An Art Intervention to Promote Comfort with Veterans in Long Term Care: From Not Significant (Ns) To Significance

Research Article

Walsh Sandra1, Garcia Stephanie2, Flowers Monica1*, Olenick Maria1, Parchment Yvonne1


 1Nicole Wertheim College of Nursing and Health Sciences, Florida International University, Miami, FL, USA

2Robert Stempel College of Public Health & Social Work, Florida International University, Miami, FL, USA


*Corresponding Author: Monica Flowers, DNP, APRN, FNP-BC, Nicole Wertheim College of Nursing and Health Sciences, Florida International University, 11200 SW 8th Street, AHC3-330, Miami, FL 33199, USA, Email:


Received Date: September 06, 2019    Accepted Date: October 10, 2019       Published Date: October 18, 2019


Citation: Walsh Sandra, Garcia Stephanie, Flowers Monica, Olenick Maria, Parchment Yvonne (2019). An Art Intervention to Promote Comfort with Veterans in Long Term Care: From Not Significant (Ns) To Significance. POJ Nurs Prac Res. 3(1):1-4. DOI:


Copyright: ©2019 Monica Flowers, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.




Objectives: The study objective was to promote hospitalized veterans’ comfort through an art intervention (AI). Kolcaba’s comfort theory guided the study.


Sample and setting: Researchers recruited residents from a Community Living Center (CLC) at Miami Veterans Administration Healthcare System (MVAHS). Nurse researchers and recreational therapists collaborated to deliver the AI.


Methods and variables: A quasi-experimental pre-post-test design tested the AI on veteran comfort, depression, and social connectedness.


Results: Over six-months, staff identified 81 residents as appropriate to recruit for the study. Fifty-one males and 10 females (ages 26-95) agreed (75% response rate). Due to data collection challenges, residents’ cognition, time constraints, disabilities, and respondent burden, only 18 sets of usable pre-post data were available for analysis (ns results).


Implications for nursing: The AI was “significant” to many other participants (n = 160) who were unable or unwilling to complete the research instruments. The most popular AI activity, the monoprint, has been “adopted” by recreational therapists and suggested to enhance communication with oncology patients. Kolcaba’s comfort theory will continue to be promoted during art activities on CLC I and II with extension of art activities to the bedside of CLC III Hospice residents.


Keywords: Veterans, Art, Intervention, Comfort, Long Term Care




Millions of veterans are treated at 1,700 Veterans Administration (VA) sites throughout the United States. Particularly poignant are the plights of veterans with multiple diagnoses requiring long-term care. Many veterans with serious, chronic, and/or terminal conditions are living out their lives as residents in VA Community Living Centers (CLC). The mission of a CLC “is to restore each veteran to his or her highest level of well-being. It is also to prevent declines in health and to provide comfort at the end of life” [1].


The use of the arts and alternative therapies, including music, hand massage, therapeutic touch, tender touch, singing, and using or holding musical instruments may provide comfort [2-6]. Similar activities promoted health and well-being in vulnerable groups but have not yet been tested with hospitalized veterans [7-10].




The objective of this pilot study was to promote comfort through the implementation of an art intervention (AI) with hospitalized veterans. The AI activities utilized in this study were NOT considered art therapy. Kolcaba’s comfort theory (2017) guided the study.


Sample, Setting, and Description of the AI


Nurse researchers, in collaboration with recreational therapists, offered the AI to veterans living in a long-term CLC at Miami Veterans Administration Healthcare System (MVAHS). Researchers and a recreational therapy team were present and assisted researchers during bi-weekly creative art sessions with residents on CLC I and II (CLC III Hospice residents were not available).


The AI was developed from findings in previous studies (7-10). The AI consists of three brief, user-friendly art activities: a monoprint, a ribbon gem, and a self-image portrait. Over a six-month period, the activities were offered during creative arts sessions or during individual interactions in residents’ rooms or common areas of the CLC I and II.


The objective was to increase the comfort of the residents as defined by Kolcaba (2017) [11]. Kolcaba (2017) defines comfort as “the immediate experience of being strengthened by having needs for relief, ease, and transcendence met in four contexts (physical, psycho-spiritual, sociocultural, and environmental); much more than the absence of pain or other physical discomforts” (p. 196). The purpose of this pilot study was to test the effects of the AI with CLC I and II residents. Approximately 15-20% of CLC I and II residents are oncology patients, and others are “at risk” due to a history of cancer (personal communication, nursing administration, 3/18/2019). The research question was: “Does comfort increase, depression decrease, and social connectedness increase in residents after participation in the AI?” The hypothesis was: Residents that participate in the AI will have increased comfort and social connectedness and decreased depression scores post AI when compared to pre-test scores. Residents served as their own controls.


Methods and Variables


Researchers received ethics approval from Florida International University and the MVAHS’s Institutional Review Boards (IRB). Researchers followed the approved IRB protocols to recruit potential subjects. Residents who agreed to participate completed a short demographic data sheet and three instruments. After pre-testing, the interventionist assisted the resident to complete the AI. If a resident desired to participate in the AI but did not want to participate in the research or was cognitively impaired (per medical diagnosis) and could not understand the research process, the resident participated in the AI the same as research participants but did not complete the research instruments.


Instruments consisted of a 34-item version of Kolcaba’s comfort scale (2017), one five item faces scale that was researcher generated (similar to the Wong-Baker FACESTM), and one social connectedness binary scale (researcher generated – two pictures with one portraying isolation/ and one portraying a person in a social group). Every resident (with one exception) throughout the six months of data collection needed assistance to complete the instruments. Some residents completed the same activity several times.




Descriptive and inferential statistics addressed the study objective and tested the hypothesis. One hundred sixty participants were approached and, while very excited to complete AI activities, were either unwilling or unable to complete the research portion of the study. Another 81 residents agreed to participate in the research, but data was collected on 61 (75% response). Participants were predominantly male (84.1%) and lived on CLC 1 (62.8%) where the group activity room was located. Ages ranged from 26 to 95. Of these 61 participants, the majority of residents (63.6%) completed the monoprint activity.


A paired t-test and Wilcoxon signed-rank test compared pre and post general comfort scores, faces, and social connectedness scale on matched pre-post test data. The results; though, non-significant revealed positive outcomes in the hypothesized directions [Table 1].


Table 1: Results of paired t-test and Wilcoxon-Signed Rank for General Comfort, Faces and Social Connectedness Scale of MVAHS Residents (N=61*)

Before AI

After AI







General Comforta












Social Connectednessc







aPaired t-test, t=0.66, df=17, 95% CI [-11.53, 22.09], d=0.16, p=0.52 

bWilcoxon Signed Rank, Faces: Z=-1.41, p=0.16

cWilcoxon Signed Rank, Social Connectedness: Z=-1.00, p=0.32

*Residents with Baseline data only=17; Matched Baseline & Post-test data=18; Post-test data only=26 


Discussion and Implications for Nursing


Researchers found qualitative “significance” in the knowledge that large numbers of persons (n = 160) enthusiastically participated in the AI within the CLC environment even though they did not complete the research instruments. The presence of co-morbidities in residents, physical and mental, contributed to the difficulties in data collection with residents. In future studies with similar populations, researchers need to be mindful that response burden may eliminate potential participants. In this study, use of only one measure, the faces scale, would have reduced response burden not only for residents but also for staff and family members/friends who did not have the time nor interest to complete the research instruments. Additional reasons that residents did not complete both pre and posttests included residents’ cognition, loss of concentration and/or interest, time constraints, hearing and eyesight problems, and non-matching ID numbers on pre and posttests.


Researchers suggest three areas to inform practice.


1) The AI activities posed no risk and were benign, easy to implement, and excellent vehicles to promote positive communication between persons in the CLC environment. The adoption of the user-friendly monoprint by recreational therapists as useful in practice was “significant” to researchers. Additionally, one of the recreational therapists suggested that the monoprint would be a useful activity to promote comfort and communication among oncology patients and their families (personal communication, 2/10/19) (Figure 1).


Directions and supplies to create a monoprint. Time required—less than five minutes that includes a demonstration from the interventionist and “return” demonstration from participant. 

Directions/supplies—art supplies* are available from art/crafts stores or from an arts supply catalogue or via the internet. 

1. Cover –ups/aprons for participants may be needed depending on the setting. The paints suggested are staining. Also, package of wipes to clean off Plexiglas after each monoprint. 

2. *Blank creative greeting cards—made of hard stock 4 X 6 inches. Or provide blank post-cards (4 X 6) for persons who may want to mail their artwork to others. Or any other card stock would be OK. 

3. *Precut mats, 5 X 7, to “frame” the 4 X 6 monoprint. In the current study, one frame was provided to each participant. 

4. *Artists’ masking tape to secure the monoprints in a mat (frame). 

5. *Several bottles of Dr. Ph Martin’s liquid water colors. Offer vivid colors. Be sure to include primary colors—red, blue, and yellow and perhaps secondary colors–purple, green, and orange. The interventionists did not offer black or brown as these colors do not produce pleasing results. Interventionists encouraged participants to choose three colors only to avoid “mud”. Liquid water colors can be expensive (cost $3-5 per small bottle) but will last a long time. 

6. Show the participant how to drop colors at random from droppers onto a piece of Plexiglas or any type of flat washable, unbreakable surface -such as a cookie sheet or a thick piece of plastic. 

7. Mash (press) the card or postcard down on top of colors, lift, and let dry. After drying, some persons use a black pen to “create” an image on top of the colors or write a greeting on the monoprint. Many participants placed a monoprint in a mat to decorate their surroundings or gave the monoprint to a friend or family member. Most participants made many monoprints and then chose one to “frame”. Researchers encouraged the participant to sign and date their monoprints.

8. If “framing”, cut four pieces of masking tape and use the masking tape to “mount” the monoprint inside a precut mat. A 5 X 7 precut mat will fit into a standard size frame.

Figure 1: Monoprint instructions and illustrations


2) Additional interprofessional collaboration is needed and desired. Until the present pilot study was underway, nurse researchers were unaware of the purpose, objectives, aims, and activities of recreational therapists. When recreational therapists became knowledgeable about Kolcaba’s theory (2017), they agreed that theoretical concepts were consistent with recreational therapists’ goals. Researchers and recreational therapists concluded that increased knowledge about other healthcare professions would enhance comfort for residents and improve patient outcomes.

3) Art related interventions enhance the CLC environment and promote comfort. Researchers noted the appreciation and desire of residents for increased 1:1 prolonged engagement with researchers and/or staff. The chief medical officer and chief administrative nurse of the CLC have requested that researchers recruit artists, musicians, and university students from the community to provide increased 1:1 bedside engagement with CLC III (Hospice) residents (personal communication, E. Aguilar & Z. Sanabria, 3/19/19).


Knowledge Translation Statements 

  1. Hard-to-reach residents, staff, families, and visitors respond positively to art activities. Nurse leaders can promote the use of brief activities in common areas. Volunteers could provide and oversee such activities with no need for additional personnel.
  2. Nurses can promote environmental enhancement, particularly in long-term care and/or oncology settings, by resident participation in art activities or the use of visual art on walls that are meaningful to residents, healthcare staff, and visitors [12]. The art created during such projects can be displayed in hallways and/or rooms to personalize the environment.
  3. Additional volunteers are needed to offer support to CLC residents. Many veterans are “forgotten” and living out their lives with little or no personal contact from persons other than the CLC staff. While recreational therapists offer 1:1 sessions when possible, there are not enough recreational therapists to meet the needs of many isolated residents.

During group AI sessions, many agitated and/or depressed residents were cognitively unable to complete research instruments. Yet, they completed one or more AI activities. Staff noted some remarkable and surprising positive changes in these residents during and/or following the AI. Further investigation is needed to promote individualized, creative approaches with “hard to reach” residents. Researchers suggest future qualitative research to investigate residents, staff, and family/visitor reactions to similar interventions.


Interventionists and recreational therapists promoted Kolcaba’s (2017) comfort concepts of ease, relief, and transcendence during AI implementation. Future plans are to extend art activities to CLC III (Hospice). CLC administrators will continue to collaborate with University faculty to utilize university students from healthcare and other professions to participate in art related endeavors at MVAHS.




Wallace Gilroy Endowed Nursing Research Fund – Faculty Grant (2017-2018); FIU Graduate Nursing students, VA Recreational Therapists: Elizabeth Campos, Maria Garcia, and Sam Hutchinson; VA Nursing Administrator, Dr. Zahira Sanabria; VA Nurse Managers: Ms. Carmen Prieto and Dr. Gaye Belgrave.


**A manual of the activities with descriptions of each activity, step by step instructions, pictures, and list of supplies is available from the first author.



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