Facilitating Imagine Arts in residential care homes: the artists’ perspectives

Abstract Introduction: This study explores factors affecting the successful facilitation of a residential arts programme. The aim was to identify barriers and describe how they could be overcome, this was both formative, to help shape the programme, and summative, to inform best practice and future arts interventions. Methods: An exploratory qualitative design examined the views of the artists administering the arts programme. Results: Data were analysed using thematic analysis. Four main themes were identified; contextual factors, perceiving and responding to needs, facilitating relationships and building confidence. Conclusion: Findings provide insight into practical aspects of facilitating arts programmes in residential care. Some of the identified barriers may have simple solutions which can easily be incorporated into everyday best practice. This research provides a start for understanding the role of artists within care homes and how they aid the implementation and integration of arts programmes into the care of people with dementia.


Introduction
National Institute for Health and Care Excellence (NICE) guidelines (2013) stipulate that meaningful activity should be provided in care homes; residents should be provided with support to engage in activities in line with their abilities and preferences. Literature suggests that creative arts activities have benefits for people living with dementia, including improved attention, stimulating memory and enhancing communication and engagement (Rylatt, 2012;Young, Camic, & Tischler, 2015). Activities including dance (Guzmán-García, Mukaetova-Ladinksa, & James, 2012), visual art (Camic, Tischler, & Pearman, 2014), music and singing (Osman, Tischler, & Schneider, 2014;Wigram, Nygaard Pedersen, & Ole Blonde, 2002) have all demonstrated positive effects. Despite the benefits of creative arts, care homes often lack the provision of stimulating activity (Hancock, Woods, Challis, & Orrell, 2006); staff have limited time and opportunity to devote to providing social and emotional assistance to residents (Schneider, 1997).
Dementia is characterised by an impairment of cognitive functioning, involving a decline in mental, behaviour and emotional functioning (Burns & Iliffe, 2009). One in three people over the age of 65 in the United Kingdom will develop dementia; this number is expected to double in the next 40 years (Alzheimer's Society's, 2014). A report conducted by Luengo-Fernandez, Leal, and Gray (2010) estimates that 37% of all persons with dementia are living in long-term care facilities at an annual cost of £9 billion. One study estimated a prevalence rate of 75% for dementia in South East London care homes (Stewart et al., 2014).
Recent reviews have evaluated visual arts and cultural opportunities as psychosocial interventions for persons with dementia (Beard, 2011). There have been suggestions that participation in creative activities later in life cultivates successful ageing by promoting purpose, meaningfulness and hope for the future (Fischer & Sprecht, 1999). Participation includes art appreciation through visits to galleries as well as active involvement in creative activities. Studies have used a range of outcomes to investigate the effects of "viewing and making", on older people in residential care in general. A longitudinal study found that attendance in a professionally led participatory arts programme improved ratings of physical health, morale and decreased loneliness in older adults (Cohen et al., 2006). Evaluations of visual arts programmes have evidenced increased social interaction, pleasure and self-esteem both for older adults in general and for those with a diagnosis of dementia (Kinney & Rentz, 2005;Wikström, 2002). A study of art appreciation discovered that participants with dementia respond to art according to their aesthetic preference, in the same manner as age-matched control subjects without this disorder, this demonstrates that aesthetic preference may be sustained despite cognitive decline in people living with Alzheimer's Disease (Halpern, Ly, Elkin-Frankston, & O'Connor, 2008). In an exploratory study conducted by Ullán et al. (2012) individuals diagnosed with mild (n = 13) and moderate (n = 8) dementia found, through participant observation, that dementia presented no impediment to participation in an artistic educational programme. Moreover, it proved a positive self-reported experience for individuals with dementia.
In Nottingham, UK, the Arts Council England and the Baring Foundation have funded four independent national programmes, each with the theme of Arts and Older People in Care. One of the programmes, Imagine Arts, is managed in collaboration between a national care home provider, a local arts organisation and the city council, as well as local arts providers. It is a three year project with the aim of encouraging partnerships between care providers and arts organisations whose purpose is to give residents access to creative and cultural experiences. This exploratory service evaluation comes midway into the three year programme which concludes in 2017. This evaluation does not compare the different kinds of arts activities delivered through Imagine Arts, which have previously been addressed in literature (Beard, 2011), but to scrutinise features in common which facilitate and impede the successful delivery of such activities. The analysis surrounding these features can then be used to inform future research and moreover the implementations of future arts interventions within care home settings and populations with dementia.

Methods
We wanted to understand the process; investigate factors affecting the successful facilitation of an arts programme in a care home setting, identify barriers and how they can be overcome. An exploratory, qualitative design was chosen to examine the views of the artists participating in the arts programme; thematic analysis was employed to examine diary sheets completed by the artists. The purpose of the study was both formative, to help shape the Imagine Arts programme, and summative, to inform best practice and future arts interventions.

Informants and context
The sample for the study consisted of 32 artists who had been commissioned by the Imagine Arts programme to provide a programme of arts within the 14 care homes participating in the first year of the Imagine Arts project. The aim of the programme was to introduce arts practice that challenges, engages, stimulates and enables older people in residential care settings to have access to rich cultural offers. These were mainly local arts practitioners and arts venues such as museums and galleries who, in response to an invitation from the programme, offered a range of workshops tailored to the needs of care home residents, including those living with dementia. The practitioners received dementia-specific training, including the use of non-verbal communication with people with dementia, at the start of the study and were supported and advised throughout by the programme implementation lead from the local arts organisation. As this was a service evaluation, formal ethical approval was not required (Daykin & Joss, 2016) however all identifying information was anonymised to ensure the privacy of the participants.

Procedure
Diaries are becoming increasingly utilised as a tool to explore ongoing experiences; particularly the context of daily life occurrences (Bolger, Davis, & Rafaeli, 2003;Travers, 2011). As part of the Imagine Arts service evaluation, artists were asked to complete reflective diary sheets documenting what took place and asked to reflect on the following aspects: • Positive aspects of the session and what went well • Social reception -how the residents received the session as a group, with particular focus on social engagement, communication and interaction • Problems/difficulties encountered during the session • Areas for improvement/what could have been done better or differently • Skills gained as a result of leading/attending the session • Any other comments

Method of analysis
This study was both exploratory and descriptive. The feedback sheets were evaluated using a flexible qualitative methodology, thematic analysis, to give a detailed but complex account of the data (Braun & Clarke, 2006). An inductive approach was chosen so that the themes were derived directly from the data rather than through the researcher's presumptions or through the structure of the prompts on the diary sheet.
Using recommendations from Braun and Clarke (2006) the following process was utilised. The researcher familiarised herself with the collected data. This process involved repeated reading in an active fashion to gain a thorough understanding of the data. Next the researcher generated initial codes by working systematically through the data-set. The researcher coded the data fully, and analysed it inductively identifying recurrent themes. The coded data was then analysed for themes. A mind map was used to organise the themes and identify the main and sub-themes; themes were then reviewed with other researchers and refined. The entire data-set was re-read to ensure that the themes fitted with the data and to identify any data which may have been mis-coded. Next, the themes were defined and relevant coded data was extracted to illustrate the aspects captured within each theme. Finally the report was drafted. This involved selecting extracts of data which encapsulated each theme, and providing a comprehensible, analytic narrative explaining the rationale behind it. The report was shown to the artists, inviting them to confirm or disagree with the inferences drawn; a process of validation.

Results
A total of 21 reflective diary sheets (n = 21) were collected for six different kinds of art-form activities. The type of activities varied greatly and included: a programme of digital arts workshops delivered in partnership with company WeEngage utilising free digital arts applications (n = 5). Heritage and textile sessions where participants viewed and produced lace work (n = 6). Bespoke drama and musical performances of well-known stories were delivered by arts venues in care settings (n = 7). Working in partnership with the University of Nottingham's Mixed Reality Lab, creative workshops inspired from the work of Joseph Cornell utilised pre-made boxes to explore digital technologies and cultural activities (n = 2). Lastly, a film commission produced and showcased within care settings (n = 1).
Thematic analysis led to the identification of four main themes from the artists' feedback sheets; "contextual factors", "perceiving and responding to needs", "facilitating relationships" and "building confidence". The remaining themes refer to the content and context of the individual project strands and the way in which art programmes can be successfully developed to address the interests and needs of populations living with dementia.

Contextual factors
The first theme refers to the practical aspects of facilitating an arts session and it had two subthemes: group size and physical location.

Group size
The first theme refers to the size of the groups and the way in which the arts facilitators expressed that it influenced the quality of the delivery and the engagement of the residents. The benefit of a high facilitator-to-participant ratio is better quality engagement; facilitators have time to assist individuals who are having difficulty, allowing them to progress at their own pace and ability. Activities with older people often need to overcome barriers of impaired sight, hearing and mobility as well as the concentration problems associated with memory loss. Similarly, smaller group sizes provided the artists opportunities to work closely with the residents; this gave the artists the opportunity to gain a better understanding of their participants, their personalities and to form the foundation of a deeper relationship.
One of the artists began to sit in front of the residents on the floor and sing along with them, making direct eye contact…This helped to prompt the residents if they couldn't remember all the words, but most importantly, it helped to develop and deepen relationships between the artists and the residents. (Theatre practitioner 4) During the songs the opportunities for the workshop leaders to sit closely facing the residents and sing with them seemed to enhance their emotional connection and experience. (Theatre  practitioner 3) Nevertheless, the artists reported feeling conflicted about including a large number of residents in their programme as it was thought to affect the quality of their work. For larger groups, some artists felt it necessary to have a high ratio of workshop leaders in order to facilitate involve of all members of the group, particularly for individuals who require additional support.
There is an expectation that all the residents will be entertained and that is why they come to the lounge. Taking a smaller group away did mean that the smaller group got better quality engagement, but the others I felt were left in a state of almost abandonment. (Digital artist 5) There is a need for further consideration of what constitutes inclusive practice in populations with dementia. Ideally, arts activities would be integrated into everyday practice and an established part of the routine in residential settings, rather than infringing upon daily care routines.

Physical location
The type of space provided for the artist to work in was frequently cited with regard to the ability to be inclusive and engage with the residents. Most of artists described how they adapted the room layout, such as moving walkers to one side, to enhance participation. I think being aware of how the layout of the workshop space can affect the whole group dynamic was a useful lesson to me. In the care home setting the seating was quite static but by coming in early, moving the seats closer and persuading people to allow their walkers to be out, to the side, makes a huge difference. (Digital artist 5) The nature of the setting could influence levels of engagement, although limited research has been conducted into how the environment affects positive engagement (Chaudhury & Cooke, 2014). The arts activities typically took place in spaces open to passers-by; artists reported how their sessions were influenced by people including residents, care professionals, visitors and residents alike.
Due to the open plan space the carers, nurses, doctors and therapist would occasionally sit with the patient or pop by. This created a great atmosphere, people were curious and open to what was happening at the table and the sharing knowledge and appreciation of the patients' art activities was welcoming. (Visual artist 2) However, the use of shared spaces for arts activities could have detrimental effects as well, judging by anecdotal accounts of intrusion on workshops by care staff conversing noisily or walking through the activity room. It appeared that some care staff gave little consideration to the impact of their behaviour on the arts activity, or to the effect it may have on the individual artists and residents. Other physical factors such as heat and positioning of the group were noted to influence the facilitation of the session. Residents attending afternoon sessions were observed to be fatigued and lacked concentration. This is contrary to previous findings which suggest greater engagement in persons with dementia during the afternoon (Cohen-Mansfield, Thein, Dakheel-Ali, & Marx, 2010).

Perceiving and responding to needs
The second theme highlights how understanding and responding to the needs of participants is considered an important aspect of facilitation. In this sense, the artists recognised the necessity to be flexible in their work, in regard to its content, and to adapt it to the abilities and needs of the residents. As the sessions progressed, the artists came to an understanding of what approaches worked well, and which did not; this was significant with regards to future planning of activities as the practitioners were able to respond to the needs of the group.
It's so important to be flexible in these situations, so we abandoned our plans as they were clearly not suited to the needs of the group. (Theatre practitioner 4) [Facilitator A] had planned quite a lot of activities but soon realised that you have to go with the flow and you may not get as much done as you had planned. (Digital artist 4) Several artists revealed that they had to modify the approach and content of their sessions in order, in their judgement, to achieve greater engagement. In one instance, this included adapting a storytelling session to pantomime to encourage the active participation of the residents. One artist noted that the sessions have encouraged her to: …improvise on the spot or just think on my feet when gauging the group…also knowing how to deal with different individuals and how to respond much more, giving time to talk to the members and find a connection. (Theatre practitioner 6) The artists emphasised the importance of preparation as it allowed them to be flexible in their approach, particularly in catering for different levels of ability.
I think you can never be too prepared. I was glad I had developed additional extension tasks as the range of abilities was varied. (Textile artist 1) The pace of the residents varies and this needs to be considered. Many residents are capable of completing a task at their own pace and if the task allows for autonomy then this needs to be considered as completing a task produces visible sense of achievement and ownership by the participants. (Visual artist 1) The suggestion from most artists was that creative arts programmes are able to cater for differences in abilities, and can be adapted to make them accessible for people with dementia. Working within an elderly population will inevitably mean taking account of sight impairment, hearing loss and limited mobility, as well as cognitive deficiencies. It seemed that the use of digital work, such as activities using iPads, allowed the artists the flexibility to adapt swiftly to the individual needs of participants. Artists reported observing increases in motivation; residents were reported to independently engage in activity using the iPads. In turn concentration and enjoyment were also deemed to increase in residents who previously had not participated.
One case in particular was a man who had very little movement, [was] wheelchair bound and with limited hand control. I bought an iPad adaptor for a microphone stand, this enabled the iPad to be position[ed] exactly where the participant needed it, and with the use of an iPad pen he was able to paint and create with the iPad. (Digital artist 2)

Facilitating relationships
This theme indicates that relationships were an essential factor identified by the arts practitioners, as contributing to the successful delivery of a programme of arts in two different ways. The sub-theme of "communication with staff" is discussed in terms of the support or in some instances, opposition, the artists encountered with staff in the care homes. Whereas the sub-theme "familiarity", refers to continuity over the period of the programme, with regard to the content and the facilitator.

Communication with staff
Many artists commented on the way staff collaborated to support the art project within the care settings. For instance, staff at one location used reminiscence, in conjunction with the arts activity, to engage and find out more about their residents. Staff participation and awareness of the arts programme appeared to be important factors in the successful facilitation of sessions.
The staff at [Location A] were excellent in taking on board the ideas of the project and what it was attempting to achieve. This was a key factor in participation overall, the volunteer staff were also excellent. (Digital artist 2) However, not all of the artists reported successful collaboration with staff. There were reported problems such as staff bringing more than the recommended number of participants to a session as well as causing avoidable interruptions, for example, the arrival of the tea trolley. Complex issues evolved regarding the artists' perception of the views of care staff about creative art programmes. Most artists believed that the care staff had the tendency to view their sessions as "entertainment" rather than understanding and appreciating their additional value; arts activities provide opportunities for social and creative engagement, with the potential to improve care, wellbeing and quality of life. There appeared to be the need to work mutually with care home staff in order to ensure the effective delivery of a creative arts session. I also wonder how the nursing staff have been briefed about the project, I did not feel that they knew anything about it, although the activity co-ordinator has been very helpful, the nursing staff just shrugged their shoulders when I told them I could not work with such a large group and then just walked to the other side of the room and sat down. (Digital artist 3) There are challenges in communication between the nursing staff and artists regarding the facilitation of this session. This indicates that in addition to effective communication between the two parties there also needs to be a mutual commitment, understanding and collaboration towards shared outcomes.

Familiarity
Many of the artists expressed the view that continuity between sessions was an important aspect. Sessions where the artists followed a familiar pattern and structure were viewed as being more successful. By utilising the same facilitators every week, the participants were perceived to feel more comfortable interacting with the artists and the activity. The artists expressed the view that their repeat presence each week helped them foster relationships with the residents. As demonstrated in previous research (Kovach & Henschel, 1996), the participants were deemed to engage more when content was familiar to them; for example, when singing songs that were well-known. The developing relationship between artists and participants were frequently described and many artists expressed how their knowledge of the participants informed future sessions.
As we spend more time with the residents, we get to know them more which is really lovely, it sparks creative ideas for how we can work with them. (Theatre practitioner 7) It was in this session that we began to understand the connections they made from week to week. The [residents'] autonomy over this week's narrative and the challenge created for one of the artists, enabled continuity between sessions, which the residents enjoyed. (Theatre practitioner 4) Encouraging discussion, active participation and interaction between the facilitators and the residents was considered to elicit positive responses. Some artists described how enabling the participants' autonomy in their decisions over the content of the activity (e.g. song choice) seemed to have a beneficial effect on engagement.
[The residents] having a say on something and us delivering had seemed to [gain] a positive response. (Theatre practitioner 6) After the second session we decided to give them a choice of which story we brought to them the following week, this was yet another way they enjoyed getting involved and got them talking with care staff, us and among themselves. (Theatre practitioner 2) These are examples of occasions when empowerment of the residents was encouraged through the arts intervention, by offering them choice and control. In principle at least, such empowerment could generalise to other aspects of life in the care home, encouraging residents to exercise their autonomy more fully and to avoid the harmful psychological effects of an institutional setting.

Building confidence
This theme explores how the confidence of the facilitators, in working with elderly populations, and participants in experimenting with new creative mediums, developed over time.
In particular, the artists who described using digital technology spoke of the confidence that participants displayed during the sessions. Considering that a significant number of the older residents had never seen or used an iPad before, the artists felt that this experimental activity had proved accessible for this population.
Many people are now confidently using the iPads and don't shy away as we bring them over. (Digital artist 5) It was striking how the issue of confidence was a two-way process, not just for the residents but also for the artists, some of whom were new to working with people who live with dementia.
This has been my first step into working with older generations with creative technology and has been a very enjoyable and worthwhile experience. I have extended my experience base of client groups and have found a new place in which I feel comfortable and confident around my delivery. I have gained knowledge of slowing the pace of delivery and expectation, and how to gain trust and understanding with the participants that allow for an all-round creative experience. (Digital artist 2) The feeling of enjoyment seemed to be closely linked to the confidence of the facilitator. It appeared that most artists felt that the participants enjoyed their sessions; they described residents' positive emotional reactions to the tasks such as "lighting up" when singing. Enjoyment was also expressed by the artists themselves, and perceived to be mutual to participants and some staff. A few artists described how the first sessions would start off uncomfortably but became more sociable as they built rapport with the participants.
The residents were really getting to know us and we were getting to know them -which made everything easier and much more enjoyable for us all. We made time to talk to residents after the session and were now able to call them by their names -very important. (Theatre practitioner 4) I think it has reinforced the knowledge that a creative workshop not only provides a sense of achievement, but can also spark spontaneous confidences as the group chats comfortably whilst their hands are busy. (Textile artist 1) Data from the artists indicates that Imagine Arts has not only provided an opportunity for artists to develop the confidence to work with elderly populations, but also that there is a significant role for creative arts within residential care settings.

Discussion
This study explores several aspects deemed by artists to affect the successful delivery of an arts programme within a care home setting. Their views on how feasible each type of arts intervention proved within care home populations and on barriers to arts activities in care homes could be used to inform future practice.
The practicalities surrounding an arts intervention in relation to engagement are seldom documented and may therefore be overlooked. As might be expected, the artists perceived that smaller group sizes were easier to work with as it allowed for more opportunities to initiate engagement; similar results were found by Cohen-Mansfield et al. (2010). Locations that were open plan and unobstructed by furniture were deemed better suited for hosting arts activities. Several artists implemented small changes that enhanced the participation of residents; removing physical barriers, such as walkers and re-arranging the furniture and room layout. They used their initiative to meet the needs of different workshops. However, the consequence of removing an individual's means of mobility should be considered; the researcher observed that artists offered the residents the choice to have their walker temporarily repositioned, most were agreeable to this.
Artists need an understanding of health and social care settings, just as health care professionals need to recognise the benefits and frameworks of artistic interventions (Moss & O'Neill, 2009). At present, there is little training available to adequately prepare artists for working in healthcare settings. The Imagine Arts programme has included training about dementia care for artists, as well as training on techniques and approaches for creative interventions, although the effectiveness of this training provided has yet to be explored.
'Consistency' and 'continuity' were commonly referred to by the artists. Artists who used a similar structure for each session reported how the residents became familiar with the format and came to understand what to expect. This narrative supports literature which has found that consistency in location and care provider, and also that routines can reduce agitation in persons with dementia (McCloskey, 2005).
In the UK, policy has highlighted the need to take into account an older person's capabilities and preferences when addressing their needs (NICE, 2013). In a similar fashion, findings from this evaluation demonstrate that arts sessions which seek to empower the participants, facilitated greater engagement and responsiveness. Research has demonstrated that the abilities of people with dementia may be underrated and they are consequently provided with activities below their capability (Malone & Camp, 2007;Perrin, 1997). Many of the artists expressed how they prepared tasks which catered to different levels of ability, as the participants' abilities varied greatly. This is something to be taken into consideration by artists when planning a programme specifically for populations with dementia.
It is important to encourage the development of relationships and trust between service users and providers (Arts Council England, 2012). The providers of the arts interventions described how, over the course of their sessions in care settings, relationships were built and knowledge gained regarding the participants' needs and abilities. This knowledge gave artists the opportunities to adapt their input, utilising methods which they deemed more successful to engage participants' attention.
Utilising the knowledge of care staff could be viewed as an essential tool in facilitating a successfully engaging activity. Carers have a unique understanding of persons with dementia (Harmer & Orrell, 2008) and this knowledge would be invaluable to artists as they create programmes tailored to this population. The implementation of psychosocial interventions is contingent on staff engagement, consequently there are challenges to overcome such as additional workload, allocation of resources and the emphasis on priority needs (Lawrence, Fossey, Ballard, Moniz-Cook, & Murray, 2012). It appears that there is a need to encourage effective working relationships between artists and care professionals to generate positive outcomes for this type of programme. Nonetheless, a recent review demonstrated that creative programmes which involve and engage staff, under certain conditions, positively influences care practice and interaction (Broome et al., 2017).

Limitations
This study is limited due to its small scale, within one city in the UK, and therefore, cannot make generalisations. There are methodological limitations of using one approach, in this instance reflective diaries; a variety of methodologies could have been drawn upon to evaluate the arts programme. For example, there are many factors which may influence practice, for example, policy and organisational structures, however, these were beyond the scope of this inquiry.
One must also consider the element of response bias. The artists were commissioned by the arts organisation they reported to and therefore may have only portrayed favourable aspects of the sessions in writings that would be submitted to their paymasters. However, there is limited literature regarding the views of artists (as opposed to arts therapists) working in care settings within the context of creative arts programmes. Therefore, this analysis gives a unique perspective regarding factors which artists perceive influence this type of activity within residential care.

Recommendations for future research and practice development
Whereas this evaluation explored the views of artists commissioned within an arts programme, future research investigating the views of persons with dementia, and those of the care professionals involved, is necessary to evaluate their opinions and the impact of cultural and arts engagement in residential care populations. This evaluation did not focus on comparing the impact of different arts forms; however, taxonomy of creative and cultural arts programmes would additionally highlight the individual qualities of different art forms and their impact and effectiveness for the individual needs of those taking part.
Training of care home staff in arts activities is a neglected area of research. There is a need for research to examine the impact of training health care professionals on the benefits of the practice of arts within residential care. Likewise, accredited training would be useful for artists undertaking work in care homes (Moss & O'Neill, 2009). This analysis identifies several factors which impact upon the successful facilitation of creative and cultural arts programmes. Some of the possible barriers may have simple solutions which can easily be incorporated into everyday best practice. First, it appears beneficial for artists to have an understanding of contextual factors which may influence the delivery of their creative sessions including the setting, group size, and routines of the care home. This information will assist artists in preparing their sessions, which has been identified as important for catering to the diverse needs of care home populations. Likewise, there is a need for effective communication between arts practitioners and care personnel; an understanding of the aims and objectives of arts interventions among care staff would be appear to be mutually beneficial. Moreover, the intimate knowledge that care staff have of their residents is invaluable to artists trying to engage and encourage participation in meaningful creative activities; therefore it could be worthwhile involving care personnel in the planning prior to the commencement of a programme of arts. Nonetheless, effective partnerships between care providers and arts practitioners take time and effort to create and maintain; this is an important aspect to consider when planning a programme of arts in residential care settings.

Conclusion
Knowledge of what constitutes a successful high quality arts programme is important for informing future evidence based practice. Previous research has largely focused on how the arts can be employed to manage the behavioural and psychological symptoms of dementia (Beard, 2011); this exploratory evaluation addresses a gap in the literature by exploring the views of arts practitioners working in these settings.
The feedback provided from the commissioned artists, supports previous findings that people with dementia are able to participate in high quality arts interventions (Ullán et al., 2012). Imagine strives to succeed at bridging the gap between older people and creative and cultural experiences by inspiring the imagination of residents and offering the opportunities for creative thinking. From the perceptions of the arts practitioners, the main factors contributing to success were encouraging autonomy, fostering relationships and building confidence. The findings from this study provide evidence on which to build future programmes of arts and cultural opportunities within residential care.

Disclosure statement
No potential conflict of interest was reported by the authors.

Funding
This work was supported by funding from Alzheimer's Society (Grant number ref: 225 (AD-DTC-2014-031)) and was carried out as part of a collaborative project of the University of Nottingham and the University of Worcester.