Abstract
Reflection is essential in the formation and ethical comportment of nurses. The COVID-19 pandemic brought extraordinary challenges to nursing practice and education of nurses. A pilot collaboration between a college of nursing and a department of dramatic writing at a research-intensive urban university aimed to promote the esthetic pattern of knowing through the dramatic presentation of the experiences of nursing students and frontline nurses during the height of the COVID-19 pandemic. The playwrights wrote two short plays based on interviews with two nursing students and three experienced nurses. The project sought to enhance narrative competence and empathy development of nurses and playwrights, and to promote reflection-on-action.
Implications for Practice and Research
The overarching aim of the playwriting project was to enrich the narrative competence of nurses and playwrights alike, cultivating a culture of reflective practice. The use of authentic narrative in the dramatic portrayal of the nursing craft in plays, movies, and other media gives the public a contextualized grasp of the ethical comportment of nurses. Nursing students can become key informants in creating dramatic works and provide critique on staging plays dealing with health-care narratives.
The theater is a spiritual and social x-ray of its time. The theater was created to tell people the truth about life and the social situation.
Integration of the esthetic pattern of knowing (Carper, 1978) into nursing education is a persistent yet challenging goal. Nursing programs have been noted for not effectively teaching nursing science and the humanities (Benner et al., 2010). Within the ambit of the humanities lie subjects encompassing history, philosophy, religion, languages, literature, fine arts, performing arts, and other disciplines. To make sense of and derive meaning from the human experience is a nursing competency (American Association of Colleges of Nursing [AACN], 2021). The exigency of this competency has been further underscored by the COVID-19 pandemic, which imposed exceptional demands on the resilience and wellbeing of nurses.
Narrative competence is the capacity to immerse oneself in narratives, decipher their subtleties, and respond to them adeptly; it is this proficiency that equips practitioners with the ability to deliver care steeped in empathy, moral agency, and trustworthiness (Charon, 2001). A pilot project brought together nursing, playwriting, and artistic direction expertise in creating two short plays derived from interviews conducted with nursing students and experienced nurses. The overarching aim of the project was to enrich the narrative competence of nurses and playwrights alike, cultivating a culture of reflective practice.
Nursing Education and Drama
The value of drama in nursing education includes enhancing interpersonal skills and understanding of the patient experience, developing professional identity, and promoting self-reflection and clinical imagination (Jefferies et al., 2021). The use of authentic narrative in the dramatic portrayal of the nursing craft in plays, movies, and other media gives the public a contextualized grasp of the ethical comportment of nurses.
Patient care is a charged human drama. Nurses, as frontline responders, face physical and emotional crises, while theater artists can distill human responses into art to promote social discourse. Drama can help students apply theoretical knowledge to singular scenarios such as the COVID-19 crisis by engaging them in a reflective process, to weigh and consider future actions (Jefferies et al., 2021). While high-fidelity simulations have some element of dramatization, they are purely skills based (Suh et al., 2021). Drama provides the artistic underpinnings in presenting certain life truths to cultivate empathy.
The Process of Esthetic Collaboration
The collaborators of this pilot project were a nursing faculty member, a faculty-playwright in the department of dramatic writing from a research-intensive urban university, and the artistic director of a nonprofit off-Broadway theater in New York City.
Writing, Casting, and Reading
In 2019, the authors collaborated in a theatrical production about the closing of a well-known hospital and its rich history caring for people with AIDS. In the waning days of the COVID-19 pandemic in January 2022, one of the collaborators proposed a project described here, to develop two dramatic plays centered on the experiences of frontline nurses and nursing students at the peak of the pandemic.
An initial meeting established project goals, tasks, and a timeline. The nursing faculty member recruited two students and three nurses with experience in COVID-19 intensive care units (ICUs) or emergency departments. Students included a male junior and a female senior. Experienced nurses were a male from an emergency department, a female from a cardiothoracic ICU, and a female from a city hospital that serves minority populations.
The faculty-playwright member of the department of dramatic writing oversaw the selection of playwright participants, checking in with writers about their processes and giving them feedback after the group read the first drafts of the pieces. The artistic director worked closely with the playwriting faculty on script development and casting, guided the actors’ depictions, and staged the readings.
The Playwrights
Both student playwrights in this project had either taken a class with the playwrighting faculty member focused on writing about community, or had expressed an interest in documentary theater. Both writers are deeply engaged in theater for social justice and were chosen for their skill as writers.
The Interviews
The two student playwrights were in charge of interviews, giving them agency to frame their own questions and lead with curiosity. They also handled the logistics of scheduling the interviews, arranging the location, and managing the recording and transcription of the conversations. One playwright interviewed one student and two nurses while the other interviewed one student and one nurse. The interviews ranged from 90 min to 3 h. Follow-up phone calls were conducted as needed. Interview questions covered the pandemic's impact on nurses, self-care, care for others, and health-care equities.
The Plays
Each play was 30 min long. Coping at the Bedside is a portrait of two nurses and one patient care technician working at a private hospital during the first wave of the pandemic. It centers around the connections they build with their patients while on the frontlines amid a mass casualty. In Brown Bag Lunch, three nurses from different parts of New York City prepare a symbolic meal together. It's a reflection of three distinct experiences at the height of the pandemic, examining how a health crisis elevated inequalities and made the things that unite humanity even more prevalent, namely sustenance, love, community, and mortality.
The Casting
The two plays were artistic interpretations of lived experiences of nurses, and not docudramas. The theatrical style of the pieces called for professional actors to portray these roles with nuance, complexity, and dynamism that only actors can depict. The actors received a small honorarium provided by the College of Nursing.
The Rehearsal
Two rehearsals were held in a conference room of the College of Nursing. The initial rehearsal served as an orientation for the actors with the artistic director and the faculty playwright. During this session, script readings led to collaborative refinement of both the written material and the portrayal of the characters. A significant focus was calibrating the emotional nuances of the characterizations of nurses. The artistic director found that overly dramatic emotional expressions felt melodramatic against the backdrop of the heightened emotional tension in the situation, necessitating a shift towards more understated emotional depictions. This adjustment was pivotal in ensuring a more resonant portrayal of the characters and their experiences. The faculty-playwright was present during the rehearsals to provide feedback on the dramatization of the scripts. Due to time constraints, the nursing students and the nurses couldn’t attend the rehearsals.
The second rehearsal took place one week after the first rehearsal, a few hours prior to the public reading. The playwrights distributed revised drafts of scripts inspired by changes discussed during the first rehearsal, and the actors did a run-through of both plays to deepen their depictions and the dynamics of the pieces.
The Reading and Reflections
The Executive Vice Dean of the College of Nursing offered a brief welcome to the 60 audience members gathered in the auditorium at the College of Nursing. The two plays were read in succession without an intermission. At the conclusion of the performance, the faculty members facilitated a 15 min reflective discussion, asking the audience to share their thoughts about the play. At this time, the audience was provided with two mock prescription pads. In one of them, the symbol Rx was written as Rxflections. On this article, the audience members wrote a word or brief reflection that was later collected by the faculty. One audience member wrote: “People started appreciating the little things more when normalcy disappeared.” Another wrote: “I felt the struggle in rationalizing the problems resulting from the pandemic.”
On another mock prescription paper, the audience members were instructed to turn to the person sitting next to them and write to each other a “prescription” from a list of virtues selected by the authors and projected on the auditorium screen. The list included kindness, generosity, patience, courage, compassion, and gentleness. The “prescriber” could choose to check off as many of the following instructions as they wished: Take daily and as needed, use generously, take with meals with family and friends, do not stop abruptly, mix with love, and unlimited refills. On their way out, the audience members picked up a vial of their prescribed virtue. Interestingly, the most prescribed virtue was courage.
After the plays’ performance, the playwrights, nurses and student informants were asked to provide their feedback and reflections via email. One of the playwrights wrote, [A] student in the audience raised his hand and said he felt like ‘that character was me- that was my story.” For someone to see themselves reflected in a work on stage is how I measure my success as a playwright, and I felt pride in knowing that for an afternoon, that student felt represented.
Reflecting on the writing process, one playwright wrote, I was struck by how lucky their patients were to have these courageous, intelligent, and caring advocates in the room with them. They were generous with sharing their deeply vulnerable memories, and put a high level of trust in me. I felt honored to be the caretakers of their stories. What resonated with me is that the playwrights mixed in multiple aspects of healthcare workers’ lives and being able to shine light on the physical and emotional difficulties of what it was like to be a bedside nurse during the pandemic.
Implications for Educators
Drama is an experiential approach to learning, where learners are observer-participants. Its pedagogical use is not new. “I'm Still Here” is an example of immersive storytelling, portraying the experiences of individuals living with dementia and the emotional journey of daughters coping with their mothers’ Alzheimer's diagnosis (Dupuis et al., 2016). This dementia research-based drama blends theater, research findings, and personal narratives to offer a nuanced depiction of the struggles faced by those affected by dementia. Collaborating with an artistic director and playwright, researchers developed a script and performance aimed at fostering empathy and clinical humility (Dupuis et al., 2016). Having nursing students and nurses as informants in crafting a play about patient care gives them opportunity to bear witness to experiences that may evoke compassion, transform perception, and awaken hopeful possibilities in providing patient-centered care (Jonas-Simpson et al., 2012).
This collaborative project fulfilled the interprofessional partnerships domain of the AACN Essentials (AACN, 2021) and the National League for Nursing's clinical educator core competency of facilitating learner development and socialization (National League for Nursing, n.d.). Supporting the inclusion of arts and humanities education in the formation of health-care professionals has been shown to improve their clinical, personal, and communication skills (Fancourt & Finn, 2019; Pieris et al., 2022).
In colleges and universities that have dramatic writing programs or theater departments, nursing faculty champions can initiate an exploratory conversation to brainstorm collaboration. Stakeholders such as the chair of the humanities department or the dean of the nursing school can lend scholarly and/or logistical support. Faculty members can apply for curricular development grants for collaborative education of nursing and playwriting students. With extra care to uphold patient privacy and confidentiality, a relevant activity would be allowing playwriting students to shadow nursing students during their clinical rotations to gain insights and inspiration on the day-to-day ethical comportment of nurses. In return, nursing students can become key informants in creating dramatic works including plays, films, and videos, and provide critique on staging plays dealing with health-care narratives. Nursing and humanities education stakeholders are encouraged to apply culturally diverse approaches to esthetic patterns of knowing across the life course, grounded in health equity and inclusivity.
Footnotes
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.
Funding
The authors received no financial support for the research, authorship and/or publication of this article.
Correspondence regarding this article should be directed to Fidelindo Lim at
