How do we solve a problem like… The Evaluation of Arts in Healthcare Settings?

In August 2019 I was delighted to be appointed as Music Programme Manager at North Bristol NHS Trust. During the past 16 months, the question of how we measure the value and efficacy of programmes such as ours and how we communicate what we learn with a diverse range of stakeholders has been one I have wrestled with often.

I am not an academic. My background is in performance, education and community music, so I feel no small amount of trepidation about writing this piece addressing an extremely skilled and knowledgeable audience, many of whom have far more experience in the field than I.

During the first six months of my role (before Covid) the evaluation tools available to me were our Fresh Arts Artist and Volunteer Session Feedback Form, and Daisy Fancourt and Michelle Poon’s Arts Observation Scale. Both of which I have used “on the ground”.

From the quantitative angle, my spreadsheets and tally charts can demonstrate how many individuals have been physically present, experiencing music on offer within the hospital, but this is not the whole picture. Without understanding these encounters from the point of view of each person involved, who am I to judge their levels of engagement? Even when employing a tool such as ArtsObs, I am required to make a judgement on which emoji most resembles the complex human being I am sharing a space with. What if someone’s Parkinson’s masks their true expression? What if they have a facial injury preventing my connecting them with any of the options available? What is the impact of my process of decision making on the result? 

Qualitatively speaking, again, my personal perceptions of musical and relational “quality” when reflecting on my own, and my team’s interactions must surely come into play? Since starting work for the NHS, never have I been more convinced of the value, indeed, the wonder, of music’s power to set the empathic tone for some enormously beneficial connections, not least for myself. But with me, the art form is very much preaching to the choir. Are my internal biases impacting upon my reporting? Inevitably the answer can only be yes.

On September 10th 2020 I attended the International Centre for Community Music (ICCM) Presents Seminar: The need for robust critique of arts and health research in search of guidance and answers, but instead, found myself frustrated, with even more questions than I started off with. Professor Emeritus Stephen Clift set out an extremely cogent argument, however, as someone outside academia it felt very intimidating to offer any opinion, and therefore difficult for my perspective, and possibly those of other commissioners and practitioners to be heard.

Of course I would agree that it is important we do not paint arts in healthcare settings as an all curing panacea. Naturally I would not want the field to suffer as a result of being called to account over unsubstantiated, or unverifiable blanket claims such as “Choirs in care homes reduce falls”. But equally, I would not want the value of the work we do to be underestimated either. 

Professor Clift’s objections to terms like Intervention when describing our work are understandable, but to me the problem is beyond semantics. This is about what we place value on as a sector and society, how we express that to those in power, and how we make what we believe to be valuable available as widely as possible.

Let’s take the example of music within a care environment. I can absolutely envisage a scenario whereby engagement with music reduces the risk of falls. Perhaps residents move more because they are eager to attend sessions? Perhaps this helps them retain their strength and mobility? Perhaps their improved mood and sense of positivity around what they can do empowers them to participate more fully in their rehabilitation? Perhaps, perhaps, perhaps. Equally, I can imagine a situation where the provision of music triggers a fall. Perhaps the person being cared for was concerned the group singing may pass them by and went looking for the music without adequate support in place? Perhaps a participant overstretched themselves during a session and had an accident? Similarly, we all know someone who says ‘I can’t sing’ because of an unpleasant childhood memory of being singled out by their music teacher. 

Years ago, working on a music project in a prison for young women, I met a hugely musical young person. Despite being a very capable violinist, when offered positive feedback on her contributions she told me “Yeah, Mum and Dad gave me everything. Spent loads of money on music lessons. Didn’t work though did it?” I felt heartbroken for her. Her sense of self was such that all she saw was failure. Her parents’ investment obviously hadn’t paid off – otherwise she wouldn’t have ended up in prison. All she could see was how bad, disappointing and lacking she was. For her, the music lessons were not about celebrating a talent, or bringing her joy. They were about trying to fix her.

It is more than just the activity that creates the outcome, it is the manner in which it is delivered, how, by whom, and the recipients perception of themselves as a participant that make the difference.

The psychologist Carl Rogers outlined three core conditions necessary to create a growth-promoting climate in which individuals can move forward and become capable of connecting with their true self: congruence (honesty, genuineness, or realness), unconditional positive regard (acceptance and caring), and accurate empathic understanding (an ability to deeply grasp the subjective world of another person). To my mind it is these qualities, embodied in the most successful arts in healthcare events that create such positive outcomes for our participants. Choir, painting, dancing, making a cup of tea – it is not the activity itself that holds the key, but the conditions surrounding what takes place, the quality of relationships forged in the doing, and how participants feel about themselves before, during and afterwards that has the power. 

Now this is where it gets tricky, because how do we measure that? Give me the same practitioner, delivering in the same way, with the same equipment, but a different group, on a different day, or even exactly the same participants, but just all in a different frame of mind – the outcome will potentially be entirely different. 

This is not something we can create a reliable double blind study for. To try and do so is surely setting ourselves up to fail? A task as impossible as pinning down the precise nature of love. We can describe the outcome; we can recreate the conditions, but the vital spark? That is a magic all of its own.

As someone whose salary relies on charitable donations, working for a larger body funded entirely by public money. I fully appreciate the need for accountability. We must do everything possible to ensure the work we deliver is safe, effective and of the highest quality. How can we make these measurements?

I don’t know any of the answers, but what I do know is this. In my short time as part of the NHS I have already collected more career defining moments than I can remember. I have had the huge privilege of making someone’s day whilst they were cared for at the end of their life. I have stepped into the bedroom of people experiencing life-changing events and offered them the invitation to share the experience of joyful noise. I have enjoyed opportunities to gift people from all walks of life music, free at point of use. We have shared tears, laughter, stories of our lives. They have welcomed me with open arms, danced with me and sometimes, told me to bugger off! But through each interaction my presence has offered patients within our care the opportunity to connect with themselves and to exercise their own agency in shaping an environment that could otherwise have remained entirely outside of their control. To me, the value, the worth of this work is beyond any measure I know of. How do we solve a problem like the evaluation of Arts in Healthcare Settings? How do we catch a moonbeam in our hands?

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