The research team, led by Lütfiye Nur Uzun and Hümeyra Hançer Tok of the Department of Nursing at Sivas Cumhuriyet University’s Suşehri School of Health, recruited 80 fourth-year nursing students from a university in eastern Türkiye. Fourth-year students were a deliberate choice: by this stage of training they have accumulated enough real clinical experience to have genuine difficult patient encounters to draw upon, yet they remain at a formative point in their professional identity. The participants were randomly assigned to one of two parallel groups of 40 students each. One group received forgiveness education delivered through creative drama, an experiential technique rooted in applied theatre in which participants improvise, role-play, and embody perspectives other than their own. The other group received the same core content through case-based learning, in which written clinical scenarios are analyzed and discussed in a more traditional cognitive framework.

The intervention was compact by design. Both groups completed four educational sessions totaling 200 minutes, a format chosen to fit within the crowded final-year curriculum. What distinguished the two arms was not the quantity of instruction but the mode of engagement. In the creative drama group, students physically and emotionally inhabited scenarios involving difficult patient behavior, taking on the roles of patients, nurses, and bystanders, and exploring the motivations and inner states that drive hostile interactions on the ward. In the case-based group, students worked through comparable scenarios intellectually, dissecting causes, consequences, and coping strategies through guided discussion. The underlying hypothesis was that forgiveness, being fundamentally an emotional and relational process, might be better cultivated through embodied experience than through analysis alone.

To measure the outcome, the researchers used two validated psychometric instruments: the Forgiveness of Others Scale and the Self-Forgiveness Scale, administered before and after the intervention. The statistical analysis was appropriately rigorous for a randomized design, employing independent-samples t-tests, paired-samples t-tests, analysis of covariance, and the non-parametric Mann–Whitney U and Wilcoxon signed-rank tests where the data demanded them. Crucially, the team used ANCOVA to control for baseline differences in forgiveness scores, a step that strengthens causal inference by adjusting for whatever forgiveness tendencies students carried into the trial. The study was retrospectively registered on ClinicalTrials.gov under registration number NCT07670481, and ethical approval was granted by the Bolu Abant Izzet Baysal University Human Research Ethics Committee in Social Sciences, with the trial conducted in accordance with the Declaration of Helsinki.

The headline result is striking. Both educational approaches significantly increased students’ forgiveness of others, with p-values below 0.001, confirming that forgiveness is not a fixed personality trait but a trainable skill that responds to structured instruction. But when baseline scores were controlled for, the creative drama group pulled clearly ahead. Posttest forgiveness of others scores were significantly higher in the drama arm than in the case-based arm, with F(1, 77) = 12.899, p = 0.001, and a partial eta-squared of 0.143, a medium-to-large between-group effect. Within-group comparisons told an even more vivid story: the creative drama intervention produced a very large effect size of Cohen’s d = 1.42, while case-based learning produced a large effect of d = 1.00. In practical terms, students who had acted out the emotional architecture of a difficult encounter forgave more readily than students who had merely analyzed it.

The self-forgiveness results, however, were a sobering counterpoint. Neither the drama nor the case-based approach produced a statistically significant change in students’ Self-Forgiveness Scale scores. This asymmetry is theoretically meaningful. Forgiving others and forgiving oneself are psychologically distinct processes, and the researchers’ findings suggest that a 200-minute group intervention, however immersive, may not be sufficient to shift how students relate to their own perceived failures and shortcomings. Self-forgiveness often involves confronting guilt, shame, and self-criticism at a depth that classroom formats may not reach, and it may require longer timeframes, individualized support, or clinical supervision structures that sit outside the scope of a curriculum module.

Why would drama outperform case-based learning for forgiveness of others? The answer likely lies in the mechanics of experiential cognition. When a student plays an angry, frightened patient, she must generate that character’s inner world from the inside: the fear that curdles into aggression, the loss of control that expresses itself as contempt for caregivers. Perspective-taking of this embodied kind engages empathy circuits and emotional memory in ways that reading a case summary cannot. Forgiveness research across psychology has long emphasized that letting go of resentment requires genuinely grasping the offender’s humanity and circumstances. Creative drama operationalizes that insight directly, converting an abstract moral prescription into a lived, felt experience. Case-based learning, by contrast, keeps the learner at an analytical distance, which builds knowledge but may not transform emotional response.

The clinical implications extend well beyond a single Turkish nursing school. Burnout, compassion fatigue, and turnover among nurses are persistent global problems, and difficult patient interactions are among their most corrosive daily drivers. If unresolved anger toward patients accumulates, it degrades the therapeutic relationship, erodes job satisfaction, and can ultimately push skilled clinicians out of the profession. A brief, low-cost, evidence-based forgiveness module that measurably increases students’ capacity to release resentment offers nursing programs a practical preventive tool. The fact that the entire intervention fit into four sessions makes adoption feasible even in packed curricula, and the use of open-access published protocols and validated scales makes replication straightforward for research teams elsewhere.

There are, of course, limits to what one trial can establish. The sample was drawn from a single institution, all participants were fourth-year students at one university, and the outcomes were measured immediately after the intervention rather than at long-term follow-up, leaving open the question of whether the gains persist as students enter the workforce. The trial was also retrospectively registered, a methodological wrinkle that transparency-minded readers will note. Self-report scales, moreover, capture students’ own perceptions of their forgiveness, which may diverge from behavior in actual charged encounters. Future studies with longitudinal follow-up, behavioral outcome measures, and multi-site samples would considerably strengthen the evidence base.

Even with those caveats, the study adds a compelling data point to a growing movement in health professions education that treats emotional competence as a teachable clinical skill rather than an innate disposition. The image of nursing students rehearsing forgiveness by stepping into the role of the very patients who wound them is a vivid one, and the numbers behind it are hard to dismiss: a very large within-group effect, a significant advantage over an already-effective comparison method, and a clean randomized design. As health systems worldwide grapple with workforce attrition and the human costs of caregiving, the lesson from Sivas may be that some of the most important clinical training happens not at the bedside, but in the improvised, uncomfortable, and ultimately transformative act of playing someone else’s pain.

Subject of Research: Forgiveness education interventions for nursing students managing difficult patient encounters

Article Title: Creative drama and case-based learning for forgiveness education in difficult patient encounters among nursing students: a randomized controlled trial

Article References: Uzun, L. N., & Tok, H. H. (2026). Creative drama and case-based learning for forgiveness education in difficult patient encounters among nursing students: a randomized controlled trial. BMC Medical Education. https://doi.org/10.1186/s12909-026-10590-3

Image Credits: AI Generated

DOI: 10.1186/s12909-026-10590-3

Keywords: forgiveness, nursing education, creative drama, case-based learning, difficult patients, randomized controlled trial, nursing students, self-forgiveness, experiential learning, medical education, BMC Medical Education, Türkiye