In response to a need for improved quality and safety of health care delivery in the United States, patient-centered care (PCC) is strongly endorsed by the Institute of Medicine (IOM, 2010), the American Association of Colleges of Nursing (2008), and the American Nurses Association (Olson & Stokes, 2016). PCC is reflected in the recognition of the patient as a full partner in care, which is based on respect for each patient's values, preferences, and needs (Quality and Safety Education for Nurses, 2017). Furthermore, PCC relies on health professionals' adeptness at working with a growing diverse population, including providing culturally sensitive care (Fioravanti et al., 2018). Nurses play a vital role in providing PCC across all health care levels and settings, and the IOM (2010) called for improvements in nursing education to ensure student learning outcomes reflect competencies in PCC skills and delivery. Quality and Safety Education for Nurses (2017) offers specific PCC nursing education competencies focused on knowledge, skills, and attitudes. The purpose of this educational innovation was to improve students' understanding of PCC through role-play simulation.
The increasing use of simulation is one improvement in nursing education endorsed by numerous health care organizations, including the IOM (2010), the National League for Nursing (NLN, 2015), and the Agency for Healthcare Research and Quality (Cook, 2013). Ranging from the use of manikins and standardized patients (SPs) to role-play, simulation provides realistic scenarios with diverse perspectives, creating guided, interactive, and transformational learning experiences (Gaba, 2004; NLN, 2015). Simulation can serve to teach and measure student competencies, bridging a gap between education and practice (Fioravanti et al., 2018).
Evidence supports simulation's effectiveness as a tool for health care profession students (Aebersold & Tschannen, 2013; Cant & Cooper, 2017; Foronda, Liu, & Bauman, 2013; Kim, Park, & Shin, 2016). In particular, simulation using SPs has been found to be effective in teaching PCC skills congruent with therapeutic communication techniques, cultural sensitivity, and self-awareness of biases using trained individuals portraying patients in realistic situations, which provides an opportunity for enhanced learning through human interaction and feedback (Fioravanti et al., 2018; Kaplonyi et al., 2017; Lewis et al., 2017).
Role-play is considered a low-fidelity SP simulation described as an “active process whereby nurses simulate a situation,” which has the benefit of applying and improving communication skills (Gropelli, 2010, p. 104). Role-play type simulations offer consistency and reality to scenarios that initiate “the expectation of rapport and communication skills” (McCaughey & Traynor, 2010, p. 827). Furthermore, role-play provides opportunities for development of critical thinking and contextual learning (Tagliareni & Forneris, 2016). Previous literature supported the use of role-play in nursing education to teach PCC (Alfes, 2015; Wheeler & McNelis, 2014). Alfes (2015) demonstrated that knowledge on therapeutic interaction, skills, and attitudes toward psychiatric patients improved with the use of role-play equally to that of using SPs. Additionally, students reported improved confidence in interacting with patients during home visits after performing a home visit role-play simulation (Wheeler & McNelis, 2014).
This article describes the development, implementation, and evaluation of a faculty-led role-play simulation to teach PCC knowledge and skills in a large group setting to prelicensure students in a second-degree, accelerated nursing program. The process reflects the NLN Jeffries Simulation Theory, including the planning and incorporation of debriefing strategies post-role-play simulation (Jeffries, Rodgers, & Adamson, 2015), as well as the learning goals based on Bloom's Taxonomy (Armstrong, 2010).
Students in their first semester of an accelerated prelicensure nursing program and enrolled in their initial courses (e.g., fundamentals of nursing, pathophysiology, pharmacology, and adult health clinical) also took a 1-hour course focused on the six principles of PCC, which included culture, spirituality, gender, communication strategies, learning preferences, and patient teaching strategies. Approximately 140 students were enrolled in this course, and development of this educational innovation reflected implementation in a large classroom setting due to space and time limitations.
Three learning objectives guided development of the role-play simulation. Students were to (a) identify key PCC cultural and spiritual factors that affect nursing care and impact patient outcomes, (b) assess basic therapeutic interviewing and communication skills, and (c) discuss effective patient teaching strategies. Experienced faculty members in the PCC course collaborated to create and role-play the three scenarios. Multiple collaborative faculty sessions were held to determine the structure and then refine the scenarios to reflect the six core principles of PCC and meet the objectives of the simulation. The resulting scripted vignettes, designed to last approximately 3 minutes each, offered students a clear opportunity for recognizing and improving on the examples of communication. Language in the scripts was structured to accurately reflect the specific PCC concept being demonstrated. The three vignettes included (a) a safety scenario when caring for a geriatric person, (b) a discharge teaching scenario for a multiparous Latina woman following a first cesarean section birth, and (c) a spiritual care scenario for a patient at the end of life (Table 1). Following each role-play scenario, time was planned to allow students the opportunity to verbally analyze the effectiveness of the depicted PCC concepts. A final debriefing was planned at the conclusion of the last scenario to reflect on the value and future application of the learning experience.
Vignettes Used in Classroom Setting
The role-play simulation occurred during the ninth and final class session of a once-per-week half-semester course following 8 weeks of large classroom didactic instruction and students' application of PCC principles through various assignments. The class session opened with a brief review of the previous course content and looked at each of the core principles once more prior to the role-play simulation. Affect the overview was completed, course faculty members who wrote the scripts began role-playing the first of three developed scenarios. For example, the end-of-life cultural and spiritual care scenario used three faculty members. The first played the patient at the end of life, asking the nurse to pray with them. The second faculty member played the nurse role, acting uncomfortable and unsure of how to respond to the patient. The third faculty member acted as the unheard voice of the nurse, vocalizing the thoughts and decision-making process of the nurse. During the scene, the faculty member vocalizing the nurse's thoughts sat near the scene but not in direct view of students observing.
After each scenario, the students were encouraged to offer analysis and identify the principles of PCC as presented. Faculty prompted students with open-ended questions to enhance critical assessment of the nurse's communication with the patient. After the analysis discussion, student volunteers reenacted the scenario using appropriate therapeutic communication strategies. The format was repeated for each scenario. After the last scenario, the session concluded with an overall debriefing of the role-play activity. Students were encouraged to consider how they might implement the PCC strategies in both their upcoming hospital clinical rotations and future practice. This innovative role-play simulation provided the students the opportunity to: analyze faculty-led live simulation role-play, practice application of PCC principles via participation in scenarios, and debrief, reflecting on the experience.
During scenario analysis, faculty encouraged students to identify effective and ineffective communication between the nurse and patient. Students offered comments related to the exchanges during the scene, and their feedback initially focused on the nontherapeutic verbal and nonverbal communication exhibited by the nurse and the insensitive decision making that prompted the nurse's thoughts and actions related to the care of the patient. Students quickly recognized the lack of PCC principles reflected in nursing care during the simulation role-play. Examples identified by the students included the nurse's biases that influenced care behaviors, the nurse's lack of clarity in teaching instructions to the patient, the nurse's use of unfamiliar terms when explaining the proposed plan of care with the patient, as well as actions that revealed the nurse's assumptions regarding the patient's health literacy and knowledge level. Students also noticed the influence of patient lack of motivation or readiness to learn on the delivery of PCC. Analysis following each scenario provided an opportunity for further student-led discussion related to useful approaches when responding to situations that engage personal values such as patients' spiritual and cultural health needs or specific patient requests. Students willingly offered suggestions for appropriate PCC therapeutic communication for the scenarios. Simulation learning objectives were determined to be met during discussion, as evidenced by the student comments.
After open discussion, faculty offered students the opportunity to reenact the scenario demonstrating principles of PCC and effective and therapeutic communication. In displaying therapeutic interactions, the students demonstrated learning and reinforced the principles of PCC. In one reenactment, a student with previous experience in assisting breastfeeding women volunteered to role-play a specific scenario in this area with a faculty member as patient. The student effectively incorporated the PCC principles of culture, therapeutic communication, and patient learning preferences with patient education strategies in the patient care displayed. Faculty noted increased engagement from students during the analysis following this specific reenactment. Multiple students offered lively comments and commended the student's performance. Perhaps this can be attributed to the student's knowledge related to the content of the scenario and the ease with which the student performed in the nurse role, and it could be reflective of the combination of both a faculty member and a student doing the live role-play simulation scenario together.
Fernandez (2014) indicated that feedback and interaction from the faculty in an immediate postdebriefing session was more vital for success than following specific debriefing guidelines. During the debriefing session, many students suggested ideas for implementing PCC principles. Students cited specific ways in which they could immediately engage in PCC with patients in the clinical setting, such as routinely incorporating individual cultural and spiritual health care needs in plans of care while remaining cognizant of existing personal biases that could adversely influence patient care. Students shared that the role-play activity improved their ability to identify both ineffective and effective PCC strategies and skills. Students expressed overwhelmingly positive feedback about the live faculty-led role-play simulation during this final course session and at the end-of-semester anonymous course evaluations. Comments included:
- [I] felt the skits in the last class were effective.
- The role-playing during the last class really put it all together.
Furthermore, faculty noted in monthly group meetings an increased awareness and demonstration of PCC principles by students during their clinical rotation experiences. Faculty reported that students consistently considered their assigned patient's individual needs when discussing and planning nursing care and intentionally incorporated applicable PCC principles during the implementation of their patient's plan of care.
Incorporating PCC principles in prelicensure nursing education can be challenging but is necessary to address the recommendations of the IOM, the American Association of Colleges of Nursing, and the American Nurses Association. Using role-play simulations allowed students to engage in a process that helped reinforce the Quality and Safety Education for Nurses competencies of knowledge, skills, and attitudes surrounding PCC in a creative approach to teaching and learning. One strength of this innovative activity is that it allowed for interactive learning within allotted classroom time. Students had the opportunity to observe, analyze, evaluate, and practice interventions that focused on PCC unique to an individual's needs and capacities, promoting the critical reasoning necessary when caring for patients in the health care setting. Students reported improved cultural awareness and sensitivity, therapeutic communication, and self-awareness of biases. There is a significant gap in the literature on both using role-play simulation and the importance of teaching PCC to nursing students. The goal of this article is to stimulate further inquiry into role-play simulation as a method for teaching PCC in nursing education programs. Future recommendations include further research focused on teaching students PCC to improve health care delivery and using pre- and post-testing to measure student learning outcomes when using role-play simulation experiences. Implementation of these PCC strategies may be tailored to the unique needs of each nursing program and using role-play simulations when teaching PCC concepts can be integrated within any prelicensure curriculum.
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Vignettes Used in Classroom Setting
|Scenario||PCC Concept||Patient Statement||Thoughts of Nurse||Example of Inappropriate Language||Example of Appropriate PCC Language|
|Caring for a geriatric patient||Gender
Patient teaching strategies||“I don't want to use that pump.”||“Wonder if this old woman can figure out how to use this pump.”||“Sure you can, even my 8-year-old can use it.”||“I'm going to show you how to use your PCA pump. You will be able to control your medication to help manage your pain. How does that sound to you?”|
|Discharge teaching of a multiparous Latino status post first c-section||Culture
Patient teaching strategies||Not speaking due to language barrier.||“How many more kids is this woman going to have?! Surely this is the last!”||“Well, since this is your fourth baby, you don't need a lot of teaching, do you?” “Just keep your incision clean.”||Bring an interpreter in the room. Go through discharge teaching for a c-section. Provide culturally appropriate breastfeeding instructions.|
|End-of-life patient and a spiritual care discussion||Culture
Communication strategies||“I know I am dying. Will you pray with me?”||“I never know what to say here!”||“I'm not very good at this kind of thing.”||“What can I do to meet your needs? Who can I call for you? We have spiritual care professionals available for you.”|