“Just Join Them”: Improv and Dementia Care

Abstract

Improvisational (improv) theatre skill development holds promise for improving the dementia capability of care partners. In this report, we present analysis of data from an ongoing study on meaningful engagement and quality of life among assisted living (AL) residents with dementia. Using ethnographic methods, we collected data from persons with dementia (n=59) and their care partners (n=165) in six diverse AL communities each studied for one year. Building cumulatively on past work and existing literature, we demonstrate the potential benefits of training care partners to use improv skills. We discuss implications, including the need for intervention research.

Caregiving in the context of dementia often involves burden, stress, and emotional strain, which can affect overall health, well-being, and mortality, and negatively influence care recipients’ quality of care and quality of life (Alzheimer’s Association, 2022). Alongside seeking a cure, innovations are needed to promote positive outcomes for care recipients and their care partners, including family, friends, direct care workers (DCWs), and others, regardless of the care setting. Improvisational (improv) theatre shows promise.

Improv involves spontaneous or unplanned performance in all its forms (e.g., music, dance, dramatic or comedic theatre). “Yes, and,” the most well-known improv theatre tenet, is designed to prompt individuals to accept and build on their interaction partners’ verbal and non-verbal actions (Robbins Dudeck & McClure, 2021). Robbins Dudeck & McClure (2018; 2021) argue that other improv tenets also are used by theatrical improvisers around the globe and include actively listening and observing, collaborating, giving up control, making your partner look good, leaning into uncertainty and the unexpected, accepting failure, and pivoting; alongside “Yes, and,” these tenets contribute to an “improvisation mindset.” A nascent body of research from a variety of disciplines shows the potential benefits of improv training and their application in daily life and in personal and professional interactions. Among non-caregiver populations such training has been found to enhance divergent thinking skills, tolerance of uncertainty in social encounters, empathy, and listening skills (Felsman et al., 2020; Hoffmann-Longtin, 2018; Robbins Dudeck & McClure, 2018).

Improv classes for care partners of persons with dementia increasingly are being offered around the U.S. and elsewhere (e.g., https://beinginthemoment.org/; https://www.dadsgarage.com/seniors). Yet evidence-based research on the use of improv in the dementia care context is limited. Two known pilot studies delivered improv training to family care partners of persons living with dementia: “Improv for Care” (Brunet et al., 2021) and “Improv to Improve” (Howell et al., 2022). Using sample sizes of 15 and 5, respectively, both reported decreases in caregivers’ depressive symptoms and burden.

Our ongoing study focused on meaningful engagement and quality of life among assisted living (AL) residents with dementia also points to the potential benefits of improv training among care partners. This research identified four approaches used by formal and informal care partners to promote meaningful engagement among those with dementia: 1) knowing the person; 2) connecting with and meeting persons where they are (i.e., joining versus arguing); 3) being in the moment (i.e., responding to the scenario); and 4) viewing all encounters as opportunities for meaningful engagement (Kemp et al., 2021). Subsequent analysis identified “engagement capacity” as pivotal to the negotiation of meaningful engagement (Kemp et al., 2023). Researchers defined capacity as “the amount and nature of engagement resources associated with individuals, care convoys, and settings” (italics original, p. 861). Residents and care partners had an “individualized dynamic capacity for engagement” (p. 861). Residents’ capacity was tied, in part, to that of their care partners. Certain care partners, those with “exceptional capacity,” used the four approaches, attended to engagement on an ongoing basis, and, in contrast to those who were less successful at engaging or interacting with residents, demonstrated the value of being responsive to individuals and contexts.

In this brief report, we build cumulatively on past work to further conceptualize the four approaches and consider the skills needed to practice them. We present new data, which when considered in the context of relevant improv research, reveals parallels between the approaches and improv techniques. Ultimately, we suggest that improv training holds promise for increasing engagement capacity among care partners and has implications for future research aimed at improving dementia care experiences and outcomes.

Method

Data derive from a longitudinal qualitative study, “Meaningful Engagement and Quality of Life among Assisted Living Residents with Dementia” (5R01AG062310 to Kemp) that seeks to identify best practices for optimizing meaningful engagement among persons with dementia. Data were collected in six diverse AL communities over two 1-year data collection periods in Atlanta, Georgia (see Table 1). The first wave involved four sites studied between 2019 and 2020; the second included two sites studied between 2021 and 2022. We assigned pseudonyms for individuals and sites.

Table 1.

Study Home Characteristics

	Wave One				Wave Two
	Rosie’s Place	The Gardens	Holly House	Parkview	Meyer House	Oakwood
Resident Capacity	6	36	52	100	42	100
Ownership	Private	Corporate	Private	Corporate	Foundation	Private
Location	Urban	Suburban	Small Town	Suburban	Suburban	Urban
Memory Care Unit	No	All Memory	Yes	Yes	Extra Care Unit	All Memory
Monthly Fees (US$)	2,250– 3,000	5,050 – 6,175	3,450 – 4,850	3,500 – 6,175	4,550 – 6,175	6,025 – 10,250
Resident Race/Culture	African American and White	All White	African American and White	Most White	Most White/Jewish	Most White

The study is guided by the “Convoys of Care” model (Kemp et al., 2013; 2018), which posits that individuals who need care, including AL residents and persons with dementia, are located within dynamic networks involving informal and formal care partners, all of whom are consequential to their quality of life and care. Thus, as Table 2 shows, data come from interviewing residents, where possible, and their care partners, including family and friends, AL staff, external workers, and volunteers. A total of 59 residents and 165 care partners participated. Data also come from fieldnotes capturing 2,170 hours of participant observation during 759 researcher visits focused on learning about engagement in residents’ daily lives and routines, including activities run by care communities and engagement occurring during care interactions, meals, social visits, self-directed time, and off-site outings (see also, Ciofi et al., 2022).

Table 2.

Data Collection Activities by Care Community

	Wave One				Wave Two		Totals
	Rosie’s Place N = 13	The Gardens N=36	Holly House N=33	Parkview Manor N=51	Meyer House N=28	Oakwood Forest N=65	N=224
Interviews
Residents Participants
Formal interview	2	3	3	6	5	3	22
Informal interview and/or observation	2	4	5	8	0	18	37
Resident Totals	4	7	8	14	5	21	59
AL Management/Staff	3	15	13	17	8	16	72
Family/Friends/Volunteers	6	9	11	12	9	20	67
External Workers	-	5	1	6	6	8	26
Care Partner Totals	9	29	25	35	23	44	165
Research Visits	51	183	106	162	95	162	759
Observation hours	146	602	297	516	219	390	2,170

All interview and fieldnote data were stored and managed using the qualitative analytic program, NVivo (2020). Researchers used NVivo to apply codes from the project-specific codebook. Based on previous findings and the literature, we examined the applicability of improv skills. The present analysis is based on examination of the code, “care partner strategies” alongside consideration of key improv techniques (see Robbin Dudeck & McClure 2018; 2020) and the code, “resident response.” Developed a priori, these two codes reflect the study’s research aims but their accompanying subcodes characterizing strategies and responses were developed inductively and iteratively through the data collection and analysis processes. Table 3 provides detailed information about our research processes, including Institutional Review Board approval, consent, researchers, and data collection and analytic procedures.

Table 3.

Select Information on the Research Processes, Team, and Methods by Area

Research Area	Description
Approvals and Consent Procedures
Institutional Review Board Approval	Approval comes from Advarra: Pro00029867; Georgia State University: H19198; Emory University: IRB00108144
Study Site Consent	Prior to entry or data collection, we received written permission to enter and access each assisted living community site for research purposes. Written permission was given by authorized representatives of each study site to the study’s principal investigator (CLK).
Participant Written Consent	Consent forms were signed by all care partner participants and by resident participants with the capacity to consent. For resident participants who were unable to consent, we obtained proxy consent from their legally authorized representative. Researchers presented consent forms to potential participants and proxies and explained the study’s purpose, procedures, risks and benefits, confidentiality practices, and the right to refuse questions or drop out of the study. Participants and proxies were given an opportunity to ask questions. Those willing to volunteer signed consent forms. Consent was an ongoing process with withdrawal possible at any time.
Assent Procedures	We used assent procedures, seeking verbal permission, prior to speaking with resident participants whose legally authorized representatives provided proxy consent. Viewing consent as an ongoing and dynamic process, we also sought permission prior to sitting with, joining, or speaking with persons in the setting.
Research Team and Reflexivity
Size and Composition	Our research team involved 24 individuals, both female and male, ranging in age, and with different racial and ethnic backgrounds. The team included undergraduate and graduate, staff, postdoctoral, and faculty researchers with backgrounds in gerontology, anthropology, biology, sociology, psychology, nursing, exercise science, human services, and social work. All research staff had training in qualitative methods and understanding dementia and long-term care. Of the authors, [AAB, AMM, CLK, EP, and JCM], collected data during one or both data collection waves.
Participant-Researcher Relationships	Researchers were divided into teams of varying sizes based on study-home size. Each team was assigned to one site for the one-year data collection timeframe. Consistent researcher assignment allowed team members to gain rapport, introduce and acquaint potential participants with the study, and learn from participants, individually and collectively, on an ongoing basis. Consistent and sustained researcher presence in the communities allowed participants’ ongoing access to researchers.
Study Design
Interviewing	Researchers conducted in-depth semi-structured interviews face-to-face, over the phone, or via web-based conferencing. Lasting an average of just over one hour in length, most interviews, but not all, were completed in one session. Except for one participant, a family care partner who preferred that the researcher take notes rather than record the interview, all interviews were digitally recorded using audio recorders and transcribed verbatim.
Interview Guides	Interview guides varied by participant type and when appropriate inquired about residents’ life prior to and within AL, their interests and abilities, care needs, opportunities and experiences with engagement, and care partners’ roles in daily life and activities.
Participant Observation	Researchers were trained to conduct participant observations and document these observations in detailed fieldnotes using a guide attentive to the physical and social aspects of the environment. Care was taken to observe and document persons in the setting including their appearance, demeanor, interactions, and verbal and non-verbal expressions. The diverse nature of our research team, variation in observation days and times, and prolonged observation period allowed for a variety of perspectives and opportunity to document continuity and change among persons and settings over time.
Recruitment, Refusals, and Participant Retention	We recruited using in-person methods and via phone, text, and email. Fifteen people declined our invitation to participate; 29 people did not respond to our invitations. Three resident participants moved out and seven passed away during the study.
Verification and Member Checking	Researchers were able to member check interviews and ongoing analytic insights during prolonged engagement with participants in the study sites. The one-year data collection duration facilitated member checking on an ongoing basis.
Analysis
Coding within Team	Twenty team members reviewed and conducted initial coding of the data by applying codes from the codebook developed collaboratively and iteratively by the entire team. CLK led the targeted analysis presented in this manuscript.
Coding Development, Codebook, and Analytic Procedures	Established in dialogue with our research aims, existing research, ongoing data collection and thematic analysis, and modified as new concepts were identified, the project codebook contains codes that capture broad concepts relating to engagement type and scenario as well as resident, care partner, and setting factors. This broad set of codes provided the basis for higher order coding based on analytic topic or focus. Here, we examine relevant data coded at “care partner strategies” and “resident responses.” We created analysis charts, which examined these data to capture the scenario, care partner approaches, influential factors, and outcomes. After noting the similarities with improv techniques, we documented the relationship between different care partner approaches and specific improv skills.

Findings

Our analysis advances the conceptualization of each approach, including the accompanying mindset and communication techniques underpinning their application. As shown in Table 4, which identifies the intersection of each approach with specific improv tenets, we found significant overlap between the four approaches and improv skills. Below, we elaborate on the approaches and accompanying skills, noting parallels with improv.

Table 4.

Improv Tenets and Approaches to Meaningful Engagement

IMPROV TENETS (Adapted from Robbins Dudeck & McClure, 2018;2021)	FOUR KEY APPROACHES TO MEANINGFUL ENGAGEMENT (Kemp et al., 2021)
	Knowing the person	Connecting & meeting people where they are	Being in the moment	Viewing all encounters as opportunity
Listen and observe actively	X	X	X	X
Commit to what is happening			X
Be empathic and validate		X
Give and take; collaborate; say, “Yes, And…”			X	X
Offer and accept interaction		X		X
Give up control and drop agendas		X	X
Make your partner look good		X
Try, and (if you) fail, pivot			X	X
Expect the unexpected	X		X
Lean into uncertainty			X

Knowing the person

Knowing the person is an ongoing process.

We affirm that getting to know the person as an individual is crucial. Doing so involves being constantly inquisitive and observant to verbal and non-verbal communication, which are all also essential in improv. Many care partners, particularly those who are paid, do not start out knowing the person and behaviors can change. As one daughter said: “Mom is like a box of chocolates. You just never know what you’re gonna get from day-to-day.” Being open to continually learning and leaning into the process, including the unknown, and the fact that people, despite how much of their character one thinks they know, might act in unexpected ways, is as essential in dementia care as it is in improv. A direct worker summed up her approach saying, “I just pay attention, and I ask questions.” Like improv, which demands collaboration, knowing the person requires ongoing communication with the person and other care partners. Most care partners spoke about the importance of knowing the person but continually attempting to do so was not universal.

Meeting people where they are

Listening, observing, and accepting, are essential.

Actively paying attention to verbal and non-verbal communication is also key to connecting and meeting people in the moment in the context of dementia care as well as in improv. A select group of engagement partners demonstrated patience, empathy, and who met residents “where they were” in terms of orientation to time and place tended to experience less frustration and greater success than those who did not. A son whose father frequently was confused about time and place emphasized the importance of “being okay with just being where they are instead of trying to convince them otherwise.” Yet, his brother, unable to do so, was “uncomfortable” interacting with their father and avoided visiting.

Some care partners wanted residents to “remember the past and know the truth,” including a daughter who posted a sign in her father’s room about the death of family members and sale of the family farm. Experiencing these losses daily, he became depressed and withdrawn until the staff convinced the daughter to stop. One said, “She just thought that he needed to feel all his feelings. We just really had to work hard with her.” In contrast to correcting, connecting and meeting people where they are promotes inclusion, shows empathy, and reinforces dignity and respect, and is about elevating others. Meeting people on their own terms supports the essential improv tenets relating to validation, giving up control, dropping agendas (i.e., letting go of trying to do what you think should or want to happen), and “making your partner look good,” and are exemplary care practices that lead to positive outcomes for people living with dementia.

Being in the moment

Attentiveness to what is happening in the moment and flexibility are critical.

Being in the moment, whether on stage or in the dementia care context, requires being present and adaptable. Adjusting in the moment, including when someone’s narrative, needs, abilities, and attentiveness (i.e., their capacity) shift, requires pivoting. The following researcher fieldnote excerpt captures improvisation during a group musical therapy session:

[The therapist] seemed in tune with residents and adjusted when she felt something was not “clicking.” She danced and played towards residents, calling them by name, including residents who became unfocused during the activity, to get them back involved.

At times this approach requires creativity and openness to trying new things, which also implies an openness to failing and trying again a different way. Acceptance of the unknown and being okay with uncertainty about where the interaction might start, lead, or finish is as essential to success in the context of dementia care and improv performance. Approaches that accommodate a person’s in-the-moment status are critical for promoting meaningful engagement and successful care encounters. Only a few care partners were comfortable with and skilled at being in the moment.

All encounters as opportunity

Ongoing attentiveness and promotion of engagement.

Viewing all encounters as opportunities means being continually open to and seeking interaction. As is true for actors, care partners who viewed their role as attending to the relational aspects of encounters, had more positive and fruitful encounters, including during care interactions. We observed many family members and care staff who, feeling pressed for time, performed care tasks in perfunctory ways without engaging residents. However, as the following fieldnote excerpt illustrates, care tasks can be achieved while engaging with residents without adding time:

[The care worker] sat down with and started to feed a resident, Polly. While feeding Polly, she kept giving words of encouragement. She said, “the food is great today isn’t it?” “You’re almost done, good job, Polly,” “A few more bites and you’ll be done.” Polly smiled every time she was given a compliment. . . While speaking [the care worker] rubbed her hand up and down Polly’s back to comfort her. Polly smiled and continued eating her food.

Viewing each encounter as opportunity means being open to engaging and willing to extend offers, accepting invitations being given, and being conscious of not shutting down interactions, which fails to engage others whether on stage or in the care context.

Skill Development and Application

A minority of care partners in our study instinctively used the four approaches (see also Kemp et al., 2021) and accompanying improv techniques while interacting with persons with dementia; most did not. Given improv’s potential, this gap represents an opportunity for improving dementia care experiences especially because its mindset and techniques can be learned in fun and engaging ways. As shown in Figure 1, each care partner has individualized engagement capacity, which is influenced by their (a) willingness and availability; (b) roles and responsibilities; (c) approaches and strategies; and (d) dementia care training, knowledge, and competencies (see Kemp et al., 2023). Based on analysis of our data and existing research and focusing on (c) and (d), we hypothesize that improv training for care partners will increase their engagement capacity through the acquisition of key competencies and application of improv leading to increases in meaningful engagement among persons living with dementia, which in turn, will improve outcomes for care partners and care recipients.

Figure 1.

Building Care Partner Capacity through Improv Training in the Dementia Care Context

Caring for persons with dementia can be difficult, physically, and emotionally. We acknowledge that improv skills may not work in every scenario, including for example, in instances of extreme distress or aggression. However, improv principles, as our data suggest, offer a set of strategies that can be added to care partners’ toolkits, and under the right circumstances, can be helpful.

In 2016, Georgia Alzheimer’s and Related Dementias (GARD) State Plan Collaborative developed the “Competency Guide for Dementia Care” building on the Center for Medicare and Medicaid Services’ Hand-in-Hand curriculum (https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/National-Partnership-to-Improve-Dementia-Care-in-Nursing-Homes). Targeting those who employ and train DCWs, this practical guide identifies and defines priority competency areas accompanied by skill statements explaining how each is demonstrated in practice. “Person-centered care,” one competency area, contains skill statements that include “getting in the shoes” of persons with dementia and “utilizes the strengths of the person and helps in enhancing” their “abilities” (p.11) Meanwhile, a second competency area, “communication,” contains skills statements that encourage understanding “their experiences by being in the world with them” (p.12). Although written for DCWs, these statements and the training to build the associated skills have implications for all types of care partners of persons living with dementia regardless of setting and align with improv techniques.

The promise of improv training as a clinical innovation and intervention requires further investigation. It is being delivered and evaluated with positive outcomes in medical schools (e.g., Hoffman-Longtin et al., 2017; Rusiecki et al., 2023) and in hospital settings (e.g., Preis et al., 2023; Sanky, 2023). Additional work is needed to develop and refine care partner curriculum tied to specific improv skills in the context of dementia care that is appropriately tailored to diverse care partner types and populations and care settings. Subsequent pilot testing with adequately powered sample sizes and appropriate evaluation techniques also is needed. Future research should determine the efficacy, feasibility, and acceptability of improv training as an avenue for building caregiver capacity and decreasing negative outcomes while promoting positive outcomes for care partners and persons living with dementia. We conclude by responding to our own call for research and use the name of a popular improv game designed to teach people to say yes and be accepting of others’ suggestions, “Yes, let’s!”