All the World’s a Stage: Improv to Improve Healthcare

Written By: Dr. Candy Campbell, DNP, RN, CNL, CVP, LNC, FNAP

What can we do to change the culture of nursing and health care?

Honest questions deserve thoughtful answers.

Consider this: In 19991, when the Institute of Medicine (IOM), now known as National Academies of Medicine  (NAM) published their paper on To Err Is Human, they identified somewhere between 44-98,000 preventable deaths from medical errors.

This was BIG news, it and shocked the nation.  The alarm followed: If the equivalent of a jumbo-jet filled with people were dying every day, WHY was no one doing anything about it?!

In a 2008 2 study of the root cause analyses (RCA) of such errors, The Joint Commission (TJC) issued a paper on disruptive behaviors, declaring that one of the main identified problems was communication failure.

The TJC dug deep into the origin of the miscommunication. They identified perceived intimidation within the hierarchy as a persistent issue2. This included the most populous and minimized group within health care: nurses.

Through interviews and surveys, nurses confided that they did not speak up about things prior to what later became an error or adverse event because of several reasons. These included: fear of looking/feeling stupid, fear of confrontation, fear of retaliation, fear of recrimination, and not knowing what to say.

The result? Antidotes to heal the ‘speechless’ problem were trotted out from other industries.

You’ve probably heard of some. They included: Assertiveness Training, Crew Resource Management, Total Quality Improvement, Lean Six Sigma, TeamSTEPPS, and others.

What did we learn?

Fast-forward to 20133 when independent research reported the numbers of patient adverse events (PAEs) showed no improvement, despite various mandatory training programs.

As a matter of fact, since data on medical errors and/or PAEs are not always required to be reported to state/federal agencies, we can’t be sure how many mistakes are actually made.

One thing we do know: the number of PAEs has increased, despite various trainings!


Similar to the microsystems that comprise our living, breathing, heart-pounding, physical selves, ALL health care organizations exist as complex adaptive systems (CAS). There are numerous variables… and the variables are in a constant state of flux.

Moment to moment, there is constant change. Variables like: individual patient medical issues, the number of patients, their family psychosocial situations, staffing and type of personnel, and on it goes.

You’re probably wondering: If all those other communication and team building programs have failed to flatten the curve of PAEs, is the situation hopeless?

Is there a different modality, method, or some sort of evidence-based program we can utilize to unlearn bad communication habits? Is there something that will help open our minds to wonder, creativity, innovation, general good-will, and solution-finding? Something that can work to solve the problem of interprofessional miscommunication?


Unbeknown to most, there is such a program, but it’s unconventional.

As a matter of fact, it probably sounds crazy to many people working in healthcare.

Some of us in healthcare have been beating the drum to bring attention to this “new” type of program for two decades already? (With little recognition).

Would you believe one of the answers is applied improvisational exercises (AIEs) aka Improv? The main caveat here is that such trainings are facilitated by experts who have several years in the field of improv teaching/coaching.

What if I told you, there is evidence to prove it? I’m sure many of you reading this are surprised!

In 2013, I conducted doctoral studies (longitudinal, qualitative/mixed method), utilizing AIEs with interprofessional (IPE) groups at Stanford’s LPCH, to show that this method can have a measurable effect on participant ability to build and retain better professional communication, based on better personal relationships.

I can hear you shouting at your devices now: Whaaat?  Isn’t improv defined as COMEDY?

The answer is, not exactly.

In fact, there is a difference between the method and intent of teaching improv for performance, compared to learning improv for better communication and relationship-building.

So, what’s the secret? Why is this method so impactful?

Based on cognitive and behavioral psychological research, we know that humans learn best when we’re playing. That’s what makes it FUN and such good learning!

However, to understand the process, you must also enter into the activities. The cool thing is there are facilitators who are qualified to conduct such workshops within healthcare. We can improve the way we’re doing things with improv!




  1. The Institute of Medicine/National Academy of Medicine, 1999. To Err is Human: Building a Safer Health National Academy Press.
  2. The Joint Commission, July 9, 2008, Issue 40. Behaviors that undermine a culture of safety.
  3. James, J. , 201. A New, Evidence-based Estimate of Patient Harms Associated with Hospital Care. Journal of Patient Safety9(3);p.122-128 DOI: 10.1097/PTS.0b013e3182948a69.,_Evidence_based_Estimate_of_Patient_Harms.2.aspx
  4. Campbell, Candace A., 2014. Improv to Improve Interprofessional Communication, Team Building, Patient Safety, and Patient Satisfaction. Doctor of Nursing Practice (DNP) Projects. 27.


About Dr. Candy Campbell :

Award-winning actor, author, filmmaker…and nurse. Candy spent many years as a clinician (including 23 years as a NICU specialist), administrator, and (now retired) academic.

She co-founded an improv and stand-up comedy company in the San Francisco area in the early 90’s and began teaching improv to businesses in 1995.

These days, she spends her time facilitating improv workshops and retreats, speaking at nursing conferences, performing her 3rd solo show as the icon of the nursing profession, Florence Nightingale, and hanging out with her grand kids in the DC area.

Find her here:

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