Advancing the Arts as Integral to Healthcare

Arts in Healthcare is a diverse, multidisciplinary field dedicated to transforming the experience of healthcare by connecting people with the power of the arts at key moments in their lives. This rapidly growing field integrates the arts, including literary, performing, and visual arts and design, into a wide variety of healthcare and community settings for therapeutic, educational, and expressive purposes.

Throughout recorded history, we see evidence that pictures, stories, dances, music, and drama have been central to healing rituals. Today’s renewed focus on humanistic care is leading to resurgence in the knowledge and practice of incorporating the arts into healthcare services. Increasing numbers of clinicians and other professionals from the medical community are working side by side with arts professionals in both healthcare and community settings, and around the world the arts are emerging as an important and integral component of healthcare.

In two recent surveys conducted by the Society for the Arts in Healthcare, The Joint Commission, and Americans for the Arts (2004, 2007), nearly half of the healthcare institutions reported having arts in healthcare programming. The majority of these programs are in hospitals, with smaller percentages reported in long-term care and hospice/palliative care organizations. The three most common types of arts programming are permanent display of art, performances in public spaces, and bedside activities.

Research demonstrates the benefits of the arts in healthcare in hospitals, nursing homes, senior centers, hospice, and other locations within the community. Arts in healthcare programs and creative arts therapies have been applied to a vast array of health issues—from post-traumatic stress disorder to autism, mental health, chronic illnesses, Alzheimer’s and dementia, neurological disorders and brain inquires, premature infants, and physical disabilities—to improve patients’ overall health outcomes, treatment compliance, and quality of life.

New evidence is emerging that demonstrates that these programs also have an economic benefit. Data show that such programs result in patients requiring shorter hospital stays, less medication, and having fewer complications—all of which translates to a reduction in healthcare costs. However, much of the research focused on the economic benefits of arts in healthcare is anecdote rich and data poor. It is hoped that future analysis of the economic benefits of arts in healthcare programs will advance policy conversations about using the arts to simultaneously reduce health costs and raise the quality of care.

Conversely, there is a rich and growing body of research connecting arts in healthcare programs to improved quality of care for patients, their families, and even medical staff. Studies have proven that integrating the arts into healthcare settings helps to cultivate a healing environment, support the physical, mental, and emotional recovery of patients, communicate health and recovery information, and foster a positive environment for caregivers that reduces stress and improves workplace satisfaction and employee retention. Areas of focus include:

• Patient Care - The incorporation of the arts into the healthcare experience has a positive impact on patient health outcomes. The arts benefit patients by aiding in their physical, mental, and emotional recovery, including relieving anxiety and decreasing the perception of pain. In an atmosphere where the patient often feels out of control, the arts can serve as a therapeutic and healing tool, reducing stress and loneliness and providing opportunities for self-expression. Art also has the power to communicate and educate, giving it a growing role of significance in healthcare institutions. In addition, research shows that the arts can reduce patients’ use of pain medication and length of stay in the hospital, and improve compliance with recommended treatments—offering substantial savings in healthcare costs.
• Healthcare Environments - The arts create safer, more supportive, and functional environments in healthcare facilities. From architectural design to art on the walls, from access to natural lighting to the inclusion of nature through landscape and healing gardens, the physical environment has a significant impact on reducing patient and caregiver stress, improving health outcomes, enhancing patient safety and overall quality of care, and reducing costs. The physical environment also plays an important role in improving the health and safety for staff, increasing effectiveness in providing care, reducing errors, and increasing job satisfaction.
• Caring for Caregivers - Caregivers, such as family, friends, and healthcare providers in hospitals, hospices, and other health facilities, are faced with the realities of human suffering, illnesses, and death on a daily basis. Arts programming for caregivers creates a common, more normative environment, and offers caregivers an opportunity for creativity and self-expression that allows them to healthfully integrate their experiences and emotions instead of carrying them home or into the workplace. In addition, the arts give medical professionals new tools for improving diagnostic and communication skills and can be used to better communicate health and recovery information. The arts help overcome barriers by embracing diversity, reinforcing family members’ supportive role in the healing process, and changing the culture within the healthcare facility to one that is more supportive and humane.

The Benefits of the Arts in Healthcare: A Sampling of Research Findings

Perhaps at no other time in history has quality assurance in healthcare been more paramount than today. Traditionally, clinical decision-making has been based on intuition, opinions, assumptions, and experience. In today’s healthcare world, with approximately 30% of all healthcare spending going toward ineffective, redundant, or inappropriate care; capital resources scarce; the economy sagging; and the cost of healthcare becoming a hot political issue, healthcare decision-makers are demanding that decisions be based on evidence (Hayes, 2008). This strategy, called evidence-based medicine, supports the clinician’s individual clinical expertise, and combines this experience with the best available external evidence and the values and needs of the patient, in making medical decisions.

As an integral part of healthcare, arts in healthcare must be held to the same standards. Researchers have found evidence of the benefits of the arts in healthcare in hospitals, nursing homes, senior centers, private homes, or other locations within the community. Quantitative and qualitative research from across healthcare disciplines—and documented in peer-reviewed journals—provides evidence of both instrumental and intrinsic benefits of arts in healthcare. A growing body of research indicates that a physiologic process may actually take place through contact with certain images and other forms of the arts. In a very early study, Goldstein (1980) described “thrills”—tingling sensations individuals may experience when exposed to emotionally arousing stimuli. His findings showed a relationship between these experiences and the release of endorphins—the body’s own pain reliever, “relaxer,” and mood enhancer. An emerging science that is part of this physiologic research is psychoneuroimmunology (PNI), which is concerned with the correlation between stress and health. Specifically, PNI is the study of the interaction between psychological processes and the nervous and immune systems of the human body (Vedhara & Irwin, 2005).

Researchers also are interested in the effects of art in the environment and arts programming on family members and healthcare staff. For example, most hospital artists in residence programs serve families as well as patients, and often provide special workshops for staff. We know that not only can such activities help staff deal with the stress of caregiving, but also that healthcare providers 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 (Penn, 1994). Also, many medical schools, recognizing the arts as a powerful education tool, are incorporating the arts and humanities into medical curriculum (Bertman, 2007). Increasingly, nursing and other healthcare disciplines are following suit.

We have only recently begun to look at the economic benefits of the arts in healthcare. Quality of life outcomes for arts program participants are being translated into cost saving outcomes, such the need for fewer doctor visits and medication (Cohen, 2009). Other researchers are considering the impact of an active arts program integrated into the healthcare environment on healthcare staff seeking employment or considering whether to remain in their current position (Staricoff, Duncan, Wright, Loppert, & Scott, 2001; Staricoff & Loppert, 2003). With the rising healthcare cost, coupled with the need to retain nurses—the single largest group of people hospitals employ—research of this nature can have a tremendous impact on struggling healthcare systems.

“Measuring” is occurring on two levels: evaluation and what is often referred to as “traditional” research. Evaluation typically is undertaken to measure the effectiveness of a particular project or program. The purpose of basic research is broader, with interest in building theory and the knowledge base of the field. Program and project evaluation has progressed at a faster pace than traditional research activities. Nevertheless, paralleling the evidence-based medicine movement in the larger healthcare field, quantitative research in arts in healthcare is now being carried out throughout the world (State of the Field Committee, 2009). The following provides some examples of research on the various arts that support their benefit to patients.

Visual Arts

Research indicates that the visual arts also have many intrinsic and instrumental benefits in healthcare. For example, research with children with cancer indicates that engaging in drawing and painting is an effective method for dealing with pain and other disturbing symptoms of illness and treatment (Rollins, 2005a). Also, the visual arts offer a means of non-verbal communication, often bringing order and clarity to mixed-up, poorly understood feelings. While providing a vehicle for catharsis, the artwork itself offers a tool to monitor the individual’s emotional and/or developmental state and progress (Rae, 1991; Sturner, Rothbaum, Visintainer, & Wolfer, 1980). Visual arts also serve as a diagnostic tool; asthma symptoms may be revealed in children’s illness drawings (Gabriels, Wamboldt, Adams, & McTaggart, 2000). And, as with all of the arts, engaging in the visual arts provide opportunities for individuals to make choices and to be in control at a time when many things in their lives are beyond their control, an important factor in reducing stress (Rollins, 2005b).

Some of the documented benefits of participating in visual arts or art therapy activities include:

• Decreasing symptoms of distress and improving quality of life for women with cancer (Monti et al., 2006);
• Improving depression and influencing fatigue levels in cancer patients on chemotherapy (Bar-Sela, Atid, Danos, Gabay, & Epelbaum, 2007);
• Reducing acute stress symptoms in pediatric trauma patients (Chapman, Morabito, Ladakakos, Schreier, & Knudson, 2001);
• Increasing support, psychological strength, and providing new insights about their cancer experience for individuals who participated in an art therapy/museum education program (Deane, Fitch, & Carman, 2000); and
• Strengthening positive feelings, alleviating distress, and clarifying existential/spiritual issues for adult bone marrow transplant patients in isolation (Gabriel, Bromberg, Vandenbovenkamp, Kornblith, & Luzzato, 2001).

Music

A good amount of the research literature on the benefits of the arts in healthcare with patients concerns music, which has been found effective in:

• Increasing comfort level post-operatively (Pölkki, Vehviläinen-Julkunen, & Pietilä, 2001);
• Decreasing use of sedatives during procedures (Loewy, Hallan, Friedman, & Martinez, 2005; Walworth, 2005);
• Decreasing anxiety in children receiving casts for orthopedic injuries (Brice & Barclay, 2007);
• mproving depression, anxiety, and relationships in psychiatric patients (Choi, Lee, & Lim, 2008);
• Increasing heart rate and improving behavioral score in preterm infants in the neonatal intensive care unit, resulting in a deeper sleep (Arnon et al., 2006);
• Decreasing incidence of respiratory pause in premature infants, where breathing ceases for 10 seconds or less (Arnon et al., 2006; Shepley, 2006);
• Increasing quality and length of life for individuals diagnosed with terminal cancer (Hilliard, 2003);
• Increasing or decreasing the growth of neoplastic and normal human cells (Sharma, Kauffman, & Stephens, 1996);
• Shortening the length of stay by three days for premature infants in an intensive care unit as compared with a control group (Coleman, Pratt, Stoddard, Gerstmann, & Abelm, 1994);
• Lowering the heart rates, respiratory rates, and myocardial oxygen demand for patients recovering from myocardial infarction (White, 1999);
• Reducing blood pressure levels in pregnant women waiting to be seen in a high-risk prenatal clinic (Staricoff & Loppert, 2003);
• Reducing pain during intramuscular injection (Fowler-Kerry & Lander, 1987), pain during bone marrow aspiration (Pfaff, Smith, & Gowan, 1989), pain after surgery (Steinke, 1991), pain from heel-stick procedures with neonates (Bo & Callaghan, 2000), and pain associated with serious illness (Bailey, 1986; Nolan, 1992);
• Reducing the perception of pain in people with rheumatoid arthritis (Schorr, 1993); and
• Reducing nausea and vomiting in adults undergoing bone marrow transplant (Ezzone, Baker, Rosselet, & Terepka, 1998), after treatments or surgery (Standley, 1992; Steinke, 1991), and after anesthesia or chemotherapy (Keller, 1995).

Several studies have dealt with the use of music for coping with stress. For example, Ryan-Wenger and Walsh (1994) reported that school-aged children with asthma have identified listening to music as one of the four most effective and frequently used strategies for coping with their disease. Music also has been found effective in:

• Deducing stress behaviors in infants and toddlers who were hospitalized (Marley, 1984);
• Reducing stress among visitors in hospital surgery/intensive care unit waiting rooms (Rothieaux, 1997);
• Producing relaxation during cardiac catheterization (Micci, 1984); and
• Decreasing anxiety before surgery (Kain, Wang, Mayes, Krivutza, & Teague, 2001) and in outpatients undergoing flexible sigmoidoscopy (Chlan, Evans, Greenleaf, & Walker, 2000).

Some important research deals with adherence to medical regimes. For example:

• Grasso and colleagues (2000) reported on the benefits of music in establishing routine chest physiotherapy—an important component of prophylactic therapy for children with cystic fibrosis—as a positive experience for children and their families.
• In a study of adults with chronic obstructive pulmonary disease (COPD), Bauldoff, Hoffman, Thomas, Zullo, and Sciurba (2002) found that listening to music promoted adherence to a walking regimen following completion of a pulmonary rehabilitation program.

Other researchers report music’s effectiveness in significantly increasing salivary immunoglobulin A (IgA), an antibody that provides defense against various infections (Lane, 1990) and infants’ oxygen saturation levels, an indicator of respiratory regularity directly affected by the individual’s behavioral state and degree of pain (Collins & Kuck, 1991; Standley & Moore, 1995).

Dance

The literature shows that most of the experimental research about dance and movement has been done in the therapy field. Studies on the benefits of dance and dance/movement therapy for women with breast cancer include the work of Serlin and colleagues (Serlin et al., 2000), Sandel and colleagues (2007), and Dibbel-Hope (2000). All three show improvement in variables related to psychosocial functioning, self-image, and quality of life. Other work on the impact of dance/movement therapy on quality of life variables in people with medical illness include Goodill’s randomized controlled study with adults with cystic fibrosis, showing improvements in adherence with self-care regimens (Goodill, 2005a), and a large multi-site controlled study of group dance/movement therapy for older adults with neurological disorders (Berrol, Ooi, & Katz, 1997). The latter study documented strong patient satisfaction and improvement in social interaction parameters and psychomotor functioning. An early study by Westbrook & McKibben (1989) used a crossover design to compare dance therapy with exercise for Parkinson’s patients and found that only dance therapy improved psychosocial functioning.

Work in pediatric medical settings includes that of Cohen and Walco (1999) where the creative arts are integrated fully into hemotology/oncology services for developmental support, group therapy, and enhancing coping. Other studies on dance interventions with medical patients are summarized by Goodill (2005b, 2006). The effectiveness of dance/movement therapy to reduce anxiety and improve mood, social functioning, and self-concept were analyzed in a meta-analysis by Cruz and Sabers (1998), which revealed effect sizes comparable to that of other mainstream psychotherapy approaches.

More recent findings regarding the benefits of dance include:

• Being number one on a list of leisure activities that most contribute to the delay in onset of Alzheimer’s disease for those at risk of the disorder (Verghese et al. 2003);
• Increasing mobility in individuals with fibromyalgia (Bojner-Horwitz, Theorell, & Anderberg, 2003); and
• Improving balance and mobility in individuals with Parkinson’s disease (Hackney, Kantorovich, Levin, & Earhart, 2007).

Literature, Creative Writing, and Storytelling

Studies using creative writing as an intervention report:

• Improved quality of life for people with cancer after a single, 20-minute writing session while waiting for their clinic appointment (Morgan, Graves, Poggi, & Cheson, 2008);
• Improved lung function in high school-aged students, college students, and adults with asthma after written emotional expression (Bray et al., 2003);
• Decreased visits to physicians and reduced symptom complaints (Pennebaker, 1997, 2004); and
• Increased health and emotional well-being (Pennebaker, 2002).

Stories can provide a means for individuals to deal indirectly with difficult fears and realities (Freeman, 1991). Some individuals may use the story to discuss their issues and situations; others may simply enjoy a story as a fantasy escape that need not be analyzed. According to Heiney (1995), people take from a story only what they are ready to find, and what they find often may be meaning in their experiences and renewed hope. Levels of depression in individuals who were guided to read selected fiction, poetry, or literature were reduced in comparison to individuals in a control group who did not participate in the guided reading. Storytelling has resulted in a greater level of relative well-being for individuals with mild to moderate dementia that participated in group reminiscence therapy as compared to those participating in group activities or unstructured time (Brooker & Duce, 2000).

Storytelling also has been used to help children deal with both mental and physical pain (Heiney, 1995). For example, Kuttner (1988) employed a hypnotic method using the child’s favorite story and found it more effective than behavioral distraction and standard medical practice in alleviating distress, pain, and anxiety during painful bone marrow aspirations.

The power of story to distract should not be taken lightly. In 1794, before the use of anesthetics, a young boy had surgery to remove a tumor. During his operation he was told such an interesting story that it absorbed his attention and removed pain from conscious awareness. This true believer in the power of story, Jacob Grimm, wrote Snow White 18 years later (Hilgard & LeBaron, 1984).

Drama

Of all of the arts disciplines, drama has been extremely effective in creating understanding. For example, Sinding, Gray, Grassau, Damianakis, and Hampson (2006) explored audience reactions to the research-based drama Ladies in Waiting? Life After Breast Cancer. Quantitative findings indicate an overwhelmingly positive response, with approximately 90% of those who saw the production agreeing that they benefited from seeing it and indicating that they would recommend it to others. As is often the case, qualitative data revealed a more complex picture of the range of reactions, allowing researchers to describe the most valued aspects of the production, such as how it eased isolation, normalized the difficult aspects of survivorship, and provided better understanding of the few reports of distress.

Participating in drama also has garnered positive outcomes. Noice and Noice (2004) investigated the benefits of a short-term intervention for older adults that targeted cognitive functioning and quality of life issues important for independent living. Participants (124 community-dwelling persons ages 60 to 86 years) took part in one of three study conditions: theater arts (primary intervention), visual arts (non-content-specific comparison group), and no-treatment controls. After four weeks of instruction, those given theater training made significantly greater gains than did no-treatment controls on both cognitive and psychological well-being measures. A comparison of theater and visual arts training showed fewer benefits in fewer areas for visual arts.

Design Implications

Much arts in healthcare research has focused on architecture or design issues. This growing body of research confirms that the physical design of healthcare settings can contribute to either positive or negative outcomes for patients. A movement toward thoughtful evidence-based design is bringing the patient, staff, and families into the center of the health care experience; increasing patient safety; and enhancing the overall quality of care provided (Sadler & Joseph, 2008).

Environmental psychologist Roger Ulrich’s classic study of patients recovering from gall bladder surgery found that those individuals with views of a small park with trees and flowers had better nurse evaluations, took less medication, and had shorter hospital stays than individuals with a view of an adjacent brick wall (Ulrich, 1984). A later study further confirmed that visual exposure to natural environments is more effective in fostering reduction of anxiety and stress than comparable visual exposure to urban environments (Ulrich et al., 1991).

More recently, Ulrich and colleagues conducted a study that exposed 166 patients in intensive care units to one of six visual stimulation conditions: two nature pictures dominated by water and trees respectively; two abstract pictures similar in complexity to the nature conditions; and two control conditions (Ulrich, Lunden, & Eltinge, 1993). Individuals exposed to the view of water experienced less postoperative anxiety than patients assigned to the other five visual conditions. Further, they required fewer doses of strong pain drugs during the ward phase. Findings from this research suggested that placing photographs of certain natural environments in hospital settings might have positive influences on postoperative recovery.

Nanda, Debajyoti, and McCurry (2009) provide evidence that visual stimuli undergo an aesthetic evaluation process in the human brain by default, even when not prompted; that responses to visual stimuli may be immediate and emotional; and that aesthetics can be a source of pleasure, a fundamental perceptual reward that can help mitigate the stress of a healthcare environment. Also provided are examples of studies that address the role of specific visual elements and visual principles in aesthetic evaluations and emotional responses. They conclude with a discussion of the implications of these findings for the design of art and architecture in healthcare.

The topic of healing healthcare environments is becoming increasingly popular in healthcare publications. For example, Modern Healthcare magazine has addressed design in several issues. The 12 winning facilities in a design award competition that the magazine sponsored in 1996 featured indoor courtyards and gardens (Pinto, 1996). Similarly, in 2001, the magazine focused on hospital healing gardens (Tieman, 2001). Not only providing restorative or calming nature views, hospital gardens also can reduce stress and improve outcomes through other mechanisms, for instance, fostering access to social support and providing opportunities for positive escape and sense of control with respect to stressful clinical settings (Ulrich, Zimring, Joseph, Quan, & Choudhary, 2004).

Summary of Research

Evaluations, observations, and research findings demonstrate that there are both instrumental and intrinsic benefits to the arts in healthcare. Research in the field is limited but rapidly growing. Conducting research requires experience in arts in healthcare research techniques and methods and funding from sources that recognize the potential of arts in healthcare.

Another issue is a lack of clarity about what to measure and sometimes a lack of awareness about the distinction between curing and healing. To move forward with a research plan, there first needs to be clarity about what effects are intended by integrating the arts in healthcare. This clarification will drive the development of tools and methods for researching both the instrumental and intrinsic benefits of the arts in healthcare.

Both quantitative and qualitative research methods have a role in this endeavor. Patton (2002, p. 53) writes: “It is crucial for validity—and consequently, for reliability—to try to picture the empirical social world as it actually exists to those under investigation, rather than as the researcher imagines it to be, thus the importance of such qualitative approaches as participant observation, depth interviewing, detailed description, and case studies.” And further, regarding artistic criteria in qualitative research, he says, “Artistic expressions of qualitative analysis strive to provide an experience with the findings where ‘truth’ or ‘reality’ is understood to have a feeling dimension that is every bit as important as the cognitive dimension” (p. 548). Writing in the Journal of Epidemiology and Community Health, Hamilton, Hinks, and Petticrew (2003) note:

The scientific approach is well underway, and with it, mounting evidence that the arts are truly making a difference in people’s lives in hospitals, nursing homes, senior centers, private homes, or other locations within the community. Evidence also is emerging regarding economic benefits. Thus, research findings indicate that the arts can play a significant role in humanizing healthcare for individuals, families, and the healthcare providers that serve them; and can become part of the solution to our current healthcare challenges.

Moving Forward

The field of arts in healthcare is steadily moving forward. Increasingly, healthcare administrators are not only welcoming but also financially supporting arts programming in their institutions. Medical and nursing schools see the value in incorporating arts in healthcare courses or content to help their students develop their observation, communication, and other essential skills. Arts organizations, schools, and colleges are partnering with healthcare organizations to provide arts programming as well as health promotion experiences in community settings. Architects and designers are creating healthcare institutions that are not only beautiful, but also built upon a solid foundation of evidence about what supports safe delivery of care and provides the most positive outcomes for patients, families, and staff.

The State of the Field Report: Arts in Healthcare 2009 verifies that the benefits of arts in healthcare are not limited to a select group of privileged individuals. Illness has a very leveling effect and the very nature of the arts means that everyone—regardless of ethic group, race, age, economic status, or geographical region—can enjoy all that the arts can bring to healthcare experiences.

Although continued research explaining the positive outcomes of the arts in healthcare for patients, families, and staff is paramount, our current economic crisis demands that research demonstrating the financial benefits must parallel these efforts. Evidence of monetary benefits can provide the arts in healthcare field a seat at the table when tough decisions are made.

With the launch of the Society for the Arts in Healthcare’s journal, Arts & Health: An International Journal for Research, Policy and Practice, and The International Journal of the Creative Arts in Interdisciplinary Practice (recently renamed from The Canadian Creative Arts in Health, Training and Education Journal), a true sense of professionalism of the field is settling in. Professionalism also is reflected by organizations and institutions of higher education’s development of coursework to prepare individuals to provide safe and effective arts in healthcare services. Beginnings of certification and credentialing are in the air.

From the beginning of recorded history, the arts have been central to the human experience. In times of illness, our world is stripped of what civilization has added to our primal core. In the 21st century when our expansion of knowledge out paces our ability to understand and utilize it, we are beginning to pay attention to our basic human needs for safety, community, art, and music—and to unlock their meaning and harness their power. This is at the heart of the arts in healthcare movement.

To view the entire report, go to State of the Field Report: Arts in Healthcare 2009 http://www.thesah.org/doc/reports/FieldReport2%206.pdf

About the Society for the Arts in Healthcare:

The Society for the Arts in Healthcare is an international non-profit organization dedicated to advancing the arts as integral to healthcare. Although the Society is based in the American capital, its vision is to be the foremost global resource uniting the arts and healthcare. As a convening organization, the Society offers an annual international conference (in 2005, the University of Alberta Hospital program hosted the conference in Edmonton) and periodic symposia throughout the U.S. and Canada. The Society provides an extensive array of supportive and professional development services to the field, including a comprehensive website, grant opportunities for members, organization of special interest groups, and its CREATE Services, which encompasses a Clearinghouse of information, Re-granting and awards, Educational events, Arts in healthcare networks, Technical assistance, and Exhibits—all designed to aid in professional and organizational development.

The growth of the Canadian arts in healthcare industry received a boost in 2005 when the Canadian Forum on the Arts and Health was sponsored by the British Columbia Arts Council. The conference participants favored and spurred the creation of a networking organization as a national priority (Cooley, 2005), hence the movement to develop the Canadian Arts and Health Network (Sonke, Rollins, Brandman, & Graham-Pole, 2009). In February 2009, a new network, the National Network for Arts in Health Canada (NNAHC), was formed. NNAHC is a non-profit online organization that aims to bring together artists, clinicians, researchers, and others who are either working in the arts in health field or have an interest in it. It is about building a strong, open, and sharing community across the country. The website includes events, links, and a forum for discussion.

references

1. Arnon, S., Shapsa, A., Forman, L., Regev, R., Bauer, S., Litmanovitz, I., et al. (2006). Live music is beneficial to preterm infants in the neonatal intensive care unit environment. Birth, 33(2), 131–136.
   
2. Bailey, L. (1986). Music therapy in pain management. Journal of Pain Symptom Management, 1, 25–28.
   
3. Bar-Sela, G., Atid, L., Danos, S., Gabay, N., & Epelbaum, P. (2007). Art therapy improved depression and influenced fatigue levels in cancer patients on chemotherapy. Psychoonocology, 16, 980–984.
   
4. Bauldoff, G., Hoffman, L., Thomas, G., Zullo, T., & Sciurba, F. (2002). Exercise maintenance following pulmonary rehabilitation. Chest, 122, 948–954.
   
5. Berrol, C.F., Ooi, W.L., & Katz, S.S. (1997). Dance/movement therapy with older adults who have sustained neurological insult: A demonstration project. American Journal of Dance Therapy, 19(2), 135–160.
   
6. Bertman, S. (2007). One breath apart: Facing dissection. Cambridge, MA: Digitalclay Interactive.
   
7. Bo, L.K., & Callaghan, P. (2000). Soothing pain-elicited distress in Chinese neonates. Pediatrics, 105(4), E49.
   
8. Bojner-Horwitz, E., Theorell, T., & Anderberg, U. (2003). Dance/movement therapy and changes in stress-related hormones: A study of fibromyalgia patients with video-interpretation. The Arts in Psychotherapy, 30, 255–264.
   
9. Bray, M., Theodore, L., Patwa, S., Margiano, S., Alric, J., & Peck, H. (2003). Written emotional expression as an intervention for asthma. Psychology in the Schools, 40(2), 193–207.
   
10. Brice, J., & Barclay, J. (2007). Music eases anxiety of children in cast room. Journal of Pediatric Orthopedics, 27, 831–833.
    
11. Brooker, D.J., & Duce, L. (2000). Well-being and activity in dementia: A comparison of group reminiscence therapy, structured goal-directed activity, and unstructured time. Aging and Mental Health, 4(4), 354-358.
    
12. Chapman, L, Morabito, D., Ladakakos, C., Schreier, H., & Knudson, M. (2007). The effectiveness of art therapy interventions in reducing post traumatic stress disorder (PTSD) symptoms in pediatric trauma patients. Journal of The American Art Therapy Association, 18, 100–104.
    
13. Chlan, L., Evans, D., Greenleaf, M., & Walker, J. (2000). Effects of a single music therapy intervention on anxiety, discomfort, satisfaction, and compliance with screening guidelines in outpatients undergoing flexible sigmoidoscopy. Gastroenterology Nursing, 23(4), 148–156.
    
14. Choi, A., Lee, M., & Lim, H. (2008). Effects of group music intervention on depression, anxiety, and relationships in psychiatric patients: A pilot study. The Journal of Alternative and Complementary Medicine, 14(5), 567–570.
    
15. Cohen, G. (2006). The creativity and aging study: The impact of professionally conducted cultural programs on older adults. Retrieved December 17, 2008, from http://www.nea.gov/resources/accessibility/CnA-Rep4-30-06.pdf
    
16. Cohen, G. (2009). New theories and research findings on the positive influence of music and art on health with ageing. Arts & Health: An International Journal for Research, Policy and Practice, 1(1), 48-62.
    
17. Cohen, S.O., & Walco, G.A. (1999). Dance/movement therapy for children and adolescents with cancer. Cancer Practice, 7(1), 34-42.
    
18. Coleman, J.M., Pratt, R.R., Stoddard, R.A., Gerstmann, D., & Abelm, H-H. (1994). The effects of the male and female singing voices on selected physiological and behavioral measures of premature infants in the intensive care unity. International Journal of Arts Medicine, 5(2), 4–11.
    
19. Collins, S., & Kuck, K. (1991). Music therapy in the neonatal intensive care unit. Neonatal Network, 9(6), 23–26.
    
20. Cooley, N. (2005). Canadian Forum on Arts and Health 2005: Forum summary report [On-line report on Forum proceedings]. Retrieved January 20, 2009, from http://www.bcartscouncil.ca/healthcanadaforum/program/
    
21. Cruz, R., & Sabers, D. (1998). Dance/movement therapy is more effective than previously reported. The Arts in Psychotherapy: An International Journal, 25, 101-104.
    
22. Deanne, K., Fitch, M., & Carman, M. (2000). An innovative art therapy program for cancer patients. Canadian Oncology Nursing Journal, 10, 147–157.
    
23. Dibbel-Hope, S. (2000). The use of dance/movement therapy in psychological adaptation to breast cancer. The Arts in Psychotherapy: An International Journal, 27(1), 51-68.
    
24. Ezzone, S., Baker, C., Rosselet, R., & Terepka, E. (1998). Music as an adjunct to antiemetic therapy. Oncology Nursing Forum, 25(9), 1551–1556.
    
25. Ferszt, G., Massotti, E., Williams, J., & Miller, J. (2000). The impact of an art program on an inpatient oncology unit. Illness, Crisis, & Loss, 8(2), 189–199.
    
26. Fowler-Kerry, S., & Lander, J. (1987). Management of injection pain in children. Pain, 30, 169–175.
    
27. Freeman, M. (1991). Therapeutic use of storytelling for older children who are critically ill. Children’s Health Care, 20(4), 208–215.
    
28. Gabriel, B., Bromberg, E., Vandenbovenkamp, J., Kornblith, A., & Luzzato, P. (2001). Art therapy with adult bone marrow transplant patients in isolation: A pilot study. Psychooncology, 10, 114–123.
    
29. Gabriels, R., Wamboldt, M., McCormick, D., Adams, T., & McTaggart, S. (2000). Children’s illness drawings and asthma symptom awareness. Journal of Asthma, 37(7), 565–574.
    
30. Goldstein, A. (1980). Thrills in response to music and other stimuli. Physiological Psychology, 8(1), 126–129.
    
31. Goodill, S. (2005a). Research letter: Dance/movement therapy for adults with cystic fibrosis: Pilot data on mood and adherence. Alternative Therapies in Health and Medicine, 11(1), 76-77.
    
32. Goodill, S. (2005b). An introduction to medical dance/movement therapy: Health care in motion. London: Jessica Kingsley Publishers.
    
33. Goodill, S. (2006). Dance/movement therapy for people living with medical illness. In S.C. Koch, & I. Brauninger (Eds.), Advances in Dance/movement therapy: Theoretical perspectives and medical findings (pp. 52-61). Berlin: Logos Verlag.
    
34. Grasso, M., Button, B., Allison, D., & Sawyer, S. (2000). Benefits of music therapy as an adjunct to chest physiotherapy in infants and toddler with cystic fibrosis. Pediatric Pulmonology, 29(5), 371–381.
    
35. Hackney, M.E., Kantorovich, S., Levin, R., & Earhart, G.M. (2007). Effects of tango on functional mobility in Parkinson’s disease: A preliminary study. Journal of Neurological Physical Therapy, 31, 173179.
    
36. Hamilton, C., Hinks, S., & Petticrew, M. (2003). Journal of Epidemiology and Community Health, 57, 401–402.
    
37. Hayes, W. (2008). Evidence-based medicine restores focus on roi. Quality Digest. Retrieved February 1, 2009, from http://www.qualitydigest.com/inside/health-care-article/evidence-based-medicine-restores-focus-roi.html
    
38. Heiney, S. (1995). The healing power of story. Oncology Nursing Forum, 22(6), 899–904.
    
39. Heiney, S., & Darrr-Hope, H. (1999). Healing icons: Art support program for patients with cancer. Cancer Practice, 7(4), 183–189.
    
40. Hilgard, J., & LeBaron, S. (1984). Hypnotherapy of pain in children with cancer. Los Altos, CA: William Kaufman.
    
41. Hilliard, R. (2003). The effects of music therapy on the quality and length of life of people diagnosed with terminal cancer. Journal of Music Therapy, 40, 113–137.
    
42. Kain, Z.N., Wang, S.M., Mayes, L.C., Krivutza, D.M., & Teague B.A. (2001). Sensory stimuli and anxiety in children undergoing surgery: A randomized, controlled trial. Anesthesia & Analgesia, 92(4), 897–903.
    
43. Keller, V. (1995). Management of nausea and vomiting in children. Journal of Pediatric Nursing, 10(5), 280–286.
    
44. Kuttner, L. (1988). Favorite stories: A hypnotic pain-reduction technique for children in acute pain. American Journal of Clinical Hypnosis, 30(4), 289–295.
    
45. Lane, D. (1990). The effect of a single music therapy session on hospitalized children as measured by salivary immunoglobin A, speech pause time, and a patient opinion Likert scale. Unpublished doctoral dissertation. Case Western Reserve University, Cleveland, OH.
    
46. Loewy, J., Hallan, C., Friedman, E., & Martinez, C. (2005). Sleep/sedation in children undergoing EEG testing: A comparison of chloral hydrate and music therapy. Journal of PeriAnesthesia Nursing, 20(5), 323–332.
    
47. Marley, L. (1984). The use of music with hospitalized infants and toddlers: A descriptive study. Journal of Music Therapy, 21, 126–132.
    
48. Micci, N. (1984). The use of music therapy with pediatric patients undergoing cardiac catheterization. The Arts in Psychotherapy, 11, 261–266.
    
49. Monti, D. Peterson, C., Kunkel, E., Hauck, W., Peawuignot, E, Rhodes, L., et al. (2006). A randomized, controlled trial of mindfulness-based art therapy (MBAT) for women with cancer. Psychooncology, 15(5), 363–373.
    
50. Morgan, N., Graves, K., Poggi, E., & Cheson, B. (2008). Implementing a expressive writing study in a cancer clinic. The Oncologist, 13(2), 196–204.
    
51. Nanda, U., Debajyoti, P., & McCurry, K. (2009). Neuroesthetics and healthcare design. Health Environments Research & Design Journal, 2(2), 116–133.
    
52. Noice, H., & Noice, T. (2004). A short-term intervention to enhance cognitive and affective functioning in older adults. Journal of Aging and Health, 16(4), 562–585.
    
53. Nolan, P. (1992). Music therapy with bone marrow transplant patients: Reaching beyond the symptoms. In R. Spintge, & R. Droh (Eds.), Music/medicine (pp. 209–212). St. Louis, MO: MMB Music.
    
54. Patton, M. (2002). Qualitative research & evaluation methods (3rd ed.). Thousand Oaks, CA: Sage Publications.
    
55. Penn, B. (1994). Using patient biography to promote holistic care. Nursing Times, 90(45), 35–36.
    
56. Pennebaker J.W. (2002). Writing about emotional events: From past to future. In S.J. Lepore, & J.M. Smyth (Eds.) The writing cure: How expressive writing promotes health and emotional well-being (pp. 281–291). Washington, DC: American Psychological Association.
    
57. Pennebaker, J.W. (1997). Opening up: The healing power of expressing emotions. New York: Guilford Press.
    
58. Pennebaker, J.W. (2004). Writing to heal: A guided journal for recovering from trauma and emotional upheaval. Oakland, CA: New Harbinger Publications, Inc.
    
59. Pfaff, V., Smith, K., & Gowan, D. (1989). The effects of music-assisted relaxation on the distress of pediatric cancer patients undergoing bone marrow aspirations. Children’s Health Care, 18, 232–236.
    
60. Pinto, C. (1996). Going natural by design. Annual design awards show facilities are emphasizing integration of the indoors with the outdoors. Modern Healthcare, 26(45), 39–42.
    
61. Pölkki, T., Vehviläinen-Julkunen, K., Pietilä A-M. (2001). Nonpharmacological methods in relieving children’s postoperative pain: A survey on hospital nurses in Finland. Journal of Advanced Nursing, 34(4), 483-492.
    
62. Rae, W. (1991). Analyzing drawings of children who are physically ill and hospitalized using the ipsative method. Children's Health Care, 20(4), 198–207.
    
63. Rollins, J. (2005a). Tell me about it: Drawing as a communication tool for children with cancer. Journal of Pediatric Oncology Nursing, 22(4), 203–221.
    
64. Rollins, J. (2005b). The arts in healthcare settings. In J. Rollins, R. Bolig, & C. Mahan (Eds.), Meeting children’s psychosocial needs across the healthcare continuum (pp. 119–174). Austin, TX: ProEd, Inc.
    
65. Rothieaux, R.L. (1997). The benefits of music in hospital waiting rooms. Health Care Surgery, 16(2), 31–40.
    
66. Ryan-Wenger, N., & Walsh, M. (1994). Children’s perspectives on coping with asthma. Pediatric Nursing, 20(3), 224–228.
    
67. Sadler, B., & Joseph, A. (2008). Executive summary. In Evidence for innovation (pp. 2–15). Alexandria, VA: National Association of Children’s Hospitals and Related Institutions.
    
68. Sandel, S., Judge, J., Landry, N., Faria, L., Ouellette, R., & Majczak, M. (2005). Dance and movement program improves quality-of-life measures in breast cancer survivors. Cancer Nursing, 28(4), 301-309.
    
69. Schorr, J.A. (1993). Music and pattern change in chronic pain. Advances in Nursing Science 15(4). 27–36.
    
70. Serlin, I.A., Classen, C., Frances, B., & Angell, K. (2000). Symposium: Support groups for women with breast cancer: Traditional and alternative expressive approaches. The Arts in Psychotherapy: An International Journal, 27(2), 123-138.
    
71. Sharma, H.M., Kauffman, E.M., & Stephens, R.E. (1996). Effect of different sounds on growth of human cancer cell lines in vitro. Alternative Therapy in Clinical Practice, 3(4), 25–32.
    
72. Shepley, M. (2006). The role of positive distraction in neonatal intensive care unit settings. Journal of Perinatology, 26, S34–S37.
    
73. Sinding, C., Gray, r., Grassau, P., Damianakis, & Hampson, A. (2006). Audience responses to a research-based drama about life after breast cancer. Psychooncology, 15(8), 694–700.
    
74. Sonke, J., Rollins, J., Brandman, R., Graham-Pole, J. (2009). The State of the Arts in Healthcare in North America. Unpublished article.
    
75. Sperry, R.W. (1995). . Journal of Humanistic Psychology, 35(2), 7, 34. State of the Field Committee. (2009).
    
76. State of the field: Arts in healthcare 2009. Washington, DC: Society for the Arts in Healthcare.
    
77. Standley, J. (1992). Clinical applications of music and chemotherapy: The effects on nausea and emesis. Music Therapy Perspectives, 10, 27–35.
    
78. Standley, J., & Moore, R. (1995). Therapeutic effects of music and mother’s voice on premature infants. Pediatric Nursing, 21(6), 509-512, 574.
    
79. Staricoff, R.L., & Loppert, S. (2003). Integrating the arts into healthcare: Can we affect clinical outcomes? In D. Kirkland, & R. Richardson (Eds.), The healing environment without and within (pp. 63–79). London: Royal College of Physicians.
    
80. Staricoff, R.L., Duncan, J., Wright, M., Loppert, S., & Scott, J. (2001). A study of the effects of visual and performing arts in healthcare. Hospital Development, 32, 25–28.
    
81. Steinke, W. (1991). The use of music, relaxation and imagery in the management of postsurgical pain for scoliosis. In C. Maranto (Ed.), Applications of music in medicine (pp. 141–162). Washington, DC: National Association for Music Therapy, Inc.
    
82. Sturner, R., Rothbaum, F., Visintainer, M., & Wolfer, J. (1980). The effects of stress on children’s human figure drawings. Journal of Clinical Psychology, 36, 325–331.
    
83. Tieman, J. (2001). Healing through nature. Modern Healthcare, 31(2), 34–35. Ulrich, R. (1984). View through a window may influence recovery from surgery. Science, 224, 420–421.
    
84. Ulrich, R., Lunden, O., & Eltinge, J. (1993). Effects of exposure to nature and abstract pictures on patients recovering from open heart surgery. Psycholophysiology: Journal of the Society for Psychophysiological Research, 30, suppl 1, S7.
    
85. Ulrich, R., Simons, R., Losito, B., Fiorito, E., Miles, M., & Zelson, M. (1991). Stress recovery during exposure to natural and urban environments. Journal of Environmental Psychology, 11, 201–230.
    
86. Ulrich, R., Zimring, C., Joseph, A., Quan, X., & Choudhary, R. (2004). The role of the physical environment in the hospital of the 21st century: A once-in-a-lifetime opportunity. Concord, CA: The Center for Health Design.
    
87. Vedhara, K., & Irwin, M. (2005). Human psychoneuroimmunology. Oxford, England: Oxford University Press.
    
88. Verghese, J., Lipton, R., Katz, M. Hall, C. Derby, C., Kuslansky, G., et al. (2003). Leisure activities and the risk of dementia in the elderly. New England Journal of Medicine, 348, 2508–2516.
    
89. Walworth, D. (2005). Procedural-support music therapy in the healthcare setting: A cost-effectiveness analysis. Journal of Pediatric Nursing, 20(4), 276–284.
    
90. Westbrook, B., & McKibben, H. (1989). Dance/movement therapy with groups of outpatients with Parkinson’s disease. American Journal of Dance Therapy, 11(1), 27–38.
    
91. White, J.M. (1999). Effects of relaxing music on cardiac autonomic balance and anxiety after acute myocardial infarction. American Journal of Critical Care, 8(4), 220–230.