 Hi everybody and welcome to the AIN big topic. I'm Paul Z. Jackson and we don't get any bigger topics than the one that we're going to be dealing with today. And it's my pleasure to introduce Beth Boynton. I'm going to show her book Medical Improv. Excellent book. And Beth is going to talk to us on that topic and bring us upstate in current circumstances for up to the next 90 minutes. So welcome Beth, it's all yours. Thank you Paul. Nice to see everybody. Thanks for coming. I'm going to share my screen now, correct, with my, and then I'm going to find my slides and then we'll be off and running. Can you all see those slides? So Paul, I just lose myself when I, and I can't see everybody. Is it better to do it this way? We can still see everybody, at least I can. And I haven't seen your slides as yet. Okay. Let's see. Make sure I'm sharing my screen. That's it. You started screen sharing and your slides are pulling into you. Let me, how's that? There we go. That seems perfect. Thank you. I get, I can get very stressed about technology. So I'm glad you're there and the rest of you are all patient with my limitations. Thank you very much. So let me start and just ask what you're curious about. I have some planned things to talk about and share and being dialogue with you, but let's just hear from you first, if that's okay. So we're still a small number and if anyone wants to unmute and just jump in, that's fine. If we get a few more people then raise your hand, either digitally or physically. Let's just ask questions in the Zoom group chat, which is open and we can monitor those as well. Also for comments and ideas and references as we go along so we can build up a layer of other resources. I'm not seeing the chat box. Now I can see everybody. So I'm wondering, I'm going to go out and find, okay, I see it, but I lose it when I go into full presentation. So while we're looking for how we get the chat box on top of the screen, Steve has added a link to an article that is about leveraging improvisation to successfully adapt to disruption. So good article I read it earlier and recommend it. So that's the sort of thing you can put in the chat box as we go along. How are you doing with chat box, Beth? I do not see it. Okay, well, I'll monitor that for you. I'm going to drop in from time to time with the chat comments. Okay, so I think Steve's question about getting improv in with the disruption will come clear over the over the course of our time together, or at least as clear as maybe we can be at this point in time, knowing that there's not like a simple answer, but we will talk about it and we will talk about it. Curiosity. So I'll just dive in and trust that if you want me to stop at any point you raise your hand or do a chat thing and Paul will guide us. So in our time together, your questions, I do want to talk about the elephant in the room, and that is the COVID-19. Most of my work is proceeding that crisis. And yet it's such an international concern. We have, I think we have to talk about it and I do have some thoughts. So we'll see what how that mixes. And I also think that even though it is an elephant in the room, the elephant has been in the room for a while. It's just got a slightly different name on it. I think it's going to be a more urgent call to action for those of us in applied improv. I'll also talk about understanding health care, the culture, the dynamics, the challenges. Give you some examples of how I'm adapting some simple improv into healthcare situations and that seemed to be a bridge to some really good ideas and brainstorming about your ideas and vision for us. So first, you know, healthcare, and now with that cute little picture of the virus. I thought about this a lot. I reached out to a colleague of mine, Diana Crowell, who wrote this book called complexity leadership. It's a leadership book for nurses. She wrote the first edition. I co-authored the third and I do want you to know I forgot to say this earlier this morning. This has a section on medical improv in it as a leadership intervention. It's a textbook. It's not like fun to read, but I think it will help us to legitimize the work in the healthcare profession at least over time. It just came out in January. So anyway, I talked with her about how does this army of social skill builders, what can we do today? And our conversation, I think she had some great wisdom and that is to ask healthcare professionals, what do they need? What are their concerns? So my thinking is that everybody knows a nurse, everybody knows somebody or a doctor, somebody in their personal sphere of life, not as a patient, as a person, as a regular person. And if you can find a way to connect with that person who's currently working in healthcare and ask them questions like what do you need? What are your concerns? What's it like for you? And sit with them and listen to that and validate it, which is part of the skill building we do in healthcare. But that could be an important beginning to modeling what listening is in a deep way. And I think it will also serve to build a relationship with a healthcare provider who is going to be willing at some point when they're ready to be able to take in the value of the work that we do on a deep level and in a meaningful way. And that's, I guess I just have to qualify that, excuse me, probably right now, it's going to be even harder sell for teen building because it's just two people don't have time. The reality is they don't have time. So if we can make a relationship, model listening, and by the way, when we model listening in a way if I say what do you need, and I listened to that I'm actually helping to build assertiveness and other people. So, leaders who ask that of nurses who don't necessarily have a good grasp on expressing what they need they may advocate for others but they don't know it for themselves. That's a really good way to start to build assertiveness. Then I think we need to focus on using our work for play and stress relief. And I know there's stuff popping up on AI and using virtual ways for playing. I don't know that healthcare professionals are going to respond with to that with I have time because there's a tendency to be caught up in this constant reactionary mode. And yet I also know you AI and people are very creative and that we may have to create opportunities for that and that it's just incredibly important. So keep doing the online dialogue about virtual play and see where we can sneak that in. Then I think we have to be ready probably already are with skill building workshops and to consider that part of excuse my plot. Part of being ready is to understand that we I this is Beth Boynton's personal philosophy that as one system is falling apart we are also building a new one. And so how can we integrate our work into the new system and get it in at the very beginning. That's why in a way this is a really perfect time for for this work and our work. And so the places in healthcare to focus would be educational programs and continuing education orientation programs in hospitals where new nurses are just entering the field or physicians are just starting their practice. And also that I don't mean to exclude anybody that's interested. That's what I've been saying myself for the past couple years I do not try to sell this work to people. And yet I am very open to talking with anybody that's interested. So that's where the receptivity is and the readiness to embark on the work. So any questions or comments or more ideas from that elephant in the room piece. One question earlier when you're asking about questions from Joel very interested in understanding how to approach improv remotely. And I want to point out and welcome to the chain or Caesar. Hi. Hello, who has been absolutely instrumental in all of the online improvisation play sessions and conversations in China. So you may have a few things to tell us about how that worked and indeed whether any medical professionals participated. I don't know if they did or not. Anyone else has got questions then. I've got one comment. When you talked about kind of one system falling apart and building a new one. You know frequently I think of healthcare institutions as very top down and autocratic. What are your perspectives in terms of how we might be helpful in terms of those kinds of things. Well, you're right they are. And part of what applied improv provides is continual practice of pushing those limits to like rubber what I call rubberize the hierarchy, because of the sharing power. That's fundamental in improv. Where we start, we will, I think I think I will answer that question as I go on more completely Steve. Okay. It's complex. So I'm going to offer a definition. This is a little bit different than the one that's in my book it's an emerging definition. It's adapting the yes and philosophy and activities so that we can improve soft skills and critical outcomes. It's a broad definition and that's why I like it because any, any way that improv can be used to help us in any way with our outcomes and our skills to me. That's medical improv. So I think that applied improv in healthcare what language you use is less important to me, but because it has become a thing out there. It's good to have a definition and I think what makes it particularly different is that soft skill and critical outcomes If you look around online you will find there's some different interventions I think Belinda Fu and Katie Watson's definition is more geared to the field of medicine, which is great for the field of medicine. I think we need it everywhere so that's kind of why I lean towards the broad, broader definition. So, for applied improvisers to be effective in health care I think it's important to understand a few things. And first is how do the soft skills that we build and I'm talking emotional intelligence, communication skills, human interactive skills, teamwork, leadership, all the stuff we do. How are they related to key outcomes and we'll talk about that. Then I think it's important that you understand why it's so hard in healthcare to develop and practice the skills. And then third, how do we tweak the rules of improv so that they are most effective for the healthcare audiences and that's just a couple of places that it can be helpful to tweak them. So, first, what are the critical outcomes that I'm talking about. And, and I will qualify that most of my work has been in the states, and most of my research is in the states, however, in talking with other people, like you guys and other places I think the problems are kind of worldwide, but maybe some differences in some different language. But patient safety, number one, patient experience or customer satisfaction is another way to put that language, the health of the workforce, and ultimately cost effectiveness. So those are the critical outcomes. I think that because we teach soft skills they impact everything. But those are the big ones. In my next few slides. Let's look at how our soft skills important in these critical outcomes. So first, why do soft skills matter in patient safety. Well, medical errors are the third leading cause of death in the United States. It's been a known issue for almost 20 years now. And I've seen the statistics bounce around a little bit, fifth place, first place, seventh place, but the medical errors are huge, huge problem. Statistics in this country are as high as 100,000, I mean 1000 1000 deaths per day because of error in the United States. That's the highest number I know but it's a legitimate number and I'm happy to prove that anytime. Importantly underlining underlying those causes of those problems the most common reason we're making mistakes. There's three areas that show up its communication, its leadership and its human factors soft skills. So we have this huge problem and the underlying chronic pervasive reason is the soft skill factor. And it's still true. Even after 20 years of trying to fix it. I've been teaching improv and health care when I got my master's was around the turn of the century, and that was around the time that I was also taking improv classes, and building a consulting business on teaching communication because we were starting to see how important it was. The connection of the neuroscience that will come up later is that we know the fight, flight or freeze is that it's harder for us to access our critical thinking when we're stressed in the health care environment and so we can make, we can have a knowledge base that we can't get to if we're so stressed that we can't think that will make more sense eventually in the environments that we work in are often, often intensely stressful. My opinion, we're not getting at the roots of the problem, the roots of communication problem and human development in a way that's effective. I'm not trying to but not successfully. Questions out there so far so I keep going. Steve has a question. Oh, keep going. Thank you. I have a question. Yeah, like especially in Wuhan like in quarantine time in the peak time like February. We know that the patients crowded in the hospital and that they're quite big tense between the patients and doctors and nurses. So that's what I mentioned here is that like communication and how to release their relief their like tension and also pressure. That's the case. Yeah, I, and I want to I hear you. It sounds like a huge issue. And I want to have an answer for you Chang. I think that it's this place between the difference of preventing that kind of tension. I think that our work is very helpful in preventing it. Because even to the extent that we learn to identify social cues better as a nurse if I if I can read that body language better through practicing improv. I can deescalate. And yet, if we're if I'm trying to help you answer a question with a situation where it's existing right now. I'm not sure how helpful that will be right at this moment to be perfectly honest with you. And then I go back to that. What can we do right now, you know, listen to the healthcare professionals that you know have conversations to build a relationship, and then maybe you are creating the conditions where the teaching can be more effective. It's like, I think sometimes violence like preventing violence is one thing containing it is another, you know, our. So, I hope that's helpful and I wish I had more insights for you. Thank you. There's a couple of other questions, Beth. Oh, yeah. If that's the way to pronounce it has one do you want to speak your own question and I'll come in with mine. You need to unmute. That's it. Hello, hello. Hi, we can hear you. Okay, great. Thanks. Hi, I'm Jebe from Copenhagen, Denmark. I wanted to pose the question. How do you find that medical improv relates to the medical simulation trend tradition I find that I just started in healthcare this month have a background as an actor and facilitator and I find that there's a long and very strong tradition to using these kinds of methods, although it's termed in the use different terms, but, but the medical simulation tradition, I think it's really strong in this, in this area. So I'm just curious how you find that medical improv relates to that to that tradition because I see a lot of links but I'm curious to. Yeah, there are a lot of links. I think it's a matter of the healthcare system, like what medical simulation is for some that might not know is like this these are the programs where we practice clinical like practice a code of practice starting an IB or whatever situation in healthcare they're created so that students get to practice or practicing or clinicians get to practice. I think what we need to do in terms of improv is to create opportunities where the very fundamental skills are being built first because this there are elements of personal growth that don't they probably do get an opportunity for growing in the typical med sim issues people will learn oh I should have thought of that or I should have said this under that situation. The problem is, from my perspective that they're very clinically oriented. And so that's good I shouldn't say that's necessarily a problem. What's missing is this deep personal growth of learning to be more assertive and learning to be better listeners. I have some good examples of that. So it's like, it's like, we need to insert this work as a precursor to that work. Thanks to my question, which is, as you've shown communication is indisputably important in healthcare. And we also know that applied improvisation can raise communication skills. So how can our network, AI and applied improvisers do more to enable these two worlds to meet for mutual benefit, where and how are we already successfully making those connections. I'm not expecting you to answer that straight off the top of your head, but I think that's a good question for us as a community to be addressing and exploring there's a clear need and a clear offer. Which I think are not disputable, but they're not coming together as much as they might as far as I know. Absolutely. And that is an incredibly important question. And I would say, at least as a beginning is that the establishing the relationships and as more as familiar as applied improvisers can be with what they deal what the dynamics are. The bringing the work into healthcare will be like from an informed place. The more informed we are, I think the more effective I think an applied improviser can walk into a room full of nurses and have a positive effect. So it's not like you have to do it, but I think that you will have a more a bigger impact if you understand the dynamics and the nature of the work. Yes, let's ask that question and let's talk about it and I would be very happy to be a resource at any time. Thank you. Keep thinking. So patient. So another critical skill, a critical outcome that soft skills can help is patient experience customer service. We know from evidence that clinical outcomes are better when people feel that they're engaged and empowered that they feel heard. So teaching listening skills, one of what one of the ways to do it is to model them is extremely important. And so, you know, it's funny, you know the activity, same time story, also known as a story mirror where one person talks and the other one says it at the same time. I use that as a listening activity. And I had a nurse tell me once when she did that that was the first time she ever felt heard. And I was like, yes, it was like an awareness for me of where is that where is where do we need to meet them where they are in terms of the skill building. Because how do we expect somebody that doesn't know what it's like to be heard to be a good listener. So big moment for me. So patient experience and soft skills trust and communication are also very important in the placebo effect. And that's that take a sugar pill and you have there's a 30 to 35% improvement in your symptoms in many situations. So we don't really know what that is. There was a good episode on hidden brain a few months ago that had some good examples and healthcare about that might be worth Googling and listening to but ultimately, we know we build trust and improve communication and positive relationships and improv. So that will we can help healthcare professionals be better there. They'll automatically be better in any therapeutic relationship. We also know that patients and families are becoming more vocal about what they want so that this again raises the point of how important it is for healthcare professionals to be able to listen and communicate with folks so that we are hearing them. One of the most well read articles on my blog is called the importance of listening and healthcare. Unfortunately, I did not write it. It was written by Ali Nitsky, but I'm seeing that like more and more people are watching that. So in a way, Paul, I think, maybe there's at least an interest in the soft skill going on out there. And by the way, before this COVID-19 nightmare. Or exciting opportunity or both happened. I was seeing a trend of more inquiries for applied work. So medical improv. So I think there's some energy shifting. And ultimately in the United States hospital reimbursement is dependent on survey results from patients that and many of the questions in our survey have to do with communication. Did you understand the medication that you were given? Was your doctor respectful? Those kinds of things. So we are starting to at least measure them. And the workforce to break this down into physical harm and psychological harm. These are just some reality checks for you to know about. I would not be surprised that they are similar in other countries and happy to hear from you if you know that they are or aren't. Huge chance of being assaulted doctors and nurses more than a cab driver in an urban area. Up to a third of nurses experience back or musculoskeletal injuries every year. And the number of injuries are higher for nurses than construction workers. And so in these statistics that are interesting. There's the violence towards healthcare professionals like for instance somebody running into the emergency room with a gun. That kind of stuff or somebody that's, you know, I had a patient try to choke me once when they were withdrawing from morphine. It's like patient to to nurse. But there's also just the physical demands of the job itself that that are, you know, moving patients around and, you know, we can have protocols but there's not enough staff. I gave the example earlier of boosting up a patient in bed which really should have two people if not more. So I'm in a room by myself with a patient that needs to be moved and they're crying and pain, something urgent is going on, and I'm yelling out to I need help I need help, but we don't have enough staff to come and help me. And so I try it myself and then I have a back injury. Then I go to the doctor's office and I get into the system with the healthcare occupational health and they're saying well what happened you shouldn't have done that by yourself and it's like. It's a staffing issue, which also is related so so the soft skill component are we need to ask for help, which I did in that scenario, I need to be able to set limits which I did not do I could have said no. I can't move you I hear you're in a lot of pain and I want to help you but I can't move you till somebody else comes. So there's an indirect idea that the more healthcare professionals that are able and willing to speak up about what we can and cannot do and respect each other for those those limits that we will start to have a stronger collective voice to get more staffing. Staffing has been an issue since I've been in healthcare and that's like over 30 years ago. So the communication part of the that seems to be indirect but it is definitely there, in my opinion. And then the psychological harm and we talked about this fair amount this morning that there is a serious pervasive problem of bullying and emotional abuse in healthcare. It tends to be you know there's the doctor to the nurse nurse to nurse the higher you are up on that hierarchy that you mentioned earlier Steve. The more likely yours to see that abuse as a as a more aggressive form of disrespect. If you're in nursing or home health assistance or in housekeeping you might see is more passive aggressive abuse. It's, you know, gossiping and undermining. In any case the what what what improv can do for us is to help us learn how to have respectful relationships respectful communication. That's the opposite of all this we are so creative as human beings to come up with all these different ways of being just respectful to each other. That it, you know, so I see improv as a way to start to build healthy, healthy skills and healthy relationships won't help what Chang's talking about right now in this moment but in the long run, it will, I believe. And we also have as you might expect if we have all this bullying going on we have burnout compassion, fatigue, suicide, so there's a doctor whose job now or whose life's work is in helping doctors who are considering suicide because those statistics are growing up. So, and you know what to bring this back to soft skills. You know, if I if we talk about burnout. I need to be as a nurse I need to know how I'm feeling. So I have to have the self awareness that's an emotional intelligence piece. I also need to be able to express that in a respectful way that's an assertive piece. I also have to be able to be expressing it to somebody who's able and willing to listen and validate me. It's another soft skill, often what happens is if I said oh I can't work overtime. I might get a response. Well, I've worked overtime, you know, or there's the door. So we're not really cultivating the skills in the way and I'll say again because the more I say it the more I think the idea of having finding a healthcare professional and modeling listening could really be one of those butterfly effects that has a system wide effect in time. So any questions about that so far the critical outcomes. Yes. So I'm going to invite Kevin to speak he's come up with some research on the UK. Some statistics on medication errors and so forth, and also an example of where there's an opportunity for collaboration. My stats were just to back up your stats basically no more than that. But in the UK there are 200 million medication errors in a year. And, you know, 80,000 nurse injuries into their backs every year in the UK, which are related to work and 3600 are retired, forced to retire early. But the example I have is just to give you my background and help organizations with change and process improvement operation excellence so one piece of work I did was in delayed discharge. So this is when the patients medically fit. But for all sorts of reasons they can't be discharged. And those reasons are, you know, friend, a family and friends not that to look after them. No one said to issue medication that the bathroom can be hasn't been adapted. There's no place in the care home. And what happens is because of a lack of collaboration, then often the people making those decisions decisions make the most costly and maybe the least effective decision because they just need to move this patient on, rather than making the best decision for the patient in the in the in a in a fuller picture. So examples of this, just a very simple example is that friends and family asked to collaborate and asked, for example, could you could you turn up early in the morning before you before you go to work and administer this drug to your mother. And they say yes, I'm happy to do that. Well they can be discharged because someone in the morning will turn up and give the drug but because those questions aren't asked. Then people are moved into into holding positions, which actually don't suit them or anybody else. And that I know for a fact because I've actually spoken to those care workers, you know, interviewing them, and some of them are very good at trying to work out improvise and try and find out the best solution talking to all the different stakeholders. And some of them think, I just, you know, I just, I'm just going to move this patient on and get on to my next patient, you know. Yeah, so I'll pause that thank you. Thank you for sharing that Keaton, hopefully I'm saying your name right that's a, it's a great example I think it helps us to look at, well how did that problem happen in the first place. You know that this was our social system strong enough to support that person I mean that's like a complex quite big question. And that person wasn't ready to go home they would that was like a clinic the clinical problem has been solved, but it's a social problem that's keeping in them in the hospital. Right. And I think we're seeing that and have been forever we have created a system. And I think that has to do with. I hope this is going to make sense because it does. But it's like we are system healthcare providers. Let's talk about nurses and doctors in general that there's a lot others have a tendency to go into that business because there are intrinsic rewards from helping people from taking care of people. Now, if those intrinsic rewards are out of whack and become more secondary gains, like I'm in this business because I'm fulfilling an emotional deficit of some sort and I haven't addressed that, then it gets mixed up with clinical decision making. So, so here's I'll give you an example on a small scale and then ask you to just imagine what it would be like on a big scale. I'm a nurse and I'm taking care of somebody and we have a really nice report going on. And I know that the, let's say I'm leaving that job. And so this now there's this loss of the therapeutic relationship. If I have healthy boundaries, I'm going to do things like, Oh, I want to introduce you to Margaret because Margaret's really a great nurse and I know you're going to have a successful relationship and she's going to be able to help you. She's going to be even better than I am. Sometimes what happens because of those secondary gains is like we're getting something from the relationship that's not necessarily healthy. You know, in terms of being clinicians that we're getting the secondary gain that might keep me from, I might think well, that relationship is telling you that I'm a good girl. I'm a good person. So we thrive a little bit on that. That makes some sort of sense psychologically. So now think about, let's say doctors and nurses on a large scale. I'll probably get a lot of mail now if this people are watching this. But if there is if there was some element of secondary gains that are part of our decision making that that can contribute to a system that's like this, you know, we're we nurture the dependence. You know, we should be nerd. We should be empowering people, but we nurture the dependence and then we resent it. You know, because we don't have time anyway. So complex question complex example and hopefully helpful thinking. I did not put in a slide like I said I would about cost effectiveness and soft skills, but I will just say that when we're not operating as a team and communicating, then we're doing things that and billing for things that we shouldn't and I think your example Keaton that you just said we're going to a higher level because we didn't have an effective communication in a much more simpler way where people are coming into appointments, but we don't have their records yet. So there's a communication issue and the appointments wasted everybody's times wasted. People get resentful because we don't have the time to waste, so on and so on and goes, but there are billions of dollars that gets get wasted in this country, because of what we do or don't do that we shouldn't be doing that have a communication element. So what makes healthcare unique, different from a business of maybe building phones or something. Not to say that those businesses aren't high stress but here in healthcare, almost everything we do is urgent to somebody. And so there is like this chronic nature of urgency that goes on. And we do also think that sometimes our secondary gains give us like this helps us to avoid doing some of the work that we should be doing. But also the high stakes. If we make a mistake, a simple mistake could lead to a huge problem and I mean that horrible outcome for somebody, all those medication errors. And some of the sentinel events they seem absolutely ridiculous that we would in surgery cut off the wrong leg, or do the wrong surgery on the wrong person it seems completely ludicrous. I will show you an activity called overload in a few minutes, or we'll talk about it a little bit but this goes back to the higher thinking, can we access our higher thinking. And you might just make a side note to Google interruption awareness, which is a video from a few years ago, where I use the overload activity to show some statistics although they're dated at this point but they do link to this, the high stress component that we can't think in the moment. And, you know, now that I think of it does a Brigham and Women's Hospital in Boston which is a fairly well known teaching hospital has a simulation department called Spartus. And the reason I'm bringing up bringing it up is because I'm going to be going down whenever we can schedule it to meet with a physician who's a director of that and his name is Charles Posner. And I happen to note in his in their annual report a quote from him, and it is about with respect to patient safety he says almost always the answer is in the room. And I think that and so he's in charge of the simulation department will kind of ties everything together that we're not getting at the answer that's in the room. Partly because of stress and partly because of communication skills. He, he understands the problem. I don't really honestly think yet because we haven't gone deep into a conversation understands that how deeply rooted the problem is in terms of social emotional learning. So that and that goes back to that precursor question yet they met some stuff. Anyway, we mentioned blaming and bullying cultures. Soft skills is different from clinical skills. Most healthcare professionals, even the educators in healthcare attempt to be really good at teaching how to start an IV or what are your, what's the anatomy and physiology the much more intellectual things, even though there can be a hand I coordination issue. It's not the same as the personal growth for developing self awareness and self confidence. I see another perspective those are the kinds of soft skills that improv is like so golden for that we so need. But it's different so we don't get that much exposure to it. I'd like to say a minute, talk a minute about the emotional risk in this personal growth. And this is on both sides. Listening and speaking up have an emotional risk that's often either undervalued or not understood or just not even known when I'm learning to be assertive. And that's been part of my life work as a person and as a mom and a nurse and whatever. To take the risk of saying an idea or concern means I'm making myself be more accountable and putting myself out there in a place that can feel scary to me. On the other hand, if I'm learning how to listen, I'm learning to let somebody else in on the equation. There may be liability issues that make that even more complicated. But again, there's an emotional risk of letting go in sharing power. So I think that's one of the reasons why, even though we've been trying to improve communication, we haven't gone down at a depth that has helped us to learn how to share power, which we all know that improv is amazing, provides amazing opportunities to do that. Team composition is changing all the time. I do that working team development know there's a process anytime people come and go in the team, the process begins and ends again. This just makes it be like this constant ongoing change. I probably already made the point that we have don't have experience sharing power that's in that in the hierarchy that it's kind of top down and not more wishing wavy that it needs to be educational programs. One of my books is another a different textbook a successful nurse communication is a textbook textbook for nurse communications. One of the challenges and selling that book is that many nursing programs do not have courses that are for that are just for communication. And the reason for that is that their curriculum is so packed with clinical stuff that we don't have time to focus on it. It's not a, I don't offer it as an excuse my answer is make the time but that's the reality. We need to know that patients are vulnerable. They could be intimidated by the power dynamic. And they have a range of dependency some people an older person might come in who's been taught all his or her life. Oh, do what the doctor says. So we think that that. How do we empower that person versus how do we empower somebody that comes in that in that may actually know more about their diagnosis than we do. It's an interesting dynamic healthcare my feeling is healthcare professionals need to need to be able to respond to this continuum of dependency while always shifting towards empowerment. And also leaders need to be collaborative and directive and be able to shift between the two of those and I know that you know how wonderful and how many activities can help build those skills and improv in the simple ones with mirroring. It's important because we in the hierarchy we have people at the top that are used to just being directive and people at the bottom who are just used to being, you know, following the rules, when in reality we need those people at the top the doctor needs to be able to, or the nurse whoever's in charge of the situation needs to be able to direct a clinical decision making at the same time that they are receptive to getting input so that the housekeeper can say, Hey, wait a minute, there's this blood on the floor or the nurse can say hey wait a minute that's the wrong leg. We have to be able to be able to do both not just one questions on that stuff or comments. I'm writing some stuff about mistakes, which is one thing. Then I've noted some points about this really interesting question that improvisation may have some answers to of how healthcare professionals shift from patient dependency or staff dependency towards empowerment. Kevin says here in the UK GP is often asking first, what did you read on Google, when the patient is presenting in order to connect with patients. Right. And I mentioned that improvisational activities, almost all have some elements that illustrates a non hierarchical way of working. We'll see in your examples later. Yes. Yeah. I think that's a great example of community. That's a great empowering statement to walk in the room you're showing that you're confident. You're in your role as I'm sorry I don't remember what your role is but some sort of a healthcare professional, and you're saying what have you learned on Google so you automatically build a relationship you starting to build trust by saying I want to know my information really is not going to be helpful, unless we have a relationship and hey maybe I'll learn something it's it's a it's that's a confident place to come from onward. I'm going to say just a couple of things about the rules and I'm sure we all have different rules and the rules that I have in my book I sometimes use all of them and I sometimes just use yes and and but there are a couple that are worth mentioning in terms of the difference between health using applied improv and health care. And one is, I don't celebrate failure. And the reason for that is that creates such an emotional reaction with all of the mistakes and all the pressure we have to do things right. I tend to use language that's let's celebrate risk taking we're human we make mistakes so you can get that in there. And that actually helps create conditions so that instead of a blaming culture granted it may take years to get there but instead of a blaming culture we're creating a culture where it's okay to be wrong. And that can be pretty scary if if what you did was wrong caused a big problem for somebody but anyway it's just it's a language thing it's my preference. Avoiding questions I've seen some improved instructors use that rule and some don't and I've come to learn that if I'm working with a group of nurses or or women if it's not health care specific. I am more likely to use that role. And maybe you guys have seen this as well I'd be curious but I know that if I'm building assertiveness. If I'm with a group that needs to build assertiveness, they need to not ask questions because asking questions gives their power away instead they need to ask questions I mean to. They need to make statements declarations. I think you know that. But if I were dealing with a group of physicians, I might not use that rule at all. In fact, I might say it's okay to ask questions because that is part that can create an environment for making room for other people part of a listening of moving over and sharing your power a little bit. So it's just a little dicey in terms of when I use that rule or not. I find that health care professionals need to be nudged to say hey you know it's okay you can make things up and that's just a. Oftentimes, we're so you know our clinical brains and intellectual brains are trying to say the right thing. We're trying to have permission and just kind of, you know, say just relax you can make it up. And lastly, I added this rule observers play an important role, because a woman in one of my classes a psychologist was terrified she was so terrified and doing improv and I do non performance. I guess that that word can sometimes performing is means different things to I do improv for people to play and grow. She said she came up to me after she said she just couldn't do it she was so scared. And it makes me got me to start to thinking that there are people sitting around in the room that I'm much more afraid than I realize. And new new classes I usually say it's okay to watch I asked that you participate in a deep brief so I give them a role to, you know, pay attention and notice what you whatever the context is if we're learning assertiveness or we're building trust or diversity or whatever. Be an active observer, and then maybe later on in the class, invite them to participate so I give a little room for that. You guys, have you found that you use the same rules and healthcare or any thoughts on that. While people are thinking of coming in. I really support these things that you're saying that where applied improvisation thinks it can just take stuff from the stage and there's no adaptation to real life. I'm going to all these horrible traps of, for example, celebrating mistakes, which is just completely inappropriate and is approachable within applied improvisation, and indeed theater improvisation by rewording things, celebrating restaking, encouraging people to have a go being more aware of context dependency than anything that anyone has to say. So some of these traditional rules of improv, as soon as anyone thinks that any kind of universal these to trouble, and you've got some great examples here of how you've modified what's coming there. I think part of what the applied improvisation network should be doing is working out what principles do apply beyond the theater or even better without the theater. So taking performance as well and it's a great step. So I'm sure other people might want to come in on that just to raise a hand and jump in if you would. Yeah, this is Steve. I think I like the reframe there Beth in terms of celebrate risk taking instead of failure. The other term I'm hearing now is for a long time and creativity innovation was like fail faster. Now I'm hearing a reframe of learn faster. And that seems to resonate better with the world, the world that I work in in terms of manufacturing those kinds of things. So I really like your reframe there. I like learn frame learn faster too. And maybe it's a judgment call for the for the vibe that you're feeling in the room a little bit. I think because risk taking is is really where we're asking people to grow in terms of speaking up and listening that it might. Yeah, and I think that industry wide I like risk take celebrate risk taking better because the stakes are so high. So I like the idea of just reframing it. So it's Joel I can see how I really like the reframing of risk taking for the business context I don't. I'm not in the medical field at all. This is fascinating. And how does, how does that go down with people the notion of celebrating risk taking in a medical context on the healthcare context. With my work. It's pretty good. I think my skills, creating a safe environment to begin with and doing low risk activities at first, and then giving an example. Yeah, is a great way to kind of ease into that and then people have the experience. And I usually like, you know, I might make a mistake and go and then we all laugh and it's okay to kind of create an environment Honestly, and another thought along that line Joel is that I think I do think people want to learn and want to have these experiences so as we make it safe, then that there is a relief from it. You know, a natural human evolution going on. Yeah. Any other thoughts about the like principles or Move on. Catherine here. I really like this. It's great. In fact, I've instantly made some notes and I wouldn't change a couple of things in my own in processions immediately. So thank you. One thing I was one thing I have added to this, which I've started to do is really when I'm very diverse bunch of people is I've asked them to be themselves. And I know that sounds obvious. Why would people not be themselves. But I often say just be yourself all the way. So for some risk taking is not about. I don't know if they're quite become loud. That's not what we're asking risk taking is to within the confines of where they are to take risk, if that makes it makes it for them for me, risk taking, I'm quite a, you know, I guess I'm an extrovert, my risk taking made to shut up, you know, and that's something, you know, often or maybe I don't do and that might be the risk I need to take is to just go quiet and let's see what other people have to say. So I think that's for me I just just a point to make. I think it's a beautiful point because in the magic of improv when you do that, when you have that awareness and you do that your partners automatically going to have the opportunity and maybe a nudge to speak up. So you're teaching each other while you're learning and you're learning different things in the same moment. And that's why I get like, oh my God, that's it can help us in so many ways. I'll have an example coming up that will illustrate that in a video in a second. So thank you. And something into that as well which is that that risk taking that happens in the workshop is different from the risk taking that happens in your real life so we're not training risk taking. What we're doing is training the epimedia that point about psychological safety. So it's, and there's plenty of research that shows that the more psychologically safe the environment, the fewer mistakes get made. And there's a very interesting thing thing here about that there's, there's an increasing amount of understanding that if you can get the team working better, and it takes soft skills to do that. There are fewer errors, and fewer failures, but getting people in the room is great but then they end up going back into their, into their everyday work and you've got the systemic impacts that stop that. And it's almost like we're in this situation where everybody knows this is right. We're going to get past the systemic barriers to, well hang on now you're just going to play as a, as a response because we're really busy and, and, and it's a, it's a thing which. Do you know the idea of square square wheel syndrome. I'm getting it from what you're saying. The square wheel syndrome is there's a guy pushing a wheelbarrow that has square wheels it's really hard. Yeah, and he's there somebody comes running up with a round wheel. And they can look like I've met a round wheel and he goes go away I haven't got enough time to look at that. It's a kind of it's one of those things where if you've been persuade people and get them to slow down. You can massively improve things. I think there's a lot of what you've, you've, you've talked about today has been the kind of, we need to get past that square wheel syndrome because nobody's going to disagree with what, what, what we're saying. But how do we get get past the system to allow it to happen. Well, I don't have, it's a great question. You're not expecting me to answer really, although I do think that this is a helpful step in that direction, because it looks at it from a, it's a systems. It's a leadership book for nurses with a mindset of how do we fix the system. And one of the interventions is improv so and it just came out we're not there yet but I think so this that this every time I think we model. A skill we're helping at what's I guess I tell myself. Just keep doing it just keep going. Just keep swimming. It's not going to be easy we do have we have what the healthcare system needs I believe that intellectually, spiritually, physically I guess emotionally. So, make that come about isn't going to be easy. However, right because even though it's like this crazy nightmare time with the virus and everything all over the globe it's also bringing people together and having conversations. And as one system falls apart and another one is being born week, we can be intentional I believe about making sure this stuff gets into any new system from the very beginning. So I want to be very intentional about that. That's all I know, I'm going to go on to the next slide. So here's an example. This is going to be an example of using extremely simple activity called radical acceptance. You might know it is three things. I learned it from Jude trader wolf. And then when I started trying it I saw wow this is really getting helping us get to the depth of where the learning needs to be. And it's so simple here, but it's quite profound so this is how the game is played this quick clip I'm going to first make it big. So that's how the activity is played. It's you pick any category in this case it was dessert and then you have this increasing responsiveness of affirmation and I cannot under estimate or over value whatever the the value of doing this activity in healthcare is extremely important because it gives people a chance to see what it feels like to feel affirmed, which might be missing you might imagine it missing and in a system where blaming and judging and bullying our predominant the feeling that affirmation from a group. Well at the same time the group is practicing to affirm their colleague. So it's a very fundamental. And in terms of finding your voice, we're also getting to this place of member I mentioned earlier about the neuroscience of being able to get to our higher thinking, and Dr. I have a comment about the answer being in the room. This is where we're going to build those skills. I've done this. I'm going to and I'm going to give you an example in a minute but I'm going to keep talking to I've seen people do this activity, and literally freeze the heart is so scary. Excuse me and again so that's that's that's feedback for me to say oh my goodness I really need to make this activity as safe as, as safe as possible, which I do by telling people you can say the same thing three times. You can say your name or the word pine cone, if that's what you want. There's the group to be patient so they are listening and then they are kind of practice so in this moment. We're diving into this human evolution of where fight flight or freeze exists, but we creating safe opportunities outside the clinical environment to start to practice to work through those impulses that limit our ability to communicate. This in this next. This is the same activity just somebody else doing it. And in these first few seconds you're going to see what I'm talking about in terms of working through this, the deep rooted fight flight or freeze and finding her voice. So let's make that bigger. So did you see were you able to see that first couple of seconds. It's almost imperceptible if you weren't looking for it you might not see it but it's like this. strawberries. Played again sure. Sorry. No, you're welcome or whatever. I love this moment. So that's a type of experience that if you were more extroverted. I might not even have that experience of what might have been hard for you in that moment was waiting to say yes. So we have an introverted person who's finding their voice, they're working through their impulse that keeps them from speaking up an emergency to say that's the wrong leg or that patients are allergic to that or there's blood on the floor. It's the same place, but what we're doing is creating safe opportunities to practice and with our peers. So what we get is a result of a positive experience. Meanwhile, the people that are waiting for her to talk they might be thinking say brownie or you know they might have an idea that they wanted to say. So it's a very root it's at the very root of. I think human evolution, and that's the place that we're not getting with on with the med sim. It's the departments that we already have we're not going that deep. And we should. Any thoughts about that, or questions. Does it make sense. Yeah. Yeah, I was just wondering what the rules are and how you may be set up. Sure, sorry. It's basically pick a category. And could be desserts, it could be fruit. So it's a rising enthusiasm. And usually I will give an example. And, you know, I sometimes will share. I remember a time when I was being open house with my friend Liz. She's in the brown teaches mindfulness. And we had an open house for a while. And this family came in with a couple of teenagers that seem to be very shy. We're playing this activity. And one, and so they got in the circle. And you could just sort of see the anxiety. And one of the guys that was, it was his turn. And he said blueberries. And we all said yes. And he said blueberries again. And we all said yes. And he said blueberries again. And so what I think he was doing, whether he was conscious of it or not, was he was help making it safe for the next person. You know, we didn't have to be perfect or create, you know, you didn't have to create cream brulee with, you know, hot sauce or whatever. And so then what happened was this young man, probably 15 or 16, he did say something. And we all said yes. And the grin on his face was like, I can see it. You know, it was like, so that moment for him gave him a social experience. Of taking a risk and getting a positive feedback that hopefully that goes in the bucket of social, positive social experiences. See another talk, go ahead. Okay. So I'm going to move on. Is this, I'm not in my same screen, but I guess it's okay. Right. So this is another activity that has a lot of. So this is another activity that has a lot of influence from improv. And application in healthcare. Primarily, because once it can be done fairly quickly. And have a profound impact. Both things are important. What can we do in healthcare that's quick and meaningful. And this comes from the status work. If you've read Keith Johnstone's. Or Kat Coppett's book, they both talk a lot about, they have some great status activities. So my friend Liz and I created this as kind of a, it's much simpler. Basically what it is. I have people in the room walk around in high status, give some language. And this isn't even in my book because it's so, so new. You know, act like you're superior. You know everything. Nobody else knows anything and just walk around. We all as human beings knows, know what that feels like either because sometimes we act that way, or we have been acted like, you know, we've had other people in our lives act that way towards us. Then I go to the other extreme. Okay. What's it like to be inferior? You don't know anything. Everything you say is useless, blah, blah, blah. People automatically, they know what those, those ways of being are. Then I have them get in pairs. So they're facing each other like you can see these two are, and we have one start out in high status or arrogance or whatever the terms language you're using. I tend to stay away a little bit from status because that can be like a edgy point within the hierarchy. So just be creative around your language superiority inferiority. One starts out high, one starts out low. Over the course of like 30 seconds to a minute. They switch. And then I encourage them to come back to the middle and find a place where they feel dignity for themselves and each other. And I have done this several times with different groups and it is incredibly profound. It is a visceral reaction. People, they, when they contact each other and you can see it here. I'll show you another picture that has a couple more, but I'll show you that in a second as an example of it. But look at these different moments. These are the moments where we're finding dignity in ourselves and each other. And it is, oh, can give each other hugs, high five shake hands. There's a lot of ways to express it, but we're either tapping into something that we know as human beings and have maybe forgotten or not used to expressing. Or maybe we're evolving. I really don't know, but it's, it's quite profound. I don't know. I don't know. I don't know. And would you like to see it? I'll show you Liz and I doing it. Doesn't take long. Anyway, so that's, and I honestly, I think if you can include that, try it with your non-health care. If you have groups that are more. Available for, for your work right now, not necessarily healthcare professionals try it. But it is a great way to start having conversations about these kinds of things like how is a hierarchy and how can we relate to each other? If I have to be in a, as a nurse, if I'm supposed to be in that leadership directive place, I can do that. But that doesn't mean I have to give up my humanity or my respect for you. I did a cultural sensitivity workshop recently where I did not mention improv. This was for nurse assistance, but I did that activity early on. And then once they knew how to do it, I could like easily say, okay, just take a minute and do it and find the, the dignity with a new partner. And so I could sort of sprinkle it throughout the activity. So, you know, you just take 15 or 20 minutes initially, maybe a little longer for debriefing. People have a profound experience, but then you have something that you could use a nurse manager. If I were doing train the trainer, which I see being more my, my career path is to help other people teach this stuff. If they were to do that activity, teach it once, then they could be doing that. I'll also, you know, at every clinic, every meeting or maybe not every, so it doesn't get boring, but once every three months, they could say, all right, do that, find somebody that you don't know well or that you, um, that's new that, or just, just do it because it's good to remember that we're human beings too. Any thoughts about that activity? I experienced the activity in your workshop in the, uh, Stony wrote there in conference. Um, it was great. And then I've used it since a couple of workshops. Yeah. Do you find it like it's like, it's like this beautiful humanity moment? Yes. Um, it could be used as a, a form of greeting in team meetings and that sort of thing. Um, and when people have an experience like that in a workshop, I think it's good to invite them to notice when they're having that dignity relationship in their work over the next few days. It connects very much as well with solution focused therapeutic stance of the client being the expert. In their lives. Yeah. Just a quick question. Is this non-verbal the way you facilitate this exercise? Um, mostly I'm a little vague with that with my instructions. It's not the name, but it's like when I have people walking around in the high. Superiority as they may say a phrase or two. I'd be from for that. But it's not about a dialogue. No, I really like this exercise. Thank you for sharing. Oh, you're welcome. Thank you. I actually have a, a sheet somewhere, a PDF that has like several, that has all of these different people on video, these one minute clips. If you want them reach out. If you want them to reach out to you. If you want them to reach out to you. If you want them to reach out to you. If you want them to reach out to you. If you want them to reach out to you. And I think you could use it in almost any, any team building or leadership. And in fact, Paul, when you were talking about, it's like. This could even be, we could do it from six feet. We can make it a social distancing thing. Or try it anyway. I love it. I love it. I just want, first of all, this is great stuff. And secondly, with that activity is I'm running some mental health groups online. All my things have moved online. Okay. That looks like it'll transfer to an online activity. Very simply. With the depth, the perception of the screening, being able to lean in and just kind of give those ideas. So I'm going to. that it would be really hard to do and I think maybe that's just because I like to be in a room. So I would love to hear that will be a great blog post. Right and I'm not and I'm not excited about moving everything online. I'll tell you that I'm trying to find joy in it right there but I'm definitely trying to create you know those non-verbal verbal communications because as I'm working with clients they're it's very interesting to watch the behavior when I get them on the screen right away you know we have to get over we're watching ourselves but then I decided to teach that into a teachable or put that into a teachable moment where oh look you can watch your body language online now and kind of assess what information you're giving back with my younger clients they're doing a lot of goofy you know faces we're trying to get around that and then with my older clients they're feeling a little bit held back with the screen so I'm trying to go real gentle with you know how our body is sitting how our tonality is and where our eyes are and well that's a great support of me thank you very much. Oh you're welcome I really please please let us know how that goes that'll be that's definitely going to be a blog post. Other feedback or thoughts? So we're like eight minutes I'm going to zip along here um physical phone um this I need some guidance on time management Paul and everybody. I think people are familiar with it as an activity and maybe if you show a few seconds not the full five minutes. Okay so just give you a little context this is in New York we've just talked a little bit about communication and making mistakes in healthcare. We'll watch Gary start it out and then I'll zip to the ending um we'll see what okay so you know how it's played let's see where we are. All right so I think this is uh this is about to be the end there were probably 12 or 15 people in the line and Gary and Nancy Mose from the Allen Alde Center are going to show you what Gary started and what she ended up with. This becomes you know how to play you know how it's like and this is a group of people with a lot of theatrical experience so I've done it with nurses their motions are often smaller but then you can still see the people adding and taking away so this becomes a great activity to talk about communication being much more challenging than we realize we think we know what we're doing but we don't we think we know that we're being understood when we're not and the conversation can be um extremely helpful in starting to brainstorm on how can we make our communication better so this for me this isn't really about an intellectual experience as much as it is about engagement what are your ideas and so people will have ideas like we'll do teach back and slow down and you know have a check-in and so then I say okay now you can use all your ideas and do it again and oftentimes it's improved so people have an opportunity to to make improvements and hopefully they have a physical experience that lasts longer and if you want to read more context that eye-opening activity is a blog post with a full video in it and you guys use that activity before okay and handoffs I'll just mention quickly notorious that's maybe a united states term but that is a place where there are notorious errors where we're giving a lot of information about a patient from one clinician to another and here we're just trying to do three pieces of information case in point I referred to this earlier overload if you google on interruption awareness you can find actual video of it one person is charged with counting to a hundred by fours which this person carless she's a nurse she was charged to do well somebody in front of her is acting as a mirror that she's supposed to follow one person on one side simple personal questions person on the other simple math she's got her fingers here probably out she's at like 20 she's counting to 20 and she's already getting frustrated and anxious and somebody says how many children do you have and she's like two so what I've seen in doing this is it opens up the door to experiencing and having a shared experience of how stressed we all are we're all running around being so stressed so we actually it can be it's funny because we're like oh that's how I feel every day so it brings that up but also and paul has some ideas I want to make some room for in a second but it creates opportunities to have self-awareness about our stress limits mine are different than yours which gives us an opportunity to speak up and say as I develop my awareness and my skill at expressing it and meanwhile hopefully we're also creating cultures that are more willing to listen and honor each other's limitations that we're doing all of that and that it also creates a door for conversations around communication skills like delegating and setting limits and constructive feedback which are great workshops in and of themselves so this can be integrated paul what was your comment earlier about I've put it in the chat as well the activity if you allow people to say pause or to say stop they can test their stress threshold practice being assertive and then have another go when they're feeling a tiny bit calmer and see if they can go further so it's a really nice use of the group to improve your skills and awareness awesome so we've got about two minutes if there's some concluding things you want to ask or say and then I'll say what's coming up next in AI and world thank you I will just say this one little vision thing and even in the midst of our crisis it is and it's a lofty vision but I think the applied improvisers have a skill set that we desperately need in healthcare as you can see and that because healthcare also interfaces with all almost all forms of human diversity that if we whatever we can get into healthcare we will have a rippling effect for the world so I there thank you I appreciate everybody's questions and listening and everything wow thank you Beth um I'm sure people can write a few things in the comments by way of thanks for appreciation encourage everyone to do that and there's a round of applause from Gerald as well and would like to remind everyone that there's going to be lots more AI and online both these big topics about once a month AI and 60 minute socials where you can turn up and talk about whatever's on our minds and there's going to be a new series as part of these webinar programs on watching AI and videos and discussing them which Angelina Castellini is currently arranging so thanks all very much for coming your questions and participation thanks again to Beth one more mention of her book medical improv and we'll see you all again soon there's her contact details if you want to get in touch I'm going to stop the recording now thank you all very much indeed