Practice Matters

From our readers: Using theater improvisational games to enhance interpersonal skills in nurses

Nursing requires an effective set of interpersonal skills. A key to meeting this expectation is the ability to develop effective interpersonal communication. This is best accomplished by being able to self-reflect as a nurse. Basic theater improvisational exercises promote a person’s ability to recognize the impact of their communication patterns as part of their interpersonal skills. The teamwork of nurses working together on a unit, dynamics of nurses and managers, and relationships with patients all can benefit from simple improvisational (improv) games tailored to your specific needs.

The basics

My experimental foundation for using theater improvisational activities as an instructor derives from the Dramaturgic Model, Rehearsals for Growth (RfG) developed by psychologist Dr. Daniel J. Wiener. Summarized, a goal for RfG improvisational games is for the participant to relinquish set expectations, reduce reliance on control, and embrace the spontaneity of the present moment during interactions with others. The seminal work that Dr. Wiener builds on is the theory of Dramaturgy set forth by sociologist Dr. Erving Goffman in the late 1950s. Essentially Goffman says life is a stage, we are always performing, and what others see from us is what we choose to reveal to them.

Application to nursing

The goal of improvisational activities for our purposes is to help nurses reflect upon their verbal and nonverbal communication patterns, self-evaluate what is being communicated by their interactions, and recognize what the interpretation might be by others. Whether we are managers, instructors or bedside nurses, our personal interactions matter because of our invested common goal of providing quality care to patients.

If the improvisational exercise is successful, the participants have recognized their preconceived notions and expectations that may hinder effective interpersonal skills. Further goals would include encouraging acceptance, promoting attentiveness and responsiveness to cues from others (especially the nonverbal ones), and preventing impulsive reactions by nurses. Ultimately, the hope is that the nurse is able to replace a reliance on controlling relationships with being self-aware and responsive to the interpersonal nature of relationships.

Setting the stage

Theatrical improvisational games can be integrated into a variety of settings. First, the leader considers the desired outcome of the exercise. If you are the leader, ask yourself what you are hoping to accomplish. As a nurse instructor, you can use these activities to help novice nurses develop interpersonal skills. If you are working with expert nurses, maybe you are using this activity to relieve burnout. For managers, goals may include determining the dynamics, resolving the conflicts, or improving teamwork among nurses on the unit. These activities could be connected to performance evaluations.

Here are two tips for the process known as “playing the game.”


Tip #1: Don’t discuss the goals for the activity in too much detail or you will lose the element of spontaneity. Of course, if you are asking for volunteers, it is only fair that they be aware of the elements of the game. For example, share that the nurse will be pretending and relying on only nonverbal communication as the form of interaction. The most important guideline is to convey that the atmosphere is intended to be supportive, and that there is no right or wrong response. If nurses are anticipating that you are critiquing them for correct or expected behaviors, then that influences the interactions that you wish to be real.

Tip #2: Keep the game brief. Two minutes seems like an eternity to the players. One minute will likely suffice. I would also suggest not keeping score. It is human nature to feel competitive when someone is keeping score. The goal of the game is not winning. Instead, encourage that it is an opportunity to let down, let go, and feel safe to put it all out there.

Playing the game

Ping-pong is the game I choose to promote discussion about interpersonal skills and the impact of nonverbal communication. Ask for two volunteers. Player one is P1 and player two is P2. Avoid using the word opponent. Offer the explanation mentioned above for the rules of the game (no talking; rely on nonverbal communication). Have the nurses pretend to choose their ping-pong paddles and choose their side of the table. Then simply say something like, “Okay, let’s play pretend ping-pong for a minute.”

Next, observe during the game. Depending on what you are hoping to accomplish, here are some general observations. Assess if one or both players pretend to pick up the ping-pong ball to begin the game. What does that say about who assumed to be the leader or assumed they would serve first? Do the players volley back and forth endlessly? This may indicate hesitation on both players’ part to really engage.

During their plays, are there aggressive hits that P1 may hit like it is an obvious ace but P2 returns the ball? What patterns of dominance, passiveness, willingness to relent, or refusal to appear as the loser take place? Would you consider that pairing different players would result in a different game?

A key to evaluating attentiveness and responsiveness of the nurses is to observe whether P1 and P2 seem to be playing the same game or each his or her own game. How much eye contact takes place? Were the efforts coordinated so that the appearance was a fluent game? Are the players accepting of each other’s actions and enjoying the activity? Does there appear to be a struggle to gain control of the game, which may reveal the climate of their working relationship? Were the players comfortable with pretending? Did anyone volunteer to shake hands before or after the game? Was there any mention of keeping score? Was there a sense that the game increased a sense of partnership versus opposition? Are the nurses in the moment of the game or too aware of the observer’s reactions? How real did the game seem?

Did either player pretend to miss the ping-pong ball and act like they were walking over and picking up the ball from the floor? This would show a true investment in the game by a player wanting to make it believable. What does that say about the player’s investment as a nurse?

After the match

Once you have concluded the game, you can decide how much of the discussion among the players, you, and the others present is guided from your preset agenda. l would suggest not having a true agenda. Allow the players to interpret the meaning of their interaction. You may learn the most by not directing the discussion with specific comments. Instead, ask the players about how they felt. If the discussion doesn’t flow, open communication by complimenting the fact that the nurses’ volunteering shows their ability to take risks. This can be tied to conversations about when nurses share about themselves it indicates a willingness to grow. Continue with the comment that discussions about a pretend game still serve to solve real-life challenges in the work setting.

Further prompts include asking the players if they felt hesitant or uneasy like they were on display. This works well when exploring nurses’ vulnerabilities. This can be tied to appreciating patients’ vulnerabilities if you are hoping to improve caring behaviors in nurses. This also can be used to support education about developing a self-awareness of the nurses’ responsiveness and attentiveness skills regarding the needs of others. The game can be focused on just one aspect of the examples mentioned here or tailored to many situations.

Finding the “real moments”

My suggestion would be for whatever game or activity (the Internet has dozens of them for group work) you choose, appreciate the “real moments” that reveal themselves. Those real moments are the teachable moments—the moments that make the difference. The realization by nurses that their nonverbal communication is misrepresenting them or they are being misunderstood based on their interpersonal skills is very powerful.

In psychiatric nursing, therapeutic communication includes understanding the term transference. Defining transference can be long and complicated. The definition includes the impact of every important relationship we have experienced in our lives since infancy on who we are as individuals. According to transference, all of the interactions of our past contribute to our perceptions and interpersonal skills. Simply stated, transference is the baggage we bring into relationships. Improvisational games help nurses identify their baggage.

In all circumstances, quality patient care and outcomes will improve when nurses know themselves. Theater improvisational games can contribute to this goal.

Elizabeth Delaney is an assistant professor of nursing in the Ohio University Southern School of Nursing in Ironton.

From our readers gives nurses the opportunity to share experiences that would be helpful to their nurse colleagues. Because of this format, the stories have been minimally edited. If you would like to submit an article for From our readers, click here.

Selected references

Donmoyer R. Pedagogical improvisation. Educational Leadership. 1983;40(4):39-43.

Goffman E. The Presentation of Self in Everyday Life. Garden City, NY: Doubleday; 1959.

Wiener DJ. Rehearsals for Growth: Collected Papers, 1991-2004. Leverett, MA: Self-Published; 2004.

Wiener DJ. Using theater improvisation to assess interpersonal functioning. International Journal of Action Methods. 1999;52(2);51-69. http://connection.ebscohost.com/c/articles/3015896/using-theater-improvisation-assess-interpersonal-functioning. Accessed June 6, 2012.

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