Evaluation of the impact on audiences of Inside Out of Mind, research-based theatre for dementia carers

Abstract Background: A play about dementia care was taken on tour, funded by the Big Lottery through Arts Council England, to six cities. This paper explores its impact, mainly on professional carers. Methods: Mixed methods were applied; semi-structured self-completion questionnaires and subsequent telephone interviews to a stratified sample of respondents. Framework analysis was used, paying particular attention to critical comments. Results: Post-show questionnaires were submitted by 1035 (19%) and 64 people were later interviewed. Audience members expressed heightened awareness of the needs of people with dementia, with greater appreciation of the care process itself and of the challenges faced by professional dementia carers in hospitals and other long-term settings. Conclusions: This production of Inside Out of Mind afforded an effective medium for knowledge transfer. It engaged audiences with key issues – including dignity, identity and loss – and enabled them to reflect on these issues, while encouraging appropriate practical responses.


Introduction
Research-based theatre is a medium which has been positively evaluated in relation to knowledge transfer and workforce education (Rossiter et al., 2008). Audiences have typically been university students on their way to a professional qualification or medical personnel already registered with a professional body (Fix et al., 2012;Wasylko & Stickley, 2003). Lay publics with an interest in a particular topic have sometimes been co-creators as well as audiences for such productions (Lightfoot, Taboada, Taggart, Tran, & Burtaine, 2015;Quinlan & Duggleby, 2009). De la Croix et al. reported that medical students engaged in arts-related activities felt that this helped them to form a professional identity, to reflect, thus improving self-awareness, to empathise more with patients and to communicate better (de la Croix, Rose, Wildig, & Willson, 2011).
The workforce paid to look after individuals with dementia is large and growing, in proportion to the prevalence of dementia. The job of caring has minimal entry qualifications, carers occupy a low status in occupational terms, and employers in health and social care have shrinking budgets for training and workforce development. Compared to doctors and nurses, this workforce has received relatively little attention in relation to the use of applied theatre. An exception is the work of Pia Kontos and colleagues in Canada (Kontos, Mitchell, Mistry, & Ballon, 2010) who have included health care aides, nursing home staff and informal carers in their evaluations of the impact of drama as an educational tool. In an earlier paper, we argued that ethno-drama could be accessible to this non-traditional audience. That analysis concerned over 1000 paid care workers. We found that, even when the theatrical language used was complex and unfamiliar, audience members could evidently relate to the emotional content, which gave them access to the work as a whole. We therefore had reason to expect an impact on audience members working in the field, because it has been argued that this kind of approach can "shift" the perspective of health care professionals (Jonas-Simpson et al., 2012) and reinforce recognition of the personhood of people with dementia (Kontos & Naglie, 2007). As for lay members of the audience who were unfamiliar with the environment portrayed, we had little prior knowledge, although anecdotal responses to the first production led us to expect that they would not be indifferent.

Aim and objectives
The aim of the analysis presented here was to explore how far the experience of attending a play about dementia care in hospital may have a discernible influence on the attitudes or behaviour of the audience members. The purpose of the play was to recognise and re-present the work of people who care for other people with advanced dementia in hospital and care homes. The project group which instigated the tour were motivated by a desire to enable as many people as possible to see Inside Out of Mind, but we particularly wanted to engage those people whose working lives the play portrays: basic-grade health and social care support workers caring for older people with advanced dementia. 1 We wanted to reach this workforce to engender self-affirmation and self-esteem. We also wanted to reach their colleagues in the National Health Service (NHS) and in social care; including nurses, doctors and allied professionals who frequently encounter patients with dementia, managers of residential homes and hospitals, and commissioners of services for people with dementia.
The play was designed to stimulate consideration on all sides of how far society relies on paid carers to look after people with dementia, and the demanding nature of the work they are required to undertake. However, a sceptic might contend that the audience members were merely seeking entertainment or an escape from the daily routine, and so went home oblivious to the messages behind the script, or that its content was forgotten soon after leaving the theatre. We therefore set out to explore its short-term and medium-term impact. To achieve this, we first had to fill the seats for 34 performances in six theatres with as many as possible of our target audience; health and social care support workers. Without getting this audience into the theatre, we could not achieve our intended impact. This intention may be described as to effect change in the thinking and behaviour of audience members concerning people with advanced dementia and -in particular -with regard to those people who are paid to care for them. Marketing efforts therefore focused on Health Education England workforce development leads, as well as managers in NHS trusts and residential homes which employ these people. The shows were also open to the general public.
This paper describes the evaluation of the impact of the show on audiences, made up largely of health and social care employees. First, the nature of the production is described, including its origins in research. A few characters are introduced with brief details of how these roles were realised. We then describe the evaluation methods, profile the respondents, outline the findings and discuss these in the light of our aims.

The work
Inside Out of Mind is a 90-minute play whose script was derived directly from field notes of participant observation in dementia wards. Three postgraduate researchers worked as health care assistants in separate dementia wards for several months in 2009. The enquiry sought to understand this little-researched workforce and it produced the expected academic outputs (Bailey, Scales, Lloyd, Schneider, & Jones, 2015;Lloyd, Schneider, Scales, Bailey, & Jones, 2011;Schneider et al., 2014). More than half a million words of field notes were subsequently entrusted to the writer, Tanya Myers, whose personal experience of dementia and extensive reading around the subject together with her professional skills shaped the script.
In the play, the characters with dementia are all fictional, while the people who care for them are amalgams of the personnel with whom the researchers worked. The role of the ethnographer is also included; in the script, she is actively researching the fictional ward using participant observation. Thus, the work includes the perspective of a newcomer for whom the environment is alien, just as it is for the audience at the outset of the performance. By evoking the past lives of individual patients with advanced dementia, it shows that they are rounded human beings, whose present behaviours have deep roots. Roles include: a French Resistance fighter who remains traumatised by the war; a prima ballerina who is anxious that her husband will punish her for staying out; and a former librarian who captures the heart of an ex-footballer. The librarian's husband, whom she no longer recognises, brings family carer to the stage. On entering the ward for a visit, he witnesses the couple's illicit kiss. The ways in which the husband and the ward staff deal with this infatuation, and other situations commonplace in dementia care (James, 2011), are the substance of the play.
At times, the rich soundscape and digital projection bring to life the patients' recollections of the past and their perceptions of the present. Central to performance is the doubling of the actors who play the people with dementia; they move in and out of the "patient" roles while also portraying the members of staff on the ward. The script presents these personnel as people with lives outside work: a student cramming for exams; a new grandmother who has not slept all night; a newly engaged nurse having second thoughts about marriage. In line with the research reports [ref ], the team dynamic is important; this gives the show scope for a song and dance ensemble. The skilful direction of the production, with lightning costume changes and the theatrical use of objects such as a doll, keys or the tea trolley, illustrates that in optimal circumstances, the ward functions like a finely tuned machine. Nonetheless, the carers are seen as underpaid and underappreciated, juggling competing demands in an imperfect environment. Through use of verbatim dialogue and real-life situations derived from participant observation, the play seeks to establish its authenticity with a professional audience. It opens up the world inside the locked ward and shows that, despite the bewildering effects of dementia on patients, the work of the carers is rich with comedy and camaraderie, love and loss.

Methods
The evaluation design was a mixed-methods case study. It was constrained by limited resources. We collected data at two time points, using complementary methods chosen pragmatically in consideration of their robustness, feasibility and the available resources; a survey and telephone interviews. Questions for each were developed by the author and refined in consultation with the core production team. They had to meet the needs of arts professionals -to understand the audience, particularly non-traditional theatregoers -as well as the needs of the research enquiry.
We first collected data about audience responses using a self-completion questionnaire on the day of the performance. The questionnaire asked for initial responses to the performance, using a Likert scale to measure enjoyment from 1 (not at all) to 5 (a lot). It also gathered demographic information about the audience members: age, gender, ethnicity, disability status, whether they worked in the field or had family members with dementia. It asked where they had seen the show, whether they had attended an audience discussion and whether they had been to the theatre before. In the remaining space available on two sides of A5 card, the questionnaire asked what people thought of the show in general, and -to those who were familiar with people with dementia in their personal or professional lives -what messages they took away from it.
The questionnaire also included an opportunity for respondents to agree to being followed up by telephone one month later. The second phase of data collection entailed a stratified, random sample of 30 of these willing participants for each of the 6 venues. This included all those people who rated their enjoyment as three or below and a one in three sample of the rest. An independent researcher, a doctoral student who had not seen the play, sought to contact these 180 individuals 1 month after they had seen the show. She made at least three attempts on different days and at different times to reach each person. An introductory script and semi-structured questionnaire were used to explore their views. Questions included: whether they were a family or professional carer or a person with dementia; whether they had discussed the play, if so with whom; what stuck with them about the play; whether it was their first theatre experience, and if so what they thought; how seeing the show affected their work their views on dementia carers; and how it affected their views on people with dementia. Respondents were then asked to agree or disagree with the following assertions that the impact of the play on them: "was not great"; "was moderately powerful at the time"; "has given me food for thought"; "has made a positive difference to how I see people with dementia"; "has made a positive difference to how I see dementia carers"; and "has made a lasting impression".

Data analysis
The questionnaire and telephone interviews were analysed by the author using the questions posed as a framework for analysis. Descriptive statistics for the pre-coded responses were generated using a conventional software package (SPSS-17). Responses to semi-structured questions were transcribed, similar ones were grouped together and representative quotations selected to convey each perspective identified. Particular attention was paid to critical or negative comments made, to correct for the bias which arises from most people's preference for giving socially acceptable responses when being interviewed or completing questionnaires. Therefore, in the results below, the critical comments are given greater consideration than their number might warrant.

Audience profile
The final audience total was 5426, of whom 1035 people completed feedback questionnaires when they saw the show (19%). Of these respondents, 19% attended the Gulbenkian Theatre, Canterbury, 14% were from Derby Theatre, 16% from Northcott Theatre, Exeter University, 26% from The Curve, Leicester; 18% from Nottingham and 7% from Warwick University Theatre. This broadly reflects the distribution of the total audience by theatre. The age profile of the audience who returned questionnaires indicates that it was dominated by the people of working age, 20-64 (90%). Five per cent considered themselves to have a disability, and 4% had a hearing impairment. At least one performance at each venue had a sign-language interpreter. Thirteen per cent of the audience were not white British, these people were largely Asian or Asian-British (5%), black or Black-British (3%). One-third (34%) of the audience respondents had a relative with dementia and 76% worked at least occasionally with people with dementia.
The audience was dominated by professional carers. Over 1000 tickets were prepurchased by employers or training agencies and allocated to direct-care workers in dementia services.
Although the questionnaire did not differentiate between entry-level support workers and personnel with a qualification in nursing, we know from ticket sales that the audiences were made up of a significant proportion of support workers. In fact, the show was used as a training opportunity for groups of support workers in three of the sites, and in all areas, it was promoted as an opportunity for this workforce to participate in an innovative learning experience.

Initial reactions
The self-completion questionnaire distributed at each performance asked "Overall, how did you enjoy the performance?" and the options were "not at all", "a little", "moderately", "quite a lot" or "a lot". Only 2% responded in the first two categories, 8% said they had enjoyed it "moderately", 31% "quite a lot" and 58% "a lot" (percentages do not add up to 100 due to rounding).
The quotations used below are coded as follows: respondent number; gender (M/F); works in the field of dementia (W) or is responding simply as a participant (P); and where they saw the play.
Two comments presented below reflect the preponderance of satisfied audience members in response to the invitation to say what they thought of the play. Many of those working in the field reported that they had taken home messages about the need for empathy, respect and compassionate care focusing on the individual person. This ethos -often referred to as "person-centred" care is a familiar one, widely promoted as a standard of good practice in dementia care and attributed originally to Kitwood (Kitwood, 1997). For instance: Remember the life dementia patients had before the diagnosis. (0423,F,W,Canterbury) Others picked up on the impact on patients of noise on the wards as something they had hitherto not realised. Some messages taken home by the respondents highlighted needs for improvement or investment in services, and other systemic problems, including lack of recognition for the people doing the job. These comments were sometimes tempered with the respondent's own knowledge of the field, for example the following comment offers a manager's perspective: [A]wareness matters, and education of public is vital for ensuring the next generation of carers, nurses and other health care professionals provide better and more person centred care. Let's not forget that the funding and the staff ratio to the number of clients is also crucial. (0359, F, W, Canterbury) Negative comments were relatively scarce, except that several people alluded to the confusion generated by the writer/director in the surreal opening scene, designed to portray dementia from the inside. The following respondents rated their enjoyment as "a little" or "moderate". Appreciate the work and research that has gone into the production -the "real" voice really grounds the play. However as a lay audience member I found the narrative and staging confusing, often incoherent -although this might have been the playwright's intention. (0174,F,P,Nottingham) This was indeed the playwright's intention and one which proved challenging to a number of audience members. There were also some mistaken expectations about the educational aspects of the show: I was expecting a play of two parts i.e. bad practice and good practice of the care of people with dementia. (0420, F, W, Canterbury) Focussed on staff too much, not enough on families' emotions, and patients were a bit overlooked. (0613, F, P Exeter) The initial responses overall were positive and the criticisms came mainly from members of the general public. As stated, only two per cent of the audience indicated in the post-show questionnaire that they did not enjoy the play. Some of these people had inaccurate expectations like those quoted here, a few indicated that they were unable to engage with the theatricality of the work, and a few -all members of the general public -felt that the material was too serious or depressing for a show. Professional carers largely endorsed the production's authenticity and relevance to their situation in the questionnaire survey.

Medium-term effects
Two-thirds of those who completed post-show questionnaires agreed to be followed up (680, 66%) and gave their telephone number or email for this purpose. As noted above, we included all the dissatisfied respondents in the follow-up survey sample and several attempts were made to contact each person. The number of telephone interviews achieved was 64. Ten of these people had rated their enjoyment of the play as three (moderate); none of the more dissatisfied audience members proved contactable by phone in this way within 4-6 weeks of attending the performance.
Of these 64 interviewees, seven were male (11%) and three (5%) stated that they were disabled. Forty-four (69%) were working with people with dementia in some capacity. This included employees in the NHS (15), social or residential care (12) and in the voluntary sector (11). Other respondents were health or social care students, researchers, managers or commissioners of dementia care. Eight were family carers as well as working in the field. These "others" included, for example, a medical student, people working in learning disability, a Dementia Champion and several members of the public who had a particular personal interest in the topic of dementia. None was a person with dementia but 30 were current or former family carers for a person with dementia.
One month after seeing Inside Out of Mind, 60 of the interviewees (94%) agreed with the statement that the play had made a "lasting impression" on them. Fifty-nine (92%) agreed that it had given them "food for thought". The high satisfaction ratings found in the questionnaire were therefore stable over this period. Forty-eight interviewees (75%) said it had made a positive difference to how they see dementia carers, and 45 (70%) said it had made a positive difference to how they see people with dementia. In the following sections, we look first at the lasting impressions of the show, in particular the scenes and characters which had "stuck" in their memories. We then go on to consider the practical responses which the show engendered, and finally to discuss what audience members hoped to see come out of the production.
Even at a distance of one month, a number of people retained distinct impressions of scenes from the play. For instance, several recalled the intentionally disorientating opening scenes: The introduction was very memorable. It made the audience feel lost and really set the scene. In the telephone interviews, as in the questionnaire responses, a minority of people stated that they found the first half "confusing" and said that the second half "made more sense".
The tightly-choreographed portrayal of the dynamics of the ward, noisy and frenetic at times, was mentioned appreciatively by several interviewees, and a number of people from an NHS background particularly referred to its authenticity or the atmosphere of "chaos": It was unique. It was like one of the best comedies like Fawlty Towers or The Office where there's so much going on you need to see it again. (0511, M, W, Warwick) There was also a sense that the show offered a glimpse of an unseen world, familiar to the audience but little-known outside.
It was very intense. Not many people understand what it's like. (0514, F, P, Warwick) She would say that she enjoyed it but husband found it "too frenetic" -she told him that's how it is on a ward. (0750,F,W,Exeter) By contrast, one retired NHS professional thought that the "view of the secure ward seemed quite "cleaned up" -he knows from experience these can be even more stressful". (0540, M, W (retired), Warwick).
A residential care worker said that the play led her to reflect that her charges are "not just people with dementia -they're people with lives. " (0028, F, W, Derby).
The emotional impact of the production on the audience members was apparent from the reflections that people shared with us. Several were struck by the moving situation that arises in the play when the husband witnesses his wife kissing another man, and accepts this with sad and ironic resignation.
He found the play unforgettable. It was disturbing and upsetting but had a strange beauty and a positive message. (0146,M,P,Nottingham) Clearly aspects that impressed some people favourably had the opposite effect on others. The two following audience members differed totally in their views, which are reported here by the interviewer: She found the play to be "amateurish" It did not do a good job of presenting the problem. It gave little examples and only showed things she already knows. She would have liked more insight into what dementia is like. (0407, F, P, Canterbury) She loved how it was done. She is a regular theatregoer and the use of music and lighting added to the experience. The visual experience was very powerful. She found it poignant seeing the relationship between two patients and when the husband saw his wife having feelings for someone else. (0403,F,W,Canterbury) It is noteworthy that the first comment came from a member of the public, who presumably did not have the prior understanding of dementia which the professional audience for the most part brought to the show. On balance, the audience's judgement of the play one month after seeing it reflected the initial impressions; the vast majority praised the work, and it spoke, in particular to the professionals whose day to day working lives it reflected. The general, considered view is expressed in the following quotation from an NHS service manager: It was a very honest representation of what happens in hospital care and breaks down stereotypes. It really brought home the pressure placed on carers. (0202,F,W,Nottingham) Twenty-five people stated that the play made them more aware, more mindful of the individuality of people with dementia, or more sensitive to their needs. Several people (4) stated that the play had made them more empathic towards patient's families. However, such changes are difficult to prove, so we asked about any practical steps taken by audience members. Allowing for the bias which self-report can bring, most people interviewed by phone reported after one month that they had discussed the play with others who had seen it (58, 91%). A majority (53 people, 83%) discussed it with others who had not seen the show. In addition, one person gave information about the play to some friends at the gym because she felt it had "opened her eyes". Another felt that the play had enabled her to speak more easily about dementia to an aunt who is caring for her husband with the disorder. A third had written to the Vice Chancellor of the university to acknowledge its support for the production, and had spoken about the play to local church groups.
Thirty-eight interviewees worked with people with dementia in the NHS, social care or the voluntary sector, and 29 said it had affected the way they worked. Many talked about it with co-workers, including those who had not been able to attend themselves, and to other people with a professional or personal interest in the topic. One manager said that having seen the play, she would take more care in choosing staff for a dementia care centre. A nurse said that whereas before she would focus on the paperwork, now she focuses more on the patient. One person had sought out more dementia training since seeing the play. Another stated that after seeing the play, she had become a Dementia Friends champion: You are always learning with dementia -the wrong word or wrong action can make an impact and you learn to become more aware of these. (0502, F, W, Warwick) Therefore, a number of respondents reported doing things which they would not otherwise have done as a result of seeing the show. These actions indicate increased empathy for people with dementia and their carers, a measure of confidence in discussing the topic and, in a few cases, a clear determination to improve provision for people with dementia.
However, for nine people, seeing the play had "not really" changed the way they work, although one said that she wanted more dementia training as a result.
I'd like to think I am a bit more empathetic after seeing the play and hope I understand a bit more about how a patient who has dementia might feel, but I'm not sure if I've actually changed anything … I feel I identify with the nurses as trying to do their best whilst being tired and stressed. (0397,F,W,Canterbury) It may be that the scope for service improvement seems to be restricted by the unrelenting demands of the job, leaving personnel feeling disempowered to change anything beyond their own feelings. Indeed, some interviewees demonstrated a keen understanding of the difficult job that professional dementia carers do: It was good to see the carers -some people don't understand the challenge [of the job]. It's a very hard role. (0757,F,W,Leicester) This respondent works as a ward clerk so observes the "hard role" daily, but even members of the public appeared to have gained greater awareness of the pressures on staff: He enjoyed the talk at the end -there seemed to be several groups of staff (who care for dementia patients) and it was coming across that they were trying their best and felt under a lot of stress. (0033, M, P, Derby) Some respondents familiar with dementia care had an almost evangelical reaction, advocating for the show to be seen widely: She would like NHS nurses to see the play as part of their training. (0013, F, W, Derby) He would love it if the play could be brought to Birmingham where he is based as he would like to take all 100 employees to see it. He saw the play two days running and would love to see it again. It was very powerful and left a big impression. (0511,M,W,Warwick) A number of people commented on the educational potential of the work, including the following person who worked in surgical wards, rather than a dementia service.
She would like the play to be compulsory for all hospital staff -from cleaners to doctors, as it would help to give them more insight. (0008,F,W,Derby) Many of the people interviewed recommended wider dissemination of the play -to other parts of the country and to a broader audience, as well as to different levels of staff in health and social care. These endorsements confirm its suitability for a wide range of audiences who work with people with dementia.

Discussion
The messages of the play -concerning the individuality of the person with dementia, the need for sensitivity and the tough nature of the caring job -are reflected here in the qualitative comments from the questionnaires and follow-up interviews. This provides evidence that they were assimilated and retained, at least in the medium term. The fact that the telephone interviewer herself had not seen the play makes it less likely that this impact is over-emphasised in the follow-up data.
These results underline the power of drama to engage hearts and minds. A few dissenting responses came from lay audience members, but the theatrical representation of a dementia ward had a powerful impact on professionals who were familiar with such settings from their own work in hospitals and residential homes. The mechanisms in operation in this process are likely to include the pertinence of the subject matter to the life of the audience member, the authenticity of the script, the skill of the performance, and the quality of the production. In addition, seeing a play in the company of colleagues may increase the likelihood that it will be a subsequent topic of discussion in the workplace.
de la Croix et al. (2011) found five themes inherent in the experience of medical students exposed to arts-based educational inputs. One theme was that this fostered their appreciation of the role of the arts in their own career formation. There were also four instrumental effects identified by the medical students. They reflected that the arts helped them to: build their role identity; develop greater empathy towards patients through close observation; improve their own self-presentation and awareness of personal stress; and refine their communication skills. Our evaluation findings are broadly consistent with these four effects. Our professional respondents were appreciative that their work with dementia patients had been recognised, thus reinforcing their role identity. Many said that their empathy had grown towards patients and their relatives. They also reflected on the effects of workplace stress and the dynamics of the caring environment. Finally, there was an acknowledgement from our respondents of the need to take time to listen to patients and families, thus communication may be expected to improve as a result of seeing the play.
In the telephone interviews, we found evidence of an enduring impact of seeing the play. The experience evidently reinforced professional carers' pride in their work and their understanding of their role in the wider narrative of dementia, although testimonies to this effect were not elicited from family carers who formed a minority of the audience. Gjengedal, Lykkeslet, Sorbo, & Saether, (2014) report the use of drama to build resilience in relatives of people with dementia through the sharing of experience as a universal human challenge: This creates a new experience of dignity and an understanding of the importance of what they are in the middle of. One is not alone in the experience of grief and pain. From the recognition of a painful daily life, comfort, consolation, and new insight spring forth. (Gjengedal et al., 2014, p. 609) We infer from our analysis that similar effects may have been generated in the carers who saw the play, both for the professional carers and for some of the family carers.
It is interesting to note what people did not mention in interviews, including some technical glitches that dogged a few performances and difficult parking arrangements on university campuses in the daytime. They were more concerned on the whole that an even greater number of people should get to see the show. Importantly, even the minority who took exception to aspects of the play appear to have reflected on the content enough to engage their critical faculties; they were not indifferent to it. In that regard, it was nonetheless effective.
By comparison with other means of academic dissemination such as peer-reviewed publications and conference presentations, the presentation of ethnographic field notes in the form of a play afforded a powerful medium for sharing results. It gave access to large and diverse audiences, both academic and non-academic. It engaged them with detailed and nuanced findings, giving them time to digest these and reflect on them. It opened up the possibility of discussions, immediately after the performance and in the longer term. These discussions were held with family, friends and colleagues, both those who shared the theatre experience and those who did not see the play. In short, we argue that the play enabled audiences to assimilate research findings effectively. Moreover, on the basis of the diverse practical reactions adopted by the respondents whom we followed up, we consider that Inside out of Mind has had a positive influence on aspirations for service improvement in our target audience of dementia carers.

Limitations
The methods deployed to evaluate audience's reactions to the show were pragmatic and complementary. First, a self-completion questionnaire captured the views of a large number of people, but only on a superficial level. The second, in-depth telephone interviews, gathered detailed information from a small sample of people. We know enough about their representativeness to aid the interpretation of what they told us. The findings are restricted to topics which the production team deemed relevant; little scope was available for respondents to set the interview agenda.
While some people who rated the show (only) moderately enjoyable were contacted, those who were less satisfied did not agree to be followed up, so the respondents were all people who had rated the performance positively. This analysis therefore omits the small proportion who rated it below average. Although the self-exclusion of the most dissatisfied audience members is therefore a limitation, the telephone interviewer was independent of the project team, and the comments gathered in these interviews demonstrate that selfselection did not result in entirely positive feedback.
It is possible that the people who told us that their approach to dementia care had altered as a result of seeing Inside out of Mind are entirely atypical. However, improvements in services seldom come about in a uniform way. They are more likely to stem from individual innovators or leaders who inspire others to follow suit. In that respect, it would be sufficient for Inside Out of Mind to have a lasting effect on a small number of health and social care professionals who are in influential positions for it to effect positive change -for instance in attitudes towards people with dementia or in the working practices in a given setting.

Conclusion
The 5426 people who watched the touring production of Inside Out of Mind, like the 2000 or so who attended the first production, sat for two hours in a darkened theatre, listening, absorbing and reflecting on the messages, engaging emotionally and intellectually with the content and interpreting the scenes. We know from the findings of this evaluation that most of these people went on to discuss it with friends and colleagues. Of those working in the field, a high proportion reported that it improved the dementia care they provide.
While a small minority of viewers judged the play's portrayal of dementia care to be unconvincing, most of the audience found much to which they could relate, and retained vivid memories of the themes and issues portrayed. Attending the show had positive effects on perceptions of people with dementia with respect to their individuality and vulnerability. It also raised the audience's appreciation of the importance of dementia carers and the stresses they undergo.
We therefore conclude that this evidence supports the feasibility and effectiveness of using theatre for research knowledge exchange. We reached large numbers of people who could relate to the exploration of their own working lives on stage, and the show was also seen by interested members of the public. It is not possible to generalise from this case study to other research-based theatre. Nonetheless, this example adds to a growing body of literature on ethno-drama which explores its functions in awareness-raising and in the formation of professional practitioners.