CREATIVE DRAMA-BASED FORGIVENESS TRAINING FOR NURSING STUDENTS

CREATIVE DRAMA-BASED FORGIVENESS EDUCATION FOR DIFFICULT PATIENT ENCOUNTERS AMONG NURSING STUDENTS: A RANDOMIZED CONTROLLED TRIAL

Nursing students frequently encounter difficult patient behaviors that may evoke negative emotions such as anger, frustration, and helplessness. Forgiveness may be a useful resource for managing these experiences; however, evidence on effective educational approaches for fostering forgiveness in nursing education is limited. This randomized controlled trial evaluated the effects of creative drama-based and case-based forgiveness education on nursing students' forgiveness of others and self-forgiveness in the context of difficult patient encounters. Eighty fourth-year nursing students were randomly assigned to either a creative drama group or a case-based learning group. Both groups participated in four educational sessions (200 minutes in total). Outcomes were assessed using the Forgiveness of Others Scale and the Self-Forgiveness Scale before and immediately after the intervention.

Study Overview

• Status: Completed
• Conditions: Nursing Students
• Intervention / Treatment: Other: Creative Drama; Other: Case-Based Learning

Detailed Description

Nursing students interact with patients with diverse characteristics during clinical practice. While some patients are cooperative and communicative, others may display aggressive, anxious, demanding, resistant, manipulative, or verbally abusive behaviors. Such difficult patient behaviors may evoke negative emotions in students, including anger, frustration, helplessness, anxiety, and emotional distress. These experiences may also negatively affect students' caregiving relationships, communication processes, and professional development.

Forgiveness is defined as a dynamic process through which individuals transform negative emotions, such as anger, resentment, hostility, and the desire for revenge, into more understanding, accepting, and compassionate responses. In addition to forgiving others, self-forgiveness may help individuals acknowledge their own mistakes and cope more adaptively with feelings of guilt, regret, and self-criticism. Therefore, forgiveness is considered an important personal and professional resource that may support healthcare professionals and students in coping with difficult interpersonal experiences.

However, evidence regarding effective educational approaches for fostering forgiveness in nursing education remains limited. The abstract and multidimensional nature of forgiveness requires students not only to understand the concept theoretically but also to experience it, develop different perspectives, and cultivate empathy. In this context, student-centered and experiential teaching methods, such as creative drama and case-based learning, may represent potentially useful approaches for developing forgiveness skills.

This randomized controlled pretest-posttest study aimed to evaluate the effects of creative drama-based and case-based forgiveness education on nursing students' forgiveness of others and self-forgiveness in the context of difficult patient encounters. The study was conducted with 80 fourth-year nursing students enrolled in the nursing department of a university in Eastern Türkiye. Participants were randomly assigned to either a creative drama group (n=40) or a case-based learning group (n=40).

Both groups participated in four structured educational sessions totaling 200 minutes. The interventions were based on difficult patient scenarios and were organized around the themes of forgiveness of others and self-forgiveness. In the creative drama group, students actively participated in role-playing, enactment, perspective-taking, empathy development, and reflective activities. In the case-based learning group, students analyzed the same scenarios, identified problems, discussed potential causes, and evaluated alternative courses of action. Outcomes were assessed using the Forgiveness of Others Scale and the Self-Forgiveness Scale before and immediately after the intervention.

• Study Type: Interventional
• Enrollment (Actual): 80
• Phase: Not Applicable

Contacts and Locations

Study Locations

• Turkey (Türkiye)
  • Sivas
    • Sivas, Sivas, Turkey (Türkiye), 58600
      • Sivas Cumhuriyet University

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Adult; Older Adult
• Accepts Healthy Volunteers: Yes

Description

Inclusion Criteria:

• Fourth-year nursing student enrolled in the nursing department of the study university
• Aged 18 years or older
• Able to speak and understand Turkish
• Not repeating the academic year
• Willing to participate and provided written informed consent

Exclusion Criteria:

• Refused to participate or withdrew consent
• Did not meet the inclusion criteria
• Did not complete the educational intervention or post-intervention assessments

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Other
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: None (Open Label)

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Creative Drama	Other: Creative Drama; Participants received creative drama-based forgiveness education focusing on forgiveness of others and self-forgiveness in the context of difficult patient encounters. The intervention consisted of four structured sessions totaling 200 minutes. Educational activities included role-playing, improvisation, perspective-taking, empathy development, and reflection exercises. Students experienced both nurse and difficult patient roles and explored the emotions and unmet needs underlying difficult patient behaviors from multiple perspectives.
Active Comparator: Case-Based Learning	Other: Case-Based Learning; Participants received case-based forgiveness education focusing on forgiveness of others and self-forgiveness in the context of difficult patient encounters. The intervention consisted of four structured sessions totaling 200 minutes. Difficult patient scenarios were used during the sessions, and students read and analyzed the cases, identified problems, discussed underlying causes and different perspectives, and evaluated potential courses of action.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Forgiveness of Others	Change in Forgiveness of Others Scale (FOS) scores from baseline to immediately after the educational intervention. Forgiveness of Others Scale (FOS): The Forgiveness of Others Scale was developed by Rye (1998) and later revised by Rye et al. (2001) to assess individuals' tendency to forgive others (Rye et al., 2001). The Turkish validity and reliability study of the scale was conducted by Havare and Gizir (2020). The Turkish version consists of 15 items, and items 1, 3, 4, 5, 8, 10, 12, and 14 are reverse scored. Responses are rated on a 5-point Likert-type scale ranging from "strongly disagree (1)" to "strongly agree (5)." Higher scores indicate a greater tendency to forgive others. The Cronbach's α coefficient of the Turkish version was reported as 0.75 (Havare & Gizir, 2020). In the present study, the Cronbach's α coefficient calculated from the pretest data was 0.77 for the experimental group and 0.81 for the control group.	Baseline and immediately after completion of the intervention (same day)

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Self-Forgiveness	Change in Self-Forgiveness Scale (SFS) scores from baseline to immediately after the educational intervention. Self-Forgiveness Scale (SFS): The Self-Forgiveness Scale, developed by Wohl, DeShea, and Wahkinney (2008), was designed to assess individuals' tendency toward self-forgiveness (Wohl et al., 2008). The Turkish validity and reliability study of the scale was conducted by Havare and Gizir (2020). The Turkish version consists of 12 items rated on a 4-point Likert-type scale ranging from 1 (never) to 4 (always). Higher scores indicate a greater tendency toward self-forgiveness. The Cronbach's α coefficient of the Turkish version was reported as 0.87 (Havare & Gizir, 2020). In the present study, the Cronbach's α coefficient calculated from the pretest data was 0.74 for the experimental group and 0.78 for the control group.	Baseline and immediately after completion of the intervention (same day)

Collaborators and Investigators

• Sponsor: Abant Izzet Baysal University

Study record dates

Study Major Dates

• Study Start (Actual): April 6, 2025
• Primary Completion (Actual): April 6, 2025
• Study Completion (Actual): April 6, 2026

Study Registration Dates

• First Submitted: June 22, 2026
• First Submitted That Met QC Criteria: June 22, 2026
• First Posted (Actual): June 26, 2026

Study Record Updates

• Last Update Posted (Actual): June 29, 2026
• Last Update Submitted That Met QC Criteria: June 25, 2026
• Last Verified: June 1, 2026

More Information

Terms related to this study

• Keywords: Nursing Students; Forgiveness; Creative Drama; Case-Based Learning; Difficult Patient
• Other Study ID Numbers: FORGIVE-RCT-2025

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No