Overload: The Simple Improv Exercise That Shines a Light on Nursing Stress

How constant interruptions lead to errors and burnout

Illustration of a nurse covering her eyes and leaning on her elbow while there is a tray of narcotics in front of her on the counter

Some years ago, while growing my consulting business and working on my second book on nurse communication, I took a job working 12-hour weekend shifts on a secure unit for residents with dementia.

I loved working with this population when we were staffed properly. Unfortunately, more often than not, someone would call out, leaving me and one aide to care for 20 patients with moderate to advanced memory loss, language difficulties and cognitive decline.

Those shifts were 12 hours of being pulled in every direction at once. By the end of shift on Sunday, I was worn out, physically and emotionally.

This led inevitably to mistakes.

I remember one Sunday evening when, while doing the narcotics count with the incoming nurse at the end of my shift, we discovered that I had made a medication error. Fortunately, the patient was fine, but I just wanted to cry and give up!

During the year or so that I kept this position, my close friends and family could see that I was drained. Yet, I could not really explain what was so draining about that job, or why it would leave me so overwhelmed that I could make a potentially serious mistake and not even notice until hours later.

Even my colleagues, who’d often been in that same boat, had trouble explaining this sense of overwhelm.

The “Overload” Exercise

I already had a strong interest in using the techniques of improvational theater as educational tools. I’d developed several classroom-tested activities to build assertiveness (“I Am”) and raise awareness about general communication (“‘Yes, and …’ ‘Yes, but …’”).

Around this time, I came across an activity called “Overload” in Nancy Hurley’s 2009 book 175 Theatre Games: Warm-Up Exercises for Actors. The exercise was intended to help actors practice concentration and listening, but I saw right away that it might also be useful for nurses.

In April 2011, I tried this exercise for the first time at a theater in New York with a group of about 20 or so students and teachers from NYU. The group included people with backgrounds in theatre education, nursing and healthcare communication.

To introduce the exercise, I shared some statistics from the Institute of Medicine and The Joint Commission’s research on communication and medical errors.

I invited four volunteers to come to the front.

  • One person would count to 100 by fours (4,8,12 and so on).
  • Two people would stand on either side of this person. One would ask the counter very simple personal questions like, “What’s your favorite color?” or, “How many children do you have?” The other would ask easy math problems like, “What’s 2 plus 3?” or, “What’s 5 divided by 1?” The counter was asked to quickly respond to these questions.
  • The fourth person was instructed to stand in front of the counter and make slow, moving gestures with their arms and head, which I instructed the counter to try to mirror.
The results were jaw-dropping.

The same invisible stress that I’d felt and had so much trouble articulating in my direct care work as a nurse suddenly became clearly visible. Each of the tasks I’d asked the counter to perform was simple and low-stakes, but trying to deal with these interruptions all at once left the counter overwhelmed within moments.

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The impact could be seen and felt in a visceral way. It was easy to see how someone dealing with this type of overwhelm could make mistakes, become irritable and get burned out! Afterward, we had a great discussion about how hard it was to concentrate and answer simple questions simultaneously. Everyone involved empathized with the counter.

Improv to Improve Communications

I immediately recognized the activity’s possible applications in helping nurses address communication-related issues. From that day, I knew that improv was going to become the focus of my work.

After I came home, I gathered a small group of practicing and student nurses to pilot and film a workshop on interruption awareness, which you can see on my YouTube channel, www.youtube.com/user/bethboynton/videos.

I offered improv workshops in a friend’s barn and learned about the medical improv curriculum developed by Northwestern University’s Katie Watson, J.D. In 2017, I wrote the healthcare industry’s first book on this subject, Medical Improv: A New Way to Improve Communication.

“Overload” is a simple activity that can be used in a variety of ways. I weave this exercise into my workshops to teach skills associated with emotional intelligence, communication and team leadership. All of these things are related.

For instance, when nurses become more aware of their own limits regarding stress, it develops their ability to identify stress in others. This exercise is also a great way to stimulate discussion of key skills such as setting limits, delegation, and giving and receiving constructive feedback. Because it is experiential, nurses internalize the lesson and continue to develop its insights when they go back into the clinical setting.

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Try It Yourself

Interested in trying “Overload” with your nursing team?

First watch the “Interruption Awareness” video on YouTube and practice the activity with a few colleagues. Once you feel confident about how the exercise works, see if you can lead an in-service to try it with a larger group. This exercise often evokes responses like these:

  • “Now, I understand how some mistakes happen.”
  • “I noticed myself tuning out the tasks that were harder for me and focusing on what felt easier.”
  • “I thought I was counting, mirroring and answering questions correctly until we debriefed and my colleagues told me that I made some big mistakes!”
  • “You could see her stress level rising in a matter of seconds.”
  • “I noticed myself getting really irritated.”

Practical Follow-up Questions

After going through the exercise, use these questions to spark dialogue:

  1. What did you notice as a participant or observer about stress and concentration?
  2. What stress factors are common in our work?
  3. What are some individual variables that may influence stress levels?
  4. What can we do to minimize stress on our unit?
  5. How can we support each other better?
Change team member exchanges like these …

Nurse A: I am too tired to work any overtime safely.

Nurse B: Well, I worked overtime yesterday, so I don’t see why you should get out of it.

Nurse A: Can you help with Mr. B’s admission?

Nurse B: I’ve got my own problems to deal with.

… to more collaborative exchanges like these:

Nurse A: I am too tired to work any overtime safely.

Nurse B: I can see that you’re stressed out. Let me rearrange my schedule so I can work late.

Nurse A: Can you help with Mr. S’s admission?

Nurse B: I can’t — I’m maxed out too. But, the nurse manager just walked into her office. Maybe she can help.

Stress = Toxic Behavior

“Overload” makes visible the invisible yet very common experience of dealing with overwhelming stress. The exercise helps to transform individual overwhelm into a shared experience emphasizing empathy, compassion and mutual support.

This can go a long way towards reducing toxic behaviors exacerbated by stress, such as nurses judging, gossiping and undermining each other.

When nurses develop respect for our own and each others’ limits, we open the door to constructive dialogue about mitigating chronic problems such as inadequate staffing and nurse burnout. That in turn will have a positive impact on patient safety, patient experience and nurses’ career satisfaction.

It’s also cemented my love for medical improv as a teaching tool. This past fall, I piloted a one-day train-the-trainer intensive called Medical Improv 101, teaching nursing leaders to use a few simple activities that can be integrated into in-services, staff meetings, orientation processes and other group activities.

As with any fitness program, practicing these exercises regularly can create a positive ripple effect of respectful communication throughout our organizations. Like many of you working on the front lines, I am relentless when I see something that will help!

Beth Boynton, RN, M.S., CP, is an organizational development consultant and the author of Medical Improv: A New Way to Improve Communication. Reach her at bethboynton.com.

JASMIN MORA is a Los Angeles-based illustrator. Reach her at www.jasminmora.com.

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