Putting Healthcare Centre Stage

Link to the dissertation in GUPEA

In this dissertation, two worlds come together: one of them, healthcare; the other, the theatrical arts. These two worlds are being engaged together to investigate how partner-creating processes are established in encounters between patients and healthcare professionals in healthcare settings. The aim is to contribute to a more profound understanding of the encounter between patients and healthcare professionals in a healthcare context striving for a more person-centred care. The following research questions have served as guideline for my investigations: First, how can the theatrical arts be employed as a tool for examining what happens in patient encounters? Second, how can actors’ professional competency be used as a resource for analysing the multifaceted interplay between role and person, in both patients and healthcare professionals in this encounter? And third, how can the capacity for more person-centred care be developed using the theatrical arts as a resource? To manage the methodological challenges that accompany such a study, I have developed a model subsequently applied to empirical material comprising three healthcare encounter dialogues and used as a ground for elaborating themes, and key activities, that could serve to balance the asymmetry in healthcare relationships, thereby strengthening a partner-creating process in such encounters.

This research project, which came into being through a cooperative effort between the Academy of Music and Drama and the Gothenburg Centre for Person-centred Care (GPCC), at Gothenburg University, builds on experiences from my own theatrical practice as director and actor. Two methodological concepts are brought in from the theatre, the Magic If and Given Circumstances (Stanislavski 2008), which belong to a category of techniques that actors and directors use during rehearsal work to examine and analyse a theatrical manuscript. In this kind of rehearsal, the text- and role-interpreting processes aim to create a performance for the stage. However, in this dissertation, theatre expertise is employed to develop a research methodology for examining human interaction in the context of health care. The model developed in the thesis is inspired by the philosophical anthropology and critical hermeneutics of Paul Ricoeur (Ricoeur 1990/92). As such, it should be recognised as a practical application of Stanislavski’s theatrical-methodological approach “read” through the theoretical lens of Ricoeur’s theory of interpretation (Ricoeur 1976).

Starting from a playing approach, I focus on how the dynamics between person and role can be put into play in healthcare. I see these two, playfulness (as a mode of exploration) and role-creation (as agency given in the personal interpretation of the role) as two key ways for theatre to contribute to a better understanding of encounters within healthcare. In my study, I address roles as both something given (meaning there are certain factors that all persons must adhere to in their interpretation of the role, “the general role”) and as something negotiable (open for personal and unique interpretation); and I recognise interpretation of roles as a kind of perspective-taking – a sort of viewpoint of the self. I also discuss the possibility of a co-creation of the role to adapt it to the unique person. When I speak of “the personal interpretation of the general role” I mean that the role-interpreting process is about understanding the role, understanding what expectations, limitations, and possibilities come with the role, but also understanding oneself in the role. Interpreting a role thus also occurs through interaction with others, because we always recognise ourselves in our roles in context alongside other people.

This thesis draws on research from several research fields, both performing arts and theatre, Artistic Interventions in Organizations, healthcare research, and philosophy of the self. My path through this landscape has been influenced by my previous work with artist-driven development projects in organizations (Brattström 2016), and aligns with the development of artistic research and the interest in new methods and collaboration with other research disciplines. By integrating competences from both theatre and healthcare in this project, the aim is to contribute to conceptual and methodological development in both healthcare and arts, and is thus beneficial for both fields. This shows the potential art offers as a cognitive resource for exploring encounters of complex social interaction, in this instance, those occurring within a healthcare context.

We live in a time when person-centred care is increasingly emphasised. Both patient-organizations and healthcare professionals have long sought a change toward a care that strengthens the patient’s position as a fellow human, a care-relationship based on a partnership between patient and healthcare professional.  Person-centred care is both effective and appreciated by patients, in controlled studies it has been shown that person-centredness recognised as applied ethics in healthcare, can contribute to measurable changes and positive effects, both from a patient perspective and in terms of cost and effectiveness (Britten et al. 2020). As such, a shift to more person-centred care has been on the strategic agenda in the majority of Sweden’s regions. Such a profound change of approach has, however, proven itself to be ‘easier said than done’, and the actors within healthcare are looking for methods and approaches that can contribute to a greater degree of person- centeredness. There is, therefore, a need for a deepened understanding of how a partnership between healthcare professionals and patients can be created and maintained. The phenomenon of partnership needs to be both understood and explained, according to the approach of critical hermeneutics.

Person-centred care is based on the recognition of a partnership between patients and healthcare professionals, building a relationship together in which patients are given space to be active partners in their own care. Person-centred care  takes as its starting point the patient’s own situation, their unique resources, conditions, and the specific needs of that person (Ekman et al. 2020). Central elements in the ontology of human action that lay the foundation for person-centred healthcare are the questions of how we come into being and develop in relation to other people, and how this process takes place in the context of concrete situations. Human beings are self-reflective and react to our surroundings relationally. This implies the need for reflected ethical beliefs on each care action. (Ekman 2022).

For the theoretical development of person-centred care at GPCC, Paul Ricoeur’s understanding of the ethical vision as “aiming at the ‘good life’ with and for others, in just institutions,” (Ricoeur 1990/1992, p. 172) has been of great significance. It can also be considered a starting point for a person-centred care within healthcare institutions too (Kristensson Uggla 2022). Ethics are recognised as an integral part of being a person. The capacity to be responsible for one’s own actions is, according to Ricoeur, an essential part of what characterises and defines us as human beings. The ethical vision that forms the foundation for person-centred care must therefore also be understood against a backdrop painted with the basic tenets of Ricoeur’s concept of personhood.

Central to Ricoeur’s philosophy is the view of the human as simultaneously capable and vulnerable. Ricoeur (1992) talks of the homo capax, the capable human being, as a “wounded Cogito” (Cogito blessé). His starting point here is a foundationally relational and dialectic view of the human as both acting and suffering. We need each other in order to develop. Through encounters and interactions with others, we become who we are. Existing is also “becoming.” In encounters with others, we are constantly created and re-created as persons because we at once both “discover” and “invent” ourselves through those interactions (Kristensson Uggla 2019/2024). A human being is not just an unchangeable thing (idem), but also a self (ipse) that sustains an identity in a state of constant change. Self-understanding is a question of interpretation – Ricoeur speaks of a “hermeneutics of the self” (Ricoeur 1990/1992) that is about understanding oneself in a concrete reality together with others. By reading Stanislavski’s theatrical-methodological concept through the lens of Ricoeur’s theory of interpretation, I have gained insight into how I can use actors’ and directors’ competencies to examine and explore the partner-creating processes in the healthcare encounter.

A concept of personhood that emphasises dynamic and relational aspects in the self-reflective human also has relevance for creative processes involved in an actor's role-interpretation work. The work of interpreting a role in a theatrical context is characterised by the actor investigating and testing, in practice, a preliminary understanding of the theatrical situation by performing it (Sjöström 2007). The interpretation of the role grows in iterations between playful testing and analysis on the stage during the rehearsal process. In the collective investigation and creation that the rehearsal entails, the actor simultaneously “discovers” and “invents” the character.

In the process of creating a role for the stage, one can discern two different aspects of the concept of “role”: on the one hand, there is the role in the sense of ‘the scripted role’, meaning the role embedded in the script of a play. On the other hand, there is the role as ‘the character’, meaning the unique embodiment of the scripted role arising from the actor's personal interpretation of the role in the context of a specific production (Cohen 2013, Bergman Blix 2010). 

In Stanislavski’s Magic If method, the role-interpretation processes focus the actor on developing an understanding of the role's situation (Rynell 2008, Merlin 2014). The character is created through the actor’s encounter with the world which opens up for the actor when they imagine the world “as if” they were themselves experiencing the role’s specific situation. Stanislavski speaks of the actor enacting a human being on the basis of the role’s “given circumstances” from his own first-person perspective. It is, then, the idea of the disclosure of a world; of a way of seeing things, rather than the idea of acting as representing another (the character) that guides the actor in the role-interpretation process. This distinction is also central to this thesis, for the understanding of the kind of role interpretation and role-shaping processes that occur outside the context of the theatre, that is, when it comes to the interpretation and shaping of our social or professional roles. In other words, the actor is not pretending to be another person or acting “as if” they were the other person. The actor is putting him or herself into the other’s situation. She is asking herself, ‘If I were in the circumstances given in the script, what would I do, and how would I do it?’ These questions are answered by the actor in the form of action on stage.

In the world of the theatre, a rehearsal is a collective creative process in which different perspectives and interpretations of the dramatic text (often a play script) are systematically tested and refracted against each other before being synthesised into a whole. This process is about creating a performance that will then remain alive and fresh when repeatedly performed in front of an audience. During the rehearsals, the performance takes shape through repeated experiments in which the actors investigate the text precisely by performing it on the stage, the situations are investigated through playing them out. Together, the actors and the director reflect on the results, then they compare and synthesise their individual perspectives on what happened during the experiment on the stage. With a starting point in this shared analysis, they modulate the Given Circumstances: in a new experiment with the same scene, certain conditions are changed while others are kept the same. This pattern is repeated during the rehearsal process, in an ongoing interplay between experimental and analytical phases.

Inspired by Kristensson Uggla’s concept laboratory of interpretation (Kristensson Uggla 2019/2024), I have chosen to regard the theatre’s rehearsal process as an interpretation lab in which the director and actors investigate and create together (both “discover” and “invent”) the interpretation of the play’s script that will later become the performance. In this context, I describe the working relationship between the director and the actors as a creative partnership based on their respective expertise. In my thesis, I call the experimental phase of the rehearsal process “playing the game,” and the analytical phase “negotiating the rules of the game” (Brattström 2016). 

During a rehearsal, the director and actors are responsible for various perspectives in the shared interpretation process. The actors investigate the text in the manuscript from “an actor’s onstage perspective”. This means the actor explores the script’s situation as a playful first-person perspective on stage. This is where the actor can draw from Stanislavski’s Magic If to enable stepping more easily into the game; into the investigative play. The actor acts as if they were in the role’s situation as it appears to them personally. The director observes the experiment that the actor is involved in, from what I refer to as a “director’s auditorium perspective.” The director, positioned off stage in the auditorium, is interpreting the onstage action as if the director were part of a future audience, sitting in the auditorium watching the presentation of the theatrical performance come alive for the first time. 

During rehearsals the actors and the director systematically engage in, and shift between, different perspectives and attitudes towards the text presented in the play’s script, interpreting and exploring the text, making it come alive on stage. The director and actors’ dialogue and collaboration relies on two key competencies. I have called them “the ability to recognise the Given Circumstances at play” (i.e., using the actors’ trained ability to make themselves physically and mentally receptive to, and able to recognise, the Given Circumstances at play in the dramatic situations in the text) and “the art of modifying the Given Circumstances at play” (i.e., making use of the actors’ training in recounting, analysing and adapting Given Circumstances relevant for shaping the dramatic situations in the text). This method of conducting the rehearsal process, as an interpretation laboratory, lays the foundation for the research method I have developed and employed to analyse healthcare encounter dialogues in the study.

Turning now to the empirical material, the healthcare encounter dialogues used in the study were created and analysed using the following six steps in the investigation model:

1. Observation and creation of dialogue manuscripts

The first step involves observation and audio documentation of healthcare encounters between patients and healthcare professionals. This is followed by transcription of dialogue audio recordings. By merging transcribed dialogue with observation notes, I create a dialogue manuscript.

2. Review with reference group (workshop/focus group discussion)

Here, the dialogue manuscripts are investigated and analysed in a similar manner to how I, in the role of director, prepare theatrical text material before rehearsals with actors. The preparatory “director’s readings” is an initial analysis of the dialogue material. This preliminary reading is then tested, modified, and deepened in relation to what occurs in the following steps in the investigation.

3. Investigative theatrical readings and interviews with actors (rehearsal laboratory experiments)

There follows a review of the initial reading with a reference group where the reference group was invited to an interactive workshop and focus group discussion. A “conceptual space” is created which, in the next step, introduces the actors to the investigatory theatrical readings in the rehearsal laboratory experiment.

4. Compilation of documentation from rehearsal laboratory experiments (thematic analysis)

In this step, the dialogue manuscript is examined through several staged readings of the material together with the actors. The actors read the dialogue manuscript through several times, shifting between the different roles. In connection to the readings, the actors reflect on, and are interviewed regarding, their experiences. The staged readings and interviews are documented on video.

5. Compilation of documentation from rehearsal laboratory experiments (thematic analysis)

The video documentation from the rehearsal laboratory experiments is compiled and analysed. A number of themes are then identified in the interview material. The documentation is cut into shorter sequences and compiled into interview films. Certain key quotations are selected from the interview material and transcribed. These key quotations are organised in a thematic register that, in turn, functions as supporting documentation for formulating a thorough interpretation (i.e., a detailed reading of the material as a whole).

6. An elaborate reading of the material (comprehensive understanding) 

In this last step, I return to the “director’s reading” created in Step 2. I compare my initial manuscript analysis with the results from the review with the reference group, in Step 3, and with the thematic reasoning that had crystallised through the interview material from Steps 4–5. By comparing results from the different levels of examination, the initial manuscript analysis is modulated and deepened, and a complete, thorough interpretation (reading) is created of the material. The detailed reading is also formulated in relation to a selection of theoretical resources such as the relevant literature for this specific study.        

In the dissertation’s second part, I present my interpretations of the empirical material, that is, of the three healthcare encounter dialogues (included are links to the filmed documentation from the rehearsal laboratory experiments). The healthcare discussions are represented in the text through different materials in a quasi-collage form, interwoven with analyses in which I move between perspectives of the different roles in my reading, also at times quoting the actors’ statements from the investigations in the rehearsal laboratory experiments. My particular focus was on the challenges that emerged regarding partner-creating processes in the encounters between patient and healthcare professional. Reflecting on what potential means exist for overcoming the challenges that arose through an analysis of the empirical material, I highlighted ‘activities’ in the conversation practice that could serve to balance the asymmetry in healthcare relationships, thereby strengthening a partner-creating process in such encounters. Below is a selection of themes that came to the fore in my analysis: 

The first theme is titled: “Preparing the ground for interaction”. This theme focuses on preparations: How can the healthcare professional and the patient, in their own ways, prepare the conversational situation in order to facilitate a partner-creating process in the healthcare encounter? In this context, I specifically discuss preparations relating to space, temporality, and role.

The second theme I have titled “The existential potential in the healthcare encounter as a boundary situation.” The healthcare encounter is here construed as a boundary situation (Jaspers 1970), suggesting that an existential potential can be activated in the dialogue between patients and healthcare professionals when construing the healthcare encounter as such (Schuster 2006). I discuss two specific activities highlighted in the analyses that could serve to balance the asymmetry in the relationship between patients and healthcare professionals and give way to reciprocity in their communication, thereby strengthening the process of partnership creation.

The first activity that might facilitate such reciprocity is humour, more specifically, how a playful, humorous approach to the conversation can function as a means for emphasising the healthcare professional and the patient as equal persons – as human beings who happen to have find themselves in a care situation that is fundamentally unequal. Joking with each other becomes, in my interpretation of the study’s healthcare encounter dialogues, a way of playing with the perspective of the role. It is a way – through the conversation - to emphasise the temporary nature of the asymmetry given in the healthcare situation. The playful, humorous approach that comes to the fore in the analyses of the empirical material builds, as I see it, on recognising both the reversibility of the roles we play (i.e., that every unique person has the capacity to inhabit many different roles – the healthcare professional and the patient might just as well have found themselves in the other role and on the other end of such a conversation) and the nonsubstitutibility of the person inhabiting the role (i.e., that it in the specific conversation being had, it is those specific unique individuals speaking, who need to be respected precisely as the specific individual

The second activity that might facilitate reciprocity is concerned with physical touch. Discussion here uses my interpretation of the healthcare encounter dialogues to examine how, under certain conditions, physical touch should be able to help support a patient. As Schuster puts it: “In the encounter between a nurse and a suffering patient touch can be an invitation to this shared existence and an affirmation of the other’s human worth, in the midst of the unworthy” (Schuster 2006, 171). Despite the experience of vulnerability, through touch, the persons involved in this boundary situation are better able to maintain a concentrated presence as physical human beings, and to better pay attention to the other in the course of their conversations and communication with each other.

Returning to the core themes that emerged during the analysis of the healthcare encounters, a third theme arose which I have titled “How patient narratives open up playful approaches in the healthcare encounter.” Paradoxically, playfulness can be something very serious – in this case, it is about "imagination and sympathy". In relation to this theme, I develop the manner in which exploring patient narratives in the interaction between patient and healthcare professional can initiate a playful approach within the conversation, and how the parties’ engagement in a playful approach to each other can in turn contribute to lessening the asymmetry in the healthcare situation. This opens up for a more mutual partner-creating process in the encounter. 

The healthcare encounter can also be seen as an interpretive work in interchange between close proximity and more distanced analytical perspectives. In the healthcare encounter, the patient and the healthcare professional act within a framework for their given roles in the healthcare situation. The healthcare encounter, however, simultaneously means an encounter between the unique individuals who inhabit these roles. There is a specific, unique individual inhabiting the roles of ‘healthcare provider’ and ‘patient’. In the field of tension between role and individual    between “role-bound” dimensions and personal dimensions in the encounter – an interpretive space also arises. In the study, I choose to speak of this as a “negotiation space” for the personal interpretation of the general role. This highlights the role of interpretation as a determining factor in the process of partnership creation.

The personal interpretation of the role is impacted by what happens in the encounter and by interactions with others. The role can also be re-interpreted and re-negotiated in interaction with others. In the context of the healthcare encounter the person who is a patient acts within the framework of the role simultaneously interpreting and re-shaping the role. This type of dynamic and complex role interpretation, taking place in the interaction with others, is characterised by simultaneous discovery and invention of the role. As self-reflective human beings, we interpret and understand ourselves in new ways through interaction with others. Understanding ourselves in new ways, impacts how we interpret our roles. These role interpretation processes occur as we act in and through our roles, in our encounters with others. 

In summary, the study investigates the interplay of the personal and the role-bound in healthcare relationships, with a focus on the process of partnership-creation. I have explored how the conditions for establishing partnership in the healthcare encounter are impacted by how the patient in the current situation understands their role and themselves in the role. The research and analysis presented in this thesis show how the interpretation of the patient-role can be co-created and re-interpreted in collaboration between patients and healthcare professionals during the healthcare encounter. 

The analysis evokes many questions, for example: How (and in what ways) do healthcare professionals recognise the unique person of the patient acting within the framework of the patient role? How are the possibilities and limits of the patient role understood and established in the encounter? In what concrete ways do healthcare professionals sympathetically listen to and remain open to how the patient expresses their unique interpretation of their patient role (e.g., how they want and are able to play it)? How can the patient and the healthcare professional work together to create an understanding – for example, of how the patient can utilise their personal resources within the framework for their interpretive version of the patient role?  

Returning now to the theatrical perspective, the question of what it means to be human alongside other humans is continuously subjected to artistic explorations and investigations. Theatre provides a powerful lens through which to examine the complexities of human existence, or it in the words of literary theorist and philosopher Mikhail Bakhtin: “the concrete diversity of being” (Bachtin, 1991).

In my work as actor and director, the concepts of person, role and play are central. I embrace the idea of the rehearsal process as a continuation, a sort of professionalised version of a child’s playful investigations of the world. In child’s play, there is space for elements of both entertainment and examination. It is fun – and essential – to play. We learn through play. Through play, we can examine the world and our potential roles in it. In play, we can test different imaginative ways of representing the world and ourselves. We can test out, and get a feel for, how the world could be or might be. We can examine how it could present itself to be experienced when we exist in the world as we imagine it, thanks to the agreed-upon conditions of play. 

The Magic If, as a methodological tool in theatre, functions within the actor’s rehearsal process as a systematic way of imagining the world differently. In theatrical play, the actor approaches their interpretation and performance by methodically testing the story from the perspective of the role. 

In essence, interpreting a role for the stage is not about trying to play someone else. As an actor, my focus in the interpretation process is not on playing the role itself. I play myself out of the role as Cohen put it (Cohen, 2013), or perhaps better, I play myself within the role, with the situation. I do not play “as if” I am another person, I test out how I would be if I found myself in the scripted situation. The role becomes my perspective, my entry point, my viewpoint in an interpretation of the world that the text or story has put at my disposal. Through experiencing the world from the first-person perspective of the role, I put myself in play within that world; I take it on, I meet the world as myself from a certain role perspective

Throughout the thesis, I have problematised a generally accepted understanding of role and roleplay as an approach that “stands in the way of” or hides the “true” or “authentic” person. Through this study, I instead invite the idea of the personal interpretation of the role as a uniquely personal perspective, a personal viewpoint, a possible way of looking at things, and as one of many expressions of the self.  In this way, I approach Ricoeur’s position, who speaking of "play as the mode of being of appropriation", states: “To understand is not to project oneself into the text; it is to receive an enlarged self from the apprehension of proposed worlds which are the genuine object of interpretation” (Ricoeur 1981, 182). This is also how the Stanislavskian Magic If is understood in the context of the study.

Through the analysis of the healthcare encounter dialogues in the study, the interplay between patient and healthcare professional during the healthcare encounter emerges as a dynamic interchange between proximity and distance. In their dialogue, the patient and the healthcare professional oscillate between close involvement through their encounter and more distanced analytical perspectives. In this interchange, understanding and analysis do not exist in a mutually exclusive relationship but rather function as two different attitudes which, in the encounter, complement each other. A playful approach and distanciation, proximity and separation: The close understanding and the distanced analysis function together as two interacting poles in a larger interpretive context.

The ability to shift perspective, to imagine and test out the world in a different way, to playfully seek out and interact with what we do not yet know or understand in order to attune ourselves to what is initially unfamiliar – this is an ability we all have. It is, of course, how we attempted to approach an understanding of the world from the very beginning – by “playing” with it and playing in it. This is about not just being able to enter a situation as yourself and truly play, but also about being able to step outside the experience and observe the play from a certain distance. Such interplay between gaining a playful understanding and engaging in distanced analysis is central to the actor’s work. 

Likewise, I suggest, in healthcare – as in the encounter between the patient and the healthcare professional – interpretive work is characterised by such an interplay, wherein understanding and critical analysis are not pitted against each other as an either/or juxtaposition but rather function as complementary poles in a playful dialectic – one which also comprises a resources for a partner-creating process. This playful interchange in the encounter between patient and healthcare professional creates the opportunity for the role to become a pathway to understanding the perspective of the unique person in their specificities of their unique personal situation.

English Summary:

The English summary was translated by Suzanne M. Cheadle and edited by Dr. Harris Wiseman (Cantab) and Dr. Joel Speerstra (Academy of Music and Drama)

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