian and Irish healthcare contexts. Information was gathered through semi structured interviews with a total of 21 hospital arts co-ordinators between February and August 2009.
The interviewees worked in a variety of settings: acute hospitals, mental health and primary care. They had different focuses for their work: visual art, buildings and, a few, participatory/performance art. They included people who were employed, self employed or on short contracts. They came from a wide variety of professional backgrounds, over a half with Fine Art or Art History training. The vast majority were women, reflecting their dominance in this field.
The research questions were:
- What makes a good arts co-ordinator?
- What is distinctive about the job?
- Is arts and health a speciality within arts practice, health practice, or something new sitting on a continuum between the two?
- What does the above imply for effective recruitment and professional development?
- What does the future hold for this role?
The findings indicate that the arts co-ordinator role is not always understood in hospitals, even those with a long running programme. Although the posts are usually junior, job descriptions are often extensive and demanding covering strategic/political roles to practical tasks. There is potential for confusion with arts therapy and on a wider front, the role is surrounded by a complexity of ethical dilemmas. There is some progress on establishing specific training, Continuing Professional Development opportunities and a new national network. Arts co-ordinators themselves could support the sector by offering shadowing or student placements.
Further Resources
The International Academy for Design and Health
The International Academy for Design and Health is a non-profit organisation with an interdisciplinary network dedicated to stimulating research concerning design, health and culture, The website includes references to a wide range of research.
Enhancing the Healing Environment: Reading List (2010)
A list of items held by the Kings Fund Information and Library Service or freely available on the internet on the topic
© Joanna Morland, 2010
