The following are offered as examples of pilot and small and large population studies that indicate the efficacy of the arts in the healthcare environment. These are, of course, selected references that point to the scope and diversity of the studies of arts in healthcare. It is clear that, although there are many discrete studies in a variety of areas of interest to the arts in healthcare movement, there do not appear to be many long-term follow-throughs with more studies on the same topic adding to the solid research knowledge base.
A 1996 study from the Dept. of Pathology, the Ohio State University, showed that sound had an effect on the growth of neoplastic and normal human cells. Specifically, five human tumor cells lines (lung, colon, brain, breast, and skin) and one normal cell line (fibroblasts) were tested in triplicate for each of an average of four experiments. Primordial sounds or hard rock music sounds were compared for their effects on cell growth. When primordial sounds were used, growth of cells with tumors significantly decreased the average growth across cell lines; on the other hand, when hard rock music was used, growth of cells with tumors significantly increased the average growth across cell lines, although the effect was not consistent(1).
- Sharma HM, Kauffman EM, & Stephens RE: Effect of different sounds on growth of human cancer cell lines in vitro. Altern Ther Clin Pract 3(4):25-32.
A 1983 study shows that there may be a difference in the effects of live vs. tape-recorded music on hospitalized cancer patients(2). This factor may affect future programs of music in the hospital environment. Music may mitigate the effects of nausea and emesis of patients undergoing chemotherapy(3). The idea of using music listening for palliative purposes during treatment of cancer patients dates back to 1948, University of Chicago hospital, where the use of music in the surgical suite was also used specifically for patients under local, regional, and spinal anesthesia(4).
- Bailey L: The effects of live versus tape-recorded music on hospitalized cancer patients. Mus Ther 3(17-28), 1983.
- Standley J: Clinical applications of music and chemotherapy: The effects on nausea and emesis. Mus Ther Perspect 10:27-35, 1992.
- Pratt RR: The historical relationship between music and medicine. In RR Pratt (ed). The third international symposium on music in medicine, education, and therapy for the handicapped (p. 264). Lapham, MD: University Press of America.
Music may also affect children with preoperative anxiety(5). Thirty-three premature infants (chosen with exclusionary criteria) in an intensive care unit were exposed to 4 days of a randomly ordered 3-part intervention of sung or spoken lullabies, sung by either a male or female voice. These infants were carefully compared by two neonatologists and a physician/statistician with 33 infants in the same unit who did not experience the music. The 33 infants who listened to the sung and spoken lullabies left the unit nearly 3 days sooner than their counterparts in the control group(6)
- Chetta H: The effect of music and desensitization on preoperative anxiety in children. J of Mus Ther: 18-100, 1981.
- Coleman JM, Pratt RR, Stoddard, RA, Gerstmann D, & Abel H-H: The effects of the male and female singing voices on selected physiological and behavioral measures of premature infants in the intensive care unity. IJAM 5(2): 4-11, 1994.
A study in 1997 showed that selected music can have a self-perceived stress reduction benefit for visitors in hospital surgery/intensive care unit waiting rooms. Implications for supervisors and healthcare personnel are discussed in the study(7).
- Rothieaux RL: The benefits of music in hospital waiting rooms. Health Care Surgery 16(2): 31-40, 1997.
Asthma symptoms may be revealed in children's illness drawings(8). Children's drawings may also be a way to reveal a child's response to cancer(9)
- Gabriels R., Wamboldt M, McCormick D, Adams T, & McTaggart S: Children's illness drawings and asthma symptom awareness. J of Asthma 37(7): 565-574.
- Rollins J: Childhood cancer: Siblings draw and tell. Ped Nurs 16(1): 21-27, 1990.
Directed visual arts activities can play a role in the behavior of children with disabilities(10).
- Banks S, Davis P, Howard V, & McLaughlin T: The effects of directed art activities on the behavior of young children with disabilities: A multi-element
baseline analysis. Art Ther: J of the AATA 10(4): 235-240, 1993.
Relaxation and distraction can reduce stress and anxiety during dental procedures. These effects may be measured by salivary IgA, self-report, or other measures of tension and stress(11), (12).
- Corah NL, Gates EN, & Illig SJ: The use of relaxation and distraction to reduce psychological stress during dental procedures. J. Am Dental Assoc 98: 390-394, 1979;
- Goff LC, & Pratt RR: Music listening and S-IgA levels in patients undergoing a dental procedure. IJAM 5(2): 22-26, 1997.
A 1999 collaborative study at Duke University looked at the effect of using art, with or without privacy, to help patients relax during the venipuncture procedure to decrease their perception of pain. Results were inconclusive although the study raises some important questions about the effects of color on culture, personality, biology, genetics, learning, and experience. Another point is determining of criteria for art work selection(13).
- Palmer J, Schanberg L, Taylor C., et al.: The effect of art on venipuncture induced stress. Presented at SAH conference on Diabetes 2, April 2002, Durham, NC.
The medical literature shows little controlled research supporting the benefits of art in the healthcare environment. The Center for Health Design advocates the inclusion of design guidelines in requirements established by the Joint Commission on Accreditation of Healthcare Organizations The Center and the Picker Institute have sponsored investigative studies that address patients' and families' perceptions of care of high quality(14).
- Rubin, H.R and Owens, AC. A Concept Paper to Develop a Research Agenda to Determine the Effects of the Healthcare Environment on Patients' Health Outcomes. The Center for Health Design. 1995.
Another study compared the effects of photographs of nature scenes, computer-generated abstract art, a blank panel, or nothing on heart surgery patients. Less postoperative anxiety was experienced by patients who looked at a picture of open water with trees(15).
- Ulrich R. The effects of photographs of nature scenes, computer-generated abstract art, a blank panel, or nothing on heart surgery patients. Presented at the Conference of the Society for the Arts in Healthcare on Diabetes and the Arts, 2002.
The literature shows that most of the experimental research about dance and movement has been done in the art therapy field. Nevertheless, this research makes points that are applicable to the arts in healthcare movement. For example, an annotated bibliography of dance/movement therapy shows the range of disorders that can be addressed by dance and movement, including adolescent illnesses, anxiety, childhood illnesses, eating disorders, family, geriatrics, mood disorders, neuroses, personality disorders, physical and sexual abuse, schizophrenia, somatic disorders, substance abuse, and traumatic brain injury. The bibliography covers studies from 1940 to 1990(16).
- Fledderjohn H, & Sewickley J: An annotated bibliography of dance/movement therapy. Columbia, MD: American Dance Therapy Association, 1993.
Inactivity is one leading cause of morbidity among older people. On the other hand, movement and exercise promote an active and productive lifestyle. The Oxford Health Plans of New York are one group that offers cost-effective programs to elderly people, including Tai Chi, which is in the Range of Motion Dance Program(17).
- Scott AH, Butin DN, Tewfik D, et al.: Occupational therapy as a means to wellness with the elderly. Phys & Occup Ther in Geriatrics 18(4): 3-22, 2001.
In the January 2002 issue of the Journal of Advanced Nursing, a systematic review of studies about the effectiveness of music as an intervention for hospital patients concluded that music is appropriately used during normal care procedures. Since the cost is relatively inexpensive and there are no contraindications reported, music is recommended as an adjunct to normal care practices(18).
- Evans D: The effectiveness of music as an intervention for hospital patients: A systematic review. J Adv Nurs 37(1): 8-18, 2002.
An article in a 2001 issue of the medical journal Lancet comments that medical settings can foster the creation of art(19).
- Foster H: Medical settings foster the creation of art. Lancet 357(9268): 1627, 2001.
Patient response -- Children
The drawings of children between the ages of 5 and 12 can help a child health professional assess and monitor emotional and developmental progress during an illness or hospitalization. Known as the Ipsative Method, psychosocial adjustment and coping are assessed using the child's own drawings as a standard for comparison. There are guidelines available for this technique(20)
- Rae WA: analyzing drawing of children who are physically ill and hospitalized, using the ipsative method. Children's Health Care 20(4): 198-207, 1991.
Healing Icons is an art support program for patients with cancer who are 16 and older. In the program, patients create a three-dimensional mixed-media art piece to convey a unique personal perspective on receiving a diagnosis of cancer and then experiencing treatments. Healing Icons provides a way for unstructured expression of feelings and thoughts participants, families, and staff in a cancer center have reported positive clinical evaluations(21).
- Heiney SP, & Darr-Hope H: Healing Icons: Art support program for patients with cancer 7(4): 1 chart, 1 bw, 1999.
Another important factor in assessment is found in children's human figure drawings, which can convey their feelings of being prepared as well as their anxiety about surgery. EIs (emotional indicators) of children, aged 4-12 years, increased only in those children who were both unprepared and anxious(22).
- Sturner RA, & Rothbaum F: The effects of stress on children's human figure drawings. J. Clin Psych 36(1): 324-331, 1980.
Music, storytelling, and humor are increasingly recognized by the nursing profession as appropriate and effective interventions to help children cope with illness, hospitalization, and pain. These interventions may help children talk about emotional issues raised during hospitalization(23).
- Grimm DL, & Pefley PT: Opening doors for the child "inside." Ped Nurs 16(4): 368-369, 1990.
Patient response - Adults
Patient biographies have become more valuable in recent years particularly in the care of older people. Nurses who share an interest in the arts with a patient can build a relationship through the art medium itself, using it to help a patient tell his or her life story and find a place of connection with a caregiver(24).
- Penn B: Using patient biography to promote holistic care. Nurs Times 90(45): 35-36, 1994.
When the elderly are taught how to use relaxation, imagery, music, or any of the arts, their sympathetic response to stress is reduced and the calming effect of the parasympathetic system takes over. Gerontological nurses can incorporate the arts and other kinds of alternative methods into innovative preventive and wellness-oriented programs for hospitals, clinics and communities(25).
- Dossey BM: Complementary and alternative therapies for our aging societies. J. Gerontol Nurs 23(9): 45-51, 1997.
Pain associated postoperative pain may be managed by nonpharmacological means as well as prescribed medications. After hospital discharge, many cancer patients must provide their own self-care, using suggestions from healthcare providers and independently developed plans for pain management. In a 2001 study, postsurgical cancer patients increased their use of relaxation strategies that included imagery and music. The study suggests that nurses in cancer units may benefit from learning about teaching similar strategies to heir patients(26).
- Kwekkeboom KL: Pain management strategies used by patients with breast and gynecological cancer with postoperative pain. Cancer Nurs 24(5): 378-386, 2001
Patients with life-threatening illnesses such as cancer may engage in art activities in order to mourn, grieve, and celebrate life. The arts also empower patients to endure painful treatment and post-treatment conditions, and to find healing and meaning in their experience. Artists can be part of an interdisciplinary team in which art has been incorporated into cancer patient care as well as the cancer unit setting(27).
- Bailey SS: The arts in spiritual care. Semin Oncol Nurs 13(4): 242-247, 1997.
Nature photography is recommended for use in a hospital. Color photography, when coupled with nature, can be a healing medium on conscious and subliminal levels. Reproductions of scenes in nature can emit a healing energy(28).
- Oberlander R: Beauty in a hospital aids the cure. Hospitals 53(6): 89-92, 1979.
The year 2000 International Conference on Health and Design, held in Stockholm, proposed the theory that physical environment affects well-being. The conference was a forum for physicians, health planners and architects to discuss the quality of hospital design(29).
- Martin C: Putting patients first: Integrating hospital design and care 356(9228): 518, 2000.
Integration of indoors with the outdoors is a trend in healthcare facility design. The 12 winning facilities in a design award competition sponsored by Modern Healthcare featured indoor courtyards and gardens. The healing role of nature is now emphasized in healthcare building design(30).
- Pinto C: Going natural by design. Annual design awards show facilities are emphasizing integration of the indoors with the outdoors. Mod Healthc 26(45): 39-42, 1996.
In a study of 120 undergraduates, a videotape of different outdoor natural vs. urban settings was presented. Data concerning stress recovery during the presentations were obtained by self-ratings of affective states and physiological measures. Recovery was faster and more complete when participants were exposed to the natural rather than the urban environments. Concerning cardiac response, there was a pattern that showed a strong parasympathetic component to the responses to the natural but not to the urban environments. These results reinforce Ulrich's psychoevolutionary theory that restorative influences of exposure to nature involve a shift toward a more positively toned emotional state(31).
- Ulrich RS: Stress recovery during exposure to natural and urban environments. J of Environ Psych 11(3): 201-230, 1991.
In the year 2001, the magazine Modern Healthcare focused on hospital healing gardens in the United States. Background information is given on the Good Samaritan Regional Medical Center in Phoenix, the Medical University of South Carolina in Charleston, and the St. Francis Hospital in Milwaukee. Some facilities incorporate wooded areas in the hospital grounds(32).
- Tieman J: Healing through nature. Mod Healthc 31(2): 34-35, 2001.
Twenty-four papers about innovations in healthcare design, presented at Center for Health Design symposia since 1988, have been republished, updated, and enhanced with 29 color plates. The designs emphasize innovation, cover new design possibilities, and focus on sensitive approaches, patient-focused care, design impact, therapeutic outcomes, and design technologies. Examples from pediatric and long-term care facilities, hospitals, and medical offices are given(33).
- Marberry SO: Innovations in healthcare design. New York: John Wiley, 1995.
In 1999, the World Symposium on Culture, Health, and the Arts was held at Manchester Metropolitan University. Participants discussed the effects of art on medical outcomes, therapeutic benefits of landscapes and gardens in a report to the Journal of the American Medical Association(34).
- Friedrich MJ: The arts of healing. JAMA 281(19): 1779-1781, 1999; The Manchester Conference, held in April 1999 at the Metropolitan University in England, was called "Culture, Health, and the Arts World Symposium."
According to the American Journal of Maternal/Child Nursing, nurses must be prepared to offer new treatment methods when caring for children. Nurses need to be more familiar with human caring theory as well as complementary and alternative medicine and ways to integrate them into general care. A "Nurse's Tool Box" is suggested in which materials for drawing, storytelling, music, and humor are included. The article advises nurses that, by using these tools, they can mend children in ways they never have before(35).
- Ward SL: Caring and healing in the 21st century. Am J of Matern/Child Nurs 23(4): 210- 215, 1998
Performance Arts Medicine is an important part of modern medical practice. PAMA, the Performing Arts Medicine Association, publishes a journal and conducts conferences regularly. Performance Arts Medicine Clinics, such as the Cleveland Clinic and the Miller Clinic, specialize in injuries of dancers, instrumentalists and vocalists. Performance medicine specialists also practice privately, especially in urban areas in which there is a high concentration of artists. The Alexander Technique, Pilates, and Feldenkrais
are used both for preventive measures as well as curative purposes(36).
- Performance Medicine Web sites are available with more information for professional artists and nonprofessionals.
Performance arts majors appear to have important unmet health needs. A questionnaire was administered to 71 college students enrolled in dance, drama, and musical theater programs to assess health care problems, injuries, risk-taking behaviors, and sources of care. Many students reported a desire for help with depression, fatigue, and chronic bone or joint pain. Thirty-seven percent did not report a regular physician; 39 students reported 87 injuries involving the back, foot, ankle, and knee; 12% reported sustained injuries that occurred at least on a monthly basis; 72% of injuries occurred in class. Although eating disorders were not highly reported, alcohol use was reported by 71%(37).
- Werner MJ: Medical needs of performing arts students. J. Adolesc Health 12(4): 294-300, 1991
Researcher and Editor: Rosalie Rebollo Pratt, Vice-President, International Society for Music in Medicine; Director, Research & Development, Music Health Institute, West Plains,
Contributors: Janice Palmer, Founding Director, Cultural Services Program, Duke University
Medical Center, Durham, NC
Amy Hamblin, Director, Art Program, University of
Washington Medical Center, Seattle, WA