As the COVID pandemic drags on and we are faced with outbreaks of infectious diseases both new (monkeypox) and old (polio), health care workers are turning to improv theater for help navigating sensitive conversations with vaccine-hesitant patients. Researchers at the University of Rochester Medical Center (URMC) have developed a program that combines improv theater techniques with coaching on how to tap into patients’ inner motivations to help health care workers guide their patients toward vaccination.
The program, described in a JAMA Arts and Medicine article published today, left nearly 80 percent of its health care worker participants feeling more confident and able to improve their conversations with patients. And nearly 30 percent believed their patients got the COVID vaccine as a result of the change in their conversational approach.
The Theater for Vaccine Hesitancy program featured one-hour workshops where team members reenacted poorly executed real-world conversations between a provider and a vaccine-hesitant patient. After a short debrief, the team ran the scene again. This time, health care workers in the audience had the opportunity to step into the scene as the provider and change the conversation.
This “forum theater” exercise was adapted from an improvisational theater program developed in the 1970’s, called Theatre of the Oppressed. In 2017, members of the URMC department of Health Humanities and Bioethics started using the Theatre of the Oppressed model to help health care workers and students know how to react to instances of racial, sexual or gender bias or discrimination.
“We were originally funded by the Centers for Disease Control and Prevention to address COVID vaccine hesitancy among rural health care workers, but had to pivot when vaccination mandates were announced,” said John Cullen, Ph.D., professor and director of Diversity and Inclusion at the University of Rochester Clinical and Translational Science Institute and lead author of the JAMA article. “We knew that Theatre of the Oppressed was an extremely effective tool for practicing challenging conversations with patients, so we adapted it to help coach health care workers to engage in conversations about COVID vaccinations.”
Improvisation helps health care providers build the skill and muscle memory for facilitating these sensitive conversations, but the true science of the Theater of Vaccine Hesitancy program lies in a psychological theory of human motivation, called Self Determination Theory. Developed by two University of Rochester psychologists in 1985, this widely accepted theory suggests that people are more likely to choose a behavior if their psychological needs of competence, autonomy, and relatedness are met.
“External motivators like mandates or monetary incentives have not worked for all of our patients and in some cases actually increase mistrust of public health and health care systems,” said Holly Ann Russell, M.D., associate professor in the department of Family Medicine and in the Center for Community Health and Prevention. “So, we wanted to coach frontline health care workers on how to tap into patients’ intrinsic motivation instead.”
Each Theater for Vaccine Hesitancy workshop kicked off with a primer on Self Determination Theory, reviewing how to support patients’ psychological needs. Attendees were trained to empathize and connect with the patient, acknowledging and expressing interest in the patient’s perspectives and feelings. They were also reminded to respect the patient’s power to make their own decisions, but provide concrete recommendations and specific examples of how getting vaccinated fit with a patient’s value system without preaching or arguing.
Ultimately, the Theater for Vaccine Hesitancy workshop, which was part of the CDC-funded Finger Lakes Rural Immunization Initiative, trained health care workers to listen and connect with their patients rather than lecturing or cajoling. Or as one participant put it, to “ask more than tell.”
It also gave participants a low-stakes forum to practice what they’d learned, which not only built their confidence but was a fun and unique educational experience that fostered a welcome sense of camaraderie in a time of burnout.
“Being a participant who improvised one of the conversations was incredibly useful for building my confidence,” said Eliane Grace, a medical student at URMC. “Receiving group feedback and seeing what others would do differently was also very useful.”
"The interactive workshop provided space to explore both in and out of my comfort zone,” said Al Ogawa, another URMC medical student who participated in the program. "The non-judgmental environment, peer feedback, and space for creativity spurred growth."
Cullen, Russell and co-author Savanah Russ, M.P.H., believe their program could be another important tool in the global fight against vaccine hesitancy, and that the combination of improv theater and motivational theory offers a glimmer of hope for providers looking to change conversations with the vaccine-hesitant.
The project described in this publication was supported by a Prevention Research Center Supplement from the Centers for Disease Control and Prevention under award number 6 U48DP006394-02-01 and by the University of Rochester CTSA award number UL1 TR002001 from the National Center for Advancing Translational Sciences of the National Institutes of Health.