Sextou, P. & Hall, S. (2015) 'Hospital Theatre Promoting Child Wellbeing in Cardiac and Cancer...

67

ATR 3 (1) pp 67ndash84 Intellect Limited 2015

Applied Theatre Research Volume 3 Number 1

copy 2015 Intellect Ltd Article English language doi 101386atr3167_1

Keywords

applied theatreaudience participationchildrenhospitalrelaxationwell-being

PersePhone sextouNewman University United Kingdom

sharon hallNewman University United Kingdom

hospital theatre Promoting

child well-being in cardiac

and cancer wards

abstract

This article examines the delivery of a theatre initiative with child audiences in a hospital context It reports on a mixed-method evaluation of a bedside site-specific performance at high-risk wards based in a Childrenrsquos Hospital NHS Trust in England It acknowledges the circumstances of the children and the conditions of the location and examines the potential of supporting children during their stay in hospital through entertainment and relaxation The article discusses the experiences of those who participated in the performance including children parents and guard-ians It discusses the experience of taking theatre into health care and the strengths and challenges of using a hospital space as a lsquostagersquo It concludes that a synergy between the artist and the child is important to this type of intervention seeking to provide children with both entertainment and relaxation as an important strategy for their well-being in hospital

ATR_31_Sextou_67-84indd 67 22515 94152 AM

Persephone Sextou | Sharon Hall

68

This article is about a portable bedside theatre intervention that was toured at a Childrenrsquos Hospital NHS Trust in England during the period 2010ndash13 The intervention aimed to allow wider access to the benefits of creative performance and offer equal opportunities to children in the selected wards to experience in hospital what many people would only see in the theatre

a brief history of the Project

This cross-disciplinary study was first piloted in 2010ndash11 in three wards at the same hospital general pathology cardiac and oncology It aimed to inves-tigate theatrersquos contribution to meeting the childrenrsquos needs for entertain-ment and relaxation in health care beyond clinical treatment A portable short performance research tools and audience leaflets were piloted to ensure the language and approaches used in both the play and the interview question-naires were comprehensible to this age group

The pilot suggested a bedside performance methodology that aimed to improve childrenrsquos well-being during their stay in hospital There were posi-tive indicators from the evaluation of the pilot study The theatre intervention was perceived to distract the childrsquos mind from illness help them with taking medication help them with pre-operative stress and benefit parents in high-risk hospital wards by giving them a better experience in hospital too (Sextou and Monk 2013) The pilot study suggested some changes to improve the next phase While the pilot targeted children aged from 5 to 12 years the audi-ence suggested that the intervention would be more suitable for children aged from 4 to 10 years It was also highly recommended by the parents of children with cancer and cardiac problems to offer the play more exclusively to chil-dren with serious illness as it was appreciated particularly by these children Both recommendations were adopted in the main phase This article evaluates the next phase of the bedside theatre study (2012ndash13) and further discusses how this example of theatre in hospital was improved and how it affected the performance and child well-being in high-risk wards such as cardiac and cancer This article affords an overview of the bedside theatre intervention and makes observations about the approach and specific interpretations of how theatre operates in hospital space and clinical culture from the audiencersquos perspective

theatre for children in hosPital

Theatre for children in hospital is a general term and pluralistic phenomenon that consists of multiple practices and practitioners (van de Water 2012) To contextualize the work presented here we will attempt a definition of our intervention without claiming any labels or classification We donrsquot want to be preoccupied with debates about terms such as applied theatre applied drama community-based and site-specific theatre However we do believe that the bedside theatre project is applied in a non-traditional social context (hospital wards) with specific audiencesparticipants (children with a serious illness) and because of its intention to employ performance in the service of child well-being According to Thompson (2005 14) lsquoApplied theatre might concentrate on processes of applicationrsquo

This study is engaged with children in hospital with a focus on the process of applying theatre as a potential strategy for relaxation and entertainment Similar to Nicholsonrsquos (2005) claim we found that because of this focus the study also has its own special agenda which is informed by the particular site

ATR_31_Sextou_67-84indd 68 21015 24730 PM

Hospital theatre

69

at which it takes place and the particular audience with which it engages In other words bedside theatre in hospitals has its own possibilities and barri-ers These depend on two main factors the special conditions of the loca-tion (eg hospital routines limited space on the wards emergencies lack of privacy emotionally charged atmosphere) and the special circumstances of its participants (eg illness risk isolation stress vulnerability) Locality and audience characteristics are taken into account in both the preparation and touring of bedside theatre by adopting a theatrical transaction that involves children in what Prentki and Preston (2009 10) term theatre lsquoforrsquo a commu-nity The present project commutes between lsquoparticipationrsquo and lsquospectatingrsquo Children in bed are not only audience members but also participants in the story through dialogue and physical expression Although bedside theatre cannot promise nor claim any lsquotransformationrsquo of the lives of the children who participate in it it aims to open possibilities for improvement ndash a better stay in hospital

At the same time the intervention has a role to play in health care as a vehicle for examining the beneficial potential of performing initiatives with children in clinical settings and promoting the dialogue between the arts and health care (Staricoff 2006) While this field is in its infancy some thought-provoking work has emerged in researching childrenrsquos health experiences through performing arts Storytelling in paediatric palliative care (Done 2001) and clown performances in paediatrics successfully explore the intersection of the two disciplines ndash artistic and medical It is found for instance that the clown doctor methodology in particular has a positive impact on hospitalized childrenrsquos lives Weaver et al (2007) Battric et al (2007) Kingsnorth Blain and McKeever (2010) and De Lima et al (2009) report on the benefits humour has in clown performance for sick children and the reduction of childrenrsquos anxiety concerning illness hospitalization and the associated medical proce-dures However bedside dramatic performance in child health care remains widely unexplored The bedside performance discussed in this article should be seen as a trial that allows artists to experiment with applied theatrical forms with specific audiences in a specific location supporting children during their stay in hospital and brightening up hospital spaces

the research rationale

The objective of the study was to investigate how theatre might improve child well-being in hospital through relaxation and entertainment considering the childrenrsquos clinical circumstances and experiences in high-risk wards

This study set out two specific tasks to examine the potential of relaxa-tion inherent in the delivery of bedside theatre performance and to capture evidence about how it influenced participantsrsquo well-being The articlersquos overall aim through these tasks was to provoke new ways within theatre and health research to engage with the practices of arts-based research for supporting childrenrsquos well-being in health care

Children experience stressors in hospital Peterson and Shigetomi (2006) define clinical stressors as physical stress such as pain immobility loss of control and possible side-effects of the medical treatment alongside emotional stressors from the impact of surgery disruption and the shock caused by the medical incident They argue for the importance of child relax-ation prior to and after medical or surgical procedures and the contribu-tion of coping techniques to minimize child stress and anxiety The bedside



70

performance presented in this article aims to engage the child in the fictional world through the dramatic form and divert their minds from hospital stres-sors and the psychological experience of their illness

There is a lack of lsquonormalityrsquo in a childrsquos life during a stay in hospital relat-ing to the experience of lsquomedicalizationrsquo (Aldiss et al 2008) A childrsquos life in a hospital is full of medical treatments emergencies medication and routine care all potentially causing unpleasant experiences boredom and isolation (ESRC 2007) In their studies Kostenius and Oumlhrling (2009) describe the lack of privacy in a hospital ward as an external stressor Having a small space in relation to a large number of people in the room and being separated from significant others during the stay in hospital may maximize the effect of clinical stressors on child well-being We anticipated that while children participated in a bedside thea-tre performance they would also experience special attention as individuals Although we could not claim a significant place in the childrsquos life we could help through audience participation to minimise their feelings of separation

Particular issues arise within a process of delivering bedside theatre in a hospital within a process that blends fantasy with difficult reality With refer-ence to the IOU Theatre companyrsquos observations during The Consulting Room which was performed on-site in the Royal London Hospital in 1999 a hospi-tal is a lsquocontested spacersquo in a sense that lsquois marginal in that it houses sick-ness hellip a margin between life and deathrsquo (Govan Nicholson and Normington 2007 133) We do agree that hospitals have their own narratives but these can also be stories of life winning over the battle with death In the eyes of the artist who sees the opportunity to use theatre to give the child a different experience of hospital life a hospital may also house life and joy By achieving this theatre can be potentially be lsquoa tool to improve environments and serv-icesrsquo in health care (Brodzinski 2010 27ndash28) Why is there a need for improve-ment in hospital environments and services Research evidence shows that children experience hospital spaces as lsquopotentially disordering spaces for chil-dren ndash they are not yet familiar ldquoplacesrdquo in which they know how to be and what to dorsquo (Curtis 2007 21) James Curtis and Birch (2007) in their ESRC-funded report Space to Care Childrenrsquos Perceptions and Experiences of Hospital Space looked at the inside of the hospital and found that lsquothe current set up of hospital space limits social interaction open plan spaces mean children are constantly watched some spaces are too small other spaces are locked and not readily availablersquo We are mindful of hospital space not being a theatre stage However we are interested in examining how theatre in the hospital environment could contribute towards making children feel less bored and isolated and help them see the space around their bed in a new way Children may become witnesses to fantasy while going through challenging realities

The meanings of wellness and un-wellness had to be negotiated A sick child could easily be stigmatized by the artist as a citizen of the kingdom of the lsquoun-wellrsquo (Sontag 2002) The question of wellness ndash supposing such a thing can be measured or evaluated ndash raises concerns about who is well and who is not Who judges who is well and who is unwell Who benefits from whom (the audience from the artist or the artist from the audience) Such questions are contentious as they are key issues in the field of applied theatre with specific audiences Rather than the child being defined as a lsquosick individ-ualrsquo a vulnerable person and a passive recipient of the performance the thea-tre piece was designed to encourage them to interact with the artists during the play The present study work draws upon Javisrsquos (1992) view of the role of individual care with children who suffer from chronic or terminal illness as


Hospital theatre

71

one of immense importance to the patientndashnurse communication Similarly to the patientndashnurse relationship we felt that the provision of individual bedside performance would help the child to communicate and collaborate with artists in lsquotellingrsquo the story together We wanted both the children and the artists to be equally encouraged to participate in the theatre event as both were consid-ered qualified to experience theatre

Methodology

The research team

The study was designed and evaluated by two researchers one from the field of drama and applied theatre in particular and one from social sciences who worked with vulnerable children and young people The performance was presented by selected third-year drama students from a UK higher educa-tion institution Objective and fair selection criteria helped to ensure recruit-ment of the best students for this project (General Council of the Bar 2012) Criteria included excellence of understanding applied theatre in health and well-being environments evident work placement experience as community artists and advanced acting and oral communication skills Research was conducted in collaboration with the hospitalrsquos arts department link nurses and ward managers Before the study was conducted ethical approvals were gained from NHS REC the specific site research development office (RD) and the higher education institution that employs the researchers

The research participants

This studyrsquos participants were children with diagnosed cardiac problems and cancer who participated in a bedside performance and their parents or guard-ians A total of 26 participants enrolled in the study thirteen children and thirteen adults including both parents and guardians The children comprised five boys and eight girls aged from 4 to 10 years Children in oncology were long-term patients (over ten days) while the most frequent length of stay for children from the cardiac ward was three to five days A small group of the children and parents had English as an additional language but this did not exclude them from participating in the study as the level of understand-ing and communication in English was good The performance was housed in the cardiac and oncology wards at the Childrenrsquos Hospital Participants enrolled voluntarily via parental discussion with the link nurses The research-ers provided leaflets with information about the project specially designed for parents and children All the names used in this article are pseudonyms chosen by the child participants No previous experience in drama or theatre was required to enrol

The research tools

The authors addressed their aims through a mixed-method approach Data were collected prior to performance by a short pre-performance question-naire during the performance by observation and after the performance by a post-performance standardized interview

The questionnaire was administered by the social studies researcher with the children and the accompanying adults parents and guardians on the day of the performance before the bedside performance was presented to the children Child clinical stress affects the whole family (Rokach and Matalon



72

2007 301ndash4) and therefore the questionnaire aimed to collect the views of the participants to gain insight into the possibilities and barriers for theatre for children in hospital as perceived by the audience The short questionnaire covered topics such as how long the child had been in hospital their general feelings about their treatment and their expectations of the performance

The researcher then observed the performance and the childrenrsquos responses to it The purpose was to establish new insights about the improvement of childrenrsquos well-being and examine the performancersquos contribution into new areas of critical inquiry such as public health Bedside performance was presented exclusively to each child by two artists to provide opportunities for observation of each childrsquos physical and verbal reactions to the performance and to generate children and adultsrsquo reflections on the role of theatre in health care The researcher made direct observations using the event sampling tech-nique by watching the performance rather than taking part Event sampling is suitable for observing an event of a particular length ndash the performance ndash and an aspect of behaviour in which the researcher is interested ndash the childrenrsquos participation in the performance Direct observation is suitable for observing childndashadult interactions on the spot under specific circumstances and for offering contextual data about settings and individuals (Regents of the University of Michigan 2013) The observer wrote narrative descriptions of the childrsquos behaviour in a factual manner trying to capture the details of child behaviours and conversations with the artists Data also included the childrsquos age and gender the hospital ward and the date Data were collected on recording sheets with space for narrative descriptions similar to those used for child observations in child care and education (Arthurs 2014) Examples of the recorded dialogues between the children and the artists are provided in the findings section below

Post-performance standardized face-to-face interviews with children and parentsguardians took place on the day following the performance with the social science researcher aiming to understand their personal responses The interview style was informal following a simple semi-structured format using open questions (Bryman 2008) For example the researcher asked lsquoDid you enjoy the play What did you like Not like How did the play make you feel Why Did the play make you forget that you were in hospital (Why Why not) Did the play make you feel betterforget about being ill Would you like to see more plays when yoursquore in hospital (Why Why not) Can you suggest anything to those actors to make the play betterrsquo The children and parents were mainly interviewed alongside each other Data were collected in words describing opinions and feelings in context For example both children and parentguardians offered various opinions about the performance taking place at the bedside instead of them watching the play with a larger audience Opinions ranged from very positive to recommendations for the provision of theatre performances to children and their families from across the hospital Interviews were recorded on a dictaphone and transcribed by the researchers within one week of the collection date

The authors discussed their data collaboratively Similar to the views of Atkinson and Rubidge (2013) they found arts-based interventions with chil-dren in health care a great opportunity for an interdisciplinary exploration of child well-being from the perspective of both the artist and the scientist They made notes on their data which were analysed using simple descriptive statistics for the pre-performance questionnaires and grounded theory analy-sis techniques (Strauss and Corbin 1998) for the post-performance interviews


Hospital theatre

73

They combined these with direct observations of the event (performance) and reflections from the artists to compare their findings and explore areas of similarity and difference within the scope of the study

Stages of the research

The methodology of the study evolved into two main stages connecting with the hospital and performing in hospital

Stage 1 Connecting with the hospital

Link nurses played the role of contact points for the research team to make arrangements about the times of the performances and the number of children who agreed to participate in the research study During the period of connect-ing with the hospital a preparation for the implementation of the study took place Four visits to the hospital enabled the researchers to observe hospital life develop an understanding of the non-ideal conditions within which bedside theatre operates and develop new ways to respond to these conditions For example it was decided that the performance would be delivered after tea time when the children were more settled and when most visitors had left Considering the lack of space between beds and monitors in high-risk wards it was necessary to minimize the size of costumes and the number of props In view of some of the children feeling lethargic because of their medication and chemotherapy treatments it was decided to give children the right to stop the performance by putting their hand up at any time during the perform-ance Bearing in mind that medications are planned at certain times and the performance would have to be interrupted by the nurse it was decided to encourage the artists to remain in role and to integrate possible interruptions in their performance Thanks to these small adaptations to the intervention a more suitable practice to the conditions of the hospital occurred While modi-fications were generally small this adaptability to the specific (non-theatrical) environment was considered an important innovation in understanding the application of theatre in a hospital context

Stage 2 Performing in the hospital

The study lasted only seven days as agreed with the hospital to reduce any possible interference the project could have to the hospitalrsquos operation The study included a 30-minute theatre performance with music and breathing practice based on an adaptation of a bedtime story written by Lori Lite (2001) Space allotted for the bedside performance was usually what was available between the childrsquos bed a monitor and a chair for the visitors Other essen-tial medical equipment for paediatric care were located in the room includ-ing cardiac defibrillators cardio-respiratory monitors oxygen masks and pulse dosimeters catheters and phlebotomy equipment Performances were delivered to children on a one-to-one basis in cardiac and oncology wards as well as to their families The artists encouraged the children to interact both verbally developing a dialogue with the characters when possible and physi-cally practising the breathing with the characters This arrangement aimed to negotiate the institutional context of the site and treat the child as an audience with ability to participate in the event ndash not as a lsquodisabledrsquo patient as this can disempower a child by entrenching a dependence on adults and can make them feel even more vulnerable than they already are



74

Symbolization of space

Two artists played the boy and the rainbow The story begins with a boy watching a rainbow by a calm pond The artists encouraged the child to visualize a pond next to their bed by which the characters of the story and the child gathered to enjoy the colours of the rainbow embracing them The aim was to symbolize the bedside space through the childrsquos imagination and invite the audience to make meaning with the relationship that devel-ops between the child and the artist This is some kind of investment in the aesthetic with significance As Anthony Jackson (2007 37) puts it lsquoit is in the appeal to our aesthetic imaginations and sensibilities that the reader or observer becomes an active maker of meaning hellip any analysis of that expe-rience must take full account of the perception of the audiencersquo Although there can be no guarantee that symbolism would work for each child in the performance in the same way we do know that in theatrical contexts the aesthetic may have more to do with the ways things are communicated between the artist and the audience By the symbolization of the space we sought to encourage the child to make meanings of the things the artists were saying and the ways the child could lsquoreadrsquo and lsquoseersquo things by step-ping into the fiction We sought to help them lsquoescapersquo from the messages of illness in the hospital environment

Communication with the child

The rainbow started dancing gently at the bedside while the boy was playing a calm melody on his guitar The music aimed to create atmosphere engage the child in the fiction and help her focus on the story despite the distractions in the room (monitor sounds loud TV visitors) The rainbow encouraged a dialogue with the child aiming to stimulate each childrsquos imagination and engage them even deeper into the story Responses varied from child to child ranging from nodding to full sentences Then the boy introduced the child to the turtle a soft toy with a red shell and big brown friendly eyes (pillow size) Our choice of using a soft toy as a puppet drew on research findings about their common use in health care to reduce stress help children to adapt to hospitalization decrease fear anxiety and frustration prepare for an operation and facilitate communication between the child and the health-care team (De Lima et al 2009 Athanassiadou et al 2009) We used the turtle as a friendly lsquoconductorrsquo between the child and the artist ndash two complete strangers

Breathing

The rainbow the boy and the turtle told the child about their adventures in the park The rainbow lsquobroughtrsquo colours to the child ndash long organza fabrics attached to the rainbowrsquos colourful hat which she waved one by one above the childrsquos bed Each colour was described as flowing to a different part of the childrsquos body going up from the feet to her head In between colours the boy guided the child to observe the sensations of her body closely and imagine that each colour was filling her with warmth All children agreed to this which was a positive reassurance for the artist that the children were engaged in the story The turtle (animated by the boy) taught the child how to breathe and how to observe the movement of her chest while breathing At this stage breathing plays an important part in the story as it focuses on the relaxing effects of breathing on body and mind (Crane 2009) When the hospitalized childrsquos pre or post-operative stress overwhelms the nervous


Hospital theatre

75

system the body is flooded with chemicals that wear the body down The breathing response puts the body and the mind into a state of stability (Robinson et al 2013)

At the end of the play the child was offered a few moments to enjoy the relaxation An opportunity was also given to reflect on the experience by asking questions or giving their opinion on the characters and the story This was optional and it was decided by the artists depending on the childrsquos preference

Findings

Entertainment and enjoyment

Pre-performance data showed that the children were looking forward to the play and thought they would enjoy it After the performance the majority of the children were clearly positive about the play They described a range of positive emotional responses from feeling excited to feeling relaxed together

It was funny all the way through(DonkyKong male aged 8)

It made me feel very happy inside hellip and it did make me feel calm as well

(Pikachu male aged 8)

This finding addresses some of the needs parents and guardians expressed pre-performance about their children being in hospital some of the chil-dren were feeling tired and worried about their condition ndash especially in oncology

Figure 1 Newman University Drama (CADLab) students perform for children in paediatrics at Heartlands Hospital NHS Trust Birmingham



76

Most of the children had reported pre-performance that they were lsquoboredrsquo and lsquomissed their friendsrsquo Other children were in a good mood and willing to interact with the artists verbally For those who were not having a good day the performance helped them to have fun

The majority of the parents and guardians were also positive before the play thinking their children would enjoy it After the performance the parentsguardians valued the individual attention offered by the bedside approach

I think she felt quite special(Mum of lsquoDaisyrsquo female aged 8)

Yes that was good wasnrsquot it (Dad) (The child nods positively) Very intimate indeed

If hersquos happy I am happy too Itrsquos so good to see him smile So good(Mum of Pikachu)

I thoroughly enjoyed it I felt totally relaxed(Nan of lsquoLucyrsquo female aged 4)

These responses indicate that the bedside performance met the audiencersquos expec-tations of the play as entertainment It was enjoyed by children who did and did not like being in hospital and it was valued by both the children and their fami-lies The enjoyment of the performance by the child also had a positive impact on the parents as it lifted their mood by enabling them to see their child having a good time in hospital suggesting a deeper value than simply entertainment

In most cases the artist managed to encourage effective communica-tion with the child during the performance Some children imagined that they were outdoors in the fields taking a break from the hospital life Others communicated with the turtle while the artist used the turtle to lsquoteachrsquo the child a helpful breathing practice Observations recorded in the form of narra-tive descriptions offer evidence to support this

The child repeats the breathing with the turtle in through the nose and out through the mouth the artist asks lsquoIs it OK to do it once morersquo the child nods breathing is repeated successfully

The child happily chats with the artist [boy] She says she likes the rain-bowrsquos hat the artist asks the child to imagine she is in the countryside the child closes her eyes for a few seconds she opens her eyes again the artist asks her to imagine she is in a field full of grass and asks lsquoCan you smell the grassrsquo she replies lsquoNorsquo the artist says lsquoThatrsquos OK can you tell me what can you seersquo she says lsquoThe grass and a big cowrsquo

The child is quiet and reserved she avoids eye contact with the artist the artist brings out the turtle [puppet] from his prop basket he changes his voice into a turtle the child looks at the turtle the turtle says lsquoWhat a fancy nightdress you haversquo the child smiles looks at her mum turns back to the turtle the turtle asks lsquoDo you want to find out what happens nextrsquo the child speaks She says lsquoYesrsquo

These observations show that for entertainment and enjoyment to happen in performance the artist has to establish the art form in order to help the


Hospital theatre

77

child believe in the play they are watching in a symbolic way and engage the audience through imagination However it was observed that sometimes the performance became a complex endeavour For example there was one occa-sion where the communication between the artist and the child (a 7-year-old boy) was broken by an emergency and the child lost interest in the play Information from observation records reveals

The child watches the play with interest he looks at the artist he participates in the scene verbally he says lsquoI know the colours of the rainbowrsquo a nurse joins in she tries to give him an injection the child is upset and loses contact with the artist the performance is interrupted the artists wait in the room for the nurse to finish the child cries there is no mum or dad around the nurse tries to calm the child no success he says lsquoNo I donrsquot want it go awayrsquo Itrsquos a moment of crisis one of the artists [the rainbow] says lsquoMy colours are tired too Do you mind if I go to get some rest for a while and come back laterrsquo The child cries he is in pain he does not reply to the artist the nurse talks to him commu-nication with the artist is lost the artists walk out of the room quietly

The artists remained calm and professional they stayed in role throughout the incident and dealt with what the child was experiencing with sensitivity but the tough reality disengaged the child from the fiction

Challenges arose when differences became apparent between what the children seemed to be capable of doing in the performance because of their condition and what they actually did when the performance began Children in tired moods were lifted up and spoke to the characters whereas other children in a good mood fell asleep during the performance which could be perceived either as an indication of tiredness or relaxation On all occasions the artists respected the childrsquos preference The artists encouraged the children to make symbolic and metaphorical associations to see the world presented through the lsquoeyesrsquo of the characters but at the same time they got on with the level of participation that was achievable

Physical well-being and relaxation

Another welcome finding is that the majority of the children remembered and used breathing exercises that were repeated throughout the story to cope with clinical stress Several participants demonstrated the breathing on the day following the performance without being prompted to do so

Interviewer What else do you remember

The breath er [demonstrates] hellip the turtle showed me how to do it(Lightning McQueen male aged 4)

Some parents also reported that their children used the breathing exercises that the turtle taught them before going for a pre-operative cardiac procedure The children recalled breathing as part of the overall theatrical experience Post-performance interviews offered evidence that they also remembered the characters of the play which shows that the artistic context was effec-tive It made the breathing a lasting memory which turned out to be a useful relaxation pre-operative tool because it linked it to personal theatrical experience As Rosersquos mum stated



78

[To] be honest with you later on Rose had to have a procedure done and we did keep saying do you remember what the turtle told you just breathe slowly try and breathe slowly and she actually did remember albeit she was quite upset at the time she did try and do the breathing you know so it actually helped

I think if we say breathe how the turtle told you to breathe hellip there you go [nods in direction of Rose who is demonstrating the breath-ing exercises] See you remember donrsquot you [to Rose] In through your nose and out through your mouth thatrsquos what he said wasnrsquot it hellip very good

(Mum of Rose female aged 5)

The importance of this response relates to the benefits of relaxation for chil-dren who experience pre- or post-operative stress from their illness in high-risk wards and may help explain why bedside theatre can afford well-being benefits with cardiac and cancer patients

Other parents also reported that the play helped the children relax by diverting their minds from the hospital conditions

It relaxed her calmed her took her mind off whatrsquos going on around her(Mum of Belle female aged 10)

The turtle captured her attention Those magnetic eyes She was living the story which was great

[Mum of Daisy]

But are children in hospital able to find a middle way between living in fantasy and living in reality In hospitals while the artist invites the child into the fictional world the audience is expected to use their imagination to enjoy the performance as if they were in the theatre We welcome these responses but we struggle to accept that theatrersquos role in hospital is one of protecting its audiences from reality rather it is one of encouraging them to discover their ability to remain relaxed while they stay in hospital Our audi-ences were given a story which they enjoyed It was observed that the chil-dren became attuned to the ways in which they could collaborate to maintain calm In doing so as reported by the participants we claim this intervention as a potential strategy that can support children to manage their illness as an aspect of reality

Potential for socializing and recovery

Despite having fairly low expectations of their own enjoyment many of the parentsguardians identified additional benefits for themselves

I thoroughly enjoyed it I felt totally relaxed(Nan of Lucy female aged 4)

This finding relates to the parentsrsquoguardiansrsquo need for socialization with other parents while their child is in hospital However some would have preferred to watch the play in larger groups with more interaction with other children and parents


Hospital theatre

79

I really like the individual attention I think thatrsquos really nice but I think you could do something to a small group of children

(Mum of Daisy)

Our interpretation of these comments is that gathering as an audience could give children and parents a better social experience in the hospital too To acknowledge the importance of socializing and the parentsrsquo feeling of isola-tion the provision of performances to larger groups of children in the hospital should be considered

Some parents also suggested that the play would have been more helpful during a later stage of the childrsquos recovery This is a valid suggestion because it offers scope for investigation about the impact of relaxation inherent in our bedside theatre methodology on recovery from illness However any benefits of the relaxation in pre-operative situations would be missed

discussion

The aim of this discussion is to focus on our selective reflections from the process of conducting theatrical research in a health-care setting providing a wider overview of the research project By doing this we aim to enhance the readerrsquos understanding of theatrersquos role in a hospital environment and the dynamics of the artistndashchild relationship and achieve a greater clarity of the theatrical experience in health care Letrsquos make an attempt to describe this experience

The findings of this study place us face to face with the application of theatre within contexts where there is human pain and discomfort There is evidence that audience satisfaction is possible even if the audience is in pain or in a bad mood Bedside performance met the audiencersquos expectations of the play as entertainment and relaxation it was enjoyable and valued by children with serious medical conditions in high-risk hospital wards for capturing their attention and helping them to forget their pain In this study theatre is not perceived by its audiences as a teaching tool or a community expression or a political weapon but rather as a window for a different experience of illness and a potential strategy for recovery

All the efforts of this study to collect data by questionnaire interviews and observations led us to a realization despite the stressors and the pain a child experiences in hospital theatre does have a role to play it can enter-tain and comfort A focus on who we entertain and comfort is important to identify awareness of our being in a hospital for the child ndash not for our ambi-tions as artists and researchers Constant reference to the audience rather than ourselves deepens our understanding that it is the child who makes the performance happen in hospital This is because the child has the power to either let the artist lsquoenterrsquo their private space and share the hospital experience with them or lsquolockrsquo them out It is not the child who goes to meet the artist but the artist who visits the child in hospital This modification in the dynamics of the artistndashaudience relationship can be seen to provide a condition for new perspectives on a particular democratic synergy that develops between the child and the actor in hospital settings

One girl in oncology said lsquoI am tiredrsquo but despite this she wanted to have the play presented to her It seems as if some power in that girl resisted her physical and emotional exhaustion Her physical weakness together with the pain was overcome by a desire to watch theatre to give a place to the



80

possibility of having a good time in hospital Bedside theatre opened up this possibility We are mindful not to claim magical powers for the project but we learn to accept that exploring theatre for children in hospital is a great opportunity to negotiate personal meaning ndash a process incorporating learn-ing about our own potential as artists in health care Realizing the serious-ness of the girlrsquos condition as in the case of most of the studyrsquos participants the artist begins to experience theatre as a practice of widening hospital life That girl like other children who participated in the study had stayed in a hospital ward more than she had in her own bedroom but bringing more of the outside world into this experience for her or others is not an easy task No simple action on the artistsrsquo part can achieve the stabilization of a health condition or the acceptance of living in a hospital as fun However the artists visited the girl to play a role in that difficult period of her life promising simply to be there for that girl through the art form

Bedside theatre as it is presented in this article is not superficial and one-dimensional It is composed with attention to detail with an attitude of reflection This form of theatre in hospital works when it engages the audi-ence in the aesthetic experience Although it is essentially problematic to define the lsquoaestheticrsquo experience in theatre and this is even more the case in hospital it can be achieved by the creation of aesthetic distance which is bound with the interplay between imagination and understanding real-ity Here is not the place to survey the aesthetics of theatre but one main concept should be noted if the preparation of the artist to perform in hospi-tals is to be understood that of staying in role By performing to a lsquotiredrsquo girl with cancer with an emphasis on the experience for both the artist and the child the artists fulfil their presence in the same place and at the same time share a story

One of the challenges of this project was to develop understanding of the audience in hospital wards in order to create opportunities for them to experience theatre in bed in beneficial ways There was important learn-ing that it is difficult to benefit children in hospital through theatre unless the performers accept the audiencersquos clinical conditions as an aspect of life Therefore the research team and the artists paid attention to the child as an individual not an ill person While it is difficult to understand each childrsquos clinical condition and personal circumstances and address all their needs the study shows that a relationship of engagement between the child and the artist during performances can be found in hospital wards Nevertheless the types of audience participation that can be achieved with children in hospi-tals may vary from project to project from child to child and from artist to artist A bedside theatre play may mean something different to each of the artists and something different to every child in hospital ndash and will prob-ably generate different reactions from the audiences in different wards and hospitals

At this point it might be desirable to reach a conclusion about how and why bedside theatre is successful or not and what the artist needs to do in the future to spell out a critical vocabulary This is not possible the experience of theatre in clinical environments is unpredictable What is appropriate here is an indication of some of the lsquoaesthetic concernsrsquo of the study its limitations and the lessons that have been learned and some concluding thoughts This could be seen as a sort of lsquoheritagersquo for those artists and researchers who wish to become involved in this theatrical approach as a more attractive alternative to a list of conclusions


Hospital theatre

81

liMitations

The limitations of the evaluation relate to the characteristics of the sample and the analysis of the data The participants represented a small particular group of individuals with the children in the group seriously ill The sample was some-times limited by the childrenrsquos capacity to reflect and respond verbally because of their condition although this was not the case on most occasions The sample size limitation reflects the small period of time given to the implementation of the study by the NHS however this could be extended by conducting a multi-hospital study As in all evaluations the participantsrsquo views could be affected by the researcherrsquos interpretation The data were analysed by more than one researcher which minimized the risk of personal misinterpretation During the study there were no particular responses that were difficult to analyse Ideally clinical measurements of the impact of bedside performance on child physical stability and improvement would have been used However this is something that would be possible only in collaboration with clinical researchers In future medical applications it would be useful to investigate how bedside theatre might be entwined with paediatric clinical research looking into the potential benefits of theatrical interventions for patients who suffer from terminal illness to find better ways of treating patients with the help of the arts

concluding thoughts

It is evident that bedside theatre performance that incorporates relaxation tech-niques is perceived to be an intervention that can provide children entertain-ment distraction from the experience of illness and relaxation as an important strategy of their well-being in hospital The project reveals that theatre can relate to the child who experiences illness in clinical environments Theatre works as a specialized input into hospital life and offers children a different experience of and managing strategy for being in hospital

We have also come to some realizations The actorsrsquo ability to commu-nicate with the child is an important factor in every performance What is happening during the performance is based on a special relationship of sensi-tivity respect and trust with the audience Any interaction with the child would require intelligence to build trust with the child and sensitively engage them with the play This points to the interplay of child and artist where the child commands the attention of the artist the artist responds to the child through the symbolic use of space and objects in the art form (play) and the child responds to the artist at a level of symbolic meaning through intellectual verbal and physical lsquolanguagersquo

Devoting time and love to theatre in hospitals is a skill in itself which can be developed through constant effort passion motivation and hard work We learn that it is impossible to benefit ill children through theatre unless we accept their condition as a phase of change and pay attention to the individual not the ill person we learn that more efforts for providing theatre for chil-dren in hospital are to be continued in order to provide evidence for including theatre on the agenda of health promotion with the highest level of dramatic experience and compassionate care

The Bedside Theatre project for hospitalized children (2012ndash13) was funded by the WA Cadbury Trust and the Grimmit Trust Without this support and despite our impulse there is little hope of continuing our efforts to bring theatre to children in hospitals The best satisfaction of all is that despite our struggle to find subsidy and the challenges of entering the hospital culture



82

and bypassing the barriers of NHS strict regulations there are moments when we feel rewarded for what we do for the children Hopefully these moments may act as a motivation for continuing the work for the only way to realize theatre performance in specific applied contexts is to do it

RefeRences

Aldiss S Horstman M OrsquoLeary C Richardson A and Gibson F (2008) lsquoWhat is Important to Young Children Who Have Cancer While in Hospitalrsquo Children amp Society 23 2 pp 85ndash98

Arthurs K (2014) lsquoWhat is a Narrative Observationrsquo eHow Education httpwwwehowcominfo_8738612_narrative-observationhtml Accessed 20 November 2014

Athanassiadou E Tsiantis J Christogiorgos S and Kolaitis G (2009) lsquoAn Evaluation of the Effectiveness of Psychological Preparation of Children for Minor Surgery by Puppet Play and Brief Mother Counsellingrsquo Journal of Psychotherapy and Psychosomatics 78 pp 62ndash63

Atkinson S and Rubidge T (2013) lsquoManaging the Spatialities of Arts-based Practices with School Children An Inter-disciplinary Exploration of Engagement Movement and Well-beingrsquo Arts amp Health 5 1 pp 39ndash50

Battrick C Glasper EA Prudhoe G and Weaver K (2007) lsquoClown Humor The Perceptions of Doctors Nurses Parents and Childrenrsquo Journal of Childrenrsquos and Young Peoplersquos Nursing 1 4 pp 174ndash79

Brodzinski E (2010) Theatre in Health and Care London Palgrave MacmillanBryman A (2008) Social Research Methods Oxford Oxford University PressCrane R (2009) Mindfulness Cognitive Based Therapy Abingdon Routledge Curtis P (2007) Space to Care Childrenrsquos Perceptions of Spatial Aspects of

Hospitals Full Research Report Swindon ESRCDe Lima RAG Azevedo EF Nascimento LC and Rocha SMM (2009)

lsquoThe Art of Clown Theatre in Care for Hospitalized Childrenrsquo Revista da Escola de Enfermagem da USP 43 1 pp 178ndash85

Done A (2001) lsquoThe Therapeutic Use of Story-tellingrsquo Paediatric Nursing 13 3 pp 17ndash20

ESRC (2007) lsquoSpace to Care Childrenrsquos Perceptions of Spatial Aspects of Hospitalsrsquo httpwwwesrcacukmy-esrcgrantsRES-000-23-0765read Accessed 2 March 2013

General Council of the Bar (2012) Fair Recruitment Guide 2012 A Best practice guide for the Bar httpwwwbarcouncilorgukmedia165213recruitment_guidev22_18sept_merged_readonlypdf Assessed 30 April 2013

Govan E Nicholson H and Normington K (2007) Making a Performance Devising Histories and Contemporary Practices Abingdon Routledge

Jackson A (2007) Theatre Education and the Making of Meanings Manchester Manchester University Press

James A Curtis P and Birch J (2007) Space to Care Childrenrsquos Perceptions and Experiences of Hospital Space httpwwwshefacukpolopoly_fs1221751fileResearch-briefing_James_spacetocarepdf Accessed 5 March 2014

Javis P (1992) lsquoReflective Practice and Nursingrsquo Nurse Education Today 12 pp 174ndash81

Kingsnorth S Blain S and McKeever P (2010) lsquoPhysiological and Emotional Responses of Disabled Children to Therapeutic Clowns A Pilot Studyrsquo Evidence-Based Complementary and Alternative Medicine httpwwwncbinlmnihgovpmcarticlesPMC3137396 Accessed 20 November 2014


Hospital theatre

83

Kostenius C and Oumlhrling K (2009) lsquoBeing Relaxed and Powerful Childrenrsquos Lived Experiences of Coping with Stressrsquo Children amp Society 23 3 pp 203ndash13

Lite L (2001) A Boy and a Turtle New York LitebooksNicholson H (2005) Applied Drama the Gift of Theatre London Palgrave

MacmillanPeterson L and Shigetomi C (2006) lsquoThe use of coping techniques to mini-

mize anxiety in hospitalized childrenrsquo Behaviour Therapy 12 1 pp 1ndash14Prentki T and Preston S (2009) The Applied Theatre Reader Abingdon

RoutledgeRegents of the University of Michigan (2013) Child Care and Early Education

Research Connections httpwwwresearchconnectionsorgchildcaredata-methodsfieldresearchjspdirect Assessed 15 June 2014

Robinson L Segal RMA Segal J and Smith M (2013) lsquoRelaxation Techniques for Stress Reliefrsquo httpwwwhelpguideorgmentalstress_relief_meditation_yoga_relaxationhtm Assessed 12 March 2013

Rokach A and Matalon R (2007) lsquoTailsrsquo A Fairy Tale on Furry Tails A 15-year Theatre Experience for Hospitalized Children Created by Health Professionalsrsquo Paediatrics amp Child Health 12 4 pp 301ndash4 httpwwwncbinlmnihgovpmcarticlesPMC2528678 Accessed 10 February 2013

Sextou P and Monk C (2013) lsquoBedside Theatre Performance and Its Effects on Hospitalised Childrenrsquos Well-beingrsquo Arts amp Health An International Journal for Research Policy and Practice 5 1 pp 81ndash88

Sontag S (2002) Illness as Metaphor and AIDS and Its Metaphors Harmondsworth Penguin

Staricoff LR (2006) lsquoArts in Health The Value of Evaluationrsquo Perspectives in Public Health 126 33 pp 116ndash20

Strauss A and Corbin J (1998) Basics of Qualitative Research Techniques and Procedures for Developing Grounded Theory (2nd edn) Thousand Oaks CA Sage

Thompson J (2005) Digging Up Stories Applied Theatre Performance and War Manchester Manchester University Press

Van de Water M (2012) Theatre Youth and Culture A Critical and Historical Exploration London Palgrave

Weaver K Prudhoe G Battrick C and Glasper EA (2007) lsquoSick Childrenrsquos Perceptions of Clown Doctor Humourrsquo Journal of Childrenrsquos and Young Peoplersquos Nursing 1 8 pp 359ndash65

SuggeSted citation

Sextou P and Hall S (2015) lsquoHospital theatre Promoting child well-being in cardiac and cancer wardsrsquo Applied Theatre Research 3 1 pp 67ndash84 doi 101386atr3167_1

contributor detailS

Persephone Sextou is an applied theatre researcher with special interest in theatre for children in hospitals and the role of the artist in partnership with NHS Trust (UK) She is a Senior Lecturer in Drama at Newman University (UK) and the artistic director of the Community amp Applied Drama Laboratory (CADLab) She has a PhD in drama and theatre in education (University of London) She is published widely both nationally and internationally and is a member of arts editorial boards and organizations worldwide Her projects



84

tour in the United Kingdom Europe and Gambia (West Africa) with fund-ing from HEfCE and UnLtd UK trusts and charities and EU organizations

Contact Newman University Genners Lane Bartley Green Birmingham B32 3NT UKE-mail psextounewmanacuk

Sharon Hall is a dramatherapist who worked with and looked after children and young people who had sexually harmed others before pursuing ESRC-funded PhD research in the area of working holistically with these young people Since being awarded her doctorate she has worked as a lecturer and now senior lecturer at Newman University primarily based in the department of Working with Children Young People and Families She also enjoys teach-ing about dramatherapy and youth justice

Contact Newman University Genners Lane Bartley Green Birmingham B32 3NT UKE-mail shallnewmanacuk

Persephone Sextou and Sharon Hall have asserted their right under the Copyright Designs and Patents Act 1988 to be identified as the authors of this work in the format that was submitted to Intellect Ltd



68

This article is about a portable bedside theatre intervention that was toured at a Childrenrsquos Hospital NHS Trust in England during the period 2010ndash13 The intervention aimed to allow wider access to the benefits of creative performance and offer equal opportunities to children in the selected wards to experience in hospital what many people would only see in the theatre

a brief history of the Project

This cross-disciplinary study was first piloted in 2010ndash11 in three wards at the same hospital general pathology cardiac and oncology It aimed to inves-tigate theatrersquos contribution to meeting the childrenrsquos needs for entertain-ment and relaxation in health care beyond clinical treatment A portable short performance research tools and audience leaflets were piloted to ensure the language and approaches used in both the play and the interview question-naires were comprehensible to this age group

The pilot suggested a bedside performance methodology that aimed to improve childrenrsquos well-being during their stay in hospital There were posi-tive indicators from the evaluation of the pilot study The theatre intervention was perceived to distract the childrsquos mind from illness help them with taking medication help them with pre-operative stress and benefit parents in high-risk hospital wards by giving them a better experience in hospital too (Sextou and Monk 2013) The pilot study suggested some changes to improve the next phase While the pilot targeted children aged from 5 to 12 years the audi-ence suggested that the intervention would be more suitable for children aged from 4 to 10 years It was also highly recommended by the parents of children with cancer and cardiac problems to offer the play more exclusively to chil-dren with serious illness as it was appreciated particularly by these children Both recommendations were adopted in the main phase This article evaluates the next phase of the bedside theatre study (2012ndash13) and further discusses how this example of theatre in hospital was improved and how it affected the performance and child well-being in high-risk wards such as cardiac and cancer This article affords an overview of the bedside theatre intervention and makes observations about the approach and specific interpretations of how theatre operates in hospital space and clinical culture from the audiencersquos perspective

theatre for children in hosPital

Theatre for children in hospital is a general term and pluralistic phenomenon that consists of multiple practices and practitioners (van de Water 2012) To contextualize the work presented here we will attempt a definition of our intervention without claiming any labels or classification We donrsquot want to be preoccupied with debates about terms such as applied theatre applied drama community-based and site-specific theatre However we do believe that the bedside theatre project is applied in a non-traditional social context (hospital wards) with specific audiencesparticipants (children with a serious illness) and because of its intention to employ performance in the service of child well-being According to Thompson (2005 14) lsquoApplied theatre might concentrate on processes of applicationrsquo

This study is engaged with children in hospital with a focus on the process of applying theatre as a potential strategy for relaxation and entertainment Similar to Nicholsonrsquos (2005) claim we found that because of this focus the study also has its own special agenda which is informed by the particular site


Hospital theatre

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The research tools





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Breathing



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[Mum of Daisy]







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discussion







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[Mum of Daisy]







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Breathing



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[Mum of Daisy]







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Hospital theatre

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Breathing



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[Mum of Daisy]







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discussion







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concluding thoughts







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[Mum of Daisy]







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concluding thoughts







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[Mum of Daisy]







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discussion







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concluding thoughts







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[Mum of Daisy]







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Sextou, P. & Hall, S. (2015) 'Hospital Theatre Promoting Child Wellbeing in Cardiac and Cancer...

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Transcript of Sextou, P. & Hall, S. (2015) 'Hospital Theatre Promoting Child Wellbeing in Cardiac and Cancer...