Conflict management and communications skills in the ICU: A qualitative study on forming junior critical care nurses with drama pedagogy

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However, current critical care curricula often do not offer training in such skills. To address this gap, drama workshops were developed in this study to improve non-technical skills in post-graduate critical care nursing education. Aim We aimed to understand critical care nursing students’ perceptions of the drama programme, which focused on communication, teamwork and conflict management in the ICU. Methods Focus groups and one individual interview with 19 participants recruited from a post-graduate (or master’s) critical care programme were conducted. Thematic qualitative analysis was used to analyse the data. Findings Four themes were identified: Personal and professional development, Gaining new insights - the power of reflection, Challenges in engaging with drama workshops, and Challenges in creating an authentic environment. The findings suggest an increased awareness of teamwork and individual responsibilities. However, engaging in drama workshops also involved challenges. In particular, the participants were concerned about meeting performance expectations, which introduced pressure and distress. Creating an authentic environment was emphasised as an essential factor for effective and meaningful drama workshops. Conclusion This study emphasises the potential of drama workshops to foster ICU nurses’ personal growth and enhance their professional competences. It highlights the importance of a purposefully tailored drama programme/education and an authentic environment to create meaningful learning experiences in critical care education. Implications for Clinical Practice Teamwork in the ICU can benefit from drama-based learning programmes as it increases awareness regarding the significance of collaboration within the healthcare team. Moreover, it can help develop nurses’ non-technical skills, which are essential in caring for critically ill patients and initiating effective interprofessional interactions. Critical care Drama Education Focus groups Learning method non-technical skills communication teamwork Introduction Intensive care units (ICU) are high technological environments where new staff must be prepared to deliver the advanced care required by critically ill patients. To ensure ICU patient safety, nursing students must gain clinical competence in providing a high standard of care to patients [1]. ‘Clinical competence’ refers to the ability to identify and respond to abnormal conditions in a patient’s health and ensure appropriate care [2]. In ICU nursing, achieving clinical competence entails meeting three key requirements: compliance with clinical regulations, adherence to nursing ethics principles and implementation of effective nursing interventions [1]. Caring for critically ill patients requires both technical (e.g. airway suctioning) and non-technical skills (teamwork, managing stressful situations and engaging in critical thinking to make informed decisions about patient care), with the latter considered vital competences in securing patient safety [3]. They complement technical skills and contribute to what is known as ‘professional competence’ [4]. However, current critical care education curricula do not have training content to foster non-technical skills [5]. To address this gap, we developed and evaluated an intervention to improve nursing students’ non-technical skills using drama workshops. The programme focuses on communication and teamwork including conflict management and can be used in post-graduate specialised CCN education. ICUs are complex and stressful environments due to high patient acuity and multidisciplinary involvement. Over 70% of ICU staff perceived conflicts, in which nurse–physician conflicts were most common, followed by nurse–nurse and staff–relative conflicts [6]. Communication skills are crucial in maintaining teamwork not only with fellow staff but also with patients and their families. Communication and conflict management knowledge are often included as theoretical content in critical care curricula; however, there is limited evidence of skills training for critical care nurses (CCNs) in their post-graduate studies. Nursing education, including post-graduate studies and specialisation pathways, varies across countries as they implement distinct nursing regulations and educational frameworks. This contributes to variations in the scope of practice, education and training of nurses. Many European countries offer post-graduate education for nurses to become certified CCNs. However, having a critical care diploma or certificate is not always required for working in ICUs [7]. Using drama in education is an effective pedagogical strategy in nursing education, as it supports the development of ethical, relational and communication skills among students [8]. By engaging in drama activities, nursing students interact with peers, adopt different roles and explore various perspectives, leading to increased self-awareness and understanding of others [9]. A critical review revealed that drama enhanced nursing students’ interpersonal skills, understanding of patient experience, professional identity development, communication skills, self-reflections and critical thinking [10]. Drama-based learning also equips students with conflict management skills, preparing them to manage future conflicts effectively. However, some may feel hesitant to participate in drama-based learning activities. Shy or embarrassed students, as well as those who are unfamiliar with drama, may not fully engage in the exercises, limiting their own and others’ abilities to leverage the full potential of drama [9, 11]. Most studies that explored drama as a teaching strategy to enhance nursing students’ interpersonal skills have focused on undergraduate nursing programmes. Given the lack of studies exploring drama at the post-graduate level, particularly regarding the critical care programme, this study aimed to explore CCN students’ perceptions of a drama programme that focused on communication, teamwork and conflict management in the ICU. Methods We employed a qualitative design using focus groups and interviews. Focus groups involve gathering data through group discussions centred around pre-determined topics using a structured or a semi-structured design [12, 13]. Their primary objective is to elucidate individual and collective perspectives of the phenomenon under study [12, 13]. However, only one student participated in one of the data collection sessions, resulting in an individual interview. We followed the consolidated criteria for reporting qualitative research ( COREQ ) guidelines in reporting the study [14]. Drama workshops The drama workshops are part of a Master of Critical Care programme that aimed to help students gain non-technical skills in conflict management, teamwork and communication in the ICU. Two workshops were delivered and led by a drama pedagogue and a senior lecturer in critical care. Each drama workshop had three phases: Framing and warm-up, Drama exercise - performing the scenarios and Reflection and discussion. The first workshop was held during the first three weeks of the post-graduate CCN programme. It provided an orientation in the drama technique with pre-prepared ICU conflict cases featuring miscommunication and conflicts with patients, relatives and healthcare personnel in the ICU. It lasted approximately three hours. The second workshop was conducted after students had completed the 8-week clinical training in the ICU, approximately halfway through the programme. One 8-hour day was used to follow up on miscommunication and conflict management in the ICU using drama pedagogy. The students were asked to discuss a case about miscommunication or conflicts they witnessed during their clinical training, and then a drama workshop was performed based on the cases they observed. Setting and sample The 40-week CCN programme was a full-time Master’s in Nursing Science programme offered at Gothenburg University in Sweden. The inclusion criterion was being enrolled in the course, so all students (n = 60) were invited to participate. A total of 19 CCRN students accepted the invitation to participate in this study. Their previous working experiences as RNs ranged between 2 and 10 years. Data collection Data were collected through six focus group interviews and one individual interview with nursing students, which were conducted in Swedish after the final workshop. The participants were provided with oral and written study information, and their voluntary participation was stressed. Focus groups were conducted by [XX] and [XX], who were not involved in the drama workshops. The interview guide was developed based on the literature, with input from critical care and drama experts. The focus groups held in the university’s conference room were scheduled during lunch breaks when the students had campus-based activities. The participants were offered lunch and beverages. The focus groups started with a short presentation of the study’s main aim. Thereafter, the participants were invited to introduce themselves and cite their previous experiences as nurses and whether they had already experienced drama workshops. The interview guide consisted of the following questions: Can you tell us about any drama workshop experiences during your studies? How was your experience playing various parts in the drama workshops? What have you learned about conflict management, teamwork and communication? Which part of the workshop was valuable for your learning and understanding of the topics discussed? Is there anything we can do to improve the workshop? Prompt questions (e.g. ‘Can you please tell us more?’ ‘Can you please give us an example?’ and ‘Do you all agree on this or is there anyone who thinks differently?’) were raised as needed. The focus groups lasted between 60 and 90 minutes, while the individual interview lasted 60 minutes. The interviews were transcribed verbatim. The researchers conducting the focus groups did not participate in the drama workshops. Data analysis Data were analysed through a thematic analysis [15] . The analytical process is characterised by a dialectical pattern that moves from the whole to the parts, generating a ‘new whole’ in the process. The analysis was conducted in three phases: preparatory, coding and reporting. First, the data were collected, transcribed and analysed in Swedish. The Swedish members of the research group started the preparatory phase by reading each interview text carefully to gain an understanding and sense of the whole text. We also identified meaning units consisting of text segments corresponding to the aim of the study and the subject matter. These units were then subjected to open coding (i.e., systematic grouping of the codes by the contents and labelling them). Thereafter, we critically examined the codes by posing questions to the text, such as ‘What does this mean?’ and ‘How can I be sure of that?’ Our intention was to identify the related meanings that corresponded to the aim of the study. The meanings were compared against each other and against the interviews, generating overall themes as conceptualised by the reporting phase Elo and Kyngäs [15]. The non-Swedish-speaking researchers participated by re-examining the emerging findings once they were translated into English, helping refine the analysis. To ensure credibility and establish trustworthiness, the authors used several strategies: we called our pre-understanding into question, used an audit trail and discussed our findings with peers at a scientific seminar. The findings were carefully reviewed by all the authors, and amendments were made prior to finalisation. Moreover, the authors exercised reflexivity by using a critical approach during research to establish trustworthiness. Ethical considerations Oral and written information about the study was provided, in which students were informed that they could withdraw at any time and that any decision not to participate would have no consequences. Written consent to participate in the study was obtained from all the participants before collecting data. The researcher who conducted the interviews (XX and XX) did not participate in the workshops. The project was approved by the Swedish Regional Board of Ethics in Gothenburg (D no: 371-16). Findings A total of 19 students participated in the focus group interviews, which included 18 female students and 1 male student. The data analysis revealed four themes (Table 1). Table 1: An overview of the themes and exemplary quotes Themes Exemplary quotes Personal and professional development Hm you know, body language. There are other ways to demonstrate it as well. We could lean forward or lean back … or look in a different direction. It seems that these actions contribute more to the learning process than just relying on understanding body language. (FG6) It feels like this should already be somewhat a common knowledge; that one should be mindful of not appearing closed off and maintaining eye contact. It’s like if someone hasn’t realised this in their profession as a nurse, they might have missed an important aspect of their work. (FG1) Gaining new insights - the power of reflection Well, that’s actually what I find a bit difficult to put into words right now, but if I say that learning, for me, is more (pause, breathe), perhaps there is a guiding aspect to it. However, this drama pedagogy or workshop didn’t direct us. It didn’t tell us what was right. It didn’t explain or show the way, not at any point, not even in the end, and for me, that’s probably part of learning something. It somehow requires a guide, whether it’s a teacher, a mentor or a supervisor. Someone who says, ‘Here are the rules, and they apply’. It includes someone guiding me to some extent. I think that’s possibly why I haven’t thought of it as learning, but more as reflection, as I mentioned earlier. Nevertheless, it’s still valuable, of course, to reflect. (IP1) For me, personally, I don’t think that it was the drama itself, but it is…when we analysed what we saw. (FG3) Perceived challenges in engaging with drama workshops I think discussions would be much better, and you can see and reflect oh…it is this one…[I] can approach this problem. Drama requires something of me that I can’t give. (FG5) You know, this is really a personal thing to stand there and play the scenario… I really don’t think people should be forced. It doesn’t fit everybody…my personality. I thoroughly believe it should be voluntary… (FG6) Challenges in creating an authentic environment Here we are, four walls and a circle of chairs…this is not a natural environment for us, we don’t work here, and this is not a place where we nurse patients. (FG2) This programme is really hard. I mean, you have to study so much and all the assignments. This and that, and all of a sudden you are doing drama. [It’s] seemingly meaningless. (FG1) Personal and professional development One theme that emerged from the focus groups was the participants’ increased awareness of the importance of teamwork and each member’s individual responsibility for the outcome of conflicts and other situations. The participants also described how they were reminded of the significance of body language in their communication with patients, their families and teammates. During the workshop, they had the opportunity to engage in self-reflection and gain valuable insights into different interpretations and analyses of conflicts. Through introspection and the consideration of perspectives, they developed a deeper understanding of the complexities involved. Some participants eagerly embraced the workshop, expressed their enthusiasm and actively participated. The workshops were found to be enjoyable and fun, facilitating a playful transition between seriousness and humour while addressing the dilemmas presented in the scenarios. The active involvement of the entire group enhanced the exploration of each scenario. From the students’ narratives, their previous working experiences evidently played an important role in shaping their comprehension of the conflicts they faced. However, these also presented a challenge, as they sometimes struggled to recognise their own perspectives, perceiving them as faults or shortcomings. The participants expressed that while they did not learn any clear conflict management strategies, they became aware of how to approach future conflicts. Gaining new insights - the power of reflection The time for reflections and the subsequent discussions following each drama workshop were highly appreciated and perceived as more meaningful than the acting itself. Engaging in the activity served as a catalyst for reflection, wherein conflict situations and teamwork became embodied and understood in new ways. The participants’ indicated that group discussions brought clarity to the conflicts and facilitated a deeper level of comprehension. Furthermore, they believed that dedicated time for reflection and discussion helped them gain self-insights and offered opportunities to revise one’s immediate understanding of actual scenarios. However, the reflections were not viewed as skill-based learning, even though they were considered important. Instead, they provided a platform for discerning the differences in behaviours and approaches that emerged during the discussions. Furthermore, the participants’ prior experiences and knowledge, acquired through years of clinical practice in different wards (as indicated above), made it challenging to reframe their thinking into the ICU. Consequently, they suggested that their behavioural patterns could not be influenced by only two drama workshops and considered the workshops as insufficient occasions for meaningful transformation. Challenges in engaging with drama workshop s While acknowledging the advantages of engaging in drama and recognising its potential to provide tools for reflection and conflict management, the students described a sense of pressure to perform and act, emphasising the need to adopt a role and be someone other than themselves. This was coupled with a perception that conflict situations were exaggerated, despite being rooted in cases derived from authentic clinical cases (first workshop) and their own observations (second workshop). The participants stressed that joining a drama workshop without prior acquaintances with fellow students triggered insecurity and vulnerability. This was evident during the first workshop session, when the group members were still unfamiliar with one another. Thus, their focus was divided between the workshop itself and their fears of being observed and not meeting performance expectations. This created challenges in terms of openly sharing reflections and maintaining their focus on the workshop’s content. What appeared to be specifically challenging for them was the fact that they sometimes had to play the role of ‘a bad nurse’. They expressed discomfort in acting out inappropriate behaviour, which conflicted with their desired professional identity. They felt the need to justify their actions during role play, which did not align with how they wished to be perceived in their profession. This meant the un-dignification of their professional self-esteem and, therefore, a shifting focus from learning and reflecting to performing why the essence of drama education was lost. Challenges in creating an authentic environment One recurring theme that emerged from the data was the participants’ desire for an authentic environment, specifically an ICU patient room. There were frequent discussions about feeling uncomfortable when conducting drama workshops in a classroom setting, which lacked the safety of and resemblance to an actual ICU. This discrepancy was identified as an obstacle to fully understanding the purpose of the workshops. The students mentioned the simulation centre as a more realistic environment with which they were familiar and a place they associated with a sense of clarity regarding certain tasks and expectations. The participants compared the drama workshops to other learning activities in the critical care programme, expressing that the workshops felt too abstract and required a greater need for theoretical understanding. Furthermore, some suggested that incorporating professional actors/actresses would be more beneficial, particularly if they portrayed patients or family members, while the students took on the role of nurses during the drama sessions. The participants believed that this arrangement could enhance the authenticity of the workshops and create a deeper sense of reality. Discussion In this study, we sought to explore post-graduate CCN students’ experiences of a drama programme focused on communication, teamwork and conflict management in the ICU. Our findings revealed that drama workshops can have a positive impact on both professional and personal growth, facilitating students’ skills in conflict management, teamwork and communication. However, they also presented challenges as students felt pressured to focus more on acting and performing rather than being present in the process of drama and reflection. Furthermore, the environment in which the workshops took place, a traditional classroom, posed a significant challenge in terms of creating a sense of safety and authenticity. This prevented participants from fully engaging and connecting with the content of the workshops. To the best of our knowledge, this is the first study examining post-graduate CCN students’ experiences of a drama programme in the context of critical care education, as well as its contribution to the development of nurses’ non-technical skills. Such skills consist of social (teamwork, leadership and communication), cognitive (situational awareness, decision-making, cognitive readiness and task management) and personal management (stress and fatigue management) skills necessary for safe and effective performance [ 16 ]. One aspect in which we believe the drama workshops made a significant contribution is conflict management. CCN students gained new insights into their responsibilities as team players and discovered new ways to approach conflicts and their possible interpretations. This finding is consistent with those of previous studies [ 8 , 17 ]. Arveklev-Höglund, Wigert [ 8 ] demonstrated that drama has the potential to enhance non-technical skills for nursing students, particularly communication skills. Similarly, our findings confirm the result of Uzunoz and Demirhan [ 17 ] that drama in higher education has the potential to increase critical thinking and students’ openness and ability to initiate divergent thinking. We also found that drama activities were a powerful tool in enhancing CCN students’ learning through reflection. A concept analysis of reflection in nursing professional development [ 18 ] describes the essence of reflection with a four-fold pattern, thereby filling the gap between theory and practice, expanding the role of nursing and enhancing competency, and addressing nurses’ educational and learning needs and responsibilities. Moreover, from a philosophical perspective, reflection is linked to the two overarching themes of ‘knowing’ and ‘not knowing’ [ 19 ]. In other words, reflection involves learning from one’s experiences based on a process of internalising and processing emotions and reactions, which leads not only to formulating other strategies for the future but also to being aware of one’s lack of knowledge, i.e. being alert and curious in situations [ 18 , 19 ]. This indicates a transformation of one’s perspective with a critical attitude and openness. When students acquire these qualities/skills, they are better equipped to deliver high-quality care for critically ill patients and their families. Our findings showed that CCN students experienced some pressure and discomfort in meeting performance expectations, particularly when playing the role of a bad or unprofessional nurse. Speculating whether these feelings stemmed from shyness or were perceived as conflicting with their professional identity remains challenging. However, even individuals who are generally shy can benefit from engaging in drama because assuming a new role and envisioning themselves as someone else can facilitate personal growth [ 20 ]. Nevertheless, the resistance felt by the CCN students in our study was more likely associated with their perceptions of the professional image expected of a competent nurse. This is supported by statements from several participants who expressed a preference for being ‘themselves as a nurse’ in the scenarios. Behaving unprofessionally and displaying inappropriate conduct are widely regarded as unacceptable by most nurses [ 21 ]. Thus, it is crucial for CCN students to acknowledge this fact, as such behaviour can have a harmful impact on staff, patients and the entire organisation [ 21 ]. Furthermore, we observed that the CCN students were more used to participating in simulation workshops that emphasised clinical skills training. They lamented a lack of an ‘authentic environment’ during the drama workshop and did not feel entirely safe. In simulation workshops, the creation of an authentic environment is highly significant. While drama has numerous benefits for nursing education in non-technical skills, simulation appears to be the optimal approach for teaching technical skills, such as vital signs assessment Jefferies, Glew [ 10 ]. Based on our findings, it is suggested that incorporating authentic environments into drama workshops for students could be advantageous. Finally, our findings both confirm and contradict a previous study on learning through drama in a specialist post-graduate nursing programme in paediatric care by Arveklev-Höglund, Wigert [ 11 ]. Their findings indicated two different perspectives among students: some preferred active participation in the drama workshops, while others preferred a more passive role by observing their peers in the scenarios. Furthermore, while the students in the study of Arveklev-Höglund, Wigert [ 11 ] expressed that drama facilitated their learning and preparedness for their professional role, our study found conflicting views. In particular, while some CCN students in our study preferred passive rather than active participation, they still acknowledged the valuable knowledge gained from the drama workshop. Strengths and limitations This study has several strengths. First, the focus groups were facilitated by two researchers independent of those responsible for conducting the drama workshops. This ensured that the CCN students felt comfortable sharing their experiences freely, without any potential bias or influence. Additionally, the students displayed a genuine interest in participating in the interviews, and their responses exhibited diverse perspectives. The decision to use focus groups not only deepened our understanding of the value of incorporating drama in critical care education but also emphasised the importance of tailoring a programme suited to the critical care curriculum, ensuring its meaningfulness for the CCN students. One limitation of focus groups is the potential risk of groupthink, which cannot be entirely ruled out in this study. The participants may have been influenced by the opinions of others, potentially hindering the full disclosure of individual perspectives. Although an individual interview was conducted as part of this study, it was not initially planned. Moreover, despite utilising an interview guide, there was the possibility of unintentionally influencing the discussion [ 12 , 13 ]. Nevertheless, we gained valuable insights into the CCN students’ experiences of participating in drama workshops and their learning processes. Conclusions Drama workshops have the potential to cultivate personal growth and enhance the development of professional competences among CCN students. By emphasising individual responsibilities in conflict management and achieving desired situational outcomes, students’ awareness is increased. Reflections and discussions during the workshops enabled a deeper understanding of conflicts, leading to increased clarity and the emergence of valuable insights that facilitated transformative learning experiences. However, for drama education to be effective in the context of critical care, a clear connection must be established between the drama programme and the desired learning outcomes. In particular, learning objectives must be designed according to constructive alignment [ 22 ] to make workshops more meaningful for CCN students. Declarations Author’s Note This study is part of a larger collaborative international programme (Erasmus Plus) between University of Gothenburg, Sweden and Griffith University, Australia, entitled “Drama in Intensive and Acute Care, DIAC”. Ethical Statement and Grant Numbers The study was conducted in accordance with the Helsinki Declaration. Written information was provided and informed consent was obtained from all subjects prior to data collection. The study was approved by the Swedish Ethical Review Authority, (D no: 371-16). Authors’ contributions SO was involved in conceptualizing the study design, methodology, developed the interview guide and collected data, analysed the data and wrote the main paper. SAH was involved in developing the interview guide, collected the data and wrote the main paper. FL was involved in conceptualizing the study design, methodology, and wrote the main paper. WCH was involved in conceptualizing the study design, methodology and wrote the main paper. MR was involved in conceptualizing the study design, methodology and wrote the main paper Acknowledgement We would like to acknowledge all the students who participated in the study and Professor Margret Lepp for her support. Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Consent for publication; All the participants have given their written informed consent to publish the findings of the study. There are no personal details or identifiable information that could compromise anonymity in the manuscript. Availability of Data and Materials; De-identified excerpts from the focus group transcripts are available from the corresponding author upon reasonable request. Full transcripts are not publicly available due to confidentiality agreements with participants. Funding Statement Erasmus Plus funded exchange program for staff between University of Gothenburg and Griffith University but not this specific study. Clinical Trial Number N/A References Lakanmaa, R.-L., et al., Competence requirements in intensive and critical care nursing – Still in need of definition? A Delphi study. Intensive & critical care nursing, 2012. 28 (6): p. 329-336. Ääri, R.-L., S. Tarja, and L.-K. Helena, Competence in intensive and critical care nursing: A literature review. Intensive & critical care nursing, 2008. 24 (2): p. 78-89. Gordon, M., D. Darbyshire, and P. Baker, Non-technical skills training to enhance patient safety: a systematic review. Medical education, 2012. 46 (11): p. 1042-1054. Epstein, R.M. and E.M. Hundert, Defining and Assessing Professional Competence. Journal of the American Medical Association, 2002. 287 (2): p. 226-235. 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Cite Share Download PDF Status: Published Journal Publication published 02 Mar, 2026 Read the published version in BMC Nursing → Version 1 posted Editorial decision: Revision requested 23 Nov, 2025 Reviews received at journal 20 Nov, 2025 Reviewers agreed at journal 28 Oct, 2025 Reviews received at journal 06 Oct, 2025 Reviewers agreed at journal 16 Sep, 2025 Reviewers agreed at journal 31 Jul, 2025 Reviewers invited by journal 14 Jul, 2025 Editor assigned by journal 08 Jul, 2025 Submission checks completed at journal 07 Jul, 2025 First submitted to journal 07 Jul, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7027754","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":486468743,"identity":"5798f448-c12c-4176-ae51-25aa5e59370c","order_by":0,"name":"Sepideh Olausson","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABBElEQVRIiWNgGAWjYBAC+QYGhgM8DAcYGNihIvyEtBgcgGlhhopINhDSAiJQtIAMwa+FvffggTcVdxj4mZmfSf74Y5NnfH6NAeOPCtxa5HvOJRycc+YZg2Qzm5k0b1tasdmNNwbMPGfwWHMjx+Awb9thBoPDDGbSjA2HE7fdOGPAzNiGR8v9N0At/0Ba2L8BHXY4cfOMMwaMP//hs4UHqKUBpIXHTIKH7XDiBv4eAwbeBjzeP5MH9MuxwzySzTzF1kC/JM64wVZwmOcYHu+3nz384U3NYTl+9vaNN4Ehltjff3jjwx81eBwGjBQECQYSCaBoIqwFCfAT0DAKRsEoGAUjDgAAoKFYY72Vsm8AAAAASUVORK5CYII=","orcid":"","institution":"University of Gothenburg, Sahlgrenska University Hospital","correspondingAuthor":true,"prefix":"","firstName":"Sepideh","middleName":"","lastName":"Olausson","suffix":""},{"id":486468744,"identity":"a0ed46fb-9556-480f-919a-82ef22e1afce","order_by":1,"name":"Susanna Arveklev-Höglund","email":"","orcid":"","institution":"University West","correspondingAuthor":false,"prefix":"","firstName":"Susanna","middleName":"","lastName":"Arveklev-Höglund","suffix":""},{"id":486468745,"identity":"14dec46e-68ca-4edf-b7c2-b91241c63626","order_by":2,"name":"Frances Lin","email":"","orcid":"","institution":"Flinders University","correspondingAuthor":false,"prefix":"","firstName":"Frances","middleName":"","lastName":"Lin","suffix":""},{"id":486468746,"identity":"fbb021d7-fea0-46e9-91bc-3715b3bc0091","order_by":3,"name":"Wendy Chaboyer","email":"","orcid":"","institution":"Griffith University","correspondingAuthor":false,"prefix":"","firstName":"Wendy","middleName":"","lastName":"Chaboyer","suffix":""},{"id":486468747,"identity":"df276898-b821-4329-b384-4071eb8d0dce","order_by":4,"name":"Mona Ringdal","email":"","orcid":"","institution":"University of Gothenburg","correspondingAuthor":false,"prefix":"","firstName":"Mona","middleName":"","lastName":"Ringdal","suffix":""}],"badges":[],"createdAt":"2025-07-02 09:38:17","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7027754/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7027754/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12912-026-04487-1","type":"published","date":"2026-03-02T15:59:07+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":104250718,"identity":"eaf6db00-c774-4e36-b87d-5ecf544c4ea7","added_by":"auto","created_at":"2026-03-09 16:06:33","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":622181,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7027754/v1/bf5fa1b2-2233-47da-b33b-9677c22f868d.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Conflict management and communications skills in the ICU: A qualitative study on forming junior critical care nurses with drama pedagogy","fulltext":[{"header":"Introduction","content":"\u003cp\u003eIntensive care units (ICU) are high technological environments where new staff must be prepared to deliver the advanced care required by critically ill patients. To ensure ICU patient safety, nursing students must gain clinical competence in providing a high standard of care to patients [1]. \u0026lsquo;Clinical competence\u0026rsquo; refers to the ability to identify and respond to abnormal conditions in a patient\u0026rsquo;s health and ensure appropriate care [2]. In ICU nursing, achieving clinical competence entails meeting three key requirements: compliance with clinical regulations, adherence to nursing ethics principles and implementation of effective nursing interventions [1].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCaring for critically ill patients requires both technical (e.g. airway suctioning) and non-technical skills (teamwork, managing stressful situations and engaging in critical thinking to make informed decisions about patient care), with the latter considered vital competences in securing patient safety [3]. They complement technical skills and contribute to what is known as \u0026lsquo;professional competence\u0026rsquo; [4]. However, current critical care education curricula do not have training content to foster non-technical skills [5]. To address this gap, we developed and evaluated an intervention to improve nursing students\u0026rsquo; non-technical skills using drama workshops. The programme focuses on communication and teamwork including conflict management and can be used in post-graduate specialised CCN education.\u003c/p\u003e\n\u003cp\u003eICUs are complex and stressful environments due to high patient acuity and multidisciplinary involvement. Over 70% of ICU staff perceived conflicts, in which nurse\u0026ndash;physician conflicts were most common, followed by nurse\u0026ndash;nurse and staff\u0026ndash;relative conflicts [6]. Communication skills are crucial in maintaining teamwork not only with fellow staff but also with patients and their families. Communication and conflict management knowledge are often included as theoretical content in critical care curricula; however, there is limited evidence of skills training for critical care nurses (CCNs) in their post-graduate studies. Nursing education, including post-graduate studies and specialisation pathways, varies across countries as they implement distinct nursing regulations and educational frameworks. This contributes to variations in the scope of practice, education and training of nurses. Many European countries offer post-graduate education for nurses to become certified CCNs. However, having a critical care diploma or certificate is not always required for working in ICUs [7].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eUsing drama in education is an effective pedagogical strategy in nursing education, as it supports the development of ethical, relational and communication skills among students [8]. By engaging in drama activities, nursing students interact with peers, adopt different roles and explore various perspectives, leading to increased self-awareness and understanding of others [9]. A critical review revealed that drama enhanced nursing students\u0026rsquo; interpersonal skills, understanding of patient experience, professional identity development, communication skills, self-reflections and critical thinking [10]. Drama-based learning also equips students with conflict management skills, preparing them to manage future conflicts effectively. However, some may feel hesitant to participate in drama-based learning activities. Shy or embarrassed students, as well as those who are unfamiliar with drama, may not fully engage in the exercises, limiting their own and others\u0026rsquo; abilities to leverage the full potential of drama [9, 11]. Most studies that explored drama as a teaching strategy to enhance nursing students\u0026rsquo; interpersonal skills have focused on undergraduate nursing programmes. Given the lack of studies exploring drama at the post-graduate level, particularly regarding the critical care programme, this study aimed to explore CCN students\u0026rsquo; perceptions of a drama programme that focused on communication, teamwork and conflict management in the ICU.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eWe employed a qualitative design using focus groups and interviews. Focus groups involve gathering data through group discussions centred around pre-determined topics using a structured or a semi-structured design [12, 13]. Their primary objective is to elucidate individual and collective perspectives of the phenomenon under study [12, 13].\u0026nbsp;However, only one student participated in one of the data collection sessions, resulting in an individual interview. We followed the consolidated criteria for reporting qualitative research (\u003cem\u003eCOREQ\u003c/em\u003e) guidelines in reporting the study [14].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDrama workshops\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe drama workshops are part of a Master of Critical Care programme that aimed to help students gain non-technical skills in conflict management, teamwork and communication in the ICU. Two workshops were delivered and led by a drama pedagogue and a senior lecturer in critical care. Each drama workshop had three phases: Framing and warm-up, Drama exercise - performing the scenarios and Reflection and discussion. The first workshop was held during the first three weeks of the post-graduate CCN programme. It provided an orientation in the drama technique with pre-prepared ICU conflict cases featuring miscommunication and conflicts with patients, relatives and healthcare personnel in the ICU. It lasted approximately three hours. The second workshop was conducted after students had completed the 8-week clinical training in the ICU, approximately halfway through the programme. One 8-hour day was used to follow up on miscommunication and conflict management in the ICU using drama pedagogy. The students were asked to discuss a case about miscommunication or conflicts they witnessed during their clinical training, and then a drama workshop was performed based on the cases they observed.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSetting and sample\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe 40-week CCN programme was a full-time Master\u0026rsquo;s in Nursing Science programme offered at Gothenburg University in Sweden. The inclusion criterion was being enrolled in the course, so all students (n = 60) were invited to participate. A total of 19 CCRN students accepted the invitation to participate in this study. Their previous working experiences as RNs ranged between 2 and 10 years.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData collection\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData were collected through six focus group interviews and one individual interview with nursing students, which were conducted in Swedish after the final workshop. The participants were provided with oral and written study information, and their voluntary participation was stressed. Focus groups were conducted by [XX] and [XX], who were not involved in the drama workshops. The interview guide was developed based on the literature, with input from critical care and drama experts. The focus groups held in the university\u0026rsquo;s conference room were scheduled during lunch breaks when the students had campus-based activities. The participants were offered lunch and beverages. The focus groups started with a short presentation of the study\u0026rsquo;s main aim. Thereafter, the participants were invited to introduce themselves and cite their previous experiences as nurses and whether they had already experienced drama workshops. The interview guide consisted of the following questions:\u0026nbsp;\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eCan you tell us about any drama workshop experiences during your studies?\u003c/li\u003e\n \u003cli\u003eHow was your experience playing various parts in the drama workshops?\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eWhat have you learned about conflict management, teamwork and communication?\u003c/li\u003e\n \u003cli\u003eWhich part of the workshop was valuable for your learning and understanding of the topics discussed?\u003c/li\u003e\n \u003cli\u003eIs there anything we can do to improve the workshop?\u0026nbsp;\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003ePrompt questions (e.g. \u0026lsquo;Can you please tell us more?\u0026rsquo; \u0026lsquo;Can you please give us an example?\u0026rsquo; and \u0026lsquo;Do you all agree on this or is there anyone who thinks differently?\u0026rsquo;) were raised as needed. The focus groups lasted between 60 and 90 minutes, while the individual interview lasted 60 minutes. The interviews were transcribed verbatim. The researchers conducting the focus groups did not participate in the drama workshops.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData analysis\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData were analysed through a thematic analysis [15] . The analytical process is characterised by a dialectical pattern that moves from the whole to the parts, generating a \u0026lsquo;new whole\u0026rsquo; in the process. The analysis was conducted in three phases: preparatory, coding and reporting. First, the data were collected, transcribed and analysed in Swedish. The Swedish members of the research group started the preparatory phase by reading each interview text carefully to gain an understanding and sense of the whole text. We also identified meaning units consisting of text segments corresponding to the aim of the study and the subject matter. These units were then subjected to open coding (i.e., systematic grouping of the codes by the contents and labelling them). Thereafter, we critically examined the codes by posing questions to the text, such as \u0026lsquo;What does this mean?\u0026rsquo; and \u0026lsquo;How can I be sure of that?\u0026rsquo; Our intention was to identify the related meanings that corresponded to the aim of the study. The meanings were compared against each other and against the interviews, generating overall themes as conceptualised by the reporting phase Elo and Kyng\u0026auml;s [15]. The non-Swedish-speaking researchers participated by re-examining the emerging findings once they were translated into English, helping refine the analysis. To ensure credibility and establish trustworthiness, the authors used several strategies: we called our pre-understanding into question, used an audit trail and discussed our findings with peers at a scientific seminar. The findings were carefully reviewed by all the authors, and amendments were made prior to finalisation. Moreover, the authors exercised reflexivity by using a critical approach during research to establish trustworthiness.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical considerations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOral and written information about the study was provided, in which students were informed that they could withdraw at any time and that any decision not to participate would have no consequences. Written consent to participate in the study was obtained from all the participants before collecting data. The researcher who conducted the interviews (XX and XX) did not participate in the workshops. The project was approved by the Swedish Regional Board of Ethics in Gothenburg (D no: 371-16).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFindings\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 19 students participated in the focus group interviews, which included 18 female students and 1 male student. The data analysis revealed four themes (Table 1).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 1: An overview of the themes and exemplary quotes\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"680\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 245px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eThemes\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 435px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eExemplary quotes\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 245px;\"\u003e\n \u003cp\u003ePersonal and professional development\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 435px;\"\u003e\n \u003cp\u003e\u003cem\u003eHm you know, body language. There are other ways to demonstrate it as well. We could lean forward or lean back \u0026hellip; or look in a different direction. It seems that these actions contribute more to the learning process than just relying on understanding body language. (FG6)\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eIt feels like this should already be somewhat a common knowledge; that one should be mindful of not appearing closed off and maintaining eye contact. It\u0026rsquo;s like if someone hasn\u0026rsquo;t realised this in their profession as a nurse, they might have missed an important aspect of their work. (FG1)\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 245px;\"\u003e\n \u003cp\u003eGaining new insights -\u0026nbsp;the power of reflection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 435px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;Well, that\u0026rsquo;s actually what I find a bit difficult to put into words right now, but if I say that learning, for me, is more (pause, breathe), perhaps there is a guiding aspect to it. However, this drama pedagogy or workshop didn\u0026rsquo;t direct us. It didn\u0026rsquo;t tell us what was right. It didn\u0026rsquo;t explain or show the way, not at any point, not even in the end, and for me, that\u0026rsquo;s probably part of learning something. It somehow requires a guide, whether it\u0026rsquo;s a teacher, a mentor or a supervisor. Someone who says, \u0026lsquo;Here are the rules, and they apply\u0026rsquo;. It includes someone guiding me to some extent. I think that\u0026rsquo;s possibly why I haven\u0026rsquo;t thought of it as learning, but more as reflection, as I mentioned earlier. Nevertheless, it\u0026rsquo;s still valuable, of course, to reflect. (IP1)\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eFor me, personally, I don\u0026rsquo;t think that it was the drama itself, but it is\u0026hellip;when we analysed what we saw. (FG3)\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 245px;\"\u003e\n \u003cp\u003ePerceived challenges in engaging with drama\u0026nbsp;workshops\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 435px;\"\u003e\n \u003cp\u003e\u003cem\u003eI think discussions would be much better, and you can see and reflect oh\u0026hellip;it is this one\u0026hellip;[I] can approach this problem. Drama requires something of me that I can\u0026rsquo;t give. (FG5)\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eYou know, this is really a personal thing to stand there and play the scenario\u0026hellip; I really don\u0026rsquo;t think people should be forced. It doesn\u0026rsquo;t fit everybody\u0026hellip;my personality. I thoroughly believe it should be voluntary\u0026hellip; (FG6)\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 245px;\"\u003e\n \u003cp\u003eChallenges in creating an authentic environment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 435px;\"\u003e\n \u003cp\u003e\u003cem\u003eHere we are, four walls and a circle of chairs\u0026hellip;this is not a natural environment for us, we don\u0026rsquo;t work here, and this is not a place where we nurse patients. (FG2)\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eThis programme is really hard. I mean, you have to study so much and all the assignments. This and that, and all of a sudden you are doing drama. [It\u0026rsquo;s] seemingly meaningless. (FG1)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003ePersonal and professional development\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOne theme that emerged from the focus groups was the participants\u0026rsquo; increased awareness of the importance of teamwork and each member\u0026rsquo;s individual responsibility for the outcome of conflicts and other situations. The participants also described how they were reminded of the significance of body language in their communication with patients, their families and teammates. During the workshop, they had the opportunity to engage in self-reflection and gain valuable insights into different interpretations and analyses of conflicts. Through introspection and the consideration of perspectives, they developed a deeper understanding of the complexities involved. Some participants eagerly embraced the workshop, expressed their enthusiasm and actively participated. The workshops were found to be enjoyable and fun, facilitating a playful transition between seriousness and humour while addressing the dilemmas presented in the scenarios. The active involvement of the entire group enhanced the exploration of each scenario.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFrom the students\u0026rsquo; narratives, their previous working experiences evidently played an important role in shaping their comprehension of the conflicts they faced. However, these also presented a challenge, as they sometimes struggled to recognise their own perspectives, perceiving them as faults or shortcomings. The participants expressed that while they did not learn any clear conflict management strategies, they became aware of how to approach future conflicts.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eGaining new insights - the power of reflection\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe time for reflections and the subsequent discussions following each drama workshop were highly appreciated and perceived as more meaningful than the acting itself. Engaging in the activity served as a catalyst for reflection, wherein conflict situations and teamwork became embodied and understood in new ways. The participants\u0026rsquo; indicated that group discussions brought clarity to the conflicts and facilitated a deeper level of comprehension. Furthermore, they believed that dedicated time for reflection and discussion helped them gain self-insights and offered opportunities to revise one\u0026rsquo;s immediate understanding of actual scenarios.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHowever, the reflections were not viewed as skill-based learning, even though they were considered important. Instead, they provided a platform for discerning the differences in behaviours and approaches that emerged during the discussions. Furthermore, the participants\u0026rsquo; prior experiences and knowledge, acquired through years of clinical practice in different wards (as indicated above), made it challenging to reframe their thinking into the ICU. Consequently, they suggested that their behavioural patterns could not be influenced by only two drama workshops and considered the workshops as insufficient occasions for meaningful transformation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eChallenges in engaging with drama workshop\u003c/strong\u003e\u003cstrong\u003es\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWhile acknowledging the advantages of engaging in drama and recognising its potential to provide tools for reflection and conflict management, the students described a sense of pressure to perform and act, emphasising the need to adopt a role and be someone other than themselves. This was coupled with a perception that conflict situations were exaggerated, despite being rooted in cases derived from authentic clinical cases (first workshop) and their own observations (second workshop).\u003c/p\u003e\n\u003cp\u003eThe participants stressed that joining a drama workshop without prior acquaintances with fellow students triggered insecurity and vulnerability. This was evident during the first workshop session, when the group members were still unfamiliar with one another. Thus, their focus was divided between the workshop itself and their fears of being observed and not meeting performance expectations. This created challenges in terms of openly sharing reflections and maintaining their focus on the workshop\u0026rsquo;s content. What appeared to be specifically challenging for them was the fact that they sometimes had to play the role of \u0026lsquo;a bad nurse\u0026rsquo;. They expressed discomfort in acting out inappropriate behaviour, which conflicted with their desired professional identity. They felt the need to justify their actions during role play, which did not align with how they wished to be perceived in their profession. This meant the un-dignification of their professional self-esteem and, therefore, a shifting focus from learning and reflecting to \u003cem\u003eperforming\u0026nbsp;\u003c/em\u003ewhy the essence of drama education was lost.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eChallenges in creating an authentic environment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOne recurring theme that emerged from the data was the participants\u0026rsquo; desire for an authentic environment, specifically an ICU patient room. There were frequent discussions about feeling uncomfortable when conducting drama workshops in a classroom setting, which lacked the safety of and resemblance to an actual ICU. This discrepancy was identified as an obstacle to fully understanding the purpose of the workshops. The students mentioned the simulation centre as a more realistic environment with which they were familiar and a place they associated with a sense of clarity regarding certain tasks and expectations.\u003c/p\u003e\n\u003cp\u003eThe participants compared the drama workshops to other learning activities in the critical care programme, expressing that the workshops felt too abstract and required a greater need for theoretical understanding. Furthermore, some suggested that incorporating professional actors/actresses would be more beneficial, particularly if they portrayed patients or family members, while the students took on the role of nurses during the drama sessions. The participants believed that this arrangement could enhance the authenticity of the workshops and create a deeper sense of reality.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this study, we sought to explore post-graduate CCN students\u0026rsquo; experiences of a drama programme focused on communication, teamwork and conflict management in the ICU. Our findings revealed that drama workshops can have a positive impact on both professional and personal growth, facilitating students\u0026rsquo; skills in conflict management, teamwork and communication. However, they also presented challenges as students felt pressured to focus more on acting and performing rather than being present in the process of drama and reflection. Furthermore, the environment in which the workshops took place, a traditional classroom, posed a significant challenge in terms of creating a sense of safety and authenticity. This prevented participants from fully engaging and connecting with the content of the workshops.\u003c/p\u003e\u003cp\u003eTo the best of our knowledge, this is the first study examining post-graduate CCN students\u0026rsquo; experiences of a drama programme in the context of critical care education, as well as its contribution to the development of nurses\u0026rsquo; non-technical skills. Such skills consist of social (teamwork, leadership and communication), cognitive (situational awareness, decision-making, cognitive readiness and task management) and personal management (stress and fatigue management) skills necessary for safe and effective performance [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eOne aspect in which we believe the drama workshops made a significant contribution is conflict management. CCN students gained new insights into their responsibilities as team players and discovered new ways to approach conflicts and their possible interpretations. This finding is consistent with those of previous studies [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Arveklev-H\u0026ouml;glund, Wigert [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] demonstrated that drama has the potential to enhance non-technical skills for nursing students, particularly communication skills. Similarly, our findings confirm the result of Uzunoz and Demirhan [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] that drama in higher education has the potential to increase critical thinking and students\u0026rsquo; openness and ability to initiate divergent thinking.\u003c/p\u003e\u003cp\u003eWe also found that drama activities were a powerful tool in enhancing CCN students\u0026rsquo; learning through reflection. A concept analysis of reflection in nursing professional development [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] describes the essence of reflection with a four-fold pattern, thereby filling the gap between theory and practice, expanding the role of nursing and enhancing competency, and addressing nurses\u0026rsquo; educational and learning needs and responsibilities. Moreover, from a philosophical perspective, reflection is linked to the two overarching themes of \u0026lsquo;knowing\u0026rsquo; and \u0026lsquo;not knowing\u0026rsquo; [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. In other words, reflection involves learning from one\u0026rsquo;s experiences based on a process of internalising and processing emotions and reactions, which leads not only to formulating other strategies for the future but also to being aware of one\u0026rsquo;s lack of knowledge, i.e. being alert and curious in situations [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. This indicates a transformation of one\u0026rsquo;s perspective with a critical attitude and openness. When students acquire these qualities/skills, they are better equipped to deliver high-quality care for critically ill patients and their families.\u003c/p\u003e\u003cp\u003eOur findings showed that CCN students experienced some pressure and discomfort in meeting performance expectations, particularly when playing the role of a bad or unprofessional nurse. Speculating whether these feelings stemmed from shyness or were perceived as conflicting with their professional identity remains challenging. However, even individuals who are generally shy can benefit from engaging in drama because assuming a new role and envisioning themselves as someone else can facilitate personal growth [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Nevertheless, the resistance felt by the CCN students in our study was more likely associated with their perceptions of the professional image expected of a competent nurse. This is supported by statements from several participants who expressed a preference for being \u0026lsquo;themselves as a nurse\u0026rsquo; in the scenarios. Behaving unprofessionally and displaying inappropriate conduct are widely regarded as unacceptable by most nurses [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Thus, it is crucial for CCN students to acknowledge this fact, as such behaviour can have a harmful impact on staff, patients and the entire organisation [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eFurthermore, we observed that the CCN students were more used to participating in simulation workshops that emphasised clinical skills training. They lamented a lack of an \u0026lsquo;authentic environment\u0026rsquo; during the drama workshop and did not feel entirely safe. In simulation workshops, the creation of an authentic environment is highly significant. While drama has numerous benefits for nursing education in non-technical skills, simulation appears to be the optimal approach for teaching technical skills, such as vital signs assessment Jefferies, Glew [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Based on our findings, it is suggested that incorporating authentic environments into drama workshops for students could be advantageous.\u003c/p\u003e\u003cp\u003eFinally, our findings both confirm and contradict a previous study on learning through drama in a specialist post-graduate nursing programme in paediatric care by Arveklev-H\u0026ouml;glund, Wigert [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Their findings indicated two different perspectives among students: some preferred active participation in the drama workshops, while others preferred a more passive role by observing their peers in the scenarios. Furthermore, while the students in the study of Arveklev-H\u0026ouml;glund, Wigert [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] expressed that drama facilitated their learning and preparedness for their professional role, our study found conflicting views. In particular, while some CCN students in our study preferred passive rather than active participation, they still acknowledged the valuable knowledge gained from the drama workshop.\u003c/p\u003e\u003cp\u003e\u003cb\u003eStrengths and limitations\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThis study has several strengths. First, the focus groups were facilitated by two researchers independent of those responsible for conducting the drama workshops. This ensured that the CCN students felt comfortable sharing their experiences freely, without any potential bias or influence. Additionally, the students displayed a genuine interest in participating in the interviews, and their responses exhibited diverse perspectives. The decision to use focus groups not only deepened our understanding of the value of incorporating drama in critical care education but also emphasised the importance of tailoring a programme suited to the critical care curriculum, ensuring its meaningfulness for the CCN students.\u003c/p\u003e\u003cp\u003eOne limitation of focus groups is the potential risk of groupthink, which cannot be entirely ruled out in this study. The participants may have been influenced by the opinions of others, potentially hindering the full disclosure of individual perspectives. Although an individual interview was conducted as part of this study, it was not initially planned. Moreover, despite utilising an interview guide, there was the possibility of unintentionally influencing the discussion [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Nevertheless, we gained valuable insights into the CCN students\u0026rsquo; experiences of participating in drama workshops and their learning processes.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eDrama workshops have the potential to cultivate personal growth and enhance the development of professional competences among CCN students. By emphasising individual responsibilities in conflict management and achieving desired situational outcomes, students\u0026rsquo; awareness is increased. Reflections and discussions during the workshops enabled a deeper understanding of conflicts, leading to increased clarity and the emergence of valuable insights that facilitated transformative learning experiences. However, for drama education to be effective in the context of critical care, a clear connection must be established between the drama programme and the desired learning outcomes. In particular, learning objectives must be designed according to constructive alignment [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] to make workshops more meaningful for CCN students.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthor\u0026rsquo;s Note\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study is part of a larger collaborative international programme (Erasmus Plus) between University of Gothenburg, Sweden and Griffith University, Australia, entitled \u0026ldquo;Drama in Intensive and Acute Care, DIAC\u0026rdquo;.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Statement and Grant Numbers\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was conducted in accordance with the Helsinki Declaration. Written information was provided and informed consent was obtained from all subjects prior to data collection.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe study was approved by the Swedish Ethical Review Authority, (D no: 371-16).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSO was involved in conceptualizing the study design, methodology, developed the interview guide and collected data, analysed the data and wrote the main paper. SAH was involved in developing the interview guide, collected the data and wrote the main paper. FL was involved in conceptualizing the study design, methodology, and wrote the main paper. WCH was involved in conceptualizing the study design, methodology and wrote the main paper. MR was involved in conceptualizing the study design, methodology and wrote the main paper\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to acknowledge all the students who participated in the study and Professor Margret Lepp for her support.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclaration of Conflicting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.\u003c/li\u003e\n \u003cli\u003eConsent for publication; All the participants have given their written informed consent to publish the findings of the study. There are no personal details or identifiable information that could compromise anonymity in the manuscript.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eAvailability of Data and Materials; De-identified excerpts from the focus group transcripts are available from the corresponding author upon reasonable request. Full transcripts are not publicly available due to confidentiality agreements with participants.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eFunding Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eErasmus Plus funded exchange program for staff between University of Gothenburg and Griffith\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eUniversity but not this specific study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical Trial Number\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eN/A\u0026nbsp;\u003cbr\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eLakanmaa, R.-L., et al., \u003cem\u003eCompetence requirements in intensive and critical care nursing \u0026ndash; Still in need of definition? A Delphi study.\u003c/em\u003e Intensive \u0026amp; critical care nursing, 2012. \u003cstrong\u003e28\u003c/strong\u003e(6): p. 329-336.\u003c/li\u003e\n\u003cli\u003e\u0026Auml;\u0026auml;ri, R.-L., S. Tarja, and L.-K. Helena, \u003cem\u003eCompetence in intensive and critical care nursing: A literature review.\u003c/em\u003e Intensive \u0026amp; critical care nursing, 2008. \u003cstrong\u003e24\u003c/strong\u003e(2): p. 78-89.\u003c/li\u003e\n\u003cli\u003eGordon, M., D. Darbyshire, and P. Baker, \u003cem\u003eNon-technical skills training to enhance patient safety: a systematic review.\u003c/em\u003e Medical education, 2012. \u003cstrong\u003e46\u003c/strong\u003e(11): p. 1042-1054.\u003c/li\u003e\n\u003cli\u003eEpstein, R.M. and E.M. Hundert, \u003cem\u003eDefining and Assessing Professional Competence.\u003c/em\u003e Journal of the American Medical Association, 2002. \u003cstrong\u003e287\u003c/strong\u003e(2): p. 226-235.\u003c/li\u003e\n\u003cli\u003eBenner, P.E., \u003cem\u003eClinical wisdom and interventions in acute and critical care : a thinking-in-action approach\u003c/em\u003e. 2. ed, ed. P.E. Benner, P.L. Hooper-Kyriakidis, and D. Stannard. 2011: New York : Springer.\u003c/li\u003e\n\u003cli\u003eAzoulay, E., et al., \u003cem\u003ePrevalence and factors of intensive care unit conflicts: the conflicus study.\u003c/em\u003e American journal of respiratory and critical care medicine, 2009. \u003cstrong\u003e180\u003c/strong\u003e(9): p. 853.\u003c/li\u003e\n\u003cli\u003eRafferty, A.M., et al. \u003cem\u003eStrengthening health systems through nursing: Evidence from 14 European countries. World Health Organization. Regional Office for Europe. \u003c/em\u003e. Health Policy Series, , 2019.\u003c/li\u003e\n\u003cli\u003eArveklev-H\u0026ouml;glund, S., et al., \u003cem\u003eThe use and application of drama in nursing education \u0026mdash; An integrative review of the literature\u003c/em\u003e. 2015. p. e12-e17.\u003c/li\u003e\n\u003cli\u003eArvekle-H\u0026ouml;glund, S., et al., \u003cem\u003eNursing students experiences of learning about nursing through drama.\u003c/em\u003e Nurse Education In Practice, 2018. \u003cstrong\u003e28\u003c/strong\u003e(1): p. 60-65.\u003c/li\u003e\n\u003cli\u003eJefferies, D., et al., \u003cem\u003eThe educational benefits of drama in nursing education: A critical literature review.\u003c/em\u003e Nurse education today, 2021. \u003cstrong\u003e98\u003c/strong\u003e: p. 104669-104669.\u003c/li\u003e\n\u003cli\u003eArveklev-H\u0026ouml;glund, S., et al., \u003cem\u003eSpecialist nursing students\u0026apos; experiences of learning through drama in paediatric care.\u003c/em\u003e Nurse Education In Practice, 2020. \u003cstrong\u003e43\u003c/strong\u003e.\u003c/li\u003e\n\u003cli\u003eKrueger, R.A., \u003cem\u003eFocus groups : a practical guide for applied research\u003c/em\u003e. 5. [updated] ed, ed. M.A. Casey. 2015: Thousand Oaks, Calif. Sage Publications.\u003c/li\u003e\n\u003cli\u003eWibeck, V., \u003cem\u003eFokusgrupper : om fokuserade gruppintervjuer som unders\u0026ouml;kningsmetod in Eng (Focus groups interviews as a research method)\u003c/em\u003e. 2., uppdaterade och ut\u0026ouml;k. uppl. ed. 2010: Lund : Studentlitteratur.\u003c/li\u003e\n\u003cli\u003eTong, A., P. Sainsbury, and J. Craig, \u003cem\u003eConsolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups.\u003c/em\u003e International journal for quality in health care, 2007. \u003cstrong\u003e19\u003c/strong\u003e(6): p. 349-357.\u003c/li\u003e\n\u003cli\u003eElo, S. and H. Kyng\u0026auml;s, \u003cem\u003eThe qualitative content analysis process.\u003c/em\u003e Journal of Advanced Nursing, 2008. \u003cstrong\u003e62\u003c/strong\u003e(1): p. 107-115.\u003c/li\u003e\n\u003cli\u003eGundrosen, S., E. Sollig\u0026aring;rd, and P. Aadahl, \u003cem\u003eTeam competence among nurses in an intensive care unit: The feasibility of in situ simulation and assessing non-technical skills.\u003c/em\u003e Intensive \u0026amp; critical care nursing, 2014. \u003cstrong\u003e30\u003c/strong\u003e(6): p. 312-317.\u003c/li\u003e\n\u003cli\u003eUzunoz, F.S. and G. Demirhan, \u003cem\u003eThe effect of creative drama on critical thinking in preservice physical education teachers.\u003c/em\u003e Thinking skills and creativity, 2017. \u003cstrong\u003e24\u003c/strong\u003e: p. 164-174.\u003c/li\u003e\n\u003cli\u003eTashiro, J., et al., \u003cem\u003eConcept analysis of reflection in nursing professional development: Concept analysis reflection.\u003c/em\u003e Japan journal of nursing science, 2013. \u003cstrong\u003e10\u003c/strong\u003e(2): p. 170-179.\u003c/li\u003e\n\u003cli\u003eHeath, H., \u003cem\u003eReflection and patterns of knowing in nursing.\u003c/em\u003e Journal of advanced nursing, 1998. \u003cstrong\u003e27\u003c/strong\u003e(5): p. 1054-1059.\u003c/li\u003e\n\u003cli\u003eAshton-Hay, S., \u003cem\u003eDrama: Engaging all Learning Styles\u003c/em\u003e, in \u003cem\u003e9th International INGED (Turkish English Education Association) Conference\u003c/em\u003e. 2005.\u003c/li\u003e\n\u003cli\u003ePavithra, A., et al., \u003cem\u003eUnprofessional behaviours experienced by hospital staff: qualitative analysis of narrative comments in a longitudinal survey across seven hospitals in Australia.\u003c/em\u003e BMC health services research, 2022. \u003cstrong\u003e22\u003c/strong\u003e(1): p. 410-410.\u003c/li\u003e\n\u003cli\u003eBiggs, J.B., \u003cem\u003eTeaching for quality learning at university\u003c/em\u003e. Fifth edition ed, ed. C. Tang and G. Kennedy. 2022: Maidenhead : McGraw Hill, Open University Press.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Critical care, Drama, Education, Focus groups, Learning method, non-technical skills, communication, teamwork","lastPublishedDoi":"10.21203/rs.3.rs-7027754/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7027754/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eWorking as a nurse in intensive care units (ICUs) necessitates the possession of technical and non-technical skills in providing high-quality care to critically ill patients. However, current critical care curricula often do not offer training in such skills. To address this gap, drama workshops were developed in this study to improve non-technical skills in post-graduate critical care nursing education.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAim\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe aimed to understand critical care nursing students’ perceptions of the drama programme, which focused on communication, teamwork and conflict management in the ICU.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFocus groups and one individual interview with 19 participants recruited from a post-graduate (or master’s) critical care programme were conducted. Thematic qualitative analysis was used to analyse the data.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFindings\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFour themes were identified: \u003cem\u003ePersonal and professional development,\u003c/em\u003e \u003cem\u003eGaining new insights - the power of reflection,\u003c/em\u003e \u003cem\u003eChallenges in engaging with drama workshops, \u003c/em\u003eand \u003cem\u003eChallenges in creating an authentic environment. \u003c/em\u003eThe findings suggest an increased awareness of teamwork and individual responsibilities. However, engaging in drama workshops also involved challenges. In particular, the participants were concerned about meeting performance expectations, which introduced pressure and distress. Creating an authentic environment was emphasised as an essential factor for effective and meaningful drama workshops.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study emphasises the potential of drama workshops to foster ICU nurses’ personal growth and enhance their professional competences. It highlights the importance of a purposefully tailored drama programme/education and an authentic environment to create meaningful learning experiences in critical care education.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eImplications for Clinical Practice\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTeamwork in the ICU can benefit from drama-based learning programmes as it increases awareness regarding the significance of collaboration within the healthcare team. Moreover, it can help develop nurses’ non-technical skills, which are essential in caring for critically ill patients and initiating effective interprofessional interactions.\u003c/p\u003e","manuscriptTitle":"Conflict management and communications skills in the ICU: A qualitative study on forming junior critical care nurses with drama pedagogy","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-17 10:01:39","doi":"10.21203/rs.3.rs-7027754/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-11-23T12:50:47+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-20T11:40:26+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"181512767057309119032809280237459013426","date":"2025-10-28T05:49:44+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-06T20:11:50+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"4909078425632245912643735051021976426","date":"2025-09-16T13:51:36+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"123670965480518532660169771814660850093","date":"2025-07-31T14:03:42+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-07-14T22:43:36+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-08T05:52:19+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-07T11:40:29+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Nursing","date":"2025-07-07T11:37:33+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"fa8c0394-37a2-4977-8fc4-c3251f7ea898","owner":[],"postedDate":"July 17th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-03-09T16:03:01+00:00","versionOfRecord":{"articleIdentity":"rs-7027754","link":"https://doi.org/10.1186/s12912-026-04487-1","journal":{"identity":"bmc-nursing","isVorOnly":false,"title":"BMC Nursing"},"publishedOn":"2026-03-02 15:59:07","publishedOnDateReadable":"March 2nd, 2026"},"versionCreatedAt":"2025-07-17 10:01:39","video":"","vorDoi":"10.1186/s12912-026-04487-1","vorDoiUrl":"https://doi.org/10.1186/s12912-026-04487-1","workflowStages":[]},"version":"v1","identity":"rs-7027754","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7027754","identity":"rs-7027754","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}