Acting to teach communication skills to nurses.

BACKGROUND: Interpersonal and communication skills are core competencies for nursing students. Empathetic, patient-centred communication improves patient outcomes and the care experience. Nursing trainees have reported a lack of preparation and confidence in communication and interpersonal skills with patients and members of the health care team. Acting-based hands-on training may provide a novel approach to develop communication in nursing students. APPROACH: The corresponding author worked as a professional actor before pursuing a medical career. He created an acting-based workshop, inspired by classic acting exercises taught in drama conservatories for decades, to develop core communication and interpersonal skills for health care professionals. The course creator and an instructor with no acting background each facilitated the workshops. The initiative was taught to over 200 preclinical baccalaureate freshmen and sophomore nursing students as part of their clinical skills courses at one institution. EVALUATION: Participants were asked to rate their self-efficacy for skills developed in the workshop using a 5-point Likert scale. A 4 or 5 rating was considered agreement. Most participants agreed the workshop developed their skills of self-awareness, observation, teamwork, flexibility, nonverbal and verbal communication, trust, mindfulness, body language awareness, active listening, and sensitivity to emotions expressed by others. IMPLICATIONS: An acting-based teaching intervention is efficacious in instilling core communication and interpersonal skills to preclinical nursing students based on participants' self-efficacy ratings. This innovative way to teaching communication provides students with an experiential environment conducive to learning. Similar ratings between sessions suggest that health professions educators with no formal acting training can successfully teach this course.

BACKGROUND

Effective communication enhances the patient–nurse relationship, leading to improved patient outcomes. Poor communication is associated with suboptimal health outcomes and patient satisfaction. Empathetic communication may also help foster connection with patients. Empathetic nonverbal behaviours have been associated with improved patient ratings of their health care providers' competence and warmth. Skills of empathetic communication and active listening in baccalaureate nursing students have been associated with improved patient‐centred care.

The development of communication skills in nursing students may lend itself well to interactive learning. Innovative approaches to teaching communication skills are necessary to foster long‐term retention and apply these skills to clinical care scenarios. Role‐playing in simulated scenarios has been shown to increase nursing graduates' ratings of caring self‐efficacy, but most hands‐on, experiential curricula do not develop communication skills through acting exercises.

Nursing students, including at our institution, report a lack of preparation and confidence in communication and interpersonal skills. Clearly, there is a need to train nursing students in these essential skills to prepare them to serve their patients and interact with colleagues in the clinical sphere. Participatory teaching modalities rooted in theatre may provide an innovative approach to develop these skills.

APPROACH

Previous initiatives suggest that theatre principles provide medical educators with tools to teach communication. Improvisation exercises inspired by the theatre world have been used to teach patient‐centred care to nurse practitioner students. Acting‐based training offers a novel means to teach communication and interpersonal skills to nursing students.

Theatre‐based training in the health care professions uniquely fits the learning needs of adult learners. By participating in concrete exercises to develop skills central to health care practice, students engage in experiential learning. This pedagogical approach effectively applies Kolb and Fry's experiential learning model: learners engage in role play and are invited to tap into their personal experiences to develop their empathy. Pedagogy inspired by the theatre world has been well received by participants, including nursing students. Nursing education has been shown to be enhanced by drama initiatives through improving students' understanding of patients' experiences and perspectives, developing their empathy and self‐awareness, and optimising their communication skills.

Nursing leadership at our institution identified a gap in the clinical skills curriculum, namely that preclinical nursing students shared written and verbal feedback that they were not getting sufficient practice to communicate with patients and members of the health care team. The corresponding author (ADV), worked as a professional film and theatre actor before pursuing a career in medicine. He created an acting‐based workshop to teach communication and interprofessional skills to health care professionals. The initiative adapts classic acting exercises, taught for over a century in acting conservatories worldwide, to the needs of health care practitioners. This innovation was previously taught to medical students and emergency medicine residents. To fill the gap identified, these workshops were facilitated for undergraduate baccalaureate nursing students as part of core preclinical skills courses.

The initiative comprises two workshops. The first session focuses on skills of non‐verbal communication: empathetic body language, mirroring, and making judicious eye contact. The second workshop develops skills of verbal communication: active listening, learning not to interrupt, and embracing silence. Skills such as mindfulness and presence in the moment are developed longitudinally across both workshops. Following each exercise, the facilitator debriefs with participants and discusses clinical correlates (please see Table 1 for a list of activities and suggested discussion with participants).

TABLE 1

Workshop curriculum

Activity	Facilitator instructions	Suggested facilitator‐led discussion
Shake It Off	1. Following the facilitator's lead, students count down from 8 loudly and shake off each of their four limbs in quick succession. 2. Students are directed to “shake off” any emotions, anxieties or stress they bring to the session with them today.	This warm‐up tackles the concept of mindfulness: becoming aware of your own state of mind and emotions. You can use “Shake it off” before you meet a new patient, after a difficult patient encounter, before and after emotionally charged conversations, and even on your way to and back from the clinical environment. Becoming aware of your own emotional state allows you to approach each patient with an open mind, giving them the full attention and care they deserve.
Yes but, No Because, Yes and	1. Students form pairs. 2. A prompt is given to each pair to start a conversation. 3. Each conversation occurs a total of three times. The rule of the activity is that each of the participants' sentences must start with either “yes, but,” “no, because” or “yes, and.”	Patient communication breakdowns often occur because patients feel their concerns are not being acknowledged. How can you apply “Yes, and” in clinical practice? Conflicts can also occur with co‐workers. When facing disagreements with other members of the health care team, how can you use “No, because” to constructively express your opinion?
Pass the Impulse	1. Participants form a circle. 2. Learners are directed to make eye contact with someone in the circle and toss them a softball. 3. Additional “patterns” are tossed around the room—such as names of fruits, pointing at someone. 4. All impulses are combined, until one or more of the impulses die out and the exercise comes to an end.	What made the impulse die out? Listening is more than just using our ears, but engaging all our senses. We know to close the loop in verbal communication, but how can we use our body language to non‐verbally close the loop as well? We were able to share multiple impulses at once, but only by focusing on each impulse at once. Instead of multi‐tasking in clinical practice, consider consecutive tasking, focusing your attention on one task—and one individual—at a time.
What do I see?	1. Students form pairs. 2. Instructions in mindful breathing are provided. 3. Each participant inhales a breath for three sounds and vocalises an “uh” sound loudly upon exhalation 4. After an exhale, each learner makes one‐word observations commenting on their partner—their dress, appearance, stance, demeanour, and any impression they feel they give off.	Consider making mindful breathing a part of your daily routine, clinically and outside of work. Studies show that it can decrease your anxiety and improve your sense of presence in the moment. Before premature closing on patients, take a step back, and ask yourself “What do I see?” to form fresh opinions. Realise that the person's demeanour and body language may tell you a different story than what this person verbally shares with you.
Mirror Mirror	1. Students form pairs. 2. Participants are directed to physically mirror their partner using their body language only. 3. Prompts are provided to each participant to take on a specific emotion, and their partner mirrors their body language.	You can use mirroring to express empathy non‐verbally with patients. This can mean pulling up a chair to get at the level of the patient, or mirroring their voice volume to make a connection. If they look concerned, echo that concern with your body language to show empathy non‐verbally.
Good Listener, Bad Listener	1. Students are directed to share a story with their partner. 2. Their partner is directed to use their body language to show good listening skills. 3. Participants then share a different story with their partner who is directed to use their body language to display bad listening skills.	How can we maintain eye contact with patients, especially when utilising the electronic medical record? How do we show a caring attitude when we are constantly distracted by our mobile devices and interruptions in the clinical setting? Think back on what it felt like to be on the receiving end of a “bad listener” to realise the importance of connecting with your patients.
Storytelling Circle	1. Participants form a circle. 2. They are directed to tell a story that makes logical sense, going around the circle. 3. For a prompt, they are provided a setting, character, and prop. 4. The rule of the activity is that each person's sentence must start with the last word of the preceding sentence.	Studies show that on average, health care professionals interrupt patients after less than 20 seconds. How can we use this exercise to focus on what our patients and team members share with us? If you think of what you will say next, you are not truly listening to the person you speak with. Listen to the end of what your patient tells you before you speak. Then think of what you will say next. Then respond. This also forces you to develop comfort with silence.
Cocktail Party	1. Participants are given a setting: a social function after their yearly university research conference. 2. Each student is given a card from a deck that they are instructed to hold face up on their forehead. Participants do not know what their card displays. 3. Learners are directed to walk the room, and treat others according to the status ascribed to them by their card: “Kings” being of the highest status and “2's,” the lowest status. 4. Participants are then directed to form a line in ascending order from highest to lowest perceived status, flip the cards, and observe where they fall in the line‐up.	Being a health care worker ascribes you a certain status. If you find you are not getting through to a patient, take a step back, and consider inquiring about their past encounters within health care settings, which may have been suboptimal. Be weary of premature closing with patients. Their age, gender, dress and race might feed into your unconscious biases. Approach each patient encounter with an open mind, and consider patients' social determinants of health before judging them for any reason.

At the conclusion of each workshop, participants engage in a semiscripted standardised patient vignette, in which they role play a patient and nurse provider. They are tasked with applying to the encounter the communication skills developed in the workshop. The vignettes centre around breaking difficult news and admitting a medical error, challenging discussions we felt nurses may be made privy to or involved with on the clinical stage but that that they did get practice with in their preclinical coursework. A communication toolbox summarising the skills taught is shared with participants upon completion of the activities.

Several educational principles underlie our initiative. Our workshops were inspired by the well‐studied concept of forum theatre—which embraces experience sharing to foster connection —in that group debrief and verbal self‐reflections strategically follow each exercise. Participants are encouraged to share difficult interpersonal and interprofessional encounters they have experienced and brainstorm how they might implement the workshop tools in their clinical practice when navigating future challenging patient encounters. Because all theatre exercises are contextualised for the clinical arena, our initiative embraces the concept of “applied theatre” which has been shown to enhance participants' personal and professional development by situating the exercises in a health care setting that participants can relate to. Through acting out clinical prompts, nursing students simulated their future work in health care, applying the concept of the health care provider as a performer on the clinical stage.

The workshops are entirely interactive and participatory, and especially tailored to the unique pedagogical needs of adult learners as they foster active learning and experiential applications. Our approach applies Kolb and Fry's experiential learning model of “doing and reviewing,” which involves concrete experiences and reflective observations. As one example, for the exercise “yes, and,” participants engage in a conversation with a set of rules (please see Table 1). They role‐play a difficult communication with a peer, activating Kolb and Fry's four‐stage educational theory of “experience, reflection, conceptualization, and experimentation.” We similarly embraced Kolb's principle of “experience‐guided learning” in that participants act in exercises as, respectively, themselves, providers, and patients, offering them the opportunity to live out others' perspectives to develop their empathy. Our hands‐on approach implements this adult learning theory to foster a safe environment for experimentation and active engagement.

Finally, by encouraging experience sharing, we embraced dramatist Augusto Boal's critical pedagogical praxis of the facilitator and student participants considered equal co‐instigators of their learning, inciting constructive dialogue and encouraging personal and professional self‐growth. This approach activates and validates participants' identities and individual backgrounds to “act up” realistic vignettes and practice communication tools that they can feel empowered to implement in their future clinical practice.

The workshops were trialled as part of two beginner‐level Freshmen and Sophomore nursing courses in which students learn to interview patients. Workshops varied in length from 30 to 90 min. Each session included 18 to 30 students. A total of 225 students (n = 225) participated during the 2019–2020 academic year. The course creator taught most workshops. He trained a physician faculty, with no acting background, to teach a subset of the workshops independently.

EVALUATION

After each workshop, participants were asked to anonymously answer 5‐point Likert scale paper surveys (1: strongly disagree to 5: strongly agree) to evaluate the experience and assess self‐efficacy for skills developed. Although participation in the workshops was mandatory, survey participation was voluntary. Across all workshops, survey participation was greater than 95%. This study was approved by the Institutional Review Board. Informed and image consents were obtained from participants.

Across all workshops delivered, greater than 90% of participants agreed or strongly agreed the course engaged them in teamwork, improved their awareness of their body language and that of others, and developed their mindfulness and presence in the moment. Greater than 85% agreed or strongly agreed the workshop developed their skills of active listening, sensitivity to emotions expressed by others, self‐awareness, situational awareness, and observation, were challenged to step outside their comfort zone, felt safe to take risks, and were provided a new approach and specific tools to develop their communication skills. Greater than 80% agreed or strongly agreed the workshop developed their skills of verbal and nonverbal communication, increased their awareness of unconscious biases, and developed their flexibility.

Written feedback by participants was supportive of the experience:

“I really enjoyed these workshops and they help me to open up and step out of my comfort zone”;

“It felt nice to see some of my ‘stone cold’ classmates lighten up. It boosted my confidence in them”;

“I enjoyed learning about communication skills as we do not focus on this in our classes”.

Nursing faculty who attended the workshops felt it was a worthwhile use of curricular time, and asked that the experience be repeated in subsequent years.

IMPLICATIONS

A novel acting‐based intervention is efficacious in instilling core communication and interpersonal skills to preclinical nursing students based on participants' self‐efficacy ratings. This innovative way to teaching communication provides students with an experiential environment conducive to learning. This initiative is unique in that unlike many theatre‐based courses for the health care professions, clinical correlates and applications are provided to participants. Similar ratings between sessions suggest that health professions educators with no formal acting training can successfully teach this course. Feedback from five nursing faculty in attendance and student participants indicated it targeted development of essential clinical communication skills, suggesting this curriculum can be helpful for other clinical teachers.

This novel acting‐based intervention is efficacious in instilling core communication and interpersonal skills to preclinical nursing students based on participants' self‐efficacy ratings.

To ensure ongoing implementation, two virtual sessions were held to train nursing faculty to teach the course. Deployment has been delayed due to the COVID pandemic as preclinical courses at our institution transitioned to online learning. Since then, a different version of this course has been taught virtually to medical students at another institution. This was well received by participants, and suggests that the initiative may be adapted to video‐based teaching modalities.

Future studies should be conducted to assess if these skills maintain overtime, or if refresher sessions are needed. As a next step, we are conducting the workshops for resident physicians combined with prevignettes and postvignettes with standardised patients to assess any improvement in communication skills as assessed by neutral observers.

CONFLICT OF INTEREST

The authors have no conflicts of interest to declare.

ETHICAL APPROVAL

The study was submitted to and approved by our Institutional Review Board (IRB). All participants signed informed consents for participation in the study. Survey participation was anonymous and voluntary.