Role Play to Teach Cultural Competency

by Ijeoma Ekeocha, Pharm.D., PGY1 Pharmacy Practice Resident, the Johns Hopkins Hospital

Cultural competence is the capacity and awareness to care for a diverse patient population. Such awareness often requires being respectful and sensitive to the cultural differences of patients.¹ In a world where patients may come from all walks of life, cultural competence is an essential skill that must be taught in curriculums intended to equip learners with the necessary tools to interact with people. One method that instructors can use to develop cultural competence is role play, which can be particularly useful in patient care settings.  Role play encourages learners to express their feelings and portray individuals from various backgrounds.  There are few opportunities for learners to do so in traditional teaching settings.² In one study where role play was used in an industrial psychology course, students reported that role play was more valuable than conventional teaching approaches.³

Role play has been around for decades, and was originally developed to effect attitudinal changes during psychotherapy.  In 1956, Moreno, founder of psychodrama, utilized players to recite pre-defined lines.  This became the basis for role play in educational settings today.¹ The definition of role play has since evolved.  It is a tool that promotes active learning and cultivates learner knowledge, skills, and attitudes.⁴  Role play entails the “acting-out of a specific situation based on the adopting of another character ‘role’.”⁵  An in depth look at the technique unveils questions to ponder. Are the roles actual, imitational, or fictional? Are they spontaneous or scripted? How structured and extensive should the role be?²

Using role play to teach cultural competence gives learners the opportunity to learn the material from a different perspective. When learners engage in role play, they take on a new persona. This provides students with deeper insights into the responsibilities of members of the healthcare team, such as the role of the nurse, dietitian, or patient. While every role on the healthcare team is important, the patient’s role is at the center. Therefore, when using role play to teach cultural competence, students should assume the role of a patient.  In so doing, it cultivates the student's interpersonal abilities.

Participating in role play allows learners to practice and develop skills and techniques that would be useful when encountering patients in real life. As learners get more exposure through these constructed exercises, it gradually increases their understanding of other cultures.  This, in turn, translates into increased respect for other cultures. Respect of others is a critical component of cultural competence that must be cultivated in school and necessary for success in clinical practice today.³

To successfully implement role play exercises, instructors must deliberately bring to light various issues that students may face in practice. Specific items that instructors should consider when developing role playing activities include: ³

• Objectives
• Time frame for the activity
• Role specifications
• Monitoring the role play process
• Relating role play to theory
• Delineating criteria to grade performance
• Indicating the role of observers
• Facilitating constructive analysis

When designing a role play exercise, instructors must consider the type of role play and clinical content to include. There are five types of role play, all of which can be employed depending on the anticipated outcome. The first type of role play is “Role-play as a creativity technique.” This type of role play is designed to elicit ideas from the role play experience. Learners must “bodystorm,” meaning they take part in a staged situation, which allows them to empathize with the character in the given situation. The actors transform into the characters which offers insight into the specific role.⁶

Another type of design is “role play as a research method.” This type of role play is most often use in settings to trial software in scenarios which can be useful in determining the success of marketed products. In these simulated scenarios, designers use role play to analyze feelings and insights of the end users while operating their product.⁶ This form of role play is often created for testing in a predetermined environment to identify how individuals will react in the real world.

While role-play can evoke ideas from the individual involved, it can also serve as a valuable tool for spectators.⁶ By incorporating concrete and intangible ideas, role-play can reveal important messages to the audience. This type of role play may be recorded so that students are able to replay the scenario and watch themselves through a recording. This role play is often used in schools so that students can learn from and evaluate their own performances.

“Role play as an artifact” is the result of a user experience.⁵ In this case, the role play is a product of the experiment. For example, this type of role play can be used to highlight a specific failure mode seen in the medication use system. A medication safety officer may design a role that includes an insulin pen that is verified appropriately by the Pharmacist, filled incorrectly by the technician, and is incorrectly checked by the checking pharmacist. This scenario allows pharmacy personnel to explore different failure modes of the medication use system through the use of role play drawn from a previous experience.

Lastly, role play can be used as a training method.⁶ This type of role play is often utilized in classrooms to help learners safely practice appropriate actions in simulation environments.⁶ Examples of this type of role play can be seen in mock code situations intended to prepare practitioners for real world emergencies.

In order to equip students with skills necessary to achieve the intended outcome of the role play, instructors must methodically develop a design that is tailored appropriately to their learners, which means considering the proficiency level of the learners. Once a design has been selected, teachers must incorporate a narrative that reflects the environment being portrayed. This step includes providing students with a clear and detailed description of the role in addition to information about the environment.³

Because role-playing may be carried out by different people, it can be difficult to reproduce. Therefore, instructors must provide materials such as a scripted dialogue(s), prop(s), and detailed setting description to help create an authentic scenario.⁶ In addition, the instructor must be cognizant of gender identification, race, and other demographics which will help bring the role to life.

During the final step, instructors should focus on debriefing with learners. This step is extremely important as it allows the students to reflect and evaluate the role portrayed. Instructors must encourage students to debrief after each role play and to analyze key issues that occurred during the activity.²  It is through reflection that new knowledge is generated.⁶

While all the steps outlined are important in creating a successful role play, I believe the most critical steps include the narrative and debriefing. In the narrative, instructors choose a role play type that will allow him/her to achieve the learning outcome.  Just as it is important for learners to debrief following a role-play activity, instructors must assess the learner’s performance during the activity. To assess the role play activity, instructors can use rubrics designed to assess oral communication.  Rubrics contain the framework of expectations for a specific learning exercise. The instructor’s assessment coupled with the learners self-evaluation will help maximize learning. In addition, role play may be assessed by students’ reaction to the simulation.³

Role play can be a useful learning tool that allows students to creatively develop and practice skills needed in various clinical settings. Role play is a useful and unique technique to teach cultural competence as it drives students to develop interpersonal skills required to communicate with patients from different backgrounds.

References:

1. Shearer R, Davidhizar R. Using Role play to develop cultural competence. Educational Innovations. 2003;53(6):273-76.
2. Kodotchigova MA.Role Play in Teaching Culture: Six Quick Steps for Classroom Implementation. Identity, Culture and Language Teaching.2002:1-7.
3. DeNeve KM, Heppner MJ. Role Play Simulations: The Assessment of an Active Learning Technique and Comparisons with Traditional Lectures. Innovate Higher Education.1993;21(3):231-56.
4. McIlvired DE, Prucka SK, Herbst M, Barger C. The use of role-play to enhance medical student understanding of genetic counseling. Genet Med. 2008;10(10):739-55.
5. Shapiro S, Leopold L. A Critical Role for Role-Playing Pedagogy. Perspectives. 2012;29(2):120-30.
6. Thoring K, Mueller RM. The Role of Role-play: Intangible Systems Representation for Business Innovations. International Design Management Research Conference. 2012 Aug 8-9; Boston, MA.

Gettin’ Diigo With It: Social Bookmarking in Higher Education

by Tara L Blesh-Boren, PharmD, PGY-1 Pharmacy Practice Resident, Sinai Hospital

As I sat down to begin working on this blog, I reflected on how nice it would be to increase my efficiency… or stretch time, but I’ve never been too successful at that! It seems that never-ending bumps in the road alter my well-designed schedule. When I was unable to find those important web links I was sure were saved in my browser, the irony of my situation hit me. Why, you ask? Because my blog topic was about using social bookmarking to enhance learning. A good bookmarking tool would have prevented the conundrum I had found myself in! One of the many benefits of social bookmarking is having an easily accessible, one-stop resource to quickly retrieve discoveries made during journeys through cyberspace. So, let’s discuss social bookmarking and how it might be used in higher education a bit more.

Social media use for collaborative learning has been rapidly increasing in higher education, with more than a 20% increase between the years 2012-2013 alone.¹  Most often, faculty are asking students to use social media to create original documents (or other media) in teams or to participate in collaborative discussions, rather than passive learning through lectures or assigned readings. Social bookmarking tools have been increasing in popularity, with several companies offering products with slightly different features.

Top social bookmarking sites such as Diigo, delicious.com, and StumbleUpon provide a variety of ways to bookmark sites and discover related sources that have been identified by other users. While StumbleUpon allows the user to discover new sources based on tags, saved preferences, and ‘liking’ new material the site suggests, it doesn’t allow group formation. This limits the utility of StumbleUpon for collaborative classroom work. Delicious.com and Diigo both allow users to selectively share saved bookmarks for web sites, articles, videos, and a plethora of other online media all in one place.² One can organize these resources via unique titles, keyword tags, lists, and topic groupings. Both programs are cloud-based, allowing users to access information from anywhere, at any time. Since most students possess smart phones or digital devices, mobile apps are also available, further increasing adaptability. Where Diigo excels above some of its competitors is the ability to annotate the bookmarked materials. Users can make specific comments, highlight, and post sticky notes anywhere on the pages, and share these publicly or within created groups.

How does this translate to collaborative learning in higher education? Both delicious.com and Diigo support creation of private groups, which allows educators to invite students in their class to share and interact without compromising student privacy. Since a large percentage of instructors feel trepidation about incorporating social media into the classroom due to privacy concerns, this minimizes this potential roadblock.¹ Users create their own username, which is the only identifiable source of information shared within class groups.

This all sounds great, but you’re probably asking, “How can a bookmarking tool be used to enhance learning?”  Certainly, it is a valid question! Gao recently published a case study looking at a collaborative learning activity designed with Diigo.³ Students evaluated an online article and participated in a group discussion utilizing highlights, comments and sticky notes to discuss and critique the assigned reading. Students’ comments often built upon a previous post or further developed someone else’s ideas. The author reported that the activity stimulated self-reflection, elaboration, and internalization. None of the students reported conflicts arising from the discussion, and the majority found Diigo supported learning and the tool helped them to effectively critique the article.

Social bookmarking and annotation opens up a realm of possibilities for use in health professional education. Utilizing social interactions, exploiting the availability of online media, and creating activities that stimulate “unintentional” learning opportunities, online collaborative learning is grounded in the social cognitive and situated learning theories.^4,5 Students develop skills in information organization, resource sharing, and group discussion; together this advances critical thinking skills, meta-cognition, improved reading comprehension, and incorporates real-life application to classroom activities.^5,6

A recent article in the American Journal of Pharmacy Education suggests social bookmarking can be utilized in pharmacy education to create a shared library for students to access resources during a project or course.⁷ Moreover, students can create this resource library themselves. In my opinion, this is a limited view, and I envision other possibilities.  For example, social annotation could be used in multiple courses throughout the pharmacy curriculum. One could create collaborative teams in therapeutics and assign a difficult patient case for small groups to follow over a semester. Students could highlight relevant sections of evidence-based guidelines, leaving comments and discussing how to best apply evidence to the patient case. The other groups in the class would do the same, creating an interactive, collaborative learning environment that might allow greater exposure to clinical application of class materials. One could also employ the bookmarking and social annotation function for a literature evaluation course. All of these methods help student build collaboration, organizational, and research skills, which are all essential to becoming a competent health professional.

One must utilize social media and bookmarking tools only if they naturally help achieve the learning objectives of the course.  These tools should enhance learning, not direct it. With the exponential increase of social media in education, and the desire to engage students in collaborative tasks mirroring the real-world, social bookmarking offers a very strong addition to the arsenal of tools we can use to create dynamic, engaging learning environments. I dare you to try it out for yourself. But I must warn you. It can be addicting!

References

1. Seamean J, Tinti-Kane H. Social media for teaching and learning. Pearson Learning Solutions. [Internet]. 2013. [cited 2014 Oct 10].
2. Ruffini MF. Classroom collaboration using social bookmarking service Diigo. [Internet]. 2011 Sep 17. [cited 2014 Oct 16].
3. Gao F. A case study of using a social annotation tool to support collaboratively learning. Internet and Higher Education. 2013;17:76-83.
4. Piaget J. The equilibration of cognitive structures: the central problem of intellectual development. 1^st ed. Brown T, Kishore JT, translator. Chicago: Univ of Chicago Pr, 1985. 178 p.
5. Lave J, Wenger E. Situated learning: legitimate peripheral participation. 1^st ed. Cambridge: Cambridge University Press, 1991. 138 p.
6. Novak E, Razzouk R, Johnson TE. The educational use of social annotation tools in higher education: a literature review. Internet and Higher Education. 2013;15:39-49.
7. Cain J, Fox BI. Web 2.0 and Pharmacy Education. Am J Pharm Educ. 2009;73:Article 120.

The Socratic Method for Developing Critical Thinking

by Naaseha Rizvi, Pharm.D., PGY1 Pharmacy Resident, Johns Hopkins Bayview Medical Center

Starting my second week of my internal medicine rotation, my preceptor told me that I would be responsible for leading the pre-round group discussion sessions from now on.  Our “group” included not only the preceptor and myself, but also two advance pharmacy practice experience (APPE) students. I had watched my preceptor lead these sessions effortlessly the first week, so I thought “this can’t be that hard, right?” Wrong! After the first few sessions, I realized the questions that I asked were random and unsystematic.  The students were not benefitting from our discussion at all!  I remembered back to my days as an APPE student.  Some of my best preceptors were able to stimulate critical analysis by asking the right questions in the right order. They got me to think about my thinking – metacognition. I wanted to be able to do this for my students!  I decided to do some research.

There are many ways to teach critical thinking skills to students. A particularly tried and true method was developed by the ancient philosopher, Socrates.   Consequently, the teaching method is called the Socratic Method or Socratic Questioning. After a logical series of specific, systemic questions, Socrates observed that students were able to develop self-generated knowledge and regulate their thoughts.¹ The key to this method is to ask the right questions in the right sequence. Poorly thought-out questions can intimidate and confuse students.  Bad questions can even limit a student’s ability to think critically.² Questions generate an inquisitive mind, a mind that keeps forming new questions to find more answers, which may lead to more questions and so on and so forth.³

Why is it necessary to teach critical thinking skills? In order to provide the best care to patients, practitioners utilize the knowledge that comes from previous patients with similar diseases as well as current medical knowledge. The ability to make a logical and defendable connection between these two sources of knowledge to the current situation is critical thinking.¹ Three principles are important to keep in mind when teaching or stimulating critical thinking: 1) it is a skill that takes time to develop; 2) learners must use certain metacognitive strategies; and, 3) critical thinking relies on domain knowledge that the learner already possesses. It is challenging to validate methods for teaching critical thinking and the ability to yield consistently positive results to show improvement.¹ Different methods of instruction to develop critical thinking include group learning, case-based learning, concept mapping, and experiential education. The evidence regarding the effectiveness of the teaching strategies in promoting critical thinking is lacking.¹

How is the Socratic Method applied? How does it work? The Socratic Method requires the student to look at the deep structure of the question. To do so, they must have basic domain knowledge in the content area. The underlying goal of the Socratic Method is to prove opinions with facts. Therefore the student must have a frame of reference before the Socratic Method may be used. The authors of a recent article in the American Journal of Pharmaceutical Education outline the elements of the Socratic Method (See Table 1). The mnemonic PAPER CLIP (figure 1) can be used to construct a sequence of questions which stimulate deeper thinking.¹ Three types of questions are often used: exploratory, spontaneous and focused.² Exploratory questions show how much the student knows and may be used to introduce a new topic or review past discussions that may relate to the current topic. Spontaneous questions can be used to probe the student in exploring their beliefs and assumptions; they allow the student to reflect on the issue at hand. Focused questions narrow the discussion on what the preceptor would like the student to think about, stimulating them intellectually.²

Table 1. Effective  Socratic Questioning1

Raise basic issues Probe beneath the surface structure Pursue problematic areas of thought Aid students in discovering the truth of their own thought Aid students in developing sensitivity to clarity, accuracy, relevance and depth Aid students in arriving at judgments though their reasoning Help students analyze purposes, assumptions, questions, points of view, information, inferences, concepts and implications.

Figure 1.

By using this method of questioning, the student (hopefully) becomes inquisitive and motivated to learn. This method is quite different from another form of questioning called “pimping,” which may do more harm than good in terms of teaching critical thinking.¹ Although the effectiveness of the Socratic Method has not been studied, a few articles describe its benefits in health professional education. In one study conducted at the Robert Wood Johnson Medical School, third and fourth year medical students participated in a series of 90-minute conferences.  The instructors used a traditional didactic method as well as the interactive Socratic Method interchangeably.  Each method was used approximately the same amount of time. After the conference, students were given a survey to determine their preference. The majority of students preferred the Socratic Method over the didactic method (93.3 vs 6.7%, p < 0.001).⁴

After constructing the Socratic questions, it is important to use them in an effective manner.²  Avoid compound questions that require multiple answers as it can cause confusion. Provide a safe environment where students can express their thoughts openly. Questions should be balanced in their cognitive level. Lastly, it is important to provide enough “wait time” after asking a question. For higher-order questions that stimulate critical thinking, as much as 1-2 minutes should be given for best responses.²

The Socratic Method is very well suited for students on experiential rotations.  The learner needs adequate domain knowledge in order for the Socratic Method to be most effective. Therefore, it may not work as well in a first year course where foundational knowledge needs to be acquired. In the pharmacy curriculum, the experiential rotations provide an opportunity for one-on-one interaction.  This is an ideal opportunity for the preceptor to use the Socratic Method. Students on experiential rotations typically have the foundational knowledge needed.  They just need to learn how to apply it towards patient care by learning how to think critically. By developing this vital skill, students will be well equipped to practice pharmacy.

References:

1. Oyler DR, Romanelli F. The fact of ignorance: Revisiting the Socratic Method as a tool for teaching critical thinking. Am J Pharm Educ. 2014;78: Article 144.
2. Tofade T, Elsner J, Haines ST. Best practice strategies for effective use of questions as a teaching tool. Am J Pharm Educ. 2013;77: Article 155.
3. The Critical Thinking Community.  The Role of Socratic Questioning in Thinking, Teaching, and Learning. 2013. Accessed October 25, 2014.
4. Zou L, King A, Soman S, et al. Medical students' preferences in radiology education a comparison between the Socratic and didactic methods utilizing powerpoint features in radiology education. Acad Radiol. 2011;18:253-6.