An incredible piece from Sally Knocker, Consultant Trainer at Meaningful Care Matters, debates what is positive and problematic in relation to the increasing use of murals in care homes.

Many years ago, I worked in a care home in Kensington and Chelsea in London, England. I remember that the houses for people living with dementia were named after famous streets and squares in the area. The ideas seemed to make sense in terms of familiarity.  However, one woman living with dementia saw the large fake ‘Sloane Square’ street sign near the door of the home area, and looked both perplexed and annoyed, saying, “If this is Sloane Square, then I will eat my hat!”    

A more recent story was where a lively mural of a village street scene, including horse and cart and a variety of probably Victorian era images, was installed in a Butterfly Home. I had liked it because there were children playing and a few dogs in the picture, and I thought it would cheer up a very long and quite bland looking hallway. When going to check it out, a man living in the home smiled wryly at me and said, “Do they really think we are that old?!” 

People living with dementia aren’t stupid! This may seem like such an obvious statement, but it is important when considering the choice of murals that we don’t patronise or confuse people. 

Many people have quite strong views on this topic, but I am comfortably ‘on the fence’ in the sense that I have seen some wonderful large murals in Butterfly care homes which have brought lots of happiness and conversation. With that being said, I have also seen some ill-thought-out artwork which has done the opposite, and just doesn’t make sense or add any joy to people.

Location, Location, Location

In an interesting feature by Sue Learner in 2018 (Carehomesuk), there were some important critiques of the trend for large murals. Anna Park, Care Consultant, shared, “I understand the idea of bringing reminiscence therapy to life with colourful, nostalgic murals, but I think the scale, design and permanence of them aren’t always dementia-friendly, with many commercial companies jumping on the bandwagon without an understanding of the main principles of good dementia design.” A quick internet search reveals lots of companies who are providing what are described as ‘dementia friendly’ murals. One of the murals shared in the 2018 article was of a huge aeroplane mural across a whole wall in the dining room of one care home. What is striking with this example is that it had no relationship with food or mealtimes. One of the important principles of design in the Butterfly Approach is to have images that relate to the function of the room and are, therefore, helpful in terms of orientation. Wendy Mitchell, the late Writer and Dementia Activist, agrees with this, commenting, “As a navigation tool to indicate the function of a room, they have some purpose, but they must be contextually relevant and not add to a sense of bewilderment.” (Carehomesuk, 2018)

Local Themes Using Local Talent

Some of the best murals I have seen in care homes have involved local artists coming in to create bespoke art, which involves talking to the people living and working in the home, so that what is created is relevant and relates to the interests and backgrounds of people living there. Involvement of the people whose home it is seems obvious, but is often overlooked (Winton, E., & Rodgers, P. A. 2019). In one of our Irish Butterfly homes, in St Brendan’s CNU in Co. Galway, Anita Boyle, the artist has created some beautiful murals of the lake and other landmarks in the area, as well as a café façade and smaller features, such as vases with roses, an old radio etc.   

St Brendan’s have also involved a group of St Brigid’s Art & Design students with their teacher, Siobhan Treacy, to create a mural with interactive and sensory elements, including lights which go on inside a house and tactile flowers around the outside of the house.   

Nature scenes are likely to promote wellbeing for most people, but it will again be important to consider what kind of nature might be relevant and interesting to individuals living in the home – forests, mountains, lakes or beach scenes. When talking to Anita, the artist at St Brendan’s, I encouraged her to include some ‘live’ elements to her landscape, such as a dog running beside the lake, a woman pushing a pram or some children playing in a park. These can literally bring the landscape to life and are more likely to prompt a conversation, for example, “Did you used to walk your dog near the lake?”  “What games did you play outside as a child?” etc.  

Keeping it Real

Murals of shopfronts are popular in some of our Butterfly Homes. Whilst these don’t really convey a sense of ‘home’, they do offer a feeling of a destination or a sense of going out for those who spend long periods inside. It is important to offer some ‘real’ objects to engage with linked to these murals, for example some fresh fruit in a basket near a fruit store mural or a clothes rail with dresses, shirts, scarves etc near a fashion shop scene. This gives a more interactive and sensory element than just the ‘flat’ picture.  (Sas, C., Davies, N., Clinch, S., Shaw, P., Mikusz, M., Steeds, M., & Nohrer, L. 2020)

Appetising food related murals in dining areas can cue everyone into eating and help promote an appetite. We will still need to be aware that food preferences are varied, so imagine if it was something you disliked or were allergic to greeting you on the walls of the dining room – or something that you wanted and then it wasn’t on the menu! 

Truth or Lies?

What about murals or wraps on objects which are pretending to be something which, they aren’t? We encourage care homes following the Butterfly Approach to disguise their medicine or housekeeping carts with something more fun and colourful. Some have found some creative wraps or decals to do this well, including pictures of post boxes, flowers and birds. It is certainly less institutional looking, but some might argue that this involves an element of deception on a medicine trolley/cart (even if some of us will remember the Mary Poppins song that ‘A spoonful of sugar helps the medicine go down… in a most delightful way!’)

Regrettably, there seems to be little published research on this topic. However, arguably, some writers assert that we already know a lot through what has been tried and tested. (Evans, S. C., Waller, S. & Bray, J. 2022) There have been some critiques of murals, which are ‘hyperreal’ also known as ‘trompe l’oeil’, which are meant to deceive the eye. People living with dementia already often face perceptual and spatial awareness difficulties, so these could further confuse or unsettle people. (Andrews, J and Quirke, M in Carehomeuk article, 2018) 

Some murals I have seen are pretend pieces of furniture, for example, a love seat on a wall, which is surely likely to lead to people falling trying to sit on it.

Decals of bookshelves or libraries are often used to disguise an exit door, but do we consider how frustrating and confusing it might be to reach for a book and for it to be just a picture? Others would argue in their defence that the titles and authors on the book spines would themselves provoke positive memories and discussions, and they will be helpful in distracting someone from wanting to leave. However, it would make much more sense to have a library mural in a reading nook area, with a side table, lamp and actual books, chosen with some consultation as to the reading preferences of people living in the home. 

There is an increasing focus in design in relation to dementia specialist elements, which might enhance our understanding of what works best for people and offers more freedom of movement, particularly in ‘secure’ environments where people understandably feel frustrated and trapped.   (Anderson DC, Kota SS, Yeh L, Budson AE. 2023)  The current thinking around disguise of exits suggests merging the colours and pattern of the walls with the elevator or door, so they become hidden, rather than making them a feature or destination. 

In one home I remember in Bristol, UK, there was a mural of a stable door, with a very life-like photograph of a horse looking over the door. When I looked closer, there were lots of stains of porridge near the mouth of the horse, where people had obviously been feeding him. When I asked the home manager, she said the horse was a much-loved character in the home, so arguably this ‘deception’ had generated a great deal of pleasure. This is not dissimilar to the use of dolls, which become very real babies in the reality of some people living with dementia. 

A pretend window view in a bathroom with no window is another debatable feature. Will the view of the outside hills and the sunshine make the bathtime experience more pleasurable, or will it be disorientating? Most anecdotal evidence I have gathered is that they lessen the claustrophobic feel of the bathroom and enhance the experience, more than being a negative feature. A large mural of a map of the world in a bathroom can also be a wonderful conversation starter about the places people enjoy visiting or would like to visit. I personally find the predominance of seaside themes in bathrooms somewhat predictable, but I know many love them!

Context is Everything

So, what can we conclude in relation to what is positive or problematic in relation to the increasing use of murals in care homes? It seems that context is everything, and so often the very best murals have been chosen and created in consultation with people living and working in a home, as in the St Brendan’s example. Images which help people in terms of orientation to the function of the room or the direction of the hallway to help with wayfinding are surely a good addition. Ultimately, the ‘proof is in the pudding’, as you will see the reactions people have to murals and whether people stop and smile when they look at the images, and talk about the things they see with enjoyment. You might need to be prepared to admit you have made a mistake if the reactions aren’t positive, and particularly if they cause any distress, so it’s obviously better and more cost-effective to do your homework in advance if you can!

At Meaningful Care Matters, we would argue that it takes much more than changing walls to create real culture change to reduce the sense of an institution. However, it can certainly have a transformative impact on the look and feel of an environment for those living and working there, with the ultimate goal of deepening the feeling of being at home and having things which bring joy.

Please do let us know your experience and share your images and stories with us via admin@meaningfulcarematters.com