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Nurses can play an important role in the planning, interior design, and decor of hospices. The role of nurses in the selection of art for hospices has not been documented previously. It is important for all nurses to advocate for their terminally ill patients by ensuring environments of care that promote privacy, comfort, are aesthetically pleasing and appropriate for dying patients and their families. Researchers have found that certain types of art may negatively impact patients and families. It is prudent, then, for nurses to consider the use of art to enhance the bedroom environments of dying patients, where patients will most likely spend their final moments of life.
Hathorn states, "In 2001 I watched as my mother died at the age of 91 years. Racked with pain and unable to speak virtually all day, she looked at the picture at the foot of her bed and said, "That's such a pretty picture." She said it not once, but twice that afternoon. The image, with its winding path and rays of sunlight filtering through the trees, obviously meant something to her and seemed to give her comfort. Art has the ability to touch us deeply, and profoundly, in our most vulnerable moments. It serves as a focal point in the environment that we are confined in, which can offer an emotional escape."1 We are often quick to dismiss such a minute part of the environment; yet, when the patient scans around his or her surroundings, it is this focal point that often the eyes and the mind rest upon. It is up to us, as designers, to make this rest restorative." Nurses can play an important role in the planning, interior design, and decor of hospices. The role of nurses in the selection of artwork as decor for hospices has not been documented previously. It is important for nurses to advocate for their terminally ill patients by ensuring environments of care that promote privacy and comfort and are aesthetically pleasing and appropriate for dying patients and their families. One of these ways is for nurses to participate in the selection of appropriate colors, lighting, design, furniture, and decor, including art.
The most prominent precursor to the art initiative in hospitals today is Florence Nightingale who, in her Notes on Nursing, described the patients' need for beauty and making the argument that the effect of beauty is not only on the mind, but on the body as well.2 Since then, art continues to have a growing presence in health care environments. During the depression, artists were put to work painting murals in US Hospitals. In the 1970-1980s, US hospitals began to decorate with art, but without consideration to the therapeutic benefit of art. Beginning in the early 1990s, a new interest in therapeutic environments generated the belief that art is intended to contribute more than decorative value to health care environments. Today, there is a shift to more rigorous evidence-based designs, which is both the process and product of scientific analyses of health care environments.3
Interior designers have had a long history of using evidence-based approaches in designing and planning art for use in health care settings. Numerous evidence-based studies have revealed recurring qualities that characterize positive and negative choices of artwork for health care environments.1 With these characteristics in mind, and considering the unique needs of patients at the end of life, we predict that the use of artwork in hospice settings may not be entirely positive. This article reviews artwork typically used in hospices and end-of-life health care environments and briefly considers the nursing opportunities for the therapeutic use of art in end-of-life care. Finally, this article identifies the advocacy role of the nurse in making recommendations for use of art in hospice settings that creates a calming, peaceful, and therapeutic environment of care for dying patients and their families.
Health outcomes can be impacted by viewing different types of art in health care settings. Robert Ulrich,4 director of the Center for Health Systems and Design at Texas A&M University, produced groundbreaking research that found viewing natural scenes in a hospital aids stress recovery by evoking positive feelings, reducing negative emotions, and blocking or reducing stressful thoughts. According to Ulrich,4 when exposed to nature scenes measures of health outcomes improved. These clinical indicators included blood pressure and pain, patient/family satisfaction, length of stay, and economic outcomes. Other researchers found that when people view scenes that are universally preferred such as a beautiful vista, a sunset, or a grove of trees, the brain activates an opiate-rich pathway, creating a natural morphine-like high.5 Ulrich et al6 found that patients who viewed pictures of nature used weaker painkillers than those who viewed abstract art or nothing.
Researchers have found that blood pressure declined within 3 minutes of showing a nature picture7; in addition, researchers have found that showing nature images to patients with Alzheimer disease reduced aggression and agitated behavior.8 In terms of satisfaction, a case study using the above design criteria resulted in 90% of patients and visitors rating the hospital as good or very good.1 Comments from the study described the artwork as deinstitutionalizing the hospital, giving comfort, cheering and uplifting, ridding of anxiety, and contributing to higher perceptions of overall quality of care. One researcher found that nature images produced lower blood pressure than did arousing pictures such as a sailboat in the wind or a dramatic seascape, even though "the arousing pictures were rated as aesthetically pleasing" (R. G. Coss, Picture Perception and Patient Stress: A Study of Anxiety Reduction and Postoperative Stability [unpublished paper]. Department of Psychology, University of California, Davis; 1990).
Hathorn and Nanda1 conducted a postoccupancy study of criterion-based art selections for the Mays Clinic at the MD Anderson Cancer Center.1 An on-site questionnaire was administered with 210 patients and visitors, and an online questionnaire was administered with 240 staff members. When asked about the role of art, patients and visitors mentioned that it served as a distraction, diminished the institutional character of the hospital, gave comfort, was cheering and uplifting, reduced anxiety, and contributed to the overall quality of care. Of the total comments, 89% were positive, and 9% were negative. Staff were also asked to rate the artwork. Seventy-nine percent of the comments were positive, 7% were negative, and 14% had no opinion. Positive comments included serving as a distraction for patients, setting the mood, promoting conversation among patients, inspiring trust, deinstitutionalizing the hospital, affording an escape from immediate surroundings, and being soothing, relaxing, and comforting. Table 1 summarizes recommendations for selecting art for health care settings.
Two different theoretical perspectives, biophilia and emotional congruence, are helpful in understanding why certain types of art have been found effective in improving health outcomes. Biologist E. O. Wilson9 hypothesized the existence of biophilia as "the innately emotional affiliation of human beings to other living organisms." Biophilia proposes that millions of years of evolution have left modern humans with a genetic predisposition to respond positively to nature settings that fostered well-being and survival for early humans. Biophilia theory predicts that nature art will promote restoration across diverse population groups if it contains features and properties such as calm or slowly moving water; verdant foliage; flowers; foreground spatial openness; park-like or savannah-like properties such as scattered trees, grassy, and understory; and birds, deer, and other nondangerous wildlife. In addition to nature art, humans may be genetically predisposed to pay attention to and be positively affected by images of smiling or caring human faces. Biophilia theory may be useful for identification of features and subject matter that should be avoided when selecting art for stressed patients such as those in hospice. Biophilia theory suggests that humans tend to respond negatively with reactions such as stress, fear, and avoidance behaviors to natural elements and situations that have signaled threats or dangers throughout evolution. These disturbing and often stressful stimuli include but not are limited to reptilian images such as snakes and spiders, nearby large mammals staring directly at the viewer, pointed or piercing forms, shadowy enclosed spaces, and angry human faces.10
In addition to biophilia theory, another perspective provides a possible explanation for understanding patient responses to health care art and provides evidence to support appropriate art selections for hospice. Emotional congruence theory suggests that our emotional states bias our perception of environmental stimuli in ways that match our feelings.11 Emotional congruence theory suggests that happy or pleasant feelings are likely to promote happy or positive associations and memories, whereas fearful feelings will cue anxious or fearful associations. An important implication for the selection of art for hospices is that patients tend to perceive, interpret, and have associations with art in ways that match their emotional states or feelings.11 This link implies that, in a stressful health care environment, negative emotions are likely to be projected on to the surrounding environment. Risks associated with inappropriate artwork selections may be both emotional and physical. Ambiguous art, or art where the content is subject to interpretation by the viewer, should be avoided. In the emotionally charged atmosphere of a hospice, ambiguous artwork may tap into the most easily available emotions. The popular use of abstract art therefore may pose a possible threat to the well-being of both patients, families, and caregivers. This also may explain the adverse reaction to art described in research studies.1,4,6,8 Researchers have found that "material with tone that is congruent with current mood is most easily retrieved from memory."11,12 Ulrich and Gilpin10 reported on an art installation that was intended as therapeutic but in fact triggered emotionally charged memories causing patient agitation and distress. The installation was removed for medical and ethical reasons. Ambiguous art may increase delirium, trigger fear and anxiety, or cause resurfacing of traumatic memories when patients continuously view such art from their deathbeds.
Patients at the end of life face a critical step of letting go. Byock13 talks about the 5 steps in dying well: "I forgive you," "forgive me," "thank you," "I love you," and "goodbye." Healing involves talking about feelings and forgiveness of self and others. Grassman14 added 2 more steps, "let go" and "open up," because she believes they complete the purpose for saying the first 5. Finding inner peace is critical for a good death.15 (Grassman D. Wounded Warriors: Their Last Battle [PowerPoint presentation]. West Palm Beach Veterans Affairs Medical Center, National Hospice Month Presentation; 2008). Hospice nurses can play a critical role in assisting their dying patients to heal emotionally and experience a peaceful death through use of art. Nurses must remain prudent when considering appropriate artwork for hospices, especially art placed in the bedrooms, where patients usually spend their last moments of life.
Artworks positioned on the walls of hospitals, hospices, and community living centers are selected to promote feelings of comfort and provide positive distractions and soothing visualizations for patients, staff, and visitors. Tellis-Nyack16 recommended the use of art to promote a more homelike atmosphere and to decrease the institutional appearance of long-term-care environments. Christa Hijlo, PhD, RN, national director of VA Community Living Centers, notes that hospice patients may find comfort in viewing art depicting scenes of familiar locales (oral communication, December 23, 2011). Linda Neiber, senior national patient care administrator for VITAS Innovative Hospice Care, recommends use of culturally appropriate art selections (oral communication, December 27, 2011). She noted that pictures of the famous Viscaya Museum and the Miami Freedom Tower were selected by their staff for the new Miami Hospice unit, which caters to a large Cuban immigrant population. Great care and sensitivity to the population served should be applied when selecting hospice artwork.
The artwork is often a focal point and a memorable feature of the room for bedridden hospice patients. Harris et al17 found that the artworks on the walls were the most common room features remembered in terms of patient satisfaction and the second most common hospital feature overall. Martin18 raises the issue of (dying) patients' free choice. As they enter the active dying phase, hospice patients are usually confined to their beds and may be deprived of free choice in regard to their deathbed views. Depriving patients of free choice in this regard raises the ethical question of what art to display to "a captive population of vulnerable patients" (R. G. Coss, Picture Perception and Patient Stress: A Study of Anxiety Reduction and Postoperative Stability [unpublished paper]; Department of Psychology, University of California, Davis; 1990).19 Hathorn and Nanda1 especially urged consideration for the "needs of special patient populations [like those in] palliative care." The artwork on a hospice bedroom wall may be the last thing the patient sees before death. It is important then to ensure that artwork selected does not become a negative distraction. Ulrich19 defines a negative distraction in a health care setting as "environmental elements that assert their presence, are difficult to ignore, and are stressful." The first 2 qualities are given in a hospice setting because bedridden patients will inevitably focus on the artwork in a room. For many dying patients, as death approaches, they become more inwardly focused limiting their world to their bedroom. An important goal then is to choose artwork that promotes peace, does not create stress, and honors that "sacred space."20
Ulrich19 found that "arousing pictures that may be aesthetically pleasing to designers and health care staff can be stressful to anxious patients for whom calming stimulation is more psychologically supportive."1 An example of how minute details of artwork can mean different things for different populations can be seen in the pilot study conducted by Hathorn and Nanda,1 where savannah or park-like images such as scattered trees, grassy, and understory and birds, deer, and other nondangerous wildlife, normally therapeutic in other settings as outlined later, were found to be lonely and desolate for patients in long-term-care settings.1 Patients' needs should be carefully considered when selecting artwork for the hospice setting to ensure a peaceful and therapeutic environment.
Ulrich4 summarized evidence-based guidelines for selecting positive health care art. Artwork of nature figures appears prominently in the discussion. Landscapes are preferably open, lush, verdant, depicting warm seasons and "positive cultural artifacts" such as barns and old buildings. Waterscapes should be calm and not turbulent. Pictures of flowers should be fresh, not wilting, and of a type familiar to patients, not exotic. Concerning figurative art, it should contain sympathetic human faces and nurturing interactions. Art selections should convey a sense of security or safety with unambiguously positive subject matter.4 Carpman and Grant21 found that patients preferred pictures of nature over pictures of people. Lyons5 noted that "the primary criteria for restorative art are that we'd prefer to be inside those scenes." As patients view artwork with more instinct than rational thought, Ulrich4 suggested that viewers dislike "situations that have signaled threats or dangers throughout evolution." In terms of figurative art, Friedrich22 and Ekman et al23 found that the figures should have "unambiguously positive facial expressions and gestures that are caring or nurturing." Ulrich4 adds that the people should have "happy, laughing, or caring faces." It may be difficult to find art selections with these criteria (Table 2).
In turn, Ulrich4 describes negative artwork as ambiguous, emotionally provocative, surreal, claustrophobic, containing sharp edges, or having dark shadows. Ulrich4 found that caution should be exercised before displaying ambiguous, challenging art in patient spaces or high-stress waiting and treatment areas. Abstract artwork, characterized by ambiguity, is the major culprit for producing negative patient reactions. Ulrich conducted a study of psychiatric patients' response to art. The psychiatric unit was extensively furnished with a diverse collection of wall-mounted paintings and prints. Interviews with patients indicated strongly negative reaction to artwork that was ambiguous or surreal or could be interpreted in multiple ways. The same patients reported having positive feelings and associations with respect to nature paintings and prints. It is risky to decorate a hospice bedroom with art that is ambiguous or subject to interpretation or that has obvious negative connotations. Viewers, already stressed or in a negative emotional state, are likely to respond negatively to art that they cannot understand or that contains negative images. Ulrich et al24 noted this occurrence most significantly when patients in a psychiatric ward physically attacked certain abstract paintings over a period of 15 years. For patients with dementia, ambiguous artwork can "threaten whatever fragile[horizontal ellipsis]sense of order they retain." The use of medications for treatment of pain and anxiety with their potential for altering a patient's sensorium and perception of his/her environment raises the concern of appropriate art selection and placement of art in the view of a hospice patient's deathbed (Table 3).
Review of use of art in health care suggests a new opportunity for hospice nursing staff. Nurses can advocate for the well-being of their patients and families by the use of art as a therapeutic intervention in end-of-life care settings.
Two different theoretical perspectives, biophilia and emotional congruence, are helpful in understanding why certain types of art have been found effective in improving health outcomes. Biophilia theory predicts that nature art will promote restoration across diverse population groups if it contains features and properties such as calm or slowly moving water; verdant foliage; flowers; foreground spatial openness; park-like or savannah-like properties such as scattered trees, grassy, and understory; and birds, deer, and other nondangerous wildlife. Biophilia theory may be useful for identification of features and subject matter that should be avoided when selecting art for stressed patients such as those in hospice.
Emotional congruence theory suggests that happy or pleasant feelings are likely to promote happy or positive associations and memories, whereas fearful feelings will cue anxious or fearful associations. In a stressful health care environment, negative emotions are likely to be projected on to the surrounding environment. Emotional congruence theory suggests that our emotional states bias our perception of environmental stimuli in ways that match our feelings.22 An important implication for the selection of art for hospices is that patients tend to perceive, interpret, and have associations with art in ways that match their emotional states or feelings.22 Theories of biophilia and emotional congruence would predict caution regarding the instinctual and visceral, rather than rational, response to visual art. The effects of medications and the dying process itself may further compromise a dying person's ability to accurately interpret the environment, including art on the bedroom wall.
Nurses have demonstrative creative uses of art that promotes peace, serenity, and healing environments of care. Several nursing interventions are worthy of note. Use of wall art stencils depicting tranquil scenes of nature accompanied by words of hope and encouragement can be used. Construction of family photo collages highlighting the significant life events of patients' family history can stimulate life reviews and meaningful and sometimes forgotten memories. Donated art from volunteer artists, patients, and families can be incorporated into the decor. Hathorn and Nanda1 described an Art-Cart program where patients can choose their own room art from a traveling cart. Giving patients the "ability to decorate [their rooms]"25 fosters a sense of control, which is one of the principles of supportive design.24 As the bedroom and its art may be the last thing the patient sees before dying, this perceived sense of control is very important. Families have decorated their loved ones' hospice bedroom windows with removable plastic film window art, purchased at craft stores depicting seasonal decorations, creating a beautiful and inexpensive stained-glass-type effect. Hospice nurses have shown creative uses of art as a means to connect with patients and provide social support and comfort to hospice patients and their families.
Nursing input into the creative use and selection of art for hospices has not previously been reported in the literature. Like the design of a hospice itself, identification and selection of art for hospices can be challenging and complex. Nurses are rarely if at all provided such opportunities to participate in these nonclinical design activities. Nurses are in a unique position to make art selections that advocate for their patients while positively impacting the environment of care. Through use of art that evokes peace, comfort, tranquility, and healing, nurses can continue to intervene on their patients' behalf and impact positive change.
Recommendations identified by several authors support the need for careful selection of art for all health care environments but especially in end-of-life care settings such as hospices. In light of health care budget shortfalls, funding to obtain artwork that is aesthetically pleasing and appropriate for the decoration of hospices can be problematic but not impossible. Recognizing hospice funding limitations and rising to the challenge, the grant-funded "Art for Hospices Program" (Art for Hospices, electronic communication, 2012) is one funding source that donates art student paintings to hospitals, community living centers, and hospices across the United States. Art galleries, art therapy programs, and hospital volunteers and staff can also be rich sources for donated art. Nursing input into the selection of art for hospices, especially art selections for dying patients' bedrooms, should be made with concern for the impact such art has on the cultural, psychological, emotional, interpersonal, spiritual, and physical needs of the dying person and his/her family.
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