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Art Intervention With Family Caregivers
and Patients With Cancer
Sandra M. Walsh, RN, PhD, and Sharlene Weiss, RN, PhD
Key Points . . .
Purpose/Objectives: To describe the implementation and preliminary
evaluation of an art intervention at the bedsides of patients with cancer
and their family caregivers.
An "Art Infusion" intervention was designed to provide stress
Data Sources: Field notes from ongoing encounters with family
relief and promote positive feelings in family caregivers and pa-
caregivers and patients with cancer, research literature, and descriptions
tients with cancer while patients were receiving treatment at a
of other programs.
regional comprehensive cancer center.
Data Synthesis: An "Art Infusion" intervention was developed and
offered to family caregivers and patients with cancer during treatment at
Prior to implementation of the intervention, volunteers partici-
a comprehensive cancer center. Training of interventionists, timing and
pated in a training program that included study and discussion
delivery of the intervention, and the availability of art activity choices were
of Hogan's End-of-Life Model, role playing, and learning how
key factors in the intervention's success.
to implement program activities.
Conclusions: Family caregivers and patients with cancer are interested
Since 2001, more than 450 family caregivers and patients with
in and responsive to art interventions. Additional research is needed to
cancer have participated in the intervention and continue to ex-
quantify the effects.
Implications for Nursing: Art interventions enhanced and extended the
press appreciation for these creative activities.
scope of care for family caregivers and patients with cancer. Nurses are in
key positions to establish, supervise, and promote such interventions.
used a variety of aesthetic methods to tap inner creativity, use
form to make meaning, and promote feelings of empowerment
he positive effects of creative arts activities in a vari-
T
(Predeger). In their work with children, Heiney and Darr-Hope
ety of vulnerable patient populations have been re-
included family members as they assisted children and family
ported (Carlisle, 1990; Heiney & Darr-Hope, 1999;
members in coping with difficult feelings during and after hos-
Walsh, 1993; Walsh & Hardin, 1994; Walsh & Webb-Corbett,
pitalization.
1995; Young-Mason, 2000). Arts-in-medicine programs have
The health and welfare of family caregivers, particularly those
been established in hospitals to implement creative arts activi-
caring for patients who are terminally ill, are compromised se-
ties for both family caregivers and patients (F. Falk & P.
riously (Carter & Chang, 2000; Chan & Chang, 1999). Re-
Jacobsen, personal communication, November 5, 2001; Lane &
searchers report that 20%30% of family caregivers suffer from
Graham-Pole, 1994). Lane (1994) has provided a model for cre-
psychological and mood disturbances (Blanchard, Albrecht, &
ative approaches with patient populations. Lane and Graham-
Ruckdeschel, 1997). Usual roles and responsibilities often are
Pole and Samuels and Lane (2000) have documented case stud-
shifted, adding distress and decreasing caregivers' quality of life
ies that describe family caregivers and patients who reported
(Steeves, 1996; Weitzner, Jacobsen, Wagner, Friedland, & Cox,
transforming, illuminating experiences during and after their
1999; Weitzner, McMillan, & Jacobsen, 1999). Investigators
participation in creative arts activities. The benefits of participa-
tion in arts activities have been reported in patient populations
including children with cancer (Heiney & Darr-Hope), hospital-
Sandra M. Walsh, RN, PhD, is a professor at Barry University in Mi-
ized pediatric patients with cancer (Lane & Graham-Pole), pal-
ami, FL, and a research specialist at South Miami Hospital in Coral
liative care patients (Shaw & Wilkinson, 1996), women with
Gables, FL. Sharlene Weiss, RN, PhD, is an associate professor in the
School of Medicine at the University of Miami in Coral Gables, FL.
breast cancer (Predeger, 1996), adolescents who are suicidal
Partial funding was received from the University of Miami General
(Walsh, 1993), adolescents who have survived natural disasters
Research Support Award. (Submitted June 2002. Accepted for publi-
(Walsh & Hardin), and patients recently discharged from psy-
cation February 4, 2003.)
chiatric units (Walsh & Minor-Schork, 1997). For example, in
a qualitative study of patients with breast cancer, participants
Digital Object Identifier: 10.1188/03.ONF.E115-E120
ONCOLOGY NURSING FORUM VOL 30, NO 6, 2003
E115
treatment with the corresponding fears of treatment failure and
have identified problems in family caregivers related to stress,
depression, physical health, and social support (Robinson &
patients' death despite medical efforts. Thus, during hospitaliza-
tion, family caregivers would be experiencing the "dedicating
Austin, 1998), psychosocial resources (Goode, Haley, Roth, &
resources," "negotiating treatment," losing the battle," or "death
Ford, 1998), anxiety (Higginson & Priest, 1996), and quality of
life (King et al., 1997; McMillan, 1996; McMillan & Mahon,
occurs" categories of the ELM. The Art Infusion intervention
was developed to help reduce stress and anxiety as families
1994; Weitzner McMillan, et al., 1999).
moved through these ELM processes.
Family caregivers are difficult to reach because they are re-
luctant to focus on themselves even when they acknowledge
During the interventionists' preparation for implementation of
Art Infusion, they studied these five ongoing processes, de-
their need for help (Walsh, Estrada, & Hogan, in press; Walsh
scribed initially in Hogan's theoretical grief-to-personal growth
& Schmidt, 2003). Family caregivers' ongoing and consuming
framework, which Hogan later relabeled as the ELM (Hogan &
focus on patients prevents them from taking part in interven-
DeSantis, 1994, 1996; Hogan, Greenfield, & Schmidt, 2002;
tions that may provide stress relief (Weitzner & McMillan,
N.S. Hogan, personal communication, May 30, 2002), and sub-
1999; Weitzner, McMillan, et al., 1999). Researchers have sug-
sequently in the family caregiver study (Walsh et al., in press).
gested that new, innovative approaches are needed to reach vul-
Thus, knowledge of Hogan's work helped interventionists to
nerable caregiver populations (Boyle et al., 2000; Ferrell, 1996;
identify and understand the vulnerabilities of patients and family
Kozachik et al., 2001; Meisel, Snyder, & Quill, 2000). No stud-
caregivers following a cancer diagnosis. Although the Art Infu-
ies have been reported that focus on using creative art ap-
sion intervention was not a direct outcome from this framework,
proaches solely with family caregivers.
communication with patients and family members during the
The purpose of this article is to describe the implementation
Art Infusion implementation was based on the interventionists'
and preliminary evaluation of a unique intervention to infuse art
awareness and sensitivity to ELM family processes during pa-
into nursing care of family caregivers and patients. In an effort
tients' hospitalization and treatment.
to provide interventions during times of caregiver accessibility,
Art Infusion was modeled after the arts-in-medicine pro-
the "Art Infusion" intervention was offered to family caregiv-
grams at H. Lee Moffit Cancer Center and Research Institute
ers and patients while patients were receiving treatment at in-
at the University of South Florida in Tampa (F. Falk & P.
patient and outpatient sites in a regional comprehensive cancer
Jacobsen, personal communication, November 5, 2001) and
center in the southeastern United States. The timing and deliv-
Shands Hospital College of Medicine at the University of
ery site of the intervention was a key factor so that hard-to-reach
Florida in Gainesville.
family caregivers would be receptive and available (Walsh et
al., in press; Walsh & Schmidt, 2003).
Training Program
Conceptual Framework
Before the implementation of Art Infusion, the authors con-
The End-of-Life Model (ELM) guided the timing of the art
ducted a three-hour workshop at the comprehensive cancer cen-
intervention and promoted the interventionists' understanding
ter to train volunteers who had expressed interest in the project.
of the family caregivers' struggles following the diagnosis of a
These volunteers were a mix of professional artists, art students,
life-threatening disease. The ELM defines the processes expe-
and undergraduate and graduate nursing students. To prepare for
rienced by family caregivers from the time of diagnosis of a life-
the program, one of its leaders attended a "train the trainer"
threatening disease to patients' death (Hogan, Morse, & Tason,
workshop sponsored by a nonprofit organization that promotes
1996) (see Figure 1). Findings from a subsequent study with
art activities with vulnerable populations in healthcare settings,
family caregivers of patients with cancer support the processes
Very Special Arts (VSA) of Florida, to learn specific training
described in the ELM (Walsh et al., in press). Participants in the
techniques for individuals working with patients who are termi-
study described family struggles as they attempted to cope with
nally ill and their families. Workshop leaders decided that
stressors after patients' cancer diagnoses. Therefore, additional
screening prospective participants to obtain information from
caregiver and patient stress was anticipated during patients'
volunteers was essential. The screenings addressed participants'
reasons for wanting to work with patients who are terminally ill
and their families, previous volunteer experiences with vulner-
1. Getting the news--Getting the diagnosis
able groups, and volunteers' current state of physical and mental
A. Shock
health. The coordinator of volunteer services, who assisted with
B. Calculating the odds
recruiting and coordinating volunteers for the project, also par-
2. Dedicating resources
A. Family being there for the patient
ticipated in the workshop and eventually helped implement the
B. Accommodating care
Arts at the Bedside program.
3. Negotiating treatment
At the beginning of the three-hour workshop, introductions
A. Fighting for life
were made and workshop leaders encouraged participants to
B. Enduring stress
share their reasons for involvement in the project. The lead-
C. Shutting it out
ers presented didactic information and situations (including
D. Maintaining hope
the ELM) that the volunteers would encounter when working
4. Losing the battle
with family caregivers and patients with cancer. Trainees then
A. Seeing the obvious
participated in a number of role-playing situations where sce-
B. Ending the suffering
narios were presented that highlighted various difficulties that
5. Death occurs
they could encounter at the bedsides of patients who are ter-
Figure 1. End-of-Life Model
minally ill. After role playing and discussion, the five Art In-
fusion intervention activities were shown using a computer
Note. Based on information from Hogan, Morse, & Tason, 1996.
ONCOLOGY NURSING FORUM VOL 30, NO 6, 2003
E116
presentation that included graphics and directions for each ac-
tivity. All activities were easy to implement and required no
previous art experience. Workshop trainees then practiced
constructing each of the objects that would be offered to fam-
ily caregivers and patients.
As the workshop progressed, trainees became acquainted
and noted each other's talents. During discussions, artist train-
ees expressed hesitation about approaching the bedside, but
they were very comfortable with the art activities and han-
dling art supplies. Conversely, nurse trainees felt confident
about approaching patients and family members but were
somewhat insecure about implementing art activities. There-
fore, to take advantage of the unique skills that would comple-
ment one another, the group decided that a nurse and artist
team would offer the intervention.
Implementation
Figure 3. Detail of a Completed Silk Wall Hanging Activity
Art Infusion was presented first to family caregivers and
patients as a service available to interested parties. Coordina-
tion and cooperation between the interventionist team and
ties were tested during multiple intervention studies (Walsh,
staff were essential from the beginning of the project. A unit
1993, 2000; Walsh & Estrada, 2000; Walsh & Hardin, 1994;
manager was recruited to refer the interventionist team to in-
Walsh & Minor-Schork, 1997; Walsh & Webb-Corbett,
terested patients or family members and, more importantly,
1995). After the family caregivers or patients decided to try
alert the team to situations where patients may be physically
one or more of the activities, the intervention team helped the
isolated because of low white blood cell counts or placed on
participants with instructions and supplies.
precautions that would prohibit the team from working with
The team often noted uncertainty from family caregivers
them.
and patients when they first approached them about participa-
Art Infusion activities were not considered a form of art
tion in the project. However, when they recognized that their
therapy but rather a package of creative art activities designed
participation was voluntary and Art Infusion was offered as a
to promote a creative experience, distract caregivers and pa-
free service with a variety of activities, they became more re-
tients, promote focus on something positive, and increase
ceptive. Participants began to ask questions about the length
communication between family caregivers and patients. Art
of time each activity would take or how much skill was re-
Infusion supplies were introduced to participants by the inter-
quired. Additionally, when uncertainty about the future was
vention team via the "ArtKart," which was stocked with sup-
an ever-present reality, some choices and control over their
plies and pushed into the patient area (see Figure 2). Examples
situation during participation may have been appealing to the
of each activity were displayed on the side of the ArtKart. A
caregivers and patients.
detail of one completed activity (a silk wall hanging) is illus-
trated in Figure 3. A written "menu" of activities was provided
to patients and family caregivers as they considered art activ-
You decide what you want to do. The nurse and artist team will start you on
ity choices (see Figure 4). The menu's five creative arts activi-
the activities, and, if you want to continue after 15 minutes, will leave additional
supplies with you. You can seek their help at any time.
1. A "healthy" image poster of self or others. Make a fun poster of yourself
or a family member using a picture placed on top of an image that
you choose from an image workbook. Time: about 15 minutes per image
2. Monoprint art activity. Choose your favorite colors to make abstract de-
signs using watercolors. This is very quick and easy. Try it. You will want
to make several. Time: about one to two minutes per print
3. A mandela (circle) creation. All family members can be involved in this
circle creation containing a drawing or painting of anything such as your
favorite foods, favorite sayings, or an abstract of colors. Time: can take as
long as 45 minutes
4. A silk wall hanging. Painting on silk is easy and fun. One person or a group
of people can paint on a small piece of silk. This can be completed in 30
45 minutes, and the team will help you prepare the wall hanging when you
finish.
5. Greeting cards to keep or send to others. Draw your own design or even
use one of your monoprints. Can be made in one to two minutes, or you
can take a long time and use many of the supplies from the ArtKart. It de-
pends on you.
Figure 4. "Menu" of Art Activities for Patients and Family
Figure 2. ArtKart and Interventionist Team
Members
ONCOLOGY NURSING FORUM VOL 30, NO 6, 2003
E117
Results
plies when they returned home. Table 1 lists additional ex-
amples of responses to Art Infusion.
The current study's authors developed several assump-
When the project began, the purpose was to determine the
tions about how and why Art Infusion is effective. These as-
interest and feasibility of offering family caregivers and pa-
sumptions originated from this project and parallel dis-
tients the opportunity to participate in creative art activities in
cussions by Young-Mason (2000) on the healing power of
cancer center settings. From the onset, brief field notes were
art.
made regarding numbers of contacts and types of activities
Family members and patients were provided with an oppor-
chosen. In 215 encounters with patients and family members,
tunity to create something new and different at a time when
no one activity was preferred over others. A monoprint that
they were highly stressed. The structured activities gave
could be created quickly and required little concentration and
them a new focus and something to do. Although many
effort seemed most user friendly. After participants created
family members would not leave patients' sides, they said
one monoprint, they usually wanted to continue and often
they were not interested in reading nor could they concen-
made several versions to use as small pieces of art or created
trate on any task. Yet when family members and patients
monoprint designs on blank note cards or postcards.
were approached, family members said that they could not
Art Infusion was well received, useful, and feasible. How-
resist trying a new and intriguing activity if they could re-
ever, continued operation of the project is dependent on the
main with the patients. Therefore, family members' energy
availability of artists and other volunteers. Future funding will
was diverted, and they appeared to enjoy and benefit from
be needed for research efforts, art supplies, and staff salaries.
creative activities.
Positive responses and anticipated significant results of the
This intervention returns participants to childhood and puts
ongoing quantitative study are hoped to provide an impetus
the right side of the brain to work. One patient noted that he
for funding a full-time Art Infusion interventionist to promote
had not colored since grade school and laughingly said he
and supervise the program.
may consider art as a new activity for the future.
Family caregiver and patient participation and staff recog-
Family members and patients have reported in previous
nition of the positive effects of the program in inpatient and
investigations that they felt vulnerable with little or no con-
outpatient situations led to a research proposal being funded
trol over the healthcare system (Councill, 1993). Thus, a
by the University of Miami's General Research Support
choice of five different activities provided participants with
Award to measure outcomes with family caregivers (Walsh,
some control, including the ability to stop activities at any
Martin, & Schmidt, in review).
time. By choosing from a menu of activities, they were able
Family caregivers and patients continue to report that they
to make decisions about the types of activities that inter-
not only enjoyed creating their works of art, but also felt less
ested them at times when they felt that they had few choices
anxious as they participated in Art Infusion. Direct quotations
about other matters in the healthcare system (Walsh et al.,
included, "I almost forgot how stressed I was," "This is fun
in press).
and helps me to relax," and "I immediately felt better when I
Art Infusion provides patients and caregivers with some-
started choosing the colors for the poster image." Participants
thing different to talk about with others. Involvement in the
often continued with activities for several hours and, in some
art activities appeared to enhance positive communication
cases, throughout their hospital stays. One patient scheduled
between family caregivers and patients, between patients
for discharge called her son and said, "Don't pick me up un-
and nurses, and between family caregivers and nurses. Par-
til late this afternoon. I need to complete several art projects
ticipants laughed, discussed activities, and offered advice
before I leave." Several participants indicated that they had a
regarding how to proceed with activities.
renewed interest in art and planned to purchase additional sup-
Table 1. Art Infusion Participants' Responses
Participants and Situation
Reaction to Art Infusion
Five family members were gathered around a dying patient (who died the next
The patient was alert and smiled when he viewed the posters. Family members
day). They all created image posters of themselves and placed the posters on
began to talk among themselves and also smiled occasionally.
the wall of the room for the patient to view.
A fragile, older woman requested the ArtKart but then said, "I do not have the
Her son, although initially not interested, began to help his mother create the
strength." However, she was able to press postcards onto a small piece of
monoprint postcards. The patient said she finally found something she could
plexiglass to make abstract monoprints that contained her favorite colors.
send to her grandchildren, "even though I'm so sick."
A daughter-in-law had spent long hours at the bedside and immediately wanted
The patient and his wife watched their daughter-in-law with interest as she
to try each activity. She kept many supplies and worked diligently on various
created various objects. They then requested that her art be displayed in the
activities for many hours.
room.
A businessman receiving chemotherapy said he always had wanted to be a bas-
He laughed and said it was a good joke. He put the poster on a bulletin board
ketball player, so he made a basketball player self-portrait.
in his room.
A dying woman and her family created a silk wall hanging together. This woman
The family had good memories about creating the silk piece together and, af-
loved beautiful clothes and bright colors.
ter the patient died, they placed it in her casket.
ONCOLOGY NURSING FORUM VOL 30, NO 6, 2003
E118
Participants, after completing one or more activities, had
is required to make a referral, participate, or simply encourage
something tangible to share with others. These creations
patients or caregivers to complete the activities. As a result of
involvement in arts activities, family caregivers and patients
often became gifts that family members gave to one an-
may require less time and attention. The authors also anticipate
other. This ability to create and give things to others at times
when they felt useless and insignificant has been valuable,
that positive communication will continue during and after
these activities as family members share thoughts about their art
particularly to some patients who are very ill.
activities with one another and nursing staff. In the programs
that already are established, nurses are collaborating with oth-
Outcomes
ers to provide different and creative interventions with patients
and families (F. Falk & P. Jacobsen, personal communication,
During the first year of the project, with teams available six
November 5, 2001; Lane & Graham-Pole, 1994). Thus, nurses
to eight hours per week, the groups worked with 215 patients
who are interested and willing to learn new approaches may be-
and caregivers. To the intervention team, the most evident and
come involved more significantly in promoting similar creative
gratifying outcome often was displayed on the smiling faces of
arts activities and programs with a variety of patients and family
those who were able to create something beautiful, humorous,
members.
or inspirational during such difficult times. The husband of a
The outcomes of Art Infusion are evaluated continually, and
patient who was diagnosed with mouth cancer told the interven-
quantitative outcomes will be reported at the completion of
tion team that he and his wife had been extremely anxious and
the research project. Future qualitative work, including in-
depressed since the diagnosis. While his wife was receiving
depth interviews with participants, also may provide new in-
chemotherapy, he created a silk wall hanging with "I love you"
formation about how the intervention works. If quantitative
written on the silk. When the husband gave his wife this gift,
results from the current investigation determine that Art Infu-
her eyes filled with tears, and she began to smile. She held the
sion is effective, future plans may include expansion of the
silk piece on her lap and continually looked at it. Both said that
project to other healthcare facilities.
their participation in Art Infusion provided a positive experi-
ence for them during very difficult times.
Summary
The study's research portion was completed after 40 sub-
jects had enrolled. Results were highly significant (p < 0.01)
Family caregivers and patients with cancer noticeably
on three self-report measures that showed lowered stress, re-
changed their demeanors and attitudes as soon as they en-
duced anxiety, and increased positive emotion in family
gaged in creative art activities. They became animated, de-
caregivers after participation in arts activities (Walsh et al., in
bated about colors and designs, and laughed and joked about
review). A growing body of literature demonstrates that stres-
one another's efforts. Art Infusion is a novel approach that
sors are associated with decreased immune function (Ader,
merits further investigation both quantitatively and qualita-
Cohen, & Felten, 1995; Baron, Cutrona, Hicklin, Russell, &
tively with family caregivers because researchers continue to
Lubaroff, 1990; Cacioppo, Poehlmann, Kiecolt-Glaser,
suggest that new, innovative approaches are needed for the
Malarkey, & Burleson, 1998; Herbert & Cohen, 1993;
h a r d - t o - r e a c h family caregiver population (Aranda &
Kiecolt-Glaser, Marucha, Malarkey, Mercado, & Glaser,
Hayman-White, 2001; Ferrell, 1996; Kozachik et al., 2001).
1995). Therefore, in future studies, researchers plan to take
Nurses and artists were able to learn during a three-hour
salivary cortisol measures before and after the intervention to
workshop how to facilitate and implement the intervention.
enhance self-report findings. The use of cortisol to measure
During this implementation and preliminary evaluation, Art
stress has been discussed by Bartlett, Kaufman, & Smeltekop
Infusion provided distraction, promoted communication, and
(1993) and Antoni et al. (2001).
appeared to be a comforting and stress-reducing intervention.
Currently, three intervention teams are in place, and more
Family members and patients validated that participation
than 450 family caregivers and patients with cancer have par-
helped them to have illuminating, joyful memories even during
ticipated in Art Infusion since its implementation in 2001. The
very difficult times. The use of creative art activities was an
initial idea of creating nurse and artist teams to capitalize on
innovative and useful approach to infuse art into the nursing
the unique talents of both nurses and artists has been vali-
care of family caregivers and patients with cancer.
dated. The team approach also provided team members the
opportunity to debrief one another after what were often very
Support and encouragement are acknowledged from artists and intervention-
poignant events. Thus, team members were able to share their
ists Wilma Siegel, MD, Marianela Borsten, Lynette Huber, BA, Amparo Roca,
responses and reactions with others.
MS, and Margaret Fears-Lewis, BSN. Additionally, Inpatient Unit Manager
Miriam Hernandez, BA, and Volunteer Services Coordinator Sue Radcliffe,
MA, of Sylvester Comprehensive Cancer Center in Miami, FL, facilitated imple-
Nursing Implications
mentation of the intervention.
Nurses are in key positions to determine whether patients and
family caregivers are likely to benefit from a creative art ap-
Author Contact: Sandra M. Walsh, RN, PhD, can be reached at
proach (Carlisle, 1990; Councill, 1993; Heiney & Darr-Hope,
swalsh@mail.barry.edu, with copy to editor at rose_mary@earth
1999; Walsh & Hogan, 2003; Young-Mason, 2000). Little time
link.net.
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