- Email: [email protected]
Using interactive theater to improve provider-family communication and promote inter-professional education and practice in palliative care
Journal of Interprofessional Education & Practice 4 (2016) 15e20
Contents lists available at ScienceDirect
Journal of Interprofessional Education & Practice journal homepage: http://www.jieponline.com
Using interactive theater to improve provider-family communication and promote inter-professional education and practice in palliative care Diane K. Pastor, PhD, MBA, NP-C, FNAP a, *, Candace Ashton, PhD, LRT/CTRS a, Robin P. Cunningham, MSN, RNC a, Stacey Kolomer, PhD, MSSW a, Barbara J. Lutz, PhD, RN, CRRN, FAHA, FAAN a, Stephanie Smith, PhD, RN a, Patricia H. White, MS, BS a, Ben Saypol, PhD b a b
University of North Carolina Wilmington, USA Theater Delta, Chapel Hill, USA
a r t i c l e i n f o
a b s t r a c t
Article history: Received 11 November 2015 Received in revised form 16 May 2016 Accepted 2 June 2016
Background: Palliative care practice often includes the need for health providers to have difficult conversations with patients and families. These conversations may include discussing diagnoses, prognoses, test results and care options. Purpose: This innovative project used interactive theater as a means of teaching undergraduate and graduate health professional students evidence-based methods for delivering difficult health news in health care settings. Method: The university partnered with a professional interactive theater company to host a production focused on care team communication and delivery of difficult health news to family caregivers of an older adult experiencing an acute stroke. Discussion: The use of this modality allowed audience members to interact with the actors, who remained in character, to discuss the case scenario. Conclusions: Audience members were surveyed using an investigator-developed posttest survey instrument, and positive quantitative and qualitative data confirmed the usefulness and feasibility of using interactive theater in educating health professionals. © 2016 Elsevier Inc. All rights reserved.
Keywords: Interactive theater Palliative care Interprofessional education
Introduction One of the more difficult tasks for health providers is delivery of ‘bad’ or difficult health news to patients and their families, particularly in the setting of adult palliative care. ‘Bad’ news means lifealtering health news or life limiting diagnosis or prognosis. Patients and families need to hear this news in order to begin making decisions for care.1 What do families and patients value in receiving difficult health news? Jurkovich, Pierce, Pananen and Rivara2 found that it was especially important that providers had knowledge not
Funding source: College of Health and Human Services, UNCW. The authors have no disclaimers or credits. * Corresponding author. 601 South College Road, Wilmington, NC 28403-5995, USA. Tel.: þ1 910 962 3482; fax: þ1 910 962 3723. E-mail address: [email protected] (D.K. Pastor). http://dx.doi.org/10.1016/j.xjep.2016.06.002 2405-4526/© 2016 Elsevier Inc. All rights reserved.
only in the content of the message, but in the strategy they used to deliver the news. Communicating difficult or ‘bad’ news is an essential competency for health providers, especially at the end of life,3 but it can be challenging and stressful. Communication training may be lacking in health provider education. Skills in knowing how to use evidence-based strategies to communicate with patients and families about a patient's terminal health status allows providers, patients and families to explore joint decision making.4 Communication skills can be taught, retained, and practiced.5 Beale and Kudelka6 asked clinicians what they found particularly difficult about these kinds of patient encounters and clinicians stated that their toughest challenges included: (1) talking about end of active treatment and initiating palliative care, (2) telling patients about recurrence of disease, (3) little training in breaking bad news science, (4) being honest but not taking away hope e finding that balance and (5) not feeling comfortable in dealing with patients' emotions or their own.
16
D.K. Pastor et al. / Journal of Interprofessional Education & Practice 4 (2016) 15e20
Purpose The purpose of this article is an evaluation of the method of using interactive theater as an educational tool to increase knowledge about communication in palliative care for health professionals and health professional students. Interactive theater was used with a group of inter-professional health care students and community clinicians. A mid-sized public southeastern university partnered with a professional interactive theater group to work toward the goal of promoting attitude and intended behavior change among audience members seeking to improve their awareness of the need to develop communication skills with family members around end of life decision making. There were three parts to the project: (1) develop a realistic script focusing on conversations between providers and family members around end of life decision making on behalf of loved ones (2) use an interactive theater methodology to promote audience participation, engagement of these issues, and dialogue around these issues and (3) evaluate the impact and efficacy of this methodology as a means to educate a local university health care community around these issues. Background: the university This health professional college was founded in 2010, and brought together several schools educating future health providers. The college acts as the doorway for the university to make a positive impact on the health and quality of life of residents in the region, state, and beyond. This college joined several schools educating health professional students with a mission to enhance health and quality of life across the lifespan for individuals, families and communities. Strategies employed to meet this mission include innovation and excellence in workforce development, scholarship, research, professional service and community engagement. The interactive theater program took place during a university-wide Health & Human Services Week, the College's signature health care community engagement event which included a variety of programs highlighting faculty, student, and community expertise in the health and human services professions. An interdisciplinary group of university faculty collaborated to write an internal grant to fund the interactive theater group's performance in spring 2015 on campus. Once the grant was funded, plans began to develop a partnership with the interactive theater group. Plans also included advertising the performance to our campus community (students, faculty and staff) and community health providers and agencies providing care to adults with serious illness. Developing a partnership: interactive theater The exchange of ideas between universities and the community provides mutual benefits for all involved.7,8 Allied health professions, particularly nursing and social work, emphasize the importance of community education as an integral part of the values of each profession. Engaging with local partners allows students to learn and faculty to stay connected to their fields of practice while meeting the needs of the local area.9 While allied health disciplines struggle to bring inter-professional groups of students together in the classroom and in the community due to with conflicting course schedules, facilitating inter-professional events may be a contributing factor to successful communities of clinicians. A key component to community education is creating an experience that is welcoming. This includes being accessible, affordable, and applicable. In seeking a partnership with a professional interactive theater performance group, the university sought to raise awareness about
provider patient communication in adult palliative care settings. The university was able to provide space and accessibility and the event was free to attend. Health care students, faculty and local community partners (hospitals, hospices, and community and public health practitioners) were invited to attend the event that addressed an issue of interest to all e how to start conversations around end of life decision making. The protocol was submitted to the University's Institutional Review Board (IRB) and it was determined to be exempt from further review. Our partnership with the professional interactive theater group grew out of the personal experience of one of the authors, who had attended a prior local performance of this theater group last year relating to perinatal palliative care. The experience of viewing and participating as an audience member was both powerful and empowering, particularly since it involved the smallest and most vulnerable of patient populations. As the authors began exploring means to involve both university and community participants in the initiation of discussions surrounding end of life decisions for adults, excitement grew as consideration was given to the possibility of utilizing this interactive theater group to raise awareness of these concepts here on campus. After contacting the director of the theater group, the authors were informed that the theater group was already working on the development of an interactive theater performance focusing on an adult palliative care scenario. The scene involved a provider breaking bad news to two family members about the terminal diagnosis of their aging parent, and the crux of the conflict was a difference of opinion between the family members about the choices for care for their loved one.
Interactive theater Interactive theater is a burgeoning experiential leaning methodology that has been used to educate diverse communities around a wide variety of health and health education issues. It has been used to: (1) educate gastroenterologists better ways to communicate around functional diagnosis such as Irritable Bowel Syndrome and raise awareness of cultural competence10; (2) foster critical dialogue around diversity issues with medical school faculty11 and college/university faculty12,13; (3) improve public-private dialogue in developing nations14 and provide sexual assault education with undergraduate students15; and (4) address HIV and other reproductive health issues with teens in communities in developing nations among others.16 Intimate partner violence prevention was the focus of a community-generated approach to use interactive theater with multiple Asian communities.17 Lightfoot and colleagues also used this modality to pilot an HIV prevention intervention to educate a Southern U.S. high school student population about sexual health, HIV knowledge and HIV stigma reduction.18 Medical students at a Midwestern medical school also responded positively when interactive theater was used to stimulate reflection about evidence-based strategies to break bad news to patients with cancer.19 Psychologist Wayne Beach is currently using theater to produce “When Cancer Calls,” a National Cancer Institute-funded film project to document how family members communicate about and manage cancer.20 Theater Delta is a five year old company founded by Director Dr. Ben Saypol, based in Chapel Hill, North Carolina, that has developed interactive theater projects with numerous medical communities, colleges and universities, the United States military, the World Bank, and other communities. Since Theater Delta's inception in 2010, they have developed numerous projects in the field of medicine which explore ethical challenges related to health and health care. Examples include physician-patient communication in the hospital setting, provider-patient communication in perinatal
D.K. Pastor et al. / Journal of Interprofessional Education & Practice 4 (2016) 15e20
and pediatric palliative care settings, inter-professional education, and even patient education and advocacy. Methods: format of the interactive theater performance The interactive theater performance at the university was conducted on April 7, 2015 and lasted 90 min. The script contained a scenario where two adult children (a son and a daughter) attended a care planning meeting with an inpatient critical care physician, caring for the two siblings' mother who had suffered a stroke five days earlier. The performance had three core components: (1) a highly realistic scripted scene that introduced, in a simulated health care meeting, key issues to be explored by audience members; (2) an opportunity for audience members to interact with the characters while actors remained in their roles e as the provider and two family members; and (3) opportunity for full participation in a facilitated dialogue, in which audience members shared their reactions to the scene and the interaction, identified the main issues or challenges, and offered examples for developing various clinical skills. The audience had the opportunity to ask the physician character and the “patient's” son and daughter characters questions about what they experienced during the care meeting. This allowed audience members to consider the choices of the physician and family member and analyze the reasoning behind their choices, as well as the impact of those choices on the family members and vice versa. These three core components are framed by an introduction by the facilitator, explaining the format, and a closing where the learning outcomes are reviewed and the audience is educated as to resources for further exploration of the issues. This comprehensive three step approach provides a structure for communities e in this case health professions students, faculty, staff, and local health care providers e to observe, analyze, and work to improve their knowledge about communication in adult palliative care settings. While the performance focused on adult palliative care, interactive theater can and has been used to address a variety of issues in health care as outlined above. It is also important to note that this is but one of many formats for interactive theater. The components of scripted scenario, techniques for audience interactions, and facilitated conversation can be implemented in a variety of ways. Interactive theater is a flexible medium, and formats can be adapted to meet the needs of the communities and their issues of concern. Script development process To ensure a realistic script and constructive conversation, one that accurately represented and raised the issues present in a problematic interview between a physician and family members in an adult palliative care settings, Theater Delta (in collaboration with university faculty) engaged in a comprehensive script development protocol. First, Theater Delta researched current academic literature on the subject of Adult Palliative Care and Breaking Bad News and conducted interviews and focus groups with providers and family members who have experienced the delivery of a terminal diagnosis. These actions were completed to understand the key issues and current norms/beliefs around provider-family communication in adult palliative care settings. Second, Theater Delta observed, over the course several days, eight challenging conversations between palliative care doctors and intensivists with family members of patients facing almost certain death to get a sense for how these occur and sound in real life. These observations were observed at a local regional medical center. Third, they identified teaching points related to communicating difficult health news for the participants (see below). Fourth, using the literature review, the data from the
17
interviews and focus groups, the data gathered during observations, and the teaching points related to communicating difficult health news, Theater Delta devised a high quality realistic script. The creative process includes: brainstorming, outlining, role-playing, writing, feedback from medical consultants (including university faculty) and the creative team, and revision. The focus of this performance was adult palliative care, focusing on the skills and competencies involved in breaking bad news to family members whose loved ones are facing almost certain death and facilitating the ensuing decision making in terms of next steps. Theater Delta's work script development protocol, including the selection of teaching points related to communicating difficult health news and writing of dialogue, is based squarely on research including a literature review, interviews of providers and family members who have experienced these issues, and observation of actual provider-patient interactions. The facilitation points were developed collaboratively by university health professions faculty and the theater director, using both research evidence and clinical experiences in palliative care work as foundation. For this performance, the research resulted in the designation of the following learning facilitation points: Understand. Understand what the family knows (disease, treatment options, likelihood of success) and what their primary concerns are before diving head first into the conversation. Be direct and clear. Be clear and direct with the bad news e avoid giving false hope Allow for silence and reaction/tears and processing. Do this. It is critical. Less is more. Less information at the beginning is better. Then ask if they have questions. And use their questions to impart more important information. And avoid unnecessary jargon. Be empathetic and warm. Maintain good eye contact. Exude warmth and compassion as authentically as possible (It's about HOW you say it). Do not get enter into an adversarial position with family members.
Results Seventy five adults attended the performance. The audience included undergraduate and graduate nursing, social work and recreation therapy students enrolled at the university. Others included invited health professionals working in palliative care in our local community (nurses, advance practice nurses, social workers and social service agency employees). A post-performance anonymous electronic survey was voluntarily completed by a convenience sample of 44 audience members (response rate: 59%) immediately after the completion of the performance and audience interaction. Theater Delta developed the survey, and it included both closed and open ended questions, to evaluate the impact and efficacy of using this methodology as a means to educate the local university community around these issues. A four-point Likert scale was used for survey responses, with higher scores reflecting more positive perceptions of the performance. Three sets of results are presented here: (1) the forced-choice survey responses, (2) a qualitative descriptive analysis of the open-ended responses, and (3) a report of an undergraduate recreation therapy class's assignment responses after attending this performance. Forced-choice question responses The survey instrument asked respondents to answer 10 forcedchoice questions, presented in Table 1. A Likert scale response from
D.K. Pastor et al. / Journal of Interprofessional Education & Practice 4 (2016) 15e20
18 Table 1 Post-performance survey responses. Question #
Question content
Percent strongly agreeing
Mean score
1 2 3 4 5 6 7 8 9 10
Were the scenes and characters realistic? Were post-performance conversations thought-provoking and constructive? Did the characters enhance the theater experience? Was the facilitator effective in the role? Did you leave the performance with more information than you came in with? Did the performance impact you in some way related to the issues presented? Did the performance lead you to re-evaluate an opinion regarding the issues presented? Did you intend to change some of your behaviors about the issues? Would you be likely to attend another Theater Delta performance? Would you recommend Theater Delta's performance to others?
68 82 84 89 77 63 35 36 67 73
3.7 3.8 3.8 3.9 3.8 3.6 3.3 3.3 3.7 3.7
1 to 4 was provided with 1 ¼ Strongly Disagree; 2 ¼ Disagree; 3 ¼ Agree; and 4 ¼ Strongly Agree.
(3) The experience was emotional and effective The audience responded with comments about the emotionality of the performance:
Open-ended responses Six open-ended questions were included in the anonymous online post-performance survey, and are presented in Table 2. Three of the authors (Pastor, Kolomer and Saypol) collaborated to identify descriptive themes in the 44 survey responses to the 6 open-ended questions. All are doctorally prepared health educators and are experienced in the use of qualitative data analysis techniques. Using open line coding, the team used a two-step process. First, individuals identified themes in the data, and then they collaborated to review individual analyses and come to consensus about the themes in the data: (1) Timing is everything
“The reality of this performance helped me to understand the process of giving back news better, both emotionally and practically.” “This was emotionally and intellectually engaging.” “I struggled with these same problems when my grandmother passed away, but I have a better understanding now.” “Loved the student interaction.” (4) Ways that I will change my behavior in practice Health providers and students were in the audience of this performance and stated: “Listen first, then act.”
Respondents stated: “You are dealing with real people and real issues and you need to meet them where they are.” “First, ask how people feel and what they know.” “These palliative care conversations need to happen early and it's important to open communication about end of life care wishes.” (2) Strategies and techniques to have difficult conversations Some audience comments included: “We start hard conversations with questions.” “As a provider of care, to facilitate effective communication, let them speak and ask them questions. They will help me set my teaching.” “Be gentle.” “There is a method of doing this right.” Table 2 Post-performance survey open-ended questions. 1. What information did you learn from this performance? 2. How has this performance impacted you? 3. How has this performance led you to re-evaluate your ideas or opinions about communication in serious illness? 4. If you intend to change any behavior after this performance, how will you do so? 5. What were the most effective aspects of this Interactive Theater experience? 6. What aspects of this interactive Theater performance could use improvement?
“I want to continue these conversations with employers, friends, coworkers and more specifically, with patients and with families.” “You should develop a relationship. It's about relationships and about communication.”
Undergraduate student responses A class of undergraduate recreation therapy (RT) students attended the presentation and wrote a “reaction paper” to address the following three questions: (1) What is palliative care? (2) Identify some of the issues related to palliative care and what was new learning for them regarding palliative care that they did not know before the presentation. (3) What role can recreation therapy play in palliative care and would this be an area they would like to be involved with? The vast majority of these students stated that they were unfamiliar with palliative care before attending this performance, or they did not know there was a difference between palliative care and hospice. In addition, for many of them it was their first encounter with advance directives. Although this knowledge is important for any health care provider to have, it was not surprising that some if this was new to many of the students. Palliative care and advance directives do not appear on the list of the top knowledge areas in a recent study by the National Council for Therapeutic Recreation Certification (NCTRC) (2014) and is not
D.K. Pastor et al. / Journal of Interprofessional Education & Practice 4 (2016) 15e20
mentioned in the curriculum competency requirements established for the profession by the Committee on Accreditation of Recreational Therapy Education (2010) (CARTE) a committee of the Committee on Accreditation of Allied Health Education Programs (CAAHEP). According to NCTRC, while the majority (32%) of Certified Therapeutic Recreation Specialists (CTRTs) work in hospital settings, most of these are behavioral health hospitals, and only 5.1% of CTRSs work in sub-acute care. Although end-of-life issues are not specially identified recreation credentialing or accrediting bodies, the need exists for recreation therapist to be knowledgeable in this area to be effective health care providers and team members. This was evident to the students and one student wrote, “… It is imperative that recreation therapists be well informed and aware of what has already been presented to the patients/family members, as well as where they are with their understanding and processing of the situation.” Another area related to the philosophy of palliative care. One student succinctly put it this way: “The current state of medicine is a rescue culture meaning anything less than recovery is failure. We need to switch from a rescue culture to properly bringing about transition to death a reality.” Two specific issues related to palliative care emerged from the students' reflectionsdcommunication and validation of feelings. In regard to communication, one student wrote: “Overall it really reiterated the importance of effective communication, not only between care providers with the treatment team, but also between the patient and the health care providers.” Another student wrote: If the palliative care doctor begins a conversation with asking where the patients/family members are in their understanding of the situation, asking open ended questions, and practicing active listening skills, then the patients/family members will all be on the same page and the palliative care doctor will be able to provide any new updates without confusing either party. The presentation also increased the students' understanding of the role of the palliative care physician and that “the palliative care doctor is not their [patient's] normal doctor.” Not only was the role of the palliative care physician and team made clear, but the student's gained some insight empathy for the process involved with communicating with family members. The doctor came across very real with the family about the palliative care situation but students recognized that the doctor should have communicated with more sensitivity. One student wrote: Trying to give the information to the family members can be tricky for the doctor because they have to give all of the options to the family to allow them to make a decision without making their own opinion direct or forcing their viewpoints on the family … I think that job is hard because they are meeting the family for the first time and have to break bad news to them and could potentially be viewed as heartless or uncaring because of their job role on the case. Another theme, that of validating family members' feelings, was as important to the students as was communication: “The presentation made me aware of how important it is to validate the feelings of the family members and make sure they fully understand what palliative care really is.” Another student stated: When working with a family and patient that are receiving palliative care it is most important to let the family express their feelings. If they are feeling upset hold their hand/give them a
19
hug, actively listen to them, ask questions, give them time to process what is going on. Do not impose your ideas/or believes with the families decision. As far as potential applications for the role of the recreation therapist (not present in the scene), the students consistently echoed the importance of quality of life and how this should extend to those receiving palliative care. Some students were more specific with how quality of life can be facilitated. For example, “RT interventions can include helping a patient search for meaning, confronting fear, deal with loss of control, and issues of loss,” and “we can provide an escape for those patients to enjoy themselves.” Still another role of RT in palliative care noted was, “I think the support group would be more beneficial for the patient and family.” Another shared, RT can “have a significant impact when working with individuals with serious or life threatening diseases. Our services are usually provided in a safe environment that creates a comfortable place for our clients to share.” Most of these students did not feel “ready for what this entails” when responding to the question about being involved in this area as an RT. “As an RT we learn that being mindful and allowing the patient and family to talk makes it a lot easier on the therapist or physician. RT can play a role in palliative care by providing assessments and daily living activities for the patient … I do not think I could discuss future plans for a family's loved one that is suffering/dying.” One student was the exception and explained that she could work with “a population like this because I have lost more than 20 people in the past four years and I think I can assist people and help them with coping and preparing for death.” This educational experience brought together the skill sets of multiple parties and inter-professional colleagues. The process involved forming this partnership, identifying the objectives and focus of the presentation, and integrating the lessons learned into curricular changes in the health professional programs at the university. Lessons learned and conclusions This experience required regular communication among university faculty, administration, funder, university health program directors and the interactive theater group. Many of the details about goals and purpose of the performance, script development and room setup were worked out collaboratively. Replication of this project in other settings would be possible with funding source, an interprofessional team focused on bringing a creative modality to health education and consultation with an interactive theater or performing arts group willing and able to engage in scholarly work to produce a realistic and evidence-based script and performance. Advertising included inviting local health providers in primary care settings, palliative care teams, long term care, home care and hospice. We collectively used our professional networks to spread the word about this unique performance widely. Scheduling the performance at a time when many faculty and students could attend required us to work with administration responsible for room scheduling and class and clinical schedules. About one-third of the audience were from organizations outside of the university. The use of an immediately available electronic survey captured a 59% response rate among audience members, a limitation of this study. This format for data collection also allowed easy sharing of the data among the faculty involved in this project, improving data analytic strategies.
20
D.K. Pastor et al. / Journal of Interprofessional Education & Practice 4 (2016) 15e20
Building an inter-professional team to collaborate on this project strengthened the quality of the performance, attendance, audience participation, and manuscript preparation, because it allowed us to view the experience from a variety of world views and professional paradigms. It also provided our students with a model of inter-professional collaboration. In order to face the real challenge of being able to fund an event like this without charging admission, we found it necessary to seek and secure buy-in from many community stakeholders such as the dean, directors, community engagement leadership and faculty across disciplines. The impactful scene of a physician character struggling to communicate with two adult children characters, discussing the choices of care for their mother (who suffered a stroke five days earlier) fully engaged the audience members and elicited many responses from them. The audience appreciated the opportunity to interact with the actors, as well as the lively interactive discussion facilitated by the theater director. One nursing faculty member related to the scene positively, as her own father had recently died and she felt that the medical information given to her family by the physician was “lacking.” One nursing student related that although it had been five days since the “patient” in the scene had sustained a stroke, the provider did not first ask the family “what they already knew.” A benefit was that several palliative care clinicians from the local community were present, and they shared their experiences in delivering difficult news and assisting families to begin making plans for end of life care. This performance allowed us to open the doors for an interprofessional audience, to provide education about how to best communicate with our patients and their families. While this performance was only one example, it certainly encourages other program evaluation on the Interactive Theater methodology, which very well might prove in the near future to be a universal evidence-based strategy to develop and practice skills in delivering ‘bad’ news in health care settings. This paper presents evaluation of using interactive theater as an educational tool to increase knowledge about communication in palliative care. References 1. Campbell ML. Breaking bad news to families of hospitalized patients. Mich Fam Rev. 1995;1(1):39e46.
2. Jurkovich G, Pierce B, Pananen L, Rivara F. Giving bad news: the family perspective. J Trauma. 2000;48(5):865e873. 3. Arnold RL, Egan K. Breaking the “bad” news to patient and families: preparing to have the conversation about end-of-life and hospice care. Am J Geriatr Cardiol. 2004;13(6):307e312. 4. Marcus JD, Mott FE. Difficult conversations: from diagnosis to death. Oshsner J. 2014;14(4):712e717. 5. Emmanuel LL, von Gunten CF, Ferris FD. The Project to Educate Physicians on End-of-life Care (EPEC). Module 2: Communicating Bad News. Robert Wood Johnson Foundation; 1999. 6. Baile WF, Buckman R, Lenzi R, Glover G, Beale EA, Kudelka AP. SPIKES e a sixstep protocol for delivering bad news: application to the patient with cancer. Oncologist. 2004;5:302e311. 7. Longsworth N. Making Lifelong Learning Work: Learning Cities for a Learning Century. London: Kogan Page; 1999. 8. Porter M. The Competitive Advantages of Nations. New York: The Free Press; 1999. 9. Dowling B, Powell M, Glendinning C. Conceptualizing successful partnerships. Health Soc Care Community. 2004;12:309e317. 10. Saypol B, Drossman D, Scvhmulson M, et al. A review of three educational projects using interactive theater to improve physician-patient communication when treating patients with irritable bowel syndrome. Span J Gastroenterol; May 2015:268e273. Link: http://www.reed.es/articulo.php?volumen¼107&numero¼5&seccion¼origin ales&articulo¼2754. 11. Kumagai AK, White CB, Ross PT, Purkiss JA, O’neal CM, Steiger JA. Use of interactive theater for faculty development in multicultural medical education. Med Teach. 2007;29(4):335e340. 12. Kaplan M, Cook C, Steiger J. Using Theatre to Stage Instructional and Organizational Transformation. Change, the Magazine of Higher Learning. 2006: May/June: 33e39. 13. Agogino AM, Ng E, Trujillo C. Using interactive theater to enhance classroom climate. In: Proceedings of the 2001 NAMEPA/WEPAN Joint National Conference: “Co-Champions for Diversity in Engineering.” WEPAN/ NAMEPA.2001:Apr. 21e24. Alexandria, VA. Champaign, IL: Stipes Publishing L.L.C.; 2001, 67-61. 14. Saypol Ben. Interactive Theater, an Engaging Knowledge Management Tool for IFC Training! World Bank. Washington, DC: © World Ban; 2011. License: CC BY-NCND 3.0 IGO https://www.openknowledge.worldbank.org/handle/10986/10440. 15. Rodriguez JI, Rich MD, Hastings R, Page JL. Assessing the impact of Augusto Boal’s ‘Proactive performance’: an embodied approach for cultivating prosocial responses to sexual assault. Text Perform Q. 2006, July;26(3): 229e252. 16. Saypol B. Effective Practices for Establishing an Interactive Theatre Program in a University Community [dissertation]. [Boulder]: University of Colorado at Boulder; 2011:252. Retrieved from ProQuest. (Order No. 3453786). 17. Yoshihama M, Toman RM. Using interactive theater to create socioculturally relevant community-based intimate partner violence prevention. Am J Community Psychol. 2015;55:136e147. 18. Lightfoot M. HIV prevention for adolescents: Where do we go from here? Amer. Psychol. 2012;67(8):661e671. 19. Skye EP, Wagenschultz H, Steiger JA, Kumagai AK. Use of interactive theater and role play to develop medical students' skills in breaking bad news. J Cancer Educ. 2014;29(4):704e708. 20. Beach W. When cancer calls. Accessed at: https://www.f6s.com/waynebeach#!
Contents lists available at ScienceDirect
Journal of Interprofessional Education & Practice journal homepage: http://www.jieponline.com
Using interactive theater to improve provider-family communication and promote inter-professional education and practice in palliative care Diane K. Pastor, PhD, MBA, NP-C, FNAP a, *, Candace Ashton, PhD, LRT/CTRS a, Robin P. Cunningham, MSN, RNC a, Stacey Kolomer, PhD, MSSW a, Barbara J. Lutz, PhD, RN, CRRN, FAHA, FAAN a, Stephanie Smith, PhD, RN a, Patricia H. White, MS, BS a, Ben Saypol, PhD b a b
University of North Carolina Wilmington, USA Theater Delta, Chapel Hill, USA
a r t i c l e i n f o
a b s t r a c t
Article history: Received 11 November 2015 Received in revised form 16 May 2016 Accepted 2 June 2016
Background: Palliative care practice often includes the need for health providers to have difficult conversations with patients and families. These conversations may include discussing diagnoses, prognoses, test results and care options. Purpose: This innovative project used interactive theater as a means of teaching undergraduate and graduate health professional students evidence-based methods for delivering difficult health news in health care settings. Method: The university partnered with a professional interactive theater company to host a production focused on care team communication and delivery of difficult health news to family caregivers of an older adult experiencing an acute stroke. Discussion: The use of this modality allowed audience members to interact with the actors, who remained in character, to discuss the case scenario. Conclusions: Audience members were surveyed using an investigator-developed posttest survey instrument, and positive quantitative and qualitative data confirmed the usefulness and feasibility of using interactive theater in educating health professionals. © 2016 Elsevier Inc. All rights reserved.
Keywords: Interactive theater Palliative care Interprofessional education
Introduction One of the more difficult tasks for health providers is delivery of ‘bad’ or difficult health news to patients and their families, particularly in the setting of adult palliative care. ‘Bad’ news means lifealtering health news or life limiting diagnosis or prognosis. Patients and families need to hear this news in order to begin making decisions for care.1 What do families and patients value in receiving difficult health news? Jurkovich, Pierce, Pananen and Rivara2 found that it was especially important that providers had knowledge not
Funding source: College of Health and Human Services, UNCW. The authors have no disclaimers or credits. * Corresponding author. 601 South College Road, Wilmington, NC 28403-5995, USA. Tel.: þ1 910 962 3482; fax: þ1 910 962 3723. E-mail address: [email protected] (D.K. Pastor). http://dx.doi.org/10.1016/j.xjep.2016.06.002 2405-4526/© 2016 Elsevier Inc. All rights reserved.
only in the content of the message, but in the strategy they used to deliver the news. Communicating difficult or ‘bad’ news is an essential competency for health providers, especially at the end of life,3 but it can be challenging and stressful. Communication training may be lacking in health provider education. Skills in knowing how to use evidence-based strategies to communicate with patients and families about a patient's terminal health status allows providers, patients and families to explore joint decision making.4 Communication skills can be taught, retained, and practiced.5 Beale and Kudelka6 asked clinicians what they found particularly difficult about these kinds of patient encounters and clinicians stated that their toughest challenges included: (1) talking about end of active treatment and initiating palliative care, (2) telling patients about recurrence of disease, (3) little training in breaking bad news science, (4) being honest but not taking away hope e finding that balance and (5) not feeling comfortable in dealing with patients' emotions or their own.
16
D.K. Pastor et al. / Journal of Interprofessional Education & Practice 4 (2016) 15e20
Purpose The purpose of this article is an evaluation of the method of using interactive theater as an educational tool to increase knowledge about communication in palliative care for health professionals and health professional students. Interactive theater was used with a group of inter-professional health care students and community clinicians. A mid-sized public southeastern university partnered with a professional interactive theater group to work toward the goal of promoting attitude and intended behavior change among audience members seeking to improve their awareness of the need to develop communication skills with family members around end of life decision making. There were three parts to the project: (1) develop a realistic script focusing on conversations between providers and family members around end of life decision making on behalf of loved ones (2) use an interactive theater methodology to promote audience participation, engagement of these issues, and dialogue around these issues and (3) evaluate the impact and efficacy of this methodology as a means to educate a local university health care community around these issues. Background: the university This health professional college was founded in 2010, and brought together several schools educating future health providers. The college acts as the doorway for the university to make a positive impact on the health and quality of life of residents in the region, state, and beyond. This college joined several schools educating health professional students with a mission to enhance health and quality of life across the lifespan for individuals, families and communities. Strategies employed to meet this mission include innovation and excellence in workforce development, scholarship, research, professional service and community engagement. The interactive theater program took place during a university-wide Health & Human Services Week, the College's signature health care community engagement event which included a variety of programs highlighting faculty, student, and community expertise in the health and human services professions. An interdisciplinary group of university faculty collaborated to write an internal grant to fund the interactive theater group's performance in spring 2015 on campus. Once the grant was funded, plans began to develop a partnership with the interactive theater group. Plans also included advertising the performance to our campus community (students, faculty and staff) and community health providers and agencies providing care to adults with serious illness. Developing a partnership: interactive theater The exchange of ideas between universities and the community provides mutual benefits for all involved.7,8 Allied health professions, particularly nursing and social work, emphasize the importance of community education as an integral part of the values of each profession. Engaging with local partners allows students to learn and faculty to stay connected to their fields of practice while meeting the needs of the local area.9 While allied health disciplines struggle to bring inter-professional groups of students together in the classroom and in the community due to with conflicting course schedules, facilitating inter-professional events may be a contributing factor to successful communities of clinicians. A key component to community education is creating an experience that is welcoming. This includes being accessible, affordable, and applicable. In seeking a partnership with a professional interactive theater performance group, the university sought to raise awareness about
provider patient communication in adult palliative care settings. The university was able to provide space and accessibility and the event was free to attend. Health care students, faculty and local community partners (hospitals, hospices, and community and public health practitioners) were invited to attend the event that addressed an issue of interest to all e how to start conversations around end of life decision making. The protocol was submitted to the University's Institutional Review Board (IRB) and it was determined to be exempt from further review. Our partnership with the professional interactive theater group grew out of the personal experience of one of the authors, who had attended a prior local performance of this theater group last year relating to perinatal palliative care. The experience of viewing and participating as an audience member was both powerful and empowering, particularly since it involved the smallest and most vulnerable of patient populations. As the authors began exploring means to involve both university and community participants in the initiation of discussions surrounding end of life decisions for adults, excitement grew as consideration was given to the possibility of utilizing this interactive theater group to raise awareness of these concepts here on campus. After contacting the director of the theater group, the authors were informed that the theater group was already working on the development of an interactive theater performance focusing on an adult palliative care scenario. The scene involved a provider breaking bad news to two family members about the terminal diagnosis of their aging parent, and the crux of the conflict was a difference of opinion between the family members about the choices for care for their loved one.
Interactive theater Interactive theater is a burgeoning experiential leaning methodology that has been used to educate diverse communities around a wide variety of health and health education issues. It has been used to: (1) educate gastroenterologists better ways to communicate around functional diagnosis such as Irritable Bowel Syndrome and raise awareness of cultural competence10; (2) foster critical dialogue around diversity issues with medical school faculty11 and college/university faculty12,13; (3) improve public-private dialogue in developing nations14 and provide sexual assault education with undergraduate students15; and (4) address HIV and other reproductive health issues with teens in communities in developing nations among others.16 Intimate partner violence prevention was the focus of a community-generated approach to use interactive theater with multiple Asian communities.17 Lightfoot and colleagues also used this modality to pilot an HIV prevention intervention to educate a Southern U.S. high school student population about sexual health, HIV knowledge and HIV stigma reduction.18 Medical students at a Midwestern medical school also responded positively when interactive theater was used to stimulate reflection about evidence-based strategies to break bad news to patients with cancer.19 Psychologist Wayne Beach is currently using theater to produce “When Cancer Calls,” a National Cancer Institute-funded film project to document how family members communicate about and manage cancer.20 Theater Delta is a five year old company founded by Director Dr. Ben Saypol, based in Chapel Hill, North Carolina, that has developed interactive theater projects with numerous medical communities, colleges and universities, the United States military, the World Bank, and other communities. Since Theater Delta's inception in 2010, they have developed numerous projects in the field of medicine which explore ethical challenges related to health and health care. Examples include physician-patient communication in the hospital setting, provider-patient communication in perinatal
D.K. Pastor et al. / Journal of Interprofessional Education & Practice 4 (2016) 15e20
and pediatric palliative care settings, inter-professional education, and even patient education and advocacy. Methods: format of the interactive theater performance The interactive theater performance at the university was conducted on April 7, 2015 and lasted 90 min. The script contained a scenario where two adult children (a son and a daughter) attended a care planning meeting with an inpatient critical care physician, caring for the two siblings' mother who had suffered a stroke five days earlier. The performance had three core components: (1) a highly realistic scripted scene that introduced, in a simulated health care meeting, key issues to be explored by audience members; (2) an opportunity for audience members to interact with the characters while actors remained in their roles e as the provider and two family members; and (3) opportunity for full participation in a facilitated dialogue, in which audience members shared their reactions to the scene and the interaction, identified the main issues or challenges, and offered examples for developing various clinical skills. The audience had the opportunity to ask the physician character and the “patient's” son and daughter characters questions about what they experienced during the care meeting. This allowed audience members to consider the choices of the physician and family member and analyze the reasoning behind their choices, as well as the impact of those choices on the family members and vice versa. These three core components are framed by an introduction by the facilitator, explaining the format, and a closing where the learning outcomes are reviewed and the audience is educated as to resources for further exploration of the issues. This comprehensive three step approach provides a structure for communities e in this case health professions students, faculty, staff, and local health care providers e to observe, analyze, and work to improve their knowledge about communication in adult palliative care settings. While the performance focused on adult palliative care, interactive theater can and has been used to address a variety of issues in health care as outlined above. It is also important to note that this is but one of many formats for interactive theater. The components of scripted scenario, techniques for audience interactions, and facilitated conversation can be implemented in a variety of ways. Interactive theater is a flexible medium, and formats can be adapted to meet the needs of the communities and their issues of concern. Script development process To ensure a realistic script and constructive conversation, one that accurately represented and raised the issues present in a problematic interview between a physician and family members in an adult palliative care settings, Theater Delta (in collaboration with university faculty) engaged in a comprehensive script development protocol. First, Theater Delta researched current academic literature on the subject of Adult Palliative Care and Breaking Bad News and conducted interviews and focus groups with providers and family members who have experienced the delivery of a terminal diagnosis. These actions were completed to understand the key issues and current norms/beliefs around provider-family communication in adult palliative care settings. Second, Theater Delta observed, over the course several days, eight challenging conversations between palliative care doctors and intensivists with family members of patients facing almost certain death to get a sense for how these occur and sound in real life. These observations were observed at a local regional medical center. Third, they identified teaching points related to communicating difficult health news for the participants (see below). Fourth, using the literature review, the data from the
17
interviews and focus groups, the data gathered during observations, and the teaching points related to communicating difficult health news, Theater Delta devised a high quality realistic script. The creative process includes: brainstorming, outlining, role-playing, writing, feedback from medical consultants (including university faculty) and the creative team, and revision. The focus of this performance was adult palliative care, focusing on the skills and competencies involved in breaking bad news to family members whose loved ones are facing almost certain death and facilitating the ensuing decision making in terms of next steps. Theater Delta's work script development protocol, including the selection of teaching points related to communicating difficult health news and writing of dialogue, is based squarely on research including a literature review, interviews of providers and family members who have experienced these issues, and observation of actual provider-patient interactions. The facilitation points were developed collaboratively by university health professions faculty and the theater director, using both research evidence and clinical experiences in palliative care work as foundation. For this performance, the research resulted in the designation of the following learning facilitation points: Understand. Understand what the family knows (disease, treatment options, likelihood of success) and what their primary concerns are before diving head first into the conversation. Be direct and clear. Be clear and direct with the bad news e avoid giving false hope Allow for silence and reaction/tears and processing. Do this. It is critical. Less is more. Less information at the beginning is better. Then ask if they have questions. And use their questions to impart more important information. And avoid unnecessary jargon. Be empathetic and warm. Maintain good eye contact. Exude warmth and compassion as authentically as possible (It's about HOW you say it). Do not get enter into an adversarial position with family members.
Results Seventy five adults attended the performance. The audience included undergraduate and graduate nursing, social work and recreation therapy students enrolled at the university. Others included invited health professionals working in palliative care in our local community (nurses, advance practice nurses, social workers and social service agency employees). A post-performance anonymous electronic survey was voluntarily completed by a convenience sample of 44 audience members (response rate: 59%) immediately after the completion of the performance and audience interaction. Theater Delta developed the survey, and it included both closed and open ended questions, to evaluate the impact and efficacy of using this methodology as a means to educate the local university community around these issues. A four-point Likert scale was used for survey responses, with higher scores reflecting more positive perceptions of the performance. Three sets of results are presented here: (1) the forced-choice survey responses, (2) a qualitative descriptive analysis of the open-ended responses, and (3) a report of an undergraduate recreation therapy class's assignment responses after attending this performance. Forced-choice question responses The survey instrument asked respondents to answer 10 forcedchoice questions, presented in Table 1. A Likert scale response from
D.K. Pastor et al. / Journal of Interprofessional Education & Practice 4 (2016) 15e20
18 Table 1 Post-performance survey responses. Question #
Question content
Percent strongly agreeing
Mean score
1 2 3 4 5 6 7 8 9 10
Were the scenes and characters realistic? Were post-performance conversations thought-provoking and constructive? Did the characters enhance the theater experience? Was the facilitator effective in the role? Did you leave the performance with more information than you came in with? Did the performance impact you in some way related to the issues presented? Did the performance lead you to re-evaluate an opinion regarding the issues presented? Did you intend to change some of your behaviors about the issues? Would you be likely to attend another Theater Delta performance? Would you recommend Theater Delta's performance to others?
68 82 84 89 77 63 35 36 67 73
3.7 3.8 3.8 3.9 3.8 3.6 3.3 3.3 3.7 3.7
1 to 4 was provided with 1 ¼ Strongly Disagree; 2 ¼ Disagree; 3 ¼ Agree; and 4 ¼ Strongly Agree.
(3) The experience was emotional and effective The audience responded with comments about the emotionality of the performance:
Open-ended responses Six open-ended questions were included in the anonymous online post-performance survey, and are presented in Table 2. Three of the authors (Pastor, Kolomer and Saypol) collaborated to identify descriptive themes in the 44 survey responses to the 6 open-ended questions. All are doctorally prepared health educators and are experienced in the use of qualitative data analysis techniques. Using open line coding, the team used a two-step process. First, individuals identified themes in the data, and then they collaborated to review individual analyses and come to consensus about the themes in the data: (1) Timing is everything
“The reality of this performance helped me to understand the process of giving back news better, both emotionally and practically.” “This was emotionally and intellectually engaging.” “I struggled with these same problems when my grandmother passed away, but I have a better understanding now.” “Loved the student interaction.” (4) Ways that I will change my behavior in practice Health providers and students were in the audience of this performance and stated: “Listen first, then act.”
Respondents stated: “You are dealing with real people and real issues and you need to meet them where they are.” “First, ask how people feel and what they know.” “These palliative care conversations need to happen early and it's important to open communication about end of life care wishes.” (2) Strategies and techniques to have difficult conversations Some audience comments included: “We start hard conversations with questions.” “As a provider of care, to facilitate effective communication, let them speak and ask them questions. They will help me set my teaching.” “Be gentle.” “There is a method of doing this right.” Table 2 Post-performance survey open-ended questions. 1. What information did you learn from this performance? 2. How has this performance impacted you? 3. How has this performance led you to re-evaluate your ideas or opinions about communication in serious illness? 4. If you intend to change any behavior after this performance, how will you do so? 5. What were the most effective aspects of this Interactive Theater experience? 6. What aspects of this interactive Theater performance could use improvement?
“I want to continue these conversations with employers, friends, coworkers and more specifically, with patients and with families.” “You should develop a relationship. It's about relationships and about communication.”
Undergraduate student responses A class of undergraduate recreation therapy (RT) students attended the presentation and wrote a “reaction paper” to address the following three questions: (1) What is palliative care? (2) Identify some of the issues related to palliative care and what was new learning for them regarding palliative care that they did not know before the presentation. (3) What role can recreation therapy play in palliative care and would this be an area they would like to be involved with? The vast majority of these students stated that they were unfamiliar with palliative care before attending this performance, or they did not know there was a difference between palliative care and hospice. In addition, for many of them it was their first encounter with advance directives. Although this knowledge is important for any health care provider to have, it was not surprising that some if this was new to many of the students. Palliative care and advance directives do not appear on the list of the top knowledge areas in a recent study by the National Council for Therapeutic Recreation Certification (NCTRC) (2014) and is not
D.K. Pastor et al. / Journal of Interprofessional Education & Practice 4 (2016) 15e20
mentioned in the curriculum competency requirements established for the profession by the Committee on Accreditation of Recreational Therapy Education (2010) (CARTE) a committee of the Committee on Accreditation of Allied Health Education Programs (CAAHEP). According to NCTRC, while the majority (32%) of Certified Therapeutic Recreation Specialists (CTRTs) work in hospital settings, most of these are behavioral health hospitals, and only 5.1% of CTRSs work in sub-acute care. Although end-of-life issues are not specially identified recreation credentialing or accrediting bodies, the need exists for recreation therapist to be knowledgeable in this area to be effective health care providers and team members. This was evident to the students and one student wrote, “… It is imperative that recreation therapists be well informed and aware of what has already been presented to the patients/family members, as well as where they are with their understanding and processing of the situation.” Another area related to the philosophy of palliative care. One student succinctly put it this way: “The current state of medicine is a rescue culture meaning anything less than recovery is failure. We need to switch from a rescue culture to properly bringing about transition to death a reality.” Two specific issues related to palliative care emerged from the students' reflectionsdcommunication and validation of feelings. In regard to communication, one student wrote: “Overall it really reiterated the importance of effective communication, not only between care providers with the treatment team, but also between the patient and the health care providers.” Another student wrote: If the palliative care doctor begins a conversation with asking where the patients/family members are in their understanding of the situation, asking open ended questions, and practicing active listening skills, then the patients/family members will all be on the same page and the palliative care doctor will be able to provide any new updates without confusing either party. The presentation also increased the students' understanding of the role of the palliative care physician and that “the palliative care doctor is not their [patient's] normal doctor.” Not only was the role of the palliative care physician and team made clear, but the student's gained some insight empathy for the process involved with communicating with family members. The doctor came across very real with the family about the palliative care situation but students recognized that the doctor should have communicated with more sensitivity. One student wrote: Trying to give the information to the family members can be tricky for the doctor because they have to give all of the options to the family to allow them to make a decision without making their own opinion direct or forcing their viewpoints on the family … I think that job is hard because they are meeting the family for the first time and have to break bad news to them and could potentially be viewed as heartless or uncaring because of their job role on the case. Another theme, that of validating family members' feelings, was as important to the students as was communication: “The presentation made me aware of how important it is to validate the feelings of the family members and make sure they fully understand what palliative care really is.” Another student stated: When working with a family and patient that are receiving palliative care it is most important to let the family express their feelings. If they are feeling upset hold their hand/give them a
19
hug, actively listen to them, ask questions, give them time to process what is going on. Do not impose your ideas/or believes with the families decision. As far as potential applications for the role of the recreation therapist (not present in the scene), the students consistently echoed the importance of quality of life and how this should extend to those receiving palliative care. Some students were more specific with how quality of life can be facilitated. For example, “RT interventions can include helping a patient search for meaning, confronting fear, deal with loss of control, and issues of loss,” and “we can provide an escape for those patients to enjoy themselves.” Still another role of RT in palliative care noted was, “I think the support group would be more beneficial for the patient and family.” Another shared, RT can “have a significant impact when working with individuals with serious or life threatening diseases. Our services are usually provided in a safe environment that creates a comfortable place for our clients to share.” Most of these students did not feel “ready for what this entails” when responding to the question about being involved in this area as an RT. “As an RT we learn that being mindful and allowing the patient and family to talk makes it a lot easier on the therapist or physician. RT can play a role in palliative care by providing assessments and daily living activities for the patient … I do not think I could discuss future plans for a family's loved one that is suffering/dying.” One student was the exception and explained that she could work with “a population like this because I have lost more than 20 people in the past four years and I think I can assist people and help them with coping and preparing for death.” This educational experience brought together the skill sets of multiple parties and inter-professional colleagues. The process involved forming this partnership, identifying the objectives and focus of the presentation, and integrating the lessons learned into curricular changes in the health professional programs at the university. Lessons learned and conclusions This experience required regular communication among university faculty, administration, funder, university health program directors and the interactive theater group. Many of the details about goals and purpose of the performance, script development and room setup were worked out collaboratively. Replication of this project in other settings would be possible with funding source, an interprofessional team focused on bringing a creative modality to health education and consultation with an interactive theater or performing arts group willing and able to engage in scholarly work to produce a realistic and evidence-based script and performance. Advertising included inviting local health providers in primary care settings, palliative care teams, long term care, home care and hospice. We collectively used our professional networks to spread the word about this unique performance widely. Scheduling the performance at a time when many faculty and students could attend required us to work with administration responsible for room scheduling and class and clinical schedules. About one-third of the audience were from organizations outside of the university. The use of an immediately available electronic survey captured a 59% response rate among audience members, a limitation of this study. This format for data collection also allowed easy sharing of the data among the faculty involved in this project, improving data analytic strategies.
20
D.K. Pastor et al. / Journal of Interprofessional Education & Practice 4 (2016) 15e20
Building an inter-professional team to collaborate on this project strengthened the quality of the performance, attendance, audience participation, and manuscript preparation, because it allowed us to view the experience from a variety of world views and professional paradigms. It also provided our students with a model of inter-professional collaboration. In order to face the real challenge of being able to fund an event like this without charging admission, we found it necessary to seek and secure buy-in from many community stakeholders such as the dean, directors, community engagement leadership and faculty across disciplines. The impactful scene of a physician character struggling to communicate with two adult children characters, discussing the choices of care for their mother (who suffered a stroke five days earlier) fully engaged the audience members and elicited many responses from them. The audience appreciated the opportunity to interact with the actors, as well as the lively interactive discussion facilitated by the theater director. One nursing faculty member related to the scene positively, as her own father had recently died and she felt that the medical information given to her family by the physician was “lacking.” One nursing student related that although it had been five days since the “patient” in the scene had sustained a stroke, the provider did not first ask the family “what they already knew.” A benefit was that several palliative care clinicians from the local community were present, and they shared their experiences in delivering difficult news and assisting families to begin making plans for end of life care. This performance allowed us to open the doors for an interprofessional audience, to provide education about how to best communicate with our patients and their families. While this performance was only one example, it certainly encourages other program evaluation on the Interactive Theater methodology, which very well might prove in the near future to be a universal evidence-based strategy to develop and practice skills in delivering ‘bad’ news in health care settings. This paper presents evaluation of using interactive theater as an educational tool to increase knowledge about communication in palliative care. References 1. Campbell ML. Breaking bad news to families of hospitalized patients. Mich Fam Rev. 1995;1(1):39e46.
2. Jurkovich G, Pierce B, Pananen L, Rivara F. Giving bad news: the family perspective. J Trauma. 2000;48(5):865e873. 3. Arnold RL, Egan K. Breaking the “bad” news to patient and families: preparing to have the conversation about end-of-life and hospice care. Am J Geriatr Cardiol. 2004;13(6):307e312. 4. Marcus JD, Mott FE. Difficult conversations: from diagnosis to death. Oshsner J. 2014;14(4):712e717. 5. Emmanuel LL, von Gunten CF, Ferris FD. The Project to Educate Physicians on End-of-life Care (EPEC). Module 2: Communicating Bad News. Robert Wood Johnson Foundation; 1999. 6. Baile WF, Buckman R, Lenzi R, Glover G, Beale EA, Kudelka AP. SPIKES e a sixstep protocol for delivering bad news: application to the patient with cancer. Oncologist. 2004;5:302e311. 7. Longsworth N. Making Lifelong Learning Work: Learning Cities for a Learning Century. London: Kogan Page; 1999. 8. Porter M. The Competitive Advantages of Nations. New York: The Free Press; 1999. 9. Dowling B, Powell M, Glendinning C. Conceptualizing successful partnerships. Health Soc Care Community. 2004;12:309e317. 10. Saypol B, Drossman D, Scvhmulson M, et al. A review of three educational projects using interactive theater to improve physician-patient communication when treating patients with irritable bowel syndrome. Span J Gastroenterol; May 2015:268e273. Link: http://www.reed.es/articulo.php?volumen¼107&numero¼5&seccion¼origin ales&articulo¼2754. 11. Kumagai AK, White CB, Ross PT, Purkiss JA, O’neal CM, Steiger JA. Use of interactive theater for faculty development in multicultural medical education. Med Teach. 2007;29(4):335e340. 12. Kaplan M, Cook C, Steiger J. Using Theatre to Stage Instructional and Organizational Transformation. Change, the Magazine of Higher Learning. 2006: May/June: 33e39. 13. Agogino AM, Ng E, Trujillo C. Using interactive theater to enhance classroom climate. In: Proceedings of the 2001 NAMEPA/WEPAN Joint National Conference: “Co-Champions for Diversity in Engineering.” WEPAN/ NAMEPA.2001:Apr. 21e24. Alexandria, VA. Champaign, IL: Stipes Publishing L.L.C.; 2001, 67-61. 14. Saypol Ben. Interactive Theater, an Engaging Knowledge Management Tool for IFC Training! World Bank. Washington, DC: © World Ban; 2011. License: CC BY-NCND 3.0 IGO https://www.openknowledge.worldbank.org/handle/10986/10440. 15. Rodriguez JI, Rich MD, Hastings R, Page JL. Assessing the impact of Augusto Boal’s ‘Proactive performance’: an embodied approach for cultivating prosocial responses to sexual assault. Text Perform Q. 2006, July;26(3): 229e252. 16. Saypol B. Effective Practices for Establishing an Interactive Theatre Program in a University Community [dissertation]. [Boulder]: University of Colorado at Boulder; 2011:252. Retrieved from ProQuest. (Order No. 3453786). 17. Yoshihama M, Toman RM. Using interactive theater to create socioculturally relevant community-based intimate partner violence prevention. Am J Community Psychol. 2015;55:136e147. 18. Lightfoot M. HIV prevention for adolescents: Where do we go from here? Amer. Psychol. 2012;67(8):661e671. 19. Skye EP, Wagenschultz H, Steiger JA, Kumagai AK. Use of interactive theater and role play to develop medical students' skills in breaking bad news. J Cancer Educ. 2014;29(4):704e708. 20. Beach W. When cancer calls. Accessed at: https://www.f6s.com/waynebeach#!