Benefits of Nature Imagery and Visual Art in Healthcare Contexts: A View from Empirical Aesthetics

Abstract

Public enthusiasm for the arts is high, a trend reflected in the increasingly commonplace incorporation of art in healthcare settings to enhance patient health and wellbeing. The primary aim of this critical narrative review is to evaluate the evidence for the health benefits of the most common art intervention in healthcare—visual art in the built environment. This review synthesizes 25 experimental studies of adult patients passively exposed to nature imagery (n = 17) or other visual art (n = 8). Additional aims are to identify methodological limits and conceptual gaps, integrate the evaluation of studies with insights from empirical aesthetics, and propose a research agenda to advance understanding in ways relevant to clinicians, hospital designers, and policymakers. The efficacy of nature imagery is surprisingly robust given the limited evidence, consistently indicating reduced stress, pain, and anxiety and enhanced patient satisfaction. The impacts of other visual art forms and on other psychological and clinical outcomes are promising but inconsistent, requiring additional testing. Key opportunities for the future include tailoring interventions to the needs of different contexts and populations, deepening engagement, leveraging emerging technologies, capitalizing on underlying mechanisms, and demonstrating economic benefits. With rigorous, scientific study, this young field can inform hospital design, improve patient outcomes, and enhance the culture of healthcare.

1. Introduction

Is art good for what ails you? Currently, public enthusiasm for the arts is high. A national survey revealed that over 72% of the American adult population attended an arts or cultural event, such as going to the theater, a museum, or a musical performance, in the previous year. This high attendance rate reflects the widespread belief that the arts are valuable. 81% of adults agree that the arts are a “positive experience in a troubled world” and 69% agree the arts “lift me up beyond everyday experiences”. A total of 68% believe the arts improve healing and the healthcare experience, and most (76%) believe doing so positively impacts their personal health and wellbeing [1].

Aligned with these intuitions, a scoping review commissioned by the World Health Organization [2] outlined many benefits of arts engagement to health and wellbeing, as did a major review commissioned by the All-Party Parliamentary Group on Arts, Health, and Wellbeing in the UK [3]. Correspondingly, a movement to humanize hospital experiences with various forms of arts programming is underway, especially in the US, UK, and Scandinavia [3,4,5]. Nearly half of US hospitals have arts programs aimed at improving patient outcomes and experiences in these environments [5,6]. Major medical centers were early adopters of this movement, with such models proliferating in the past three decades [4]. Arts in healthcare is “a diverse, multidisciplinary field dedicated to humanizing the healthcare experience by connecting people with the power of the arts. This growing field integrates the arts, including literary, performing, visual arts and design, into healthcare settings for therapeutic, educational, and recreational purposes” [5] (p. 110). Relevant programs include bedside art, art therapies, performing arts in the healthcare environment, the arts in medical and health education, and the design of the built environment. Installing permanent art displays is one of the first steps most healthcare administrators take when initiating arts-based programs [6]. Collections and programming often feature local artists and community arts organizations, though some draw from renowned art collections, collaborating with major institutions such as the Louvre in Paris, and the National Gallery and Victoria and Albert Museum in London [7,8].

In the US, hospitals fund most of these programs (56%). Healthcare organizations primarily invest in the arts to benefit patients (80%) and to create a healing environment [9]. People appreciate this investment, as evident in a large-scale survey of over 1000 patients at the Cleveland Clinic, where patients are exposed to one of the largest and most diverse collections of art in any American hospital [10]. When asked about the diverse collection of over 7000 contemporary artworks adorning the space, 76% of patients reported noticing the art and 73% reported that viewing the art improved their mood—an effect that increased to 91% if they stayed more than one day. A total of 61% credited the art with reducing stress and 39% with improving their comfort and pain. Overall, 78% reported the art made a positive impact on their impression of the institution.

Other site-specific opinion surveys paint a similar picture. Cusack and colleagues [11] found people in waiting rooms rate visual art on par with entertainment like TV, magazines, puzzles, and books. Similarly, a randomized controlled trial (RCT) of “Open Window”, a dedicated set of art “channels” on video display in patient rooms, reported that only 30% of users preferred traditional TV [12]. People also notice the absence of pleasing art. A survey of 400 healthcare consumers found that they believe that art is important for health and wellbeing—and the aspect of the hospital environment with which they are the least satisfied [13,14].

The agenda of incorporating arts in healthcare assumes efficacy. Is this assumption warranted? Research to date is limited. First, most support comes from program evaluations using surveys or qualitative studies entailing semi-structured interviews, observations, or focus groups. These data encourage institutional support and provide insights into subjective experiences. However, persuasively demonstrating the value of arts in healthcare requires the mainstay of scientific research—quantitative research with hypotheses, condition manipulations, and outcome measures. Such investigations are rare.

The primary aim of this critical narrative review is to synthesize evidence from peer-reviewed, quantitative studies of the health and wellbeing impacts of passively viewing art in healthcare environments, as this is the most common way people encounter art in healthcare. It does not consider children or interventions that entail active participation in art-making or other forms of art therapy. It builds upon other reviews conducted within the past 10 years [15,16,17,18,19,20] by incorporating more recent research. It also is distinguished from previous reviews by pooling findings from two species of visual art that are often considered separately—nature imagery and other visual art. Additionally, it integrates the evaluation of these studies with insights from empirical aesthetics. Earlier reviews either have a narrower scope, focusing on particular patient populations [18,20], outcome measures [17,20] visual art forms [16,17,18], or timespans [14], and/or they have a broader scope, including non-healthcare environments [15,17], additional art forms like music [14,19,20], children [17,19], qualitative studies [14,15], or active forms of art engagement [14,18,19]. In addition, none offer the critical appraisal from the allied discipline of empirical aesthetics that is presented here.

This review has four objectives, each addressed by one of the following sections (

Table 1. Review objectives.

	Objective	How Addressed
O1	To critically review the evidence for the benefits of viewing visual art in clinical environments, underscoring consistent findings and promising trends.	This objective is addressed in Section 3 (“Current Evidence Base”), which is subdivided by the art type (nature imagery vs. other visual art forms) and healthcare context (waiting rooms, procedure/exam rooms, patient rooms, and shared and public clinical spaces). The results are synthesized in Section 3.3 (“Summary”).
O2	To identify methodological limits of current research and make recommendations.	Limitations of the existing literature are discussed in Section 4 (“Methodological Limits”). This section also recommends design features to prioritize in future studies to strengthen the rigor.
O3	To uncover gaps in knowledge and draw upon theory and evidence from empirical aesthetics to address them, when possible.	Eight major knowledge gaps are presented in Section 5 (“Outstanding Questions”), each augmented by related findings in empirical aesthetics research conducted in labs or museum settings.
O4	To propose a research agenda to advance this evidence base in ways relevant to arts in health as a matter of policy.	The outstanding questions of Section 5 motivate eight valuable areas of future work to build upon or clarify the existing evidence base. High-priority, relatively unexplored areas are indicated in Section 7 (“Future Directions”).

). Evidence-based design for healthcare environments considers many physical factors of the built environment, ranging from spatial layout, acoustics, ventilation, thermal comfort, wayfinding, flooring, and furniture to visual aesthetics like lighting, color, access to or views of nature, and artwork. The beneficial effects of natural daylight are robustly demonstrated [21], and, while clear correlations between specific colors and moods are lacking [21], the use of colored walls over bare white ones is generally endorsed and favored [22]. In the following sections, we report evidence indicating that nature imagery and other visual art are also preferable to standard, bare walls (colored or white) and confer clinical, physiological, psychological, or behavioral benefits to patients.

2. Methods

Given the limited empirical research on arts in healthcare, the variety of disciplines from which it emerges, and the varied disciplinary interests and standards the studies reflect, a narrative review approach was adopted. Systematic reviews are optimal for addressing a narrow question in a specific domain and aim to be comprehensive of all studies meeting fixed inclusion and exclusion criteria, whereas narrative reviews are more flexible, iteratively refined, and do not claim to be exhaustive. Narrative reviews are suggested for contexts that are under-researched and that “require a meaningful synthesis of research evidence that may be complex or broad and that require detailed, nuanced description and interpretation” [23]. The specific type of narrative review here is a critical review, a narrative synthesis that brings a specific, informed interpretative lens—in this case, the perspective of empirical aesthetics—to draw upon “existing theories and models to allow for synthesis and interpretation of diverse studies”. (p. 416). The interpretative angle built into a critical review is therefore an intentional bias aimed to capitalize on the knowledge of the reviewing authors to bring coherence to a varied empirical literature.

Articles were gathered for review in a multi-step process. Initially, two databases were searched, Elicit (https://elicit.com (accessed on 1 February 2024)) and the Cochrane Central Register of Controlled Trials (https://www.cochranelibrary.com (accessed on 24 March 2024)). Elicit (query: experimental studies of the impact of visual art in healthcare environments) identified 49 papers and Cochrane identified 75. Reviewing titles from Cochrane reduced this cohort to 16. These 65 papers were screened for the following inclusion criteria: adults (>18 years old); healthcare environment (hospital, outpatient clinic, or assisted living home); visual art intervention (nature imagery, artistic photographs, paintings, murals, videos, or slide shows of such); experimental (condition manipulation) or observational (pre/post-intervention) design. Qualitative studies and studies consisting solely of a preference/opinion survey, involving children, art therapy or art-making, or conducted in labs or museums were excluded. Matching papers were read to identify in their citations additional primary research meeting the inclusion criteria. This process was repeated for all papers until none were further identified. Last, entries from 2022 to 2024 in the Research Database hosted by the Center for Arts in Medicine at the University of Florida (https://www.zotero.org/groups/4516700/center_for_arts_in_medicine_research_database/library (accessed on 1 April 2024)) were checked for newer publications.

In total, 25 papers were identified for review: 16 investigating only realistic nature imagery, 5 investigating only other visual art forms, and 4 including both types (

Table 2. Overview of studies, grouped by type of art and context.

Lead Author [Reference]	Design	Context	Type of Art	Outcomes	Health Condition	Sample Size	Observed Benefits
Gómez -Urquiza [24]	RCT	Waiting room	Nature imagery	Physio; Psych	Otolaryngology surgery	180 (60 per condition)	Viewing photographs while listening to music while waiting reduced anxiety and stress more than photographs alone, and both more than the no art condition.
Harper [25]	Experimental	Waiting room	Nature imagery	Physio; Perceptions	Various, non- emergency	113 (within subjects design)	Viewing landscape photography posters while waiting reduced blood pressure more than standard medical posters.
Nanda [26]	Pre/Post-observational	Waiting room	Nature imagery	Behav	Various, emergency	Not reported	Reduced restlessness, noise, staring, and desk inquiries, and increased positive social interaction observed after the installation of art depicting nature.
Aburas [27]	Experimental	Exam/ Procedure room	Nature imagery	Clinical; Physio; Perceptions	Labor and delivery	50 (24 intervention; 26 control)	Laboring mothers with access to a looping video of nature imagery reported more positive perceptions of doctors, and their newborns showed better health, than mothers with just TV access.
Diette [28]	RCT	Exam/ Procedure room	Nature imagery	Clinical; Psych; Perceptions	Flexible bronchoscopy	80 (41 intervention; 39 control)	Patients with a bedside view of nature murals paired with nature sounds reported reduced pain during procedure than patients without any nature art and sounds.
Heinzerling [29]	RCT	Exam/ Procedure room	Nature imagery	Clinical; Physio; Psych; Perceptions	Psychedelic therapy	20 (10 intervention, 10 control)	Watching a nature-themed video during a psilocybin treatment session was associated with reduced blood pressure compared to the standard protocol (bodyscan meditation).
Lee [30]	RCT	Exam/ Procedure room	Nature imagery	Clinical; Perceptions	Colonoscopy	157 (52–53 per group)	Reduced pain and dose of patient-controlled sedatives for patients in the combined audio–video distraction condition (scenic views + music) compared to video only or no distraction.
Lembo [31]	Experimental	Exam/ Procedure room	Nature imagery	Psych	Flexible sigmoidoscopy	37 (12–13 per condition)	Reduced stress with combined audio–video stimulation (ocean views + sounds) compared to audio alone or no intervention conditions.
Miller [32]	Experimental	Exam/ Procedure room	Nature imagery	Clinical; Psych	Burn treatment	17 (8–9 per condition)	Reduced pain intensity, pain quality, and anxiety when patients viewed nature videos during dressing changes for severe burns compared to no video distraction.
Navidian [33]	RCT	Exam/ Procedure room	Nature imagery	Clinical; Perceptions	Flexible bronchoscopy	60 (30 intervention, 30 control	Increased tolerability (reduced discomfort and increased satisfaction with the procedure) for patients in combined audio–visual distraction condition (nature scenes + music) compared to patients with no distraction.
Sogabe [34]	RCT	Exam/ Procedure room	Nature imagery	Clinical; Physio	Esophago-gastroduodenoscopy	289 (71–73 per condition)	Improved vital signs and mood when the procedure was paired with any distraction (music, nature imagery, or combined audio–visual stimulation) compared to no distraction; strongest effects with combined audio–visual distraction.
Ulrich [35]	Experimental	Exam/ Procedure room	Nature imagery	Physio; Psych	Blood donation	872 (174–260 per condition)	Reduced stress (heart rate and blood pressure) when donors viewed nature videos rather than urban scenes, and in low-arousal (nature or quiet) than high-arousal (urban or daytime TV) conditions.
Hill [36]	RCT	Patient room	Nature imagery	Clinical; Perceptions	Vaginal prolapse	92 (46 per condition)	Patients in rooms with a nature image and music access reported greater satisfaction with their care, the hospital, and the environment than those recovering in standard rooms.
Lalezari [37]	RCT	Patient room	Nature imagery	Psych	Cardiac	220 (55 per condition)	Reduced stress and anxiety for cardiac patients in rooms with ceiling-mounted nature scenes, especially when paired with nature sounds
Pati [38]	Experimental	Patient room	Nature imagery	Clinical; Psych; Perceptions	Various	180 (100 intervention; 80 control)	Lower stress, anxiety, and blood pressure, and greater satisfaction with the environment for patients in rooms with ceiling-mounted nature displays than those in standard rooms.
Wichrowski [39]	Experimental	Patient room	Nature imagery	Perceptions	Physical rehabilitation	76 (47 intervention; 39 control)	Patients reported more positive appraisals of rooms with nature-themed enhancements (bed curtain + wall posters) compared to patients in standard rooms.
George [40]	RCT	Patient room	Nature imagery; other visual art (includes landscapes)	Clinical; Psych; Perceptions	Cancer	180 (2:1 ratio intervention to control)	More positive impressions of the hospital environment for patients in rooms with a hung painting, whether selected or assigned, than if no art hung on the wall.
McCabe [12]	RCT	Patient room	Nature imagery; other visual art (includes landscapes)	Psych; Perceptions	Stem cell transplant	164 (75 intervention; 89 control)	Reduced anxiety and, to a lesser extent, depression for patients in rooms with Open Window intervention (projected art and nature images + audio) compared to patients in standard rooms with only TV.
Nanda [41]	Mixed methods	Shared space of psychiatric unit	Nature imagery; other visual art (includes landscapes)	Clinical	Psychiatric	Not reported	Reduced need for medication to treat patient anxiety and agitation when nature art hung on the wall compared to when representational or abstract artworks on the wall.
Trevisani [42]	Survey	Shared space of inpatient ward	Nature imagery; other visual art	Clinical; Perceptions	Cancer	239	Display of photographs associated with enhanced adaptation to hospital environment; benefit was greatest for less anxious and less impaired patients.
Eminovic [43]	RCT	Patient room	Other visual art	Clinical; Psych	Orthopedic	80 (40 intervention, 40 control)	Improved quality of life for patients recovering in rooms with colored walls and abstract art than those staying in standard white-walled rooms without art.
Finkel [44]	Mixed methods	Shared space of inpatient ward	Other visual art (includes landscapes)	Perceptions	Cardiac	45 (15 per condition)	Perception of ward with landscape, abstract, or mixed artwork compared was all was received positively, but the greatest positive impacts (on mood, stress, comfort, and hospital perceptions) was associated with landscapes.
Lone [45]	RCT	Shared space of inpatient ward	Other visual art (includes landscapes)	Clinical; Physio; Psych; Perceptions	Cancer	80 (40 intervention, 40 control)	Greater hope and wellbeing, and reduced anxiety reported by patients with access to an art “gallery” during their stay. Stronger effects for patients with more knowledge and interest in art.
Chang [46]	Pre/Post-survey	Shared space of nursing home	Other visual art	Perceptions	Seniors	33	Greater stimulation of memories reported by residents after the installation of wall art reflecting local culture.
Kincaid [47]	Pre/Post-observational	Shared space of nursing home	Other visual art (nature-themed)	Behav	Dementia	12	Reduced door-testing behavior by residents after the installation of nature-themed murals obscuring a locked exit doorway.

Nature Imagery: Realistic depictions of nature in photographs, videos, slideshows, etc. Other visual art: All other visual art of various media; may include artistic renderings of nature such as landscape paintings. Behav: Behavioral. Examples include agitated movements and social interactions. Clinical: Examples include pain medication, symptoms, complications, and the length of stay. Physio: Physiological. Examples include measures of blood pressure, heart rate, and heart rate variability. Psych: Psychological. Examples include surveys of stress, anxiety, and mood. Perceptions: Patient perceptions. Examples include appraisals of art interventions, quality of clinical care, and the wiliness to repeat procedures. *Waiting area was an exam room.

). These studies spanned four decades (1992–2023) and 10 countries (Austria, China, Denmark, Iran, Ireland, Italy, Japan, Spain, Taiwan, and the US). They also varied widely in terms of design, healthcare context, outcome measures, patient population, sample size, and statistical approach, an unavoidable heterogeneity given the limited evidence base.

3. Current Evidence Base

3.1. Impact of Art Depicting Nature

The value of daylight and windows with views of nature for health and wellbeing is well-established [48,49]. For instance, in a seminal study in the mid-1980s, patients recovering from gallbladder surgery with a window view of nature required shorter stays and less potent analgesics (painkillers) than patients with a view of a brick wall. Consistent with the Biophilia Hypothesis—the proposition that humans have an innate affinity for features of nature based on our evolutionary history [50]—this landmark study preceded many others exploring the benefits of nature, nature views, and biophilic design elements. Hospital designs with natural light and window views are now widely considered standard best practices [51,52]. What about visual representations of nature? Given space constraints, limited access to exterior walls, and largely urban views, it is important to understand if a window-sized print of a tree can substitute for a window view of an actual tree. Are other types of nature imagery, like photography slide shows, video footage, and large-scale murals, helpful? In the following sections, the evidence that realistic nature imagery in four clinical environments confers benefits to patients is reviewed.

3.1.1. Waiting Rooms

Several studies suggest that nature imagery reduces stress in patients waiting for care. Nanda and colleagues (2012) compared the behaviors of patients in the waiting rooms of two hospital emergency departments, before and after the installation of visual art depicting nature. Researchers observed reduced restlessness (pacing, stretching, front desk queries, getting up from seat, and fidgeting), noise levels, and staring at other people, and increased positive social interactions like conversing [26]. In an RCT of pre-operative patients in the waiting area for a surgery unit, Gómez-Urquiza and colleagues (2016) collected physiological and self-report indices of stress (state anxiety, heart and respiratory rates, and diastolic and systolic blood pressure) [24]. A total of 180 patients were randomly assigned to one of three of the following waiting environments: a standard space, a space with a looping video of landscape photography, or the same video accompanied by relaxing classical music. The groups did not differ on any measures at admission, but immediately before entering the operating room, the intervention groups experienced less stress and differed from the control group on all of the outcomes—an effect driven by the group exposed to the video plus music. Viewing the video alone only impacted the respiratory rate.

Another well-powered study by Harper and colleagues (2015) considered a different source of pre-procedure anxiety, “white coat hypertension”, or the elevated blood pressure observed in medical office settings [25]. After baseline blood pressure measurements, patients were randomly assigned to an exam room with standard medical posters or one with landscape photographic art. After 10 min of waiting, arterial pressure, systolic blood pressure, and diastolic blood pressure were all lower for the patients in the room with photography, which is consistent with a calming effect of nature imagery. A total of 63% of patients also preferred this room, describing it as calming, relaxing, peaceful, soothing, and nice (versus professional or educational). These studies suggest realistic nature imagery in waiting rooms reduces physiological, behavioral, and psychological stress and anxiety.

3.1.2. Procedure Rooms

Consistent support for the benefit of realistic nature imagery to patients has been best demonstrated at a critical care point: while undergoing invasive, uncomfortable, or potentially stressful procedures. In the early 1990s, a clinical trial by Miller and colleagues (1992) compared the standard of care with a novel distraction–relaxation technique—bedside videos of scenic beauty accompanied by music—on pain and anxiety during dressing changes for burns [32]. Patients who viewed the nature videos reported less pain intensity, pain quality, and anxiety immediately after dressing changes than those with no such distraction.

These anxiolytic and analgesic benefits of nature videos were replicated in patients undergoing other invasive procedures. In an early, small study, Lembo and colleagues (1998) randomly assigned patients undergoing routine flexible sigmoidoscopy to no intervention, nature sounds, or combined audio and visual nature imagery [31]. Patients in the combined audio–video condition reported reduced abdominal discomfort, anger, and anxiety during the procedure. Subsequent RCTs using similar interventions during invasive procedures confirm that nature imagery combined with music is preferable to nature imagery alone, and both are preferable to no distraction. Diette and colleagues (2003) reported better pain control when patients undergoing bronchoscopies viewed a bedside nature mural and nature sounds before, during, and after the procedure. However, ratings of anxiety, the ability to breathe, satisfaction with care, willingness to return, and ratings of the room did not differ between the intervention and control groups [28]. Another bronchoscopy RCT by Navidian and colleagues (2018) assigned patients to either combined audio–visual distraction or no distraction. They found shorter procedure durations, less severe dyspnea, cough, and pain, and greater willingness to return for a repeat procedure in the intervention group [33]. Lee and colleagues (2004) similarly found that patients watching a series of scenic views with music needed lower doses of sedation during flexible sigmoidoscopy. They reported less pain than patients watching nature scenes without music or a control group receiving no distraction [30]. Both distraction groups were more satisfied with their care and more willing to return for a repeat procedure.

A large RCT of upper endoscopies by Sogabe and colleagues (2020) compared nature images, nature images plus music, just music, or no distraction at five points before, during, and after the procedure [34]. All three forms of distraction improved vital signs and mood. In particular, the nature images or images plus music reduced sympathetic nervous system activity (heart rate variability), blood pressure, and pulse elevation observed without distraction. Negative affective states improved in all distraction groups, with the strongest effects in the combined condition.

Patients also respond positively to nature imagery during less invasive, but nonetheless stressful, experiences. Aburas and colleagues (2017) randomly assigned women in labor to a standard room with television or a room with a TV set playing a 30 min series of nature images [27]. The two groups of mothers did not differ in vital signs, labor duration, or the use of pain medications but their babies differed on an index of newborn health (Apgar score). Other research links Apgar scores with maternal stress and labor complications, suggesting the better scores for babies born to women in the intervention room reflect less maternal stress during labor and delivery. Ratings of quality of care from the patient perspective positively correlated with how many minutes of nature TV mothers watched. Women with access to the video also felt that their doctors took them more seriously and were more sympathetic. As recruitment fell short of the planned sample size, these results await confirmation.

Ulrich and colleagues (2003) considered the following four conditions on blood donor stress in a clinic waiting room: watching a video of nature scenes, watching a video of urban scenes, watching regular daytime television, or a blank screen/no video [35]. All of the participants had their blood pressure and pulse recorded and completed a survey of emotions while waiting and just after donating. No differences in mood were observed, but, at both time points, the pulse was lower after viewing nature than urban scenes, no TV than daytime TV, and in the low-stimulation conditions (nature videos or no TV) than the high-stimulation conditions (urban scenes or daytime TV). Blood pressure followed a similar pattern that did not reach statistical significance. This study suggests that the common practice of continuously running regular television in waiting rooms is stressful.

More recently, Heinzerling and colleagues (2023) demonstrated the benefit of a nature-themed video accompanied by music for individuals with alcohol use disorder undergoing a small RCT of psilocybin treatment [29]. Compared to standard procedures involving listening to music with eyeshades, watching a 42-min nature video was associated with reduced peak blood pressure (but not cortisol levels or self-reported anxiety).

3.1.3. Patient Rooms

Experimental studies of the benefits of nature imagery in patients’ rooms are more limited than those conducted in procedure rooms. An influential abstract ([53], described in [54]) described patients exposed to a picture of nature at the foot of their bed while recovering from heart surgery. Patients with nature imagery experienced less post-operative anxiety and needed less analgesics than patients assigned to the other visual conditions (computer-generated “abstract art” or no image).

Two decades later, Pati and colleagues (2016) randomly assigned 180 patients with various health conditions to rooms with large ceiling-mounted, back-lit photographic sky compositions or standard rooms with traditional ceiling tiles [38]. Patients exposed to ceiling art were more satisfied with their environment and had lower blood pressure. Use of nausea medication and self-reported stress, anxiety, and pain were all lower in this group, but these differences were not statistically significant. A small RCT by Wichrowski and colleagues (2021) showed a similar pattern with nature-based room enhancements (a nature-themed curtain and nature wall posters) compared to standard rooms [39]. Rehabilitation patients randomly assigned to the rooms with nature decor rated room quality, quality of stay, sleep quality, and overall care higher, but these differences were not significant. The enhanced rooms were, however, rated more strongly on a list of positive adjectives, and qualitative data showed more frequent positive appraisals for these rooms and more frequent negative ones for the standard rooms.

Another RCT by Hill and colleagues (2020) investigating the impact of nature imagery paired with music on post-operative recovery observed effects on patient perceptions [36]. Patients in rooms with landscape art mounted at the foot of their bed and with access to music reported greater satisfaction with their care, the hospital, and the environment than those assigned to standard rooms, and were more likely to recommend the hospital. These patients also overwhelmingly affirmed that the music (98%) and art (84%) benefited their health. Though properly powered, other measures did not differ between the groups (narcotic use, nursing- and self-reported pain, length of stay, urinary retention rates, and complications).

In contrast to these equivocal studies, an RCT conducted by Lalezari and colleagues (2022) showed the robust effects of a nature ceiling display installed in the recovery rooms of a cardiac care unit [37]. Patients were randomly assigned to a nature ceiling display, nature sounds, combined nature ceiling display plus sounds, or control/typical tiles. Interventions occurred twice daily, totaling three hours, for the duration of their stay. Stress and anxiety were lower for the intervention groups at discharge but not the control group. The average decrease in stress levels was similar for the combined and display-only groups, but the combined group had a greater impact on anxiety.

3.1.4. Shared and Public Clinical Spaces

Shared and public spaces of hospitals and other healthcare environments include corridors, lobbies, common rooms, dining halls, and break areas. Although realistic nature imagery may adorn their walls, studies of their impact are limited. Nanda and colleagues (2011), however, provide compelling support for their value, comparing the behavioral and clinical impact of realistic nature imagery (a landscape photograph) with an abstract artwork (a Jackson Pollack print), non-realistic representational art (Vincent Van Gogh’s The Fields), and no artwork in a lounge of a psychiatric unit [41]. Over the course of 2–3 weeks, patients required less pro re nata (“as needed”) medication for anxiety and agitation when realistic nature imagery was displayed compared to non-realistic representational art or abstract art. Compared to no art, the nature photograph was associated with a 60% reduction in medication.

3.2. Impact of Other Kinds of Visual Art

3.2.1. Waiting and Procedure Rooms

Despite the common use of non-nature art prints in the waiting rooms of medical offices, to our knowledge, their specific impact has not been studied. Similarly, studies of non-nature visual art during medical procedures are lacking.

3.2.2. Patient Rooms

Patients prefer rooms with artwork [55,56,57]. An RCT by Eminovic and colleagues (2021) of orthopedic post-operative recovery specifically tested abstract art [43]. Control patients were randomly assigned to a standard, white-walled room. Intervention patients were assigned to a room with pastel-colored walls and minimalist, abstract wall art. Mood, anxiety and depression, quality of life, and pain ratings were measured pre-operatively, 3 days post-operatively, and 6 days post-operatively. Quality of life improved in both groups post-operatively, but more so for the art-enriched patients by the end of the intervention. Mood, anxiety–depression, and pain did not differ between groups; however, this is perhaps because the artworks were not clearly in the patients’ line of view (example images show them displayed at the head of the bed).

An RCT with cancer patients by George and colleagues (2018) provides a model of experimental rigor and challenges the assertions about the impact of visual art [40]. Patients receiving treatments requiring a minimum 3-day stay were randomly assigned to either selecting a framed artwork to be hung in their room, having a framed artwork randomly assigned and hung, or having only a blank white board hung in their line of vision. Contrary to expectation, no differences were found between the conditions on any of psychological measures (anxiety, mood, depression, and sense of control) or clinical outcomes (self-reported pain, length of stay, and quality of life). The only supported prediction was that the perceptions of the hospital environment were more positive for patients in rooms with art. Notably, the recruitment and retention fell short of the sample size indicated by power analyses (169 vs. 180), a small but perhaps meaningful discrepancy when considering the difference in the length of stay between patients receiving artwork versus those that did not (6 versus 9.5 days) just missed significance thresholding (p = 0.05). Alternatively, these null results raise the possibility that the benefits of a single artwork diminish during extended stays.

A similarly sized RCT by McCabe and colleagues (2013) aligns with this interpretation [12]. Patients undergoing stem cell transplantation were randomly assigned to standard rooms or ones with the “Open Window” (OW) intervention. OW consists of a virtual window, created by a video projector plus audio, connected to nine artist-curated “channels” depicting classic artworks, visual abstraction, people and locations of personal significance, and nature. Researchers tracked self-reported levels of anxiety, depression, and stress at seven time points, from the day of admission to 6 months post-admission. Patients randomly assigned to the intervention reported reduced anxiety the day before, a week later, and 60 days later. Depression ratings showed a similar but weaker effect. Intervention and control group distress levels did not differ. Intervention patients reported a more positive experience of the procedure and were enthusiastic about OW: only 30% preferred watching regular television, and 61% viewed OW up to an hour a day. A total of 64% reported viewing the art helped them to deal with the confinement and isolation of their treatment, and 74% said it provided a sense of connection with the outside world. Overall, this study demonstrates a meaningful benefit of visual art to mood, and the value of variety and choice during extended hospital stays.

3.2.3. Shared and Public Clinical Spaces

Most studies assessing the impact of viewing visual art in healthcare settings focus on artwork in public spaces, like atria and corridors, or shared ward spaces. For example, Trevisani and colleagues (2010) found 25 artistic photographs portraying daily life were positively received by 239 mobile patients staying in an oncology ward for at least 3 days [42]. Most patients were positively impacted by the display: 92% viewed the photographs and 86% reported repeatedly visiting them. For 72%, the photographs made their stay in the hospital more pleasant. Most patients reported this restorative effect of the art, though patients reporting anxiety or those with a worse clinical status were less likely to perceive this benefit.

The only RCT of art displayed in a common space, conducted by Lone and colleagues (2021), entailed 18 original artworks hung in a separate area of an oncology post-operative recovery ward, creating a small gallery [45]. Patients viewed art without guidance for 15 min a day. Researchers measured typical psychological, physiological, and clinical outcomes like pain, anxiety, mental wellbeing, heart rate, blood pressure, and use of pain medications, and two uncommon measures, art familiarity and hope. At baseline, no differences were observed between groups, but patients in the art-viewing group reported higher hope, mental wellbeing, and lower anxiety than patients who did not visit the gallery. All three measures correlated with a more positive impression of the institution. Hope and anxiety scores were more strongly affected if patients visited art exhibitions two or more times a year, and wellbeing scores were also higher if they were knowledgeable about art. Although viewing the gallery did not impact pain or physiological measures, this study demonstrates the value of unstructured art viewing on psychological outcomes and patient perceptions of their provider, and of including measures of art participation and positive moods like hope.

The RCT by Lone and colleagues [45] was not designed to look at different kinds of art separately, leaving open the possibility that some types have a greater impact than others. Finkel and colleagues (2021) compared 28–30 original, contemporary artworks of three types—landscape, abstract, and mixed—in the corridors of cardiothoracic surgery units [44]. Patients responded positively to the artworks, with more participants endorsing positive impacts (on mood, stress, comfort, institution impression, and satisfaction with experience) in the ward featuring landscapes. Abstract or mixed art did not elicit negative feelings like anxiety or discomfort.

Chang and colleagues (2013) and Kincaid and colleagues (2003) both considered the impact of murals in the shared space of a nursing home, an environment in which many residents manage various health conditions, reduced autonomy, and memory loss [46,47]. In the former, a survey queried the aesthetic appeal, convenience, and propensity to recall old memories before and after installing murals reflecting local culture. Scores on the Recalling Old Memories subscale increased. A similar but weaker trend was observed for the Aesthetics subscale. The latter study targeted a behavior specific to people with memory disorders. The mural obscured the presence of a locked door that residents frequently attempted to exit. Results showed a large decrease in door-testing behaviors after the installation of the nature-inspired mural. Further, all 12 residents tested doors before the installation but only 3 did so afterward. These studies highlight the importance of art tailored to the specific needs and health conditions of the population viewing them.

3.3. Summary

Despite the small set of studies, evidence for the health and wellbeing benefits of realistic nature imagery has been demonstrated in waiting rooms and during procedures. In these environments, researchers observed improvements in psychological outcomes, like self-reported stress and anxiety, as well as corresponding physiological indices, like blood pressure, respiratory rate, and or heart rate, and relevant clinical measures associated with pain and discomfort. The benefits of realistic nature imagery during hospitalization were also observed, though generally weaker; researchers frequently reported non-significant differences on some outcome measures. These findings are summarized in the Observed Benefit column of Table 2.

When considering other forms of visual art, promising effects have been observed, but the findings are weak and more variable than those observed for realistic nature imagery. The reason for the differences between visual art forms is unclear, though many possibilities exist. Foremost, studies of non-realistic nature imagery and other visual art are fewer in number (n = 8). They also focus on different contexts, including inpatient rooms and shared/public spaces rather than waiting and exam/procedure rooms. A few RCTs model high experimental standards [12,40,43,45]. Other studies in this category are generally of lower quality, include fewer outcome measures, and use more heterogenous stimuli.

4. Methodological Rigor

The arts in health field faces similar challenges as those that apply to the early days of other applied research domains, such as art therapy. Descriptive and qualitative studies dominate the evidence, which are hard to translate to specific clinical practices. Only 25 quantitative studies were identified as appropriate for review, even with broad inclusion criteria. Although it is possible that some studies were missed by our search, our iterative strategy was intended to be comprehensive. As evident in Table 2, these quantitative studies varied widely in design, artwork types, outcome measures, population, and healthcare settings. This heterogeneity is to be expected in a broad review. More problematic is that these studies also varied widely in methodological quality, thus limiting their inferential import (

Table 3. Design features of studies, grouped by art type and context.

Lead Author [Reference]	Type of Art	RCT	Power Analysis	Randomization	Control: No Intervention	Control: Active	Effect Sizes
Gómez-Urquiza [24]	Nature imagery	Y	Y	Y	Y	Y	N
Harper [25]	Nature imagery	N	Y	Y	Y	N	N
Nanda [26]	Nature imagery	N	N	N	Y	N	N
Aburas [27]	Nature imagery	N	Y *	Y	Y	N	Y
Diette [28]	Nature imagery	Y	N	Y	Y	N	N
Heinzerling [29]	Nature imagery	Y	N	Y	Y	N	N
Lee [30]	Nature imagery	Y	Y	Y	Y	Y	N
Lembo [31]	Nature imagery	N	N	Y	Y	Y	N
Miller [32]	Nature imagery	N	N	Y	Y	N	N
Navidian [33]	Nature imagery	Y	Y	Y	Y	N	N
Sogabe [34]	Nature imagery	Y	Y	Y	Y	Y	N
Ulrich [35]	Nature imagery	N	Y	Y	Y	Y	N
Hill [36]	Nature imagery	Y	Y	Y	Y	N	N
Lalezari [37]	Nature imagery	Y	Y	Y	Y	N	N
Pati [38]	Nature imagery	N	N	Y	Y	N	N
Wichrowski [39]	Nature imagery	N	N	Y	Y	N	N
George [40]	Nature + Other	Y	Y	Y	Y	Y	N
McCabe [12]	Nature + Other	Y	Y	Y	Y	N	N
Nanda [41]	Nature + Other	N	N	N	Y	Y	N
Trevisani [42]	Nature + Other	N	N	N	N	N	Y
Eminovic [43]	Other visual art	Y	N	Y	Y	N	N
Finkel [44]	Other visual art	N	N	N	N	Y	N
Lone [45]	Other visual art	Y	Y	Y	N	Y	N
Chang [46]	Other visual art	N	N	N	Y	N	N
Kincaid [47]	Other visual art	N	N	N	Y	N	N

Y = Yes, present in the study. N = Not reported in the study. * Power analysis conducted but the sample fell short by >50%.

).

Many studies were not powered adequately to address their questions of interest, relying on convenience samples in 13/25 studies rather than power analyses. Difficulty in distinguishing true null effects from non-significant or weak effects caused by underpowered samples is exacerbated by the failure to report effect sizes in all but two studies. Studies also infrequently include an active control group or comparison condition (only 9/25), making it difficult to attribute benefits to the art versus other aspects of the intervention or the environment. Half of the reviewed studies (12/25) were randomized controlled trials—the highest standard for intervention testing. Nonetheless, none included all of the desirable design features indicated in Table 3. Studies involving nature imagery were more likely to include these desirable design features.

Even when designed rigorously, most studies suffer from the difficulty of blinding. It is not feasible to limit exposure to patients only, leaving open the possibility that any observed effects are mediated in part by the impact of the art on the clinical team and the care they provide. For the standards of laboratory-based research, this confound might be a “bug”. In a clinical setting, it might very well be a desired feature.

Going forward, the field would benefit from more randomized controlled trials. Even when not practical, some features are important, including larger sample sizes motivated by power analyses, effect size reporting, and active control groups or well-matched comparison conditions. Other science “hygiene” practices, such as the preregistration of designs, hypotheses, and analyses, would improve the interpretation confidence, especially when the interventions are novel, the samples are small, or randomization is difficult. Ideally, the outcome measures should extend beyond surveys of patient satisfaction or self-reported stress, which are vulnerable to responder biases, and include objective measures as well. Studies including measures at more than one level—behavioral, psychological, physiological, and clinical—are more reliable and facilitate cross-study comparisons. Integrating rich subjective reports of experience with quantitative measures will inform new directions.

Rigorous quantitative research requires multidisciplinary partnerships between hospital administrators and care teams with researchers skilled in experimental design, outcome measurement, and data analysis, as well artists or experts in curating visual art. A critical barrier to progress remains inadequate funding to conduct such rigorous, multidisciplinary research.

5. Outstanding Questions

Gaps in the existing evidence base raise eight broad questions to advance the science of art’s health and wellbeing benefits. Research from empirical aesthetics conducted in the lab or museums can corroborate or contextualize some of the arts in healthcare findings, informing the direction of future studies.

5.1. Which Type of Art Is Best?

Are some art themes more effective than others? For instance, nature-based artworks, such as waterscapes, landscapes, flowers, or garden scenes, are typically endorsed over other forms of representational art. Abstract art, surreal, ambiguous, and challenging images are discouraged [51,52]. Should hospitals adhere to such sweeping guidelines?

Studies of the benefits of realistic nature art are usually distinct from studies involving other types of visual art. Nature-themed art is generally preferred in in-patient hospital rooms [58] and waiting rooms [11], a pattern echoed in qualitative studies [15]. Lab-based studies also find that non-patient populations prefer images of real-world scenes over abstract art images [59], favor landscape paintings over other styles [60], and show greater agreement in aesthetic evaluations when considering real-world scenes [59]. Combining these lines of research, nature-themed art, whether realistic or artistically rendered, is likely to appeal to most and unlikely to cause distress.

Current guidelines recommend against displaying abstract art, based on early studies with low quality [53] or limited examples [41]. Some speculate that it can be agitating, particularly for mental health patients [54], or that it is a negative distraction [20] because it is difficult to understand. Others contend the data condemning abstract art are insufficient and overlook the variety of forms this style can take [19,61]. For instance, abstract art with visual features like symmetry, fractal dimensionality, and organized complexity may be preferred over more random abstractions. These properties mirror patterns found in nature and are generally preferred and elicit longer viewing when present in art and architecture [62,63,64,65,66].

Further, some studies refute the presumed negative impact of abstract art. Benefits of visual art have been reported in studies only entailing abstract art [43] and the widespread patient enthusiasm for the art in the Cleveland Clinic—a large collection of contemporary art replete with abstract works—challenges the assumption of negative effects [10]. Nielsen and colleagues (2017), for instance, found no stressful effects associated with abstract art loaned from a contemporary art museum [67].

Outside clinical contexts, art-naïve people generally prefer representational work over abstract art [68,69,70], but this observation does not mean abstract art leaves negative impressions. Aesthetic appraisals of abstract art are more variable [59,71], with preferences linked to differences in temperament, social attitudes, cultural context, and expertise [69,72,73,74]. The tendency to prefer representational art is reduced when viewers are provided additional information about the artist or the artwork [75,76,77]. Thus, abstract art need not be avoided, but its sensitivity to viewer characteristics makes it more appropriate in settings that allow for a diversity of images and greater engagement.

5.2. How Will Evolving Technology Impact Research?

Rapid changes in technology motivate new questions. Immersive, multi-sensory experiences during procedures may increase the benefits of single-modality, two-dimensional visual art, as has been observed in studies of multi-sensory biophilic designs versus single-modality interventions [78]. Immersion in virtual nature environments can decrease anxiety during chemotherapy treatment [79], make the treatment duration feel shorter [80], and reduce the pain and increase the tolerability of burn wound treatment [81]. Physiological and psychological benefits of virtual reality (VR) nature have also been observed in the high-stress environments of intensive care units [82,83]. As the technology advances and becomes more common, it could extend to other high-stress points in patient care, like pre-operative waiting rooms. VR could also be leveraged by applied researchers before moving to healthcare environments to ensure installations use maximally effective choices [84].

Another way that changing technology could impact the arts in the health landscape is the increasing digitalization of our lives. The digital menu of art offerings in the Open Window RCT [12] could become common as hospitals shift from traditional television sets in patient rooms to screens that also serve as channels with content that hospitals can augment. Recent research indicates minimal differences in the aesthetic or emotional impact of viewing artworks in person versus on a computer screen [85]. The replacement of TVs with screens offers a rich opportunity to provide more varied and personalized art to patients, potentially magnifying the benefits.

5.3. Does the Clinical Context Matter?

The selection of art should be optimized for different healthcare contexts. The demands of waiting rooms, procedure and exam rooms, and post-operative recovery and long-term hospitalization rooms differ, inviting artwork targeted to the stresses and goals of each. Likewise, primary care offices, outpatient clinics, and hospitals serve the general population, but other institutions serve specific populations, such as those with dementia or mental health disorders, whose needs might differ. Critical considerations are the level and quality of illness of patients and the duration of their stay.

For hospitals, the primary goal in waiting areas may be to reduce stress and anxiety and to boost morale. Research to date has focused only on reducing apprehension. Another unaddressed feature of waiting areas is that art may mitigate the anxiety and negative impressions of long waits. Goals for visual artwork during exams or procedures present additional challenges—to also reduce pain and discomfort. Existing research with nature imagery is promising. Inpatient recovery has additional goals of improving clinical outcomes and speeding recovery. Patients hospitalized for longer periods often face complex health challenges, making artwork that lifts their spirits and distracts from their confinement particularly apt.

A common observation outside the clinical environment is that art is preferred if it is more familiar. This “mere familiarity effect” [86], coupled with observed changes in aesthetic evaluations associated with repeated viewing [87,88], may recommend challenging art, too, to contexts that invite repeated views. That is, contrary to guidelines eschewing abstract art, it may offer the kind of optimal ambiguity for inviting deeper engagement and layers of meaning with repeated encounters [89].

Arts programming in long-term care and hospice or palliative care facilities constitutes less than 10% of reported programs [6]. Given the growing population of seniors, optimizing visual art to the cognitive and emotional profile and concerns typical of residents in such facilities is an important goal. Conditions that predominantly affect seniors, such as memory disorders, indicate altered aesthetic preferences. Aesthetic judgments of portrait photography, for instance, deteriorate in Alzheimer’s disease, though judgments of paintings and photographs of landscapes do not [90]. Even with deficits in explicit recall or language, patients with Alzheimer’s disease and frontal temporal lobe dementia express consistent aesthetic preferences over time, suggesting an enduring value of art engagement in these populations [91,92]. Both patient groups, however, show sensitivity to the emotionality of artworks that differs from their healthy peers [93,94]. Engaging with art can stimulate new understanding, including personal transformation and spiritual insight [95]. The nearness of mortality in older age and hospice/palliative care invites the additional benefit of providing spiritual support in uncertain or existentially demanding circumstances. The use of art in the service of spiritual care is incorporated in some hospital programs [96] but remains largely unstudied.

Mental health facilities are another environment in which relevant studies are scarce. Features that might disturb, agitate, or upset patients, such as ambiguity, uncertainty, surreality, or emotionally negative or provocative content, are advised against [54]. Instead, soothing nature imagery or figurative art featuring people engaging in positive or nurturing behaviors are suggested. That patients with mental health conditions are prone to respond negatively is a largely untested assumption. Responses to the diverse artwork displayed at the Cleveland Clinic showed positive effects were especially endorsed by patients with post-traumatic stress symptoms and generalized anxiety [10]. Individuals with mood, personality, and psychotic disorders do express aesthetic preferences that differ from the general population [97,98,99,100], indicating the need for further research tailored to mental health populations.

5.4. Should Individual Differences Be Considered?

Aesthetic experiences are unavoidably subjective. However, integrating findings from empirical aesthetics and the art in healthcare fields offers some general lessons. Many hospitals that include art programs rely on professionals, like artists, art therapists, and child life specialists, to guide their approach, and increasingly rely on paid healthcare art administrators [6]. The opinion of experts might contrast with the preferences of patients and caregivers. Nanda and colleagues (2008) compared the preferences of hospital patients and design students, finding differences, and a stronger link between emotional response and preference in patients [101]. Similarly, an RCT found that the positive mood benefits of art differed depending on art familiarity [45]. These observations align well with empirical aesthetics research. Art experience alters aesthetic evaluations, preferences, and impacts in other environments [102,103], highlighting an overlooked moderator of aesthetic experience in the healthcare research.

Hospitals and other healthcare environments serve culturally diverse constituencies [5,6]. Lab studies show that viewers find artworks coming from their own culture more beautiful and likable [75]. Including culturally diverse artworks that mirror the demographics of the surrounding community can increase their relevance to patients, potentially enhancing their benefits. But what of the widely held belief that the arts build bridges between cultures and communities [1]? When viewers are provided with information about culturally unfamiliar artworks and their makers, own-culture bias diminishes [75]. Thus, diverse art collections in healthcare may benefit community cohesion, too, if contextually enriched—a promising possibility in long-term settings like nursing homes or rehabilitation units that serve diverse populations and allow for deeper engagement.

Given the diversity of cultures and art experiences of healthcare consumers, one solution is to diversify collections such that something appeals to everyone rather than aim for everything appealing to everyone. Larger spaces of waiting rooms and public or shared areas invite this approach. For individual patient rooms, appealing to personal preference may be beneficial. In one such program [104], patients selected a poster for their room weekly from a varied collection. Interviews with patients, caregivers, staff, and volunteers identified many benefits of the artworks (creating a more pleasing and personalized environment, enhancing mood, stimulating memories and reflections, providing distraction and alleviating boredom, and prompting conversation), which they largely attributed to the offering of patient choice.

5.5. What Is the Impact on Caregivers and Clinical Staff?

People directly administering care to patients, i.e., clinical staff and the friends and family visiting them, are largely neglected in empirical studies [105]. Healthcare staff generally agree that artworks benefit patients [41,104,106,107], noting improved communication between staff and patients, a more pleasing environment, and a calming effect. However, a large study of healthcare providers in two Chinese hospitals paints a different view [108]. In this group, art objects were rated as “neither unimportant nor important” and valued less than those features that more directly impact functionality (like cleanliness, lighting, and spatial layout). A similar survey of environmental features deemed to be important and effective by staff working in mental and behavioral health settings also favored window views and good lighting as more important than visual art [109]. These studies suggest important differences between key populations.

Attention to art in spaces used by staff (break rooms, nursing stations, on-call rooms, etc.) would presumably contribute to staff wellbeing and have downstream benefits on the quality of care provided. Along these lines, Nejati and colleagues (2016) asked nearly 1000 nurses to rate the restorative features of hospital staff break areas, including nature artwork. The ratings indicated that the nature imagery was ranked intermediate—more than indoor plants but less restorative than window views or direct access to outside [110]. Some studies also suggest that staff prefer different artworks than patients [26,61].

Only 42% of American healthcare organizations with arts programming report doing so to benefit their staff [6], and only a quarter specifically measure the effect of their arts program on relevant considerations like staff satisfaction, retention, and recruitment. To our knowledge, no empirical studies directly measure the health and wellbeing benefits to staff or caregivers, and few consider their opinions. Understanding how visual art impacts job productivity and satisfaction, stress and fatigue, and patient—caregiver interactions is an important opportunity for future research.

5.6. How Can the Benefits of Visual Art Be Maximized?

Typically, the impact of art increases when people engage with it more deeply. Interventions in healthcare may be enhanced by similar modifications that invite deeper, more personal, or more social engagement. Such engagements can occur during longer-term hospitalization, which allow repeated viewing and involve more visitors.

Social engagement may be a benefit of art engagement and a means to enhance its other salutary effects. Semi-structured art dialogs with healthcare staff in a psycho-geriatric facility showed that artworks supported patient wellbeing and stimulated conversation and memories [107]. In an RCT of women living in a seniors’ apartment [111], residents that viewed and discussed artworks had lower systolic blood pressure and reduced medication use than the control group (which discussed current events), and these effects persisted four months later. They also reported fewer negative moods and physical symptoms, and more positive moods. Guided conversation around artworks, compared to independent viewing, can also ameliorate anxiety, provide positive distraction, decrease boredom, and sometimes mitigate depression [112]. These benefits of social art viewing accord with the nascent social prescribing movement, whereby museum visits are prescribed to enhance wellbeing and ameliorate loneliness [113,114,115,116].

One little noted finding in the large survey evaluation of the impact of the Cleveland Clinic’s arts programming is that almost 80% read the labels accompanying displayed art. Typically, arts in healthcare studies do not report whether information about artworks is displayed, suggesting even basic attributions like the maker, title, and year of creation may not be shared. A decontextualized display of art misses a rich potential to increase viewer engagement and impact. Lab and museum studies show that aesthetic evaluations of liking and understanding are enhanced by adding titles [76,117,118], and information about maker, technique, and historical context [75,77,119,120]. Adding plaques with basic information or QR codes to direct viewers to richer details has the potential to enhance benefits.

Another opportunity to deepen engagement capitalizes on the considerable unstructured time spent waiting for physicians, procedures, and discharge. How little time does a person need to spend viewing artwork to experience benefits? Investigations of dose–response relationships are absent in the arts in healthcare studies. Do benefits increase or change with repeated or extended viewings? Museum studies of longer engagements (“slow-looking”) demonstrate that aesthetic evaluations and psychological outcomes are positively influenced by longer looking times, especially when viewers report high levels of immersion [121,122]. Rather than an inconvenience, the waiting inherent in receiving healthcare could amplify the benefits of exposure to visual art.

5.7. What Mechanisms Explain the Benefits of Visual Art?

Researchers propose evolutionary, cognitive, social–emotional, and neural mechanisms to explain the salutary effects of visual artwork. These mechanisms are not mutually exclusive [12]. Understanding when they apply, and for whom, can inform strategies to amplify their effects. Putting them to test can discriminate effects that are unique to art from other aspects of an intervention, thereby enhancing the field’s scientific credibility.

Evolutionary explanations are especially relevant to discussions of nature imagery. Prospect/Refuge theory [123] proposes that humans have innate preferences for unobstructed views (prospect) and safety (refuge). Similarly, the Biophilia Hypothesis [50] proposes that humans are innately predisposed to prefer natural environments and scenes of nature with features matching habitats for which humans are optimally adapted (vegetation, water sources, sunlight, etc.). Attention Restoration Theory [124,125] posits that being in or viewing nature offers a respite from the mental fatigue caused by typical cognitive demands.

The foremost cognitive explanation is that viewing art provides positive distraction. Reorienting attention from a painful sensory stimulus to a pleasant one may reduce the intensity of the pain [32,126,127]. This idea is supported by lab research demonstrating reduced pain when viewing beautiful rather than ugly paintings [128] and when chronic pain patients are prescribed art gallery visits [129]. Processing Fluency Theory [130] suggests that the ease of processing determines the aesthetic experience, following a U-shaped curve. At the extremes—too easy or too difficult—a viewer is not engaged. The more fluently the perceiver can process an object, the more they like and enjoy it. Given its familiarity and adaptive relevance, preferences for nature art are often attributed to its presumed visual fluency [101].

Curiosity may also mediate some benefits [131]. Patient curiosity may be stirred by a desire to learn about the art, avoid boredom, experience novelty, surprise, and incongruity, or search for higher meaning [61,132]. A role for curiosity mediating art’s health benefits accords with Aesthetic Cognitivism [95], the philosophical claim that art engagement can serve as a vehicle for new knowledge and understanding.

Other explanations for the benefits of art viewing appeal to its emotional and social impacts. Many studies assume viewing art reduces anxiety and stress [17]. Salivary cortisol levels and systolic blood pressure—physiological markers of stress associated with increased anxiety—can be reduced in as little as a single, brief visit to an art gallery [133,134]. Given the link between pain and anxiety, alleviating anxiety may also reduce pain [32].

Viewing art may also increase positive feelings, as observed in studies of benefits associated with visiting art museums [114]. Allowing patients to select artwork for their rooms may enhance their sense of agency in a context in which they otherwise have little control [135]. Engaging with art can also promote positive affect, like uplift and hope [136], or provide spiritual support [96]. Emotional Congruence Theory [137] posits that art reception is biased to match one’s own emotional state. “Viewers in hospitals may seek out art that provides them with an outlet for even their distressing or existential concerns, rather than solely seek to distract themselves” [61] (p. 31). Last, viewing art may benefit patients, staff, and caregivers by fostering meaningful conversation amongst them. Social support, in turn, improves immune system function [111,135,136].

Three psychological and neural frameworks of aesthetic experience seem particularly relevant to arts in health. The Aesthetic Triad [138] conceptualizes aesthetic experiences as emerging from the interaction of the following three neural systems: perceptual–motor, emotion–valuation, and knowledge–meaning. The Vienna Integrated Model of Art Perception [139] elaborates how the perceptual, emotional, and cognitive aspects of engagement unfold over time. The Neuroarchitectural Triad [140] recognizes the interaction of visual art with the larger built environment, the aesthetics of which can shape our emotions, interactions, and cultural identity [141]. All three models recognize the following two neural systems engaged when viewing art: (1) reward areas when art evokes pleasure likely contribute to art’s wellbeing effects; (2) the default mode network likely mediates the distraction of immersive art experiences that invite reflection and mind-wandering.

5.8. Do Practical Benefits Accrue Beyond Individual Wellbeing?

Embedding art in healthcare facilities requires high-quality multidisciplinary research; such efforts need sustained financial support. The return on such investments, however, extends beyond the health and wellbeing impacts of patients.

The economic ramifications for healthcare facilities are many: improved clinical outcomes, reduced complications, fewer procedures and pain medications, and shorter stays. Fewer procedures also free up nursing hours for other tasks [142], increasing the efficiency of care delivery. The improved wellbeing of staff reduces burnout and turnover, a significant financial consideration given an ongoing nursing shortage [6]. Greater patient satisfaction with care and shorter stays also translates to greater market share for hospitals [143]. In the long term, arts interventions that enhance health and wellbeing are low-cost strategies to reduce the burden on public health services [144]. Despite its meaningfulness, few programs evaluate their economic benefits [6,144].

Individual studies, however, hint at economic benefits of the arts in healthcare. Nanda and colleagues (2011) tracked the ratio of pro re nata (PRN) medication issued by nurses in response to signs of patient anxiety and agitation and estimated the average savings for PRN incidents to be USD 27,526/year—a 60% cost savings to patients and the hospital—when realistic nature art was installed in a psychiatric unit [41]. A novel application of a conventional cost–benefit analysis estimated the cost reduction associated with installing mood-uplifting paintings to shorten hospital stay lengths [145]. Using conservative estimates and modeling cost–benefit ratios for three major hospitals (the Mayo Clinic, Johns Hopkins, and Mass General), the benefits initially exceeded costs by 2.5–3.5 times, resulting in a net benefit of USD 4–8 million projected 10 years out. When estimated at the state level, projected benefits exceeded USD 160 million for a large state like California (see also [135,142,144] for examples of the savings associated with music interventions and social prescribing).

Patients also infer the quality of medical care at an institution from the presence (or absence) of art [55,146], influencing customer satisfaction, loyalty, and favorable word-of-mouth recommendations [57]. Patient satisfaction with hospital art also strongly predicts patient likelihood of recommending the hospital [147]. Moreover, patient satisfaction is related to both inpatient mortality [148] and hospital readmission within 30 days [149]. Since 2012, hospital reimbursement rates for Medicare and Medicaid patients are tethered to patient satisfaction, creating incentives for American hospitals to optimize patient perceptions of care, which are swayed by the aesthetics of hospital spaces [147,150]. Studies that link the health benefits of visual art to other, non-health outcomes, like cost savings, can make a stronger case for investment in arts in healthcare programming and research.

6. Conclusions

For the past forty years, the field of arts in healthcare has been growing globally and showing promise. This review synthesized the current state of knowledge concerning the health and wellbeing benefits of exposure to visual art in healthcare environments for adult patients. The objectives of this review were addressed by critically evaluating 25 studies, spanning four decades and involving clinically and geographically diverse populations.

O1.

To critically review the evidence for the benefits of viewing visual art in clinical environments, underscoring consistent findings and promising trends.

Humanizing the healthcare environment to include visual art is more than a design trend. It is good medicine. The benefits of nature imagery are observed in every study undertaken; support for other forms of visual art is promising but should be considered with care. In particular, realistic nature imagery benefits patients by reducing psychological and physiological indices of stress and anxiety, as well as pain perception. These effects are most consistently observed in studies involving invasive procedures or in waiting rooms. Other forms of visual art elicit some promising, but generally weaker or inconsistent, benefits, a preliminary conclusion based on fewer studies of more variable rigor.

The inherent subjectivity of art engagement prevents prescriptions for the built environment that will appeal to every viewer. Nonetheless, available evidence makes general recommendations for healthcare arts administrators reasonable. When selecting art, context matters. Tailoring selections to the psychological demands of different healthcare environments and the clinical and psychological characteristics of the target patient population can strengthen interventions. For patients who are not critically ill and have long waits, distraction is an important consideration. More complex art, be it ambiguous or abstract, might help offset boredom and engage them during their wait. Such art might be embedded in a collection of “safer” nature-themed art so as not to overwhelm. For patents in higher anxiety, short-duration situations, like waiting for or experiencing invasive procedures, art that serves to calm and to distract is invaluable and well demonstrated with realistic nature imagery. Immersive technologies such as VR may prove most useful in these respects, particularly when sedation is minimal. Promoting agency and encouraging deeper engagement through information and dialog may be particularly useful for patients with long hospitalizations or in care homes, who might otherwise be restless and lacking stimulation.

O2.

To identify methodological limits of current research.

While the evidence to date supports the widely held intuition that art is good for one’s health, solid claims are limited by the inconsistent quality of studies, varied interventions and outcome measures, and heterogenous populations in what remains a small body of research. Larger sample sizes, effect size reporting, and active control conditions are needed. Ultimately, advancing knowledge and establishing confidence in the promising results observed so far will necessitate more well-powered RCTs. Studies that extend beyond acute care situations, and that consider the diversity of patient populations and their varied needs, will enhance utility of the research.

O3.

To uncover gaps in knowledge and draw upon theory and evidence from empirical aesthetics to address them, when possible.

Research quantifying the benefits of visual art in healthcare settings are on the rise but still limited. Eight major knowledge gaps emerge from the existing literature. These desiderata include a clearer understanding of which art types are best in which clinical contexts and for which patient populations. Other unknowns include the benefits of visual art for other key constituents like healthcare staff, caregivers, and visitors, and how newer technologies may be leveraged to increase their benefits or access. Strategies for enhancing art engagement and impact are taking shape in empirical aesthetics scholarship, but not yet explored in healthcare environments. Similarly, the underlying mechanisms of benefits remain theoretical and not leveraged to any advantage. Last, indirect benefits to consumers and healthcare providers, in the form of savings, remain mostly unexamined.

O4.

To suggest a research agenda to advance this evidence base in ways relevant to arts in health as a matter of policy.

Gaps in the current knowledge of visual art’s health and wellbeing benefits are reformulated as questions in Section 5 to stimulate research in promising directions to advance the field. Suggestions for breaking them down into narrower, concrete questions amenable to experimental study are offered in

Table 4. Research questions for advancing the field.

	Knowledge Gap	Suggested Experimental Questions to Address the Gap
1	Which type of art is best?	Does the realism of nature imagery matter? How do nature-themed, representational, and abstract art compare? How do different types of abstract art compare? What is the ideal ratio of different art types? Do patients prefer art from the community over well-known art? Does the thematic content of representational art matter? How do patient preferences differ from the general population?
2	How will evolving technology impact research?	Are benefits of visual art strengthened by immersive experiences like virtual reality (VR)? Can VR be used before installation to determine best interventions? Are benefits reliably magnified when visual art is paired with music? How do the benefits of visual art compare to those of other art modalities or arts interventions in healthcare? Does the variety and personalization afforded by digital formats strengthen benefits?
3	Does the clinical context matter?	What are the primary concerns of patients at various points in clinical care or in different types of healthcare environments? How can art selections be targeted to those concerns? How does the impact of visual art vary as a function of wait duration or repeated exposure? Do certain contexts favor greater challenge, ambiguity, or novelty more than others? Do different patient populations have specific needs that are best met by different types of visual art?
4	Should individual differences be considered?	How important is patient choice for reaping the benefits of visual art? How do differences in temperament, expertise, cultural background, age, gender, and neurotype impact patient preferences and impacts? Is personally relevant art more impactful than other art types?
5	What is the impact on caregivers and clinical staff?	How do the preferences and psychological needs of staff, caregivers, and patients differ? Can visual art reduce the negative aspects of the healthcare environment for caregivers and visitors? Can visual art improve the quality and efficiency of clinical care, or reduce staff turnover, burnout, errors, fatigue, and stress? Does visual art impact interactions between patients, staff, and visitors?
6	How can the benefits of visual art be maximized?	Does visual art lead to greater social interaction? Do guided conversations about artworks strengthen their impacts? Can benefits be enhanced by the provision of additional information or viewing guidance? How long or consciously do patients need to view art to reap benefits? Which outcome measures are most reliably affected or most malleable?
7	What mechanisms explain the benefits of visual art?	Which underlying mechanisms drive the observed benefits of visual art? For whom? Under which conditions? How specific is the benefit of visual art to the art itself vs. other aspects of the intervention? How does the impact of visual art compare to other aesthetic features like natural light, furnishings, paint, etc.? How is the impact of visual art modulated by other aspects of the built environment, like the physical layout, amenities, or the psychological dimensions of the spaces?
8	Do practical benefits accrue beyond individual wellbeing?	How does visual art sway patient perceptions of an institution, the probability of recommending it, or its market share and reputation? Does the presence of visual art influence staff recruitment and retention? How does visual art impact cost of care for consumers or institutions?

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7. Future Directions

Three areas that have not received much attention but could have large impacts on care merit highlighting. First, intentionally considering the population served by a facility would mean including diverse artwork sensitive to the local culture. Such attention is likely to increase the perception that care offered by an otherwise distant, bureaucratized healthcare system is personalized. Second, on the assumption that satisfied staff provide more kind, empathetic, and error-free care, staff wellbeing is paramount. The use of art in staff spaces, like break and on-call rooms, has not garnered much attention by administrators, let alone been studied empirically. Finally, the use of art as spiritual succor has been ignored. Sanctuary spaces in hospitals sometimes seem like an afterthought, even though the historical antecedents of hospital architecture are rooted in religious spaces [151]. Art could be used with sensitivity in such spaces and in hospice settings, in which patients and families face mortality, loss, and grief.

Healthcare in the US is big business and, in nationalized healthcare systems, a major financial investment by governments. Administrative support for much-needed research and programming is more likely if an economic argument for these design enhancements can be made. Patient and caregiver impressions and reviews presumably help the reputation and subsequent market appeal of healthcare facilities. Beyond these competitive benefits, monetary savings in staff turnover, the use of medications and other interventions, and the length of hospital stays are likely. Such economic analyses, when conducted, have been promising. A clearer understanding of these economic benefits would accelerate research and programming, and impact policy related to the aesthetics of the built environment. Incorporating such analyses in future studies is an important goal, requiring multidisciplinary collaborations that include hospital administrators.

Arts in health research and practice is in its early days. While promising, tantalizing questions await rigorous scientific pursuit of their answers. In a system that is increasingly bureaucratic, anonymous, and alienating, incorporating insights from empirical aesthetics with the applied sensibilities of hospital designers, clinicians, and arts in healthcare administrators promises to rejuvenate the care in healthcare systems.