1) The document evaluates the inclusion of art-related education in a health promotion course for nursing students from 2001-2005. It describes how art was positively evaluated by most students as increasing awareness of healthcare environments and promoting empathy. 2) It then describes a specific project where students provided input to introduce art into a clinical skills laboratory. 3) The document provides an example of how art can be used in nursing education to encourage empathy and discusses its potential benefits.

1. Using art in pre-registration nurse
education
Sally Robinson
Department of Health, Wellbeing and the Family,
Canterbury Christ Church University, Canterbury, UK
Abstract
Purpose – The paper comprises an evaluation of the inclusion of art-related education within a
health promotion course for student nurses, which ran for four cohorts from 2001 to 2005, and a
description of a project to introduce art into a clinical skills laboratory as part of the course.
Design/methodology/approach – The art-related aspects of the course were evaluated by
analysing qualitative comments from a questionnaire completed by a total of 83 students from the four
cohorts. In addition, lecturers were invited to write their reflections. Only the 2003-2004 cohort worked
on the clinical skills laboratory art project in which students acted as a focus group, and later carried
out interviews with patients.
Findings – The art-related education was positively evaluated by most students, and appeared to
have increased their awareness of health care environments. For some, it had promoted emotional
awareness, empathy for patients and had been a therapeutic and enjoyable experience. A specification
for art work to be introduced to the university’s clinical skills laboratory was produced.
Originality/value – Using the arts in pre-registration nurse education is relatively new in the UK,
and this work provides an example of its potential to encourage empathy among student nurses for the
experience of patients in health care settings. The paper provides an example of how art work could be
introduced into health care settings.
Keywords Nurses, Education, Health education, Hospitals, Arts, United Kingdom
Paper type Research paper
Introduction
The UK is witnessing the advancement of the arts in mainstream health care and
health promotion. This appears to be the result of three key drivers. At an international
level, the Vienna Recommendations on Health Promoting Hospitals directed that
hospitals should be “oriented towards quality improvement, well-being of patients,
relatives and staff”, and should “focus on health with a holistic approach and not only
on curative services” (World Health Organization, 1997, p. 2); and the United Nations
Education and Scientific and Cultural Organisation (UNESCO) argued that the
relationship between creativity, health, the arts and healing was fundamental to
human well being (Journal of Advanced Nursing, 1999). Secondly, perhaps informed by
criticisms that mental health promotion was all too frequently misunderstood as the
provision of services for those with mental illness (Secker, 1998; Friedli, 1999) and that
public health practitioners tended to neglect the mental health potential of their work
(Hart, 1999), the British Government made mental health promotion Standard One of
the National Service Framework for Mental Health (Department of Health, 1999a,
The current issue and full text archive of this journal is available at
www.emeraldinsight.com/0965-4283.htm
Many thanks to Tony Crosse who very generously volunteered his time for this project, and the
Sidney de Haan Research Centre for Arts and Health for providing funding for the art work.
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Received July 2006
Accepted February 2007
Health Education
Vol. 107 No. 4, 2007
pp. 324-342
q Emerald Group Publishing Limited
0965-4283
DOI 10.1108/09654280710759241

2. 2001), stating that the Health and Social Services should promote mental health for all.
In 1997 and 1998, in response to criticisms that medical care emphasised technology at
the expense of humane care, the Declaration of Windsor called for medical education to
include arts and humanities within medical education (Philipp et al., 1999). By 2003 the
General Medical Council (2003) had agreed that “special study modules” could be
undertaken as part of medical education, thus enabling some universities to introduce
arts-based studies.
The recent developments were underpinned by a slowly growing body of evidence
that the arts were important for promoting well-being. They had a role to play in the
primary prevention of ill health, in alleviating the suffering of the sick and supporting
the well-being of staff (Haldane and Loppert, 1999; Staricoff, 2004; Macnaughton et al.,
2005). The work of Arts for Health in Manchester and Healing Arts at St Mary’s, Isle of
Wight, along with the research undertaken by the Centre for Arts and Humanities in
Health and Medicine at the University of Durham (e.g. Macnaughton et al., 2005), the
Chelsea and Westminster Hospital Arts Research Project (e.g. Staricoff, 2004) and the
Centre for Medical Humanities at University College, London (e.g. Kirklin, 2001; Kirklin
and Richardson, 2003) are notable examples.
Meyrick (2001) summarises the British “art for health field” as comprising five
components:
(1) the Built Environment;
(2) Art in Hospitals;
(3) Medical Humanities;
(4) Art Therapists; and
(5) Community Arts.
She describes Medical Humanities as the use of literature, visual art and drama in
medical education in order to promote doctors’ empathy and communication skills. It is
salutary that, with the exception of the arts therapists, all other health and social care
professionals were omitted from this concept of the “art for health field”. Nursing is one
omission. From 2001 to 2005 the five components were built into a health promotion
course taught to pre-registration Adult and Child Nursing students at Canterbury
Christ Church University, Kent. The course included music, literature, drawing,
humour and art. An overview of the entire course, and its evaluation, is described in
Robinson (2007).
This paper describes the art-related aspects of the course, and how these were
evaluated by the students and lecturers. It also describes an art-related project, the
Clinical Skills Laboratory Art Project, which was carried out with the 2003 to 2004
cohort of students culminating in the production of works of art.
Hospital environments
Meyrick (2001) describes the “built environment” as using art and design in the
creation of healing healthcare environments, and “art in hospitals” and as using visual
arts to improve the experience of patients, staff and visitors in hospitals. The
importance of the hospital environment can be illustrated by three studies. Ulrich
(1984) assigned 23 patients recovering from surgery in a Pennsylvanian hospital to a
room with a view, and 23 matched patients to similar rooms facing a brick wall. The
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3. nurses’ notes and the patients’ use of painkillers were examined. Ulrich (1984)
concluded that patients with a view had shorter stays in hospital, fewer negative
evaluative comments in the nurses’ notes and took fewer strong painkillers than those
who faced the brick wall. The findings from this study are supported by Hartig et al.
(2003), who found that sitting in a room with a view of trees reduced diastolic blood
pressure more rapidly than sitting in a room without a view. White and Heerwagen
(1998) changed the view from a waiting room with a mural showing mountains, trees
and grass, to a view of a blank wall. They found that the patients’ heart rates and their
own self-ratings indicated that they were less stressed and calmer on the days the
mural was shown.
The theme of nature arose in the reflections of Robert McCrum. An award winning
journalist, novelist and editor, he unexpectedly found himself in hospital recovering
from a stroke. He wrote:
. . . the world seemed almost unbearably precious. Shut away in my room, with the finest
English summer in memory scorching outside, I had a craving for sky, earth and sea, which I
satisfied in the oddest way by watching sport and nature programmes on television
(McCrum, 1998, p. 50).
This experience of wanting the “outside to come inside” might be explained by the
work of Morris (2003), who carried out an extensive literature review into the health
benefits of being exposed to the natural environment. She concluded that it “enhances
personal and social communication skills, increases physical health, enhances mental
and spiritual health, sensory and aesthetic awareness and it can enhance the ability to
assert personal control and increased sensitivity to one’s own well-being” (pp. 13-14).
Staricoff (2004) suggests that the hospital environment also affects health care staff.
Having an active arts programme integrated into the work environment has been
linked to staff satisfaction, improved recruitment and retention of staff, and the
provision of good quality care. So, today, it is encouraging to see that National Health
Service Estates, the Kings Fund and the Commission for Architecture and the Built
Environment (CABE) are all working towards improving the design of British
hospitals. The King’s Fund, a charity based in London, launched its programme
“Enhancing the Healing Environment” in 2001. It funds nurse-led teams to work with
patients to improve health care environments (King’s Fund, 2006). Anecdotal reports
suggested that initial development was slow because nurses simply did not know what
to do with the opportunity. Yet in one survey, 90 per cent of nurses said that they
believed that a well designed environment was significantly related to patient recovery
rates, that patients behaved better in well designed wards and that working in poorly
designed health settings increased stress levels (Commission for Architecture and the
Built Environment, 2003). Peter Senior, director of Arts for Health in Manchester says:
If the arts have any value for society then they must have relevance in important places such
as hospitals where there is a basic human need for beauty, humour and spiritual uplift. Art
within hospitals and health care buildings should aim to complement not only the
architecture but also the healing service (Arts for Health, n.d., p. 7).
Interest in art in hospitals is increasing. Paintings in Hospitals, a British charity, was
founded in 1959 with the objective of loaning works of art to hospitals (see www.
paintingsinhospitals.org.uk). Today it is delivering to 250 hospitals across the country.
Some of their paintings were selected for a scientific evaluation of the effects of visual
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4. arts within the Chelsea and Westminster Hospital in London (Staricoff et al., 2004). The
paintings were introduced in, or near to, the treatment room of the Medical Day Unit
and included landscapes, marine pictures, portraits, figurative and abstract work. The
paintings were changed every week. Ninety-one patients agreed to complete the
Zigmond and Snaith Hospital Anxiety and Depression Scale over a period of 24 weeks.
The researchers found that 79 per cent of the patients gave a very positive response to
the pictures in terms of expressing attraction and enjoyment. For 47 per cent of the
patients, the art was highly effective at helping to distract them from their worries.
When asked about whether the art had changed their mood for the better, 80 per cent
gave a very positive response. Sixty-five per cent cited that it had eased stress to a
greater degree and 27 per cent to a moderate degree. Eighty-seven per cent of the
patients considered that the art work had made a notable contribution to making the
environment pleasant.
Using the arts in nurse education
Modern nursing was conceived as being holistic in its approach towards people by its
founder Florence Nightingale (Dossey et al., 2005). More than a century before the
Ottawa Charter for Health Promotion (World Health Organization, 1986), Nightingale
paid attention to holistic care and the settings in which people were nursed. The
twentieth century saw a long debate about whether nursing was an art or a science as
the rise of technical and economics-led health care systems diminished the value placed
on the art of nursing (Ehrhart and Furlong, 1993), leaving it open to accusations of
being excessively subjective, arbitrary, unverifiable and therefore untrustworthy (Le
Vasseur, 1999). Yet by the 1990s health promotion had become central to the
competencies required of a nurse (Department of Health, 1997; 2004), and studies were
showing that nursing students were lacking education relating to mental and
emotional health (Mead et al., 1997; English National Board, 2001). There were
concerns that nursing had become too technological and functional, and one way of
redressing the balance lay in incorporating the arts into nurse education (Levine, 1997).
Coghlan Stowe and Igo (1996) explain that it is vital for student nurses to use the arts
and humanities in their education in order that they can learn the difference between
being technically competent and being a professional who can facilitate healing and the
promotion of well-being.
The whole human condition is represented throughout the arts and humanities and
so they present a rich vein for learning. Sarginson (2003) explains that whereas
textbooks can describe symptoms, types of pain, and the psychology of illness, they
cannot describe how it feels. The arts can. A piece of music, a poem or a painting can
express emotions that are otherwise difficult to articulate. McDonald et al. (1999)
explain that for health education to be effective, it needs to begin with understanding
people’s reality, that is the culture which embodies their aspirations and their history.
For example, Ehrhart and Furlong (1993) asked student nurses to present case studies
of clients to their peers. In addition to the more usual case history, the students had to
include a piece of literature, music, art or photography which best represented the,
“entire realm of the patient’s well being” (p. 22). Their examples eloquently
communicated the salient points of a patient’s history, culture, feelings and beliefs. In
this way the arts can encourage more culturally sensitive and empathic nursing
practice (Greiner and Valiga, 1998).
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5. Art can be used to facilitate the development of important health promotion
competencies. In Philadelphia nursing students are directed to works of art in their
local art gallery in order to answer questions about the subjects, environments and
activities represented in the art work (Davis, 1992). They are asked to assess the
mental, physical and environmental activities within the paintings, to consider the
stage of life of the subjects and to predict any potential health gains and or losses.
Davis reports that the exercise hones the students’ skills of perception and problem
solving and, in turn, enhances their confidence in their abilities to assess humanity
across time and cultures.
Art has been described as medium that can evoke inspiration, imagination and
creativity. Greiner and Valiga (1998) point out that these are the very qualities
needed by nurses if they are to be flexible and effective in their health promotion
work. Whitman and Rose (2003) asked nursing students to produce a piece of art
work in order to express their philosophy of nursing. The day of the sharing of
the work was also the last day of the class prior to graduation, and they brought
in posters, drawings, paintings, boxes and so forth. The students reported finding
the task challenging, but the spirit within the classroom was magical, intimate and
respectful. It was described as a powerful and creative way to spend their last day
together.
The act of engaging in the creative process of producing art, that is the colouring,
sticking, drawing, sculpting and painting, is associated with improvements in
well-being. Heenan (2006) reported on using art therapy within a community-based
mental health organisation. The participants reported that the process of creating art
was associated not only with improved skills and knowledge, but also improved
self-esteem and self-confidence. Waller (2006) explains that within art therapy, people
can sublimate their feelings into images. The process of creating the art work can help
the “artist” get in touch with their feelings and begin to recognise them, even when
they can not be expressed in words. Art work can “contain” feelings, and can be a “way
in” to beginning to talking about them. De Petrillo and Winner (2005) carried out an
experiment which asked participants to draw a picture based on their feelings or one
based on copying shapes, in response to tragic images being shown to them. In a
second experiment, participants were asked to complete a word puzzle after seeing the
tragic images. The authors found that the completion of a word puzzle did not improve
mood, as measured by Russell et al.’s Affect Grid, whereas the act of drawing did. They
suggest that the making of art improves mood through catharsis or through a
redirection away from negative feelings.
So art can also provide a vehicle through which nursing students are able to express
their inner thoughts and feelings. Whitman and Rose (2003) explain that through this
process nursing students can become more sensitive to themselves, and learn what it
means to be fully human. From here, they begin to learn how to heal and become better
able to promote their own health and that of others. Wikstrom (2000) asked student
nurses to examine a reproduction of a painting of an elderly woman in a “sickbed”.
They were asked to write about their feelings as well as the caring issues that emerged.
They discussed their thoughts in small groups, and the main themes were recorded.
Wikstrom (2000) reports that it became clear that the exercise had heightened the
student nurses’ sensitivity and empathy towards another’s situation. However
Wikstrom (2000) cautions that using art in nurse education can awaken distressing
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6. feelings of anxiety and so the teacher needs to be prepared to work with the students’
emotional responses.
These examples suggest that the process of working with art can be creative,
healing and challenging, but through it students can develop skills of perception,
thought, empathy and sensitivity.
Context
Holistic Health Promotion course
The Holistic Health Promotion course was compulsory for four cohorts of final-year
students studying Bachelor degrees in Adult Nursing and Child Nursing at Canterbury
Christ Church University from 2001 to 2005. The average class size was 25 students,
most of whom were students of Adult Nursing. Some of the students’ lessons took
place in the clinical skills laboratory owned by the University, called St Paul’s ward.
The course comprised 11 teaching sessions, which were interrupted by two months
where students worked, observed and learnt in health care settings. These two months
provided a useful opportunity for students to carry out activities in the work place that
related to the course, and thereby deepened their learning.
Reading was recommended for the students for each session. In relation to art,
students were encouraged to see the work of Michele Angelo Petrone, a professional
artist, who painted a series of pictures in order to express his experience of Hodgkin’s
disease (Petrone, 1999a, b). In his book The Emotional Cancer Journey, he writes:
“What everybody has to understand is that physical illness needs emotional tendering
as well as conventional treatment” (Petrone, 1999b, p. 22). His emotional journey is
written in words under each of his pictures. The art and the writing complement to
make the emotion experienced at each moment in time crystal clear to the onlooker.
Students were also encouraged to read about how art and design had been
introduced to enhance health care environments such as hospitals (Waller and Finn,
2004; Kirklin and Richardson, 2003).
Art therapy
The Adult Nursing students were introduced to the work of an art therapist who works
in a hospice. She brought along paintings, with the painters’ permission, and told the
stories behind them. An extract from a published interview illustrates her approach
towards her patients:
And they’ve had things stuck in them, they’ve been stuck in machines, their body has
changed. Who are they? So I’m working with people who are perhaps traumatized. They can’t
talk about anything. They are very, very frightened or angry, but they don’t show any of
these feelings because they have to be nice [. . .] I’m not saying, “Let’s face this depression”.
I’m saying, “What would you like to do today? What can I do for you?” . . . and we work from
that premise (Robinson and Clift, 2002, p. 13).
The Child Nursing students listened to someone who works both as a child art
therapist and child psychotherapist. Students were shown anonymous slides of
children’s art therapy, whilst the therapist explained what to look for in the art as the
child progresses towards better health and well being.
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7. Using art to articulate feelings
In another lesson students were taken through an exercise devised by Gersie and King
(1990, p. 255), which aims to explore feelings around trust. In pairs, one student held a
pen in the hand with which they did not normally write. Their partner asked what they
would like to draw or write, and placed their own hand over to guide the hand holding
the pen. After some time to experiment, the partners swapped roles. They were asked
to word-associate around the word “guidance”, and choose one of these words to talk
about. They shared their experiences and thoughts about trusting another to guide
them, and made links to the feelings of patients. Next, they were read a folk story that
concerned an act of great trust. The students were asked to create a large picture that
evoked the word “trust” to them. Paint, pens and collage materials were provided.
After this, they were asked to jot down words associated with trust and mistrust.
These were shared and discussed. Finally their own pictures were shared. In this way
the students “trusted” the others with the personal content of their own pictures.
In a later lesson, the students were invited to choose whether to allocate “feeling
words” within a sentence completion exercise; for example, “When someone ignores me
I feel . . . ”. Or they could choose to draw how it felt to be a student nurse. The drawings
acted as a “way in” to articulating feelings, often feelings about stress and challenge,
which were then shared and acknowledged in a safe environment.
Community arts
The students visited Project Sunlight, a healthy living centre based in Gillingham. A
derelict laundry was converted for premises using ideas from a design competition
held with local people. The centre comprises a wide range of community services
including primary health care, social enterprises, education and office space for
charities. Large murals, stencils, paintings and papier mache´ art work fill the
cavernous space and it provides a cheerful, stimulating and welcoming atmosphere.
Hospital art
The students visited Medway Maritime Hospital, in Kent, where the Healing Arts
Programme, led by Tony Crosse, has introduced a wide range of art. This includes
high-quality paintings mostly produced by Tony Crosse in consultation with or at the
request of staff, as well as the work of local artists. The visit drew students’ attention
towards the hospital setting, something to which many appeared to have paid little
attention until this point.
Built environment
During the two months in which the students were learning in health care settings,
they were asked to carry out a number of small exercises. These included:
Walk round the setting where you are working, and having a close look at the physical and
social environment. Write an evaluation of how health promoting the environment is, with
particular reference to mental, emotional and spiritual health.
Walk around the building where they were working for 15 minutes and pay particular
attention to the sounds around you. Jot them down. How do the sounds make you feel? How
could they be represented visually?
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8. The health fair
The health fair took place on the last day of the course. This was an event organised by
the students, in which each student had to produce a visual display of an aspect of the
course. Each student was supplied with a large, free-standing display board. They
were provided with guidance on the principles of good design such as the utilisation of
space, use of colour, alignment and the presentation of letters and words. The aim was
to say something of importance using images rather than many words. The health fair
gave the students the opportunity to experience the process of producing art work, and
to demonstrate and share their learning. The students’ displays included themes such
as health care environments, senses, pet therapy, emotional health, spiritual health,
play, literature and health, music and health, psychological aspects of eating, seeing
the “person not the patient” and holistic care.
The clinical skills laboratory art project
The clinical skills laboratory art project was carried out with the 2003-2004 cohort of
students only, in addition to the work described. In response to concerns that some
British nurses were qualifying without some of the core clinical skills essential to their
role (Department of Health, 1999b), many universities introduced clinical skills
laboratories in which some of these skills could be taught. At this university, the
laboratory comprised a mock hospital ward containing 12 beds, a cot, a nurses’ station
and a wide variety of hospital equipment. It was laid out as a “Nightingale ward”,
whereby the beds were lined against the walls facing one another, leaving a wide aisle
down the middle. Each bed had its own set of striped mustard and lilac privacy
curtains and a locker. Pillars, supporting the ceiling, were positioned at intervals on
each side of aisle. To the side of every bed-head was a white-framed window. The walls
were painted very pale blue and complemented by a mid-blue carpet. The 21 nursing
students who studied the course from 2003 to 2004 were invited to participate in a
project to introduce works of art into this ward. All the students gave permission for
this work to be published.
Methods for the evaluation
Evaluation of the art-related education
To evaluate the whole course, all of the students from each cohort completed an
anonymous questionnaire, distributed on the last day, which included an invitation to
add comments about the most positive aspects of the course, and comments about
which aspects could have been better. The art-related education was evaluated by
analysing the comments written by the four cohorts of students who completed the
course. This comprised 83 students. The two lecturers who taught the course also
wrote their own evaluations at the end of each course, and these were reviewed for any
art-related comments.
The clinical skills laboratory art project
The ward was both a learning environment for students as well as a mock ward for
imaginary patients and the art work needed to be appropriate for both roles. The
project had five phases. In Phase 1, Tony Crosse, the arts co-ordinator from Medway
Maritime Hospital, facilitated an informal unstructured focus group discussion with
the students about the type of art that they might like to see in the ward. The
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9. discussion took place in the ward. He asked open questions and written notes were
made of the students’ ideas.
Phase 2 took place during the two months spent in health care settings. The 21
female students were asked to carry out individual interviews with three patients each
using these guidelines:
Explain to three patients that you are writing a brief for an artist to create a work of art
for a hospital ward. Ask them what they would like you to tell the artist e.g. colour,
design, mood, size, function, message, “something to make me feel . . . ”.
Prior to beginning the interviews, the student nurses had to seek written permission
from the unit manager, which was later presented to the course tutor. They were also
cautioned that any participants had to:
.
fully understand the purpose of the work;
.
agree to co-operate; and
.
be made fully aware that they did not have to participate.
Students were reminded to keep the identity of patients anonymous.
The students reported that the interviews had taken place at times of convenience,
and most had taken no more than five minutes. One student wrote:
I explained to each patient what I was doing for the exercise and read them the exercise [from
the written instructions], gained verbal consent from them and showed them I had been given
authority by the ward manager to interview patients. I asked them what type of pictures they
would like to see around the ward.
Many patients reacted very favourably to being asked for their thoughts. Students
noted down the patients’ views at the time. The findings were not added to patients’
records, nor shared with anyone except fellow students and lecturers on return to the
University.
Phase 3 occurred when the 21 students returned to university. The two lecturers
facilitated the class. Each student was asked to report verbally what the patients had
said. These were summarised on a white board. Gradually these comments were
grouped into themes, to which all the students agreed. Following this, the students
were asked to write down all that they could remember from the interviews, including
the patients’ age, sex and location. Only 11 students returned written comments,
concerning 33 of the patients. Of the 33 patients, six were being cared for in hospices
and 27 in hospitals around Kent. The latter included specialities such as gynaecology,
general surgery, general medicine, coronary care, a clinical decision unit, haematology
and ear, nose and throat. The patients comprised 20 females and 13 males with an age
range from 12 to 89.
In Phase 4, the themes were presented to Tony Crosse. Again he worked with
the students, in the location of the ward, to bring together the students’ initial
thoughts, the patients’ thoughts and his own experience of introducing art into
health care environments. Out of this emerged the final specification for the art
work.
In Phase 5, all the students and staff were invited to participate in the production of
the art, and two members of staff did so. Five months after the completion of the course
the art was displayed.
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10. Findings of the evaluation
The clinical skills laboratory art project
In Phase 1, the students’ initial thoughts, emerging from the focus group discussion,
showed that they wanted to see a variety of art work. They wanted hanging pictures
that could be changed. They thought that it would be good to use the support pillars as
there was not much wall space. They wanted sensitive images and art that would
“work with the colour of the curtains”. Themes such as nature, the seaside and stained
glass windows emerged.
In Phase 3, the findings from the interviews with patients were grouped into themes
based on oral feedback from all 21 students in class. Both tutors and students agreed
that the themes were:
.
colours;
.
themes/topics;
.
moods; and
.
other.
These are shown below, along with the associated sub-themes. Illustrative examples of
what the patients said are taken from the written notes submitted by the 11 students.
Colours
Not white. Yellow. Not blue/cold. Co-ordinating. Cheerful. Bold/bright. Not red. Fresh
colours.
For example, one student reported on an interview with a 72-year-old woman in a
surgical ward: “She said she would like colour, nothing dull and it had to be something
that would lift the spirit of the ward in general”. Another student reported that a
44-year-old woman, who was receiving treatment for uncontrolled diabetes, “Liked
bright colours to ‘brighten the place up’”. Another student interviewed an 89-year-old
woman in a coronary care unit, and wrote: “This lady would like to see pictures that
were bright and colourful – like Christmas decorations”. A man in his fifties, in a
medical ward, was reported as wanting “Something fresh and green”.
Themes/topics
Outside scenery. Beach. Sea. Waterfalls. Animals. Sunset. Wild life. Woodlands.
Abstract. Window/stained glass. Scene of table with lemonade. Not floral. Something
with a personal link to staff, e.g. local history. Clowns.
Nature was the most frequently mentioned topic (60 per cent of the 33 patients). For
example, a 65-year-old man in a medical ward was reported as wanting to:
. . . see paintings of animals, in their natural environment . . . wild life in woodlands and fields.
He said . . . he can imagine himself standing in the woods with the smell of pine from the wood
bark and the scent of bluebells, and watching the wild life snuffling around looking for food.
A woman in her fifties, in the same ward, wanted to “see pictures of waterfalls, lakes
streams, rivers and ponds. She was attracted to water . . . it was such a natural place to
sit under the tree in the sunshine and take time out to think”. A student who had
interviewed a 48-year-old woman in a haematology ward wrote that she wanted,
“sunny, sandy beach, clear water, palm trees because they create shade, and a bobbing
boat. No people because it would spoil the effect”. In medical wards, a 70-year-old
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11. woman wanted pictures of sky, clouds and birds, and a young man in his twenties
wanted to see mountains because they elicited a sense of escapism. Four patients, in
three different hospital-based environments, reported that what they really wanted
were more windows in order to see the scenery and have more daylight, and a
72-year-old man in a hospice talked extensively about how he happily spent each day
looking out of the window. One of the patients liked the idea of having speckled,
coloured light coming through “stained glass windows”.
Moods
Cheerful. Uplifting. Romantic. Escapism. Intriguing. Busy. Lots of things to find.
Stimulating. Multi-faceted. Inviting. Peaceful. Tactile/textured. Magical.
The patients cited a range of preferences about the mood of the art work. Seventeen
(53 per cent of the 33 patients) wanted it to be uplifting and cheerful. One student
reported that a 64-year-old woman in a gynaecological ward said: “The overriding
feeling of the painting should be uplifting”. A 42-year-old woman in a hospice wanted
the mood to be happy and humorous – “Something to make me smile” – as did a
12-year-old in a children’s ward who was reported as saying: “Art that would be
relaxing and make you happy”. Three patients wanted the pictures to be stimulating.
A 37-year-old man on an acute medical ward was “keen to have a busy, stimulating
mural painted on wall because he found it very boring being in hospital”.
Other
Not too small in size. Fresh appearance. Bringing the outside in. Create space. Counter
the claustrophobic atmosphere. Consider walls, floor and ceilings.
Five patients mentioned the importance of the size of the paintings. One student
reported the views of a 35-year-old man on an ear, nose and throat ward. She wrote:
“Not small paintings. Need to see them from across the room”. When recording the
interview with a 69-year-old woman on a gynaecology ward, a student wrote: “There
was a picture on the ward of a field with sheep, but the patient said that this was too
small and uninteresting. She expressed that if the picture was much bigger it would be
easy for the whole bay to see it from their beds”. Another student wrote that her
70-year-old female patient in an acute medical ward was bed-bound and therefore
wanted a painting on the ceiling. Several of the students described health care
environments as claustrophobic. One student, writing about her interview with an
89-year-old woman in a coronary care unit wrote: “From her position, she could not see
the outside at all . . . her bed was facing the wall of filing cabinets and she said it
seemed like an office, not very nice”. A 43-year-old man in a clinical decision unit
remarked that he disliked facing the trolleys that were parked in the middle of the bay.
In Phase 4, the specification was agreed, as shown, and in Phase 5 the art work was
produced accordingly.
(1) The art should contain variety. The pictures should be hanging, rather than painted on the
walls, so that they can be changed. In view of having limited wall space, the pillars should be
used for art.
Twelve works of art were produced on canvas for hanging in the ward. These
comprised ten tall, narrow pictures of single flowers, which hung on the pillars, and
two large rectangular pictures containing multiple images, which hung on two walls.
All the images could be easily seen from a distance of more than five metres.
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12. (2) Some of the art work should be complex so that people can look at it for a long time, many
times, keeping them stimulated.
One of the rectangular pictures contained 12 paintings of butterflies situated within a
grid. Each butterfly was different. The predominant colours were green, blue and
yellow. The other rectangular picture contained 15 circular images (see Figure 1).
Again, these were placed within a grid, and each image was different. Some were round
blocks of colour, some were spirals and some comprised radiating lines from a centre.
The colours were mainly purple, pink, orange, blue and grey. Both these rectangular
pictures contained plenty of absorbing detail.
(3) The theme of nature should be included as it appealed to both students and patients. The
mood should be bright and cheerful.
The theme of the four seasons was considered, but who would want to be in winter’s
corner? The flower pictures were simple and elegant. The flowers were enlarged
photographic images including a rose, a lily (see Figure 2), a carnation and a thistle.
Each flower, with its long stem, was set against a pale, plain background such as lilac,
grey or purple.
(4) Work with the windows.
Tony Crosse explained that sick people can be particularly sensitive to certain images,
finding them scary. He had found that animals, such as frogs, can be disliked by
people, whereas butterflies were usually appreciated. Above each window was a
smaller window that could not be opened. Each was approximately 30 cm high and
90 cm wide. Onto several of these Tony used coloured plastic film to create images of
stained glass windows. Each window contained black-lined pictures of butterflies,
flowers and sunshine in yellow, blues and greens (See Figure 3).
Today St Paul’s ward is used as a learning environment for hundreds of student
health professionals who come to practice their clinical skills. Each is now exposed to
the art work hanging on the walls and a plaque which explains the project. Although
Figure 1.
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13. Figure 2.
Figure 3.
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14. no structured evaluation of the project has taken place, the technicians who work there
on a permanent basis report that they hear students remarking on the art work, and
using it as a point of discussion.
Evaluation of the art-related education
Some of the students’ written comments referred to the art-related sessions in
particular, although some of these inevitably encompassed wider aspects of the course
as well. For example, four comments concerned creativity. Three students described
the sessions as fun and/or creative. One wrote that the course “enabled us to be creative
in our own ways”.
The lecturers’ evaluations noted that for each cohort, many students appeared to go
through a similar journey from initial resistance, through acceptance, to genuine
enthusiasm. With reference to the act of producing art, one lecturer wrote:
A student who initially sat with arms folded and asked in an irritated voice more than once,
“Why are we doing this?” was, by the end, enthusiastically sharing the therapeutic value of
producing a collage for the health fair. The student said, “I was so engrossed. I admit I was
very sceptical at first, I just couldn’t see the point, but now I do”.
Another wrote:
. . . an interesting and challenging course. I admit at first I was quite sceptical with
regards to some of the subject areas covered, but after further reading I do feel more
enlightened.
Many students commented on how much they had enjoyed producing the visual
displays (12 comments), which they made for their health fair. One wrote: “The display
really boosted morale and provided good escapism for the group”, and another wrote:
“The display was a very good opportunity to conclude our learning. Doing the displays
was therapeutic in itself”.
The art therapists’ talks were listed by 12 students as one of the most positive
aspects of the course. One wrote:
I enjoyed the guest speakers . . . It helped me to put theory into practice . . . It’s taught me
about looking in depth at the patient as a whole.
Five students commented on feelings, and always in a way that reflected the “journey”
observed by the lecturers. One student wrote:
I have been able to explore my own feelings and open my mind to a new holistic approach to
care.
Another three revealed greater empathy with patients. For example, one wrote that the
most positive aspect of the course had been “Learning about how art and holistic
therapies can improve patients’ medical/hospital experiences”, and another wrote that
“It opened my mind to the importance a nurse can and should place on patients’
emotional/social well-being as well as physical, and the different ways this can be
achieved”. Another wrote:
At the beginning of the course it was difficult to understand how this type of health
promotion was relevant, however since going through the course I believe I have learnt a lot
and gained a greater understanding of holistic health promotion and a greater understanding
of emotional care.
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15. A lecturer wrote of one student:
She [said she] certainly didn’t trust health professionals. Yet as the course progressed she
began to express personal issues through art work and talk to the class about them.
The most frequently cited positive aspects of the course (36 comments) were the visits
to Medway Hospital and the Sunlight Centre. One typical comment was:
It taught me to be more aware of their surroundings, and how I can make them better, how I
can make a difference – small or large. I loved the trips to Medway Hospital and the Sunlight
Centre. Both were informative, educational, inspirational and fun.
The course had evidently raised some students’ awareness of the environment. Their
comments included:
. . . had never thought about art . . . being used before. Good to think about the environment
which patients are in and how to optimise it.
This [course] has opened my eyes to art in nursing and made me appreciate my surroundings
in a busy underfunded environment.
I have learnt so much about holistic health and the art of healing. It has really made me think
about what I can do with the environment I will work in.
The course has made me think about the environment I work in and I believe this will
influence me in the future.
Some of the students’ comments reflected the debate about whether nursing is a science
or art. One student wrote:
I feel that this module has really opened my eyes to how there are many ways to
promote health, . . .there is no need to just follow the normal medical approach when
caring for patients.
Another mentioned “The nice feeling that . . . nursing/caring was not just scientific
and technical”. A lecturer wrote:
Student discussed how she had entered the nursing degree feeling “open and free”. Through
her first and second year she had felt more and more constrained into a metaphorical box
citing reductionist and technological approaches to nursing care which had made her feel
very disillusioned . . . Through this course the student said she had been encouraged to see
that there may be opportunities to work in areas which allowed her to be the kind of nurse
that she wanted to be.
However, in contrast, a small group of students in one cohort stayed in the initial stage
of “resistance” throughout. One summarised their views by writing:
We . . . just feel that learning about drugs and IVs [intravenous infusions] etc. would have
helped us better. Thank you.
Discussion
Evaluation of the art-related education
Although most students were very positive about the course, some students were
initially very resistant, and a small minority in one cohort remained resistant to the
end. The findings suggest two possible reasons. Firstly, it appeared that the course
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16. might have challenged some preconceived ideas that nursing was primarily about
technical competence and the students might have felt that the inclusion of the arts was
excessively subjective and unscientific (Le Vasseur, 1999). Secondly, although the
lecturers were careful to keep a safe environment, and tried to utilise Carl Rogers’ core
conditions of empathy, congruence (genuineness) and unconditional positive regard
(acceptance) within the work (Hough, 1998), Wikstrom (2000) cautions that using art in
nurse education can be emotionally challenging for the students, and so some
resistance was understandable. Some students commented on how the course had
encouraged them to examine their own feelings and how it had helped them to
empathise with patients, features that have been noted by several authors writing
about using the arts in nurse education (Ehrhart and Furlong, 1993; Greiner and
Valiga, 1998).
The act of producing art was described as being enjoyable and therapeutic by
several students. This supports the findings of Heenan (2006) and De Petrillo and
Winner (2005). The production of a visual display for the health fair in particular was
mentioned by some students as a highlight. As Whitman and Rose (2003) found in their
nursing course, this type of event served to be a very positive, creative way to end the
course. Indeed some students noted that the course had allowed them to be creative,
which is encouraging as creativity is a vital quality needed by nurses to be effective in
their work (Greiner and Valiga, 1998).
Many students finished the course with a greater awareness of both the built health
care environment and the use of art within such environments. Studies have shown
that the environment affects the well being of staff as well as patients (Staricoff, 2004;
Commission for Architecture and the Built Environment, 2003; Staricoff et al., 2004).
This is encouraging as it is with nurses that the King’s Fund is working on its
Enhancing the Healing Environment programme (King’s Fund, 2006).
The findings suggest that introducing art-related education into pre-registration
nurse education was beneficial in terms of raising awareness about how health care
environments can be improved. For some students, it helped them to explore feelings.
The findings support the view that using art in nurse education needs to be carried out
with sensitivity and care.
The evaluation of the art-related aspects of the course was based on the comments
written by students who had been asked to evaluate the whole course. Later, it was
thought useful to evaluate the art-related aspects. Had the author set out to research the
art-related education initially, the findings might have been more detailed. For example
although some students wrote about some points for improvement for the course, with
reference to their assessments and the timing of the course, no student made any
negative comments, or points for improvement, about the art-related aspects
specifically, which could be a consequence of the limitations of the method of inquiry.
The clinical skills laboratory art project
Within the clinical skills laboratory project, the theme of nature emerged from both the
students and the patients for the art work. Some patients wanted windows rather than
paintings. These findings complement those of Ulrich (1984) and Hartig et al. (2003),
who reported improvements in patients’ health and well being when they were exposed
to nature as opposed to plain walls or rooms without views, and might be explained by
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17. the work of Morris (2003) which suggested that being exposed to the natural
environment can enhance physical, mental, spiritual and social health.
The project was successful in terms of providing a vehicle through which students
could learn about the role of art in health care environments. It allowed the students to
participate in a very simple research project that enabled them to practice their
communication skills, in particular those of listening to patients, and to participate in a
project from initial ideas to completion. The process could be replicated in any health
care setting with staff and patients.
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Corresponding author
Sally Robinson can be contacted at: sally.robinson@canterbury.ac.uk
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