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Playful care: what lies beyond the red nose

Michael Balfour, Kirsty Martin, Julie Dunn, Wendy Moyle, Marie Cooke and Judy Wollin discuss their work with Playful Engagement, an award-winning arts and health program for people in the mid- to advanced stages of dementia.

Playful Engagement is an award-winning Australian arts and health partnership that seeks to affirm and celebrate personal identity, boost confidence and support emotional well-being of people with dementia. The program has been operating in Wesley Mission Brisbane’s aged care facilities for four years as a partnership and research project between Griffith University, Wesley Mission Brisbane and Queensland-based applied theatre practitioners The Lamingtons.

It was initially funded by the Department of Health and Ageing (now Department of Social Services), followed by a three-year multidisciplinary Australian Research Council Linkage grant as well as receiving recent funding from Brisbane City Council. The program was awarded a Queensland State Government Creative Partnerships Award in 2013.

The Playful Engagement project aimed to assess the benefits of relationship-based arts practices for people with dementia in aged care facilities and their carers, in order:

  1. To determine the benefits of playful engagement on social isolation, depressed mood and quality of life of residents of aged care facilities who are living with dementia.
  2. To determine the benefits of playful engagement on the community of carers, including those directly and indirectly involved with the project.
  3. To analyse the playful engagement in order to identify practice that achieves the most significant responses from people living with dementia in residential aged care facilities.

Introducing The Lamingtons

The Playful Engagement program is focused on relationship-based play with people who have mid- to late-stage dementia. The playfulness engages spontaneity, imagination, creative expression, communication and interaction, which are all instrumental in enhancing quality of life of all ages. The Lamingtons are elderclowns (Clark Crystal and Anna Yen) specifically trained in working with people who are living with dementia in residential aged care facilities.

IMG_8170At the core of the playful engagement fostered by The Lamingtons is responsivity to the moods and attitudes of the residents. Rather than using prepared set pieces or conceptualising their work as entertainment, the key to The Lamingtons’ playful practice is affirming and celebrating personal identity and individual life experience, to boost confidence and self-esteem, build relationships and to support emotional health and well-being.

Playful Engagement is premised on the characters of Tiny and Dumpling Lamington. Clark Crystal is a tall ‘Tiny’ Lamington, while his identical twin sister is Dumpling Lamington (Anna Yen). They dress in character from the 1950s and each wears a red nose. Their story is that they live together out of town with their mischievous dachshund dog Peg. They get the bus to the care centres to visit the residents once a week. They carry their suitcases with them, which are also home to their games, wigs, Australian Women’s Weeklies, wool for knitting, musical instruments, sheet music, silk and other materials, and toys that squeak. They are always lost, tangled, confused, hopeless and late and they are clowns.

They are not the ‘traditional’ clowns that need a laugh from their audience in the first eight seconds. However, they display clear clown characteristics. In addition to the red nose the other dominant attribute of the classic clown shared by The Lamingtons is their low status. They are clowns who want to visit you and share some time with you. They ask permission to share some of your time in whatever way or need you may have on that day. They are prepared and comfortable to play, trip, sing, knit and tell bad jokes. They are fine to sit and be still and silent. They are okay with tears. They do not come with prepared routines, or the need to make participants laugh, but instead create the possibility for all manner of play and responses.

Clowns in context

Playful Engagement is part of a wider clowning for well-being way of thinking that has been in operation now for almost 15 years. The idea to use clowns in aged care facilities was initially inspired by John Killick, then Writer in Residence at the Dementia Services Development Centre, University of Stirling, after he observed the Hearts & Minds Clowndoctors program at the Royal Hospital for Sick Children in Edinburgh. He suggested the practice would work for people with mid- to late-stage dementia and so, in 2000-01, a pilot study was created, funded by the Scottish Arts Council.

Clark Crystal was involved in this pioneering work, and is now one of the leading practitioners in the field, setting up the Playful Engagement program in Australia. Since then the Elderflowers, as the performers were named in the UK, have been delivering their program in Iceland, Finland, Austria, Ireland and UK. The Elderflower work was one of the inspirations for John-Paul Bell and Dr Peter Spitzer establishing this work in Australia, and led them to work with researchers to develop the SMILE (Sydney Multisite Intervention of LaughterBosses and ElderClowns) Study. [For a detailed account of the study, which evaluated the effects of humour therapy in residential aged care facilities, see AJDC Vol 1 No 1 June/July 2012.]

 

About the research

The Playful Engagement study research data collection was recently finalised. The research involved visits by The Lamingtons offered to 60 residents with a diagnosis of dementia living in five Wesley Mission sites in South East Queensland, and for whom consent* was given for them to take part in the study.

The program was conducted at each of the sites for six weeks and residents were visited once a week during that period. Through the combination of playful engagement and studying the playful activities, insights are offered into the role of, and potential benefits of, play in residential care for people with dementia.DSC07862

The mixed method study employed multiple data collection methods including: surveys of staff and families; observations completed by members of the research team; video recordings; interviews with participants (where appropriate), family members and staff; and practitioner journals completed by the applied theatre practitioners. Baseline data was collected before the elderclown work began and was compared to end-point data. Social biographies and medical baseline data for individual participants were collected and generated before the program started in order to support the development of individualised interactions with the participants that encourage and value personal and social communication.

 

Playful visits: a snapshot

Exploring approaches to enhancing the quality of life was key to the project, but validating and respecting all the different feelings and experiences of a resident on any given day was equally important. During the playful visits, accepting and celebrating who the resident was on that day or at that moment opened up the language of the practice. Each visit was a journey and each journey had a story.

To paint a picture of the diverse nature of play, included here are summaries of visits with three different residents. The descriptions highlight the range of skills and approaches that were used in the Playful Engagement practice and how those specific styles related to the individual resident. What did that person need on that day and what sort of play was most suitable to their personality and temperament?

The examples show a clear connection between person-centred care and playfulness. The exemplars combine the team’s observations and the stories they wrote during the visits. All residents’ names have been changed and information excluded in the exemplars to maintain the privacy of participants.

A visit with Fiona

Fiona displayed a wide range of emotions during the visits. During the first visit with Fiona we were barely tolerated, but the shift in this woman astounded us all. Such was the close connection she came to have with Tiny and Dumpling, one could be forgiven for thinking they had been friends for many years. There was warmth and an affection that lasted throughout the visits.

DSC07838Fiona spent a lot of time walking around the residential unit and this became embedded into the practice – the walking together with Tiny and Dumpling became a type of journeying for her. She laughed, she cried and they sang together. Sometimes the speech was not comprehensible but there was a pattern of relating that included singing, memories and a little dancing.

We commented in our journals on how she seemed during one particular visit: “It was like she had champagne. It was like she was giddy. That movement was interesting. The wandering was focused around the dance. It was not confused and meandering”.

We learnt through the visits with Fiona that movement could be accommodated within the play. For Fiona, the movement played a crucial role in her level of comfort. She was most relaxed when she was moving.

For Fiona, the songs and the rapport and relationship that these visits brought about were unmistakeable. She was up and down and giddy and sad. Her visits are a strong case for the wide breadth of emotions displayed by people with dementia that clearly illustrate the diversity of the work. They also remind us of the diverse nature of the physical and emotional condition of these men and women we visited. The visits with Fiona are a statement about how, within the time and the space of these visits, there are no judgments, no rules, everything is okay and everyone is accepted in the moment.

Somehow, in the moment of play there is a release. It might be tears, some personal revelation, laughter, song or a range of other responses. They are, nonetheless, moments of revelations that often mark a clear shift in the relationship. The shift is about the meaning that the residents themselves attach to the moment rather than response to a given script or expectation put on them. The meaningful engagement and connection is the main aim of the work.

At times the wigs came off, the red nose was pulled to one side and there was a sense that what was needed was not the ‘clown’ but a friend coming to have a ‘cuppa’. This, however, was not every visit each time – Tiny and Lamington are clearly not the everyday visitors. They hold a unique place in the hearts of the residents. They were invited to share secrets; they heard the private truths of the people they visited. It was so seldom about the weather, although sometimes it was.

 

A Visit with Jeanette

There was a freedom in those visits, a space that is not easily defined. It is unburdened from the decades of emotional layers of relationships that accompany familial links. The uniqueness of this relationship means that not only can the resident be who they want and need to be on that day – ie Marilyn Monroe or Doris Day – but this will be accepted and it will be celebrated. There is no judgment and there is no wrong. Whatever they think and feel is okay.

A visit with Sheila

One resident whom we visited no longer spoke English. It was not her mother tongue and she had reverted to her first language. The play was at first big and fun and lots of giggles. It opened up the discussion about language in play and the inclusive aspect of fun and engagement. It also highlighted the difficulties for people who do revert to their mother tongue, even though they may have spoken English for several decades before the onset of their dementia symptoms.

Play with Sheila was often slapstick and took place in the outside courtyard. Her dementia was quite advanced and at times she appeared to get lost in the play. This was noted and shifts would happen in the play. She was a woman who had a clear history and connection with textiles. Some days, if Sheila seemed tired, the play would be smaller and quieter. The quieter play with Sheila involved sitting and touching the soft materials that Dumpling brought along with her in her bag. Sometimes there was some translation of the language and this seasoned the visits with some verbal language, but the play was the most powerful communication tool.

In talking about visiting Sheila, Crystal says: “I don’t know. That lady just encourages more clown, so I just responded to it”. The visits with Sheila offered the revelation about how we often over-rely on verbal language. We realised that we are used to relying on language to dictate the meaning. This is the gift of play; it’s all about that moment. There is enormous potential for play in people with dementia who may not be verbal or, like Sheila, may have reverted to their mother tongue with the onset of dementia.

Early findings

Feedback we received from care and nursing staff was often “When are you coming back?” – they found themselves drawn into the play – and made comments like “Oh, I didn’t think she was going to enjoy this, but just look at her laughing”. Based on the interviews with staff and phone calls from family and loved ones there was an overwhelmingly positive response to the playful visits. Comments from daughters and sons about the “change in mum” or “the difference you made to mum’s last days” speak to the community focus of the work.

Given the time constraints of the Playful Engagement project, inevitably we face the question of ‘where to now?’

There are different ways in which the sustainability of the Playful Engagement work can be discussed. One suggestion is to train more clowns so that more residents can effectively benefit from these professional playful visitors. Certainly there are clear arguments for training more individuals who can recreate the practice along the lines of The Lamingtons’ philosophy.

So what of the staff who approached us and said – “we would like to know more” and “we would like to be more playful with the residents”? Feedback from staff included requests for some kind of training. Staff told us that they wanted an opportunity to benefit from this process. They are at the so-called ‘coalface’ and therefore they are the ones who need the support and training to make a positive impact on the quality of life for the people they care for on a daily basis.

Other work has seen staff involved in playful activities, for example the SMILE project’s idea of the LaughterBoss, where selected aged care staff are trained to use their creative skills to introduce humour, laughter and play into their facility.

In the next few months, the Playful Engagement team will be working with Wesley Mission Brisbane to develop staff training that helps translate some of the fundamental elements of playful engagement and integrate it with everyday encounters. The premise of this approach is not to create specialist staff that clown, but rather to enhance and enable staff to discover imaginative ways of building relationships with their residents.

Sustainability of the work

Feedback we received from care and nursing staff was often “When are you coming back?” – they found themselves drawn into the play – and comments like “Oh, I didn’t think she was going to enjoy this, but just look at her laughing”. Based on the interviews with staff and phone calls from family and loved ones there was an overwhelmingly positive response to the playful visits. Comments from daughters and sons about the “change in mum” or “the difference you made to mum’s last days” speak to the community focus of the work.

Given the time constraints of the Playful Engagement project, inevitably we face the question of where to now?
There are different ways in which the sustainability of the Playful Engagement work can be discussed. One suggestion is to train more clowns so that more residents can effectively benefit from these professional playful visitors. Certainly there are clear arguments for training more individuals who can recreate the practice along the lines of The Lamingtons’ philosophy. So what of the staff who approached us and said – “we would like to know more” and “we would like to be more playful with the residents”. Feedback from staff included requests for some kind of training. Staff told us that they wanted an opportunity to benefit from this process. They are at the so-called ‘coal face’ and therefore they are the ones who need the support and training to make a positive impact on the quality of life for the people that they care for on a daily basis.

Other work has seen staff involved in playful activities, for example the SMILE project’s idea of the LaughterBoss, where selected aged care staff are trained to use their creative skills to introduce humour, laughter and play into their facility.. In the next few months, the Playful Engagement team will be working with Wesley Mission Brisbane to develop staff training that helps translate some of the fundamental elements of playful engagement and integrate it with everyday encounters. The premise of this approach is not to create specialist staff that clown, but rather to enhance and enable staff to discover imaginative ways of building relationships with their residents.

The implications for the work of practitioners

What are the implications for health care professionals trying to understand the practice? The practice reinforces:

  1. The notion of person-centred care. The importance of knowing the person and their background beyond simple facts about them. Social biographies that are meaningful.
  2. Importance of special visits with one participant and small group work, rather than an ‘entertaining the room of people’ model of practice.
  3. Strong benefits of two practitioners and mixed gender, as individuals often respond to one or other gender, and this opened up different opportunities for communication.
  4. The engagement was enhanced by having two practitioners undertake the visit, as it led to different kinds of play; the dynamic of three (two practitioners and participant) took off any ‘perceived’ pressure and focus of ‘having’ to be social.
  5. Playfulness as having many faces and components including, in particular, a willingness to play with language and ideas.
  6. Status and the lowering of status is a critical aspect to the work. Playing with status is key to being a clown (the clown has the lowest status, and therefore is one that residents can boss around, confide, empathise with). Shifts in status can also be achieved through the use of a thoughtful question (especially one that has a correct answer).
  7. Clues in the room. Using what is present to support a more engaged interaction. Here status can also be a factor. For example, an image of a horse might suggest that the individual is knowledgeable or interested in this area. So rather than just asking “is this your horse” and asking other questions about that horse, questions about horses that position the resident as an expert on that subject serve to lift their status.
  8. Carrying a prop or an item that is surprising or able to stimulate spontaneous ideas that are outside the everyday. Everyone loves a surprise. Objects were used by the elderclowns in many diverse ways, for example a small object carried in your pocket might promote new ideas. Even a photo of something that can be used to promote a question or a discussion (eg a photo of a garden).

Conclusions

Playful Engagement has demonstrated the potential of innovative partnerships between residential aged care institutions, university researchers and creative artists in designing, implementing and evaluating positive and creative relationship-centred care practice. The partnership has led to further practice with Wesley Mission, staff training and the program being rolled out to other aged care providers. Significantly, the project adds further depth to the evidence and need for creative and innovative work that can have important influence on the quality of life for people who have dementia.

Professor Michael Balfour is Chair, Applied Theatre, Kirsty Martin is Research Assistant and Julie Dunn is Associate Professor, all from the School of Education and Professional Studies, Griffith University, Queensland; Professor Wendy Moyle is Director, Centre for Health Practice Innovation and Professor Marie Cooke a Research Member, Centre for Health Practice Innovation, both in the School of Nursing and Midwifery, Griffith University; Professor Judy Wollin is the Director, Quality and Research, Wesley Mission Brisbane. To follow up on this article, email Michael at: m.balfour@griffith.edu.au

*The Playful Engagement research was given ethical approval by Griffith University Human Research Ethics Committee and Wesley Mission Brisbane provided permission for the study to be conducted in its facilities.

Professor Michael Balfour is Chair, Applied Theatre, Kirsty Martin is Research Assistant and Julie Dunn is Associate Professor, all from the School of Education and Professional Studies, Griffith University, Queensland; Professor Wendy Moyle is Director, Centre for Health Practice Innovation and Professor Marie Cooke a Research Member, Centre for Health Practice Innovation, both in the School of Nursing and Midwifery, Griffith University; Professor Judy Wollin is the Director, Quality and Research, Wesley Mission Brisbane. To follow up on this article, email Michael at: m.balfour@griffith.edu.au

*The Playful Engagement research was given ethical approval by Griffith University Human Research Ethics Committee and Wesley Mission Brisbane provided permission for the study to be conducted in its facilities.

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