Journal of Nursing Education

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EDUCATIONAL INNOVATIONS 

Using Role Play to Develop Cultural Competence

Ruth Shearer, MSN, RN; Ruth Davidhizar, DNS, RN, CS, FAAN

Abstract

ABSTRACT

Role play is a useful teaching strategy for nursing education. This strategy can simulate patient behaviors, as well as demonstrate nursing interventions that students must learn to be clinically competent. Role play is a dramatic technique that encourages participation to improvise behaviors that may be encountered in nurse-patient situations. Using this technique, participants may test behaviors and decisions in an experimental atmosphere without risk of negative effects in a relationship. Role play is useful in developing cultural competence because participants may experience diverse roles.

Cultural competence is the ability to care for patients in a culturally sensitive and appropriate manner. In role play, students may participate as culturally diverse patients or as nurses encountering patients from different cultures. Various teaching strategies facilitate successful use of role play in the classroom, including defining a time frame, selected roles, specific objectives, references, and grading criteria. Tb optimize learning, the importance of exploration and analysis must be emphasized. Many benefits and potential problems accompany use of role play.

Abstract

ABSTRACT

Role play is a useful teaching strategy for nursing education. This strategy can simulate patient behaviors, as well as demonstrate nursing interventions that students must learn to be clinically competent. Role play is a dramatic technique that encourages participation to improvise behaviors that may be encountered in nurse-patient situations. Using this technique, participants may test behaviors and decisions in an experimental atmosphere without risk of negative effects in a relationship. Role play is useful in developing cultural competence because participants may experience diverse roles.

Cultural competence is the ability to care for patients in a culturally sensitive and appropriate manner. In role play, students may participate as culturally diverse patients or as nurses encountering patients from different cultures. Various teaching strategies facilitate successful use of role play in the classroom, including defining a time frame, selected roles, specific objectives, references, and grading criteria. Tb optimize learning, the importance of exploration and analysis must be emphasized. Many benefits and potential problems accompany use of role play.

Role play is a strategy that has been used to teach cultural diversity awareness, including ethnic, social, racial, and religious differences (Tomasulo, 1999). This strategy provides the opportunity for students to simulate interactions between patients and nurses. The scenario and behaviors of the actors should be analyzed and discussed. Analysis provides an opportunity to express feelings, increase observational skills, provide rationale for possible behaviors, and critique nursing interventions (Lowenstein, 2001). Analysis also enables new behaviors to be suggested and explored before an actual interaction occurs.

Historically, role play was developed out of the desire to effect attitudinal changes during psychotherapy. Moreno (1946), the founder of psychodrama, required players to recite designated lines or to answer specific questions. This technique provided the foundation for the development of role play as an educational tool. In role play, players are encouraged to express thoughts and feelings spontaneously. Role play has been found to be more effective than lecture. In a study by DeNeve and Hepner (1997), students reported that use of role play was stimulating, increased their learning, and was more valuable, compared to the traditional lecture method.

Role play is an adaptable technique that can be used in various situations. It may address practice of skills and techniques or changes in understanding, feelings, and attitudes. When role play is used to practice skills and techniques, instructors design the role play with emphasis on acquisition of skills and overcoming problems. When role play is used to address changes in understanding, feelings, and attitudes, problem solving and relationships are emphasized. Instructors are responsible for guiding students and helping them cope with emotions and negative feelings that may be generated in the role play (Lowenstein, 2001).

Role Play to Teach Cultural Competence

Role play is useful in developing cultural competence because participants may experience diverse roles. Students may experience how individuals from cultures other than their own may react in specific settings. Students also may practice nursing interventions for responding to culturally diverse patients. Participating in a culturally diverse scenario will help students develop beginning skills and techniques in cultural competence, as well as change their understanding, feelings, and attitudes. The development of communication skills is essential to cultural competence.

According to Chrisman and Schultz (1997), respect toward others is vital for development of cultural competence. Respect must be developed in education because it is required in practice when nurses encounter differences in beliefs, rituals, speech, symbols, power status, gender, ethnicity, or sexual orientation. A respectful attitude values the core of humanity in other individuals. Although nurses do not need to approve of the differences, respect is essential if cultural competence is to be demonstrated in practice (Lenburg, 1995). According to Chrisman and Schuìtz (1997), two frequent types of cultural diversity training are valuing diversity and managing diversity.

Valuing diversity focuses on learning about oneself in relation to others who are different and the development of respect. Managing diversity is skill oriented and is more likely to include cultural information about religion or family practices of various ethnic groups. Managing diversity may include development of communication skills and conflict resolution skills and the ability to be creative in multicultural situations. When the role of the patient or nurse is assumed or observed in role play, students may value and manage diversity. Self-awareness, which contributes to cultural sensitivity and the development of interpersonal skills and knowledge, which are needed in the development of cultural competence, can be developed by the use of role play.

Finally, role play is a particularly useful teaching strategy in the development of cultural competence because the primary media is communication. Role play enables students to practice both verbal and nonverbal communication techniques used in addressing culturally diverse patients, as well as to experience what it may be like to attempt to communicate when cultural orientation differs between patient and nurse (Chauhan & Long, 2000).

Strategies for Successful Implementation of Role Play

Successful use of role play as a teaching technique does not "just happen." Rather, role play must be deliberately employed by instructors using specific strategies in a skillful manner. Use of specific preplanned strategies can provide the necessary structure for the achievement of learning objectives. Instructors' skills also may minimize problems and negative learning. Instructors can preplan by:

* Identifying objectives for the experience.

* Providing students with a time frame.

* Providing guidelines for role specifications.

* Monitoring the role play process.

* Relating role play to theoretical concepts.

* Delineating grading criteria.

* Indicating the role of the observers.

* Facilitating constructive analysis.

Identifying Objectives for the Experience

The first step in role play is identification of the learning objectives. Not only must the instructor have specific objectives and learning outcomes in mind, but these objectives should be explained to the students. Role play may be simple or elaborate depending on the learning objectives (Lowenstein, 2001). Learning objectives also may vary from simple to complex depending on the desired outcomes. For example, if a specific communication problem is being demonstrated, role play may be simple and can easily be provided to students immediately before the role play verbally or on a small piece of paper. On the other hand, a situation that involves complex cultural beliefs and conflicts may require students to complete more preplanning and a have broader knowledge base. With a complex situation, objectives may be included in written course materials.

Providing Students With a Time Frame

Adequate time frames must be based on the learning objectives. The time frame should include time for planning and executing the role play. Even if a role play is spontaneous and the instructor asks a student to role play a part on the spot, it is helpful to allow students time to "warm up" to the role. Other role plays are elaborate and require preparation time for details, such as investigation of the literature for relevant information; collection of props, including special attire for the players; preparation of learning handouts for the audience; and in some cases, preparation of a script to ensure specific points are communicated.

Regardless of the nature of the role play itself, it is important to have adequate time to plan and prepare students for the experience, and for discussion and analysis after the role play. Role plays may be as brief as 5 minutes but more commonly are 10 or 20 minutes in length (Lowenstein, 2001). van Ments (1983) identified three sections of role play (i.e., briefing, running, debriefing) and suggested that time spent on each part be divided equally, with emphasis on debriefing or analysis.

Providing Guidelines for Role Specifications

The amount of detail provided to students on the roles to be played varies with the objectives. In any case, the scenario and characters need to be described in enough detail to elicit responses that will meet learning objectives. In some situations, the instructor may provide the parameters of the role play, while the students provide the details based on a literature review. The instructor generally will want to encourage students to respond to interactions in the role play in a spontaneous and natural manner and, thus, experience the emotions and feelings of the characters.

Monitoring the Role Play Process

It is the instructor's responsibility to set the stage for learning to occur and to monitor the action. Setting the stage includes providing directions to the observers and players, indicating the time frame, and telling students when to begin. Monitoring may include ensuring that students role play within the allotted time and that observers can hear what is said, terminating the role play when the objectives have been met, or intervening if learning objectives are not being attained and the experience is becoming counterproductive.

Relating Role Play to Theoretical Concepts

When learning objectives include application of theoretical information by students in preplanning, the instructor may provide guidelines on the literature to be used, how it is to be referenced, and how much detail is needed. In one scenario, the assignment was to relate the ~. Giger-Davidhizar Model of Transcultural Nursing (Giger & Davidhizar, 1999) to a patient-nurse interaction. Therefore, the students were required to read and provide sources describing the GigerDavidhizar Model, which was implemented through use of a pamphlet dis- * tributed to the observers. When transcultural nursing concepts are role played and a model is used, students need adequate orientation to the various models available and may need help from the instructor to ensure the concepts of a model are adequately represented.

Delineating Grading Criteria

If the role play is a graded classroom assignment, students should be apprised of the grading criteria. Students who are observers may be asked to grade students who perform the role play. If this technique is used, it is important that the expectations of the students as graders are clear and that popularity is not the criteria on which players are graded.

Indicating the Role of the Observers

To ensure maximum learning for student observers, they must be briefed on their role and the format that will be used in analysis. In some cases, student observers may be provided with questions to answer related to specific behaviors they should look for in the interaction. On the other hand, the instructor should inform the observers that their role is to assess the interplay and analyze the dynamics that occur. It is the observers' duty to identify the systematic steps used to make judgments and decisions in the interaction. The instructor should explain each student's responsibility for active learning and participation in the discussion. Students may be asked to evaluate other students who present scenarios.

Facilitating Constructive Analysis

As facilitator, the instructor is responsible for channeling the discussion to meet the learning objectives. The instructor should avoid monopolizing the analysis and instead should ask students to explain how the learning objectives were met. Comments and observations from different students will help other students understand the variety of interpretations possible in one interpersonal situation. Discussion of a role play may be a way to develop students' critical thinking skills (Jenkins & Turick-Gibson, 1999) by encouraging them to creatively determine more effective nursing approaches and recognize actions that may be counterproductive to a situation involving culturally diverse patients (Hess & Gilgannon, 1985).

Benefits and Potential Problems

Benefits of using role play range from cost effectiveness and active learning to modeling expected performance levels and increasing self-confidence and assertiveness in participants (Kuipers & Clemens, 1998). Benefits related to development of cultural competence include the opportunity for students to experience diverse roles and develop skills in responding to culturally diverse patients. However, without adequate planning and adherence to specific learning objectives, role play may be a costly use of class time. When culturally diverse situations are role played, it is possible to reinforce stereotypes of ethnic and cultural groups. Debriefing after the role play can provide a setting to discuss the stereotypes and to reinforce the need to view each individual as unique.

Sample Role Play Scenario

The following is an example of how role play may be used in a clinical setting.

One student was dressed as a Vietnamese man wearing a long smock with a dirty string tied around each upper arm. Hia head was lowered, and he avoided eye contact. In one hand, he held a coin that he rubbed up and down on his opposite arm. Intermittently, he would atop the coin-rubbing procedure and place his fìngere and thumbs on both temples and slide them to the center of his forehead between his eyes. Then, the skin between his eyes would be pinched and twisted slightly. The smell of vapor rub permeated the room.

A second student was dressed in a white laboratory coat and portrayed a culturally incompetent nurse. The nurse was frustrated with the patient's lack of eye contact and crouched on her knees in an attempt to obtain eye contact. The nuree also frequently touched the patient and even pushed one side of his head in an attempt to gain eye contact. He pulled away out of fear that vital forces were leaving his body from the side she had not touched. When the patient inhaled from the container of aromatic oil he pulled from his pocket, the nurse and other patients in the room complained about the smell. The nurse jokingly commented about the strings on his arms. She noted bruises on his limbs and forehead and commented on the side that "he must be mentally ill."

A third student stood in the corner and wore a halo of tinsel around her head. She wore a sign around her neck that identified her as the "culturally competent angel." The angel interjected explanations regarding Vietnamese folk practices and cultural behaviors. She described why the nurse's behaviors were inappropriate.

At the end of the role play, the students presented their classmates with a handout summarizing Vietnamese cultural behaviors and folk practices. The angel provided further information relating the Giger-Davidhizar Model of Transcultural Nursing Assessment to Vietnamese culture. The observers were provided with an opportunity to ask questions and evaluate the role play.

Summary

Role play is a valuable teaching strategy for nursing education and particularly for helping students develop cultural competence. This article discussed role play as a teaching strategy and provided examples of how it can be used in the classroom to achieve learning objectives. Strategies for successful implementation were described. This participative learning technique has been very effective. Students consistently are enthusiastic in their classroom presentations and meet all the learning objectives. Role play adds variety and enhances learning in the classroom as students prepare for clinical practice.

References

  • Chauhan, G., & Long, A. (2000). Communication is the essence of nursing care: Breaking bad news. British Journal of Nursing, 9, 931-938.
  • Chrisman, N., & Schultz, P. (1997). Transforming health care through cultural competency training in cultural diversity in nursing: Issues, strategies and outcomes. Washington, DC: American Academy of Nursing.
  • DeNeve, VL, & Hepner, M. (1997). Role play simulations: The assessment of the active learning technique and comparisons with traditional lectures. Innovative Higher Education, 21, 231-246.
  • Giger, J., & Davidhizar, R. (1999). Transcultural nursing: Assessment and intervention. St. Louis: Mosby.
  • Hess, C., & Gilgannon, N. (1985, September). Gaming: A curriculum technique for elementary counselors (ERIC Document Reproduction Service No. 267322). Paper presented at the Annual Convention of the American Association of Counselors, New York.
  • Jenkins, P., & Turick-Gibson, T. (1999). An exercise in critical thinking using role playing. Nurse Educator, 24(6), 11-14.
  • Kuipera, J., & Clemens, D. (1998). Do I date? Using role play as a teaching strategy. Journal of Psychosocial Nursing and Mental Health Services, 36(7), 12-17.
  • Lenburg, C. (1995). Introduction and context to promoting cultural competency. Washington, DC: American Academy of Nursing.
  • Lowenetein, A. (2001). Role play. In A. Lowenstein & M. Bradshaw (Eds.), Role play and Fuszard's innovative teaching strategies in nursing (3rd ed., pp. 123-133) Gaithersburg, MD: Aspen.
  • Moreno, J.L. (1946). Psychodrama (Vol. 1). Boston: Beacon Press.
  • Tomasulo, D. (1999). Action methods of teaching cultural diversity awareness. In Issues of education at community colleges: Essays by fellows in the mid-career fellowship program at Princeton University 1998-1999. Princeton, NJ: Princeton University Press.
  • van Ments, J. (1983). The effective use of role play: A handbook for teachers and trainers. London: Kogan Press.

10.3928/0148-4834-20030601-10

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