Medicine for the soul

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One percent of the construction budget for Swedish hospitals is earmarked for art. The actual value is more difficult to measure – but studies show clear effects. Patients recover more quickly and staff become more alert. Jenny Damberg considers the motives for art in health care. 

Under the one percent rule, one percent of the cost of publicly funded construction projects is earmarked for art. The rule is applied at the state level, and to varying degrees by counties and municipalities. At New Karolinska Solna, the one percent rule applies to administrative space. In areas where health care is provided, the corresponding figure is two percent instead.

Taken together, this results in a budget for commissioned artwork and art purchases of SEK 118 million – which makes this project unique in scope. By comparison, Public Art Agency Sweden has an annual budget of SEK 33 million to spend on art while Moderna Museet has SEK 3–4 million in grants for art purchases annually.

"In a way, the hospital becomes almost like a huge art gallery. And it is up to us to take advantage of this opportunity. It's wonderful to see that there is room here for so many outstanding young Swedish artists," says Margareta Hamark, project manager at the Communications Department at Karolinska University Hospital and a member of the New Karolinska Solna's Art Council.

The hospital will be inaugurated in 2017 and even though all of the "permanent works", i.e. the commissioned works that are integrated into the buildings themselves, have been ordered, to date only one has actually been completed. The 340 square meter work adorning two outside walls of a garage is the creation of artist Kristoffer Zetterstrand.

Using 27,500 tiles, the work portrays medical history through a mosaic designed as low-resolution pixel graphics in the style of the popular computer game Minecraft, which Zetterstrand also had a hand in creating. An integrated QR code enables curious observers to access a website by mobile phone for an interactive explanation of the work.

Art is to be art

"The current state of technology is mirrored in the art purchased for New Karolinska Solna," says Inga-Lill Bäckström, project manager of the art unit at Stockholm County Council. Lighting technology has rapidly advanced over the past few years. Reliable, energy-efficient LED lighting has been accompanied by a strong advance in light art.

In addition, a great deal of photo art has been purchased and a call for applications for audio art for two waiting lounges will soon be announced. Also under consideration is development of an art app that could be accessed via screens in patient rooms and by visitors on their personal digital devices.

The art program at New Karolinska Solna states that the function of art is to be art. This may sound obvious, but it is an important statement according to Inga-Lill Bäckström.

"Art cannot overly assume the guise of medicine or functionality. Art is what it is. It must convey the humanistic, the aesthetic and the poetic. It embodies a different dimension in the otherwise highly technological hospital environment."

In the hospital, art encounters an audience that has not actively sought it out. Pluralism among the observers is great. New Karolinska Solna expects its visitors to represent over 80 nationalities and all age groups. For the artist, this means embracing a different paradigm than when working independently.

Aleksandra Stratimirovic has created several commissioned artworks for hospital environments, including the current Karolinska Solna, where she has bedecked the ceiling of one of the radiation therapy treatment rooms in the oncology clinic with colorful points of light that are in motion and create new color constellations. Stratimirovic finds it important to speak with both patients and staff in order to meet their needs and requests.

"Many people felt the room was somewhat impersonal. At the same time these are complicated rooms in which to integrate art. Little room is available for anything beyond the therapy equipment and few materials are able to withstand such high levels of radiation. I chose to work with something that would create a more pleasant atmosphere. Non-intrusive, but it is there for observers to enjoy, to relax and perhaps to find hope."

How do you feel about working with such limitations?

"I enjoy it. Finding solutions is exciting and for me it is important to contribute something to such environments. No one comes here to view art, but it should still be there, for those who want to enjoy it," says Aleksandra Stratimirovic.

Art in care environment

Art in the care environment follows the times – and has long done so. In her book Konst på sjukhus (Art in hospitals), Birgitta Rapp, former research director and head of the research program "Kultur i vården – vården som kultur" ("Culture in care – care as culture") run by the Stockholm County Museum, Stockholm County Council and Karolinska Institutet, presents the history of art in Swedish hospitals.

This history began as early as 1551, when Gustav Vasa broke the church monopoly on care by opening Danviken, Sweden's first state-run hospital, to which several triptych doors from the St. Klara convent were moved. The religious motifs were intended to provide spiritual care – both to admonish and to grant comfort.

Hospital care was inadequate for a long time. Patients who could afford it engaged private doctors for house calls. Not until the nineteenth century did care institutions gain higher status. Stockholm built lavish hospitals such as Sophiahemmet and Sabbatsberg, where great emphasis was placed on the interior. Florence Nightingale's focus on large windows for natural light, effective ventilation and to catch a glimpse of nature clearly had an influence.

Time has proven her right: a Canadian study from 1998 showed that more sunlight in intensive care units shortened the length of the hospital stay. The researchers also found a correlation between gloomy rooms and higher mortality.

A decisive shift in the state's role as a mediator of art occurred in 1937. That is when Arthur Engberg, Social Democratic Education Minister, proposed the one percent rule. Public Art Agency Sweden was founded that same year. The first state-financed permanent art installation in the hospital environment, Prince Eugen's mural "Kopparormen," was created in 1939 when Karolinska Hospital was built. It is still a favorite among many today, according to Inga-Lill Bäckström.

"I think everyone likes it. It is a landscape depicting Mont Sainte-Victoire in Provence, which was also a popular motif for Paul Cézanne. But it is also symbolic of the triumph over illness."

Architect and architecture researcher Alan Dilani has 20 years of experience designing care environments. He runs a research center, the International Academy for Design and Health, and is the publisher of World Health Design. The key is to shift the focus from disease to health, according to Dilani. Or, in other words, from a pathogenic to a salutogenic approach.

"The patient should be healthy when leaving the hospital. Sweden needs to embrace this development. Rather than focusing on risk factors and just curing disease, health factors should also be considered: What makes people healthy and allows them to stay healthy?"

This is where art and design play an obvious role.

"Hospitals must be designed as a work of art, not merely from the standpoint of function. This is important for both patients and staff. The staff work around the clock in this environment. In order for them to feel good and work well, positive stimuli must be made available. Half of all healthcare errors are due to the human factor, when medical personnel lose focus. This is because they only use the left side of the brain when they focus on their work, which consumes a lot of energy," says Alan Dilani and continues:

"Exposure to art and design activates the other half of the brain, which helps the individual to relax, while allowing for increased creativity. However, this requires that the art can be interpreted. That's why in many cases abstract art may generate anxiety, rather than alleviating it."

Two newly built examples that Alan Dilani points to are St. Olav's Hospital in Trondheim, "the world's best hospital" in his opinion, and the Royal Children's Hospital in Melbourne, where visitors are greeted by a twelve-meter high aquarium in the entrance hall.

"Nature, as we all know, is the ultimate when it comes to restoring thoughts and energy. This is exactly the feeling that we strive for when designing healthcare environments. Organic forms, beautiful shapes, art, elements of nature and color – we know all this can stimulate human well-being. And that is important. People must become mentally strong to overcome their illness."

Moreover, works of art can also serve as milestones, which visitors can use to navigate. This purpose is important since patients are often already stressed and weak, which impairs their ability to orient themselves. Works of art and other markers are perceived as welcoming and relaxing. This generates a sense of hope and satisfaction, according to Alan Dilani.

One particular work of art at Karolinska is particularly attractive to visitors, according to Inga-Lill Bäckstrom. And that is a bench located at the main entrance in Solna, where artist KG Bejemark has immortalized poet Nils Ferlin in a life-sized sculpture.

"There is always someone sitting there. I think they feel a sense of security next to him."

Text: Jenny Damberg

Effects of art

Positive impact. The positive impact of art on a patient's condition was noted by 55 percent of personnel in a 2006 survey of 17 healthcare facilities in Region Skåne. Among patients and their families, the same survey showed that 64 percent believed that art enhances contentment. Moreover, 31 percent felt that art makes people feel better.

Relieves pain. Viewing a work of art perceived as beautiful reduces perception of pain, as shown by Italian researchers Marina de Tommaso, Michele Sardaro and Paolo Livrea in 2008. In their study, subjects were exposed to painful laser radiation, at the same time that they were asked to view works of art that they had previously assessed as ugly, neutral or beautiful. The research trio was awarded the alternative Ig Nobel Prize for their findings in 2014.

Reduces stress. Patient stress can be reduced by the presence of calming elements in the hospital environment. Among these are music and art that the individual appreciates, the opportunity for entertainment and especially nature, according to a US study (Ulrich et al., 2004) on patients aged 5–17.