Nursing research article critique paper

*© Oncology Nursing Society. Unauthorized reproduction, in part or in whole, is strictly prohibited. For permission to photocopy, post online, reprint, adapt, or othenwise reuse any or all content from this article, e-mail pubpermissions@ons.org. To purchase high-quality reprints, e-mail reprints@ons.org. Online Exclusive Article Preferences for Photographic Art Among Hospitalized Patients With Cancer Hazel Hanson, MSN, RN, ACNP-BC, OCN®, Kathtyn Schroeter, PhD, RN, CNOR, CNE, Andrew Hanson, MSN, RN, FNP-BC, CCRN, Kathryn Asmus, MSN, RN, OCN®, and Azure Grossman, BSN, RN, OCN® A lternative and complementary therapies may increase patient satisfaction, wellbeing, and outcomes and may be beneficial during extended stays. Music therapy, art therapy, massage therapy, meditation, and relaxation have helped many people v^ith cancer (American Cancer Society, 2012).

Complementary therapies have been evaluated with the cancer population, but little is known about the specific impact of photography (Geue et al., 2010; Oncology Nursing Society, 2009). Many hospitals now provide patients with meditation rooms and healing gardens. Thoughtfully selected artwork, including photographs, paintings, prints, and sculptures, also are found on display throughout hospitals. Although many patients and visitors can take advantage of walking outside, patients with cancer, by virtue of their decreased white blood cell counts, often are prohibited the benefits of communing with nature. Photography, however, may be one way for patients to experience the benefits of nature. In addition, although fewer patients with cancer reqtiire hospitalization at the current study facility, those that do typically are hospitalized for extended stays. The researchers of the current study have noted that, during those stays, the patient’s quality of life (QOL) and experience of the hospital environment become vitally important. Nightingale (1860) wrote about the significance of the environment for its impact on physical health, mental health, and recovery. She recognized that to regain health, people need adequate ventilation, odor reduction, and windows for natural light and outdoor views. Nightingale (1860) believed that integrating the natural environment with views of the outdoors was a strategy to improve human comfort. More than 150 years later, the impact of the aesthetics of the hospital environment on patients and healing is still being explored. Photographic art is a form of aesthetics that may positively impact a patient’s hospital experience. The primary purpose of this descriptive Oncology Nursing Forum

• Vol. 40, No. 4, July 2013 Purpose/Objectives: To determine the preferences of patients with cancer for viewing photographic art in an inpatient hospital setting and to evaluate the impact of viewing photographic art. Design: Quantitative, exploratory, single-group, post-test descriptive design incorporating qualitative survey questions. Setting: An academic medical center in the midwestern United States. Sample: 80_men (n = 44) and women (n = 36) aged 19-85 years (X = 49) and hospitalized for cancer treatment. Methods: Participants viewed photographs via computers and then completed a five-instrument electronic survey. Main Research Variables: Fatigue, quality of life, performance status, perceptions of distraction and restoration, and content categories of photographs. Findings: Ninety-six percent of participants enjoyed looking at the study photographs. The photographs they preferred most often were lake sunset (76%), rocky river (66%), and autumn waterfall (66%). The most rejected photographs were amusement park (54%), farmer’s market vegetable table (51%), and kayakers (49%). The qualitative categories selected were landscape (28%), animals (15%), people (14%), entertainment (10%), imagery (10%), water (7%), spiritual (7%), flowers (6%), and landmark (3%). Some discrepancy between the quantitative and qualitative sections may be related to participants considering water to be a landscape. Conclusions: The hypothesis that patients’ preferences for a category of photographic art are affected by the psychophysical and psychological qualities of the photographs, as well as the patients’ moods and characteristics, was supported. Implications for Nursing: Nurses can play an active role in helping patients deal with the challenges of long hospital stays and life-threatening diagnoses through distraction and restoration interventions such as viewing photographic images of nature. Knowledge Translation: Nurses can use photographic imagery to provide a restorative intervention during the hospital experience. Photographic art can be used as a distraction from the hospital stay and the uncertainty of a cancer diagnosis. Having patients view photographs of nature is congruent with the core nursing values of promoting health, healing, and hope. E337 study was to deternüne the preferences of patients with cancer for vievdng photographic art. The secondary aim of this study was to evaluate whether viewing photographic art is perceived by patients as being distracting, restorative, or both. Theoretical Framework Two theoretical frameworks. Nightingale’s (1860) and Han’s (1999), were used in this study design. Nightingale purported that nurses should manage their patients’ environments so as to assist nature in the overall reparative process. The nurse must construct environmental settings that are appropriate for the gradual restoration of the patient’s health and coordinate the external factors associated with the patient’s surroundings that can affect the patient’s life or physiologic processes (Nightingale, 1860). Han’s (1999) midrange theory. Integrated Landscape Assessment Theory, provided the current study with the foundation that identified and defined the constructs and concepts that were measured, as well as their relationships. Landscape assessment predicts “how attributes of environments relate to a wide range of cognitive, affective, and behavioral responses” (Wong, 1989, p. 6). Viewing high-quality aesthetic scenes evokes positive feelings, whereas viewing lowquality scenes evokes negative feelings. A person’s response to the scenes positively or negatively impacts his or her functioning and sense of well-being. Han’s (1999) theory explains the relationship among the physical qualities of photographs and people’s moods and preferences for specific photographs. Applied to this study, qualities of the photographs and the person’s mood determine his or her preference for types of photographs. Theoretical constructs include psychophysical factors (e.g., openness, depth, penetration), psychological factors (e.g., coherence, legibility, mystery, complexity), mood states (e.g., relaxed, anxious, fatigued, grouchy) and preferences for specific photographs (e.g., category, delivery method, viewing time). Literature Review The significance of viewing nature as a method to enhance healing was documented in a landmark study of two groups of hospitalized postoperative patients, one group with a window view of deciduous trees and the other group with a view of a brick wall (Ulrich, 1984). Findings indicated significantly shorter postoperative hospital stays and decreased pain levels in the group who viewed the trees. Ulrich and Gilpin (2003) recommended guidelines for selecting art for patients by arguing that viewing water, landscapes,flowers,and figurative art conveyed E338 optimism and safety to patients. Kaplan (1995) also recommended inclusion of natural passages. Subject matter that portrays uncertainty, negativity, overcast scenes with ominous weather, or surreal qualities should be avoided (Hathom & Ulrich, 2001; Marberry, 1995; Ulrich, 1991). Photographs of nature have been associated with improv ed outcomes in patients undergoing short-term noxious procedures and treatments. Nursing research article critique paper

Researchers studied the viewing of different forms of photography and the impact on pain associated with dressing changes (Miller, Hickman, & Lemasters, 1992), sigmoidoscopies (Lembo et al., 1998), and bronchoscopies (Diette, Lechtzin, Haponik, Devrotes, & Rubin, 2003). Changes in patient outcomes were attributed to distraction. Findings indicated an improvement in outcomes across all the studies ranging from decreased pain and discomfort, need for sedation, and side effects of therapy. Similar positive outcomes are noted in people receiving chemotherapy treatment who viewed scenes of nature via virtual reality (Schneider, Ellis, Coombs, Shonkwiler, & Folsom, 2003; Schneider & Hood, 2007). Women with breast cancer experienced a significant decrease in anxiety (Schneider et al., 2003). Participants with breast, colon, or lung cancer (men and women) enjoyed the experience and perceived the treatment as shorter, but no significant differences in symptom distress were observed (Schneider & Hood, 2007). Again, the authors postulated that the nature scenes improved participants’ outcomes because they were distracting. Other researchers believe the positive effects of viewing or being present in nature are restorative rather than distracting (Hartig, Korpela, Evans, & Gärling, 1997; Herzog, Black, Fountaine, & Knotts, 1997). Attention Restoration Theory (Kaplan, 1995, 2001; Kaplan & Kaplan, 1989) suggests one’s actual presence in or viewing of photographs of nature results in restoration from mental fatigue. Being present in nature and viewing photographs of nature is associated with positive health outcomes (Cimprich, 1993; Diette et al., 2003; Lembo et al, 1998; Miller et al., 1992; Schneider et al., 2003; Schneider & Hood, 2007). Explanations for these positive effects range from the satisfaction people experience being in a pleasant setting to an actual experience of restoration experienced when, without effort, a person who is fascinated by a picture experiences a sense of being somewhere else. In their effort to understand the restorative nature of photographic art, researchers had healthy individuals identify nature scenes they perceived a s restorative (Feisten, 2009; Berman, Jonides, & Kaplan, 2008; Han, 2007; Herzog et al, 1997).Nursing research article critique paper

Participants preferred nature rather than urban scenes (Berman et al., 2008; Herzog et al., 1997) or sports or entertainment scenes (Herzog et al., 1997) and chose photographs of tundra and coniferous forests over deserts and grasslands (Han, 2007). Vol. 40, No. 4, July 2013 • Oncology Nursing Forum Patients valued art in their hospitalized rooms and preferred images of realistic art with nature content, including animals, water, flowers, and landscapes (Nanda, Eisen, & Baladandauthapani, 2008; Nanda, Ha thorn, & Neumann, 2007). Patients liked nature images offering a sense of familiarity, greenery, or environments in which they could envision themselves. In contrast, the students ranked abstract art and stylized nature significantly higher than the patients. Although positive effects have been observed, little is known about the best process to make photographic art available to hospitalized patients. Some gaps exist in the literature related to the therapeutic use of photographic art, including poor understanding of the mechanism for how photographic art works. Two mechanisms have been proposed. Photographic art works by distracting people from their current unpleasant or noxious situation or by relieving mental fatigue and restoring the person (Cimprich, 1993; Diette et al., 2003; Hartig et al., 1997; Herzog et al., 1997; Kaplan, 1995, 2001; Kaplan & Kaplan, 1989; Lembo et al., 1998; Miller et al., 1992; Schneider et al., 2003; Schneider & Hood, 2007). Another gap is the contradictory information that exists about the types of photographs people prefer and differences in preferences across ages, genders, and personal health states (Berman et al., 2008; Feisten, 2009; Han, 2007; Herzog et al., 1997; Nanda et al, 2007,2008). As a result of the literatiire analysis, the following research questions were identified.

• How do patients like viewing the photographs? • What are patients’ general predispositions toward viewing photographic artwork? • What category of photographs and which specific photographs do patients prefer? • What category of photographs and which specific photographs do patients reject? • What types of delivery formats do patients prefer when viewing photographs? The authors hypothesized that patient preference for a category of photographic art (dependent variable) is affected by the psychophysical and psychological qualities of photographs and the patient’s mood and characteristics (e.g., age, gender, race or ethnicity, performance status, socioeconomic status [SES], QOL, fatigue). Methods The current study used a quantitative, exploratory, single-group, post-test descriptive design in addition to incorporating some qualitative survey questions for analysis. Nursing research article critique paper

A convenience sample of 90 people hospitalized for treatment of cancer was recruited. Patients were eligible for this study if they were aged 18 years or older, admitted to the blood and marrow transplantation (BMT) or hematology/oncology services for at least 24 Oncology Nursing Forum • Vol. 40, No. 4, July 2013 hours, medically stable, able to participate in the research as determined by the RN responsible for their care, English speaking, able to consent, and able to view the photographs on a computer screen. Setting The stiidy took place on the 12-bed BMT and 15-bed hematology/oncology inpatient units of the 450-bed Froedtert Hospital and the Medical College of Wisconsin, an academic medical center in the midwestern United States. All patient rooms for this study were single occupancy and located on the fourthfloorof an eight-story wing of the hospital.

Most of the rooms have an exterior window with a view of buildings and parking lots with land and trees in the distance. Six rooms on each unit face a courtyard, which contains shrubbery and trees along with a small fountain; however, trees and ñowers in the courtyard are visible only when standing or sitting in a chair next to the window. The rooms are painted beige; have healthcare informationflyers,printed signs, or posters affixed to walls; and have a clock and 24-inch television mounted to the wall along with a DVD player. Neither the rooms nor hallways contained photographic art. During the patients’ stay, many kept greeting cards or pictures of family, friends, or pets on their window sills or bulletin boards. Because of their immunocompromised conditions, patients usually were confined to the vtnit except to leave for tests or procedures. The majority of patients admitted to both the BMT and hematology/oncology units have a diagnosis of leukemia, lymphoma, or multiple myeloma. The average length of stay for patients in these settings is 12.4 days for BMT and 6.8 days for hematology/oncology. The average number of patients admitted to the BMT and hematology/oncology units is 18 and 40 patients per month, respectively. Measures Several measures were used to collect and analyze data for this study. Demographic and descriptive information: Demographic and descriptive information that was collected included age, gender, diagnosis, number of days hospitalized, service, unit, race or ethnicity, and marital status. The number of days hospitalized was defined as the day of admission to the day the patient viewed the DVD that contained the photographs. That information was obtained from the unit census report. Performance status: The Eastern Cooperative Oncology Group (ECOG) Performance Status is a simple assessment tool used to measure physical functioning in patients with cancer.

The ordinal scale is graded by healthcare providers (Oken et al, 1982). Patients receive a score ranging from 0 (fully active without restriction) to 5 (dead). E339 Table 1. Participant Characteristics (N = 80) Characteristic Age (years) Length of stay (days) X SD Range 49 7 15.48 12.91 19-85 1-107 Characteristic Gender Male Female Marital status Married Single Divorced Widowed Live with significant other Separated Education 8th grade or less Some high school High school graduate or GFD Some college or two-year degree Four-year college graduate More than four-year college degree Race Caucasian African American Bi racial American Indian Asian Mexican Service Hematology Blood and marrow transplantation Diagnosis Leukemia Lymphoma Other Multiple myeloma ECOG score 0 1 2 3 n 44 36 51 14 7 6 1 1 2 1 14 30 19 14 72 3 2 1 1 1 54 26 27 23 19 11 47 23 3 7 FCOG—Eastern Cooperative Oncology Group Socioeconomic status: The Hollingshead (1975) Four-Factor Index of Social Status measures SES and was used as a variable predictive of health outcomes (Lawson & Boek, 1960). The Hollingshead measure is a well-researched tool that computes an individual’s SES based on education, occupation, and spouse’s education and occupation, if applicable (Cirino et al., 2002). Quality of life: Quality of life was assessed with the QOL Linear Analog Scale-Assessments (LASA), a simple tool measuring perceived level of functioning. The tool consists of five single-items, each targeting a specific domain of QOL (Brown et al., 2008).

The domains include physical (e.g., fatigue, activity level), emotional (e.g., depression, anxiety, stress), spiritual (e.g., sense of meaning, relationship with God), intelE340 lectual (e.g., ability to think clearly and concentrate), and overall well-being. The 11-point linear scales range from 0 (as bad as it can be) to 10 (as good as it can be). When used with patients with cancer, the QOL LASA had a Cronbaeh alpha ranging from 0.83-0.88 (Locke et al., 2007). The results of this five-item scale are comparable with results of lengthier measures of QOL. Fatigue: As recommended by the Fatigue Guidelines Panel of the National Comprehensive Cancer Network ([NCCN], 2013) Oncology Practice Guidelines, a singleitem, numeric rating scale was used to measure general fatigue intensity during the past three days. The 11-point linear rating scale ranged from 0 (no fatigue) to 10 (worst fatigue imaginable). The simple tool is used in outpatient oncology settings and is predictive of poor outcomes (Butt et al., 2008). Visual Arts Research Survey: Based on the literature (Han, 2003,2007; Hartig et al., 1997; Kaplan & Kaplan, 1989; Ulrich & Gilpin, 2003), the researchers developed a survey to match the purpose of the study. The Visual Arts Research Survey contained 35 questions focusing on patient preferences for photographic art, mood state or emotional response, and distraction or restoration.

Two open-ended questions were used to allow participants to express their preferences and to give any other comments regarding the overall study process. Participants were given two pages containing thumbnail images of all the photographs on the DVD and asked to select the images they would like to see in their hospital room and those they would not like to see. Photographs A DVD of 60 photographs was displayed on laptop computers for this study. The DVD used software allowing participants to control the length of time each photograph was displayed on the computer screen. The photographs used in this study were chosen from the personal collections of a freelance photographer and a nationally recognized photographer whose photographs have been used in previous research (Nanda et al., 2007). Nursing research article critique paper

Han’s (2007) intricate selection criteria guided the research team in evaluating the selected photographs based on the following criteria: horizontal layout, high photographic quality, openness, variety, and complexity. Prior to making the final selection of photographs to be used in this study, a small group of people with cancer (patient advisory board) shared their thoughts on photographs. As a result of their comments, bright, cheerful colors and variety were considered in selecting the photographs. Categories for the photographs (e. …