A need exists for developing training interventions for nurses regarding conflict management and leadership to facilitate professional development. Therefore, we aimed to explore and describe the use of applied drama to support professional development with focus on nursing leadership and conflict management of nurses (practitioner, lecturer) in Indonesia.
A descriptive qualitative method was performed using four scenarios (forum play) with 19 participants (nurses) and was analysed by qualitative content analysis.
The data were divided into two parts: 1) A description of four scenarios and 2) Four themes - sharing different perspectives, developing self-reflection, understanding the role of emotions in the communication and managing sensitivity and developing empathy.
Nursing leadership and conflict management skills play a key role in developing professional development in nursing. Drama, using forum play as experiential learning, improve nurse's knowledge and skills in holding a leading role to ensure a high quality of care within a satisfied working environment.
Conflict management, Drama, Nursing leadership, Professional development
A need exists to developing training interventions for students in nursing education as well as for nurses regarding conflict management and leadership to improve professional development throughout the world. The competence to handle conflicts using nursing leadership cannot be learned solely by theoretical education. When learning about conflict management and nursing leadership, practical training and an experiential learning approach are central, in which personal conflict experiences can be processed and managed [1]. A study by Arveklev, et al. [2] showed that drama enables nursing students to learn about conflict and conflict management. Additionally, drama supports students to manage future conflicts.
Competence areas for nurses, such as (1) Legislation in nursing and safety planning, (2) Leadership and development in nursing, and (3) Education and supervision, have been deemed in international research to be weak areas that need to be highlighted and further developed internationally in current and future nursing education programs [3]. In a study of nursing students' self-reported competence and comprising 543 nursing students who had just completed their academic three-year nursing bachelor's programmes at 10 universities/university colleges, the lowest mean score differences were found for the competence areas 'value-based nursing care' and 'leadership in and development of nursing' [4]. Therefore, the present study was aimed to broaden the knowledge regarding nurses' experiences with conflict management, focusing on nursing leadership skills through forum play to support professional development in nursing.
Drama as a pedagogy can stimulate life-long learning skills that enhance the personal development and professional attitudes of students and healthcare professionals [2,5,6]. Drama is regarded as the pedagogy of experience and is related to experiential learning, which is 'a process whereby knowledge is created through the transformation of experience' [7].
A specific pedagogical form of applied theatre is forum theatre. In Sweden, the term forum play has been used and developed by Byréus [8] based on the Brazilian theatre director Augusto Boal's Theatre of the Oppressed that was inspired by Paolo Freire's Pedagogy of the Oppressed (1970). Boal developed a community theatre practice that has become a pedagogy, and his work is increasingly finding application in schools. One of Boal's most famous techniques is forum theatre. In a forum play, situations are drawn from the participants' own experiences and stories from real lives. The situations are improvised and illustrated to discuss conflicts. Forum play utilises an open-ended dramatized story to invite participants to change the process of a conflict, or explore and possibly reduce the level of a conflict through various alternative actions [9]. In recent studies from Sweden, forum play can be an innovative educational model that creates space for reflection and learning in health care practices and offers learning to behave ethically in abusive situations [10,11].
Conflict is a natural and unavoidable part of all human relationships. Several definitions of conflict exist, proposing that it can be constructive or destructive and involve action or no action [1]. Conflict is a process involving two or more people who perceive the opposition of another [12]. Effective handling of conflicts involves three levels: (1) The individual, (2) Team and (3) Organisational levels. Moreover, a conflict can be task-oriented or relation-based. A task-oriented conflict involves workflow efficiency and quality of care, such as equipment needs or compliance with policies that lack an emotional undertone. A relation-based conflict involves interpersonal dynamics such as personality frictions or differences in norms and values; examples are assigning blame to others or using disrespectful language [13]. Interprofessional conflicts can be individual, interpersonal or organisational:
• Individual: Stress and fatigue, perceptions of others' seemingly selfish motives, and judgment towards colleagues' competence.
• Interpersonal: Prior unresolved conflicts, dehumanisation, power differentials, or communication breakdown.
• Organisational: Navigation within complex organisational structures and noncompliance with group norms [13].
Leadership could be defined as an art of motivating a group of people to act towards achieving a common goal by capturing the essentials of being able to inspire others (followers). However, a difference exists between leaders (informal position) and managers (formal position). Managers are responsible for the unit's goal and resources i.e., the budget for staff and task fulfilment according to individual, group and organisation levels. Leaders, on the other hand, communicate an idea based on knowing the skills and capabilities of others (motivate followers) and is a change agent with or without a formal position. This is clearly described in leadership theories based on tasks and relationships due to management versus leadership. Other aspects are the behaviours of leaders and followers compared with organisational theory, providing a framework to understand complex organisations and helping to understand the management process [14]. Effective leadership and management in nursing require skills in three major areas:
• Technical skills such as clinical expertise and knowledge, for example, in nursing.
• Human skills to work with individuals in an effective leadership role, and
• Conceptual skills as understanding the complexities of the healthcare organisation [15].
Leadership does not occur randomly; it requires planning to influence and affect people by analysing the situation - for example, a conflict among staff (intrapersonal) - through behaviour and resources, such as task- and relation-oriented tasks, as well as conflict management [16]. Several different styles of leadership exist and include (1) Situational leadership, (2) Transactional leadership, and (3) Transformational leadership.
(1) Situational leadership concerns selling/directing the unit's task (unable and insecure follower with low competence). Due to the improvement in the confidence of the staff member, leader telling/coaching is performed according to the unit's task (low/middle competence), participating/supporting (capable but not confident follower; middle competence) and relation-based delegating (very capable and confident follower; high competence).
(2) Transactional leaders are those who guide and motivate their followers towards established goals by clarifying roles as well as task requirements. However, transformational leaders focus on visions as change agents; for example, followers help them to view old problems in new ways.
(3) Transformational leaders inspire staff members to exert extra effort and transcend their own self-interest to achieve team goals, producing performance beyond the transactional approach as visionary work [17].
Shared vision and strategy i.e., shared leadership are stressed to ensure the support of processes through a visible nursing leadership [18]. The present and available nursing leadership at the ward/unit level [19] encourages staff to improve the quality of care using kind but firm leadership [20]. Nursing leadership could be described as a role model within clinical nursing [21]. Therefore, shared vision and conflict management using drama could be a tool demonstrating experienced situations to learn and improve healthcare [2,5,6]. The above overview regarding nursing leadership and conflict management could be mixed to improve professional development among nurses. Additionally, competence cannot be learned solely on a theoretical level. Therefore, drama is a pedagogical tool that nurses can use to learn from experienced situations to improve healthcare [8].
We aimed to explore and describe the use of applied drama to support professional development with a focus on nursing leadership and conflict management for nurses (practitioners and lecturers) in Indonesia.
The Indonesian National Nurses Association, INNA [22], comprises approximately 500,000 nurses who account for approximately 60% of the total healthcare providers in Indonesia. Nursing education in Indonesia has four levels: diploma nursing (vocational, three years), bachelor's in nursing (professional, four years), and master's in nursing (advanced, two years) such as medical surgical nursing, paediatric nursing, maternity nursing, community nursing, psychiatric nursing, and nursing management. The final level is a four-year doctoral programme in nursing offered at a few universities (five) in Indonesia.
A nursing competency-based curriculum has been developed and applied nationally, and nursing leadership is a nursing competency hampered by the capability in managing conflict among staff or clients within healthcare [23]. Nursing students are not accustomed to engaging in open communication and self-reflection to manage their conflicts professionally [24]. Therefore, drama, as a new pedagogical form using forum play in nursing education, could be a tool to implement student-centred learning in Indonesia.
This study utilised a qualitative approach closely related to ethnography [25]. The researchers were very interested in using a survey to observe and share the experiences of the participants through dialogue and observation. Field notes were recorded by two of the authors (KR, WW), while the third author (ML) led the drama workshop.
An international coordinator at the university sent out an inquiry, and nurses, both practitioners and lecturers involved with nursing education, showed interest in participating in the scheduled workshop (applied drama) in November 2017. The first 20 individuals who responded to the invitation were included according to the inclusion criteria; nurses, practitioners and lecturers involved with nursing education at one university in Indonesia who can understand and speak English. Ethical clearance was approved by the university board (KE/FK/1032/EC/2017), guidelines for human and social research were considered throughout the study [26]. All participants (n = 19, one drop out due to sick leave) were informed (written by the inquiry; verbally at the workshop) about the aim and study procedures, and confidentiality was assured.
The participants (n = 19) comprised four male and 15 female nurses at the bachelor's, master's and doctoral levels aged between 23 and 49 years. The participants came from different professional areas: lecturers (n = 6), registered nurses (n = 5), master's students (n = 5), senior lecturers (n = 5) and first-line managers (n = 3).
The data gathered comprised observations and field notes related to the workshop designed for the participants in two steps:
• Listening to a verbal presentation of the theory of conflict management and nursing leadership, and
• Active participation in a drama workshop with specific key moments for data collection: The forum play phase and group reflection phase.
The presentation included the ABC theory of conflict is described as a triadic construct consisting of three concepts: (A) Attitudes and assumptions, (B) Behaviour, and (C) Contradiction. All three features should be considered to manage a conflict constructively. Conflict management requires an evaluation of the participants' perception of the conflict and is influenced by gender, educational background, and professional socialisation [27]. These five conflict management styles have been used as a framework when exploring conflict in several health care studies [1,27,28].
In a conflict situation, two dimensions are considered: The intention to satisfy our own needs (assertive) and the needs of others (cooperative). Kilmann and Thomas [29] constructed a conceptualisation of five conflict management styles:
• "Competing (lion): High in assertiveness and low in cooperativeness.
• Accommodating (camel): Low in assertiveness and high in cooperativeness.
• Avoiding (turtle): Low in both assertiveness and cooperativeness.
• Compromising (fox): Intermediate on both dimensions.
• Collaborating (owl): High in both dimensions". [p. 24]
The Situational Leadership Model was described by Hersey and Blanchard and Hersey, et al. [15,16] as task and relationship behaviours. The authors argued that it is insufficient to use one single style of leadership; effective leadership varies regarding task relevance as well as relationship relevance related to those involved. Therefore, nurse leaders need to adapt their leadership style to the ability and willingness (maturity level) of their followers (staff, patients, relatives and students) and the nursing task that needs to be performed. The situational leadership model is described as follows:
• Selling/Directing (unable and insecure follower; low competence)
• Telling/Coaching (unable but confident follower; low/middling competence)
• Participating/Supporting (capable but not confident follower; middling competence)
• Delegating (very capable and confident follower; high competence)
Nursing leadership could be described as situational based regarding the followers (task-relations based). According to the characteristics of the nursing situation, nurse leaders (personality included) are change agents using leadership skills to improve the quality of healthcare by guiding people/groups/teams to accomplish common goals. Nursing leadership concerns influencing beliefs, opinions, or behaviours by inspiring others in the team to improve health and well-being. Teamwork brings together a range of people with different knowledge levels, skills, and experiences to meet the patients' needs by best practice [14].
The drama workshop was built on earlier research in the field of drama and conflict management [1] and was conducted in an open-spaced classroom at the university, lasted for three hours and was facilitated by ML (an authorised drama teacher, RN and researcher). The drama workshop comprises warm-up exercises, improvisations and scenarios illustrating conflict situations that could explore the escalation and de-escalation of conflicts through forum play. The forum play resulted in four scenarios built on the participants' experiences. The scenarios were as follows:
1. Proposing a new project that was rejected
2. Implementation of a care delivery system without an assessment of it
3. One-way implementation of new routines, resulting in re-assignments
4. Hidden reasons (bullying) for workplace shifting
The outcome of the forum play and these four scenarios were used as data and were analysed based on the following parameters: Who were the involved parties in the conflict, was the conflict symmetric or asymmetric, was the conflict task-oriented or relation-based, and what are the interventions and outcomes. Because the four scenarios were developed by the participants and not the authors, they are presented in the results. Additionally, they were used as mentioned as data for analyses.
Examples of situations, such as positive and negative aspects of conflict management focusing on nursing leadership, were explored with the participants after the scenarios were performed, and clarifications and further elaborations were made due to the scenarios. The scenarios lasted for approximately 20 minutes and were performed by a group of participants (4-5 nurses). Two of the authors (KR, WW) took notes regarding the content of the scenarios, and the third author (ML) moderated the scenarios as well as the group reflections after the scenarious were performed.
The four scenarios from the forum play were analysed in three parts as follows:
• First, each scenario was described using the following parts: symmetric or asymmetric conflict
• The conflict was related to individual, interpersonal or organisational matters
• The interventions were inspired by situational leadership, transactional leadership, or transformational leadership.
The field notes from the group reflection were analysed using manifest qualitative content analysis [30,31] to interpret the meaning from the content of the data to address trustworthiness [32] with examples drawn from the area of the nurses' experiences with conflict management, focusing on nursing leadership skills through forum play. Second, all the written notes regarding participants' reflections from the whole drama workshop were analysed as follows (Table 1): 1. The notes were read and re-read to obtain an understanding of and familiarity with the text; 2. Meaning units (words, sentences or paragraphs) corresponding to the content areas were selected using an inductive approach concerning (a) Feelings and (b) Power; 3. Each meaning unit was condensed into a description of its content and was labelled with one of 22 codes; 4. Subcategories were identified and grouped according to the codes; and 5. Four themes were identified - sharing different perspectives, developing self-reflection, understanding the role of emotions in the communication and managing sensitivity and developing empathy.
Table 1: Description of the four forum theatre performances. View Table 1
This research obtained approval from The Medical and Health Research Ethics Committee of the Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada. Moreover, this study followed ethical guidelines for human and social research throughout the study and did not focus on negative effects on the participants [26]. Content analysis illustrated the use of several concepts related to the research procedures to achieve trustworthiness: credibility, dependability and transferability [32]. The qualitative research design relied on trustworthiness, transparency, verification, and reflexivity and was "information-driven", which can be helpful when developing insightful and artful interpretations within professional development in nursing [33]. In summary, respect for the individual nurse was a main concern during the study. All the nurses were informed about voluntary participation and their right to withdraw at any time and that their answers would be kept confidential. The results were described in themes without identifications, and respect for the participants' integrity and autonomy was thereby shown [26].
The findings were connected to specific key moments in the workshop: (1) The four scenarios of the forum play, and (2) The group reflection and lesson learned from the participants at the end of the workshop. The four scenarios were as follows:
• Scenario 1: Proposing a new project idea that was rejected
• Scenario 2: Implementation of a care delivery system without an assessment of it
• Scenario 3: One-way implementation of new routines, resulting in re-assignments
• Scenario 4: Hidden reasons (bullying) for workplace shifting
Four themes emerged, each emphasizing what the participants saw as key learning areas from their drama experience; sharing different perspectives, developing self-reflection, understanding the role of emotions in the communication and managing sensitivity and developing empathy.
In this theme, sharing different perspectives regarding conflict management and nursing leadership was described due to professional development. The nurses highlighted that they learned from other participants' experience in facing different angles of the problem or conflict when using scenarios (applied drama). Moreover, they stressed the use of leadership theories as tools when conflict situations occur. One participant described it as "There are many ways to solve the conflict… you need to see it from the other side or the other perspective". The nurses also highlighted that solving the problem or disparity depends on the nursing situation that has arisen and why they, as nurses, need leadership theory. Conflict management was highlighted as being balancing due to a thin line, with a limited ability to assume the entire burden alone, and pointing out the significance of sharing the problem or different perspectives of nursing with others to seek support and/or help. This theme was described by the following quote, "When we have conflict with patient, sometimes it is difficult to solve it because it could be related to a policy/regulation or a third party".
The theme of developing self-reflection is described as self-monitoring and uses a mirror to reflect and try to solve one's own problem regarding conflict management. The use of self-reflection when difficult nursing situations occur was highlighted as a tool due to professional development. The nurses described that the scenarios of the forum theatre taught them self-reflection, a new way of learning by personal experiences. However, the nurses stressed the future need to extend theoretical knowledge regarding leadership theory as well as conflict management to become a "lion" (focus on I) and then to be able to switch and become a "turtle" (focus on avoidable behaviour) due to the nursing situation. This theme was expressed as, "Besides being a good leader, we also have to be a good follower", highlighting the need to know themselves by being mirrored back. The nurses argued that the types of leadership need to be chosen, when to become a lion and when to become a turtle. One participant described her learning from self-reflection as, "From the activities that we performed during the scenarios of the forum theatre, it is like a self-reflection. I learned a lot about the leadership styles…Self-reflection is important to solve conflicts. The solution to a conflict might come from inside of ourselves".
This theme relates to understanding the role of emotions in the communication regarding experiences with conflict management focusing on nursing leadership skills through forum play. The participants stressed that when a nurse leader develops leadership skills, he or she gains better understanding regarding the nursing situation at the workplace. They argued that transformation needs to be planned to learn and understand the role of emotions within the communication. The nurses experienced safety without anxiety when transformation was applied/started. One participant described it as, "Each interaction might become a conflict. To solve this conflict, we need methods that can be used based on the situation".
The nurses highlighted that the scenarios of the forum theatre were well structured for conducting conflict management using nursing leadership as a managerial tool. Moreover, the nurses also stressed the significant of interpersonal as well as intrapersonal collaboration to understand the complexity of communication due to the role of emotions.
In this theme, statements related to managing sensitivity and developing empathy were described. The participants highlighted that the scenarios of the forum theatre increased their empathy by forcing them to be involved and interact with each other, which was a different way of learning than they were used to. Additionally, they stressed that dealing with conflicts was about being culturally sensitive as a nurse. Moreover, the nurses argued that healthcare professionals working in clinical settings have several people to collaborate with and that managing sensitivity and developing empathy are crucial aspects. If and/or when problems or disparities occur, the nurses often believe that they must solve the problem by themselves, which causes anxiety at the workplace. They described this situation as, "The same effects occur when we as nurses have a problem with a patient; sometimes, we look into what we have done to the patient, whether it is right or wrong and why the education program of the patient needs to be improved to prevent conflicts with patients". By assessing the scenarios of the forum theatre, the nurses highlighted that they improved their skills on how to manage conflicts and argued that nurse leaders should not only manage other persons (staff, patients, relatives) but also manage themselves to be an effective and qualified nurse leader.
The present study explored and described the use of applied drama to support professional development with a focus on nursing leadership and conflict management for nurses (practitioners and lecturers) in Indonesia.
The results described professional development as sharing different perspectives to develop nurses' self-reflection to understand the role of emotions in communication viewed as managing sensitivity and empathy in nursing. According to Benner's [33] novice-expert and Bloom's taxonomy [34,35], nurses develop knowledge and skills (knowing how, knowing what) due to the extension of clinical experiences (characterisation, understanding) using a theoretical approach (nursing leadership, conflict management). Benner [33] describes professional development by these stages; novice (newly educated nurse), advanced beginner (limited experience), competent (2-3 years of experiences, long term goals), proficient (long-term experiences, holistic understanding) and expert (solid experiences, intuitive grasp of clinical situations). The prerequisites to becoming an expert in nursing are grounded by experience from different professional areas, such as different healthcare settings. Nurses (at the bachelor's, master's, and doctoral levels) in this study used sharing, developing, understanding and managing problem-based nursing situations. According to nursing leadership and conflict management, this theoretical point of view improves professional development facilitated with drama workshop. The conclusion is improved learning using mixed experiences of different conflicting nursing situations analysed with theory in nursing, leadership and conflict management. These learning processes were developed by the drama workshop using participants with different knowledge levels and nursing experiences who were presented scenarios that reflected the experiences of the group of participants [1,8,36].
Moreover, nurses' professional development according to sharing (cognitive), developing (cognitive), understanding (affective) and managing problem-based nursing situations (psychomotor) could be related to Bloom's [34,35] three domains: Cognitive (knowledge-based), affective (emotion-based) and psychomotor (action-based) perspectives. Cognitive knowledge, as evidence-based nursing, is described as comprehension, application, analysis, synthesis and evaluation domains. Moreover, affective knowledge, as emotional-based nursing, is described with receiving, responding, valuing, organizing and characterizing affective domains. Action-based knowledge (psychomotor domain) describes perception, set, guided response, mechanism, complex response, adaptation and origination.
Participation in the applied drama workshop influenced and supported nurses' professional development using the above three knowledge perspectives (cognitive, affective, and psychomotor). In the drama-in-education movement, initially centred in the UK, participants were collaborative learners and were engaged in learning by shifting role perspectives in a fictional or fictionalised context. Drama relates to conflict and pedagogy and can be described as "the clashes and conflicts or personality, of values, of attitudes, of emotions, of interests both internal and environmental, of status and power, of philosophy and ideology, of ethics and morals". (1, p. 8)
A central element of all drama is tension. Keywords and concepts are shared between drama and conflict resolution, such as the words protagonist and antagonist, which are used to label the main parties in a conflict. Drama provides the participants with three distinct perspectives of experiences, and this type of learning could be viewed as an art [36] related to conflicts:
1. The opportunity to explore the viewpoint and attitude of the protagonist,
2. To deconstruct the enemy image by playing the antagonist,
3. To view the conflict situation more objectively by playing the third parties, such as bystanders and other participants in the conflict [1].
Moreover, sharing different experiences regarding conflict situation in nursing requires theoretical tools to develop professional development. Although professional development is described by cognitive (sharing perspective), affective (understanding emotions) and psychomotor domains (managing conflict management), we also add theory in nursing leadership (transformational, transactive and situational leadership) and conflict management (ABC model) to support and improve professional development. According to the theoretical perspective, task- and relation-oriented approaches in nursing leadership [16] as well as conflict management (perceive the opposition of another) are used towards the specific situation (maturity of the team/staff) to develop nurses' professional growth. the behaviour of nursing leaders and their followers (staff, patients, and relatives) provides a framework to understand complex healthcare settings such as conflicting nursing situations. Task- and relation-oriented perspectives are two sides of a conflict situation that need to be visible to manage. Sometimes, nurses need to be transactive (goal oriented) and sometimes transformative (change agent) depending on the tasks and relationship at the workplace, as well as, staff members' professional growth [17]. By using theory (leadership, conflict management, novice-expert, Blooms taxonomy), nurses obtained tools to improve the quality of healthcare by knowing how and what that to do in complex nursing situations with emotion involved due to human reactions and art as experiences [36,37].
The study intends to contribute to a deeper insight in supporting professional development for nurses. Using forum play is a new form of pedagogy for the participants and could be described as the use of forum play is a new form of pedagogy for the participants it could be described as unfamiliar. Therefore, it is significant to use an authorized drama teacher to facilitate safe and comfortable learning areas for forthcoming participants. Another limitation is that the drama workshop was only offered once at one University in Indonesia, and several workshops at different universities could broaden the data collection by various experiences. However, a convenient small sample is related to qualitative methods used as described by Polit and Beck [32]. The sample was heterogenic, although the participants were interested in and motivated to learn this new learning method. Moreover, the relationship of the authors and participants showed no interdependence, the workshop was well described (content of lecturing), and the data were analysed using a well-known scientific method (qualitative content analysis). Therefore, the methods can be described as systematic qualitative research that relies on trustworthiness, transparency, verification, and reflexivity, helpful to develop insightful and artful interpretations within professional development in nursing [32].
The use of applied drama in combination with theory such as leadership and conflict management play a key role in developing professional development in nursing. Combining conflict management and leadership with drama as the pedagogy of experience is related to the experiential learning exploration practice in nursing. Using nurses' experiences together with a pedagogical approach such as forum play facilitates professional growth, including the improvement of knowledge and skills.
The authors declared no potential conflicts of interest with respect to the research, authorship or publication of this article.
We thank the teachers and managers at Universitas Gadjah Mada who organised the data collection, especially Yanuar Eri and Pertiwi AP, as well as the teachers at Universitas Gadjah Mada who participated in the workshop. We also thank the Linnaeus-Palme Partnership, Higher Education Council, funded by Swedish International Development Cooperation Agency, Sida.
All the authors contributed to the design, interpreted the data, and critically drafted and revised the article for important intellectual content. All the authors read and agreed to the final version of the article.
The authors received no financial support for the research, authorship, and/or publication of this article.