Altay, N., Kilicarslan-Toruner, E., & Sari, Ç. (2017). The effect of drawing and writing technique on the anxiety level of children undergoing cancer treatment. European Journal of Oncology Nursing, 28, 1-6.

To determine the effect of drawing and writing technique on the anxiety level of children treated for cancer during hospitalization.

A five-day therapeutic program to reduce anxiety of children in treatment for cancer was implemented to understand the effect of continuous therapeutic play. Drawing, writing, and mutual storytelling techniques were pre-arranged in the child’s room. Drawing supplies were given to the children. The State Anxiety Inventory was administered on the first day. Drawing was implemented on the first and third days. Children were asked to draw a picture of a child in the hospital and to write a self-created story with a beginning, a middle, and an end about his or her drawing. Mutual storytelling was implemented on the second and fourth days. While listening to the story of the child, the researcher analyzes the themes and psychological meaning for the child. The researcher responds with a story that is similar but has a more positive ending. On the fifth day, the State Anxiety Inventory is administered for the second time.

• N = 30   
• AGE: Mean = 12.56 years (range = 9-16)
• MALES: 7 (23%)  
• FEMALES: 23 (77%)
• CURRENT TREATMENT: Chemotherapy, combination radiation therapy and chemotherapy
• KEY DISEASE CHARACTERISTICS: Leukemia, solid tumor, lymphoma
• OTHER KEY SAMPLE CHARACTERISTICS: Had received two or more courses of chemotherapy; child and parent consent to participation

• SITE: Single site   
• SETTING TYPE: Inpatient    
• LOCATION: Gazi University, Ankara, Turkey

• PHASE OF CARE: Active anti-tumor treatment
• APPLICATIONS: Pediatrics

Quasi-experimental (pre- and postintervention evaluations of a single group)

• Descriptive data collection
• State Anxiety Inventory
• Wilcoxon test

The five-day program was evaluated on the first and fifth day. The State Anxiety Inventory mean score (38.63 [SD = 4.38]) for children after the intervention decreased when compared to the mean beginning score (42.63 [SD = 4.64])  (Z = -4.57, p < 0.05). Only 2 of the 30 children wanted to keep the drawings after the intervention.

Drawing and writing and mutual storytelling techniques can be used to reduce the anxiety levels of children in treatment for cancer. The five-day program time interval and intervention could be implemented in future research.

• Small sample (< 30)
• Risk of bias (no control group)
• Risk of bias (no random assignment)
• Unintended interventions or applicable interventions not described that would influence results
• Other limitations/explanation: No information was provided on who implemented the writing and drawing program, although there is a mention of nursing staff or the "researcher" doing this but it was not made clear who this was and what training he or she had.

Writing and drawing can enable children to express their emotions and fears in an artistic format. Nurses should use these techniques to help uncover the hospitalized child’s anxiety. Training for interpretation and projective techniques in therapeutic communication with children would be helpful in hospital settings.