A Rapid Evidence Review of the impact and efficacy of arts-based interventions to support healthcare professionals

MASC Report. Written 2022.

Executive Summary

Background

It can be argued that involvement in the arts can help reduce anxiety and burnout levels in hospital staff through providing them safe spaces to play, relax and tell their stories. In a 2019 report on the role of arts to improve wellbeing Daisy Fancourt and Saoirse Finn noted that involvement in the arts can improve wellbeing for participants, stating that

Arts engagement can enhance multidimensional subjective well-being, including affective well-being (positive emotions in our daily lives), evaluative well-being (our life satisfaction) and eudaimonic well-being (our sense of meaning, control, autonomy and purpose in our lives) (2019). 

Performance arts in particular can have a positive impact on wellbeing with organisations like The Garage and The Mental Health Foundation recommending participation in performance arts as a useful way to improve participants' sense of wellbeing (see The Mental Health Foundation, 2019 and The Garage, 2021). Prior to the COVID-19 pandemic, anxiety, stress and burnout levels in hospital staff were already high (see Peterson et al, 2008, Cheng and Cheng, 2017 and Koinis et al, 2015) with one study estimating that over 60% of all healthcare workers prior to the pandemic experience burnout symptoms in their day to day life (see Mohanty, et al, 2019). Performance arts techniques like acting, singing or storytelling have been used successfully within healthcare settings to decrease anxiety and stress levels for the staff involved (see Williams et al 2018, Nurser et al, 2018, De-Vecchi et al, 2016 and Gillam, 2018).  However, the need to support the mental health and wellbeing of hospital staff became more pressing during the COVID-19 pandemic, with many hospital staff reporting an increase in their stress, anxiety and burnout levels (see May et al, 2021, Rana et al, 2020 and Spoorthy, et al 2020). It is important to note that when used correctly and with the appropriate set up and time given to interventions that performance arts within healthcare settings “can be a powerful tool for supporting health” (Fancourt, 2017:41). 

Aims

This review aims to summarise the limited body of research on how effective and impactful performance arts based interventions are at supporting the mental health and wellbeing of hospital staff. This review has a specific focus on whether performance arts based interventions are effective at reducing burnout symptoms and anxiety levels in hospital staff. Finally this review seeks to provide data to inform further research in the field. 

Definitions

There are various definitions of the key words used in the review. This study uses Cambridge Dictionaries' definition of wellbeing and burnout and acknowledges Baxter and Lows 2017 definition of applied theatre as a foundation for further exploration on the topic.  Additionally this review seeks to define performance within arts in health, relating White’s 2013 performance theory to an applied theatre setting.  

Wellbeing “the state of feeling happy and healthy” (Cambridge Dictionary, 2019). 

Burnout “the state of having no energy or enthusiasm because of working too hard” (Cambridge Dictionary, 2022) 

Applied Theatre is typically defined as “theatre making with, for and by particular groups of people and in locations that are not traditionally associated with theatre” (Baxter and Low 2017:5). There are many different strands of applied theatre, from immersive theatre pieces that use Augusto Boal's Theatre of the Oppressed technique to explore solutions to social issues, to site specific performance pieces that use their surroundings and communities within their locations, as inspiration and performers, applied theatre has many uses. Within the context of this review, “applied theatre” is used to describe an event in a hospital that has an intended element of performance (whether storytelling, clowning or even sitting and talking over a cup of tea). 

Performance also has a lot of definitions. Within this review, a combination of definitions of performance are used: 

Firstly: “the action of entertaining other people by dancing, singing, acting, or playing music (Cambridge Dictionary, 2019a). 

And secondly: “a particular action, deed, or proceeding” (Dictionary.com, 2019). 

Within the broader scope of applied theatre, practitioners argue that a performance does not need to include an audience in order for it to classify as a performance. Instead, the intention behind the action being performed is important (White, 2013). White argues that if the performer is intending to share their piece of work, it classifies as a ‘performance’ regardless of whether anyone is there to witness it. Importantly within White's performance theory, the piece being performed does not have to entertain its audience, it merely needs to be an action or deed that is intended to be performed. Within this review, “performance” is used to describe an action, deed or piece of work that is either being shown to other people or being created with the intention of exploring the well-being benefits of said action, deed or piece of work. 

Asset-based interventions: this term is typically used to describe an intervention that “places the emphasis on people’s and communities’ assets, alongside their needs” (Social Care Institute for Excellence, 2017). 

Review Protocol

Search protocol

To collect the papers for this review, 3 databases were searched: Pubmed, Taylor and Francis and CINAHL. The initial search for “asset-based interventions” brought up limited to no results, so specifying “performance arts based interventions” was needed to widen the scope of the searches. Initial searches with the keywords “applied theatre”, “acting” and “performance arts” also resulted in no applicable results across all three databases. With so few results being found across all databases, the searches and keywords kept broadening to include a wide variety of searches and keywords, including but not limited to: “community theatre” “arts-based interventions” “burnout” “music” and “singing”. Eventually 24 different key words related to performance arts, applied theatre and hospital staff wellbeing were collated. Due to the same search failing to yield results across multiple databases, 12 different searches using a variety of combinations of the keywords were used to collect the 24 articles from the databases used within this review (see appendix 2). Because of the time constraints of the author, grey literature was not included in the searches. Therefore this review focused solely on peer reviewed journal articles or studies. Additionally a snowball search of all included article bibliographies was conducted, which resulted in a further 10 articles being found, 9 of which were used within the final review. 

Inclusion/exclusion

This review only uses papers published after 2003 and that are written in English. To be included, the papers must clearly state they use performance arts and or applied theatre based techniques with hospital staff in a hospital building. Additionally the papers must state that they seek to improve the wellbeing of the staff involved and have a clearly identifiable method used to achieve this. Provided the report graded above a low on the critical appraisal section and achieved all other criteria, it was included. There was no specific search location or specific staff criteria.

Critical Appraisal tools

Two appraisal tools were selected to appraise the papers. JBI was used to appraise any randomised control trials and quantitative studies. MMAT was used to appraise qualitative studies and any mixed method studies. A point was awarded any time a paper answered YES. Scores were then given; anything that scored between 0-35% was marked low quality, anything 36-75% was marked medium and anything 76% and above was marked high. Due to some studies being limited in both time and participants, not all papers appraised reached the required medium mark. Of the initial 30 articles collated, 24 were included in this review, of which 14 graded high. Of these 14 reports 10 were music related and 4 were applied theatre related. The remaining 10 papers graded medium, of which 10 were music related and 0 were applied theatre interventions. 

Synthesis 

For ease of access, the 24 reports included in this review have been divided into two topics: music based interventions (which include singing interventions) and applied theatre based interventions. Due to the limitations of the review study design, this is not a complete list of all performance arts based interventions. This review merely aims to give an overview of the two common themes of interventions within the field of performance arts for wellbeing. 

Music 

Using music to manage hospital staff's wellbeing is a relatively new and under-researched area. However researchers have noted that “both passive and active engagement in music have been reported to reduce stress” (Finnerty et al, 2022). Of the 20 music related articles collated, 8 were specifically using ambient music as an intervention. Of these 8 articles, 2 were systematic reviews (see Finnerty et al, 2022 and Raglio et al, 2020) and the remaining 6 were studies (see Ploukou and Panagopoulou, 2018, Apps and Sunderland, 2021, Preti and Welch, 2012, Gatti and Silva, 2007, Moss et al 2007 and Harrop-Allin et al, 2017). All 8 articles were in agreement that ambient music within hospitals is positively impactful for the wellbeing of the staff involved. 5 of the 8 reports stated the intervention was effective (Ploukou and Panagopoulou, 2018, Apps and Sunderland, 2021, Gatti and Silva, 2007, Moss et al 2007 and Harrop-Allin et al, 2017). Of the remaining 3 studies, 2 did not have enough data from participants to confirm the effectiveness of the intervention (Preti and Welch, 2012 and Raglio et al, 2020) and the final report said the interventions collated were hardly effective (see Finnerty et al., 2022). This was due to time constraints for the staff involved. 

3 studies reported on the impact and efficacy of music therapy interventions (see Yıldırım and Çiriş Yıldız, 2022, Kacem et al, 2020 and Brooks et al, 2010). All three reports agreed music therapy was both effective at reducing stress, anxiety and burnout levels in staff and also had a positive impact on the overall wellbeing levels of the staff involved. 

A further three studies investigated whether making music with hospital staff would have an impact on their wellbeing (see Bittman et al, 2004, Bittman et al, 2003 and Sonke et al, 2014). 1 report concluded music making was effective in its aim to positively impact on the wellbeing of staff (see Bittman et al 2003). 1 report did not have enough data to confirm the impact and efficacy but did have positive results overall (Bittman 2004). The final report was mixed in its outcomes, with some staff having positive outcomes and others having little change in their stress and anxiety levels. The study concluded that while it did have good outcomes overall, music making was not an effective intervention for hospital staff due to the staff’s time constraints making it hard for them to attend sessions (see Sonke et al, 2014). 

3 studies focussed on group drumming with hospital staff (see Maschi et al, 2013, Archambault et al., 2018 and Newman et al, 2015). All 3 reports concluded that drumming had a positive impact on the wellbeing of staff involved, however only 2 concluded that the intervention was effective, with Archambault's report having too few participants to reach a conclusion. 

The remaining 3 reports were assorted music or singing based interventions. 2 focussed on storytelling through music (see Phillips et al, 2020a and Phillips et al, 2020b). Both these reports noted positive impacts on the wellbeing of staff involved. They both also concluded that the intervention was effective. The final report was a choir based intervention that noted positive impacts on the wellbeing but was not sure the intervention would be effective long term, again due to time constraints on the staff (see Vaag et al, 2013). 

Applied Theatre

Applied theatre interventions, like music based interventions, are also critically under-researched. Applied theatre researchers have noted that applied theatre interventions in hospitals “have the ability to decrease anxiety and pain, and positively elevate mood[...] [as well as provide] reductions in routine stress and improved working conditions among healthcare providers” (Blain et al, 2011). 4 of the 24 articles found were assorted performance arts based interventions that involved an element of applied theatre based performance. One study looked at the impact of clowning on oncology nurses’ wellbeing (see Blain et al, 2011). The study concluded that clowning had a positive impact on the anxiety, stress and burnout levels of the nurses on the ward. However due to the small sample size and short time frame the study took place in, it was not possible to conclude how effective the intervention was. 2 reports used a variety of playful interventions to try and support the wellbeing of hospital staff. One report used a relaxed tea and storytelling idea (see Callis et al, 2021). This report was not conclusive on both the wellbeing outcomes or the efficacy of the project. This was due to a small sample size. The other report used playful arts-based therapies to try and improve staff wellbeing levels (see Italia et al, 2008). The study concluded that the playful therapies did have a positive impact on the staff involved and the intervention was effective in its aim to impact the wellbeing of the participants. The final study of the 4 applied theatre based interventions focussed on a 5 component intervention approach - cognitive, somatic, dynamic, emotive and hands-on (Sallon et al, 2015). Music, singing, creative writing practices, listening circles and dance were among some of the interventions used. The study concluded that all applied theatre performance based interventions used were both effective at reducing stress and anxiety and had a positive impact on the general wellbeing levels of the staff involved (see Sallon et al., 2015).

Challenges

Several challenges were noted within the papers found. 3 of the 20 studies found that time constraints prevented staff from attending and or made them feel more anxious due to concerns over patient care. One study attempted to reduce this challenge by scheduling the intervention outside of the staff's shifts but subsequently ran into the issue that staff were reluctant to come in on their days off (see Sonke et al, 2014). The other two interventions did not attempt to reduce this challenge, choosing to note it was a challenge they faced instead (see Finnerty et al, 2022 and Vaag et al 2013). 

COVID-19 was noted as a challenge in 1 report. The report specifically focussed on the challenges for the nurses working with people who tested positive for the virus, prior to the vaccine being released (see Yıldırım and Çiriş Yıldız, 2022). The authors noted that COVID-19 contributed to higher levels of burnout, anxiety and stress for the nurses working across the hospital, stating that one challenge for the participants themselves was that those “who have direct contact with a potentially fatal virus are confronted with high anxiety about personal and family health and the stress of balancing this anxiety with ethical obligations of continuing to provide nursing care” (see Yıldırım and Çiriş Yıldız, 2022). COVID-19 is still a challenge in many hospitals around the world today (see Magnavita et al, 2021, Ness et al, 2021 and Magnavita et al 2021b).

Limitations

With regard to the studies included in this review, there are several limitations to the data appraised. 25% of the papers found did not have enough participants to reliably confirm the efficacy or impact of their intervention (see Newman, et al, 2015,  Callis et al, 2021, Archambault et al, 2018, Preti and Welch, 2012, Blain et al, 2011, Apps and Sunderland, 2021). An additional 16.7% of the papers appraised did not have enough data collected, despite higher participant numbers and so therefore their efficacy and impact was also unconfirmed (see Vaag et al, 2013, Harrop-Allin et al, 2017, Raglio et al, 2020 and Bitman et al, 2004). Finally 20.8% of papers did not have enough time to conclude on the impact of the intervention (see Brooks et al, 2010, Gatti and Silva, 2007, Maschi et al, 2013, Ploukou and Panagopoulou, 2018 and Yıldırım and Çiriş Yıldız, 2022). 

Conclusion

This review has aimed to discuss the impact and efficacy of performance arts based interventions that seek to improve the anxiety, stress and burnout levels of hospital staff. Working creatively within a hospital has many challenges and more work needs to be done within the field of performance arts for wellbeing to determine just how effective and impactful long term interventions are. However  performance arts have been shown to be a useful way to improve the overall well-being of the participants involved and can offer participants new ways to positively deal with their mental health and wellbeing. Due to the many limitations on the data included within this review, it is not possible to state whether performance arts based interventions are effective in their aims to positively impact the wellbeing of hospital staff but the limited results available in peer reviewed literature shows a promising future for performance arts based interventions that seek to support the mental health and wellbeing of hospital staff. 

Recommendations

This review has identified several large gaps in the literature and has noted important topics for further research on performance arts based interventions for hospital staff wellbeing. 

• Larger and longer studies are needed on the potential benefits of clowning based interventions for healthcare staff 

• Larger and longer studies are required to reliably confirm the potential benefits of applied theatre based interventions for reducing stress and burnout of hospital staff 

• Larger studies on the benefits of music based interventions for hospital staff

• Further studies are required to investigate the benefits of storytelling based interventions for hospital staff 

• A review or study looking at how performance arts based interventions can be made more accessible for the staff involved is also needed

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