Introduction and background

The Exeter Health Care Arts Project (EHCA) is the subject of research and evaluation by Arts for Health, commissioned by the Royal Devon and Exeter Healthcare NHS Trust and funded by the Arts Council of England. (Arts for Health is a specialist department of the Faculty of Art and Design, Manchester Metropolitan University. Its field is the introduction of artworks and performances in all health care settings from general practitioner surgeries right up to elaborate hospital care. Its core activities are research, consultation and advice, teaching and the carrying out of commissioned projects.) The evaluation of EHCA from its inception in 1992 up to 1998, was begun in 1998 and carried out over two years. This paper presents key findings from the full report to the trust.¹

There were no appropriate models or precedents to follow in carrying out the evaluation. With 25 years behind the movement for arts in health care considerable achievement is evident. Artworks and arts activities in health care settings are now spreading rapidly throughout the world. The period of “evangelism”—of persuading health care professionals that the arts are of value within their facilities—has been very productive, but now serious attention is being focused on evaluation.

Existing literature on the evaluation and effectiveness of the arts in health care is seen to fall into three groups as follows.

Anecdotal reporting

The earliest anecdotal reporting of significance occurs in Florence Nightingale's book Notes on Nursing² with which she began the proper consideration of the quality of health care environments. Some who have introduced art in a particular setting have sought comments from users and this feedback has often been published. Not surprisingly most is positive and supportive of the artists and organisations involved,^3–5 and recent books covering the subject also tend to rely on arts projects which are presented uncritically.⁶ Negative examples are rare in the literature.^7–8 The collection of handwritten comments by visitors to the new St Mary's Hospital, Newport, Isle of Wight forms a substantial and very interesting body of “evaluation” free from any researcher's intervention or interpretation.⁹

Systematic evaluation

Some systematic studies have been made using a variety of techniques,^10–11 but there are well recognised and challenging issues involved in researching art in hospitals. The first is that the field of study extends on both sides of the interface between art and science, between a “soft”, qualitative, and a “hard”, quantitative, body of knowledge. Systematic research in the arts (other than historical research) and on their effects upon people in general is not extensive and arts practitioners certainly do not require or depend upon it for their work. By contrast, research in health care, especially in clinical science and in health economics, is so strongly established and so powerful in its quantitative findings that it has become indispensable for clinicians and managers. Demonstrating to them that the arts contribute to health care in the quantitative terms to which they are professionally accustomed has certainly been attempted but it has been effective only when focused on strictly limited areas.

The second issue besetting research is that arts in health care settings are but one element of the total health care environment occupied by patients, staff and visitors. When evaluating their perceptions and experiences in a particular setting it is difficult to separate the impact of artworks from that of the design of the building, the ambient conditions, and so on.¹²

A third issue concerns the uniqueness of each setting. Studies, especially those modelled on clinical trials require elaborate design, measurement and analysis. A number of such projects have been completed successfully. The most important—and endlessly quoted—is Roger Ulrich's retrospective study View from a Window,¹³ an example of a “natural” experiment. Recently another study, a comparable “natural” experiment, showed a difference in outcomes between patients who had suffered myocardial infarctions treated in either sunny or sunless rooms.¹⁴ Although neither of these was specifically about art the results appear to demonstrate significant quantifiable effects on the clinical outcomes.

Roger Ulrich has gone on to investigate the impact of art, collaborating with clinicians in some very well designed and executed studies.^15–16 His researches illustrate that “scientific” quantitative studies have to be tightly focused to obtain precise results. For example his View from a Window research was applied to adults undergoing elective surgery for a single condition (cholecystectomy) in a hospital stay of about eight days while his study of the effects of showing different pictures to patients recovering postoperatively from open heart surgery was made in an intensive care unit.¹⁷ No comparable work has been attempted for other hospital patients in other settings.

Peter Scher has proposed making assessments on the basis of simple positive and negative experiences reported by hospital users in preference to adopting arbitrary scales.^18–19 Other important recent evaluation work has been undertaken in settings for primary health care,²⁰ mental illness,²¹ environmental design quality¹⁸ and wayfinding.²²

The need for evaluation and its methodology

There is widespread agreement about the need for evaluation.^12–26 There is also the very important need to satisfy those public, private and charitable funding bodies that the objectives of arts projects are being met,^27–28 and a growing demand for the application of established management techniques of monitoring and assessment.²⁹ In the UK, the arts councils and regional arts boards who allocate considerable sums across the whole spectrum of arts have important needs for feedback.^30–32

A very clear analysis of all aspects of evaluation by François Matarasso makes an important contribution to our understanding³³ and includes practical guidance that should enable better evaluation. Most recently the conferences at Windsor³⁴ on Humanities in Medicine arranged by the Nuffield Foundation have generated a report by Robin Philipp that forms a compendium of valuable material for researchers as well as for the “users” to whom it is addressed.³⁵

At present evaluation methodology needs considerable development so that reliable evidence-based knowledge of effective practice can be gathered and disseminated.

Method

Four lines of enquiry were followed.

First, the full history, circumstances and achievements of EHCA were carefully researched and recorded.

The inception phase of the arts project was from autumn 1990 to March 1992 as the first phase of the new hospital building was completed. An arts project Briefing document was prepared and the Regional Health Authority pledged initial funding. By the end of 1991 a part-time Arts Co-ordinator was appointed. The establishment phase began with the completion of the new building in April 1992. By March 1998 the project was well established and, in succession to the arts co-ordinator, a full-time Arts Manager took over the development of EHCA. The aims and objectives of the arts project were elaborated in a number of trust documents while the finances of the project were monitored and annual summaries of income and expenditure were reported.

Second, a detailed Inventory was made of all 348 artworks introduced to the hospital by EHCA and in place when the research commenced. A model form of inventory for arts projects in health care facilities was devised and used by Arts for Health for this evaluation. In compiling the inventory, a considerable number of artworks that were not part of the arts project were seen displayed within hospital departments and 154 of these were listed separately.

Music performances, poetry readings, and so on arranged by EHCA have been relatively few in number. Their impact cannot compare with the visual artworks at the new hospital which are available while on display to virtually all the building's users especially in “public” areas and circulation spaces. Performances are usually “one-off”, only experienced by those present on the occasion.

Third, an opinion survey was made (1) to find out about the effect of specific artworks in their actual locations on the experiences of a significant number of hospital users (patients, staff, and visitors), and (2) to find out users' opinions about the EHCA project. A set of questionnaires was designed for interviews with users in situ with the majority of questions being structured, but some subjective assessments and open-ended comments were also sought.

Questionnaire 1 was “About this artwork in this place” and questionnaire 2 was “About the Exeter Health Care Arts Project”. These were used in four specific locations. Strictly representative samples of users in some locations would be extremely difficult to define and a practical approach was decided upon for interviewing. Defining and carefully choosing a sample of precise statistical validity, with pilot testing, was well beyond the available resources. In total 378 users were interviewed in situ.

Fourth, an opinion survey was obtained from a sample of front-line clinical staff to assess their experiences of the EHCA project, and also their experiences of its effects on users. These staff have training and experience in observation and are in direct contact with patients, aware of all their responses to the health care they receive and to the hospital environment. The clinical staff's assessments and their advocacy of patients' views/needs are therefore of the greatest significance. The hospital is also their working environment and their own assessments of the artworks and of EHCA are therefore of key importance.

Questionnaire 3, “About the Exeter Health Care Arts Project”, involved clinical staff exclusively and augmented questionnaire 2 in the postal survey. For interviews with clinical staff in situ, it was used in addition to questionnaires 1 and 2. (Clinical staff are defined as medical and nursing staff, and staff in professions allied to medicine who work in direct personal contact with patients.)

Questionnaires were sent to a random sample of 20% of clinical staff, using the internal hospital post. The sample was stratified to reflect proportionately the numbers in each staff grade. Three hundred and forty-eight sets of questionnaires were posted and 125 were subsequently returned completed, a 36% response, equivalent to 7% of all clinical staff. Within the total of those interviewed in situ there were 40 clinical staff who had not been selected for the postal survey. These staff completed questionnaires 2 and 3 at the interview and this data is separately identified in the analysis. Thus in total the responses of 9.3% of clinical staff at the hospital have been obtained.

Results

In total and in each breakdown for those interviewed in situ (378) and in the responses to the clinical staff sample survey (125) there were consistently more females than males. Only three inpatients and one daypatient were interviewed in situ. About one in six outpatients and one in four visitors were on a first visit to the hospital.

Questionnaire 1

Users at each location were asked six questions about the specific artwork in place there. Three of the locations were in hospital departments: radiotherapy, orthodontics and orthopaedics; the fourth was the Oasis restaurant, a large self service facility open to all hospital users. With the exception of users of the orthodontic treatment room, a marked proportion of all respondents (20.4%) had not noticed the specific artwork before being interviewed.

Respondents were asked to assess the artwork, using a set of twelve semantic differentials. The words were chosen to be plain and clear and the scale was made as simple to use as possible yet allowing expression of a full range of responses. Assessments made were 1, 2, 3, 4, or 5 with the value 1 corresponding to one possible attribute of the artwork and value 5 to its opposite. If the respondent assessed the artwork as being neither one nor the other the value 3 was used, with values 2 and 4 for intermediate assessments. Assessments made in this way have to be viewed with caution as they rely on respondents' command of language and ability to make the relatively fine distinctions. Where, in one or two cases only, the respondents' assessments were spread over the full range, 1 to 5, without any strong tendency towards a particular assessment, the resulting calculated average may be misleading. The averages are shown graphically in figure 1. Respondents were asked whether they had noticed the specific artworks. Then, to obtain an indication of the degree of users' satisfaction with an artwork respondents were asked whether they would like to see it remain, removed, or replaced. Users were also asked whether they had discussed the artwork with another person, a possible indication of the impact it may have had on them. Responses to these three questions are shown in table 1.

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Figure 1

Subjective Assessments of three art works Questionnaire 1 - ABOUT THIS ART WORK IN THIS PLACE - Question 4 Averages for all Responses

Questionnaire 2

The same respondents were then interviewed using questionnaire 2 about the EHCA project, the first question being to find out whether it was known to them. Of the total group of users, 33% said yes, as did 72.8% of the clinical staff.

Of these “user” respondents, 90.2% approved of money being raised for the arts in health care. In the survey of clinical staff, 72% also approved; none expressed disapproval but the remainder (28%), left the question unanswered.

Again, 90.4% of users agreed that arts in health care settings make a positive difference to their experience of health care and/or of visiting hospital, and 64% of clinical staff confirmed that arts made a positive difference to the experience of working in health care.

The great majority of staff interviewed in situ said that the arts in health care settings made their experiences better or more agreeable. The remainder said it made no difference but none said the arts made their experiences worse or less agreeable in any way. Of the clinical staff sampled, 30.0% said it made no difference and only one respondent was negative.

Questionnaire 3

Questionnaires 2 and 3 were sent to a representative sample of all clinical staff in the postal survey. Clinical staff among those interviewed in situ were also asked to respond to questionnaire 3. Among all clinical staff, 72.8% considered that the arts project had a positive effect on their own and their patients' morale. Among the random sample who received the postal opinion survey, 18.4% considered the arts project had no effect, and two staff considered the effect on morale to be negative. The effect of the arts project on the healing process itself was considered to be positive by 30.4% of the random sample (compared to 70% of those interviewed in situ) whereas 51.2% of the sample (25% in situ) considered that there was no effect.

Among staff interviewed in situ, 42.5% considered that the arts project had therapeutic benefits, as did 17.6% of the sample; however, the only specific benefits they cited could be characterised as stress relief (about 11); one respondent cited “increased and faster recovery”. A small majority thought the benefits would diminish if there was no arts project.

When asked whether they considered that the quality of the environment had observable effects on users the great majority of clinical staff (88% of the postal sample and 92.5% of those interviewed in situ) replied “yes”. The positive qualities were stressed by respondents and frequently described with precision. Respondents were asked whether arts activities had ever been integrated into their own clinical work. Only 15.2% of the sample (25% in situ) had such experience and 11 of the 30 responses referred to arts activities arranged with EHCA. Those staff who believed the arts could be successfully integrated into their own work formed 31.2% of the sample (52.5% in situ).

Evaluation and discussion

A just assessment of any enterprise should first compare the results achieved with the objectives explicitly stated by its sponsors. Initially the principal aim of the EHCA project was simply: “…to humanise the environment, create more attractive places to sit and wait, and to help people feel more comfortable in navigating their way round the building.”

As the project developed a number of additional objectives, such as “to alleviate stress”, were stated but the Trust chose no indicators by which to assess progress towards the reaching of those objectives. In this respect the EHCA project is not at all unusual. Eight key results of the evaluation are discussed below.

Economic aspects and financing the arts in health care

Can the arts project be seen as value for money? This is a most difficult question to answer as there is no body of comparative detailed project data and cost information to consult. Data from similar projects cannot reliably be compared in detail as they record income and expenditure in a variety of different ways.

Some primitive cost indicators may be of use for development in the future. The income of EHCA for the six years under review was £224,461. Total expenditure for this period amounted to £206,711 of which £88,639 was on artworks (capital expenditure) and £118,072 on project management and sundries (revenue expenditure). In relation to the Trust's total spending this was equivalent to approximately 0.1% of capital spending on average per annum and no more than 0.025% of revenue spending on average per annum. The cost of EHCA has been well below the “1%-for-art” policy implemented for capital projects in some European countries. This formula relates the capital cost of artworks only to the scale of a new facility; for existing facilities another measure is needed.

Obtaining the extensive display of visual art, initiating performances, arts activities and participation, and preparing the successful bid for substantial National Lottery funding—these have all been accomplished through the work of a part-time Arts Co-ordinator. Our own, informed opinion of the professional and artistic quality of the commissioned works is very high, comparing very favourably with other health care arts projects, and endowing the hospital environment with some significant, permanent assets. The overall positive responses of users is established by the surveys. These considerations leave no doubt that, at a total cost below £35,000 per annum, the Trust has obtained excellent value for money.

Some 90% of respondents interviewed and some 70% of clinical staff approved of money being raised for the arts in health care; similar percentages stated that the arts made a positive difference to their experiences of health care. This level of support for what is seen suggests that there may be an unexpressed need or demand for it.

Responses to artworks by users

The evaluation of visual art is not a matter of general consensus except perhaps for acknowledged historic masterworks. People do not usually visit hospitals to see the artworks. However, for users in this health care setting where the display of artworks has stated functions the evaluation should attempt to find out the responses evoked. There is as yet little understanding of the interaction of users with displayed works as they occur. It was decided to obtain precise information in preference to repeating the generalised enquiries used elsewhere, and the results justified this approach.

The effect of an artwork in a health care setting on an individual depends first on the individual being aware of it. Having observed it the individual may read any information on display about it and may discuss the artwork with another person. These and other matters of fact were established for those interviewed at six specific locations, together with their subjective assessments and whether they would like to see the work remain, or be removed or replaced. The Walled Garden was considered the most successful but none of the six averaged truly undesirable assessments.

Effects on morale

It had been suggested that a positive effect on morale was linked to enhancement of the healing process. Without inferring this or any other link the effect on morale may be gauged by the observations of clinical staff over an extended period.

Clinical staff were asked whether, from their own experiences, they considered that the Arts project has effects on the morale of patients and on the morale of staff, and if so, whether the effects were positive or negative. In the sample survey of clinical staff the majority answered “yes” and “positive” on both counts. Only one or two respondents thought the effects were negative and 18.4% considered that there was no effect. The additional clinical staff who responded to the same questions at the in situ interviews gave yet more support. This is a very strong endorsement for the arts project from clinical staff on their own and on their patients' behalf, further reinforcing the case.

Effect on the healing process

Of those in the sample survey who answered the question about the effects on the healing process 32.8% said “yes” with positive effects and 51.2% said “no”. The additional clinical staff interviewed in situ divided 70% “yes” and 25% “no”.

This may be summarised by saying that while perhaps a third or more of the staff are convinced of the positive effect of the arts project on the healing process about a half of them are not. Possibly some are not yet convinced of it for a number of reasons such as:

• in a large acute hospital the range of conditions treated, for patients of almost every type, cared for in a variety of spaces, is too great for experiences of healing to be generalised;

• some of the staff surveyed or interviewed may have had little experience of working in any health care facility with an arts project;

• clinical staff observe the healing process within the wards and clinical departments of the hospital. Most of the artworks installed by EHCA are not placed in these areas.

The situation in a hospital differs markedly from exhibitions or galleries displaying works made simply to exhibit—as “gallery art”. The majority of artworks installed by EHCA are loans and purchases that may be regarded as “gallery art” both in their origin (not made by the artist for a hospital setting) and in their placement in the hospital street, stairways, corridors, cafeteria and so on. Although the hospital street may be used as an exhibition gallery, as such it has several disadvantages; at times it can be very busy indeed, the natural and artificial lighting is very variable and often unsuitable for viewing artwork, and viewing distances are very limited.

Nevertheless users do look at artworks in these areas at most times and a number of respondents also commented favourably about this in questionnaires. In particular “gallery use” of the circulation areas is notable at less busy times such as evenings and at weekends. Inpatients who are ambulant or in wheelchairs benefit from a “stroll along the street” to look at the artworks and this further suggests that the arts project contributes positively to the healing process. This pattern of “gallery strolls” by inpatients has been observed in other hospitals with works displayed in extensive circulation areas (for example, St Mary's Hospital, Isle of Wight, and the Chelsea and Westminster Hospital). Comments confirmed that a number of clinical staff recognise this as an element of health care, providing both distraction from stressful experiences and some physical exercise.

Therapeutic benefits

Separate questions for evaluation suggested by the Trust inferred a distinction between the healing process and the therapeutic benefits of health care. If the term therapeutic benefits is understood to mean clinical outcomes then, as with morale and with the healing process, in the absence of detailed clinical evidence the best guidance for assessment is from those in direct contact with patients.

Only 17.6% of the clinical staff sample said they were aware of therapeutic benefits from the arts project; of those interviewed in situ 42.5% said they were aware of them. A significant majority in the sample survey were not aware of any therapeutic benefits while the evidence offered by those who responded positively was not very strong. The commonest effect described (by nine respondents in the sample survey and nine interviewed in situ) was that of distracting patients and, in some cases, calming or stimulating them, thus relieving some of the stress engendered by illness and its consequences

Integration, participation, and interaction

No more than a quarter of the sample of clinical staff surveyed and interviewed in situ reported that arts activities had been successfully integrated into their professional work. Some comments in response to the questionnaires confirm that those staff who do have such experience are fully convinced of its effectiveness.

In the inventory of the EHCA project 18 entries are classified as “active”. Patients and visitors have some active contact with these artworks either through their authorship or in their enjoyment. There is some evidence that these artworks have a greater effect than works—on loan or purchased—that are simply chosen for placing in the health care setting. Another positive aspect of these works is that in most cases detailed information about how they came about and about the participants is part of the display. In the form of photographs, text, preparatory sketches and models these are valuable—and valued—displays in themselves.

An exemplary demonstration of this is The Theatre Trail.

This work was initiated by a staff nurse in the operating department. The aim was to relieve the anxiety experienced by children on their journey to the operating department to undergo surgery. The nurse proposed the idea of a series of visual distractions for this project and as a result EHCA commissioned the artist, Meg Surrey, to create the work. She did so in full cooperation with the staff nurse and while gaining understanding of the health care setting as artist-in-residence.

A series of panels brightly painted in acrylic are placed along the route taken by the child on a bed-trolley. En route the nurse and attendants with the child point out the trail and engage the child's interest with questions, etc. This is a regular part of the clinical work of the staff and its success is outstanding. The Theatre Trail was originated by a nurse, developed as part of continuing education for staff and implemented by EHCA. It involved an in-house artist working in close cooperation with staff to create professional work of high quality that is considered by clinical staff to achieve its stated purpose effectively in continuous usage.

Environmental quality

Visual artworks form part of the physical environment of the hospital and their immediate settings must also have effects on the way users experience them. The overwhelming majority of clinical staff considered that the quality of the environment where health care takes place has observable effects on users.

This may seem unsurprising as, in general, most people recognise that the environment affects them. However, this question was put to front-line clinical staff about the environment, specifically where health care takes place and where both staff and patients are concentrating on what is happening to the patient. Their answers given to the follow up open question asking for a description of the qualities and their effects were more numerous than for any other open question. The comments were generally clear, confident and, as a group, consistent and confirm both the need for obtaining good environmental quality and the significance of the staff's own assessment of it.

Communication and awareness of the EHCA project

People do not use hospitals on account of the artworks to be found there and although health care arts projects are increasing in number throughout the UK most health facilities do not have one. Awareness of an arts project is an important indicator of the effect of an arts project on the users, and thus indirectly, of the value of the project, for two main reasons:

1. All hospital staff should be aware of it as a resource from which their own department can benefit and each should be aware of it so as to enable patients, visitors and new staff to share its benefits.

2. As part of the community it serves the art project should be known to a significant proportion of those who use the hospital. It should also become well known to local arts and arts related organisations and to local professional artists.

In assessing the extent to which users of the hospital were aware of the arts project the survey found that only 31.1% of patients and visitors (excluding those on first-time visits) knew of the EHCA project. The 72.8% of the sample survey of clinical staff who knew of the project was lower than might have been expected.

Key staff could become more active advocates and facilitators for the arts project, for example heads of wards and departments could inform their own staff and encourage them to involve patients and to become involved themselves. The involvement of local schools, colleges, museums and galleries has been significant and successful. Activities that have the effect of drawing out latent resources for the arts within the hospital and the community will also make EHCA better known.

Conclusions

The commission to evaluate the Exeter Health Care Arts Project did not seek recommendations as to the future and indeed there have already been many significant developments since 1998. The following conclusions drawn from this research and evaluation should have general application.

Awareness and communication

There is a growing knowledge and understanding of the value of arts in health care among users and within the whole of our culture. There can be few places where social inclusion is more complete than a major National Health Service hospital serving the whole population of a large area. This new awareness can be developed into active support and positive involvement, including the raising of funds.

Staff participation

This investigation has established that there is a significant amount of untapped potential staff support for the arts. Staff have much to contribute in suggesting and developing new ideas for arts initiatives that have a direct and positive healing effect on patients. This has also been demonstrated in some of the work evaluated and in the support by front-line staff for integrating arts activities into their professional work.

Resources

A successful arts project should develop to become an integral element of the hospital or health facility. All arts projects in health care are dependent on partnership funding from a range of sources, and much of this is in the form of grants for specific one-off commissions—capital expenditure—and may not be used for revenue. An arts project budget should identify core revenue costs and there should be an ongoing commitment by the host health care facility to obtain support for this.

The value of arts in health care

This research and evaluation is the first independent examination of its kind of a health care arts project. As such it is an exploration of methodology as well as a contribution to basic knowledge in this relatively new but rapidly expanding branch of arts activities. All aspects of the arts in health care require further proper research, especially where these touch community and educational activities. Much is claimed for the arts' contribution to healing, caring and even curing, and this is frequently met with scepticism by some clinical workers. Only good evidence based on tested methods will bridge the wide gap between enthusiasts and sceptics. The report of the Exeter evaluation is a first step and it is hoped that it will lead to further independent and objective research.