Health Care Anal

DOI 10.1007/s10728-009-0131-2

ORIGINAL ARTICLE

Aesthetic, Emotion and Empathetic Imagination:

Beyond Innovation to Creativity in the Health
and Social Care Workforce

Deborah Munt Æ Janet Hargreaves

! Springer Science+Business Media, LLC 2009

Abstract The Creativity in Health and Care Workshops programme was a series
of investigative workshops aimed at interrogating the subject of creativity with an
over-arching objective of extending the understanding of the problems and possi-
bilities of applying creativity within the health and care sector workforce. Included
in the workshops was a concept analysis, which attempted to gain clearer under-
standing of creativity and innovation within this context. The analysis led to
emergent theory regarding the central importance of aesthetics, emotion and
empathetic imagination to the generation of creative and innovative outcomes that
have the capacity to promote wellbeing in the health and social care workforce.
Drawing on expertise in the field, this paper outlines the concept analysis and
subsequent reflection.

Keywords Concept analysis ! Creativity ! Empathetic imagination !

Aesthetics ! Emotion ! Health and social care workforce ! Innovation !
Wellbeing

Introduction

The NHS Next Stage Review, initiated in 2007 and led by Lord Darzi [8], led to,
amongst other things, a statutory duty for the NHS to encourage innovation. It also
places much greater emphasis on notions of quality and quality assurance, shifting
the emphasis from a purely target driven, heavily performance managed service.

D. Munt (&)
Open Art, Apartment 8 Creative Lofts, 15 Northumberland Street, Huddersfield HD1 1DT, UK
e-mail: deborah@open-art.org.uk

J. Hargreaves
Human and Health Sciences, University of Huddersfield, Queensgate, Huddersfield HD1 3DH, UK
e-mail: j.hargreaves@hud.ac.uk

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Additionally the Department of Health report on arts and health (2007) mandated
creative artists, health practitioners and academics engaged in delivery and
education for health and social care to actively use and embed creativity into all
aspects of their practice [5]. Clearly the rhetoric of ‘innovation’ and ‘creativity’
peppers key government and health sector papers and ‘creativity’ appears as an
increasingly desired and required competence for health sector employees.
However, what this means is not fully defined or understood, nor is how we go
about cultivating it and this is providing a barrier to its practice and development.
Praise for creative or innovative practice, in the absence of definitions that are
recognised and owned within the sector, run the risk of pigeon-holing creativity in
narrowly defined managerial terms.
The meaning of the terms ‘creativity’ and ‘innovation’ have become blurred
amongst this rhetoric and increased usage of them has done little to enhance
understanding. Thus, in order to develop a coherent basis from which to justify practice
and frame research and evaluation, it is necessary to develop a better shared
understanding of the concepts involved. This paper sets out how a process of concept
analysis with a group of participants from health, care, arts and medical higher
education backgrounds, was used to attempt the definition and the greater understand-
ing of the differences between ‘creativity’ and ‘innovation’ and identify emergent
theory regarding the role of creativity in health and wellbeing. It captures the process
based on the reflective perspectives of two participants, the authors of this paper, one of
whom brings to this a background in nursing, leading to an associate deanship in a
university school of human and health sciences whilst the other brings a background in
arts and arts and health practice as the director of a creative organisation. The process of
writing the paper has involved a negotiation of the respective recollections and
interpretations of the exercise and its outcomes in order to test and clarify the findings.
The concept analysis was intended to act as a starting point to better understanding with
no real expectation of a conclusion. It remains in an unresolved state, as an open line of
enquiry and therefore the paper also picks up further thinking that has resulted from
additional discussion and debate amongst the authors.

Background

One of the discussions that occurred repeatedly in The Creativity in Health and Care
Workshops programme centred on the definition of creativity and innovation and the
distinction between them. We questioned whether we needed to define the concepts
or whether this would prove to be a futile distraction given that definitions for
creativity, in particular, can be as subjective as the creative experience itself.
However, this felt like a challenging but crucial piece of work when we considered
that the health and care sector seemed more comfortable with the notion of
‘innovation’ and less with ‘creativity’. The purpose of the research programme and
the primary interest of the participants was the exploration of the nature of creativity
in order that it can be better cultivated within the health and care context. Most
participants of the programme had a fundamental belief that creativity had something
very significant to offer and an intuition that this offer was something much more

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than innovation alone—but at that stage we were struggling to pin point what that
was. It became clear as we progressed that we had a wealth of ideas and different
theoretical perspectives, but were struggling to conceptualise creativity and
innovation singly, or as a collective. This difficulty is not unique to the focus on
health and wellbeing. For example Clegg [6] and Kleinman [15] are amongst many
writers in higher education who are seeking to better understand the place of, and
restrictions to creativity within learning and teaching. We came to understand that
other questions we were playing with, such as whether it was possible to be creative
without being innovative or innovative without being creative, or how you foster
either, felt out of reach unless the distinctions could be better understood. Although
we knew we were only ever looking to reach an agreement amongst ourselves, on the
basis that an agreement across this diverse group might have some resonance with
others, we took up the challenge because we felt this issue to be impeding our
progress and preventing us from moving forward, simply for the fact of shying away
from a difficult challenge.

Concept Analysis

Concept analysis, as used in this paper is taken from Walker and Avant [17]. This text
is well used within nursing, as an aid to teaching, and as a structure for theory
generation. Nursing as an aesthetic or craft based activity can be tracked back through
history. For example in western culture early iconography identifies one of the six acts
of charity said to constitute Christian duty as women caring for the sick [14]. However
a theoretical or researched base to the discipline only began to be developed in the
latter half of the twentieth century. Originally published in the 1980s, Walker and
Avant offered a timely process to aid nurse theorists in marrying the emergent
academic and scientific elements of their discipline with an ancient traditional art.
The advantage of concept analysis is that is offers a structured process which is
effective in exploring new, but also in articulating understanding of well established
concepts. Walker and Avant’s model has been used in many publications covering
many concepts from organisational issues such as ‘practice development’ with regard
to infection control [13], to ‘aggression’ in a mental health setting [16]. These
suggested that the process was well tested and useful for our purpose so we decided to
embark upon it to see if this could help us in articulating our understanding of
creativity and innovation as, using it as the structure of one of our workshops.

The Process

The concept analysis from Walker and Avant [17] contains a number of stages:
1. Select a concept
2. Determine the aims or purposes of analysis
3. Identify all of the uses of the concept that you can discover
4. Determine the defining attribute

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5. Construct a model case

6. Construct borderline, related, contrary, invented and illegitimate cases
7. Identify antecedence and consequences
8. Define empirical referents
Within our workshop we did not reach the end, nor felt the need to at the time, as
the first few stages alone deepened our collective understanding considerably.
In selecting our concepts (stage 1) we decided to run two concept analyses in
parallel—one on ‘creativity’ and one on ‘innovation’. This parallel process usefully
allowed us to see more clearly the similarities but crucially the differences that
would enable us to articulate the chosen concepts in a way that had specific
relevance for the health and care sector (the purpose of the analyses–stage 2).
This was important to us because, despite having met on several occasions and
having had lengthy discussions, we could not find a ‘that’s it’ point, which captured
what we felt but could not fully articulate. We felt the use of the words creativity and
innovation had almost become so general and overused as to become meaningless or
else where there was more specific understanding we felt that it borrowed heavily
from the world of business, in which ‘creativity’ and ‘innovation’ were only
considered legitimate when evaluated for their commercial value.
Clegg echoes this concern with regard to health care education stating:
within this realm (i.e. the ‘neo liberal’ language and culture of managerialism)
creativity is reduced to the level of an academic ‘buzzword’ [6, p. 222].
He further suggests that this represents a ‘deep ideological shift’ in which
managerialism and consumerism are taking over from the aesthetic and intellectual
concerns of health professional education. With the range of professions, disciplines,
functions, objectives and types of environments in the health and care sector making
for a complex series of arenas in which creativity might need to be at play, we
concluded, like Clegg, that ‘creativity’ and ‘innovation’ required a more sophisti-
cated understanding that could challenge this trend. For many participants of the
group this had been a need for many years—‘what does creativity have to offer that
innovation does not and therefore ultimately why should we bother?’—was at the
core of the challenge in cultivating more creative ways of working in the sector.
In identifying all of the uses of the chosen concepts (stage 3) we took some help
from the Google ‘define’ function to add to our own collective knowledge and
understanding. This was useful in generating debate—taking us beyond our own
positions and encouraging us to test our own and each other’s assumptions. During
this stage there was very little discussion about the relevance of the health and care
context to the concepts—it was purposefully broad–but in identifying the defining
attributes of the concepts (stage 4), we found we were unable to do this without
considering the context, although on reflection this was really only true for
innovation.
A sorting exercise for the defining attributes involved selecting only those words
that we felt strongly would apply to the concepts in context. This was an iterative
process—we challenged each other to include/exclude, and started trying to apply
the words to various innovations, or acts of creativity that we were aware of in our

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various experiences and practice. Although the focus of the workshop programme
was on ‘cultivating creativity within the health and care workforce’ we found it
helpful in this process to consider the ultimate purpose of a more creative
workforce. We therefore started to engage with questions about use of creativity in
promoting health and well-being and improving and enhancing health and care
service delivery and drew on examples of practice with patients as well as the
workforce in order to illuminate and really test our understanding of the concepts.
Essentially by identifying ways in which neither creativity or innovation alone
would do, we were drawing on stage 6 of the process—model, borderline, related,
contrary cases–in order to complete stage 4.
Something started to happen as we went through this process—we would not
claim that all the words that we included in either list were exclusive, or that the lists
were in anyway definable as ‘correct’ or ‘exhaustive’; further, we did not get to a
point of feeling that the exercise was complete. However, as we undertook the
sorting exercise we began to envision the concept rather than being restricted by the
language.
For the innovation part of the concept, we were quite clear that the ‘product’ or
‘change’ needed to be ‘new’, or ‘as new’ in the context in which it was being used
and that it needed to be delivering some kind of ‘improvement’. This did not preclude
the fact that an innovation might be time limited. For example the use of sticking
plasters or the use of topical local anaesthetic was once new and innovative but after
time they were not considered so. Then, when plasters were first impregnated with
local anaesthetic to deliver slow release topical pain relief this was an innovation.
Again, after time in use as a well established treatment, ‘innovative’ was not an
accurate descriptor until the same process was used to deliver other new benefits and
outcomes e.g. nicotine patches.
We debated whether it is possible to be innovative without creativity—this felt
rather messy and we came to no clear conclusions at the time. There are
perspectives that view creativity as the ‘ideas generating stage’ of innovation—with
innovation being a more prolonged process that involves the application of those
ideas in context. A more convincing perspective to us is that innovation is in fact a
subset of creativity—or one of the many possible outcomes of creativity–with the
creative process including aspects such as problem identification, analysis, critical
judgement, application and testing, evaluation and adaptation alongside the more
commonly understood aspects of play, experimentation and ideas generation. Many
of the stages of creativity and innovation do, again, parallel each other so pinning
down the differences is key if we are to convince others that the efforts and risks
involved in creativity are worth it.
For the creative part of the concept, we were very conscious of the similarities
between creativity and innovation and struggled for some time—knowing that we
had a deep seated, intuitive conviction that there was a difference but articulating it
was always just a little beyond our reach. We discussed whether creativity was
always a ‘good thing’ or ‘positive’ and concluded this was not a defining attribute
given that history is peppered with cases of creative acuity, applied towards a
negative end. We also debated whether it was possible to be creative without being
innovative. With creativity we did feel that the creation of ‘new ideas and products’

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was a defining attribute but with the ‘new products’ specifically this can differ from
innovation. As a result of a creative process a new product can arise but this is ‘new’
in the sense that it has been brought into being where it did not exist before, rather
than new as ‘original’ and ‘never been done before’. For example one may create a
painting or design new ‘infection resistant’ clothing for workers in an operating
theatre but these need not necessarily be original. These same products could in fact
potentially be applied to different contexts in which they are ‘as new’ and be seen as
innovative but the point is that, although originality and newness is usually an
outcome of creativity it is not absolutely essential whereas for innovation, it is. The
arts based practitioners particularly agreed that there are many artists who create
work that is not particularly original and this corresponds to Eisner’s [10] description
of ‘aesthetic organising’—one type of creativity that ‘creates order and beauty from
chaos’ but for which originality is not a prerequisite.
Other defining attributes for creativity were identified, such as experimentation,
flexibility, re-conceptualization but were also associated with innovation so did not
help with distinction.
In searching for that essential difference we kept coming back to three attributes—
aesthetic, emotion, imagination. The examples we each offered used words and
phrases such as ‘human dimensions’, ‘humour’, ‘relationships’, ‘beautiful and
stimulating environments’, ‘connections’, ‘sense of belonging’, ‘thoughtfulness’,
‘interactive’ and ‘intuitive’. Recognition of empathy emerged, of sensitivities and of
the ambiguity involved and the need for creative imagination and as we tried to
articulate our thoughts and feelings the characteristic that emerged was ‘empathetic
imagination’. Out of the hubbub of debate there was a point in the workshop where
we all just stopped talking to think about this, realising that we had found an
articulation that felt right. On further reflection we have attempted to define
empathetic imagination for ourselves and reached:
The creative process through which an individual engages emotionally with a
subject, whether that be putting themselves in the shoes of another human
being or immersing themselves deeply in a topic or context and then,
crucially, responding with imagination to that experience.
In order to understand this more fully we felt a need to explore empathy in its
own right: The central role of empathy in creativity is explained by Mike De Sousa
[9] of AbleStable:
Those who produce creative products must be in touch with their feelings, as
well as being able to empathise easily with others…Without empathy, the
creative product is often far poorer. Whether it’s a painting that emotes strong
feelings, or a toothbrush that gives a sense of pleasure as its design fits its use
perfectly, the ‘emotional value’ of the work is key to its success.
‘‘Design fits its use perfectly’’ is an important aspect here because that is achieved
because of the emotional dimension—without the emotional dimension the result
would fit less perfectly. But also important is that de Sousa in the same paper goes
on to say:

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Many of the characteristics of creativity, such as intuition, spontaneity, a sense

of timelessness and heightened awareness, are not rooted in the intellect but in
more fundamental emotional responses. We learn best when we enjoy, we
create at our best when we are emotionally charged. Creative products that
have little ‘creative charge’ fail to connect…’ [9].
After further discussions and reflections two important queries emerged. Firstly
the notion of empathy alone started to feel insufficient and secondly, when
challenged, we felt imagination was also a defining attribute of innovation, making
imagination a defining attribute of both and therefore not distinguishing creativity
from innovation.
De Sousa’s explanation illustrates the essential role of empathy in creativity but it
also illustrates that there is more at play. Empathy represents only one aspect of our
emotional repertoire and creativity involves much more. Although it captures the
idea of engaging deeply with another human being it does not sufficiently
encompass the idea of deeply engaging in other matters—contexts, domains,
subjects, environments etc.-or the various other aspects of emotion and emotional
intelligence we use in the process. What takes place in the creative process that
differs from the process of innovation is an opening up emotionally, a highly
sensitized state, a deep level of immersion and engagement, an omni-directional
perspective and an imaginative response.
There are links here to the notions of ‘immersion’ and ‘flow’—often overlapping
in meaning, with blurry edges of their own. Concepts of immersion vary
considerably—some such as Space Odyssey describing it as a state in it itself,
characterised by a feeling of acute presence, of being in the moment1 whilst others,
such as Csikszentmihaly describe immersion as a process, of entering deep into a
domain or field, developing profound levels of competency and internalizing an
existing system (1991). Similarly, from the nursing literature expert practise as
described by Benner [2] and Benner et al. [3] is characterised by the practitioner
being intuitively ‘in the moment’.
‘Flow’ is more universally understood as:
the way people describe their state of mind when consciousness is harmoni-
ously ordered, and they want to pursue whatever they are doing for its own sake
Csikszentmihaly [7, p. 6].
Flow achieves a deep state of concentration and absorption, through intense focus
on an activity and results in the achievement of a perfect state of happiness. Flow is
alternatively known as ‘the zone’. It links directly back to emotion, as Goleman
[11, p. 90] explains:
Being able to enter flow is emotional intelligence at its best; flow represents
perhaps the ultimate in harnessing the emotions in the service of performance
and learning. In flow the emotions are not just contained and channelled, but
positive, energized, and aligned with the task at hand.

1
Immersion is defined by space odysseys here: www.artgallery.nsw.gov.au/sub/spaceodysseys/glossary.
html.

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Creativity can be fuelled by emotion, can channel and harness emotion and can
be the producer of emotion. Emotion and creativity are intertwined as are emotions
and aesthetics. A full exploration of emotion and its links to aesthetics and empathy
merits a separate paper, but essentially emotions are a synthesis of physiology and
psychology—sensation and thought—although cognition is not always necessary
for emotion to take place. Goleman [12, p. 97] again: ‘‘Just as the mode of the
rational mind is words, the mode of the emotions is non verbal’’. The aesthetic
attributes of creativity allow us to go beyond the cerebral—to provide access to
different means for dealing with the mode of emotions. Aesthetics provide
physiological stimulus—what we see, what we hear, what we touch, smell and taste
all have the ability to trigger emotional response.
The buildings we create and the interactions we take part in communicate
emotion all the time whether we are conscious of it or not, whether we intend it or
not and whether we have taken time to think about doing it proactively, or not.
The workshop and our further reflections have led us to this; it is the combination
of aesthetics, emotion (empathy being an important part) and imagination that
distinguish creativity from innovation. The ability to use aesthetics (of the senses) as
a means of stimulation—as a means by which to become immersed–to open up and
engage deeply with a context/subject—to trigger emotional experience and content.
The ability then to use those emotions in the process of exploration and heightened
performance and to further use aesthetics, emotion and imagination, in an endless
series of combinations, in the response that is given back—the outcome.
In taking the concept analysis further a model case is needed (stage 5). Whilst not
undertaking this aspect fully within the workshop we have since drawn on one of the
many examples cited during the workshop, the development of the Evelina
Children’s Hospital. Many healthcare buildings today are very concerned with the
design quality of the environment and its ability to improve and enhance the patient
experience and the patient journey. Additionally, research has been undertaken to
identify the ways in which hospital design impacts on the staff that work within them
[4]. A number of hospitals have thus taken an approach similar to the Evelina which
aimed to develop a brief to ‘Design a hospital that does not feel like a hospital’.2
The attributes of creativity are clearly demonstrated through the overall approach
and aesthetics are at play throughout. The architecture of the building is distinctive; it
maximises natural light and ventilation and includes six themed floors identified by
themes of the natural world; Ocean, Savannah, Beach, Mountain and Arctic. The
different floors include colours, designs on floors and art works to help with place
making and way finding. The use of non-text directions in hospitals is not new
although was innovative when it was first introduced. Coloured lines along the floor
leading from, for example, an A & E department to the X-ray or plaster room, have
been used for many of years as a way of helping service users to navigate their way
around often complex building structures without the need for literacy. The crucial
difference here is the regeneration of this concept to include a process of opening up
and of real engagement with the context; with the feelings, thoughts, needs and desires

2
The official site for the Evelina children’s hospital: http://www.guysandstthomas.nhs.uk/services/
managednetworks/childrens/evelina/about/design.aspx.

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of children and staff who would be using the building; with the notion of a ‘healing
environment’; with the practical requirements of a hospital. This highly sensitized,
omnidirectional and empathetic perspective has then been followed up with
imaginative response that has resulted in solutions that are highly sensitive, deeply
appropriate, aesthetic, emotionally supportive to patients and functionally extremely
useful and have much greater impact and value than ‘just’ coloured lines on the floor.
The same process led to poems written by children and well known poems writ large
throughout the building; large Children of the World sculptures (that look like play
dough) to welcome people to the building; interactive art works such as the Teleport
Zone which uses the latest media and film technology to project patients into other
settings and worlds (not done previously so also innovative in this context); gardens
for respite, recuperation and tranquillity and many other interventions. These types of
interventions are considerate of how people feel in hospital; anxious, daunted,
frightened, out of place, confused. They build in familiarity (children know play
dough), practical support (place making and way finding), emotional support (spaces
for peace and contemplation), distraction (interactive elements that patients can
engage with), humour (encouraging play and laughter for both children and adults)—
all of which appeal to the senses of staff, visitors and patients, to the non verbal and
well as verbal. In 2006 Evelina was shortlisted for the Royal Institute of British
Architecture (RIBA) Stirling Prize and won the Channel 4 People’s Choice Award—
testimony indeed to the appreciation that the public have for this building.
Having reached this stage of concept analysis, we felt an antecedent to the
concept–empathetic and emotionally engaged creativity–included notions of security
and safety and that consequences included compassion and the capacity to bring
about positive change related to health and wellbeing (stage 7). In the model case
above this could be reduction of fear for patients and families, but also ease of
moving through the building, aesthetic experience, humour and fun for staff as well
as service users. Through exploring the interrelatedness of aesthetics, empathy,
creativity and emotion we have identified some of the empirical referents (stage 8).
We felt that we had arrived at a satisfactory point in our deliberations and
stopped the analysis, acknowledging that the final stages were less well developed
and that our conceptualisation needs theoretical testing and refining.

Conclusions

In the land of the sick, emotions reign supreme… Goleman [12, p. 164].
This paper does not attempt to justify belief in the multitudinous benefits of an
emotionally engaged health and care sector. Whilst acknowledging that there are
complexities with it we start from the premise that, particularly within the current
discourse of quality, personalization and subjective experience espoused by Darzi, it
must be so. Our task was to explore the defining attributes of creativity and
innovation and extrapolate from our learning the key differences between the two.
We have reached a stage, in an iterative process, where we feel confident to say that
creativity differs from innovation because it engages the empathetic imagination,

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including an aesthetic and emotional dimension above and beyond that which
innovation offers. Innovation on the other hand, by definition, offers outcomes that
are original in context whereas for creativity this is usual but not necessary.
The attributes of creativity—generation of ideas and/or products, imaginative,
flexible, experimental, aesthetic, of the senses and of the emotions combined with
the attributes of innovation—products or changes that are original or as new in the
context, designed to make improvement—represent something which should be of
interest to the health and care sector.
The Darzi Review espouses the need for quality, to deal with subjective
experience and for innovation. The workforce needs to be equipped for this.
Creativity offers the health and social care workforce a means of approaching
many of its challenges more positively; in ways which will result in the inclusivity
of people and variables in the mindset of the user and will cultivate sensitive,
enriching, satisfying and high quality responses in the form of new ideas, ways of
working and innovations.
Darzi’s Review speaks also of ‘‘change fatigue’’ [8, p. 13] in the NHS and
acknowledges staff have been subjected to many upheavals. The National Health
Service has strived, since its inception in 1948, to offer the people of Britain the
very best health care, at the point of need and regardless of circumstance. This has
rarely been easy and subsequent Governments have attempted to develop policy that
maintains the delicate balance between limitless demand and financial capacity [1].
Local government, in their responsibilities for health and social care, also face
similar challenges. As Britain reaches the close of the first decade of the twenty-first
century and approaches a global recession, the health and social care workforce are
justifiably weary of yet another NHS reorganisation. When it comes to the
workforce, the Review places emphasis not only on its effectiveness but also on its
morale. The theoretical position that this paper introduces contends that, in so much
as creativity affords a means to engage the emotional dimension of the workforce, it
may well play a useful role in creating a sense of joy and belonging in the process of
change and in bringing about creative and innovative outcomes.
Finally, in thinking about how creativity might be nurtured in the workforce, we
wonder whether it might be possible to further develop this concept analysis and to
deconstruct training and development activities, and the process of change
management, using empathetic imagination as a framework.
In conclusion, we acknowledge the limitations of this work to date recognising
that further exploratory and evaluative work is required. However, we believe the
concept analysis offers a justification, perhaps even an imperative, to not just seek
innovation but to develop strategies that help cultivate creativity in the health and
social care workforce, perhaps with empathetic imagination at its core.

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