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Arts & Health
An International Journal for Research, Policy and Practice
ISSN: 1753-3015 (Print) 1753-3023 (Online) Journal homepage: http://www.tandfonline.com/loi/rahe20
Cultural plan model: integrating cultural and
creative activities into care units for the elderly
Tuulia Koponen, Marja-Liisa Honkasalo & Päivi Rautava
To cite this article: Tuulia Koponen, Marja-Liisa Honkasalo & Päivi Rautava (2017): Cultural plan
model: integrating cultural and creative activities into care units for the elderly, Arts & Health, DOI:
10.1080/17533015.2017.1315436
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ARTS & HEALTH, 2017
http://dx.doi.org/10.1080/17533015.2017.1315436
Cultural plan model: integrating cultural and creative
activities into care units for the elderly
Tuulia Koponena,b, Marja-Liisa Honkasaloc and Päivi Rautavaa,d
aDepartment of Public Health, University of Turku, Turku, Finland; bWelfare Division of Turku City, Turku
Municipal Hospital, Turku, Finland; cResearch Center for Culture and Health, University of Turku, Turku, Finland;
dTurku Clinical Research Centre, Turku University Hospital, Turku, Finland
ABSTRACT
Background: The European Capital of Culture Action introduced a
research and development project called Cultural Plans for Senior
Citizens in 2011 in Turku, Finland. The project aimed at improving
the quality of life of the elderly living in a long-term care (LTC)
environment.
Methods: Developmental work research.
Results: The cultural plan was developed as a part of the care plan,
and this turned the nursing personnel’s focus from traditional nursing
to nursing based more on the cultural needs of the elderly clients.
The elderly who were involved in the project described the cultural
activities as bringing meaningfulness into their lives in the LTC units.
Conclusion: The project systematically integrated professional artists
into elderly care.
Introduction
The European Union hosts the European Capital of Culture Action, a year-long project during
which a city would operate a program of events to highlight its contribution to the common
cultural heritage and welcome people and performers from other member states (European
Commission, 2012). The city of Turku was nominated for the year 2011.
It was within this framework that a research and development project entitled “Cultural
Plans for Senior Citizens” was launched. The motto of the year was “Culture does good” – a
slogan promoting the concept that culture is inherent in each individual regardless of age
or domicile (Saukkolin, 2012). The project aimed at integrating culture, i.e. creative activities
into the life of elderly citizens living in long-term care (LTC) units. The primary goal was to
enable creative activities to be included on an individual basis into the care process and care
plan. Another goal of the project was to create an active network involving municipal admin-
istrators, volunteer organizations and artists. Altogether, this project focused on the eect
of the project on the well-being of the elderly, the nursing personnel and the elderly care
environment.
© 2017 Informa UK Limited, trading as Taylor & Francis Group
KEYWORDS
Well-being; care; plan;
culture; creative activities;
artist
ARTICLE HISTORY
Received 1 November 2016
Accepted16 January 2017
CONTACT Tuulia Koponen tuulia.koponen@hus.fi
2 T. KOPONEN ET AL.
Participants and methods
Two project workers and the project leader presented personally the implementation process
to the participating LTC units in 2011. The European Social Fund project, Dimples 2009–2012,
provided the professional artists for the LTC units for cultural contributions in poetry, dance,
puppet theater, theater and cinema (Malmivirta & Taivainen, 2012). There were a total of
about 400 events or workshops for the elderly within the framework of this project.
In this “Cultural Plans for Senior Citizens” project, we created a systematic structure to
introduce creative activities as an integral part of the care of the elderly to promote their
experience of well-being, self-esteem, social capital and quality of life in the LTC units.
Creative activities were brought into the everyday life of the ve participant LTC units through
implementation of cultural plans. Culture was dened as the entirety of cultural and creative
activities which bring signicant well-being. In practice, these activities included theater
visits, concerts, poetry and art forms brought into the care environment of the elderly, whose
role was either active participation or passive enjoyment.
The main aim of the project was to integrate cultural plans into the working process using
the developmental work research method. The developmental work research method pro-
ceeds from evaluation of current action to modeling and analyzing of novel courses of action
to implementation and nal assessment of the new courses of action (Engeström 1995). This
approach is typically used to investigate activity systems in research as well as developmental
projects, and it has been used in Finnish health care research since the 1980s.
In this project, the rst phase was to create cultural plans as part of the care plan. The
personal needs and wishes regarding creative activities of the older people were investigated
using the life history questionnaire developed by the Cultural Plans for Senior Citizens pro-
ject. The life history questionnaire covers the period from childhood to retirement, and
includes hobbies, subjects of interests (e.g. music, dance, literature, poetry, ne arts and
handicraft skills) and interest in learning or trying something new.
The second phase was to implement the cultural plans into the electronic patient record
system. The documentation instructions for the nursing personnel emphasized documenting
and assessing any change or signicance they observed or were told of by the elderly about
how engaging in creative activities had aected their well-being.
In the third phase, assessment of the quantity and quality of the cultural plans (n = 24)
was followed up by monitoring them at the beginning and the end of the project (April 2010
and September 2011). In this project, we wanted to understand how changes occur when
this new tool, the cultural plan, was used. The cultural plan data consisted of the number
and content of the entries made after implementation of the cultural plan in 2010 (n = 100)
and one year later in 2011 (n = 1594). The implementation process included written instruc-
tions, lectures and tutoring provided for the nursing personnel involved in the project. The
active role of the nursing personnel was the key success factor. The personnel understood
the importance of cultural activities for the elderly and observed the positive impact of
cultural activities for the elderly.
The quantity of the entries made to the cultural plan was analyzed by assessing by entries
documented in the written instructions and lections given. The quality of the entries was
assessed by content analysis. At baseline no systematic protocol regarding the implemen-
tation of cultural activities was available, but data were collected by routine care practice in
some LTC care units.
ARTS & HEALTH 3
In the fourth phase, the well-being experienced by the elderly and the personnel was
assessed by interviews. The experiences of the cultural and creative events by the elderly
were collected by interviewing a group of 8 randomly selected individuals out of 24 follow-up
participants and 17 randomly selected sta members (out of 95). The inclusion criteria for
the elderly were that the participant was cognitively able to reply and wanted to participate.
Informed consent was obtained from each participant.
A semi-structured interview method with open questions was used for qualitative data
collection. The interviews were carried out in the summer of 2011. The themes for the par-
ticipants’ interviews covered daily living experiences, experiences of the creative activities
and the signicance of the creative activities for their well-being. The nursing personnel’s
themes covered the signicance of the cultural plans on the care process and the relationship
between the creative activities and the well-being of the elderly.
Results
There were ve participating LTC units: two units in a nursing home, two LTC units in a pri-
mary care hospital and one dementia unit for severely demented patients. Altogether, there
were 164 elderly and 134 nursing personnel involved in the project. The mean age of the
elderly was 83 years and 60% (n = 97) had a diagnosis of dementia.
There was a signicant increase in the entries describing the creative activity needs and
those describing how the documented needs were carried out. The number of entries
increased in one year from 100 to no less than 1594.
The quality of the documented entries by the nursing personnel varied. Most entries were
made as instructed and were structurally correct. These entries described the older people’s
participation and personal feelings toward the cultural and creative activities in which they
had participated. However, in some of the entries the nursing personnel had not either yet
understood or accepted the concept idea of cultural activities being part of the new care
process introduced by the project. The content varied from describing the patient’s general
behavior and even the nursing procedures, to a specic description of the desired cultural
event.
The results of the qualitative data analysis and the follow-up show that the provision of
cultural activities in the LTC units was sucient. The older people experienced individual
encounters and the cultural events brought positive variation to their ordinary days in the
care environment and a feeling not just only being there as an object of care. (The texts in
italics are citations from the interviews.) Most of the interviewed individuals mentioned that
they came to know each other better and they commented when one is kept busy, one will
not have time to feel lonely. Cultural activities and workshops made them feel better. Some
had hoped for more diverse artists and had expected the performances of specic artists.
Some had expected more striking events and some had feared that there would be cultural
events with no end. Those of the elders who had lower expectations were more positively
surprised at the number and diversity of the events than those who had higher
expectations.
Expansive learning through teaching and tutoring took place with all participating actors.
The expertise and personal learning curves of the artists progressed and evolved into a new
way of making art. The nursing personnel welcomed the artists into the care process and
4 T. KOPONEN ET AL.
most of the elderly enjoyed and greeted the cultural and creative activities produced by the
artists.
After the cultural events became integrated into the care, the nursing personnel (n = 17)
observed that the elders seemed more positive and happy, because they now had other
things on their mind than usual. During the cultural events the elderly communicated more
with each other than before and some of them experienced positive changes of mood and
less fatigue. Among the nursing personnel, some of the observations were:
• The pleasing events aected old person’s mood and spirit a great deal. The cultural
events added or maintained activity and spirit.
• The general feeling of depression has disappeared.
• The happenings have aected the feeling of solitude. Clients usually wanting to be
alone stayed no longer in their rooms when cultural and creative program was on the
agenda of the day.
• An elderly in good mood was easier to care for because minor pains and aches no longer
bothered after a pleasant cultural experience.
• Cultural events seemed to make the older people feel also physically well.
During the project, the nursing personnel realized that the concept of culture meant both
high and low culture and that culture is an individual experience for a person. The cultural plan
was patient-centered. The cultural plan represents the fact that care is just not given from above;
the old person can decide for himself or herself. Nurses had also more shared common matters
to talk about with the elderly. The culture events and the care process were linked together
so that instead of an ordinary working day, the day turned out to be just lovely. A satised elderly
brings a smile to a nurse’s face.
Discussion
In a Finnish research study of the older people, Pitkälä, Routasalo, Kautiainen, and Tilvis
(2009); Pitkälä, Routasalo, Kautiainen, Sintonen, and Tilvis (2011) used “art and inspiring
activities” to describe group activity consisting of visits by various artists, visiting cultural
events or sights, as well as production of art by the elderly. In the community, art participants
from various backgrounds created a piece of art together (Matarasso, 1997). Honkasalo
(2013) applies the notion of culture in an ethnographic way to denote learned behavior,
ways of life, values and experiences. In this project, we use creative activities to describe
activities involving cultural and art functions.
The Finnish policy context
The Finnish national guidelines for older people’s care (Ministry of Social and Health Care,
2008, 2011; The Finnish Ministry of Education and Culture, 2010) strongly emphasize the
quality of life of the elders by promoting health and well-being and improving the quality
of care services and their eectiveness. They also stress the development of new services
and care concepts to support the elderly’s functional ability, well-being and health. Despite
the challenging nancial situation in Finland – which includes plans to reduce LTC units –
there is still a strong willingness to ensure good quality of life for the elderly of the society.
ARTS & HEALTH 5
Corresponding results have been published in Sweden (Gustafsson, 2013) and one may
assume that health promotion, arts and artistic practices play a signicant role in all Nordic
countries as a means to improve the quality of life of elderly living in LTC units (Priebe &
Sager, 2014). According to Gustafsson (2013), elderly care is an important forum for imple-
menting cultural activities.
Similar ndings to ours on a positive connection between, on the one hand, cultural
activities and art and, on the other, well-being, empowerment, connection-making and
quality of life of people, regardless of age, have been reported recently also from other
countries. (Hallam, Creech, Varvarigou, McQueen, & Gaunt, 2014; Nenonen, Kaikkonen,
Murto, & Luoma, 2014; Sapuona & Pamer, 2016).
Cultural plan as part of the care plan
In Finnish health and social care, every patient with chronic diseases is cared for according
to an individualized care plan made by health care professionals in collaboration with the
patient. The cultural plan is an open-ended qualitative list of activities that the patient is
willing to include in the care as a separate part of the care plan. It guarantees that creative
activities chosen and performed by the person are as important as is medical care or treat-
ment for the care of the elderly. The cultural plan has a structured design of regularly imple-
mented creative activities for older people and it is integrated as a part of their care. Here,
we report the impact of the cultural plan implemented as an essential part of the care plan.
The results show that planning well and using a diversity of methods in the implemen-
tation process assures that the new tool may be implemented swiftly in the work process.
The number of the cultural plan documentation entries rose from 100 to no less than 1594,
and most entries were also documented as instructed. The increased number of entries
shows that the older people’s individual hopes regarding cultural and creative activities are
taken seriously and can become an integral part of care. The increase in the number of entries
and the descriptions of the elderlies’ experiences and feelings about the cultural and creative
activities show clearly that a change took place in the nursing personnel’s way of thinking
and acting. Care included now the experience of well-being arising from the cultural and
creative actives integrated into the nursing process.
This program is unique in that it implements a new tool into the cultural plan, which
aects both the work process and the quality of life of the patient. We are not aware of
comparable research carried out elsewhere. The cultural plan is a new tool for the work in
LTC units. To be eective, it needs continuous use within the work communities and strong
commitment and support by the management.
In the context of Nordic research on the welfare of elderly, it is still unique to bring cultural
activities into the lives of the elderly living in LTC units and to integrate systematically creative
activities, including cultural and art functions, into the care process. Our results show that
a new way of thinking of the quality of life for older people was introduced by integrating
cultural activities within the cultural plan of the care process. The activities included in the
plan were visits to older people living in LTC units. At the same time, the nursing personnel
had the opportunity to enjoy the cultural activities together with them. Sharing the same
cultural experiences brought a new social sense among the older people and the nursing
personnel. This shared experience generated a new sense of collectivity among the personnel
and the elders. An important nding was that the older people have the desire and ability
6 T. KOPONEN ET AL.
to enjoy creative activities, such as cultural events and visits by artists, even at the very end
of their life. In this project, the older person’s active or passive role did not aect signicantly
how he or she experienced the creative activities. During the implementation of the cultural
plan the quality and coverage of the nursing documentation also improved, as well as the
number of entries.
The use of the cultural plan as part of the care plan changed the traditional focus of the
nursing personnel toward a new cultural nursing procedure, which is illustrated by the con-
siderable increase in the documentation entries. Expansive learning through teaching and
tutoring was also documented by the nursing personnel, the other actors, the elderly and
the artists.
The follow-up time of the study was only 24 months, but considering this patient group
it can be considered a long time. A challenge to the success of this project was the high age
and the comorbidity of the participating elderly subjects – circumstances aected their
ability to function throughout the two program years. A requirement for successful imple-
mentation is, further, that there is a continuous dialog between the work community and
the project leaders and members.
One of the key challenges of the project was its short duration. The Turku Cultural City
2011 project lasted for only 12 months, this allowed insucient time to document its full
eects. However, the involved participants reported unanimously that proving cultural activ-
ities for the elderly is important for the well-being of the elderly. Despite the brevity of the
cultural city project itself, implementation and documentation of cultural plans into the life
of the elderly at LTC units continues. This proves that the importance of including cultural
activities and their relevance to the care process.
Conclusion
Our results imply that cultural activities are as important as health care in providing a good
quality of life for older people. The results were so encouraging that the 24-h LTC units
decided to involve all its 1500 clients in the cultural plan. Our future research will focus on
dierences in the quality of life between elderly with versus without creative activities in
their care. Another focus will be set on management and leadership – core functions which
needed to ensure that nursing personnel include cultural aspects into their work with elderly.
Disclosure statement
No potential conict of interest was reported by the authors.
Funding
This research has been undertaken as part of the ArtsEqual -project funded by the academy of Finland's
Strategic Research Council from its Equality in Society -programme (project no. 293199).
References
Engestrom, Y. (1995). Kehittävä työntutkimus: perusteita, tuloksia ja haasteita [The origin of activity
theory; basis, results and challenges] (pp. 11–12). Helsinki: Painatuskeskus. 87–92, 126–130, 229.
ARTS & HEALTH 7
European Commission. (2012). Ex-post evaluation of 2011 European capitals of culture. Final report for
the European Commission DG education and culture by J. Rampton, N. Mozuraityte, H. Andersson
& E. Reincke. Ecorys UK. Retrieved May 22, 2016, from https://ec.europa.eu/programmes/creative-
europe/sites/creative-europe/les/les/ecoc-2011-evaluation_en.pdf
Gustafsson, K. (2013). Kulturens betydelse inom äldreomsorgen [The signicance of culture in the elderly
care]. Retrieved February 22, 2016, from http://www.hh.se/forskning/samspelettforskningsmagasin/
samspel2013/kulturensbetydelseinomaldreomsorgen.65440085.html
Hallam, S., Creech, A., Varvarigou, M., McQueen, H., & Gaunt, H. (2014). Does active engagement
in community music support the well-being of older people? Arts & Health, 6, 101–116. doi:
10.1080/17533015.2013.809369
Honkasalo, M.-L. (2013). Culture, health and well-being - what are the premises for equation. In J.
Vahlo & S. Ruoppila (Eds.), Turku 2011 capital of science and culture (pp. 120–139). Hämeen Kirjapaino
Oy. Retrieved February 22, 2016, from http://www.utu.//yksikot/hum/yksikot/hktl/tutkimus/ktt/
Documents/Tieteen_kulttuurip%C3%A4%C3%A4kaupunki_netti.pdf
Malmivirta, H., & Taivainen, A. (2012). Merkittävien ihmisten yhteiskunta. Hymykuopat-hanke kunnan
tarpeisiin vastaajana [Dimples project]. (Vol. 15, 102–108). Somero: Sälekarin kirjapaino.
Matarasso, F. (1997). Use or ornament? The social impact of participation in the Arts. Comedia (pp. 75–78).
London. Da Costa Print. Retrieved July 20, 2011, from http://www.disseminate.net.au/les/webles/
OrnamentMatarasso.pdf
Ministry of Education and Culture. (2010). Art and culture for well-being – Proposal for an action
program 2010–2014. In H.-L. Liikanen (Ed.). Retrieved April 24, 2015, from http://www.minedu./
export/sites/default/OPM/Julkaisut/2010/liitteet/OKM9.pdf?lang=
Ministry of Social Aairs and Health. (2008). National framework for High-quality services for older
people. Publications 2008 (p. 3). Retrieved April 24, 2015, from http://www.stm./julkaisut/nayta/-/_
julkaisu/1063089#en
Ministry of Social Aairs and Health. (2011). Care and attention on a 24-h basis. Working Group
(Ikähoiva) Memorandum. Selvityksiä 2011 (p. 28). Retrieved April 24, 2015, from http://www.stm.
/julkaisut/nayta/-/_julkaisu/1554171#
Nenonen, T., Kaikkonen, R., Murto, J., & Luoma, M.-L. (2014). Cultural services and activities:
The association with self-rated health and quality of life. Arts & Health, 6, 235–253. doi:
10.1080/17533015.2014.897958
Pitkälä, K., Routasalo, P., Kautiainen, H., & Tilvis, R. (2009). Eects on psychosocial group rehabilitation
on health, use of health care services, and mortality of older persons suering from loneliness: A
randomized, controlled trial. Journal of Gerontology, 64A, 792–800.
Pitkälä, K., Routasalo, P., Kautiainen, H., Sintonen, H., & Tilvis, R. (2011). Eects of socially stimulating
group intervention on lonely, older people’s cognition: A randomized, controlled trial. The American
Journal of Geriatric Psychiatry, 19, 654–663.
Priebe G., & Sager M. (2014). Konst och hälsa. In Sigurdsson O. (Ed.) Kultur och hälsa. Ett vidgat perspektiv
(pp 55–90). Göteborg: Göteborgs universitet
Sapuona, L., & Pamer, E. (2016). The transformative potential of the arts in mental health recovery – an
Irish research project. Arts & Health, 8(1), 1–12. doi:10.1080/17533015.2014.957329
Saukkolin, J. (Ed.). (2012). European Capital of Culture Turku 2011. Final report of the Turku 2011 foundation
about the realization of the Capital of culture year (pp. 4–9). Tampere: Hämeen Kirjapaino Oy.
