The impact of the arts in healthcare on patients and service users: A critical review

3.1.1 Contextual background

The 53 studies exploring the effects of music listening were undertaken across a number of different countries and clinical settings and utilised a range of qualitative and quantitative methodologies (Table 2). The majority (49/53) adopted quantitative methods, including pre- and post-study test designs, a range of tools and measures were used including the State-Trait Anxiety Inventory (STAI), Visual Anxiety Scale (VAS) and Hospital Anxiety and Depression Scale (HADS).

3.1.2 Emphasis on measurable effects and clinical outcomes

There were just four studies that were informed by a qualitative approach. Two of these studies were by the same lead author who applied semi-structured interviews to examine paediatric and adult cancer patients' views about music (O'Callaghan, Baron, Barry, & Dun, 2011; O'Callaghan et al., 2014). The exploratory study by Dennis (2011) examined the effects of music listening and caregiver singing during personal care for residents with dementia in a care home, while a mixed-methods approach was undertaken by Trangeberg and Stomberg (2013) who used semi-structured interviews and a quantitative anxiety scale to examine the effects of music listening on patients during anaesthesia.

The quantitative studies using a pre- and post-test study design compared and measured the degree of physiological change that occurred following a music listening intervention and/or the effects of music listening on patients/service users in relation to anxiety, stress and pain levels. Nineteen studies primarily assessed the effect of music listening on anxiety and stress in a variety of different clinical and therapeutic settings. For instance, Bae, Man Lim, Hur, and Lee (2014) investigated the effects of music listening on anxiety levels for patients undergoing regional anaesthesia for a range of surgical procedures. In contrast, Kipnis, Tabak, and Koton (2016) evaluated the effect of background music on preoperative anxiety in elective surgery patients, whereas Hsu, Chen, Chen, Tseng, and Lin (2016) examined the effects of music listening on anxiety levels for patients undergoing knee replacement.

Measuring the effect of music listening on pain management was the next most common focus with 11 studies studying this phenomena. However, while the focus across the studies was similar, the settings differed. For example, Guétin et al. (2012) examined the effects of music listening in the management of patients with chronic pain, whereas Jose, Verma, and Arora (2012) assessed the effectiveness of music listening for managing pain in cardiac surgery patients. A number of studies also examined the effect of music listening in relation to both anxiety and pain levels, Chlan et al. (2013) tested whether music listening reduced anxiety and sedative levels during ventilator support in critically ill patients, and Angioli et al. (2014) investigated the effects of music listening on anxiety and perception of pain during gynaecological procedures.

The remaining quantitative studies examined the effects of music listening in relation to healthcare. A number of studies looked at perceptions of care and/or patient satisfaction in a range of different context settings, from a perioperative setting to Accident and Emergency (Kilic et al., 2014; Mogos, Angard, Goldstein, & Beckstead, 2013). Length of hospital stay and the relationship between music listening was the focus of two studies, one in relation to patients on a ventilation machine (Szilagyi, Dioszeghy, Frituz, Gal, & Varga, 2014), and the other in relation to abdominal surgery patients (Vaajoki et al., 2012). Zhou, Li, Yan, Dang, and Wang (2011) also examined duration of hospital stay, along with depression rates for breast cancer patients after a mastectomy. Similarly, Travers and Bartlett (2011) evaluated a radio programme that broadcasted music relevant to residents in a residential care setting who grew up in the 1920s–1950s and looked at depression, quality of life and loneliness. However, Eggert et al. (2015) measured the effects of music and nature images on engagement for those diagnosed with dementia.

The findings from the music listening papers are discussed under the following headings: impact on anxiety, stress and pain; wider healthcare benefits; personally valued features of music listening; musical style and preferences; and tensions and limitations.

3.1.3 Impact of music listening on anxiety, stress and pain

The papers that explored anxiety, stress and pain in relation to music listening overwhelmingly reported positive outcomes, which in most cases were also statistically significant. For example, in examining the effect of music listening on anxiety and pain levels for women undergoing a hysteroscopy, Angioli et al. (2014) found women allocated to a music listening group during surgery experienced significantly lower anxiety after hysteroscopy and less pain during and after the procedure. Similar effects were also recorded over a longer timeframe, as Koca-Kutlu and Eren (2014) found when they examined the effects of music listening on patients during 12 sessions of haemodialysis. The authors report that the 30 patients in the music group displayed significantly lower pain and nausea scores than the 30 patients in the control group who did not listen to music.

A reduction in depression scores was also reported in a number of the reviewed papers. For example, Zhou et al. (2011) found, after a mastectomy, women in the music listening group had significantly lower depression scores than the control group. Likewise, Guétin et al. (2012), investigated the effects of music listening in the management of chronic pain, found the music group had significantly reduced anxiety and depression scores in comparison to the control group. Additionally, Schneider et al. (2015) reported evidence of strong positive effects on the quality of life of hospitalised patients who received live therapeutic harp music during the first 24 hr of their hospital stay.

There were also a number of positive significant effects reported in relation to physiological changes that are commonly associated with stress and anxiety. For example, Vaajoki et al. (2011) measured the effects of music listening on blood pressure, heart rate and respiratory rate in abdominal surgery patients. Music was played on the evening of the operation and on the first and second post-operative days. For those in the music group, respiratory rate and blood pressure was measured as significantly lower than the control group. Additionally, Lin, Lin, Huang, Hsu, and Lin (2011) found that VAS ratings for anxiety and pain were significantly lower for patients assigned to the music group for spine surgery than those who were not, and 1 hr after surgery, blood pressure was also significantly lower in the music group than the control group.

3.1.4 Wider healthcare benefits

There were a number of areas where music listening was described as potentially benefiting the wider healthcare system. One such area was in relation to patient satisfaction. In the study by Mogos et al. (2013), higher ratings for care were given by patients who had live music at the bedside in comparison to those who did not. Harp music vigils were also offered to terminally ill patients in the study by Ganzini, Rakoski, Cohn, and Mularski (2013), which involved family members completing a short survey in relation to observed effects and perceived benefits. From this, the authors report that music vigils have the potential to improve the patient and family member's experience of the dying process.

The cost-effective benefits of music listening were frequently identified in the reviewed papers, as the interventions were considered to be safe, inexpensive and largely easy to incorporate into the routine care of patients (Comeaux & Steele-Moses, 2013; Ganzini et al., 2013; Jimenez-Jimenez, Garcia-Escalona, Martin-Lopez, De Vera-Vera, & De Haro, 2013; Korhan et al., 2014; Kushnir, Friedman, Ehrenfeld, & Kushnir, 2012; Ozer, Ozlu, & Gunes, 2013; Trangeberg & Stomberg, 2013; Vaajoki, Pietilä, et al., 2011).

Further cost-effective benefits of music listening were in reducing hospital stays for patients. In the study by Zhou et al. (2011), duration of hospital stay was significantly shortened in the music group for breast cancer patients compared to the control group. Similarly, Szilagyi et al. (2014) reported that length of stay and time spent on a ventilator was significantly reduced in the study music group.

3.1.5 Personally valued features of music listening

There were only a small number of papers that considered music listening from a more exploratory and personalised study design. O'Callaghan et al. (2011) explored the relevance of music from the perspective of paediatric cancer patients. From the semi-structured interviews undertaken with children and their parents, the authors suggest that the adverse experiences of cancer are often alleviated by listening to music and that music has the potential to alleviate distress. Similar findings were echoed when O'Callaghan et al. (2014) examined adult cancer patients' views about music's role before and after diagnosis. The authors found that music was often used and adapted by many patients to ameliorate cancer's aversive effects. Patients spoke about how music provided emotional support that reduced their symptoms and strengthened their capacity to endure treatment, ongoing survival and impeding mortality.

In the paper by Dennis (2011), the effects of music listening and caregiver singing during personal care for residents with dementia were examined, music and singing were found to aid a reduction in the residents angry vocabulary, improved their diction and number of words used, and more eye contact was made with caregivers. Likewise, in the mixed-methods study, Trangeberg and Stomberg (2013) explored patients' experiences of music listening during anaesthesia, and music listening was found to offer patients a sense of calm and detachment from what was going on around them and was overall a positive, empowering experience.

3.1.6 Musical style and preferences

There were a few studies that examined attitudes towards music in the wider hospital setting. Overall patients responded positively and welcomed background music, recognising that it could improve mood and relieve pain (Kilic et al., 2014; Perez-Cruz et al., 2012). For those studies that examined the individual effects of music listening, the selection of music style was often made by the study investigators. Usually the music was slow in tempo; typically 60–80 beats per minute, such as traditional and classical music (Lee et al., 2012). There were a number of studies, however, that allowed patients to choose their own preferred music style (Jafari, Zeydi, Khani, Esmaeili, & Soleimani, 2012; Zhang et al., 2014), which was found to be of importance from the patient's perspective. Trangeberg and Stomberg (2013) found that to facilitate the positive effects music listening can have on the individual, it is important that the patient has the opportunity to select the music that is meaningful to them.

3.1.7 Tensions and limitations

The choice of music in many of the studies was chosen by the study investigators, who similarly all favoured a slow-tempo style. Consequently, there was very little consideration for individual preferences and likings. Indeed, very few studies provided any evidence to support their choice of slow-tempo music, which raises questions around the assumptive and accepted nature of this style of music.

Additionally, a number of studies investigated the effects of music listening on patients who were mechanically ventilated, most of whom were reported as being in a critical condition within an intensive care ward. It was not always clear in the papers the level of patients' consciousness and the extent to which they could consent to the intervention (Beaulieu-Boire et al., 2013; Chlan et al., 2013; Puggina, da Silva, & Santos, 2011; Szilagyi et al., 2014). In the study by Ganzini et al. (2013), assent was provided by family members to examine the benefits of harp vigils for terminally ill patients. However, Olischar, Shoemark, Holton, Weninger, and Hunt (2011), who examined the effect of music on the brain activity of newborns in relation to sleep cycles, made no references to ethical consent or assent. Overall, there was little or no discussion on the ethical issues in gaining consent or assent from patients in a critical condition. Often the only references made to ethics were the confirmation that ethics approval had been granted from the necessary approving boards.

At a broader descriptive level, there was an inconsistent use of terms, as a large number of the papers included incorrectly applied the term “music therapy” to the intervention of music listening (e.g. Jose et al., 2012; Korhan et al., 2014; Li, Zhou, Yan, Wang, & Zhang, 2011; Lin, Lu, Chen, & Chang, 2012; Lin et al., 2011; Liu & Petrini, 2015). In relation to patient outcomes, this may be inconsequential, but differentiation between “music listening” and “music therapy” is crucial to avoid blurring the processes between the therapeutic relationship and participation in the arts activity in and of itself. In a number of quantitative studies (e.g. Guétin et al., 2016; Jimenez-Jimenez et al., 2013; Korhan et al., 2014; Szilagyi et al., 2014), the small sample sizes of less than 40 participants also limits the generalisability of the findings.

3.2.1 Contextual background

As previously stated, the remaining 16 studies used a range of art forms. Five papers used singing and dance, and five used other arts activities, which ranged from music, dance and creative writing to poetry, ceramics and drawing. Four papers focused on the visual arts, and poetry and reading were the art forms used in the remaining two papers (see Table 3 for details).

Geographically, these 16 papers were drawn from fewer regions. The clinical and therapeutic setting where the different art form papers were undertaken also varied but the setting did not determine the art form used. For example, the art activity in the three mental health inpatient setting papers included music, drama and painting and dance (see Table 3).

3.2.2 Emphasis on evaluation of the art form intervention

The focus for the majority of the different art form papers were concerned with evaluating the direct effects of the art form on the target group. Unlike the music listening studies, where papers were predominately quantitative, the research designs were more varied, with six qualitative, six quantitative studies, and four mixed-methods studies.

Semi-structured interviews were largely applied in the qualitative studies. Such interviews were used by Guzman-Garcia, Mukaetova-Ladinska, and James (2012) to examine the effects of a dance-based intervention on people with dementia, exploring the views and experiences of both residents and care staff. In the quantitative papers, clinical outcomes were evaluated in three out of the five papers. For example, Crone et al. (2013) investigated the processes and outcomes of an arts intervention for patients with common mental health problems, such as anxiety, depression and stress. The art intervention was a 10-week programme to which 202 patients were referred and took part in a variety of participatory arts activities, such as poetry and ceramics in small groups. The Warwick–Edinburgh Mental Well-being Scale was completed pre- and post-intervention to examine the effects and changes in overall mental well-being.

In the four mixed-methods studies, a range of different data collection methods were applied. Observations, reflective diaries and questionnaires were used by Dowrick, Billington, Robinson, Hamer, and Williams (2012) to evaluate a reading intervention for people with common mental health problems, whereas Froggett and Little (2012) used semi-structured interviews and the Herth Hope Index to evaluate the effect of a dance intervention in a mental health inpatient setting.

The findings from the different types of art form papers are themed around four areas that consist of improvement in health and well-being, enjoyment and satisfaction, wider healthcare benefits, tensions and limitations.

3.2.3 Improvements in health and well-being

In a number of papers, improvement in well-being was reported. For example, Crone et al. (2013) found well-being scores improved for those with common mental health problems who completed a person-centred arts programme. Similarly, although the art form was different in the studies by Baumann, Peck, Collins, and Eades (2012), and Guzman-Garcia et al. (2012), both studies reported improvements in well-being that was aided by the mental stimulation and interaction gained from the intervention.

A reduction in anxiety levels was recorded by Froggett and Little (2012) and Mouradian (2013). Likewise Dowrick et al. (2012) reported a reduction in depressive symptoms for those with common mental health problems attending reading groups for 12 months. Thomson, Ander, Menon, Lanceley, and Chatterjee (2012) and Caddy, Crawford, and Page (2012) found improvements in scores in psychological measures of those who participated in creative activities. The evaluative feedback comments for an art-project for older people in a mental health trust by Shorters (2011) reported that creative expression had a role in recovery from mental distress that the authors suggest could be as important for some as medication. A similar finding was drawn in the study by Hurdle and Quinlan (2014) in their interviews with artists who delivered participatory art activities to patients in a hospital setting, as most artists felt participation in the arts could facilitate healing and well-being.

3.2.4 Enjoyment and satisfaction

A common shared theme across this strand was the enjoyment and satisfaction patients/service users gained from the art intervention. For example, the young people with cystic fibrosis who took part in individual singing sessions expressed a high degree of enjoyment and satisfaction from the initiative (Yoon-Irons, Kuipers, & Petocz, 2013).

Gaining a sense of connection with others was also a valued feature in the study by Froggett and Little (2012) who evaluated a dance intervention in a mental health inpatient ward. Service users reported a feeling of inclusion from and within the group that was aided by a sense of everyone being in it together. Dancing also helped service users to relax by releasing tension. The study by Haraldsottir (2011) evaluated poetry reading and writing sessions for hospice patients and identified that the intervention was positively received by patients and enabled connections with staff by fostering dialogue and sharing of stories.

3.2.5 Wider healthcare benefits

Nature art displays were found to significantly decrease the number of queries made at the front desk and significantly increase social interaction in the study by Nanda et al. (2012), who examined emergency department patients' behaviours to displays of nature. From the observations recorded, the authors reported a significant reduction in restlessness, noise level and people staring at other people in the waiting room. The authors conclude that a simple visual intervention can improve the patient waiting experience in the emergency department, which has implications for patient satisfaction levels.

3.2.6 Tensions and limitations

In some of the different art form papers, a tension was identified in relation to whose voice was being heard and whose was being ignored. The study by Hurdle and Quinlan (2014) only sought the artists' perspectives in their review of a hospital-based arts programme, which limits the transferability of the findings. The robustness of findings that draw upon feedback comments from those receiving the art intervention was another area of weakness in some studies. For example, it was unclear in both the papers by Haraldsottir (2011) and Shorters (2011) what the response rates were and how these comments were gathered and analysed. A lack of contextual background and detail was another area of weakness identified. For instance, the study by Low et al. (2016) is published as a short communication piece, but does not provide a link or reference to where the results of the study can be examined in greater depth.