Creative health: challenging student nurses to learn from the arts | Nursing Times

Introduction

Creative health is a relatively new phenomenon in healthcare and there is a paucity of evidence about it in nurse education. It is defined by the National Centre for Creative Health (NCCH) (nd) as “creative approaches and activities, which have benefits for our health and wellbeing” and can contribute to preventative health measures, management of long-term conditions and recovery from illness. Activities can include arts, crafts, dance, film, literature, cooking and activities in nature, such as gardening. Implementation approaches involve:

• Developing healthcare services, such as social prescribing;
• Educating professionals;
• Workforce development.

The aim of this article is to share, and reflect on, the value of a creative-health placement at one university from a student perspective and explore its impact on student learning and understanding of art-based activities. Involving students as partners in the project provided a critical insight and insider perspective.

In 2014, an All-Party Parliamentary Group on Arts, Health and Wellbeing (APPG AHW) led by Lord Howarth initiated an inquiry about the use of the arts in healthcare. The resulting report recommended the formation of a national strategic centre for arts, health and wellbeing – the NCCH (APPG AHW, 2017). This organisation, a registered charity, supports and advises on creative health, with designated individuals to champion the arts, drawing health and social care organisations into collaboration with art and cultural organisations.

The NCCH has carried out a series of roundtable reviews exploring health and wellbeing in the education system and workforce development, and recommends that higher-education institutions provide education on creative health. The resulting report articulates an ambition to embed creative health as an integral part of health and social care provision (APPG AHW and NCCH, 2023).

Social prescribing, as outlined in the NHS Long Term Plan, is a key component of personalised care that connects individuals to local community activities and groups, through a social prescribing link worker, to address social, practical and emotional needs affecting their health and wellbeing (NHS, 2019). Arts on prescription has grown as a potential solution to psychosocial problems; APPG AHW and NCCH’s (2023) review includes case studies that show effective returns on investment.

The APPG AHW’s (2017) report stressed the importance of accredited modules in evidence-based and practical arts for health professionals. In addition to these recommendations, understanding public health is a fundamental aspect of becoming a nurse registrant.

Platform 2 of the Nursing and Midwifery Council’s (NMC’s) (2018) future nurse standards (‘Promoting health and preventing ill health’) stresses the importance of improving and maintaining the mental, physical and behavioural health and wellbeing of people and populations. It stipulates that registrants need to engage in public health and community agendas. This is reinforced in the NHS Long Term Plan, in which social prescribing was recommended to widen and diversify health and wellbeing inventions and chapter 2 of the NHS Long Term Plan focuses on NHS action on prevention and health inequalities. It has also been acknowledged that one in five GP appointments are for social reasons and the use of social prescribing led to a 40% reduction in GP visits (National Academy for Social Prescribing, nd).

Creative health practices such as music, dance, literature and visual arts are used to promote self-esteem, reduce loneliness, aid community networks, improve the quality of life for an individual, and aid healthy ageing (Fancourt and Finn, 2019; APPG AHW, 2017). While there are no known examples of creative-health placements for student nurses published, there is an existing evidence base supporting the use of arts for wellbeing.

In particular, the APPG AHW produced a systematic review of all available evidence that formed part of the 2017 report. Evidence includes improvements in:

• Physical health with pre-existing long-term conditions, such as chronic obstructive pulmonary disease and hypertension;
• Mental health wellbeing;
• Peri- and post-natal care;
• Providing high-quality end-of-life care (Fancourt and Finn, 2019; APPG AHW, 2017).

There is an emerging evidence base citing the benefits of social prescribing in nurse education, but a lack of information on how public health theory is translated into action in students’ or registrants’ practice (Donaghy et al, 2022). As such, we took the opportunity in our 2018 pre-registration nursing curriculum to include the creative-health recommendations, and promote creative health and social prescribing to new students. This was added as a programme aim and built into the teaching strategy, which included simulation.

We wanted to offer our nursing students the opportunity to experience the benefits in practice and help initiate early changes in their educational journey. As knowledge developed, we sought and gained permission from the NMC, in relation to its (2022) recovery standards, for approval to deliver alternative methods of simulated practice of up to 600 hours across the pre-registration nursing programme; this included a creative-health placement.

The placement

The placement was designed to offer practical experience of the arts to pre-registration student nurses. It aimed to integrate the arts into a formalised practice-based learning experience and used as a basis the NMC’s (2018) Annexe A proficiencies (communication and relationship management skills) and the importance of person-centred care. The placement was mapped to the practice assessment document, including the assessment of professional values, proficiencies and the episode of care, and we employed indirect practice supervisors and assessors, as recommended by Knight et al (2022).

Over two placements, starting in February and May 2022, 60 first-year student nurses from all four fields of nursing were allocated to this placement, as part of their predetermined placement circuit. They attended regular sessions (four times a week) facilitated by community artists with expertise in the visual arts, music and dance. In these sessions, they participated in art-based practices, such as drawing, sculpture, dance and music creation. The first placement was for six weeks, the second for five.

Experiencing the arts directly, these activities challenged students to reassess their preconceptions about their own creativity, health and wellbeing, and so deepened their understanding of person-centred care. Some of the resulting artworks reflect this process clearly; Fig 1 shows a ‘self-portrait of feelings’ produced by one student during the placement.

Drawing on these experiences, the students put this knowledge into practice by hosting creative-health cafes. These took place four times a week, and students developed, advertised and facilitated their own creative-health sessions with members of the public under the artists’ guidance.

Students then had to research and engage with local social prescribers (once a week), allowing them to develop a working knowledge of support systems, build relationships with the local community and see creative practices in action. They were asked to record this activity as evidence for their practice assessor. The timing of the placement, in the winter and spring of 2022, as we moved away from the constraints of the Covid-19 pandemic – namely, lack of in-person learning, student isolation and challenges forming friendships – affected students’ wellbeing; this is reflected in some of their comments.

Students from the first placement were employed and paid to support an ongoing research project that ran alongside; their feedback led to the development of this article as they felt it was important to share their experiences. We used the final day’s group evaluation to draw together the reflections and experiences for the collective student perspective and one student wrote their own personal experience (Box 1). Permission to use the feedback was granted by the faculty ethics committee.

Outcomes

Students were asked to complete a narrative about the placement, and were asked:

• How did it feel to take part in the placement?
• Did this change during the placement?
• What aspects about the placement would you change?

Students initially had difficulty taking the placement seriously and there were several negative comments about being allocated it compared with their peers on “traditional” placements. They underestimated the skills involved in being creative and lacked confidence engaging in art-based activities. They found it difficult to connect with their own nursing practice, with many focusing on skills acquisition, rather than appreciating what they could learn. Before the placement, the placement team received comments such as:

“I would like a proper explanation of why you think putting students into a university simulation suite is in any way adequate for a six-week placement.”

“I need to know how to change your bed or change a dressing; I don’t need to know how to draw a picture.”

However, almost all of the students came to appreciate the value of creative health in nursing. At the end of the placement, they reported having learned a variety of skills, such as proactiveness, communication, collaborative working and confidence building. Comments included:

“At the end, I could see how important it is in providing person-centred care.”

“The experience of creative health has been eye opening and has changed the way I will deliver healthcare. I will definitely be suggesting some of the preventative methods to patients.”

Other benefits cited were the opportunities to make friendships, and build working relationships with peers and the local community:

“I’ve learnt to socialise better with colleagues and peers.”

Students also found techniques for stress relief and relaxation useful, not only as tools to care for others, but also to manage their own wellbeing. One said:

“Something I started to pick up on last week, but have noticed has followed me through into this week, is my awareness around my own thoughts and feelings. When working with the artists, I have felt relaxed, enjoyed the sessions and been able to go home and enjoy my evening with my family; however, on the day when I have been on my spoke visit, I do recognise that I feel different at the end of that day.”

Many were surprised by how much social prescribing was on their doorstep. One summed up their experience with:

“We need to move from over medicalisation and from a prescriptive service to more a supportive one.”

Overwhelmingly, the students appreciated the learning and, when asked to describe their experience, they used words such as “inspiring”, “influenced”, “enjoyable”, “life affirming”, “fulfilling”, “beneficial” and “informative”.

Challenges

A small number found the experience emotionally draining and intense. One student said they were “tired and mentally drained”, and some felt the length should be altered:

“I believe that this placement is too long and could be shortened.”

Others found the indirect supervision model difficult:

“Hardly seen practice supervisors and assessors throughout the placement.”

Evaluation

The placement challenged students’ ideas about what constitutes nursing. The experience helped them contextualise person-centred care and understand the wider healthcare offer. In the placement evaluation, 75% (45 out of 60) reported that engaging with social prescribing increased their knowledge of health and wellbeing interventions. In total, 67% (n = 40) in placement one and 70% (n = 42) in placement two felt their perceptions of a typical nursing placement had been challenged.

Conclusion

Experiencing creative health encouraged students to step outside of their comfort zones by asking them to confront unfamiliar ideas, engage with people in unfamiliar ways and consider an alternative form of practice. As creative health is a relatively unknown area in nursing, we anticipated some negativity about the concept, but students’ learning and reflection has made us appreciate how creative health can benefit wellbeing.

All nurses can take away an important lesson from this – namely, that great potential for learning lies in uncertainty and being brave enough to try something different. Further, as nurses we need to move away from the focus of acute care and skills acquisition, and appreciate all forms of practice. This is just the start of our creative-health journey; we intend to enable all first-year pre-registration student nurses to experience the benefits of creative health and social prescribing.