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107
ATR 6 (2) pp. 107–119 Intellect Limited 2018
Applied Theatre Research
Volume 6 Number 2
© 2018 Intellect Ltd Article. English language. doi: 10.1386/atr.6.2.107_1
PERSEPHONE SEXTOU AND ANATOLI KARYPIDOU
Newman University, Birmingham, United Kingdom
What does the actor need
to perform in health care?
Emotional demands, skills
and competencies
ABSTRACT
This article aims to explore the required skills and competencies of the actor who
works in health-care systems. A narrative inquiry gave the opportunity for partici-
pants to elaborate on their understandings of their direct or indirect engagement
with theatre in hospitals. Data were collected in the form of ten narrative inter-
views with experienced actors in hospitals and drama trainees. Inductive thematic
analysis of this collection of qualitative data was used to allow findings to emerge
from frequent or significant themes inherent in the semi-structured interviews. The
study demonstrates a defensible emphasis on key themes, including the predictable
professional skills such as acting in participatory dramas, using theatre improvisa-
tion and puppetry, and interpersonal skills such as emotional intelligence and empa-
thetic awareness.
KEYWORDS
applied theatre
emotional intelligence
empathy
health care
improvisation
metaxis
puppetry
qualitative data
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John o’Toole and PeTer o’Connor
INTRODUCTION
The body of research that supports the beneficial role of diverse applications
of applied theatre in relation to the health and wellbeing of populations in
public health settings such as hospitals, hospices and care homes has grown
considerably in the United Kingdom in recent years (APPG 2017). Research
on government policy-making and health-care services (Parkinson and White
2013) and the methodologies linking theatrical interventions to individu-
als and communities in clinical contexts (Baxter and Low 2018; Brodzinski
2010) attest to the value of value theatre. More specifically, research evidence
captures the perceived wellbeing benefits of using interactive bedside perfor-
mance with children in hospitals (Sextou and Hall 2015), from drama with
older people that transforms patterns of doing, thinking and feeling as a route
to wellbeing (Wimpenny and Savin-Baden 2014) and from participatory thea-
tre with people experiencing recovery from mental health issues (Torrissen
and Stickley 2018). These studies demonstrate how arts projects in health care
have provided a valuable means to create new ways of creative engagement
with vulnerable audiences. However, there is little evidence on the needs of
the artist and the skills and competencies that they need to perform in health
care both sensitively and professionally.
The literature suggests that further investigations are necessary in the
training of artists in health care (Moss and O’Neill 2009); more specifically,
there is a need for ‘the development of undergraduate and postgraduate
courses and professional modules dedicated to the contribution of the arts
to health and wellbeing’ (APPG 2017:155–56). The authors acknowledge the
demand in this field, particularly in relation to the complexities and emotional
demands of the location. In this study, therefore, we aimed to develop a better
understanding of the behaviours and incidents that actors witness on hospital
wards, how they respond to them as artists, what skills they use and what they
recommend as useful practice for actors in health care. This study’s aim was
to contribute to discussions about the skills of artists in health care; the arti-
cle argues for the development of new courses in applied theatre and, more
generally, in arts and health.
RATIONALE
Building on the research and literature, this project acknowledges that
working in child health care is stressful (Pelander and Leino-Kilpi 2010).
Numerous research studies suggest high levels of work-related stress, exhaus-
tion and burnout among child health-care practitioners (Pantaleoni et al.
2014). Paediatric health-care professionals often deal with demanding situ-
ations that may induce strong emotional reactions (Mukherjee et al. 2009).
Emotional burnout has also been reported by nurses who work with children
with chronic conditions (Maytum, Heiman and Garwick 2004). Considering
that strong emotions are implicit in health-care interactions, there is currently
an increasing interest in enlisting emotionally competent personnel in health
care (Stratton, Saunders and Elam 2008). Indeed, the skills to understand, use
and regulate emotional information in oneself and others have recently been
acknowledged as compulsory to ensure a high quality of health-care service
(Birks and Watt 2007). Lee and colleagues (2015) argue that the abilities related
to emotional intelligence could be important predictors of professionals’ well-
being and resilience in intensive care paediatrics, where efficiently adapting
to emotionally demanding conditions could be a core requirement. Because
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What does the actor need to perform in health care? …
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theatrical interactions in hospitals take place in a situation fraught with strong
emotions, marginalization, risk, trauma and suffering caused by illness, the
authors of this study start from the premise that performing in child health care
can be emotionally demanding. It is necessary to explore the practitioner’s abil-
ity to deal with the demands of the location both efficiently and professionally.
METHODOLOGY
To contextualize the study in relation to the demands placed on both audi-
ences and actors by theatre in clinical settings, we include a brief description
of artistic practice based on our personal experience.
Hospital performances for children are generally interactive, improvi-
satory and flexible interventions. They aim to engage the audience in crea-
tive distractions from their clinical condition, help them to relax and bring
normality to their stay in hospital. Some of these performances are more inti-
mate than others and can happen one to one at the bedside, while others
target small groups of children in the same room. Performances may vary in
content, length, style and techniques (e.g. interactive storytelling, puppetry) to
suit the preferences of the artist and the needs of the audience (for example,
blind children would benefit from sensory activities). Hospital performances
are intended to be inclusive because audiences come from various cultural
and social backgrounds. Communication can be challenging. Some children
have English as their second language and others have limited verbal skills.
Children with developmental delays may also have limited ability to commu-
nicate well. Where possible, the artist facilitates non-verbal communication.
The audience’s level of engagement may also vary depending on the children’s
age, moods and the seriousness of their health condition. The artist has to
follow the hospital’s safety policies and health regulations, which may put
restrictions on using materials, costumes and props, and on what decisions
can be made about the dimensions of the performance space. These restric-
tions can be overcome by a collaboration between the artist and the clinical
staff. In hospitals, the artist is in a process of continuous negotiation between
accepting illness as reality and transforming the hospital experience in posi-
tive ways through theatre.
For the purposes of this pilot study, we employed a raw text qualitative
method. Face-to-face, semi-structured, audio-recorded interviews of set ques-
tions were used to offer space for divergence and to allow a flow of ideas
and answers (Wisker 2009). We used the interviews to explore the views of
research participants on any deviations from traditional acting training, where
the body and the text are the main working sources, into an awareness of the
body and emotions (Bryman 2008). The interviews lasted approximately one
to one and a half hours each, and were carried out at the premises of a higher
education Institution in the United Kingdom over a period of seven months
(December 2016 to August 2017).
The method that has been used for data analysis is inductive thematic
analysis (Thomas 2006), to allow findings to emerge from frequent or signifi-
cant themes inherent in interview data. The approach is not limited by prior
assumptions and theories or hypotheses, as in deductive analysis, but rather
welcomes any unplanned effects or side-effects arising from the study.
Emerging themes were developed by studying the transcripts repeatedly and
considering possible meanings. We coded our reviews of the transcripts sepa-
rately and in parallel to make the process more objective.
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RESEARCH PARTICIPANTS
Ten research participants took part in this pilot study. These were five applied
theatre practitioners (ATPs) holding an acting qualification either from a
higher education institution (HEI) or an acting school, and five drama trainees
(DTs) who were attending an undergraduate drama degree with the focus on
applied theatre in HEIs at that time. The ATP participants had previous direct
practical experience of performing to patients in public health care for a period
of one to six years. The DTs had one to three years’ experience of observing
various ATPs (other than the participants) delivering theatrical interventions
in clinical settings during their studies. Eight of the participants were female
and two were males. This reflects the gender gap that traditionally exists in
drama subjects at UK universities (The Guardian Education 2013).
The guiding principle for this pilot study was to provide a voice for the ATPs
and DTs to identify the daily encounters of performing in clinical settings and
the skills they needed to deal with them. Although we acknowledge that hospi-
tals are emotionally challenging environments demanding emotionally compe-
tent personnel in health care, we decided not to ask direct questions about their
emotional competencies but rather ask them to talk about their direct or indi-
rect experience of hospital performance and be open to the emerging data.
The interviews were divided into three main parts. The first part focused
on the participants’ knowledge of applied theatre practices and approaches to
health care generally, and their previous experience in this field. Our aim was
to understand whether or not the participants were acquainted with theatre
practice in health care. Sample questions were:
• How do you perceive an actor’s role in health care?
• What is your experience of hospital performance?
In the second part, the focus was on the participants’ experiences of using
hospital as a ‘stage’, as opposed to performing in a main house theatre. Our
goal was to explore what factors define hospital performance. Sample ques-
tions were:
• What child behaviours and incidents do you normally experience during
theatrical interventions on hospital wards (either directly or indirectly)?
Can you give us an example?
• Can you recall how you responded to that incident as an artist?
The third part of the interviews aimed to elicit the participants’ views on the
skills required to perform effectively in health care, and give voice to their
recommendations. Sample questions were:
• In your view, what skills are necessary to ensure efficiency and profession-
alism in hospital performance?
• Can you give us an example of using (or observing) one of those skills in
context?
Ethical approval for the study was granted through the authors’ HIE Research
Ethics Committee. All participants received information sheets about the study
prior to the interviews by email and gave their written consent. The interviews
were audio recorded and transcribed.
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DISCUSSION OF FINDINGS
The analysis of data suggests that at times the emergent themes are unified
and interconnected. Most of the research participants referred to professional
acting skills in relation to interpersonal competencies, showing some difficulty
in separating them. We would like to think that this ‘difficulty’ is not necessar-
ily a weakness. On the contrary, it may be an indication of interrelated links
between the professional role of the applied theatre practitioner and the inter-
personal, more delicate side of the job that deals with emotions and needs
soft skills. Consequently, it became more sensible for us to view the themes
as equally important and dynamic entities that were related to one another. In
accordance with the aim of the study, this allowed us to discuss the partici-
pants’ views together rather than separately. Significant themes were evinced
frequently in two main interrelated areas of discussion: (1) participatory acting,
improvisation and puppetry; and (2) emotional intelligence, emotional aware-
ness and empathy.
When we asked the participants what behaviours and incidents they had
experienced during hospital performance, they reported both positive and
less positive incidents and behaviours. Positive experiences generally involved
performances to children who were open to communication and responsive.
Less positive experiences involved incidents that affected performances in
some ways – for example, audiences that were distracted by clinical proce-
dures taking place during the performance and by emergencies that happened
to other children on the same ward.
We asked the participants about their own experience of such inci-
dents, seeking a better understanding of how the actors felt and how they
dealt with them during the performance. We expected a variety of individ-
ual responses; participants were not likely to respond to the environment
consistently, because they came with different levels of experience and
familiarity with clinical environments. Some DTs revealed anxiety about
performing to sick children. ATPs generally reported confidence and a sense
of enjoyment during the performance. More specifically, the more experi-
enced an ATP was in performing in health-care settings, the more confi-
dent they appeared to be in using the aesthetics of performance to remain
focused and professional.
Six of the participants – both ATPs and DTs – mentioned the word
‘distance’ to describe their experience of hospital performance. They reported:
You need some quiet focus when lots of things are going on around you
to provide distance for yourself.
(DT)
I wouldn’t want to shut myself off because I don’t think that’s effective
but provide some distance for myself to protect me so that I can go on
and perform.
(DT)
In dealing with a challenging situation when a nurse rushes into the
room, you must react in character, you know what I mean, not to break
the aesthetics of the piece, just because something is happening and
keep your distance.
(ATP)
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John o’Toole and PeTer o’Connor
All ATP participants with direct experience of hospital performance suggested
some competencies that helped them to maintain a professional distance
from the emotional information communicated by children on the wards.
They suggested adaptability to situations, presence in the now, calmness, self-
awareness and professionalism:
You have to be adaptable which is hard because you have to be in the
moment with the story but then you can’t completely get lost in it
because you have to be aware of what’s going on around you at all times
so that there’s a balance.
(ATP)
You need to be calm, considering the role that you have taken on, need
to be aware of who you are and who the child thinks that you are, to not
break that fiction that you have created … ‘That’s not real’ – acting skills,
you know!
(ATP)
The competencies described by these participants are not unknown to
applied theatre practitioners. The aesthetics of participatory performance
allow us to enter an imaginative world – even though we are aware that it is
not completely separate from reality. The audience is a contributor to interac-
tive performance rather than a passive recipient of a complete artistic prod-
uct (Jackson 2007). Therefore, distancing from reality becomes a complicated
problem in participatory dramas. The barriers between reality and fiction
are lifted to allow interaction between actors and audiences. To bring this
notion into hospital performance, the actor and the child share a story that is
separate from the hospital reality but, because it takes place within a domi-
nant context and setting, reality can’t be ignored, as the research participants
suggested.
When we asked the participants to give us examples of behaviours or inci-
dents on the wards that couldn’t be ignored during a performance, a participant
described an incident with a nurse who interrupted the intervention to take a
blood test. The child was unwilling to cooperate in taking the test because of a
previous bad experience in finding a vein. He cried and made noises. We asked
the participant how that had felt and how he had dealt with it:
There has to be a degree of attachment but you can’t get too emotionally
involved, you might get upset, I suppose you’ve got to keep that profes-
sionalism … but at the same time you’ve got to show your emotions
as well. So it’s a delicate balance I guess between showing that side of
emotion to do with the performance – and that’s acting as well, isn’t it?
(ATP)
The limitations of distancing in participatory theatre in health care, and the
requirement to reflect on emotions, were also acknowledged by other partici-
pants:
Something might happen during the session and a doctor has to come
in at which point you need to be aware of what’s going on, you need to
be a caring professional.
(ATP)
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You have to be friendly, welcoming, have empathy for the child …
you have to be sensitive to the whole experience, and caring and have
patience and reflect on emotions.
(DT)
These statements suggest a process of dealing with real incidents during
performance that involves mindfulness of emotions and attentiveness.
Thompson (2015) argues that attentiveness and care are at the heart of
applied theatre practice in health care, and are the outcome of a sensitive and
ethical approach to performance in challenging environments. In the context
of hospital performance, being a caring professional seems an obvious compe-
tency. Working with children affected by health conditions requires a practice
of kindness and compassion. Yet is it possible for an actor to be caring towards
a sick child as an audience without responding to the child’s identity as a sick
person? Who does the actor care for: the child as participant or the child as a
patient, or both? If we accept that a child in hospital has ‘a dual citizenship’ as
a citizen in the ‘province of illness’ (patient) and a citizen of fantasyland (audi-
ence), then performing to a sick child would be no different from acting in
metaxis, a generally recognized condition in applied theatre, defined as bring-
ing the two almost autonomous worlds of fiction and reality together in inter-
active participatory dramas. The dialogue between the world of the audience
and the world of the play is known as the context of metaxis in Theatre of the
Oppressed (Boal 1979). The word ‘metaxis’ might not have been in the vocabu-
lary of the research participants, but they described it. Their replies showed
that when they performed in hospital, they were present in and belonged to
two different worlds: the fictional story and the reality of illness. Performing ‘in
between’ two worlds is a skill required by actors in participatory theatre that
seems to work well for actors in health care. It may be that it helps them to
balance their focus and respond to the demands of the location. It seems that
incorporating that experience in their acting and showing emotions in charac-
ter is part of what it means to be an actor.
We asked the participants what skills were necessary to ensure efficiency
and professionalism in hospital performance. Eight participants talked about
puppets as the children’s most favoured tools for engaging them with the
fictional world. Two ATP participants who employed puppetry in their work
found puppets ‘helpful in encouraging communication’ with audiences, and
they suggested ‘collaboration between actors and puppeteers’. More specifi-
cally, they said:
Obviously, the kids can relate to that (puppets) because they play with a
lot of toys and it’s easy to use puppets to mask everything when you are
performing alone one to one with a child.
(ATP)
Instead of using my body to bring the story I am using a puppet and I
am projecting on to it to bring the story to life and it all becomes more
engaging.
(ATP)
For two drama students who observed interventions, puppets were repre-
sented as excellent tools for making safe emotional connections with the
audience:
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John o’Toole and PeTer o’Connor
Puppets take children’s minds off … they remind them of home.
(DT)
It is very important to tell a story through a puppet … it makes it more
relatable and safer.
(DT)
Puppets are exemplars of emotional protection in creative interventions
(Adams 2008). Creative interactions with puppets have been used widely
with children in therapy to foster healing, engage the child, generate a rich
description of their experience and facilitate the imaginative creation of new
meanings (Desmond et al. 2015). Puppets are also used in paediatrics by play
specialists to take the child’s mind off clinical procedures, and the pain and
fear associated with them (Great Ormond Street Hospital NHS 2018). The
participants appreciated puppets as tools to engage children in the story, and
to keep them focused and connected to fiction; some of them used puppets as
a source of play and for normalizing their hospital experience.
Four practitioners – all ATPs with experience – acknowledged empathetic
awareness of self and others as a critical element of their work in hospitals. An
ATP with six years’ experience of performing in health care said:
You can’t get completely lost in your role and your lines. You’ve got to
be concentrated on your role but also have a greater sense of aware-
ness of yourself and what goes on in your surroundings and know how
to respond to your emotions … A lot of it is about emotional intelli-
gence, understanding yourself, understanding the child, and how you
might react to this situation thinking about how you come across to the
child in that situation and what the child’s face tells you and what your
language and what your face and your body is doing to that child at that
moment.
(ATP)
Another ATP mentioned attentiveness skills:
I think you get yourself into a frame of mind before you go in. You can’t
ignore your emotions: you are in role and so I think it is beneficial. You
are not on your own; you are able to connect with the audience because
you are in role in the moment.
(ATP with two years’ experience)
The above quotes coincide with Goleman’s (2014) theory of focus and the
importance of being aware of our own awareness. According to Goleman,
focus helps us to handle emotions, our inner world and our thoughts, and
to manage them for the better. In the context of performing for sick children,
focus relates to the perspective actors can take that allows them to monitor
their inner world and remain professional during challenging incidents. Lee
and colleagues (2015) also argue that emotional intelligence-related abilities
could be important predictors of professionals’ wellbeing and resilience in
intensive care paediatrics, where the ability to efficiently adapt to emotionally
demanding conditions could be a core requirement. According to Mayer and
Salovey (1997), emotional intelligence is concerned with the individual’s ability
to use emotional information to facilitate various cognitive processes, such as
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What does the actor need to perform in health care? …
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information processing, focus of attention and decision-making. We appreciate
that these theories need further discussion in future studies because they may
be particularly useful approaches for actors in health care, especially when they
encounter unpredictable emotional incidents during performance.
The study offers indications that empathy and improvisation are concepts
worth exploring. Interviews revealed participants’ recognition of empathizing
with the patient-audience’s situation in developing their interaction with the
audience:
Theatre and empathy go hand in hand I think because you need to
understand the people you perform to and so you can treat them like
people, as opposed to sick children.
(DT)
Just have to show to the child that you, as a person, understand they are
going through a difficult time … and give them a chance for commu-
nication as an empathetic person and in a greater understanding a
non-judgmental person.
(ATP)
If, for example, a child is in hospital and we are performing, and some-
body comes, and I must improvise but I can see the child is distressed,
I would be able to show empathy through my improvisation. I mean,
so I wouldn’t improvise in a way that was static and robotic; I would
improvise in a way which was tailored to the situation … So, if you can
show empathy in that moment of improvisation, and if you can impro-
vise with the story in empathy, the child is relaxed, and they are like ‘the
practitioners are right there with me, and we’re in synch in a way’.
(ATP)
Empathy involves a deep understanding of the patient’s inner self and expe-
riences, as opposed to sympathy which involves the action of affectively
connecting with the patient (Fields et al. 2011). Understanding the emotions
and experiences of others may assist ATPs to take a caring and compassionate
approach to their practice, maintain personal wellbeing, provide good-quality
social support to colleagues and establish positive interpersonal interaction
with the audience. While empathizing with the audience in real incidents,
improvisation could be of great assistance in incorporating incidents and
emotions from reality into the dramatic dimensions of the story in a natural
way. Understanding experiences and responding to them in the context of this
article could benefit the actor through engaging their ability to deal with what
may be a stressful incident in child health-care and other community contexts.
CONCLUDING THOUGHTS, ASPIRATIONS AND RECOMMENDATIONS
Actors in health care belong to a wider group of artists who work with children
in hospital, including clowns known as giggling doctors, storytellers, puppeteers,
magicians, musicians, singers and visual artists. Some of the findings about the
specific skills required of an actor in child health care may also apply to profes-
sionals in the same or similar contexts. The findings of this study might form a
basis for further recommendations that would improve the provision of training
for a larger group of artists across the arts in the health and wellbeing sector.
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John o’Toole and PeTer o’Connor
We are aware of the limitations of a pilot study (i.e. small sample, short
period, one method), but we are confident that the present study reveals
useful indications of important concepts that are generally under-investigated,
including the distinctive demands of the hospital location on human emotions
during theatrical interventions and the role of aesthetics in emotional protec-
tion. More specifically:
• Hospital performances in child health care are representative examples
of applied theatre practice that involve participatory acting and improv-
isation, and efficiency in bringing reality and fiction into a collaborative
dialogue in performance.
• Actors are required to develop an all-round awareness of emotions during
performance, including their own and those of their audience.
• Actors need to be adaptable to situations, present in the now, calm, self-
aware, emotionally aware, professional, friendly and welcoming. They
need to have empathy for the child, to be sensitive to the whole experi-
ence, and to be caring, patient and reflective about their emotions (they
must have emotional intelligence and empathetic awareness).
• Actors would benefit from hands-on practical experience and opportuni-
ties to familiarize themselves with the clinical environment and gain confi-
dence in hospital performance.
We recommend further investigations in the form of larger studies in this
field in order to understand better the training needs of actors in health
care concerning emotional protection in interactive applied theatre
performances.
• The concept of emotional awareness, intelligence and attentiveness may
play a particularly important role in applied theatre with vulnerable
audiences – for example, sick children, young people at risk, young offend-
ers, elderly people in care homes, audiences in prisons, rehabilitation
centres, palliative care services and refugee camps.
• The beneficial role of puppetry in hospital performance for children also
generates further research opportunities for future investigation, exam-
ining whether puppetry in hospital performance is a way to maintain
the fictional while interchanging information and emotions with the
surroundings outside the performance.
Arguably, the degree to which an ATP can moderate levels of stress during
performance in clinical surroundings is subject to individual differences (Birks
and Watt 2007). Therefore, if emotional intelligence and empathetic aware-
ness affect applied theatre programmes, then it will be important to determine
whether emotional intelligence and empathy can be improved by training.
There is a need to also determine what kind of training would be effective
for the ATP’s work and whether an ATP’s emotional intelligence score would
matter in their choice to work in health care.
How actors employ and apply their skills to various situations may vary
from person to person, and from performance to performance. We recom-
mend additional research with larger groups of participants in studies
with longitudinal impact. We suggest cross-disciplinary research between
theatre, psychology and creative therapies, aiming to develop a new body
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of combined knowledge and expertise. This may challenge the traditional
contexts of applied theatre by exploring wider social and personal aspects of
development, such as discovering one’s self and emotional existence, being
aware of people’s needs, caring for individuals and communities, and find-
ing meaning in professional and personal life through theatre in health care.
If that requires a change in the culture of applied theatre education and
work spaces, the question is whether we are ready to dare to undertake this
innovation.
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SUGGESTED CITATION
Sextou, P. and Karypidou, A. (2018), ‘What does the actor need to perform in
health care? Emotional demands, skills and competencies’, Applied Theatre
Research, 6:2, pp. 107–19, doi: 10.1386/atr.6.2.107_1
CONTRIBUTOR DETAILS
Persephone Sextou is a Reader in Applied Theatre at Newman University,
Birmingham and director of the university’s Community and Applied Drama
Laboratory. She is widely published in the field of applied theatre, health and
wellbeing. She is the author of the book Theatre for Children in Hospital: The
Gift of Compassion (2016).
Contact: Faculty of Arts, Society and Professional Studies, Newman University,
Genners Lane, Bartley Green, Birmingham B32 3NT, United Kingdom.
E-mail: p.sextou@newman.ac.uk
Anatoli Karypidou is a Senior Lecturer in Psychology in the Faculty of Arts,
Society and Professional Studies, Newman University, Birmingham.
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Contact: Faculty of Arts, Society and Professional Studies, Newman University,
Genners Lane, Bartley Green, Birmingham B32 3NT, United Kingdom.
E-mail: a.karypidou@newman.ac.uk
Persephone Sextou and Anatoli Karypidou 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.
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