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The online version of this article can be found at:
DOI: 10.1177/1466424007087806
2008 128: 85The Journal of the Royal Society for the Promotion of Health
Norma Daykin, Ellie Byrne, Tony Soteriou and Susan O'Connor
Review: The impact of art, design and environment in mental healthcare: a systematic review of the literature
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JRSH 2008;128(2):85-94 The impact of art, design and environment in mental healthcare REVIEW 85
March 2008 Vol 128 No 2 Copyright © The Journal of The Royal Society for the Promotion of Health 2008 JRSH
SAGE Publications, Los Angeles, London, New Delhi and Singapore
ISSN 1466-4240 DOI: 10.1177/1466424007087806
The impact of art, design and
environment in mental healthcare:
a systematic review of the literature
Authors
NNoorrmmaa DDaayykkiinn
((BBAA,, MMSScc,, PPhhDD))
Professor of Arts and
Health, UWE Bristol,
Glenside Campus,
Blackberry Hill, Stapleton,
Bristol, BS16 1DD, UK
Tel: 0117 32 88 474
Fax: 0117 32 88 437
Email: norma.daykin@uwe.
ac.uk
EElllliiee BByyrrnnee
University of the West of
England,
Bristol, UK
TToonnyy SSootteerriioouu
Avon and Wiltshire Mental
Health Partnership NHS
Trust, UK
SSuussaann OO’’CCoonnnnoorr
Avon and Wiltshire Mental
Health Partnership NHS
Trust, UK
CCoorrrreessppoonnddiinngg aauutthhoorr::
Norma Daykin, as above
Key words
arts; design; environment;
mental health; systematic
review
BACKGROUND
Arts have been utilised in a number of ways in
mental health settings. Art therapy is an established
discipline in mental healthcare, used with a number
of client groups.
1,2,3,4,5
Art is also used as a diagnostic
tool in conditions such as depression
6,7
and in the
field of substance abuse.
8,9
These activities exist within the expanding
domain of ‘arts for health’, a broad movement that
encompasses a wide range of disciplines and
Abstract
AAiimmss::
There has been a burgeoning interest in arts and the environment in healthcare. While
research has been undertaken on the clinical impact of disciplines, relatively little research has
studied the impact of broader arts for health interventions. This paper reports findings from a
systematic review of the arts for health literature, encompassing research on the impact of
visual art, design and the environment on the well-being of patients and staff in mental
healthcare settings.
MMeetthhooddss::
A systematic review of over 600 papers published between 1985 and 2005 on the
impact of arts, design and environments in mental healthcare was undertaken. The review
includes a discussion of contextual and policy literature, as well as 19 reports of quantitative
and qualitative studies that met our inclusion criteria.
RReessuullttss::
The largest number of studies focused on the aspects of art, design and environment
that were relevant to mental healthcare. These studies suggest that this can affect health,
including physiological, psychological, clinical and behavioural effects. Exposure to stressful visual
and aural environments may reduce levels of stress and enhance recovery. Architectural design
consideration is important in mental health settings, especially for patients with conditions such as
dementia that can make wayfinding difficult. Exposure to art in healthcare environments has been
found to reduce anxiety and depression. Environment features have also been found to affect
staff, and improvements in visual and acoustic conditions may reduce risks of errors in some care
settings. Qualitative studies provide insights into factors affecting the impact of arts, including
issues of power and control, perceptions and influence of key stakeholders, and user
participation. A key issue to emerge from this study is that arts interventions do not necessarily
address the lack of control exercised by patients in healthcare environments.
CCoonncclluussiioonnss::
While there is extensive literature on the impact of design, environment and the
arts on health, there is still a need for further research that addresses methodological
challenges of evaluating complex interventions. Our review found evidence that environmental
enhancements can have a positive impact on health and well-being of staff and patients in
mental healthcare. Arts, when considered within this framework of evidence-based design, can
also contribute to well-being, offering reassurance and creating identity in healthcare settings.
Further research is needed in this area, as well as research that explores the contribution of
other models of art that do not fit within the framework of ‘evidence-based design’. Finally,
responses to the arts are contingent on a number of complex social and political factors;
further understanding of these is needed in order to inform future research and evaluation of
the arts in healthcare.
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86 REVIEW The impact of art, design and environment in mental healthcare
JRSH The Journal of The Royal Society for the Promotion of Health March 2008 Vol 128 No 2
practices, from art therapy through to
public art and architecture. Since the early
1980s, the contribution of design,
environment and arts to clinical and
non-clinical outcomes in health has been
recognized. While research in this field is
less developed than in other areas, such as
art therapy, there is increasing evidence that
attractive environments can enhance the
experiences of healthcare service
users.
10,11,12,13,14,15
The socio-economic and policy contexts
of different countries have influenced
approaches to the arts in healthcare. In the
US, with its market-led model,
environmental enhancements are seen as
contributing to having economic benefits as
well as risk reduction.
14,16
The Private
Finance Initiative in the UK may also have
encouraged some convergence of these
agendas. Other issues, such as participation
and social exclusion
17,18,19,20
have been
influential. Guidance on building design
from the Department of Health reflects
these trends; hence, the use of arts to create
healing atmospheres is emphasized along
with the role of arts in encouraging civic
pride.
21,22,23,24
While there is some convergence of
agendas, the growth of the arts for health
agenda has raised challenges. First, there is a
need to identify the respective contributions
of the varied disciplines involved in arts for
health. As well as art therapists, an
increasing number of stakeholders are
involved in projects, such as arts agencies,
artists, community arts workers and
designers. These groups may draw on
different perspectives when it comes to
artworks and environments in healthcare.
Another question is that of what
constitutes ‘appropriate’ art. Research has
suggested naturalistic environments are
supportive of recovery, while abstract
images, along with noisy, institutional or
urban environments, may contribute to
increased stress.
14,25,16
This research has
influenced policy, and official advice
identifies key aesthetic and functional
considerations such as engendering a non-
institutional atmosphere, distracting
patients from stress and anxiety, helping
people to navigate their way around and
fostering a sense of ownership and pride in
public buildings.
26,27,28,21
Another question relates to how to
evaluate the impact of arts.
18,19,29
While there
is a growing body of evidence concerning
clinical outcomes, particularly of music,
2
many arts for health interventions do not
focus on clinical indicators, rather they
address a variety of psychological, social and
spiritual dimensions.
30
White and Angus
29
note a lack of clarity
about the aims of arts for health projects
and a lack of appropriate measurement
tools. Hence Angus
30
reviewed over 60
evaluations of UK community-based arts
for health projects, finding many of these to
be unstructured, drawing on qualitative
information but providing little
information about the use of procedures
and making little attempt at data analysis.
30
Medical and biological models tend to
dominate scientific and health services
research on the impact of arts.
2
In contrast,
sociological approaches, including theories
of social and cultural capital,
29,31
as well as
reflexivity and identity construction
through arts,
32
have received less attention
although these models often influence arts
for health practice.
30
This paper focuses on the impact of arts,
design and environment in healthcare
settings with a particular emphasis on
mental healthcare. The study was carried
out as part of a two-year evaluation of a
commissioned arts programme in a UK
mental health trust. The review draws on
qualitative and quantitative evidence
relating to the impact of design,
environment and the arts in mental
healthcare.
METHODS
A search of electronic and manual
resources was undertaken between January
and April 2006.
34
This began with an
electronic search of 14 databases (Table 1)
using the terms outlined in Figure 1. The
results were saved to a RefWorks folder. In
Electronic databases searched and search results*
Database Number of initial hits
AMED 21
ARTbibliographies Modern 31
ASSIA 14
Avery Index to Architectural Periodicals 16
BNI: British Nursing Index 2
CAB Extracts 13
CINAHL 135
DAAI: Design and Applied Arts Index 7
HMIC 63
IBSS 1
LISA: Library and Information Science Abstracts 16
PsycINFO 173
SPORTdiscuss 4
Web of Science (SSCI; AHCI) 104
TOTAL (including duplicates) 600
TOTAL (excluding duplicates) 525
* After some preliminary searching it was agreed to exclude the following:
• Embase (154 hits, out of first 20 only one or two relevant)
• EBM (140 hits, out of first 20 none relevant)
• Medline combined (864 hits, out of first 20 one relevant but this had been picked
up elsewhere)
Table 1
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total there were 600 papers, 525 after the
removal of duplicates.
The selection of papers was an iterative
process involving several stages. The
inclusion and exclusion criteria presented in
Figure 2 were used to determine which
papers to include. The process involved
screening of abstracts for relevance as well
as full text screening of 68 papers by two of
the authors (ND and EB). The review
included papers on arts, architecture or
design initiatives in healthcare. Papers on
the impact of art therapy and participatory
arts were excluded, reflecting this study’s
focus on the contribution of arts to the
design and environment of healthcare
facilities.
33
To make the search as comprehensive as
possible, further searches were done on key
authors as well as citation searches on
significant papers. This identified a further
68 papers, the full texts of which were
screened using the inclusion and exclusion
criteria. The review process then proceeded
through several stages and a large number
of documents that provided useful
background information but did not
directly report research was excluded: these
included contextual documents. No studies
were excluded on grounds of research
design: the review included quantitative
intervention studies as well as qualitative
research.
The process identified 19 quantitative,
qualitative and mixed-methods research
studies investigating the impact of art,
design and environment in healthcare
settings. An overview of the search strategy
is provided in Figure 3.
Critical appraisal of the studies was
undertaken by ND and EB using standard
critical appraisal tools (CASP 2002). A data
extraction sheet (Figure 4) was used to
summarise the papers.
Of the 19 studies, 10 used outcome
measures to assess various effects of arts,
design and the environment, including
physiological effects,
35,36
psychological
indicators of well-being and stress,
37,38,39
and
clinical and behavioural effects.
40,41,42,43
Two
studies used validated assessment tools to
evaluate physical environments and
facilities,
44,45
while seven mixed-methods
studies examined subjective responses and
views of patients and staff concerning arts,
design and environment of healthcare
facilities.
36,46,47,48,49,50,51
The two reviewers were in broad
agreement that of the 19 studies that were
identified, none would have met the
stringent inclusion criteria used in
systematic reviews such as those undertaken
by the Cochrane Collaboration.
The methodological challenges of
evaluating the clinical effects of art,
design and environment are illustrated in a
report of a systematic review of art therapy
for schizophrenia.
1
Of 61 reports
identified, only two randomized controlled
trials comparing group art therapy with
standard care
52,53
met the inclusion criteria.
Ruddy and Milnes’ discussion of excluded
studies reveals some of the difficulties
encountered when seeking to evaluate
clinical outcomes of complex interventions
such as arts initiatives. The methodological
characteristics of the studies in this
review mirrored those reported by
Ruddy and Milnes,
1
including lack of a
control group, lack of randomization,
lack of blinding, incomplete data due to
high levels of attrition, and failure to
report power calculations to ascertain the
The impact of art, design and environment in mental healthcare REVIEW 87
March 2008 Vol 128 No 2 The Journal of The Royal Society for the Promotion of Health JRSH
Word group 1 Word group 2 Word group 3 Word group 4
Art Patient* Hospital Evaluat*
Arts User Ward Research
Artist* Users Wards Qualitative
Painting* “mental health” Unit Quantitative
Architectur* “mental* ill*” Units Evidence
Sculpture* psychiatr*
* Terms within word groups combined using “or”; word groups combined using “and”.
Search terms used in the electronic search*
Figure 1
Inclusion and exclusion criteria
Figure 2
Inclusion criteria
Papers on arts, architecture or design initiatives in healthcare
Papers on participatory arts in healthcare
Artists in residence
Intervention studies and other sorts of literature
International research
English language
1985 onwards
Exclusion criteria
Not relevant to arts or design initiatives in healthcare
Not relevant to participatory arts in healthcare
Art forms (music, drama, play, dance)
Art therapy where art was a purely diagnostic intervention
Patient arts
Not English language
Pre-1985
Poetry and creative writing (added during full text screening phase)
Dissertation theses (added during full text screening phase)
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sample size needed to demonstrate
significant results.
However, key methodological challenges
were addressed in some of the studies as the
following two illustrations show. The study
by Ulrich et al
35
was a naturalistic
experiment that used a repeated post-test
comparison group design to assess the
effects of environmental conditions,
including nature and urban environments,
on stress in US healthcare consumers
undergoing stressful procedures (blood
donation). Of 942 blood donators eligible to
take part, less than 10% declined to
participate and data were available for 872
consenting participants. Semi-random
procedures were used to determine which
stimulus to use on a given day. In another
example, Staricoff and Loppert
37
carried out
a naturalistic experiment with
chemotherapy and antenatal patients at a
UK hospital that addressed randomization
by collecting data for six months at the same
time and day each week during intervention
and non-intervention periods.
While current research on arts, design
and environment may be limited, a wide
range of studies was included in order to
illustrate some of the innovative, pragmatic,
methodological approaches that have been
developed to address the problems of
evaluating complex interventions.
Further, while it is valid to view the
randomized control trials as the ‘gold
standard’ for evaluating clinical outcomes, the
claims of arts interventions extend more
widely than this to include impact and
process issues for which a wide range of
methodologies, including qualitative research,
are available. This review therefore includes
non-experimental research including surveys,
qualitative research and case studies.
FINDINGS FROM THE STUDIES
A summary of the study findings is
provided in Table 2. Here the findings are
discussed in relation to three topics: the
impact of arts interventions in healthcare
settings; the impact of design and
environmental conditions; and perceptions
of art, design and environment in healthcare
settings.
The impact of arts interventions in
healthcare settings
Few studies directly examined arts
interventions, and while none of the studies
specifically examined the effects of artwork
on patients and staff in mental healthcare
settings, some of the study findings were
relevant to these groups. The study by
Staricoff and Loppert
37
measured
psychosocial indicators in various groups of
patients following art interventions. While
the authors note that the small sample sizes
make it difficult to detect significant results,
a key finding was that depression and
anxiety were respectively 34% and 20%
lower in the experimental levels than in
controls not exposed to arts. Art
interventions may contribute to behaviour
improvements in some patients. Kincaid
and Peacock
43
assessed the effects of an
installation of a wall mural painted to
disguise an entrance/exit doorway on
repeated door-testing behaviour among
elderly residents in a US nursing home.
Twelve out of 20 residents took part in
quantitative and qualitative data collected
by an observer over 12 weeks. The authors
note several limitations of the study,
including the small sample, the lack of
control group, and the possible impact of
the observer’s presence, but nevertheless
report a significant reduction in door-
testing behaviours following the wall
installation.
The impact of design and
environmental conditions in
healthcare settings
Eight studies examined the impact of
environmental conditions, sometimes
taking into account aesthetic as well as
functional considerations. For example, the
study by Ulrich et al
35
examined
physiological measures, including blood
pressure and pulse rate, as well as
psychosocial self-report measures, to
compare the effects of nature conditions
with other conditions on patients
undergoing a stressful procedure (blood
donation) in a US hospital. The study found
that stress was higher during periods of
exposure to urban environments, including
television. In contrast, nature images and
sounds were associated with lower levels
of stress.
These results agree with those of an
earlier randomized experimental study
36
that compared the effects of exposure to
natural and urban settings on recovery
88 REVIEW The impact of art, design and environment in mental healthcare
JRSH The Journal of The Royal Society for the Promotion of Health March 2008 Vol 128 No 2
Full text scrutiny of 68 papers
that met inclusion criteria
Full text scrutiny of 136 papers
Critical appraisal of 19 empirical
studies identified
525 Initial hits in electronic search
Citation and author search
Additional screening of 68 further
papers identified
Overview of the search strategy
Figure 3
Data extraction sheet
Figure 4
Study aims and design
Population/setting
Intervention
Methods
Sample
Data collection
Measures used
Data analysis
Main findings
Implications
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The impact of art, design and environment in mental healthcare REVIEW 89
March 2008 Vol 128 No 2 The Journal of The Royal Society for the Promotion of Health JRSH
Findings from the studies
Ulrich
et al
(2003) Changes in physiological indicators including blood pressure and pulse rate as well as psychosocial
self-report measures favouring nature conditions over television and urban conditions.
Staricoff and Experimental data found that depression and anxiety were lower in patient groups exposed to arts than
Loppert (2003) in controls not exposed to arts.
A survey of patients, visitors and staff found that over 95% of respondents noticed the works of art.
Patients were more supportive of art than staff, but art was generally perceived positively as enhancing
well-being and diminishing stress levels, improving mood and distracting from worries.
A follow-up survey of staff found that respondents were concerned about their working environments and
had a clear preference for working in modern hospitals.
Ulrich
et al
(1991) Physiological and psychological indicators suggested recovery from stress was faster and more
complete when subjects were exposed to natural settings as opposed to the other environments.
Blomkvist
et al
(2005) Staff perceptions of working conditions improved following changes in acoustic conditions in a study of
36 nurses in a coronary care unit.
Schofield (2003) Use of a Snoezelen multi-sensory environment led to reduced anxiety in the intervention group
compared with controls. Qualitative interview data identified key themes of calm, sleep, continued
effect and environment from patients’ accounts.
Kincaid and Peacock Door-testing behaviours reduced following the installation of a wall mural painted to disguise an
(2003) entrance/exit doorway in residents aged over 65 in a US nursing home.
Baldwin (1985) A non-significant reduction in seclusion rates was found following the reorganization of the physical
environment from non-social to group arrangements of ward dayrooms in a maximum-security hospital.
No changes in medication rates were found. Nursing reports generally reflected favourable attitudes to
the intervention.
Donald
et al
(2000) A non-significant reduction in falls was associated with vinyl flooring compared to carpets in a study of
elderly patients in a community hospital.
Passini
et al
(1998) Patients with dementia of the Alzheimer’s type (DAT) were more able to make way-finding decisions
based on information of explicit architectural nature than based on decision making using planning,
memory or inferences.
Duncan (2003) Found no short-term change in approval ratings in patients and staff following installation of a
commissioned art installation in an NHS hospital hydrotherapy room. Longer term evaluation showed
more positive ratings by patients but no change in staff ratings.
Benjamin and Assessed specialized environments for people with dementia in the UK, finding these unsuitable for
Spector (1990) wheelchair users and poor in relation to safety features, prosthetic aids and orientation aids.
Timko (1996) Assessed facilities in US psychiatric and substance-abuse residential treatment programmes. Patients
in programmes with more physical amenities had better outcomes and were more involved in
self-initiated and community activities.
Table 2
(continued)
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following exposure to stress (a video
featuring work accidents) on 120 male and
female volunteers in a US university setting.
Physiological and psychosocial data
suggested that recovery from stress was
faster and more complete when subjects
were exposed to natural settings as opposed
to the other environments.
Clinical effects of an environmental
intervention were examined in a number of
studies. Baldwin
41
studied the impact of a
reorganization of the physical environment
from non-social to group arrangements of
ward dayrooms. The study included
residents from 10 wards in a maximum-
security hospital. A non-significant
reduction in seclusion rates following the
experimental condition was reported.
Casualty incidents were also reduced
following the intervention, though very
small numbers of incidents were reported
overall. No changes in medication rates were
found. Nursing reports generally reflected
favourable attitudes to the intervention.
Another study focused on behavioural
responses to the environment, investigating
the impact of architectural design on
way-finding in patients with dementia in a
large hospital.
40
The study compared 14
patients with dementia of the Alzheimer’s
type (DAT) and a matched control group of
28 subjects. Participants were observed as
they found their way to a named destination
in a large hospital. A key finding was that
DAT patients were incapable of developing
an overall plan to solve the wayfinding task
and incapable of producing decisions
involving memory or inferences. Conversely,
they were better able to make decisions
based on information of an explicit
architectural nature.
Two studies used structured assessment
tools to evaluate healthcare facilities. An
early study by Benjamin and Spector
45
assessed a British sample of four specialised
environments for people with dementia and
the elderly, reporting that at this time all the
facilities were poorly adapted for people
with disabilities: poor in relation to safety
features, prosthetic aids and orientation
aids. More recently, Timko used the Physical
and Architectural Characteristics Inventory
(PACI) to assess the facilities in 164 US
psychiatric and substance-abuse residential
90 REVIEW The impact of art, design and environment in mental healthcare
JRSH The Journal of The Royal Society for the Promotion of Health March 2008 Vol 128 No 2
Francis
et al
(2003) Mixed-methods UK study assessed the impact of funded arts in NHS hospital trusts. Found that despite
initial perceptions of projects as “the icing on the cake” a wide range of benefits was associated with
the arts. Key themes included value for money; therapeutic benefits; enhanced experiences of care;
uplifting environments; reducing vandalism and aggression; privacy and dignity for patients; identity,
welcome and reassurance; enhancing staff morale; and community, cultural and public benefits.
Lawson
et al
(2003) Mixed-methods study of patients in the process of transferring from old to new accommodation. Clinical
differences emerged, including reduced length of stay for patients in newer buildings. Patients were
aware of quality of the environment. Those in the newer buildings expressed more satisfaction with the
appearance, layout and overall design of their wards as well as with their care than those in older
buildings. Patients preferred natural lighting and a view from a window. Lack of control exercised by
patients was a feature of both old and new environments.
Scher and Senior Evaluation of the Exeter Healthcare Arts Project (EHCA). Questionnaire and interview data revealed that
(2000) a marked proportion of respondents had not noticed the artwork prior to the study. The majority of
respondents approved of money being raised for the arts in healthcare, with patients voicing stronger
support than clinical staff.
Douglas and Survey of UK inner-city hospital past-patients. Found that patients favoured those aspects of the
Douglas (2005) environment that engendered enhanced comfort, privacy and normality. They liked windows that
provided a view outside.
Chen and Sanoff US hospital survey found that patients expressed a greater need for privacy than staff believed they
(1988) had, with the majority of medical and mental health patients preferring a private room. Diverse
views were found and participatory processes are needed to allow stakeholders to support their
judgements and clarify their intentions in programmes of hospital improvement. Mental health
patients appeared to have more definitive and polarised reactions to their environment than other
groups.
Table 2 (continued)
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treatment programmes.
44
The study found
that patients in programmes with more
physical amenities had better outcomes and
were more involved in self-initiated and
community activities.
A number of other studies examined the
impact of environmental conditions in a
variety of healthcare settings. These
reported safety issues, including a non-
significant reduction in falls associated with
vinyl flooring compared to carpets in a
study of elderly patients in a community
hospital, and found significant
improvements in staff perceptions of
working conditions following changes in
acoustic conditions in a study of 36 nurses
in a coronary care unit.
42,38
The authors
conclude that improved conditions and
speech intelligibility enhanced staff well-
being, reducing risks of conflicts and errors.
Finally, Schofield
39
examined cancer
patients’ responses to a specialist
environment (Snoezelen) that was
associated with enhanced sense of calm.
Perceptions of art, design and
environment in healthcare settings
The remaining studies examined subjective
responses to healthcare environments using
a range of methodologies. This group
included five studies focusing directly on
arts
8,37,47,48,50
and two studies focusing on
perceptions of healthcare environments.
49,51
Duncan
48
used a pre- and post-test design
to evaluate responses to an art installation
in an NHS hospital hydrotherapy room.
This study used a questionnaire to assess the
environment by a non-random sample of
staff and patients before installation and
one and three months post installation of
the commissioned art. The study found no
significant change in approval ratings of
either patients or staff one month post
installation. After three months, patients
rated the changes to the environment more
positively than in the first month, although
there was no significant change in staff
responses after three months. The author
suggests that staff responses may reflect the
difficulty of adapting to changes in the
visual environment.
A large mixed-methods UK study
examined a wide variety of hospital projects
in a number of hospitals ranging from
integrated art and interior design to
commissioned and purchased artworks.
46
This study assessed the impact of grants
awarded to 32 UK National Health Service
hospital trusts for environmental
improvements to patient areas. The research
used in-depth interviews with project
teams, sponsors and any artists, architects or
designers involved, as well as follow-up
interviews in six case study sites. A focus
group was conducted, which included a
cross-section of those involved in the
programme, as well as nursing, estates, and
design professionals and trust sponsors. The
interviews focused on identifying key
factors that had supported or hindered
projects.
The study found that while many projects
were initially perceived as ‘the icing on the
cake’, sponsors commented on how much
had been achieved for so little money. The
scheme persuaded NHS trusts that a high
impact could be made for relatively small
sums. Key benefits of arts were identified
including: therapeutic benefits; enhanced
experiences of care; reducing vandalism and
aggression; providing greater privacy and
dignity for patients; promoting a sense of
identity; and enhancing staff morale and
motivation.
Patients’ perceptions of the environment
were also examined by Lawson et al in a UK
study that used a questionnaire and focus
groups.
50
The study included 140 general
medical patients in two hospitals, in the
process of transferring from old to new
accommodation. The authors report that a
commonly held view, that patients are often
too ill to be aware of quality of the
environment, is not supported by the data.
Patients in the newer buildings expressed
significantly more satisfaction with the
appearance, layout and overall design of
their wards. There were no significant
improvements reported in specific areas
(lighting, noise, air quality and
temperature). Rather, the gains seem to
relate to spatial and visual differences.
A key issue to emerge from this study is
the lack of control exercised by patients in
both old and new environments. Hence, the
design of the new wards did not allow
patients to control aspects of lighting, noise,
air quality and temperature. Nevertheless,
patients rated their health improvement
better in the newer wards and they also gave
a higher rating to the treatment and the
staff. Clinical differences emerged, including
reductions in length of stay for some
conditions and reductions in requests for
pain-killing medication. Staff gave more
positive ratings of patient progress in the
new facilities. Finally, a key finding
reinforces that of other studies: that patients
preferred natural lighting and a view from a
window.
Two additional studies used
cross-sectional surveys following an arts
intervention. A survey was undertaken as
part of the evaluation of the Chelsea and
Westminster Hospital Research Project.
37
An anonymous questionnaire was
distributed to a non-random sample of
patients, visitors and staff in public areas and
wards where works of art were present, over
a one-year period. Over 1000 questionnaires
were returned. While the sample was large
and included a cross-section of the
population, it is difficult to assess patterns of
response and non-response from the report.
The study found that over 95% of
respondents noticed the works of art, which
were generally perceived positively and as
diminishing stress levels, improving mood
and distracting from worries.
A follow-up survey used a postal
questionnaire to assess staff attitudes
towards an active hospital arts
programme.
37
Of over 2000 staff who
received questionnaires in payslips, 325
responded (15%). The study found that
respondents were concerned about their
working environments and had a clear
preference for working in modern hospitals.
The impact of arts on well-being and staff
experiences were also explored in a study
evaluating the Exeter Healthcare Arts
Project (EHCA), which included 348
artworks and performances in a newly built
district hospital in the UK.
47
A series of
attitude surveys were undertaken by
patients, staff and visitors to the hospital.
Three questionnaires were distributed
among various groups, including a random
sample of 20% of clinical staff, with 125
responses (36%). Interviews were
undertaken with a non-random sample of
378 service users.
The data collection explored perceptions
of the attributes of the arts as well as
experiences of the EHCA project and staff
observations of its effects on users. The
authors note the low response rates,
particularly among males: questionnaire
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and interview data were combined to bring
staff responses up to 9% of all staff.
In contrast to the study by Staricoff and
Loppert,
37
the study found that a marked
proportion of respondents had not noticed
the artwork before being interviewed. On
the other hand, the majority of respondents
approved of money being raised for the arts
in healthcare, with patients voicing stronger
support than clinical staff, a finding also
reported in other studies.
37,48
The other studies examined perceptions
of design and environmental issues in
healthcare settings. Douglas and Douglas
surveyed 785 UK inner-city hospital past-
patients.
49
The main finding was that
patients favoured environments that made
them comfortable, able to keep some
privacy and normality, and that they liked
windows that provided a view.
Staff and patients’ perceptions of the
environment were also examined in a survey
of 60 staff and patients in a US hospital
survey that generated 55 (90%) returns.
51
Patients expressed a greater need for privacy
than staff believed they had, with the
majority of medical and mental health
patients preferring a private room. The
study identified some differences between
different types of patients with mental
health patients appearing to have more
definitive reactions to their environment
than other groups.
The study addresses the diversity of views
and some important differences between
staff and patients as well as between
patients. The authors note that consensus is
difficult to achieve, hence the importance of
participatory processes that allow
stakeholders to support their judgements
and clarify their intentions in programmes
of hospital improvement.
51
DISCUSSION AND CONCLUSIONS
This review has identified a growing body of
research literature that examines the impact
of design and environment, and to a lesser
extent, arts on health. A number of
methodological issues emerge from the
review. In relation to outcomes studies,
there is a need for further research that
addresses issues of sample sizes,
randomization, homogeneity between
experimental and control groups, blinding
and use of power calculations to ascertain
the sample size needed to demonstrate a
significant result.
Our review also encompassed mixed
methods and qualitative studies. While we
found some extensive studies, including
good examples of qualitative research, there
was a general lack of detailed reporting of
procedures for data collection and analysis
making it difficult to evaluate this research.
A common method of qualitative data
analysis used is content analysis, but of the
studies that employed this method only one
reported in any detail the methods used to
extract themes from the data.
39
Hence there
is a need for more qualitative research in
this field that pays attention to procedures
and reporting of data collection and
analysis. Rather than descriptive reporting
of data, research is needed that explores in-
depth perceptions, meanings and impacts of
an arts intervention on patients and staff in
mental healthcare.
The diversity of settings, interventions
and outcome measures used in these studies
means that it is difficult to synthesise the
data, although this review does draw
attention to some key findings that may be a
useful guide to future research.
Key findings from the review
include evidence that exposure to the
arts may reduce anxiety and depression
in specific groups of patients.
37
Further,
there is evidence that the arts can positively
affect clinical and behavioural outcomes.
43
More often, the contribution of arts is
considered in the context of evaluation of
broader environmental issues. Positive
effects of environmental conditions have
also been identified including reduced
stress,
35,38
reduced risk,
38,42
improved
way-finding
40
and enhanced perceptions
of healthcare environments.
39,41
The
research also identifies potentially
negative effects of many common
environmental conditions in healthcare
such as excessive noise.
35,38
Evidence favours
nature conditions over urban
environments.
35,36
The arts are most commonly understood
within this framework of evidence-based
design. This emphasises the importance of
reassurance, identity and calm;
8,35,36,39,41,43
privacy and normality;
49
and practical
considerations such as way-finding.
40
The research reviewed backs up a
growing consensus that supports art that is
calming, with naturalistic and domestic
imagery over abstract or challenging art.
This raises the question of whether there is a
role for other models of art that might be
perceived as challenging. While these
models do not fit within the framework of
‘evidence-based design’ they may have
support from other groups of stakeholders
involved in arts for health, including artists
and patients.
30
This is a key question for
further research and is being explored in
our two-year study of the impact of
commissioned arts in a mental healthcare
setting.
Attitude surveys indicate high levels of
approval for arts, particularly among
patients.
37,47
However, the difficulty of
adapting to changes in the visual
environment may cause staff to respond
negatively to arts.
48
This raises the question
of what factors influence perceptions of the
arts in healthcare settings. Issues such as the
degree of control exercised by patients and
staff have been identified as important.
48,50,51
It has also been noted that the
characteristics of particular settings and
different client groups might affect
responses, with views about the
environment in mental health more
polarised than in other sectors.
51
Finally, the
review points towards the diversity of
responses to arts in mental health settings
and the importance of participation in
relation to the mediating influence of
power, control and stake.
Limitations of the study
The review has a number of limitations. The
literature search was comprehensive and
systematic, and produced a very large
volume of literature and it was a labour-
intensive process to reduce this to a relevant
body of work. The use of bibliographic
software (RefWorks) was extremely useful
for ensuring that this process was
systematic, transparent and valid.
The search strategy was focused towards
mental health services and although
searches of the wider literature drew in
studies of visual arts in healthcare, some
relevant studies outside mental health
settings may have been excluded. Further,
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the search strategy was focused towards the
contribution of arts to the environment:
studies of participatory art and arts
therapies were excluded.
Finally, the study only included published
literature; some of the ‘grey’ literature may
have been excluded along with US
dissertation abstracts, which were difficult
to obtain. The review applied broad
methodological inclusion criteria to
encompass randomized control trials as well
as a range of quantitative and qualitative
research. Critical appraisal of the studies
was undertaken and when presenting the
findings, this paper has sought to recognize
validity issues.
By undertaking this systematic review of
the literature the authors hope to contribute
to the development of the evidence base
surrounding the impact of arts and
environment on patients and staff in
healthcare settings.
ACKNOWLEDGEMENTS
This project was funded by the Estates
and Facilities Division of the Department
of Health. The views expressed in it are
those of the authors and not necessarily
those of the Department of Health. The
project team includes Mark Palmer (UWE
Bristol); Nola Davis (Avon and Wiltshire
Mental Health Partnership NHS Trust; and
Jane Willis and Joanna Espiner (Willis
Newson Arts Consultancy, Bristol).
The impact of art, design and environment in mental healthcare REVIEW 93
March 2008 Vol 128 No 2 The Journal of The Royal Society for the Promotion of Health JRSH
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