Impact in Qualitative Research: Alex Mermikides on Generating Research Impact through Arts-Based Exploration of Nursing

Dr Alex Mermikides is the D’Oyly Carte Senior Lecturer in Arts and Health in the School of Medical Education at King’s College London. Her expertise is in contemporary theatre and performance, and she is interested in how this artform can be employed as research methodology (as well as pedagogical approach) in the context of healthcare, illness and disability. In this blog post, Alex outlines a project she conducted before coming to King’s, which involved making a performance about nursing. Unexpectedly, the project was submitted as an Impact Case Study in the 2021 Research Excellence Framework, achieving a 4* rating. Here she describes how this came about and shares some tips on maximising impact in the run up to REF 29.

The idea that creative arts practice – painting, dancing, creative writing, photography or, in this case, making a performance – can be a form of research has gained credence within the arts and humanities disciplines in the UK, as confirmed by a recent blog by the Arts and Humanities Research Council. However, its capacity to generate impact in relation to health and healthcare, may not at first seem obvious. Even I was surprised when my performance, Careful, was chosen as one of only two Impact Case Studies to be submitted to the 2021 REF by Guildhall School of Music and Drama (where I was then employed) for its impact on nursing education and policy.

This was not the intention at the start of the project in 2016: my aim had been to explore feminist concepts of care that were then entering debates within performance studies and that resonated with my personal experience of caring for a seriously ill relative. I was drawn to the figure of the nurse and the cultural associations of this female-dominated profession (including the contestable idea that this is because women are ‘naturally’ caring). This curiosity led me to approach two nursing educators at Kingston University. Our discussions turned to the Nursing and Midwifery Council’s response to the Francis Report 2010, its promotion of ‘compassion’ and ‘care’ as core values, and the implications of this for nursing education. My partners identified two challenges: how to teach the subtle and somewhat intangible qualities involved in providing ‘compassionate care’ and b) how to do so without adding to the emotional demands of a profession already suffering from high levels of attrition and ‘burn-out’. I decided to use the process of making Careful to explore nursing students’ understandings and experiences of ‘compassionate care’, and to test whether concepts and methods from the world of performance might help address these challenges.

During a five-month residency in the nursing school, I used ethnographic methods to explore how nurses learn to ‘perform’ care and conducted a series of research workshops with theatre professionals, nursing students and educators to explore common concerns and transferable concepts. Working with an ensemble of theatre professionals, I then created fictional characters and scenarios based on the themes emerging from the background research, including the main emotional stressors students reported in relation to care: caring too much; being unable to provide adequate attention; maintaining empathy with ‘difficult’ patients, vigilance exhaustion; and (following the Francis Report) fear of being judged as not caring enough. We used physical theatre techniques to get ‘under the skin’ of nurses by observing and embodying basic nursing procedures and translating them into choreographed movement. These scenarios and movement sequences were composed into the initial performance which was staged in the simulated hospital ward - with the audience in beds to accentuate the theatrical nature of nurse-patient interactions. This device foregrounded nurses’ perspectives while putting viewers in the patient’s position, highlighting the intersubjectivity and embodied aspect of clinical encounters.

What I learned from making Careful was that care can be understood as a skilled practice rather than an inherent (female) virtue. Like performance, this skilled practice depends on subtle orchestrations of words, gestures, bodies and objects in space in ways that convey emotion and meaning and impact how other people (especially patients) feel. This suggests that approaches used to train performers are adaptable for nursing education, to help nurses manage the unique emotional content of their clinical encounters. This insight led to an invitation to develop a practical class for year 1 BSc Adult Nursing students at KU (June 2017), raising students’ awareness of how body language, movement and pace can help patients feel secure in their presence. Two further classes on different topics for years 2 and 3 students were launched in summer 2018 and 2019. I was also invited by University of the West of England to run a webinar on using creative methods in healthcare education (May 2020).

All these developments meant that by the time it came to prepare the Impact Case Study, around 600 students had participated in workshops, around 2000 people had seen the performance live or as a recording, 1,300 students at 9 UK and European institutions had received digital work packs and 40 or so nursing educators had engaged with the project. Luckily, I had had the foresight to collect participant feedback from most of these activities (including a follow-up survey of the first cohort of workshop participants), which provided a solid evidence base for impact on individual students and educators. To strengthen the impact case study, I was encouraged by my institution to explore the policy implications of the project. I decided to do this by convening a virtual symposium, Performance for Care (March 2020), showcasing Careful alongside other initiatives involving performance and nursing education. This attracted over 400 healthcare educators and arts and health practitioners and policymakers internationally, including the President of the Royal College of Nursing, the Deputy Head of Research and Evaluation at Public Health Wales and representatives from the All-Party Parliamentary Group of Arts, Health and Wellbeing, with several inviting me to follow-up meetings and presentations. Their testimonials were no doubt important to achieving the surprising 4* rating.

What I learned from this experience (top tips):

• Research what is meaningful to you, follow your personal curiosity and passion, rather than chasing impact from the outset. I believe that it was the personal investment at the heart of this project that helped me forge important and lasting partnerships and that left an impression on participants and stakeholders. There is an emotional and relational component to ‘impact’.
• At the same time, be systematic and consistent gathering feedback from participants along the way – I was so thankful to have stacks of participant and audience response forms to help quantify the impact of the work in numerical terms. On the other hand, I had not kept track of all the activities associated with the project and had to spend hours piecing together the timeline so that the narrative for the Impact Case Study was clear.
• Be brave in sharing your research with people of influence. At first, I really resisted the idea of showcasing my research to policy makers and influential figures, and I cringed when I heard that they were being approached to write testimonials about me. However, this led to genuinely interesting conversations with them that have advanced my thinking and confidence as a researcher.