Health care inequities persist, and it is difficult to teach health professions students effectively about implicit bias, structural inequities, and caring for patients from underrepresented or minoritized backgrounds. Improvisational theater (improv), where performers create everything in a spontaneous and unplanned manner, may help teach health professions trainees about advancing health equity. Core improv skills, discussion, and self-reflection can help improve communication; build trustworthy relationships with patients; and address bias, racism, oppressive systems, and structural inequities.Authors integrated a 90-minute virtual improv workshop using basic exercises into a required course for first-year medical students at University of Chicago in 2020. Sixty randomly chosen students took the workshop and 37 (62%) responded to Likert-scale and open-ended questions about strengths, impact, and areas for improvement. Eleven students participated in structured interviews about their experience.Twenty-eight (76%) of 37 students rated the workshop as very good or excellent, and 31 (84%) would recommend it to others. Over 80% of students perceived their listening and observation skills improved, and that the workshop would help them take better care of patients with experiences different than their own. Six (16%) students experienced stress during the workshop but 36 (97%) felt safe. Eleven (30%) students agreed there were meaningful discussions about systemic inequities. Qualitative interview analysis showed that students thought the workshop helped develop interpersonal skills (communication, relationship building, empathy); helped personal growth (insights into perception of self and others, ability to adapt to unexpected situations); and felt safe. Students noted the workshop helped them to be in the moment with patients and respond to the unexpected in ways more traditional communication curricula have not. The authors developed a conceptual model relating improv skills and equity teaching methods to advancing health equity.Improv theater exercises can complement traditional communication curricula to advance health equity. 

Exploring the Value of Improvisational Theater in Medical Education for Advancing the Doctor–Patient Relationship and Health Equity

Background: Recent research has shown beneficial results for music-based interventions (MBIs) for persons living with Alzheimer’s disease and related dementias (AD/ADRD), but reports often lack sufficient detail about the MBI methodology, which reduces replicability. A detailed checklist for best practices in how to report MBIs was created in 2011 by Robb and colleagues to remedy the lack of detail in MBI descriptions. The implementation of the checklist specifically in AD/ADRD research has not been established. Given the complexity of music and the variety of uses for research and health, specific MBI descriptions are necessary for rigorous replication and validation of study results. Objective: This systematic mapping review utilized the “Checklist for Reporting Music-Based Interventions” to evaluate the current state of MBI descriptive specificity in AD/ADRD research. Methods: Research articles testing MBIs and reviews of MBI efficacy published between January 2015 and August 2023 were scored using the checklist and the results were summarized. Results: Forty-eight studies were screened, and reporting was inconsistent across the 11 checklist criteria. Ten out of 48 studies fully reported more than 5 of the 11 criteria. Only one of the 11 scoring criteria was at least partially reported across 47 of 48 studies. Conclusions: Thorough reporting of intervention detail for MBIs remains limited in AD/ADRD MBI research. This impedes study validation, replication, and slows the progress of research and potential application of music in practice. Greater implementation of the reporting guidelines provided by Robb and colleagues would move the field of MBI research for AD/ADRD forward more quickly and efficiently. 

Inconsistent Music-Based Intervention Reporting in Dementia Studies: A Systematic Mapping Review

The objective of this research was to determine if a personalized music intervention reduced the frequency of agitated behaviors as measured by structured observations of nursing home (NH) residents with dementia.The design was a parallel, cluster-randomized, controlled trial.The setting was 54 NH (27 intervention, 27 control) from four geographically-diverse, multifacility NH corporations.The participants were 976 NH residents (483 intervention, 493 control) with Alzheimer's disease or related dementias (66% with moderate to severe symptoms); average age 80.3 years (SD: 12.3) and 25.1% were Black.The intervention was individuals' preferred music delivered via a personalized music device.The measurement tool was the Agitated Behavior Mapping Instrument, which captures the frequency of 13 agitated behaviors and five mood states during 3-minute observations.The results show that no verbally agitated behaviors were reported in a higher proportion of observations among residents in NHs randomized to receive the intervention compared to similar residents in NHs randomized to usual care (marginal interaction effect (MIE): 0.061, 95% CI: 0.028-0.061). Residents in NHs randomized to receive the intervention were also more likely to be observed experiencing pleasure compared to residents in usual care NHs (MIE: 0.038; 95% CI: 0.008-0.073)). There was no significant effect of the intervention on physically agitated behaviors, anger, fear, alertness, or sadness.The conclusions are that personalized music may be effective at reducing verbally-agitated behaviors. Using structured observations to measure behaviors may avoid biases of staff-reported measures. 

Using structured observations to evaluate the effects of a personalized music intervention on agitated behaviors and mood in nursing home residents with dementia: results from an embedded, pragmatic randomized controlled trial

Personalization of Reminiscence Therapies in the Nursing Home Setting: Lessons From an Embedded Pragmatic Trial of a Music Intervention.

Demência é uma síndrome que envolve variados sintomas cognitivos e comportamentais, os quais impactam diretamente na qualidade de vida do afetado. A maioria dos tratamentos disponíveis são individuais e fora do padrão econômico geral. Desse modo, a terapia musical se mostra promissora por seu caráter não farmacológico acessível e possibilidade de execução em grandes grupos, o que evidência a relevância desse estudo.

Aplicabilidade da musicoterapia em pacientes com demência: uma revisão integrativa da literatura

In pragmatic trials, on-site partners, rather than researchers, lead intervention delivery, which may result in implementation variation. There is a need to quantitatively measure this variation. Applying the Framework for Implementation Fidelity (FIF), we develop an approach for measuring variability in site-level implementation fidelity. This approach is then applied to measure site-level fidelity in a cluster-randomized pragmatic trial of Music & MemorySM (M&M), a personalized music intervention targeting agitated behaviors in residents living with dementia, in US nursing homes (NHs).Intervention NHs (N = 27) implemented M&M using a standardized manual, utilizing provided staff trainings and iPods for participating residents. Quantitative implementation data, including iPod metadata (i.e., song title, duration, number of plays), were collected during baseline, 4-month, and 8-month site visits. Three researchers developed four FIF adherence dimension scores. For Details of Content, we independently reviewed the implementation manual and reached consensus on six core M&M components. Coverage was the total number of residents exposed to the music at each NH. Frequency was the percent of participating residents in each NH exposed to M&M at least weekly. Duration was the median minutes of music received per resident day exposed. Data elements were scaled and summed to generate dimension-level NH scores, which were then summed to create a Composite adherence score. NHs were grouped by tercile (low-, medium-, high-fidelity).The 27 NHs differed in size, resident composition, and publicly reported quality rating. The Composite score demonstrated significant variation across NHs, ranging from 4.0 to 12.0 [8.0, standard deviation (SD) 2.1]. Scaled dimension scores were significantly correlated with the Composite score. However, dimension scores were not highly correlated with each other; for example, the correlation of the Details of Content score with Coverage was τb = 0.11 (p = 0.59) and with Duration was τb = - 0.05 (p = 0.78). The Composite score correlated with CMS quality star rating and presence of an Alzheimer's unit, suggesting face validity.Guided by the FIF, we developed and used an approach to quantitatively measure overall site-level fidelity in a multi-site pragmatic trial. Future pragmatic trials, particularly in the long-term care environment, may benefit from this approach.Clinicaltrials.gov NCT03821844. Registered on 30 January 2019, https://clinicaltrials.gov/ct2/show/NCT03821844 . 

/pdf/measuring-implementation-fidelity-in-a-cluster-randomized-1ass4mpu.pdf

Measuring implementation fidelity in a cluster-randomized pragmatic trial: development and use of a quantitative multi-component approach

The arts can touch places that are difficult to recognize and understand, capture in words, or measure by numbers-whether you're an artist, a patient, or an educator. This ineffability presents a dilemma for practitioners and researchers in arts in health when questions of legitimacy, efficacy, program implementation, and research funding are tied to outcomes-based research. Ethical tensions arise when traditional public health and clinical research methods are the wrong tools for capturing what's vital about the arts. This article argues that being a responsible arts in health researcher requires interrogating what counts as evidence, especially when the insistence on rigor risks oversimplifying and diminishing the power of the arts. It further argues for equity in arts in health research, including equity in investigative strategies that value both the arts and the research.

https://journalofethics.ama-assn.org/sites/journalofethics.ama-assn.org/files/2022-06/stas2-peer-2207.pdf

What Are the Right Tools for Studying Arts in Health Interventions?

Pragmatic Trial of Personalized Music for Agitation and Antipsychotic Use in Nursing Home Residents With Dementia

<h2>Abstract</h2><h3>Objectives</h3> We conducted 2 trials of a music intervention for managing behaviors in nursing home (NH) residents with dementia, before (2019) and during (2021) the pandemic. In this report, we compare adherence fidelity across the trials using the Framework for Implementation Fidelity (FIF). <h3>Design</h3> Cross-sectional, descriptive implementation comparison. <h3>Setting and Participants</h3> Fifty-four NHs randomized to receive the intervention (27 pre-COVID, 27 during COVID) <h3>Methods</h3> We compare the trials on the following FIF criteria: coverage (number of residents receiving the intervention); duration (minutes of music received per exposed day); frequency (percentage of residents with nursing staff use of music in the past week); and details of content (adherence to core components of the intervention). We report NH-level performance in each domain and compare characteristics of NHs in the bottom (low) and top (high) terciles of adherence. <h3>Results</h3> Across FIF domains, adherence fidelity was lower during COVID compared with pre-COVID: <i>coverage</i>, residents exposed (COVID: 7.5, SD 5.6; pre-COVID: 12.7, SD 3.6); <i>duration</i>, music minutes per exposed day (COVID: 2.5, SD 5.1; pre-COVID: 27.1, SD 23.9); <i>frequency</i>, percentage of residents with nursing use of intervention in the past week (COVID: 15.0, SD 31.5; pre-COVID 40.4, SD 25.6); and <i>details of content</i>, compliance with core components of the intervention (COVID: 8.3, SD 1.9; pre-COVID 9.6, SD 2.0). In both trials, high–adherence fidelity NHs had better nursing staff ratios, greater percentages of Medicare residents, and lower percentages of Black residents, compared with low-fidelity NHs. <h3>Conclusions and Implications</h3> Adherence fidelity was worse in the COVID vs pre-COVID trial, despite adaptations between trials intended to reduce staff burden and increase clinical targeting of the intervention. Results may point to the long-term effects of COVID on quality improvement capacity in NHs and/or a lack of available resources in most NHs to implement complex behavioral interventions without direct research support. 

Pragmatic Implementation of a Music Intervention in Nursing Homes Before and During COVID-19.

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Measuring implementation fidelity in a cluster-randomized pragmatic trial: development and use of a quantitative multi-component approach

What Are the Right Tools for Studying Arts in Health Interventions?

Pragmatic Trial of Personalized Music for Agitation and Antipsychotic Use in Nursing Home Residents With Dementia

Pragmatic Implementation of a Music Intervention in Nursing Homes Before and During COVID-19.