An Innovative, Arts-Based Approach to Interprofessional Education

Obesity is a global health concern that is challenging to address at the health system level. This is partly because health professionals perceive themselves to be poorly equipped to effectively handle weight management issues. Compounding this are the biases held by health professionals towards clients living with excess weight. This project aimed to address these biases among health professionals through the use of live, dramatic arts as a pedagogical tool to disseminate findings from an original research study that explored multiple health system perspectives on weight management. Using an interprofessional learning format, the research team facilitated four, interprofessional education (IPE) workshops in universities across Atlantic Canada with health professional students and their faculty. Post-workshop evaluations indicate that the workshop was well received; the live, dramatic presentation of professional-client perspectives on obesity management was effective for not only facilitating understanding about the original research findings, but in provoking thought about issues of weight management and providing an opportunity for attendees to engage in interprofessional learning. The majority of participants perceived that this workshop would positively benefit them in their future work as health professionals. Received: 03/1/2017 Accepted: 09/11/2017 © 2017 Price et al. This open access article is distributed under a Creative Commons Attribution License, which allows unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. H IP & An Innovative, Arts-Based Approach to Interprofessional Education EDUCATIONAL STRATEGY 3(2):eP1131 | 2 Introduction Obesity is a complex and challenging issue in modern society, and there is a strong imperative to improve capacity within the health system to support individuals with obesity and associated conditions (Dietz et al., 2015). Managing obesity at a health system level requires attention to the prevailing discourses that continue to position excess weight as a problem of personal responsibility rather than recognizing the role of other contexts (e.g., environmental, cultural, social, political) as key influencers on a person’s body weight (Puhl & Heuer, 2010; Salas, 2015). Discourses (repeated understandings, knowledges, practices) (Foucault & Gordon, 1980; Foucault, 1972; Foucault, 1982) shape not only how a person experiences obesity and their selfidentity (see, Wadden & Didie, 2003), but they also shape how others might understand the issue. Since obesity is primarily represented as a matter rooted in personal choice and autonomy, this renders those persons experiencing obesity as persistently stigmatized, misunderstood and held personally responsible for their body weight (Aston, Price, Kirk, & Penney, 2012; Puhl & Kyle, 2014; Puhl et al., 2015). Currently, the manner in which obesity is understood and managed within the health system is inadequate; moreover, while health professionals play a critical role, they are poorly equipped in weight management practices and care delivery (Dietz et al., 2015). Three Cochrane systematic reviews focusing on improving health professional management of obesity concluded there has been little change in health system structures or health professional practice and limited changes to the evidence base (Flodgren et al., 2010; Harvey, Glenny, Kirk, & Summerbell, 1999; Harvey, Glenny, Kirk, & Summerbell, 2002). This lack of progress is a worrying reflection of the limited attention that has been paid, and resources devoted to, improving obesity management within the health system, both in terms of how health professionals are trained and in how services are structured. Consideration of the health professional-client relationship is particularly critical within obesity management (Aston et al., 2012; Puhl & Heuer, 2009); however, this relationship may be compromised, due to the perpetuation of bias and stigma among health professional groups towards those persons living with obesity. Numerous studies have identified health professional groups, which include physicians, nurses, dietitians, and psychologists, as describing those living with excess body weight as persons lacking selfcontrol or willpower, lazy and with poor compliance (Harvey, Summerbell, Kirk, & Hill, 2002; Puhl, Wharton, & Heuer, 2009; Puhl & Heuer, 2009; Puhl & Brownell, 2001). Weight biased attitudes lead to stigma, which in turn is a factor in health professionals’ use of disrespectful communication and ambivalent care strategies with their patients (Dietz et al., 2015; Phelan et al., 2015). Bias and stigma can then augment the perception of criticism and lack of understanding experienced by clients from the professionals from whom support and care is sought (Budd, Mariotti, Graff, & Falkenstein, 2011; Kirk et al., 2014; Mold & Forbes, 2013), influencing not only client interactions within the health system for weight management purposes, but whether clients will continue to access healthcare for other related care issues (Drury, Aramburu, & Louis, 2002; Lewis et al., 2011). Given the social and cultural contexts of obesity, and the widespread existence of weight bias among different groups (Puhl & Kyle, 2014), the education of future health professionals to mitigate these biases is of utmost importance (Alberga et al., 2016; Dietz et al., 2015). Changes in health care delivery have also resulted in a growing need for interprofessional collaboration (IPC) (Accreditation of Interprofessional Health Education (AIPHE) Standards Development Working Group, 2010) and the management of obesity within the health system is no exception to this. Dietz and colleagues recently summarized that with regards to obesity management, the education and training of health professionals “...needs to address their biases about patients with obesity ... and ability to work collaboratively with interprofessional teams” (Dietz et al., 2015). The purpose of this article is to provide a description of an innovative approach to interprofessional education within a weight management workshop and discuss its implications for collaborative practice concerning complex biological and social health conditions.


Introduction
Obesity is a complex and challenging issue in modern society, and there is a strong imperative to improve capacity within the health system to support individuals with obesity and associated conditions (Dietz et al., 2015).Managing obesity at a health system level requires attention to the prevailing discourses that continue to position excess weight as a problem of personal responsibility rather than recognizing the role of other contexts (e.g., environmental, cultural, social, political) as key influencers on a person's body weight (Puhl & Heuer, 2010;Salas, 2015).Discourses (repeated understandings, knowledges, practices) (Foucault & Gordon, 1980;Foucault, 1972;Foucault, 1982) shape not only how a person experiences obesity and their self-identity (see, Wadden & Didie, 2003), but they also shape how others might understand the issue.Since obesity is primarily represented as a matter rooted in personal choice and autonomy, this renders those persons experiencing obesity as persistently stigmatized, misunderstood and held personally responsible for their body weight (Aston, Price, Kirk, & Penney, 2012;Puhl & Kyle, 2014;Puhl et al., 2015).
Currently, the manner in which obesity is understood and managed within the health system is inadequate; moreover, while health professionals play a critical role, they are poorly equipped in weight management practices and care delivery (Dietz et al., 2015).Three Cochrane systematic reviews focusing on improving health professional management of obesity concluded there has been little change in health system structures or health professional practice and limited changes to the evidence base (Flodgren et al., 2010;Harvey, Glenny, Kirk, & Summerbell, 1999;Harvey, Glenny, Kirk, & Summerbell, 2002).This lack of progress is a worrying reflection of the limited attention that has been paid, and resources devoted to, improving obesity management within the health system, both in terms of how health professionals are trained and in how services are structured.
Consideration of the health professional-client relationship is particularly critical within obesity management (Aston et al., 2012;Puhl & Heuer, 2009); however, this relationship may be compromised, due to the perpetuation of bias and stigma among health professional groups towards those persons living with obesity.Numerous studies have identified health professional groups, which include physicians, nurses, dietitians, and psychologists, as describing those living with excess body weight as persons lacking self-control or willpower, lazy and with poor compliance (Harvey, Summerbell, Kirk, & Hill, 2002;Puhl, Wharton, & Heuer, 2009;Puhl & Heuer, 2009;Puhl & Brownell, 2001).
Weight biased attitudes lead to stigma, which in turn is a factor in health professionals' use of disrespectful communication and ambivalent care strategies with their patients (Dietz et al., 2015;Phelan et al., 2015).Bias and stigma can then augment the perception of criticism and lack of understanding experienced by clients from the professionals from whom support and care is sought (Budd, Mariotti, Graff, & Falkenstein, 2011;Kirk et al., 2014;Mold & Forbes, 2013), influencing not only client interactions within the health system for weight management purposes, but whether clients will continue to access healthcare for other related care issues (Drury, Aramburu, & Louis, 2002;Lewis et al., 2011).
Given the social and cultural contexts of obesity, and the widespread existence of weight bias among different groups (Puhl & Kyle, 2014), the education of future health professionals to mitigate these biases is of utmost importance (Alberga et al., 2016;Dietz et al., 2015).Changes in health care delivery have also resulted in a growing need for interprofessional collaboration (IPC) (Accreditation of Interprofessional Health Education (AIPHE) Standards Development Working Group, 2010) and the management of obesity within the health system is no exception to this.Dietz and colleagues recently summarized that with regards to obesity management, the education and training of health professionals "…needs to address their biases about patients with obesity … and ability to work collaboratively with interprofessional teams" (Dietz et al., 2015).The purpose of this article is to provide a description of an innovative approach to interprofessional education within a weight management workshop and discuss its implications for collaborative practice concerning complex biological and social health conditions.

Background
Interprofessional education (IPE) promotes collaboration and teamwork in healthcare delivery within the philosophy of patient-centered care.IPE is most  et al., 2013).In their systematic review of the literature, Fraser and al Sayah (2011) identified that the integration of arts within health research (both as a form of knowledge production and knowledge translation) emerged with increased qualitative inquiry within the health sciences, particularly the use of theatre as a frequent arts-based dissemination strategy.As an engaging pedagogical tool (Price et al., 2007), the use of arts and theatre is suggested to be more effective than conventional teaching methods for enhancing practitioner skills for complex physical (Colantonio et al., 2008;Mitchell, Jonas-Simpson, & Ivonoffski, 2006) and social health-related conditions (Eakin & Endicott, 2006;Rossiter et al., 2008).Theatrical productions based on qualitative research findings are grounded in real life scenarios, encompassing verbatim quotes and embodying recurrent themes that represent a personified and vital piece that health care professionals can empathize with (Gray, Fitch, Labrecque, & Greenberg, 2003).These productions enable the audience to better appreciate the experience of the person that is living with the health-related condition or challenge (Gray et al., 2000;Rosenbaum, Ferguson, & Herwaldt, 2005;Shapiro & Hunt, 2003).
Theatre as a tool for knowledge translation has received tremendous reviews from students, health care professionals, family members, patients and audiences alike (Colantonio et al., 2008;Gray et al., 2000;Mitchell et al., 2006;Rosenbaum et al., 2005).This is because dramatic productions stimulate emotive, tangible and intellectual reactions that allow the spectator to look beyond the literal meaning and move towards a greater understanding of the human condition (Colantonio et al., 2008;Eakin & Endicott, 2006;Rossiter et al., 2008).Colantonio and colleagues (2008) argue that theatre makes an exceptional tool for education because it inspires thought on both the affective and cognitive level, enabling audiences to learn and engage through sensory stimulation as opposed to more traditional forms such as publications, lectures and conferences (Colantonio et al., 2008).Furthermore, Rosenbaum and colleagues (2005) noted that "[…] a dramatic presentation may speak more directly to students and residents who are tired and have little time to read stories" (p.623).
Recent studies also suggest that didactic curriculum approaches may be limited in their ability to affect meaningful changes in obesity management practices of health professionals (see, Acosta et al., 2014;Ren et al., 2016).
Our project focused on disseminating the results of a qualitative research study using the dramatic arts and a workshop-based, IPE forum.Briefly, the 'Balancing the Scales' study was a qualitative exploration of obesity management from the perspectives of persons identifying as overweight or obese (clients), health professionals (providers), and policy makers (the system) (Kirk et al., 2014).Grounded in feminist, post-structural methodology, this study explored the role of social, institutional and political structures in the assessment and management of obesity.The findings from the 'Balancing the Scales' study were unique insofar as they not only provide an understanding of the clients' perspective in care delivery but also how providers, despite best intentions, described the struggle to provide quality care using best evidence.The findings have implications for health professional training in order to improve relationships between health professionals and individuals living with obesity, with the goal of improving overall obesity management through IPC.
Because of the richness of the data and the potential impact of the findings to influence collaborative practice, the participant narratives were translated into a script for the purpose of dramatic representation (Kirk, Price, Aston, & Vallis, 2013).Ethics approval for 'Balancing the Scales' was received from Dalhousie University, which included approval to translate unidentifiable participant quotes into a dramatic script for use as a pedagogical dissemination tool.The 'Balancing the Scales' narrative script focuses on the interaction between a health professional (family physician) and a client identifying as overweight or obese, and highlights the verbal and non-verbal tensions that exist in managing care for those experiencing excess body weight.An IPE workshop based around this dramatic presentation was then developed and piloted at four health professional universities across Atlantic Canada.The purpose of these pilot workshops were: 1) to disseminate the findings of the original study using an innovative, interactive approach within IPE forums across Atlantic Canada, and 2) to promote interprofessional collaboration and respect in addressing complex and chronic health conditions.The purpose of this article is to provide a retrospective on these workshops and their potential as an innovative, arts-based approach to IPE.

IPE Workshop Approach
The IPE workshop was developed in collaboration with input from both the research and workshop team members.The workshop was developed for a 3-hour time period and included several key components, all of which are described below.The workshops were facilitated by a lead investigator (PI or Co-PI), a research coordinator and project coordinator and two dramatic actors.
After initial remarks that included an introduction to the team and a general overview of the purpose of the IPE workshop, the participants were provided an introduction to the 'Balancing the Scales' drama.The dramatic play was introduced to participants as one that was intended to promote thought and discussion about obesity management; participants were encouraged to not just watch the presentation but also to make note of how they might change the scenario as presented to result in a more positive experience.
Immediately following this introduction, participants watched the live dramatic presentation.As previously described, this presentation depicts, over the course of 15 minutes, an interaction that takes place between a "physician" (health professional) and a "person living with obesity" (patient) against the backdrop of a clinical setting.The words spoken in the drama come from the actual interviews with study participants.Internal monologue (directed at the audience) and external dialogue (directed at each other) highlight the tensions described by research participants in either their experience of living with obesity or managing obesity within their practice.
Immediately following the presentation of the 'Balancing the Scales' , participants were provided an opportunity to share their initial reactions to the play through a Think/Pair/Share activity.Briefly, participants were asked to organize into interprofessional pairs and to reflect on a set of key questions that were developed by the workshop team to invoke reaction and response to the experience of watching the play [Appendix A: Table 1].Workshop participants were encouraged to draw on personal and professional perspectives and experiences in their reflections.As part of this activity, participants were also asked to write down any reflections or comments, which were then collected by the workshop team to be used as part of the workshop evaluation.Paired groups were then asked to verbally report back to the larger workshop group in a debrief session that was facilitated by the lead researcher (PI or co-PI).The research coordinator also compiled field notes throughout the debrief pertaining to any verbal statements that were made by workshop participants.At one workshop, a participant indicated that what had stood out for him was how the tension between the health professional and the patient shaped the communication between them: "people are not saying the things that need to be said to facilitate the supportive interactions." Another workshop participant reflected on the internal monologue within the play, and remarked at the feeling of "disgust" conveyed by the person depicted as living with excess body weight.This participant, a licensed health professional and faculty member, further stated: "I don't want to come across like I don't care" when reflecting on her work with clients living with excess body weight.
Immediately following the debrief session, the workshop facilitator provided a general overview of the research study 'Balancing the Scales' and its primary findings.During this presentation, workshop participants were reminded that while it was a physician depicted in the drama, it could be any health professional who shared the practitioner's frustrations, which was an important finding from the original study (Kirk et al., 2014).This was an important message for the workshop participants from an interprofessional perspective insofar as highlighting that multiple health professions are critical to the management of obesity within the health system.
The final portion of the workshop was focused on the 'Script Rewrite' activity.This activity required that participants worked as part of interprofessional learning groups (3-4 persons) to re-envision their practice and rewrite a section of the narrative script that would be then re-enacted (with new direction) by the dramatic actors.The question that was posed to workshop participants was: how would you rewrite part of the play to make the scenario a more positive obesity management experience?
Interprofessional groups were given excerpts from the script-2 different monologues and 2 different dialogues for a total of 4 different scenarios.Participants were then instructed to 'rethink, ' 're-envision' and 'rewrite' the section of the play that they were assigned.
Participants were encouraged to consider the language that was used as well as the setting-other characters or stage props that could be used that would have created a more positive experience.This process allowed for groups to work together with the purpose of generating new ideas about working in obesity management practice that may be less stigmatizing.Actors then re-enacted each group's revised script with the groups each describing what they had changed and why.

Workshop Evaluation
Our workshop evaluations were based on both the attendee (learner) perspective and the subjective perspectives that were documented by the workshop team during post-workshop debriefing.From the learner perspective, the team developed a post-workshop, paper-based evaluation that asked participants to rate aspects of the workshop.This evaluation form was circulated to workshop participants immediately following the conclusion of the workshop and the research team collected completed forms as participants left the room.Workshop participants were asked to complete a post-workshop evaluation of the following areas using a Likert scale of 1 to 5 (1=low, 5=high): 1) usefulness of the dramatic play in helping to understand the findings of the original study; 2) the utility of the workshop to facilitate reflection and discussion concerning weight and weight management; 3) the utility of the workshop in provoking thought about the issue of weight management; 4) the utility of collaborative exercises within the workshop (e.g., Think/Pair/Share and Rewriting the Dramatic script) to support reflection about personal bias and stereotypes pertaining to obesity and/or obesity management; 5) the utility of the workshop to future practice as a health professional; and 6) the utility of the workshop on its ability to provide opportunities for collaboration.In addition, workshop participants were provided space on the evaluation form to provide additional comments about the workshop to the team.
From the workshop team perspective, debriefing meetings were held immediately following each of the workshop sessions.During these meetings, the team discussed observations about the workshop delivery in consideration of workshop goals and objectives.

Workshop Observations
Based on the experience of delivering the IPE workshops, and the workshop and research team debrief that occurred following the sessions, there are several observations that the team considered to impact the learner experience.First, is the observation is that the learner experience was enhanced when executed within a culture that supports IPE or, at a minimum, was executed within a setting where collaboration between and among differing health professionals or health professional students exists.One workshop was conducted during a class that was deliberately composed of students representing a variety of different health professional programs.The structure of this class was one that embraced interprofessional collaboration as a component of the day-to-day learning environment.Specifically, students were already arranged in pre-assigned interprofessional groups for smallgroup work for the duration of the term.As a result, the small-group activities of the workshop occurred seamlessly (from a logistical perspective), and the tone of the workshop suggested that students were engaged in the learning process and valued the opportunity to listen and learn from their colleagues.
The team also noted that the learner experience was enhanced when attendees were able to reflect on practical experiences in relation to the issue.Students who had real-world experience working with clients around the issue of weight management (e.g., through clinical placements, observerships, volunteering) helped to facilitate richer discussions and dialogue about this topic and had an easier time reflecting on how experiences from their own professional practice could have occurred in a more positive way-for the client, provider and the client-provider relationship.
Overall, this aided group discussion and encouraged insights that added value to the workshop.Conversations included: considering appropriateness of referrals for imaging a person with a large body size; communication, roles, and responsibilities of different health professionals; and the concept of "wellness" and "weight." As one participant stated: "They [patient with excess body weight] aren't in crisis, they feel that they live a healthy lifestyle.That we [health professionals] automatically go to weight and weight loss…" By contrast, those attendees with limited to no experience in the field, or having only theoretical or foundational understanding of the issue of weight management, had difficulty engaging in a collaborative manner with the activities and discussion and therefore, we considered that this may have negatively impacted their learning in this format and the type of discourse that took place during the debrief.
Finally, we observed that the size of the workshop made a difference.Workshops with a smaller number of attendees were perceived by the workshop team to be more supportive of collaborative learning in terms of the ability for the workshop team to facilitate, as well as the ability for attendees to feel engaged in the learning process.
Moreover, larger workshops required a learning venue that was not ideal for small-group work or break-out sessions (e.g., lecture theatre), which would require a reconsideration of how to best support IPE learning within a large population.
Post-workshop evaluations [Appendix B: Table 2] (n=229, 68.3% of estimated attendance) indicate that the workshops were well received.The live, dramatic presentation of provider-patient perspectives on obesity management was indicated by 94% of respondents to be helpful in facilitating understanding about the 'Balancing the Scales' study.In addition, 93% of respondents indicated that the workshop was useful in providing an opportunity to discuss issues of weight and weight management; a further 98% of respondents indicated that this format was useful in provoking thought about weight and weight management.Attesting to the power of this approach, one workshop participant shared on their evaluation form: As someone who is struggling with weight loss, it was very powerful to hear how other people feel and hear the similarities between their thoughts and mine.As a health care student, the implications for my own practice have been profound … This workshop was very well done and I hope that MANY other students and health care professionals get to experience this and learn from this.
Respondents also responded positively to the collaborative workshop activities.The 'Think/Pair/Share' debriefing activity was indicated by 82% of respondents to be useful for reflecting on own biases and stereotypes, while the 'Re-writing the Script' activity was indicated by 87% as effective for this type of reflection.Further comments provided by workshop participants reiterated the value in the approach to how the workshop was delivered.spondents (92%) perceived that this workshop would positively benefit them in their future work as health providers, while another 89% of respondents indicated that the workshop provided opportunities to collaborate with others.Summarized another participant on the value of the workshop to future work as a health professional: "This was a great interactive workshop that I think will help us in future care.We can definitely apply this information in practice."

Discussion
This dissemination project aimed to address weight bias and it's associations with obesity management, as it currently exists among health professionals and within the broader Canadian health system.Using an interactive, IPE format, and live, dramatic arts as a pedagogical tool, we piloted workshops at universities across Atlantic Canada with both health professional students and their faculty.The workshop itself challenges a number of widely held, but ultimately unhelpful, assumptions of obesity that may be held by health professionals and other key players in the health system.By drawing on past research findings, these workshops provided an opportunity for health professional students and other attendees to learn with, about and from each other while working collaboratively to problem solve approaches to obesity.
Participants developed an understanding into how health professionals from different disciplines experience similar struggles in meeting the needs of clients in clinical practice.The workshops also brought attention to the issue of weight bias and stigma that is an important contributing factor to poor weight management within our health system.In doing so, our goal was to contribute to a paradigm shift in terms of the health and social system through which issues of bias and stigma play out.
Live theatre has been successfully used to explore, express and inform conversations around complex and emotive healthcare topics.This project used live drama in an IPE format as a tool to simulate reflection and empathic and constructive discussion around the issue of excess body weight and weight management.It was designed to contribute to supporting participants' future development as ethical, analytical, collaborative health professionals.Based on evaluations from this Atlantic Canadian pilot, our dramatic presentation of health professional-client perspectives on obesity management was overwhelmingly effective for not only facilitating understanding about the original research findings, but in provoking thought about issues of weight management and providing an opportunity for students to collaborate with one another about the issue.Findings suggest that the participants perceived the approach to be an engaging pedagogical tool, with the potential to enhance their future practice as collaborative health professionals.
We acknowledge that there are limitations with our pilot.Specifically, we did not employ any objective measures of attitudinal change (i.e., pre-/post-workshop measures) among attendees.Despite this limitation, we suggest that the approach that we employed stimulated an emotive response among many participants, which we hypothesize contributed to the sense of learning that was described by several participants and accounted for the positive feedback received.Future extension of this work is in development and is being designed to employ a more robust, multimethod evaluation, to assess how health professional students learn about, with and from each other (e.g., Curran, Mugford, Law, & MacDonald, 2005), and the impact of this workshop on changing health professional students' attitudes, beliefs and potential practice towards individuals living with obesity (e.g., Cunningham, Preacher & Banaji, 2001;Greenwald et al., 2009) and broader management of obesity within the health system (adapted from Harvey, Summerbell, Kirk, & Hill, 2002).
The interprofessional perspective of this project is of further significance given the growing emphasis on teamwork, especially in managing complex and chronic conditions such as obesity (Alberga et al., 2016;Dietz et al., 2015).This innovative dissemination format may also be adapted for educating and supporting health professional teams concerning other complex chronic diseases (e.g., mental illness, addictions) or for supporting clients with complex needs (e.g., those who are marginalized or stigmatized based on class, culture, race, sexual identity, etc).Our team is continuing to develop this piloted workshop to be disseminated across Canada, with the support of national stakeholders.In addition, we are in the process of developing an IPE mini-course based on this workshop.Collectively, we anticipate this work will impact the way in which weight is addressed within the health system, which in turn should impact population health status and outcomes.These workshops can help reduce bias against individuals with larger bodies, both within the healthcare system and in society as a whole, to influence policy and to stimulate change within health care training and education as they relate to obesity.Workshops such as these have the potential to lay the foundation for such necessary shifts in social discourse around people living in larger bodies.