Effective communication, empathy, and critical thinking are vital to the nursing profession and can positively influence patient outcomes (Kourkouta & Papathanasiou, 2014). However, traditional teaching modalities may not transfer these critical skills. Sheldon and Hilaire (2015) found that less than 27% of recent nursing graduates felt confident communicating with patients and their families, as well as in interdisciplinary teams in the hospital; 78% were unsatisfied with their communication skills. In response to new graduates' gaps in these skills, the Carnegie Foundation report Educating Nurses: A Call for Radical Change advocated for comprehensive changes to nursing education in the United States, including adding innovative teaching methods to strengthen connections between classroom and clinical skills. Authors of the report outlined the need to foster improvement in nurse–patient and interprofessional communication and collaboration (Benner, Sutphen, Leonard, & Day, 2009).
Based on the Carnegie Foundation report, the Institute of Medicine acknowledged the need to incorporate more interactive and innovative teaching methods in nursing and medical schools to strengthen students' communication skills (Institute of Medicine, 2010). Patient simulation, storytelling, and the use of theatre in nursing education are powerful tools that allow students to explore clinical situations in a safe environment, practice communication skills, reflect on the patient experience, encourage ethical and critical thinking, and use interview skills. Using theatre in the classroom not only allows students the opportunity to understand another person's perspective and experience—it gives nursing students the opportunity for self-reflection, allowing them to think about their own biases, expertise, and gaps in communication (Arveklev, Wigert, Berg, Burton, & Lepp, 2015). Limited research is available on the use of theatre in nursing education, but a study of medical students by Reilly, Trial, Piver, and Schaff (2012) found that theatre practice increased awareness of both verbal and nonverbal communication during patient encounters for medical students.
One of the reasons that the use of theatre is well suited for nursing education is that the process of empathy is at the heart of narrative theatre. Empathy, the ability to understand and affirm another person's perspectives and feelings, is an essential component of the nurse–patient relationship (Kourkouta & Papathanasiou, 2014). Mearns, Thorne, and McLeod (2013) defined empathy as a process that involves being with the patient and understanding the unique meanings attached to their illness experience (p. 57). When individuals participate in documentary theatre, they engage at a new level. They can no longer view “the other” as an abstraction but instead experience “the other” as a fellow human (Blank & Jensen, 2005).
Nurses need to develop empathy to provide meaningful patient care. Therefore, nurses can practice their empathetic skills through theatre-based learning experiences to build their capabilities of understanding patients' backgrounds to guide their care. The purpose of this article is to describe an innovative educational activity integrated into a professional development course on global health, in which nursing students write monologues in the voice of individuals involved in global health.
As part of a professional development class focused on global health nursing, the first author (H.F.B.) developed an unfolding assignment for nursing students in their senior year at Emory University University, led by theatre practitioners from the Found Stages theatre company. Groups of four to five students were asked to write a 5-minute monologue based on an interview with an individual involved with global health or global health issues in the voice of the interviewed person. In this course we used Jacobsen's (2019) definition of global health as “a multidisciplinary, multisectoral field in which diverse partners from around the world act together to improve population and environmental health” (p. 1). The Monologue Project was woven throughout the semester-long course and was supported by a small internal community-engaged learning grant from Emory University. The objectives of this experience were to prepare nursing students to become global health citizens by improving qualitative research, interviewing, artistic skills, gaining presentation experience, and ultimately increasing their empathy for individuals.
For this project, nursing professors and students worked with a local immersive theatre company, Found Stages, to develop five class sessions:
- What is a monologue and who are key informants?
- How to develop an interview guide.
- How to use qualitative data to develop a monologue.
- How to present a monologue.
- Final monologue presentations.
Group assignments included creating an interview guide, conducting the key informant interview, producing a written monologue, individual recording of the monologue, and a group presentation of the monologue to classmates, faculty, and interviewed community members.
Six key informants were interviewed for this assignment:
- A nurse who was working in an emergency room in New York City on 9/11.
- An LGBT (lesbian, gay, bisexual, transgender) parent who adopted a young child.
- A refugee from Southeast Asia.
- A Peace Corps volunteer who lived in Swaziland.
- A nurse volunteer who worked with Doctors without Borders in Sudan.
- A founder of a childcare center in a South African township during Apartheid.
After students completed a draft of their monologues, each group submitted their manuscripts for feedback from the theatre professionals. Feedback included clarifying specific ideas and wording, as well as stylistic and content suggestions. For example, the theatre professionals recommended that characters use first-person rather than third-person narration and that the students consider making some of the general ideas in the monologues more specific by using detailed examples of events that the key informants experienced. This phase was critical to develop students' empathy for the key informants and allowed the students to truly understand the multifaceted nature of global health in their community and the world by placing themselves in the position of the key informant. As the next step in the process, students rewrote the monologues based on feedback. Final monologues demonstrated that the characters had unique and realistic speech patterns, and the structure of the writings followed a dramatic arc. The majority of the monologues contained both humorous and cathartic moments.
The student groups presented their revised monologues to an audience of students, faculty, staff, and key informants on the final day of the course. Following the presentations, the students completed a postproject evaluation questionnaire, as well as a two- to four-paragraph reflection on the assignment. We also received anecdotal feedback from the key informants related to their experience being interviewed, providing feedback on the monologues, and listening to the presentations.
By the end of the project, the student groups had written and presented five monologues based on the interviews with the key informants described above. Each monologue included language and emotion specific to the key informants. The following is an excerpt from one of the monologues based on an interview with a nurse who had worked with Doctors Without Borders:
And though I helped treat many patients during my time in Sudan, I'll never forget one man who pleaded for me to treat his daughters. The father came to the clinic telling me that his daughters at home were very sick and there was no way he could bring them to us. At first, I really didn't know what to do… [pause] I mean… [pause] I felt kind of helpless. There were already so many other patients here in the clinic, and all I could do was tell the father that he had to bring his daughters [shrugs]. But this man was distraught. He began to tell me of how his wife had just been killed and how his daughters were the only children— and family—that he had left. He forced me to see what was going on with his kids, and with that, I had to step away from the madness of my environment and look further at the humanistic side of what I was doing.
Of the 26 students, 25 completed a post project evaluation questionnaire. Over 80% of the students felt they gained empathy, improved writing and interviewing skills, and developed their presentation skills (Table 1).
Postproject Student Evaluation
In addition to the post project questionnaire, all 26 students submitted a two- to four-paragraph written reflection with the following prompts:
- What did you like about this project?
- What would you do differently?
- What did you learn from this experience?
- Is there anything else you want to add?
Students noted that this project helped them to build empathy, develop presentation and writing skills, improve interviewing skills, use creativity, participate in team building, and learn about real-world experiences. Students stated that this project was a unique and nontraditional experience within their nursing education. One student wrote:
I am very glad that we were able to work on such a creative project, which is uncommon in nursing school. Nursing is about art as much as it is about science, but it does not always feel that way.
Another student noted:
I began to consider the informant's emotional process; the empathy I felt guided the themes for the monologue. Sharing my informant's journey changed my conceptualization of the expected outcomes from a task to a process of understanding. Expected outcomes in nursing care and practice should not be focused on tasks, but rather on understanding patients through empathy.
Although the students stated that they gained important skills during this project, there were also aspects of the project they found challenging. In response to the question of how the project could be done differently, many students thought it was anxiety-inducing to present their work to a public audience, the project felt overwhelming at times, that there were too many project steps, and that not everyone liked to act or felt they had adequate creativity for the project. One student wrote:
At the start of the project, I was extremely nervous about how to approach all components of the task. I was anxious about scripting the draft, as I wanted to ensure that the questions were simultaneously respectful of privacy and personal experience and also effective in evoking our interviewee's story.… And the thought of performing the piece in front of peers, professors, and potentially all the interviewees, left me imagining the intense stage fright.
Some of the key informants provided anecdotal feedback around this project. They enjoyed telling their story and found the process important to impart real-life information to these future nurses. One key informant said:
As I listened to the students present my monologue, I was moved by their passion and enthusiasm. I heard my own voice, felt my own emotions, and relived the experience through their words. Their empathetic approach to my story assured me that the events that occurred on September 11, 2001 (9/11) would be remembered and those that lost their lives that day would never be forgotten—a new generation of nurses would share the story.
This article describes the integration of a monologue-based theatre component into a global health nursing professional development class to increase empathy in nursing students. Empathy was enhanced using key informant interviews, empathetic communication skills, and monologue narratives. Listening to narratives allowed students to develop a deeper awareness of the experience of the individual, creating an empathetic connection between the student and informant (Elliott, Bohart, Watson, & Greenberg, 2011). As stated by Mearns et al. (2013), “empathy is a human skill more than a technical one—it is simply the humanity of one human being towards another” (p. 55). The use of empathetic verbal and nonverbal communication, such as maintaining eye contact, being nonjudgmental, avoiding interruptions, and paraphrasing have been perceived as empathetic in qualitative research (Myers, 2000). These techniques were used by nursing students during the monologue presentations.
A review of literature by Derksen, Bensing, and Lagro-Janssen (2013) found that empathetic patient–provider relationships improved patient satisfaction, perception of the ability to cope with an illness, and clinical outcomes. Consistent with previous research, educational theatre has been used to enhance experiential learning in nursing education. The assignment described in this article allowed students to speak in the voice of their key informants, which provided the opportunity to experience as close as possible to the lived experience of the key informants and to articulate, through empathy and performance, the complex social inequities in global health, without actually having those experiences.
There were several limitations that should be addressed if future educators choose to include a monologue project in their curriculum. First, a comprehensive evaluation of the key informants' experience during the monologues would help to inform the process. Second, an objective assessment of empathy would improve understanding of how this exercise influenced students in their future roles. Finally, it would be interesting to explore the students' perceptions of the stories told by the key informants and the empathetic connection developed during this process.
We have adapted this project in subsequent semesters to address the students' feedback around the project being anxiety inducing by allowing the students to be leaders in different components of the project—for example, one student could lead on the interviewing portion without having to be the main performer. We have also increased the amount of in-class time allocated for the project to consolidate the activities so there are fewer individual steps.
The innovative use of a monologue-based theatre component in an academic course increased empathy in undergraduate nursing students. This educational activity was in contrast to the traditional lecturing models used in nursing education and allowed students to understand the lived experience of the key informants' journey. The use of theatre in academic teaching represents a new model of education that reminds students of the humanity of people by discovering and listening to individuals' stories and deepening their empathy for others.
- Arveklev, S.H., Wigert, H., Berg, L., Burton, B. & Lepp, M. (2015). The use and application of drama in nursing education—An integrative review of the literature. Nurse Education Today, 35(7), E12–E17. doi:10.1016/j.nedt.2015.02.025 [CrossRef]25819267
- Benner, P., Sutphen, M., Leonard, V. & Day, L. (2009). Educating nurses: A call for radical transformation. San Francisco, CA: Jossey-Bass.
- Blank, J. & Jensen, E. (2005). The uses of empathy: Theater and the real world. Theatre History Studies, 25, 15–22.
- Derksen, F., Bensing, J. & Lagro-Janssen, A. (2013). Effectiveness of empathy in general practice: A systematic review. British Journal of General Practice, 63(606), E76–E84. doi:10.3399/bjgp13X660814 [CrossRef]23336477
- Elliott, R., Bohart, A.C., Watson, J.C. & Greenberg, L.S. (2011). Empathy. Psychotherapy, 48, 43–49. doi:10.1037/a0022187 [CrossRef]21401273
- Institute of Medicine. (2010). The future of nursing: Leading change, advancing health. Washington, DC: The National Academies Press.
- Jacobsen, K. (2019). Global health and health transitions. Introduction to global health (pp. 1–18). Burlington, MA: Jones & Bartlett Learning.
- Kourkouta, L. & Papathanasiou, I.V. (2014). Communication in nursing practice. Materia Socio-Medica, 26, 65–67. doi:10.5455/msm.2014.26.65-67 [CrossRef]24757408
- Mearns, D., Thorne, B. & McLeod, J. (2013). Person-centered counselling in action. London, United Kingdom: SAGE.
- Myers, S. (2000). Empathic listening: Reports on the experience of being heard. Journal of Humanistic Psychology, 40, 148–173. doi:10.1177/0022167800402004 [CrossRef]
- Reilly, J.M., Trial, J., Piver, D. & Schaff, P. (2012). Using theater to increase empathy training in medical students. Retrieved from https://escholarship.org/uc/item/68x7949t
- Sheldon, L.K. & Hilaire, D.M. (2015). Development of communication skills in healthcare: Perspectives of new graduates of undergraduate nursing education. Journal of Nursing Education and Practice, 5(7), 30–37. doi:10.5430/jnep.v5n7p30 [CrossRef]
Postproject Student Evaluation
|Statement||% of Students Who Agreed (n = 25)|
|I found the Monologue Project allowed me to gain empathy for other people.||88 %|
|I found the Monologue Project improved my interviewing skills.||84 %|
|I found the Monologue Project improved my interview question writing skills.||80 %|
|I found the Monologue Project allowed me to develop my presentation skills.||80 %|
|I found the Monologue Project allowed me to develop my artistic skills.||68 %|