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Supportive Art Making as a Therapeutic Tool for Nurses.

The idea of art as medicine dates to antiquity, and the role of the arts in health care is well documented. Research has shown several emotional and mental health benefits of therapeutic art making on various populations, including individuals coping with cancer (Clapp, Tyor, Di Folco, & Mackinnon, 2018). There are hospital committees solely dedicated to environmental enhancement, selecting music and artwork that elicit calm and promote healing. Medical schools around the country are incorporating fine art in medical curricula to formally teach observational skills to enhance visual diagnostic skills in physicians (Dolev, Friedlaender, & Braverman, 2001). Seeking innovative ways to support their patients, healthcare professionals are turning to the arts and collaborating with creative arts therapists to broaden their scope and reach.

Creative arts therapists--art therapists, dance/movement therapists, drama therapists, music therapists, poetry therapists, and psychodrama therapists--are integrative mental health and human services professionals who embody this unique intersection of art and health. Creative arts therapists enrich the lives of individuals, families, and communities through the clinical, evidence-based application of art and creative processes. In art therapy, clients use art making within a therapeutic relationship to achieve therapeutic goals, including improving cognitive and sensory-motor functions, fostering self-awareness, cultivating emotional resilience, and resolving conflicts (American Art Therapy Association, 2017).

Medical art therapy is defined as the specific use of art therapy with individuals who are physically ill, experiencing trauma to the body, or undergoing aggressive medical treatment (Malchiodi, 1993). Medical art therapists are frequently embedded within interprofessional team models and play an important role in supporting the psychosocial needs of children and families in pediatric medicine. Art therapy practiced in the medical setting helps individuals and families communicate and cope with pain, anxiety, complex health-related issues, lifestyle transitions, grief, and loss. It is important to note that art therapy facilitated in a medical setting differs from art therapy facilitated in a psychiatric setting, due to differences in the environment, treatment goals, family presence, and specific restrictions of certain art materials that might be unsafe or inappropriate for the setting.

Although only art therapists (or other mental health professionals who hold an additional credential) should facilitate art therapy, nurses and other health professionals may incorporate supportive art making with patients within their professional scope. 'Art as therapy,' in contrast to the use of art within a psychotherapeutic context, is the idea that art making and the creative process is, in and of itself, therapeutic (Malchiodi, 2012). Various professionals use art in different ways, with physical, social, emotional, or educational goals in mind. For example, a child life specialist working in the emergency department might use art following a painful procedure to elicit self-soothing. A physical therapist might engage a patient in a large gestural painting to invite rehabilitative movement. A hospital teacher might incorporate art in a lesson plan to create a more engaging assignment. Nurses may turn to art to strengthen the relationship with their patients, invite healthy expression, and support coping efforts by nurturing the internal resource of creativity. There is a place for everyone around the 'art table,' so long as goals, boundaries, and intentions are clearly defined.

Facilitating Coping through Supportive Art Making

When faced with uncertainty and pain so often accompanying serious illnesses, children are tasked with discovering ways to cope. Psychological coping is defined as a person's cognitive or behavioral efforts to tolerate or reduce internal or external demands of a stressful situation, which are exceeding the person's resources (Folkman, Lazarus, Gruen, & DeLongis, 1986). Coping involves two major functions: managing the problem that causes stress and regulating one's emotional response. Internal resources--the skills, practices, and abilities that support an individual to feel grounded, supported, or relaxed--are essential to draw upon in times of need. Creativity is one such internal resource that can be nurtured by all members of the child's healthcare team. Creativity requires expression, problem solving, adaptability, and flexibility of thought--all of which come into play in a child's efforts to cope.

Nurses play an essential role in the healing process by supporting emotional needs of patients and their loved ones. One challenge nurses face is managing children's pain, and feelings of anxiety may intensify pain levels. Nurses may take initiative to support emotional needs of the child and family in addition to their other nursing duties. The development of a positive nurse-patient relationship is paramount for the delivery of quality care (McCabe, 2004). Positive interpersonal relationships, including an emotionally supportive nurse, may improve satisfaction of care received (Johansson, Oleni, & Fridlund, 2002). Nurses are encouraged to use non-pharmacological tools to alleviate distress; art can become a tool in the nurse's arsenal of key nursing strategies.

As a child I worked with said, "I like art! Art does not hurt." Art is a safe and healthy way for our patients to tell their stories without the limitations of language and without pain. It is our duty as the patient's advocate to hold these stories, share them when warranted, and nurture a safe environment for continued expression so children can make meaning of their experiences.

In The Expressive Arts Activities Handbook, Darley and Heath (2008) emphasize that even basic, innocuous art projects can be profound and reflective. Art therapists can attest that certain subjects within art making and select art materials may bring up feelings that require psychotherapeutic intervention. It is important that whoever facilitates the art making experience sets expectations and tone, and collaborates with appropriate team members if an issue arises that is out of one's professional scope.

Nursing Strategies for Supportive Art Making

The nurse's role in facilitating a creative experience is one of support. To this end, the child should be encouraged to choose what they want to create. The point of the interaction is not to create 'good' art or art that makes sense. To support the child in this goal, technical skill should not be emphasized. but rather, on children's effort and choices surrounding their creative experience. The creative process should be viewed as an avenue for expression ans connection. For example, children can rip up their artwork at the end, and nurses, in their supportive role, may join in on this process. The child's relationship with the nurse is an important element of the experience; with proper support, the child may feel uninhibited. The nurse should have no expectations or rules (unless the child's safety is compromised).

Creating Safe Space

Emotionally nurturing spaces can be difficult to carve out in the clinical setting where the focus is typically on medical intervention. Safe spaces should be intentionally cultivated and can serve as a place of refuge. Psychologists have identified the main elements used to foster emotional safety. D.W. Winnicott, a pediatrician and psychoanalyst, coined the term holding environment to describe a supportive environment that a therapist creates for a client. This space echoes the nurturing and caring behavior felt between infant and caretaker that results in a sense of trust and safety (Winnicott, 1971). Rogers, a humanistic psychologist, theorized that individuals need a specific environment to grow--an environment that is genuine, accepting, and empathic (Schneider, Bugental, & Pierson, 2001). Creating an environment void of criticism and judgment allows children to be themselves. Providing an undistracted, supportive presence fosters emotional safety, which is the foundation of meaningful, creative work. Nurses may adopt these ideals when engaging a child in supportive art making.

Art Materials as Therapeutic Tools

Children with chronic or life-limiting conditions may endure frequent poking and prodding as well as pain that heightens anxiety. The hospitalized child is suddenly introduced to new sights, smells, and sounds that disrupt basic rhythms of life such as sleep and meal time. The multisensory nature of art making can awaken dulled senses, sooth senses acute from suffering, and provide pleasurable experiences amidst discomfort and pain.

The art materials themselves are what hold such power in a child's efforts to cope. Materials can be soft, soothing, and malleable, inviting the child to use art as a coping tool throughout a creative process. Art therapists pay close attention to material selection when working with patients, as the properties of art materials may evoke different responses in different patients. Take watercolor paint for example: one child grappling with feeling constricted may respond well to the watercolor's fluidity, feeling a sense of freedom in the creative experience; another child needing control may feel frustrated by their inability to control the material. Certain materials may also be contraindicated for certain populations because the material may be triggering or invite regression. Nurses can collaborate with art therapists, child life specialists, and recreational therapists for direction in this area. Art-based mindfulness activities, such as drawing to music, can support emotional regulation and empower children to participate in the work of feeling better or getting well.

Supporting Connection

Serious illness threatens one's sense of connection to both self and others. Immuno-compromised children may be isolated for months in the hospital or at home. When coping with feelings of isolation, art making may serve an important role in supporting connection. Creating art side-by-side or working collaboratively can build trust between nurse and patient, and help the child feel a sense of comfort. Creating art with a child introduces a different way of relating within the clinical environment and can 'level the playing field.' Something as simple as scribbling on a page together after administering medication, can invite a supportive and playful exchange that may humanize an otherwise sterile medical interaction.

Fostering Control

Children confronted with illness may grapple with feelings of self-blame and punishment, and often feel out of control. A non-directive approach within art making can mitigate this loss of control by placing control back in the hands of the child. Using a non-directive approach, the nurse does not ask the child to make anything in particular, or for anyone in particular. The nurse does not attempt to direct the child's actions, conversation, or artistic choices. Children choose the materials they will use, what they will create, how they will create it, and where the piece goes at the end. Children also choose to stop art making whenever they wish. The child leads the way and the nurse follows along, providing as many choices as possible, including the choice to abstain altogether. Giving the option to choose not to do something can actually be empowering in an environment with limited choices. The goal for the art making experience is to allow for complete self-direction. This may challenge the passivity, helplessness, and victimization that often marks the experience of being a patient.

Activating Expression

For children with serious illness, "becoming an object of medical processes can raise significant issues of identity' (Tjasink, 2010, p. 75). Inviting a creative process may provide a more comfortable, disarming, and tangible way to process complex illness experiences. An adolescent girl with osteosarcoma refused to verbally communicate with her healthcare team but turned to clay to repetitively sculpt her tumor--and then furiously destroy it--discovering an appropriate way to release her anger. A school-aged boy who received a heart transplant was mourning the loss of his organ and discovered a productive way to channel his grief by writing letters to his 'old' heart. A child who was bullied for physical differences due to his scoliosis safely disclosed these issues in a self-portrait. Oftentimes, children are searching for ways to project experiences and express feelings, and can direct themselves when given the proper tools, emotional safety, and support. In these instances, the children spontaneously created these pieces of art and writing without direction or prompting from their care provider.

Rode (1995) describes art therapists, child life specialists, and other psychosocial professionals who facilitate creative expression with ill children as "translators of experience" (p. 106). Although it is not the nurse's responsibility to translate and/or analyze a piece of artwork or miraculously know the meaning of a child's symbols, nurses may engage children in a supportive dialogue about their creations to shine light on the child's experience. If the child is interested in sharing about his or her artwork, the nurse can ask open-ended questions to invite in-depth responses. Asking, "What can you tell me about your picture?" as opposed to simply complimenting the artwork invites the child to elaborate on their creations. The nurse should avoid labeling anything in the artwork, even if it seems obvious, so the child can identify the subject matter and reveal what he or she feels comfortable sharing. Nurses should express curiosity and take interest in what the child has created. Some children will not want to talk about their artwork and sometimes the artwork will speak for itself.

Occasionally, concerning themes may present themselves in the artwork. Furthermore, symbols in a child's artwork may precede verbalizations of issues ranging from worries to larger mental health issues. Nurses can look out for any kind of exaggerated or distorted body parts because this could indicate a misconception related to their illness experience. Themes of violence and self-harm displayed in artwork should not be taken lightly and may require inter-professional collaboration. Simply voicing concerning artwork during medical rounds can allow for proper support to be provided to patients, a synergistic interaction of healthcare providers.

Art as Legacy

Art and creative experiences can play a very special role in the life of a dying child. Creating in the face of illness is an important statement of one's personhood, one that asserts that the individual is living, growing, connecting, and relating, thus challenging the ferality of disease. Providing materials and encouraging family art making at the bedside may provide meaningful interactions for family members to reengage with their respective roles of parent and child. If the child is too weak to participate, creating a designated area within a patient's view for loved ones to leave messages can serve as a visual reminder of comfort and love.

Legacy building interventions are those that support memory making during difficult healthcare experiences (Sisk, Walker, Gardner, Mandrell, & Grissom, 2012). For patients with life-limiting illness or those at the end of life, legacy building may be at the forefront of the child's needs. A hand print of an infant, a recorded interview between mother and child, and a handwritten letter from a teenaged boy are just some of the legacy-building activities that nurses have assisted with. Collaging photographs and inviting families to bring meaningful objects from home can also provide rich opportunities for memory making and reminiscing. Any piece of art can serve as a legacy piece and has the potential to become what Winnicott (1971) calls a a transitional object, a meaningful object that brings psychological comfort, throughout a bereavement process. For children with life-limiting illnesses, recognizing that children's creations, and their act of giving them away, holds symbolism laden with meaning that affords enormous value to their loved ones. Many times, it is the way that a child begins the difficult process of saying goodbye. For these reasons, nurses should treat artwork as an extension of the child, handling it with care, and finding a safe place for storage. Arrangements should be made to send artwork left behind to the family's home, if possible.

The spiritual needs of the dying child can also surface in art and play if given the opportunity. One child was able to express her fear of being alone in her dying process in a drawing of her hospital room. Her nurse and family members were able to provide her with much needed reassurance that she would not be left alone. Another adolescent drew pictures of heaven with her nurse and engaged in a conversation about what would happen to her when she died, and if her family would be okay. Recognizing the child's need for expression is an essential component of a child's care, especially when navigating the complex terrain at end of life. The arts have the potential to heal the spirit even when medicine cannot heal the body.

A Note on Permission and Safety

Facilities have different policies; thus, it is important that nurses may need to receive appropriate permission from supervisors before engaging in art with patients. Nurses should use non-toxic art materials and follow infection control procedures. The age of the child will dictate what materials will be appropriate and safe. Nurses should consult with supervisors and the child's care team to provide experiences that support development and, if necessary, psychiatric needs.

As Councill (2012) eloquently states, "Art therapy brings familiar materials and the universal language of visual expression to the foreign land of medicine" (p. 238). However, art can be used as therapeutic tools by many different disciplines so long as intentions are clearly defined. Art, play, and other creative interactions in a medical environment can humanize the healthcare experience, affirm life, and help give voice to experiences that may be indescribable with words alone.

Conclusion

Supportive art making is a unique form of child-centered communication. The blank canvas welcomes projection, expression, and containment. Art can be destroyed, repurposed, and revisited. The creative process can serve as an outlet for children to release aggression, ask questions, and discover ways to relax. Its creator can simultaneously examine and gain distance from his experience by looking at their piece of art. Through art, children may challenge the tight grip of illness, re-author their personal narrative, or leave a part of themself for generations to come.

Frequently, in a clinical or medical setting, emphasis is placed on what a child cannot do, or parts of the child that are unwell. Fundamentally restorative and developmentally sensitive, supportive art making places a strong focus on children's abilities and strengths, the parts of them that are healthy. By nurturing the internal resource of creativity, nurses can support patients in their coping efforts. In turn, nurses will receive a more holistic view of the child for whom they are providing care.

References

American Art Therapy Association. (2017). About art therapy. Retrieved from https://arttherapy.org/about-art-therapy

Clapp, L.A., Taylor, E.P., Di Folco, S., & Mackinnon, V.L. (2018). Effectiveness of art therapy with pediatric populations affected by medical health conditions: A systematic review. Arts & Health. doi:10.1080/17533015.2018.1443952

Councill, T. (2012). Medical art therapy with children. In C. Malchiodi, Handbook of art therapy (pp. 222-240). New York, NY: The Guilford Press

Darley, S., & Heath, W. (2008). The expressive arts activity handbook: A resource for professionals. London, England: Jessica Kingsley Publishers.

Dolev, J.C., Friedlaender, L.K., & Braverman, I.M. (2001). Use of fine art to enhance visual diagnostic skills. JAMA, 286(9),1020-1021.

Folkman, S., Lazarus, R.S., Gruen, R.J., & DeLongis, A. (1986). Appraisal, coping, health status, and psychological symptoms. Journal of Personality and Social Psychology, 50(3), 571-579.

Johansson, P., Oleni, M., & Fridlund, B. (2002). Patient satisfaction with nursing care in the context of health care: A literature study. Scandinavian Journal of Caring Sciences, 16(4), 337-344.

Malchiodi, C.A. (1993). Introduction to special issue: Art and medicine. Art Therapy, 10(2), 9. doi:10.1080/07421656.1993.10758983

Malchiodi, C. (Ed.). (2012). Art therapy and health care. New York, NY: Guilford Publications.

McCabe, C. (2004). Nurse-patient communication: An exploration of patients' experiences. Journal of Clinical Nursing, 13(1), 41-49.

Rode, D.C. (1995). Building bridges within the culture of pediatric medicine: The interface of art therapy and child life programming. Art Therapy, 12(2), 104-110. doi:10.1080/07421656.1995.10759140

Sisk, C., Walker, E., Gardner, C., Mandrell, B., & Grissom, S. (2012). Building a legacy for children and adolescents with chronic disease. Journal of Pediatric Nursing, 27(6), e71-e76. doi:10.1016/j.pedn.2012.04.008

Schneider, K.J., Pierson, J.F., & Bugental, J.F.T. (2001). The handbook of humanistic psychology: Theory, research, and practice. London, England: SAGE Publications, Inc.

Tjasink, M. (2010). Art psychotherapy in medical oncology: A search for meaning. International Journal of Art Therapy, 15(2), 75-83.

Winnicott, D.W. (1971). Playing and reality. London, England: Penguin Books.

Sarah Yazdian Rubin, ATR-BC, LCAT, CCLS, is a Board-Certified Creative Arts Therapist and a Child Life Therapist, SYR Art Therapy, Nashville, TN.
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Title Annotation:The Children's Corner: Perspectives on Supportive Care
Author:Rubin, Sarah Yazdian
Publication:Pediatric Nursing
Article Type:Report
Date:Mar 1, 2019
Words:3334
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