Interactive Theater Research Paper

JNSD

Journal for Nurses in Staff Development & Volume 27, Number 2, 65Y68 & Copyright B 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Interactive Theater
An Innovative Conflict Resolution Teaching Methodology
Anne L. Meng, MN, CPNP, RNC, AE-C

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John Sullivan, MA

The incidence of verbally abusive families has dramatically increased in pediatric hospitals. A workshop incorporating interactive theater was designed to support staff in developing assertive communication skills to manage verbal abuse. Professional actors performed skits based on clinical scenarios. Participants entered the scenarios at any point to change the communication style and affect a positive outcome. Interactive theater enhances emotive
learning that is essential to affect behavioral change. This is a useful strategy for educators to include in any training that is designed to change behavior.

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orking in a healthcare facility is considered the third most dangerous job in the United
States (Gilmore-Hall, 2001). An online survey conducted by the American Nurses Association found that 17% of nurses were physically assaulted in the previous year, and 57% reported verbal abuse (Distasio,
2002). In fact, nonphysical violence has become so common that it is considered normative (Lanza, Zeiss, &
Reirdan, 2006). Most studies of workplace violence examine areas such as psychiatric or emergency room settings, where violence is known to be a problem.
However, a Canadian survey (Pejic, 2005) concluded that verbal abuse is as common in pediatric settings as it is in other nursing environments, with 91% of pediatric nurses identifying themselves as victims of verbal abuse.
Pediatric nursing staff in a children’s hospital identified verbal abuse from parents as a significant stressor in their work environment. Staff often resorted to contacting campus police to manage parents, but this was clearly not an ideal first-line strategy. The identified problem was a lack of assertiveness skills among staff.
The purpose of this article was to describe an innovative staff development initiative that incorporated interactive

Anne L. Meng, MN, CPNP, RNC, AE-C, is Advanced Nurse Practitioner and Special Projects Coordinator, Department of Nursing Practice and
Professional Development, University of Texas Medical Branch, Galveston.
John Sullivan, MA, is Codirector, Public Forum and Toxics Assistance
Division/NIEHS Center for Environmental Toxicology, University of
Texas Medical Branch, Galveston.
ADDRESS FOR CORRESPONDENCE: Anne L. Meng, 1244 Deer Ridge
Drive, League City, TX 77573 (e-mail: [e-mail]).
DOI: 10.1097/NND.0b013e31820eee5b
Journal for Nurses in Staff Development

theater (IT) as an emotive learning strategy to enhance application of assertiveness skills in clinical practice.

REVIEW OF LITERATURE
Workplace violence includes nonphysical acts such as threatening behavior, verbal abuse, verbal threats, obscene telephone calls, intimidation, or harassment of any nature, including being followed, sworn at, or shouted at (Anderson & Stamper, 2001; Distasio, 2002).
Verbal abuse is behavior that humiliates, degrades, or otherwise indicates a lack of respect for the dignity and worth of another individual (Pejic, 2005).
Verbal abuse is related to physical violence. Physical violence increases sevenfold for those who experience nonphysical violence. Risk of physical violence is high in verbally abusive environments, even though different individuals perpetrate these two forms of behavior. It is theorized that nonphysical violence creates a culture of disrespect that is conducive to the emergence of physical violence, whether by the same or different individuals
(Lanza et al., 2006).
Most perpetrators are men, and the majority are patients (Anderson & Stamper, 2001; Gerberich et
al.,
2004); one in four is a visitor, but abusers can also be coworkers, managers, or physicians (Anderson & Stamper,
2001). Perpetrators are likely to be cognitively impaired, especially those who commit physical violence
(Gerberich et al., 2004). In a pediatric study, the source of abuse was evenly dispersed among patients, parents/ visitors, and physicians (Pejic, 2005). Authoritarian behavior is often associated with violence toward staff, but findings are mixed. In the latter case, authoritarian behavior may be interpreted as showing strong leadership (Ray &
Subich, 1998).
Violence is more likely to occur in the evening or at night, with patients with a history of violence, among staff who work alone, in understaffed areas, in medically underserved communities, and where there is poverty and access to guns and alcohol (Anderson & Stamper,
2001). Younger age has been associated with increased likelihood of assault (Gerberich et al., 2004).
Inexperienced staff who lack formal safety training and staff with low self-esteem are most vulnerable to workplace violence (Anderson & Stamper, 2001). Individuals who tend to respond to threatening situations with www.jnsdonline.com Copyright @ 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

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anxiety, that is, trait-anxious persons, and those who believe that the outcomes of their actions are contingent upon events outside their control, that is, persons with an external locus of control, tend to be more involved in confrontations with patients than are persons with internal loci of control, or those who believe that their own actions control events. Violence creates tension among all staff and changes the comfort level on the unit. It generates feelings of powerlessness and depression; thus, absenteeism often increases. Staff may change positions or leave the profession altogether (Anderson & Stamper,
2001). Other effects of violence include reduced productivity, decreased staff morale and reduced quality of life, chronic pain, muscle tension, loss of sleep, family disruption, anxiety, helplessness, irritability, and sadness.
Staff who experience nonphysical violence over time may be at risk for mental health problems such as acute stress disorder or posttraumatic stress syndrome. The effects of nonphysical violence can be greater than the effects of physical violence (Gerberich et al., 2004). Anger, irritation, sadness, and depression were frequently reported by employees who experienced nonphysical violence (Findorff, McGovern, & Sinclair, 2005).
There is a tendency for managers to focus concern on physical assaults, but the nature of nonphysical violence creates a gradual deterioration in workers’ well-being that is equally serious and destructive (Findorff et al.,
2005). Verbal abuse ultimately affects quality of patient care. The negative effects of verbal abuse decrease critical thinking and ability to concentrate on the task at hand. Furthermore, team relationships are negatively affected by lack of respect for other professionals, and there is a decline in commitment to organizational goals
(Pejic, 2005). Interestingly, violence experienced by staff also has a negative association to patient ratings of quality of care (Arnetz & Arnetz, 2001). It is suggested that patient avoidance behaviors may be a strategy for coping with the negative effects of violence. Negative attitudes generated toward patients keep the caregiver on guard and result in staff spending less time with patients.
Nursing staff appear to tolerate a large number of abusive incidents, as evidenced by their failure to report them. However, when questioned, they indicate a strong sense of futility about reporting (Findorff et al., 2005).
The reasons that staff cite for failure to report incidents include concern for a vulnerable patient, lack of support from management, fear of retribution or blame, rationalization that the patient was cognitively impaired, belief that only physical injury required reporting, the timeconsuming nature of the task, and the belief that no management change would result and that verbal abuse was part of the job (Pejic, 2005).
Efforts to reduce violence should start with the goal of reducing nonphysical violence among patients and em66

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ployees (Lanza et al., 2006). Patients and families should be assessed for violence upon admission. A system for alerting the team, such as flagging the chart of high-risk patients, should be put in place (Anderson & Stamper,
2001; Gilmore-Hall, 2001; Pejic, 2005), and meetings with families to facilitate a smoother admission should be part of the management plan (Pejic, 2005). Institutional policy should require that patients be informed on admission that the facility has a zero-tolerance policy for violence (Distasio, 2002; Gilmore-Hall, 2001; Lanza et al., 2006) and that the facility will support employees who pursue legal action against patients who assault them (Distasio, 2002). Policies need to clearly define nonphysical violence, provide reporting procedures, state consequences, and evaluate outcomes (Lanza et al.,
2006). Mechanisms need to be in place to report violence
(Gilmore-Hall, 2001).
Other management strategies include setting up a training response team to assist on the scene (Distasio, 2002;
Gilmore-Hall, 2001; Lanza et al., 2006), provide annual staff education to review institutional policy and strategies to recognize and defuse violent behavior, stress the importance of reporting, and ensure adequate staffing.
In summary, the literature clearly indicates that verbal abuse is destructive to the health and well-being of nurses in the workplace. Furthermore, verbal abuse negatively affects quality of care. Strategies need to be in place to reduce the incidence of verbal abuse.

METHODS
Because the institution had a well-developed ‘‘violence in the workplace’’ policy and flagging admission charts was deemed unrealistic, an alternative strategy was sought. Because the characteristics of staff help determine susceptibility to abuse, training workshops were the intervention of choice. Additional data were sought to aid in the design of the intervention.
A survey was conducted among pediatric nursing staff to determine the incidence and frequency of verbal abuse in the past 3 months, personal and professional reactions to verbal abuse, and reporting practices of the staff. Survey results indicated highest incidences of verbal abuse in the pediatric chronic care and intensive care units. Types of abuse consisted primarily of yelling, condescending comments, abusive comments disguised as jokes, and ignoring or controlling the conversation. A variety of reasons were given for failing to report the abuse, including lack of physical injury, incident perceived as not important, the nurse understood the patient, lack of time, fear of blame, and perceptions that it was part of the job or that reporting would not result in change.
Based on survey results, the workshop design included
4 hours of didactic content on the effects of verbal abuse, review of the zero-tolerance institutional policy,
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and interactive dialogue on assertive communication strategies. The remaining 4 hours were dedicated to
active practice of desired assertive behavior via IT.
The IT format selected for the workshop incorporated principles and techniques of Boal’s (1979) ‘‘Theatre of the
Oppressed.’’ Boal’s methodology is useful for healthcare professionals, union organizers, counselors, teachers, and social justice advocates to analyze their issues from multiple points of view using simulated scenes drawn from their lives. The technique emphasizes interaction and allows participants to toggle between facts and feelings to explore both subjective and objective perceptions of their collective problem. Participants replace characters in conflict situations to experiment with new actions to achieve conflict resolution. Because solutions are grounded in the facts and feelings of real life, participants are able to transfer knowledge and insights directly from the workshop into their professional lives.
Boal’s techniques recognize that participants are not necessarily actors. Thus, in this methodology, participants cycle through a graduated series of basic acting games, image-making exercises, and scene improvisations that segue seamlessly into the theater component. The process begins with a trust exercise, followed by a facilitator-led introduction to molding the human body to create images of conflicts or concepts central to the workshop topic. Small groups of participants are then guided to form images of central concepts, power relationships, and key nursing values. These images are configured as still photos. This imagery exercise often uncovers attitudes, biases, and behaviors that call for a reflective look inward. Interestingly, the key nursing value depicted in this workshop was a circle of caring professionals surrounding the child and family. This image coincidently expressed the official departmental vision statement.
The second step in the process is a short series of brief sociometry games to assess the experience and conceptual background of the audience (Sternberg & Garcia,
1998). Staff are asked to rate various aspects of their workplace experience on a sliding scale. Sociometry questions for this workshop focused on staffing, training, supervision, workload, and safety issues.
When participants are sufficiently ‘‘warmed up,’’ the facilitator introduces basic terminology: antagonist, protagonist, ally, core conflict, ‘‘spect-actor’’ intervention, ‘‘hot seat,’’ and Rashomon. Workshop participants are considered spect-actors because they are spectators who become actors. The hot seat is an interview strategy where a core actor is invited to sit for questioning by the audience to determine the motivation for his or her actions.
Rashomon is an analytic strategy where characters from the scene freeze their action at a critical point and
‘‘think aloud’’ to make their underlying thoughts and feelings evident.
Journal for Nurses in Staff Development

After the terminology is clarified, actors perform two skits created from clinical data provided by the staff, which depicts verbally abusive parent-to-staff exchanges.
The actors were hired from community-based improvisational theater groups. Actors were given clinical story material from which they developed dramatization of the skits prior to the workshops. The scenes they created were designed with ‘‘open doors’’ or points of frustration that motivate members of the audience to come through the door and become spect-actors, replacing the protagonist and inserting their own actions into the drama to revise the outcome. This experience provides a safe forum to allow the audience to experience emotions that accompany the new (i.e., in this case, assertive) behavior.
This type of emotive learning experience increases the likelihood that the new behaviors will be incorporated into the individual’s practice repertoire.
After the skit reviews, participants vote on which scene they wish to further develop. The antagonist from the skit of choice is then invited to sit on the hot seat, where he or she is interviewed by participants to uncover the motivation for the angry behavior. As participants question the antagonist about the events that led to the event and particular life circumstances, it becomes evident that multiple life stressors taxed the antagonist’s coping reserves beyond manageable limits. Participants begin to appreciate that the anger directed at them has no personal basis, rather it is an expression of unmet needs requiring therapeutic nursing intervention.

Sample Skit
The emergency room (ER) staff called the pediatric unit to report that a 3-year-old unconscious girl was being admitted. The ER nurse expressed anger because the child was allowed to ride a horse solo. She stated that the grandmother (guardian) was irresponsible and negligent.
The pediatric nurse shared the ER nurse’s angry sentiments and later met the grandparents and child in the hall of the pediatric unit outside the assigned room.
The grandmother looked at the crib in the room, held both hands up, shook her head from side to side, and with a raised voice said, ‘‘Oh no! We won’t put her in there. It’s like putting her in jail. We need a real bed.’’
The nurse and grandmother exchanged angry words.
The nurse sought to control the situation by citing institutional policies. The grandmother threatened the nurse with statements alluding to her powerful community ties.
The dialogue deteriorated. The grandmother threatened to take the child against medical advice. The nurse told the grandmother that she could not let an unconscious child leave against medical advice and she called her supervisor. The supervisor affirmed that a crib was necessary and offered to locate another hospital for www.jnsdonline.com Copyright @ 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

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transfer but was not successful. The grandmother continued to rant and the nurse threatened to call security to escort her off the unit. The grandmother reluctantly agreed to have the child placed in a youth bed with the side rails raised. However, during the duration of the ensuing 3-day hospitalization, the grandmother was verbally abusive to all staff.

Immediately after the dramatization, individual actors formed body sculptures that captured their view of power dynamics among the characters. The facilitator guided discussion to explore diverse perceptions of these power relationships. This discussion was followed by an invitation to the grandmother, as antagonist, to sit in the hot seat to address questions from participants. Participants learned that the child was abandoned by her mother.
The grandmother stated that she was tired after raising five children and had no other family support but felt compelled to raise the child. Also, while in the ER, the grandmother observed a distraught child in a crib. No staff attended to this child. The distraught child caught his leg in the side rail and experienced damage to his leg. This participant-driven interview provided background data necessary to understanding the rational, but misdirected, source of the grandmother’s anger.
With this new understanding, the skit was re-played.
Participants were now instructed to stop the skit at any point of their choosing and enter the scene to replace the protagonist, in this case, the pediatric nurse. The new protagonist was instructed to use assertive communication skills to affect a positive outcome. This process was continued until all participants who wished to change the outcome had an opportunity to do so. At this point, the antagonist was invited to sit in the hot seat once again. Participants questioned the antagonist to determine the reasons for her change in behavior. The antagonist pointed out that assertive comments that also expressed empathy ‘‘took the wind out of her sails’’ and prevented her from resorting to anger. Proposals and outcomes were recorded by a note taker for inclusion in departmental agendas. The performance concluded with the facilitator recapturing single words or phrases from participants that best captured feelings and ideas engendered during the performance. Participants used one or more of these reactions to create a capstone image to summarize the performance. The final IT activity was a round table debriefing that summarized the activities of the workshop and addressed the application of assertiveness skills into clinical practice.
The verbal abuse workshop was repeated on three occasions to accommodate staffing schedules. Attendance at the first offering was poor, and participants cited stage anxiety as the reason for nonattendance. However, during the debriefing, participants commented that sociometry
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and gaming strategies made it comfortable for them to segue easily into the role of spect-actor. They said that they would return to the unit and advise their colleagues that there was no cause for anxiety. Participation at the second and third workshops increased. Evaluations from every participant were excellent. Staff pointed out that they are physically active in the clinical area and they appreciated the active format of the workshop as opposed to didactic presentations. Participants identified the dramatized material as highly relevant to their clinical work, and nurses who are usually reticent were observed to actively engage in the activity. Perhaps, the most positive evaluation was the feedback from staff on the unit who demonstrated their new assertiveness skills during clinical rounds. CONCLUSION
Verbal abuse from patients toward staff is increasing in frequency and has a destructive impact on the emotional health of staff and on quality of patient care. Stunning increases in volume of verbal abuse demand that supports be made available for staff. Staff can benefit from assertiveness training, especially if that training includes an emotive learning component. Interactive theater is an effective and innovative approach to providing staff with an emotive learning experience that increases the likelihood of application of such skills in clinical practice.

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