Impact of Medical Improvisation on Therapeutic Use of Self: A Randomized Controlled Waitlist Study

Medical Improv

Medical improv was introduced to health professions education as a novel way to address communication and interpersonal skills. This approach works to build interpersonal competencies by helping medical professionals develop the ability to listen closely to patients, focus on lived experiences and present circumstances, accept others’ ideas, and support one another through practice (Gao et al., 2019; Mehta et al., 2021). Theatrical improvisation involves a predetermined structure or foundational understanding followed by actors working together to react spontaneously and develop a cohesive scene. Typically, occupational therapy practice also follows a predetermined pattern of care with the interpersonal skills of instinct and improvisation guiding frequent adjustments in conscious communication and decision-making (Krusen, 2012).

Medical improv does not create actors of medical professionals but strengthens their abilities to respond to unexpected situations and interact with others who are different from themselves (Mehta et al., 2021). The Alda Center for Communicating Science (Bass, 2016) approach, or the Alda Method, focuses on connecting with and responding to others, knowing your audience and goal, empathy, and clarity. It uses verbal and nonverbal improvisation exercises, role-playing, and storytelling to teach students empathic communication (Kaplan-Liss et al., 2018). Individualized improv exercises are chosen to build awareness of self and others, developing empathy while cementing the ideas of communication, partnership, and connection (Alda, 2017). Gao et al.’s (2019) scoping review on the role of improv in health care identified components of best practice for improv program design: development and facilitation with combined theatrical and health care expertise; creating a safe and low-stakes environment; and using reflection, feedback, and guiding questions to explicitly connect medical improv to clinical practice.

In a recent program evaluation of the Alda Method, Preis et al. (2022) suggest that medical improv can improve communication in patient–practitioner relationships and recommend including occupational and physical therapists in medical improv training to improve communication and health care team cohesion. After the pilot inclusion of medical improv in an occupational therapy seminar, Krusen (2012) identified improvisation as an adaptive skill that blends art and science to meet the demands of dynamic, unpredictable health care environments.

Intentional Relationship Model

The intentional relationship model (IRM; Taylor, 2020) is the central conceptual model for the therapeutic use of self within occupational therapy education and practice and systematically outlines interpersonal aspects of the treatment process (Popova et al., 2022; Yazdani et al., 2021). The IRM suggests that competence in six therapeutic modes—advocating, collaborating, encouraging, empathizing, instructing, and problem-solving—is required for client and family-centered practice (Taylor, 2020). Each mode is a way of interaction, delivered verbally or nonverbally as intentional and dynamic communication guided by client and environmental characteristics (Yazdani et al., 2021). Appropriate mode choice and use involves a therapist’s ability to recognize 12 interpersonal characteristics, such as need for control, capacity for trust, preference for touch, and capacity for reciprocity. The IRM also identifies 11 inevitable interpersonal events, such as expression of strong emotion, power dilemmas, contextual inconsistencies, and boundary testing, which, dependent on the therapist’s appropriate management, may positively or negatively affect the therapeutic relationship (Taylor, 2020). Self-efficacy of therapeutic use of self is shaped by therapists’ perceptions of IRM components: effective therapeutic mode use, recognition of interpersonal characteristics, and management of interpersonal events (Yazdani et al., 2021).

Experiential Learning

This study assesses perceptions of occupational therapy students’ therapeutic use of self within a standardized patient (SP) experience (SPE). SPEs can have a positive effect on occupational therapy students’ performance skills and perceptions of fieldwork readiness (Sakemiller & Toth-Cohen, 2020). Hands-on experiential opportunities, such as SPEs, foster development of critical reasoning and therapeutic communication (Goldbach & Stella, 2017). Experiential learning in addition to academic coursework may combat clinical educator and student concerns with regard to inadequate hands-on experience, communication, and confidence levels in fieldwork students (Goldbach & Stella, 2017; Yazdani et al., 2021). This integration of experiential learning activities can blend academic concepts with the active decision-making required for fieldwork and clinical practice, facilitating competence and confidence. Student confidence in required competencies directly affects performance in clinical practice (Wolden et al., 2019). Application of learning to a real-life context, both within the medical improv intervention and the SP encounter, will support student self-efficacy and fieldwork and career readiness as students rehearse learned skills within a safe, simulated environment.

Purpose

Researchers hypothesized that the addition of medical improv to academic coursework would increase perceptions of occupational therapy students’ therapeutic use of self. A comparison of occupational therapy students randomized into intervention and waitlist control groups provides information about the effect of medical improv on student therapeutic use of self.

Method

Procedures

The study was completed in four stages (see Figure 1).

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Figure 1.

Study stages.

▪ Stage 1: All participants met for the course and study introduction and provided informed consent. A blind randomized block design randomized the cohort into two equal-sized groups.

▪ Stage 2: The 6-wk course required participation in five weekly lectures, 2 consecutive weeks of laboratory, and one SPE. The medical improv intervention served as the laboratory. The intervention group participated in the laboratory during Weeks 2 and 3 of the course.

▪ Stage 3: A family-centered SPE was completed during the fourth week of the course. Participants were provided with a case study of a child who was recently diagnosed with autism, and they were asked to complete an occupational profile with a SP acting as the parent of the child. The participants were blindly randomized to one of six SPs who were blinded to group assignment.

▪ Stage 4: The waitlist group participated in 2 consecutive weeks of 2-hr medical improv exercises. The intervention group met for lecture only.

Results

Discussion

All participants demonstrated a significant increase in self-efficacy of therapeutic use of self after the medical improv intervention. At Stage 2, there was a significant difference between the intervention group and the waitlist control group in the SETUS modes, SETUS traits, and SETUS total score subtests and a significant interaction effect in the SETUS modes subtest. Effect sizes for the SETUS subtests ranged from large to moderate (ds = .93, .57, .48, and .64, for SETUS modes, SETUS traits, SETUS events, and SETUS total scores, respectively). The waitlist control group responded with comparable increases in self-efficacy of therapeutic use of self after their intervention stage of the study. These findings provide the first evidence for the positive effects of medical improv in building self-efficacy of therapeutic use of self in occupational therapy students.

To our knowledge, this is the first study that addresses medical improv using a controlled design. Analysis of the SETUS within-group change only produced outcomes like those of the Hussain et al. (2018) article, the basis for the a priori power analysis. This study produced a positive response to medical improv that was similar to the responses from other health care professions who consider the components of therapeutic use of self as fundamental to their practice (Solman & Clouston, 2016). Obstetrics and gynecology residents (Cai et al., 2019), medical students (Neel et al., 2021), and occupational therapy students in this study demonstrated increased confidence in communication and empathy from pre- to posttest after medical improv intervention. This research further contributes to the body of literature by including increased rigor in study design and application of medical improv to occupational therapy.

The ECRS scores did not show a significant difference between the groups and may have been affected by a ceiling effect and social desirability bias. Because of the generous scoring by the SPs, there was limited room to demonstrate change. The SPs reported that they were “easy graders” and “wanted to help the students feel ready to become OTs.” Future studies could include increased training of SPs to establish interrater reliability or have blinded, trained researchers watch the recording of the experience and score the participants.

The mixed-methods ANOVA identified a significant interaction effect in the SETUS modes scores and not the SETUS traits or events subtests. The participants reported they were most familiar and comfortable with the intentional relationship model (IRM) concept of therapeutic modes. The other components of the IRM—interpersonal characteristics and interpersonal events—were not taught as explicitly throughout the curriculum, and many participants required explanations and practice examples. This may have affected participant perceptions of self-efficacy of interpersonal characteristics and events. An IRM review and the selection of improv exercises targeted toward these components of the IRM model may be helpful in achieving improvements in these areas. A larger sample size may also be beneficial in increasing power in comparisons between groups.

Although 36 may be a relatively small sample size, it represents an entire cohort of occupational therapy students, potentially increasing generalizability to other occupational therapy programs. Participants included students who were intrigued by improv and those who reported that it was well out of their comfort zones. The inclusion of the medical improv intervention within a required course reduced self-selection bias, allowing the researchers to gather data from those who were interested in improv and those who may not have agreed to participate in an external improv study.

The waitlist control group participated in a replication of the intervention, allowing for a comparison of the intervention and waitlist control groups’ response to medical improv intervention. Both groups demonstrated a positive change in self-efficacy of the therapeutic use of self with similar increase in scores. This similarity suggests that the study is reproducible. A manualized intervention may be helpful in supporting successful application of medical improv in educational settings. A medical improv manual could provide structure and procedures that also allow for individualization and student-centered practice (Blanche et al., 2011).

Implications for Occupational Therapy Practice

Therapeutic use of self is a distinguishing feature of occupational therapy, a cornerstone of the occupational therapy process, and integral to occupational therapy outcomes (AOTA, 2020). However, there is limited focus within occupational therapy education and a lack of clarity in its practice (Solman & Clouston, 2016). Medical improv provides an opportunity to increase the emphasis on the development of therapeutic use of self by integrating theory and practical experience. This study has the following implications for occupational therapy practice:

▪ The inclusion of medical improv in required coursework could enhance IRM delivery within occupational therapy programs, supporting ACOTE (2018) Standard B.2.1.

Conclusion

The study findings provide preliminary evidence for the effectiveness of medical improv and suggests that its inclusion in occupational therapy education will support the development of the therapeutic use of self and build the adaptive skills required to provide high-quality health care for clients and their families.