Art for Health's Sake

An evidence-based approach

Upali Nanda

Upali Nanda

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Upali Nanda, has a Bachelor of Architecture from School of Planning and Architecture, New Delhi, a Master of Arts from National University of Singapore, and a PhD from Texas A&M University. She is the Vice President and Director of Research at American Art Resources, where she conducts research on Visual Images for Healthcare Environments.

The human mind and body are so intrinsically linked that \"feeling\" better is a huge step towards \"being\" better. This makes the role of art very critical in today\'s healthcare.

They say a picture is worth a thousand words. In a museum, we can stand and ponder on what these thousand words may be. We can look at a picture, wonder, and let our thoughts wander.

But, what about art in a hospital?

In a hospital, patients, visitors and staff are all under constant pressure and in a state of stress and anxiety. Patients want to feel better and care givers want to make patients feel better. Good doctors, good infrastructure, good medication and a clean, safe environment is all that should be needed to achieve this objective. And yet, there is a growing movement away from the cold, sterile, pearl-white and disinfectant-smelling environments of yore to more humane environments that are less frightening to the patient and less stressful to the staff. The key is in perceptions-the human mind and body are so intrinsically linked that "feeling" better is a huge step towards "being" better. And this is where the role of art becomes so critical.

Today, nearly 50 per cent of all hospitals in the US have art programmes. In 2003, the Society for the Art in Healthcare (SAH) and the National Endowment for the Art (NEA) undertook an analysis of Joint Commission on Accreditation of Healthcare Organizations (JCAHO)-affiliated hospitals to determine the current level and characteristics of art activities in healthcare (Wikoff, 2004).

Two thousand hospitals responded that they had art programmes in place-73 per cent of those reported permanent displays of visual art in the hospital; 32 per cent reported having rotating exhibits, typical art by local or regional artists. The study found that 96 per cent of hospital art programmes were intended to "serve patients directly." The primary reason given for having art programmes was "benefit to patients" (78.8 per cent), noting them "specifically to be a part of their mental and emotional recovery (72.8 per cent)." The study also found that 25 per cent of hospitals with art programmes allow patients an opportunity to choose their own art. In the US$ 41 billion healthcare construction industry in the US, by a conservative estimate, US$ 2 billion will be spent on art for new hospital constructions this year. Yet, despite the obvious support for art in the healthcare setting, finding resources for information on how to create a successful and empathetic art programme is difficult. The popular notion is to consider Visual Art as nothing more than pictures that can entertain, but not heal. Over the past decade or so, there has been a growing body of evidence to prove otherwise. Studies have now linked the effect of Art to measurable health outcomes, such as reduction in stress, pain perception and anxiety and increase in satisfaction and restoration. These studies form the evidence base for a more responsible and ethically driven aesthetic of what is being termed as "Evidence-based Art."

The evidence base on healthcare visual art: A quick overview In Florence Nightingale's Notes for Nursing ([1860], 1969), she describes the patients' "need" for beauty and argues that the effect of beauty is not only on the mind, but on the body as well. Since that first emphasis more than a century ago, art has continued to have a presence in the healthcare environment. During the Depression, artists were put to work on painting murals in US hospitals. In the 1970s and 1980s, hospitals in the US began to "decorate" with art-but without particular consideration to the "therapeutic benefit" art might have had. The early 1990s saw a new interest in therapeutic environments, which emphasised art that was intended to contribute more than decorative value to the hospital environment. Today, there is yet another shift to more rigorous evidence-based design, which is both the process and product of scientific analysis of healthcare environments (Hamilton, 2003). In the context of art, this refers to the process and product of scientific analysis of the impact of art on healthcare environments; on patients and care givers. This implies that art interventions must not only base decisions on the best available research findings, but also commit to the process of generating new evidence base on these interventions. According to Ulrich and Gilpin (2003), within the healthcare environment, the important outcomes relevant to art / health research are the health outcomes, which include:

  • Clinical indicators: Observable signs and symptoms related to patients conditions such as length of hospital stay, intake of pain medication or biological markers such as blood pressure and heart rate
  • Patient / Staff / Family-based outcomes, such as patient ratings of perceived pain, satisfaction with healthcare services, staff-reported satisfaction etc and
  • Economic outcomes such as cost of patient care or cost related to nursing turnover etc.

Focussing on the above outcomes allows the development of an evidence base that can guide best practices for creating therapeutic art programmes. In the medical community, Art interventions are often used as "positive distractions" for patients. For example, adult patients in a procedure room reported better pain control when exposed to a nature scene with nature sound in the ceiling (Diette, Lechtzin, Haponik, Devrotes, & Rubin, 2003). Murals (as distraction) resulted in a significant decrease in reported pain intensity, pain quality and anxiety by burn patients (Miller, Hickman, & Lemasters, 1992). Breast cancer patients reported reduced anxiety, fatigue and distress during chemotherapy when exposed to virtual reality intervention displaying underwater and art museum scenes (Schneider, Ellis, Coombs, Shonkwiler, & Folsom, 2003). A similar finding was made when patients were asked to enter a virtual environment by playing video games or wearing a headset (Hoffman, Patterson, Carrougher, & Sharar, 2001). In a 2002 study researchers found that with the use of soundless nature video there was a significant increase in pain threshold and pain tolerance.

Art has also been seen to have 'stress reducing' effects. Evidence from heart-rate recordings and questionnaires showed that stress in a dental clinic was appreciably lower on days when a large mural was hung at the back of a waiting room (Heerwagen, 1990). In another study, ceiling mounted pictures shown to highly stressed pre-surgical patients on gurneys, resulted in lower blood pressure when the images were of serene nature scenes (Ross, 1990). While it has become increasingly common to use art interventions to distract patients from their pain or stress, the body of work on the appropriate image content used for such interventions remains small.

Research by Ulrich and Gilpin (2003, p.123) suggests that nature art (or art with views or representations of nature) will promote restoration if "it contains the following features: calm or slowly moving water, verdant foliage, flowers, foreground spatial openness, park-like or Savannah like properties (scattered trees, grassy undershot) and birds or other unthreatening wildlife," Ulrich and Gilpin (2003) also suggest that in addition to nature art, humans are genetically predisposed to notice, and be positively affected by smiling or sympathetic human faces.

In a landmark study conducted in 1984 in Pennsylvania, Ulrich found that post-operative gall-bladder surgery patients whose rooms had windows with views of a park had better outcomes than those patients whose rooms had windows with views of a brick wall. Patients complained less to staff, needed analgesic pain medication of lesser strength, and were discharged earlier (Ulrich, 1984). In a study with post-operative heart patients in Sweden (Ulrich, Lunden and Eltinge, 1993), it was found that exposing heart surgery patients in intensive care units to pictures of nature improved outcomes. On the other hand patients reacted strongly in a negative manner to abstract art. This is one of the few studies that highlights not only the positive impact of appropriate art, but the potentially harmful effect of inappropriate art. The study shows that it is risky to place art in a hospital that is ambiguous, subject to interpretation, or that has obvious negative connotations. Because, when viewers are stressed or in a negative emotional state, which they often are in a healthcare setting, they are likely to respond in a negative manner to art that they cannot understand or that contains negative images or icons. Ulrich and Gilpin (2003) suggest that the explanation for the appropriateness of nature images, and inappropriateness of abstract or ambiguous images, lies in the two basic theories: Evolutionary Theory and Emotional Congruence Theory. Evolutionary Theory holds that man's evolutionary survival skills in a natural world have hardwired humans to find nature calming and restorative. Emotional congruence suggests a person perceives his or her emotional state in a manner congruent with their current emotional state. In a hospital environment, it is likely that the high stress that patients and staff are under colours their responses to the art.

In fact, the usual yardstick for art evaluation may be quite inadequate and inappropriate in healthcare settings. Nanda and Hathorn (2006) conducted an art preference study with inpatients at St.Lukes Episcopal Hospital in Houston, and found that patients preferred nature scenes and representative images over-stylised or abstract art, even when the latter were rated as "best-sellers" by different online art vendors. The study is yet another indicator that high quality art, or even popular art, is not always appropriate art for healthcare settings. In fact, there were many pictures, which the patients said they would like to put in their homes, but not in their hospital rooms. This shows the distinction patients make between their emotional state at home and in the hospital.

An area where more investigation is warranted in an increasingly global healthcare market is the role of ethnicity on Art Preferences. In a small preliminary survey conducted in a large urban midwestern hospital Hathorn and Ulrich (2001) found that Caucasians' and African-Americans' responses to figurative art depicting caring faces and positive body language were the same. Results also showed that both groups preferred representational paintings of nature landscapes and rural areas showing spatially open settings in clear, sunny weather, with water features and verdant vegetation. Paintings of gardens with flowers were also rated as appropriate.

Implementing evidence-based art: Mays Clinic, M.D. Anderson Cancer Center, Houston, Texas, USA

In 2002, the University of Texas M. D. Anderson Cancer Center made a decision to change the fundamentals of its art programme from an art-for-art's sake to a evidence-based approach; one that used previous research to determine appropriate art content for patients and staff in the hospital. The approach was also committed to evaluating the results of any art intervention, and collecting evidence on the effectiveness of the art-intervention that was implemented. An art programme based on guidelines developed from previous research was developed to address the following goals:

  • Create a healing and hopeful environment
  • Relieve stresses associated with a healthcare environment
  • Reflect and enhance images developed through design and architecture
  • Address a culturally and regionally diverse population
  • Accommodate needs of special patient populations
  • Reflect overall standard of excellence
  • The art selection criteria were as follows:
  • Landscapes: Regional, generic or seasonal
  • Positive fall and winter landscapes
  • Waterscapes: Regional, generic, or seasonal
  • Floral: Familiar flowers, garden / bouquet style
  • Flowers in vases (used sparingly for variety)
  • Figurative: Observational rather than Interpersonal, people in positive relaxed nature surroundings

Still lifes (used sparingly for variety)

In February 2007, a Post-Occupancy Evaluation (POE) of the Art programme implemented at the Mays Clinic, M.D. Anderson was undertaken to understand the effectiveness of the applied guidelines, and the need to change based on user feedback. Five units were identified to conduct the surveys with the patients and visitors: Radiation / Oncology, Breast Imaging, CT Imaging, MRI and Outpatient and Diagnostics. Each of these clinics hosted artwork that adhered to one or more of the art criteria. An on-site questionnaire was administered to 210 patients and visitors, and an online questionnaire was administered to 240 staff members. Eighty-four per cent of Patients / Visitors thought the artwork in the Mays Clinic, overall, made them feel much better (15 per cent) or better (68.5 per cent). When asked about the role of art, patients / visitors mentioned that art served as a distraction, made the hospital de-institutionalised, gave comfort, was cheering and uplifting, helped get rid of anxiety and contributed to the perception of the overall quality of care. The staff of M.D. Anderson were also asked about how appropriate they thought the artwork in the Mays Clinic was for the patients. Ninty-seven per cent of the staff thought the art was highly appropriate (56 per cent) or moderately appropriate (41 per cent).

Overall, both the quality of the artwork and the emotional / healing effect of the art were rated positive. Also, the rate of response was indicative of an involvement in art by all the users, which is significant. Finally, it is important to note certain themes that were emergent from the qualitative data in the POE about the role of art:

  • Healing: Making patients and staff "feel" better
  • Positive Distraction: Allowing patients and visitors to focus on something other than their (and the people around them) condition
  • Branding: Improving the perception of care at the hospital, and serving as an element that users identify with
  • De-institutionalisation: Making the hospital less intimidating
  • De-stressor: Both patients / visitors and staff use favourite pieces of art to de-stress This is particularly true for the staff
  • Way finding: Prominent pieces of art serve as landmarks for patients

The M.D. Anderson case study is an example of basing design decisions on best available evidence, and then evaluating the success of the implemented design decisions. While the tools used (on-site and on-line surveys) are basic, they form the foundation for an ethical approach to healthcare art, one that goes beyond mere aesthetic considerations.

If a picture is worth a thousand words, then these words must be carefully chosen, and clearly spoken, via the medium of art, to convey the message to patients and care-givers alike that every aspect of their environment is aimed at making them feel better and get better.

About American Art Resources:

American Art Resources is USA's leading evidence-based art consulting firm. Their expertise is in producing award winning art programmes, unique to each client, that are based on patient specific needs, community resources, and produced within defined budget / time constraints, targeted exclusively at the healthcare industry.