PreScribed (A Life Written for Me): A Theatrical Qualitative Research-Based Performance Script Informed by General Practitioners’ Experiences of Emotional Distress

Abstract

Keywords

arts based methods performance based methods interpretive description methods in qualitative inquiry secondary data analysis

Introduction

The arts and humanities have long been employed within health and medicine for educational, research and therapeutic reasons and have proven valuable for communicating lived experiences of health, illness and recovery (Fraser & al Sayah, 2011; Shapiro & Hunt, 2003). Art therapy, for example, has been successfully employed to facilitate recovery from mental illness (Van Lith et al., 2013) while the performing arts, namely, music, dance, theater and film, have been appropriated for use within the research life-cycle, for example, as a valuable method of data collection or in the transfer of knowledge to non-academic audiences (Fraser & al Sayah, 2011; Rossiter et al., 2008). The arts have been employed to communicate about embodied thoughts, feelings and experiences relating to health and illness (Fraser & al Sayah, 2011; Rosenbaum et al., 2005). Performance art such as theater and dance, for instance, have facilitated storytelling and been used as a conduit for capturing and communicating about emotive, painful, sensitive, stigmatizing and challenging experiences, such as abuse, terminal cancer and mental ill health (Eli & Kay, 2015; Gray et al., 2000; Sandelowski et al., 2006).

Theater, in particular, has been embraced by researchers and non-researchers as a means to raise awareness and catalyst for conversations to disseminate research findings to lay/public audiences and to influence policymakers (Rossiter et al., 2008). Theater has been chosen as a means to inspire thought, critical reflection, emotional engagement and personal transformation (Radbourne et al., 2013). Although research findings are often published and reported in various textual mediums (such as academic papers, blogs and social media), text alone can sometimes obscure or dilute the subjective and intersubjective embodied experiences of research participants. Conversely, live theater is an embodied, expressive, dynamic art form which engages audiences while effectively communicating rich and detailed narratives, contexts, embodied experiences and emotions. Performance art or live theater has the capacity to animate research by breathing life into it. Both also provide a multi-sensory experience for audiences by drawing on the spoken word, movement, sound and visual engagement and are therefore able to connect and engage with diverse audiences on different sensory levels (Radbourne et al., 2009, 2013).

This paper includes the script from a research-informed, theater-based production titled PreScribed (A Life Written for Me), which depicts the life of a distressed General Practitioner (GP) who is on the verge of breaking down and burning out. The piece explores the expectations, pressures and demands placed on doctors while working in a healthcare system with escalating expectations and diminishing resources. The vulnerability of doctors, their sometimes-arduous journey into medicine and the dramatic irony inherent in the ill health of care providers, whose emotional distress often remains hidden from public view, are revealed in the production. Drawing on Goffman (1959/2002), the researchers will critically reflect on how the artistic collaboration illuminated the parallels in performativity employed by artists and GPs. We make reference to Goffman’s performativity theory in relation to impression management and dramaturgical metaphors to reflect on similarities between the ways in which artists and doctors perform roles, follow scripts, use props etc when on stage (Goffman, 1959/2002). The system and culture within medicine, in which stigma, shame and consequential isolation compound the stress and distress commonly experienced by GPs, are examined. The key intentions of the performance piece were to raise awareness of the experiences of doctors as well as to provide a voice and insight into the thoughts, feelings and vulnerabilities—all of which often remain unseen—of the GP study participants who inspired the piece (Riley et al., 2018a; Riley et al., 2018b; Spiers et al., 2017). These aims are similar to the aims of qualitative researchers, suggesting a dual methodological intention.

In this paper, the authors provide context for the collaboration between artist and researchers and report on the creative process involved in the co-production of the script, where research findings were imaginatively transformed into live theater. The researchers reflect on the collaborative process and merits of drawing on principles of co-production and provide examples of how these were enacted. The researchers discuss the value of co-production principles in artistic collaboration and hope that sharing their experiences and the script may encourage researchers and artists to collaborate in the future. The researchers report on: (1) the Research (2) Collaborative Origins (3) the Artist (4) Collaborative Process (5) Researcher Reflections and (6) the Script.

The Research

The aim of the original study was to explore the sources of stress/distress for GPs as well as to identify what helps and hinders them when they seek support for distress and mental ill health. In this interpretative study, we conducted in-depth qualitative interviews with 47 GPs from across the UK. The research findings, reported elsewhere (Riley et al., 2018a; Riley et al., 2018b; Spiers et al., 2017), relate to:

Sources of stress/distress: (1) emotion work—the work invested and required for managing and responding to the psychosocial component of GPs’ practice, and dealing with abusive or confrontational patients; (2) practice culture—practice dynamics and collegial conflict, bullying, isolation and lack of support; (3) work role and demands—fear of making mistakes, complaints and inquests, revalidation, appraisal, inspections and financial worries.

GP participants’ in-depth experiences of distress and mental ill health. GPs’ distressing experiences and weighty psychological and physical symptoms relating to chronic stress, anxiety, depression and/or burn-out were reported, with a quarter articulating thoughts of suicide. Many talked about shame, humiliation and embarrassment at their perceived inability to cope with the stresses of their job and/or their symptoms of mental illness.

Barriers and facilitators to help-seeking, which included work itself, stigma, and symptoms. Specifically, GPs discussed feeling a need to attend work, the stigma surrounding mental ill health, and issues around time, confidentiality, and privacy. Participants also reported difficulties accessing good-quality treatment. GPs reported cutting down or varying work content or asserting boundaries to protect themselves.

Collaborative Origins

The Chief Investigator (Ruth Riley) of the GP study responded to a call—for researchers to work with artists—from the Centre for Public Engagement at the University of Bristol’s Elizabeth Blackwell Institute (EBI). The proposal was accepted by the EBI, who subsequently put out a national call for artists, who were asked to submit their ideas for collaboration based on a summary of the research. A two-stage application process took place, comprising shortlisting followed by a live pitch before a panel. The interview panel included artists, creative directors, an EBI representative and the investigator, who selected experienced theater maker Viv Gordon for the collaboration. The EBI financed the collaboration and production with funding from Wellcome.

The Artist

Viv Gordon is a theater maker, survivor activist and arts and mental health campaigner. She campaigns for access and inclusion in the arts for artists and audiences with mental health needs, suggesting that art about mental health should be made by artists with relevant lived experience. Viv wrote the research-informed theater piece PreScribed (A Life Written for Me), which was performed at Edinburgh Fringe 2017 (Zoo Venues) and Feel It Festival, Bristol, 2016, before being toured to arts and health conferences and GP trainings nationally. Viv read excerpts from the script at the annual Elizabeth Blackwell’s Annual Lecture alongside the then Chair of the Royal College of General Practitioners in 2017. Audience members were provided with brief information about the research-informed theater piece and signposting information to mental health charities if needed. Audiences were asked to complete a brief evaluation form to capture the impact of the piece. Audience members were instructed to post completed feedback forms in a box on departure. We collected quantitative and qualitative data with questions designed to capture audience impact in terms of their subjective experiences of the show and changes in awareness about the challenges of working as a GP and mental illness among this population of doctors.

The Collaborative Process

The collaboration between researchers, artist and the center for public engagement at the University of Bristol was guided by co-production principles to develop the theater piece, a creative research output. The collaboration drew on established co-productive principles relating to power sharing, inclusivity in relation to the valuing of diverse perspectives, skills, knowledge and ensuring reciprocity and building relationships (Kothari et al., 2011). We provide worked examples of how co-productive principles were transformed into practice and how authentic collaboration, empowerment, open communication and equitability between key stakeholders (such as the artist, researchers, participants, public engagement representatives from the University) were realized in the co-production of the theater piece (Beckett et al., 2018).

Firstly, the Chief Investigator’s (CI) interpretative epistemological orientations recognize and value multiple realities and epistemic resources (Crotty, 1998; Patton, 1990) and therefore align with co-productive principles. Artist, researcher and participant experiences and input were equally valued in the co-production of knowledge and its mobilization; both in the development of the script and the performance.

The valuing of epistemic resources and commitment to democratize research outputs can be evidenced in the decision to adopt non-text modes of dissemination. Employing a theater-based output in contrast to text was underpinned by principles of co-production which aim to democratize the process of knowledge production and exchange (Beckett et al., 2018). Opting for performance art as a non-text vehicle for knowledge exchange could reduce the potential for greater reach and inclusivity (Killion & Wang, 2000) in contrast to the potential for exclusivity of more conventional approaches to disseminating knowledge (such as journal articles).

Mechanisms for enabling co-production such as empowerment require awareness and recognition of potential power imbalances between stakeholders. One such example of how this was enacted was the choice of setting for meetings. To ensure the artist and researchers met on an “equal footing,” the decision was taken to hold meetings on “neutral” territory, for example, in cafes beyond the university’s “ivory towers.” Despite the researchers’ awareness of power dynamics through the practice of reflexivity and efforts to mitigate the potential for power imbalance in co-production, inequity in power sharing could have been conferred, albeit unconsciously, through the researchers’ and public engagement team’s affiliation to a University and status which that confers (Williams et al., 2016).

Other recognized co-productive mechanisms include facilitative leadership style characterized by drive, ambition, enthusiasm, and tenacity (Heaton et al., 2016) which were evidenced in the CI, who developed and fostered relationships with the EBI, artist and wider research community for the purpose of knowledge mobilization.

At the outset, the artist, Viv Gordon, and researchers, Ruth Riley and Johanna Spiers, discussed the research findings as well as the wider context and background to the research. They discussed their shared vision for the theater piece and agreed to meet regularly to discuss the development of the script and shared ideas. Both artist and researchers shared the ambition and vision that the theater piece could play a transformative role in terms of potential to inform and influence audiences while also validating the experiences of GPs (and anyone else) who may be living and working with mental illness. The researchers shared 20 of the 47 anonymized transcripts with Viv to help inform the content of the script while leaving artistic license for her to interpret the transcripts and introduce new material to weave the piece together. The researchers also connected the artist to study team members, who included GPs and a medical student; these conversations provided additional context and insight into the day-to-day life of GPs (for example, the challenges faced by long hours, patient workload, the challenges of 10-minute appointment systems, bureaucracy, administrative burdens, de-professionalization, loss of autonomy) and insight into the training required to become a GP. These insights were integrated in the script and reflected in the staging and props, thereby enhancing the credibility and authenticity of the narrative and the performance.

Originally, Viv had intended to read all the transcripts but the data available in the sample was rich and detailed enough to inform the development of the script. Viv Gordon's imaginative interpretation saw patients reimagined as jellies, the introduction of a practice manager to provide an additional dynamic on stage and music to establish the emotional climate through scenes.

The script weaves together verbatim quotes—illustrating common experiences among participants—with Viv's own words, based on her subjective experience of mental ill health to inform her writing and performance. In this way, the combined accounts and experiences of artist and participants provided additional authenticity and veracity to the script and performance. A dress-rehearsal where Viv also sought input from creative directors and peers followed the iterative script development. PreScribed was premiered at the Feel It Festival in Bristol in 2016, and, later, performed at Edinburgh Fringe in 2017.

Researchers’ Reflections

There are clear epistemological alignments between qualitative research and the development of a theater script. Both draw on interpretivism, with the recognition of multiple truths and realities and the valuing of shared meanings and subjectivity (Crotty, 1998; Patton, 1990). In particular, the recognition of the importance of embodied emotions and the value and validity of using emotions as data (Hubbard & Kemmer, 2001) within analysis are recognized in both processes. The value of utilizing emotions as data in qualitative data aligned with and complimented the processes and expressiveness of performance art. X interpretation and creative energy drew on her lived experiences and reactions, reflections and emotional response to the data and convey an authenticity to the GP characterization which resonated with audiences. The artist and audience’s response to the data provided some validation for the research findings and added credibility to the analytic research process. The following quotes are taken from audience feedback collected from Edinburgh Fringe (2017)

The first thing that struck me was that I have never thought of the person behind the GP mask…. Who cares for the carers?

[I’ve learnt about] the shame of admitting to another doctor that you are struggling…Thank you for this work.

It should be noted that the feedback response rate was low (approximately 15%) and therefore any conclusions we infer above may not be generalizable. The extant literature (Radbourne et al., 2010; Sedgman, 2019) debates the methodological strengths and weakness of approaches to audience capture but is beyond the scope of this paper.

The artist who drew on the study data to inform the development of the script shared her interpretations of the data. Having an additional perspective also presented an opportunity to add validity to the analytic process. XX observed the striking similarities to the performativity (a la Goffman, 1959/2002) of artist and GP, particularly for study participants who performed the role of the invulnerable care provider, often in order to conceal their shame in relation to a perceived sense of failure for not coping. Drawing on dramaturgical metaphor (reference to scripts, props, roles) employed by Goffman (Goffman, 1959/2002), and with reference to GP participants’ narratives, it could be argued that doctors perform the role of care provider when on stage, taking care of vulnerable patients while ignoring or hiding their vulnerability to perform this role convincingly. Backstage, they may internalize the shame associated with not coping or illness. The performance is supported through the deployment of props such as the computer screen and paraphernalia associated with the consultation room (for example, stethoscope, blood pressure machine, screen and so on) and employing well-rehearsed scripts to stage manage the consultation which, as the script states, involves “…a series of meaningless interactions in which I [the GP] don’t matter.” Being an audience member cast a spotlight on these parallels in performativity.

Observation from the audience also provided reflective space to consider the stories, meanings and emotions associated with participants’ narratives. The emotionally expressive performance piece resonated with our interpretations, observations and experiences of conducting the interviews and analyzing the data. The performance piece highlighted the emotion work required to manage the feelings of patients and on stage managing your emotions, which often requires one to perform in ways that are incongruent with feelings. Fruend (Freund, 1990) argued that the emotion work invested in impression management and incongruence between authentic self and performed role is stressful; he termed this incongruence “dramaturgical stress,” which can lead to burnout. The artist’s choice of title for the theater piece that is, “PreScribed” (A life written for me) is a reflection of the scripts performed by doctors, early in their careers, which are often shaped by emotion cultures which are intolerant of vulnerability. Watching this play out on stage was a salutary experience.

With the benefit of hindsight, we would have sought consent from research participants to invite them to take part in the collaborative process to ensure their perspectives, experiences and input were incorporated within the co-production. Additionally, we would have sought consent for the artist to be able to listen to the recorded interviews; X only had access to the transcripts and was therefore denied the audio cues which provide additional context and meaning. We learnt that the collaborative process requires an investment of resources and therefore any future grant would need to consider time and cost in the budget.

While we acknowledge that this paper includes tentative early reflections on an innovative methodological development, we hope that future researchers may use our experiences as a starting point for their own similar projects.

The Script

The scene opens with the GP talking with her counselor (unseen). Consecutive scenes depict and explore her daily demands and contributing factors toward her decline into mental ill health. The final scene concludes with the GP taking up tennis, which provides her with temporary release, relief and enjoyment. However, this is short-lived as the GP poignantly states in her final line, ‘And someone always wakes me up And I always wish they hadn’t’ which reflects the finding that one in four of the study participants had experienced suicidal thoughts at some point during their career. A moving and poignant end to the 40 minute piece.

PreScribed

(a life written for me)

By Viv Gordon

Characters

DOCTOR LOWRY:

A middle-aged female GP experiencing a high functioning mental breakdown

MISS PRINGLE:

The practice manager. A silent, omnipresent, efficient and helpful woman

Viv Gordon [Name of Artist]

Scene 1

DR LOWRY

IT IS EARLY MORNING. WE ARE INSIDE A GENERAL PRACTIONER’S CONSULTING ROOM IN A DOCTORS SURGERY. A BEETHOVEN PIANO SONATA IS PLAYING ON THE SURGERY PA. DOCTOR LOWRY IS ASLEEP IN HER DOCTOR’S CHAIR FACE DOWN ON HER DESK. SHE IS SURROUNDED BY PAPERWORK. A MEDICAL SCREEN IS TO THE REAR OF THE STAGE. A SECOND CHAIR FOR PATIENTS SITS IN FRONT OF THE SCREEN.

THE MUSIC CHANGES TO LITTLE BOXES BY MALVINA REYNOLDS. MISS PRINGLE ENTERS DSR WEARING A BICYCLE HELMET. SHE WAKES THE DOCTOR BY LOUDLY PLACING A CUP OF TEA NEXT TO HER HEAD. DR LOWRY STARTS AND IMMEDIATELY ENGAGES IN A TANGLED, COMIC CHOREOGRAPHY WHERE MISS PRINGLE EFFICIENTLY PASSES HER LETTERS, PRESCRIPTIONS TO SIGN, PHONE CALLS, HER COMPUTER KEYBOARD AND PATIENT NOTES. THE ATMOSPHERE IS OVERWHELMING AND IT IS HARD FOR THE DOCTOR TO KEEP UP.

THE DANCE ENDS WITH DR LOWRY PERCHED ON TOP OF HER DESK TAKING A CALL ON A LANDLINE. THE MUSIC ENDS. MISS PRINGLE EXITS DSR

(TALKING ON PHONE)

Morning! How can I help…. ? Oh Mum! (COVERS PHONE AND ADDRESSES AUDIENCE) It’s my mum….

(TO MUM) Yes, brilliant thanks. 4.30. No, it’s a practice not a match. No mum it’s a practice. Not a match. No one else will be watching. No, I don’t think he would like that…

Look I’ve got to go Mum.

Yes, very busy. Yes, I will. I’ve got a sandwich…Thanks.

Bye. You too. Bye….

(HANGS UP PHONE AND ADDRESSES AUDIENCE)

My life is ludicrous

By profession I “know best”

My parents are proud

My father clothes his own inadequacy with my considerable achievements

I am a success

Woo

A SHOSTAKOVICH WALTZ BEGINS. IT IS TIME FOR MORNING SURGERY. DR LOWRY JUMPS OFF HER DESK, BRUSHES HERSELF OFF, LOOKS AT HER WATCH AND TAKES A DEEP BREATH. MISS PRINGLE ENTERS DSR WITH A MEDICAL TROLLEY LADEN WITH JELLIES REPRESENTING PATIENTS. SHE HANDS THE DOCTOR ONE OR TWO JELLIES AT A TIME FOR A CONSULTATION, “SITTING” THEM ON THE PATIENT’S CHAIR. SNATCHES OF “CONVERSATION” CAN BE VAGUELY HEARD OVER THE MUSIC. DR LOWRY HAS A CONSTANT EYE ON THE TIME/HER WATCH

Ooh dear that’s a nasty cough

Make sure you finish the course now, you know what happened last time

Congratulations! 16 weeks! Wonderful news! You might just feel a little prick

Etc

AFTER EACH APPOINTMENT, THE JELLIES/PATIENTS ARE PLACED AROUND THE ROOM. THEY ARE AMASSING EVERYWHERE. AFTER A WHILE MISS PRINGLE LIFTS DR LOWRY ONTO THE TROLLEY AND WHEELS HER AROUND CONTINUING TO HAND HER JELLIES AND PLACING YET MORE JELLIES INTO QUEUES AROUND THE ROOM

(ADDRESSING AUDIENCE) Every day I engage in a rapid series of one-way interactions in which

I Don’t Matter

I am there to listen, to empathise, to make sound steady judgements decoding difficulty, paranoia and pain until with the composure and surety of science I refer, prescribe and recommend.

I do this with enviable expertise for each and every life I encounter Except for one

Mine.

THE SCENE ENDS WHEN MISS PRINGLE SHOVES DR LOWRY OFF THE TROLLEY DSL, PLACES THE DOCTOR’S CHAIR CS AND EXITS DSR

Scene 2

DR LOWRY

THE DOCTOR’S CHAIR IS SPOTLIT. (ADDRESSING AUDIENCE) This is a metaphor—OK?

HER VOICE AND BODY LANGUAGE BECOMES CHILDLIKE

So—you’re 8 years old and you see this chair

And this chair is amazing…

And you think that you’d really like to sit in the chair

And very much like that to be your chair

And when you tell people that you want to sit in the chair They are really happy

And really excited

And very proud

And they tell you that because you are a very clever girl

And if you are very good for a very, very long time

You will…

(SQUIRMING WITH EXCITMENT) Eventually…

Be able to sit in the chair…

HER VOICE WAVERS BETWEEN CHILD AND ADULT THROUGHOUT THE FOLLOWING TEXT

And that attention, that approval is really quite seductive and very quickly everything becomes quite “achievementy” and you no longer do things just for enjoyment but because you have your “eyes on the prize” (as your dad likes to say).

THROUGHOUT THE FOLLOWING TEXT, MISS PRINGLE ENTERS DSR AND HANDS DR LOWRY AN ENDLESS STREAM OF CERTIFICATES, FOLDERS AND BOX FILES WITH EACH ACHIEVEMENT. THE DOCTOR CIRCLES AROUND THE CHAIR COLLECTING THESE FROM THE “DOOR” AND PLACING THEM ON HER DESK MAKING A HUGE PILE, TALKING AND MOVING AT INCREASING MOMENTUM, GETTING SHORT OF BREATH.

So, it starts with RAD ballet exams, piano grades and girl guide badges

And you try extra hard to be helpful and kind and thoughtful.

And you have a whole wall in your bedroom covered in certificates although you do spend a decreasing amount of time at home to see them.

And by the time you are 12, you are grade 6 ballet and grade 7 piano.

And you are consciously building a good CV by taking on positions of responsibility and leadership at guides.

And you do the Duke of Edinburgh awards scheme demonstrating resilience and determination and through that you start volunteering at an old people’s home.

And then by the time you are 16 you have 12 O levels—mainly As and a B (you don’t get any Cs) and the one B is disappointing but “character building” says your mum and “focussing” says your dad…

And you leave school having been head girl (which will look good on your UCAS application) and all your friends are going off on camping trips and things but you spend your summer volunteering in a hospice, which actually is extraordinary.

And you start college doing 5 A levels but you have to drop one in your second year because “silly you”—you get bit distracted by a boy.

But you end up with 3 As and another frustrating B but it’s good enough to get into Exeter which is not quite as good as Bristol but still….

And the medical degree is, you know, gruelling.

And you find that having been the best at everything your whole life you now are just very middle of the road.

And quite shockingly you fail your second-year exams which is an entirely new experience that you decide not to tell your parents about.

And in your third year you attend an optional lecture entitled “What’s up Doc?” which is about looking after yourself while you look after everyone else.

And everyone including the lecturer treats it as a bit of a joke because after all we are the crème de la crème of steady sturdy individuals.

And after five relentless years demonstrating that—you graduate.

MISS PRINGLE HANDS HER A GRADUATION SCROLL WHICH SHE THROWS IN THE AIR WITH A BREIF “YAY”

And progress on to your two-year foundation programme which is more of the same really except now at least you do get paid which does take some of the pressure off.

And then by the time you are 25—you’ve only got three years left of speciality training in general practice and then…

A PAUSE. MISS PRINGLE EXITS. DR LOWRY FIXATES ON THE CHAIR.

(SLOWLY) You’ve done it! And you get to sit in the chair

SLOWLY APPROACHES CHAIR WITH EMOTION AND REVERENCE TO SIT IN IT, CARESSING IT

(SLOWLY) And you feel important and useful and proud.

(SUDDENLY BABBLING) And to start with it’s kind of how you expected

And it’s not that it’s without flaws

But you feel hopeful that you can make a difference

And you think you’ll never be like some of the doctors you see

Who really shouldn’t…(LAUGHS EMBARRASSEDLY SLIGHTLY FLUSTERED)

SHE MOVES CLOSER TO THE AUDIENCE WHEELING THE CHAIR ABOUT. SHE SEEMS ALMOST HYSTERICAL AND PUSHES HERSELF VIGOROUSLY AROUND THE STAGE

And wonderful things happen like you really connect with a community and people ask to see specifically you and you bump into someone in Tescos (FIXES EYE ON ONE AUDIENCE MEMBER) and they wouldn’t even be here if you hadn’t treated them and asked the right questions and made quick decisions and you can see in their eyes that they are grateful and you’re grateful too because really it is a privilege to help people at their most vulnerable…

(HER MOOD AND TONE DROPPING) But over time what starts off as normal ups and downs is compounded by almost constant shifting expectations…

Mounting expectations

And it’s no longer enough just to be a really good doctor

Now you have to be a really good doctor in less than ten minutes to 40 plus patients a day and deal with more and more bureaucracy and less and less autonomy, imposed contracts and ridiculous targets on ever dwindling resources.

MISS PRINGLE ENTERS AND HANDS THE DR SOME SURGICAL GLOVES THEN LEAVES. THE DOCTOR PUTS THE GLOVES ON DURING THE NEXT SPEECH

And you’re not sure if you’re being paranoid but you start to feel a bit like you’ve been set up and you’re just a quite well paid pawn in a horrible political game where no one wants to say—you know—no government is going to say, well, the NHS can’t carry on, because—we can’t afford it, because the population is massive, people are living much longer…

No government’s gonna say we can’t have the NHS anymore. So, they just push and push and push and shift the goalposts and just make it so intolerable that it breaks, and then it’s our fault, not theirs…

And it’s no longer a case of “will something go wrong” but more a case of “when will something go wrong” because you’re making hundreds and hundreds of clinical decisions every day, and, um—they’re not all gonna be right.

MISS PRINGLE ENTERS CARRYING A SMALL JELLY IN HER HANDS WHICH SHE PLACES IN THE DOCTOR’S HANDS THEN LEAVES. DURING THE FOLLOWING TEXT, THE DOCTOR LOOKS AT HER HANDS AS SHE TRIES TO HANDLE THE JELLY WHILE IT DISINTEGRATES AND FALLS APART ONTO THE FLOOR

(SLOWLY WITH EMOTION) And sometimes……. sometimes patients die

Like a child dies

And people have questions

And understandably they really do need to know that you haven’t missed something

And you are pretty sure you didn’t miss anything

But also terrified in case you did miss an actual important thing

And if you’re lucky everyone is satisfied and there is no enquiry

But it turns out you’re not lucky

And it takes so long

And you feel so bad for minding because your children are alive

And everyone around you is carrying on like normal

But nothing feels normal anymore

And you’re beginning to hate sitting in the chair so much

But you hate the idea of getting out of the chair even more

And you’re no longer sure—who you are—without the chair

And anyway somebody has to sit in the bloody chair

And you’d just like to talk to someone

But you feel so ashamed

And the thought of going to see someone who does the exact same job as you and telling them that you can’t manage that job is impossible

And it doesn’t matter that you’ve spent your whole life being good

Because everyone who has been so proud is now going to watch you fall

They’re going to watch you fail

And you are so gutted

Because all you’ve ever done

Is try.

FIRST TRY BY TRACEY CHAPMAN PLAYS TO A CHOREOGRAPHY. THE DOCTOR PUSHES HER CHAIR BACKWARDS AWAY FROM THE MESS ON THE FLOOR. SHE TAKES OFF HER SURGICAL GLOVES AND DROPS THEM TO ONE SIDE. MISS PRINGLE APPEARS AS IF FROM NOWHERE AND CATCHES THEM. THE DOCTOR SLIDES OFF HER CHAIR ONTO THE FLOOR. SHE CARRIES THE CHAIR ON HER BACK. SHE WRESTLES WITH THE CHAIR AND WITH HERSELF, TRYING TO PULL HERSELF TOGETHER BUT FAILING. SHE REACHES FOR HER DESK BUT FINDS HERSELF SLIDING DOWN THE HUGE PILE OF FOLDERS SHE HAS RECENTLY PLACED THERE. AT SOME POINT, MISS PRINGLE ENTERS AND CLEARS UP THE JELLY ON THE FLOOR. EVENTUALLY, THE DOCTOR MANAGES TO SIT BACK ONTO THE CHAIR, HUNCHED OVER, AND THE MUSIC FINISHES.

Scene 3

DR LOWRY

AN ALARM SOUNDS LIKE A DINNER BELL. DR LOWRY STARTS. SHE LOOKS AT HER WATCH. SHE IS SHAKEN. ANOTHER BEETHOVEN PIANO SONATA IS PLAYING.

11 o’clock

(TAPS HER WATCH) Coffee break

Part of our new wellbeing strategy

(STANDING. STEELING HERSELF) All senior management expected to attend. Except mainly people don’t come. How can you if you’re with a patient or…unable to face anyone?

MISS PRINGLE ENTERS DSR PUSHING A MEDICAL TROLLEY WITH TWO MUGS, A PLATE OF PINK WAFERS AND A STUFFED HEDGEHOG ON IT. SHE STOPS CS AND PUTS THE TROLLEY BREAKS ON LOUDLY. DR LOWRY MOVES TOWARDS HER INDICATING HER.

One person who is reliably there is…

Janet Pringle. Practice Manager.

Probably the kindest and most peculiar woman I know

She’s so buttoned up—Lord knows what’s going on in her head I like to imagine she has a secret wild side.

THEY ENGAGE IN A SUBTLY WEIRD DANCE LOOKING AT EACH OTHER AWKWARDLY—NOT SURE WHICH CUP TO PICK UP ETC.

She loves hedgehogs

She runs marathons in a hedgehog suit in aid of hedgehogs

We never chat or anything

But I think she might be my best friend

She’s the only person who understands what is going on here anyway.

DR LOWRY TAKES A SIP OF TEA AND FREEZES. MISS PRINGLE PUTS DOWN HER TEA AND BEGINS A WILD DANCE. AT THE END OF HER DANCE SHE PICKS UP HER CUP AND DR LOWRY UNFREEZES AND OFFERS HER A BISCUIT.

It’s usually pretty awkward

We’re not supposed to talk about work

We’re definitely not supposed to talk about the latest casualty who’s been signed off with stress

While we play out this little façade, in there, my computer screen is showing an ever-expanding list of test results, prescription requests, letters and home visits

So by the end of the break I’m usually more overwhelmed than at the beginning

Who knew a wellbeing measure could make you feel so isolated.

COFFEE BREAK IS OVER. MISS PRINGLE GRABS THE CUP AND A BISCUIT OUT OF THE DOCTOR’S HANDS. SHE LOUDLY KICKS THE BREAKS OFF ON THE TROLLEY AND EXITS LEAVING THE DR TO RETURN TO HER CHAIR.

Scene 4

DR LOWRY

DR LOWRY IS SITTING AT HER DESK TYPING—SHE HAS TO LOOK AROUND A MASSIVE PILE OF FOLDERS FROM SCENE 2 TO SPEAK TO THE AUDIENCE, WHICH SHE DOES INTERMITTENTLY.

It’s no surprise really, is it, that so many of us, you know, top ourselves

Did you know that? Cheery isn’t it?

We are in the top three professions in the suicide statistics Well we’re high achievers aren’t we

We like to be top in everything

COMING OUT FROM BEHIND DESK/PILE

I mean everyone is so busy being ok

And it’s so unacceptable to be not ok

And of course, if we do reach that point well (PAUSE) we know too much don’t we

About the body…

And, we have access to some Very Strong Drugs So…

There are no mistakes.…

No messing around.…

Actually—Have you heard the one about GP’s and boiling frogs? It’s not a joke

SHE PICKS UP HER HANDBAG AND SITS WITH HER BAG ON HER LAP RUMMAGING DISTRACTEDLY THROUGH IT AS SHE SPEAKS DIRECTLY TO AUDIENCE

It was a recent article in a GP journal likening our experience to this rather revolting fact.

So—(HER HAND BECOMES A FROG) If you put a frog in a pan of boiling water, straight away it’ll jump out (HER HAND LEAPS) and be like “No, no way, I’m not having that.” But if you put it in normal, you know, cold water and then gradually, very very slowly heat it up, it will adapt to the change and it will keep on adapting as it gets hotter and hotter (HER HAND IS LIKE THE WATER HEATING UP) to the point where you can actually boil the frog to death without it putting up any resistance. (HER HAND “DIES”)

And that resonates, (SHE GETS OUT A PACKET OF FAGS AND KEEPS RUMMAGING) I think that—in many ways—rings true, all the incremental changes creeping, creeping, creeping on and we’re not going to realise it and one day it will just be broken, and we’ll all just be broken…

(SHE FINDS HER LIGHTER)

And people do—I mean not me but people do turn to other means like alcohol and drugs.

(SHE TRIES TO LIGHT HER FAG BUT THE LIGHTER IS BROKEN)

Or families suffer, relationships are suffering because it’s really you know it’s just really too much.

(TRYING THE LIGHTER AGAIN. HER SPEECH GETTING MORE RAPID)

And anyone who can get out is getting out and why wouldn’t you…? And I understand but that does actually put more pressure on those of us that are left.

(TRYING AGAIN SHE IS STARTING TO SHOUT NOW)

And it’s all heartbreaking really because you do this job because you properly care.

And it’s very worrying too because—financially, you know, as a partner in the practice, if it, if it goes under and we are always on the brink of it going under well I will be personally responsible for hundreds and hundreds of thousands of pounds of debt (HYSTERICAL NOW) which means that we will lose our house and it’s very hard to believe that that is in fact the case.

MISS PRINGLE ENETRS WHILE SHE IS SPEAKING AND HANDS HER A PHONE WHICH SHE YELLS INTO

Not now mum…

SHE LOOKS SLIGHTLY HORRIFIED AND COLLECTS HERSELF

Ah Mr Hunt…

Your suppositories?

Oh, there really is no need for her to do that

But you can just use your own finger

No really, it’s my pleasure

Bye now.

(TO AUDIENCE) Yes everybody that was Jeremy Hunt and I did just tell him to stick it up his arse.

SHE RETURNS TO TRYING TO LIGHT HER FAG WHEN MISS PRINGLE BURSTS IN, SNATCHES IT FROM HER MOUTH AND SPRAYS AIR FRESHENER AROUND HER

Scene 5

DR LOWRY

A FRANTIC MOVEMENT SCENE TO KLEZMER MUSIC. AFTERNOON SURGERY. THREE (IMAGINARY) PATIENTS COME FOR APPOINTMENTS. THE SCENE IS SLIGHTLY COMIC. DURING THE APPOINTMENTS THE DOCTOR IS PROFESSIONAL AND EFFICIENT BUT IN BETWEEN SHE IS FALLING APART, CAVING IN AND VERY EMOTIONAL. MISS PRINGLE BUSTLES AROUND OFFICIOUSLY. ON ONE OCCASION SHE SEES THE DOCTOR FALLING APART AND, HORRIFIED BY THIS DISPLAY OF EMOTION, DISCREETLY AND COMICALLY HIDES HERSELF. WE SEE FROM DR LOWRY’S BODY LANGUAGE THAT THE FIRST IS VERY TALL AND ANNOYING, THE SECOND IS ELDERLY AND NEEDS A VAGINAL EXAMINATION. MISS PRINGLE HANDS THE DOCTOR A PHONECALL WHILE SHE IS GIVING THE VAGINAL EXAMINATION.

(ON PHONE—HER VOICED STRAINED) Mum! Yes, wonderful thanks. Spag bol? Yes. They love it. (SHAKING HER HEAD) Oh isn’t there—well—never mind. I think they’ll be fine with Fusilli. Mum—I’m really in the thick of it—it’ll be fine—really. Gotta go.

THE THIRD PATIENT NEEDS A HERNIA CHECK.THE SCENE ENDS WITH HER CUPPING PATIENT THREE’S BALLS AND TELLING HIM TO COUGH.

Scene 6

DR LOWRY

AT THE BEGINNING OF SCENE 6 DR LOWRY IS STILL CUPPING PATIENT THREE’S BALLS

(TO AUDIENCE) You know what does my head in? When you tell someone you’re struggling and they say…“Hey! At least we don’t live in Syria!”

Sorry but…what sort a response is that?

SUDDENLY REALISES PATIENT THREE IS THERE. REMOVES HER HAND FROM HIS BALLS AND USHERS HIM OUT, FLUSTERED AND EMBARRASSED

(TO PATIENT) I’m so sorry. Yes, yes everything seems fine. Let’s just wait on those blood tests and speak again. Do say hi to Mrs Colin won’t you…

(TO AUDIENCE) Like…really…what actually is that response? It’s so……ismissive……

No one says that to you if you break your arm

And it’s so……simplistic…

Surely life isn’t some sort of trauma top trumps where only genocide counts

AND…

It’s bloody exploitative of the Syrian people who not only have to survive the most unthinkable circumstances but also have to function to make everyone else feel better

Isn’t that the cornerstone of global capitalism?

MISS PRINGLE ENTERS WITH A CLIPBOARD AND HOLDS IT WHILE THE DOCTOR SIGNS DOCUMENTS WITH INCREASING ANGER THROUGH THE FOLLOWING TEXT

Hasn’t it always been that someone has to suffer unimaginably to make us all put up with our own disappointing but definitely better lives?

I know…Let’s all focus on Syria, South Sudan, wherever…so we can fool ourselves that our government is somehow benevolent

And while we’re looking over there, tucked up on our cosy prescription sofas, our society…our communities are dismantled bit by sorry bit.

(STABBING CLIPBOARD WITH PEN) Are we really that stupid?

MISS PRINGLE EXITS WITH CLIPBOARD

You only have to spend one week in general practice or any other frontline service to see the devastation on your own doorstep. (INDICATING TO JELLIES SCATTERED AND QUEUED AROUND SURGERY) Half the people we see have ABSOLUTELY NOTHING WRONG WITH THEM that isn’t directly caused by this insidious fragmentation. It is actually like living inside a bad joke with a malfunctioning punchline.

Doctor Doctor—I’m slowly starving because I can’t afford to feed myself AND my kids.

Doctor Doctor—silly me I’ve “walked into that cupboard” again

Doctor Doctor—I’m losing my mind because I’m working a frontline job with no support or supervision…

Do you know that rickets is making a comeback because people are too scared to let their kids play out? Safer on the iPad eh—no stranger danger there…

Just this week I’ve seen five adults who went straight from abusive family to care home to heroin addiction to methadone script—I’m not sure that’s what Beveridge meant when he said cradle to grave.

And look—today I received this (TAKES A LETTER WE’VE SEEN IN SCENE 1 OUT OF A FOLDER) —a new directive telling me that we have to replace a drug that works perfectly well with a cheaper one. And we have to explain to patients that continuing with a successful prescription is now considered some sort of gratuitous self-indulgence.

SHE SCRUNCHES UP THE LETTER AND THROWS IT. IT IS CAUGHT IN A WASTEPAPER BASKET BY MISS PRINGLE, WHO HAS JUST APPEARED.

We get these all the time…

Look (SHE TAKES MORE PAPERS OUT OF THE FOLDER)

Blah blah blah hand sanitation—no shit Sherlock (SCRUNCHES AND THROWS. MISS PRINGLE CATCHES)

Blah blah blah CAMHS referrals—apparently it’s no longer enough for a young person just to “feel” suicidal…(SCRUNCHES AND THROWS. MISS PRINGLE CATCHES)

Blah blah blah forward strategy—ha! What? When? (SCRUNCHES AND THROWS. MISS PRINGLE CATCHES)

Blah blah blah Fit for Work assessments—Come on everybody! Clap along to the systematic erosion of disability benefits (SCRUNCHES AND THROWS. MISS PRINGLE CATCHES AND EXITS)

Just this morning (INDICATING PATIENT’S CHAIR) I’ve seen three lonely, lonely people who come at least once a fortnight because they LITERALLY HAVE NO-ONE ELSE TO TALK TO.

(APPROACHES AUDIENCE. SHE IS RANTING NOW) In the business, and make no mistake these days it is a business, we talk about heart sink patients, the ones who come week in week out with medically unexplained symptoms. There’s quite a lot of those now…. You’ve sent them for every test, every scan, every possible investigation and there is NOTHING discernible wrong with them.

Does your heart sink because they’re annoying? No.

Your heart sinks because there is nothing you can do to help them, because maybe, just maybe, it’s not them that is broken.

And so, you’re now in the quite weird position where you’re a very highly qualified government puppet who can sit and listen and nod and apologise.

When you open your eyes you can’t help but question why losing it is seen as such a very personal deficit

It’s as if we think we were designed to cope…With this…

SHE THROWS HER ARMS OPEN TAKING IN THE WHOLE SURGERY. DURING THE FOLLOWING TEXT SHE IS CONFRONTATIONAL, SHOUTING, EYEBALLING AND POINTING AT THE AUDIENCE.

I mean I am looking at you and I’m thinking

If you are not angry

If you are not at least on some level in despair Then WHAT THE FUCK

Is the matter with you?

SHE SCURRIES BACKWARDS EMBARRASSED AT HER OUTBURST AND FINDS HERSELF SITTING HUNCHED ON THE PATIENT’S CHAIR. MISS PRINGLE ENTERS WEARING HER BIKE HELMET. SHE LOUDLY EMPTIES THE BIN, OBLIVIOUS TO OR IGNORING ANY EMOTION IN THE ROOM THEN EXITS WITH BIN BAG THROUGH AUDIENCE.

THERE IS A LONG PAUSE BEFORE THE DOCTOR SPEAKS. WHEN SHE DOES HER SPEECH IS SLOW AND FALTERING, BREAKING WITH EMOTION AND VULNERABILITY

Sorry…

Actually, I’m not sorry…

My therapist suggested I find some way of letting off steam, of self-managing the unmanageable, she asked me what I love….

She said “What do you love?”

(SHAKING HER HEAD ON THE VERGE OF TEARS) I couldn’t remember….

(LAUGHING BITTERLY) I ended up asking my mum….

SHE WALKS TO BEHIND THE SCREEN AND HER HEAD POPS UP OVER THE TOP. BEHIND THE SCREEN SHE IS CHANGING INTO A TENNIS OUTFIT DURING THE NEXT SPEECH

(SPEEDING UP NOW) And my mum said “Didn’t you and your friend Tina used to like tennis?”

And I was like “No mum, YOU like tennis, we were crap at tennis, we liked the way John McEnroe legitimised tantrums in sport”.

And she said “PLEASE” because she really needs someone to play with because Pat is on a cruise and anyway everyone at the Tennis Club is dying to meet me because she’s told everyone all about me.

And I said “You cannot be serious mum. No, no way, there is no way on earth you will get to parade me in front of all your Daily Telegraph reading Bupa health plan Tennis friends—who as far as I’m concerned are very much part of the problem”

SWEET DREAMS BY EURYTHMICS BEGINS TO PLAY. DR LOWRY EMERGES FROM BEHIND THE SCREEN IN FULL TENNIS WHITES WITH SWEAT BANDS AND TENNIS RACQUET. A COMEDY MOVEMENT SEQUENCE WHERE THE DOCTOR PLAYS HER MUM AT TENNIS. WE SEE HER LIMBERING UP, SERVING, RALLYING, LEAPING ENTHUSIASTICALLY AROUND THE STAGE, FALLING OVER AS SHE REACHES FOR A SHOT, GETTING UP AND BRUSHING HERSELF OFF.

AFTER A WHILE MISS PRINGLE GOES INTO THE AUDIENCE WITH RUBBISH BAGS FULL OF SCRUNCHED UP PRESCRIPTIONS AND PAPERWORK. SHE THROWS THEM AT THE DOCTOR AND ENCOURAGES THE AUDIENCE TO DO THE SAME. DR LOWRY TRYS TO BAT THEM AWAY WITH HER RACQUET HITTING SOME AND MISSING OTHERS. SHE KEEPS GOING UNTIL SHE IS EXHAUSTED AND SLUMPS OVER TO CATCH HER BREATH. WE SEE HER SURROUNDED BY BALLS OF PAPER WITH MORE SHOWERING IN FROM THE AUDIENCE. THE MUSIC FADES

Scene 7

DR LOWRY

DR LOWRY STANDS, TAKES OFF HER SWEAT BANDS AND PUTS HER TENNIS RACQUET DOWN. SHE IS STILL REGAINING HER BREATH AS SHE SPEAKS. A BEETHOVEN PIANO SONATA IS PLAYING.

Do you know what

Its good…

Getting out of breath

Blood pumping

You fall down you get up again

You know where you are

You win or lose instantly no waiting for results…No agonising wait

Right now I’m buzzing

It endorphins a-go-go

But you know what?

It’s just a sticking plaster

It makes no difference

Not really

You know it was my granddad made me want to be a GP

He worked his whole life in one small community practice on the Somerset coast

He knew everybody and everybody loved him He was selected from 64 hopefuls to get that job

When he retired they advertised his position four times but no one applied

No one….

He died at the age of 83 cared for by two women in their 50 s who he’d brought into the world

He’d delivered them at home and then they delivered him

That’s what made me want to be a GP

I miss him

And I miss what he stood for

And I wish we could go back

Every night I dream I am asleep on the beach where he lived

The sea comes in and I am asleep and I’m drowning

And someone always wakes me up And I always wish they hadn’t.

THE MUSIC SWELLS. DR LOWRY PICKS HER WAY THROUGH THE PAPER BALLS BACK TO HER DESK AND STARTS TO TYPE ON HER COMPUTER. SHE CONTINUES TYPING AS THE LIGHTS AND MUSIC FADE—THE SOUND OF THE TAPPING KEYBOARD CONTINUES IN THE DARKNESS. THEN STOPS.

END

Conclusion

In conclusion, it may be suggested that qualitative researchers and artists can draw on co-productive approaches to create resonant and powerful pieces of work which communicate the emotions and experiences of research participants in ways that traditional academic dissemination methods cannot. The artist was also a methodological asset and added validity to the interpretative process. This piece was well-received by both public and GP audience members, who fed back that they felt enlightened and validated by the play. We would recommend such collaborations for exploring emotive topics where participants may not have a forum to express their voices. Based on audience feedback, theater proved an accessible and engaging medium to disseminate research findings to diverse public audiences.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Department of Health Disclaimer

The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the NIHR School for Primary Care Research, NIHR, NHS or the Department of Health.

Ethical Approval

Ethical approval for the research was granted by the Southmead Research Ethics Committee (reference number: 15/SW/0350)

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The study was funded by NIHR School for Primary Care Research. Viv Gordon and PreScribed were funded by the Elizabeth Blackwell Institute, University of Bristol, UK from Wellcome and The British Arts Council

ORCID iD

Ruth Riley

References

Beckett

Farr

Kothari

Wye

le May

(2018). Embracing complexity and uncertainty to create impact: Exploring the processes and transformative potential of co-produced research through development of a social impact model. Health Research Policy and Systems, 16(1), 118.

Crotty

(1998). The foundations of social research: Meaning and perspective in the research process. Sage.

Eli

Kay

(2015). Choreographing lived experience: Dance, feelings and the storytelling body. Medical Humanities, 41(1), 63–68. https://doi.org/10.1136/medhum-2014-010602

Fraser

K. D.

al Sayah

(2011). Arts-based methods in health research: A systematic review of the literature. Arts & Health, 3(2), 110–145. https://doi.org/10.1080/17533015.2011.561357

Freund

P. E.

(1990). The expressive body: A common ground for the sociology of emotions and health and illness. Sociology of Health & Illness, 12(4), 452–477.

Goffman

(2002). The presentation of self in everyday life (p. 259). Doubleday. (Original work published 1959)

Gray

Sinding

Ivonoffski

Fitch

Hampson

Greenberg

(2000). The use of research-based theatre in a project related to metastatic breast cancer. Health Expectations, 3(2), 137–144.

Heaton

Day

Britten

(2016). Collaborative research and the co-production of knowledge for practice: An illustrative case study. Implementation Science, 11(1), 20.

Hubbard

G. B.

Kemmer

(2001). Working with emotion: Issues for the researcher in fieldwork and teamwork. International Journal of Social Research Methodology, 4(2), 119–137.

10.

Killion

C. M.

Wang

C. C.

(2000). Linking African American mothers across life stage and station through photovoice. Journal of Health Care for the Poor and Underserved 11(3), 310–325.

11.

Kothari

MacLean

Edwards

Hobbs

(2011). Indicators at the interface: Managing policymaker-researcher collaboration. Knowledge Management Research & Practice 9(3), 203–214.

12.

Patton

M. Q.

(1990). Qualitative evaluation and research methods. Sage.

13.

Radbourne

Glow

Johanson

(2013). The audience experience: A critical analysis of audiences in the performing arts. Intellect Books.

14.

Radbourne

Glow

Johanson

(2010). Measuring the intrinsic benefits of arts attendance. Cultural Trends, 19(4), 307–324.

15.

Radbourne

Johanson

Glow

White

(2009). The audience experience: Measuring quality in the performing arts. International Journal of Arts Management, 16–29.

16.

Riley

Spiers

Chew-Graham

C. A.

Taylor

Thornton

Buszewicz

(2018a). Sources of stress and distress in general practitioners: A qualitative study. BMJ Open, 8(1), e017361.

17.

Riley

Spiers

Chew-Graham

C. A.

Taylor

Thornton

Buszewicz

(2018b). ‘Treading water but drowning slowly’: GPs’ experiences of living and working with mental illness and distress – a qualitative study. BMJ Open, 8(5), e018620.

18.

Rosenbaum

M. E.

Ferguson

K. J.

Herwaldt

L. A.

(2005). In their own words: Presenting the patient’s perspective using research-based theatre. Medical Education, 39(6), 622–631.

19.

Rossiter

Kontos

Colantonio

Gilbert

Gray

Keightley

(2008). Staging data: Theatre as a tool for analysis and knowledge transfer in health research. Social Science & Medicine, 66(1), 130–146. https://doi.org/https://doi.org/10.1016/j.socscimed.2007.07.021

20.

Sandelowski

Trimble

Woodard

E. K.

Barroso

(2006). From synthesis to script: Transforming qualitative research findings for use in practice. Qualitative Health Research, 16(10), 1350–1370.

21.

Sedgman

(2019). On rigour in theatre audience research” Contemporary Theatre Review, 29(4), 462–479.

22.

Shapiro

Hunt

(2003). All the world’s a stage: The use of theatrical performance in medical education. Medical Education, 37(10), 922–927.

23.

Spiers

Buszewicz

Chew-Graham

Gerada

Kessler

Leggett

Manning

Taylor

Thornton

Riley

(2017). Barriers, facilitators, and survival strategies for GPs seeking treatment for distress: a qualitative study. British Journal of General Practice, 67(663), e700–e708.

24.

Van Lith

Schofield

M. J.

Fenner

(2013). Identifying the evidence-base for art-based practices and their potential benefit for mental health recovery: A critical review. Disability and Rehabilitation, 35(16), 1309–1323.

25.

Williams

B. N.

Kang

S.-C.

Johnson

(2016). (Co)-contamination as the dark side of co-production: Public value failures in co-production processes. Public Management Review, 18(5), 692–717.