My Dissertation PDF

THE PERSPECTIVES OF HEALTHCARE
PROFESSIONALS IN THE SOUTH EAST REGION
ON THEIR EXPERIENCE OF THE PARTICIPATORY ARTS IN
A MENTAL HEALTH SETTING
Úna Kavanagh
Masters in Arts and Heritage Management 2014

The perspectives of healthcare professionals in the South East region
on their experience of the participatory arts in a mental health setting
Úna Kavanagh
Research Supervisor: Ms. Susan Connolly, MA.
A dissertation submitted in partial fulfilment of the requirements for the degree of
Masters in Arts and Heritage Management
in Waterford Institute of Technology
29th
August 2014

I
PLAGIRISM DECLARATION
I certify that this dissertation is all my own work and contains no plagiarism. By submitting
this dissertation, I agree to the following terms:
Any text, diagrams or other material copied from other sources (including, but not limited to,
books, journals and the internet) have been clearly acknowledged and referenced as such in
the text by the use of ‘quotation marks’ (or indented italics for longer quotations) followed by
the author’s name and date [e.g. (Byrne, 2008)] either in the text or in a footnote/endnote.
These details are then confirmed by a fuller reference in the bibliography.
I have read the sections on referencing and plagiarism in the handbook or in the WIT
plagiarism policy and I understand that only submissions which are free of plagiarism will be
awarded marks. By submitting this dissertation I agree to the following terms. I further
understand that WIT has a plagiarism policy which can lead to the suspension or permanent
expulsion of students in serious cases. (WIT, 2008)
Signed: ______________________________________________________
Date: ________________________________________________________

II
DEDICATION
To Caroline, Mam, Jim and Rosie ♥

III
ACKNOWLEGDMENTS
Thank you to all in the Waterford Healing Arts Trust, especially to Claire, Mary, June and
Stefanie. I wouldn’t have a research question if it were not for Claire Meaney, my lovely
work placement mentor in WHAT, so thanks for the research ideas and setting the ball
rolling. I learned a lot about the art of editing from Mary Grehan, and her wealth of
knowledge on Arts and Health was invaluable. To June Bolger and Stefanie Fleischer who
always showed an interest and asked me how I was getting on with my dissertation. The
supportive chats were much appreciated and needed.
I would like to say a huge thank you to the interviewees who participated in this study and for
freely giving their time and sharing their experiences, even though they were all really busy.
Thank you to Fionnuala Brennan for the kind support and encouragement to our class
throughout the year in regard to our dissertations, and to all the team of staff behind the MA
in Arts & Heritage Management, especially Dr. Rachel Finnegan, the course leader.
To Susan Connolly, my research supervisor, for her approachability and flexibility in regard
to the way I work, last minute.com...ahem! You don’t know how much it meant to me that I
could work in my own way on this dissertation and that you supported that. Thank you.
To my good friend, Trisha, for her support and generosity, and for listening to me talking
about my research subject; a true friend indeed.
To Caroline, for all the help and support she always gives me, and for listening to my many
stress related rants and cheering me up and making me giggle with her insanely witty
humour. A girl couldn’t ask for a better best friend; I’d be truly lost without her. ‘Knowledge
cannot replace friendship. I’d rather be an idiot than lose you.’ ~ Patrick to Spongebob.
I am indebted to my beautiful Mother, Mary, my hero, and the most patient, good and kind
person, without whom I couldn’t have got through this year. I owe you so much and couldn’t
have done it without you.
To all my fellow classmates: Peter Brennan, Heather Haskins, Sandra Kelly, Denise Kienzle,
Kathleen Lane, Jennifer Marshall, Kery Mullaly, Michelle O’Brien, Jayne Sutcliffe and
Joanne Tuohy, with whom I had the pleasure of sharing a year of one another’s company and
who walked ‘the higher level of confusion’ road with me. If Carlsberg made classes! What a
truly wonderful group. The support and unity of our class and the endless laughs we all
shared got us through. Good times and great memories to treasure! 

IV
ABSTRACT
The focus of this research is in the area of Arts and Health, and more specifically, an
exploration of the perspectives of healthcare professionals in the South East region on their
experience of the participatory arts in mental health settings, in which service users are
actively engaged in the participatory arts. The healthcare professionals are all mental health
nurses who work in different types of mental health settings, from acute inpatient hospital
services, to community health settings and day care centres.
Such a study is important in order to determine the impact of the participatory arts, if any, on
service users in the South East region, and the role of the participatory arts in mental health
settings in terms of care planning and recovery approach from the perspectives of mental
health nurses who are the primary caregivers most in contact with service users and are the
largest staff group involved in the provision of mental health care in Ireland.
The methodological research approach adopted in this dissertation was qualitative in nature
and involved undertaking a literature review, observation, and action based research in the
form of face to face, semi structured, in depth exploratory interviews. Four healthcare
professionals were interviewed to gather relevant data and the data collected was triangulated
and presented as a case study.
The findings from this study show that all research participants were unanimous in the belief
that the participatory arts benefited service users in mental health settings, and where
participation was not possible, the receptive arts provided some measure of comfort and
solace for clients.
The main conclusions drawn from this study are that the research participants are unified in
the belief that engagement with the participatory arts is important to service users in mental
health settings and should be prioritised in the development of care planning and budgetary
matters.
This dissertation recommends that there should be more collaboration between staff, service
users, artists and other relevant organisations in the delivery of an effective recovery
approach which would incorporate the arts into mental healthcare. There is room for more
thorough research in Arts and Health in terms of impact on service users, resources, funding
and cost effectiveness. There should be greater liaison between the HSE and the Arts Council
in this research.

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TABLE OF CONTENTS
Plagiarism declaration………………………………………………………………………….I
Dedication……………………………………………………………………………………..II
Acknowledgements…………………………………………………………………………..III
Abstract………………………………………………………………………………………IV
Table of contents……………………………………………………………………………...V
List of abbreviations and acronyms………………………………………………………...VIII
List of figures………………………………………………………………………………...IX
Chapter 1 Introduction………………………………………………………………………1
1.0 Research question………………………………………………………………………….1
1.1 Rationale…………………………………………………………………………………...2
1.2 Relevance to the area of arts management and location of research………………………3
1.3 Delimiting factors for this study…………………………………………………………...3
1.4 Position of researcher……………………………………………………………………...4
1.5 Summary of chapters………………………………………………………………………4
Chapter 2 Literature Review………………………………………………………………...6
2.0 Introduction………………………………………………………………………………..6
2.1 Mental health policy in Ireland……………………………………………………………6
2.2 Arts and health policy in Ireland…………………………………………………………10
2.3 The participatory arts in a mental health setting………………………………………....12
2.4 The medical humanities in healthcare professional education……...…………………....19
2.5 Conclusion……………………………………………………………………………......22

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Chapter 3 Methodology………………………………………………………………….....23
3.0 Introduction………………………………………………………………………............23
3.1 Purpose……………………………………………………………………………...........23
3.2 Theory…………………………………………………………………………………....24
3.3 Rationale for choice of qualitative approach……………………………………..............24
3.4 Data description and analysis.……………………………………………………………25
3.5 Sampling strategy………………………………………………………………………...26
3.6 Reliability and validity.…………………………………………......................................27
3.7 Ethical considerations.…………………………………………………………………...27
3.8 Challenges faced………………………………………………………………………….28
3.9 Conclusion..........................................................................................................................29
Chapter 4 Findings……………………………………………………………………….....30
4.0 Introduction………………………………………………………………………………30
4.1 The value of the participatory arts in a mental health setting……………………………31
4.2 Changing attitudes to mental health in Ireland…………………………………………...33
4.3 Relevance of the participatory arts to care planning and education……………………...34
4.4 Experience and training of research participants………………………………………...35
4.5 Conclusion………………………………………………………………………………..36
Chapter 5 Discussion………………………………………………………………………..37
5.0 Introduction………………………………………………………………………………37
5.1 The place of the participatory arts as part of care planning and recovery approach……..38
5.2 Partnership with arts and health organisations.…………………………………………..39
5.3 Education of healthcare professionals……………………………………………………40
5.4 Impact of the participatory arts on service users…………………………………………41

VII
5.5 Conclusion.……………………………………………………………………………….42
Chapter 6 Conclusion & Recommendations………………………………………………44
6.0 Introduction………………………………………………………………………………44
6.1 Research objectives………………………………………………………………………45
6.2 Research limitations……………………………………………………………………...45
6.3 Theoretical conclusions…………………………………………………………………..45
6.4 Recommendations………………………………………………………………………..46
Glossary………………………………………………………………………………………48
References……………………………………………………………………………………50
Bibliography………………………………………………………………………………….57
Appendices…………………………………………………………………………………...73
Appendix A: Information sheet for research participants in interviews.……………….........A1
Appendix B: Participant informed consent form…………………………………………….B1
Appendix C: Interview questions for healthcare professionals……………………………...C1
Appendix D: Interview transcripts…………………………………………………………..D1
Interview A……………………………………………………………………………..........D1
Interview B…………………………………………………………………………………D19
Interview C…………………………………………………………………………………D32
Interview D………………………………………………………………………………....D35
Appendix E: Images from mental health documents in Australia…………………………...E1
Appendix F: Images of clown-doctors………………………………………………………F1
Appendix G: The arts and humanities in healthcare professional education………………..G1
Appendix H: Images of the participatory arts in mental health settings………………….....H1
Word count: 16,487

VIII
LIST OF ABBREVIATIONS AND ACRONYMS
AHCI Arts and Health Coordinators Ireland
AMNCH Adelaide and Meath incorporating the National Children’s Hospital
AVFC A Vision for Change
CAHHM Centre for Arts and Humanities in Health and Medicine, Durham
CAHP Cork Arts + Health Programme
HIQA Health Information Quality Authority
HPE Health Professional Education
HSE Health Service Executive
GTI Galway Technical Institute
NHS National Health Service
MHC Mental Health Commission
WIT Waterford Institute of Technology
WHAT Waterford Healing Arts Trust

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LIST OF FIGURES
Fig.1: Front cover of a Vision for Change.
Fig.2: The artwork by Pauline Miles titled The Journey depicts the view from the front seats
of a vehicle travelling on a road to a distant horizon - journey of hope and new beginnings.
Fig.3: The artwork by Pauline Miles titled The Advocate depicts a speaker standing at a
lectern addressing an audience with images relating to art on the screen immediately behind
the speaker - recovery is different for everyone.
Fig.4: The artwork by Pauline Miles titled The Journey – Rowing My Own Boat depicts a
figure paddling a small boat or surfboard towards three boats. The central boat, Recovery, is
flanked by two boats Hope and Support - maximising choice and self-determination.
Fig.5: The artwork by Pauline Miles titled The Kitchen Table depicts the interior of a kitchen
and meals area with a figure standing at a bench. Most of a person’s recovery occurs at home.
Fig.6: The artwork by Pauline Miles titled There are Many Points of View depicts a figure
standing in a room with artist materials on work surfaces and different views of external
images on the far wall.
Fig.7: ‘Guthlan’ Carolyn Fyfe discusses her journey of recovery and healing. The art is called
the Journey. The journey of recovery and healing starts from the outer circle identifying the
challenges that a person would experience. The colours: Brown - the challenges to make the
change in your thoughts/emotions (trying to move ahead). Black are the dark times
(depression). Mauve - identified the reasons and have moved forward. White - you have the
control. As you get closer to the centre it represents the wellness of health - socially,
emotionally and spiritually. It is a long journey and you need to have people who can let you
explain your story and they theirs.
Fig.8: ‘Guthlan’ Carolyn Fyfe depicts the journey of layers that have impacted the social and
emotional wellbeing of Indigenous people from invasion, colonisation and segregation to
assimilation. As the layers and their impacts are removed, a person’s journey of healing and
recovery starts. Fyfe explains: I never really had a name for this piece of art. I painted it to
help educate others on the impacts of invasion, colonisation, segregation to assimilation and
how this journey has affected the wellbeing of our Indigenous race socially, emotionally,
culturally and spiritually - mind, body and soul.
Fig.9: Dr. Crazyface and Dr. Scatterbrain with five year old Dylan Fagan in the National
Children's Hospital in Tallaght, Dublin.
Fig.10: Clown-doctor at work.
Fig.11: Four year old Harley Slack who had his limbs amputated and had to be resuscitated
three times in hospital after contracting meningitis has fun with the Clown Doctors. He also
made a Christmas card for his parents. He used reindeer and snowman sponges on the front
and his hospital ‘play’ lady had written ‘Happy Christmas’ inside and he signed ‘Harley’ by

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putting the paintbrush in his mouth. While this is not in a specific mental health setting, the
child’s condition would have caused severe stress both to himself and to his family.
Fig.12: Illness as Human Experience.
Fig.13: Nurse-Patient Relationship.
Fig.14: Sacred Work of Palliative Nursing.
Fig.15: Suffering.
Fig.16 - 23: Arts + Minds music workshop.
Fig.24: The Leeside Seratones, an Arts + Minds choral project involving HSE Cork mental
health staff, service users and friends, performing with Choral Leader Liz Powell in the
Crawford Art Gallery.
Fig.25: Artist Jo Nichols (centre) working with the Arts + Minds Time to Dance group.
Photograph by Ger McCarthy.
Fig.26: An arts facilitator working with an arts on prescription group.
Fig.27: Participatory art session.
Fig.28: Wandering Methods, participatory art workshop for older people. Photograph by Lian
Bell.
Fig.29: Arts Ability: Towers by Ray and Tom, Recreational Therapy Unit, St. Senan’s
Hospital, Enniscorthy (RT). Photograph by Rory Nolan.
Fig.30: Arts Ability: Floyd Patterson and Jerry Quarry by Francis Joseph Power, County
Wexford Community Workshop (New Ross) Ltd. (CWCW). Photograph by Declan Kennedy.
Fig.31: Arts Ability: Twelve Disc After Heron by Tom, Killagoley Training & Activation
Centre, Enniscorthy (KTAC). Photography by Rory Nolan.
Fig.32: Votive #1 featured in the 2013 Let’s Connect exhibition at the Dunamaise Arts
Centre, Portaloise, which explored the significant connections between art and mental health;
the power that art can play in shaping ideas and how it provides a strong medium to
communicate for people who sometimes struggle to engage with society. It serves to
normalise the experience of mental health illness and prevent stigmatisation and exclusion of
people who are sometimes on the margins of society. Oils on canvas, Éilis Crean.

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Chapter 1
INTRODUCTION
1.0 Research question
The general focus of this research is in the area of Arts and Health, while the specific aim is
to gather qualitative feedback from healthcare professionals in the South East region on their
experience of the participatory arts in the mental health settings where they work, in which
service users are actively engaged in the participatory arts. The healthcare professionals
interviewed are all mental health nurses who work in different types of mental health settings,
from acute inpatient hospital services, to community health settings and day care centres.
The term ‘perspectives’ is a broad one, therefore in order to avoid being vague and to
facilitate the participants, the questions asked were divided into five categories; the perceived
impact of the participatory arts on service users from the viewpoint of mental healthcare
professionals, the inclusion of the participatory arts in mental health care planning policy,
partnership programmes between mental health settings and arts and health organisations, the
healthcare professionals own interest in the arts, and whether the arts and humanities should
be included in the education of healthcare professionals.
All of the above categories can be linked with the arts in a mental health setting. Since an in
depth study of each one is beyond the scope of this dissertation, the principal focus will be on
the perceived impact of the arts on service users from the healthcare professionals’ viewpoint,
while the ancillary aspects will remain on the periphery of the discussion in the literature
review and the findings and discussion chapters.
There has been a gradual shift in attitude towards the arts in healthcare. The impact of the
inclusion of the arts into mental health settings is increasingly recognised, but the level of
research is relatively sparse in comparison to that of other factors associated with health and
wellbeing, such as the biomedical approach. (Moss, Donnellan & O’Neill, 2012, p.106)
Psychiatric nurses play a pivotal role in mental health services, are the largest staff group
involved in the provision of mental health care in Ireland (Department of Health and

2
Children, 2006), and are responsible for a wide range of services in community and hospital
environments. What I wanted to learn more specifically is what the primary caregivers of
service users, who are in constant contact with them, think of the participatory arts in their
mental health workplace, and what the role of the participatory arts means to them in terms of
care planning. ‘Staff members are a very useful source of information since they often know
service users on a professional as well as a personal level and will have interesting insights.’
(Tsiris, Pavlicevic & Farrant, 2014, p.105)
Therefore, given the relatively undeveloped research undertaken in this area, I decided to
interview four mental health nurses in the South East region to document their experience of
the participatory arts in a mental health setting. Their unique perspectives could give valuable
insights into the development and implementation of arts programmes within healthcare
contexts. The research aim was to garner qualitative feedback, in order to set the parameters
for future research.
1.1 Rationale
I have chosen this area of study to explore the perspectives of healthcare professionals on
their experience of the participatory arts so as to help create new knowledge in an area where
constant research is needed, but because of financial and time constraints, is not always
possible. The healthcare professionals chosen for this study are all mental health nurses. The
rationale for this choice is that they are the primary care givers who have most contact with
the service users on an ongoing, day to day basis. These staff had never been interviewed in
depth before on the role of arts participation in their workplace; therefore it is possible that
their unique insights might provide new areas of discussion in the fields of arts and health.
Since my current work placement is in Waterford Healing Arts Trust (WHAT), the
knowledge gained might be of use in relation to their participatory arts and mental health
programme in partnership with the Waterford and Wexford Mental Health Services. Focusing
on a small area, such as the South East, enables an evaluation of the place of the participatory
arts in mental healthcare, thus helping to build a new body of knowledge and information. It
also provides a foundation for the future planning of arts programmes in mental health
settings. In Creative Arts as a Public Health Resource: Moving from Practice-based
Research to Evidence-based Practice, Clift (2012) argues that the challenge now in the

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healthcare context is to devise progressive research programmes which provide a strong body
of knowledge for evidence based practice.
1.2 Relevance to the area of arts management and location of research
The audience for this research comprises healthcare professionals, arts and health
coordinators, artists involved in the field of arts and healthcare, the Health Service Executive
(HSE), which is at the centre of healthcare in Ireland, and The Arts Council of Ireland. The
potential benefits of this study include a qualitative analysis based on the perspectives and
observations of healthcare professionals who are involved in the implementation of
participatory arts programmes for service users on a continuous basis. Their observations can
contribute to the ongoing debate on arts and health, enhance the future development of
participatory arts programmes in mental health settings, and provide new insights for arts and
health and healthcare professional managers.
1.3 Delimiting factors for this study
As a newcomer to arts and health and a novice researcher in this area, my approach to the
identification, critique and synthesising of the literature and findings may lack the expertise
of a more experienced researcher. Prior to undertaking the Masters Degree in Arts and
Heritage Management, and engaging in a college work placement in WHAT from November
2013 to August 2014, I had no previous in the area of arts and health.
I have a background in visual art and have always been interested in art therapy; thus it was a
natural progression to be drawn to the area of arts and health. While these two areas appear
similar in nature, their core value is different. ‘There is a clear distinction between arts and
health practice, where a key goal is the experience and production of art, and the arts
therapies, where the primary goal is clinical.’ (Arts + Health: Arts and Health Editorial
Policy, 2013, p.4)
Another limiting factor is that arts and health is a broad topic and much that is of interest has
to be omitted or peremptorily discussed in order to meet the narrower criteria of this research
study.

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1.4 Position of researcher
This area of research has been chosen as a result of an interest in the field of arts and health,
and my work in WHAT has prompted me to investigate, from the healthcare professionals’
viewpoint, various claims that involvement in the participatory arts by service users is an
important aspect of mental healthcare provision. Participatory arts programmes claim many
benefits for people with mental health difficulties, and the aim of this research is to explore
the validity of such claims from the viewpoint of each mental health nurse working in their
own mental health setting.
The growing interest in the area of the arts in healthcare in Ireland is relatively new, largely
under researched, and merits further study. In The Creative Path and the Road to Recovery,
Dr. Nasir Warfa, senior lecturer in psychiatry in London University, argues that despite a
growing awareness of the benefits of arts in healthcare, mental health treatment is still
dominated by a biomedical approach, making it difficult to integrate arts based activities into
the system. (Lynch, 2014)
The literature studied also reveals that Ireland has not progressed as well as other countries in
the promotion of arts and health. While some progress has been made, there is further scope
for research in the development, implementation and appraisal of arts programmes in mental
health settings.
1.5 Summary of chapters
The literature review chapter is structured to allow for the exploration of several aspects
relevant to the perspectives of healthcare professionals on their experience of the
participatory arts in a mental health setting. For this reason, the literature review has been
divided into the following headings: Mental Health Policy in Ireland, Arts and Health Policy
in Ireland, The Participatory Arts in a Mental Health Setting and The Medical Humanities in
Healthcare Professional Education.
In the methodology chapter, the research design and data collection methods for this research
study are identified and explained. This is a qualitative exploration of data collected from
four mental health nurses by means of face to face, semi structured in depth interviews.

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In the findings chapter, the data collected is presented, examined and synthesised in relation
to the literature reviewed. The discussion chapter identifies themes in relation to the
interviews and the literature reviewed. The final chapter makes recommendations to various
organisations, including the HSE, The Arts Council and The National Network of Arts and
Health Coordinators Ireland (AHCI).

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Chapter 2
LITERATURE REVIEW
2.0 Introduction
The main focus of this dissertation is an exploration of the perspectives of healthcare
professionals in the South East region on their experience of the participatory arts in a mental
health setting. It is a qualitative study, where all relevant aspects of the topic are discussed, to
allow for a fluid, comprehensive picture to emerge of the diversity of human experience. The
literature is reviewed under the following headings: Mental Health Policy in Ireland, Arts and
Health Policy in Ireland, The Participatory Arts in a Mental Health Setting and The Medical
Humanities in Healthcare Professional Education.
A challenge faced in this study is that each of the three concepts, mental health, the arts, and
qualitative research can be difficult to define, and consequently the arguments about them are
sometimes controversial. The arts are difficult to define in an objective way. ‘Mental health
can also be culturally and subjectively determined; and qualitative research is diverse, and
often regarded as the poor relation of scientific research.’ (Stickley, 2012, p.viii)
Nevertheless, the type of study undertaken here is best suited to the qualitative method, since
it is reliant on the exploration and analysis of the personal perspectives of the participants.
Also, the arts in healthcare is a relatively new concept in Ireland, and is sometimes regarded
with suspicion, though simultaneously growing more popular as a way to complement mental
healthcare.
Taking into account the growing awareness of the arts in healthcare, the review explores
relevant literature in a systematic way, drawing on many different sources, books, journals
and databases, which discuss theory, practice and policy. A meta-ethnographical approach
was used to synthesise the main themes in the literature reviewed.
2.1 Mental health policy in Ireland
A Vision for Change: Report on the Expert Group on Mental Health Policy (AVFC) argues
that each citizen should have access to comprehensive mental health provision of the highest

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standard. (Department of Health and Children, 2006) It proposes a holistic view of mental
health and recommends an integrated, multi-disciplinary approach to addressing the
biological, psychological and social factors that contribute to mental health problems,
stressing that a recovery oriented approach is vital. However, there was little exploration of
the meaning of a recovery oriented approach, except for an acknowledgement that ‘…the
principles and values of recovery mark a substantial shift in how services are developed,
delivered and evaluated.’ (Higgins & McDaid, 2014, p.66)
The recommendations of A Vision for Change (AVFC) report include greater consultation
with service users, carers and providers. In the course of consultations carried out by the
Expert Group on Mental Health, service users articulated their views on what needed to be
changed. The areas of change most sought were in the training of healthcare professionals,
the involvement of service users in service planning, and the delivery of community based
interventions that are effective in promoting recovery and re-integration. In 2008, the Mental
Health Commission (MHC) published A Recovery Approach within the Irish Mental Health
Service: A Framework for Development. (Higgins, 2008) This document highlights the need
for a paradigm shift in how people think of mental illness, and how people living with mental
distress are supported. (Higgins et al, 2014)
The following themes emerged from the AVFC report. There is a need for multi-disciplinary
teams offering a range of treatment and care to service users, a need to adopt a recovery
perspective at all levels of service delivery and a need for service users to be treated with
dignity and respect. Services should respond to the needs of service users, who may be held
back more by the practical problems of living rather than by their symptoms. There should be
access to psychological ‘talk therapies’ and social therapies. There is a need for community
based services and for formalised links between specialised mental health services, primary
care, and mainstream community agencies to provide support and care. It is essential for
service users to be active participants in their own recovery rather than passive recipients of
care.
The report concluded that integration into mainstream community life was the ultimate goal
of recovery. The vision of the Expert Group on Mental Health is to create a mental health
system that addresses the needs of the population through a focus on the requirements of the

8
individual. The importance of the human interaction at the heart of treatment and care was
stressed, and it was acknowledged that the artificial separation of biological from
psychological factors has been an enormous obstacle to a true understanding of mental health.
It is now recognised that mental disorders are a complex interaction of many causal factors
and that the over emphasis on the biological model can prevent provision of effective social
and psychological interventions. It is noted that this imbalance may be driven by reliance for
funding on pharmaceutical companies who want to promote their products.
Fig.1: Front cover of a Vision for Change.
From: Department of Health and Children, A Vision for
Change: Report on the Expert Group on Mental Health
Policy, 2006.
Throughout the 288 page document, no mention was
made of the use of the arts in healthcare, though The Irish
Association of Creative Arts Therapists is cited in
Appendix 1 in the list of submissions to the Expert Group
on Mental Health. In the list of 268 references, there was
none which was arts related. Ironically, there is an artistic
representation on the front cover: A butterfly symbol is
used to portray mental health and it is explained that the Greek word for butterfly is ‘psyche’,
which is also the word for ‘soul’. This is followed by a quotation from Thomas Bullfinch in
The Age of Fable, using the symbolism of a butterfly emerging from its chrysalis to denote
recovery from mental health. This is significant as it implies that the arts have a place in
healthcare. However, it does not go beyond implication.
The goals of mental health care should be to promote wellbeing and to help people cope with
their illness. In 2004, The National Institute for Mental Health in England published a
definition of recovery as ‘a personal process of overcoming the negative impact of diagnosed
mental illness despite its continued presence.’ (Barker, 2011, p.83) It stresses that recovery
focuses on wellness rather than illness and can occur without professional intervention.
Similarly, in A Recovery Approach within the Irish Mental health Service (Higgins, 2008),
recovery is seen as a transformational ideology which challenges stereotypes about mental
health and treatment.

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The arts in healthcare, although developing, are not widely practised in Ireland. It may be that
some facilities utilise the arts, but until it is enshrined in a combined HSE and Arts Council
policy document, it will not be widespread. The literature review documents successful
projects that have been conducted in Australia, Britain, North America and elsewhere, and
thus highlights the paucity of such literature published in Ireland.
Both the Australian Health Ministers’ Advisory Council’s A National Framework for
Recovery-oriented Mental Health Services: Policy and Theory (Australian Health Ministers’
Advisory Council, 2013), and A National Framework for Recovery-oriented Mental Health
Services: Guide for Practitioners and Providers (Australian Health Ministers’ Advisory
Council, 2013) utilise imagery and descriptions of artworks created by service users in their
publications, unlike Ireland’s A Vision for Change: Report on the Expert Group on Mental
Health Policy (Department of Health and Children, 2006)
Mental Health Reform Ireland’s analysis of the mental health system in Ireland supports the
need for major transformation. (Mental Health Reform, 2014) They state on their website that
mental health services have not been prioritised by the Irish government, that the quality of
services lag behind international best practice and that there is an over reliance on the
medical model and in-patient treatment. This is at odds with the ideals laid out in AVFC
which they state has not yet been fully implemented.
Mental Health Reform Ireland (2014) explains that the recovery model central to AVFC will
challenge the traditional psychiatry base. Successful implementation will require a paradigm
shift in how mental health is understood and how services are provided. They state that the
HSE has primary responsibility for delivery of AVFC, but that the action needed to
encourage a cultural change to bridge the gap between AVFC policy and practice will be
challenging. They state that service users have a low visibility because of the nature and
stigma of mental illness, but that the service user movement is growing in strength and will
become a radical challenge to the status quo.
The recent publication Healthy Ireland: A Framework for Improving Health and Wellbeing
2013-2025, is a new Government plan that involves every part of Irish society in improving
our health and wellbeing, and sets a vision where ‘everyone can enjoy physical and mental
health and wellbeing to their full potential.’ (Department of Health 2013, p.6) This will

10
require a conceptual shift from illness to a ‘wellness’ trend, where the focus is on positive
mental health. (Higgins et al, 2014)
2.2 Arts & health policy in Ireland
The development of arts and health in Ireland can be mapped through policy and strategy
documents and literature arising from national conferences. The Arts Council’s Arts and
Health: Policy and Strategy (2010) is the most recent policy document specific to arts and
health published by a government agency in Ireland and outlines the values that underpin its
approach to arts and health practice, and strategic actions for the five-year period 2010 –
2014. Prior to this document, The Arts Council published Mapping the Arts in Healthcare in
the Republic of Ireland (2001), The Arts & Health Handbook, A Practical Guide (2003), and
Arts and Health: Summary Policy Paper (2005).
One of the proposals arising from The Arts Council’s Arts and Health: Policy and Strategy
(2010, p.10) is the development of a strategic partnership with the HSE at national level in
order to ‘facilitate practical collaboration across respective Arts and Health policies, facilitate
cross sector learning and develop shared understanding and language relating to Arts and
Health practice, build a strategic framework for the sustainable development and support of
Arts and Health practice, at national and regional level, into the future.’ The HSE has funded
various projects on a local level but does not have a national policy on arts and health.
On the other hand, Australia is at the forefront of arts and health practice, and in July 2014,
Health and Arts Ministers in Australia joined forces to publish the country’s National Arts
and Health Framework. (National Arts and Health Framework, 2014) This means that the
arts and health sector has now received state, territory and federal backing. ‘The Framework
has been developed to enhance the profile of arts and health in Australia and to promote
greater integration of arts and health practice and approaches into health promotion, services,
settings and facilities.’ (National Arts and Health Framework, 2014, p.1) The framework
contains links to a range of information relating to arts and health practice including
resources, research findings and evidence of the value of a collaborative approach to arts and
health. It has relevance for all agencies, departments and organisations with a role in
promoting health and wellbeing and in delivering health care and services, including arts
agencies and all those already engaging with arts and health practice.

11
The Australian Institute for Creative Health (The Institute for Creative Health, 2014) which
supported and coordinated the development of the framework highlights the formal
endorsement. The Institute’s Chairman, Michael Brogan, says: ‘A national framework signals
what we are trying to do in arts and health as a nation.’ (London Arts in Health Forum, 2014)
Australia’s Health and Cultural Ministers aim to improve the health and wellbeing of all
Australians and recognise the role of the arts in contributing to this objective. (National Arts
and Health Framework, 2014, p.1) If Ireland could initiate a similar policy, tailored to its own
needs, it would fulfil The Arts Councils partnership aim, and their aims to learn from the
experience of other similar international organisations in promoting and supporting the
practice of arts and health. (The Arts Council of Ireland, 2010, p.10)
Warner (2013, Arts + Health), Principal Community Social Worker with the HSE South,
suggests that a social model of health should be incorporated into the arts and health policy
and practice in Ireland. The social model of health considers the social factors that determine
health and wellbeing, for instance, social or community networks, economic and
environmental conditions. He asserts that there is currently an insufficient focus on these
aspects in the arts and health debate. The health services are only one element in terms of
promoting individual and community health and wellbeing. The social model encompasses a
broader range of sectors, such as education, housing and local government. This has
implications for the arts and health debate, in that the agenda needs to be broadened to
include aspects such as inequalities in healthcare, social inclusion, advocacy, early
intervention and relevant recovery models.
He argues that arts and health is a partnership between two very diverse sectors, and there is a
need for discussion not only between the sectors, but within them. On the health side, there is
a need to move from limiting terminology, such as healthcare settings, and to recognise the
validity of the arts not just in traditional healthcare settings, but across the wider community.
Extending the range of settings in which the participatory arts are practised will enhance the
importance of arts and health, through emphasis on individual and community health, and
will provide opportunities for greater access to the arts to groups otherwise excluded from
therm. He concludes that it will involve collaborative partnerships at local, regional and
national level to create a truly efficient social model of health.

12
2.3 The participatory arts in a mental health setting
Beyond Diagnosis: The Transformative Potential of the Arts in Mental health Recovery
(Sapouna & Pamer, 2012), is a seminal Irish document based on research findings from an
Arts + Minds (Arts + Minds Cork, 2014) action research project, involving service users,
healthcare staff and artists, to investigate the impact of the arts in mental health settings, with
particular emphasis on care planning. Arts + Minds is a HSE and arts and health run
initiative, set up in 2007, which began as a series of music workshops, but later expanded its
range of arts programmes.
The principal aims of Arts + Minds are the enhancement of mental health and wellbeing of
service users through engagement with the arts, to enable them to participate fully in the
cultural life of their community and to facilitate partnership between service users, health and
arts professionals. Their ideal is to develop user accessible programmes informed by national
arts policy to promote the value of arts in mental healthcare. The research was underpinned
by the philosophy of Arts + Minds, which is to consider the potential for integrating the arts
into mental health care planning. Service users played key roles in articulating how they wish
to transform their lives. The ethos of the project is informed by principles of inclusion and
recovery. Evidence based research was constructed in the form of service users’ narratives,
and the findings showed that participants’ creative skills, confidence and concentration were
enhanced.
The study found that institutionalisation and social isolation are still problems for service
users. They revealed that participation in the arts gave them more choices and more control in
their lives. Both staff and service users recognised arts participation as part of a recovery
approach, and staff acknowledged a gradual move from a biomedical approach to a fuller
awareness of the power of creativity to enhance the lives of service users. ‘Making the arts an
integral part of mental health requires an appreciation from the multi-disciplinary team.’
(Sapouna et al, 2011, p.23)
In The Weapons of Life: A Case for Arts Participation as a Creative Response to Mental
Health Problems (Dineen, 2012), Dineen argues for arts participation as a creative response
to mental health problems, and believes that persuasive arguments can be made to use the arts

13
in healthcare as a recovery approach. ‘The inclusion of an arts programme sits comfortably
within the context of the Irish Mental Health Policy.’ (Dineen, 2012, p.14)
The research concluded that the arts are filtering slowly into the system, although mental
health is still dominated by the biomedical model of care. These considerations have led to
my research topic: the perspectives of mental health professionals on the impact of the
participatory arts in a mental health setting. The focus was narrowed to the views of mental
health nurses in the South East to investigate their partnership with WHAT and how it could
benefit them. My interview questions were based on those for mental health staff in Beyond
Diagnosis (Sapouna et al, 2011, p.52) to ascertain whether there would be a variation of
responses in a different location. As they were from an Arts + Minds project, I adapted them
to suit my research of the participatory arts in mental health settings from the health
professionals’ perspectives. I noticed there were three strands of questioning: the impact of
the participatory arts on service users, care planning policy, and partnership with arts and
health organisations. I added two more strands of questioning which I thought were relevant,
the healthcare professionals’ own interest in the arts and their views on the inclusion of the
arts and medical humanities into professional healthcare training.
In Mental Health, Psychiatry and the Arts, a Teaching Handbook, Tischler (2010) presents a
case for the inclusion of the arts in care planning, practice and education. The author argues
that art highlights core human emotions and provides a safe way to engage with difficult and
painful emotions that might arise in mental healthcare. (Tischler, 2010, p.2) Tischler
describes the experience of establishing a humanities course into the medical curriculum: The
Arts in Psychiatry. Following extensive research, the Arts in Psychiatry programme was set
up in Nottingham University and was welcomed by healthcare professionals and students.
Tischler argues that biological techniques alone for understanding mental illness reveal little
about the reality of living with depression or other such ailments. The practitioner is also
reliant on verbal exchange to make sense of the individual’s distress. This emphasises the
importance of ‘perception, subjectivity and interpretation in mental healthcare.’ (Tischler,
2010, p.3) The arts and humanities integrate physical, emotional, psychological and spiritual
elements, and their inclusion can lead to a holistic and patient-centred approach to mental

14
healthcare. ‘The combination of arts with medicine evokes the German idea of
Wissenshchaft, a science that includes both science and humanities.’ (Tischler, 2010, p.3)
Tischler states that education courses should emphasise reflection and participation which
may be an antidote to the largely reductionist learning, currently predominant in mental
health education. Tischler believes that by shifting the current emphasis of psychiatry from
the biological study of the brain to a broader study of the mind, a more holistic model for
understanding and interpreting mental pathologies may be attained.
In Qualitative Research in Arts and Mental Health (Stickley, 2012), Stickley presents auto
ethnographical accounts of service users, artists and professional healthcare workers through
a series of articles, written by experts in the field of arts and health. The main thread of
discussion is the belief in the efficacy of the participatory arts in terms of personal and social
outcomes.
In chapter one, Parr, in an essay entitled The Arts and Mental Health: Creativity and
Inclusion describes research carried out between 2003 and 2007 on two city mental health
and arts related projects in Scotland, Art Angel, based in Dundee and The Trongate Studios in
Glasgow’s city centre. A broad spectrum of arts activities was organised for people with
mental health difficulties.
Interviews conducted with participants from both these facilities revealed that they
experienced stability and wellbeing as a result of their involvement in the projects. Parr
interpreted their experiences in terms of moving into different artistic geographies, from
individual isolation to social inclusion. Artists encountered ‘interior creative space’ as a calm,
safe ‘location’ which could be accessed as part of a strategy for recovery. (Stickley, 2012.
p.7)
In an article entitled Catching Life: The Contribution of Arts Initiatives to Recovery
Approaches and Mental Health (Stickley, 2012, pp.199-212), a National Study conducted in
Britain is described in which members of vulnerable groups were interviewed about
participation in arts based projects. The main focus was on recovery.

15
New notions of recovery were inspired by service users’ accounts. It emerged that recovery
was not just the clinical absence of symptoms, but a sense of empowerment and purpose in
the service user which amounted to their moving towards the type of life they wanted to lead.
Arts participation and creativity often featured in individual recovery journeys, and research
suggests that involvement in the participatory arts did have a range of therapeutic benefits for
those with mental health needs. They also reported an increased awareness of their latent
abilities, such as sensory perception. It helped them to engage with other aspects of their lives
and improved their motivation and coping strategies. Thus, it was found that recovery is
linked to creativity. In some cases, it also led to freedom and independence, in that they
discovered a new sense of identity and did not necessarily wish to belong to mainstream
society which had rejected them.
Qualitative Research in Arts and Mental Health (Stickley, 2012) is a useful work in that it
presents examples of arts based projects that have used various qualitative methods to explore
the links between arts and mental health. The research endeavoured to reflect the voice of the
participant, concentrating on their personal experiences, perceptions and the unique
expression of their inner world. A recurring theme is the need to shift the focus from the
medicalisation of mental illness to a more holistic model. As long as mental healthcare
remains dominated by reductionist science, researching the place of the arts will be largely
neglected. There is also the danger of ‘commodifying’ the use of the arts to make it fit in with
the health agenda and conform to the statutory services provision. (Stickey, 2012, p.214)
Wholeperson Healthcare, the Arts & Health (Serlin, 2007) explores various forms of arts in
healthcare through a series of articles by healthcare professionals. In the chapter entitled
Applications of Art to Health (Serlin, 2007, pp.1-21), Graham-Pole examines the links
between the arts and the auto immune, hormonal and other systems of the body. He cites the
neuroscientist, Candace Pert, whose groundbreaking research showed that new brain wave
patterns are produced and the body’s physiology changes from stress to relaxation when
exposed to creative and inspirational activities. (Serlin, 2007, p.16) Thus, they argue that the
arts have become a potent, holistic force for human healing, and their perceived value in
research and healthcare is increasing.

16
In History of the Arts and Health across Cultures (Serlin, 2007, pp.23-41), Sonke-Henderson
states that until the sixteenth century, health and illness were considered by every known
culture to be spiritual matters, before the reductionist ideals of Western medicine
predominated, separating mind, body and spirit. This reduced illness to a physical matter and
established medicine as a purely physical science. (Serlin, 2007, p.25)
The mid to late 20th
century saw the gradual introduction of the arts in healthcare. Sonke-
Henderson cites their colleague, Graham-Pole as calling this a ‘second renaissance’ in
Western healthcare. Reductionist ideals were once again expanded to take into account the
service user’s emotional, psychological and spiritual attributes as part of the whole person.
This created a balance in the ‘sterile, discomforting, and scientific environment of Western
hospitals.’ (Serlin, 2007, p.38)
Using The Creative Arts in Therapy and Healthcare (Warren, 2008) provides a series of
articles by various artistic and healthcare experts in the field of arts and health on the benefits
of a broad spectrum of the arts. The editor, Warren, is the Artistic Director of the Fools for
Health clown-doctor programme. In chapter eleven, entitled Arts for Children in Hospitals:
Helping to Put the ‘Art’ Back in Medicine (Warren, 2008, pp.181-195), the author, Rollins,
states that ‘a small but growing body of research supports that physiological processes may
take place through contact with the arts.’ (Warren, 2008, p.12) Rollins continues that studies
indicate a relationship between arts experiences and the release of endorphins, and states that
technology makes this visible when patients at the hospital are attached to monitors to gauge
oxygen saturation levels. When music is being played, the level rises on the monitor, even if
the patient is unconscious.
Fig.9: Dr. Crazyface
and Dr. Scatterbrain
with five year old Dylan
Fagan in the National
Children's Hospital in
Tallaght [Online
image].
From: Irishhealth.com,
2006.

17
In Healing Laughter: The Role and Benefits of Clown-doctors Working in Hospitals and
Healthcare (Warren, 2008, pp.213-228), Warren discusses the role of clown-doctors in
hospitals and healthcare, stating that it is a relatively new phenomenon. The initiative, begun
in 2001, was a catalyst for change as the programme gathered strength in Europe and Canada
and delivered services to diverse healthcare facilities to children and adults. (Warren, 2008,
p.213) Clown-doctors are specially trained artists who work in hospitals and are a blend of
artist and healthcare worker. ‘They work in pairs, wear a red nose, use a minimal amount of
make up, wear a white lab coat and are usually referred to as doctor (e.g. Dr. Haven’t-A-
Clue).’ (Warren, 2008, p.214) They work with patients, their families and the healthcare team
to promote wellbeing through the use of humour, improvisation and music. They interact
with their audience in a public space where healthcare is delivered. They are not merely
entertainers, but accepted members of a multi-disciplinary team of healthcare workers.
Warren states that they help to humanise the healthcare experience, reduce anxiety in children
awaiting surgery, and make hospitals more accessible and user friendly.
The Arts in Healthcare: Learning from Experience (Haldane & Loppert, 1999) examines
widely different arts in healthcare projects from the design of hospitals to the use of visual
arts. In an article entitled Evaluating the Arts in Healthcare and Mental Health Promotion
(Haldane et al, 1999, pp.96-114) Dr. Philips explores the use of poetry in patient recovery.
According to Philips, there is growing evidence that looking inwards, or ‘inscaping’ and the
process of linking thoughts and emotions and writing them down is beneficial to mental
health, especially if the words are written in a poetic way, with cadence and rhythm. (Haldene
et al, 1999, p.101) Personal experience is a powerful motivating factor and the ensuing visual
and emotive imagery is evocative in charting personal progress. According to Philips, poetry
has been likened to medicine because it explores aspects of communication and demonstrates
the complexity of the human condition. (Haldene et al, 1999, p.103) Philips also states that
poetry can reduce stress and anxiety and improve wellbeing by helping the service user to
unburden negative thoughts and feelings, thus reducing the need for medication.
The National Health Service (NHS) publication, Improving the Patient Experience, The Art
of Good Health Using the Visual Arts in Healthcare (2002) focuses on enhancing the patient
experience by effecting improvements in the physical environment. It showcases examples of
the application of visual arts in healthcare settings and examines the benefits to service users

18
and staff. In section five, Creative Activity - Therapeutic Activity and New Skills for Patients
and Staff (NHS Estates, 2002, p.53-62), the power of creative activity is discussed, especially
for long stay mental health patients. Participation in creative activities can help people to
alleviate boredom and offers a way of connecting to everyday life. ‘On an acute mental ward,
patients say that life can seem anything but normal, surrounded by other people in varying
degrees of mental illness.’ (NHS Estates, 2002, p.53) They see taking part in creative
activities as ‘normalising’ and comforting. Taking part in an art project sometimes helps with
functionality also, as mental illness can affect vision and cognition, so ‘[c]oncentrating on
colours, shapes, forms and textures can help to improve vision and cognitive skills.’ (NHS
Estates, 2002, p.53) The arts also provide important links between acute and community
mental health services, helping people reduce the isolation and loneliness that contributes to
relapses, by keeping in touch and forming friendships through art projects.
Stickley supports the view that even though recovery has become the main focus of mental
health policy in the UK, there are few models of practice showing how mental health nurses
can promote recovery through the use of participatory arts. (Stickley, 2010) His article in
Nursing Times, Does Prescribing Participation in Arts Help to Promote Recovery for Mental
Health Clients? explores the experiences of people who engaged in an arts for prescription
programme. The study conducted employed narrative enquiry techniques and the participants
were interviewed three times during the course of one year. Results showed that participants
benefited greatly from the programmes in terms of having a safe place to come to,
experiencing peer support and gaining access to voluntary work and education. (Stickley,
2010)
Art based activities mark a shift from verbal communication to active engagement with the
process of creating, which enables a meaningful interaction between service user, artist and
health workers. Arts based interventions also have the potential to enhance overall feelings of
wellbeing, and to provide meaning and purpose through a range of goal oriented activities.
Creative arts activities provide an avenue for self expression and motivation, thus reinforcing
personal empowerment and increasing self esteem. (Yaqub & Burwash, 2013) Results from
the studies showed that the art making process had a transformative effect which effected
internal changes contributing to recovery. (Yaqub et al, 2013)

19
Similar outcomes were demonstrated in studies conducted in Salford, England by Makin and
Gask (2011). The research explored the value of an arts on prescription programme to aid the
process of recovery in people with chronic mental health difficulties, who had previously
experienced psychological talk based therapies. Recovery was perceived by participants as
returning to normality through enjoying life again, setting goals and resuming former
activities. (Makin et al, 2011) Active engagement with the arts was seen to aid the process of
recovery by enabling the participants fulfill these criteria. The arts based programmes aided
recovery in ways not always achieved by talk therapies alone. (Makin et al, 2011)
Participatory arts projects for people with mental health needs consistently claim benefits
such as increased confidence, social participation and psychological wellbeing. However, the
evidence to support these claims is weak. (Hacking, Secker, Kent, Shenton & Spandler, 2008)
Leckey (2011) contends that there seems to be a lack of clarity in relation to the definition of
mental health. It is a nebulous concept open to different interpretations. This, in turn, affects
how the effectiveness of the participatory arts in mental health settings is measured. (Leckey,
2011) In terms of policy, outcome evaluation is important for several reasons. (Hacking et al,
2008)
2.4 The medical humanities in healthcare professional education
Young-Mason (2003, p.66) asks in their paper, Art, Literature, and Nursing Phenomena,
‘How do nurses continue to evolve their understanding of the human condition? How do they
continue to develop their aesthetic perception?’ They answer these questions by suggesting
that literature and the arts ‘…are attempts to comprehend and communicate the human
experience.’ (Young-Mason, 2003, p.66) This idea is echoed in Biley & Galvin’s (2007,
p.802) article, Lifeworld, the Arts and Mental Health Nursing in which they argue that the
arts ‘…has the potential to reach and express the depths of human experience when used as
an approach for enquiry.’
The term Medical Humanities, first coined in 1976 by Australian Surgeon, A R Moore
(Moore, 1976), covers an evolving interdisciplinary field of medicine that draws on the
creative and intellectual strengths of diverse disciplines such as the humanities, social science
and the arts in pursuit of medical educational goals. The arts and humanities can enrich
understanding of health, medicine and disease by providing insights into the human

20
condition, and are concerned with the history and culture of human health, disease and
medicine, and how research into these areas can influence policy and practice. They
investigate the experiences, narratives and representations of health and illness often ignored
by the biomedical sciences alone, and help to develop and nurture skills of observation,
analysis, empathy, and self-reflection, skills that are essential for humane medical care.
(Hurwitz, 2003; Reilly, Ring & Duke, 2005; Biley & Galvin, 2007, Brett-MacLean, 2007;
Macneill, 2011)
British research papers by Robinson (2007), Holistic Health Promotion: Putting the Art into
Nurse Education and Using Art in Pre-registration Nurse Education conclude that
introducing a Holistic Health Promotion course and art related education for student nurses
was welcomed by most students and had positive effects on them, such as increased
awareness of health care environments and more empathy for patients. They found the
inclusion of arts therapeutic and enjoyable experience. Similar findings were discovered in an
Irish research paper, Evaluation of an Art in Health Care Elective Module – A Nurse
Education Initiative (McCabe, Neill, Granville & Grace, 2013) in which nursing students’
experiences of undertaking an arts and health module was evaluated.
In Honouring the Patients’ Voice in Health Professional Education (Shah in McLean &
Kelly, 2010, pp.349-368), Shah states that there is increasing recognition that patients have a
vital role to play in Health Professional Education (HPE) and claims that healthcare is
experiencing a paradigm shift from a paternalistic to a patient centred approach, where the
individuality of the patient and their need to be involved in decision making regarding their
care are taken into account.
Shah makes a case for the use of arts and humanities in HPE in this context, and advocated
Participatory Action Research which was undertaken in The University of British Columbia,
incorporating various groups to develop, evaluate and refine patient-led interdisciplinary HPE
workshops. This combined the direct sharing of patient narratives with the use of a literary
narrative of illness, and the involvement of patients who were also health professionals. The
workshops focused mainly on mental illness.
Charon, a physician and literary scholar, pioneered the Narrative Medicine Movement and
called it ‘the clinical cousin’ of literature in medicine. ‘Narrative Medicine provides an

21
approach to the hands on use of literature in medicine.’ (Shah in McLean, 2010, p.357)
Shah’s own experience of mental illness reinforced this theory, changing the way she
practised medicine. Shah claims it led her to exercise more empathy and greater validation of
patients’ experiences.
Literature providing evidence of the role the arts can play in the healing process is increasing,
and how it is used to enhance the physical environment for service users, provide
psychological support and communicate health information (Huxley, 1997; Staricoff, 2004;
Daykin & Byrne, 2006; Stuckley & Nobel, 2010), but despite this, undergraduate healthcare
professional education rarely covers this aspect of education.
However, the arts and humanities are slowly filtering into healthcare professional education
in Ireland. In June 2014, Dr. T Stickley, Associate Professor in Mental Health at the
University of Nottingham gave a lecture in the School of Nursing and Midwifery in Trinity
College Dublin, in conjunction with the Irish Institute of Mental Health Nursing. The lecture
was entitled, Being Human: Creativity in Mental Health Care, which dealt with the
implications for mental health practice in Western healthcare becoming increasingly focused
on evidence-based medicine, and a culture more driven by targets and goals. Stickley calls for
a re-focusing of care towards a more creative approach; one where practice is led by values,
not by targets.
In Galway Technical Institute (GTI), The Music of What Happens: A Students Guide to Arts
and Health (Macleman, 2014) was created to redress a gap in GTI’s Nursing Studies
Programme, and to support students in exploring their own creativity whilst introducing the
guiding values of arts and health practice. This guide was made by and for students, and is
intended as an educational resource for future year groups studying Art and Applied Health
and Social Sciences at GTI.
WHAT are also establishing links with student nurses in Waterford Institute of Technology
(WIT) in a bid to incorporate the arts into their professional training and practice. Integrating
the medical humanities into healthcare professionals’ curriculum ‘…advances the objectives
of a profession that operates at the intersection of science and art.’ (Frei, Alvarez &
Alexander, 2010, p.676)

22
2.5 Conclusion
The literature reveals that the implementation of the arts in a mental health setting has
beneficial effects on the wellbeing of service users. Significant research, conducted in other
countries, notably Australia, Britain and North America, highlights these benefits. However,
on examining mental health policy documents in Ireland, it was found that there is a
significant gap between theory and practice. The documents make recommendations for
sweeping changes, for instance in patient centred recovery approach, but there is a
discrepancy between the ideals and aspirations and their implementation.
There is no mention of the arts in the Mental Health Commission’s; A Vision for Change:
Report on the Expert Group on Mental Health Policy, nor is there a national arts and health
policy framework. There is insufficient provision for the arts in healthcare professional
training to date. Not enough research has been undertaken in Ireland on the potential benefits
or the cost effectiveness of the arts in mental health settings, and despite growing enthusiasm
for the arts in some settings, it is not widespread, and Irish health services are still dominated
by the biomedical model of recovery. Even in settings where the arts are welcomed in
healthcare, there is confusion about definitions and outcomes. The term ‘arts in healthcare’ is
nebulous and elusive. Participation in the arts is sometimes confused with the radically
different discipline of art therapy. The literature has revealed a need for more thorough
training and clarification in this regard.
Taking these factors into account, the research question that emerges is: What are the
perspectives of healthcare professionals on their experience of the participatory arts in a
mental setting? I decided to interview four mental health nurses to discover their opinions on
the impact of the participatory arts on service users in their specific areas of mental
healthcare.

23
Chapter 3
METHODOLOGY
3.0 Introduction
Methodology, research design and data analysis for this research study are discussed in this
chapter. The primary research undertaken was an exploration of the perspectives of
healthcare professionals in the South East region on their experience of the participatory arts
in a mental health setting in their workplace. The general methodological research technique
was qualitative, involving a literature review, observation, and action based research in the
form of face to face, semi structured, in depth interviews. Four healthcare professionals were
interviewed to gather relevant data. The data collected is triangulated into a case study to
discern possible commonality of themes. An attempt to obtain a comprehensive picture of
human experience underpins this choice of methodology.
3.1 Purpose
The purpose of this study is to explore the healthcare professionals’ experience of the
participatory arts in a mental health setting, and to examine the perceived impact of the
participatory arts on service users, their role in care planning policy, partnership with arts and
health organisations, and their thoughts on the medical humanities. Through this exploration,
the aim was to gain further insights from primary caregivers and generate new ideas for
future research, since the use of the arts in healthcare, although developing, is a relatively
new concept in Ireland.
Dineen (2013, Arts + Health) in The Weapons of Life: A case for arts participation as a
creative response to mental health problems, asserts ‘I would argue that arts programming
can be justified within the context of current government policy on mental health and that
persuasive arguments can be made that the arts in mental healthcare are an effective tool in
the recovery process.’ Mental health nurses are primary caregivers in mental health settings,
thus garnering qualitative feedback from them will provide useful insights and information in
regard to Dinnen’s statement, and can contribute new knowledge to this area of research for
the South East region.

24
3.2 Theory
Since a Relativist approach rejects the idea of absolute standards for judging truth and relies
more on the personal perspectives of individuals (Robson, 2002), it was deemed to be the
most suitable epistemological approach. The aim of the research was not solely to accumulate
empirical facts, but also to generate working hypotheses upon which to build future research.
Thus, the phenomenological study of direct human experience is a major epistemological
approach in this study, where truth and value are determined by subjective perspectives of
healthcare professionals rather than purely objective reality. This, in essence, constitutes a
constructivist or interpretivist approach. In this approach, language is recognised as an
important vehicle to convey these meanings. Therefore, the in depth interviews provided an
atmosphere conducive to this purpose. ‘Meanings are constructed by human beings as they
engage in the world they are interpreting.’ (Crotty, 1998, as cited in Creswell, 2003, p.9)
3.3 Rationale for choice of qualitative approach
In depth interviews are an optimal means of collecting data on individuals’ personal
perspectives and experiences, especially where sensitive issues, such as mental health
difficulties are being explored. Seale (1998, p.203) observes that the researcher can ‘…use an
interview to find out about things that cannot be seen or heard, such as…the reasoning behind
their actions and their feelings.’ By interviewing mental health nurses who work in mental
health settings, I had the opportunity to probe any line of questioning that was particularly
interesting, which might be beyond the scope of my original set questions and could reveal
rich material to allow broader investigation in that area. Ritchie, et al (2004, p.58) highlights
that an interview also provides ‘for in depth understanding of the personal context within
which the phenomenon is located.’
Language plays an important role in terms of its use to represent multi-faceted aspects of
experience. Qualitative methods can also help to identify abstract factors such as
inclusiveness, isolation or social status. Such intangible factors come within the remit of this
study, since there are many ‘grey areas’ and contradictory beliefs associated with mental
health. Thus, a qualitative approach was deemed to be the most suitable method for an
exploration of the use of the participatory arts in a mental health setting.

25
Direct observation is another qualitative method used in my research. Observation is the
selection and recording of behaviours of people in their natural setting. It is useful for
obtaining information that is otherwise inaccessible, and for conducting research when other
methods are inadequate.
I attended one art and two music workshops where I interviewed healthcare staff in a mental
health setting. This was to gain firsthand experience of art and music participatory
workshops, to which I was unaccustomed. There was a stipulation that I participate in these
workshops rather than merely observe. I did this with the permission of the service users and
the artists and musicians presenting the workshops. For ethical reasons I chose not to record
these observations in a journal, because of the personal nature of these workshops. However,
it was still a valid and worthwhile experience, as my participation provided me with
invaluable insights into the dynamic between artists, healthcare staff and service users, and
made me aware of what exactly participatory workshops in a mental health setting entailed.
3.4 Data description and analysis
I telephoned the four participants and explained the research to them. Three people wanted a
set of questions emailed to them prior to the interview. This did not detract from the
spontaneity of the interviews, as the set format was not always adhered to in the course of
conversation. The interviews were conducted over a three week period at dates and times
convenient to the research participants, and ranged in length from 45 minutes to one hour.
Three of the participants were interviewed in their own workplace, and one in WHAT. All
participants wished to be interviewed during working hours in their workplace, except one,
who said there would be too many interruptions if the interview took place in their office.
Open ended questions were mainly used to enable participants to express their views. They
were asked specifically about the perceived impact of the participatory arts on service users
from their own perspective, and also about the implementation of the arts into care planning
policy and educational training for healthcare professionals. They were also asked about
partnership with arts and health organisations and their own interest in the arts.
The questions were selected to observe the general modus operandi of the implementation of
arts and health projects in mental health settings. In the course of the data analysis process,

26
emerging themes were identified and triangulated into a case study. According to Robson
(2002, p.89), the typical features of a case study include the ‘selection of a single case (or a
small number of related cases) of a situation, individual or group of interest or concern.’
Miles and Huberman (1994, p.267) argue that ‘[t]he aim is to pick triangulation sources that
have different biases, different strengths so that they can complement each other.’
Yin (2003) categorises case study into three types, exploratory, explanatory and descriptive.
Exploratory case study investigates the ‘why’ as well as the ‘how’ of the research area. An
exploratory case study is used in this dissertation, as the healthcare professionals in the case
study are interviewed to explore their perceptions of the participatory arts in a mental health
setting. Oppenheim (1992, p.67) verifies that ‘the exploratory interview is to develop ideas
and research hypotheses rather than to gather facts and statistics.’
3.5 Sampling techniques
A purposive sampling technique was employed, in that all participants were mental health
nurses, selected on the basis that they possessed a certain degree of knowledge that would be
a key factor in understanding the role of the participatory arts in a mental health setting.
According to Ritchie (2004, p.78), ‘[t]he sample units are chosen because they have
particular features or characteristics which will enable detailed exploration and understanding
of the central themes and puzzles which the researcher wishes to study.’
A snowballing technique was used in that the participants were recommended by a work
colleague in WHAT, who knew they were exposed to participatory arts workshops in their
workplace. This work colleague, an experienced arts and health manager, examined the list of
interview questions I had prepared, to assure suitability and relevance to the research
question.
A flexible rather than a fixed design approach was used. This allowed for some measure of
reflexivity on the part of both the researcher and the participants, and allowed the research
design to unfold during the process of data collection. (Robson, 2002)

27
3.6 Reliability and validity
The researcher should be unbiased, objective, without any prejudice or preconceived views
on the subject, as this may result in distorted or corrupted data. Oppenheim (1992, p.145)
states that ‘validity…tells us whether the question…measures what it is supposed to
measure’, therefore to ensure accuracy and consistency in the interviews, the same set of
questions were asked of all participants.
The research participants in the study were not known to me, thus minimising the risk of bias.
While there is a view that reliability is more difficult to establish in flexible design research
than in a fixed one, care was taken to ascertain the reliability of the interviews, and to ensure
that there were no leading questions nor any sharing of views on the part of the interviewer.
Prompts and probes were used only when the questions required further development. The
interviews were conducted in a fair, objective way.
The interview questions were piloted with an experienced arts and health manager to test the
clarity and relevance of the questions. Valid strategies and research techniques were
employed to gather and analyse data. Three out of the four interviews were audio taped and
the transcripts are available in the appendix of this dissertation. Participant C, who didn’t
permit their interview to be audio taped, typed out answers to interview questions and
submitted them after the interview, and these are also in the appendix.
3.7 Ethical considerations
Participants were provided with an explanatory ‘plain language statement’ via email prior to
the interview, detailing the introduction to the research study, its objectives, details of what
involvement in interview phase of the research study will require, and confidentiality of data.
They were also provided with an ‘informed consent form’, detailing the research study title,
clarification of the purpose of the research, objectives of this research, and clarification of
particular requirements as highlighted in the plain language statement.
The interviewees were informed that they could withdraw from participation in the research
at any stage; before, during or after the interview had occurred, and their confidentiality
would be assured by the researcher. The anonymity of the participants was safeguarded in

28
order to enable them to express their views and recount their experiences freely, without
undue stress. Oppenheim (1992, p.105) emphasises ‘that steps must be taken to ensure that no
information will be published about identifiable persons or organisations without their
permission.’
Interviews were recorded with the permission and solely at the discretion of the participants
on a digital recording device. All interview recordings were treated with utmost
confidentiality and names disguised. This electronic raw data and transcripts of these
recordings by the researcher will be saved as password protected files on a computer fitted
with anti-virus software. Physical raw data, such as hand written notes, et cetera, will be held
for five years in secure researcher’s archives, and a copy of all original data to be retained by
the researcher with an electronic password for a period of five years.
Each participant signed the informed consent form indicating their willingness to take part in
the interview. All interviews were conducted in a professional manner at a time convenient to
the participant. The data was collected in a discreet manner and caused no discomfort or
invasion of privacy of the individuals concerned.
3.8 Challenges faced
Initially, it was difficult to establish a date and time for each interview, as the research
participants found it difficult to find time in their busy work schedules; consequently, the
process of establishing dates and times was time consuming. One participant had to cancel on
the morning of an interview due to a colleague’s absence, so the interview had to be
rescheduled. Another didn’t agree to being interviewed because of time constraints and
severe staff shortage, but expressed their willingness to be interviewed in the future when
staffing issues had been resolved. These time constraints and staffing issues reflect a wider
problem in the healthcare system in general.
Distances had to be travelled to reach interview venues, and transcribing the audio tapes was
time consuming. Since one participant did not wish to be audiotaped, collating the interview
and taking notes made the task doubly challenging. For this reason, I choose to interview a
fourth person who agreed to their interview being audiotaped, so as to have adequate

29
information to triangulate the case study for the research findings. Oppenheim (1992, p.67)
stresses that ‘it is essential for exploratory interviews to be recorded…in this way they can be
analysed afterwards, for there is much that will have escaped the busy interviewer.’
3.9 Conclusion
This chapter has outlined the methodology, research design and data collection methods for
the research study. The study focused on the perspectives of healthcare professionals in the
South East region on their experience of the participatory arts in a mental health setting. The
areas explored in the interviews were the perceived impact of the participatory arts on service
users, the role of the participatory arts in care planning, partnership with arts and health
organisations, health care professionals’ own interest in the arts, and their thoughts on the
medical humanities.
It was a qualitative research study employing four face to face, semi structured, in depth
interviews in order to collect data from healthcare professionals. The data collected was
triangulated and presented as a case study. Ethical considerations and issues relating to
reliability, validity, data storage and analysis were taken into account as required. The
findings from this research can potentially benefit the arts and health community, comprising
healthcare professionals, service users, arts and health managers, artists involved in running
participatory workshops and the HSE. The National Network of Arts and Health
Coordinators Ireland would welcome further research on the benefits and potential positive
outcomes of this fusion of arts and healthcare.

30
Chapter 4
FINDINGS
4.0 Introduction
Introducing art and culture into the life and fabric of health services is now regarded as best
practice in health care internationally and there is an increasing acceptance of the idea that
participation in the arts can have beneficial effects on the mental health and wellbeing of
service users. (Daykin & Byrne, 2006) Though slowly becoming recognised in Ireland as an
integral part of mental healthcare, the impact of the arts has been largely under researched in
relation to other countries. The literature review identifies gaps in the knowledge of arts and
health in Ireland and a discrepancy between theory and practice in some respects. This is
borne out in the findings from the interviews conducted in this study.
Specific areas of research relating to arts and health from the perspectives of four mental
health nurses are presented in the findings. These are the value of the participatory arts in a
mental health setting, the training and experience of the participants, changing attitudes to
mental health in Ireland and the relevance of the participatory arts to care planning and to the
education of healthcare professionals, as these were the major themes emerging from the
study. Difficulties with regard to the implementation of arts programmes will be mentioned,
but will be developed more fully in the discussion chapter. These difficulties mainly arose
from recessionary cutbacks, inadequate staffing levels and subsequent heavy workloads.
All of the participants interviewed were experienced nurse managers working in various
mental health settings, from acute inpatient hospital services, to community health settings
and day care centres. Face to face, semi structured, in depth interviews were conducted.
Three of the interviews were audio taped and the conversations transcribed verbatim.
However, words which could lead to the participants’ identity have been omitted to safeguard
their anonymity. The transcripts are included in the appendix. This was a qualitative,
phenomenological study.

31
4.1 The value of the participatory arts in a mental health setting
All four participants affirmed that the arts programmes implemented in their respective work
places had a beneficial effect on service users, enhancing their quality of life and increasing
self esteem. Participant A, who works in an acute hospital setting, described a collaborative
art piece undertaken with the help of a facilitator from WHAT in which staff and service
users participated. It comprised a mosaic of squares, made up of four panels, each with
twenty-eight artworks and contains the work of approximately ninety people. The panels
represent the themes of sky, sea, forest and land, and the artwork is about being part of nature
and life and the fact that we are all connected. The artwork featured in the Wellness
Exhibition in Garter Lane. Participant A observed that it contributed to a sense of
achievement and co-operation in staff and service users alike. ‘Staff, service users all
contributed to the pieces and it’s just, it’s beautiful. I think it’s under viewed where it is
currently, so we’ve decided to…we’ve had a think about it and we’re going to move it to a
more focal point’.
Participant B spoke of music programmes undertaken in conjunction with WHAT’s
participatory arts and mental health projects in the day care centre where they work.
Participant B reported that involvement in these music workshops lightened the mood of the
service users, inculcated a sense of empowerment and provided a non threatening, non
invasive and relaxing environment. In the case of all mental health settings in the study,
engagement with the arts programmes is voluntary and the service users have a say in
running the workshops, which are tailored to suit individual needs. According to participant
B, music can also have a deeper resonance for service users, enabling them to tap into
hitherto incommunicable feelings or memories. ‘Say if somebody comes out and says oh, “I
feel a little bit tearful”, and they might start telling you other stories as to why they were
tearful…that you’re kind of linking into something new with them that you didn’t know
before.’
Both participant C and participant D work with people who have enduring mental health
needs, and both agree that involvement in the arts can have long term benefits for service
users. Participant C claims that the arts can help to provide different ways for people to
express themselves and to explore their latent creativity. Participant C thinks it can improve

32
confidence and social skills which are integral components of mental health. Participant C
observed that engagement with arts programmes can decrease negative outlook and induce a
calming effect on service users.
Participant D cites several examples of the impact of music on service users, both in a
participatory and receptive capacity. A woman with Alzheimers ‘who was never into music’
now looks forward to the day on which the music workshop is held. According to participant
D, music can aid service users to release difficult emotions, particularly those who have
trouble communicating verbally. Another service user who had Huntingdon’s disease did not
normally want to engage with other people and stayed in bed all day. The musicians asked
permission to go to her bedside, and while she was agitated at first, the music relaxed her and
helped her gain acceptance and trust. Participant D described this experience as a learning
curve for them as a healthcare professional.
One of the musicians said, “Can I bring the music to her bedside?”, and she
would get agitated when she’d see them coming, but once they started playing
soft music, she just totally relaxed, and she’d go…she accepted them and trusted
them, so it was wrong of me to assume she wasn’t suitable, because bringing the
music to the bedside as well as to the group, are you with me?
Another service user never participated actively in the music workshops, but regularly
walked by the window during the sessions. Participant D said, ‘He was listening from his
own distance.’
Participant D also refers to the value of puppetry and drama workshops conducted in the
mental health setting where they work, stating that it helped service users experiencing
communication difficulties to engage meaningfully in relationships. Participant D sees
puppetry and drama as a means of stimulating imaginations which have been blunted by
illness or medication.
All participants concurred that engagement with the arts, whether receptive or participatory,
helped to dissolve barriers to communication and played an important role in the recovery
process. Participant B stated, ‘It could open windows or doors for you.’

33
4.2 Changing attitudes to mental health in Ireland
Participant A believes that, in line with the Mental Health Commission’s recommendations, it
is crucial to allow for a recovery approach in which the service user plays a significant role.
‘It is very much part of the mental health forum now to include service users. It’s essential, I
personally think.’ Also, terminology has changed; the emphasis now is on maintaining health
rather than on treating illness. ‘I think we need to change our mindset about what we think of
mental health. Rather than the abnormalities, we talk about the fact that we want to maintain
and protect mental health.’ Participant A goes on to state that the arts play a role in offering
choices to service users in different workshops, in which participation is voluntary. There is
no pressure to participate and the enjoyment of service users is paramount.
All of the participants in the research believed that the paternalistic approach in mental health
care is giving way to a more patient centred one. The Advocacy Movement is gathering
strength and service users have the opportunity to make their voices heard regarding their
care. The traditional medical model is being replaced by one which seeks to instil a sense of
empowerment and a measure of control to service users. Participant A states, ‘They’re
experts in their own recovery, we’re just part of the journey.’
Participant B, too, sees the recovery plan as building on the service users’ strengths and
regards participation in the arts without coercion as part of a holistic recovery journey.
Participant C has embraced change to the extent that they have brought alternative and
complementary therapies into their work. As clinical nurse manager, their aim (Participant C)
is to endeavour to help clients to maximise their health and social wellbeing, by using the
resources available as effectively as possible. Participant C considers the use of the arts as
part of her role.
According to Participant D, who trained in the UK and worked there for eight years, Britain
is ahead in terms of innovative arts and health programmes for the enhancement of mental
health, stating that Ireland is now at the stage of development existent in Britain in the late
1980s. Like the other participants, they believe in a holistic model of individual care plans,
voluntary participation in arts and health programmes and collaboration with other
organisations in the wider community. Rapport and proactive feedback are of the essence.
Participant D confirms, ‘Communication is the key.’

34
Based on these observations, it is reasonable to believe that the views of these individuals
reflect similar views of a changing mental health system in the broader setting.
4.3 Relevance of the participatory arts to care planning and education
All of the participants considered the integration of the arts into mental health care planning
to be important, but all cited lack of resources, financial cutbacks and recruitment embargos
as major barriers to the successful implementation of arts programmes. This topic will be
dealt with more comprehensively in the discussion chapter. The participants also believed
that an arts and health module should be incorporated into the training of healthcare
professionals. None were offered such options in their own professional training.
According to participant D, attitudes are changing in relation to the place of the arts in care
planning and education. They believe there is a definite place for an arts and health module in
healthcare professional training. ‘I think it has to start in the college with the students, that’s
where the education starts, when you are training people, you know.’ They themselves have
done a course in arts and health and have used the expertise gained from it in their workplace.
Participant D claims that nurses are more open to new ideas and change in relation to arts and
health than other healthcare professionals. They refer to Mary Dineen, a community mental
health nurse involved with Arts + Minds Cork and Beyond Diagnosis, the Transformative
Potential of the Arts in Mental Health Recovery (2012) as an advocate for change in the area
of arts and health practice.
Participant C thinks that the inclusion of the arts into care planning could be beneficial to the
clients’ mental health and could aid recovery. ‘The workshops can be entertaining, encourage
latent skills or talents and decrease anxiety and stress and improve self esteem.’ Participant B
believes that the partnership with WHAT and the programmes it facilitates are of vital
importance in the promotion of the arts in mental healthcare, as did the other participants.
Participant A says in this regard: ‘I couldn’t praise the relationship between arts and health
highly enough. We have stronger bonds over the years, particularly the Waterford Healing
Arts Trust, because that’s our first link, I suppose.’

35
4.4 Experience and training of research participants
Participant A is clinical nurse manager in an acute inpatient hospital setting, with twenty-four
years’ experience. They have also worked in other related areas, such as rehabilitation and
methadone programmes. They are very much involved in partnership with WHAT and other
arts and health facilitators. They have a personal interest in the arts and are keen to promote
the aesthetic aspects of the hospital experience. They stress the significance of arts and music
programmes in a mental health setting.
Participant B is nurse manager in a day centre for people with mild to moderate mental health
issues, with thirty years’ experience. They have worked in various mental health settings, but
their present workplace was their first experience of the arts in healthcare. They are
enthusiastic about the arts programmes, particularly the music workshops, but have not
previously had a personal interest in the arts. However, they state that their interest has
broadened from their experience in their workplace.
Participant C is a job sharing clinical nurse manager in an activation therapy unit which
operates as a day service catering for community based service users with enduring mental
health issues. The service users attend from their own homes and from a rehabilitation unit on
hospital grounds. The unit acts as a day care type service. The staff aims to provide support
for service users to live as normal and meaningful a life as possible and to develop their
individual potential in a supported environment. They deal with the day to day mental health,
social and medical needs of those attending, as well as providing daily programmes of
therapeutic, individual and group activities along with learning opportunities and activation
programmes.
Participant C has thirty five years of experience in mental health work. They have been
working in the activation therapy unit for thirteen years and have been involved in developing
and organising programmes and activities for the unit. They have done courses in
complementary therapies which they have incorporated into the workplace. Participant C has
a personal interest in the arts.
Participant D is a clinical nurse manager in a day care centre, with thirty one years’
experience. They trained in the UK and worked there for eight years. Since then they have

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