Laughing Matters: What the principles of improvisation can teach us about compassion in health care

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27 / 3 / 2015 Midnight

By Ryan Offutt

Compassion at work

Over the past 20 years we’ve seen incredible developments in our understanding of the positive impact of compassion in professional life. Research from my field of work psychology has shown that compassion within organisations leads to better organisational performance and better welfare for those who hear bad news. Within healthcare, doctors and nurses who fail to express adequate compassion with patients are more likely to be sued for malpractice.

These research findings affirm what we know and experience – compassion matters, especially in healthcare. Maxine Craig, in her May 2014 NHS OD blog, rightly points out how integral compassion is to high quality care, and wrestles with the question of ‘how’ best to increase compassion across the NHS.

I have worked with trainee GPs and medical students over the past two years, exploring how improvisation (improv) training can help improve consultation quality between medical professionals and patients. Based on our continued positive experiences and feedback from both workshop participants and healthcare trainers, I believe that improvisation training is a great answer to the question of how to increase compassion in healthcare.

Why improvisation?

Because every interaction with a patient is improvised – there is no script for each patient consultation. Improvisation is an overlooked skill set that can be improved and developed through increased self-awareness and training in how we communicate when we have no script to follow.

Improv training workshops feature a series of engaging, on-your-feet, collaborative activities, and exercises designed to encourage listening and responding spontaneously. An improv workshop is different from traditional, scenario-based role play. Rather than simulate or role-play scenarios from the work environment, we invite participants to forget about work for a few hours and focus instead on what’s right in front of them.

We have found that doing activities with no obvious connection to work help people relax and be themselves, rather than their ‘work selves.’ However, during workshops we do provide moments to reflect on how the games and activities mirror instances from their professional experience. These moments help each person connect training with practice and help them spot their own improvisational strengths and areas where they can improve.

Improv comedy for healthcare?

The basics of improvisational comedy provide a fantastic training platform for in-the-moment communication skills that shape all human interaction. Improv-based training helps people better manage themselves in the moment, getting people ‘out of their own heads’ and more connected with others. This new awareness enables people to listen better, respond and build on others’ verbal and non-verbal communication and cues. Improv training also highlights each individual’s attention and listening limitations, and helps each person better manage distractions and competing demands when they interact with others.

Great carers and great comedic improvisers need the same foundation to perform their crafts; full attention, active listening, being completely in-the-moment with others, accepting-and-adding to the conversation, and adapting. Improvisation-based training helps drive improvement in all of these interpersonal skills. This training creates a fantastic foundation for compassionate care.

Compassion – more than just a feeling

Before we dive into how improv-based training can help individuals unlock greater compassion in their care work, it is helpful to define what we mean when we talk about compassion.

Compassion is comprised of two steps.

First, there is a deep sympathy or sorrow for another’s suffering, accompanied by a strong desire to alleviate their suffering.

This is followed a behavioural expression that emanates from this felt experience, whether the response is understanding, support, solutions or action.

Compassion is not just sympathy – it must have a behavioural response. And compassion is not just professional competence and skill – compassion includes a genuine emotional response to another’s suffering.

Genuine compassion demands attention, listening and active response.

How improv helps develop the right mindset for compassion

Organisationally, it’s no good to tell people to ‘be more compassionate’, and worse still to say ‘we’ll be measuring it.’

Compassion is, by its very definition, a genuine, intrinsic response, followed by a behaviour emanating from the experience of that response. External incentives like management and coaching, however well-intentioned, are ineffective means of bringing increased compassionate care.

Rather than ‘training for compassion,’ it is better to focus on developing the right internal mindset for compassion – a set of essential skills that give care providers the best possible foundation from which they can provide compassionate care.

What’s the link between compassionate care and great improv comedy? Deep listening.

People often think that improv is simply ‘being funny on the spot.’ The reality is that the best improvisers are great listeners.

Their ability to listen completely allows them to genuinely and spontaneously respond to their fellow players. In comedy, what delights the audience is when they see genuine connections between actors on stage, not funny gags. We have a rule in our improv comedy performance group – ‘no gagging.’  This means no making jokes that break ‘the reality of the scene’ or ‘break the fourth wall.’

In that moment when you make a ‘gag,’ you stop responding to your fellow player, choosing your own agenda instead of collaborating with your acting partners. ‘Gagging,’and pursuing your own agenda, kills the momentum of an improv scene in its tracks. The same is true when providing compassionate care – dominate the conversation and go your own way, and your audience switches off.

Listening - the foundation of both a compassionate consultation and a great improv scene.

In my training sessions, before I begin, I ask participants if there have been times in the recent past when they’ve asked questions to patients and then not heard at all what the patients’ response was – every time the majority of the room puts their hands up.

This behaviour is the healthcare equivalent of ‘gagging,’ or ‘killing the momentum’ of the consultation.  

Just as an actor cannot create a great improv scene without deep listening, a medical professional cannot show compassion if he or she doesn’t listen deeply enough, through both verbal and non-verbal communication, to know what to be compassionate about.

In our workshops we play a variety of silly games in partners in groups to help us ‘feel’ what deep listening is like. I often say that the deep listening activities we run are like ‘going to the gym’ for your mind. If you don’t exercise your listening muscles, you’ll rely instead on ineffective listening shortcuts and habits.

A glimpse into an improv workshop - The ‘So What You’re Saying Is’ Game.

The games and exercises we use in our workshops are all designed to improve individuals’ improvisational awareness and skills, such as deep listening, focus, accepting-and-adding in conversation (rather than driving ahead with your own agenda).

One such game we often play is ‘So what you’re saying is,’ which people play in pairs (Player A and B).

Here’s how it goes:

  • Player A begins by making a simple statement to start a story, such as:‘Yesterday I went shopping at Waitrose for carrots.’
  • Player B would then respond to player A with two key steps. They would begin by saying, ‘so what you’re saying is’, then would paraphrase what player A said without using any of the same words
  • Then player B would repeat the steps, paraphrasing and adding what happens next, and players A and B would carry on creating the story for two minutes.

Here’s an example of the game:

If player A begins, saying

‘Yesterday I went shopping at Waitrose for carrots,’

Player B might respond,

‘So what you’re saying is I travelled to a high-priced supermarket to buy some orange root vegetables.’

Having paraphrased what Player A said, Player B would then add more information to the story:

‘I went to the till but when I went to pay I realised I forgot my wallet.

Player A might then say,

‘so what you’re saying is, when I approached the cash register I discovered that my billfold was not on my person...’

and so on.

This game is a great example of a fundamental rule of improvisation: ‘yes-and.’

What do I mean by ‘yes and?’ It means ‘accepting-and-adding’ – a way of communicating that reflects that the speaker has been heard by you, the listener, and you are building on the same communication, rather than pursuing your own agenda and taking over. In the above game, each contribution each player makes to the story should fit with what the other player said, ‘accepting and adding.’ As they improvise, the players create a story as if they are speaking with one voice.

When played poorly, this game also provides the opportunity to experience what it feels like when your partner goes off on their agenda without building on what you have said (players who are ignored get frustrated with their partners very quickly!)

This is another strength of improv training – it’s a risk-free, safe environment for people to experience ‘bad communication.’ Being on the other end of a ‘bad communication’ experience can often be the catalyst that motivates people to make significant changes in how they interact with patients at work – through improv they experience first-hand how much deep listening and collaborative conversation matters.

The ‘So what you’re saying is’ game, as with all activities in improv-based training, is relaxed, fun and light-hearted, but the skills people discover and develop while playing form the foundation of effective improvised communication at work.

It’s important to note that professional training doesn't need to be ‘intense’ or ‘serious’ to be effective. In fact, training research has consistently shown that people learn more in training workshops if they’re in a good mood – why not make training as fun as possible to maximise its impact?

Improv training – laughing matters

Over the past two years we have found improv-based training to be a highly effective, empowering and enjoyable approach to help junior doctors and medical students grow and develop the key skills that enable compassionate patient care. Our feedback shows that 95% of our workshop attendees felt the workshop would improve their ability to communicate with patients. Also, over 95% would recommend improv training to a colleague. I believe improv training is important for anyone involved in patient-facing roles that have to think on their feet, not just doctors.

Compassion is critical to effective patient care and great patient experience. However, simply telling medical professionals to ‘be more compassionate’ is a poor approach to the challenge. Instead, we need to empower professional to improve their ability listen deeply, to manage their non-verbal communication and interpret the non-verbal communication of others, to have collaborative conversations, to tell stories, and to focus. Improv training is an engaging, fun way to increase individuals’ ability to work with compassion.

Why not improv to boost compassion? After all, there’s no ‘script’ for compassionate care – it’s always improvised.

Ryan Offutt is a work psychology researcher at Leeds University Business School, trainer and improvisational comedy coach in Sheffield, and can be reached at r.b.offutt@leeds.ac.uk

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