Using art in pre-registration nurse education

Using art in pre-registration nurseeducation

Sally RobinsonDepartment 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 ahealth promotion course for student nurses, which ran for four cohorts from 2001 to 2005, and adescription 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 byanalysing qualitative comments from a questionnaire completed by a total of 83 students from the fourcohorts. In addition, lecturers were invited to write their reflections. Only the 2003-2004 cohort workedon the clinical skills laboratory art project in which students acted as a focus group, and later carriedout interviews with patients.

Findings – The art-related education was positively evaluated by most students, and appeared tohave increased their awareness of health care environments. For some, it had promoted emotionalawareness, empathy for patients and had been a therapeutic and enjoyable experience. A specificationfor 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 theexperience of patients in health care settings. The paper provides an example of how art work could beintroduced into health care settings.

Keywords Nurses, Education, Health education, Hospitals, Arts, United Kingdom

Paper type Research paper

IntroductionThe UK is witnessing the advancement of the arts in mainstream health care andhealth promotion. This appears to be the result of three key drivers. At an internationallevel, the Vienna Recommendations on Health Promoting Hospitals directed thathospitals should be “oriented towards quality improvement, well-being of patients,relatives and staff”, and should “focus on health with a holistic approach and not onlyon curative services” (World Health Organization, 1997, p. 2); and the United NationsEducation and Scientific and Cultural Organisation (UNESCO) argued that therelationship between creativity, health, the arts and healing was fundamental tohuman well being (Journal of Advanced Nursing, 1999). Secondly, perhaps informed bycriticisms that mental health promotion was all too frequently misunderstood as theprovision of services for those with mental illness (Secker, 1998; Friedli, 1999) and thatpublic health practitioners tended to neglect the mental health potential of their work(Hart, 1999), the British Government made mental health promotion Standard One ofthe National Service Framework for Mental Health (Department of Health, 1999a,

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Many thanks to Tony Crosse who very generously volunteered his time for this project, and theSidney de Haan Research Centre for Arts and Health for providing funding for the art work.

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Received July 2006Accepted February 2007

Health EducationVol. 107 No. 4, 2007pp. 324-342q Emerald Group Publishing Limited0965-4283DOI 10.1108/09654280710759241

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 atthe expense of humane care, the Declaration of Windsor called for medical education toinclude arts and humanities within medical education (Philipp et al., 1999). By 2003 theGeneral Medical Council (2003) had agreed that “special study modules” could beundertaken as part of medical education, thus enabling some universities to introducearts-based studies.

The recent developments were underpinned by a slowly growing body of evidencethat the arts were important for promoting well-being. They had a role to play in theprimary prevention of ill health, in alleviating the suffering of the sick and supportingthe 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 ofWight, along with the research undertaken by the Centre for Arts and Humanities inHealth and Medicine at the University of Durham (e.g. Macnaughton et al., 2005), theChelsea and Westminster Hospital Arts Research Project (e.g. Staricoff, 2004) and theCentre for Medical Humanities at University College, London (e.g. Kirklin, 2001; Kirklinand Richardson, 2003) are notable examples.

Meyrick (2001) summarises the British “art for health field” as comprising fivecomponents:

(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 inmedical education in order to promote doctors’ empathy and communication skills. It issalutary that, with the exception of the arts therapists, all other health and social careprofessionals were omitted from this concept of the “art for health field”. Nursing is oneomission. From 2001 to 2005 the five components were built into a health promotioncourse taught to pre-registration Adult and Child Nursing students at CanterburyChrist Church University, Kent. The course included music, literature, drawing,humour and art. An overview of the entire course, and its evaluation, is described inRobinson (2007).

This paper describes the art-related aspects of the course, and how these wereevaluated by the students and lecturers. It also describes an art-related project, theClinical Skills Laboratory Art Project, which was carried out with the 2003 to 2004cohort of students culminating in the production of works of art.

Hospital environmentsMeyrick (2001) describes the “built environment” as using art and design in thecreation of healing healthcare environments, and “art in hospitals” and as using visualarts to improve the experience of patients, staff and visitors in hospitals. Theimportance of the hospital environment can be illustrated by three studies. Ulrich(1984) assigned 23 patients recovering from surgery in a Pennsylvanian hospital to aroom with a view, and 23 matched patients to similar rooms facing a brick wall. The

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nurses’ notes and the patients’ use of painkillers were examined. Ulrich (1984)concluded that patients with a view had shorter stays in hospital, fewer negativeevaluative comments in the nurses’ notes and took fewer strong painkillers than thosewho 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 bloodpressure 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, treesand grass, to a view of a blank wall. They found that the patients’ heart rates and theirown self-ratings indicated that they were less stressed and calmer on the days themural was shown.

The theme of nature arose in the reflections of Robert McCrum. An award winningjournalist, novelist and editor, he unexpectedly found himself in hospital recoveringfrom a stroke. He wrote:

. . . the world seemed almost unbearably precious. Shut away in my room, with the finestEnglish summer in memory scorching outside, I had a craving for sky, earth and sea, which Isatisfied 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 thework of Morris (2003), who carried out an extensive literature review into the healthbenefits of being exposed to the natural environment. She concluded that it “enhancespersonal and social communication skills, increases physical health, enhances mentaland spiritual health, sensory and aesthetic awareness and it can enhance the ability toassert 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 beenlinked to staff satisfaction, improved recruitment and retention of staff, and theprovision of good quality care. So, today, it is encouraging to see that National HealthService Estates, the Kings Fund and the Commission for Architecture and the BuiltEnvironment (CABE) are all working towards improving the design of Britishhospitals. 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 withpatients to improve health care environments (King’s Fund, 2006). Anecdotal reportssuggested that initial development was slow because nurses simply did not know whatto do with the opportunity. Yet in one survey, 90 per cent of nurses said that theybelieved that a well designed environment was significantly related to patient recoveryrates, that patients behaved better in well designed wards and that working in poorlydesigned health settings increased stress levels (Commission for Architecture and theBuilt 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 suchas hospitals where there is a basic human need for beauty, humour and spiritual uplift. Artwithin hospitals and health care buildings should aim to complement not only thearchitecture 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, wasfounded 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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arts within the Chelsea and Westminster Hospital in London (Staricoff et al., 2004). Thepaintings were introduced in, or near to, the treatment room of the Medical Day Unitand included landscapes, marine pictures, portraits, figurative and abstract work. Thepaintings were changed every week. Ninety-one patients agreed to complete theZigmond 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 tothe pictures in terms of expressing attraction and enjoyment. For 47 per cent of thepatients, 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 centgave a very positive response. Sixty-five per cent cited that it had eased stress to agreater degree and 27 per cent to a moderate degree. Eighty-seven per cent of thepatients considered that the art work had made a notable contribution to making theenvironment pleasant.

Using the arts in nurse educationModern nursing was conceived as being holistic in its approach towards people by itsfounder Florence Nightingale (Dossey et al., 2005). More than a century before theOttawa Charter for Health Promotion (World Health Organization, 1986), Nightingalepaid attention to holistic care and the settings in which people were nursed. Thetwentieth century saw a long debate about whether nursing was an art or a science asthe rise of technical and economics-led health care systems diminished the value placedon the art of nursing (Ehrhart and Furlong, 1993), leaving it open to accusations ofbeing excessively subjective, arbitrary, unverifiable and therefore untrustworthy (LeVasseur, 1999). Yet by the 1990s health promotion had become central to thecompetencies required of a nurse (Department of Health, 1997; 2004), and studies wereshowing that nursing students were lacking education relating to mental andemotional health (Mead et al., 1997; English National Board, 2001). There wereconcerns that nursing had become too technological and functional, and one way ofredressing 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 artsand humanities in their education in order that they can learn the difference betweenbeing technically competent and being a professional who can facilitate healing and thepromotion of well-being.

The whole human condition is represented throughout the arts and humanities andso they present a rich vein for learning. Sarginson (2003) explains that whereastextbooks can describe symptoms, types of pain, and the psychology of illness, theycannot describe how it feels. The arts can. A piece of music, a poem or a painting canexpress emotions that are otherwise difficult to articulate. McDonald et al. (1999)explain that for health education to be effective, it needs to begin with understandingpeople’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 studiesof clients to their peers. In addition to the more usual case history, the students had toinclude a piece of literature, music, art or photography which best represented the,“entire realm of the patient’s well being” (p. 22). Their examples eloquentlycommunicated the salient points of a patient’s history, culture, feelings and beliefs. Inthis way the arts can encourage more culturally sensitive and empathic nursingpractice (Greiner and Valiga, 1998).

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Art can be used to facilitate the development of important health promotioncompetencies. In Philadelphia nursing students are directed to works of art in theirlocal art gallery in order to answer questions about the subjects, environments andactivities represented in the art work (Davis, 1992). They are asked to assess themental, physical and environmental activities within the paintings, to consider thestage 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 problemsolving and, in turn, enhances their confidence in their abilities to assess humanityacross time and cultures.

Art has been described as medium that can evoke inspiration, imagination andcreativity. Greiner and Valiga (1998) point out that these are the very qualitiesneeded by nurses if they are to be flexible and effective in their health promotionwork. Whitman and Rose (2003) asked nursing students to produce a piece of artwork in order to express their philosophy of nursing. The day of the sharing ofthe work was also the last day of the class prior to graduation, and they broughtin posters, drawings, paintings, boxes and so forth. The students reported findingthe task challenging, but the spirit within the classroom was magical, intimate andrespectful. It was described as a powerful and creative way to spend their last daytogether.

The act of engaging in the creative process of producing art, that is the colouring,sticking, drawing, sculpting and painting, is associated with improvements inwell-being. Heenan (2006) reported on using art therapy within a community-basedmental health organisation. The participants reported that the process of creating artwas associated not only with improved skills and knowledge, but also improvedself-esteem and self-confidence. Waller (2006) explains that within art therapy, peoplecan sublimate their feelings into images. The process of creating the art work can helpthe “artist” get in touch with their feelings and begin to recognise them, even whenthey can not be expressed in words. Art work can “contain” feelings, and can be a “wayin” to beginning to talking about them. De Petrillo and Winner (2005) carried out anexperiment which asked participants to draw a picture based on their feelings or onebased on copying shapes, in response to tragic images being shown to them. In asecond experiment, participants were asked to complete a word puzzle after seeing thetragic images. The authors found that the completion of a word puzzle did not improvemood, as measured by Russell et al.’s Affect Grid, whereas the act of drawing did. Theysuggest that the making of art improves mood through catharsis or through aredirection away from negative feelings.

So art can also provide a vehicle through which nursing students are able to expresstheir inner thoughts and feelings. Whitman and Rose (2003) explain that through thisprocess nursing students can become more sensitive to themselves, and learn what itmeans to be fully human. From here, they begin to learn how to heal and become betterable to promote their own health and that of others. Wikstrom (2000) asked studentnurses 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 thestudent nurses’ sensitivity and empathy towards another’s situation. HoweverWikstrom (2000) cautions that using art in nurse education can awaken distressing

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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.

ContextHolistic Health Promotion courseThe Holistic Health Promotion course was compulsory for four cohorts of final-yearstudents studying Bachelor degrees in Adult Nursing and Child Nursing at CanterburyChrist 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 tookplace 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 monthswhere students worked, observed and learnt in health care settings. These two monthsprovided a useful opportunity for students to carry out activities in the work place thatrelated 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 professionalartist, who painted a series of pictures in order to express his experience of Hodgkin’sdisease (Petrone, 1999a, b). In his book The Emotional Cancer Journey, he writes:“What everybody has to understand is that physical illness needs emotional tenderingas well as conventional treatment” (Petrone, 1999b, p. 22). His emotional journey iswritten in words under each of his pictures. The art and the writing complement tomake 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 beenintroduced to enhance health care environments such as hospitals (Waller and Finn,2004; Kirklin and Richardson, 2003).

Art therapyThe Adult Nursing students were introduced to the work of an art therapist who worksin a hospice. She brought along paintings, with the painters’ permission, and told thestories behind them. An extract from a published interview illustrates her approachtowards her patients:

And they’ve had things stuck in them, they’ve been stuck in machines, their body haschanged. Who are they? So I’m working with people who are perhaps traumatized. They can’ttalk about anything. They are very, very frightened or angry, but they don’t show any ofthese 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 fromthat premise (Robinson and Clift, 2002, p. 13).

The Child Nursing students listened to someone who works both as a child arttherapist and child psychotherapist. Students were shown anonymous slides ofchildren’s art therapy, whilst the therapist explained what to look for in the art as thechild progresses towards better health and well being.

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Using art to articulate feelingsIn 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 apen in the hand with which they did not normally write. Their partner asked what theywould like to draw or write, and placed their own hand over to guide the hand holdingthe pen. After some time to experiment, the partners swapped roles. They were askedto word-associate around the word “guidance”, and choose one of these words to talkabout. They shared their experiences and thoughts about trusting another to guidethem, and made links to the feelings of patients. Next, they were read a folk story thatconcerned an act of great trust. The students were asked to create a large picture thatevoked 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 waythe 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 “feelingwords” within a sentence completion exercise; for example, “When someone ignores meI feel . . . ”. Or they could choose to draw how it felt to be a student nurse. The drawingsacted as a “way in” to articulating feelings, often feelings about stress and challenge,which were then shared and acknowledged in a safe environment.

Community artsThe students visited Project Sunlight, a healthy living centre based in Gillingham. Aderelict laundry was converted for premises using ideas from a design competitionheld with local people. The centre comprises a wide range of community servicesincluding primary health care, social enterprises, education and office space forcharities. Large murals, stencils, paintings and papier mache art work fill thecavernous space and it provides a cheerful, stimulating and welcoming atmosphere.

Hospital artThe students visited Medway Maritime Hospital, in Kent, where the Healing ArtsProgramme, led by Tony Crosse, has introduced a wide range of art. This includeshigh-quality paintings mostly produced by Tony Crosse in consultation with or at therequest of staff, as well as the work of local artists. The visit drew students’ attentiontowards the hospital setting, something to which many appeared to have paid littleattention until this point.

Built environmentDuring 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 andsocial environment. Write an evaluation of how health promoting the environment is, withparticular reference to mental, emotional and spiritual health.

Walk around the building where they were working for 15 minutes and pay particularattention to the sounds around you. Jot them down. How do the sounds make you feel? Howcould they be represented visually?

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The health fairThe health fair took place on the last day of the course. This was an event organised bythe students, in which each student had to produce a visual display of an aspect of thecourse. Each student was supplied with a large, free-standing display board. Theywere provided with guidance on the principles of good design such as the utilisation ofspace, use of colour, alignment and the presentation of letters and words. The aim wasto say something of importance using images rather than many words. The health fairgave the students the opportunity to experience the process of producing art work, andto demonstrate and share their learning. The students’ displays included themes suchas health care environments, senses, pet therapy, emotional health, spiritual health,play, literature and health, music and health, psychological aspects of eating, seeingthe “person not the patient” and holistic care.

The clinical skills laboratory art projectThe clinical skills laboratory art project was carried out with the 2003-2004 cohort ofstudents only, in addition to the work described. In response to concerns that someBritish nurses were qualifying without some of the core clinical skills essential to theirrole (Department of Health, 1999b), many universities introduced clinical skillslaboratories in which some of these skills could be taught. At this university, thelaboratory comprised a mock hospital ward containing 12 beds, a cot, a nurses’ stationand 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 aisledown the middle. Each bed had its own set of striped mustard and lilac privacycurtains and a locker. Pillars, supporting the ceiling, were positioned at intervals oneach side of aisle. To the side of every bed-head was a white-framed window. The wallswere painted very pale blue and complemented by a mid-blue carpet. The 21 nursingstudents who studied the course from 2003 to 2004 were invited to participate in aproject to introduce works of art into this ward. All the students gave permission forthis work to be published.

Methods for the evaluationEvaluation of the art-related educationTo evaluate the whole course, all of the students from each cohort completed ananonymous questionnaire, distributed on the last day, which included an invitation toadd comments about the most positive aspects of the course, and comments aboutwhich aspects could have been better. The art-related education was evaluated byanalysing the comments written by the four cohorts of students who completed thecourse. This comprised 83 students. The two lecturers who taught the course alsowrote their own evaluations at the end of each course, and these were reviewed for anyart-related comments.

The clinical skills laboratory art projectThe ward was both a learning environment for students as well as a mock ward forimaginary patients and the art work needed to be appropriate for both roles. Theproject had five phases. In Phase 1, Tony Crosse, the arts co-ordinator from MedwayMaritime Hospital, facilitated an informal unstructured focus group discussion withthe students about the type of art that they might like to see in the ward. The

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discussion took place in the ward. He asked open questions and written notes weremade of the students’ ideas.

Phase 2 took place during the two months spent in health care settings. The 21female students were asked to carry out individual interviews with three patients eachusing these guidelines:

Explain to three patients that you are writing a brief for an artist to create a work of artfor 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 permissionfrom the unit manager, which was later presented to the course tutor. They were alsocautioned 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 [fromthe written instructions], gained verbal consent from them and showed them I had been givenauthority by the ward manager to interview patients. I asked them what type of pictures theywould like to see around the ward.

Many patients reacted very favourably to being asked for their thoughts. Studentsnoted 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 theUniversity.

Phase 3 occurred when the 21 students returned to university. The two lecturersfacilitated the class. Each student was asked to report verbally what the patients hadsaid. These were summarised on a white board. Gradually these comments weregrouped into themes, to which all the students agreed. Following this, the studentswere asked to write down all that they could remember from the interviews, includingthe 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 hospicesand 27 in hospitals around Kent. The latter included specialities such as gynaecology,general surgery, general medicine, coronary care, a clinical decision unit, haematologyand ear, nose and throat. The patients comprised 20 females and 13 males with an agerange from 12 to 89.

In Phase 4, the themes were presented to Tony Crosse. Again he worked withthe students, in the location of the ward, to bring together the students’ initialthoughts, the patients’ thoughts and his own experience of introducing art intohealth care environments. Out of this emerged the final specification for the artwork.

In Phase 5, all the students and staff were invited to participate in the production ofthe art, and two members of staff did so. Five months after the completion of the coursethe art was displayed.

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Findings of the evaluationThe clinical skills laboratory art projectIn 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 picturesthat could be changed. They thought that it would be good to use the support pillars asthere 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 stainedglass windows emerged.

In Phase 3, the findings from the interviews with patients were grouped into themesbased on oral feedback from all 21 students in class. Both tutors and students agreedthat the themes were:

. colours;

. themes/topics;

. moods; and

. other.

These are shown below, along with the associated sub-themes. Illustrative examples ofwhat the patients said are taken from the written notes submitted by the 11 students.

ColoursNot white. Yellow. Not blue/cold. Co-ordinating. Cheerful. Bold/bright. Not red. Freshcolours.

For example, one student reported on an interview with a 72-year-old woman in asurgical ward: “She said she would like colour, nothing dull and it had to be somethingthat would lift the spirit of the ward in general”. Another student reported that a44-year-old woman, who was receiving treatment for uncontrolled diabetes, “Likedbright colours to ‘brighten the place up’”. Another student interviewed an 89-year-oldwoman in a coronary care unit, and wrote: “This lady would like to see pictures thatwere bright and colourful – like Christmas decorations”. A man in his fifties, in amedical ward, was reported as wanting “Something fresh and green”.

Themes/topicsOutside scenery. Beach. Sea. Waterfalls. Animals. Sunset. Wild life. Woodlands.Abstract. Window/stained glass. Scene of table with lemonade. Not floral. Somethingwith a personal link to staff, e.g. local history. Clowns.

Nature was the most frequently mentioned topic (60 per cent of the 33 patients). Forexample, 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 woodbark 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, lakesstreams, rivers and ponds. She was attracted to water . . . it was such a natural place tosit under the tree in the sunshine and take time out to think”. A student who hadinterviewed 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 bobbingboat. No people because it would spoil the effect”. In medical wards, a 70-year-old

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woman wanted pictures of sky, clouds and birds, and a young man in his twentieswanted to see mountains because they elicited a sense of escapism. Four patients, inthree different hospital-based environments, reported that what they really wantedwere more windows in order to see the scenery and have more daylight, and a72-year-old man in a hospice talked extensively about how he happily spent each daylooking out of the window. One of the patients liked the idea of having speckled,coloured light coming through “stained glass windows”.

MoodsCheerful. 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 studentreported that a 64-year-old woman in a gynaecological ward said: “The overridingfeeling of the painting should be uplifting”. A 42-year-old woman in a hospice wantedthe mood to be happy and humorous – “Something to make me smile” – as did a12-year-old in a children’s ward who was reported as saying: “Art that would berelaxing 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, stimulatingmural painted on wall because he found it very boring being in hospital”.

OtherNot too small in size. Fresh appearance. Bringing the outside in. Create space. Counterthe claustrophobic atmosphere. Consider walls, floor and ceilings.

Five patients mentioned the importance of the size of the paintings. One studentreported 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 theinterview with a 69-year-old woman on a gynaecology ward, a student wrote: “Therewas a picture on the ward of a field with sheep, but the patient said that this was toosmall and uninteresting. She expressed that if the picture was much bigger it would beeasy for the whole bay to see it from their beds”. Another student wrote that her70-year-old female patient in an acute medical ward was bed-bound and thereforewanted a painting on the ceiling. Several of the students described health careenvironments as claustrophobic. One student, writing about her interview with an89-year-old woman in a coronary care unit wrote: “From her position, she could not seethe outside at all . . . her bed was facing the wall of filing cabinets and she said itseemed like an office, not very nice”. A 43-year-old man in a clinical decision unitremarked 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 wasproduced accordingly.

(1) The art should contain variety. The pictures should be hanging, rather than painted on thewalls, so that they can be changed. In view of having limited wall space, the pillars should beused for art.

Twelve works of art were produced on canvas for hanging in the ward. Thesecomprised ten tall, narrow pictures of single flowers, which hung on the pillars, andtwo 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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(2) Some of the art work should be complex so that people can look at it for a long time, manytimes, keeping them stimulated.

One of the rectangular pictures contained 12 paintings of butterflies situated within agrid. Each butterfly was different. The predominant colours were green, blue andyellow. 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 roundblocks 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 rectangularpictures contained plenty of absorbing detail.

(3) The theme of nature should be included as it appealed to both students and patients. Themood should be bright and cheerful.

The theme of the four seasons was considered, but who would want to be in winter’scorner? The flower pictures were simple and elegant. The flowers were enlargedphotographic 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 bypeople, whereas butterflies were usually appreciated. Above each window was asmaller window that could not be opened. Each was approximately 30 cm high and90 cm wide. Onto several of these Tony used coloured plastic film to create images ofstained 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 studenthealth professionals who come to practice their clinical skills. Each is now exposed tothe art work hanging on the walls and a plaque which explains the project. Although

Figure 1.

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Figure 2.

Figure 3.

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no structured evaluation of the project has taken place, the technicians who work thereon a permanent basis report that they hear students remarking on the art work, andusing it as a point of discussion.

Evaluation of the art-related educationSome of the students’ written comments referred to the art-related sessions inparticular, although some of these inevitably encompassed wider aspects of the courseas well. For example, four comments concerned creativity. Three students describedthe sessions as fun and/or creative. One wrote that the course “enabled us to be creativein our own ways”.

The lecturers’ evaluations noted that for each cohort, many students appeared to gothrough a similar journey from initial resistance, through acceptance, to genuineenthusiasm. 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 ofproducing a collage for the health fair. The student said, “I was so engrossed. I admit I wasvery 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 withregards to some of the subject areas covered, but after further reading I do feel moreenlightened.

Many students commented on how much they had enjoyed producing the visualdisplays (12 comments), which they made for their health fair. One wrote: “The displayreally 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 displayswas therapeutic in itself”.

The art therapists’ talks were listed by 12 students as one of the most positiveaspects of the course. One wrote:

I enjoyed the guest speakers . . . It helped me to put theory into practice . . . It’s taught meabout 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 tocare.

Another three revealed greater empathy with patients. For example, one wrote that themost positive aspect of the course had been “Learning about how art and holistictherapies 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 beachieved”. Another wrote:

At the beginning of the course it was difficult to understand how this type of healthpromotion was relevant, however since going through the course I believe I have learnt a lotand gained a greater understanding of holistic health promotion and a greater understandingof emotional care.

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A lecturer wrote of one student:

She [said she] certainly didn’t trust health professionals. Yet as the course progressed shebegan 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 visitsto 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 Ican make a difference – small or large. I loved the trips to Medway Hospital and the SunlightCentre. Both were informative, educational, inspirational and fun.

The course had evidently raised some students’ awareness of the environment. Theircomments included:

. . . had never thought about art . . . being used before. Good to think about the environmentwhich patients are in and how to optimise it.

This [course] has opened my eyes to art in nursing and made me appreciate my surroundingsin a busy underfunded environment.

I have learnt so much about holistic health and the art of healing. It has really made me thinkabout 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 willinfluence me in the future.

Some of the students’ comments reflected the debate about whether nursing is a scienceor art. One student wrote:

I feel that this module has really opened my eyes to how there are many ways topromote health, . . .there is no need to just follow the normal medical approach whencaring for patients.

Another mentioned “The nice feeling that . . . nursing/caring was not just scientificand technical”. A lecturer wrote:

Student discussed how she had entered the nursing degree feeling “open and free”. Throughher first and second year she had felt more and more constrained into a metaphorical boxciting reductionist and technological approaches to nursing care which had made her feelvery disillusioned . . . Through this course the student said she had been encouraged to seethat there may be opportunities to work in areas which allowed her to be the kind of nursethat she wanted to be.

However, in contrast, a small group of students in one cohort stayed in the initial stageof “resistance” throughout. One summarised their views by writing:

We . . . just feel that learning about drugs and IVs [intravenous infusions] etc. would havehelped us better. Thank you.

DiscussionEvaluation of the art-related educationAlthough most students were very positive about the course, some students wereinitially very resistant, and a small minority in one cohort remained resistant to theend. The findings suggest two possible reasons. Firstly, it appeared that the course

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might have challenged some preconceived ideas that nursing was primarily abouttechnical competence and the students might have felt that the inclusion of the arts wasexcessively subjective and unscientific (Le Vasseur, 1999). Secondly, although thelecturers were careful to keep a safe environment, and tried to utilise Carl Rogers’ coreconditions of empathy, congruence (genuineness) and unconditional positive regard(acceptance) within the work (Hough, 1998), Wikstrom (2000) cautions that using art innurse education can be emotionally challenging for the students, and so someresistance was understandable. Some students commented on how the course hadencouraged them to examine their own feelings and how it had helped them toempathise with patients, features that have been noted by several authors writingabout using the arts in nurse education (Ehrhart and Furlong, 1993; Greiner andValiga, 1998).

The act of producing art was described as being enjoyable and therapeutic byseveral students. This supports the findings of Heenan (2006) and De Petrillo andWinner (2005). The production of a visual display for the health fair in particular wasmentioned by some students as a highlight. As Whitman and Rose (2003) found in theirnursing course, this type of event served to be a very positive, creative way to end thecourse. 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 intheir work (Greiner and Valiga, 1998).

Many students finished the course with a greater awareness of both the built healthcare environment and the use of art within such environments. Studies have shownthat 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 itsEnhancing the Healing Environment programme (King’s Fund, 2006).

The findings suggest that introducing art-related education into pre-registrationnurse education was beneficial in terms of raising awareness about how health careenvironments 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 outwith sensitivity and care.

The evaluation of the art-related aspects of the course was based on the commentswritten by students who had been asked to evaluate the whole course. Later, it wasthought useful to evaluate the art-related aspects. Had the author set out to research theart-related education initially, the findings might have been more detailed. For examplealthough some students wrote about some points for improvement for the course, withreference to their assessments and the timing of the course, no student made anynegative comments, or points for improvement, about the art-related aspectsspecifically, which could be a consequence of the limitations of the method of inquiry.

The clinical skills laboratory art projectWithin the clinical skills laboratory project, the theme of nature emerged from both thestudents and the patients for the art work. Some patients wanted windows rather thanpaintings. These findings complement those of Ulrich (1984) and Hartig et al. (2003),who reported improvements in patients’ health and well being when they were exposedto nature as opposed to plain walls or rooms without views, and might be explained by

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the work of Morris (2003) which suggested that being exposed to the naturalenvironment can enhance physical, mental, spiritual and social health.

The project was successful in terms of providing a vehicle through which studentscould learn about the role of art in health care environments. It allowed the students toparticipate in a very simple research project that enabled them to practice theircommunication skills, in particular those of listening to patients, and to participate in aproject from initial ideas to completion. The process could be replicated in any healthcare setting with staff and patients.

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