It is estimated that by the end of the decade, close to $60 billion will be spent on healthcare construction, which implies that close to $300 million will be spent on art in healthcare. In the current economic climate, this investment cannot go unchallenged. Does the investment in art reap tangible, measurable, and accountable benefits to a healthcare organization?
Only if we are able to make this case can art dodge the risk of being value engineered. Inclusion of art is of particular significance in mental health settings, where patients are “perceptually” vulnerable. In this context then, art must be chosen carefully, creatively, and conscientiously.
Prior studies on art, mental health, and healthcare settings
Today, there is a compelling body of evidence that makes a case for the impact of positive distractions, such as art, on clinical and behavioral outcomes, including reduced stress, anxiety, and pain perception. Many of these studies have been conducted in acute care settings in high-stress areas, such as ICUs, waiting rooms, and procedure rooms.
In the context of mental health, researchers have long speculated that the physical environment in which treatment occurs has an impact on both the treatment process and its outcome. The few empirical studies that evaluated the effects of psychoenvironmental design have shown a decrease in pathological behavior, selective behavior, and attitude changes among both staff and patients, with a significant decrease in the rate of patient violence, an increase in patient-staff interaction, and improved morale among both patients and staff.1
However, a review of literature reveals there is a lack of studies in mental health settings that isolate the healing impact of particular environmental variables.2 We conducted a study that addresses this criticism by investigating the impact of a focused intervention using visual art.
Our study
The objective of this study was to determine the impact of different art conditions on levels of patient agitation in a psychiatric holding facility. Three distinct art conditions—abstract art, abstract representational art, and realistic nature—were introduced inside a psychiatric holding unit lounge (Figure 1).
The nature art displayed was a realistic photograph that followed the description of a savannah scene and previous guidelines for appropriate healthcare art.2 The abstract-representational image was a painting similar to the photograph in content, color, and composition; but it was rendered in an abstracted style. Previous research has been criticized for the use of computer-generated imagery that controls for color and composition as lacking in artistic merit. Addressing this criticism, a comparable high art piece by Vincent Van Gogh was selected. The final art image was a chaotic abstract painting by Jackson Pollock with contrasting colors and non-representational content. This image was selected to provide a stark contrast to the other two images (Figure 2).
During the study, nurses on the floor were asked to observe patient behavior. At the end of the three-month period, data from the hospital on PRN medication prescribed and patient census was collected; nurses were not informed at the time of the study that PRN data would be analyzed. PRN is the anti-anxiety medication that is given to patients on a need-only basis for elevated levels of agitation.
Since this is a medication that is not routinely prescribed, it is a robust and objective measure of agitation. Researchers compared the ratio of PRN medication to patient census across three different art conditions and a control condition (with no art). PRN costs were provided by the hospital per PRN incident. Costs were compared across different intervention conditions to make a case for the impact to the financial bottom line of the hospital.
Finally, focus groups with 22 nurses were conducted to secure qualitative information pertaining to patient behavior and the staff’s perception.
Key findings
The focus groups revealed that not many differences were noticed in patient reaction to the realistic nature image and the nature-based abstract representational art. Nurses reported that patients looked at the artwork a lot but did not react verbally or physically to it. Some negative responses to the abstract image were reported—one patient threw the image, another requested it be turned around, and a third kept reorienting it. Overall, nurses thought that artwork in the room was a positive environmental element for their patients.
The ratio of PRN/patient census was significantly lower on the days when the realistic nature photograph depicting a savannah scene was displayed, as compared to the abstract art condition and the control condition (no art). Statistically significant differences were not found between the abstract art and abstract representational condition; between the nature art and abstract representational art; and between the control condition and abstract art conditions.
The lack of a statistically significant difference between the abstract representational art (which had a nature theme similar to the realistic nature photograph) and the chaotic abstract image is interesting and warrants further investigation.
Overall, there was a reduction in the average PRN per day on days when art was present as compared to days with no art. So it seems fair to say that some art is better than no art. A comparison of the cost of a PRN incident per day (which includes staff time and pharmacy time) and the cost of PRN medication per day, showed a reduction in cost for days that art was present compared to the control condition (no art).
Based on a cost of $60.30 per PRN incident, provided by the hospital, we calculated the projected savings for each condition. Based on the findings, a total annual savings of $27,526 was projected when nature art was displayed, $7,517 with the abstract representational image (nature-based), and $4,167 when abstract (non-representational art) art was present (Table 1). A statistically significant difference between the PRN medications requested was only found between the realistic nature image as compared to the control condition (no art).
Implications for art programs
The presence of artwork can impact levels of anxiety and agitation in psychiatric patients and, in turn, the total cost incurred by a hospital in prescribing medication for anxiety and agitation. Realistic images of nature that depict a savannah-like image conducive to evolutionary wellbeing, and supported by Biophilic theory, can potentially lower patient agitation levels.
The study shows that the type of art image displayed can have a powerful impact on patient health (and provide a cost savings). With the paucity of research on mental health environments, further research on other types of art that can impact patient anxiety is justified. This research also can be extended to other visual variables (wall colors, lighting, window views, etc.) to better understand how specific environmental variables impact health, as well as personal and institutional wellbeing.
A paper on this research was published in the Journal of Psychiatric and Mental Health Nursing in December 2010. HCD
Acknowledgement
Deborah Owen, Director of the Department of Psychiatry at East Alabama Medical Center; Rana Zadeh, graduate student at Texas A&M University; and Robyn Bajema, Research Assistant at American Art Resources.
Upali Nanda, PhD, Assoc. AIA, EDAC, is Vice President, Director of Research at American Art Resources in Houston. She can be reached at upali.nanda@americanartresources.com. Sarajane L. Eisen, PhD, IDEC, IIDA, AAHID, is Assistant Professor, Interior Design, at Texas Christian University. She can be reached at sarajane.eisen@tcu.edu.
References
1 Christenfeld, R., Wagner, J., Pastva, G. & Acrish, W.P. (1989);Diette, G. B., Lechtzin, N., Haponik, E., Devrotes, A., & Rubin, H. R. (2003; Hathorn, K. & Nanda, U. (2008); Higgs, W. (1970); Miller, A.C., Hickman, L.C., & Lemasters, G.K. (1993); Minde, R., Haynes, E. & Rodenburg, M. (1990); Schneider, S.M., et al. (2003); Stahler, G.J., Frazer, D., & Rappaport, H. (1984); Sommer, R. & Ross, H. (1958); Ulrich, R. S. (1984); Ulrich, R. S. (1991); Ulrich, R. S. and L. Gilpin (2003); Whitehead, C.C., Polsky, R.H., Crookshank, C., & Fik, E. (1984).
2 Daykin, N. (2008). Review: The impact of art, design, and environment in mental healthcare: a systematic review of the literature. The Journal of the Royal Society for the Promotion of Health, 128(2): 85-94.
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