The Significance of Improvisation in Paediatric Healthcare: The from where you are project

by Small Things Dance Collective and Alder Hey Children’s Hospital

Lisa Dowler, Cath Hawkins, Vicky Charnock, Lorna O’Brien, Helen Traynor and Kellie Rixon MBE

Alder Hey Children’s Hospital• Alder Hey Children’s Hospital

in Liverpool is one of the largest and busiest children’s hospital in Europe.

• We treat over 200,000 patients a year and employ 2,500 staff.

• The hospital is a top performing Trust, rated excellent by the Independent Healthcare Commission.

Alder Hey Arts

• Alder Hey Arts formed in 2002, chaired by Dr Jane Ratcliffe. This group advises and supports arts projects

• Alder Hey has been developing an innovative and pioneering arts for health programme since 2005 when arts organisations were invited to work in partnership with the hospital, known as Cultural Champions.

• It is participatory, patient centred and patient led.

• We consult with patients and families to develop the programme.

• We have been awarded Investing in Children Membership each year since 2010.

Alder Hey Arts

• We work with approximately 2,000 patients directly each year and deliver over 200 workshops in all art forms: dance, music, digital arts, storytelling, animation, creative writing, performance and visual arts.

• We work across all areas of the hospital from A&E, waiting rooms, wards and clinics. We also deliver projects in our community sites.

• Many of our projects focus on supporting long term patients and their families.

•We introduced dance and movement sessions in 2006, when Lisa was working initially with the local dance agency.

•Sessions were open house, with all patients invited to attend. Patients experienced many benefits: having fun, partaking in physical exercise, sense of belonging to a group, combating the effects of isolation.

•Whilst popular and successful for those who attended, we quickly realised that many patients were unable to leave their ward or bed to attend.

Small Things Dance Collective

• Artist-led organisation founded in 2002, with a commitment to creating process-oriented new work.

• We work with Improvisation and Contact Improvisation and value spontaneous, non-stylised movement described by Helen Poynor as, “a process orientated approach to movement based on the natural structure of the body rather than a stylised vocabulary, practising in any condition - that is one’s personal condition (physical, mental and emotional) - and the conditions in the environment in which one is working.” Poynor, H (2005)

from where you are pilot project• Developed out of a desire to document

and evaluate our one to one sessions • Our company Small Things Collective

received funding in 2008 from Lottery Awards for All and EHU to research the effects of our practice

• Research question- ‘An investigation of measures to evaluate the practice of dance improvisation, on the neuro-medical and oncology wards of Alder Hey Children’s Hospital’

• Devised observation sheet

Somatic approaches• One way of facilitating the release of muscular tension and a

sense of well-being is through refined touch.• We use non-directive touch, which is about listening, being

with, not doing to, a meeting place. Very different to other touch qualities experienced in the hospital.

• We also approach the sessions playfully. Working creatively relates to a basic human urge to play. Play is part of a child’s developmental journey, how they learn, through the senses, about themselves and their relationship to the world.

• This work can help regain a sense of self as well as re-establishing movement patterns that have been damaged as well as new pathways.

“Matthew was not feeling great and not very enthusiastic, but once the balls came out and the stretchy cloth, he really enjoyed throwing, pulling and tugging. Cath really got him involved and moving about and smiling. Just the simplicity of the balloons made all the difference, not just for Matthew, but for me too!” Mum of oncology patient aged 7.

“Sarah loved the session and is already asking when the next one is. Movement to music is fun and I don’t think the children see it as ‘therapy’ although it is and therefore very beneficial in their rehabilitation” Mother

“Sarah clearly benefits from the dance sessions, in gaining a sense of movement. Using the hoist for speed and access of different movement/levels. She visibly enjoys her participation giving self esteem and positive body image in what she is able to achieve. These sessions are invaluable to Sarah.” Julie Sellers, Senior Play Specialist

from where you are 2011-13

• Continuing ward based weekly sessions

• Hospital film and performance project Invisible Duets

• CPD opportunities, apprenticeships and workshops

• Creating an evidence base, quantitative and qualitative research

• Supported by the National Lottery through Arts Council England and the Big Lottery Fund, Edge Hill University’s REF IF, Alder Hey Children’s Hospital, PH Holt Foundation and Warrington Borough Council

• Each week Small Things have two artists resident at the hospital.

• We work across three wards currently, including Cardiac, Neuromedical and Orthopaedic.

• This work and its development has been supported by the Hospital Play Specialists.

• In 2012 we spent six sessions at the Dewi Jones Unit, a closed acute psychiatric unit as well as other wards across the hospital.

• Within our weekly sessions we incorporate our research and apprentices.

Ward based weekly sessions

Dewi Jones Unit

Think its very relaxing and has strangely given me more confidence, so thank you!

“Enjoy doing cartwheels over elastic and being outside.”

Invisible Duets“The difficulty with this subject is explaining in words how dance in paediatric healthcare actually works and what is achieved by this multi-sensory activity. Film with some background information illustrates this most easily, particularly when absorbed engagement by all participants is illustrated. Only by writing in professional journals and discussing it at conferences is the potential of such innovative activity to reach the audience which can develop it.” Dr Jane Ratcliffe, Consultant in Paediatric Intensive Care, Alder Hey

Invisible Duets

• To capture and make visible transformative creative interaction

• To collaboratively develop engaging participatory practice

• To continue researching performance in environments

Performing in a shared bay on the Neuromedical ward

Following the children’s interest, audience responsive performance

Somatics and Technology Conference, Chichester University, June 2012

International Conference: Sustainable Creativity in Healthcare, Arts Care 21st Anniversary, Belfast, May 2012

Collaborators• Dancers on film Lisa Dowler and children on the Neuromedical ward • Film and images June Gersten-

Roberts• Live performers Lisa Dowler and Cath

Hawkins• Costume and images Paula Hampson• Soundscore Philip Jeck featuring cello

by Georgina Aasgaard and voices of children and young people on Neuromedical

CPD and apprentices

• For the last two years of the project we have had 8 apprentices accompanying us for 5 days each.

• They have the opportunity to observe and also participate as appropriate.

• We offer open evening dance and health sessions, mainly exploring improvisation and somatic practice.

• Healthful Dancing retreat is in its third year with the addition of a symposium this year.

“Listening to experience ad hearing just how far reaching these practices can go has been inspiring and encouraging.” Dance and Health session participant“I feel this will support my work as I am less experienced in this field and seeing and hearing from other professionals allowed me to see the paths in which I can take when working in this way.” Apprentice“My perception has greatly changed as I become more aware of the individual, person centred approach to this work.” Apprentice

Healthful Dancing Retreat"Honestly, it was better than I imagined. Guest artist's were fabulous. I enjoyed the opportunity to be creative both indoors and out. I also felt part of a group and that I was heard when I spoke.“ Healthful Dancing 2012 participant

"I have learnt lots of new ideas to take with me into healthcare settings.“ Healthful Dancing 2012 participant

Hospital Play Specialists

• Helen Traynor, Hospital Play Specialist on the Neurology ward at Alder Hey hospital for 18 years.

• I have also been working on the Pain team assessing pain in children with complex needs for the last 7 years.

• Role of Hospital Pain Service.

Role of Hospital Play Specialist on the Neuromedical Ward

• To provide appropriate play activities according to the child’s development

• To prepare children for medical procedures• To provide distraction/support while medical procedures

take place• To facilitate external agencies working with children (e.g.

dance artists)• To carry out teaching sessions• To refer patients to other agencies (internal and external)• To support families

Collaborative Working on the Neuromedical Ward

• Patients with complex needs who are unable to communicate verbally

• Agitated and have stiffness of their limbs • Somatic practice – observed significant improvement – less

stiffness, decreased heart rate, improved mood and general well being

• Long term patients – often many months – work carried out on a weekly basis, noticeable changes in body language/posture

• On request from Physiotherapist one patient had somatic work before therapy session - easier to work with her as limbs more relaxed

The role of the Play Specialist on the cardiac ward

• Cardiac ward: 20 bedded ward with day case heart procedures and open heart surgery

• Play – facilitated & structured

• Preparation for procedures – blood tests, theatre visits, chest drain removal, operations

• Distraction therapy – bubbles, books, relaxation, techniques

• Advocate for the patient

Collaborative working on the Cardiac Ward

• Patients who have a Fontan operation – longer post operative recovery

• Chest drains in for up to 6 weeks – pain / anxiety

• Patients need to be mobile as soon as possible – chest infections / drain fluid

• We wanted to reduce anxieties about mobilising

• We wanted to reduce parental anxieties of their child’s capabilities

Case Study • Sarah – 2 ½ years old, 2 chest drains sit out on a chair, anxious about standing & walking Joint session – play specialist & cath and apprentice Sam engrossed in the session

Artist as researcher• When discussing approaches to art-based research, expressive

arts pioneer Shaun McNiff states, “I have also consistently found that trying to fit my experience into another’s theoretical framework results in missing opportunities for experiencing the experience in a new way.”(2010:64)

• In designing our research we utilised a practitioner-researcher model, considering our practice, “…as a life-long mode of research.”(2010:63), an active process which is not merely in the pursuit of theory, but a fluid and evolving growth of embodied knowledge through praxis.

• The move towards quantitative research was a response to our experience of practicing in a clinical context, to speak to clinicians in a meaningful language, not a move away from narrative.

"I liked the ball game because it was funny and the way we were catching the balls,heading it and it hit the telly! I liked playing with the ribbons and tickling myself withthe feathers and I liked Iggy the squid. I liked the music on the iPad and I would like to do it again. I liked stretching the stretchy stuff and the big bouncy ball and the one that lights up."

"Danny had open heart surgery five days ago. He has managed to stand himself upbut hadn't walked since before his operation. Today he has played with some ballsand musical instruments and managed to walk across the room with your help.Thankyou so much, Danny had a fantastic time."

"Felt great, really relaxing, took all the weight(big sigh), feel like I can move again,soothed my pain, feel like I'm loose again"

"I found this very good for my son. Who doesn't speak to any of the nurses and finds it hard to trust anyone after a traumatic time two years ago. He really got into this and didn't stop talking, he was really happy and it made his hospital stay fun."

Designing the Somatic Dance and Pain Study

• In consultation with the hospital’s Research Department, the hospital pain service and play specialists, we created sheets to allow us to collect data which included a pain assessment before and after sessions and narratives of patients, caregivers staff and artists.

• We utilise age appropriate validated pain assessment tools FLACC (2 months- 7 years), FACES (older children/teenagers who can assess own pain), PPP (patients with complex needs/non-verbal) and CRIES (33 weeks gestation-2 months)

Scores out of 10 for 4 patients post-surgery aged 14 months to 14 years

“Absolutely fantastic!!My son who is 14 years old has just had major heart surgery and Lisa and Cath did a brilliant job relaxing him. Thank you!”

“First attempt of mobilising, was wheeled to the play area… Took a few steps to sit on a chair, was very anxious about moving. During the session he was smiling and enjoying what he was doing, doing things without realising e.g. stood up to blow a feather across the table/ reaching up to drop feathers from a height. He walked back to his room after the session. “ Play Specialist

“After the session the nurse came to discuss his pain medication. His mum said he didn't seem in pain, so they decided not to give him his scheduled medication.” Artist

Scores out of 10 for 6 patients post surgery aged 11-17

“ She has been struggling to sleep and has been very restless. This has been excellent for her, relaxed her a lot and she fell asleep. When she woke her pain had gone.” Mother

“She looks very chilled out and her body very relaxed.” Mother

“Mum said she was very quiet, yet this changed as we worked with her. She began to chat and tell us about her many surgeries. She visibly relaxed as we used the body balls and hands on.” Artist

Although one participant who had come off her pain medication that day, did not change her pain score she said, “I feel relaxed, it was a nice experience.”

“I explored Abby’s responses to different touch qualities. She settled with a weighted touch around her back. I later traced her bones in her arms and legs. Both parents felt she looked much calmer and more relaxed. Previously she had been vomiting her feeds. She was on a feed while we worked together and she managed to keep it down.” Artist

“She’s not fighting, she looks much more settled.” Dad

“Cath held Henry’s hand and rolled a soft ball on his arms. I held his feet, gently listening here. When we first touched him his heart rate went up, showing his anxiety. However very quickly he relaxed and his heart rate dropped significantly. His face softened as did the high tone of his legs. His feet became heavy and the tension in his ankles reduced. Cath noticed the same at his wrists. He fell into a deep sleep after being very unsettled.” Artist“He’s having ‘real’ sleep, not drug induced, when his stats fall too far and he can’t be roused.” Mum

Findings Neuromedical

Cumulative Findings

Summary of Research

• 92% of participants so far have experienced reduced pain or their perception of their pain has changed. This is further supported by their narratives.

• Nature of improvisation, meeting, connecting, listening deeply to another person, to their subtle dances that shifts awareness and experience for participant and practitioner.

• The spaces we create and inhabit are both bodily and metaphysical. Accompanying another on in their journey of imagination is transformative.

• Being at ease and excited in not knowing, working without structure allows us to navigate a bustling ward, flow in, between and around with sensitivity.

• This instinctive knowing, tracking significance is what we do and it fits well within acute medical settings when often things are unknown and medical practitioners are also relying on instinct and experimentation.

• Small Things have in many ways improvised our relationships and development of our work, in response to the context and professional relationships we have forged. However as Stephen Levine states, “Improvisation, then, cannot be understood as self-expression, doing whatever one feels in the moment….Spontaneity…is what characterises an act that is an appropriate response to what is given….a response that meets the prior situation in a way that allows us maximum freedom within the framework that is provided to us.” (Levine, S 2013)

“An improviser doesn't know what's going to happen next, but they know what's going to happen next is going to be their life at that moment. They're committed to it, you know; they're adventurers in that way.”(Zaporah, R 2013)

Summary: The significance of Improvisation in Paediatric Healthcare

References

Levine, S K(2013) ‘Expecting the Unexpected: Improvisation in Arts-based Research’ Journal of Applied Arts and Health, Vol 4 No 1 pp 97-104

McNiff, S (2010) Arts-Based Research, Shambahla

Poynor, H (2005) ‘Breathing Space-Artists Exploring Health’, Animated Spring 2005, pp15-19

Zaporah, R (2013) Contact Quarterly