In addition to learning clinical skills, family nurse practitioner (FNP) students must develop communication skills for the advanced practice role. Effective communication is crucial because poor communication can result in medical errors, poor health outcomes, decreased patient satisfaction, and unhealthy work environments (Institute for Healthcare Communication, 2011). As health care providers, nurse practitioners use communication and listening skills to obtain medical histories, develop rapport, establish patient-centered plans of care, and work in diverse interprofessional health care teams. At times, they will have difficult conversations, such as giving bad news and responding to conflict and anger. This article describes an innovative improvisation workshop presented to FNP students to improve their communication skills.
Teaching improvisation (improv) theater skills is one strategy that has been used to improve communication for health care professionals. Improvisation is a form of theater that builds on spontaneous, unscripted dialogue (Watson, 2011). A guiding principle of improv is to “make your partner look good,” and this is accomplished through building conversations that focus on affirmation, listening intently, and being present in the moment (Boynton, 2017; Fu, 2019; Watson, 2011). Using the phrase “yes, and” is the foundation of improv because it facilitates dialogues of cooperation and keeps a conversation moving forward (Boynton, 2017, Fu, 2019; Kaplan-Liss et al., 2018: Shochet et al., 2013). Improv exercises strengthen listening and observation skills, as well as the ability to think quickly. Individuals learn to focus on others, not themselves, resulting in increased trust and team building (Boynton, 2017; Watson, 2011, Watson & Fu, 2016).
The use of improv in medical education is growing. When improv exercises are adapted for medical provider education, it is called medical improv (Watson & Fu, 2016). Some medical schools have added improv classes as electives, with favorable student reviews (Kaplan-Liss et al., 2018; Watson & Fu, 2016). Medical students who participated in a 50-minute lecture and two exercises thought the experience increased their self-awareness, and they expressed interest in more experiential learning (Del Vecchio et al., 2017). Three months after participating in an improv workshop, neonatologists and fellows noted that their communication skills had improved (Sawyer et al., 2017).
Other health professions are incorporating improv in their curricula to improve communication. Counseling educational programs have used improv to increase empathy and relational and counseling skills (Bayne & Jangha, 2016; Farley, 2017; Lawrence & Coaston, 2017). Pharmacy faculty used improv to teach patient interviewing and education skills (Boesen et al., 2009). Thompson and Stetzler (2019) investigated the use of improv with graduate dietetic and nutrition students and found increased perceptions of collaboration skills, team building, thinking on the spot, permission to make mistakes, confidence speaking in groups, and responding to difficult situations.
Drama and theater have been used in nursing education to improve communication skills and empathy. Watkins and Addison (1990) used interactive theater workshops that incorporated drama, improv, and self-reflection to explore students' emotions and attitudes about aging. To improve mental health nursing students' communication skills, Dickinson et al. (2016) had students watch a dramatic monologue, engage in group discussions on ways to improve communication skills, and then practice those skills with the actor. Forum theater, which includes audience participation with an actor, has been used to help students explore interpersonal relationships, communication skills, power, and oppression (Love, 2012; McClimens & Scott, 2007; Middlewick et al, 2012). Whereas these examples describe the use of theater in the context of clinically focused scenarios, improv training for health professions uses exercises that do not center around health care topics. This approach gives students the freedom to be creative and take risks to learn new communication skills without worrying about patient interactions (Shochet et al., 2013; Watson & Fu, 2016).
Literature specific to the use of improv theater in nursing or nursing education is scarce. However, it has been advocated for use in leadership development (Trepanier & Nordgrom, 2017), for use in case management (Treiger, 2019), and to improve communication and trust within interprofessional teams (Campbell, 2014; Kaplan-Liss et al., 2018). Despite the limited literature on using improv theater in nursing, we think teaching improv skills is a novel educational strategy in advanced practice education that will prepare students with the skills needed for routine and unexpected conversations.
FNP students participated in an improv workshop designed to improve communication skills through experiential learning. The workshop was taught by instructors from a local professional theater group. In addition to teaching classes for the community, this organization provides corporate improv workshops to local, regional, and national businesses and organizations to promote team building. The instructors have many years of theater training. One instructor was a trainer for standardized patients at the local medical school and had experience in teaching communication skills needed for health care professionals.
Two cohorts of FNP students (N = 58) participated in a 2-hour workshop in their first semester of clinical rotations. Most of the students were female, with a mean of 8 years of health care experience. Most had no previous knowledge of improv and had never attended a communication training workshop. After the workshop, students completed a questionnaire to assess their perceptions of the workshop. The evaluation was approved by Old Dominion University's Institutional Review Board.
At the workshop, students progressed through four improv exercises: zoom, name seven things, one-word story, and “yes, and.” Doing the exercises in this order allowed students to become more comfortable as the workshop moved from large-group to small-group exercises. The exercises did not center around health care topics. However, when debriefing after each exercise, the instructors shared their perspectives on the relevance of each exercise to health care communication. The instructors demonstrated each exercise, and all students participated in each exercise. The intention of using improv to improve communication is not comedy, but the spontaneous nature of the exercises often leads to humorous outcomes (Watson, 2011).
For this warm-up exercise, students stand in a circle. Someone starts by saying “zoom” and pretends to pass the “zoom” to the person on their right or left. Going in the same direction, the next person passes the “zoom.” After doing this for a few seconds, another command is added: “erk.” When an individual receives the “zoom,” they can then either continue the “zoom” or say “erk” to reverse the direction of the exercise. The last command is “oil slick.” When an individual points toward the ceiling making a circular motion and says “oil slick,” the “zoom” skips the next person. As the exercise continues for 2 to 3 minutes, each person says either “zoom,” “erk,” or “oil slick.” This exercise teaches listening skills and keeps each participant present in the moment. Listening skills convey respect and are important for patient interviews and in conversations with others.
Name Seven Things
This exercise strengthens the ability to think on one's feet and to speak with confidence. The students stand in a circle, and one student is given a topic, such as celestial navigation. The student must quickly state seven things about that topic, and the group claps after each response and counts aloud the number of responses, such as clap “one,” clap “two,” and so on. The subject matter is often completely unfamiliar to the participant, any response is acceptable, the more outrageous the better. Then that student points to another student and gives them a topic for naming seven things, and this continues until each student has participated. This exercise builds confidence in speaking, which can be difficult when individuals are uncomfortable in a conversation.
In this exercise, students create a story one word at a time. Five to seven students stand in a line at the front of the class. The audience provides a place and an activity as a theme for the story, and the instructor gives a fictitious title to the story using the place and activity. Starting with the student at the beginning of the line, each student says one word to build the story; often, it can be started with “once upon a time” to get the exercise rolling. Each person continues with one additional word until they reach a point where the group feels they are finished; then the group looks at each other and takes a bow. This exercise generally takes just 1 to 2 minutes. The exercise improves listening and not anticipating the direction of the story or dwelling on what is coming next in the tale. These skills are important when interviewing patients to prevent jumping ahead to a diagnosis or plan without hearing the patient's full story.
The phrase “yes, and” is the foundation for improv. For this exercise, two students sit in chairs in front of the class. They use the words “yes, and” to build a dialogue. One student makes a statement such as “I am going to the zoo today,” and the other student responds by saying, for example, “yes, and it is a beautiful day to go to the zoo. There are many animals there.” Students should respond with more than one sentence, and they are discouraged from asking questions. Adding “because” can keep the conversation moving forward. Using “yes, and” validates the individual and builds conversation as opposed to “yes, but” which can feel oppositional and takes the conversation into a negative realm. If students say “no” at any point, it can shut down the conversation. During the debrief, instructors can point out that this makes the conversation much harder to move forward. Learning to use “yes, and” allows students to respond in a positive, affirming manner when faced with unexpected, challenging, or uncomfortable conversations that often occur in health care (Boynton, 2017; Sawyer et al., 2017; Shochet et al., 2013).
After the workshop, students were asked if they felt this kind of training was beneficial for improving communication with patients, and 41% answered it was somewhat beneficial and 59% answered it was very beneficial. When asked if they would recommend this training to other health care providers, 37% reported they were somewhat likely to recommend and 63% mentioned they would be very likely to recommend it.
Additionally, the students were asked to comment on what they felt they took away from the workshop. Several comments reflected the application to the clinical setting, such as:
- I felt as though this was very helpful in getting one to move beyond their comfort zone. I can see the correlation with improv and difficult conversations.
- This workshop was a lot of fun and I can see the value of the improv principles in the health care setting.
- This was amazing! The energy was positive and not all encounters are going to go as planned. Using these techniques will help with these times.
Some students commented on the enhancement this training provided for general communication:
- It illustrated how the words “yes and” has more of a positive connotation versus “yes but.”
- I can see how we can apply this to our interactions and communication.
- I would recommend this workshop to anyone in a profession in which communication is needed.
- It showed me how I need to get out of my head and listen! Thank you!
Although most students enjoyed the workshop, some students might be uncomfortable with public speaking or this type of learning. Faculty should acknowledge these concerns and can share that studies show that improv training helped students feel more confident with their communication (Thompson & Stetzler, 2019; Watson, 2011). Faculty may also be concerned that some students might not see the value of improv exercises. However, Shochet et al. (2013) found that most medical students thought the improv exercises were relevant for clinical practice. Nevertheless, it is imperative that faculty debrief after each exercise to explain the relevance of the skills to clinical practice (Fu, 2019; Watson, 2011).
Using improv exercises was a novel approach to teach FNP students communication skills, and it was well received by the students. Amid serious learning, the students appreciated a workshop that was fun and included laughter. The exercises helped them to focus on listening skills, being present in the moment, and responding in a positive manner.
To gain knowledge and skills to incorporate improv in the FNP curriculum, we attended a Medical Improv Train the Trainer Workshop hosted by the Center for Bioethics & Medical Humanities of Northwestern University Feinberg School of Medicine ( http://www.medicalimprov.org). Additionally, we attended several improv classes at a local theater.
These experiences facilitated development of improv workshops for each clinical course. By threading improv throughout the curriculum, we can add more complex exercises as students progress in the program. Future plans include investigating whether students use the skills they learned and if this results in changes in communication. The FNP students participate in standardized patient sessions each semester, and communication skills such as empathy are assessed. Evaluating those scores will be used to measure changes in communication.
All nurses need effective communication. Improv exercises, such as the four described in this article, can be used in all levels of nursing education. Resources for faculty interested in adding improv exercises in their classes include university theater departments, community theater groups, online sources, and improv trainer classes.
Through experiential learning, improv exercises provided innovative tools to enhance communication skills for FNP students. Nursing education can add this unique, safe, and fun way to learn communication skills to build trust, support, and acceptance with patients, colleagues, friends, and family.
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