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.