Theatre in paediatrics: can participatory performance mitigate educational, emotional and social consequences of missing out school during hospitalisation?

ABSTRACT

This paper relays the findings of the evaluation of an applied theatre project for children in hospital as perceived by hospital teachers. A mixed qualitative approach was used. Data were analysed using thematic analysis to explore the teachers’ views on children’s engagement with learning and the improvement of the hospital experience as a whole through applied theatre. The article presents examples of children’s stories that illustrate the findings. The study concludes that applied theatre in paediatrics can engage children with hospital tuition and learning during treatment; improve the management of emotions; help them relax and communicate with the outside world.

Keywords:

• Applied theatre
• children
• arts & health
• education
• hospital

Introduction

Growing evidence on the effects of arts-based practices in child healthcare shows that they offer genuine opportunities for addressing children’s needs and create a healing environment, enhancing their well-being and improving their treatment experience (Cowell, Herron, and Hockenberry 2011; Tawell et al. 2015). Research into bedside, arts-based activities, such as bedside theatre and puppetry in healthcare, found that they distract hospitalised children from pain and have a positive impact on them. This includes stress reduction and improved psychological and physiological well-being in hospital settings (Eisen 2006; Sextou 2016; Astles 2020). The use of art sensory activities based on the positive distraction theory with paediatric patients (preschool children 4–6 years old) reduces pain perception with positive psychological outcomes (Sparks 2001). The All-Party Parliamentary Group on Arts, Health and Well-being Inquiry Report (APPG 2017) and the World Health Organisation European Region Review on the impact of arts on health and well-being (2019) also demonstrate strong evidence that hospitalised children taking part in arts-based activities can be healthier, happier and more resilient in coping with stressful hospital experiences (Lopez-Bushnell and Berg 2018). These findings suggest, that the performing arts in paediatrics need to be further investigated to support children’s learning and well-being.

The importance of maintaining a connection to learning, in order to mitigate educational and social consequences is highlighted in the literature (Gilmour et al. 2015). Research shows that ‘school absence resulting from illness is a problem with major educational and social consequences. It is expected that children that miss curriculum work while being in hospital face difficulties in catching up with their class peers upon their school return and they lose educational and social opportunities to progress (Ratnapalan, Rayar, and Crawley 2009). Disconnection from peers due to hospitalisation has profound effects on children’s social and emotional wellbeing’ (No Isolation 2020). Yet, it is the difficulty in engaging with learning during illness that demands the need for the boost of their positivity, confidence and resilience. It is, therefore, necessary to explore how the difficulty of engaging with learning can be effectively managed through participatory arts.

Most children’s hospitals in the UK have education departments that can support the child and offer tuition while they are undertaking treatment. The aim of tuition for sick children is to continue education. It helps the child catch up on missed work, enabling them to maintain their pupil-role and smoothing the way for reintegration with their peers (Craigen 2014). In 2000, the General Assembly of Hospital Organisation of Pedagogues in Europe (HOPE) recommend the introduction of playful, extra-curricular activities to the school curriculum, to improve child communication and reform children’s perceptions about learning during hospitalisation. Desai and Pandya (2013)  argue that hospital tuition programmes facilitate a clearer child focus on communication in paediatric settings towards improving the focus on children's holistic health and well-being. This article focuses on the potential of participatory arts on the improvement of children’s learning and communication ability; using applied theatre as an exemplar. I intend to provide insight through the analysis of responses from 10 hospital-based teacher-respondents, on their capacity to accompany the artists within the acute hospital setting.

Background

The ‘Bird Island’ project consists of two main parts, an interactive bedside performance (20 min) and art-making activities (10 min), both facilitated by professional actors, storytellers, puppeteers and craft-makers. For the needs of theatrical performance, we employed a range of techniques such as acting, storytelling, puppetry and improvisation, breathing, singing and art installation.

The story

Puppet Sam plays the main character of a sick child in colourful pyjamas, who stays in hospital and dreams of adventures with her imaginary collie dog Lollie. Sam and Lollie go on adventures together at the seaside and they visit Sam’s grandfather who lives in a cherry orchard. However, as in real life, everything does not go smoothly and so in one of Sam’s dreams, Lollie gets sick and the girl feels sad. The following day, Sam tells her mother about her dream. The mother tells Sam how once, she had a dog too and had to take him to the vets when he had an allergic reaction to being stung by a swarm of bees. She reassured her that after a few days of medical treatment and care, he recovered well. Sam absorbs this message and the following night she dreams of Lollie all alone suffering from a bee sting lying under the cherry trees on her grandfather’s farm. As it can happen in dreams, the colours of the sky turned grey and the world felt empty with Lollie being unwell. Sam realises that she can play her part in helping Lollie recover. She decides to be brave and strong to look after Lollie. Sam whispers in her ear ‘All I can do is love you’ and gives her a warm, adoring kiss. As in all stories magic works. The kiss is transformative and brings Lollie back to her old self. In no time, the sun is shining and the cherry trees are blooming again. Lollie jumps around barking and licking Sam’s face (Sextou 2018).

The dramatic frame

O’Toole (1992, 26) describes the act of entering a dramatic situation as ‘entering a ‘play-frame’ that ‘provides some protection from external consequences for those who step inside it.' The ‘imagined worlds’ that we create when we use bedside performance in hospital are also ‘space–times,' to use Edmiston’s words (2000), where children can use and explore moments and experiences normally unavailable to them. In drama, ‘reality’ is different from the real-life patient experience. By ‘reality’ I mean the life of the characters in the fictional story that is different from reality outside fiction. The fiction agreed by the participant as ‘non-real’ but still believed ‘as-if’ it was real within drama. The dramatic frame allows artists to meet children on a metaphorical ground. It also helps the child distinguish between life in hospital and life in fantasyland (Sextou 2016, 31).

In this study, dramatic framing creates multiple layers of sufficient emotional protection for the child. For example, the storyteller animates Puppet Sam as a ‘mediator’ between the child and her character. The puppet, as mediator in hospital settings, enables empathic communication and offers emotional safety to children of fragile health (Astles 2020). The artist performs a short ritual to help Sam fall asleep. She takes Sam in her arms and covers her with the shawl with slow and gentle movements. Then, she starts singing a bedtime lullaby and moves her body to the music. This ritual pattern is repeated three times in the story. Children sing alongside the artist to help Sam fall asleep. They know Sam is asleep when she starts snoring. The storyteller says ‘Sam is fast asleep now. She is dreaming. Would you like to see into her dream?' and the child dives into Sam’s dream. At the end of each dream, the artist performs an ‘awakening’ ritual. She asks help from the child to count down from ten to one and they together call Sam’s name as many times as it takes to wake her up. With a calming and reassuring approach, the artist immerses the child in Sam’s dream and brings them back out of the dream. Dreams in our story aim to maximise the potential of fictional protection as the child steps inside them.

Location and year

The project took place between October 2016 and September 2019 during school term days on NHS sites twice a week. Performances toured on a rota between 10am and 3pm with a lunch break on various hospital wards, including paediatrics, cardiac, oncology, haemoglobin pathology, dialysis, neurosurgery, paediatrics intensive care (PICU) and complex care wards. Occasionally, performances occurred in hospital school premises to a small group of children in-patients who attend lessons in the classroom.

Audience

Children in-patients aged 4–8 years were the focus target audience for the project. The audience suffered from various short-term, long-term, and life-long conditions. These included chest infections, hand, foot and mouth diseases, and pre- or post-operative stress, cancer, heart and kidney failure, leukaemia, and other complicated clinical syndromes combining haematological problems with developmental delays, severe vision or hearing impairments, causing them physical pain, clinical anxiety and discomfort (Crane 2009).

Some long-term patients took part in the project three or four times within a school term. For long-term patients with special needs (i.e. vision impairment, low concentration span, etc.), the performance was tailored to meet these needs. This was done by using sensory activities, altering the length of the show or creating opportunities for the children to lead the performance. To keep their interest and attention engaged, we added new characters to the story; we increased our range of lullabies and introduced Jo, a new large puppet that made children curious about the story. As a result, the project developed an endless repertoire of child-originated adaptations of the original story.

Art-making activities

The children used hospital-approved art materials and equipment to create collages, hanging mobile art, puppets and small 3D statues, mainly animals, inspired by the characters of the story. Children were allowed to keep their artwork. Each child was provided with a hand puppet in a sealed pack and was encouraged to use it in the performance and during their tuition sessions as a way of recalling the theatrical experience.

Research methodology

Despite advances in research, the evaluation of arts-based projects in healthcare has been a ‘complex area’ that employs a broad range of methodological designs and tools (Tesch and Hansen 2012). According to Putland (2008) there are tensions faced by arts and health in evaluating activities and a need to develop a dialogue between the arts and other scientific disciplines to overcome these difficulties. The All-Part Parliamentary Group Report on Arts, Health and Well-being (2017) proposes the need for interdisciplinary dialogue and co-production between artists and non-artists across conventional boundaries in the systems of arts, health and social care. Prior (2020), Sextou and colleagues (2020) recommend developing appropriate frameworks and cross-disciplinary opportunities in arts, health, education and psychology aiming for high-quality services.

In response to these criticisms and demands, I wanted to provoke innovative methodological pathways within the evaluation of arts-based activities and foster an interdisciplinary dialogue between applied theatre research and education in paediatrics. This study is pioneering a new approach to the evaluation of the efficacy of the arts in child healthcare through the collection and analysis of hospital teachers’ viewpoints. This study aims to provide a platform for understanding that hospital teachers contribute different perspectives on perceiving and understanding hospitalised children’s worlds and perspectives that can either complement or challenge artistic ways of knowing.

Participants

The study involved hospital teachers in the evaluation of applied performance for children in hospital. The aim was to use the teacher’s skills and voice in reading sick children’s emotions, behaviour and responses to theatrical intercessions during hospitalisation. Hospital teachers witness stories of vivid imagination, creative thinking, bravery, courage and expression of emotions. Sarah Steinke and colleagues (2016, 41) argue that the role of hospital teachers is especially significant as they ‘attend medical and psychosocial meetings, engage in research more than traditional teachers and assist in the coordination of care between hospital and school environments.' Further studies indicate that hospital teachers are expected to develop higher levels of emotional self-awareness and understanding of emotions, as well as empathic feelings towards their students compared to mainstream school teachers (Hen 2020). Hospital teachers need to be intuitive and familiar with their pupils’ emotional worlds and educational abilities (Csinády 2015). I chose teachers as participants for the evaluation of the ‘Bird Island’ project because of their unique position in relation to children’s experience of play and learning, both naturally related to normality, their responsibility to evaluate activities effectively and they are having the knowledge to do so. The aim was to explore the project’s strengths and weaknesses from a different angle to the artistic view.

Collection of data

The data were collected by semi-structured face-to-face interviews from a committed team of 10 hospital primary teachers from the James Brindley Academies at Birmingham Children’s Hospital. The study occurred in the middle of the 3rd year of the project (2018–2019) collecting sufficient data based on the teachers’ three-year rich pool of experiences of the project and observations. The participants accommodated the artists on the wards to meet the children bedside in line with the hospital’s safeguarding policies during that period. It was this experience of seeing these teachers watching the storyteller and child participating in theatre bedside followed by their reflections of the project with incredible educational insight that inspired the current research.

The study applies a purely data-driven qualitative research strategy, using interviews. It is exploratory. The experiences of experts relevant to the research topic were explored. I designed interview questions to investigate predetermined and unexpected topics. The use of an interview schedule enabled the exploration of the participant’s view on the topic via the use of a flexible question guide (Howitt 2007). To elicit unstructured responses and generate discussion, a mixture of open-ended, scheduled (scripted) ‘probe’ questions relevant to the research question were used (McIntosh and Morse 2015).

Indicative probe questions

1. From your experience of accommodating the ‘Bird Island’ project on the wards, what is your view of its suitability to children in hospital?

2. Have you noticed any immediate effects of the project on child mood/behaviour/communication?

3. Have you followed up the project in your teaching session with the child?

4. How did the children respond to hospital tuition when you followed up the project?

5. As result have you noticed any difference in their engagement with tuition bedside?

Unscheduled (improvised) questions naturally emerged from the dialogue (Berg 1989) to help the participants express their perspectives in more depth. Unscheduled questions aimed to generate additional data about the hospital teachers’ observations and illustrated ways in which the project has affected the audience.

Indicative unscheduled questions

1. Can you give us an example of how the children responded to the project such as observations of changes in mood/behaviour/communications with teachers, nurses and their families?

2. Are there any stories or thoughts about involving children in the project that you want to share?

However, I could not predict or define how the teachers connected with the performance; what stories they had observed; how they interpreted them and how they wanted to communicate them during the interviews. Therefore, the stories in this article are stories that the teachers wanted to tell.

Analysis of data

The data were analysed by the inductive thematic analysis technique to identify and report themes that run through the collected data. Words and phrases were grouped together, which led to the emergence of themes. A theme was considered a significant piece of information related to the research question (Braun and Clarke 2006). The researcher also kept reflective journals throughout the data collection process to ensure reflexivity in qualitative research inquiry (Ortlipp 2008). Reflective notes particularly focused on children participation, mood and behaviour in performance in response to performances.

This study complies with the researcher’s institution code of research ethics (gained RE approval in March 2018). Hospital teachers as participants were approached via email and introduced to the aims of the study, the voluntary nature of their participation and the estimated length of interview. Participants were then invited to present any queries to the researcher. If participants showed an interest to participate in the study, they were asked to express their interest to the Head Teacher of the school. Face-to-face interviews were then arranged at convenient times for the individual, on the same day, at the school’s premises. Interviews were recorded via a Dictaphone for transcription and participants were informed of this before the researched obtained their consent to participate. They were debriefed at the end of the interview by the researcher and each participant was given a copy of the debrief sheet for their personal records.

Discussion of findings

Theme 1 – improved communication with adults

Communication, both verbal and non-verbal, is found to be pivotal to the child’s experience of hospital and a vital component of healthcare (Clarke 2019). Interviews revealed participants’ recognition of bedside performance as a means of improving communication with children:

Some children look so tiered, bored with no energy, which is unusual for a child and no appetite to do anything when the artists meet them. Lollie's story had positive impacts on their moods.

There were changes on their face expressions (i.e. happy faces, smiles and giggles). Their faces started looking interested in what was happening when the tree was plugged in and the fairy lights were on.

Most of the children got on better with getting out of their own zone when they started to talk about how they would give Sam advice to help Lollie. They enjoyed the project bedside and asked for more.

Example:

I remember a girl who was in the cardiac ward waiting for an operation. The nurse told us that she was anxious because her operation was scheduled for the afternoon of that day and that before we arrived she spoke aggressively to her dad. The project was just perfect for that child. It diverted her mind from her surgery to the story and gave her something to talk about. She also made her own puppet and asked if she could take her with her in the theatre room. She got out of bed to help Sam ‘travel’ from her bed to the next child. She even made introductions! She was a great advocate of the show who clearly wanted every child in the room to meet Sam and play with Lollie. When the storyteller passed her bed to walk out of the ward, the girl looked at her mom and said ‘mommy can we bake cookies for Lollie?’ She used her own cookware colourful play set to cook for Lollie with help from her mom and then agreed to take Lollie on a train journey to breathe fresh air and have a picnic in the countryside.

The notion of facing boundaries in the communication of pain during hospitalisation is not new. A critique of studies (Pelander and Leino-Kilpi 2010) found that children sometimes have bad experiences, alongside good ones, during hospitalisation. Most of the worst children’s experiences are around pain that is concealed. The problem here is that pain is an unpleasant experience that the child has not always the language to communicate it. I want to point out that my personal attitude towards the problem of communication with children in hospital is best expressed in Lascaratou’s (2007) theory of pain language. She argues that we should not assume that pain does not exist when pain is not verbalised and that there is no suffering, physical and emotional, when patients are silent. Although the complexity involved in the experience of pain is not the topic of this article, it is necessary to acknowledge that pain, as a dominant element of the hospital experience, exists both as a sensation and an emotional experience. Thus, improving communication with children through participatory theatre is an important finding that strengthens its role in enhancing children’s hospital experience.

Theme 2 – expression of emotions

Carter and Simons (2014) argue that children do not always have the vocabulary to communicate emotions to adults. Sometimes they are too scared to tell others how they feel. Therefore, the best way to assuage their fears is by recognising and communicating with them. As Bolton observes (1984), drama does not protect children from emotions, but rather protects them into emotions within the dramatic frame. Instead of telling them how to feel and how to behave, we included children in the story as much as it was appropriate for their age and level of understanding and let them be in the safety of the dramatic frame. Hospital teachers voiced:

Children who have been quiet and withdrawn since coming to the ward, really come out of their shells.

Sam put the children at ease with the environment and allowed them to feel less inhibited by what was continuing with them.

Feelings of happiness and joy were common throughout the performance. Children talked about emotions that they spotted in the story such as how it feels being ill.

Older children seemed to understand that crying is normal when they are ill and that we should all accept that. As Sam says in the story ‘it is OK to cry. ‘ It’s great to have a story about emotions. It's educational.

Two of the teachers referred to performance as a condition of protection. They said:

Children are shocked by what's going on in their lives. It's a challenge to get them talk about how they feel. Sam's story is good fun. Kids love it and talk about it. This is good. It makes them more aware of feelings I guess. The story created the conditions for sharing feelings through puppets. Puppets worked as their ‘emotional shields’, a protective condition for them to address pain.

The joy of the story was down to the fact that Lollie the dog was ill, but Sam playing the child was well. The story is like a tool for revealing illness, analysing it, within protection.

Based on the awareness of the high stress environment in hospital, these observations are important to the study. We wondered, however, whether children had emotional reactions to illness. The original stimulus in the story was illness that happens to ‘others’ (dog). The aim was to manage emotions and avoid ‘triggered reactions’ (Lazaroo and Ishak 2019) to illness. I wanted to create a distance to the suffering of the puppet within the safety of the dramatic net, helping children empathise with Sam rather than relating to the dog and by achieving that, maintain control of the situation. Children were connecting with the scene of the dog being ill. Because they experienced illness they were curious to know whether the dog would heal, thus, in my view, they engaged in the story. The teachers mention that most children spoke fondly of Sam and gave her advice with strong words of encouragement to help the dog heal:

They seemed to understand the value of caring more and tried to give Sam advice on how to help her dog by saying ‘give her a cuddle’, ‘take her to the vet's’, ‘give her a treat’ etc.

Example:

A girl (age 6) in oncology was shy at the beginning and didn’t say much but after a while she took off her wig and smiled at Sam (Puppet), well and to the storyteller, and then she gave her wig to her mum and felt totally relaxed with the storyteller and Sam being there. She even talked to Sam. When the storyteller asked her what they should do to help Lollie feel better, she said that Lollie was scared and wants Sam to give her a hug, and it kind of felt like she was asking Sam to hug her and so I prompted the storyteller to suggest if she would fancy a hug by Sam, and the girl said “yes”. Children with cancer, you know, don’t like strangers around them. That girl trusted Sam and found comfort in the puppet.

We should not assume that the girl needed a hug because she felt lonely or neglected or scared in her illness. We wonder, however, and want to explore what the spontaneous reaction to the puppet meant, what it served in that moment and how it helped that girl find comfort. We can understand that bedside performance can provide hospitalised children a sense of safety to express emotions.

Theme 3 – -engaging with learning and hospital tuition

There is something unique in relation to the topic of learning during treatment because learners are in physical pain and emotional anxiety. Social isolation correlates with emotional pain and clinical anxiety (Mintz, Palaiologou, and Carroll 2018 ). Many children with long-term illness are away from school for prolonged periods. They lose their social network and miss their friends. As a result, it is not surprising that many children, especially long-term patients, are less able and willing to do the school work during their hospital stay. This is alarming because it leaves them isolated, anxious and feeling ‘left behind’ in their learning. The performance, in the teachers’ opinion, influences their pupils’ appetite to engage with them verbally by recalling the performance experience and retelling the story. Teachers report:

We have seen some children have shown more communication skills when the puppet and tree has been around and more appetite for sitting with the teacher and do homework.

I know they are relating the performance to personal happy experiences and that travels them outside the hospital and it relaxes them. So as an observer then I can go oh you’ve just talked about that, I can tick that off that one you are engaging with an unfamiliar adult, two you are engaging with a story, three you are using your imagination, but you are also relating to personal experience, which is knowledge of the wider world.

If children have seen the performance more than once, some people can recall what has happened and can then discuss what they would do, for some children they’ve shown an emotional response, which is obviously a deep insight into our teaching to know how they respond to feelings.

It’s been interesting, helpful to our teaching and we have used lots of text to discuss and try getting some communication through charts and things with children during their hospitalisation.

Example:

Lollie’s story was inspirational for my pupil (age 5) and his family. They were thoroughly engaged with the actress and puppet throughout the sessions. In fact, not only did he love the story but he loved the puppet's hair and pulled the puppet's face toward him whilst the story was being told. Both pupil and parent loved the story session and the relaxing atmosphere the prop created on the ward. It was so much fun to hear my pupil retelling the story from memory. The whole intervention engaged him in literacy without even knowing it.

The teachers telling their experience demonstrates enthusiasm and surprise in seeing children participating in follow-up literacy activities without even knowing that they were doing their homework. These above quotes articulate some of the benefits involved in participatory theatre as an educational tool in paediatrics.

Theme 4 – increased enjoyment and pain management

The perception and management of pain in paediatrics is complicated by how pain is identified and communicated from child to parents and from parents to nurses or teachers and so on (Carter and Simons 2014). In teachers’ view, the ‘Bird Island’ project offered the children opportunities for a ‘happy escape' from the hospital, replacing boredom with action and, helping with pain management:

Jonathan imagined vibrant, happy images of Sam playing on the beach with her dog on a sunny day. Children have a healthy imagination and they enjoy stories because they apply their imagination to visualise other worlds and escape in places where they feel safe and relaxed.

It was that boy with vision impairment who perceived puppet Sam really well. He asked to touch the puppet and put his fingers in her mouth many times and joined happily. He has to imagine everything, but it was nice that he was given a chance to visualise what the puppet looked like.

Example:

It was quite a moving experience for the staff on the ward to watch a child who was very poorly to engage in a session. After an initial refusal, the child saw the tree and was captivated by it. After some discussion with me about what he could see he agreed to listen to the performance and became immersed in it very quickly. For twenty minutes the storyteller was able to discuss things that the child liked, they talked about their own experiences, his favourite toy and seaside visits. This performance acted as a form of escapism for this child. Nursing staff were commenting on how beautiful it was when they began to sing and talk, as this was the first time the child had spoken to anybody that day. On that day we saw a glimmer of the child we all knew.

Hospital teachers experience the sense of trepidation of teaching a child bedside that has no energy, desire and willingness to do homework when they feel pain. In the example above, the teacher reflects on the story as a pain management tool of making ‘escapism’ from pain possible. However, Lollie’s story is not an obvious pain story. It is not written to portray or represent pain in fiction. The word pain is used only once in the story. The story is about love and compassion and how these qualities can affect people’s relationships when they are facing difficulties such as illness. But, because the pupils are residents of a clinical setting, the teacher’s focus is on child suffering and the experience of pain. So, it is not surprising that the teachers use ‘happy’ and ‘happiness’, as overstatements as they may seem, as they strive to talk about children in pain and link them to the practice of storytelling. In a way, the use of such overstatements proves how attentive the teachers are to the children’s emotional experience. Nevertheless, it is hard to conclude that teachers understand how children experience pain and how they benefit from the performance in solving pain management issues.

Theme 5 – calmness and relaxation

Peterson and Shigetomi (2006) argue that relaxation in paediatrics helps children to prepare for medical or surgical procedures as a coping technique that minimises clinical stress and anxiety. The teachers report that the bedside story relaxed the great majority of children, giving them a focus other than their health condition through breathing. In their own words:

I’ve watched pupils relaxing by start talking about running along the beach, eating this ice cream or that ice cream and actually it’s because they’re living through the eyes of Lollie. So they’re hearing Lollie and Sam’s story and they are doing all these wonderful things together and they relax with the characters. I have seen Bird Island having a long-term happiness and relaxation effect on children. Children start talking about all the wonderful things that they’ve enjoyed doing in the story and actually they bring their own personal experience.

The story created an atmosphere in which the children were kept happy and calm.

Because actually children are not used to being here so for them, the story, a friendly face, coming along with a puppet, and the tree, it’s all very non-medical, it’s not frightening which is kind of what we as teachers are, it’s relaxing.

As soon as children start playing with Puppet Joe to find Lollie under the bed, that often helps the pupils to engage because play is normality for them, and they don’t relate that to the hospital but watching the story, that it’s engaging and they have the opportunity to talk and think nice thoughts actually it’s a distraction and that distraction helps a lot with their relaxation and well-being.

Example:

Puppet Sam sang relaxing lullabies with that girl who was recovering from a heart operation. She had been very quiet since then. Sam falls asleep 3 times in the story I think and it was amazing watching her singing ‘Twinkle Twinkle little star’ again and again to help Sam fall asleep. She was relaxing without knowing it. The slow tempo of the lullaby relaxed her muscles and soothed her mind. She started smiling at Sam. It worked really well for her but even children who looked nervous at the beginning of the story, after singing they started breathing normally.

The above quotes offer indications that applied theatre performance in paediatrics helps with relaxation. I was present to witness moments of joy and relaxation with children but also, moments of ambiguity in performance, moments when children were not responding and remained silent. I am aware that there is no absolute relaxation in a clinical context. How we relax is very personal. I appreciate that the theme of relaxation revealed in this study needs further investigation in future research.

Stories

Teachers also reported stories of children that deeply affected them in the way they interacted with artists and the story. I have edited the stories to remove identifiers such as names or wards and assist the narrative flow. As I have come to witness these stories myself, I have tried to reflect on the incidents trying to honour the children who participated in the project. Because stories in paediatrics are powerful in being able to affect both minds and hearts, when you read these stories, allow some time to engage with them and prepare to be affected.

Emma’s story

We met Emma and her mother resting quietly. Emma was a child suffering from ‘locked-in’ syndrome. The syndrome is typically caused by a lesion in the pons, effectively the part of the brain stem that acts as a bridge between the brain and body. In its ‘traditional form' those children with the syndrome are almost completely paralysed and sometimes only able to move their eyes up and down, or to blink. They cannot move but they are fully conscious. In Emma's case, she could move the lower part of one arm, she could smile, blink and move her eyes:

During the performance Emma was staring at puppet Sam. Her eyes followed the puppet around the room. Mum reported “Emma enjoyed the show. She was fully focused on the performance and smiled during the musical parts”. The mother also explained that Emma looks up right when she wants to communicate happiness and satisfaction. She did that repetitively during the performance. According to her mother, Emma was fully aware of what was happening around her, but she needed a ‘nudge’ (a strong stimulus) to express her thoughts and emotions in her own way. ‘Because she doesn't speak, it doesn't mean that she doesn't feel and think!’ said mum. From watching Emma's reactions during the show, it was evident that the child was both connected with the puppet and stimulated to communicate with her environment. The fairy lights on the tree also got her attention and she blinked when she was asked if she liked it. The storyteller spent extra time with Emma after the performance. She covered Emma with the sensory blanket, which had stitched butterflies and bees made of various fabrics-surfaces. Emma touched the soft felt-made bees. She blinked to respond to the stimulus. Mum said that this was an indication of happiness. The storyteller sang the lullaby to Emma once more and Emma looked up to the right again. Mum was extremely happy to see her child responding and communicating with her where the words were not available.

We discussed Emma’s experience with her allocated hospital teacher of the day. We acknowledged that we will never know exactly what Emma was thinking during the story but we do know that she enjoyed it and stimulated her to communicate with her surroundings. The ways in which Emma interacted with puppet Sam raise a marvellous prospect: how can one use intimate theatrical performance to help a child, who is generally unable to communicate with the outside world, to respond to the environment and experience enjoyment?

Abraham’s story

We met Abraham at the hospital, awaiting a transplant. He had cognitive developmental delays and learning difficulties that limit his understanding of the world around him. We observed low concentration, lack of ability to recognise and name objects; limited verbal communication and interaction with adults; difficulty in making connections between words and pictures. We performed ‘Lollie’ to him seven times within the school year:

At the beginning, the child did not recognise any of the birds, bees, butterflies and cherries on the portable tree that we used in our performance. The child was unable to name those items, making connections between the story, the puppet, the tree and the invisible dog. He could not imagine a dog that was not physically present. He was, however, looking at the tree for a few seconds and then, moved their attention down to the floor and then, back to the tree for a while. This happened many times. To make a positive difference to this child’s experience, we (hospital teacher and teacher assistant) decided to support him in making connections between the characters of the story. To achieve this we gave the child a pack with a brand-new dog hand puppet and encouraged him to use it during the performance to imagine the dog. The child kept the dog after the show and practiced with it with assistance from us.

We performed a month later. We observed that he used his dog puppet to interact physically with Puppet Sam and started making a connection with her. This was evident by watching him smiling at Sam and reach out to touch her hair. He was clapping hands when Sam was singing and pointing at the tree when Sam was asking questions about bees and butterflies:

After a few months, we observed more improvements. For example, Abraham could recognise the birds and the bees on the tree and he would sing the lullaby with Puppet Sam. He would make the sound ‘bzzzzzzz’ for the bees and even dance on the bed with excitement. That child who did not speak and recognise anything from the story could now give simple commands to the dog ‘sit’, ‘stay’ ‘up’, ‘down’. He laughed, lively cheered and enjoyed their time in hospital.

According to his hospital teacher, by the end of the school year the child had made a progress in concentration, recognition, communication, interaction. The project helped the child be ‘happier’ (and I use the word because the teachers used it). The hospital teacher also reported that they followed up Lollie’s story with Abraham. He gradually became more willing to work with them on the story bedside and more confident in modelling clay. The child’s mother said how impressed she was by the child’s improvement over time. However, it is not known what the lasting benefits of the performance are on the child after the end of the project.

Helen’s story

We visited Helen in PICU many times throughout the year. She was reluctant to engage in conversation. One of the difficulties in communication with that girl was that she did not speak much English. So we sang her a song and interacted on her terms. Over time, she could sing with the puppet and giggle at the story. She could recognise colours from the tree, and make paintings of butterflies from the tree and various story scenes:

One day, Helen listened to the story but remained very quiet while lying down in bed. She would only speak with a whisper when invited to engage. We later learnt midway through the performance that she was soon to be taken to theatre. For a child who is in anticipation of a surgery the benefits of the project were doubled. The show engaged her with fun activities and distracted her from her situation. Helen started coming out of her shell when engaging with Lollie, the imaginary dog, throwing the ball for her and giving her cuddles and a big kiss. She smiled at the puppet and played as normal while the actress tried to keep her relaxed. On another day, Helen would hide under her blanket whenever anyone apart from her parents came to see her, only peeking out occasionally to see what was going on or to reach for her toys. When a nurse came and disconnected her from the machine, she darted off to run up and down the ward after being cooped up in bed for so long. At that time she spotted the puppet and tree entering the ward. With enthusiasm, the girl came back to her bed and listened to the story with the other patient and her mum. She participated in joy, laughter and had many suggestions to Lollie for calming her dog. Afterward, she made objects and characters out of clay.

Her teacher commented that that was the longest time she had interacted with anyone in one session.

Reflections

I noted that the teachers expressed surprising levels of appreciation towards puppets when observed the children’s reactions. The ways in which teachers described how children responded to puppets introduce new information about the use of puppets in hospital tuition. As playful objects that provide a sense of emotional safety that also makes them a valuable pedagogical tool. Fourie (2010) states that puppetry as an educational means enables a focused and creative learning experience as the children are playing in a non-threatening and non-judgmental way. Matt Smith (2020, 56) points out that ‘puppets can enable us to have the confidence to be odd, as a puppet is always other’. In a hospital context, it is ok for the puppet as ‘other’ to look strange or weird. I use the words ‘strange’ and ‘weird’ intentionally because I have heard children in oncology often using them to describe the way they look following chemotherapy. Children related to puppets in the ‘Bird Island’ project because the performance employed the puppet as a creative agent and a mediator allowing children to connect with the artist through the puppet. Children accepted the possibility of staying creative and playful (like the puppet) during illness. Puppet oddness, Smith continues (2020, 57), is a great collaborator unlocking imagination and ‘creativity without conforming to types, models or what is correct or appropriate'. The practice of involving puppets and objects in the ‘Bird Island’ performance empowered children as creative participants, and not as vulnerable people defined by illness. Puppets supported the transformation of sick children into co-creators and co-storytellers. This achieved a natural engagement with learning outside of traditional teaching methods.

In my book (2016) I explain that puppets operate as mediators between the artist and children. They create a ‘safe space’ for both involved parties where they can communicate and express their emotions. Thanks to the capacity of the puppet to protect the participant when entering an unknown emotional place, puppets become tools of empathetic communication. Puppets contribute to the emotional safety of participants who experience fragile situations (Astles 2020). The above stories prove that the use of puppets as an invitation for engagement and interaction provided a child-friendly and protecting environment that generated avenues of spontaneous communication and expression of feelings. Because Sam is a representation of a sick child, and because children identified with her, the puppet unlocked the children’s hesitancy to communicate with teachers and encouraged them to cooperate with them during lessons. It may also be that in the imaginary world of the story children felt reassured by the narrative and they opened up to the possibilities of the narrative. For example, Sam says to her dog ‘it is ok to cry!' Most children cry in hospital. Although this is an understandable reaction to pain, crying is not always accepted as good behaviour. The puppet gave ‘permission’ to the children to be who they wanted to be without judgement. It offered them the vocabulary to express they were in pain, which is important to the healing process. Puppets create a ‘healing environment’ with positive effects in child treatment (Cowell, Herron, and Hockenberry 2011).

We cannot, and should not assume, however, that all children who participated in the project had the same positive experiences. Yet, the stories teachers told us provide evidence that bedside performance using puppetry in healthcare can distract children from their difficulty and can help them to move from their hospital reality to a less painful or traumatic one – a worry-free fictional world. In the companion of the puppets, communication boundaries can become elevated with care and compassion in healthcare settings.

Limitations of the study

A potential limitation is that of participant bias. Research participants are humans who served as the instrument for data collection. Their gender, sexuality, ethnicity, class, and theoretical approach may affect observation, analysis, and interpretation (Kawulich 2005). Hospital teachers shared their opinions and observations based on their specialised understanding of children as hospital pupils. All the data in this article represent views of incidents that the teachers saw through their own professional lenses. Also, as mentioned earlier in the methodology, the selection of stories was out of the author’s control. The participants decided what stories and examples they wanted to contribute to the study. Because of the small sample (three stories), they are all presented in this article. It is possible that the teachers ‘cherry picked’ the best examples of child participation in the project to prove their pupils’ progress in hospital tuition. Indeed, they also claimed a positive contribution of the school towards the project’s aims for enhanced well-being and learning during hospitalisation. Nevertheless, it was clear to the researcher during the interviews that as the teachers knew the children in the stories, they have cared for the stories as would hope we will care for their pupils. The teachers’ approach to offering their views and sharing stories that they had witnessed on the hospital wards had a strong sense of ethical responsibility, respect to the children and professionalism.

As the project used combinations of art forms to engage the child as an audience, such as storytelling, puppetry, art installations and singing, the complexity of the approach caused a multiplicity of possible interrelated outcomes. Therefore, ‘the cause and effect’ acquisition is difficult to analyse. One art form was more effective by joining its strengths with another art form, but the multiple effects on the whole performance experience are difficult to discern and define. The term ‘multiple effects’ refers to multiple ways that different stimuli and artistic tools benefit audience participation, the relationship between the artist and child-spectator, the exchange of emotions, the making of meanings, and as such, have various cognitive, emotional, metaphorical and symbolic dimensions. For example, relaxation may have been achieved by the soothing voice of the storyteller or the friendliness of the puppet or a combination of both. I want to mention, however, that it would be impractical to only deliver the art forms singularly to identify the one responsible as that would take away from the benefit. Also, it would be unethical to separate the art form from the benefit of 1:1 interaction in a safe space. Therefore, we used a combination of art forms. We avoided making speculation of possible associations between the stimuli given (visual, vocal, etc.) and the focus remained on the positive outcome rather than the fragmentation of its causes.

Concluding thoughts

The study provides evidence that participatory drama performance helps children engage with learning and do more homework while they are in hospital. It is helpful to teachers in understanding how the children feel, what they need and what suits their needs. More specifically, the ‘Bird Island’ project motivated sick and injured children to engage with literacy KS1 and KS2 and creativity during hospitalisation. Participatory performance connected hospitalised children with adults through storytelling, object theatre and puppets by using puppetry as an empathic and caring medium of connection with patients. A gentle and respectful approach to children’s sickness created a sense of care, well-being and comfort in illness that relaxed and improved hospitalised children’s moods. The use of dreams and puppetry created emotional safety in fiction and encouraged hospitalised children to express their emotions; communicate with the outside world; respond to the environment and experience enjoyment.

In the teachers’ views, there is a role for artists to engage in using storytelling, puppetry, singing and art installations as a vehicle for interactive learning in hospital. These may be particularly useful approaches for artists in healthcare, especially when they encounter boundaries of collaboration with children who need strategies to manage clinical stress.

Seeing the evaluation of theatre-based activities in child healthcare as an interdisciplinary dialogue between artists and teachers where understanding is constructed with others is at the heart of using the hospital teachers’ viewpoints in drama research in paediatrics. While the artist is attentive to the audience’s needs and interests in performance, the teachers have the time and skillset to follow up the performance and offer their insight. Developing cross-disciplinary methodologies between creative arts and education for the evaluation of the arts in child healthcare is a remarkable opportunity. It allows for the realisation of empirical research alongside the artistic process.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Notes on contributors

Persephone Sextou

Persephone Sextou is a Professor in applied theatre for health and well-being and Director of the Sidney De Haan Research Centre at Canterbury Christ Church University, Kent, UK, and adjunct research fellow at Griffith University in Australia. She is the Director of the Community & Applied Drama Laboratory and author of the book ‘Theatre for Children in Hospital. The Gift of Compassion’.