Promoting Care Giving Interventions through the Dance of Caring Persons (After Pross et al.)

Health and social care staff work in complex workplace cultures that expose them to human suffering, distress and ‘dis-ease’. To defend themselves from emotional and physical pain, staffs undertake tasks, rituals, customs and practices to ameliorate discomfort. This serves as psychological and physical protection from their clients; alien to the ethos of person centred compassionate care. The dance of caring persons is a metaphor for the physical and emotional interaction of a caring relationship. Being facilitated through each of the dance steps offers one way to reignite caring professions. We outline a workshop process aimed to re-engage care staff with an intention to care. Self-care is the first step, which at an intentional, meaningful level requires a moment of mindfulness as internal bodily awareness. Noticing one’s emotional state increases self-awareness and an ability to focus on the here and now, from which to relish the breadth and depth of human experience. The second step includes a moment of performance; through intentional use of non-verbal communication to welcome and engage with others. The third step of the dance is active and effective verbal communication used to purposefully enter into a caring relationship. The fourth step is critical creative discussion, following mutual reflection of what has gone before. Step five is resonance; delving deeper into understanding the emotional and body senses, exploring the words exchanged, their intention and ‘true’ meaning. Step six is the creation of a ‘collage of caring’. Fragments of mutual learning, emotive expression and reactions (impact) are captured in the final exchange undertaken by all involved in the caring process. The dance of caring persons aims to identify the dance steps each person contributes to the context of caring. Such a compendium of caring provokes a deeper understanding of self in relation to the other, within the context of health and social care interactions.


Introduction
There is increasing evidence to suggest that global health care systems are failing to deliver high quality safe and effective health care [1][2][3]. High levels of work related stress and burnout is thought to be responsible for an exodus of qualified caring professionals from health and social care services. Over time the emotional burden of care, also known as the 'labour of caring' [4,5] has produced negative health outcomes for healthcare professionals. The consequences of this 'burden of caring' has been used to explain poor institutionalised care high levels burnout and intention to leave the caring professions [6]. With approximately 10% of qualified nurses annually leaving health care, worsening a global health workforce crisis [7]. Whilst employee support and wellbeing programs have been provided as part of organizational stress management, the importance of adequately preparing staff for work-related stress is often overlooked. This may serve to compromise the caring workforce both currently and in the future. Recruits into professions such as nursing, find the training and clinical workplace atmosphere a potentially bullying, stressful and toxic environment making them question the altruistic intentions present at the outset of their careers. This may play a significant part to what has led to a global workforce shortage that requires significant changes to how people practices are being understood in complex workplace settings around the world [8].

Preparing the workforce, through a dance of caring persons
London South Bank University's School of Health and Social Care (HSC), in collaboration with the Bethlem Gallery, housed at the Bethlem Museum of the Mind (http://www.museumofthemind.org.uk) developed an artist in residence programme to produce a future workforce fit for purpose. The goal was to support an artist, who had personal experience of using health care services, to import a variety of creative learning opportunities for improved compassion and resilience. An internal review of the undergraduate pre-registration courses for health professional at HSC aimed to integrate creative learning within a contemporary curriculum. The artist in residence project gave academics an 'outsider' perspective through working alongside a three dimensional artist. The artist in residence, as a traumatic head injury survivor, and someone fully appreciative of the impact and potential of caring services. One work stream from the artist in residence programme was the creation of a Dance of Wonder Workshop, after Pross et al. 's [1] Dance of Caring Persons.
The Dance of Caring Person's [1] is described as ; a relational model that supports a way of being with others that respects and explicitly values each person; including how people relate to each other in teams, and in organisations (p: 28). This paper describes the development of an extended version of the original Dance of Caring Persons; which has emerged from an experimental and experiential project. This creative workshop co-created with the artist in residence, was first presented at the Enhancing Practice Conference; unearthing the architecture of practice patterns, Edinburgh.
Pross et al. [1] outlines how organizational structures are predominantly hierarchical, significant organizational 'top' and a workplace 'bottom' level, which influences the status of caring roles [9]. Implicit in this hierarchical structure are values that espouse compassionate person centred practices, but in reality create roles and positions of authority, power, and control. As a result, organizational structure can serve to objectify individuals to accomplish system objectives. When organizations hold such values and systems, persons fail to see how to effectively contribute, and feel devalued and disrespected. In contrast, the Dance of Caring Persons supports a way of working together that both respects and values each person's unique and significant contribution, challenging traditional bureaucratic models. The Dance of Caring Persons reconsiders how people within an organization, and those it serves, to relate to one another.
The Dance of Caring Persons evokes an image of a circle with each individual in the dance bringing a unique contribution to the organization. As with legendary King Arthur's round table, no one person is considered more important. The circle engenders interaction that is respectful, honoring and celebratory (Figure 1), where each person is valued and recognized as essential to supporting the mission and goals of the institution.

Six steps to the dance of caring persons
Step 1: First a moment of mindfulness According to Mills starting from a point of self-compassion extends compassion to others through a process of self-kindness, mindfulness and a sense of common humanity. Mindfulness traditionally stems from a Buddhist philosophical approach to inherent humane resilience. It provides a readily taught practical approach to manage stress, pain, physical health problems and depression. Mindfulness has rapidly become a panacea of stress management among professional groups to increase positive outcomes and emotional relief to individuals and improved strategies for personal resilience [10].
Mindfulness teaches individuals to respond and react calmly to emotive stimulus, rather than avoiding or negatively judging situations and relationships. Experiential avoidance occurs when a person is unwilling to remain in contact with their emotional, cognitive or physiological sensations stimulated by being in close contact with others. In contrast, a mindful approach involves being clear and accepting sensations and situations, thus not allowing one's self to be defined or influenced by others. A mindful approach embraces and observes the initial reactions and responses. These are observed, noted and then allowed to pass. Participants of mindfulness are taught how to breathe and to take conscious notice of how their body is reacting and responding and to then seek a calmness to descend. Allowing the time and space to consider acceptance of the situation is key to this process [11].
The first stage in the Dance of Caring Person's is a 3 min mindfulness meditation. The aim is to allow a moment of stillness. Centering the person within their current situation to focus attention on their ability to interact. Caring from a place of peace rather than anxiety or fear of what the interaction may or may not stimulate. This becomes a process of self-compassion as the first step to effective caring interventions.

Step two: A moment of performance
The mindfulness practice of self-care and preparedness allows the caring interaction to be entered thoughtfully and purposefully. Stimulating observations of the situation, taking into account the nonverbal connections, prior to entering into any dialogue. Participants are therefore guided in step two of the dance through nonverbal interactions. Greeting and moving about each other in silence. This second step in the dance concentrates attention on expressed bodily sense, heightening sensory perception of the situation about to be entered.

Step three: A moment of exchange
The next step in the dance explores human connection through verbal interaction. The notion of introducing oneself, by name, has resurfaced in health care settings, where brief encounters and rushed interactions overlook the conventional greetings of introducing oneself by name. Being polite and addressing a person by name provides one entry point to personal identity and the important use of language in placing a person within their social world [12]. The Dance moves on from personal reflection and preparedness into consideration of self in relation to others. The choice of words spoken to introduce and welcome an exchange is undertaken consciously and meaningfully.
Step four: A moment of resonance Iacoboni [13] identifies a common understanding of the goal of the caring exchange is through building a rapport and close connection. Within the workshop, the Dance partners are invited to sit back to back. They physically rest on each other as a symbol of support which represents a moment of comforting, safe, human contact. Each person is invited to capture on paper an image, words or statement about their caring dance encounter. A pause helps to find space to critically reflect and comment upon each other's contribution to the act of caring. The pause allows learning be maximized, emphasizing and reinforcing the reciprocity of the caring act, through receiving knowledge and feedback [14,15]. Sitting back to back also provides a process of mirroring, symbolic of mutuality.
Step five: A co-created conversation Following a moment of reflection and resonance the dance partners are then invited to return to face each other for the next phase of their thoughtful caring conversation.
Step five of the dance encourages a free flowing conversation, dancing backwards and forwards as new insights, learning and happenings unfold. A caring act becomes a process for sharing, reshaping, reproducing and refocusing attention on each other's contributions. Caring, as an interactive dance provides mutual learning opportunity to be taken into the next phase of the working relationship towards improved health and wellbeing.
Step six: A collective collage of caring Once the creative conversation subsumes, the dance moves into its final closing steps bringing the caring dance to a close. Dance partners are invited to join with other members of the dance troupe to share their experiences. Reflecting and going over the steps to the dance becomes another opportunity for learning from new and associated perspectives. The closing steps aims to capture the metaphors, images, pulling aspects of the learning together into a larger collage that encapsulates a creative caring dance. Within a workshop setting this process can be used to achieve the creation of a larger collage of caring, to be taken back to the workplace as a reminder and visual representation of the collective experiences. This collective collage of caring can then be displayed within the workplace to remind and reaffirm the dance as a commitment to contribute effectively to a person centred culture of caring.

Discussion
The Dance of Caring Persons is used here as a metaphor for the physical and emotional interaction of care. We have specifically thought how the Dance of Caring Persons can be used as part of an intentional care intervention to promote a person centred relationship. The Dance itself takes into consideration the unique contribution caring provides, learning to co-create the performance element of caring as a specific intentional human interaction.
Palo-Bengtsson et al. [16] propose dance as, "a process of discovery, a creative feeling that transports the caregiver into a new reality" (p: 164). The Dance of Caring Persons therefore provides the potential for creating a physical and emotional preparedness that enhances a sense of movement towards authentic use of self, in relation to other, in the intentional performance of caring. Palo-Bengtsson et al. [16], explain how dance as a caring intervention promotes emotional effects and reciprocity within a caring exchange. A distinction between use of traditional dance and movement therapy does however need further attention. Little research to date has been achieved in this area.
Percy [17] writes that through an 'interdependence, the interior felt sense of personal integrity and the exterior expression of socialcultural narratives come together with the aim of producing and revealing congruence (or not) between moral selves and socially enacted ethics' (p: 106). In other words, the act of caring when seen through the metaphor of the Dance of Caring Persons is reinstating a critical creative conscious caring process. For health and social care professionals, this helps us re-learn and embrace caring, as a human exchange with a mutually beneficial outcome [18,19].

Conclusion
The Dance of Caring Persons builds on the assumption that personhood is enhanced through caring. Personal transformation can occur when all involved in the experience increase understanding of how to meaningfully engage as a caring person. The Dance of Caring Persons works to highlight caring as a thoughtful, meaningful and intentional relationship between self and other.
From a philosophical stance, the dance workshop steps can be seen as a critical creative act [14]. The Dance of Caring Persons provides; a process that has implications for transforming practices. Through an enhanced understanding of care, as a therapeutic intervention, it has potential for impact across an entire healthcare organisation's culture. The Dance of Caring Persons provides a creative approach to (re)learning how to engage in a thoughtful and mindful human interaction. The Dance steps, when facilitated as a workshop provide a creative learning space, allowing for a return to the delight of human interaction on an intentionally caring level. Unfolding awareness of the personal and professional potential of caring is required to ensure person centred workplace cultures can promote wellbeing for all.