The research, conducted at Hakkari University during the 2025–2026 academic year, involved 76 nursing students divided into an experimental group of 38 third-year students and a control group of 38 fourth-year students. The experimental group received a four-session role play–based SUD education program, with each session lasting 45 to 60 minutes in the nursing skills laboratory. Students rotated through three roles—patient, nurse, and observer—portraying individuals with various SUD histories, practicing active listening and motivational interviewing techniques, and providing structured peer feedback.

Researchers measured outcomes using the Toronto Empathy Questionnaire (TEQ), the Communication Skills Inventory (CSI), and the Attitudes Toward Mental Illness Scale—Substance Related Subscale (ATMI-SRS). Linear mixed models with restricted maximum likelihood estimation served as the primary analysis, supported by ANCOVA and mixed ANOVA, with a Bonferroni-adjusted significance level of α = 0.017.

The results were striking. The experimental group showed a 57% reduction in stigmatizing attitudes, falling from a mean of 13.34 to 5.74 on the ATMI-SRS, while the control group managed only a 15% reduction, from 13.21 to 11.21. The time × group interaction coefficient was β = −5.61 (p < 0.001, d = 1.62). Empathy scores in the experimental group surged from 32.84 to 50.45 on the TEQ (β = 11.92, p < 0.001, d = 1.74), and communication skills climbed from 114.79 to 140.39 on the CSI (β = 20.06, p < 0.001, d = 1.67).

Notably, the intervention effect on stigma reduction was larger among students with higher baseline stigmatizing attitudes. Conditional effects analysis revealed that the model-estimated posttest difference between groups grew from −4.27 points at the 25th percentile of baseline stigma to −6.81 points at the 75th percentile, suggesting that role play may be especially powerful for students who enter training with the strongest biases.

The findings converge across multiple analytical approaches. A supplementary two-way mixed ANOVA confirmed significant time × group interactions for all three outcomes, and a robustness check using binomial generalized estimating equations (GEE) on the dichotomous ATMI-SRS items yielded an odds ratio of 0.32 (95% CI 0.20–0.50), indicating lower odds of endorsing stigma items over time in the experimental group relative to controls.

However, the authors caution that the quasi-experimental design carries substantial limitations. The experimental and control groups consisted of different academic-year cohorts—third-year versus fourth-year students—meaning that academic year was completely confounded with intervention group. The control group also demonstrated considerably higher baseline empathy (49.00 vs. 32.84, d = 2.20), raising the possibility of regression-to-the-mean effects inflating the experimental group’s gains. No blinding procedures were employed, and the same individuals who delivered the intervention also assessed outcomes.

The observed effect sizes (d = 1.62–1.74) substantially exceed the typical range of d = 0.30 to 0.80 reported in nursing education interventions, prompting the authors to call for replication using randomized controlled designs with blinded assessment before drawing firm causal conclusions. The study was also conducted at a single university with 38 students per group, limiting generalizability.

Despite these constraints, the convergence of findings across linear mixed models, ANCOVA, mixed ANOVA, conditional effects analysis, and binomial GEE provides preliminary evidence that structured role play may represent a promising experiential educational approach for addressing stigma, empathy, and self-reported communication skills in SUD-related nursing education. The authors recommend multi-site randomized controlled trials with larger samples, longitudinal follow-up, and investigation of whether improvements translate into observable clinical practice and better patient outcomes.

Substance use disorder remains one of the most stigmatized health conditions encountered in clinical settings, and the attitudes that healthcare trainees carry into practice are often formed long before they meet their first patient. Prior research has documented that nursing students, like other health-professions students, may absorb stereotypical beliefs about people who use drugs from broader societal and media narratives, and that these beliefs can persist even as students advance through their education. Because nurses represent the largest segment of the healthcare workforce and typically spend the most direct time with patients, unaddressed stigma among nursing graduates has practical consequences: it can shape how patients are approached, how pain and withdrawal symptoms are interpreted, and whether individuals with SUD feel safe enough to disclose substance use and accept referral to treatment.

The theoretical rationale for using role play in this context draws on established principles of experiential learning. Rather than receiving information passively, students in role play–based programs must inhabit a perspective, respond in real time to an interaction partner, and then reflect on that experience during structured debriefing. This cycle of enactment and reflection is thought to engage affective processing in ways that lectures on addiction cannot, potentially loosening automatic associations that underlie stigmatizing responses. The four-session structure used in the Hakkari study—rotating students through patient, nurse, and observer roles—follows this logic. Playing the patient role in particular is intended to give students a visceral sense of how judgment, dismissiveness, or moralizing language feels from the receiving end, while the observer role allows them to notice communication patterns in peers that they may not recognize in themselves.

The choice of outcome measures in the study reflects the multidimensional nature of the problem. The Toronto Empathy Questionnaire captures an affective-cognitive trait that has repeatedly been linked in the broader literature to reduced negative beliefs about mental illness, and prior work among medical and dental students has suggested that targeted training, including psychiatry coursework, is associated with higher empathy. The Communication Skills Inventory addresses the applied dimension, since even well-intentioned clinicians can struggle with the practical mechanics of engaging a patient who may be ambivalent about change, guarded about disclosure, or experiencing withdrawal. The Attitudes Toward Mental Illness Scale—Substance Related Subscale isolates the stigma component specific to substance-related conditions rather than mental illness generally, which matters because stigma toward SUD tends to be more severe than stigma toward many other psychiatric diagnoses and is often framed in moral rather than medical terms.

The statistical approach deserves some explanation for readers less familiar with longitudinal designs. Linear mixed models allow repeated measurements from the same person to be analyzed while accounting for the correlation among those measurements, and they handle the pretest–posttest structure of the study without requiring complete data from every participant. The Bonferroni adjustment, setting the significance threshold at α = 0.017 across three primary outcomes, is a conservative correction that reduces the risk of false-positive findings when multiple hypotheses are tested simultaneously. The convergence of this primary analysis with ANCOVA, mixed ANOVA, and the binomial generalized estimating equations robustness check strengthens confidence that the observed patterns are not artifacts of a single modeling choice, even though it cannot overcome the design limitations inherent in non-randomized allocation.

The finding that students with higher baseline stigma showed larger reductions is particularly noteworthy from an educational standpoint. Interventions often produce ceiling effects among participants who already hold favorable attitudes, leaving the students most in need of change relatively untouched. If role play genuinely reaches students with the strongest initial biases, as the conditional effects analysis suggests, then embedding such methods early in nursing curricula could target the population where stigma reduction efforts matter most. This pattern is consistent with the idea that experiential perspective-taking works by directly challenging entrenched assumptions rather than simply reinforcing attitudes students already hold.

At the same time, the magnitude of the reported effects warrants careful interpretation. Effect sizes above 1.6 standard deviations are rare in educational research, and the confounding of academic year with intervention status means that differences in coursework exposure, clinical experience, and maturity between third- and fourth-year students could contribute to the observed gaps. The substantially higher baseline empathy in the control group also complicates interpretation, because groups that start at different points may drift toward different endpoints for reasons unrelated to the intervention. These are precisely the kinds of threats to validity that randomized designs with concurrent cohorts and blinded outcome assessment are designed to eliminate, which is why the authors frame their results as preliminary rather than definitive.

The broader context supports continued investigation. Systematic reviews of stigma-reduction training in health professions have emphasized that many existing programs are brief, theoretical, and rarely evaluated with rigorous comparative designs or long-term follow-up, leaving open the question of whether attitude changes persist once students enter actual clinical environments. Simulation and community-informed approaches targeting opioid use disorder have shown similar promise in helping students recognize and challenge their own biases, suggesting that role play sits within a family of experiential methods that may share common mechanisms. Whether the gains observed in a skills laboratory translate into observable behavior at the bedside—measured, for example, through standardized patient encounters, clinical instructor ratings, or patient-reported experiences of care—remains the critical next question.

For nursing programs considering curricular change, the study offers a concrete and relatively low-cost template: a small number of structured sessions, clear role assignments, practice with specific techniques such as active listening and motivational interviewing, and peer feedback, all deliverable within existing laboratory facilities. As multi-site randomized trials accumulate, the field will be better positioned to determine whether role play–based education should become a standard component of pre-licensure preparation for addiction care, and whether the empathy, communication, and attitude improvements it appears to produce endure across the transition from classroom to professional practice.

Subject of Research: Nursing Education Research

Article Title: The effect of role play-based education on nursing students’ stigmatizing attitudes, empathy levels, and communication skills toward the care of individuals with substance use disorder

Article References: Ataman Bor, N., Berşe, S., Akçoban, S., & Avcı, E. (2026). The effect of role play-based education on nursing students’ stigmatizing attitudes, empathy levels, and communication skills toward the care of individuals with substance use disorder. Frontiers in Public Health, 14, Article 1941630. https://doi.org/10.3389/fpubh.2026.1941630

Image Credits: AI Generated

DOI: 10.3389/fpubh.2026.1941630

Keywords: nursing education, substance use disorder, stigma, empathy, communication skills, role play, simulation, quasi-experimental study, Türkiye, Frontiers in Public Health, effect, role