“Although an objectified clinical gaze has been both powerful and essential for scientific discovery, science alone cannot guide the daily practice and ethical comportment of clinicians” (Benner, 2011, p. 342).
Recent calls to transform nursing education challenge faculty to help students integrate clinical and ethical reasoning with scientific content across the curriculum (Benner, Sutphen, Leonard, & Day, 2010). Nurse educators are moving in this direction by including active learning strategies that require students to engage in clinical reasoning and to imagine the habits and skills needed for responding to particular patients in complex clinical situations. These strategies include unfolding case studies, reflective writing assignments, and the use of the humanities and action methods (Benner et al., 2010; Binding, Morck, & Moules, 2010; Freeman & Bays, 2007; McLaughlin, Freed, & Tadych, 2006; SmithBattle, Leander, Westhus, Freed, & McLaughlin, 2010).
Dramas have also been endorsed by nurse educators, but they may be underused as a pedagogical tool. This article reviews the literature regarding the use of drama in educating health professionals and describes the introduction of student-created dramas in an undergraduate course on teen sexuality and shares the results of student evaluations.
Dramatic performances are described as an effective tool for enhancing nursing and medical students’ understanding of patients’ perspectives. For example, Welch and Welch (2008) required that nursing students attend dramatic performances to better understand patients with mental health conditions, whereas others described the benefits of drama in exploring end-of-life issues (Lorenz, Steckart, & Rosenfeld, 2004) or living with illness (Kontos & Naglie, 2007; Shapiro & Hunt, 2003). In a course described by Rosenbaum, Ferguson, and Herwaldt (2005), first-year medical students performed already-developed scripts that highlighted patients’ illness and health care experiences. Those educators concluded that dramas foster empathy and convey the complexity of clinical situations from the vantage point of patients and clinicians. However, none of these reports have described student-created dramas.
A 2-credit elective course on teen sexuality included a series of assignments that were designed to help students listen carefully to teens’ perspectives on sexuality and to develop the ethical and relational skills that allow the Other to be seen and understood. The course is founded on team-based learning principles. Michaelson, Knight, and Fink (2004) defined team-based learning as “a particular instructional strategy that is designed to (a) support the development of high-performance learning teams and (b) provide opportunities for these teams to engage in significant learning tasks” (p. 9). According to these authors, course assignments are crucial in creating teamwork that fosters student engagement and learning.
The 15-week course is offered to upper-level undergraduate nursing students enrolled in a traditional program and an accelerated program for students with prior degrees. Teen sexual behavior is examined historically and internationally within emerging frameworks on adolescent development from the perspectives of teens, parents, and clinicians and with respect to research and policy. The course encourages students to examine their personal assumptions, identify gaps in knowledge and programs, and explore research evidence and policies. Class sessions focus on the topics of trends, issues, and controversies in teen sexuality; adolescent development in context; sexual minority youth; teen mothers and fathers; sex education; parents and teen sexuality; communicating with teens about sex; decreasing risk-taking and promoting healthy development; and the transition to young adulthood. Because teens’ perspectives are often overlooked in clinical and policy discourse on teen sex, course assignments require that students listen, examine, reflect on, and dramatize teens’ perspectives, their relationships with significant others, and their interactions with clinicians. Groups of four to five students are formed during the first class session and are assigned a teen population (i.e., sexually abstinent teens, sexually active teens, teen mothers, teen fathers, or teens who identify as lesbian, gay, bisexual, or transgender), which becomes the focus of all assignments.
For the first assignment, students conduct a voice-recorded interview that elicits teens’ perspectives on their concerns, strengths, and struggles, as well as their experiences with health care professionals. Only individuals 18 years or older who have had the relevant experience as teenagers (e.g., being gay, being a teen parent) are invited by students to be interviewed. Potential informants are advised that the purpose of the interview is to develop students’ understanding and sensitivity to teens who have faced similar situations. They are also told that the content of their interviews will be shared with fellow students and the instructor but that their names and identities will not be divulged.
To prepare students to conduct interviews, I present a mini-lecture on developing an interview guide. We discuss issues related to interviewing informants and protecting their confidentiality. After the student groups develop and revise interview guides with my feedback, individual students or pairs of students from each team recruit interviewees and conduct their interviews. Occasionally, the author assists students to connect with an interviewee, but most students successfully recruit a university student or a person from their social circle with the relevant experience. To maintain confidentiality, students are instructed to use pseudonyms when they transcribe the interviews and to remove all identifying information. After transcribing the interview, each student individually completes an eight- to 10-page reflective paper that (a) describes the teen’s situation; (b) summarizes the key points of the interview and explains how the content is similar to, or divergent from, assigned readings; (c) identifies the student’s personal biases and how his or her assumptions about this group of teens were confirmed or challenged by the informant; (d) identifies the student’s strengths and limitations in eliciting the interviewee’s perspective; and (e) describes the implications of the interview for health professionals. The paper, along with the transcript, is submitted to me for evaluation; transcripts are also shared with the student’s group. Three or four interviews are typically completed by each student group.
Although students are given the option of developing a dramatic or traditional presentation on the teen population assigned to them, all groups have chosen to develop and perform dramas based on their creative adaptation of interview material, pertinent research, and clinical literature. All group members are required to perform in at least one scene of the drama, and one scene must portray a clinical situation. The groups develop a script using guidelines that were developed for the course, and some class time is devoted to developing their scripts. A draft of the script is submitted for my constructive feedback 2 weeks before students perform their dramas on stage in an action-methods classroom. Immediately after each performance, I ask the student group to describe how they incorporated interview material into their script before facilitating a discussion about the themes of the play and inviting questions from the audience. The groups submit their final script with an annotated bibliography of 10 to 12 relevant articles.
Due to my extensive experience interviewing pregnant and parenting teens and family members for research purposes (SmithBattle, 2010), I expected the interviews to augment class readings and discussion with the real-world perspectives of teens. I also believed the interviews would provide an insider perspective that might challenge students’ personal biases regarding their assigned population. Because I had no previous experience developing dramas from interview material, I secured university funding to consult with a faculty member who teaches playwriting at a local university. She developed student guidelines for developing dramatic scripts, as well as a grading rubric for instructor evaluations. After the first time the course was offered, we independently evaluated students’ scripts using this rubric, and minor differences were resolved by mutual agreement.
Ten groups have performed on stage since the course was first offered in 2009. As expected, each drama has focused on a teen protagonist and his or her interactions with significant others and with a nurse. Students have effectively integrated interview material with content from readings or class discussions into their scripts (e.g., rates of violence against lesbian, gay, bisexual, or transgender teens; myths about contraceptive methods). Students incorporated simple props into their plays with materials available in the classroom or laboratory or items they owned or made. They used creative techniques to portray characters and to develop the action and themes of their plays.
For example, the experience of a transgendered protagonist was portrayed by two student actors who stood back to back with their arms linked. The first actor, while facing the audience, described struggling with his identity and experiences of feeling judged and misunderstood. The second actor, when turned around to face the audience, expressed the protagonist’s reflections on being unknown and expressed his hopes and dreams for being accepted and living a full and meaningful life. A teen mother group creatively structured their play with a series of monologues that portrayed the different perspectives of the protagonist and her boyfriend, mother, girlfriend, and clinic nurse. Dressed in white shirts and black pants, each actor stepped forward to deliver his or her reactions to learning of the teen’s pregnancy. Their drama ended with a final monologue by the protagonist who described giving birth and deciding to keep her baby.
Although many students are initially apprehensive about these nontraditional assignments, the completed assignments have demonstrated that students have satisfied course objectives with great creativity. Final evaluations have also been uniformly positive, as documented in the course and teacher evaluations and through the use of a detailed questionnaire that asks students to evaluate each assignment anonymously. Using a Likert scale of 1 to 5, where a score of 1 = no learning and 5 = learned much more than I expected, 44 (93.6%) of 47 students rated the teen interviews a 4 or 5. Writing the reflective paper was rated a 4 or 5 by 31 (66%) of 47 students, and 35 (74.5%) of 47 students gave a 4 or 5 to creating a dramatic script. Finally, observing the performances of other teams was rated a 4 or 5 by 41 (95.4%) of 43 students.
Despite the students’ concerns about interviewing someone whose experience differed from their own, the students reported that they appreciated learning “first hand” about “real-life” situations that extended beyond their typical comfort zone. According to the students, conducting an interview was “eye-opening,” “thought provoking,” and “changed my view completely.” Writing the reflection paper encouraged students “to think critically and to make connections” between the interviews, readings, and discussions and was a “great way to remember content.” The paper also helped students “to process and analyze the interview” and “to assimilate knowledge and apply theory.” The students’ papers further suggested that the assignment encouraged them to listen carefully to their interviewee, to reconsider what they thought they knew about this group of teens, and to imagine how they might respond as a nurse to teens’ concerns, strengths, and struggles.
Creating a script was also evaluated positively by students for promoting teamwork and providing a “summary” of what had been learned by each team. Performing and watching the dramas on stage helped students to appreciate various perspectives as dramatized by a wide range of characters. One student expressed, “The dramas really hit home with the many voices and players in each situation.” Many students echoed the comment by stating, “I loved it; it promoted teamwork, education, and creativity.” “I loved watching the dramas.” “I learned a lot.” Watching groups’ performances were “entertaining,” “informative,” and a “great way to learn.” As one student said, “I loved visually seeing the plays and really getting the whole semester out on the stage.” Although a few students complained about the time-consuming nature of the assignments, the teams worked well together, as reflected in positive peer evaluations. One student believed that team learning “held us accountable to our assignments and readings.” Although some students recommended more class time to work on group assignments, the groups used class time in this course much more effectively than I had witnessed in prior courses using group assignments.
One item on the questionnaire asked students to describe the “dramatic presentation that impressed or affected them the most and why.” The following comments demonstrate how the students’ dramas engaged their peers on emotional and intellectual levels and generated important considerations for responding to complex clinical situations:
- The transgender play was so powerful and so sad. They did a great job of showing the boy’s struggles.
- The skit about a lesbian teen moved me because it resonated with my own experience and seemed to be based on really listening to the interviewees’ experiences.
- I loved the teen dad skit because I don’t think I ever really thought about what they go through.
- The teen mom skit was presented in a unique and impactful way, with valuable information that made me think. It provided different insights into an often judged group.
- The sexually active teen group portrayed misconceptions by teens and the problems they face.
Finally, and consistent with positive course evaluations, the students reported that they would recommend the class to others.
In conclusion, a major goal of my teaching for the past 17 years has been to promote students’ ethical and relational skills of receptivity, openness, dialogue, understanding, and personal reflection. To this end, I developed a series of assignments to promote the skills of listening, engaging in dialogue, taking various perspectives, and reflecting on the experiences of others. This approach exemplifies an action-methods strategy, which asks students “to ‘act’ or ‘show’ rather than merely ‘talk’ or ‘tell’ about their experiences” (McLaughlin et al., 2006, p. 1).
The students were provided with sufficient guidance and feedback for completing novel assignments. Positive student evaluations suggest that the assignments promoted seeing the Other and furthered students’ understanding of caring for sexually abstinent and sexually active teens. Nurse educators may consider including similar assignments when the intent is to develop the habits of thought and relational skills involved in listening, understanding, and reflecting on patients’ perspectives on health and illness.
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