Is the environment important to hospitalized patients? Yes. Pediatricians have understood its importance for many years. Many children’s hospital wards are decorated with fairytale figures, such as Peter Pan and Cinderella, well known to patients. This is not to hasten healing or alter the prognosis but, rather, to make the stay in hospital less difficult than it might otherwise be. Why is the same attitude not taken with adult patients?
A number of years ago we opened a state-of–the-art bone marrow transplant unit in St James’ Hospital in Dublin, Ireland. As Medical Director (author SM), I was impressed with the clinical environment but was troubled by the lack of any ‘personal space’ for the patients. It was forcefully brought home to me when a patient, undergoing a bone marrow transplant, asked for flowers to be placed at the window outside her room. I told her to write to the C.E.O as he was more likely to respond to her request than a similar request coming from me. The C.E.O responded by arranging for flowers to be placed outside her window but none of the other transplant rooms!! I was then determined to do something that would make the environment ‘less clinical’ whilst adhering to infection control guidelines.
We established an Advisory Board consisting of a Medical Director/ Principal Investigator, head nurse, clinical psychologist, art historian, hospital arts officer, and artists. We began within the general environment of the transplant unit. We had discussions with many artists and eventually decided to paint the walls of the airlock and the corridors. We conceived the project when we attended a conference in the Irish Museum of Modern Art (IMMA) where we met the artist, Eric Glavin. He gave an impressive talk on the use of ‘signage’ in his art, and we asked him to look at the transplant unit and come up with some ideas. He suggested painting the walls of the airlock and corridors with colors of county football teams. In Ireland everybody knows their ‘county colors’ and thus patients, staff and visitors could easily identify with the painting. A number of patients had given a small donation for ‘improvements’ to the unit so, following discussion with a senior nurse in the unit (Liz Higgins), the money was used to pay the artist to paint the unit (Figs. 1 and 2).
The quest then began to find a way of improving the environment for patients, and specifically to improve their quality of life. Quality of life (QoL) is considered, in this essay, as the ability to provide patients with serious illnesses the resources to minimize stress, anxiety and depression. A yearlong discussion took place, which culminated in a meeting with the artist Denis Roche at the Media Lab Europe (European Research Partners of MIT Media Lab). He developed the idea of a virtual window on the walls of patients’ rooms that would attempt to alleviate a sense of isolation. The virtual window contained multiple channels including a virtual portal to a familiar place with which the patient had a strong connection. The installation of this virtual window together with projection facilities and a simple remote control (Fig. 3) were greatly facilitated by a hospital physicist and artist, Fran Hegarty. Initial funding for a pilot study was provided by a charitable body, The Bone Marrow for Leukaemia Trust (BMLT).
I decided to carry out a randomized prospective clinical trial to measure the effect of our intervention on anxiety, depression and the expectation of undergoing a bone marrow transplant (Clinical Trial gov identifier. NCT 00348959,) as I felt that doctors would not believe the effect of this type of intervention unless it was statistically verified. In order to fund the study, I applied for a grant from the Irish Cancer Society (ICS,) which was successful. A senior nurse from the School of Nursing and Midwifery at Trinity College, Dublin, Catherine McCabe (C McC), then became a member of the team.
The study ran from June 2006 until August 2009, and the results were published in 2011. All patients referred for allogeneic HCT were interviewed by C McC. Following agreement to participate, patients were randomized to a room with/without ‘Open Window’. This led to anxiety in some patients if they were allocated to a room without ‘Open Window’. All patients were treated with the same transplant protocols and treated by the same medical and nursing staff.
The study enrolled 96 patients to the intervention arm and 103 to the control group. Those participating in the intervention arm had significantly lower levels of anxiety and depression on the day of the HCT, and less anxiety at days 7 and 60 compared with patients in the control arm. Participants in the intervention arm also reported a significantly better experience of the transplant procedure when compared with those in the control group. We concluded that this art intervention had had a positive influence on health-related quality of life and patients’ experience of having an HCT. The details of the study can be found in reference.1
When qualitative data were analyzed, patients in the intervention arm commented freely on their likes and dislikes about the ‘Open Window’ project and how it made them feel. Here is a typical example: ‘It kind of took me out of this place for a bit, to somewhere I can picture myself sitting down having a picnic’. 2 An unexpected finding was the opportunity provided for patients to discuss ‘Open Window’ with staff and visitors rather than their medical complaints.
Following the presentation of ‘Open Window’ at the annual meeting of the European Hematology Association (EHA), the EHA decided to adopt ‘Quality of Life’ as its theme of the year in 2013-14.3. However, although ‘Open Window’ was presented to professional groups of health-care workers from Singapore to the National Institutes of Health in Bethesda and the European Society for Blood and Marrow Transplantation (EBMT), surprisingly, it failed to generate much interest among doctors. Less surprisingly, the study and its results were also rejected by numerous well respected medical journals, although it was favorably mentioned in a World Health Organization European report.4
In order to understand the thinking behind ‘Open Window’ it is necessary to outline how ideas about art had changed in the past 50 years, during which a tectonic shift occurred in western culture. In the gradual move from modernism to postmodernism, art was no longer seen simply as an object in the form of a painting or sculpture. The field expanded to include art in the form of installation, performance, photography, video, or film, underpinned by concepts and ideas. Allied to this was the dismantling of modernist ideas of the genius ‘godlike’ artist or author, the prestige given to originality, and the idea of the virtually static, passive viewer. All these shifts did not happen overnight. As with any historical change they took place gradually and were supported by theoretical, philosophical and literary texts. “The Death of the Author” (1966) by Roland Barthes,5 for example, was immensely influential in terms of shifting the pendulum from the author/artist to the reader/viewer. Artists such as Marcel Duchamp, (one of the most influential artists of the twentieth century), were pivotal both conceptually and with works of art. His lecture, “The Creative Act” (1957), suggested that the viewer contributed as much as the creator to a work of art.6
The democratization of art was another underlying goal in the face of modernist elitist attitudes. Thus, art often bypassed the gallery or museum in favor of quotidian places, occupied by ordinary citizens. Pop art led the way by taking ordinary objects and treating them as art in much the same manner as Duchamp’s ready-mades, like the urinal called Fountain, which were conceived to be art objects.
The effect of this shift has been revolutionary, opening up new forms of art, creating new spaces within which to view them, and forging a new role for the spectator/viewer, who gradually became an active participant. As with any revolutionary change, it was not adequately understood initially by the public or the art establishment and was resisted in a variety of ways, often dismissed as ‘not art’. ‘Open Window’, was conceived according to the postmodern principles outlined above.
The Advisory Board oversaw the selection of images feeling it important to provide individual patients, each at an extremely vulnerable juncture in their lives, with images that would not be disturbing, provocative, or offensive. Thus, a bank of images was accumulated that ranged from static views of landscapes/seascapes, abstraction, flowers, and animals to moving images of water, landscapes or animals, often with accompanying music. The latter proved to be the most popular choice of patients (see video).
A most important feature of the moving images was that they were constructed to move more slowly that most television or film images. This was designed to induce a more contemplative experience. Hegarty, the artist of the Wind Chimes series (2003) recently told the authors:
My intention was to make an audio-visual piece that brought nature images and a gentle soundscape into these clinical spaces. I was aware that slow Delta wave EEG signals are associated with relaxation and restorative sleep. These waves have a periodicity of less than 4 Hz. I felt it would be interesting to explore gentle movement in nature that had a similar periodicity and video it to use that as source material.
I wanted the music to have the quality I admire in early Japanese ambient electronic music, engaging, yet simple. I used a tempo of 60 beats per minute so that slow moving elements in the music would naturally fall one second apart or 1Hz, mirroring the speed of movement I was hoping to capture in the video. The video was edited without any computer enhancement. When finished, it felt to me that the piece had become a study of wave motion…one of the ways energy is transferred in the physical world. This felt like a good metaphor for the positive energy I hoped the audio-visual would bring.
There was also a bank of reproductions of classical art, in the form of mosaics, paintings and sculptures.
Another crucial factor was that the patient was in charge of ‘Open Window’. Therefore, they could choose to view from any of 9 channels. This was facilitated by a specially designed remote control, as mentioned, that required little strength in these very ill patients. They could also keep the TV on at the same time, if they wished. Finally, none of the computers and other machinery used to operate ‘Open Window’ was visible in the patient’s already machine-cluttered room.
The radical shift in thinking in the arts world outlined above had now entered a medical one. And this may be relevant to the general medical dismissal of ‘Open Window’, in spite of the fact that it was statistically demonstrated to be of great emotional benefit to critically ill patients. In this context, it is worth noting that nurses and clinical psychologists were not as antagonistic as doctors. Like global warming, the case for art having a positive effect on patients’ well-being has been accepted for many years.7 So, the question to be asked is: Why are doctors not interested? Like many questions the answer is complex. Most medical students receive their education in a didactic fashion from teachers who believe in the concept of evidence-based medicine and rely solely on the use of quantitative research. Qualitative research is frowned upon as being inferior, and doctors believe it should remain within the realm of psychologists, philosophers and sociologists.
However, it is our belief, as Sir William Osler said: ‘The good physician treats the disease. The great physician treats the patient’.8 This implies a holistic approach, treating the patient, body and soul, and in this case the environment, of hospitalized patients. In an attempt to encourage a holistic approach to medicine many medical schools have included ‘medical humanities’ in their curricula. The success of this approach in making doctors more ‘caring’ awaits definitive analysis but it is unlikely that ‘medical humanities’ will prove detrimental to medical practice.
Architects and hospital designers are becoming more aware of the importance of patients’ environment on their QoL.9 The situation, however, may be different in private versus public hospitals. Private institutions may advertise a patient-friendly environment to attract patients whereas this does not pertain in public hospitals.
Although the technology used in ‘Open Window’ has been superseded by mobile telephone and the internet, we still believe that an ambient art intervention will benefit patients in a very different way from that of talking to a loved one using mobile phone technology.
New strategies of audience participation have been part of art practice since the 1960s. This included a change of context in how an artist related to an audience. What was created was less important than the kinds of relationships established. ‘Open Window’ espoused this approach. Not only did ‘Open Window’ prove to be a success with patients, in an extremely difficult environment, and at a time of great stress with death a real possibility, but it pointed to the way that art can sensitively be used to assuage a sense of isolation, despair, powerlessness and panic in human experience.
Many doctors advocate on behalf of their patients for a more empathetic, humane environment, in the face of the ‘molecular revolution’ and more sophisticated technological therapeutic interventions. Of course, the scientific basis of medicine should continue to flourish, but humane treatment and an awareness of the importance of the patients’ environment and QoL should also be fostered.
About the authors
Shaun Richard McCann received his M.B. from University College Dublin. He became a Member of The Royal College of Physicians in Ireland (MRCPI), by examination, in 1973. He was a specialist medical fellow at the University of Minnesota from 1974-76. The main focus of his research then was red cell structure and function, especially in hereditary spherocytosis. Click here to learn more.
Brenda Moore-McCann received her M.B. at University College Dublin and was medical director of a non-governmental agency, Family Planning Services, before taking a Diploma in the History of European Painting at Trinity College Dublin followed by a B.A. (Mod) in Art History and Classical Civilisation. She received her PhD at Trinity College Dublin in 2002. Click here to learn more.