Transitions Theatre: An Arts-Informed Interprofessional Education Workshop

Abstract

Introduction

Transition from pediatric to adult care has significant implications for health outcomes in youth with special health care needs. To optimally support the transition, health care and social service providers must work collaboratively with youth and families in service planning, implementation, and evaluation. Based on interviews with 15 youth and their families, we developed an arts-informed interprofessional education activity titled Transitions Theatre using the method of readers’ theater.

Methods

Three educators with lived experience (one former pediatric rehabilitation client and two parents of youth with special health care needs) and three academic/clinical educators codesigned the transitions. We conducted four online workshops (14–20 participants each).

Results

A total of 67 people participated: 59 students from 11 health disciplines and seven postlicensure clinicians and one trainee from five disciplines (e.g., occupational therapy, life skills coaching, early childhood education). Twenty-six participants answered both pre- and postworkshop surveys and reported a positive shift in their understanding of client and family perspectives, their roles in transition support, and other providers’ roles in transition support. After the workshop, learners felt more confident with transition support and interprofessional collaboration. The perspectives of the educators with lived experience aligned with the theater scripts and enhanced learners’ empathetic engagement with the topic.

Discussion

The evidence-based teaching approach of readers’ theater and our coteaching model offered learners a unique opportunity to learn about the challenges clients and their families face at the time of transition to adulthood and identify their role in an interprofessional transition support.

Educational Objectives

By the end of the session, learners will be able to:

• 1.Address the multifaceted needs of young adults with special health care needs (young clients) and their families when they transition from pediatric to adult care.
• 2.Integrate a holistic, client- and family-centered understanding of transition to adulthood into their practice.
• 3.Explain their professional roles in an interprofessional team supporting young clients and their families in transition to adulthood.
• 4.Advocate for young clients and their families navigating the transition from pediatric to adult services.

Introduction

Transition from pediatric to adult care has significant implications for health outcomes in young adults with child-onset disabilities or chronic health conditions. The literature has repeatedly suggested that there is a considerable gap between pediatric and adult services that hinders developmentally appropriate care provision.^1–3 Several researchers have indicated that suboptimal transitions can increase the risk of preventable complications and hospital admissions due to nonadherence, inadequate health management, and the loss of follow-up care by adult health providers.^4–7

With increased survival rates for persons with severe medical conditions and disabilities, the focus of transition support in pediatric services has extended from clinical services to multiple aspects of life transitions.^2,8 Following a paradigm shift toward client- and family-centered care,⁹ transition to adulthood services has gradually encompassed not only clinical transfer but also additional vocational, educational, and social needs of youth with special health care needs (i.e., young clients) and their family members/caregivers.^10–12 A smooth, coordinated transition to adult care requires an open, ongoing collaboration among a variety of health care and social service providers, young clients, and their families. Pediatricians, family physicians, and other health care and service providers (e.g., physiatrists, occupational therapists, speech language pathologists, physiotherapists, social workers, psychologists, life skill facilitators) all have unique roles in transition support services.

The increasingly holistic conceptualization of transition to adulthood demands health professions educators choose an approach that helps learners better understand the unique, multifaceted needs of young clients and families as well as their own professional role in multidisciplinary transition support services. It is vital to offer health care and service providers a safe learning environment where they can learn client and family perspectives and try out new behaviors and communications conducive to collaboration with clients, families, and other professionals.

Recently, creative arts-informed approaches have garnered interest among health professions educators as a promising means of engaging learners in experiential learning and building a safe and open space for the discussion of sensitive topics. One of the methods widely used in health education is a theater-based approach. MedEdPORTAL has published a handful of interactive, theater-based activities in provider-patient partnerships,¹³ conflict resolution,¹⁴ active learning on diversity and inclusion,¹⁵ and patients’ racial bias toward health care providers.¹⁶ Learners’ feedback on these activities has been overwhelmingly positive, indicating that the theater method can be effective in addressing affective and behavioral components inherent in medical communication.

Among theater-based approaches, readers’ theater is an interactive reading activity in which learners take on roles, read unrehearsed scripts, and engage in reflective group discussions. First implemented at the Brody Medical School at East Carolina University in the late 1980s,¹⁷ medical readers’ theater has spread across North American medical schools as a way of teaching students ethical, cultural, and emotional aspects of medicine. Building on the success of the method in medical schools, readers’ theater has extended to interprofessional education (IPE) to teach pre- and postlicensure health professionals about topics such as person-centered care¹⁸ and patients’ experiences of interacting with health care and service providers.^18,19

The readers’ theater method has proven particularly conducive to IPE curricula. Compared to traditional theater, which requires theatrical expertise and equipment (e.g., costumes, makeup, props, stage sets), this method is less resource intensive and more easily adaptable to diverse educational settings. Unlike clinical simulations in which students act out clinical scenarios, readers’ theater allows participants to read with emotions guided by scripts that offer a glimpse into patient experiences with health care systems.¹³ This vicarious experience enables compassionate learning and stimulates collaborative discussion among health care and service providers from diverse disciplines. Based on the shared experience of putting themselves in clients’ shoes, participants can develop a team approach and learn from, with, and about each other.

While traditional readers’ theaters in health have used stories derived from fictional literature,¹⁷ scholars and educators have begun creating their own scripts based on qualitative research data such as interviews, focus groups, and field notes to incorporate research evidence into education. Langlois and colleagues¹³ devised verbatim readers’ theater based on interview transcripts featuring lived experiences of successes and challenges in developing a patient-provider partnership. The verbatim theater was implemented in the University of Toronto's IPE curriculum, and approximately 1,100 students across diverse health care disciplines have participated in this activity. Student evaluations indicate that the verbatim theater is a valuable and engaging approach to help students broaden their understanding of patient-provider partnerships. Students also appreciate having patient educators as discussion facilitators, as their lived experience adds richness to the discussion. Langlois and colleagues emphasized the significance of facilitator training to maximize the benefit of an IPE activity for learners.¹³

The learning activity described in this publication was developed based on narrative interviews with eight youth (17–22 years old) with disabilities and seven family members who have supported their children transitioning to adulthood. Using themes generated from participants’ narratives, the lead author collaborated with an artist researcher to create two scripts: one featuring a youth's experience and the other focusing on a parent's perspective. As part of a participatory member-checking process, we conducted a pilot readers’ theater with seven youth with disabilities and four family members. Participants reported that they found the readers’ theater method engaging and stimulating and felt they could strongly relate to the scripts.

Building upon the pilot project, we aimed to explore the pedagogical potential of readers’ theater in IPE training for health care and service providers, students, and trainees. Following the National Interprofessional Competency Framework developed by the Canadian Interprofessional Health Collaborative,²⁰ the IPE activity addressed two key competency domains for effective collaborative practice: role clarification and patient-, client-, family-, and community-centered care. Learners’ self-reported competencies in these two areas were measured using a pre-/postworkshop survey and qualitative reflections.

Methods

Three educators with lived experience and three academic/clinical educators codesigned the Transitions Theatre IPE workshop. The educators with lived experience were persons with firsthand experiences of pediatric and/or adult health services and consisted of one former pediatric rehabilitation client and two parents of young clients. The academic/clinical educators had backgrounds in IPE, occupational therapy, and heath communication. We designed the workshop as a 1.5- to 2-hour stand-alone session, with each session accommodating 15–20 learners. Although we originally intended to run the workshop in person, the COVID-19 pandemic necessitated its adaptation to a virtual format. We offered all four workshops via the Zoom videoconferencing platform, using breakout rooms to facilitate the script reading and discussion activities in small groups. We used REDCap (Research Electronic Data Capture), an online survey platform, to administer surveys before and after each workshop. The Holland Bloorview Kids Rehabilitation Hospital Research Ethics Board granted the study ethics approval (#20–878, May 11, 2020).

Preparation

Prior to the first workshop, all facilitators joined a 1-hour training session covering how to moderate the interactive reading activity and group discussion over Zoom, the use of a solution-focused approach during small-group discussion, and tips for setting up a learning atmosphere conducive to interprofessional dialogue (Appendix A). The term solution-focused approach refers to a set of communication techniques designed to help individuals build capacity to move toward their preferred futures.²¹ This approach has been used in clinical and postsecondary education settings to enhance learners’ engagement and self-efficacy, as well as to improve learner-educator collaboration.²² Throughout the workshop, facilitators employed solution-focused techniques such as generative questions, positive and empowering language, amplifying successes, reframing problems to solutions, and highlighting strengths to create an open and welcoming learning environment (Appendix A).

One week before the IPE workshop, a workshop coordinator emailed each participant a link to an anonymous preworkshop online survey (Appendix B) and a Zoom invitation. The preworkshop survey asked three questions assessing participants’ understanding of (1) client and family perspectives on transition, (2) their roles in an IPE team, and (3) other professionals’ roles in an IPE team, along with two questions gauging participants’ confidence in (4) partnering with clients and families in transition support and (5) providing support according to client and family needs and hopes. The workshop coordinator preassigned learners to breakout groups (with a maximum of five members each) to ensure each group represented diverse professions.

Workshop Flow

Each workshop started with a brief overview of transition to adulthood services in current pediatric rehabilitation followed by a review of learning objectives and the readers’ theater method. One of the facilitators then guided a discussion of group norms with participants by asking them to describe behaviors and attitudes conducive to a positive learning experience during the workshop. Another facilitator recorded responses on a blank PowerPoint slide while screen sharing (Appendix C). This introductory process took about 15 minutes. Participants then moved to breakout rooms with one to two facilitators in each to engage in the script reading activity and small-group discussion (with a maximum of five learners per breakout room). The workshop coordinator stayed in the main room to keep time and manage technical needs.

In small groups, participants first introduced themselves by answering the icebreaker question “How would you describe your health care provider role to a 10-year-old?” This question aimed to let learners explain their role in simple and clear language to those without preexisting knowledge of their profession. The group then moved on to the script reading activity. Both scripts took the form of monologues, one by a youth (Appendix D) and one by a parent (Appendix E), each consisting of 10 short lines. Facilitators displayed the scripts for learners using the screen sharing feature. Each participant took turns reading out loud their assigned lines from the script (Appendices F and G provide a demo of Transitions Theatre). After the reading activity, facilitators guided a group discussion by asking the following questions:

• •Which part of the script stood out to you? Which part do you feel is most relevant to your professional or personal life? Why?
• •If you were to support this person [the protagonist of the script], what important perspective does your profession bring to the situation?
• •What do you think is your responsibility as a [clinical role] in supporting this [youth/parent]?

Following the small-group activity (approximately 45 minutes), all participants moved back to the main room and took a 10-minute thinking break. Facilitators prompted learners to think about the reflective question “What would you like to highlight about your health care provider role in transition support?” during the break and to share their reflections when they reconvened as a group. Learners then debriefed their experiences with the readers’ theater activity and discussed their perceived role in transition support and potential collaboration with clients and families. Facilitators concluded the workshop with a question-and-answer session with educators with lived experience, in which they shared their own experiences around transitions and answered questions from workshop participants. The large-group session took about 45 minutes.

At the end of the workshop, the workshop coordinator emailed participants a link to an online postworkshop evaluation survey that asked for feedback on the content and facilitation of the IPE activity (Appendix B). We matched the pre- and postworkshop responses of each participant using an anonymous code provided by the participants. Immediately after each workshop, all facilitators joined a 30-minute debrief to reflect on the workshop delivery and shared ideas for improvement (see Appendix A for the facilitator debrief questions). Based on feedback from learners and the workshop facilitators, we iteratively adjusted the workshop facilitation to improve learner engagement (see the Discussion section, below, for details). No changes were made to the learning objectives, readers’ theater activity, or discussion questions.

Results

From August 2020 to April 2021, we conducted four IPE workshops with a total of 67 participants. Fourteen learners participated in the first workshop; 18, 15, and 20 learners participated in the second, third, and fourth workshops, respectively. Participants included 59 university students representing 11 health disciplines, including occupational therapy, speech-language pathology, social work, and medical students, along with seven postlicensure health care and service providers and one trainee representing five disciplines, including occupational therapy, life skills coaching, and early childhood education.

Across four workshops, 41 participants completed a preworkshop survey and 30 participants completed a postworkshop survey. Twenty-six participants (39%) completed both pre- and postworkshop surveys. Table 1 shows demographic information for participants who completed both surveys. The Figure compares participants’ pre- and postworkshop ratings on the five questions related to their knowledge and confidence in transition support and interprofessional collaboration. Postworkshop scores significantly improved for all five items. Of salience were improvements in participants’ understanding of clients’ and families’ perspectives on transition and their confidence in understanding and addressing the needs of clients and families in transition support.

Table 1. Demographic Information for Participants Who Completed Pre- and Postworkshop Surveys (n = 26).

Figure. Percentage of participants (n = 26) who rated agree or strongly agree on pre- and postworkshop survey items related to knowledge and confidence in transition support and interprofessional collaboration. Survey items were rated on a 5-point Likert scale (1 = strongly disagree, 5 = strongly agree).

Regarding the postworkshop feedback survey, most participants (92%) strongly agreed or agreed that what they had learned would be applicable to their current/future practice. The readers’ theater scripts were positively received by most learners (92%) as helping them better understand client perspectives on transition to adulthood. The workshop facilitation was particularly well received, given that all participants (100%) strongly agreed or agreed that their facilitator was effective, efficient, and offered opportunities for reflection. Table 2 includes full results regarding participant perceptions of the quality, usefulness, and relevance of the workshop.

Table 2. Participants' (n = 26) Agree or Strongly Agree Ratings.

Along with quantitative feedback, we asked learners to respond to open-ended questions on key learnings, role clarification, workshop strengths, suggestions for improvement, and general feedback. The most frequently reported key learning was the importance of collaborating with clients and families. Echoing the quantitative feedback, many learners valued the readers’ theater scripts as being helpful in understanding client and family perspectives, as illustrated by the following comment: “I loved the scripts. They were really profound and got us all in the right thinking place to approach the activity. It felt like we could really hear the patient and their family's voice in the room.” Another participant wrote, “The [readers’ theater] activity was a wonderful way to explore the thoughts and fears families have around transitioning out of the pediatrics into adult care. Fantastic discussions and prompting questions from the facilitators.”

Relatedly, the opportunity to learn from and with educators who had lived experience received an overwhelmingly positive response. One learner commented that “the perspectives of patients and families regarding transition… is something I was unfamiliar with, and this understanding will help me anticipate the needs of patients undergoing transition.” Another learner reflected on the importance of spending time to explore clients’ and families’ hopes for the future: “Sometimes additional conversations with them may seem unnecessary or there is not enough time, but I think this would really mean a lot to understand how they feel and ways I can assist them.”

Many learners felt the workshop helped them accomplish the learning objective on role clarification. Some reported that they were able to learn other professions’ approach to transition and developed an understanding of the importance of a team approach to enable holistic, client- and family-centered, transition services:

[I] was able to learn that my profession and all the other professions are involved in advocacy for a better transition process for our patients. This made me feel more unified with the other health professionals and this serves as a strong basis for teamwork.

Another learner recognized that the life transitions are “critical across all ages” and that “everyone plays an important role in the client's transition and development.”

Learners made suggestions to improve the workshop format and structure (e.g., smaller group sizes, increased time for group discussion) and recommended enhancing practical components by providing resources. When asked to share general feedback, many participants commented that their experience had been beneficial: “I really value what you have created here. It is most insightful and provides a context for supporting and advocating for our clients of all ages.” Other learners suggested expanding the workshop to address other health care and life transitions, such as the transition from acute care to rehabilitation or the transition from hospital to community care.

Discussion

The Transitions Theatre IPE workshop offered participants the unique experience of placing themselves in the shoes of young clients and their families. Participant feedback suggested that our workshop helped learners increase their understanding and confidence regarding collaboration with clients and families as well as with learners from other disciplines. The readers’ theater activity spurred immersive and engaging learning through which participants could learn from one another about effective interprofessional partnerships.

The workshop evolved over time by reflectively addressing learners’ and facilitators’ feedback. After the first two workshops, a few participants noted that their roles and responsibilities in transition support services were not as clearly understood as we intended. Some learners desired a more concrete takeaway or tangible resources directly applicable to their day-to-day clinical practice. These suggestions from learners highlighted the importance of clearly communicating the workshop's learning objectives. To address one learning objective (role clarity), we revised the icebreaker question to focus more explicitly on each learner's professional role. In the following workshops, the facilitators observed that when some learners had difficulty describing their role in plain language, other learners voluntarily stepped in to help. This collaboration among participants helped set up a supportive learning atmosphere.

By the third workshop, we recognized that we would need additional preparation to effectively incorporate a lived-experience discussion into the session. While the question-and-answer session with educators who had lived experience was very well received, learners in the first two workshops were hesitant to ask questions. Starting with the third workshop, educators with lived experience first briefly shared their experiences with transitions before opening the floor for questions. Other facilitators had a question prepared for educators with lived experience in case no learners would break the silence (e.g., “What was helpful and what was not helpful when facing transition to adulthood?”). Learners’ feedback suggested that this strategy was effective in stimulating discussion. The ongoing dialogue among the team and reflective codesign approach helped the educators with lived experience gain confidence in sharing their experiences and leading small-group discussions.

While online adaptation happened by necessity, we found serendipitous merits of virtual delivery. The online session removed geographical constraints and brought learners and facilitators together regardless of their geographical location. The ability to join the workshop from the comfort of their own home or office was beneficial for learners and facilitators with physical, geographical, or other barriers. Although online learning requires digital skills, devices, and a reliable internet connection that can limit access, learners and facilitators enjoyed the flexibility of molding their learning environment to their personal needs and preferences. Small breakout groups (five participants and one to two facilitators per group) via Zoom allowed us to create a valuable learning space in which open and in-depth discussions could take place. We also found the digital scripts accommodating for various learner needs, as facilitators could zoom in on the scripts during the reading activity to ensure all learners could comfortably read them. The 10-minute thinking break was crucial for mitigating Zoom fatigue.

Limitations and Future Directions

As this resource focuses on a niche topic (the transition of individuals with childhood-onset disabilities or chronic health conditions throughout the life span from pediatrics to adult care and on to adulthood), its transferability is inherently limited. However, the readers’ theater and coteaching method we describe here can be adapted to wider health education curricula in which an interprofessional approach is prominent. Our research-based readers’ theater proved effective in authentically representing client perspectives and engaging learners in active interprofessional discussions on compassionate care. As suggested by workshop participants, developing a repository of readers’ theater scripts on a range of health care and life transitions could be an exciting opportunity for future IPE activities. Involving persons with firsthand experience of pediatric and/or adult health care systems greatly benefited the participants in this project. Although we recognize that it may be challenging to recruit workshop facilitators with relevant lived experience, it is worth investing time to build a team that collaboratively engages in curriculum development and implementation. Educators with lived experience can be recruited from the community and trained to facilitate group discussions. Team training, cofacilitation process, and iterative improvement based on individuals’ reflections can build confidence and the individual capacity of facilitators with different levels of training and experience. Lastly, our program evaluation relied solely on learners’ self-reporting due to the exploratory nature of this project and the limitations posed by the pandemic. Future workshops can include pre/post assessment of learners’ knowledge and behaviors using experiential learning methods such as role-play or simulation.