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Candy Campbell
Improv to Improve Healthcare: A System for Creative Problem-Solving
10 9 8 7 6 5 4 3 2 1
To my dear friend and fellow-improviser, Susan Grey, JD, RN.
Here’s the book you TOLD me to write years ago. RIP. You are sorely missed.
Description
Healthcare organizations cry out for a toll to decrease untoward events
and bridge the communication gap between professional clinical teams
and clients. Discover how to guide your team to creatively problem-solve,
build emotional and social intelligence, increase workplace safety and
employee retention, and guarantee client satisfaction with the results-
don’t-lie Improv to Improve Healthcare system.
Keywords
improv; education; communication; emotional intelligence; social intel-
ligence; curiosity quotient; adaptability; spontaneous; improv theater;
patient satisfaction; team building; leadership; miscommunication;
problem-solving; staff building; educational workshop; nurses; nursing;
healthcare; clinician
Contents
Testimonials������������������������������������������������������������������������������������������xi
Previous Works������������������������������������������������������������������������������������� xv
Foreword�������������������������������������������������������������������������������������������� xvii
The Improv Principles�������������������������������������������������������������������������� xix
Preface������������������������������������������������������������������������������������������������ xxi
Preface—2nd Edition����������������������������������������������������������������������� xxvii
Acknowledgments������������������������������������������������������������������������������� xxix
Appendix A����������������������������������������������������������������������������������������129
Appendix B����������������������������������������������������������������������������������������131
Glossary���������������������������������������������������������������������������������������������133
Notes�������������������������������������������������������������������������������������������������135
References�������������������������������������������������������������������������������������������137
About the Author��������������������������������������������������������������������������������139
Index�������������������������������������������������������������������������������������������������141
Testimonials
“In Improv to Improve Healthcare: A System for Creative Problem Solving,
Dr. Candy Campbell blends her nursing, doctoral thesis, and improv theater
education to share great truths served on a platter of fun! Poor communica-
tion affects all aspects of healthcare and patient safety, and leaders are seek-
ing effective, new ways to interact and engage. Anyone who has ever been a
patient or has had a loved one hospitalized will appreciate how this unique
scientifically-proven method can impact change for the good. Every healthcare
leader, patient and family member should read and enjoy this!”—LeAnn
Thieman, Author, Chicken Soup for the Nurse’s Soul Series and Self-
Care for HealthCare
“In this important new book, Candy Campbell travels seamlessly between her
two great areas of expertise, the professional healthcare industry and the art of
improvisation, weaving them together in a compelling narrative that starkly
exposes a dangerous problem in the world of healthcare while simultaneously
providing the solution. Her joyous and lighthearted approach makes it a fast,
enjoyable and accessible read for anybody at all, regardless of their familiarity
with improvisation, and her love and passion for the healthcare profession
transforms her eloquent message into an impassioned call to action. Having
brought applied improvisation to a wide array of industries over the course
of many years, I have rarely seen it out to a more important purpose than the
one described here. As Campbell helps the reader understand, it is literally a
matter of life and death. I am deeply honored to be referenced in this book and
highly recommend it to all.”—Kenn Adams, Artistic Director, Synergy
Theater Author, How to Improvise a Full-Length Play: The Art of
Spontaneous Theater
xii Testimonials
“Candy uses her extensive and unique clinical, nursing education, acting and
improv background to bring real-world communication scenarios to life for
nurses. Perhaps more importantly, she explains, in depth, how communica-
tion is critical to save lives, solve both interpersonal and work-related prob-
lems, resolve conflict, and connect with patients, staff, physicians, and others.
A light and fun read, Improv to Improve Healthcare contains methods and
tools that are easy to learn and quick to implement, which makes it accessible
to everyone from student to administrator.”—Donna Cardillo, MA, RN,
CSP, FAAN, The Inspiration Nurse and Award-Winning Author of
Falling Together: How to Find Balance, Joy, and Meaningful Change
When Your Life Seems to be Falling Apart
“In her newest book, Candy Campbell puts a different spin on healthcare
communications; she introduces the reader to improv! Improv in healthcare—
this is serious business! Yes, this is serious business, and yes, it is worthy of a
brighter side—a side that links fun, joy, and the journey. Candy has done just
that...by putting joy in the journey and taking the reader through a series of
sketches that warm the spirit, tug at the heart, and reinvigorate the caregiver.
This is a must-read.”—Sharon M. Weinstein, MS, RN, CRNI-R, FACW,
FAAN, CSP Award-winning author of B is for Balance, 12 Steps and
Go for It ... Mastering Negotiations
“In just under 100 fast moving pages, Candy Campbell proves to us that the
greatest metaphor for work is improv. Think about it. You don’t get to choose
who you work with or who you serve or what comes at you in the moment. Yet
you are expected to make magic happen anyway. What does that sound like?
Exactly...improv! Candy shows us precisely how the core principles of improv
(like “Risk Being Imperfect” and “Focus on Your Partner”) are exactly the pre-
scription needed to improve healthcare. Believe her.”—Brian Walter, CSP,
CPAE President of Extreme Meetings Inc. Past President, National
Speakers Association
“Finally, a book that applies the brilliance of improv to the nursing profession.
When to comes to communication and leadership development, Candy shows
that Improv is the miracle drug! It improves listening skills, stimulates crea-
tive thinking, fosters teamwork, and develops leadership in adherents. Truth
be told, this book will save lives, as nurses mastering improv skills will solve
real-time problems, work dynamically with each other, doctors, staff, patients,
and be more present...especially in crisis situations. Should you buy and read
this book?
YES, and... when you hire her to train your staff, you’ll experience the
medicinal benefits of Candy!”—Craig Harrison, Founder, Expressions
of Excellence! TM, speaker and author, Stellar Service: Merge NOW
with WOW to Win Customers for Life!
“As a healthcare professional and a business owner, I’m big into facts and logic.
The short version of my takeaway notes from the book, Improve to Improve
Healthcare, is this: Candy makes a compelling argument that improv will
deepen your ability to communicate more effectively. Add to that, this book is
an easy read, really interesting, very entertaining, and seems to fill a need that
is not currently being met. It also is inspiring and makes me want to book into
an improv class with her!”—Randy Keim, MPA, BSN, RN, CSP, EFO
RandyKeirn.com speaker and author, CROSSfire: Taking the Heat
out of Conflict—A conflict resolution guide for Fire Officers
Previous Works
Channeling Florence Nightingale: Integrity, Insight, Innovation
My Mom Is A Nurse
My Grandma Is A Nurse
Improv? Really?
need, what the field of improv has to offer, and most exciting, what
Dr. Campbell lays out as a realistic and cost-effective plan of action.
In the first part of this book, she paints a compelling picture of the
problem and lays the groundwork for integrating improv into solutions.
Acknowledging the elephant in the room, it is a refreshing, albeit alarm-
ing, reality check.
From here, she takes the reader on an adventure to a new and, for
some, foreign realm of improv while making it safe and accessible to non-
actors. As the book continues, Campbell discusses the 12 principles of
improv, explains their relevance to healthcare professionals, and uses com-
pelling real-world examples to bring home key points. This is important!
Not only does she empower you to try out the activities but she also gives
you sound reason for doing them.
Candy and I have been exchanging ideas and visions for using improv
in nursing and healthcare for several years. We know that it can be chal-
lenging to see the links between the “soft” skills and critical outcomes and
even more challenging to take the leap into learning about improv as a
solution. Her doctoral thesis on using improv to improve communication
provided necessary, evidence-based scientific research.
Now, she has written this practical guide that captures the artful
approach and provides a realistic path to integrating improv into the health-
care system. Anyone willing to take a step on it will be empowered to do so.
With sincere appreciation for those of you who utilize this book and
Dr. Campbell’s work in writing it; information like this is what we need to
make healthcare safer for patients, families, and those of us who work in it.
I suppose ... but we didn’t have any shills, and improvisers don’t do
that.
Why? We depend upon ourselves, and each other, and the creative
muse or force that inspires and propels us (more on that later).
Sounds pretty woo–woo, you say?
Keep reading.
A man named Michael was among those who came forward to chat
with us. He listened to the playful banter, then pulled two of us aside and
said, “Look. I’m an engineer with (insert name of famous software company
in Silicon Valley) and I’m just wondering. Could you guys show our engi-
neers how to play nice with each other, get their egos out of the way, and
problem-solve?”
We said yes, and that’s how I began teaching improv in 1995.
An interesting twist of fate was that the others in the troupe couldn’t
make the date, so I managed alone that day.
It was fabulous fun. I incorporated theater exercises with improvisa-
tional art, music, and dance. Students loved it. Businesses loved it because
employees walked away with a vision of how they might effectively prob-
lem-solve. They were suddenly freed to think creatively, which opened the
door to innovation for these business folks. New products, new services,
and a whole new twist on the technology industry have been (and con-
tinue to be) the results!
That experience got me hooked on showing others how to
unblock, to get out of your own way. Or as Julia Cameron, author of
The Artist’s Way1 puts it, “I teach people to let themselves be creative.”
As an artist, I found that to be involved, as a facilitator in this process,
was invigorating. No longer was I the player onstage, the one who basked
in the limelight. Now, I could witness the genesis-like transformation of
students from what I call “Yikes! to Yippee!”
It was fulfilling in a way that I had never dreamed possible. Now,
I was enabling behaviors that would change lives both professionally and
personally. I branched out and began teaching improvisational exercises
to people of all ages and stages, in workshops, leadership retreats, after
school, and evening classes.
Between acting and teaching gigs, I worked full time as a nurse in a
Neonatal Intensive Care Unit (NICU). As a healthcare clinician, I was
preface xxiii
frustrated with the oft times poor communication skills (to put it gently)
used by some of our teammates.
You see, I learned customer service at an early age, working in retail
and in our family restaurant. I credit my dad, who used to say he was
schooled in the college of life, as my first customer service mentor. He’d
say, “It doesn’t matter what a customer says. Your job is to smile and let
me know about any problems. You stay calm. If necessary, I’ll throw the
bum out.”
He also had a great sense of humor.
After college, I spent five years in corporate America honing my com-
munication skills as a part of a flight crew team—Pan Am; gone but not
forgotten! We were firmly schooled in the teamwork principles that avi-
ation has embraced for more than a century: We were there to work as a
team and to serve our customers.
Later, when I began work in healthcare, I was surprised, no, shocked,
to witness the kinds of nonverbal gestures, intonations, and dastardly
comments made both behind the backs and to the faces of teammates.
More than once, I witnessed a physician slam down a chart or throw a
pencil at a nurse to get her attention!
I learned that many colleagues have never worked outside of their
chosen (healthcare) profession; some have clearly made a habit of bullying
others to initiate action.
Owing to the hierarchical framework of healthcare, those who are lower
on the proverbial totem pole mostly tolerate this behavior. Perhaps some
of them confuse assertive with aggressive behaviors. The theory of margin-
alized behavior, that is, the practice of continuing a cycle of abuse to those
perceived as lower in the hierarchy, helps to shed light on why this happens.
This made me angry because it’s just wrong. We are supposedly
all created equal, right? Then why, in the words of George Orwell, do
some folks seem to be more equal than others?2 In the recent era of
Diversity, Equity, and Inclusion discussions, this question has risen to
the fore.
We, frontline healthcare workers and first responders, must ask the next
question: When do we listen to the authoritative voice? The so-called open-
loop/one-sided communication is definitely needed in an emergency, for
teams to focus and accomplish a specific, timely objective of saving a life.
xxiv preface
Second, many business leaders expect that any new leadership or com-
munication program must be branded, licensed, and expensive in order to
be effective. Based on results from TJC, Institute of Medicine (IOM), and
National Institutes of Health (NIH), that assumption is a false equiva-
lency.4 Unfortunately, the research reflects no causal evidence that any of
the extant licensed communication programs have reduced the number
of errors, miscommunications, patient dissatisfaction, or sentinel events
in healthcare.
Alternatively, businesses, from start-ups to some of the largest cor-
porations, have adopted the premise that heightened creativity assists
employees to problem-solve and increase innovation. Look around you;
the results are in your hand. This philosophy has been über effective in
that realm. More and more businesses hire consultants to teach inno-
vation through improvisation training. After all, it is comparatively low
cost, effective, and fun!
Let’s scroll ahead now to the time when I selected the subject of my
doctoral work. I was torn. I arrived with two areas of interest: either the
multifaceted, long-term psychosocial, financial, and other effects on any
family who begets a micropremature baby, or the subject of this book,
miscommunication in healthcare.
By that time, I had already spent five years researching the clini-
cal effects of prematurity and created an award-winning documentary
film on the subject: Micropremature Babies: How Low Can You Go? 5 So,
I turned to improvisational training for my doctoral thesis as relates to
the problem of miscommunication. I realized I would need to whittle it
down from a sliver of life as improv and include Applied Improvisational
Exercises (AIEs) from the realm of theatre.6
Although I completed the doctoral work at Stanford with an interdis-
ciplinary group and our positive results were published, improvisational
training has gained little traction in healthcare.
Nevertheless, a handful of healthcare improv proponents across the
globe still work to convince the industry’s leaders to consider this method.
I can hear Viola Spolin, the first lady of theatrical improv and author of
Improvisation for the Theatre, groaning at the lag time.7
In this book, I have gone back to my original ideas and broadened
the theatrical nature of my doctoral research to include improvisation in
xxvi preface
It is with that background of doom and gloom that I’m pleased to present
this updated version of Improv to Improve Healthcare, complete with a
new publisher and modified title.
With kindness,
Candy Campbell, 2021
Acknowledgments
So many people throughout the years have added to my understanding of
the art of theatrical improvisation and by association, are partially respon-
sible for the creation of this book. My first improv teacher, Sue Walden
(Improv Works), inspired a love of learning and facilitating this method
of communication.
Further studies with so many excellent instructors at Bay Area Theater
Sports and ACT rounded out my love of improv. All of you have added
to my quest to take improv to the bastions of healthcare, where we need
it so! I must thank Dan Janal, for his gentle nudging and patience with
reading and editing the first draft.
Thanks to my fellow nurse and improv colleague, Beth Boynton, for
writing the Foreword. Also, thanks to Richard Keller and Craig Harrison
for attention to detail with final edits as well as many other National
Speakers Association (NSA) friends, most of whom have written several
books. Immense gratitude goes to Emily Filibert for interior design and
Mark Jonell for the cover art.
Kudos and thanks to book agent, Nigel Wyatt, for intro to BEP, plus
BEP editors, Scott Isenberg and Charlene Kronstedt along with the tech-
nicial formatting assistance of the Exeter team for bringing the expanded
2nd edition to life!
Also, thanks to my bevy of National Nurses in Business and NSA
colleagues. These folks have commiserated and encouraged me to keep on
keepin’ on. I am grateful!
Sincere thanks,
Candy Campbell
CHAPTER ONE
Elude
∼
It may seem a strange principle to enunciate as the very first require-
ment in a hospital that it should do the sick no harm. It is quite neces-
sary, nevertheless, to lay down such a principle.
—Florence Nightingale
4 Improv to Improve Healthcare
The RN hurried to prepare the area for the chest tube placement, a
sterile, bedside procedure. She assisted the MD with his gown and pulled
the instrument tray to the left side of the bed.
It looked like the situation was well in hand.
Then, to her surprise, the physician asked the RN to move the instru-
ments to the opposite side of the bed. She complied, and asked, “Do you
need anything else?”
“Nope,” he quipped. “Got it.”
The nurse went back to the central station and looked again at the
X-ray. She thought the lung collapsed on the left side, not the right side.
However, she reminded herself, she was sometimes confused when inter-
preting X-rays. She wished the RT was nearby to confer with him, but he
was charting next to the bedside, in case the physician needed assistance.
So, she decided against it and went back to her charting.
That was the first mistake.
03:34 am: The alarms sounded loudly, the RT jumped up, and the
physician swore. The stronger lung had been punctured with the chest
tube; now both sides were compromised.
That was the second mistake.
It did not go well for the baby.
Consider the crushing news of this miscommunication on the par-
ents. These sorts of sentinel events are like a wound that festers. In the
end, the insult (an interesting moniker for a wound), plus the ripple effect
of the impact of grief upon the family, the employees, the hospital admin-
istration, and everyone concerned, is tragic ... and preventable. This prob-
lem seems to be evergreen in healthcare.
My premise? There is a better way to learn to communicate at work.
This closed-loop communication method, deliberately practiced through
improvisational exercises, leads to safer teams, increased patient safety and
patient satisfaction, and happier employees.
Now, if you are a person who has heard the word improv, but you
equate it with one of the television programs that showcases highly edited
versions of comedy-based scenes, please believe me, it’s not the same thing.
For more than two decades, I have had the pleasure of leading
groups of people of all ages and stages to learn this valuable method of
6 Improv to Improve Healthcare
communicating. Some take the classes for personal growth and also for
the fun of it! Others, who are fortunate to work for business execs that
value teamwork and innovation, jump at the chance to embrace this tool.
Alas, the healthcare industry seems to be a late comer to the party (Note:
I was happy to learn that some medical schools and at least one school
of pharmacology have begun to include improv in their classes. Interest-
ingly, I have found no school of nursing that has encompassed this proven
technique. That sad truth prevails, even with the second edition of this
book!)
So, what do YOU say? Are you ready to dive in?
to so-called never events. These events should never occur because they
include:
Aside from not speaking up, what are other found causes?
The IOM has repeatedly stated that communication error also contin-
ues to be cited as the number one cause of delay in treatment.
In 2002, TJC launched their annual National Patient Safety Goals
(NPSG).8 Included on that original list was the goal “to improve the
effectiveness of Interprofessional Communication (IPC) among caregiv-
ers,” which they defined as including oral, written, and Internet com-
munications. According to a 2016 report by the Agency for Healthcare
Research and Quality (AHRQ), because it is an evergreen problem, the
IPC goal remains on each NPSG list.9
However, when healthcare consumers (that includes all of us, eventu-
ally) look at the scientific community, we may lose hope in the scientific
method, which so far has yielded no positive change. Indeed, the needle
of concern has now moved to the more worrisome side of the measure-
ment scale. Righteously indignant consumers might cry out, “Isn’t there
some way to impact this problem?”
Healthcare is more than merely the sum of its parts. Unlike a simple
device that only functions if everything works together, healthcare has an
untold number of parts moving in complex variations and continues to
function, if only ineffectively. We are more like the human body whose
internal parts adapt to myriad changes than a machine. Healthcare is the
epitome of a CAS.
How can healthcare professionals model best practices and flex to
make positive changes for our patients?
Let us be more like the experienced surfers who scan the waves
before and during engagement. Surfers know that to resist the power
of nature leads to disaster. They rely on experience and ability to spon-
taneously adapt to continual change to find a way to ride the waves.
That is the kind of wisdom we in healthcare need to develop. We need
what Sidney Dekker described in the book Just Culture: Balancing Safety
and Accountability.15 In the end, we all must learn together and flex
accordingly.
Since the inception of the theory, just culture in healthcare has been
embraced. Unfortunately, the movement toward the realization of such
a culture has had limited success. The reason? Simple: trust. Yes, at the
foundation, the just culture principle is based on mutual, assumed trust.
Trust.
Even if all the previous suppositions are true, how can we nurture
trusting relationships in a continually changing workplace? In one work-
day, people come and go so quickly, we barely have time to know their
names, let alone build a trusting relationship. If trust is the foundational
requirement of a just culture, can such a model ever truly exist?
That is the question we shall use to begin our study of what we might
call the improv mind.
Elude 13
Corpus Collosum
Hippocampus
Thalamus
Hypothalamus
Amygdala (2)
14 Improv to Improve Healthcare
persons who are able to learn and create for the fun of it as having certain
characteristics, namely curiosity, persistence, and humility.
In this regard, the practice of experiential learning through improvisa-
tion often resembles something akin to a spiritual exercise. The results are
so absorbing, so intrinsic, and so satisfying for the performer as well as the
audience! The goal is to align with our unseen creative energy to establish
relational ties. Is this not the same energy that sustains our very existence
on this celestial globe? This galaxy? The universe?
For those who question this process, I’d like to ask your indulgence
until you have done the work in person. I find push-back comes generally
from those who consider themselves to be scientists who rely on logical
thought; the so-called noncreative types. I get it. Ironically, once they have
experienced it, these are the very same doubters who declare the method
so soundly.
Why?
There are many theories.
Mine is that, as humans, when forced to socialize into groups, we
artificially categorize ourselves into roles that serve to stultify creativity.
Consider this: When I taught as a substitute in an elementary school,
I was impressed that the kindergarten students volunteered for every task,
great or small, took enthusiastic interest in every learning opportunity,
and were basically fearless. When I taught a junior high class, they rarely
raised their hands, seemed generally bored, and appeared fearful of mak-
ing any wrong move. (Everyone has experienced feelings of insecurity and
fear of the unknown when we were the stranger; some of us recall those
days with dread!)
Since my work as an artist lends to interest in the creative process, my
biggest surprise was when I gave a simple test of creativity to the mid-
dle-school classes. It went like this:
I held up an empty vegetable can. The class had two minutes to name
as many possible uses for the object. They thought of five or six.
When I gave this test to the kindergartners, who were not yet literate,
they shouted out answers and came up with anywhere from 10 to 30 uses!
I wondered if the older students might be intimidated by speaking
up. Therefore, with the next class, I changed the exercise. That time, each
16 Improv to Improve Healthcare
student was given three minutes to individually write a list of as many uses
as possible. Sadly, the results were similar. Rarely did any middle-schooler
find more than six uses.
And why did the young children do so well?
Easy.
They let their imaginations fly. After all, five- and six-year-olds live large
in their imaginations. Aside from the usual (pencil holder, one half of a
phone line, flowerpot, and cup), some of the kindergarten answers included:
The point of this story is that, as we age, our creativity tends to get
squelched.
The great news is that creativity is like a muscle: It gets stronger when
we purposefully exercise it!
Elude 17
• One stood at the head and said the animal was large with a
thick tail.
• Another stood in the middle and said the animal had a head
as large as the side of a building.
• The one standing by the tail said the animal was a wily snake
that lived in a tree.
Now, it’s time to get out your journal or notebook and pen. Please
try these two exercises at home before you introduce the exercise to your
team. These are warm-ups to get your right-brain creative juices flowing.
Consider the following image:
18 Improv to Improve Healthcare
Debrief:
Debrief: