The educational value of improvisational actors to teach communication and relational skills: Perspectives of interprofessional learners, faculty, and actors
Introduction
Communication with patients and families in today's health care environment is increasingly complex. Whether focused on disclosure of medical error, prenatal diagnoses made possible by new technologies, or ethical quandaries arising from the ability to sustain life, today's clinicians routinely face difficult conversations as part of day-to-day patient care. Effective communication is therefore increasingly a critical component to the delivery of quality care. It can also build trust, improve clinical outcomes, and decrease litigation [1], [2], [3], [4], [5].
Recognizing the relational complexities inherent to these conversations, medical educators are emphasizing principled communication skills, to build trust and partner with patients [6], [7], [8], [9], [10]. They are also increasingly turning to role-play, simulated or standardized patients, and other such experiential teaching modalities to practice difficult conversations in a safe learning space [11], [12], [13]. While learners are taught strategies and even protocols to approach challenging conversations, the reality is that no two clinical conversations are the same. A successful approach in one setting may be inadequate or even problematic with another patient or family. Relational proficiency in challenging conversations necessitates recognition of, and flexible response to, variable patient and family cues. Educators are stymied not only by finding a way to teach this relational flexibility, but also how to evaluate it. They also face the challenge of successfully bridging lessons from instructional settings to clinical practice [8].
Several approaches have been taken to the simulated patient's role in education and research, often focusing on standardized patients [12], [14], but relatively less is known about the experiences of simulated patients in such educational interventions, [15] or the perceived value of improvisational actors to teach communication and relational skills from the integrated perspectives of learners, faculty, and actors themselves. Although standardized patients and actors have been used interchangeably, in this report we distinguish between the two. While standardized patients are traditionally guided to provide a “standard” performance – the same each time – actors are highly improvisational. By definition, no two conversations are the same.
We developed the Program to Enhance Relational Communication Skills (PERCS) in response to the growing need for interprofessional educational programs centered on challenging health care conversations [13], [16], [17], [18], [19]. A central component of the PERCS approach is the use of live enactments with professional actors to portray patients and family members using improvisational techniques.
The purpose of this study was to examine the value of actors in this educational paradigm from the perspectives of interprofessional learners, teaching faculty and the actors themselves.
Section snippets
Participants and educational workshops
Since 2002, the Program to Enhance Relational and Communication Skills (PERCS) has trained more than 3000 local, national and international learners. The workshops, which include enactments with professional actors portraying the role of patients and family members, range from 4 to 8 h, and involve approximately 15–25 interprofessional learners gathered around common ethical communicative challenges. Learners include doctors, nurses, medical interpreters, and psychosocial professionals (e.g.,
Participants
Of all workshop learners, 191/192 (99.5%) completed questionnaires and 188/191 (98.4%) submitted both pre- and post-surveys. The average participant age was 37.6 ± 10.7 with a median of 7 years of clinical experience (range 1–42). Of the learners, 60% were nurses, 22% were physicians, 11% were psychosocial professionals and 7% were medical interpreters (Table 1). We received survey responses from 31/33 (94%) PERCS faculty members, and 10/10 (100%) of actors.
Learners
Most learners had optimistic
Discussion
Our study findings suggest that improvisational actors can have an important role in communication and relational skills training. For both learners and faculty, the value attributed to actors was nearly universal (97–100%), and independent of direct participation versus observation in the enactment – a finding that has potential implications regarding scalability of training efforts. Similarly, the perceived value of actors was also independent of professional backgrounds – including doctors,
Disclosures
None for all authors.
Previous presentations
Portions of this paper were presented in part at the International Pediatric Simulation Symposia and Workshops, New York, NY. April 2013, and the International Conference on Communication in Healthcare, Sept 2013, Montreal, Canada.
Acknowledgments
The authors thank David M. Browning MSW, BCD, Robert D. Truog MD, Elizabeth A. Rider MSW, MD, Allyson McCrary, BA, Diane M. Gentile, BS, and all the PERCS participants and faculty for their contributions to this work. SKB thanks the Arnold P. Gold Foundation for a career development award through a Gold Professorship.
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