Evaluation of Artworks Royal Aberdeen Children’s Hospital 2006 – 2009 June 2009 Delday and Douglas, rgu insert Insert rach rgu art logo logo

2.4 Note to reader
Case study evidence is in the appendices on the accompanying CD.

Each case study has it’s own Appendix that includes: A Diary of Events which tracks the project alongside the evaluation methodology; full transcripts of the interviews; observation notes and any other relevant material. A Summary of the RACH commissioning process is presented as a step-by-step outline along with the collation of RACH documents used in the process.

The Diary and Summary provide the reader with an overview.
3. Summary of Findings
Key qualities in the delivery of the programme (three case studies) were, first of all, the ambition of the aim – to ensure user consultation directly informed the production of high quality artworks. Secondly it was the breadth of stakeholders involved in each project. This was possible because of the rigorous commissioning process and the mutually supportive relationships between the Art Group, a dedicated coordinator working on site, along with the involvement and support of hospital staff.
The quality of the consultative process was considerable. Staff felt fully involved and informed and enjoyed the experience and thought that the artists working in the hospital added value to the services of departments. In some cases the staff took part in the workshops and were surprised at the range of activities artists undertook and learned from this. The children, families and external youth groups benefited from the artists’ workshops and activities – with significant educational and therapeutic value, as well as enjoyment. The resulting and diverse artworks were considered appropriate for children, families and staff, of high aesthetic quality and vital, having energy.
The impact of the finished works was considerable. Staff felt their working environment was vastly improved and reported significant clinical benefits (e.g. less threatening, enabling distraction). Children and families also thought that the artwork had improved the different areas by making the hospital more interesting and more pleasant.
The artists found the thoroughness of the consultancy greater than in any other commissions for public art they had worked on and, while they found this challenging, it deeply and fundamentally affected practice and the resulting aesthetic. The artists were able to respond imaginatively to the challenges because of the excellent support given by the coordinator, Art Group and staff.

In one case study the project was withdrawn from one of the two sites. While this was, in part, due to the need for more planning, the issues arising showed, in sharp relief, the qualities of an emergent model reflecting the ambition of the RACH approach and some of the risks involved.

One outcome is an emergent model based on cooperative working; one which relies on trusting in the creative process, tries to manage multiple expectations and, with stakeholder learning, is intrinsic to the process. Questions arising from the development of the model have significance for the wider sector where public consultation is used to produce art.
4. Remit of the evaluation
An important benefit of an evaluation is the learning drawn from the experience.
The evaluation, as with a case study, gives a flavour of and insight into the complexity of the processes and includes the responses from the range of stakeholders involved including staff, patients and families, external youth groups, the artists and the Art Group. Due to the sheer number of people involved not every perspective could be included at each milestone of the project. However, key people in the process were interviewed and questioned so it is considered that an accurate depiction is given for each case study.

The qualitative evidence from staff on the therapeutic benefits of the artists’ processes and the final artworks was given in the understanding that the examples were anecdotal, i.e. not proven by hard ‘scientific’ methods. They are nevertheless observed and judged by highly experienced and professional clinicians.

The evaluation cannot (and did not intend to) give quantitative information. However, given the positive responses by staff to the completed artwork, interviewed just 2 weeks to 2 months after installations were completed, the projected value of the work in purely numerical terms (patient turnover) will be considerable.
As with many evaluations, the timescale for completion was usually just after the art is installed. This is a weakness of evaluation in a general sense, rather than the RACH brief for evaluation.

The need for longitudinal studies seems clear.

5. The case studies in full
5.1 Case study 1 Graphic Novel
5.1.1 The brief
The brief was for the artist to produce a graphic novel for use by children admitted to the hospital. The artist would work with patients enabling them to ‘visually express their experiences of being in hospital’. The artist would engage children through creative consultancy sessions to produce material that would direct and inform the content of the graphic novel for adolescents (the target age group was 12+ years). The artist would also consult with staff for their input.⁴
A note on the role of the play staff in the delivery of the programme

The play staff played a crucial part in the delivery of a number of the projects across the programme. They were extremely supportive and involved in this case study, as well as the treatment rooms and the entrance to the Surgical and Medical wards projects (Case Studies 3a and 3b), and the x-ray project (not in this evaluation).

The play coordinator described the role of the play staff as:
‘… providing play and emotional support for children and families who are dealing with illness in hospital and community. The play specialist role within the hospital is to work as part of a multi-disciplinary team to reduce the ill effects of hospitalisation and to ensure that families have as positive an experience and journey through health care as possible.’

Having been involved in the first phase she was extremely keen for the artist’s workshops to continue and had ‘repeatedly’ spoken to the coordinator about this. She described her view on the benefits of the children taking part in artist’s workshops:

‘… having ownership and seeing the end product. It’s a big part of what we do as play specialists – to build self esteem, and having the artist contribute to that and having long term pieces which the children have been part of - their ideas - and to then physically making them I think is beneficial.’
She spoke of the artist’s creating ‘a real buzz’ in the departments and believed strongly in the ‘therapeutic benefits’ of having the artist work alongside the play team and conduct workshops.
5.1.2 Summary of the consultation process
From May to September 2008, the artist conducted twenty consultations within Surgical and Medical Wards, each session lasting between two and four hours. Each session involved different children and, on occasion, adults (parents). There were four children who were in hospital for several weeks and were able to be involved more than once.
The artist was supported by, and worked with the play staff. The activity or play area is situated between the two wards and the artist worked in this area as well as with patients at their bedsides and with a few in isolation wards. The artist worked both on a one-to-one basis and in very small groups (three to four children).
Once the workshops were finished the artist created a storyboard and visuals which were then passed on to the coordinator who liaised with the Art Group and then gave feedback to the artist. During the following three months the artist developed the final artwork, in consultation with the Art Group, staff and patients. Both the artist and the coordinator gained feedback from patients at different stages of design development. The novel was published at the end of March 2009.

5.1.3 Early stage: Hopes and anticipated challenges (Art Group, coordinator and staff)
In this project there was no external youth group involved in the consultations; this was the only project where only young patients were engaged. The Art Group and coordinator acknowledged the potential difficulty of ‘positively engaging’ patients so as to include ‘their voices’.
The play staff, the Art Group and the coordinator knew the artist prior to this commission, as the artist had worked on the pilot project in the High Dependency Unit. Everyone was confident that she could work well with children. The fact that the artist lived locally had also been an important consideration at the selection stage because of the anticipated number of consultations with young patients.
At the outset hopes for the project were to create a publication ‘by children for children’, something that was ‘art and child friendly’ and which would be a ‘useful resource’ for the play staff to have and give to children and something the children could take home with them. It would be ‘fun-filled look at children’s experience of the hospital’, ‘bright and colourful with lots of images to hold the attention of older children’and be ‘of the moment’. It was also hoped that ‘the project (sic) be fun for the patients involved’. A further consideration was that it could be easily reprinted without being too costly when stocks ran out.
It was a shared concern whether the target age group would be in the hospital at the time of the artist’s consultations/workshops, to gain a ‘true picture of children’s “thoughts”’, and be well enough to take part. Subsequently it was very important that the artist be ‘flexible’ in their approach to working.
The play staff said that they ‘were really looking forward to working with the artist describing her as ‘a bubbly personality’ and ‘able to connect’ with children, and confident she would ‘come up with something really good.’
5.1.4 The artist’s process and responses (patients)
The artist was surprised by how little time the children were in the wards (a few days) and felt that this made it more challenging to develop relationships or ‘create a bond with young adults’. It was also that children were often too ill or to participate. This challenge was addressed by:
1. Adapting the artistic process

2. Staff supporting the artist

The artist started out by bringing a wide range of visual material in different styles, including her own sketchbook, to show to the children and used to talk with them. This was a way of introducing herself as artist and she felt this was ‘very powerful’ because many of the children were reluctant to draw and that there are many other ways of making images. Beginning with the children copying different styles of imagery, she gently encouraged the children to re-create what they had drawn and to develop it slightly ‘so that it becomes their own work rather than a copy of somebody else’s images’. This tactic enabled ‘the children to develop some ideas to create their own drawings which in turn provides them with a bit of self confidence’.
Many of the children were ‘happy to just chat’ and tell her about their experience or ‘journey’⁵ within the hospital and she would write this down with them.⁶ The artist worked in the play area and also with patients in their rooms if they weren’t well enough to come to the play area. Often she found that they ‘were too ill or too tired’ so it was ‘too much to ask them to read or to chat’. Overall she found working one-to-one best for the children sharing their stories with her. She found that the play area was particularly good when there were three or four children at one time and they would all ‘work together’ and this also ‘boosted their confidence’ when doing artwork. On average at each session the artist would work with five or six children where one or two would want to ‘sit down and do some work with her’.

Due to the difficulty of engaging with children of the target age (12+) she also worked with younger children, a few 10 and 11 year olds and sometimes much younger children. Her flexible approach included trying different times of the day for the workshops – mornings, afternoons and evenings. The children were busy throughout the day as there was ‘a lot going on’ so she found the slot just before tea time, between 4 and 5 o’clock, when the children were ‘hanging around’, a good time to engage with them, although this could be ‘a hit or a miss’ (whether people want to do art or not) so it was a matter of ‘just coming in and seeing what was happening.’ An effective tactic she used was to leave notebooks and pens in the wards for the children (and staff) to use ‘when they felt like it or had some spare time’. Some children explained that the television was switched off at 9-9.30pm and, because they ‘weren’t ready to call it a night’, had found it nice to have their own notepads to ‘have a bit of a doodle’. The artist described this as children having their ‘own little personal project’ and making them feel they were getting involved in.

Overall the artist spent 70% of the consultation time talking and realised that, although some of it might not directly feed into the content of the graphic novel, talking with patients had value and was addressing the brief in terms of patient enjoyment of the process.
‘…by speaking to him and having a laugh I’m including him in the project as I realise that this type of work is not only about the end product I’ve been asked to produce but also it’s about helping kids on a journey, to enhance and improve their experience of hospital …. I’ve broadened my views of how a young persons unit is run and how art, personalities and staff can help the young adults have a happy experience whilst in hospital.’
The value of spending time with people extended to include adults. For example, she recounted an instance where, working in a single room, her being there had enabled the mum to ‘have a break’ and leave for a time, while the she stayed with the young adult.
The artist’s visual style reflected the material she was gathering – she adopted a collagist aesthetic where she could incorporate little stories, the children’s drawings, and (with one older girl who she worked with for a few sessions) photography of unusual bits of the hospital (e.g. roof, power sockets). Some of the material from the much younger children was used as background textures.
Serendipity also played a part - one Saturday the artist and the coordinator, who normally worked on week days, both happened to be in the hospital. Some of the staff were more available this day and ‘keen to be involved’. Working together, the artist and the coordinator engaged staff by photographing them and getting the children to make monoprints from these ‘portraits’. These more realistic images of people along with the cartoon characters were included in the novel.
Patients’ Responses

A few responses from patients illustrate what they thought about participating:

‘Lynne showed me how to make a monoprint using oil pastels and a photograph, when I finished my picture it looked like it was drawn by a proper artist.’

‘Drawing is fun and I’ve forgotten how sore my stomach is.’

‘These bright colours make me smile.’

‘It’s nice to draw, talk and laugh all at the same time.’

‘If people see my picture maybe it will help them understand how everything works in the hospital.’

5.1.5 Staff support and involvement
Coordinator’s role to support and guide

Across all the projects the coordinator’s approach as to how the art sessions or workshops might pan out was to meet with the artist (after they were contracted) and discuss the way forward with them.⁷ The coordinator tended to take a ‘hands-off’ approach, allowing the artist to direct how the consultations in the wards might be structured and in consultation with the department staff. The coordinator’s role was to support the artist and to ‘guide’ the process through continual ‘open’, quite informal communication with the artist and department staff, whilst monitoring and directing at points when necessary. The fact that the coordinator’s office was situated within the Surgical and Medical Ward helped with this open and relaxed approach to communication with everyone (e.g. people saw the coordinator frequently and knew where she was situated).

In this project the coordinator was particularly concerned that the artist was supported emotionally, knowing that coming into close contact with sometimes very sick children might be distressing - ‘potentially quite traumatic’. She was also aware that the artist in this kind of project where the artist is ‘not seen as someone official’ or medical can become ‘a sounding board for parents or patients.’ The artist can become ‘an unofficial listener’. The artist needed to have ‘that sympathetic reaction but without actually getting emotional about it.’ To check the artist was coping (emotionally) or if any issues had arisen, she stressed her availability to talk ‘at any time’, and when not in the hospital herself that the artist had ‘plenty of staff she could speak to’.
The crucial role of the play team – a conduit between the artist, patients and other staff

Although all of the play staff were involved and helpful, one play specialist in particular took ownership by going out of her way to assist the artist. She introduced the artist to Health and Safety issues and Infection control (part of the artist’s orientation, also undertaken by the coordinator). She introduced the artist to patients, spoke to patients and explained the idea and encouraged children to participate when appropriate. She made lists of children who might be available (interested and well enough) for the artist when she was not there and informed ward managers of when the artist would be coming in. In this way the artist could maximize the number of consultations undertaken. She also collected the notebooks at the end of the day from the patients ready for the artist coming the next time.

This play specialist skillfully prepared the artist for working with the children. Where she felt it necessary she would give background information the artist might need to know (and stressed the confidentiality aspect); for example a child might be just back from theatre and tired, or they might be just about to go for a treatment and therefore some ‘distraction’ would be beneficial. Also she would explain if there were any social or family issues, such as foster care or if there was no contact with a family member – so that the artist ‘didn’t put her foot in it’ when she was speaking to the children about the graphic novel. She guided and made suggestions.
The play specialists were very aware that children in isolation rooms were in particular need of ‘a bit of company’ as they could get bored and needed stimulation.
‘It is a priority children in isolation have play intervention as they don’t have the freedom to go to the activity area. They still need input and distraction when they are in there – it’s the boredom factor when they are in the cubicle all the time. They might not want to do actual art activities, but they want the company and the support, telling them things about the outside world that they are not seeing, especially if they haven’t got family members coming in to see them.’
On occasion she assisted the artist to actually go into the isolation areas (special clothing etc) and offered to help such as ‘to laminate anything that was made so it could be removed and used’.

Aware of the challenges for the smooth running of the project she felt it crucial that staff knew when the artist was coming in, and also that the artist could ‘be flexible’:

‘I liaised with the nursing team so they were aware of whom she was and they were quite happy for her to come in even if I was not there. So, although she was kind of working under us, she was able to come in anytime if the nurses were aware. I left her a list of names along with which bays they were in and asked the artist to check with the sister in charge that it would be OK for these children to take part at that time.’
Also when the coordinator was not in the hospital (2.5 days per week):
‘When the artists are here they were working alongside us although they are working for RACH (Arts Group). They got used to going round in the hospital, but the artists knew they could always come back and ask the play staff if they had any problems.’
The play specialist gave examples where she observed the children enjoying working with the artist e.g. an older girl staying for a longer term and involved in taking photographs, a boy with two broken arms who enjoyed telling his story of the journey in the hospital, a child that was absorbed in drawing unusual aspects of what they could see from their bed.
Play staff also sought permission from parents for children’s work to be included in the novel and names and addresses were collected so they could be contacted for future involvement in the project.
An idea suggested by them was for the young participants to be able to actually see the novel through to completion by accompanying the artist to the printers to see it coming off the press (in Aberdeen). In fact this couldn’t happen due to the children being unavailable or too ill. Instead it was planned that photos taken at the printers would be posted to them.
5.1.6 Negotiating the end product
After the workshops had finished the artist interpreted the material she had gathered from the children and produced a storyboard of the whole book which she then discussed with the coordinator. The coordinator presented this to the Art Group where comments and recommendations were made and fed back to the artist via the coordinator.
The first idea by the artist was to use a main character dressed in an ‘invisible’ suit who would show children around the hospital. This was felt to be too impersonal and was changed to include more ‘real’ characters in the novel (alongside the cartoon characters) in response to the Art Group. Characters in the early visuals were also felt to be ‘too young’ and staff felt there should be ‘more about the staff roles’ in the publication. To this end the coordinator gathered factual descriptions from the staff and this appears on the inside front cover and the artist visually infused more of the staff roles throughout the novel.
Particularly those in the Art Group with educational expertise made constructive criticisms, such as typography and readability including: being able to read the images without the text because they ‘could not expect all the children to be able to read even with the target age of 12’; capital letters, difficult for dyslexics to read, so needed to be changed; titles at the bottom of the page were moved to the top of the page.
The completed novel is 24 pages with the first part giving a general introduction to the hospital followed by a series of individual stories of children’s experiences, each story appearing over one or more pages.
5.1.7 Completion of the project: reflection on process and responses to final artwork
At the outset of the project one member of the Art Group thought that she didn’t think she would like the end product but, in fact, she liked the finished product and was glad that they had made the decision to go ahead with the project idea. All of the Art Group felt that the artist had ‘responded well’ to changes and suggestions made by themselves and the staff. The publication was regarded as a ‘bright and colourful’ novel, ‘appropriate for the target age’, with lots of images for children to look at. It would be ‘a really useful tool for the play staff to use with adolescents when they are in-patients.’ It was appreciated that the artist had worked well with the children given the challenges of engaging patients in a hospital setting.
The coordinator was ‘very impressed with it, and loved it’. She found that when showing it to adults she got very different reactions to those of children (in the hospital):
‘When I take it to children – they get it straight away – or most of them do. Many children of the group it is aimed at, which is 11 – 14 years, they get it. They get the fact that it’s read page by page and they laugh at it.’
She noted that the scheduling was ‘slightly out’ because of the length of time it had taken the artist to complete the consultation phase and make the changes. It had also been delayed because the final stage to complete the work happened during the three months after Christmas (January –March 2009) and because of other projects having slipped this had impact on the amount of time the coordinator could to devote to this project.
The play specialist enjoyed working with the artist and ‘looked forward’ to the next artist’s workshop. She felt the artist had ‘a good rapport with the children’ and stressed the importance of the play staff supporting her. She appreciated all the hard work that had gone into the novel, was excited to see the end product and was pleased and very proud of the finished result and the fact that it ‘belonged’ to RACH in the sense that it was by patients for patients and included members of staff.
She thought it would definitely be useful for the play staff to use and be interesting and valuable for the children. She had given the novel to two adolescents in the medical ward (boy aged 13 and girl aged 16) and both had responded positively - they enjoyed it and liked it – it was bright, colourful, full of images to look at and would be useful in terms of explaining different areas and staff they might meet. She thought that, because of the descriptions of the staff at the beginning, it was not really for younger children.
Looking at the book she describes the content – the ‘journey’ through the hospital and explains that everyone she had shown it to had been positive and some of the children had commented on recognising individual staff members in the novel:
‘I think it’s all really good. The journey starts on the outside front cover, we see the front of the hospital, and then we go into the outpatient’s area, the waiting area. And obviously it’s the child that is experiencing that. Then it is moving through the hospital, coming up the stairs and we see the activity area, there are also facilities for the adolescents, then we meet the people that they are going to see. Here is a nurse, and here is Dr King, (oncologist in the hospital) - these were some of the photographs of the environment taken by an older girl. And then the next part is about the children’s experiences where patients spoke to the artist about their own experience of being in the hospital. Each child has a page, we start here with Gavin and his story – he’d had an x-ray (actually his story goes over two pages). Then next is an older boy, visiting his new sisters. He’d found this quite funny because he was actually visiting them and then they had to visit him in the hospital.  Then it’s the story of the girl who fell off her horse. So each story is from a different child and about the different procedures and is told in their own words – of how they found their experience. And then there are the play recreational activities– we see the play staff that can support them and provide things at their bedsides. From a play point of view we see one of the comments from a boy who has fractured both his arms – “I can’t do much so the play staff organise fun activities for me.” And here we see visitors like the magician come and provide fun for the children.’
She thought that the age group could be 10+ and that the real test of how much children appreciated the novel (and by association their stay in hospital) would be whether the children actually took the publication home with them when they left as ‘something they could relate back to.’
Cooperative working as preparation and flow

The artist was happy with the consultation process and enjoyed the experience. She found the consultancies interesting although it was a challenge to deal with the turnover of children and the fact that often they were too ill or tired. She found the support from the coordinator and the department staff excellent, in particular the play staff in terms of preparation for meeting with patients. The artist felt this crucial because she did not want to accidentally upset a child and she described how, when encountering a child for the first time, she ‘didn’t want to be surprised’ and ‘let the emotions she might be feeling show on her face.’ It was very much a case of ‘working together’. The artist thought that the coordinator had helped with ‘the flow’ of the whole process, including getting feedback from children to the visuals at the early stage and towards the end. She felt the finished novel had fulfilled the brief.

Additional feedback

The novel was given to adults at a local book club to discuss. The group included teachers and a staff nurse, and most were parents or grandparents. It was also given to staff members in the local library service and to a parent who works (freelance) for the cultural sector, including art in hospitals. Three children were also asked to respond.
The book club members put emphasis on the informational qualities of the novel and were quite critical of this: it did not give enough information about any one area/department; some of the factual information was incorrect i.e. wearing headphones in an MRI scan; some of the language level was inconsistent and for older children it might look like ‘a book for kids’; it did not include multi-cultural groups. Some found it a bit ‘visually chaotic’ and the narrative ‘a bit muddled.’ It was noted, however, that all of the children tended to look very happy and smiling and thought to be ‘bright, cheery and colourful.’
Suggestions made by the book club included: producing separate leaflets/booklets specifically for each department with more factual information, rather than bits (with ‘superficial’ information) about everything which would not apply to each child; to make two versions of the book, for the younger and the older age groups; to include other cultures in the imagery; to be more consistent in language level/tone; that it was OK to include children that might be sad or crying; to include factual information about hand washing and whether they could use mobile phones and games consoles.
Other adults thought it was attractive and that it would appeal to children and be useful, although some also found the narrative ‘a bit muddled’. Others thought it appealing because it used ‘plain language’. Two people thought that the imagery could be a bit scary for younger children.
An interesting comment (from one person) was that children in hospital can be reluctant to ask questions and that the book would be useful in terms of ‘answering a lot of their queries’ and useful for ‘information and reassurance’. A suggestion was that ‘typical questions and answers’ could have been included at the beginning of the book and that some of the language could have been simplified further.
The average target age group was felt to be 10-12/13 with as young as 8/9 and one person suggesting 8-14.
The children (aged 13, 13 and 10) all thought the book would be useful:

‘for children who might be worried about doctors’

‘to help children know what goes on, but maybe they can’t read’

‘so you do not get scared when you are having an operation’

‘it was very well put together’.

They all thought it was for much younger children than themselves.