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WHY the World Needs Improv

Calm Before the Storm

It was a Tuesday at three in the morning in an upscale community hospital 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 themselves that only a few minutes had passed.

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 instruments 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 interpreting 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 parents. 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 administration, and everyone concerned, is tragic ... and preventable. This problem 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 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. Interestingly, 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 anywhere, 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 solutions 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 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 continues 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 caregivers,” which they defined as including oral, written, and Internet communications. 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, eventually) 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 measurement 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 problem of intimidation and/or disruption: Clinical professionals who feel 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 problem of intimidation/disruption and keeping silent in healthcare hierarchies 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 preconditions 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 speaking 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 codify 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 hospitals and states to collect this sentinel event data, including fear of recrimination, 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 miscommunication, 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.

How could this be?

We have borrowed from other risk-averse industries, such as manufacturing and aviation, which have given us Total Quality Improvement (TQI) and Crew Resource Management (CRM). We’ve borrowed programs from other disciplines (e.g., assertiveness training and the amalgamated TeamSTEPPS™). 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 positive results by application of controlled breathing and meditation techniques. 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 sentinel 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.

4. Increased immigrant population with little or no previous preventative 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 conversations about specific patient care. As you can imagine, each person 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.

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, interruptions, 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 easily 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 achievable. 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.

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 spontaneously 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 workday, 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.

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 perpendicular 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 phenomena 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 corticoids) 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 comprises the emotional control center of the brain.

Limbic System = Emotional Control Center

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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 activity 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 anthropology, linguistics, psychology, and philosophy. It began with Greek notables such as Socrates, Plato, and Aristotle, who studied how to train up individuals 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 learning 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 feelings 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 concentration 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 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 improvisation 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 making 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 middle-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 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!

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:

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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 problems. 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.

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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 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

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