Lessons Learned from Teaching Nursing Students about Equality, Equity, Human Rights, and Forced Migration through Roleplay in an Inclusive Classroom

Inclusive education, sustainable development, and core nursing values all share common goals of promoting diversity, equity, social justice, and inclusion. However, prevailing norms of exclusion may shape health systems and healthcare workers’ attitudes and threaten inclusive patient care. Ongoing global conflicts and violence resulting in growing patient diversity in terms of ethnicity and migration status have led to questions regarding healthcare systems’ preparedness for inclusive nursing. Diversity-rich classrooms and collaborative learning methods, like role play, are inclusive strategies that may be useful in nursing education. The purpose of this paper is to present lessons learned from incorporating role play about forced migration in inclusive nursing classrooms. Various diversity-rich nursing student groups participated in a two-hour role play on forced migration facilitated by youth volunteers from the Swedish Red Cross Society between 2017 and 2019. This study is based on the amplified analysis of qualitative data materials, in the form of notes and summarized feedbacks, obtained from evaluating the role play as a teaching-learning activity. Three themes were identified, specifically, knowledge exchange, existential reflections, and empathy evoked. Findings suggest that working collaboratively in an inclusive environment may improve nursing students’ understanding of the vulnerabilities created by forced migration and to be better prepared for promoting social justice for this group in health care settings.


Introduction
Inclusive education is based on respect and value for diversity, individual differences, varying academic abilities, and students' participation [1]. Inclusive education is designed to reduce social exclusion [2] and is therefore closely related to the core ideas of Agenda 2030 for sustainable development goals (SDGs), that is, to leave no one behind [3]. Historically, nursing ethics and values were long founded on many of the core concepts of what is today known as Agenda 2030 [3]. These include promoting inclusion and addressing global issues like poverty, justice, inequality, and care of disempowered and vulnerable populations [4,5]. To help all patients experience trust, hope, and meaning, nursing values and ethics aim to promote social justice, diversity, equity, and equality [6,7]. Inclusive nursing care is thus described as the acceptance of patients' diversity and the capacity of nurses to attend to the individual needs of their patients [8]. However, despite global acknowledgment Aim This paper aims to present observations from a roleplay designed to teach nursing students about equality, equity, human rights, and forced migration in an inclusive classroom.

Materials and Methods
This study is based on the retrospective secondary analysis of qualitative data gathered from evaluating a roleplay on forced migration as a teaching-learning activity every term, from spring term 2017 to spring term 2020. A retrospective analysis evaluates the implementation of an educational design to develop the didactic competence within the field of nursing by describing new approaches that have been roped into the education curricula [31,32]. The data material contains a sample of three text files in word document, in the form of (i) course evaluations, (ii) written notes, and (iii) a summary of feedback from participants with regards to content, delivery, possible tips to facilitators, etc., gathered over three years. These were combined and analyzed using amplified analysis, that is, the process of combining two or more existing qualitative primary data material for the purpose of comparing or enlarging the sample [33]. The method is a variation of other previously known methods for the merging and analysis of pre-existing qualitative data such as 'amplified sampling' [31], 'aggregated analysis' [34], and 'pooled case comparison' [35]. For this study, the data from every term were originally collected for course evaluation and content development. It is important to note that although the data is being used as research material for the first time, a summary of the findings from course evaluations are often provided as publicly accessible documents in line with regulations by the Swedish Higher Education Authority.
The inspiration to use these materials for research occurred post hoc following teachers' observations of interesting dimensions in the notes generated. One of the advantages of secondary analysis of data is that it often transcends the initial purpose for which the data was collected, and provides an opportunity to focus on new aspects of the data and to apply new theoretical perspectives [33]. Thus, although the notes and summaries were originally written for the purpose of course improvement, they always revealed interesting dimensions of students' learning every term. These dimensions were related to inclusive education, collaborative learning, and sustainable development, and were considered worthy of reporting beyond the course evaluation reports.

Setting and Participants
Participants in the role play consisted of second-term undergraduate nursing students enrolled in a mandatory two-week public health module at a Swedish university college. A total of about 656 students participated between spring term 2017 and spring term 2020. The student population is often diversity-rich in terms of age, gender, political ideologies, ethnicity, and migration history. Some of the students (or their family members, friends, etc.) have experienced violence, wars, conflicts, forced migration, and refugee status, to name just a few. The module, titled "Health, equality and human rights", is part of a second term 30 ECTS (European Credit Transfer and Accumulation System) course. Intended learning outcomes for the module include being able to explain public health goals, policy documents, fundamental human rights, ethics, and their applications in health contexts. The entire module is centered on equity, equality, and a rights-based approach to health with various global health agenda, especially the sustainable development goals, as a point of departure. One of the teaching-learning activities is an educational roleplay led by 3-4 volunteers from the youth wing of the Swedish Red Cross Society. This study is based on the qualitative materials generated through notes taken, course evaluations and termly summaries of evaluating role play on forced migration as a teaching-learning activity.

The Role Play: Context and Content
To elaborate on collaborative learning also means to integrate perspectives on humanities into classroom activities through artistic teaching methods [27,28]. This may involve emphasizing a broader understanding of the world including emotions of despair, hope, loss, and other experiences that often trigger questions about human existence [27,29]. The roleplay in this study is a contribution by a third sector (civil society) organization, in this case the Swedish Red Cross. The roleplay has been designed to improve understanding about forced migration and its consequences for victims, for example, threats to their human rights before, during, and post-flight. The Swedish Red Cross is a key stakeholder in refugee issues due to the organization's provision of diverse activities and support for asylum seekers and migrants. These include legal counseling, support, medical services, and integration-related projects etc. The roleplay on forced migration is therefore based on facts, information, and the experiences of real victims of forced migration (VOFMs). It has been developed using the principles of educational drama (see [28,29]) by the youth wing of the Swedish Red Cross Society in collaboration with relevant experts.
The roleplay is a two-hour activity comprising of introduction, roleplay, reflection, and summary. Each session is held with a maximum of 30 students. The first 15-20 min of the role play is an interactive introductory lecture by the youth wing of the Swedish Red Cross Society. The aim is to provide background information like vital statistics on violence due to wars and conflicts, people affected, numbers of displaced persons, and people on the move by gender, age, and countries of origin, among others. All information is from reliable stakeholder organizations [36][37][38] such as the United Nations High Commission for Refugees (UNHCR), the International Committee of the Red Cross, (ICRC), the International Federation of the Red Cross Red Crescent Movement (IFRC), and the Swedish Red Cross among others. Students are also informed about voluntary participation and the right to withdraw at any point.
Following this introduction, a description of the roleplay is presented. Participants are then assigned roles and they immediately get into character as individuals or family members. The roles include families and individuals fleeing violence due to conflict and war, their journey, experiences, and the situations they encounter pre-flight and during flight. Depending on their roles, participants must make decisions that would help them make it through and cross borders. Individuals and families are at risk of being discovered or families being split at borders, parents must make tough decisions (e.g., which child to send ahead), and so forth. The entire roleplay is text-based with short and concise specific instructions written in large text on laminated A-4 sized papers and made available for each role and scenario. Details about specific descriptions of various roles and scenarios in the role play can be found in the digital versions available online [39,40]. At the end of the roleplay, there is a wrap-up session to summarize the activity, and additional information (e.g., distribution and characteristics of receiver countries, etc.) are presented. After the roleplay, teachers and facilitators discuss this teaching-learning activity in terms of its delivery, impact, and likely areas for improvement. Participants also provide useful feedback which is later summarized as part of the module and whole course evaluation.

Analysis
As earlier stated, this study is based on the retrospective secondary analysis of qualitative data in the form of notes and summarized feedback generated over a three-year period from evaluating the roleplay on forced migration as a teaching-learning activity. The analysis was manually conducted in three steps using the thematic content analysis process inspired by Braun & Clark (2006), and commonly used in nursing research [41]: Step 1: Reading and re-reading the combined data material from all the terms. In this initial analysis, first author repeatedly read the dataset to get a comprehensive understanding and overview of the material.
Step 2: Identifying relevant dimensions of students' learning which were not included in the final evaluation report due to being beyond the scope of course evaluation; identifying aspects that may have already been reported in the course evaluation reports but which are relevant in terms of inclusive education and sustainable development. These were documented through comprehensive memos written by first author.
Step 3: By creating and sorting memos, first and second author reflected upon recurrent themes and connected them to inclusive education and sustainable development. Reflective discussions between the authors were used to interpret and synthesize ideas until consensus was reached about how to categorize the themes presented in the results.

Results
The analysis of the combined data materials resulted in three themes: knowledge exchange, existential reflections, and empathy evoked. These are presented below.

Knowledge Exchange
There appears to be knowledge exchange in three ways: via the volunteers from the youth wing of the Red Cross Society, those who have direct or indirect experiences of forced migration, and all who have some experience from working in healthcare or during practicum. The interactive introductory and wrap-up lectures by the facilitators as well as the collaborative nature of roleplay combined to produce knowledge exchange. Most of the information regarding the nature and extent of forced migration were new (often shocking) to many of the students. A typical example is that contrary to popular beliefs, Africa, and Asia (i.e., not Europe), host the highest numbers of refugees [36][37][38]. This is exemplified by the following excerpts from the notes and summarized feedback: "There is overwhelming admiration for the young facilitators from The Swedish Red Cross who volunteer to present this role play. There is a general curiosity regarding their sources of information, reasons for being involved in the Red Cross, and if they are working or studying, etc. . . . " " . . . students think statistics on forced migration are contradictory to media reports . . . students are asking for a reference list . . . Note: request for the links to current statistics on forced migration trends presented in the interactive sessions and upload on the learning platform for students" By sharing the story of their own journey and experiences, or those of people close to them, participants with direct or indirect experiences of forced migration succeeded in further validating the contents portrayed in the roleplay. Although students were informed about voluntary participation and the right to withdraw at any time, the roleplay seemed to stimulate a willingness among those with direct or indirect experiences of forced migration to tell their story: " . . . the possibility of experiencing discomfort due to recalling own journey during roleplay must be addressed...as from next term, reminders will be repeated at regular intervals about participants' right to withdraw at any time during the roleplay . . . " Analysis of the notes and summaries showed that students tended to make a connection between the experiences portrayed in the roleplay and post-flight experiences of people with precarious migration status (PMS), including people who illegally remain in the country after their asylum applications are turned down. The current restrictive nature of the healthcare provisions for PMS patients in Sweden, unclear national guidelines, and lack of clear routines within healthcare systems for PMS patients were all woven into the experiences from the roleplay. These were described as contributing to a continuum of suffering capable of increasing inequities and inequalities in health. Furthermore, analysis shows that participants' concerns about the plight of VOFMs, and associated disappointment regarding non-action by appropriate agencies, were all supported by quotes from various human rights and public health policy documents. This is conveyed in the following notes: " . . . roleplay seems to help students to connect the dots . . . for example, there are concrete references to human rights, rights-based approach to health, and sustainable development goals as vital points of departure to develop our communities and societies . . . " " . . . so, the plan is to retain the current structure of the module i.e., all lectures on inequalities in health, human rights and public health policy documents etc., must first be held before the roleplay . . . "

Existential Reflections
The roleplay means participants assumed identities as VOFMs and were immersed in the world into which they have been thrown. These prompted questions about human suffering (especially as parents and children), and the desperate choices made in the face of threats to life and security. This is exemplified in the following excerpts from notes and evaluation summaries: "There are existential concerns regarding human suffering . . . desperate and precarious situations to the extent that an overloaded inflatable boat over the Mediterranean Sea can represent the least dangerous alternative to safety and freedom . . . " New perspectives and way of viewing certain things were observed. For example, access to healthcare, safety, and social welfare in a country like Sweden was described as "privileges taken for granted". There was almost an underlying tone of guilt for enjoying these "privileges" while many human beings are suffering. A significant aspect in all the evaluation summaries was the call for nurses to use their identity as healthcare providers and as fellow human beings to alleviate the sufferings of the vulnerable. However, there were some moral, ethical, and professional dilemmas: " . . . The roleplay seems to elicit questions and discussions regarding ethics and how to find balance in their future professional roles as nurses. Plan for next term: the teaching learning-activity requiring students to read the chapter on ethics will be converted to an interactive lecture on ethics, the lecture must be held before the roleplay..."

Empathy Evoked
A general sense of gratitude and admiration for humanitarian organizations and workers in the fields for their empathy were seen in the notes and summaries. There was reinforced empathy for vulnerabilities created by forced migration, there was also support for healthcare provisions for PMS patients, and a shift in perspective generally embracing these provisions. The following are some examples of observations from the summarized feedback: "There is a general feeling that suggests that it is easy to judge people, their behaviors and choices, hence it has been meaningful to get a taste of other people's experiences through roleplay, . . . The many suggestions to retain this roleplay as a teaching-learning activity in the module can be interpreted as positive . . . " " . . . A majority feel that it is mere noise to talk about human rights and yet exclude human beings from accessing healthcare. Many believe that their newfound knowledge will deepen their compassion and empathy . . . and contribute to reducing inequalities . . . A follow-up survey a few years from now would be appropriate." Despite the above, there is little skepticism regarding public health intervention that defy moral and legal reason (e.g., provision of free healthcare to people who illegally remain in a country). The setting and atmosphere of the roleplay seem to promote empathy, not only for vulnerable populations but also for one another, despite their conflicting viewpoints regarding equitable healthcare for all patient categories. Hostilities towards VOFMs are ascribed to a lack of knowledge about forced migration which can be addressed by expanding the reach of the roleplay to schools, workplaces teachers, politicians, healthcare workers, employers, etc., to create awareness. The following excerpt portrays the general sense of a need to promote empathy by using role play to spread knowledge about forced migration: "There are concerns that the current subtle winds of nationalism and populism can gradually become catalysts for forced migration even in stable and safe countries. . . . There seems to be a general consensus about the need to promote empathy for VOFMs, this can be achieved by extending the roleplay to many people, no matter how highly placed they are . . . "

Discussion
This scholarly presentation is based on lessons learned from using roleplay on forced migration to teach second term nursing students about inequalities, equity, and human rights in an inclusive classroom. Lessons learned show the nature of knowledge exchange, existential concerns, and empathy among participants. Because the roleplay is based on reality, it provided an opportunity for students to learn about forced migration which is otherwise too far distant to many. The interactive nature provided participants the opportunity to feel like they had something to contribute to the learning process, a vital aspect of inclusive education [42][43][44]. Collaborating with other relevant stakeholders within the community has proven to be an important aspect of inclusive education that supports diversity and leads to transformation [45,46]. Moreover, involving guest teachers is known as an effective strategy for inclusive learning, especially when the topic and guest speakers can easily be identified with [47,48]. In this case, all the 3-4 facilitators were always undergraduate students or gainfully employed youths who are active volunteers in a humanitarian organization. It is likely that listening to these young volunteers teach a global topic of interest, like forced migration, leaves a vivid impact on the students. By being exposed to authentic data sources and the true realities of forced migration, students often become stunned at the statistics about violence and VOFMs. Contrary to popular belief that Europe is the highest receiver of refugees, reliable data shows that majority of the top 10 receiver countries are in Africa and Asia [36]. Forced migration has attracted much media attention and has ideologically and politically far-reaching consequences that are felt even in healthcare. An example is the extent of care legally available to PMS patients in Sweden which is considered insufficient (from a human rights perspective) and has largely been critiqued [49].
The new knowledge gained during the roleplay on forced migration seems to stimulate reflections on inequities and inequalities in health and the ability to connect these to specific real issues, for example, the restrictive healthcare provisions for PMS patients. Participants' collective call for equitable healthcare can be described as a sign of transformative learning for sustainability [50]. Although the healthcare provisions for PMS patients is not the primary focus of this study, it is important to note that there was still a minority in the class who did not report any shift in perspective. These chose to maintain their support for the restrictive healthcare provisions for PMS patients. Collaborative learning activities, like roleplay, are relevant for inclusive education because knowledge acquired prompts learners to examine their own social, cultural, political, and moral assumptions and to recognize that their individual perspectives may not necessarily be universal [20]. On the other hand, despite evidence of increased knowledge construction when teachers encourage diverse perspectives among students [51], collaborative learning may not always be transformative (i.e., not lead to a change in perspective) [50,52]. Yet this provides teachers the opportunity to introduce students to the challenges of health politics. The involvement of multiple stakeholders with several conflicts of interest, and a lack of a single solution to population health and sustainability-related problems [53], are major challenges in health politics. An inclusive and sustainable approach to tackling this challenge not only requires respect for conflicting opinions, but also helping learners to get a holistic view, to see the local manifestations of global challenges, and to understand the short-and long-term global implications of their individual choices [53].
Findings from this study show that students in an inclusive learning arrangement may gain new knowledge that upset their preconceived realities and stimulate existential questions in them [54]. Green (2012) suggests that teachers should be attentive to existential dimensions in learning [54]. In this study, students' existential reflections often revolved around the continuum of suffering faced by VOFMs. The reflections were from three distinct perspectives, that is, their assumed identities as VOFMs, themselves as human beings, and as future nurses. These perspectives and the contents of the existential reflections fit well into Sartre's existential concepts of "the other", self, human freedom/responsibility, choice, and anguish [55][56][57][58]. In their assumed identities as VOFMs, students immersed themselves in the situation and identity of "the Other", their fears and challenges. The burden of responsibility in the pursuit of freedom and the anguish felt by VOFMs following various choices are visible. Through the eyes of "the other" (i.e., VOFMs), access to healthcare, safety, and social welfare which are available to citizens and legal residents in Sweden were classified as "privileges taken for granted". This is in stark contrast to a continuum of suffering for VOFMs; for example, tough experiences pre-flight and during-flight, followed by subsequent discrimination and limited access to healthcare after arriving in Sweden.
The roleplay on forced migration evokes increased empathy for the plight of VOFMs and PMS patients in healthcare contexts. Empathy is a vital nursing value described as the ability to place oneself in another person's context, to understand or feel what they are experiencing. The outcome is often a range of responses including the desire to help [7,25,59,60]. The roleplay brings VOFMs' terms of reference to light, thus, there is a general understanding that nurses have an important role in alleviating suffering and helping PMS patients to experience meaning and social justice in all healthcare encounters. It can be deduced that working collaboratively in an inclusive environment may result in a shift in perspective and promote inclusive attitudes among most nursing students. The foregoing can foster better relations between classmates and prepare them for professional lives as nurses caring for patients (and working with colleagues) of diverse backgrounds.
Some methodological aspects of this study are worth mentioning. Not every student is interested in drama; it is therefore important to inform and explain the aim and structure of the roleplay before and during the process. Roleplay provides a safe learning environment that should protect the emotional well-being of learners while they assume different roles [22]. However, learning activities that introduce ideas that conflict with learner's views and preconceptions may cause them to experience strong emotions such as anxiety and confusion [22]. Although voluntary participation and freedom to withdraw at any time were emphasized, a few students chose to remain but reported that the roleplay made them recall personal experiences of forced migration. It may, therefore, be necessary to repeat the instructions regarding voluntary participation and right to withdraw as many times as possible during the process. Previous research shows that educators should never assume that diversity and respect for individual differences, promoted through inclusive education, will always be appreciated by all students [23]. Educators should, however, continue to actively organize learning activities that promote the desired outcomes [23] and encourage democratic norms like dialogue in a respectful atmosphere [50]. Finally, since this study was qualitative in nature, the findings and their interpretations are limited to the study population and are thus not generalizable. They do, however, provide useful knowledge that can serve as guidelines for what to expect when implementing teaching methods such as a roleplay on forced migration [32]. This may especially be true given the relatively large sample size and the diversity of the student population included.
Furthermore, inclusive education, collaborative learning, and sustainable development all advocate "leaving no one behind" and respect for everyone's opinions [50]. However, handling tricky instances when nursing students express controversial views that may conflict with fundamental nursing ethics and values is a difficult terrain. While such views may be considered an authentic expression of self, they pose professional and ethical dilemma for others and may, or may not, have adverse implications for inclusive nursing. It is also possible that there are students who have conflicting opinions but chose to give socially desirable answers. It is important that nursing students think in terms of sustainable development goals such as equality, equity, wellbeing, inclusion, etc. However, educators should be aware that learning that transforms individuals in the desired direction for sustainable development is often processual, interactional, long-term, and cumbersome [50].

Conclusions
While significant media attention and the political implication of forced migration are felt even in healthcare, inclusive education, including teaching-learning activities like the roleplay on forced migration, can prepare nursing students in many ways. Through such roleplay, students get unbiased and current information about forced migration. Also, important traits like empathy for VOFMs and the ability to embrace inclusive nursing can be enhanced by introducing nursing students, via roleplay, to the terms of reference for the respective affected patient groups. Moreover, the roleplay provides an opportunity to reflect on other core nursing values, like social justice and helping patients to find meaning in healthcare encounters. Although these are core aspects of nursing ethics and values, the need to stay true to them through regular reflections cannot be overemphasized. Our findings also show that roleplay can likely increase the ability to recognize and address threats to inclusive nursing, such as human rights violations and inequitable access to healthcare for VOFMs and PMS patients. These are important attributes that align well with sustainable development. The existential dimensions of learning and nursing care seen in this study underscores the need for soul care for nurses and the ones being cared for. In conclusion, the roleplay on forced migration is an important approach for teaching equity, equality, and human rights, and the vulnerabilities associated with forced migration.