January/February 2019

Nursing: Arts in Health Care: A Powerful Nursing Intervention
By Mark D. Coggins, PharmD, BCGP, FASCP
Today's Geriatric Medicine
Vol. 12 No. 1 P. 8

A renaissance of the arts is taking place in health care settings across the world. Arts in health care is a movement aimed at transforming the health care experience by connecting people with the power of arts at key moments in their lives.1

The arts have a positive effect on health and well-being during times of good health and illness. Positive outcomes are associated with participation in all types of arts, including the visual arts, crafts, dance, film, literature, music and singing, the culinary arts, and other creative activities.1,2

Arts programs are flourishing in hospitals, outpatient programs, hospices, nursing and retirement facilities, and community settings. Nurses and other health care professionals are using the power of the arts to reduce patients' pain and anxiety while shortening hospital stays, reducing the need for medication, and lowering rates of complications.1 Furthermore, the arts provide additional benefits of helping to reduce nurse stress and burnout and improve job satisfaction.1

History of Arts in Medicine
The healing power of the arts has been documented throughout history.3 Pythagoras (c. 570 BC), a philosopher, mathematician, and musician, is often referred to as the father of music therapy.4 He reportedly treated many ailments of the spirit, soul, and body by having certain specially prepared musical compositions played in the presence of the sufferer or by personally reciting short selections from such early poets as Hesiod and Homer.

The use of the arts as a nursing intervention dates back to Florence Nightingale and her nurses who used music during the Crimean War to assist with the physical, spiritual, and emotional healing of sick and wounded soldiers. Specifically, they used voice and flute melodies to help reduce pain and to soothe, calm, and comfort their patients. Nightingale thought of music as an auditory modality that nurses could use to control the environment to enhance healing.5

Nightingale also understood the value of the visual arts in healing, noting, "People say the effect is only on the mind. It is no such thing. The effect is on the body, too. Little as we know about the way in which we are affected by form, by color, and light, we do know this: that they have an actual physical effect. Variety of form and brilliancy of color in the objects presented to patients are actual means of recovery."6

A Modern-Day Nursing Intervention
The use of the arts is also a modern-day nursing intervention. The physiological effects of music and the arts on patient heart rate, blood pressure, respiratory rate, oxygen saturation, skin temperature, pain, anxiety level, and mood states have been well studied.7

Interventions using the creative arts have been applied to a vast array of health issues—from posttraumatic stress disorder to autism, mental health, chronic illnesses, Alzheimer's and dementia, neurological disorders and brain injuries, premature infants, and physical disabilities—to improve patients' overall health outcomes, treatment compliance, and quality of life.1

Pain and Anxiety
Music has the ability to produce a number of positive changes in behaviors, emotions, and physiology. Music therapy and interventions have been found to be especially useful in helping to reduce anxiety and pain.

One large study demonstrated that listening to music is more effective than a sedative for reducing preoperative anxiety and equally effective in reducing physiological responses.8 In a study of self-reported pain, cancer patients identified statistically significant lower scores on the Pain Visual Analog Scale for subjects who listened to music.9

In the palliative care environment, researchers have found that music therapy reduces anxiety, pain, tiredness, and drowsiness, and increases well-being.2

Stroke and Brain Injury
Several studies have shown that listening to music soon after a stroke can speed recovery by activating regions of the brain responsible for attention, motor function, memory, and emotional processing.2,10

In one study, researchers randomly assigned stroke patients to a music listening, language, or control group. Over two months, patients in the music group self-selected any music genre—eg, pop, classical, jazz, or folk—and listened daily while the language group listened to audio books and the control group received no listening materials. Verbal memory improved from the first week poststroke by 60% in the music group, by 18% in the language group, and by 29% in the nonlistening control group. Focus attention, or the ability to control and perform mental operations and resolve conflicts, improved by 17% in music listeners while there was no improvement observed in the language and control groups. Patients from the music group also experienced less depression and confusion than did patients in the control group.11

Other studies have shown that singing and attendance at live concerts are beneficial in stroke recovery. Singing in a community choir increased confidence and motivation, enhanced movement, and improved communication in stroke patients with aphasia.2,10 A Cochrane review of studies combining music therapy with standard care—on its own or in combination with other therapies—also found that rhythmic auditory stimulation improved the speed, rhythm, stride length, and symmetry of patients' gait following an acquired brain injury.

Mental Illness
Adults experiencing mild to moderate mental illness received weekly 90-minute group drumming sessions over six or 10 weeks. Without having any specific therapeutic aims, the facilitator increased the complexity of the activity over time.

A mixed-methods evaluation used a range of psychological scales, interviews, blood pressure tests, and saliva analyses. During single sessions, stress and tiredness significantly decreased, and happiness, relaxation, and energy levels increased.

Over the course of the study, group drumming led to reductions in cortisol and an enhancement of immune responses, as well as a reduction in inflammatory activity over a six-week span and the activation of an anti-inflammatory response over 10 weeks.2

Dementia Care
Music interventions can be helpful in managing many of the behavioral problems commonly seen in dementia. Playing familiar songs can help reduce anxiety in dementia patients. Music can change the focus of attention and provide an interpretable stimulus that elicits positive memories from an earlier period in the person's life, which could prevent or alleviate anxiety or agitation.12

The therapeutic use of music and/or dancing may be offered to persons with all types and severities of dementia who also experience agitation. Weekly two-hour music sessions—involving listening, singing, playing percussion instruments, and composing—shortened the length of stay (by 6.2%), reduced the number of falls (from 47 to 31), and decreased the use of antipsychotic drugs (by 4.26% during the intervention and by 27.7% on music days).2

Music interventions also have been shown to do the following1:

• decrease anxiety before surgery;

• improve patient's comfort level after surgery;

• decrease sedative use during procedures;

• improve depression, anxiety, and relationships in psychiatric patients;

• reduce heart rate and blood pressure in persons with coronary heart disease;

• increase quality and length of life for individuals diagnosed with terminal cancer;

• decrease anxiety, depression, and mood disturbances in patients undergoing stem cell transplants;

• lower the heart rates, respiratory rates, and myocardial oxygen demand for patients recovering from myocardial infarction;

• reduce pain during intramuscular injection, during bone marrow aspiration, after surgery, and that associated with serious illness;

• reduce the perception of pain in people with rheumatoid arthritis;

• reduce nausea and vomiting in adults undergoing bone marrow transplant treatments;

• decrease anxiety in patients who listened to music in ICUs;

• induce relaxation during cardiac catheterization; and

• increase salivary immunoglobulin A, an antibody that provides defense against various infections.

The visual arts or art therapy also have documented benefits, including the following2:

• decreased symptoms of distress and improving quality of life for women with cancer;

• improvement in depression and fatigue levels in cancer patients on chemotherapy;

• reduction of acute stress symptoms in pediatric trauma patients;

• increased support, psychological strength, and the formulation of new insights in cancer patients; and

• strengthened positive feelings, reduction in distress, and clarification about existential/spiritual issues for adult bone marrow transplant patients in isolation.

Benefits to Nurses and Other Caregivers
In addition to supporting the physical, mental, and emotional recovery of patients, the arts can be healing to nurses and other health care team members as well. Studies have shown that integrating the arts into health care settings helps to cultivate a healing environment for patients and a positive environment for caregivers that reduces stress and improves workplace satisfaction and employee retention.

Furthermore, the availability of an active arts program integrated into the health care environment has been found to be a major consideration for health care staff when seeking employment or considering whether to remain in their current positions.1 Workplace stress is a significant cause for turnover, burnout, and absence from work. A study of emergency service workers found that attending cultural events during leisure time—concerts, ballet, theater, and museums—improved physical health.2

A study involving nursing staff participating in silk-screen painting demonstrated significant benefits. Participants felt an increased belonging to the community, had more energy, were able to concentrate and better maintain attention, were better able to relax after work, and felt loved more often than did those who did not participate.

Furthermore, after the art activities, the intervention group participants indicated they felt less nervous, more calm, happier, and more peaceful. They noted that participation in the art activities made their lives more meaningful while improving their ability to resolve work-related problems.

Following the study, 93% of the nurses in the intervention group noted they enjoyed art activities more, with 75% wanting to continue silk painting in the future. The majority of the intervention group reported that the art activities had a positive impact on work-related stress, general health and well-being, mood/sense of happiness, work-related fatigue (both physical and mental), work productivity, and a sense of community with others. Nearly two-thirds of the intervention group members wanted to attend various art events more often than they used to.

The range of positive emotions experienced by nursing staff in the intervention group was expressed as inspiring, enjoyable, exciting, and conducive to community building. The nurse participants stated they felt happy and relaxed throughout their engagement in arts activity. No negative experiences of the participation in arts activity were stated.10

Of additional interest is that a survey in the United Kingdom found that one in seven adults admit to coloring at work. The survey found that 80% said coloring relieves stress, 68% said it makes them more productive, and 30% would like to see more workplaces promote such activities.13

— Mark D. Coggins, PharmD, BCGP, FASCP, is vice president pharmacy services and medication management for skilled nursing centers operated by Diversicare in 10 states and is a past director on the board of the American Society of Consultant Pharmacists. He was nationally recognized by the Commission for Certification in Geriatric Pharmacy with the 2010 Excellence in Geriatric Pharmacy Practice Award.

References
1. The Society for the Arts in Healthcare. State of the field report: arts in healthcare 2009. https://www.americansforthearts.org/sites/default/files/pdf/get_involved/advocacy/research/2014/
arts_in_healthcare.pdf. Published 2009.

2. Howarth L. Creative health: the arts for health and wellbeing. Perspect Public Health. 2018;138(1):26-27.

3. Earliest references to music therapy. The History of Music and Art Therapy website. http://musicandarttherapy.umwblogs.org/music-therapy/earliest-references-to-music-therapy/

4. Pythagoras. Delamora Transformational Experiences website. https://www.delamora.life/pythagoras/

5. Poopla MM. Holistic and complementary therapies. https://www.ce-express.com/Portals/11/pdfs/N1675.pdf

6. Nightingale F. Notes on Nursing: What It Is, and What It Is Not. New York: Dover Publications; 1969.

7. Bradt J, Dileo C. Music for stress and anxiety reduction in coronary heart disease patients. Cochrane Database Syst Rev. 2009;(2):CD006577.

8. Bradt J, Dileo C, Shim M. Music interventions for preoperative anxiety. Cochrane Database Syst Rev. 2013;(6):CD006908.

9. Krishnaswamy P, Nair S. Effect of music therapy on pain and anxiety levels of cancer patients: a pilot study. Indian J Palliat Care. 2016;22(3):307-311.

10. Karpavičiūtė, Macijauskienė. The impact of arts activity on nursing staff well-being: an intervention in the workplace. Int J Environ Res Public Health. 2016;13(4):435.

11. Särkämö T, Tervaniemi M, Laitinen S, et al. Music listening enhances cognitive recovery and mood after middle cerebral artery stroke. Brain. 2008;131(Pt 3):866-876.

12. de Oliveira AM, Radanovic M, de Mello PC, et al. Nonpharmacological interventions to reduce behavioral and psychological symptoms of dementia: a systematic review. Biomed Res Int. 2015;2015:218980.

13. Leeming R. Nearly one in seven adults now use colouring books in the workplace. HR Review. April 15, 2016. http://www.hrreview.co.uk/hr-news/wellbeing-news/nearly-one-seven-adults-now-use-colouring-books-workplace/61906