Kathy Hathorn
Kathy Hathorn

Gone are the days when displaying healthcare facility art anywhere other than a waiting area was considered an extravagance. Project sponsors and designers alike these days accept that art belongs not only in waiting areas, but throughout the healthcare facility. Their conviction is prompted by a growing body of evidence indicating that exposure to art has a positive impact on viewers' health and well-being-and the healthcare sponsor's bottom line. But what exactly does “healthcare art” mean? What art belongs where? And, just as important for project planners, what's hot and what's not? Who better to comment than Kathy Hathorn, CEO/Creative Director of American Art Resources (AAR), a firm approaching its 30th anniversary planning, procuring, and researching healthcare art. Hathorn was recently voted one of the 25 Most Influential People in Healthcare Design by the readers and editors of

HEALTHCARE DESIGN, and Contributing Editor Richard L. Peck recently asked her some key questions.

Richard Peck: What do you say to the hospital project manager who has been directed to “get us some art” and asks “Just what is healthcare art and where do we put it?”

Kathy Hathorn: That really is yesterday's question. Virtually all healthcare projects these days look at an art program as part of the totality of the design. Even in smaller projects, this is much more thought out than it used to be and more integral to early programming. I recently had an owner say to me, “I'd just as soon value engineer my walls than shortchange my art budget, it's that important.”

Peck: Starting from that baseline, then, what is the first decision point a project sponsor faces regarding art?

Hathorn: The first decision usually is the hiring of an art consultant. That's because of the growing realization that proper planning for an art program takes a great deal of highly specialized work and owners, especially these days, are very limited in the FTEs (full-time equivalent employees) they can devote to it. There are plenty of consultants out there now in healthcare because it is one of more lucrative fields, now that corporate and hospitality design work has dried up. Unfortunately, however, many consultants don't necessarily offer a high degree of expertise in healthcare. The evidence supporting the use of art in the healthcare environment is growing, but Level 3 and 4 practitioners of evidence-based design are few and far between. As a result, I'm seeing a lot of newly developed evidence regarding art being lost in the process.

Peck: How do you mean evidence is being “lost”?

Hathorn: I mean there's a misunderstanding of what evidence-based art is. I'm willing to bet that if you were to ask a group of owners and consultants what appropriate healthcare art is, probably 90% of them would say nature photography. But that is far from the whole story, and I've been working hard over the past few years to address some common misconceptions. First of all, nature art is not necessarily photography; it can be any medium from painting to posters. Nor is it only landscapes. Research has shown, for example, that certain types of figurative art can be therapeutic as well. For example, in a study with acute care inpatients we found that a scene with a man and a woman leisurely working in a garden was highly popular. Figurative art that portrays people in leisurely activities, in outdoor scenes, and with a high social component resonate with patients, although issues of culture do need to be taken into account. As for nature scenes, they themselves are not necessarily therapeutic if they include images that might be disturbing. A classic example I could give you would be a savannah landscape, with blue skies and green fields-and a tiger occupying the foreground! Not very calming. Nature scenes also benefit from a relatively large depth of field, from a therapeutic standpoint.

Peck: Nature scenes do seem to be very popular with people, though, when they work. I noted, for example, a recent article in which you described a waterfall scene that was very well-received. What was it about it that made it work so well in your view?

Hathorn: That image keeps coming to the top in our research with people of all ages. This does happen to be a photograph, and it's done in full-spectrum color, with a waterfall surrounded by foliage showing a change of season. It has a very high sensory content and viewers find it highly experiential-they feel drawn in, and this seems to enhance therapeutic effect.

“Big Balance”
by Frank Boyden and Brad Rude. Commissioned by the Doernbecher Foundation and the Regional Art and Culture Council

“Big Balance”

Photo courtesy of Bill Robinson

Peck: Would art like this be recommended throughout a healthcare facility?

Hathorn: It's a general rule of thumb that, the more vulnerable the patient, the more important it is to ensure that the art is appropriate for that patient population. Unfortunately, while there is solid evidence for the impact of certain types of images on overall health and well-being, the evidence of impact on specific patient populations remains anecdotal. So, while it's reasonable to expect that the waterfall scene would improve the experience in an emergency room setting, where people are particularly stressed and sitting for long periods of time, in a urology clinic, maybe not so helpful!

Peck: What about abstract art-any role at all in the facility?

Hathorn: I get asked this question a lot. I think there can be justification for displaying abstract art in public spaces. Many people occupying these areas are not patients, families, or staff, and they are generally passing through; it is a transitory area. Research has shown us that, within abstract art, curvilinear forms are probably more suitable than rectilinear forms for highly stressed populations, since highly angular, sharp forms can elicit fear, even in abstract formats. Allowing for abstract art in appropriate settings gives the organization an opportunity, if it wishes, to be seen as innovative and cutting-edge. Perhaps it is a research-based organization that values this perception and sees this as a branding opportunity. All of MD Anderson's academic and research buildings, for example, feature abstract art with scientific overtones; as opposed to the evidence-based art used without exception in all of its patient spaces. As for patients, I'd say that it depends on who the patients are-are they lower-acuity and less apt to be stressed by more challenging abstract art, or patients facing difficult, even life-threatening illnesses? Dr. Upali Nanda, AAR's vice-president and director of research, often uses a quote from a U.K. art coordinator who says, “What happens when the art has to do ‘the night shift?’ Wall art is bolted on the wall at the foot of the bed and the patient has to look at it for a long time, long after caregivers and family have left the room. In that situation, you'd better get it right!”

Peck: What about specific colors used in painting or photography? Any thoughts on their therapeutic value?

Hathorn: We still don't know enough about this. A couple of years ago the Coalition for Healthcare Environments Research (CHER) funded a literature review that found nothing conclusive. Those of us who have had experience with this believe that people prefer colors associated with the calming elements of nature-the blues of sky and water, the greens of plants and grass. Our research has shown the popularity of blue- and green-dominated images with pediatric populations. We also think patients prefer medium-to-darker saturation as opposed to washed-out colors. But this is all anecdotal. There are still no good studies on this.

Peck: Let's talk for a moment about children's facilities which, to me, have always seemed so much more exciting visually than general healthcare facilities. Do children's hospitals operate under different rules when it comes to art?

Hathorn: First of all, I agree with you that they're more exciting. But there's been a big shift lately-a very important trend away from the contemporary iconic images, cartoon characters, animation or toys that are popular for the moment with kids, toward something quite different. For example, we're working with Phoenix Children's Hospital, which is adding a 12-floor, 600,000-square-foot bed tower and is looking for art that isn't trendy, does not indicate one culture or another, and is more inclusive, appealing to all ages and likely to maintain its appeal for 20 years or more. As an enlightened organization, they're looking for something that will appeal to staff as well. Working with the architecture firm HKS, they made a conscious effort to carefully incorporate a well-designed, comprehensive art program from the beginning, with the needs of all users in mind. Pediatric nursing can be a particularly high-stress, high-turnover position, and it can cost three times a year's salary to replace a pediatric nurse. So altogether, the art has to have a broad appeal and stand the test of time.

Peck: Reminds me of when I used to watch Sesame Street with my kids. I enjoyed the humor as much as they did!

Hathorn: That is the sense of it. A specific example I'm aware of happens to be in a project we had nothing to do with. At Doernbecher Children's Hospital in Portland, Oregon, there is a sculpture by artist Brad Rude of a little goat standing there with animals of all kinds stacked up on its head. It's a wonderfully humorous piece, and every adult who sees it laughs. It appeals to that sense of wonder we never really lose at any age.

There are other kinds of art that can be very effective with kids. As part of a research team at Dallas Children's Hospital, we did a study of the effects of different types of art in waiting rooms, including some dynamic digital art, an underwater aquarium video, and still nature images. The nature art, particularly the video, produced very positive outcomes in improving the children's behavior. Interestingly, parents rated staff performance higher, their exam room experience higher, and the overall experience higher when a positive distraction was present in the waiting room. Our research in-house has found that kids respond better to natural scenes than to iconic cartoon characters or even art produced by other children. For example, a photograph of a spotted fawn standing in a bed of wildflowers has proved to be very popular with children; this same image was one of the highest rated with adult patients.

Peck: What about the digital modalities of art? Any developments there, whether in children's or adult facilities?

Hathorn: There's a lot of talk about it and, if a couple proposals we have out on the children's hospital side are approved; they'll involve a great deal of digital, interactive art. But I don't see much call for it on the adult acute care side. I really don't think we'll see much activity here for the next five or six years because of the impact of budget cuts today. There are plasma screens being used to display nature videos along with public health announcements and restaurant menus, but as for other equipment or hard wiring that might be installed for virtual art, it just isn't being asked for right now. Meanwhile, we're doing research with plasma screen interventions to make sure we understand the needs of the new media and stay ahead of the curve.

Peck: What about another art form that we haven't discussed as yet: sculpture? Is the use of sculpture becoming more popular in healthcare environments?

Hathorn: Sculpture can be expensive and it most definitely has to be programmed on the front end of a project design; it's virtually impossible to add it as an afterthought. Phoenix Children's has developed an interesting approach using sculpture: on each of the new addition's 12 floors there will be what I call a “mascot”-a bronze animal native to the southwest serving as an icon for that floor. It won't be a realistic depiction but it will be highly representational and identifiable. As you can see, this will also be an excellent wayfinding device, an increasing use of sculpture in healthcare facilities. There is still another use for sculpture that is growing: as a gifting opportunity for fundraising. Sculpture is a lovely and gracious gift to a facility.

Peck: What about the future for healthcare art in general?

Hathorn: I see a very strong commitment by owners to using evidence-based approaches to art to improve outcomes, add to the bottom line, improve wayfinding, and serve as an adjunct to the branding program. But they are looking for hard proof that this works, and I'd say that short-term studies demonstrating the return on investment are just as important to the field of healthcare art as more in-depth, longer-term studies.

There is clearly a strong interest in this. In fact, if I were asked at this point what was the highlight of my professional career, I'd say it was seeing our research featured by the Joint Commission in almost the entire issue of its Environments of Care publication last November. Since then we have had hundreds of inquiries, emails, and phone calls from people saying they're convinced that art is very important to their organizations and asking how to get started. Typical comments were, “I want it to make my staff perform better, to make my nurses happier, to make people say good things about us.” I was absolutely amazed by this response and the high quality of the commitment we're seeing from the facility side. I think we will see that same level of demand from the design side as well.

To us, the bottom line has always been outcomes. Since we started our research department four years ago our focus has been on the philosophy of “show me the money.” Owners say, “Theory is interesting but so what-how does it affect me?” They want to see data that suggests the best ROI possible. And it's emerging all the time. In a psychiatry study we completed recently with an academic collaborator, we found that the requests for anti-anxiety medications decreased when there was evidence-based art in the room. We're constantly assessing our own projects as well. We've been collecting data, for example, from a post-occupancy evaluation at MD Anderson's Mays Clinic. One radiation oncology patient there said, “MD Anderson is not a hospital, it's an experience!” It doesn't get much better than that. HD

For more information, visit http://www.americanartresources.com

Healthcare Design 2010 April;10(4):40-46