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Practice Innovations

Creative Art Expression: Using Hand-Lettering Techniques to Reduce Stress and Anxiety in Patients With Cancer

Cindy Cao
Shanna D. Sullivan
Meghan L. Underhill-Blazey
CJON 2021, 25(1), 97-99 DOI: 10.1188/21.CJON.97-99

A creative art expression intervention using hand lettering was implemented on an outpatient oncology unit and evaluated for feasibility and its relationship with stress and anxiety in patients with cancer. Results suggest that a hand lettering intervention is feasible in this type of setting and may benefit patients experiencing stress and anxiety during outpatient treatment.


  • Hand lettering is a safe, low-cost, noninvasive, and nonpharmaceutical intervention to administer to outpatients with cancer.
  • Institutions may implement hand lettering to occupy patients with cancer while awaiting treatment.
  • Hand lettering as a creative art expression intervention has produced observed benefits for outpatients with cancer experiencing stress and anxiety.

Hand lettering is the art of drawing beautiful letters. It is an understudied form of creative art expression that is easy to use, has a low time burden, requires little resources, and can be adapted to a variety of settings. A grant funded by the Integrative Nursing Program at Dana-Farber Cancer Institute in Boston, Massachusetts, was used to develop an institutional review board–approved exploratory study using a creative art expression intervention with the guidance of a nurse scientist. This intervention was chosen specifically for patients with cancer because of the emotional distress and anxiety surrounding cancer diagnosis and treatment. A cancer diagnosis and treatment often lead to significant stress, anxiety, adjustment issues, and emotional disturbance (Underhill et al., 2012). Patients have expressed that psychological distress associated with treatment can be just as overwhelming as the physical side effects.

Previous studies have examined the effect of creative interventions on a patient’s mental, physical, and spiritual state (Bilgin et al., 2018; Lane, 2005; Saw et al., 2018). Art intervention programs currently exist in a variety of settings, including art therapy courses and art-making experiences in outpatient oncology and blood and marrow centers (Götze et al., 2009; Lawson et al., 2011). Creative art processes are one therapeutic strategy that may lead to feelings of healing and reduced anxiety through the expression of emotion (Boehm et al., 2014; Meyer, 2012).

The backbone of this creative art expression intervention was Watson’s theory of transpersonal caring (Watson, 2019). Watson’s framework incorporates the philosophy and science of caring and includes four components: human being, health, environment, and nursing (Petiprin, 2016). This model was appropriate for the application of creative art expression in this ambulatory environment because of its emphasis on the role of nursing in facilitating therapeutic relationship with human beings. Major assumptions of Watson’s theory include (a) effective caring promotes patient growth, (b) faith and hope provides a sense of well-being through meaningful belief systems, and (c) nursing communication validates positive and negative patient expressions (Current Nursing, 2020; Petiprin, 2016). This intervention provided patients the time and space to self-direct a creative experience that promoted a sense of autonomy. The nurse promoted healing through presence and encouraging exploration of words pertinent to their healing process. Such holistic nursing measures have been shown to reduce stress and anxiety and increase quality of life for patients (Liu et al., 2016). In addition, tenants of integrative nursing and Watson’s theory demonstrate that presence can promote coping and expression of feelings, leading to a deeper connection (Watson, 2019).

The primary objective of this study was to evaluate the feasibility of implementing nurse-led hand lettering in an ambulatory infusion setting. A secondary objective was to describe patient self-reported anxiety before and after using hand lettering.


The study took place on a gynecologic, thoracic, and neurologic cancer and desensitization unit at Dana-Farber Cancer Institute. Patients were screened for eligibility. To be eligible for this study, patients had to be older than age 18 years with a cancer diagnosis, receiving oral or IV chemotherapy, able to read and speak English, and have a minimum appointment time of 60 minutes. Patients with visual impairment or blindness were excluded.


Eligible patients were approached, and signed consent was obtained to participate in the study. Participants were provided with teaching sheets regarding the intervention. Patient self-reported data were collected via the State–Trait Anxiety Inventory (STAI) (Spielberger & Sydeman, 1994). The STAI is a validated 40-item instrument to measure state anxiety (the person’s current and temporary anxiety) and trait anxiety (the person’s long-standing quality or personality trait) (Spielberger & Sydeman, 1994). This measure has been widely used in oncology and art therapy in previous literature (Bilgin et al., 2018; Boehm et al., 2014; Nainis et al., 2006). Response options were ranked on a scale ranging from 1 to 4, with 4 indicating more anxiety. The subscale scores range from 20 to 80. Both the state and trait subscales were administered before the intervention.

Patients participated in a hand-lettering intervention at the bed- or chairside with the infusion nurse. The nurse guided hand-lettering techniques consisting of thin and thick stroke practices, tracing over stencils, and freehand activities with brush pens. Patients had the option to have relaxing music played during each session. A trained nurse sat with the patient for the entirety of the hand-lettering session and directed their art experience using open-ended questions, verbal and nonverbal communication cues, and active listening, which have been correlated with reducing anxiety (Trupkovic et al., 2018).

The state anxiety subscale alone was administered after the intervention. Results were then imported into IBM SPSS Software, version 24, and analyzed. On average, it took eight minutes to complete the presurvey and four minutes to complete the postsurvey.


Feasibility was measured by completion rate of patients who participated in the intervention and total cost. Fifty-three patients were screened and 52 were eligible for the study. Of the 52 patients, 47 were approached and 22 consented to receive the intervention (47% enrollment rate). Of the 22 patients who consented, 21 completed the study in its entirety (96% completion rate), suggesting that the intervention was feasible for nurses to implement and patients to participate in and complete. Table 1 includes the sample’s demographics.

The total cost for intervention materials were $52.55 to accommodate approximately 50 patients, or $1.06 per patient. Items purchased included 50 information sheets, 8.5 × 11-inch copy paper, 9 × 12-inch tracing paper, two clipboards, and brush-tip markers/pens. The cost of the RN or staff time to administer the intervention is not included in this figure. The brevity of the intervention and the low cost of materials suggested that the intervention was feasible to implement in the ambulatory oncology setting.

Anxiety results came directly from patient STAI data. The average score for the state anxiety subscale prior to the intervention was 35.41. The postadministration score was 26, a 9.41 difference. A one-sample t test showed a significant difference between pre- and postintervention STAI subscale scores (p < 0.001). Results suggest that patients may experience decreased anxiety from an RN-guided hand-lettering intervention.


Patients with cancer being treated in an ambulatory setting may experience stress and anxiety surrounding treatment (Underhill et al., 2012). Creative therapies may decrease depressive symptoms and improve quality of life (Kongkasuwan et al., 2016). Hand lettering is a creative art expression that shows promise as a therapeutic, nonpharmaceutical intervention (Martin et al., 2018). Patients experienced decreased symptoms and emotions associated with stress and anxiety after participating in this nurse-led creative activity. High-stress environments may benefit from this cost-effective, low-risk intervention without compromising patient safety (Bilgin et al., 2018).


Limitations to this study include a small sample size and lack of a control group to understand the impact of RN presence and hand lettering on anxiety. In addition, confounding variables were present within the study that may distort the effects of anxiety on patients. These variables included additional features that patients chose to include or omit, such as soothing music and deep-breathing techniques. Future research should evaluate the intervention in the same setting to determine the impact of varying institutional workflows on feasibility. In addition, further exploration is needed to understand how trained non-nursing staff or caregivers might provide this intervention to patients or if the impact is still achieved through a self-guided intervention. Additional studies highlighting hand lettering as a key intervention for stress and anxiety are also warranted to better measure its potential efficacy.

Implications for Nursing

Nurses may benefit from using hand lettering during patient care. Hand lettering is a low-cost, nonpharmaceutical option that suggests promising benefit with minimal risk of harm to patients. Institutions looking for diversionary techniques for patients may consider hand lettering as an aid during wait times, such as during chemotherapy infusion.


Hand lettering was introduced as a form of creative art expression in patients with cancer who may or may not have experienced stress and anxiety during treatment. Hand lettering was also seen as a diversional activity that could be used for patients waiting for treatment. The purpose of the study was to evaluate whether such an intervention was possible in the outpatient infusion setting and to explore anxiety in these patients before and after a creative expression intervention. The authors concluded that a hand-lettering intervention is not only feasible to implement and practice in this environment, but also may confer positive benefits.

About the Author(s)

Cindy Cao, RN, BSN, OCN®, BMTCN®, is a clinical nurse III, and Shanna D. Sullivan, MSN, RN, AGCNS-BC, is the director of integrative nursing, both at the Dana-Farber Cancer Institute in Boston, MA; and Meghan L. Underhill-Blazey, PhD, APRN, is an assistant professor in the School of Nursing at the University of Rochester in New York and a nurse scientist at the Dana-Farber Cancer Institute. The authors take full responsibility for this content and did not receive honoraria or disclose any relevant financial relationships. Cao can be reached at clcao@mednet.ucla.edu, with copy to CJONEditor@ons.org.



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