Understanding Partnerships With Patients/Clients in a Team Context Through Verbatim Theater.

Introduction: Patient partnership has come to the forefront in health care practice and education, influencing professional programs and interprofessional education curricula. While students conceptually understand the idea of partnering with the patient, the practice of doing so is more challenging. Innovative ways to teach this health care approach may be effective in enabling students to apply their learning and promote enhanced patient partnerships. This resource provides an arts-based approach for exploring notions of partnerships with patients in a team context with interprofessional collaboration. Method: This 2-hour resource features a verbatim reader's theater script and accompanying discussion questions for a small-group reading and debrief activity. The voice of individuals with lived experience is elevated to enhance student learning and connection to the topic. Quotations were taken from interviews with individuals who had experience with the health care system and from health care providers.
Results: The script and accompanying small-group discussion questions have been used in the interprofessional education curriculum with approximately 1,100 health profession students. Student response has been positive, indicating a new appreciation for thinking about partnering with patients. Discussion: Although the script has been used in the context of interprofessional education, it has the potential to be used as part of uniprofessional teaching and in practice environments, since understanding the nature of partnerships between practitioners and patients transcends all settings.

Educational Objectives

By the end of the session, learners will be able to:

Describe the role of the patient/client and team member in the relationship-centered care model.

Discuss the nature of partnerships between health care professionals and patients/clients.

Describe how communication enhances partnerships between health care professionals and patients/clients.

Explain strategies to enhance partnerships within a team context.

Introduction

The relationship-centered care framework broadens the more traditional perspective of patient-centered care. The four underlying principles of relationship-centered care are respect for the personhood and roles of participants, awareness of the part played by affect in these relationships, consideration of the reciprocal impact, and the moral foundation of relationships.[1] Relationship-centered care also considers the web of connectedness that occurs through four primary relationships: practitioner to patient, practitioner to practitioner, practitioner to self, and practitioner to the broader community. While the educational activity described below fosters development of the practitioner-to-patient relationship, an understanding of all four primary relationships helps to ground and contextualize the activity for learners. The practitioner-to-patient relationship and patient outcomes are enhanced through an understanding of partnership, where a patient's unique experiential knowledge is recognized in the process of shared decision making. For example, effective partnerships contribute to a higher degree of patient control and improved access to services.[2,3]

Health profession educators must identify approaches that encourage learners to value and understand the complexities of relationships between practitioners and patients and to translate these approaches to the practice setting. Consideration of transformative learning theory has a focus on deep learning, where educators foster a shift in meaning, in perspectives, or in the system of shared beliefs that individuals use to makes sense of lived experience.[4,5] Additionally, the context and culture of student learning are important. Social constructivism recognizes that knowledge is created through interactions and discourse amongst learners and with their surrounding environment. Thus, learning is a social process.[6]

Creative arts–based approaches with a social component have the potential to provide a disorienting dilemma seen as foundational to transformative learning. The performance text of theater presents a unique way to examine the meaning of lived experiences represented.[7] Parsons and Boydell recognized the power of the emotional component to engage both affective and cognitive dimensions of learning, which are critical to successful educational approaches.[8] Due to its social nature, theater as a mode of learning is particularly well suited to interprofessional education. Theater activities exploring accounts of illness have been used effectively as a basis for thematic exploration and collaborative discussion with health professionals.[9] Gray and colleagues studied the impact of theater on health professionals and concluded that there was potential for long-term learning.[10]

Verbatim theater is a form of documentary theater that is based on interviews, focus-group transcripts, and field notes as primary source data.[11] Only the words of the informants are used in the final script, allowing the informants to speak through the text. By retaining the exact text of the interviews, the patient voice is privileged, in line with the overall message of the patient-as-partner. Additionally, this method requires little theatrical intervention (such as a director, trained actors, a dramaturge, etc.), which lends itself well to the interprofessional education workshop setting, and could be run sustainable for many years.[9] Though reader's theater eliminates a theatrical component of the script, this method allows readers to engage with the informants by reading their words from the script. Participants are assigned roles to read without preparation, creating an immersive experience for readers and a radio-playlike experience for anyone without a role to read. Rosenbaum, Ferguson, and Herwaldt used a similar nontheatrical performance approach in their text, created from a series of interviews conducted with patients facing a range of diagnoses on the topic of their interactions with health care providers.[12] Their text was used to teach medical school students about the emotional impact of diagnoses on patients' illness narratives.

MedEdPORTAL offers several interesting learning activities that address concepts of patient-centered care and interprofessional communication and collaboration. “Keeping the Patient at the Center: Teaching About Elements of Patient-Centered Care” helps learners consider the notion of patient-centeredness through a video of a patient's experience, a first-person memoir, and consideration of patient-centered language in documentation.[13] “Understanding Patient Experience: A Course for Residents” details a 4-hour course to encourage residents to understand patient satisfaction and to consider the patient experience.[14] Activities using standardized patients, such as “Appreciation of Interprofessional Perspectives: A Standardized Patient Experience to Promote Communication Between Nursing and Medical Students,” have also been used to promote a patient-centered approach.[15] Two activities provide students with longitudinal encounters with individuals with chronic health challenges: “Understanding Experiences of Chronic Illness From the Patient Perspective”[16] and “Preparing Students for Collaborative Practice: An Overview of the 2012 Jefferson Health Mentors Program.”[17] Each of these activities provides alternative approaches to learning about patient-centered care. The learning activity described below offers a scalable and easily implementable approach that is relevant to health profession education.

This verbatim reader's theater piece and its accompanying discussion-based workshop were designed to raise the awareness about the lived experience of patients and health care providers who shared successes and/or challenges in developing a patient partnership. An additional goal of the workshop was to strengthen interprofessional communication and collaboration. These goals are aligned with and build on successful research in the area of theater-based health care education.

The verbatim reader's theater script and accompanying discussion questions described here provide an arts-based approach for exploring notions of partnerships with patients in a team context with interprofessional collaboration. The voice of individuals with lived experience is elevated to enhance student learning and connection to the topic. The arts-based approach fosters active engagement and offers an alternative to course materials or simulation. Although the script is not an experience equivalent to direct involvement with a patient, it does provide a way for participants to experience a patient's voice.

The script was created by a group of students from medicine, speech-language pathology, and occupational therapy in an effort to consider the patient as part of the health care team. We worked with a faculty advisor to create questions for interviews exploring the concept of patient partnerships with clinicians. We interviewed three health care providers (physician, speech-language pathologist, and physiotherapist) who were engaged in their respective professions' education as well as interprofessional education. We also interviewed five patients living in the community with a chronic health challenge. Each of the patients responded to a call for participation sent to individuals involved in the interprofessional education curriculum at the university. The interviews sought to determine each participant's understanding of the concept of practitioner-patient relationships. Once interviews were completed, each interview was transcribed and coded for themes. Quotes illustrating each theme were then pulled together to create a verbatim theater piece. Only the words of informants appeared in the script. By reading the script as a reader's theater piece, everyone stepped into the shoes of either a patient or a health care provider to explore the topic of partnerships between patients and clinicians.

Methods

This learning activity was implemented with both junior and intermediate learners from the health profession programs. Many of the discussion questions were designed to explore collaborative competencies, although they could be adapted for a uniprofessional context.

Logistics

Students were assigned to groups of eight, with a balance of professions represented. The format of the activity was as follows:

Welcome and overview: 5 minutes.

Review of relationship-centered care: 3 minutes.

Group introductions and icebreaker: 10 minutes.

Introductions to verbatim script and instructions: 2 minutes.

Small-group reading and discussion: 80 minutes.

Debrief: 10 minutes.

Evaluations: 5 minutes.

Preparation

The small-group facilitators included clinicians, academics, and patient educators. The University of Toronto recruits patient educators through the health mentor program, in which patients work with groups of students to discuss experiences with their chronic health challenge and the health care system. A sample training program for facilitators is included (Appendix C).

Facilitator training involved a 1-hour webinar to introduce the learning activity and review interprofessional facilitation techniques. Special considerations were required to prepare patient educators. Often, in educational settings, they have been asked to share their experiences with their particular health condition or in the health care system. As a facilitator, their role changed, and they needed to foster student learning by asking questions. In this learning activity, they were asked to discuss some of their experiences to enrich the discussion and/or to redirect comments to focus on learning objectives, but their personal stories were not the focus. Faculty provided additional support to ensure that patient educators perceived themselves as offering critical components to student preparation for future practice.

Specific skills were required for the facilitation of interprofessional groups beyond general group-facilitation strategies. A few strategies that foster collaborative competency development in learners included explaining how interprofessional collaboration can enhance patient-centered care; valuing the diversity of perspectives represented by various professions; encouraging learning with, from, and about each other; encouraging shared decision making; and discussing issues related to hidden power structures, hierarchies, and stereotypes that may exist among different health professionals.[18]

Materials Needed

Faculty copied an appropriate number of facilitator manuals (Appendix A) and scripts (Appendix B). Because scripts were collected at the end of the learning activity, this was a onetime expense. One evaluation form per participant was printed, but they could be set up in an electronic format instead. Participants used flip-chart paper and markers to record responses during the icebreaker activity.

Implementation

Small groups selected a timekeeper to keep discussion time on track for each of the scenes read. Facilitators followed the instructions in the manual.

Introductory Activity

Learners introduced themselves, providing name and profession. The following introductory activity helped to anchor the discussion. Participants recorded thoughts on flip-chart paper.

What do partnerships between patients and practitioners mean to you and/or for your profession?

Are there any differences in the way the professions represented in the group consider partnerships?

Script Reading and Discussion

Learners read their assigned role in the script. Discussion leaders guided learners through discussion questions, probing to promote deeper learning and summarizing key points.

Debrief Activity

After the final discussion, learners reconsidered their understanding of patient partnerships. The following questions guided this portion of the learning activity.

Having read the entire script, how has your understanding of patient partnership changed?

What beliefs did you have that were challenged?

Describe some of the new learning you discussed.

Reflective Writing

Reflective writing enhances the potential for transformative, deeper learning. The writing prompts used for this learning activity are below.

Consider your experience learning about patient partnerships in a team context. What was particularly impactful and why? How were differences in perspective managed in the group context?

How did your perspective change as a result of engaging in this learning activity?

Consider how you will take this learning and apply it to a team context. What one key learning will you implement in your practice?

Evaluation

Measuring participant responses is critical to further revision of the leaning activity. A sample evaluation form distributed to participants is included in this package (Appendix D).

This 2-hour learning activity has been implemented for both smaller and larger groups. Groups of eight are ideal so that every participant is able to engage with one voice.

Results

This resource was implemented twice at the University of Toronto as part of the interprofessional education curriculum. The first time, it was used with a group of 80 students representing 10 health profession programs. The second time, it was incorporated into a learning activity for approximately 900 first-year students from seven health profession programs (kinesiology, medical radiation sciences, medicine, nursing, occupational therapy, pharmacy, and speech-language pathology). Student evaluation results are provided in the Table.

Table.

Student Evaluation Results (N = 888)

Evaluation Item	Agreed or Strongly Agreed
The learning activity enabled me to achieve the stated learning objectives.	81%
I am confident that what I learned today will be applicable to future practice.	84%
The discussions allowed me to explore partnerships with patients/clients.	81%
The learning activity was a useful way to learn about partnerships with patients/clients.	87%
The learning activity provided me with an understanding of interprofessional collaboration.	82%

A number of themes emerged from learner comments in the brief reflective writing assignments and evaluations. Students acknowledged the value of patient-centered care, as illustrated by these comments:

“It is of the utmost importance to ensure that the healthcare team's understanding of the patient's best interests actually is the patient's best interests … are they aware of the patient's main concerns and goals of care?”

“It is essential that health professionals try to put themselves in the shoes of their patients to make sure that they can convey information in an effective manner.”

Learners also recognized the value of developing relationships with patients, particularly by listening closely to them. The following quotes illustrate this notion:

“This session made me realize the importance of establishing strong relationships with patients, and I will strive to do this in my future medical practice.”

“One thing I will implement in my next clinical rotation is to give myself in to the ‘imagination of the patient’ … this means to be truly present in the moment when the patient is giving their history and describing their symptoms.”

Although the notion of patient-centeredness was not new to learners, the idea of working toward inclusion of the patient on the health care team was discussed in groups. Pertinent remarks included the following:

“Some things that I took away from this activity are the importance of listening to the patient, getting the patient to be part of the healthcare team, and to not use medical jargon with the patient.”

“The importance of involving patients in their own treatment plan was reinforced … we are the educated facilitators; the patient is the ultimate judge.”

The importance of collaboration and communication among team members was evident, as illustrated by these quotes:

“[This learning activity] underscored the value of including all the professionals involved in a patient's care in the conversation, as they would each bring a different piece of the puzzle.”

“I think we all agreed on the importance of having patient-centred care and the importance of breaking down the barriers of communication between patients and healthcare providers and between different healthcare providers.”

Students recognized the differences between the various professions and appreciated the value of learning together.

“Once we saw that there were differences, we took the time to explain the details of each of our professions and how we work with the client…. My perspective did change because I was able to learn more about some of the professions that I did not know too much about.”

“I will be able to apply the things I've learned from my peers and through the voices of the patients expressed in the script to my daily approach as a future healthcare professional.”

Discussion

The use of a verbatim theater script grounded in the patient voice is a valuable and engaging approach to help students learn more about the concept of partnerships between patients and health practitioners. This resource highlights patient and practitioner voices and has been used in the context of two interprofessional learning activities for students from 11 health professions at the University of Toronto. Key lessons learned from the previous two iterations will be incorporated into the next iteration of the learning activity.

Lessons Learned

Students worked in groups of eight to reflect the number of voices in the script. When it offered the activity to approximately 900 students as part of the interprofessional education curriculum, the University of Toronto faced room-booking restrictions. Consequently, larger theater-style rooms were used to house multiple groups. Since every group had a reader or someone speaking during the discussion, the venue became noisy, and students were less engaged. Groups assigned to smaller, quieter rooms were much more engaged, discussed concepts at a deeper level, and described a more positive learning experience.

Some learners described the script as too long. The script has since been shortened, while maintaining continuity and salient quotes. Students described some discussion questions as repetitive. Thus, some of the questions have been revised to tighten up the topics.

The nature and depth of discussion were influenced by the facilitators. Patient educators were trained to act as facilitators for most groups. Although all received the same training, some patient educators were more comfortable in this new role than others. We anticipate that additional role-playing training and experience will help patient educators manage potential scenarios arising in group situations. In large-group settings, with multiple small groups of learners, the lead academic educator and patient educator acted as roaming facilitators. In these rooms, each group was asked to identify a discussion leader among the students to maintain the pace of the activity. The groups led by students had more difficulty engaging in deep discussion, with students reporting more superficial conversations, earlier finishes, and lower satisfaction with the activity. Students appreciated the additional experiences shared by patient educators when they were leading group discussions.

The manuals should be tailored according to the way in which groups need to be facilitated in different room locations. Each facilitation approach had nuances; consequently, facilitators described some confusion with their specific situations and requested greater clarity regarding their role. For instance, there were questions regarding what instructions were specific to student leads, to patient educators who were facilitating or cofacilitating, or to faculty educators who were room leads.

Limitations

This 2-hour learning activity is not adequate to address a full understanding of partnerships; however, it may be sufficient to sensitize learners to the concept. Reinforcement of relationship-centered care and particularly patient-to-practitioner relationships throughout the interprofessional or profession-specific curriculum will continue to anchor this important concept.

Evaluations were completed following the learning activity. They represent a reflection of satisfaction with the learning experience and not a translation of the learned patient-partnered approach to practice. Most of the data were gathered from students in the first year of their health science profession. Results may have been different if more senior students had been involved.

Although the script has been used in the education of prelicensure students from the health professions, exploring the concepts of patient partnerships would also be of value in continuing education and in practice settings. Practitioners value patient-centeredness, yet in in the context of busy practice settings, reminders are often necessary. Engaging in this activity with patient educators provides an additional and valuable perspective to learning about partnerships with patients.

A. Facilitator Handbook.doc

B. Your Partners Will See You Now Script.docx

C. Facilitator Orientation Slides.ppt

D. Evaluation Form.docx

All appendices are peer reviewed as integral parts of the Original Publication.