In order to compare two teaching methods for adult learners, a therapeutic behavior questionnaire was administered to 36 nurses. Three groups of 12 Ss each were studied in a control group design. The first took a communication class using videotaped role plays; the second, the controls, took a pharmacology class; the third, a post-test only cell, took a class similar to the first but without the role play experience. Findings included (a) Ss taking communication scored significantly higher in therapeutic behaviors than controls; (b) Ss having videotaped role plays scored significantly higher in therapeutic behaviors than those not having such experience; (c) results were supported by higher overall class means and more favorable student evaluations in the videotape role play group. Conclusion: videotaped role plays show promise for effecting therapeutic behavior change in nurses from a wide variety of backgrounds. THE TRAINING of medical personnel in interpersonal skills such as interviewing and communication appears to be accompanying "a recent trend" ' towards humanism in the health professions. Hays and Larson 2 list 25 therapeutic and 19 nontherapeutic interpersonal techniques for nurses, but how to teach these to highly diverse groups of adults remains an ever present challenge. Criticism of lecture/discussion methods as "too hypothetical" 3 and increasing emphasis on observable behavior change,4 have given rise to a variety of videotape recorded (VTR) "dry run" techniques including microteaching, microcounseling and simulation and role playing.5'"
Objections to these methods such as awareness of the camera, embarrassment, anxiety, over-consciousness of acting, artificiality of the situation, and defensiveness upon critique, have been found not only surmountable but outweighed by learners' improved communication skills.3'10"13
Preferences are varied regarding the use of replay. Ramey," using role plays of 12-55 minutes, found "immediate playback less desirable because of player fatigue"; and Meadow and Hewitt3 found it advantageous to wait as many as four to ten days. However, the use of "micro" formats to take advantage of videotape's instant replay feature has been successful in permitting student performance to ". . .be critiqued like football plays, analyzed and improved." 1S "The training format is 'micro' in that each skill is defined in operational terms; each training session concentrates on only one skill at a time, model tapes are only 5-8 minutes long, and the practice interviews are only 35 minutes long. - . .The practice interview is immediately replayed and the interviewer's use of that skill is discussed."1 Performance and reinforcement are thus immediately linked.
Perlberg, ef al 16 observed that VTR "provides accurate feedback. . .(leading to a process of) . - . self-confrontation. . . (where, according to Festinger's theory of cognitive dissonance). . the discrepancy between his intentions and the outcomes , .(leads to) . .changes in self-perception, behavior or both."
Rosenburg, Fried & Rabinowitz17 see replay as "...an opportunity for generalization of facilitative attitudes towards. .. patients. .. .Much of the felt impact and importance of the course. . . is due to the twin features of group interaction, videotape recording and replay."
"As McLuhan has observed, the media is the message. . .videotapes might well provide the strongest message." 18 Minehan 19 reasons that "according to the McLuhan construct. - .television is a cool medium demanding a high level of participation. . .and involvement" on the part of the viewer, and that "nursing is a cool message. . .(requiring). . . in-depth personal involvement. . . .Therefore, television is more sympathetic to the message of nursing than is any medium now available."
Those involved in continuing education, where there is perhaps even more emphasis on individual differences and observable behavior change, could well pose the question of applicability of these concepts to their students. Would, for instance, a group of nurses enrolled in a continuing education program, if given the opportunity to use videotaped role plays in an interpersonal communication class perceive themselves as significantly more willing to communicate about feelings with patients and staff and to allow them more participation in decisions than those who had had no such role play experience?
A pilot study was designed to determine the effects of two methods of teaching verbal and nonverbal therapeutic communication skills. It was hypothesized that videotaped role plays would have a significant effect on perceived therapeutic behaviors of nurses in a communication class compared to others taking a similar class without such role play experience.
According to Ruesch,2" communication includes " . .all those processes by which people influence one another." This then covers all behavior, conscious or unconscious, verbal or nonverbal, and thus constituted the definition of communication for these classes.
Instead of using volunteer or paid "patients," "disgruntled staff members" or "evaluators" as in some of the mentioned inquiries, the learners themselves took all roles in the various simulations. This multifaceted role playing gave them the opportunity to experience more fully the varied aspects of human interaction and thus develop more empathie modes of communication with patients and staff. Experience in these classes has shown, for example, that once learners had felt what it was like to be judged, threatened, blamed, or probed by a nurse, they were less likely to engage in these behaviors themselves.
The inquiry was conducted on the South Peninsula of the San Francisco Bay Area. Ss were female RNs, LVNs, and advanced student nurses who were typical of adult learners in that they represented a wide range of individual differences in age, background, experience, interests, abilities, and cognitive styles. AH were attending classes on their own time to maintain, update, or upgrade their skills.
The two communication classes were offered through a community college continuing education program where a multisensory or "mediated," autotutorial, modular nursing program had been instituted. Both were taught by an RN with special training in communication and used the same syllabus, references, and written examinations. Selected as controls were nurses enrolled in a pharmacology class offered through an adult education program and taught by an RN from a hospital intensive care unit
One of the communication classes was taught mostly by nondirective group processes while the other, the VTR group, incorporated in addition a number of the features mentioned in the foregoing inquiries: VTR, 3-8 minute simulations or role plays, instant replay, selfconfrontation, and group critique and interaction.
After a brief introductory discussion, role plays were designed to demonstrate therapeutic communication skills such as verbal and nonverbal listening techniques, open-ended questioning, congruent sending of feeling, and avoidance of discrepant messages and blocking responses. Ss chose real or hypothetical problem interactions such as listening to a patient anticipating a mastectomy or confronting a conflict situation with a staff member. They made one or two practice tapes which were privately reviewed with the instructor using a checklist of skills as a guide for preparation, final evaluation, and grading. Ss then prepared final tapes which were presented to the group for discussion and critique.
All three groups were self-selected groups at hand. They were studied without randomization but matched on pre-test scores in a control group design which included a third post-test only nonVTR group. Gp. 1 (12 Ss) took the communication course using videotaped role plays, Gp. 2 (12 Ss), the controls, took pharmacology, and Gp. 3 (12 Ss) had the communication class without videotaped role play experience. Ss in groups one and two took the pre-test upon class entry and the post-test approximately 20 class hours later. Ss in the communication classes took the post- test in the last regularly scheduled class period immediately following identical written final examinations.
Incomplete or incorrectly done questionnaires were eliminated as were pre-tests of Ss who did not complete posttests. Finally, in order to achieve statistical homogeneity, four questionnaires were randomly eliminated from Gp. 3,
The test instrument was a teacherdeveloped questionnaire on perceived therapeutic and nontherapeutic communication behavior on the part of the nurse (see Figure 1).
RESULTS AND DISCUSSION
Though originally intended as a teaching aid for reinforcing theoretical concepts, the questionnaire yielded data of sufficient interest to prompt a statistical evaluation. Pearson r for test-retest reliability, using scores of controls, was 0.85 (p < .01). Split halves coefficient of correlation, using KR No. 20 corrected for length with the Spearman-Brown formula, was 0,64 (p < -01).21
Inasmuch as these were not concurrent classes and there was no randomization between VTR and control groups, it was essential to establish their equivalence. As seen in Table I1 Student's i based on pre-test means showed no significant difference between the two initial groups. This equivalence also helped to discount instrumentation as a possible invalidating factor as well as tendencies of extreme scores to regress toward the mean.
FIGURE 1. BEHAVIOR QUIZ
By paralleling pre- and post- test means of the VTR and control groups (Table II), the possible score-raising effects of testing and the interaction of testing and treatment were evaluated. If the questionnaire were instrumental in teaching therapeutic behaviors in the VTR group, it certainly did not appear to be so for Ss taking pharmacology whose scores were actually lower on post-tests than on pre-tests (Table II). Inasmuch as post-test means of the VTR group were higher than on the pre-test and also higher than pre-or post-test scores of controls, and since, in addition, scores of the post-test only nonVTR group were higher than the pre-test means of controls, the possibility of a main effect from pretesting, rather than from the videotaped role plays, appeared weak. Lower post-test standard deviations pointed towards more homogeneity of performance on post-tests than on pre-tests, the relatively high variation from the mean probably stemming from the diversity commonly found in groups of adult learners.
Not surprisingly, Table III reveals that Ss taking communication scored significantly higher in perceived therapeutic behaviors than those taking pharmacology. More interesting, however, is the fact that posttest scores of the VTR group were significantly higher for perceived therapeutic behaviors than those of the nonVTR group, thereby providing encouragement for a main effect of the videotaped role play experience on perceived therapeutic behavior change.
Although performance in the VTR group could also have been due in part to the more directive approach used in that class, such structuring appears inherent to the use of videotaped role plays as a teaching method. VTR appears to be an effective technique in positively altering the therapeutic communication skills of nurses from a wide variety of backgrounds.
It is quite likely that others will have found different approaches more suited to their own particular needs and styles. Logue, Zenner, & G oh ma n " found, for example, that videotape role plays of job interviews had no significant effect on behavior change compared to programmed learning and comparison Ss. Although their results came from working with hospitalized psychiatric patients, "...selfconfrontation which is intrinsic in the playing back of the therapeutic encounter is quite anxiety producing and may contribute to a temporary regression in terms of efficiency of behavior," an observation probably generalizable to many segments of the "normal" population.
VTR AND CONTROL GROUP EQUIVALENCE
MEANS, DIFFEREMCES1ANDSTANDARD DEVIATIONS
EFFECT OF VIDEOTAPE ROLE PLAYS
On the other hand, Beyers ef a/ to report that "students like being able to correct and tape over their mistakes. . .this technique. .. rapidly increases students' ability to evaluate and improve their communication skills. . . .Simulated patient-interviews on videotape were successfully used for analysis by students prior to their clinical experiences." It is of note that this approach was used in conjunction with a "mediated," autotutorial, modular nursing program. Highly significant behavior changes have also been obtained using microcounseling techniques to teach selected communication skills.11,18
The actual use of VTR may be secondary to the way it is handled with the learner, for self-confrontation can be just as valuable for reinforcing strengths as it is for pointing out weaknesses. In either case, perhaps the power of the medium lies in the reliability of the feedback, for students often remark, "I knew what you were saying, but when I see it, it's real!" In light of the successes of others who have used videotaped role plays, the results of this inquiry appear sufficiently striking to merit further validation by studies using randomized groups, larger samples, and concurrent classes. Most importantly, it would be interesting to determine the effects of videotaped role plays on actual on-the-job behavior rather than limiting evaluation to perceived behavior or observation of end-product videotapes.
Findings of this inquiry were supported by more favorable comments on student evaluations of the class and instructor, and by higher class means in the VTR group (3.3) than in the nonVTR group (2.8). Another encouraging element was the atmosphere of conesiveness and mutual support in the VTR group, where each participant was able to see something of herself on videotape that she liked. During the final debriefing session, a student in her sixties remarked to the group, "I may not have as many years left as you, but I can still change!"
The generous assistance of Louis Peselnick, and the support of Barbara and James Brusstar, are most gratefully acknowledged.
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VTR AND CONTROL GROUP EQUIVALENCE
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EFFECT OF VIDEOTAPE ROLE PLAYS