Communicating to Engage: An Improvisational Theater-Based Communication Training Designed to Support Community–Academic Partnership Development

Abstract

Problem

The potential for community-engaged research to address health inequity requires deliberate effort to create trusting and equitable community–academic partnerships. A lack of evidence-based opportunities for cultivating such partnerships remains a barrier.

Approach

In 2017 and 2018 the authors designed, facilitated, and evaluated a mixed stakeholder training, Communicating to Engage, at 2 urban academic medical centers involved in the All of Us research program, Boston Medical Center and Mass General Brigham. The goal was to bring together researchers and community members to develop communication skills through improvisational theater-based co-learning. The curriculum was inspired by several evidence-based learning frameworks including community-based participatory research principles and improvisational theater techniques. A self-administered survey completed before and after the training session measured participant’s communication skills using the Self-Perceived Communication Competence Scale (SPCCS) and comfort with specific communication styles as outlined in the program’s training objectives. Paired t-tests were used to measure changes in scaled responses among combined participants and separately among self-identified community members and researchers.

Outcomes

Sixty-nine total participants across 6 workshops completed training evaluations. Overall, pre–post survey analysis demonstrated significant mean score improvement for both the SPCCS and comfort with specific communication styles. In stratified analysis, both community members (n = 26) and researchers (n = 36) reported significant improvement in scores related to comfort with specific communication styles. Only researchers, but not community members, had significant improvement in SPCCS scores.

Next steps

The Communicating to Engage program brought community and researcher stakeholders together and demonstrated improvement in self-perceived communication styles, yet researcher participants benefited more than community participants. Future innovation is necessary to further target community stakeholder communication training needs. Mixed stakeholder improvisational theater-based learning provides deliberate opportunities to build new community–academic partnerships that may enhance health equity initiatives.

Problem

Community-engaged research approaches are increasingly recognized as effective for addressing complex public health issues, especially those relating to health equity. Community-based participatory research (CBPR) is a highly collaborative approach based on principles of equitably involving community and academic partners in all aspects of the research process through co-creating research strategies and sharing expertise, ownership, and decision making. CBPR requires that all partners have certain competencies, including effective communication skills for building trusting relationships.¹ Absent these principles, success can be threatened by limited transactional sharing of community experiences and wisdom, hierarchical decision making, and unchecked academic power and privilege, which may breed community harm and distrust.²

Significant gaps in skills exist among the translational research workforce³ and few existing curricula provide opportunities for cultivating community–researcher partnerships. While there is growing investment in developing researchers’ communication skills, most of this work focuses on developing skills to communicate research results or support recruitment efforts.⁴ Few evidence-based practices build skills critical to developing successful research partnerships and, to our knowledge, none incorporate mixed-stakeholder audiences to co-learn and catalyze partnerships in a shared setting.

Improvisational theater techniques typically employ a set of parameters requiring a group to co-create a scene using spontaneous actions and communication. Because these techniques have been used to enhance direct and responsive communication, improve medical students’ empathic patient communication,⁵ and bolster researchers’ ability to communicate science to lay audiences,⁶ we saw their potential as innovative approach to building CBPR skills. To our knowledge, no research has explored how improvisational techniques with mixed-stakeholder groups enhance communication skills and partnership development. We therefore designed, facilitated, and evaluated an innovative mixed-stakeholder workshop titled Communicating to Engage (CtE).

Approach

The CtE program aims to bring together researchers and community members to improve self-perceived communication competence through improvisational theater-based co-learning. The Boston University Clinical and Translational Science Institute designed workshops for partnership cultivation at 2 sites of the New England All of Us (AoU) research program, Boston Medical Center and Mass General Brigham. In 2017 and 2018, 6 mixed-stakeholder workshops used self-administered surveys to evaluate changes in perceived communication competence scores pre- and post-participation. The Boston University Medical Campus Institutional Review Board approved this project.

Study environment

As part of the National Institutes of Health’s Precision Medicine Initiative, AoU recruit one million people nationwide to analyze biological, environmental, and behavioral health influences to better personalize treatment. The New England AoU launched in 2017 with a goal of enrolling more racially and ethnically diverse participants. CtE was designed to support AoU in community collaboration toward this goal.

Training curriculum

The CtE curriculum was fundamentally built upon CBPR principles related to co-learning and capacity building among stakeholders, promoting collaborative and equitable partnerships, embodying cultural humility and intersectionality, and committing to sustainability.² These principles informed our inclusion of community and researcher participants. We selected an improvisational theater framework as suitable for building the skills required for CBPR partnerships because of its consonance with CBPR hallmarks: building trust through communication, embracing vulnerability to deepen relationships, and breaking down hierarchical power dynamics. Inspired by techniques from the Alan Alda Center for Communicating Science at Stony Brook University and expertise of one author (C.C.), we incorporated improvisational theater techniques in specific ways demonstrated to support participants connecting with their audience, paying close and dynamic attention to others, reading nonverbal cues, and responding freely without self-consciousness.⁷ To promote using clear, vivid, and conversational language to build relationships and engage audiences, we incorporated the practice of distilling: communicating complex concepts using accessible and conversational language, and using stories, metaphors, and analogies to clarify, evoke emotion, and make personal connections.⁸

The workshop was divided into 4 parts (see Supplemental Digital Appendix 1 for detailed facilitator guide).

Part I (~10 minutes): Didactic introduction of program objectives, CBPR principles, and the importance of research partnerships. An interactive group discussion explored participant experience with communication challenges and successes.

Part II (~80 minutes): Six improvisational theater activities focusing on active listening, body language, adopting a position of inquiry, partnership development, and cultural humility. Activities were in small groups followed by full group debriefs applying the activity to building effective partnerships. For example, our time traveler activity explored the importance of taking a stance of inquiry, making rapport a goal of every conversation, and seeing communication as reciprocal. The activity prompts each researcher–community pair to act out a scenario where one person builds enough trust for the other, a time traveler from 300 years ago, to place their broken hand into an x-ray machine.

Part III (~90 minutes): Live role-playing of partnership conversations while practicing CtE concepts, skills, and techniques. Pairs provided feedback based on several learning points including distilling complex messages, removing jargon, and building trust.

Part IV (~30 minutes): Interactive discussion of applying concepts and lessons learned.

Participant recruitment

Between May 2017 and June 2018, we recruited 2 types of participants: researchers, defined as members of the AoU study staff; and community members, defined as non-academic persons from the Boston area, eligible to enroll in AoU. Research staff were invited as part of their professional development. Community members were offered a stipend of $200 for participation in the 4-hour workshop. They were identified by staff through existing relationships, hospital community advisory boards, and community outreach. Workshops were conducted in person on the medical campuses and facilitated by 2 or 3 community engagement specialists.

Data collection

A self-administered survey was completed by participants before and immediately after workshops to assess perceived changes to communication styles and competency with various settings and audiences. For anonymity and matching pre- and post-evaluations, participants created an ID. We included only participants with linked surveys in analyses.

Evaluation measures

The survey included demographic questions and scaled responses about perceived competency with the 4 communication style training objectives and with communication skills across multiple contexts and receivers using the validated Self-Perceived Communication Competence Scale (SPCCS).⁹ Each response was on a scale of 0 (completely incompetent) to 100 (completely competent), using 10-point increments.

Competence with communication styles was measured by responses to self-perception of the skill-based learning objectives:

• Recognize importance of clear oral communication as a reciprocal process to create mutual understanding and accurate transmission of information.

• Improve ability to manage mistakes and uncertainty to address power dynamics.

• Raise awareness of personal bias and adopt an other-oriented stance of inquiry, rather than expertise.

• Improve ability to focus attention on audience needs, read verbal and nonverbal cues, and adjust communication as needed.

Competence with communication skills was measured using the 12-item SPCCS,⁹ which asks individuals to rate their competence communicating in contexts or situations (public, meeting, group, and dyad) and with certain receivers (stranger, acquaintance, and friend). We report mean overall SPCCS score and subscores for each of the 4 contexts and 3 receiver groups (range 0–100). Paired t-tests measured mean changes among all participants, and separately among community members and researchers.

Outcomes

We conducted 6 workshops with 89 participants (8–15 per workshop). Among 69 participants completing both pre- and post- evaluation (78% response), 26 (38%) self-identified as community members, 38 (55%) as researchers, and 5 had missing data so were excluded from stratified analyses (Table 1). Mean participant age was 39 years, 55 participants (80%) self-identified female, 18 (26%) as African American, 12 (17%) as Hispanic/Latino, 12 (17%) as another race, and 27 (40%) as white. On average researchers were younger than community participants.

Table 1.

Demographic Characteristics of Participants by Self-Reported Status as Community Member or Researcher, From the Theater-Based Communicating to Engage Training Program, Boston Medical Center and Mass General Brigham, 2017–2018

Characteristic	Overall	Community members	Researchers
Participants, no. (%)	69 (100)a	26 (38)	38 (55)
Age, mean (SD)	39 y (18)	52 y (16)	28 y (10)
Race, no. (%)
African American	18 (26)	8 (30)	10 (26)
Hispanic/Latino	12 (17)	3 (12)	6 (16)
Another raceb	12 (17)	6 (23)	6 (16)
White	27 (40)	9 (34)	16 (42)
Gender, no. (%) c
Female	55 (80)	21 (81)	29 (76)
Male	14 (20)	5 (19)	9 (24)

Abbreviation: SD, standard deviation.

^aThe overall group included 5 participants who could not be classified as community member or researcher because of missing identifying information.

^bWith small sample sizes, American Indian, Alaska Native, Asian, multiracial, and other classifications were collapsed into “another race” to protect anonymity.

^cWe included nonbinary and gender-not-listed as response choices, however there were no responses in these categories.

Table 2 shows results of the 4 training objectives measuring perceived comfort with specific communication styles. Overall, participants reported high pre-intervention competence across all objectives (range 68–79), with the highest rating for reading and understanding body language and the lowest for managing uncertainty in front of an audience. Researchers had higher pre-intervention scores compared with community members. Post-intervention, participants reported significant increases in perceived competence across all 4 objectives (range 8–12, P < .05 for all objectives), with the greatest increase in managing uncertainty in front of an audience. Compared to researchers, community members reported similar or larger increase in competence scores except for managing personal bias, where there was no significant change among community members.

Table 2.

Learning Objectives: Changes in Mean Scores^a of Participants’ Perceived Competency With Specific Communication Styles, From the Theater-Based Communicating to Engage Training Program, Boston Medical Center and Mass General Brigham, 2017–2018

Learning objectives survey questions	Overall (N = 69)b				Community (n = 26)				Researcher (n = 38)
	Pre	Post	Mean (SD) change	95% CI	Pre	Post	Mean (SD) change	95% CI	Pre	Post	Mean (SD) change	95% CI
Communicating effectively across a knowledge barrier	73	81	10c (17.1)	5.4, 14.0c	67	78	13c (24.3)	2.5, 23.5c	77	85	8c (10.5)	4.7, 11.9c
Managing mistakes/uncertainty while presenting to an audience	68	80	12c (16.8)	8.1, 16.6c	66	76	12c (20.7)	3.2, 20.7c	71	84	12c (13.3)	7.7, 17.0c
Managing personal bias in communication with an audience	74	82	8c (17.9)	3.9, 12.9c	70	77	8 (25.7)	−3.0, 18.7	78	87	8c (10.3)	4.9, 11.9c
Reading and understanding body language cues with an audience	79	86	8c (17.8)	3.7, 12.6c	70	81	13c (22.1)	3.9, 22.1c	85	90	6c (12.4)	1.3, 9.7c

Abbreviations: SD, standard deviation; CI, confidence interval.

^aRange 0 (completely incompetent) – 100 (completely competent).

^bThe overall group included 5 people who could not be classified as community member or researcher because of missing identifying information.

^cPaired t-test P ≤ .05.

Table 3 shows results from the SPCCS, which measures perceived competence with communication skills across contexts and receivers. Overall, participants reported high perceived competence pre-intervention (mean 83), with the lowest score in public contexts (mean 80) and the highest score with friend receivers (mean 91). Pre-intervention, community members and researchers had similar scores across contexts and receivers. Perceived competence was lowest for impersonal and public situations (mean score range 76–80 for public context and stranger receiver). As contexts and receivers became more personal, participants reported higher pre-evaluation competency, where dyad context and friend receiver categories ranged from 87–91.

Table 3.

SPCCS: Changes in Participants’ Mean Scores^a for Competency Communicating Across Different Contexts and Venues, From the Theater-Based Communicating to Engage Training Program, Boston Medical Center and Mass General Brigham, 2017–2018

Scales and subscale	Overall (N = 69)b				Community (n = 26)				Researcher (n = 38)
	Pre	Post	Mean (SD) change	95% CI	Pre	Post	Mean (SD) change	95% CI	Pre	Post	Mean (SD) change	95% CI
Total SPCCS score	83	87	4c (10.8)	1.3, 6.5c	84	85	+1 (14.3)	−4.4, 7.1	83	88	5c (7.0)	2.9, 7.5c
Contexts
Public	80	85	6c (13.2)	3.1, 9.4c	81	84	4 (17.3)	−3.5, 10.5	80	87	8c (8.6)	4.7, 10.4c
Meeting	81	85	4c (15.7)	0.4, 8.1c	82	84	2 (19.2)	−5.9, 10.0	81	88	5c (11.9)	1.5, 9.4c
Group	85	88	3c (11.5)	0.1, 5.7c	85	86	1 (13.4)	−4.8, 6.0	85	90	5c (9.6)	1.3, 7.9c
Dyad	87	89	2 (8.9)	−0.2, 4.1	86	86	0 (10.4)	−4.3, 4.3	88	91	3c (6.4)	0.73, 5.0c
Receivers
Stranger	76	81	6c (15.8)	2.2, 10.0c	77	80	3 (19.5)	−4.8, 11.3	76	83	7c (11.3)	3.4, 11.2c
Acquaintance	82	87	5c (12.6)	1.7, 7.7c	84	86	2 (16.7)	−4.4, 9.4	82	88	6c (8.7)	3.2, 8.9c
Friend	91	92	1 (7.4)	−0.5, 3.0	90	89	− 1 (8.8)	−4.2, 2.9	92	94	3c (6.0)	0.6, 4.6c

Abbreviations: SPPCS, Self-Perceived Communication Competence Scale; SD, standard deviation; CI, confidence interval.

^aTotal SPCC score = [stranger + acquaintance + friend subscore]/3 for pre and post scores.⁹ Range 0 (completely incompetent) – 100 (completely competent).

^bThe overall group included 5 people who could not be classified as community member or researcher because of missing identifying information.

^cPaired t-test P ≤ .05.

Overall, participants reported a mean increase of 4 points post-intervention (P < .05). The public context and stranger receiver categories, where pre-intervention scores were low, had the largest change in the overall group (mean change 6.2 and 6.1 points, respectively). The more private and personal the context and receiver, the smaller the change in mean scores across all subscales. By participant type, researchers reported improvement post-intervention (5 points, P < .05) yet community members showed no significant improvement overall or in subscores.

Next Steps

CtE is a novel mixed stakeholder training drawing upon improvisational theater techniques to improve self-perceived communication competence as a foundation for building new community–academic partnerships. Employing improvisational theater in health professions education is an innovation with demonstrated promotion of interprofessional team development, leadership, and wellness/resilience.⁵ CtE workshops build upon the evidence in 2 important ways. First, we included a mixed audience of community and academic participants to promote co-learning and relationship development for future collaboration. Second, we expanded applying concepts and skills beyond communicating about science by focusing on communication skills that build trust, adapt to audience needs, and cultivate equitable partnerships—key competencies for community-engaged partnerships. Through co-creation of self-confidence in communication, CtE participants leave with a foundation for future collaboration.

Overall, participants reported meaningful increases in comfort with specific communication styles as outlined in training objectives and in perceived communication competence across contexts and receivers. However, we found that researchers, compared with community participants, benefited more as measured by greater post-intervention scores across all subscales. Community members generally having increases in SPCCS scores is encouraging, yet future trainings must close the impact gap between community member and researcher.

Proven approaches to raise the capacity of community members to practice CBPR have included involving them more in the training design process and providing multiple trainings.¹⁰ While it is possible that an improvisational (simulated) format may not adequately address communication issues arising in community-engaged research, increasing perceived competence communicating with researchers is necessary to relationship development.

CtE findings are limited to evaluation in one research program with a small sample size vulnerable to selection bias, so they may not be generalizable to other community–academic settings. The evaluation does not allow for longitudinal or objective assessment of communication skills, nor did it capture partnership intentions (i.e., participants’ willingness to engage in research partnerships) or outcomes. We acknowledge that one workshop is insufficient for a robust impact on communication skills and partnership development, so more rigorous longitudinal training and evaluation are important next steps. Observations to monitor communication skills in the field and follow up with community participants to capture research-related activity is necessary. To address these limitations, we are developing an online CtE module adaptable to other settings for further study.

Our findings suggest that improvisational theater-based mixed stakeholder workshops serve as a strong foundation for positively affecting self-perceived communication competence, a necessary component of successful community–academic partnerships that may advance translational science and build health equity. This training can be adapted to any environment seeking to build strong, trusting partnerships. Components of the facilitator guide may be adapted to partner needs. Regardless of health outcomes, translational research programs may benefit from adopting some CtE approaches into their relationship-building activities.