Volume 16, No. 2, Art. 29 – May 2015
Immersion, Embodiment, and Imagination: Moving Beyond an Aesthetic of Objectivity in Research-Informed Performance in Health
Julia Gray & Pia Kontos
Abstract: Growing numbers of qualitative health researchers of diverse disciplinary backgrounds are experimenting with various forms of performance (e.g., film, live theater, dance) as innovative approaches to engage broader communities in complex and critical ways with research. Despite this emerging alliance between performance and research, much of research-informed performance work is informed by an "aesthetic of objectivity," which assumes a linear trajectory between research findings and performance, and minimizes the relevance of aesthetic interpretation, which we argue is fundamental to achieving critical research-informed performative work. To move beyond this aesthetic of objectivity, we will explore our development of a research-informed film, "Fit for Dialysis." We argue that embracing the role of aesthetics, imagination, and embodiment more fully is essential to achieving the full interactive, educational, and emancipatory potential of the alliance between performance and research.
Key words: research-based drama; research-based film; arts-based research; hemodialysis; education; knowledge translation; health research; performative social sciences
Table of Contents
1.1 Research-informed performance
1.2 Aesthetic of objectivity
2. "Fit for Dialysis"
3. Immersion, Embodiment and Imagination
Within health research, an increasing emphasis is being placed on "moving research off the shelves and into practice, making it relevant and accessible to practitioners and patients" (LENFANT, 2003, p.869). Critiques of traditional text-based dissemination methods have led qualitative researchers to draw on more innovative strategies for extending research beyond the boundaries of the academy, to engage broader communities (COLE & KNOWLES, 2008; COLE, NEILSEN, KNOWLES & LUCIANI, 2004; ROSSITER et al., 2008). As such, many qualitative health researchers are turning to arts-based methods (FRASER & AL SAYAH, 2011) not only as a means to bridge the gap between research and practice, but also to facilitate critical engagement with research. Arts-based methods have a demonstrated history of increasing awareness of stagnant or oppressive situations, encouraging critical reflection, challenging personal assumptions and dominant cultural narratives, and providing a space to engage with complex ethical issues (DUPUIS et al., 2011; KONTOS et al., 2012; MITCHELL et al., 2011; ROSSITER, 2012). Because of its strength in engaging audiences in ways that are visceral, intellectual, physical, emotional, and emancipatory (GRAY, 2009; KONTOS & POLAND, 2009; MITCHELL et al., 2011; ROSSITER et al., 2008; SALDAÑA, 2003), a growing number of qualitative health researchers of diverse disciplinary backgrounds are experimenting with various forms of performance including film, live theater, and dance (BOYDELL, GLADSTONE, VOLPE, ALLEMANG & STASIULIS, 2012; GRAY, SINDING & FITCH, 2001; GRAY et al., 2000; KONTOS & NAGLIE, 2006; MIENCZAKOWSKI, 1999; PAGET, 1987; SANDELOWSKI, TRIMBLE, WOODARD & BARROSO, 2006). Research-based performance is further appealing to researchers for its potential to incorporate multiple perspectives, including those of study participants, researchers, artists, and audiences, thereby moving away from the streamlined perspective of the "all-knowing" researcher (DUPUIS et al., 2011; GOLDSTEIN, 2012; GRAY et al., 2000; ROSSITER et al., 2008). 
Given the alliance between the aesthetic of performance and the methodological and theoretical ambitions of research, it is surprising how little social and health scientists have drawn on philosophies of the arts to support the choice, development, and interpretation of performance-based interventions. This lack of attention is despite emerging calls within the health and social sciences for researchers to theorize arts-based methods (FRASER & AL SAYAH, 2011), contemplate issues of aesthetics, and collaborate with arts scholars who are well versed in philosophies of the arts (BOYDELL et al., 2012). Arts-based educational scholars also call for more attention to be paid to aesthetics (GOLDSTEIN, GRAY, SALISBURY & SNELL, 2014; SALDAÑA, 2005, 2011), out of concern that "downplaying or not appropriately attending to the conditions of art itself could have the effect of forcing art to disappear in service of research" (O'DONOGHUE, 2014, p.170). Theater scholar, practitioner, and qualitative researcher SALDAÑA advocates the importance of strong artistic quality in research-informed performance, which he argues is often overlooked in the wake of social and health scientists' desire to represent research findings as closely as possible to the original data-gathering setting. He insists that not only is it possible to have research-informed performance with strong artistic elements and solid research findings—what he terms "ethnodramatic validity" (2011, p.210), but that it is essential for the success of research-informed performance as a space for reflection and awareness. 
As we shall argue here, the absence of such theoretical and methodological engagement can be attributed to the dominance in the field of an "aesthetic of objectivity" (DENZIN, 2003, p.73), which assumes a linear trajectory between research findings and performance, and minimizes the relevance of aesthetic interpretation as an integral part of developing such initiatives. These assumptions are evident in the epistemological and methodological expectations of arts-based research commonly held by social and health scientists to 1. communicate discreet, actionable results that will be directed clearly to audience members to inform clinical practice or health policy; 2. fulfill scientific notions of rigor and validity, which valorize neutrality and distance; and 3. stay as close as possible to the research participants' experiences, as expressed in the original data gathering setting (for more discussion on these expectations, please see HODGINS & BOYDELL, 2014; MIENCZAKOWSKI & MOORE, 2008; ROSSITER et al., 2008; SANDELOWSKI & LEEMAN, 2012). With an interest in moving beyond this aesthetic of objectivity, we will explore our development of a research-informed film, "Fit for Dialysis," central to which was the film's writer and director's (author Julia GRAY) immersive, embodied, and imaginative engagement in the creation process. 
This article is organized as follows: First, we provide an overview of the field of research-informed performance to contextualize our discussion. Next we define an aesthetic of objectivity, including discussion of the problematics it presents. To redress the limitations we identify and draw on the notion of "ethnodramatic validity" (SALDAÑA, 2011, p.210), but highlight important ways by which this notion can be clarified and enriched. We then introduce "Fit for Dialysis" and build on the notion of ethnodramatic validity by drawing on theories from the arts; we provide an in-depth exploration of the writing process, one that was immersive, embodied, and imaginative. We conclude by arguing that a fuller embrace of the role of aesthetics, imagination, and embodiment is essential to achieving the full interactive, educational, and emancipatory potential of the alliance between performance and research. 
1.1 Research-informed performance
Researchers in a variety of fields engage with research-informed performance and, given their backgrounds, research-informed performance practitioners name and approach their projects in a range of ways (for details, see ACKROYD & O'TOOLE, 2010). Researchers, who have been trained in the social and health sciences, including the research methodology of ethnography, refer to their performance-based work interchangeably as "performed ethnography" (GOLDSTEIN, 2012), "performance ethnography" (DENZIN, 2003), "ethnodrama" and "ethnotheatre" (SALDAÑA, 2005, 2011), "research-based drama" (ROSSITER et al., 2008), and "ethnocinema" (HARRIS, 2012). Because of its research base, much of this performance-based work is concerned with accurately representing the experiences of the research participants. Theater artists, who have trained in the practice of making theater but are not necessarily academics, use the terms "reality theatre" (WAKE, 2010), "verbatim theatre" (BROWN, 2010; PAGET, 1987), and "documentary theatre" (FILEWOD, 1987; SMITH, 1994) to refer to their performance work. Even with a deep commitment to capturing actual events and experiences, the main focus of these artists tends to be on the relationship between crafting the performance and audience engagement. The academy more recently has seen the emergence of arts or performance scholars who engage in "research-creation" (MANNING, 2015; THAIN, 2008) and "performance as research" (RILEY & HUNTER, 2009). These arts scholars tend to have academic and artistic training, engage in artistic practice as a process of scholarly inquiry, and articulate these practices in academic spheres without confining arts processes to scientific methodological boxes (MANNING, 2015). 
Various art forms are drawn upon when engaging in research-informed performance, such as dance (BOYDELL, 2011; FOSTER, 2009), film (BARONE, 2003; HARRIS, 2012; PARSONS & LAVERY, 2012), and live theater (GOLDSTEIN, 2012; GRAY, 2009; SALDAÑA, 2011). Yet film, as an image-based, two-dimensional art form (i.e., the art form encompasses still and moving images on a flat screen), not only offers the pedagogical opportunity to challenge dominant images and perceptions (BARONE, 2003), but its accessibility and familiarity in our contemporary media-driven culture also makes it a particularly effective vehicle to achieve wide-reaching engagement (BARONE, 2003; PARSONS & LAVERY, 2012). 
1.2 Aesthetic of objectivity
Several elements are central to an aesthetic of objectivity, which may influence fully or partially a particular research-informed performance project. First, those taking up an aesthetically objective perspective tend to pursue "naturalism" and "realism" in the performed work (DENZIN, 1997, 2003; GRAY, BAER & GOLDSTEIN, in press; SNYDER-YOUNG, 2010). With an emphasis on "the data doing the talking" (MIENCZAKOWSKI & MOORE, 2008, p.452), realistic or authentic representations of the research findings, high in verisimilitude, are encouraged. The performed work tends to be confined to the text of qualitative research (DENZIN, 2003; GRAY et al., in press; SMITH, 1994; SNYDER-YOUNG, 2010), precluding other artistic modes of expression that could allow stakeholders, such as participants and audience members, to engage with the work in a multiplicity of ways. In the process of creation, the arts researcher1) is expected to present minimally altered research findings and is understood to be an objective observer, not as one who creates or invents (DENZIN, 2003; GOLDSTEIN, 2012; TRINH, 1992). Additionally, audience members are seen as passive recipients of the performance, rather than actively engaged in interpretation (DENZIN, 2003; FREIRE, 2007 ; JACKSON, 2007; TRINH, 1992). 
Critical and interpretive qualitative researchers have significantly challenged the notion of objectivity. CLIFFORD (1986), for example, discusses how ethnographers invent "partial truths" through their writing (p.7) rather than represent "culture" as an "object of description and critique" (p.3). The writing process itself, with the focus on text and rhetoric, serves to highlight the constructed nature of the ethnographer's cultural accounts. Ethnographers bring with them a range of cultural, political, and social assumptions that inform the interpretation and analysis of their findings. As CLIFFORD argues, ethnographers do not represent their research findings through their writing; they invent them. 
Much of the field of research-informed performance has been immune to this critique, viewing aesthetic interpretation, including imaginative and embodied aspects of the creative process, as a distortion of the original research findings. Often the inventive nature of aesthetic interpretation is approached with trepidation given the "researchers' ethical responsibility to create authentic representations of participants realities" (JONAS-SIMPSON et al., 2012, p.1951; see also ACKROYD & O'TOOLE, 2010; MIENCZAKOWSKI, 1999, 2009; MIENCZAKOWSKI & MOORE, 2008). Where granted a role, aesthetic interpretation is often framed as a "license for artistic interpretation" (SALDAÑA, 2005, p.32; see also GRAY et al., 2001; JONAS-SIMPSON et al., 2012; MIENCZAKOWSKI, 2009), implying liberties are taken with the work. This perspective on aesthetic interpretation overlooks the central role of embodiment and imagination in the immersive creation process, as well as how fundamental these resources are for fostering critical awareness, deepening understanding, and envisioning new possibilities. 
SALDAÑA's insights are pertinent here since he champions strong artistic quality in ethnodramatic work (2005)—dramatic literary writing emerging from research findings—and in ethnotheaterical work (2011)—theaterical performances based on research findings. Despite his scholarship focuses primarily on live theater, his critiques of poor artistic quality in ethnodrama/theater are equally germane to our discussion of performance more broadly. 
Much of SALDAÑA's scholarly work lies in providing guidelines for qualitative researchers interested in engaging with ethnotheater and ethnodrama, and as such, SALDAÑA reminds emerging qualitative/arts-based researchers that the "mounting of ethnographic reality on stage is at its most effective when the production assumes a nonrealistic—read: 'theatrical'—style" (2011, p.204). His advocacy for theatericality in live, stage-based work can help us move beyond an aesthetic of objectivity as he cautions emerging qualitative/arts-based researchers against simply replicating research findings on stage. He attests employing theatericality is possible as a means to interpret the research findings in an engaging way (p.206). Specifically, he implores emerging qualitative/arts-based researchers to "stop thinking like a social scientist and start thinking like an artist" (p.209), and argues that by trusting "artistic impulses" (p.210), it is possible to create an evocative play with theatericality yet authenticity. Good ethnotheaterical work must have both "artistic rigor" and a "truthful text"—what he refers to as "ethnodramatic validity" (p.210, see also 2005, p.32). He encourages qualitative/arts-based researchers to "free themselves from the hegemony of traditional and stifling academic discourse, and to allow their creativity and dramatic intuition to imagine aesthetic possibilities onstage" (2005, p.33). 
While SALDAÑA's encouragement for emerging qualitative/arts-based researchers to trust their artistic impulses or dramatic intuition is a significant challenge to the aesthetic of objectivity that prevails, he provides little explication of the source of such impulses or intuition. Is he referring to the emerging qualitative/arts-based researcher's embodiment, imagination, or some combination of the two? Additionally, SALDAÑA does not link audiences directly in relation to his notion of ethnodramatic validity. Yet he does discuss how researchers have "an obligation to our participants and audiences to balance creativity with credibility and trustworthiness" (2011, p.207, emphasis added), and as such, it is implied that audience members are a part of what makes a particular ethnodramatic project ethnodramatically valid. 
Further elaboration on how the qualitative/arts-based researcher imagines the reception of future audience members, and how such imagination informs the research-informed performance project is critical to provide further depth to ethnodramatic validity. Considering the reception of future audience members as part of the project's development assumes that audience members play an active role as interpreter in the moment of the performance itself (BENNETT, 1990; BOGART, 2001; CONROY, 2010; JACKSON, 2007; MAMET, 2010). This perspective would further challenge the aesthetic of objectivity by implicating a multi-interpretive process. 
By elaborating key aspects of the process of developing "Fit for Dialysis," we aim to expand on SALDAÑA's ethnodramatic validity by exploring how artist-researchers, coming from the tradition of artistic practice, engage their bodies as interpretive sites, engage in imaginative processes to relate to research findings, and envision reception of future audience members as part of aesthetic interpretation. 
2. "Fit for Dialysis"
Given the number of potential benefits that hemodialysis patients may achieve from exercise (JOHANSEN, 2007) and the low exercise participation rates in this patient population, "Fit for Dialysis" is intended to bridge research on exercise with dialysis care. The 15-minute film is based on focus group research with patients, family caregivers, and dialysis staff, and on naturalistic observations of dialysis staff and patients during hemodialysis sessions to explore the factors that enable and constrain patient exercise and counseling and support by staff. Key themes identified in this research included 1. patient desire for exercise, 2. exercise barriers such as nurses' preferences for patient sedentariness during dialysis sessions, and 3. caregiver protectiveness. These themes provide the research base for the film, which reinforces the importance of exercise counseling and support by nephrology practitioners and family caregivers, and exercise participation by dialysis patients. 
"Fit for Dialysis" was tailored to the exigencies of out-patient hemodialysis settings in terms of providing a roadmap to overcome the disciplinary silos and paternalism towards patients which inhibit exercise during dialysis, and addressing some of the life circumstances that may influence patients' self-management of exercise behaviors at home and in the community. The film was also designed to facilitate critical reflection among health-care practitioners about the manner in which organizational contextual/cultural factors influence and shape direct care practices. Such reflection is intended to assist health practitioners to see how their own practice styles signal underlying assumptions regarding the importance of exercise for wellness vis-à-vis point of care priorities and decisions, and judgments regarding patient safety. 
The film follows one storyline: the experiences of Marvin, an older hemodialysis patient. At the beginning of the film, a deconditioned and ill Marvin struggles to go down his front stairs to pick up a newspaper while his concerned wife, Claire, intervenes out of fear that he is overexerting himself. Claire is clearly sad and frustrated, longing for her formerly vibrant husband and for a shared retirement filled with travel and adventure. Marvin is clearly frustrated too. However, when in hospital to receive hemodialysis he overhears a fellow patient remark how much better she feels since she began physical therapy exercises during hemodialysis for an acute problem with her knee. Marvin inquires about the possibility of doing exercise during his dialysis sessions, but encounters resistance to this idea by each health-care practitioner he approaches. For instance, the physical therapist explains that she only works with people with acute problems on the unit; the nurse explains that exercise during hemodialysis is beyond her professional knowledge, and that it is best for him to remain immobile during hemodialysis; while the nephrologist agrees that exercise is worth pursuing, he fails to provide a prescription for exercise or further guidance about how to pursue it. Later, two nurses privately share their empathy about Marvin's desire to be more active, but express exasperation about the possibility of integrating exercise into current hemodialysis practice given their workload stresses. At home that night, when searching the Internet together to gather information on exercise and hemodialysis, Claire strongly encourages Marvin to continue pressing the nephrology staff to provide him the prescription, opportunity, and equipment to exercise. Marvin thus persists, and the physiotherapist ultimately collaborates with the nephrologist and nurses to implement exercise for wellness during dialysis for Marvin as well as the other patients. By the end, the individual, social, and family benefits of wellness through exercise are made clear. Marvin is planning a date with his wife and walks down the stairs to pick up the newspaper to check film-playing times. He is surprised by the ease with which he does this, and turns around to smile at his wife who is standing in the doorway delightfully smiling back. 
3. Immersion, Embodiment and Imagination
"To study [as an artist], you enter into a situation with your whole being, you listen and then begin to move around inside it with your imagination. You can study every situation you are in. You can learn to read life while life is happening" (BOGART, 2001, p.2)
The development of "Fit for Dialysis" involved several overlapping stages: GRAY's writing of the script in collaboration with the research team; coordinating the production itself, including hiring a film production company and actors, arranging where and when the film would be shot; filming; and editing. Our focus here will be on GRAY's process as a writer, which involved her immersion in the data, and her embodied and imaginative engagement. 
As writer and director, GRAY intensively immersed herself in the data from the original study (focus group transcripts and field notes) and a published article reporting these data (KONTOS et al., 2007). She reviewed dialysis materials (patient education binder) and consulted with members of the research team to explore substantive issues related to their respective disciplines (nephrology, exercise science, physiotherapy, geriatrics). Additionally, she drew on her personal experience of having a family member undergo dialysis treatment, and on the experience of one of the clinical researchers being a care partner for his brother, and how this experience allowed him to see the health-care system from a different perspective. Hearing about the clinical researcher's experience was an "epiphanal moment" (DENZIN, 2008, p.121) for GRAY, who understood that a similar shift in perspective needed to occur in the film. These personal experiences collectively informed an important dramatic catalyst within "Fit for Dialysis," which we return to later in the article. 
GRAY's approach was to "embody the material" as a way to understand it, in contrast to conventional research processes of academics that focus on cerebral understandings (SMITH, 2000, p.96). Documentary theater playwright, actor, and theater professor Anna Deavere SMITH (2000) discusses how insufficient it is for artists to "cover the material" or "study" issues and ideas as do traditional academics, but instead insists that artists "become the material"' (p.96). SMITH's use of language around the artists' work (e.g., embody, become, uncover) speaks to a unique level of understanding that the artist must undertake to be able to create and perform. With this immersive approach (BOGART, 2007) comes an embodied connection to the material and the work at hand. MERLEAU-PONTY's (1962) philosophical insights about the interrelationship between the body and the world as fundamental to perception are pertinent here. He argues that our bodies are how we come to be in the world; we are conscious of the world through our bodies. Our cumulative embodied experiences never leave us but remain "hidden behind our gaze" (p.83) and, in relation to the embodied, immersive work of research-informed performance, these experiences are drawn upon throughout the creative, aesthetic process. 
As a way to begin to frame this immersive and embodied process, and as a way to develop an artistic, image-based language, which GRAY could draw on in the writing process, GRAY turned to the work of Canadian developmental theater dramaturg and professor, Judith RUDAKOFF (2003). RUDAKOFF recommends the use of "image containers" when embarking on the development of new dramatic works to "create visual and iconographic links between an idea and realizable action" (p.150). In providing artifacts from the "world of the work" (p.150), referring to the cultural and social contexts that surround or are related to the arts research project, image containers can be useful when attempting to gain familiarity with particular concepts, places, people, and their interrelatedness, and can thereby provide important sources of creative action. Artifacts are gathered based on how the artist is personally drawn to a particular image as a representation of this "world of the work." Intellectual interpretation is discouraged; rather personal relationship to the image-based material is fostered. RUDAKOFF references the four elements (water, earth, fire, air) as a way to bring imagery into or structure dynamics within the performance. Each element has particular traits that can be useful in representing ideas, or when placed in particular power relationships with other elements (p.144). 
As an example of how image containers were used in the development of "Fit for Dialysis," GRAY gathered visual images (e.g., clippings from magazines, art work such as paintings, sculpture, or personal sketches), personal writings (e.g., poetry, word associations, and free association journaling), published creative writings of others (including poetry and fiction) and sought out metaphors that related to or reflected the data indirectly. In reflecting on the physiological process of kidney disease, specifically how wastes and fluids build up in the body with kidney failure causing bloating, GRAY imagined metaphors and images of stagnation, still pools of water and swamps. She focused on colors, such as murky greens, browns, and dark blues (associated with the elements of water and earth) and gathered images and colors related to these in her image container: images of swamps dripping with tendrils and overgrown vines, pools of water covered in algae. GRAY also reflected on the effects of exercise for hemodialysis patients: improvements in functional capacity (DePAUL, MORELAND, EAGER & CLASE, 2002), cardiac performance (DELIGIANNIS et al., 1999), blood pressure (MILLER, CRESS, JOHNSON, NICHOLS & SCHNITZLER, 2002), and pulse pressure (PARSONS, TOFFELMIRE & KING-VanVLACK, 2004), as well as health-related quality of life, including a decrease in anxiety and depression (PAINTER, CARLSON, CAREY, PAUL & MYLL, 2000). In contrast to the images of stagnation associated with kidney disease, the effects of exercise conjured images of wind, fresh air, cool breeze, movement, and change (all associated with the element of air). 
Parallel to this work, GRAY also began to reflect on her own experiences of being in a place of stagnation as a way to relate to the experiences of older hemodialysis patients engaging in exercise. She had been through periods of her life when she was inactive and experienced fatigue and sluggishness as a result. She recalled how invigorated she felt once she resumed physical activity, how much easier it was to do basic tasks of daily life like climbing stairs and hauling heavy baskets of laundry. Stagnation was further experienced by her in the context of unhealthy relationships. She considered the kind of reflexivity needed to recognize the importance of moving beyond these stagnant patterns to being in the world in a new way. 
Recognizing that these experiences were in no way the same as a patient undergoing regular dialysis treatment, GRAY's introspection about stagnant ways of being and perceiving, and the importance of changing those ways, was an important imaginative source regarding the experience of a dialysis patient who exercises. As KONTOS and NAGLIE (2007) have argued, embodiment is a fundamental source of imagination. Yet GRAY's imagining of the experience of the dialysis patient in no way implies that such imagining overtakes the alterity of the other. As HAMINGTON so aptly states "the alterity of the other is preserved, but not in a strictly solitary way" (2004, p.55). It was by engaging her imagination that GRAY was able to push the boundaries of her own experience and be "open to others" (PELIAS, 2008, p.187). By engaging her imagination she "play[ed] on what [she] ha[d] perceived ... incarnate[d] it" (GREENE, 2001, p.11) and moved this embodied understanding into artistic form. 
The immersive, embodied, and imaginative work that GRAY undertook, framed through RUDAKOFF's image container, significantly influenced the through-line for "Fit for Dialysis." The through-line is the main idea that drives the action of the drama forward and intersects with each character. Rather than understanding the through-line as an oversimplification of a more complex picture, it can be seen as a way to efficiently map "the intellectual structure behind the action" of the drama (MITCHELL, 2009, p.49). The through-line for "Fit for Dialysis" was moving from a place of stagnation to action. This is captured with Marvin's transformation from being stagnant physically to engaging in exercise and moving more freely. By the end of the film, Marvin feels more energetic and is able to engage in daily activities more easily because of his participation in exercise for wellness. Marvin's costume was also shaped by the image container and reflected the film's through-line of stagnation to action. At the beginning of the film, Marvin was dressed in dark brown and green clothing, with many layers, long sleeves, and heavy textures such as knitted sweaters associated with the elements of earth and (stagnant/swampy) water. As the film progresses, Marvin's costume shifts to reflect his inner journey, and by the end of the film he is wearing light khaki pants and a short-sleeve light yellow golf shirt reflecting the element of air. Marvin's internal transformative journey was powerfully conveyed with this aesthetic choice of costume. 
The health-care practitioners portrayed in the film also reflect the film's through-line of stagnation to action. At the beginning of the film, when Marvin first approaches his health-care team, each individual provider fails to accommodate his request to engage in exercise for wellness, each citing specific systemic barriers that hinder their ability to support him. However, in addition to these systemic barriers, each health-care provider is also stagnant in how they perceive their patients and their abilities as we see in the following scene between two nurses providing care for Marvin:
Hospital—Nurse's Station, Dialysis Unit
Debbie enters the Nurses Station, joining Karen, who is working on the computer. Debbie sighs as she enters the station.
Karen: (looking up from the computer) One of those days, huh?
Debbie: Changeovers. Getting everyone out, everyone in with no one crashing, no drama. Being short staffed, ugh. I know I'm preaching to the converted, thank you for letting me vent.
Karen: You'll repay the favor, right?
Debbie: (chuckles) Oh, yes. And then Marvin, Marvin Steele asked about doing exercise during his treatment.
Debbie: I guess he saw how well Libby Katz is doing. So he asked if he could do something too. On his own.
Karen: Oh. What did you say?
Debbie: I didn't think it would be a good idea. I'd be worried his needle would come loose or he might overexert himself.
Karen: We don't want the guy crashing, right?
Debbie: We just don't have the staff or the expertise to be monitoring stuff like that going on.
Karen: And, if the other patients saw and wanted to do it too? We do not have the staff for that!
Debbie: And what if something did go wrong? I don't have one patient to keep alive, I have four. So exercise, yes, it's great, it's important. But when you have a patient crashing or bleeding or the next patient coming on and screaming "where is my chair, it's my time, I want to get on, I want to get off!" there's just no way.
Karen: Absolutely. I mean, exercise is great, but ...
Debbie: Yeah, I get where he's coming from. He wants to be more active. But, the way things are, there's just no way. 
GRAY's understanding of how the combination of self-reflection and observing a loved one in a difficult time can be a strong catalyst for change informed the catalytic shift that occurs in the film with the dialysis staff finding new ways of supporting patient exercise as a team. In this excerpt from Scene 8, Risha, the physiotherapist, reflects in discussion with Dr. Lee, the chief nephrologist, on her own father-in-law's experience of end-stage kidney disease to explore current systemic barriers that were hindering Marvin's participation in exercise for wellness:
Scene 8 (excerpt)
Risha: My father-in-law is a diabetic with end-stage kidney disease. Watching his experience ...
As a health-care provider, I chose this profession because I wanted to help people. I know our system is flawed. But I work within this system in the best way that I can. But in watching my father-in-law ... In being on the other side, I am reminded of how fragile it is. I can see the cracks more clearly. I'm amazed at how difficult it is to get through the system.
He used to be active and lively before dialysis. The disease, the dialysis, it's all against him, plus the system itself. It's like he's shrunk. He's there, but like a third of his former self.
We need to look at this in a new way. This might be a way to help people.
Dr. Lee: You're right. OK, on a practical level, what do we need?
Risha: We need a regular PT2) to work with patients.
Dr. Lee: OK.
Risha: We need some kind of way of doing things, someone to check in with patients. So we need money.
Dr. Lee: Yes, money will always be a problem. I think we need to just start. Start small. I'll prescribe exercise to a small handful of patients, 4 or 5 to start.
Dr. Lee: You're already on the unit, you can work with them, monitor them as needed.
Risha: The nurses? It's important that they're on board ...
Dr. Lee: I'll talk with Debbie. We need them to encourage the patients.
Risha: I'll tell Nancy, let her know our plans, so she doesn't assign me somewhere else.
Dr. Lee: OK, great. If this works, we can look into options for a larger program. Have a regular coordinator. Maybe integrate this into the pre-dialysis clinic.
Risha: That would be great.
Dr. Lee: Let's just start and see where we get. 
The intention of the research team with "Fit for Dialysis" was to engage audiences to critically reflect on the personal and organizational practices that prevent patient engagement in exercise for wellness. As an artist-researcher, GRAY sought to engage audience members in this kind of critical reflection through what JACKSON (2007, pp.179-197) refers to as "creative gaps." These creative gaps are understood as spaces provided within the research-informed performance that allow audience members to find their own way into the ideas and journey of the performance. If the educational message is too obvious or predictable and the creative gaps are filled, the work becomes too directed and even didactic, and fails to foster critical or emotional engagement or risks rejection of the ideas altogether (JACKSON, 2007). 
Creative gaps, ultimately, take place through the aesthetic work (costume design, dramatic structure, etc.), which leads audience members through the journey of the performance and provides opportunity for them to experience alongside it (THOMPSON, 2011). Witnessing the journey of the characters holds the potential for audience members to see themselves in the characters and the storylines, and to foster awareness and questioning of their own assumptions (MAMET, 2010). 
With the ascendency of knowledge translation, qualitative health researchers are increasingly turning to performance out of dissatisfaction with textualism, which flattens out "the flux of human relationships, the ways meanings are created intersubjectively as well as intertextually, embodied in gestures as well as in words" (CONQUERGOOD, 1991, p.188, quoting JACKSON, 1989). Yet the alliance between performance and research has largely been informed by an aesthetic of objectivity, which assumes a linear trajectory between research findings and performance, and minimizes the relevance of aesthetic interpretation in favor of realism and authentic representations of the research findings. 
We have argued here that to achieve the full potential of performance in the context of health research, qualitative researchers need to embrace the role of aesthetics more fully in this performance-based work. This would grant significance to embodiment and imagination in the immersive creative process. In this sense, the process of creation is not objective or neutral; the arts researcher is an integral part of the creative process. Embracing aesthetic interpretation would further create a pedagogical space encouraging multiple entry points for audience members to reflect critically and emotionally on their own assumptions, and the complexities of the social and cultural world they are drawn into by the performance with all its textures, sounds, gestures, and movements (JACKSON, 2007, see also GRAY, 2009; ROSSITER, 2012; KONTOS & POLAND, 2009). Ultimately, if the aim with research-informed performance is critique and emancipation, a space needs to be provided for audiences to engage in complex ways with the material and to be implicated as co-interpreters. Thus, while research provides the base for the research-informed performance, it is but one influencing factor in project development. We encourage qualitative/arts-based researchers to embrace the role of aesthetics, imagination, and embodiment more fully since these factors are essential to achieving the full interactive, educational, and emancipatory potential of the alliance between performance and research. 
Support was received from an Ontario Rehabilitation Research Advisory Network Seed Grant and a Canadian Institutes of Health Research Strategic Research and Training Program in Health Care, Technology and Place (HCTP), Interdisciplinary Capacity Enhancement Grant (ICH-62329). Pia KONTOS holds a Canadian Institutes of Health Research New Investigator Award (MSH-87726).
1) It is important to clarify that we refer to those engaging in arts-based research as arts researchers since qualitative researchers, engaging with arts methods, and artists, engaging with research practices, are both merging arts and research processes. That said, we will have occasion to make important distinctions between the qualitative/arts-based researcher (the qualitative researcher who is engaging in arts-based research), and the artist-researcher (the artist who is engaging in research practices and/or is collaborating with qualitative researchers). <back>
2) PT – Physical Therapist <back>
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Julia GRAY (corresponding author) is a doctoral candidate at Ontario Institute for Studies in Education, University of Toronto. She is a research-informed playwright, director, choreographer and film-maker, and her research interests lie in performance as research, arts-based research methodologies, arts and health, aging, knowledge translation and arts for social change. She holds a Bachelor of Fine Arts and Master of Arts from York University's Department of Theatre.
Julia Gray, PhD (c)
Toronto Rehabilitation Institute – University Health Network
550 University Ave., Suite 11-175
Toronto, Ontario M5G 2A2
Tel.: +1 416-884-6941
Pia KONTOS is a senior scientist at Toronto Rehabilitation Institute – University Health Network and associate professor in the Dalla Lana School of Public Health, University of Toronto. Her research involves the use of critical qualitative and arts-based methods to transform the culture of care in long-term care and rehabilitation settings thereby making it more humanistic and quality enhancing. Research-based drama and film are drawn upon as novel approaches to educational initiatives to effect personal and social change.
Pia Kontos, PhD
Toronto Rehabilitation Institute – University Health Network
Dalla Lana School of Public Health, University of Toronto
550 University Ave., Suite 11-171
Toronto, Ontario M5G 2A2
Gray, Julia & Kontos, Pia (2015). Immersion, Embodiment, and Imagination: Moving Beyond an Aesthetic of Objectivity in Research-Informed
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