The quality of each study (Table 1) was assessed by the authors on 10 points of congruity between the research methodology and the procedural rigor for the given study design. The authors constructed a list of 10 appraisal criteria that would be relevant for assessing qualitative, quantitative, and mixed methodologies. These criteria are a nuanced adaptation of the quality measures to evaluate qualitative research as suggested by Cesario et al.33 Although Cesario and colleagues’33 work is primarily intended for appraising qualitative research, the authors found this framework a useful guide for devising a criteria scale to address mixed methodologies as well as pilot studies. The authors’ 10-point appraisal criteria are presented in Table 2. One full point was assigned to each of the appraisal criteria. Each individual study was rated as high quality, if 8 of 10 points of congruity were satisfied; good quality if 7 of 10 points were satisfied; low if 6 or fewer of 10 points were satisfied. In the authors’ appraisal, all discrepancies in grading were reconciled by consensus discussion, resulting in 100% agreement.
The classification of research designs outlined by the Johns Hopkins Nursing Evidence-Based Practice Rating Scale (JHNEBP)34 provided a framework for appraisal of the totality of evidence of retrieved studies. The JHNEBP quality-of-evidence scale is specifically a nursing evidence-based scale. It was chosen to analyze this review because of its favorable considerations of the nonexperimental elements that are inherent to qualitative studies with psychosocial outcomes, outcomes that can inform nurses’ advocacy of patients. Corresponding to the developmental nature of this science and the small number of studies, which also included pilot studies, the leveling criteria themselves are not used.
Meta-inference was used to grade the totality of the evidence according to the JHNEBP framework.34 Conclusions were generated by integrating inferences obtained from the entire body of literature to create an overall summary grade. The authors used the JHNEBP classification34 designations of high, good, and low to judge whether the quality of evidence provides a substantial foundation/building block or basis that warrants further exploration and/or immediate clinical application for art interventions as a coping strategy for promoting well-being in pediatric oncology patients in treatment. When appraising the totality of evidence, required elements to achieve a JHNEBP grade of good or higher were reasonable consistency of results among studies, sample sizes appropriate for the tradition/methodology of each study, inclusion of at least 1 study with a control group, and definitive conclusions that flow from the analysis or interpretation of the data.34
Of note, in the appraisal of the totality of evidence, sample sizes were considered adequate for qualitative studies if appropriate for the qualitative tradition of the study and if the sample generated enough in-depth data such that a pattern or dimension of a coping phenomenon under study could be illuminated. In studies wherein quantitative research with quasi-experimental or experimental formats was intrinsic to the design, sample sizes were considered sufficiently large if they supported statistical conclusions. Sample sizes for pilot studies resulting from pragmatic recruitment were judged as appropriate, if they could provide good-quality, critical and clinically meaningful insights in context, given the nature and constraints of the included patient population.
Six primary research papers addressing art therapy/art-making interventions for a cancer population aged 2 to 21 years undergoing treatment in a hospital setting met inclusion criteria for this literature review. Studies included 3 using qualitative methods27,30,32 and 3 using mixed quantitative and qualitative methodologies,28,29,31 1 of which included a randomized control trial,29 and 1 was a nonrandomized control trial.28 Two studies were pilot studies.28,29
Sample sizes ranged from 8 to 50 participants, with 2 studies involving 10 or less subjects27,32 and 4 studies with 16 to 50 participants.28–31 All studies involved both male and female subjects. Three studies included participants older than 14 years,27,29,31 and 3 of the studies did not include older adolescents.28,30,32 Diagnoses included leukemia predominately (n = 3),28,30,31 brain tumors exclusively (n = 1),32 brain tumors predominately (n = 1),29 and various malignancies (n = 1).27
Three studies involved art interventions in an inpatient treatment setting in a children’s hospital,28,31,32 1 in Italy,28 the United Kingdom and United States,31 and in the United Kingdom only.32 Two studies took place in the outpatient treatment setting in a children’s hospital,29,30 1 in the United States,29 and 1 in Italy.30 One study took place in both the inpatient and outpatient settings of a children’s hospital in the United States.27
Two studies involved structured art interventions that were theoretically based.31,32 The art intervention for 1 study had a conceptual basis and reported on prescriptive structured and free drawing.28 Three studies used free-drawing and free-form art-making interventions.27,29,30 Four studies reported on individualized art interventions facilitated by either an art therapist or trained play-worker,28,30–32 1 study reported on both individualized and group art interventions facilitated by either an art therapist or trained play-worker,29 and 1 study reported on individualized art interventions facilitated by a certified art therapist only.27
Promotion of a healthy outcome was measured by the demonstration that an art intervention implemented during treatment enhanced individuals’ physical, mental, or emotional well-being such as decreasing anxiety, fear, depression, and pain or by promoting communication with the treatment team, self-expression, social interaction, and personal growth. Quantitative outcome measures used to assess this therapeutic benefit were quantitative (validated Faces Scale, Emotional Response Checklist) responses to questionnaires,29 validated quality-of-life measurements (Pediatric Quality of Life Scale [PedsQL]) before and after art interventions,29 and a quantitative behavioral rating scale measuring enhanced well-being—authors’ own.28 Qualitative outcome measures used to assess this therapeutic benefit were thematic and/or process analysis of patients’ artwork demonstrating enhanced well-being as a recurrent theme or process in the artwork itself27,30–32 and thematic and process analysis demonstrating enhanced well-being as a recurrent theme or process in structured and unstructured interview and/or written description surrounding patients’ artwork.27,30–32
Findings: Roles of Art Interventions for Promotion of Enhanced Well-being
Three prevailing themes emerged from the data that outline the potential health outcomes of art therapy/making. Art therapy or art-making interventions implemented in either an inpatient or outpatient hospital treatment setting, facilitated by an art therapist or trained play worker, and administered before, during, or after treatments, may promote the well-being of pediatric oncology patients of both genders (aged 2–21 years) undergoing treatment by (1) reducing anxiety, fear, and pain and promoting cooperative behavior for painful or invasive treatment protocols; (2) by enhancing patient communication with the treatment team; (3) and by counteracting the disruption of selfhood that cancer treatment evokes.
Reduction in Anxiety, Fear, and Pain
Effective coping is linked to achieving a sense of physical and psychosocial well-being by meeting the demands of the situation or controlling emotion.12 One of the first and most enduring areas of pediatric psycho-oncology research have been how to help children cope with treatments and especially procedure-related distress for invasive medical procedures.3 Art interventions may promote well-being by reducing anxiety, fear, and pain before, during, and after cancer treatments.28,29 The nonrandomized controlled study by Favara-Scacco et al28 demonstrated that children provided with art therapy intervention from their first hospitalization exhibited cooperative behaviors and asked for art therapy when treatments for painful procedures had to be repeated. By contrast, children in the control group who had no art therapy interventions exhibited resistance and anxiety during and after lumbar puncture and bone marrow aspiration. This pilot study of Italian children with a diagnosis of acute leukemia concludes that art therapy can provide support for children with difficulties engaging coping skills spontaneously during painful procedures in the inpatient hospital setting.28 Madden and colleagues’29 pilot study found that the effects of individualized and group creative art therapies have a positive impact on the quality of life of patients with brain tumor receiving outpatient infusion treatment in a hematology/oncology tertiary care pediatric hospital in the United States. In the assessment of the patients aged 2 to 18 years receiving individualized creative art therapy in the randomized controlled trial component, statistically significant improvement in parent report of child’s pain (P = .03) and child’s nausea (P = .0061) was seen over the comparative group where trained volunteers sat at the patient’s bedside in the infusion room and paid attention to them through reading, talking, or watching TV. In the nonrandomized phase wherein patients aged 3 to 21 years were provided with group drawing arts sessions, a statistically significant improvement occurred in mood as measured by the Faces Scale (P < .01), and patients were happier (P < .02), more excited (P < .05), and less nervous (P < .02) as measured by the Emotional Response Checklist.29
Enhancing Communication With the Treatment Team
Studies have demonstrated that children with cancer want to have a venue for communicating with their health professional caregivers.3 Without communication, children may feel isolated and afraid, intuiting the information, but lacking a way to ask questions or process it emotionally with their caregivers.3 Effective coping is linked to achieving psychosocial well-being by having appropriate resources for communication of needs and concerns.12 The essence of art therapy is communication; effective coping may occur by reducing social, emotional, and physical constraints and encouraging self-expression with those in the treatment environment.27,30–32 Councill27 assessed recurrent themes in artwork created by pediatric oncology patients with various malignancies in several phases of the disease and treatment. The study reveals that even when relationships with the healthcare team or care givers are strained by anger or withdrawal or fatigue, or when feelings are too emotionally charged for verbal expression, “art expression can be helpful to continue the process of development through visual communication, supporting social and mental growth and mitigating the isolation of the hospital experience.”29(p87)
Twenty-two ethnically diverse children hospitalized in the United States and United Kingdom, who were undergoing in-patient treatment for acute lymphoblastic leukemia or various other malignancies were studied by Rollins.31 The investigators found that drawing is a form of symbolic communication with those present in the treatment environment, and can be used as a safe way to identify difficult issues regardless of gender, age, ethnicity, socioeconomics, and other cultural considerations. Much like sitting around a campfire, “sitting around the drawing so to speak, allowed the drawing and not the child to serve as an object of focus.”34(p213) This transfer of focus from the child to the drawing relaxed the child by relieving the pressure of being the object of direct verbal communication and served to increase conversation in both quantity and quality.31
Individualized spontaneous drawing activities of 50 Italian children in outpatient treatment for leukemia or other cancers were studied by a team of psychologists who subsequently evaluated the drawings.30 The drawings were completed in three settings: when the children were alone, with play workers, and with a psychologist. The psychologists’ interpretations of the children’s artwork revealed that graphic and pictorial communication hold great importance for sick children undergoing treatment whether in a solitary setting or with adult witnesses. The key to benefit with adult witnesses was in the child’s ability to expose their feelings to those caring for them in the treatment environment, first through the non-verbal symbols inherent in their artwork, and then through narrating their story through their art.
Individualized art-making sessions with validated collection techniques (Modified Mosaic Approach and the Draw and Write technique) were used to gather perceptions about coping with cancer care services from children ages 4 to 11 years who were undergoing combined modalities of treatment for brain tumors.32 This study from the United Kingdom found that art methods used were helpful ways for children to cope with their treatment environment by serving as an outlet for voicing what they found either distressing and/or beneficial and by mitigating their frustration with the treatment team and healthcare system.
Enhancing Self-esteem and Promoting Mastery
A major stressor for children with cancer in the treatment environment is the loss of a sense of mastery related to losses of control, identity, and self- esteem.3 Art interventions as a coping strategy, may play a powerful role for achieving psychosocial well-being by maintaining a familiar, positive identity in cancer and promoting personal growth.27,30 Councill27 found that when analyzing artwork of pediatric oncology patients who were at different points in their treatment, issues of body image, identity, and self-esteem were encountered. The efficacy of art interventions was demonstrated through a direct therapeutic benefit with respect to patients’ issues of selfhood. Whatever forms the art intervention took, it was a venue for children and young adults to seize control over their environment and normalize the abnormal childhood experiences of being a cancer patient by simulating play, school, or recreating negative experiences into positive ones. The creative process was a way of coping by resolving emotional conflicts and by fostering self-awareness and personal growth. Patients controlled their own choices of art materials, subject, and verbalization regarding their artwork. This enabled them to “experience themselves as active creators as opposed to victims of disease or helpless recipients of treatment.”27(p86)
In Massimo and Zarri’s30 study, children who were in treatment drew with adult witnesses. Process analyses revealed higher self-concept assessments due to support and validation from others. The authors explain that the opportunity for children to express themselves through drawings and other creative art forms means that they are their own, self-healing therapeutic agents. This benefit may be further guided, however, when in a setting with facilitators because there is ongoing verbal interaction, which in turn leads to both enhancement of full expressive possibilities and to a positive feedback on their self-image.
Assessment of the State of the Science
According to JHNEBP,34 adapted for this literature review, the totality of evidence warrants a good rating as it includes a good basis for further investigation of the use of art interventions as a coping strategy that promotes the well-being of pediatric oncology patients undergoing treatment. Considerable heterogeneity existed in the designs of a paucity of studies, and there were variations in the content of art interventions yielding diverse descriptions of their outcomes. However, the results consistently aligned themselves according to the therapeutic mechanisms presented.
Whereas heterogeneity can present a challenge in practical clinical guidelines, it does have benefit when illuminating psychosocial information that can guide the healing of a particular patient population. Quality information is revealed that may not otherwise be assessed, because of lack of standardized or validated tools for measurement. This review serves to extrapolate the interpretation of the outcomes to various treatment settings in an attempt to generalize the findings to pediatric cancer populations. At the same time, this type of assessment is a limitation as it may lead to bias and overestimate or underestimate of intervention effectiveness due to the heterogeneity of the outcome measures. The supportive psychotherapeutics that were an aspect of the art therapy in 2 studies28,30 may have confounded the effect of the art intervention. The variations in model and content of the arts interventions introduce the question of replicability. Thus, no standard for making specific recommendations as to type or timing of art interventions could be given.
Another limitation was the inclusion of 2 pilot studies,28,29 making assessment of their quality challenging. The primary role of a pilot study is to examine the feasibility of a research endeavor. For instance, feasibility of recruitment, randomization, intervention implementation, blinded assessment procedures, and retention are all examined in good-quality pilots.35
The authors circumvented this assessment challenge by appraising the mixed-methods research pilot studies, as pilot studies would be graded: grading the debate over feasibility of art interventions as a coping strategy for promoting the well-being of pediatric oncology patients in the treatment environment and/or identifying modifications needed in design of larger ensuing hypotheses-testing studies.
The 2 pilot studies28,29 illustrate good-quality pilot technique: experiments integrated with operations, using pragmatic recruitment.35 In the pediatric oncology treatment environment, there is difficulty with accruing, randomization, and retaining participants because of the fallout inherent in the morbidity of the diagnostic and therapeutic phases of certain cancers, making pragmatic recruitment necessary. Sample sizes of good pilot studies may be justified on the basis of a rationale other than power analysis. Sample sizes resulting from pragmatic recruitment of good-quality pilots may not support the small P values necessary for statistical power, but can provide appropriate critical and clinically meaningful insights in context, given the nature and constraints of the included patient population.
For example, the pilot study of Madden et al29 provided a good foundation for research by offering insights for intervening with brain tumors. An important insight gleaned from the study by Madden et al29 is that a smaller than optimal sample size in brain tumor subjects may need to be anticipated owing to the attrition during the early therapeutic phases of treatment. The investigators concluded that if their pilot study were to be replicated with brain tumor patients with the intent of achieving intragroup statistical significance, it would need to consider the attrition characteristics of the brain tumor population, and many more patients would need to be recruited to achieve a sufficiently large sample size to increase the power to detect differences in the groups.
Favara-Scacco et al28 provided interventions for the leukemia population, and Madden et al29 investigated the brain tumor population. The pilot studies of Favara-Scacco et al28 and Madden et al29 each demonstrated art interventions as strategies that promote well-being in the specific group of pediatric oncology patients studied and provided clinically meaningful examples of scalable infrastructure for provision of art interventions in a cancer treatment environment. Thus, an advantage to assessing/appraising these as “Good” pilot studies is that they have good potential for demonstrating and accelerating research in this area for pediatric oncology patients in general and for providing clinically meaningful results, which, although not entirely empirically based, can be useful to clinicians who treat the specific patient population studied.
Because of the heterogeneity of the 6 studies, appraisal of the consistency of the evidence results is a narrative synthesis of assessments according to each of the 3 prevailing outcome categories rather than quantitatively assessing effect sizes or further qualitative synthesis. Although the reviewed studies show consistent results, the validity of the review is threatened because of the limiting characteristics of the multiple tool measures; outcomes were not measured or analyzed in a uniform fashion, there was a lack of validated outcome measures in one of the controlled trials,28 and 1 study did not seem to build on the science created by the other.
Despite the methodological limitations, paucity of studies, and heterogeneity of the reviewed studies, further exploration of the clinical use of art interventions is warranted in the pediatric oncology treatment arena to promote anxiety relief, communication with the treatment team, and self-esteem. The favorable outcomes aligned themselves in consistent categories with definitive conclusions. No evidence exists that art interventions cause harm. Sample sizes are appropriate for the tradition/methodology of each study and support conclusions, and 2 studies with control subjects and preintervention and postintervention evaluations were included.28,29 The most recent studies29,32 used validated measurements for detecting, quantifying, and analyzing outcomes, and therefore there is a trend toward higher-quality data since 2009. Likewise, documentation of ethical research considerations, including consent of participants, was a more recent phenomenon.29,31,32 This review suggests that further research with more contemporary research methodologies is needed to better understand the short- and long-term outcomes.
Although the current review included studies of children/adolescents between the ages of 2 and 21 years, only half of the studies included older adolescents.27,29,31 Future art intervention studies should consider targeting adolescents specifically, as they are cognitively and emotionally processing the implications of a life-threatening disease at a different developmental stage than their younger cohort.3 Also, a research consideration must be given to children/adolescents who do not enjoy art and would not want to participate in such an intervention. Although art interventions may be a relatively low-cost intervention in resource-poor countries, art making may not be a part of cultural common practice. Therefore, cross-cultural considerations in such research would be needed to address applicability to various cultural groups and countries.
Does the body of evidence support a culture of clinical trials in which frontline researchers and clinicians can turn these insights into more rigorous research protocols and/or clinical processes? The review’s answer to this question is yes; there is a good basis for these pursuits. This is the assessment of the state of the science that was determined by adapting the JHNEBP framework for this literature review.
How can healthcare providers respond to this mode of assessment of the combined body of evidence? The JHNEBP grade of “Good” is used to highlight both research and clinical opportunities; that is, it identifies that there is a good basis for further investigation, and that although many research questions still remain, the imperfections of these studies should not inhibit the use of art interventions at this time, as a sensible strategy for pediatric oncology patients in treatment.
Methods being used to examine art interventions and their benefits must become more sophisticated in order to have more precise and informative answers and build on the current information with a goal toward more empiricism. Future studies on the efficacy and effectiveness of art intervention should consider using standardized art interventions, multicenter randomized controlled design with larger sample sizes to increase power and detect differences in groups, validated and uniform measurements for preintervention and postintervention outcome assessment, and ethical procedural rigor to confirm a benefit.
Implications for Nursing Practice and Research
Art interventions may be tools that facilitate communication with the treatment team, control pain and anxiety, and promote a positive self-image. Although current scientific evidence is sparse and developmental in nature, the paucity of existing evidence suggests that consideration should be given for the integration of art interventions into the nursing care plan of pediatric oncology patients undergoing treatment to help their patients cope with elements of their challenges, which may be modifiable.
Nurses recognize the therapeutic nature of art interventions in the oncology treatment setting and perceive it as a venue for promoting cooperative behaviors during treatment.28,29 Favara-Scacco and colleagues’28 and Madden and colleagues’29 investigations encourage interdisciplinary collaboration among health professionals and suggest that nurses and art therapists alike should be well versed with a variety of art interventions in order to provide synergistic management of the pain and anxiety inherent in the treatment setting.
Art making accompanied by commentary provides a broad approach to establish and maintain direct and honest communication with children undergoing treatment for cancer.27,30–32 Rollins31 suggests that nurses, child-life specialists, and play workers can all promote projective drawing by the distribution of sketchbooks for every child with cancer in treatment and that some form of simple art interventions could be included in their care plan.
Massimo and Zarri30 pointed out that the ongoing verbal interaction during art making between the art facilitator/witness and the pediatric oncology patient leads to an enhancement of a child’s self-esteem through support and validation from others. This raises the question as to how to specifically educate nurses and those most intimately involved with patients to provide appropriate comments and interactions surrounding patient artwork. Although interpretative art education is not currently a part of nursing education, nurses and art therapists can offer a team approach by actively communicating and reciprocally educating one another so that as many patients as possible can potentially benefit from such interventions.
Pediatric oncology nurses who are interested and willing to learn new approaches may become involved more significantly in researching and promoting art activities with their patients. Walsh and Weiss36 and Walsh et al37 describe the implementation and evaluation of a creative arts intervention that was “infused” into nursing care at the bedside of adult cancer patients. Combined orientations from the fields of nursing and art therapy can enhance the capacity to address a broader spectrum of patient needs from physical, psychosocial, to existential. If art therapy/art making is going to be considered an evidence-based strategy for children with cancer to cope with the challenges of treatment, there will need to be interdisciplinary research among art therapists, play workers, mental health professionals, and nurses using more contemporary standardized assessment tools. This collaboration may lead to better scientific methods aimed at understanding the therapeutic physiological and biochemical targets that art interventions activate.
There remains a substantial amount of work to be undertaken to adequately meet the psychosocial and medical needs of pediatric oncology patients in treatment settings. The answer lies not in which discipline is the most superior to meet needs, but instead in how disciplines can work collaboratively and efficiently to organize and prioritize their efforts to achieve optimal outcomes. A paucity of empirical evidence suggests that art interventions may be useful in determining what each individual uniquely perceives as stressful and serve as a venue for coping with the challenge. As nurses, we stand alongside our patients’ suffering and should consider the facilitation of art making as part of our privileged presence. Although many art interventions have been undertaken by fully trained art therapists and child-life workers, nurses can further promote the integration of arts interventions into their pediatric oncology patients’ care plan to encourage self-expression, maintain communication with the treatment team, reduce pain, and promote positive coping strategies. Nursing education should address the value of interdisciplinary collaboration with art therapists and child-life specialists. The current evidence suggests that art making, attentive listening, and discussion can support the work of healing and should be readily available. Further and higher-quality research is required before evaluating the feasibility and practicality of integrating routine and standardized art interventions into the treatment protocols for children with cancer.
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Keywords:Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved
Art making; Art therapy; Childhood cancer; Coping; Creative arts; Literature review; Pediatric oncology; Well-being