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Nurses and stress: how performing arts skills can improve self-care and communication

Training given by actors is helping NHS staff to look after themselves better

Training given by actors is helping NHS staff to look after themselves better which benefits patient care too

  • Swansea Bay University Health Board staff have received training from actors on voice and breath techniques and enhancing communication
  • Programme aims to reduce work-related stress among staff through techniques such as body-mapping
  • Awareness of non-verbal behaviour and posture are also taught, with the aim of improving the patient experience

The way that nurses walk, their posture, tone of voice and even how they use their eyes can all improve engagement with patients and colleagues and have a positive impact on workplace stress.

These techniques, commonly used by actors

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Training given by actors is helping NHS staff to look after themselves better – which benefits patient care too

  • Swansea Bay University Health Board staff have received training from actors on voice and breath techniques and enhancing communication
  • Programme aims to reduce work-related stress among staff through techniques such as ‘body-mapping’
  • Awareness of non-verbal behaviour and posture are also taught, with the aim of improving the patient experience
Picture: Benedict Johnson

The way that nurses walk, their posture, tone of voice and even how they use their eyes can all improve engagement with patients and colleagues – and have a positive impact on workplace stress.

These techniques, commonly used by actors and dancers, might not seem an obvious fit for healthcare, but they have proved to be beneficial for nurses and patients at Swansea Bay University Health Board.

Training focuses on self-care and stress management

In March, the health board, in collaboration with Swansea University and creative training organisation Performing Medicine, announced the success of a pilot project that used arts-based healthcare training to improve staff mental health and well-being.

The project took place before the COVID-19 pandemic, and focused on self-care and stress management for staff working in mental health services and the learning disabilities unit at Swansea Bay.

Interactive workshops encouraged healthcare professionals to think about, practise and demonstrate high-quality compassionate care.

Tackling staff sickness and burnout

The training was delivered by Performing Medicine, which brings ideas from the performing and visual arts into healthcare settings.

‘If we go back to when we started working with [them], we were struggling as a service group within the health board,’ explains Marie Williams, a mental health nurse and lead nurse for quality improvement at Swansea Bay.

‘There were high levels of staff sickness, elements of burnout and work-related stress. Performing Medicine made a real difference.’

The pilot scheme helped staff to cope better with work-related stress, be more confident at work, and communicate with colleagues in a more engaged and attentive way.

Staff also reported increased awareness of the importance of making time for self-care, and of how healthcare workers’ own well-being, non-verbal behaviour, pace and posture can affect other people.

‘Circle of care’ benefits everybody

Performing Medicine has since returned to deliver more sessions at Swansea Bay, including virtual workshops for senior nursing staff.

The trainers used Performing Medicine’s ‘Circle of Care’ model, which reimagines compassionate healthcare as flowing in several directions, from staff to patients and families, and to colleagues – and back again.

‘Before the pilot the nurses rarely took a break, but now they make an effort, for their own well-being, to go off the ward and reset’

Sharon Pontin, ward manager, Tonna Hospital

It uses ‘performance’ elements to do this, which include encouraging the ‘audience’ to ‘direct’ an actor who is playing out a typical healthcare scenario where an interaction hasn’t gone well, to find out what would lead to a better outcome.

‘The “performance” element comes in because you have to think about things like spatial awareness,’ says Ms Williams.

‘The performance trainers talked a lot about the muscles that we use [to deliver care] and that they use, in order to perform, to dance, to do the things they do.

‘So they bring in elements like that, which helped us to think about the way we move in a different way.’

‘Resetting’ your mind can help with relaxation

Sharon Pontin, ward manager in Suite 2 at Swansea Bay’s Tonna Hospital, which cares for older people with mental health problems, says the training had a big impact on her and her team. ‘We knew beforehand that staff were very stressed, so when we were asked if we wanted to take part in the pilot we jumped at the chance.’

Ms Pontin cites one particular self-care exercise that involved ‘body-mapping’ to help staff de-stress.

Deep breathing can help you to de-stress Picture: iStock

‘This was very simple, whereby staff could “reset” their mind when they were in a stressful situation,’ she explains.

‘It involves deep breathing, closing your eyes and thinking about your body – about your aches and pains, and making your feet feel grounded. It just makes your body feel relaxed.’

Importance of taking breaks and posture

Ms Pontin continues to use the ‘reset’ exercise, which has proved particularly useful in the face of pandemic challenges. She says that members of her team will often tell her that they are going to reset.

‘Before the pilot they rarely took a break, but now they make an effort, for their own well-being, to go off the ward and reset. They then come back refreshed to provide the best possible care for our patients.’

The training included a focus on posture and the way that staff walk, and the impact this has on others, adds Ms Pontin.

‘For example, if you walk with your head down, what does that show to the patients or staff members? Are you ignoring them? Do they feel neglected, or more vulnerable?

‘There are consequences from the way your posture is, the way you walk, the pitch of your voice.’

Use these performing arts techniques to improve your practice

  • Warm up at the beginning of the day and cool down at the end – this helps avoid injury; find a technique to help yourself feel mentally and physically prepared
  • Posture – what does your posture say to your patients or colleagues? How you enter or leave a room can have a big impact on people’s sense of being valued, seen and heard: adopt an open and relaxed posture and don't rush
  • Spatial awareness – this is important in terms of power dynamics. Think about how a patient feels if you’re standing by a bed and they are lying down: adapt your position so that they feel comfortable, such as sitting next to them on the same level
  • De-escalation and the ‘choreography’ of a room – the way you position yourself in space can help create a calming atmosphere, particularly helpful in mental health settings: be mindful and respect personal space
  • Verbal communication – many techniques around voice and breath are used in the performing arts. It’s not just about what you say, but how you say it – the pitch, tone, pace and volume. Use voice techniques to help you have the confidence to sound authoritative or gentle
  • Flexibility – in the performing arts, you don’t want to be stuck in one character. So think about the ‘audience’ (patients, families, colleagues) and the context of each situation and behave accordingly

Based on an interview with Suzy Willson, creator of Performing Medicine

Acknowledging the pressures of nursing

Giving staff the space to say how they feel – particularly in challenging circumstances – is also an important part of the training.

Andrea Bradley is now matron for nurse recruitment at Swansea Bay, but has held a number of roles over the past year, including having responsibility for staff well-being. She took part in a recent virtual training session for matrons, run by Performing Medicine.

‘I’d been a matron in the emergency department for nine years, and you become quite hardened to life experiences,’ she says. ‘I admit I was quite cynical about the training. I was thinking, how is an actor going to tell me how to improve my well-being? They wouldn’t be able to understand how much pressure I’ve worked under, or what I’ve experienced, particularly in this last year of COVID-19.

‘But they didn’t try to do that. They acknowledged the pressure of my job, they didn’t tell me they knew bigger or better. They just allowed me to say I was stressed.’

Finding time for self-care

According to Suzy Willson, creator of Performing Medicine, there is a significant crossover between the arts and healthcare, although it hasn’t always been recognised.

‘It’s a very hardcore, demanding profession, and many nurses I’ve worked with spend hours and hours working on their feet. It feels wrong to me that more training isn’t given at the very early stages of nurse education to help people be ready for those physical demands.

‘What we’re trying to get across is the idea that self-care, of attending to your own needs, is really crucial in order for you to be able to meet the needs of the patient. There’s quite a lot of research showing that well-being of staff really affects the well-being of patients.

‘But certainly when I started, I’d be having conversations with nurses and medics and asking them what self-care is, and so many really didn’t have an answer.

‘And they said they found it difficult to make time for themselves in the working day to ensure they were hydrated and were looking after their own body.

Picture: Benedict Johnson

Swansea Bay’s arts in health coordinator Prue Thimbleby, who brought Performing Medicine into the health board, says: ‘It’s a really good example of how the arts can have a positive impact on health.

‘Actors are the sorts of professionals who have put an enormous amount of work into training to do the work they do well, and they have skills they can bring to where they are needed.’

Harnessing shared experience between the arts and healthcare

The performing arts have much to offer nursing, but the learning process isn’t just one-way, says Dr Willson, who is also director of theatre company Clod Ensemble.

‘There’s a real potential right now for a closer collaboration between culture and the arts and healthcare, with loads of transferable skills. In a way, what’s happened with the pandemic has made that even clearer.

‘We’re excited to continue our work with Swansea Bay, and other healthcare organisations, but there’s also increasing collaboration between the arts and healthcare in terms of creating performance work that touches on healthcare and talks about the experiences of people who are acutely ill in hospital, or living with long-term conditions.

‘Nurses have so much to offer, so much understanding of that world – so shared experience is really crucial.’

Actors’ tips for nurses on coping with restrictive PPE

Early in the COVID-19 pandemic, Performing Medicine developed a guide to Coping with PPE, in partnership with University College London Hospitals NHS Foundation Trust.

The guide offers the following tips when wearing restrictive clothing:

  • Prepare well – make sure you are hydrated and have been to the bathroom before donning PPE
  • Orientation – walk round the space carefully when you first put the gear on to understand any spatial obstacles or challenges
  • Movement – economise your movement when you can. When wearing goggles or headgear, don’t just turn your head, turn your neck, shoulders and chest at the same time
  • Uniformity – wear a label on your back as well as the front so that people know who you are
  • Speaking – instead of raising your voice, let your voice drop to a lower pitch, as this can cut through other noise, as well as being more soothing to others
  • Acknowledge and accept what you look like – don’t forget this is weird for others too
  • Take breaks when you can – and share what works well with colleagues

Performing Medicine founder Suzy Willson explains: ‘There was a real lack of knowledge and experience of PPE at the time. When we put this resource together, at first we were a bit worried that people would think we were making light of the situation, because obviously a War Horse costume or a Star Wars outfit worn by actors has a very different purpose to wearing PPE.’

But Dr Willson says there many similarities between nurses wearing PPE and actors wearing costumes.

‘It’s similar in terms of the way it puts pressure on your body, in terms of things like orienting space, and just simple things like how do you recognise colleagues and how do you stay hydrated throughout the day.

‘NHS staff said they were really pleased there was some kind of shared experience coming from outside the sector, and the training has been very well received.’

Tips adapted from Coping with PPE

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