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Improv to Improve Healthcare

Improv to Improve Healthcare


A System for Creative Problem-Solving

Candy Campbell
Improv to Improve Healthcare: A System for Creative Problem-Solving

Copyright © Business Expert Press, LLC, 2022.

Cover & Interior design by Exeter Premedia Services Private Ltd.,


Chennai, India

All rights reserved. No part of this publication may be reproduced,


stored in a retrieval system, or transmitted in any form or by any
means—electronic, mechanical, photocopy, recording, or any other
except for brief quotations, not to exceed 400 words, without the prior
permission of the publisher.

First published in 2018 by


Peripatetic Publishing

ISBN-13: 978-1-63742-092-8 (paperback)


ISBN-13: 978-1-63742-093-5 (e-book)

Business Expert Press Healthcare Management Collection

Collection ISSN: 2333-8601 (print)


Collection ISSN: 2333-861X (electronic)

Second edition: 2021

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

Part One .The Science��������������������������������������������������������������� 1


Chapter One Elude���������������������������������������������������������������������������3

Part Two .The Art of the ‘Tudes���������������������������������������������� 23


Chapter Two Attitude or What’s Love Got to Do With It?�������������25
Chapter Three Blocking Versus Beatitudes (Blessings)�����������������������43
Chapter Four Fortitude or Courage Versus Fear������������������������������55
Chapter Five Gratitude Versus Driving�������������������������������������������67
Chapter Six Fratitude�������������������������������������������������������������������79
Chapter Seven Aptitude and Amplitude��������������������������������������������93
Chapter Eight Certitude Versus Waffling����������������������������������������103
Chapter Nine Verisimilitude Versus Story-Tude�����������������������������113
Chapter Ten Finalitude����������������������������������������������������������������121

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

“How thinking differently can make a big difference is demonstrated through-


out Candy Campbell’s book, Improv to Improve Healthcare. As a nurse
entrepreneur and business owner, I have employed many of the techniques
illustrated in Candy’s book that have proven results. Educational, innovative,
Testimonials
xiii

and entertaining, Candy outlines twelve communication principles that will


increase interprofessional communication and decrease miscommunication.
I am an advocate for improv training for increased effectiveness and enjoy-
ment in multiple healthcare delivery environments.”—Michelle Podlesni,
RN, CEO and Founder, Unconventional Nurse, and President of the
National Nurses in Business Association (NNBA)

“Candy Campbell is a benign and immensely inspirational force of nature.


From her embodiment of Florence Nightingale to her work in medical improv,
she is a trailblazer, truth teller, and innovator extraordinaire.
This book leads the reader on a journey powered by the engines of courage
and creativity. Through her examples, stories, and exercises, Candy successfully
illustrates the power of the “yes, and” attitude and how it can transform team-
work, communication, relationships, and healthcare delivery itself.
Thank you, Candy, for an important addition to the medical improv
canon and the ongoing pursuit of true leadership and teamwork in the 21st
­century!”—Keith Carlson, BSN, RN, NC-BC, Nurse career coach,
podcaster, writer, and motivational speaker, NurseKeith.com

“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!

“Dr. Candy Campbell’s book, Improv to Improve Healthcare, is an impor-


tant and vital contribution to improving healthcare communication. By using
improv techniques such as listening, courage to speak up, mutual respect, and
xiv Testimonials

openness to new experiences, she gives directions for better communication


at the bedside and at home. I have used these techniques with great effect
with my nursing students at the University of San Francisco and in my Birth
­Happens museum projects. Should be required reading for healthcare workers.”
—Elizabeth Yznaga, DNP, RN, CNM, NP Creator of “Birth Happens,
Art + History,” Adjunct Professor, School of Nursing and Health
­Professions, University of San Francisco

“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

Good Things Come In Small Packages: I Was A Preemie

My Mom Is A Nurse

My Grandma Is A Nurse

Micropremature Babies: How Low Can You Go? (film)


Foreword
Dear Healthcare Professional and Potential Improv Champion,
You’ve picked up an intriguing book, Improv to Improve Healthcare.

Improv? Really?

I urge you not to put it down.


Dr. Candy Campbell, DNP, has a unique and highly sought-after
combination of expertise in nursing and improv theater education. An
unusual expertise that makes her the perfect leader to create a bridge
between scientific approaches to solving patient safety and communica-
tion issues and this new, more effective approach that draws from the art
of improvisation.
It is no secret that, despite almost two decades of problem-solving
efforts, our patient safety errors and underlying communication failures
are pervasive and persistent! Many healthcare professionals are diligently
looking for a more effective strategy to improve communication and
related “soft” skills. If you are one of them, you will be happy to find this
engaging resource and put to use right away!
I’ve been teaching and writing about emotional intelligence and com-
munication since the turn of the century, with a growing focus on using
experiential activities from improv. These “soft” skills are tough to teach
and learn. I have seen, firsthand, that lectures, webinars, and PowerPoints
about assertiveness and listening do not work. People check off the box
that they have completed communication training and go back to work
with little, if any, change. Such training often involves information that
everyone already knows, wastes precious time and money, and doesn’t
lead to desired behavior changes.
However, when students have experiences of being heard, sharing
thoughts, and building on other people’s ideas, all while building trust,
well then, then there is core learning. This is the kind of process we
xviii foreword

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.

—Beth Boynton, RN, MS


International speaker, trainer, and author of Medical Improv:
A New Way to Improve Communication www.bethboynton.com
The Improv Principles
Accept all offers.
Risk being imperfect.
Avoid yes/no questions.
Be helpful.
Silence the Inner Editor.
Be adventurous.
Be thankful; you have what you need.
Actions speak louder than words.
Look and listen to understand, not to respond.
Focus on your partner.
Follow the Story Spine and be changed.
Treat others like you want to be treated.
Preface
It Happened One Night
As I sit down to write this book, with the desire to pass on what I have
learned about interprofessional communication in business and health-
care, I realize how my desire to blend art and science has come full circle.
“It was a stark and dormy night ...”
In my life offstage, I would have laughed and corrected that tongue-
twisted gibberish. It was raining that night, after all.
However, that night, those words tumbled out of my mouth onstage
as I performed with the improv/stand-up comedy troupe I cofounded,
The Barely Insane Players. I don’t recall a lot about that night, except one
incident that shocked the audience as well as the players. It went like this:
we kept a tray with mugs of water backstage for the company members.
It sat on a bookshelf offstage left. While three of us were onstage, one of
the players took a drink from his mug, offstage. Because it was so dark
back there, he misplaced it and caused the whole tray to crash to the floor!
As seasoned professional improvisors, we heard the din, looked at
each other in surprise, and one of our very quick-witted troupe added
a line that caused the audience to scream with laughter. (I wish I could
recall the scene and what he said! Alas, like most improv performances,
it wasn’t filmed.)
The incident stands out in my memory, because on that stark and
dormy night, a door of opportunity opened that I could never predict.
After the show, we heard the usual comments:
“Are you sure you didn’t plan the scenes? Especially that scene with
the big CRASH?”
As usual, we reassured audience members we could not/would not
plan any of our scenes in advance. After all, we took the suggestions for
the scenes from the audience. Wasn’t that proof enough?
“You coulda had some plants.”
xxii preface

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

However, we all know that most of the time, thankfully, healthcare


teams do not exist in emergency situations. That leads us to the conclu-
sion that use of a closed-loop, circular, or two-way communication model
is the more effective way to function.
In fact, The Joint Commission (TJC) shows that with the root cause
analysis (RCA) study of any healthcare sector so-called unplanned event
(you know that can’t be good—we’re not talking surprise party here),
there is a strong correlation between teams who do not use the inclusive,
two-way communication model and a series of unfortunate events. The
result might include a simple delay of treatment that spirals into other
iatrogenic emergencies!
It was my contention that if we could teach teams improvisational
exercises, we could open people’s minds to thinking differently about
two-way communication in the hierarchical model and improve results.
IF we could give teams the tools to quickly process how to flip to two-
way communication when needed (I’d say, 99% of the time!), we could
decrease the mistakes, the sentinel events, and the deaths. I had seen the
process work with teams in the business milieu; I knew it could work
in healthcare! Not only that, but the process also works to bond people
together and change the workplace culture for the better. All this, because
the administration has created a safe space to share ideas and allowed
teams to hone their skills of relationship building.
Alas, in terms of adaptation, to paraphrase Robert Frost, we still have
“miles to go before we sleep.3”
Why? Many reasons.
First, the word improvisation or improv has been redefined in the
workplace because of the production of one or two television programs
that tout it as clever comedy and nothing else, as though creating comedy
is easy. As actors often say, tragedy is easy. Comedy is hard! I know actors
who have performed on those improv shows, and the understandable
truth is that a lot of the not-so-funny or poignant scenes are cut. This is
a distinction from a theatrical improv performance that you might see
on a live stage with no exacting TV execs or demanding sponsors. The
result is that administrators are slow to adapt a program that is nothing
but fun. Hence, the reason the so-called humor in healthcare movement
has waned.
preface xxv

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

several artistic expressions. The purpose is to show you that it is possible


to create an improv mindset or an improv culture at any point in your
professional or personal life. The principles are applicable to any team or
business model when people depend on others for information, whether
in person or virtually.
If our leadership were to employ this system of advanced commu-
nication training, I’m confident that together, we can help to solve the
problem of miscommunication in healthcare.
I hope that if you, dear reader, are in a leadership position, you will
embrace this not-so-new methodology for your teams. I also hope some of
you are, or will be, healthcare leaders who decide to become early adapters.

Now, break a leg, and go change the world!


Candy Campbell, 2018
Preface—2nd Edition
Dear Readers,

The global situation, especially in healthcare, is much different now than


three years ago, when the first edition was penned. Sadly, the strains of the
pandemic have leached our resources and caused massive waves of death
and PTSD for our frontline clinicians and workers.

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.

It is my intention to help spread the positive aspects of learning through


this and other simple, but effective ways of learning. Please understand
that this is but a basic primer for the work that includes hundreds, no
thousands, possibly an infinite number of improvisational exercises. You
may have a go at creating some yourself!

As always, I appreciate the feedback of my Readers. Feel free to contact


me through my publisher, Business Expert Press.

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

WHY the World Needs Improv


Calm Before the Storm

It was a Tuesday at three in the morning in an upscale community hospi-


tal in middle America.
Within the Neonatal Intensive Care Unit, the Registered Nurse (RN)
was assigned to care for a 25-week gestation infant who weighed less than
500 g or approximately one pound, one ounce. Besides the intravenous
solution lines running through his infinitesimal umbilical arteries and
one vein, and in addition to the orogastric tube that ran to his stomach,
the baby was connected to an oscillating ventilator that delivered more
than 300 soft, quick breaths per minute to his still-developing lungs.
The nurse dutifully sat at the bedside, monitoring vital signs and every
move.
Suddenly, an alarm sounded. It was the pulse oximeter connected to
a tiny infrared light wrapped around his hand. It measured the amount
of saturated oxygen delivered to the capillary bed. She looked up at
the telemetry monitor and paused it for two minutes to evaluate the
change.
The baby’s chest was retracting, and his color wasn’t looking good,
so she called the respiratory therapist (RT) to assist. They suctioned the
baby’s mouth and endotracheal tube and found a large amount of cloudy,
white returns.
While the RN changed the baby’s equally tiny, wet diaper, the RT
collected a small amount of blood for an arterial blood gas test from
one of the umbilical lines. Both agreed the child’s breaths still appeared
labored, even after suctioning. The blood gas test, completed in less than
five minutes, confirmed the status change.
The RT called for a STAT chest X-ray and the RN phoned the
in-house pediatrician, who was on-call for the neonatologist.
When the physician arrived, the X-ray was completed, and the films
were displayed at the central station across from the patient area. Results?
Just as they thought: a pneumothorax.
Up to this point, the process worked well; they congratulated them-
selves that only a few minutes had passed.
Elude 5

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?

A Question That Deserves an Answer


You are likely aware of the problems in the U.S. healthcare industry
related to unexpected incidents of patient morbidity and mortality.
These problems are borderless. Whether here in the United States, or any-
where, we all could use some help to stem the tide of mistakes that cause
patient harm.
According to IOM reports between 1999 and 2015, more people die
from mistakes made in hospitals by healthcare personnel each year than
from highway accidents, breast cancer, or HIV/AIDS! Clearly, this is not
new news. Instinctively, we have known what Florence Nightingale told
the world in 1863, that—hospitals shouldn’t make people feel worse or
kill them! Yet, only since the advent of computers, have we been able to
gather and quantify the latest international patient population data.
One would think, since the undeniable results from the IOM were
first announced two decades ago, that by now we would have found solu-
tions to reverse the problem. Alas, that is not the case. Of course, we have
approached it scientifically, because we are scientists after all. We have
evaluated the problem. We have spent, perhaps wasted, over 15 years to
look at it under a microscope and from every angle. We have dissected
the causes and empirically proven that the problem is multifactorial.
And although statistical data vary, the IOM and TJC, both independent
watchdogs over healthcare, have long-since reported that the first step,
identifying the problem, that is, the root cause, is clear. This is because
communication error ranks as the second-most frequent contributor
Elude 7

to so-called never events. These events should never occur because they
include:

• Wrong body part


• Wrong patient
• Wrong procedure
• Unintended retention of a foreign object
• Operative and postoperative complications
• Intraoperative, immediate postoperative, or postprocedure
death

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?”

Attempts to Fix the Problem


In 2008, TJC delivered a Sentinel Event Alert (SEA) publication titled
Behaviors That Undermine a Culture of Safety.10 The report discusses,
“intimidating and disruptive behaviors in healthcare organizations,” and
outlines perceived root causes of these behaviors. The characteristics that
were unearthed in their investigations revealed the results of this prob-
lem of intimidation and/or disruption: Clinical professionals who feel
8 Improv to Improve Healthcare

threatened in any way (physically or psychologically) will usually keep


silent about the incident(s).
Moreover, the investigative results spanned all types of healthcare
organizations, no matter what size, location, or specialty. As a result, TJC
listed 11 suggested action steps for organizations to utilize with the goal
to coax cultural change (so-called Just Culture) regarding such bullying
[sic] behaviors. Despite the report, predictably and regrettably, the prob-
lem of intimidation/disruption and keeping silent in healthcare hierar-
chies persists.
But why?
According to a 2015 Nemours study, communication errors that led
to adverse events included contributing human factors, or “nanocodes.”11
More than 50 percent of the identified errors were classified as pre-
conditions to actions. The two most common preconditions included,
“channeled attention on a single issue” and “inadequate communication.”
In common parlance, we might call that situational oblivion or not speak-
ing up. The antidote, in Applied Experiential Learning terms is, state the
obvious and say, “Yes, and  . . . ”.
Albeit a noble aspiration, TJC’s attempt to gather statistics and cod-
ify proper behavior, even among those with otherwise lofty professional
goals, has been difficult to enforce. Why? TJC is a private entity that
invites healthcare organizations (HCOs) to submit details of sentinel
events voluntarily. Similarly, in the United States, national data collection
to the federal AHRQ is mandated in only 27 states. That leaves 23 states
that have no incentive to report errors.
According to TJC, there are many reasons for the reticence of hospi-
tals and states to collect this sentinel event data, including fear of recrimi-
nation, penalties, payment slow-downs, or a halt of Centers for Medicare
and Medicaid Services (CMS) and independent insurance company
repayments, not to mention lawsuits!
Meanwhile, other worldwide government versions of the AHRQ, in
an attempt to lessen the damage done in healthcare from miscommu-
nication, have been pulling out their proverbial hair. Each government
approach has been predictably scientific and academic. Several programs
have been trotted out almost as frequently as the flavor-of-the-month
since 1999. The results? You guessed it. Nada. Zip. Zero.
Elude 9

How could this be?


We have borrowed from other risk-averse industries, such as manu-
facturing and aviation, which have given us Total Quality Improvement
(TQI) and Crew Resource Management (CRM). We’ve borrowed pro-
grams from other disciplines (e.g., assertiveness training and the amal-
gamated TeamSTEPPSTM). Each of these programs includes phrases and/
or sentences to advance communication effectiveness. Other so-called
communication experts from places, such as the Mayo Clinic, tout pos-
itive results by application of controlled breathing and meditation tech-
niques. Each of these processes attempts to increase interprofessional
communication and inner peace. Do they work?

Evaluating the Results


Curious minds want to know: Have any of these branded, licensed, and
expensive programs contributed to lessening patient harm and sentinel
events?
Sadly, despite the programs-du-jour, the reported number of senti-
nel events in hospitals and other care facilities is on the rise. In 2013,
Dr. John James completed a meta-analysis of four recent U.S. studies in
the Journal of Patient Safety. An estimated 210,000 to 440,000 patients
per year suffer some type of preventable adverse events (PAEs) in hospital
at the hands of healthcare personnel “which concluded in their demise
and/or death.”12
Of the five causes identified, the study says miscommunication is
number three, behind omission and commission. These estimates are
much higher than the 2000 IOM report that states approximately 98,000
people die from hospital-induced PAEs per year.13
Academics have argued over the differences and why the number
inflated so quickly. Suffice it to say that between 1983 and now, many
changes have taken place:

1. The advent of computer technology with more sophisticated data


collecting and tracking.
2. Increased total number of patients treated.
3. An aging U.S. population.
10 Improv to Improve Healthcare

4. Increased immigrant population with little or no previous preven-


tative healthcare.

The caveat introduced by James to explain the wide variation in results


included the understanding that uniform hospital PAE reporting across
all states has not been attained.
So, let’s break it down. Who are healthcare professionals who might
be involved in an adverse event? According to the latest statistics,
there are:

• ~ 923,000 MDs currently working in the United States with


over 50 percent in specialties
• 2.9 million RNs employed
• 1.5 million Certified Nursing Assistants (CNAs)
• ~ 698,000 Licensed Vocational Nurses (LVNs)
• ~ 651,000 Medical Social Workers (MSWs)
• ~ 233,000 Physical Therapists (PTs)
• ~ 200,000 Advanced Practice Nurses (APNs)
• ~ 154,000 Speech-Language Pathologists (SLPs)
• ~ 132,000 Respiratory Therapists (RTs)
• ~ 120,000 Physician Assistants (PAs)
• ~ 134,000 Occupational Therapists (OTs)14

All of these clinical professionals may also be involved in con-


versations about specific patient care. As you can imagine, each per-
son added to the communication handoff increases the possibility of
misunderstanding.
Clearly, the programs put in place have had some success in that they
have helped teams rehearse for code blue and other emergency events.
And the warning flag has been raised in our corporate consciousness.
We healthcare workers are now aware that: (a) the problem exists,
(b) it should be addressed, and (c) we are trying to address it. In terms of
outcomes, however, the numbers don’t lie. In the current vernacular, it’s
an epic fail.
Elude 11

Human Factors, Complex Adaptive Systems,


and Just Culture
Given that more than a decade of scientifically addressing the problem
has not halted healthcare adverse events, we need to put on our corporate
thinking caps and attack the problem from a different angle. Theorists
have shown us, in terms of human factors (sleep deprivation, interrup-
tions, distractions, personal problems, stress, etc.), we humans are prone
to imperfection, not to mention the various manmade devices that assist
us. Even our most highly trained practitioners, those who excel in paying
great attention to detail, inevitably make errors.
Face it—we all break down occasionally, be it figuratively or literally.
Intuitively, we all know this, and any sane, rational mind will have
at least some trepidation when admitted into a healthcare organization.
As healthcare clinicians, we want patients to feel secure. We want
to reassure them we will do everything in our power to take good care.
Although, kind of like playing the stock market, we know we cannot
guarantee results. Whether intentional or unintentional, mistakes can
and do happen every day. Some of these are simple, noninvasive, and eas-
ily corrected. We have systems in place for such small errors. Others, not
so much. Therefore, to soothe the disquieted patient mind, the healthcare
culture has created a false impression of infallibility.
As a result, we carry on as if perfection were the norm ... and achiev-
able. Then, when imperfection raises its ugly head, we get very upset that
our false notion of perfection has been shattered and rush to play the
blame game. We behave like Oz, when Toto reveals his ruse. We don’t
want you to pay attention to the person behind the curtain.
We try to deny, and then dispatch soldiers to chase down the guilty
party. We point fingers without dissecting the problem to learn about the
issues that led to it. We fail to complete our detective work to see if the
issues remain after the guilty party has been released from service.
This is where the study of complex adaptive systems (CAS) becomes
useful and is foundational to the bulk of this work: Since we are always in
a state of flux, we need to find methods to work with change and make
the most of it, not fight against it.
12 Improv to Improve Healthcare

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.

Small word; tall order.


I trust you’ll do what you say.
I trust you’ll help when I call.
I trust you’ll behave professionally.
I trust you’ll treat me respectfully and fairly.
I trust we both have the patient’s best interest in mind. And so on.

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

Neuroscience of Acceptance and Positivity


Now that you know the problem, let’s talk about the solution! In terms of
communication, research shows that your attitude changes your altitude.
(Oh, what heights you will hit!)
The scientific explanation, according to neuroscience research,
involves the way we are wired ... literally. If you say, I was a bundle of
nerves, here’s why.
The corpus collosum is an actual bundle of nerve fibers that runs per-
pendicular to the line of the sagittal suture (like a highway), which divides
the right and left hemispheres of the brain. The deer in the headlights phe-
nomena is directly related to this bundle of nerves.
This is because, according to researchers, a frown seen from 10 feet
away—even if it wasn’t really intended to be aimed at you—may create
a release of so-called fight, flight, or freeze hormones (those adrenal corti-
coids) from the endocrine system that cause messages from either side of
the brain to be blocked.16
In turn, a blockage in the corpus collosum halts communication to
the limbic system, which is the name for the glandular matter that com-
prises the emotional control center of the brain.

Limbic System = Emotional Control Center

Corpus Collosum

Hippocampus

Thalamus

Hypothalamus

Amygdala (2)
14 Improv to Improve Healthcare

However, when your brain receives a positive stimulus and sends it


via the corpus collosum down into the hippocampus (a storage space), it
is directed toward the thalamus (the signal box), and the impulse is sent
to the hypothalamus (distribution network). The hypothalamus further
directs impulses to the autonomic nervous system and the pituitary gland.
(Recall that the autonomic nervous system is responsible for changes in
temperature, thirst, and hunger, i.e., all the systems involved in the activ-
ity of sleep and/or emotional stability.)17 Then, voilà! These stimuli allow
memory and creative thinking to take place.
Look at the graphic of the limbic system. Notice the amygdalae, two
important little almond-shaped bits of gray matter on either side of the
cerebral hemispheres. They are directly related to the process and storage
of emotions. The hormones dopamine and relaxin help advance positive
emotions, while adrenalin creates stressors that stifle and agitate.
So, what has neuroscience got to do with improv? As scientists, we
appreciate that we are remarkably made. We cannot deny the somatic
response to emotional stressors and the relationship to communication
problems; the link between stress and communication is an indisputable
physiologic process. Numerous studies of the past two decades support
cognitive research around educational psychology, or how humans learn.
The research cuts through a wide slice of learning, including anthropol-
ogy, linguistics, psychology, and philosophy. It began with Greek notables
such as Socrates, Plato, and Aristotle, who studied how to train up indi-
viduals with good character and high moral values through open dialogue.
The Greek philosophers influenced modern behavioral theorists such
as Jean Piaget and Benjamin Bloom, who gave us a taxonomy of learn-
ing and the relation to creativity, and Mihaly Csikszentmihalyi’s seminal
work on intrinsic creative motivation, what he calls flow.18, 19 In all their
theories, we see the thread of how emotional safety leads to good feel-
ings that are imperative to intellectual curiosity, growth, and innovation,
which ultimately lead to civil society.
Csikszentmihalyi explores achievement and innovation when the
so-called happy hormones percolate. The result enhances our concentra-
tion and allows us to achieve a state where we can work, fully immersed in
a creative task, that is, we’re in the groove or in the zone. He describes these
Elude 15

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:

• Doll’s hot tub


• Cave for a gopher
• Washing machine for a fairy
• Giant’s chess piece
• Box smasher
• Hamster wheel
• Anteater’s food bag
• Scrabble pieces holder
• Portable toilet
• Piece of a very large clock
• Inside part of a car
• Something big dogs wear on their neck

And my personal favorite,

• Glove for a one-armed man with a hook

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

Low-Risk Individual Exercises


Keeping an open mind and using perspective play are important parts of
releasing our creative capabilities. Consider the tale of three blind men
who stood by an elephant and were asked: “What kind of animal is this?”

• 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

Here are the instructions:

1. Focus on the image for 10 seconds.


2. If I tell you it is a picture of a young woman do you see her?
3. If I tell you it is a picture of an old woman do you see her?
4. If you cannot see both images, close your eyes tight and think of
which one you want to see. Then, look again.
5. This is an exercise to help you switch quickly from left to right
brain. Try it several times. (It will get easier.)

Debrief:

Subconscious suggestion is a powerful tool to assist in solving many prob-


lems. Similarly, our unconscious biases may influence our perception of
people, places, concepts, in the present moment and lead us to incorrect
conclusions. Think about how you experienced the exercise and write
answers to these questions:

1. Were you able to see both figures relatively soon?


2. What did you think when you tried and failed to see the other
image?
3. Did you feel frustrated? Were you intrigued? Something else?
4. After you were able to shift from one image to the other, how easy
was it to switch back to the first view?
5. How did this exercise make you feel?
6. What did you take from this exercise?
7. Share some of your aha-moments with the group.

Here’s another right-brain warm-up exercise, again from the arts.


By the time you finish these two exercises, you’ll be able to perceive
the different feel of left brain versus right brain.
Elude 19

Here are the instructions:

1. Take a full sheet of paper and pen.


2. Turn the book upside down and focus on the upside-down image
for 10 seconds.
3. Your task is to focus on the center spot of the image, ONLY, and
when I say, GO, draw the upside-down image as you see it, without
20 Improv to Improve Healthcare

trying to name or categorize any part of it. Concentrate ONLY on


the lines as curved or straight and look at spaces and notice how
they wander on the page and where they connect to each other.
4. Keep your eyes focused on that one spot as you start at the top and
draw the lines, proceeding side to side on your way to the bottom
of the paper.
5. Remember: the goal is NOT great art; the goal is concentration on
the lines!
6. Take a few minutes for this exercise. (Do not give a specific time,
or participants will be thinking about the time. Leave enough time
for most of the group to finish—usually about five minutes; adjust
accordingly.)

Debrief:

• Now, turn over your drawing. What do you think?


• Everyone hold up your drawings for all to see.
• Discuss your thoughts about this process.
• What are your aha-moments/takeaways?
Notes
Index
Letter ‘f   ’ after page number indicates figures.
acceptance, 71, 73, 124 collective communal intelligence, 107
acceptance and positivity, communication, xxi, xxiii, xxv, 10,
neuroscience of, 13–16 13, 14, 32, 71, 84, 96, 115,
active listening, 94, 96, 97, 110 124, 125, 126, 127. See also
Adams, Kenn, 116 listening
adaptability, xiv, 30, 35, 116 acceptance and positivity,
adrenalin, 14 neuroscience of, 13–16
Advanced Practice Nurses (APNs), 10 active listening, 94, 96, 110
Agency for Healthcare Research and closed-loop, circular or two-way,
Quality (AHRQ), 7, 8 xiv, 5, 96, 98
amygdala, 13f, 14 and concept of driving, 71–73
anticipatory reaction, 68 and emotional safety, 14
Applied Improvisational Exercises experiential learning, 15
(AIEs), xxv, 32, 71 inactive listening, 95
Aristotle, 14 “inadequate”, 8
The Artist’s Way, xxii issues with, in healthcare, 6–7
Association of American Medical and listening, 71
Colleges (AAMC), 84 “nanocodes”, 8
attitude, 27, 57, 68, 69, 94 nonverbal, 80–81, 94, 97
attitude of gratitude, 68, 69, 70, 71, open-loop/one-sided, xxiii, 96, 97
73 principles, 122
autonomic nervous system, 14 situational oblivion, 8
therapeutic, 94
The Barely Insane Players, xxi verbal mirroring, 94
Behaviors That Undermine a Culture of communication principles, 122
Safety, 7 complex adaptive systems (CSA), 11,
Bloom, Benjamin, 14, 86 12
Boal, Augusto, 107 concentration paradox, 104
body language. See nonverbal corpus callosum, 13f, 14
communication corticosteroids, 69
crazy card, 73
Cameron, Julia, xxii Crew Resource Management (CRM),
care, 94 9
Carter, Judy, 56 Csikszentmihalyi, Mihaly, 14
Centers for Medicare and Medicaid cultural shift, 124
Services (CMS), 8 culture, 123, 124
Certified Nursing Assistants (CNAs), Cumulative Advantage, 124
10 curiosity, 14, 15, 94, 96
certitude, 104 curiosity quotient, 96, 126
clinician, 11, 68, 114, 125 customer service, xxiii
142 Index

Dekker, Sidney, 12 Status Scene With Partners—


dopamine, 14 Round One, 87–88
driving Story Spine, 118
as a behavior, 71–72 Story, Story, Goof!, 63
concept of, 71 stretching exercises, 36
and driver, 71, 72, 73 Three Things, 60–62
and themself, 72 Truth Telling Game, 39–40
Variation, 97–98
education, 84, 87, 126 vocal exercises, 36–37
educational psychology, 14
educational workshop, xxii, 28, 30 happy hormones, 14, 35
creating safe space and removing healthcare, xxi, xxiii, xiv, 6, 68, 72,
work face, 30–35 84, 104, 114, 124, 125, 126,
physical and mental warm-ups, 127. See also communication;
35–40 improv
emotional intelligence, 28, 57, 96, adverse events increase, reasons for,
126 9–10
emotional safety, 14 and complex adaptive systems,
11–12
fratitude, 80 and emotional safety, 14
Fripp, Patricia, 124 hierarchical framework in, xxiii
Frost, Robert, xiv humor in healthcare movement, xiv
just culture in, 12
Goleman, Daniel, 126 never events, 7
gratitude, 68 organizations, intimidating and
group development stages, 45 disruptive behaviour in, 7–9
group exercises (improv), personnel mistakes and patient
Alliteration Name Game, 38–39 mortality, 6–7
Birthday Gift, 51–52 professionals and adverse events, 10
Freeze Tag—Round One, 58–59 healthcare adverse events, 7, 8, 9
Freeze Tag—Round Two, 59–60 complex adaptive systems, 11–12
Interrupting, 97 and human factors, 11
It’s Tuesday, 109–110 increase in, reasons for, 9–10
Limericks, 118 and just culture, 12
Listening Game, 74–75 professionals in, 10
mental exercise, 37–38 healthcare organizations (HCOs), 8
Nonverbal Behaviors, 87 hippocampus, 13f, 14
Nonverbal Mirroring, 73–74 hypothalamus, 13f, 14
One Voice Expert, 109
One Word at a Time Introductions, imposter syndrome, the, 57
107–108 improv, xxii, 45, 46, 57, 68, 69, 71,
One-Word Sentence, 117–118 73, 80, 85, 86, 96, 104, 105,
Round Two—One Voice, 108 115, 122, 123, 125, 126, 127.
Sound Ball, 50–51 See also improv principles;
Spelling Bee Game, 62 improv theater
Sportscaster Olympics, 98–99 certitude, 104
Status Scene With Partners— crazy card, 73
Round Two, 88–89 and culture, xxvi, 123–124
Index 143

The Improv Mind, 122 Improviser and Theatresports, 109


mindset, xxvi In Search of Excellence, 49
need for, 4–6 inactive listening, 95
and neuroscience in, 14–16 “inadequate communication”, 8
political, 107 individual exercises (improv), 17–20
principles, xix, 2, 44, 56, 68, 80, Inner Editor, 56, 58, 104
94, 104, 114, 122 innovation, xxv, 6, 14
role of imagination and creativity Institute of Medicine (IOM), xxv, 6
in, 115–116 interprofessional communication
safe classroom environment, 85–87 (IPC), 7, 9, 124, 125, 126
and safe environment, 28–29 intraprofessional
and status, 81–83, 85 communication, 124
success of story game in, 115 Intro to Improv, 125
waffling, 104–105, 110
improv culture, xxvi James, Dr. John, 9
The Improv Mind, 12, 122, 127 Johnstone, Keith, 109
improv mindset, xxvi, 57, 68, 122 The Joint Commission (TJC), xiv,
improv principles, xix xxv, 6, 7, 8, 96
accept all offers, 26–27 just culture, 12
action speaks louder than words, Just Culture: Balancing Safety and
80–81 Accountability, 12
be adventurous, 56
be helpful, 44, 45–46, 48 Koppett, Kat, 46
be thankful; you have what you
need, 68–71
focus on your partner, 104 leadership, xxii, xxv, 49, 115, 122,
follow the story spine, 114–115 127
look and listen to understand not Licensed Vocational Nurses (LVNs),
merely to respond, 94–95 10
polar questions, avoidance of, limbic system, 13f, 14
44–45 listening, 71. See also communication
risk being imperfect, 27–28 active listening, 94
silence the Inner Editor, 56–57, inactive listening, 95
58, 59 therapeutic communication, 94
treat others, as you’d like to be verbal mirroring, 94
treated, 122–123
improv theatre, xxii, xiv, xxv, 27, Mayo Clinic, 9
44–45, 46, 47–48, 48–49, Medical Social Workers (MSWs), 10
69–70, 70–71, 72, 94–95, memory muscle, 35
105–106, 116, 117 Micropremature Babies: How Low Can
creating safe space, 30 You Go?, xxv
group agreement and introduction, miscommunication, xxv, xxvi, 5, 6, 8,
31–32 9, 84, 96, 125, 126, 127. See
physical and mental warm-ups, 35 also communication
workshop introduction, 32–35 Moore, Michael, 86
Improvisation for the Theatre, xxv
improvisation, xiv, xxv, 5, 15, 27, 30, National Institutes of Health (NIH),
68, 125 xxv
144 Index

National Patient Safety Goals work face, 30


(NPSG), 7 workshop introduction, 32–35
Nemours study (2015), 8 Schaefer, Mark, 124
never events, 7 Sentinel Event Alert (SEA), 7, 8, 9
Nightingale, Florence, 6, 84 Sinek, Simon, 114
nonverbal communication, 80–81 situational oblivion, 8
nurses, 48, 84, 126 social intelligence, 28, 57, 96, 126
nursing, 6, 84 Socrates, 14
Speech-Language Pathologists (SLPs),
Occupational Therapists (OTs), 10, 10
126 Spolin, Viola, xxv, 85, 115
Orwell, George, xxiii spontaneous, 30, 35, 71, 116
Stand-Up Comedy, the Book, 56
patient satisfaction, xxv, 47 status, and improv, 81–83, 86
Pew Research Center, 122 status of status, 81–83, 86
Physical Therapists (PTs), 10, 126 Story Spine, 116
Physician Assistants (Pas), 10 storytelling, 114
Piaget, Jean, 14 subconscious suggestion, 18
pituitary gland, 14
pity party, 56 Taxonomy of Educational Objectives,
Plato, 14 86
Point of Concentration, 115 team building, 6, 26, 45, 86, 116
polar questions, 44 thalamus, 13f, 14
political improv, 107 theory of marginalized behaviour, the,
preventable adverse events (PAEs), 9 xxiii
problem-solving, xxii, 27, 35, 71, therapeutic communication, 94
115, 116, 124 Total Quality Improvement (TQD), 9
purposeful noticing, 94 Training to Imagine, 46
trust, 12, 84, 85, 86, 95, 115
Recess for Adults, 28 Tuckman, Bruce, 45
Registered Nurse (RN), 4, 10 two-way communication, xiv
relationship building, xiv, 28, 30, 35,
44, 68, 94 unconscious bias, 18
relaxin, 14 United States, 6, 8
Respiratory Therapists (RTs), 10, 126
root cause analysis (RCA), xiv verbal mirroring, 94
verisimilitude, 114
safe space, creation of
group agreement and introduction, waffling, 104–105, 110
31–32 Walden, Sue, 28
Group Agreement, 32–33 Where to Invade Next, 86