YNEDT-02650; No of Pages 2 Nurse Education Today xxx (2013) xxx–xxx
Contents lists available at ScienceDirect
Nurse Education Today journal homepage: www.elsevier.com/nedt
Big Ideas Forum theatre for practice simulation and skills development in nurse education: A student's perspective
The use of simulation in clinical skills training is standard for nurse education programmes for good reason. How can a student nurse safely undertake clinical interventions if they have not had the chance to first practise and understand the processes involved? Whether those interventions are taking a pulse, undertaking urinalysis or administering a depot, it is important that the skills are explored in the safety of a neutral space, such as simulation suite, in order to ensure no patients are hurt in the making of a nurse. However, there is not the same uniform training for the development of the interpersonal and communication skills that nurses need to master in order to be effective in their role. This paper explores how forum theatre in can be used to address the discrepancy. The exploration of using forum theatre as a method of simulated practice in the context of nurse training started with an opportunity to perform at the World Mental Health Day (WMHD) (World Health Organisation, 2010) presentation at Buckinghamshire New University in 2012. The theme of WMHD that year was Depression, so a piece of theatre was developed that explored the day in the life of a depressed protagonist, and the impact condition had on relationships with the partner and the best friend. The protagonist is eventually persuaded to seek the help of a health professional whose response seems indifferent and harassed—not at all sympathetic. The scenarios were performed once, and then a second time, wherein the drama was stopped at various junctures and the audience were invited to reflect and discuss moments of the action accordingly. If there had been more time, the work could have developed in such a way that audience members could have come onto the “stage” and taken the place of the protagonist, attempting to negotiate the barriers to communication that she faced. The origins of forum theatre are associated with Augusto Boal. He described audience members as “spect-actors” (Boal, 1992) because in his view, the development of the story told within the performance piece and the solutions to the problems suggested and enacted, are as dependent on the participation of the audience as it is on the group performing. Theatre in this context is an egalitarian and democratic process of experience, learning and rehearsal. These principles are embedded in the work of one of Boal's friends and one of his greatest influences, Paulo Friere, who is the author of the seminal text, Pedagogy of the Oppressed (Friere, 1972). Boal's forum theatre is underpinned by a philosophy firmly rooted in the belief that we all have something to teach to and learn from one another. The workshop space, the performance area, becomes a safe place not only to learn new actions or approaches, but also to practise them and make them personal. There is at once the safety of fictional distance and the visceral experience of being part of a shared, unique adventure. Forum theatre allows us to stop and magnify a moment in time, allowing us the luxury of analysis and reflection that real life rarely affords us. In the spirit of Friere's pedagogy, each participant in the group contributes something just by being there; it is an even playing field and the drama is anyone's for the making. The wonderful thing
about forum theatre techniques is that they can be used in so many different ways, to explore interactions on many different levels, in accordance with the needs of the group and the resources available. The potential for transformative development in this context is not to be underestimated. For example, the process of learning that occurs during a forum theatre workshop compliments Jack Mezirow's transformational cycle almost perfectly (Mezirow, 2011). Using the performance that took place on WMHD to explore this further, it is useful to start with Mezirow's “disorientating dilemma”, which in this instance could be described as the moment the protagonist presented to the health professional for help and support. The “critical appraisal” is what the audience started to do when they gave feedback about the thoughts, feelings and actions of the players, which also involved “perspective taking”. As the work develops, the other segments of the cycle are activated and thus forum theatre facilitates transformation of the group as a whole and each participant individually. In our daily lives we are the centre of our universe and we look at facts and people from a single perspective, our own… In daily life, we see the situation; on stage, we see ourselves and we see the situation we are in. [Boal, 1995 p. 26] The forum theatre workshop can become a rehearsal space for difficult conversations. In real life, once we have spoken or reacted, the words or actions cannot be retracted. In a workshop, there is time and space for feedback to be given, different methods of communication to be tried and room for mistakes to be made. As nurses, we rely on these skills more than many others—communication underpins the efficacy of patient care. Forum theatre is being used within pockets of nursing education curricula, by Wilson (2013) and colleagues at Southampton University, for example. The common thread seems to be that actors, service users and teaching staff perform a pre-scripted scenario and students are invited to enter the scene as the protagonist and negotiate solutions to the problem presented. There is not extensive research into the impact of this type of teaching on student's performance on placement thereafter, but there is a growing body of evidence that students find this a useful process in many ways, and they enjoyed it enormously (Middlewick et al., 2012). Further research needs to be undertaken to measure the impact that participation in forum theatre workshops has on the quality of patient care, if any, and exactly what it is about the work that informs this. The question might be whether or not it is the content of the workshops or the process of participating in them that has the most meaningful outcome in terms of the skills development of student nurses. This could have cost implications regarding its implementation, especially if actors are being employed. There is a chance that the pre-prepared scripts can make the work too prescriptive. Thompson (2012) discusses how drama workshops undertaken in prison and probation settings, using forum theatre techniques among others, are at risk of becoming more cognitive– behavioural-type workshops than creative, problem-solving opportunities. There is an accepted definition of appropriate behaviour
0260-6917/$ – see front matter © 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.nedt.2013.12.002
Please cite this article as: D'Ardis, M., Forum theatre for practice simulation and skills development in nurse education: A student's perspective, Nurse Educ. Today (2013), http://dx.doi.org/10.1016/j.nedt.2013.12.002
2
Big Ideas
and responses to conflict, for example, and participants in the group are coaxed into rehearsing this rather than exploring more creative solutions and approaches. Although this can be useful and pleasing to budget-holders and policy makers, it limits the potential for the work. The stories aren't those of the participants after all. If someone doesn't engage their creativity, how can they imagine other possibilities or alternative courses of action? Creativity is a skill that enhances cognitive flexibility (Robinson, 2013); a valued quality in nursing. Student nurses are taught to perform according to codes of conduct (Nursing and Midwifery Council, 2010) and NHS and local policies, while maintaining professionalism at all times when on duty (and off, some argue). The importance of this has been discussed ceaselessly since the Mid-Staffordshire Inquiry chaired by Robert Francis QC, and quite rightly, too (Mid-Staffordshire NHS Public Inquiry, 2012). However, communication requires flexibility of thought, thinking on one's feet, being responsive to the individual patient and the meaning of their unique experience. This requires confidence, competence, and the other qualities underpinned by the 6 Cs of Nursing (Commissioning Board Chief Nursing Officer & DH Chief Nursing Advisor, 2012). Students go onto placements soon after starting their courses so how can these vital skills be embedded quickly and effectively, in a way that is meaningful to the student and to the patients they meet? Perhaps there is an argument that forum theatre and other applied drama techniques could be used flexibly within a programme of nurse education. There could be prepared scenarios incorporating essential skills training, utilising forum theatre to engage students in a more dynamic and reflective manner, more than methods like role playing do, and a place for the techniques to be used during reflection groups. That way there is an opportunity for the students to explore their own stories and concerns as well as learning how to negotiate those of others; the new perspective-taking element of the transformative cycle. In a time of financial constraints and calls for innovation, new ideas and approaches have fertile ground on which to take root. There is a place for research into the impact that students felt participating in drama workshops had on them (if any) post-placement. It would be interesting to get feedback on whether or not they enjoyed or felt enhanced by the process immediately afterwards, maybe by comparing self-reported emotional intelligence pre- and post-workshop(s). And
then after their first placement experience has concluded, to see if, on reflection, they felt the experience of being involved in forum theatre was useful to them once in the clinical setting. The point of the process is not to produce polished actors, rather new nurses, comfortable in their role, so there is no need to hire professional actors thus ensuring that forum theatre could become a cost-effective, meaningful, transformative teaching tool for reflexive learning and skills development. References Boal, A., 1992. Games for Actors and Non-Actors. Routledge, London. Boal, A., 1995. The Rainbow of Desire. Routledge, London. Commissioning Board Chief Nursing Officer & DH Chief Nursing Advisor, 2012. Compassion in Practice Policy London. Friere, P., 1972. Pedagogy of the Oppressed. Penguin Books, London. Mezirow, J., 2011. Transformative Learning in Mezirow, J & Taylor EW Transformative Theory in Practice. Middlewick, Y., Kettle, T.J., Wilson, J.J., 2012. Curtains up! Using forum theatre to rehearse the art of communication in healthcare education. Nurse Educ. Pract. 12 (3), 139–142 [Accessed: 2012]. Mid-Staffordshire NHS Public Inquiry, 2012. Report of the Mid-Staffordshire NHS Foundation Trust Public Inquiry: Executive Summary. The Stationary Office, London. Nursing and Midwifery Council, 2010. Standards for pre-registration nursing education [online]. NMC.org. Available from http://standards.nmc-uk.org/PublishedDocuments/ Standards%20for%20preregistration%20nursing%20education%2016082919.pdf [Accessed: 10 Sept. 2012]. Robinson, K., 2013. To encourage creativity, Mr. Gove, you must first understand what it is. The Guardian 17 (May). Thompson, James, 2012. Applied Theatre: Bewilderment and Beyond. Peter Lang Ltd., Oxford. Wilson, J., 2013. Let's all play “stigma”! Learning together using forum theatre in collaboration with mental health service users and nurses. Presentation NET 2013. World Health Organisation, 2010. World Mental Health Day.
Melanie D'Ardis Mental Health, Buckinghamshire New University, 106 Oxford Road, Uxbridge, UB8 1NA, United Kingdom Tel.: +44 7877791409. E-mail address: [email protected]. 15 November 2013 Available online xxxx
Please cite this article as: D'Ardis, M., Forum theatre for practice simulation and skills development in nurse education: A student's perspective, Nurse Educ. Today (2013), http://dx.doi.org/10.1016/j.nedt.2013.12.002
Contents lists available at ScienceDirect
Nurse Education Today journal homepage: www.elsevier.com/nedt
Big Ideas Forum theatre for practice simulation and skills development in nurse education: A student's perspective
The use of simulation in clinical skills training is standard for nurse education programmes for good reason. How can a student nurse safely undertake clinical interventions if they have not had the chance to first practise and understand the processes involved? Whether those interventions are taking a pulse, undertaking urinalysis or administering a depot, it is important that the skills are explored in the safety of a neutral space, such as simulation suite, in order to ensure no patients are hurt in the making of a nurse. However, there is not the same uniform training for the development of the interpersonal and communication skills that nurses need to master in order to be effective in their role. This paper explores how forum theatre in can be used to address the discrepancy. The exploration of using forum theatre as a method of simulated practice in the context of nurse training started with an opportunity to perform at the World Mental Health Day (WMHD) (World Health Organisation, 2010) presentation at Buckinghamshire New University in 2012. The theme of WMHD that year was Depression, so a piece of theatre was developed that explored the day in the life of a depressed protagonist, and the impact condition had on relationships with the partner and the best friend. The protagonist is eventually persuaded to seek the help of a health professional whose response seems indifferent and harassed—not at all sympathetic. The scenarios were performed once, and then a second time, wherein the drama was stopped at various junctures and the audience were invited to reflect and discuss moments of the action accordingly. If there had been more time, the work could have developed in such a way that audience members could have come onto the “stage” and taken the place of the protagonist, attempting to negotiate the barriers to communication that she faced. The origins of forum theatre are associated with Augusto Boal. He described audience members as “spect-actors” (Boal, 1992) because in his view, the development of the story told within the performance piece and the solutions to the problems suggested and enacted, are as dependent on the participation of the audience as it is on the group performing. Theatre in this context is an egalitarian and democratic process of experience, learning and rehearsal. These principles are embedded in the work of one of Boal's friends and one of his greatest influences, Paulo Friere, who is the author of the seminal text, Pedagogy of the Oppressed (Friere, 1972). Boal's forum theatre is underpinned by a philosophy firmly rooted in the belief that we all have something to teach to and learn from one another. The workshop space, the performance area, becomes a safe place not only to learn new actions or approaches, but also to practise them and make them personal. There is at once the safety of fictional distance and the visceral experience of being part of a shared, unique adventure. Forum theatre allows us to stop and magnify a moment in time, allowing us the luxury of analysis and reflection that real life rarely affords us. In the spirit of Friere's pedagogy, each participant in the group contributes something just by being there; it is an even playing field and the drama is anyone's for the making. The wonderful thing
about forum theatre techniques is that they can be used in so many different ways, to explore interactions on many different levels, in accordance with the needs of the group and the resources available. The potential for transformative development in this context is not to be underestimated. For example, the process of learning that occurs during a forum theatre workshop compliments Jack Mezirow's transformational cycle almost perfectly (Mezirow, 2011). Using the performance that took place on WMHD to explore this further, it is useful to start with Mezirow's “disorientating dilemma”, which in this instance could be described as the moment the protagonist presented to the health professional for help and support. The “critical appraisal” is what the audience started to do when they gave feedback about the thoughts, feelings and actions of the players, which also involved “perspective taking”. As the work develops, the other segments of the cycle are activated and thus forum theatre facilitates transformation of the group as a whole and each participant individually. In our daily lives we are the centre of our universe and we look at facts and people from a single perspective, our own… In daily life, we see the situation; on stage, we see ourselves and we see the situation we are in. [Boal, 1995 p. 26] The forum theatre workshop can become a rehearsal space for difficult conversations. In real life, once we have spoken or reacted, the words or actions cannot be retracted. In a workshop, there is time and space for feedback to be given, different methods of communication to be tried and room for mistakes to be made. As nurses, we rely on these skills more than many others—communication underpins the efficacy of patient care. Forum theatre is being used within pockets of nursing education curricula, by Wilson (2013) and colleagues at Southampton University, for example. The common thread seems to be that actors, service users and teaching staff perform a pre-scripted scenario and students are invited to enter the scene as the protagonist and negotiate solutions to the problem presented. There is not extensive research into the impact of this type of teaching on student's performance on placement thereafter, but there is a growing body of evidence that students find this a useful process in many ways, and they enjoyed it enormously (Middlewick et al., 2012). Further research needs to be undertaken to measure the impact that participation in forum theatre workshops has on the quality of patient care, if any, and exactly what it is about the work that informs this. The question might be whether or not it is the content of the workshops or the process of participating in them that has the most meaningful outcome in terms of the skills development of student nurses. This could have cost implications regarding its implementation, especially if actors are being employed. There is a chance that the pre-prepared scripts can make the work too prescriptive. Thompson (2012) discusses how drama workshops undertaken in prison and probation settings, using forum theatre techniques among others, are at risk of becoming more cognitive– behavioural-type workshops than creative, problem-solving opportunities. There is an accepted definition of appropriate behaviour
0260-6917/$ – see front matter © 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.nedt.2013.12.002
Please cite this article as: D'Ardis, M., Forum theatre for practice simulation and skills development in nurse education: A student's perspective, Nurse Educ. Today (2013), http://dx.doi.org/10.1016/j.nedt.2013.12.002
2
Big Ideas
and responses to conflict, for example, and participants in the group are coaxed into rehearsing this rather than exploring more creative solutions and approaches. Although this can be useful and pleasing to budget-holders and policy makers, it limits the potential for the work. The stories aren't those of the participants after all. If someone doesn't engage their creativity, how can they imagine other possibilities or alternative courses of action? Creativity is a skill that enhances cognitive flexibility (Robinson, 2013); a valued quality in nursing. Student nurses are taught to perform according to codes of conduct (Nursing and Midwifery Council, 2010) and NHS and local policies, while maintaining professionalism at all times when on duty (and off, some argue). The importance of this has been discussed ceaselessly since the Mid-Staffordshire Inquiry chaired by Robert Francis QC, and quite rightly, too (Mid-Staffordshire NHS Public Inquiry, 2012). However, communication requires flexibility of thought, thinking on one's feet, being responsive to the individual patient and the meaning of their unique experience. This requires confidence, competence, and the other qualities underpinned by the 6 Cs of Nursing (Commissioning Board Chief Nursing Officer & DH Chief Nursing Advisor, 2012). Students go onto placements soon after starting their courses so how can these vital skills be embedded quickly and effectively, in a way that is meaningful to the student and to the patients they meet? Perhaps there is an argument that forum theatre and other applied drama techniques could be used flexibly within a programme of nurse education. There could be prepared scenarios incorporating essential skills training, utilising forum theatre to engage students in a more dynamic and reflective manner, more than methods like role playing do, and a place for the techniques to be used during reflection groups. That way there is an opportunity for the students to explore their own stories and concerns as well as learning how to negotiate those of others; the new perspective-taking element of the transformative cycle. In a time of financial constraints and calls for innovation, new ideas and approaches have fertile ground on which to take root. There is a place for research into the impact that students felt participating in drama workshops had on them (if any) post-placement. It would be interesting to get feedback on whether or not they enjoyed or felt enhanced by the process immediately afterwards, maybe by comparing self-reported emotional intelligence pre- and post-workshop(s). And
then after their first placement experience has concluded, to see if, on reflection, they felt the experience of being involved in forum theatre was useful to them once in the clinical setting. The point of the process is not to produce polished actors, rather new nurses, comfortable in their role, so there is no need to hire professional actors thus ensuring that forum theatre could become a cost-effective, meaningful, transformative teaching tool for reflexive learning and skills development. References Boal, A., 1992. Games for Actors and Non-Actors. Routledge, London. Boal, A., 1995. The Rainbow of Desire. Routledge, London. Commissioning Board Chief Nursing Officer & DH Chief Nursing Advisor, 2012. Compassion in Practice Policy London. Friere, P., 1972. Pedagogy of the Oppressed. Penguin Books, London. Mezirow, J., 2011. Transformative Learning in Mezirow, J & Taylor EW Transformative Theory in Practice. Middlewick, Y., Kettle, T.J., Wilson, J.J., 2012. Curtains up! Using forum theatre to rehearse the art of communication in healthcare education. Nurse Educ. Pract. 12 (3), 139–142 [Accessed: 2012]. Mid-Staffordshire NHS Public Inquiry, 2012. Report of the Mid-Staffordshire NHS Foundation Trust Public Inquiry: Executive Summary. The Stationary Office, London. Nursing and Midwifery Council, 2010. Standards for pre-registration nursing education [online]. NMC.org. Available from http://standards.nmc-uk.org/PublishedDocuments/ Standards%20for%20preregistration%20nursing%20education%2016082919.pdf [Accessed: 10 Sept. 2012]. Robinson, K., 2013. To encourage creativity, Mr. Gove, you must first understand what it is. The Guardian 17 (May). Thompson, James, 2012. Applied Theatre: Bewilderment and Beyond. Peter Lang Ltd., Oxford. Wilson, J., 2013. Let's all play “stigma”! Learning together using forum theatre in collaboration with mental health service users and nurses. Presentation NET 2013. World Health Organisation, 2010. World Mental Health Day.
Melanie D'Ardis Mental Health, Buckinghamshire New University, 106 Oxford Road, Uxbridge, UB8 1NA, United Kingdom Tel.: +44 7877791409. E-mail address: [email protected]. 15 November 2013 Available online xxxx
Please cite this article as: D'Ardis, M., Forum theatre for practice simulation and skills development in nurse education: A student's perspective, Nurse Educ. Today (2013), http://dx.doi.org/10.1016/j.nedt.2013.12.002
