There is a growing body of evidence arguing for the role of art in healing with both scientific studies and anecdotal references backing the argument. Scientific studies have focused primarily on health outcomes—the measure of a patient’s condition or progress, or indicator of healthcare quality.1 These outcomes can be broadly classified into three categories.2

• Clinical indicators, such as length of hospital stay, blood pressure, and other observable signs and symptoms relating to patients’ conditions. For example, ceiling-mounted pictures shown to highly stressed presurgical patients on gurneys resulted in lower blood pressure when the images were of serene nature scenes.3

• Patient/staff/family-based outcomes, such as patient ratings of perceived pain, satisfaction, or staff-reported satisfaction with working conditions. For example, adult patients in a procedure room reported better pain control when exposed to a nature scene with nature sound in the ceiling.4

• Economic outcomes, such as cost of patient care, staff turnover, and economic impact. For example, in a study with gallbladder surgery patients spanning eight years, it was found that patients with a view of nature had lower lengths of stay and lower intake of analgesics than those viewing a brick wall; this argues for a distinct economic benefit.5 While the economic outcome has been established with “views”, it is yet to be established with artwork per se. However, it is indicative about the role of “nature” as appropriate content for hospital art.

Based on the amount of evidence in place, the presence of appropriate art in the hospital is becoming an essential component of healing environment design. To date the research has concentrated on acute-care areas such as ICUs, and public areas such as waiting rooms, but little or no information has been collected on the experience of art in patient rooms. A prevalent but minimally documented means of getting art to the patient areas, especially the patient rooms, is the Art-Cart Program.

An Art-Cart Program is a rotating art collection that provides patients with a choice of art for their rooms. One of the oldest art programs in the country, the St. Luke’s Episcopal Hospital Auxiliary’s Art-Cart Program was launched in January 1991 with a mobile art-cart, a modest collection of 50 framed pictures, and two volunteers serving one floor of the Houston hospital. The program sought to provide framed artwork for the patients’ hospital rooms to make their stay in the hospital more pleasant.

Today the program has a collection of more than 600 framed pictures with eight volunteers visiting 13 floors, three ICUs, and three waiting rooms. Though traditionally a mobile cart containing artwork was wheeled into the rooms, because of infection concerns and issues of keeping a clear passage for medical emergencies, the cart is no longer wheeled into the rooms. Instead volunteers talk to the patients, explain the program, and show them various choices while the cart is parked in the hallway.

St. Lukes Episcopal Hospital, as a Pebble Project partner, has not only committed to services, like an art-cart, that can improve the patient experience, but also to collecting evidence on the efficacy of the art program and the appropriateness of the images used in the art. Towards this purpose, a two-phase study was conducted in June 2006 with the Research Division of American Art Resources—an observational study of the art-cart and a follow-up survey of art preferences—to affect and improve the existing service in the hospital.

In the first phase of the study, the researcher accompanied four different volunteers as they conducted their rounds, and made observational notes on choice of art for the art-cart, functioning of the art-cart, the method of establishing communication with patient, and patient feedback. A survey was also conducted with patients on what they thought of the art-cart service. The study also included in-depth interviews with the founder of the program and four active volunteers who each had more than five years experience. Some of the key findings were:

• Paintings become a means for patients to interact with volunteers, and thus provide social support.

• Choice in paintings gives patients, however fleeting, a perceived sense of control.

• Patients explore the narrative scope in paintings, and make stories around the pictures to discuss with friends and family. This is true for caregivers, as well.

• Landscapes, nonthreatening animals, and flowers are popular.

• Patients appreciate the service and make positive comments of the quality of care at St. Luke’s. It is a service that comes as a pleasant surprise to them.

Volunteers selected art for the art-cart based on six categories: places, people, nature, animals, water, and flowers. Volunteers did have their own favorites but would ensure that each of the categories was covered. Some volunteers would walk into the room with a choice of pictures in hand, while others would introduce themselves and the categories of artwork, and then return with samples from the category the patients suggested. Both methods were effective, however it is definite that volunteer bias/choice effected patient selections. For this reason, a second phase was designed to study patient preferences from the same set of artwork chosen based on definite guidelines.

Towards this objective, a survey with 17 pictures was developed that contained seven best-selling pictures from three independent art vendors, seven counter images with evidence-based elements, and three images that followed principles derived from prior evidence, as well as what was seen in the art-cart observation. Evidence-based elements were determined from Ulrich and Gilpin’s2 comprehensive guidelines for appropriate hospital art. Best-selling images were used to not only investigate if general consumer preferences differ from patient preferences, but also to adequately represent non-evidence–based art.

A total of 67 patients in the hospital rooms with a period of stay varying from two to 14 days took the survey. The survey asked them to rate the 17 paintings on two five-point scales for the following questions:

• How does the picture make you feel?

• Would you like to hang this picture in your hospital room?

A quantitative analysis of the survey results (t-tests) yielded statistically significant results for the popularity of nature images over best-selling abstract/ unique images. The study also showed a preference for landscapes over figurative art or art containing animals. Images of animals or human figures that were within a nature setting and realistic were preferred to those that were more stylized. A pair analysis comparing the best-selling art images with their evidence-based counterparts also showed statistically significant results, biased towards the latter. For example, in figure 1, the stylized nature image (A) was rated significantly lower by patients than the evidence-based realistic nature counterpart (B). In fact, simple nature scenes were preferred to the work of masters like Van Gogh and Chagall.

The analysis also revealed that while nature scenes were preferred to abstract scenes, not all nature scenes were equally appropriate. The presence of color, green verdant foliage, and positive water elements was preferred. We also found that contrary to popular belief, positive images of autumn can also get positive feedback.

In fact, the most popular image on both rating scales was an image that showed transition from autumn to spring (or vice versa) as the backdrop to a gentle waterfall (figure 2). This image got positive comments for having a sensory component, such that patients could imagine themselves in that scene and thus, offered them an escape from the hospital setting. They also enjoyed the “change of seasons,” which reminded them of the cycle of life.

Results of patient survey

We also noticed that while best-selling images elicited a greater number of comments, this was not indicative of the ranked preference. Because an image might be evocative and elicit responses, it is not implied that it can decrease stress or engage the patient appropriately within his/her high-stress settings.

Finally, patients were asked a few questions about the importance of art, the Art-Cart Program, and having a choice in the art they viewed. The table shows a matrix of results.

The survey showed that a vast majority of patients value art and choice of art in the patient rooms. Overall, this research study also provided us with a guideline for future art acquisitions, particularly for rooms where patients view the same piece of art for extended periods. HD

1. Ulrich RS. Effects of gardens on health outcomes. In Healing Gardens: Therapeutic Benefits and Design Recommendations, edited by C. C. Marcus and M. Barnes. New York:Wiley, 1999.
2. Ulrich RS, Gilpin L.. Healing arts: Nutrition for the soul. In Putting Patients First: Designing and Practicing Patient-Centered Care, edited by S. Frampton, L. Gilpin and P. Charmel. San Francisco:John Wiley & Sons, 2003.
3. Ross RG. Picture perception and patient stress: A study of anxiety reducing and postoperative stability. Department of Psychology, University of California Davis, 1990.
4. Diette GB, Lechtzin N, et al. Distraction therapy with nature sights and sounds reduces pain during flexible bronchoscopy:A complementary approach to routine analgesia. Chest; 2003(March) 123:941-948.
5. Ulrich RS. View through a window may influence recovery from surgery. Science 1984; 224:420-1.

Sidebar

The Pebble Project creates a ripple effect in the healthcare community by providing researched and documented examples of healthcare facilities where design has made a difference in the quality of care and financial performance of the institution. Launched in 2000, the Pebble Project is a joint research effort between The Center for Health Design and selected healthcare providers that has grown from one provider to more than 45. For a complete prospectus and application, contact Mark Goodman at mgoodman@healthdesign.org.