303

Marily Cintra
Since 1992 Marily Cintra has facilitated the in clu sion
of public art in eight hospitals in Au stra lia. She is the
founder and director of Iden tity, Environ ment & Art, an
arts organisation with focus on com munity participa-
tion in the design of public pla ces. In 1997 Identity won
the Au stralia Council for the Arts award Community,
Environment, Art and Design for their work at Liver pool
Hospital, a model of in no vation a nd creative place-
making. In 1998 she won the New South Wales Women
and the Arts Fel lowship for her work in arts and health.
Most re cently she founded The Arts for Health Research
Centre to support the development of critical de bate
within the conver gence of health, me di ci ne and the
arts in Australia.
Art in Health care buildings:
Is any art good art?
Marily Cintra, M.SC.
In pre industrial societies the users perfected the
best solutions for environmental design (Jones
1957, Cross 1989). Collectively people shared
the knowledge about use of materials, the im-
portance of the weather or the most conven ient
way of providing for social contact. The design
process encompassed not only a collabor ation
between the users in the present but involved
generations, providing for vertical (past and fu-
ture) and horizontal (present) collaborations.
The incredible pace of our technological
development is supported by the way we be-
came specialized. We can, individually, concen-
trate in one eld of knowledge and collectively
to go where no one has gone before.
The evolution of environmental design al-
lowed for fast development and new solutions
but also alienated the very people who use and
thereby effectively make the place (Cross, 1981,
Schneekloth and Shibley, 1995; Sancar, 1994).
This creates a need for collaborative design pro-
cesses that not only respond to the needs of the
users but that also include and empower them/
us. These processes repopulate design.
These collaborations in design are not a
return to pre-industrial design methods, but a
partnership where designers, in very specialized
elds, together with the users and other pro-
fessionals take conscious physical, ethical and
so cial considerations for the work and its re-
percussions.
In health care facility design, for example,
our understanding of the healing and wellbeing
process is a major inuence in the way we de-
sign. During the past 30 years, in our Western
society, our knowledge of the inuence of the
environment, social interactions and stress on
health and healing has informed the search for
solutions for a better health care design which
include physical, emotional, mental and social
comfort.
Health care facilities are no longer (or should
no longer be) places where we isolate the sick
and the poor, where sensory deprivation ruled
in the prison like ambiences. Today we search
for a design that takes into consideration that
one heals better in a friendly atmosphere, one
that reects the respect for ones wellbeing. In
this context, the arts, as the way we can express
our feelings, stories, relationships and connec-
tions, have a signicant contribution to health
care facility design. The arts advanced from a
decorative and secon dary aspect to a signicant
part of the design process.
The reasons for the inclusion of art in
health care design, are often linked to its con-
tribution to wellbeing (Senior and Croall 1993;
304 (IADH) International Academy for Design and Health
A R T I N H E A L T H C A R E B U I L D I N G S
Scheer 1996), Those reasons can be grouped in
two categories:
1. The arts can improve the quality of the envi-
ronment. This can be done through facilitat-
ing way nding, giving identity to the place
and providing a caring appearance to the en-
vironment.
2. The arts can improve a feeling of wellbeing
through supporting social interaction, pro mot-
ing ownership of the place by the users, pro-
moting social support and providing positive
distractions.
Creative activities within a community contribute to
a sense of vitality and to a sense of belonging, and
their nurture should be the goal of healthcare designers
and administrators. Bush-Brown (1992 p 22)
Nevertheless, as art works are very varied in
both techniques and content, we must investi-
gate if the art that we are proposing for health-
care facilities are in fact producing the results we
intend it to (Ulrich 1991, 1999; Cintra 2000)
Placemaking and arts in health care facility
Since 1992 I have coordinated the inclusion of
public art in eight hospitals in Australia. The
projects aimed to support the users in develop-
ing a place that reects what they believe are the
important issues within their place. In doing so
we were careful to involve a large number of
users from different categories such as staff, vi-
sitors and patients. This model of placemaking
has been quite successful and has strong sup-
port from the hospital communities and from
the hospital management. Although we start
with a focus on the public art, six of the eight
projects developed into on-going arts and cul-
tural programs.
The collaborative process that takes place
during the three to four months planning is
fundamental to the success of the work. This
in cludes observation of physical traces and en-
vironmental behavior, standardized questionn-
aires and focused interviews with staff, patients,
visitors and the local community, photographic
docu mentation. (Zeisel 1981)

We also use crea-
tive activities such as banner making or pain-
tings to portray the users ideas about their pla-
ce. While the hospitals size varied, the number
of patients, staff and visitors consulted in each
hospital was kept between 300 and 500.
Strong participation of the staff and local
community extends to the implementation of
the plan. The art works are rst presented as
concept design by three different artists and di-
scussed with the staff who work in the area that
the work is intended for. The staff send their
recommendation to the hospital arts commit-
tee. The arts committee, which includes staff,
representatives of the local community, desig-
ners (if the arts program is being implemented
during a redevelopment or new building) and
the arts planner, makes the nal selection.
The selected artist will then produce a nal
design for approval by the arts committee. The
nal design is produced in collaboration with
the staff of the area and the arts team. Art
works produced with community groups also
need to show their work in progress to the arts
committee.
What people think is the best art for health care faci-
lities?
During the consultation for the development
of art plans there were some common threads
in the eight hospitals. Over 4500 people took
part on the projects through focused interviews
and surveys. The questions about the preferred
ambience were open-ended questions. Peoples
responses point out that the hospital ambience
should reect nature, the local community, and
the diversity of the different services and de-
partments.
In 1999 a Post Occupancy Evaluation of the
pub lic art program was performed at Liverpool
Hospital. The evaluation was applied six years
after the design of the Arts Plan and two ye-
ars after the conclusion of the redevelopments
public art program. The POE was applied at
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A R T I N H E A L T H C A R E B U I L D I N G S
the investigative level (Preiser and Rabinowistz
1988). Its purpose was to verify the user satis-
faction and relevance to date of the artworks
commissioned during the Redevelopment Arts
Program and the community cultural develop-
ment as owing from the program.
The methodology used reected the one
used during planning, allowing for the evalua-
tion to be performed in collaboration with the
users of the place. It included questionnaire
surveys, applied randomly to staff, visitors and
patients; focused interviews (individually and in
small groups), photographic documentation, re-
view of the collection status.
The data was analyzed for frequencies and
means. The information also gave an insight
into the way the art responded to the needs of
the communities that make the hospital.
The main factors assessed were grouped
into:
Technical and Quality and maintenance of
the
Functional: works
A d e -
quacy of placement of works
Creation of landmarks.
Behavioral Adequacy of theme
Users sa-
tisfaction and comfort
with works
S t r e n g t h e -
ning of links between
the health service and the local
community.
Cultural Development of new resources;
Development; Professional and economical
de-
velopment
Support for diversity and to-
lerance
S u s t a i -
nability of innovative cul-
tural activities.
The use of questionnaire surveys, randomly
applied and also left for self-administering, pro-
vided opportunity for staff who work in differ-
ent shifts, patients and visitors to participate in
their own time. Of 300 questionnaires distrib-
uted we received 140 or 46.6%.
The surveys showed that people felt that the
works were pleasant, appropriate to the place,
calm ing, welcoming and representative of the
community. 78.2% believes that the arts makes
Friendly and cheerful
Calm and relaxing
Respect the diversity of services
Refect the local history
Refect/link with local community
Refect/portray nature
Number of Hospitals
Preferred ambience
306 (IADH) International Academy for Design and Health
H E A L T H F A C I L I T Y
A R T I N H E A L T H C A R E B U I L D I N G S
Health Care Facility Number of Desired Ambience was one that:
people
involved in
in planning
Canberra Hospital (400 beds) 650 Refected nature and included natural features:
Located in Canberra, Refected the local community and its cultural
diversity
(Oppermann and Nizette 1992) Provided a sense of the history of the place
Liverpool Hospital 300 Refected the cultural diversity of the Liverpool
700 beds residents
Located in South Western Provided a sense of the history of the place
Sydney, New South Wales
(Oppermann and Royal 1993)

Bankstown Hospital 600 Refected the soothing character of nature
400 beds 100 surveys Acknowledged the heritage and local history
Located in South Western returned Refected the rich cultural diversity of the local
Sydney, New South Wales community
(Oppermann 1996)
Sydney Childrens Hospital 450 Refected a sense of place with focus on the
200 beds 129 surveys children, including fun, interactive works that
Located in South Eastern returned are easy to maintain and durable
Sydney Supported the diversity of the hospital
(Oppermann 1997) departments.
Braeside Hospital 400 Refected the soothing character of nature, in
75 beds 150 surveys particular that of water
Located in South Western returned Had a homely feel
Sydney Acknowledged the rich cultural diversity of the
(Oppermann 1997) area
Nepean Hospital 513 Refected the local nature
450 beds 96 surveys Is friendly and calm
Located in Western Sydney, returned Represented quality of service and that builds
connections between the health facility and
local community
Addressed the special needs of the various
(Cintra, 1998) departments
Included diversity of art forms.
John Hunter Hospital 700 bed 362 Refected and created links to the local nature
Located in Newcastle, NSW 204 surveys Developed community and team spirit at the
returned hospital
(Cintra and Robinson 1999) Addressed the special needs of each department
Included a diversity of art forms
Fairfeld Hospital 150 beds 505 Refected the rich cultural diversity of the region
Located in South Western 179 surveys Addressed the special needs of each depart-
Sydney returned ment creating bright and cheerful or calming
Cintra 199 and relaxing environments.

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A R T I N H E A L T H C A R E B U I L D I N G S
Liverpool Hospital very special.
When asked to name places that had art
works at the hospital, 79.8% could name two
places and 39.5% could name ve places.
When asked which work they disliked, 80%
responded none. Thirty people named works
they disliked (20%). Most works referred as
worst were photographs (14), a tendency that
was conrmed by the interviews.
The focused interviews complemented the
information obtained through the question-
naires and allowed to investigate more in depth
the feelings and ideas of the participants in re-
lation to the arts. A total of 250 interviews in-
volved staff, patients and visitors.
The interviews revealed that staff in par-
ticular believe that the arts make people feel bet-
ter. People also felt that the arts create a calming
and welcoming environment.
The words most used to describe the arts
at Liverpool Hospital were colourful, nice and
pleasant. People would like to have more art.
Of the 205 people interviewed ve believed that
money should not be spend on arts but only on
equipment and services; and seven mention ing
that they disliked a work (all works being pho-
tographs)
Many of the art works of Liverpool Hos-
pital were made together with local community
groups, supporting the users wish to celebrate
locality and the diverse cultural heritage. One
of the favorite works identied during the POE
was the textile work, a Tivavae (traditional Cook
Islander work) which was installed in front of
the lifts to the wards on the Clinical Services
Building. The work was made by a group of
local women of Cook Islander cultural back-
ground. The artist working with the group,
also a local Cook Islander- Australian, is a staff
member of Liverpool Hospital, working on
night shifts.
There are many other works by community
artists working with groups of women for the
Delivery rooms, parents for the Feto Mater-
nal Unit, older people for the Aged Care Unit,
young people at the Childrens Ward, staff and
clients for the Sexual Assault interview and
exam ining rooms.
The processes used to ensure the quality and
signicance of the works during the implemen-
tation seemed to have worked very well with
only 3 out of 322 works being removed after
they were installed. One of the works, a photo-
story for the Post Natal Ward, was removed af-
Makes the hospital very special
Representative of the community
Welcoming
Appropriate to the place
Pleasant
Percentage of responses
Calming
308 (IADH) International Academy for Design and Health
H E A L T H F A C I L I T Y A R T I N H E A L T H C A R E B U I L D I N G S
ter a patient and her family recognized a person
on the photo as someone who was imprisoned
for committing a crime against her family.
One artist had her contract terminated after
she could not negotiate a solution to the work
with the staff. The work, an assemblage for the
Surgical Theatres staff room to be designed in
collaboration with the staff caused much con-
cern with a strong reaction against the nal de-
sign:
No to this: If this is for our tearoom NO. I want
a picture that is restful, not involving works. Restful
scenes, landscapes, non stressful. For a patient area we
want something to promote condence in the hospital,
their team not phobias, fears, shocking experiences.
This is an insult in my role as a nurse.
How the place develops
The place continues to develop after the new
buildings are open. What happened to the arts?
The observation and physical inspection during
the POE revealed that of the 322 works of the
permanent collection only ve works had been
stolen since 1994 (a remarkable small number
in comparison with the general theft within the
hospital). Only one work had been vandalized.
Many of the works are used as landmarks.
People arrange meetings by the Birds painting,
the Aboriginal meeting place, the fountain.
They use the artworks to show where the lifts
are. The Sexual Assault Service uses the art
works to identify their door instead of using the
name of the service.
During the POE we were also told of pa-
tients that come back to be photographed by
the artworks at the Cancer Treatment Centre or
about patients selecting a different bed at the
Renal Dialysis Unit to view better one of the
ceiling works.
Analyzing the ow on effect that the Re-
development Arts Program had at Liverpool
Hospital we learnt that as the redevelopment
program concluded it expanded into an on go-
ing arts and cultural program. It also expanded
to the entire Liverpool Health Service.
Various new resources were created for cul-
ture and arts activities such as temporary exhi-
bition spaces, an arts workshop, and grants and
sales of works to the value of over A$120.000
since 1997. The program supports a volunteers
group, devel oped from one of the community
projects of the redevelopment. The volunteers
work on cultural and artistic projects such as
organizing temporary exhibitions, making new
public art works for different areas of Liverpool
Hospital and for other hospitals in the region.
They also designed entertainment kits, together
with other groups in the community and a se-
ries of nger puppets to facilitate disclosure of
abuse by children, for use at the Sexual Assault
Service.
They have shown their work in exhibitions
outside the hospital and many of the volunte-
ers, who were all retired or unemployed, have
gone back to work or started studying.
The on going arts program CARE (Cultural
and Artistic Enrichment Program) has worked
closely with the migrant population, continuing
the work of supporting cultural diversity, so
important to the local community. The CARE
Program has also worked closely with the lo-
cal Aboriginal population, including their re-
presentation in the Arts Advisory Committee.
The support for the participation of Aboriginal
people in the development of the place has lead
to the approval and design of a special cour-
tyard for palliative care: The Quiet Dreaming
Place. The courtyard acknowledges the wish of
Aboriginal people to be close to nature, inclu-
ding at time of death.
How Liverpool Hospital arts compare to
other hospitals?
We have not produced a diagnostic post oc-
cupancy evaluation, which would compare the
arts programs in different hospitals. Neverthe-
less we have been able to look into the existing
art of two hospitals for which we developed
arts and cultural plans in 1998 and 1999.
John Hunter Hospital, a 700-bed teaching
hospital, 150 km north of Sydney, was ofcially
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A R T I N H E A L T H C A R E B U I L D I N G S
opened in 1991. The hospital has large corri-
dors, the hospital streets are immersed in natural
light coming from the glass ceiling on Level 3.
Many artworks were acquired during the com-
missioning by the interior designer. Works are
varied and include arts by well-known artists, by
students from the University of Newcastle and
small projects linked to local schools.
There are no records of the works acquired
during the hospitals commissioning but many
works have been removed by staff either by hid-
ing them behind closets or by moving them to
different locations. At the moment we are work-
ing on an assets registry for the collection.
During the past four years, a local artist
painted 27 mural works covering 150 square
meters. We asked staff, patients and visitors
what they felt about the murals and found out
that although the majority liked works, many
people felt that there was an urgent need for
variety. The ad hoc nature of the commissioning
gave people no control over the arts. This was
the main reason for the hospital to engage on an
arts and cultural plan.
One particular work in John Hunter cal-
led our attention during the arts planning. A
near-life size wood sculpture of a mother and
child was placed in a postnatal ward, which la-
ter changed to a Gynecology ward. Today the
sculpture greets women who had surgeries such
as hysterectomies and mastectomies or termina-
tions and still births.
The nurse unit manager did not think there
was any problem. We interviewed a support
group of women who suffered or are suffe-
ring with gynecological cancer. They were ada-
mant that the work caused distress and sadness
during their stay at the hospital. We later learned
that some patients and visitors had already com-
plained to the staff about the work.
Faireld Hospital, a 200 bed hospital located
south western of Sydney, was ofcially opened
in 1989. It is located in one of the most cul-
turally diverse areas in Australia, with 53.5% of
the population born overseas in 133 different
countries (50.6% from a non-English Speaking
country, compared to Sydney 22.3%).
In 1999 we developed an arts and cultural
plan for the hospital. As there were existing
artworks in major public areas, we asked in the
survey what people thought about the works.
From 179 responses to the survey 55.8% did
not re spond to the question, 12.8% like the
works, 11.7% do not like the work, 7.2% wants
it to be changed and 7.2 % said they had not
noticed the works.
The collage works were done in 1998 by ve
artists working with staff, patients and visitors.
A large number of small ceramic works were
also produced but there had been no plan on
how to use the works.
Although the works were produced with
the hospital communities, this was done with a
lower level of participation. There was no real
ownership of the works and people were happy
for the works to be changed.
From our work we concluded that good art
in health care facility is the one that engage the
users in a dialogue that reects the place. The
challenge to artists is to create a poetic response
that respects the needs of the people and that is
lled with empathy for the staff, visitors and in
particular, for the patients.
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intra, Marily (1999) Harmony, an arts plan for Faireld
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