1. Introduction
Research continues to demonstrate the positive impact of arts and creativity for older residents living in care home settings. In 2017, the ‘Creative Health’ report [
1] set out comprehensive evidence demonstrating the beneficial impact of the arts, with key messages that the arts can keep us well, aid our recovery, and support longer lives better lived; meet major challenges facing health and social care: ageing, long-term conditions, loneliness, and mental health; and save money in health and social care services. More recently, in 2023, the ‘Creative Health Review’ [
2] acknowledged the role of creative health in primary, secondary, and tertiary prevention as well as offering a holistic and person-centred approach across the life course, specifying: “In care homes, creative engagement improves health and wellbeing of residents and can reduce the need for medication. It can also improve the health and wellbeing of the workforce” (p. 21). This is also recognised—if briefly—in the ‘Framework for Enhanced Health in Care Homes’ [
3], which advocates for daily opportunities for meaningful activities such as music, arts, and gardening, and drawing on community assets to enhance the lives of residents and promote mental wellbeing.
There are many arts programmes being delivered in care homes and growing recognition of their value (e.g., [
4,
5,
6,
7,
8]). For example, engaging in participatory arts and creative activities has been shown to play a role in addressing loneliness and social isolation for older people and promoting social relationships within care home settings [
9,
10,
11], thus improving quality of life. Furthermore, Bosco, Schneider, and Broome [
12] analysed the social and economic value of the ‘Imagine Arts’ programme, delivering high quality arts interventions across 17 residential care homes in England. They found a social return on investment of GBP 1.20 for every GBP 1 of expenditure, with benefits for residents echoing those found in the literature—community inclusion, mental and physical health, improved cognition, and decreased social isolation. Benefits for care home staff and Activities Coordinators (whose role is to organise stimulating leisure and social activities for residents) included improved skills in caring for older people and increased confidence in using arts interventions. Care home providers and managers reported a greater variety of activities they could offer to residents and the enhanced reputation of the home. While artists reported increased knowledge of dementia and confidence in supporting older people, they also experienced a decreased sense of control in delivering activities. The authors emphasised that for such programmes to be effective, “care home personnel and artists need to work together closely in a spirit of knowledge exchange” (p. 23).
Collaborative working can be defined as: “Business relationships formed by committed organisations to maximise joint performance for achievement of mutual objectives and creation of additional value” [
13]. Interprofessional collaboration is nothing new for care homes, who work on a day-to-day basis with practitioners across health and social care services such as nurses and doctors. This is supported by initiatives such as the Quality Improvement Collaborative (QIC) approach that guides multi-professional teams through interventions designed to improve care in residential care homes [
14]. The need for effective collaboration intensified during the pandemic as reflected in the Care Quality Commission (CQC) ‘Better Care Through Collaboration’ report [
15], which stated that the creative and innovative solutions in response to the pandemic required partnership work and highlighted the benefits of collaboration within care services. However, discourse around interprofessional collaboration within care homes has largely been limited within the traditional boundaries of health and social care [
16], thus overlooking the potential contribution of the arts sector.
Collaboration across the arts and care sectors requires novel and creative approaches and practices that can account for “sometimes diverging interests and concerns” and “bridge unsettled interdisciplinary relationships” [
17] (p. 2). Nonetheless, research with nurses suggests that artists are valued within interprofessional care teams as they enhance the provision of holistic person-centred care by including meaningful cognitive and social engagement and contribute to “a culture in which creativity and interdisciplinary collaboration are more highly valued and activated” [
18] (p. 1). Fortier and Coulter [
19] conducted qualitative participatory action research to develop a conceptual framework of factors that affect cross-sectoral collaboration for arts, health, and wellbeing activities. They concluded that strengthening collaborative capacity (particularly within arts organisations), addressing structural constraints relating to power and resources, and aligning with public health agendas are essential for success. From the care sector perspective, a recent consultation asked care home residents and their families, Care Home Managers, staff, and Activities Coordinators across 67 care homes what was required for care homes to provide a daily offer of creative activities [
20]. It found that the greatest constraints were time, a lack of specialist knowledge, staffing structure and how teams work together, and ideas and resources. Meanwhile, care providers suggested they needed to work on developing community and arts partnerships, a culture shift in terms of belief in the necessity of regular creative engagement, more specialist training in arts and activities for people with complex needs, and more resources in terms of creative ideas.
To support the integration of creative health into the wider health and social care landscape, the ‘Creative Health Quality Framework’ [
21] published in 2023 outlines eight principles to drive quality and good practice, including collaborative and sustainable working. This article focuses on collaboration and its importance for sustainability, which is recognised as a key principle for sustainable organisations and central to solving complex problems of sustainability [
22,
23,
24,
25]. Our previous research on participatory arts in care homes identified the working relationship between participatory arts facilitators and care home Activities Coordinators—particularly in terms of the collaborative process—as crucial to the successful delivery of participatory arts activities for older people in care homes [
26]. This research involved extensive data collection with artists, care home staff, residents, and families, including researcher observations of the participatory arts in action; however, the findings around collaborative working emerged from the data and were not the focus of the research from the outset. In contrast, this current research focused specifically on how artists and care home staff can work together to deliver and embed creative arts during the Artists’ Residencies in Care Homes (ARCH) programme.
ARCH was led by arts charity Magic Me who facilitated the pairing of four arts organisations with four care homes in Essex to deliver innovative participatory arts experiences for residents and staff over four years, 2019–2023. The ethos behind Magic Me and the ARCH programme was to provide meaningful, high-quality participatory arts activities that are otherwise inaccessible to residents, with the aim of improving overall quality of life and promoting social justice. They also aspired to raise expectations of what the arts can be and do in care homes and increase the understanding, skills, and confidence of the arts organisations to encourage continued work in the care sector. The four homes involved were managed by the same family-run company that aspired to deliver individual, person-centred care with empathy, kindness, and compassion. They all offered residential, residential dementia, respite, and end-of-life care and ranged in size from a 40-bedroom home to a 92-bedroom home. While they all delivered various meaningful activities for residents, Care Home Managers and Lifestyle Coordinators (also referred to as Activities Coordinators) put themselves forward for the ARCH programme and embraced it as a new opportunity for a longer-term partnership to deliver immersive, participatory arts rather than more passive performance or entertainment. The arts organisations were recruited by Magic Me as Arts Council England National Portfolio Organisations (NPOs) that had experience using different forms of participatory arts with a range of different groups, though not necessarily in the care home context. Their creative practice centred around dance, theatre, and touch that intended to deepen human connection, ignite creativity and play, tell stories without words, engage with science, and promote care, curiosity, and compassion. Magic Me and the care home management company worked closely together, visiting each care home and matching them with the arts organisations based on what they had expressed about their staff and residents and the personality of the home as well as practicalities in terms of size and geography.
The research conducted alongside ARCH aimed to enhance knowledge and understanding of the collaboration between artists and care home staff in delivering creative arts experiences for older people and explore the challenges and enablers of introducing arts activities in care homes to identify best practice. A key ambition of the ARCH programme was to integrate arts and creativity into the lives of residents and the culture of care homes to promote the sustainability of impacts. Here, we explore how collaboration between arts and care partners is essential for the sustainability of creative practice and subsequent positive impacts of arts and creative activities in care homes.
2. Materials and Methods
The research took a qualitative approach across three phases of the ARCH programme: research and development (R&D), artists’ residencies, and legacy and embedding. Ethical approval was granted by the Education & Social Care School Research Ethics Panel at Anglia Ruskin University.
2.1. Phase One: Research and Development
An introduction day brought together 19 people, in person, from Magic Me, the arts organisations, the care home management company, and the research team. A dementia specialist and trainer co-led the day, offering an introduction to working creatively within care homes. The ‘sticky notes’ method [
27] was used to invite responses to questions throughout the day including how everyone was feeling about the prospect of delivering ARCH, what was seen as exciting, what were the anticipated challenges, and what skills would be needed. A focus group discussion reflected on the day and what support was needed going forwards (16 participants).
Care homes hosted an introductory day for their partner arts organisation, where care home staff and artists got to know each other through introductions, a tour of the home, and a taster of the arts organisations’ creative practice. The Care Home Managers and Lifestyle Coordinators played a pivotal role in welcoming those involved in ARCH to the homes. Researchers undertook unstructured observations to understand the preparation process and how artists and care home staff began getting to know each other. A focus group discussion was held to reflect on the visit and the hopes and concerns for the residencies (total of four focus groups). Telephone interviews were subsequently conducted with Care Home Managers to explore a strategic perspective on ARCH (total of four interviews).
The remaining R&D phase entailed arts organisations spending time in their partner home, getting to know people, learning about the care home environment, and experimenting with creative activities, building towards a longer residency in phase two. Online interviews with each care home and each arts organisation were held at the end of the R&D, reflecting on experiences and learning so far and considerations to take forward (total of eight interviews). An online interview with Magic Me (Director and Programme Director) explored the context and motivations behind ARCH, their role in supporting the R&D, and their reflections on the collaborations so far.
2.2. Phase Two: Artists’ Residencies
As phase one ended, the COVID-19 pandemic hit with significant impacts on care homes and ARCH, which was paused until restrictions began to ease and it was safe for the work to continue. Short online interviews were conducted pre-residency with arts organisations, care home staff leading ARCH (usually the Lifestyle Coordinator and/or Care Home Manager, sometimes joined by wider care home staff), the care home management company, and Magic Me to explore what might have changed since the end of phase one and their expectations for phase two (total of ten interviews).
The arts organisations then began residencies in the care homes, delivering participatory workshops, performances, and staff training using various mediums including dance/movement, textiles, music, performance, film, virtual reality, digital storytelling, science experiments, and photography.
During the residencies, researchers were unable to observe the creative practice due to COVID-19 restrictions and safety precautions on the number of visitors to the home; however, the intention of the research was to understand best practice for working together from the perspective of the artists and care home staff. Artists recorded their reflections on different sessions and the progression of their work in any format they liked (e.g., written summaries, recordings of post-session conversations between artists), which were subsequently shared with the researchers. After the residencies, online interviews were conducted with each care home and each arts organisation, respectively, reflecting on the experiences, including enablers and barriers to understand best practice (total of eight interviews).
2.3. Phase Three: Legacy and Embedding
An evaluation session brought together 16 people online from Magic Me, the arts organisations, care homes, and the research team. The ‘sticky notes’ method [
27] was adapted for the online space to reflect on what would have been useful to know at the start, what have been the key learning points, and what will be taken forward. At the end of the session, online focus group discussions were conducted with the arts organisations (six participants), care home staff (six participants), and Magic Me (Director and Programme Director), respectively, reflecting on the ARCH programme overall. The legacy phase is ongoing but has so far included the publication of a care home’s guide to creativity based on approaches and ideas from the residencies to be disseminated to Lifestyle Coordinators across the county.
2.4. Data Analysis
All interviews and focus groups were audio recorded and professionally transcribed. The dataset from each phase was explored through thematic analysis guided by Braun and Clarke [
28] to draw out key themes and identify good practice and challenges. Analysis was conducted by all members of the research team and involved deep and prolonged data immersion, thoughtfulness, and reflection, through the steps of familiarisation, initial coding, review of themes, theme definition, and labelling. Here, we present key findings that are most relevant to the focus on collaboration and sustainability under three overarching themes: setting up for success, collaboration in delivering creative experiences, and legacy and embedding for sustainable creative practice.
The thematic analysis intended to look across the four partnerships between arts organisations and care homes to find common enablers, barriers, and best practice that would be widely applicable, rather than specific to a particular creative practice or care home context. Because of this, and to protect the anonymity of the participants, the findings do not go into detail about the creative practice itself and all quotes have been broadly attributed to ‘arts organisations’ including individual artists and artistic directors across the four organisations and ‘care homes’ including care staff, Lifestyle Coordinators, and Care Home Managers across the four homes.
4. Discussion
The findings give insight into the structures, support, practicalities, and processes that led to the success of the ARCH programme. In particular, they show how the focus on and support around building trusting relationships from the R&D phase and throughout the residencies enabled collaboration between artists and care home staff that, in turn, supported the embedding of creativity in the care homes. This builds on our previous research [
26] by elaborating on how artists and care home staff can foster such trusting and collaborative relationships that subsequently lead to more sustainable creative practice. We discuss how these findings align with the collaboration and sustainability principles in relation to the recently published Quality Cycle within the Creative Health Quality Framework (CHQF) [
21], which shows how all stakeholders can work together to deliver the principles in a continuous process of learning and development across five project stages: developing your idea, building strong foundations, making detailed plans, delivering the work, and learning from the work. We also consider how the findings relate to the wider literature culminating in the argument for collaboration as critical to the sustainability of creative practice and subsequent impacts in care homes.
The first theme of setting up for success resonates with the quality cycle stages of ‘developing your idea’ and ‘building strong foundations’ from the CHQF [
21]. Under ‘developing your idea’, a collaborative approach is described as “solutions to identified needs have been developed through collaboration”, “ideas draw on shared expertise”, and “the approach to collaboration is appropriate to the context, scale and aims of the project” (p. 21). Under ‘building strong foundations’, a collaborative approach means “there is agreement around a shared vision, aims and outcomes”, “the vision for the work has been informed by wider, relevant health and social care policies and agendas”, and “sufficient time and resources are in place for collaboration and partnership development” (p. 23). Our findings exemplified the importance of these aspects, particularly in the structure around the ARCH programme developed by Magic Me, the deliberate and considered approach to forging new partnerships between arts organisations and care homes, and the reflection on the need for shared understandings and expectations. At the practice level, the need for dedicated time for setting up the partnerships and the residencies has been echoed in the literature. For example, research has identified the importance of artists having time and support to understand and adapt to the care home environment [
5] and care home staff taking part in planning meetings to discuss practicalities and their role during the creative sessions [
29]. At a strategic level, these aspects also contributed to key factors in cross-sectoral collaboration for arts and health, as outline by Fortier and Coulter [
19], such as considering the capacity and resources of partners, navigating complex care systems and policies, and alignment of the programme with wider care agendas, particularly in response to the pandemic.
Our findings relating to ‘building trust and relationships’ are represented in the framework under the later quality cycle stage of ‘making detailed plans’, whereby a collaborative approach means “there is buy-in and trust from all parties”, “there is open and honest communication between all parties”, and “democratic decision-making is in place” (p. 25). However, our findings suggest that building trust is important from the very start of the project cycle and central to promoting the sustainability of creative practice in the care home. Trust has been widely acknowledged as fundamental to human relationships and, thus, interprofessional collaboration within healthcare (e.g., [
30,
31]). Flood et al. [
31] suggested that when ‘getting to know others’ within interprofessional relationships, building ‘trust’ interplays with ‘authentic dialogue’ that goes beyond information sharing and ‘respect’ through recognising that each person has useful expertise that together would lead to something ‘more than’ what could be offered individually. Certainly, evidence shows that time to develop working relationships based on a foundation of mutual trust was important for collaboration between NHS professionals and care homes [
32] and may be even more important for working across sectors. For instance, trust between artists and care home staff may be intertwined with personal and professional perceptions about the value of the arts. Relationships were one of the key factors found by Fortier and Coulter [
19] to affect cross-sectoral collaboration for arts, health, and wellbeing activities. Cross-cultural and institutional differences in values, goals, practices, and language may create barriers to collaboration, but interpersonal facilitators included engaging in coproduction, using the skills of people who can navigate sectoral boundaries, and having stakeholders experience the arts interventions [
19]. These barriers and facilitators were evident in our findings on setting up for success as the partners developed shared understandings of the purpose of ARCH and artists spent time in the care homes, delivering a taster activity and interacting with both residents and staff to build trust. Magic Me could also be considered able to navigate sectoral boundaries given their extensive experience working with and in care homes, acting as a broker between the partners and advocating for the value of the arts, which may, in turn, strengthen trust.
The second theme of artists and care home staff collaboration in delivering creative experiences aligned with the quality cycle stages of ‘making detailed plans’ (as above) and, particularly, ‘delivering the work’ from the CHQF [
21]. Under ‘delivering the work’, a collaborative approach is described as “diverse skills, experience and resources are equally valued”, “resources are pooled to ensure the creative experience is inspiring and transformational”, and “all parties come together at key intervals to review progress” (p. 27). This is reflected, for example, in artists valuing the knowledge, skills, and experience of care home staff and encouraging their engagement in developing ideas and reflecting on the work, as well as artists being bold and ambitious but also adapting their creative approach to the care home and responding to resident needs. However, at the same time, our findings highlighted how challenging it could be for both partners to collaborate in delivering the residencies. Specifically, despite intentions, it was often difficult to engage wider care staff due to time pressures, resulting in an overreliance on Lifestyle Coordinators. This resonates with the consultation that found time along with staff structure and dynamics to be amongst the greatest constraints to providing creative activities [
21].
This has been reflected in the literature, with a review from Broome et al. [
33] identifying the care home context as important when involving care staff in creative arts interventions. For example, they found practical and logistical challenges, staff shortages, and limited financial resources were a barrier to involvement, and creative arts interventions should consider the daily routine of the environment. Such issues were likely to have intensified during the ARCH programme due to the impact of COVID-19. Broome et al. also found that incorporating training sessions could facilitate the involvement of care staff in creative arts interventions and benefit their professional development in terms of learning techniques for non-verbal communication and person-centred care, especially for residents with dementia [
33]. Certainly, workforce development is a key care element in the ‘Framework for Enhanced Health in Care Homes’ [
3], but this does not consider training in supporting or delivering creative arts interventions. Nonetheless, the Baring Foundation conducted a rapid mapping of arts in care homes training provisions [
34] and identified 65 providers offering various forms of training to both artists and care staff. Overall, the training aimed to develop skills and ideologies that artists and care staff could apply to their practice, with a focus on “person-centred arts experiences that value process over product, supporting residents to experience the arts in whatever way they can in a failure-free manner” (p. 7).
Under our sub-theme of spending time and sharing skills, care home staff reflected on learning from the residencies and, while some structured training was provided, this learning often occurred through watching artists and engaging with creative activities. Artists spending time in the home along with care staff spending time with artists are pertinent examples of ‘boundary work’ that is often invisible, slow, and difficult but crucial to cooperation within arts and health [
35]. In the context of an intergenerational arts project in a care home, De Kock et al. [
36] discussed boundary work at a personal level in terms of personal values and goals that often involve emotional labour; at a relational level in terms of attuning to those you are working with and navigating their often unspoken expectations, values, interests, or beliefs; and at the organisational level in terms of the customs, practices, epistemic traditions, power structures, and historically grounded values of different organisations and systems. They found that goals often needed re-evaluation throughout the process as expectations and desired outcomes changed, which required attentiveness, empathy, flexibility, and time for critical (self-)reflection in collaboration with partners. This is reflected across the ARCH approach in terms of developing shared understandings and expectations, building trusting relationships, communication and check-ins for collaborative working, and spending time together. Accordingly, the artists’ experience of collaboration is a clear example of how boundary work can promote sustainable creative practice.
The third theme of legacy and embedding provides the opportunity to discuss how working collaboratively is essential for generating sustainable creative practice and impacts in care homes. Importantly, despite this being the name of the final phase of ARCH, the findings represented processes and activities that happened throughout the programme, such as forging new partnerships, building legacy from the outset, and artists spending time to develop the deep connections required for embedding creative practice. In terms of the CHQF [
21], this is reflected in the quality cycle stage of ‘developing the idea’ where a sustainable approach means “all parties—participants, creative practitioners, partners, and other stakeholders—are involved in deciding what a meaningful, long-term legacy will look like” (p. 21) as well as ‘building strong foundations’ where a sustainable approach means “partnership working supports the delivery of sustainable impacts” (p. 23). The ARCH R&D phase ensured time to build relationships, while the collaborative, participatory approach of the artists specifically intended to shape a residency that would result in sustainable creative practice in the homes. Such an approach is supported by research from Hatton [
37] that advocated for slowness in collaborations and, specifically, slowness as a partnership model for artists and care homes.
Additionally, the legacy and embedding of ARCH are also seen in the CHQF quality cycle stage of ‘making detailed plans’ where a sustainable approach means “progression routes and follow-on activities are identified to support participants’ continued creative engagement” and “endings are planned to help participants transition to a range of activities or support” (p. 25). This is particularly true in terms of our sub-theme around creative outputs and endings and the collaborative approaches to empowering care home staff and preparing them for embedding aspects of creative practice into their everyday routines. Furthermore, in the quality cycle stage ‘learning from the work’, a collaborative approach means “all parties come together to review learning and consider how to take the work forward”, while a sustainable approach means “where possible, impact and outcomes are tracked beyond the end of the project” and “learning informs practices that create better futures for people and the planet” (p. 29). The ARCH programme is currently in this stage of learning from the residencies and taking the work forward, led by Magic Me with various initiatives such as developing the care home’s guide to creativity and strategic dissemination of outputs and best practice. Indeed, this demonstrates the crucial importance of Magic Me and their leadership and vision in both collaboration and sustainability aspects of ARCH. Specifically, their bringing together of arts and care sectors and brokerage of the partnerships between arts organisations and care homes paved the way for the relationships and residencies that unfolded. Such findings have also been demonstrated by Farrer et al. [
38] who explored the role of a university in facilitating an intergenerational, interdisciplinary community arts project. They found the university was able to mediate between different sectors of the community, offer resources and support structures, and promote the project, which was significant in facilitating development beyond what could be achieved by smaller partner organisations independently and in a way that was more sustainable and resilient to the changing pressures across the arts and health sectors.
There were two further issues that warrant discussion in relation to sustainability: the care home culture and ongoing funding. The overarching culture of the care home has been identified as the most important factor in determining how successful artists would be in engaging residents in meaningful creative activities [
5]. Similarly, care providers have acknowledged the need for a cultural shift in terms of attitudes around the need for creative engagement [
20]. This emerged in the ARCH findings, particularly in the challenges of involving wider care home staff and artists’ reflections on their impact in the homes. While this can, to some extent, be mediated by the selection of partners and through the early stages of forging partnerships and developing shared understandings and goals, ultimately, it will require a greater shift across the care sector supported by the growing momentum of the creative health movement. Arts programmes such as ARCH can contribute to the cultural shift required by demonstrating what is possible, for example, through the dissemination of creative outputs and research findings, and by building partnerships to advocate for the value of arts in care homes. However, it is important to recognise that care home culture has been shaped by wider structural influences such as the medicalisation, marketisation, and chronic underfunding of residential social care for older people [
39,
40] and such influences also need to be challenged in order to effect social change.
One way to challenge these influences and support a cultural shift is through increased funding for creative practice in care homes, which would increase the legitimacy and sustainability of the work. While the care home management company was supportive of incorporating creative practice in their homes, they face many competing priorities—particularly in the wake of the pandemic—and their budget for this work was limited. Accordingly, the need for funding to establish ongoing programmes of work was emphasised in the findings by both care homes and arts organisations, and securing funding is a constant objective for Magic Me. This is reflected in the CHQF [
21] recommendations for policy makers, commissioners, and funders that state, in relation to collaboration, “develop joined-up approaches to policy and funding, informed by wider health needs, priorities, and inequalities” (p. 15) and, in relation to sustainability, “prioritise investment in long-term programmes, partnerships, and practices that deliver sustainable social and environmental impacts” (p. 18). These recommendations also highlight the need to budget for the time and resources required to build strong, sustainable relationships between partners, thus aligning with the argument around collaboration between arts and care sectors for sustainable creative practice and impacts in care homes.
A key limitation stems from the impact of the COVID-19 pandemic, not only on the ARCH programme but also on the research. While the findings showed difficulties in engaging wider care home staff in the residencies, this was also reflected in their participation in data collection, linked to staff shortages and high staff turnover. While all care home staff involved in ARCH were invited to participate in all phases of the research, it tended to be only Care Home Managers and Lifestyle Coordinators who took part. Additionally, the presentation of findings draws more heavily on quotes from the arts organisations rather than the care homes in illustrating the themes. Arts organisations were perhaps more comfortable reflecting on their practice and discussing how they worked with the care homes as such collaborations were commonplace for them. Meanwhile, care home staff were keen to provide positive feedback on the programme but were perhaps less reflective on ways of working together, particularly as their priorities changed since the COVID-19 pandemic, and they were grateful for any external input to the homes.