Research and Evaluation

RESEARCH AND EVALUATION

Our art and design programme has three main areas of work:

Underpinning all of our work is an objective to grow a robust body of evidence that clearly demonstrates the impact on patient outcomes, care delivery and cost effectiveness of these programmes and enhancements. We work with a group of academic partners on project evaluation and, through the dissemination of our findings, are now collaborating and sharing knowledge with sister organisations in Japan, Korea, Australia, Europe and the US. Click the titles below to explore our research projects.

Older male patient and female artist smiling to camera during an art therapy sessionAt CW+, we have developed a method of evaluation for the artists who deliver our participatory arts workshops. This method was designed by our PhD student Greg Windle, and is a reflective way for artists to feedback about their sessions.

PART is an abbreviation of People, Area, Rose and Thorn. This criteria allows us to note the number of people that our workshops reach, and the areas they take place in within our hospitals. ‘Rose’ is a space for artists to tell us about any positive interactions or observations during their workshop while ‘Thorn’ is to make us aware of any practical issues, patient distress or artistic challenges.

This is key in providing important information on the impact we are having on patients as well as staff, and helps improve our programmes so that we can offer the highest quality of experience for those involved.

One of the patients had asked the physiotherapists to work with me again. Really great experience in the second time working with one of the patients again after a month he was re-admitted and he spoke of the impact of the session on his confidence in moving again.”
Cai Tomos, Creative Movement Workshop Facilitator

“I played happy birthday as a surprise for a nurse. She and her colleagues enjoyed this very much! Some very fun lessons with patients, and some excellent young patient bopping to music.”
Adrian Garratt, Violinist

“Sad to see one child with very low self-esteem ‘I’m not very good at this’ (and then surprised himself!)”
Emily Hall, Ceramicist

The Cardiac Catheter Lab is often a place of considerable anxiety for patients – there are worries regarding health status and the procedure itself can compound this anxiety not only in terms of the anticipation but also from the actual discomfort of the procedure itself.  Anxiety levels are often at their highest just prior to the procedure, which is often painful, and staff may find it difficult to offer verbal reassurance and comfort as the procedure can be technically demanding. Furthermore, the presence of the specialist X-ray equipment needed for the procedure means that it is often difficult to stand in proximity.

Studies show that providing holistic care with attention to the environment can potentially lead to reduction in anxiety levels and hence improvement in patient experience. Recently, there has been interest in the use of Virtual Reality (VR) as immersive techniques to reduce pain and anxiety in hospitalised patients. We are undertaking a study exploring the feasibility of VR in the Cardiac Catheter Lab environment, from a patient and staff perspective and to assess whether the use of VR can attenuate markers of pain and anxiety in patients undergoing elective procedures. For this project we are using digital content developed by us for the purpose of the study. The secondary objectives are to evaluate the effects of IR on heart rate, blood pressure, respiration, and markers of autonomic function.

The ‘Companions’ (working title) is an ongoing project between Min Young Kim, a Masters student at the Royal College of Art, and Heriot-Watt University, to create a virtual plant-avatar on a tablet which patients can care for and grow at their bedsides.

This work stemmed from the idea to incorporate virtual creatures into the traditionally clinical hospital area, a place that where organic matter is prohibited due to various control risks. The flower project bridges this gap by reducing risk and allowing patient interaction with, albeit virtual, nature. There are eight different species of plant avatar being developed. These have been inspired by specific types of flowers related to the development of contemporary medicine – including Red Poppy, Cape Periwinkle, Foxgloves and St John’s Wort.

In collaboration with the Heriot-Watt University lab, the system will simulate the lifetime events of a plant, powered by real-time environmental data sources. Such factors include temperature, humidity and wind force, which are collected from sensors mounted around the exterior of the Chelsea and Westminster hospital buildings. The system is designed not only to visually augment the data from nature but to challenge its physical architectural settings.

This project is currently still in the development phase and trials should commence this year. We’re excited to see how the implementation of biophilia benefits patients in the hospital environment.

CW+ partnered with Virtual Reality (VR) company Rescape as part of their DR.VR Junior programme, designed specifically for children in a healthcare setting. We carried out a study in the Paediatric Emergency Department at Chelsea and Westminster Hospital to evaluate the effects of Virtual Reality on pain and anxiety levels in patients, recruiting 33 participants from September 2019 to May 2020.

DR.VR is a state-of-the-art Virtual Reality kit, including an app developed specifically for clinical VR studies which measures anxiety and pain levels both pre and post VR experience. The software allows for full staff control, ensuring content is always appropriate and monitored, and ensures that patients are receiving the best quality visuals. We commissioned ten bespoke films with film company Flix Films, depicting natural settings and recognisable landmarks both in and outside London.

Our research study in our Children’s ED at Chelsea and Westminster Hospital showed promising findings. We gave patients tablets with a scale on which to rank their pain both before and after the VR intervention. On average, there was a 42.9% reduction in pain levels and a 57.6% reduction in anxiety levels. This demonstrates that digitally immersive and augmented reality interventions have the potential to improve patient experience.

Read more about our methodology, analysis and further research in the full report.

2019 saw our first PhD student, Greg Windle, publish his thesis titled ‘The Impact of Engagement with the Arts on the Health and Wellbeing of Hospital Inpatients with Dementia’ after three years of working with our arts participation programme.

Policymakers, researchers, and charities around the world have increasingly recognised the challenges faced by those with dementia as well as the potential for engagement with the arts to improve their lives. The aim of Greg’s PhD was to explore patterns of engagement with the arts and their psychosocial effects on hospital inpatients with dementia. It particularly focused on the differences in psychological impact between traditional and digital forms of art.

Greg triangulated data from studies in Chelsea and Westminster Hospital and West Middlesex University Hospital to analyse patterns of engagement in the arts and their effects on inpatients with dementia. Over the three studies, more than 200 participants were recruited, making it the largest quantitative study of visual art production as a psychosocial intervention. In one of the studies, 90 inpatients were divided into three groups, with a third accessing weekly traditional arts and music programmes, a third accessing weekly digital arts and music programmes and a third acting as a control group. This particular study found short term improvements in wellbeing and lowered anxiety in those participating in the traditional and digital art groups compared to those in the control group.

Such findings were corroborated by the other studies featured in the thesis, which overwhelmingly showed that individual engagement with the arts can increase the quality of life for those with dementia. The simple act of patients moving to day rooms, for example, led to a variety of benefits including physical exercise, opportunities to meet new people, and more home-like surroundings.

This research is the first of its kind in the UK and demonstrates how engagement with the arts can reduce isolation, increase quality of life, improve wellbeing and lower anxiety for inpatients with dementia. This highlights the need for arts in health programmes in the acute care context, which is a core principle of the work here at CW+.

Click here to read Greg’s thesis.

In 2019, we met our fundraising target for our Critical Care Campaign, which is allowing us to build a world-class Intensive Care Unit (ICU) at Chelsea and Westminster Hospital. Our research into the physical environment of the unit has been vital in identifying the areas we can improve on. We have several ongoing studies as well as exciting plans for further research.

Delirium and acute confusion is very common in Intensive Care. Current bedside diagnostic methods rely on a question-answer paradigm that is laborious and intermittent. There is evidence that eye movement is an ideal measure of inattention which is central to the assessment of delirium. Using a novel state-of-the-art machine, we have developed a learning platform that uses multiple neural networks that continuously and non-invasively tracks the eye movement and thus attention of patients. This measurement, combined with neuro-computational methods simulating expected attention, means we are able to derive a continuous automatic measure of in-attention that we hope correlates with delirium. The platform is currently being trialled in the Intensive Care Unit at Chelsea and Westminster Hospital.

We have appointed two psychologists to work with us to create our new Intensive Care Unit (ICU) at Chelsea and Westminster Hospital. It is widely recognised that the ICU is an extremely stressful environment which impacts patients, their families and staff. The ICU experience often involves a number of psychological difficulties ranging from anxiety, depression, PTSD and delirium. Multiple guidelines now recommend psychological services be implemented in critical care units. The psychologists we have appointed will be collecting data across a patient’s experience of critical care. This will include prior to their stay for planned admissions, their experience on the unit, and three months following their discharge from ICU.

The evidence collected will help create the design for future interventions in critical care, such as psychological support to patients and families during their ICU experience and for staff working on the ICU. The project will also provide rich data on the ‘before’ and ‘after’ of the redevelopment of our Intensive Care Unit and the impact of the physical environment on wellbeing. All of this is part of our approach to delivering a high standard of personalised care, reducing care costs and increasing employee retention and wellbeing.

A significant body of evidence now demonstrates that physical surroundings have a direct impact on recovery. With new acoustics, lighting, layout, furnishing and equipment in the new ICU, the patient’s brain, body and senses will rest far more effectively. Anxiety, pain and stress will be reduced, and immune response will improve significantly.

Sabrina Monteregee, our Assistant Psychologist, performed a 3-month study into patient, relative and staff experience on the current ICU environment. While her research found that the unit generally received excellent feedback on the care received in ICU and regarding staff, the unit was most highly rated as adequate/poor rather than good/excellent in terms of environment. It is our priority to transform the unit, improving the environment for patients, relatives and staff which will, in turn, improve patient outcomes.

Sabrina’s study identified several areas for improvement which correlate with existing research we are conducting into our critical care environments. She measured the noise levels in the ICU over a 2-week period, which came in at 59.65 dB(a) in the day and 55.00 dB(a) at night, which is well over the World Health Organisation’s recommendations of 30 decibels (dBs). This was found to have contributed to poor sleep as well as acting to heighten anxiety and distress levels in patients.

We are currently analysing further data focusing on light lux levels and air quality and temperature levels in our existing ICU. We have developed technology with Sensyne and Sonitus to measure data recorded from individual patients’ beds in the adults’ ICU in real-time. We hope to combine this technology with our electronic patient data systems. If successful, this will prove significant in measuring the impact of interventions such as music and visual imagery which we are planning on implementing to improve the patient experience in critical care units.

Sleep is a major contributing factor to intensive care associated illness, such as post-intensive care syndrome (PICS), and remains a prominent complaint amongst patients discharged from critical care settings. Part of Sabrina’s study included a sleep analysis on the ICU and showed that 42% of overnight stays were disturbed by noise. Whilst multiple pharmacological and non-pharmacological interventions have been trialled to combat the issues surrounding sleep in ICU settings, there has been little homogeneity in the results.

Virtual reality (VR) has been used successfully in multiple care settings including as an adjuvant to analgesia during painful procedures, as a relaxation and therapeutic aid in oncology and as a rehabilitation tool. As such, it is possible that VR may have a role in the critical care settings; however, this has never been explored.

We are working with the ICU team at Chelsea and Westminster Hospital on a Sleep Study to review the feasibility of using VR in an ICU environment and how this can impact sleep quality and, in-turn, psychological and physical symptoms. The study will involve a patient-recruitment programme and a clinical team led investigation into the use of VR, using sleep-quality monitoring software and pre/post intervention questionnaires.

‘Pulse Music’ is an intelligent music listening system, designed to use live patient data to modify the listening experience to support specific clinical goals. Inspired by the new ‘sensor-rich’ Intensive Care environment at Chelsea and Westminster Hospital, and based on recent research suggesting a link between musical tempo and a listener’s pulse, the ‘Pulse Music’ system automatically adapts the tempo of a piece of music in response to changes in a listener’s heart rate.

A recent pilot study, led by consultant cardiologist Dr Sadia Khan at West Middlesex University Hospital, investigated the potential effects of this system on a cohort of volunteer participants; the results of this are currently undergoing analysis. If successful, this system could be applied in many areas of the hospital. Its potential use in the cardiology department is of note, as slower heart rates allow clearer imagery to be captured during CT scanning, this reduces the need for retests and reduces patients’ exposure to radiation.

We have been collaborating with designers at Queen Mary University of London to create a new musical instrument designed specifically for upper limb rehabilitation in stroke patients at Chelsea and Westminster Hospital.

The instrument will support existing upper limb exercises and functional rehabilitation, but with the added expressivity and challenges of musical learning.  It will be small, portable, and infection control friendly, and therefore usable from the early stages of a patient’s rehabilitation. The team from Queen Mary’s have brought out two new prototypes in order to get feedback from patients and staff on the hospital’s stroke ward. Usage will begin with simple movements and patterns before increasing in complexity over time – just as with a traditional musical instrument.

This new musical instrument is significant in not only its functionality but in supporting and encouraging creativity and expressivity in patients. A feasibility study began in January 2020 to assess the design and accessibility of the instrument for patients on Chelsea and Westminster Hospital’s Nell Gwynne Ward.

MIRO-E

Miro-E is a robotic pet companion that was originally developed for residential care homes and education services by Consequential Robotics. With internal camera lenses and built-in touch sensors, Miro-E recognises people and faces, and responds to affection. We are currently trialling Miro-E in various paediatric departments across Chelsea and Westminster Hospital, including Burns, the High Dependency Unit and the Adolescent Room on Jupiter Ward. The aim of the trial is a feasibility study to assess the effectiveness of Miro-E as a distraction tool for children in what is normally considered a stressful environment. The clinical team will use questionnaires which we have developed, in order to establish the effects of Miro-E on stress, anxiety, cooperation and pain levels, as well as the impact distraction has on parents, carers and staff during waiting times and procedures.

A preliminary trial in the Chelsea and Westminster Paediatric Burns Unit waiting room showed a 50% decrease in patient anxiety after interaction with MiRo-E and the extent to which the child played with MiRo-E correlated positively with anxiety reduction. However, the trial also showed that MiRo-E had little impact in increasing cooperation during appointments and also highlighted some technical issues such as battery life. In order to further assess the feasibility and best use of MiRo-E, we are introducing MiRo-E to our Jupiter Ward to test whether its best use would be in treatment and consultation rooms, not just waiting rooms.

“It was interactive, distracting from why we are here, and overall fun and fascinating”
Parent of one child in our Children’s Burns Unit

PARO

PARO is an advanced interactive robot seal developed by AIST, a leading Japanese industrial automation pioneer. PARO has five kinds of sensors: tactile, light, auditory, temperature and posture, allowing it to perceive people and its environment. In interacting with people, PARO responds as if it were alive, moving its head and legs, making sounds which imitate the voice of a real baby harp seal and showing your preferred behaviour. We are currently undergoing a feasibility trial with PARO in our older patient wards and look forwards to sharing the results soon.

Previous studies have shown that a multi-sensory approach is beneficial for improving the wellbeing of individuals with dementia, and we will be looking at the effects of it in improving and increasing patient hydration, nutrition, and enhancing their dining experience. We will be working with Professor Victoria Tischler to conduct a mixed methods pre-post feasibility study to test a multi-sensory dining intervention to improve nutrition and hydration for inpatients with dementia.

This study will explore the use of smells, foods, textures and other ambience-enriching elements in hospital for people with dementia over the age of 65. The trial will be voluntary, and those involved will be invited to take part in a 2-week sensory-heightened dining experience. Interventions such as brightly coloured crockery, a hydration wheel, good grips cutlery and a visual menu board will be introduced to patients with the primary objective of increasing their fluid and food intake. Participants will have their weight, food and drink intake and health and wellbeing status recorded at the start, during and at the end of the study as well as answering various questionnaires and interviews about the experience. The conclusions drawn from this study could shape future approaches taken to caring for hospital inpatients with dementia.

The Zoo is a 90-minute-long bespoke digital artwork commission which can be played on a seamless loop, featuring moving portraits of 42 different animals, ranging from domestic to wild. The film was designed with creative filmmakers Accademia with the aim of providing a positive distraction to children waiting or being treated in the Children’s Emergency Department as Chelsea and Westminster Hospital, who can often be anxious, distressed or experiencing pain.

A pilot screening of the study found some promising results. We asked consultants, doctors, nurses and student nurses to give us their feedback on The Zoo and they reported:

  • 84% improvement in their patient’s anxiety
  • 79% improvement in their patient’s pain
  • 83% agree The Zoo benefits patients, as well as the clinicians themselves

Since The Zoo has been installed, we have had excellent feedback from patients, families and staff. Due to its success, we have also installed The Zoo in paediatric outpatient procedure rooms including Oncology, Phlebotomy, Ponseti (Club Foot), Fracture Clinic and Dental. We are currently undertaking a full clinical trial to objectively assess the impact of the intervention on the distress and perceived pain in the Children’s Emergency Department which should verify the pilot findings. This will be completed in 2020.

“The Zoo was a very pleasant distraction for both of us.
The film is so beautiful, and seems like a simple, clever way to alleviate the stress of A&E.” Mother of a child who visited our A&E Department