‘Something Profound’

An Evaluation of the Arts for Stroke

Rehabilitation Project at Lanyon

Ward, Camborne/Redruth Hospital

Cornwall College Business

Research

May 2011

Arts for Health Cornwall

and Isles of Scilly

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Contents

Page Executive Summary 2

1. Introduction 4 1.1 Arts and Health in the United Kingdom 4 1.2 Arts and Health in Cornwall 7 1.3 National Stroke Strategy 7 1.4 Lanyon Ward and Stroke Care 8 1.5 Literature Search 9 1.5.1 ST/ART Programme Scotland 10 1.5.2 Healing Arts Isle of Wight 10

2. Project Aims and Objectives 11

3. Methods 13

4. Structure of the Project 14

5. Findings 15 5.1 Patient Impact 15 5.2 Practical Issues 22 5.3 SAGE sessions 24

6. Conclusions 26

7. References 31

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I came out with that extraordinary feeling of 'something profound happened in there' but it‟s

hard to language it. (Artist)

Executive Summary

This evaluation report examines an intervention with patients in the early stages of

recovery from stroke at the Lanyon Ward for Stroke Rehabilitation at

Camborne/Redruth Hospital, administered by artists commissioned by Arts for Health

Cornwall (AFHC).

The project is the latest to be administered by AFHC, which has a track record of arts

projects in health settings, including in primary care and with elderly people.

Lanyon Ward is a specialist stroke ward for intermediate care for stroke patients

following transfer from an acute setting, prior to discharge into the community. The

unit follows guidelines laid down by the National Stroke Strategy.

Eight artists worked on the ward between April 2010 and May 2011. The activities

involved art, craft, dance and movement and creative writing.

A number of the artists also worked with SAGE groups, formed in local communities

for recovering patients following discharge. The sessions with these groups were

particularly well received.

Four Rehabilitation Support Workers (RSWs), NHS staff working on Lanyon Ward,

liaised with the artists before and during the visits, to identify suitable patients for the

activities, and to observe and take part in the sessions for training purposes.

The purpose of the evaluation was to assess the impact on patients and staff of the

artistic activity, review the management and structure of the project, and make

recommendations the future. Qualitative methods were used to record data,

including interviews with artists and NHS staff.

There were many examples of a positive impact on patients of the artistic activities, in

terms of physical and emotional wellbeing. This was exhibited in a number of ways,

from the small movement of a hand or eye to a smile or an improvement in speech.

A common thread was the number of patients who displayed a noticeably improved

demeanour following a session.

The eight artists showed the utmost professionalism and flexibility in dealing with the

requirements of the ward, which included a high turnover of patients and many

potential distractions. Although the majority of patients were elderly, the activities

were adapted for a wide age range as well as severity of condition.

The RSWs showed enthusiasm for the artistic work and did their utmost to assist the

artists in preparation and delivery, despite the many other demands on their time.

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Other NHS staff also supported the project through observing and partaking in the

sessions, particularly as it progressed over the year. The project was well supported

by the ward management.

It is hoped that the work of the artist practitioners can be continued by the RSWs and

other staff beyond the formal life of the project. The artists have left materials and

ideas with the ward staff for this purpose.

A number of recommendations are made to be considered should there be a

continuation of the work (or a new project) and if funding permits. These include:

Possible appointment of a lead artist;

Further training for NHS staff;

Expansion of work with SAGE groups;

Follow-up activities for patients discharged from the ward;

Liaison with similar projects elsewhere in the UK, notably the Healing Arts

project on the Isle of Wight;

Examination of the cost-effectiveness of the intervention.

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1. Introduction

This evaluation report examines an intervention with patients in the early stages of recovery

from stroke, administered by artists commissioned by Arts for Health Cornwall (AFHC).

Artistic activities, including craft, dance, movement, music and creative writing, were

introduced at the Lanyon Ward for Stroke Rehabilitation at Camborne/Redruth Hospital, and

in local SAGE groups, formed for the benefit of recovering patients following discharge into

the community. The project ran for twelve months from April 2010.

This report begins by summarising the background to Arts and Health practice in the UK,

then examines the history of AHFC with reference to other projects. The nature of the Arts

and Stroke Rehabilitation intervention is then discussed in depth, with reference not only to

the variety of activities carried out on the wards and in the community by the eight artists

employed on the project, but also the processes involved in administering the scheme

together with the practical issues encountered along the way. The co-operation of the NHS

staff responsible for the day-to-day running of the stroke ward was a vital ingredient in the

development of the project and the roles of the Rehabilitation Support Workers and other

professionals are examined, not only in terms of their support of the artists, but in terms of

how the techniques introduced by the artist practitioners could be sustained beyond the life

of the project for the ongoing benefit of patients.

1.1 Arts and Health in the United Kingdom (UK)

Over the past decade the role of the arts in health has received increasing attention from

health practitioners and policymakers, particularly in the UK. There has been a growth in

some regions of public funded arts and health interventions and there is growing evidence

that the arts can bring about physical changes in the body. In Bristol, for example, the Royal

Children’s Hospital was designed with the help of artists to help create a relaxed and

interesting environment for children and their families. The research of Rosalia Staricoff and

colleagues at the Chelsea and Westminster Hospital between 1999 and 2002 (Staricoff et

al., 2003) underlined that the involvement of visual and performing arts in healthcare not only

led to significant differences in clinical outcomes, reduced drug consumption and shorter

stays in hospital, but also enhanced job satisfaction for staff.

In September 2006, following these initial investigations the Department of Health

began a review of the role the arts played in the general health and wellbeing of the

population. This initiative was to become part of the increasing emphasis being placed by

the Government on taking opportunities to improve public health by working with other

agencies. A review was set up by Nigel Crisp, the former NHS Chief Executive, led by Harry

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Cayton, National Director for Patients and the Public. Following a positive response from a

wide cross-section of stakeholders the review concluded that a report should be produced as

joint publication with the Arts Council (DoH, 2007a).

This report was published simultaneously in two parts: a national strategy entitled

„Arts, health and wellbeing' (Arts Council, 2007a) and a companion publication 'A prospectus

for arts and health' (Arts Council, 2007b), the latter being a celebration of the value of the

arts in various settings related to health provision. The second publication contained a

wealth of evidence and good practice examples showing improvement in both clinical and

therapeutic outcomes. It amounted to a strong body of evidence that the arts can and do

make a major contribution to health improvements, in terms both of patient recovery and

public health preventative measures.

Until this point many had dismissed the arts as simply ‘add on’ with little value in a

technically focused health care environment. Now however it was demonstrated that

tangible benefits could be seen and that the arts should become an integral part of quality

health care delivery. Health care workers were now to be encouraged to value the

effectiveness of incorporating the arts in all health initiatives and celebrate the benefits to

patients as well as their carers and service workers. It also became clear that the term ‘arts’

could include a whole spectrum of activities and these could be incorporated into the patient

experience in a variety of ways.

Despite the evidence provided in the joint document the Government was challenged

on its lack of leadership in this area on the 6th March 2008 in the House of Lords. Lord

Howarth of Newport pressed the Government to show how they intended to develop their

policies to link art with healthcare, and concluded at the end of the debate on Arts and

Healthcare that the only way to move forward was “to put arts and health on to the regional

and local arts agenda in a systemic way” (Hansard, 2008). He found it frustrating that so

much positive evidence existed yet no real progress was being made nationally and in reality

funding for the arts had reduced by £100 million in the last 10 years. He speculated on the

effect this would have on the general health of the population.

In the latter years of the New Labour Government there were further indications that

the Arts and Health agenda was to be at the heart of NHS provision. This is evidenced in a

speech given by the then Secretary of State for Health, Alan Johnson, in September 2008:

Access and participation in the arts are an essential part of our everyday wellbeing

and quality of life. Arts therapy has an important role to play in providing better, more

personalised care for patients. I expect this role to become even more important as,

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following the publication of the Next Stage Review, we look at how we transform the

NHS, from a service that‟s excellent at recognising illness and treating it, to one that

can more successfully prevent illness and promote health and wellbeing. (Johnson,

2008)

The economic crisis triggered by the collapse of the financial markets in 2009 has

permeated to all aspects of funding and the full impact on the field of arts and health is still to

be fully assessed, although it is clear that cuts will affect all aspects of public spending.

Under the Coalition Government, current expectations are that the voluntary sector will play

an ever-increasing role in the provision of healthcare in local communities. The need for

evidence in healthcare interventions of every kind is more important as ever as the scarce

resources of the new economic landscape become more apparent. Efficient practice is

currently encapsulated in the NHS Improvement Strategy QIPP (Quality, Innovation,

Productivity and Prevention) which looks to transform the way in which key services,

including stroke, are delivered:

NHS Improvement aims to:

develop sustainable effective pathways and systems;

share improvement resources and learning;

increase impact and ensure value for money to improve the efficiency

and quality of NHS services.

Currently working with over 240 sites through piloting, implementing and

spreading improvements, NHS Improvement has the practical knowledge and „how

to‟ approach to improve the quality and productivity of services through using

innovative approaches as well as tried and tested improvement methodology. (NHS

Improvement website, 2010)

Clearly there is potential for the areas explored by Arts and Health interventions to make a

contribution to improvements in health practice, supported by rigorous evaluation and

evidence. In the region covering the intervention under discussion in this report, the

community is fortunate to have a particularly active movement in Arts for Health South West,

currently a free membership organisation which seeks to share information, support and

practice, through its website (www.artsandhealthsouthwest.org.uk) as well as training and

showcase events. Arts for Health South West was recently awarded funding via the Arts

Council National Portfolio until 2015, despite the widespread cuts in arts funding announced

in March 2011 (AHSW, 2011).

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1.2 Arts and Health in Cornwall

Arts for Health Cornwall and the Isles of Scilly (AFHC) was constituted in 2001 and operates

as a registered charity. It generates funding independently of other organisations but is a

member of Arts for Health South West (see above) and works closely within this network to

promote arts and health activity. The aim of AFHC is to “ … advocate the role of creativity in

improving health and well-being and to develop and facilitate specific projects to deliver

health improvement” (AFHC, 2008). Historically, funding has been provided by Arts Council

England as well as from public donations and other sponsors. The charity employs a

Director with an office in Penryn and administrative support. Its Board of Trustees represent

the local arts community as well as health, professional and voluntary and community

sectors. A detailed website serves as a showcase of the charity's activities -

www.artsforhealthcornwall.org.uk.

Over the period of its existence AFHC has built a considerable reputation in the field which

has attracted national attention. The organisation was in receipt of a GlaxoSmithKline Impact

award for excellence in health improvement in 2010. The judges found that:

It is a dynamic organisation with strong leadership and its work is innovative,

particularly with older people in care, dementia sufferers and homeless people.

(GSK, 2010)

Additionally, AFHC were the winners of a Guardian Public Service Award 2009 in the

category Service delivery: Care of older people. The charity implemented a range of

activities in residential homes including art and craft, dance and movement and creative

writing and reminiscence. The project had particular impact on those participants with

dementia or depression (Guardian website, 2010; Bennett and Bastin, 2009).

1.3 National Stroke Strategy

Against the background of a growing body of research into the treatment of stroke, from

initial diagnosis through to the provision of ongoing care, in 2007 the NHS produced a

National Stroke Strategy (DoH, 2007b). The document was aimed at those commissioning,

providing and receiving NHS care, and contained a number of recommendations in the form

of quality markers (QMs). Of particular interest here are those QMs concerned with

rehabilitation and support after stroke. For instance, QM10 gives a quality standard for early

stroke care:

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People who have had strokes access high-quality rehabilitation and, with their carer,

receive support from stroke-skilled services as soon as possible after they have a

stroke, available in hospital, immediately after transfer from hospital and for as long as

they need it. (p36)

The rationale behind this QM emphasises the importance of the specialist skills to be found

in an intermediate stroke unit:

Where care is transferred from a stroke unit to in-patient intermediate care, better

outcomes can be achieved when professionals with stroke expertise are part of the

rehabilitation team and specialist input remains to oversee management and transfer

back to the specialist unit if the individual is failing to thrive. (p37)

Locally, the development of the Lanyon Stroke Rehabilitation Ward at Camborne/Redruth

Hospital has addressed the need for the specialist intermediate care addressed by the

Stroke Strategy. In June 2010 the South West Strategic Health Authority (SWSHA)

conducted a clinical review of stroke services in Cornwall, to ensure that the Stroke Strategy

was on course for full implementation by the target date of 31 March 2011. The review paid

particular attention to the facilities at the Lanyon Ward:

The review team was impressed with the changes that have taken place over the last

18 months. The ward environment is unrecognisable, bright and provides better

access for patients and staff. The availability of a single room which would allow

partners and children to stay with a parent provides a good standard of care and

access for patients. (SWSHA, 2010)

Additionally, it should be pointed out that the SWSHA report preceded a further major

reorganisation of ward space. This improvement scheme has been recognised, in particular

by the artist practitioners involved with this project, as a positive move in the provision of a

welcoming environment for patients, staff, carers and visitors.

1.4 Lanyon Ward and Stroke Care

In order to put the project into context, it is important to briefly describe the pathway for

stroke patients within the NHS in Cornwall. The length of stay on the Lanyon Ward is

obviously a key factor in terms of the quantity and quality of interaction with each patient that

could be achieved by the artist practitioners.

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The first destination for stroke victims in Cornwall is the Accident and Emergency

Department at Treliske Hospital, Truro, although a minority may attend Derriford Hospital,

Plymouth, which is geographically closer to locations in the east of the county. Stroke

patients at Treliske are initially admitted to the Phoenix Ward at Treliske for a period of up to

seven days, before being transferred to Lanyon. The initial NHS guidance for this

intermediate care suggested a stay of no more than 21 days. At one point this 21-day

guideline was strictly enforced, with financial penalties in force for non-compliance, but

recently there has been a greater degree of flexibility in the interests of patient needs and

personal circumstances. An early difficulty was the requirement of the Stroke Strategy to

establish discharge support teams to ease the journey of patients back into the community –

where these were not in place, discharge from Lanyon was delayed. In addition, the

imminent introduction of a second stroke rehabilitation unit in Cornwall (Bodmin) should

result in reduced demand for beds and consequently more efficient management of patients.

At the time of the initial evaluation visit in August 2010, the basic ward layout allowed for

nine male patients and 12 female, although as with all aspects of ward management, there is

room for flexible manoeuvre according to demand. The initial assessment of patients is

conducted using standard outcome measures – occasionally at this stage patients are

identified as have no potential for rehabilitation and transferred to other appropriate care

facilities. Inevitably there is an enormous range of severity and nature of stroke, and the age

profile of the patients is also wide – it was repeatedly emphasised in the evaluation

interviews how stroke affects those in younger age groups more than is generally perceived.

Severity of condition and age were two particularly important variables to be tackled by the

artists on their ward visits, as well as the relatively high turnover of patients.

Staffing on the ward consists of 13 nursing staff, 22 healthcare assistants and four

Rehabilitation Support Workers. Specialist workers include a number of physiotherapists,

occupational therapists, speech and language therapists and their assistants.

1.5 Literature Search

A search of the literature was made in an attempt to identify similar artistic interventions to

those being undertaken in Cornwall. The search revealed that there is very little evidence

regarding this form of support conducted within inpatient rehabilitation, apart from isolated

studies looking particular effects on cognitive function following interventions such as

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listening to music (e.g. Sarkomo et al., 2008). However a couple of relevant examples of

artistic activity in stroke rehabilitation emerged from the UK and these are described below:

1.5.1 ST/ART programme, Scotland

The ST/ART (Stroke and Art) programme was run by Tayside Healthcare Trust between

2003 and 2007, financed by the Big Lottery Fund. Art practitioners worked with patients on

rehabilitation wards and in the community (as was the case in Cornwall) as well as in acute

settings. Delivery was jointly organised through voluntary groups and local Arts and

Education providers. The aspect of the project which closely matched the work in Cornwall

was the inpatient rehabilitation strand, delivered in three Scottish regions between 2004 and

2006. Projects in five different settings delivered outcomes of artworks for display on the

wards. The art practice concentrated on painting, drawing and collage (as did the work with

community groups, which also extended to use of ceramics), a narrower range of disciplines

than the project under review in Cornwall, which also incorporated dance, movement and

creative writing. Although no formal evaluation report was available for the ST/ART project,

further information and examples of work produced can be found on the project website

http://www.heartstroketayside.org.uk/default.aspx?navigationid=391.

1.5.2 Healing Arts, Isle of Wight

Healing Arts, a department of the Isle of Wight NHS Primary Care Trust, was funded by HM

Treasury’s Invest to Save Budget initiative to research the impact of art projects in three

patient groups: families and children (for the prevention of obesity); adults with moderate

mental health needs; and stroke patients and carers at the Stroke Unit at St Mary’s Hospital

in Newport. At the time of writing, the design of a website to report the findings has not been

finalised, but the Director of Healing Arts, Guy Eades, generously shared the report (Matrix

Insight, 2010) with the evaluator in advance of ‘official’ publication.

The principal aim of the third strand of the research project, named Time Being Stroke

(TBS), was to „explore patients‟ experiences of stroke and hospital stay and their perceptions

of the meaning and value of taking part in TBS during a hospital stay.‟ (p12) The art forms

available exactly matched those offered in the Cornwall project, and many of the conclusions

bear a striking similarity to those arising from this report. Here are some examples of what

was found:

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Artists … rose to numerous challenges that the work required of them, with conviction and

sensitivity, adapting and changing their approach according to need. (p16)

… whilst the project was a time limited research project, the work to embed the programme

on the Stroke Unit was undertaken effectively, and with a view to sustainability. (p16)

The most common areas of benefit for patients … were:

• pleasure / enjoyment;

• a sense of connectedness (with the artist / others);

• mental stimulation / learning / being creative;

• engagement in purposeful occupation and relief from boredom; and

• reconnection with self / life. (p17)

A cost/benefit analysis was also conducted, and the results suggested that to break even,

the programme would need to reduce the average stay per patient by 4.4 days (p18).

However on the St Mary’s Stroke Unit, average patient stays were 96 days (p18). This is

well in excess of the Lanyon Ward and clearly reflects a different model of care.

2. Project Aims and Objectives

The aims of the Arts for Health Stroke Rehabilitation programme were set out in the

evaluation brief issued in May 2010 by AFHC:

This programme will provide opportunities for people undertaking Cornwall‟s NHS stroke

rehabilitation programme to engage in a range of different art-based interventions with the

specific purpose of improving their health. The interventions will address the physical,

mental, social and emotional health and well-being of patients. It will include reinventing

past skills, building confidence, personal value and self-esteem as well as providing the

opportunities for patients to learn new skills.

Throughout the programme the staff will be informed and trained to appropriate levels in

order to ensure that patients receive the maximum benefits from the interventions and to

ensure that the programme is cost effective and sustainable in the longer term.

The programme will be based upon the available research as well as the learning and

experience gained from the activities already provided by Arts for Health Cornwall to support

the SAGE programme. It will also provide the basis of a self-guided rehabilitation

programme which will be developed.

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There will also be activities provided as part of each SAGE programme which will link to the

sessions undertaken on the Stroke Rehabilitation Wards. This will act as a reminder to

patients and their carers of what they have learned to date as well as providing a signpost to

similar community activities that patients can access in the longer term. This may be linked

to a GP referral scheme.

AFHC will recruit experienced creative practitioners, who are able to facilitate creative

endeavour in people with long-term and restrictive health conditions and who can impart

information and skills in a way which is easily understood and assimilated by patients and

staff. AFHC will provide ongoing project management and support and supervision to the

practitioners involved. (AFHC, 2010b)

The aims of this evaluation reflect the priorities of the programme:

Evaluate how successful the project has been in achieving its intended outcomes;

Evaluate and review the management of the project;

Evaluate the experiences of the creative practitioners, staff on the stroke unit,

patients and their relatives/carers;

Make recommendations for the future (AFHC, 2010b)

The ‘intended outcomes’ referred to above in the first of these aims are as follows:

People who have suffered from a stroke will attain and maintain the best health and

independence possible through meaningful creative activities as part of the NHS

stroke rehabilitation programme. Best health refers to physical, mental and emotional

health.

Staff and patients will be better informed as to the benefits of particular creative

activities, and will have developed the necessary skills, knowledge and confidence in

order to ensure the programme and its benefits are sustained.

Continued improvements to the programmes will be applied on the basis of the

evaluation of the activities undertaken.

These aims and outcomes will be referred to again in the conclusion to this report in order to

assist the reader in interpreting the evaluation findings.

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3. Methods

Qualitative methods were used to reflect the experiences of those involved in the Stroke

Rehabilitation project, namely:

Interviews with the artist practitioners involved in delivery;

Interviews with Rehabilitation Support Workers and others involved with day-to-day

care on the Lanyon Ward;

Attendance at artists meetings, and regular discussions with the Project Manager at

AFHC.

An important source of data was an online forum set up by AFHC to enable the artists and

project manager to communicate on a regular basis regarding the progress of the project, as

well as to reflect upon and evaluate individual sessions and patient interaction. Once they

had become familiar with the technology, all of the artists were fully involved on the forum,

and their comments were invaluable in terms of this evaluation, particularly as the

immediacy of the comments after each ward session allow the reader to build up a

chronological ‘story’ of how the project proceeded over the twelve months. Although the

number of forum posts made by each artist does not alone illustrate the depth of the project

record, it is relevant to record that each of the eight artists posted to the forum at least 32

times, with the overall range being between 32 and 81. In an important sense, therefore, the

artists can be said to have written much of this evaluation themselves, although this report

will hopefully serve the purpose of organising those thoughts into a coherent whole,

incorporating the opinions of other interested parties, particularly NHS staff, and assisting in

the interpretation of the observed outcomes.

Photographs of the artwork produced by patients were posted regularly on the online forum,

and examples can be found throughout this report.

Ideally, direct reflections from patients would have added a further dimension to this

evaluation. However, because of the lengthy procedures required to obtain ethical approval

for interviewing NHS patients, it was decided at an early stage that patient interviews would

not be pursued. However, it will be seen that the reflections of the artistic practitioners and

ward staff give important insight into patient response. For similar reasons, no photographs

of individual patients have been used in this report.

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4. Structure of the Project

The initiative for the Arts and Stroke Rehabilitation Project came from liaison between AFHC

and the NHS Regional Stroke Nurse Consultant, who saw the need and potential value of

artistic activity being introduced at the intermediate stage of stroke recovery already

described. AFHC have experience in assembling teams of artists to work in health settings,

and over the years have built up a lengthy directory of contacts. The following eight artists

were employed:

Lollie Brewer – craft and visual arts

Jayne Devlin – dance and movement

Sue Field – craft, particularly textiles

Victoria Field – creative writing

Rosie Hadden – craft and visual arts

Caroline Schanche – dance and movement

Megan Selby – creative expressive therapy and sound healing

Angela Stoner – creative writing

The common characteristic of the artists chosen to undertake the project was their

experience in health settings – most had worked for AFHC on other projects including Arts

for Health in Primary Care and with Older People. Some, but not all, had experience of

previous work with stroke patients, and if not had worked extensively with patients with

mental health conditions and dementia. Most of the artists had not previously met the NHS

staff working on the Lanyon Ward, although the four RSWs had undertaken the six-week

Creative Care course for NHS staff and those facilitating artistic activity in care homes, which

was run by Caroline Schanche and her colleague Noel Perkins.

It is important to describe the basic structure of the artist visits as this had an important

bearing on how the project progressed. Essentially each artist was timetabled into ‘blocks’

of visits over a concentrated period of a few weeks, returning to the project later, in some

cases after a number of months. Typically, then, an artist would visit for up to three sessions

over consecutive weeks, so in some circumstances the same patient would be seen more

than once by the same artist, although this depended on the speed of patient turnover. For

the first five months of the project there were artist visits on three separate occasions each

week. This frequency was reduced to twice a week later, as the RSWs became more

involved with delivery of activities. The original modus operandi of the project did not include

joint delivery by the artists, although as the months progressed some artists did attend

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together, often for the purposes of observation and feedback on one another’s practice.

Largely as a result of the online communication, themes were developed between artists

specialising in similar disciplines to improve the continuity of the activities. Additionally,

individual patient information was shared on the forum over the period of the stay on the

ward.

The findings section will include further observations on the structure of the project delivery

and the impact that this had on those involved, but clearly the most important place to begin

is to examine what impact the various artistic activities had on the patients themselves.

5. Findings

5.1 Patient Impact

I had my second session this morning with three new patients who were all quite elderly and

frail but all keen to have a go. As soon as I put the music on they started to respond to the

rhythm, smiling and engaging with the movement. I like to see what movements are being

offered and follow these. I then usually suggest ways to extend or expand the movement

building on what is already happening. After focusing on rhythm and stretching everyone

chose a sheet of brightly coloured tissue paper. We played with swirling it, blowing and

catching it. We then tore it into long strips which gave it a different movement quality to play

with and threw it onto white paper which I had placed on the floor. Everyone enjoyed

dancing with the paper and because their focus was on the paper they all used a wider

range of movements, particularly in the upper body. Tearing the paper required fine motor

coordination and the most frail member of the group particularly enjoyed this action. Donna

(RSW) was delighted because this lady forgets to use her left side and although it is

noticeably weaker she was using it as much as her right side. After so much movement we

looked at the way the tissue paper had landed on the white paper and talked briefly about

what the patterns and colours suggested, e.g. seaweed and flowers. We finished the session

with gentle hand massage and relaxation. (Caroline Schanche, June 2010)

This lengthy quote serves as a useful introduction to the findings of the report, as it captures

the essence of what was taking place at the ward sessions. It is important to remember that

by and large the artists were arriving at the sessions ‘cold’ in that they had little or no

knowledge of the individual patients that they would encounter on a particular day, although

it should be said that the RSWs did their best to prepare patients for the visits, and

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depending on circumstances were able to speak to the artists beforehand – this process of

session preparation improved as the project progressed.

In terms of physical responses, improvements could often be very minor – a blinking of an

eye, small movement in affected limbs etc. However to the health professionals these small

indicators were signs that the activities were having an extremely positive effect on patients

who had not otherwise been as responsive to other forms of therapy. The examples given

below have been selected reasonably randomly, but in each case the description of the

encounter gives an important flavour of the way in which the artist and patient were able to

communicate with one another, often on a first meeting.

____ (who I've met 3 times now), improves week by week. She had improved movement

range in her strong side but her affected side is unmoving without herself, or someone else,

mobilising it. However, she incorporated her torso successfully, and leant forward and back

in her chair completely unaided. She also found her mid-line successfully, and managed to

draw an imaginary line down the middle of her body.

This week she seemed as though she really wanted her effected side/arm to move and

spent a lot of time trying to move it with her good hand. I could see it was hard work for her,

and I was deeply moved by this. She is displaying so much courage and determination and

dignity. (Jayne Devlin, July 2010)

The RSWs were often pleasantly surprised when patients who had shown little sign of

progress suddenly responded to, for example, a movement exercise. In this respect, the

breathing and voice work led by Megan Selby was singled out by the NHS staff and the

other artists as frequently having an extraordinary impact, both physically and emotionally.

This description of one of Megan’s sessions is typical of the patient experience:

____ really engaged and seemed to relax, in fact it did seem he dropped off for a wee while

as when I said I'd be making a sound and he was welcome to join in there was no response,

so I continued. Still no response and even someone coming in and making a bit of a noise

he remained head drooped and eyes closed. This is quite an amazing space to be in as the

sounds are very healing and there‟s something very special about the space after this

occurrence.

So when he came to it felt like I was relating to him on a deeper more intimate level. We

spoke for a long while which was very moving as I only understood some of the words he

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used. We then sounded and moved together, again very moving. He seemed so present

with me though distant in his own world too. We spoke a while longer and then I left so I

could catch Fiona, Bev or Lizzie (RSWs). I spoke to L and she was keen to come and

shadow me with ____ this week.

I came out with that extraordinary feeling of 'something profound happened in there' but it‟s

hard to language it. (Megan Selby, October 2010)

An ongoing issue for both artists and NHS professionals was whether to engage with

patients together in a group or at a one-to-one level. Because of the degree of severity

evident amongst patients, it was often seen that individual contact was more appropriate, for

example with the breathing and voice exercises discussed above. However some of the

craft activities leant themselves towards patients working together – the RSWs observed that

with segregated wards now being the norm, this presented a rare opportunity for the male

and female patients to mix in a controlled and relaxed environment.

An example of the craft work undertaken was silk painting, led by Sue Field. Her reflective

notes capture the ward environment and the flexibility that was required in meeting the wide

range of patient needs:

Got a couple of frames for silk painting, enables people to work one handed, fixed them on

peoples own bed tables as work space. They were really good, can be adjusted to the right

height, possibilities for hand sewing too.

Did 1 to 1

____ said she'd give it a go - a better day for her today she did a silk hand for the banner

and enjoyed it. I think people have good days and bad days, not related to us and our

activity, important for us not to take things personally. ____ begged not to do art.... ____

didn‟t want to silk paint as she couldn‟t see much, so we made silk paper which she enjoyed

and her visitor was intrigued by. ____, aphasic and in bed in a side room - I needed to help

her a bit with the gutta, and there was no way she would draw a shape, her lines were like

her language, but she was very, very focussed on painting colour to the furthest edge of the

frame and enjoyed the experience, said 'thank you so much' at the end which was very

moving as her words were hard to come out. (Sue Field, June 2010)

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Example of silk painting (Sue Field)

Artist Rosie Hadden worked with a number of patients to produce banners incorporating

decorated ‘hands’:

I started work with ____ who seemed delighted to have something to do. We began to make

a banner and decided we would decorate it with everyone‟s hands around the outside and

have some words in the middle (poets please). ____ hand ended up with lots of red roses,

flowers and a dragonfly and some leaves. He worked very precisely and carefully and really

enjoyed making his choices about what to do. He is quite a humorous chap and seemed to

engage very readily with everyone around him. He was very pleased with the result of what

we had made and insisted on signing his name even though he struggled to write it with his

left hand. He also lifted his right hand up so I could draw around it as well. He was very

keen that his daughter would be able to see what he had done. (Rosie Hadden, June 2010)

Decorated hands (Rosie Hadden)

One important issue to address was finding activities that were appropriate for the male

patients – often craft can be seen as an activity that would appeal for to the women. In this

respect clock making was explored as something that would encourage the men. This

encounter was typical:

I began working with ____ who was in the day room practising doing up buttons. I

suggested we could do something more interesting to help refine his finer motor skills and

invited him to make a clock. He was quite keen and soon settled into painting a first primer

coat on his clock face. ____ had good use of both hands so I suggested that he find an

image to collage onto the clock face whilst the paint dried. He chose one of a horse and cut

19

it out first as a square image. I then suggested making it into a circular shape so he could

refine his cutting skills. He managed this fine and I was mindful of a previous comment that

cutting was perhaps asking too much of people. ____ then chose to paint a layer of red on

as a second coat as this was his favourite colour and he had been a postman. He glued and

stuck his image on and then had to leave to see visitors. He was very good company and

very positive about going home. His visitors had taken him out to the rose garden so I

ended up leaving his finished clock on the table by his bed for him. (Rosie Hadden,

September 2010)

Clock making – Rosie Hadden

Some of the most striking visual images from the project were produced from Lollie Brewer’s

work with patients using acrylic paint, producing bold colours on card. Masking tape created

a natural ‘frame’ which was removed after painting. Here are three examples, together with

the artist’s notes:

____ was brought to the dayroom, and was keen to leap straight into the work. He did two

pictures one which he said one was summer (which was red) and he did this with his right

dominant side and the blue one he painted was called winter which he did with his left hand.

He was pleased with his results and signed it with pride too.

20

____ came later in the session and said that he used to paint a lot, so it was right up his

street, especially in 1963, because he couldn't go anywhere anyway because of the snow!

He also worked on two pieces, one with his non-dominant left side which he had learned to

use following his first stroke, then he did another piece with his right hand which was much

more difficult for him as it was quite contracted, but he was assisted by Fiona (RSW). She

helped support his fingers and he was thrilled with his results and also proudly signed his

finished piece.

____ has been a patient for a number of months now and has great difficulty with her vision

and some confusion although her dexterity does not appear to be that affected. She has

very poor concentration, but with encouragement will do tasks. Normally she gets upset or

angry and gives up quickly so her piece of work was something of a milestone for her. (Lollie

Brewer, February 2011)

Poetry and creative writing was something that AFHC incorporated into the project using two

specialist artists. Clearly this form of activity was designed to probe and activate the

21

emotional side of a stroke patient, often with quite unexpected results. Again the quotations

of the artists themselves have been used to illustrate how the use of the written word can

have a profound impact:

Probably the most successful group session I've had so far - but by luck probably - when I

arrived Fiona had assembled six ladies in their day room - but at first there was such a lot of

noise both in the room and outside, I nearly gave up after the first ten minutes.

Then - miracle - it fell quiet and we were able to work for a full hour. All the participants were

over 70 so I began by reading old classic poems which relaxed and engaged them.

The conversation naturally turned to beauty and things that moved them. I'd brought along a

pile of old glossy magazines like Cornish World and BBC Wildlife and invited them all to

choose an image they found beautiful and to cut or tear it out, then make a poem about it.

____ refused - even though she'd been joining in reciting the 'old favourites'. ____, who has

aphasia flicked through the magazine but didn't want to choose anything. ____ did and

wrote herself, ____ did and I scribed her words. ____ has a visual impairment so didn't

choose a picture but said she wanted to make a poem about a rainbow. ____ chose an

image of the Scillies and was still writing vigorously when we finished - even though at the

beginning she'd said clearly that she was up for listening but certainly wouldn't want to write.

The sharing led to lots of reminiscence and exchange and we only stopped because several

visitors arrived. (Victoria Field, June 2010)

A recurring issue that arose in respect of the creative writing activities, apart from the

physical restrictions in putting pen to paper, was the stirring of emotions for patients who

were already in a fragile state following their stroke – many stroke patients also show

symptoms of depression arising from their condition. There was a realisation as the project

progressed that engaging vulnerable patients in such activity could potentially be upsetting,

although the NHS staff stressed that the two artists involved did all that they could in the

circumstances presented to them, and the utmost empathy was shown to the patients at all

times. The simple act of reading to patients was agreed by all to be a suitable activity for

many, and it appeared that the engagement with poetry worked best with the older age

group. The responses by patients at Lanyon Ward typically contrasted with the experience

at the SAGE groups (see Section 5.3) where it was found that the patients were at a stage in

22

their recovery that allowed them to show much more of a positive responsive to the emotions

that arise from exposure to the written word.

5.2 Practical Issues

From a practical and administrative viewpoint, the project was a challenge to develop,

requiring liaison between the project manager at AFHC, the NHS managers and staff at

Lanyon and the eight artist practitioners. Inevitably for a pilot project of this kind, many

lessons were learnt as the year progressed, and there was general agreement that the

communication between artists and ward staff improved as the working practices developed.

This was evident from the forum postings regarding arrangements for artist visits, where the

comments ranged from (at worst) frustration and despair to positive comments on the way in

which the artists were welcomed as familiar faces, particularly as the operating methods

became more established.

The demands that the NHS makes on its staff in a busy environment were a constant factor

throughout the period of the project. In an ideal scenario, the RSWs would be in a position

to identify suitable patients to work with the artists scheduled for the day, brief the artists

about the condition of those patients, observe and contribute to the session and have time

for some reflection on the session afterwards. The reality was that this was rarely possible

in a busy and ever-changing environment, with a high turnover of beds and many other

demands on the time of the nursing and rehabilitation staff. In the early stages of the

project, the following was a typical example of how a visit might develop:

I rang the ward the day before to discuss the patients with a RSW and was told by the ward

clerk that they were with patients and I would have to leave a message. I said I wanted to

discuss the patients, but it was a sorry, no, there isn't anyone available. I said that I would

like to do more one to one, partly so that I wouldn't be bombarded with clients, which has

been the case.

I arrived on the ward at 1:40 and decided to look through the materials and see what there

was, rather than going over prepared. It took me forever...The cupboard, which is great, I

am not complaining, but it was rammed to the gunnels and totally user unfriendly. It really

needs a sort out and after being there until 4pm and a difficult session, that was the last

thing I wanted to do!

The RSW were too busy to speak to me when I first arrived, and it took some time to

23

establish where this new cupboard was and where I could work. I didn't get a chance to talk

through the clients. I explained that I was going to do something really simple, some tissue

paper collage so anyone working on their fine motor, or someone aphasic or emotional

would find it useful.

… I left around 4pm feeling glad that ____ had enjoyed her session, but overall, unfulfilled as

a creative practitioner. I don't feel valued by the ward, I feel that we are either not

understood, or in the way. I am there again next week...any suggestions for a better

approach would be greatly appreciated. (July 2010)

A number of other posts made at around the same time (around three months into the

project), echoed this theme. Gradually, however, lines of communication were more firmly

established and when the same artist returned to the ward after a gap of a few months,

many of these issues had been positively addressed. Here is a comment from the same

artist made later in the project, serving as evidence that all those involved were working hard

to help the practical aspects of the project to run more smoothly:

Today the ward was expecting me and finally it feels like we are beginning to establish

ourselves on the unit … I am really enjoying the sessions now, it really feels like the ward

has settled into itself and the routine of us coming. Today I had an OT, Physio and Denise

(ward manager) visiting who were thrilled with the process. (November 2010)

It should also be added that there was considerable improvement work going on in the ward

during the early stages of the Arts for Health project, which inevitably added to some of the

initial difficulties. The following is a list of a number of the minor practical issues that arose

at some point during the year. Most were resolved by discussion with the ward staff and

management.

Display of work;

Storage space for art materials;

Distractions to the sessions (TV, visitors etc.). The presence of visitors was

generally positive, particularly where there was encouragement for the activity in

hand, although there were other examples where the patient was distracted and the

activity was discontinued;

Procedures for recording of artistic activity in the patient record;

Health and safety/infection issues concerning artistic materials.

24

For the most part, a suitable space was made available away from counter-distractions for

group activity. The artists, all of whom were familiar with self-evaluation techniques, were

disappointed that there was rarely time to debrief their sessions with the RSWs, which they

felt would help to embed the techniques used and reinforce the work for the future. There

was general agreement that this was simply down to the demands on the time of the staff

rather than any lack of enthusiasm for the project.

Generally there was enthusiasm from the NHS staff for the project, particularly as it

progressed and the relationship between the artists and ward staff grew. In particular the

RSWs had nothing but praise for the way in which the artists adapted to the changing

environment of the ward. The RSWs recognised that there was potential for these activities

to be employed alongside the well-established therapies to improve the patient experience

and to make a contribution to recovery.

5.3 SAGE sessions

As previously indicated, SAGE groups are set up in communities around Cornwall for those

stroke patients who have been discharged from hospital. Groups supported by this project

included those in St Austell and Falmouth. Some of the artists who worked at Lanyon Ward

also had the opportunity to work with these groups, adapting the activities for those further

along the path to recovery. Without exception, the sessions were found to be rewarding

from the point of view of the artist practitioners. A good example is that of creative writing,

which was difficult to introduce to many Lanyon patients for the reasons outlined earlier in

this report. Given the improved physical and emotional stability of the SAGE patients, there

was potential to make good progress in a welcoming environment:

The group were warm and friendly, and all couples, where one partner had had a stroke.

____ and ____ were there (the couple who came in to our training day) and ____. So I felt

quite welcomed and at home. Interestingly ____ said he could remember poems from

childhood word for word, and in his piece of writing he connected past present and future.

We simply made a list of things we'd seen, heard and felt that day, and also a couple of

tastes and smells from childhood. I asked people to choose one thing from their list and to

begin writing. I gave people five minutes.

In this group, none of the stroke patients needed help with scribing, although there was

25

some grumbling but their partners told them they could manage (and they did!)

Everyone wrote, carers, therapists, patients and myself. All but one shared their work with

the group.

It was amazing how the energy in the room lifted, and how far people journeyed in a few

minutes, and the variety of ideas, images and writing people produced. One woman said it

felt as though the room had become the world.

I pointed out that they had at least a dozen other things they could write about.

There was only time to read out one poem ... I read out Beannacht, but I gave people copies

of Snowdrops as well. I also gave out a few ideas on how to continue this process at home.

There was a real buzz in the air and a feeling of hope.

… afterwards, I confided [with group organisers] how difficult it has felt on the ward. They

both realised that the kind of work I did this afternoon would be impossible in that context.

(Angela Stoner, May 2010)

The final comment confirms the general view of all concerned that, particularly in this

discipline, there are activities that can be of greater benefit to those patients in later stages

of recovery.

Space does not permit the inclusion of lengthy examples of the poetry created both at

Lanyon Ward and at the SAGE groups, but the brief excerpt below is typical of the

imaginative writing that arose from the work with the two specialists:

Everything Lives

in response to Mary Oliver’s ‘Fall Song’

I like the word „vines‟ – it conjures up a picture

its particular leaf, a particular tree, its fruit –

you can cook them and eat them and drink them –

wine from the vine ...

26

Uneaten fruits, crumbling in the damp –

they‟ll all get eaten by birds or insects, even slugs.

My Grandad Sutcliffe had a prize-winning tree,

laden with apples but the family could have only the windfalls –

gnawed at by animals, full of peck-holes

My neighbour gave me a bag full – alive with maggots,

I tipped them all out into the garden.

„Just cut out the bad bits,‟ he used to say – then make

stewed apple, apple crumble, stuff for the freezer...

Roots and sealed seeds, wanderings of water –

the flare of autumn reminds me of bonfire night,

terrible for animals and people too – cats and dogs,

cows and sheep, horses in the fields.

From one bright vision to another –

wouldn‟t it be nice if life were like that?

There‟s no peace in the world -

except in the garden.. I‟m nearer to God in my garden

than anywhere else on earth. (Falmouth SAGE Session, November 2010, scribed by Victoria

Field)

6. Conclusions

The conclusions follow the original aims of the project evaluation as set out in Section 2:

Evaluate how successful the project has been in achieving its intended outcomes, namely;

People who have suffered from a stroke will attain and maintain the best health and

independence possible through meaningful creative activities as part of the NHS

stroke rehabilitation programme. Best health refers to physical, mental and emotional

health.

Staff and patients will be better informed as to the benefits of particular creative

activities, and will have developed the necessary skills, knowledge and confidence in

order to ensure the programme and its benefits are sustained.

27

Continued improvements to the programmes will be applied on the basis of the

evaluation of the activities undertaken.

It goes almost without saying that a project such as this will stand or fall on the skills,

adaptability and professionalism of the artist practitioners, and that the success or failure of

the project aims relies greatly on the way in which these practitioners can adapt their skills to

confront the many and varied challenges that each situation presents. What can be said is

that without doubt all of the artists employed on this project provided a professional,

sympathetic and considerate approach to the patients, and there are many examples from

those who were interviewed of genuine improvement in physical, mental and emotional

facilities as a direct result of the artistic interventions. ‘Flexibility’ was a term that came up

repeatedly when discussing the sessions, and it is important to emphasise again how

adaptable the artists were to the variety of circumstances that they encountered.

As previously discussed, one of the issues that emerged over the period of the project was

that the activities associated with creative writing were not always appropriate for stroke

patients who had experienced enormous emotional upheaval. This was recognised by the

relevant practitioners, and after discussions with the project manager these activities were

concentrated towards the SAGE community groups, where exploration of the written word

was found to have great merit.

Generally the NHS staff responded positively to the artistic activities on the ward, offering

support and showing keen interest. In particular the four RSWs showed particular

enthusiasm, and would like some kind of artistic activity to be continued following the

conclusion of the funded project. Much of the interview discussions centred on what form

this further activity might take – clearly the kind of work that might be contemplated depends

largely on whether or not there are professional artists present. The skills of the RSWs have

been improved as a result of their observation of the artists and their participation in the

patient interaction. However they are not professional artists themselves and the level of

activity that might be considered moving forward will depend on the following factors:

The skills and abilities of the RSWs;

Whether or not there will be continued input from a lead artist or groups of artists;

The enthusiasm of the NHS, both locally and at a wider level, for arts and health work

with intermediate stroke patients. The work will not thrive unless there is an

established culture of artistic activity on the ward, properly timetabled and

28

incorporated within the work schedules of responsible staff (generally the RSWs).

There also needs to be demonstrable support from the higher echelons of NHS

management to reinforce the activity on the ward.

The evidence indicated that the RSWs had developed skills to allow them to continue the

artistic activities introduced during the period of the project, and perhaps more importantly in

their reflective interviews they communicated excitement and enthusiasm regarding what

could be achieved through this additional dimension of patient interaction. Towards the end

of the formal project he artists were involved in the preparation of a ‘toolkit’ of suggested

activities that could be picked up by the RSWs afterwards. Naturally there will be a turnover

of staff at some point in the future on the Lanyon Ward, and with it the possibility that the

early enthusiasm for arts and health work will be diluted without anyone to act in a

leadership position to guide the ongoing activities. For this reason many of those

interviewed felt that a lead artist should be appointed to the ward, to add continuity to the

work and to act as a guide and trainer to those RSWs and others who interact with stroke

patients. Clearly this introduces a financial consideration which would be a matter for

consideration by the NHS funders.

Another idea to improve the service to patients was that a monthly ‘activity day’ should be

arranged on the ward, when discharged patients would be invited back to renew their

acquaintance with the ward staff and to share in some form of artistic activity. This would be

of particular benefit to those patients who for various reasons have not joined a SAGE group

following discharge. The event would present a further opportunity for staff to become

involved in the arts activities, and could also involve current patients if appropriate. It was

suggested that a nominal fee might be charged for attendance which would cover the cost of

materials.

Evaluate and review the management of the project

In general terms the project was managed efficiently, with any points of difficulty being

handled by the AFHC Project Manager through regular contact with the ward staff, or

through local discussions. The co-operation between those involved was good, with

communications between the artists and the ward staff improving as the project developed.

The artists expressed some reservations concerning the overall structure of the project. The

concerns generally related to the number of artists employed, the structure of the visits and

the leadership and co-ordination of the activity. Some artists felt that the existence of a lead

29

artist on the ward would have added continuity to the scheme as a whole and particularly to

the communication and liaison with ward staff. One model referred to was that used on the

Artists in Primary Care project, where a single artist was allocated to a General Practice to

coordinate activity with patients and staff. Similarly, some felt that eight artists was too high

a number to be involved, as there was an inevitable break in continuity between the ‘blocks’

of sessions. On the other hand, the selection of eight artists did allow the project to explore

a wider range of artistic disciplines that would otherwise have been possible.

Evaluate the experiences of the creative practitioners, staff on the stroke unit, patients and

their relatives/carers

In summary, the experiences of all of the parties involved were overwhelmingly positive.

The project was generally received with enthusiasm, practical difficulties were resolved in a

professional and co-operative manner and there were numerous examples of patients

benefitting in a host of ways, from improvement in physical control, heightened cognitive

function, improved mood and positive outlook. Although this was not a formal clinical

research project and not designed as such, the wealth of qualitative data assembled from

the key players suggests that the overall experience was of significant value to the

recovering patients, and of relevance to them as they continued their progress into the

community.

The SAGE groups were recognised as a particular help to those stroke victims further down

the road of recovery, and there was a general recognition that there were enormous social

and practical benefits of bringing these groups together. At present the pattern of SAGE

groups across Cornwall is patchy, and it is hoped that resources can be brought to bear to

widen this work into all major centres in the county.

Make recommendations for the future

A number of recommendations flow naturally from the data recording the experiences of

artists, management, staff and the patients themselves. Clearly any recommendation that

involves further input from outside of the NHS will involve financial considerations. It is

hoped that the value of the artistic activity, and the benefits that have accrued for patients,

together with their families and carers, can be translated into further funding to support both

the Lanyon Ward and elsewhere, where patients at the intermediate stage in their stroke

recovery can benefit from exposure to art, craft, dance and movement as a way of beginning

to recover lost or forgotten skills.

30

The following are therefore offered as points for further discussion:

If a similar project is planned, consider the appointment of a lead artist who would be

in residence for the life of the project. Such an individual would be responsible for

training NHS staff, would act as a point of liaison between artists, staff and

management and would generally be a central point of contact for all aspects of the

project affecting the ward.

Consider further training for NHS staff, particularly those on the front line of patient

contact, along the lines of the Creative Care course run previously by AFHC.

Proliferation of such training would help to embed artistic activity as part of standard

care, rather than as an add-on when circumstances permit.

Expand where possible the SAGE groups for those recovering from stroke, and

incorporate artistic activity at every opportunity. It is recognised that the creative

writing activities have particular benefit at this stage of the recovery journey.

Consider follow-up activities on the ward for discharged patients to maintain the link

with ward staff. One suggested option was a monthly drop-in session involving some

kind of artistic activity.

There were notable similarities between the Lanyon Ward project and the Healing

Arts project on the Isle of Wight. It is suggested that there be some liaison between

the two projects to examine and compare practice and experiences – the first step,

perhaps, towards a wider community of practice for those artists working with stroke

patients.

This evaluation did not extend to examining the cost-effectiveness of the project in

terms, for example, of balancing shorter hospital stays and reduced reliance on the

care system following discharge against the additional costs and time involved in

expanding the arts and health activities. The Healing Arts research offers some

pointers on how these issues might be approached in a further research project.

In conclusion we offer our sincere thanks to all of those artists, ward staff and management

who readily gave of their time to relate their experiences for the purposes of this evaluation.

31

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AFHC (Arts for Health Cornwall) (2010a) Website home page. [Accessed 20th October

at www.artsforhealthcornwall.org.uk]

AFHC (Arts for Health Cornwall) (2010b) Arts and Stroke Rehabilitation Project

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SWSHA (South West Strategic Health Authority), 2010. Clinical Review of Stroke Services

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Sarkomo T, Tervaniemi M, Laitinen S, Forsblom A, Soinila S, Mikkonen M, Autti T,

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