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 neuromedical 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 reestablishing 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
Ward based weekly sessions
• 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.
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 GerstenRoberts
• 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 with
the 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 up
but hadn't walked since before his operation.
Today he has played with some balls
and musical instruments and managed to walk
across the room with your help.
Thankyou so much, Danny had a fantastic
time."
"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."
"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"
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 postsurgery 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.”
Findings
Neuromedical
“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
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.
Summary: The significance of Improvisation in
Paediatric Healthcare
•
•
•
•
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)
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