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Nurse Education in Practice 12 (2012) 279e283

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Nurse Education in Practice

journal homepage: www.elsevier .com/nepr

Using online roleplay in undergraduate midwifery education: A case-study

Jane Warland*, Morgan Smith 1

School of Nursing and Midwifery, University of South Australia, City East Campus, North Terrace, Adelaide 5000, South Australia, Australia

a r t i c l e i n f o

Article history:Accepted 25 June 2012

Keywords:e-SimulationRole-playRole based simulationCommunicationCollaboration

* Corresponding author. Tel.: þ61 8 8302 1161; faxE-mail addresses: jane.warland@unisa.edu.au (J

unisa.edu.au (M. Smith).1 Fax: þ61 8 830 22168.

1471-5953/$ e see front matter � 2012 Elsevier Ltd.http://dx.doi.org/10.1016/j.nepr.2012.06.008

a b s t r a c t

Online roleplay i.e. role play which occurs using an online asynchronous discussion board, can beeffectively utilised to teach a variety of skills to midwifery students. This paper will discuss the designand implementation of an online roleplay for a small (n ¼ 19) class of final year undergraduate Midwiferystudents. It briefly describes the design of the online roleplay and outlines the expected learningoutcomes of the activity. It then outlines evaluative survey results for student evaluation of the onlinerole play. Results focus on student opinion of communication and collaboration skills developed throughparticipation in the roleplay. Students considered that the online roleplay provided themwith a means toallow communication skills to be developed and practiced. They also believed that the roleplay enablethem to practice collaboration in an authentic real world setting. Finally implications for use of thismethod of teaching in nurse/midwife education are discussed.

� 2012 Elsevier Ltd. All rights reserved.

Background

Upon graduation midwives are expected to be skilled commu-nicators, ready and able to collaborate with a range of other healthprofessionals in order to deliver quality health care (e.g. AustralianNursing and Midwifery Council (ANMC) 2006; Nursing andMidwifery Council (NMC) 2004). These skills include the abilityto successfully negotiate with others, advocate for others (even ifthey hold an opinion which differs from their own), and to be ableto clearly and succinctly argue a point of view without passion orprejudice. It therefore behoves those who educate midwives toensure midwifery students are provided with many and variedopportunities to enable them to develop a range of communicationskills. These skills include group decision making, negotiation, andother such ‘soft’ skills. Such skills enable high quality interpersonalrelationships, foster trust between students and promote reflectivethinking (Bergh et al., 2006; Bos and Shami, 2006).

Face-to-face roleplay is accepted as a useful pedagogy in healthprofessional education. However, the use of online roleplay is lesswell known. Online roleplay occurs in an online environment andtypically provides a scenario and a set of roles which students canadopt in order to solve a problem, create something, or explore anissue (Wills et al., 2010). The roleplay discussed in this paperexplored the issue of mandatory infant immunization.

: þ61 8 830 22168.. Warland), morgan.smith@

All rights reserved.

Asynchronous discussion, that is discussion which does notoccur in real time, has been shown to be an effective means offostering cognitive processing (Schellens and Valcke, 2005). Onlineroleplay can be held in real time (synchronous), in which casevirtual reality platforms, such as second life, can be used (KamelBoulos et al., 2007; Beard et al., 2009) However, online roleplaycan also be conducted via asynchronous discussion and as DeWever et al. (2008) indicate, provides several advantages forstudents, for example extra time to reflect, think, and search foradditional information before contributing to the discussion.

Online roleplay has been used in Australian higher education tofoster development of a range of skills in a variety of professions.The Australian learning and teaching council (ALTC) establishedProject EnROLE in order to assist dissemination of the teachingtechnique of online role play in university education. This projecthosts an ‘online roleplay repository’which showcasesmore than 60templates which can be used to establish an online roleplay atwww.uow.edu.au/cedir/enrole/rp_repository.html.

This paper will discuss the design and implementation of anasynchronous online roleplay, for a small (n ¼ 19) class of final yearundergraduate midwifery students. It outlines how and why theroleplay was designed, including the learning objectives and thenfinishes with student evaluation of the roleplay.

The design

The roleplay was situated as one learning activity withina course (topic/unit) about health, determinants of health, basicepidemiology and the Australian health care system. Online

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roleplay had been introduced into this course in 2009 (Warlandet al., 2012) however, that year the midwifery and nursingstudents undertook the same roleplay. In response to studentrequest a roleplay specifically for the midwifery students wasdeveloped. The learning objectives of the roleplay, as set by faculty,were to primarily focus on students acquiring an understanding ofprimary health care principles and the role of the RegisteredMidwife in the infant immunization debate. Secondary learningobjectives were to give students practice in negotiating anddebating an issue with each other, in order to foster the group workand communication skills required to participate effectively asa member of a health care team.

All of the roles had a public and private persona. The publicpersona provided information for all students involved in theroleplay about the person’s position and publically known viewsand interests (see Table 1). Private persona information was onlygiven to those students playing that role in order to give themfurther insight into how their character might respond during theroleplay. These persona gave some further background about therole including their role’s views about infant immunization, furtherbackground about how and why those views were held, ‘favourite’websites of their character, and past history with other players,including possible allegiances or personality differences.

Table 1Public persona.

Person: Dr Russell Bush.Role: New minister for health in the newly elected Sally Priest Government.Dr Bush has called this ‘virtual’ summit in order to facilitated public debate

on the issue of compulsory infant immunisation. Participants at the summitshould feel free to post their questions, and comments about the summitto the ‘virtual summit’ site labelled “attention Dr Bush” he will addressquestions and make comments in response as the summit progresses.

Organisation: PANIC (Parents against neonatal immunization coalition.)View: Against immunizationThe spokesperson for this organisation is Mr B. Pitt. He represents an

organisation of parents who have children with autism, have died ofSIDS or suffer from a range of other problems because of having animmunization in infancy. He, and others from their organisation, considerthat immunization is dangerous and are keen to lobby against making itcompulsory.

Organisation: CMView: Pro-choiceMiss Susie Tran represents the College of midwives. When it comes to

immunization the College of midwives is pro-choice and are keen to seethe status quo maintained with parents and their families able to makeinformed choice based on evidence based information.

Organisation: YES (young early shots)View: pro immunizationThe spokesperson for this organisation is Dr. Joan Walker Joan is

representing YES a newly formed group of neonatologists, paediatriciansand other health professionals who have recently been canvassing theGovernment to make immunization compulsory in the same way aswearing a seat belt is compulsory.

Organisation: PROKIDS (Parents Reducing Outbreaks in Kids Immunization-preventable Diseases):

View: Pro immunizationMs Marianne Field is the spokesperson for a group of parent activists who

support immunization. The members of this group have all been touchedby tragedy in their lives. Membership includes parents who have lostchildren to whooping cough, tetanus and other immunization preventableillnesses.

Organisation: Naturopathic Opposition e immunization (NO-Immunization)organisation of naturopaths and others who are for alternatives toimmunization.

View: against unnatural immunizationLiz Pike is the spokesperson for a group called NO-Immunization. This is a

group of naturopaths and others who believe in building immunity throughnaturopathic means. Her group believe that immunity to any disease ispossible through natural means without resorting to unnaturalimmunization.

There were five roles played by students (3e4 students per role)representing key stakeholder positions, pro-immunization, anti-immunization, pro-choice and alternative (see Table 1). Several ofthese organizations were fabricated for the purposes of the role-play. Faculty also played a role, thus allowing students to askquestions and make comments about the roleplay to faculty,without the need for them to “break role”.

The roleplay began with a seven day briefing stage. During thisweek students were given the background story and asked toresearch their role. The story was that there had been a recentAustralian Federal Election and there was a new Minister forHealth. During the election he had been canvassed by some con-cerned parents and hadmade an election promise to hold a summitof interested stakeholders to discuss his idea of making theimmunization schedule mandatory for all Australian Infants. Thepros and cons of infant immunization are often debated in the pressand media and it was therefore relatively easy to source a range ofitems both print and video, to supplement and build the back-ground story.

The roleplay itself consisted of an asynchronous online discus-sionwhich took place over a period of 10 days in October 2010. Keystakeholderswere invited to a ‘virtual summit’which allowed themto contribute to the summit wherever they were in Australia. Overthe course of the roleplay 10 days each group of students playinga role, made several posts to the ‘virtual summit.’ Just as wouldoccur in reality stakeholders met behind the scenes to discuss whatwas being “said” at the summit and to prepare a response for theircharacter. On campus students usually met face-to face anddistance students chose to communicate using a range of electronicmedia including email, Skype, Microsoft Social Networking (MSN),Face book, Twitter etc.

Debriefing is an important end phase for any roleplay (Fanningand Gabba, 2007). Debriefing for this roleplay occurred face-to-facein the week following its completion. All students, both on campusand distance, were attending a mandatory midwifery skills work-shop for another course. This provided the opportunity to meetwith all students to debrief with them. Students were asked toreflect on what happened in the roleplay, especially from theperspective of communication. They were asked to comment on:

� those aspects of communication within the group that wereeffective

� those aspects of communication that were less effective andwhy

� strategies that could be used to improve communicationeffectiveness in the future

This tutorial also provided an opportunity for all students topresent their persona’s view on mandatory immunisation, to allother students. This presentation consisted of their “persona’s”submission to the virtual summit. The submission included theirpersona’s views, with evidence, as to whether or not the Minstershould support a bill for compulsory immunisation. This was thesummative (graded) assessment for this learning activity.

Method of evaluative data collection and findings

At the end of the final tutorial students were administereda paper-based survey. Twelve students took the time to completethe survey, a 63% response rate. The student survey was based onand adapted from the Australasian Survey of Student Engagement(AUSSE) framework (Australian Council for Educational Research(ACER), 2009). In particular the questions concerning skill devel-opment, active and collaborative learning and enriching

J. Warland, M. Smith / Nurse Education in Practice 12 (2012) 279e283 281

educational experience are reported here as these bear a closerelationship to communication skill development.

Prior to the survey’s administration, ethics approval was soughtand gained from the University’s Human Research EthicsCommittee (HREC). There was no separate consent form: comple-tion of the form and returning it was taken as consent.

Survey results

Number (n) and percentage (%) responses to the student surveyare given in Table 3 and will be further discussed here. The surveyalso had three open comment questions viz;

1. What do you believe were the strengths of the roleplay?2. How do you think the roleplay could have been improved3. Any other comments?

Of the 12 students who responded to the survey, five left thesethree comments boxes blank, with only one student providingcomments to all three. This means there was little additional databeyond the Likert responses, however, such information as wasoffered is included here.

Skill development

There were four questions that provided students with theopportunity to respond as to how well they thought undertakingthe roleplay enabled them to meet the learning objectives of theactivity (as outlined above). Students responded with strongagreement to, possessing a better understanding (Questions (Q)1&2 Table 3) concerning immunization. They indicated less strongagreement to the practice and knowledge application questions (Q.3&4 Table 3). Only two students provided further comment on howtheir skills were developed, one simply saying teamwork and theother learn and act the midwife’s role in real clinical setting.

Active and collaborative learning

Questions regarding active and collaborative learning wereaimed at determining the student’s view on how well undertakingthe roleplay facilitated collaboration and communication witheach other. As Table 3 shows students were in strong broadagreement that the roleplay required them to use effectivecommunication skills and assisted them to further develop their

Table 210 common methods for measuring communication skills (adapted from Aspegren,1999).

1 Course Evaluation. The students state their opinions about the usefulnessetc. of the training

2 Written Report. The students write a report about their communication e.g.progress of an interview

3 Cognitive testing of the knowledge about communication e.g. therapeuticinterview

4 Self-rating scales5 Psychometric tests of some kind which are assumed to correlate with

communication skills6 Direct observation by an external observer, most often using a rating

scale7 Video e or Audiotaped interviews rated by an independent and trained

observer using rating scale and/or global assessment8 Objective Structured Clinical Examination (OSCE)9 Patient/Client rating of the student’s performance, often with the aid of a

rating scale10 Patient health outcome

communication style (n ¼ 11). They gave less positive responses tofinding communication with other students easy (n ¼ 8) andperception of equal role sharing (n ¼ 8). Three students also feltthat they did not get sufficient time to think about and researchtheir role’s response.

These third year midwifery students already knew each otherquite well and therefore chose the other students with whom theywould like to roleplay. This was in keeping with this roleplay designbecause each role represented a spokesperson for a like mindedgroup. However, the characters each group playedwere assigned byfaculty. This meant that some students needed to represent a viewabout infant immunization which they themselves did not hold.This was recognised as helpful by one student:

The fact that the persona assigned to each group may have differedfrom the group’s real ideas on immunization- this meant that wehad to research with a different mind set making us aware ofalternative viewpoints in regards to the issue.

The only other comment made about communication was thatone student felt the roleplay provided a great debate forum;

Overall comment

Only two students made comments to the “other comments”question about their overall impressions of the value of the role-play. These were:

Loved doing it!! and

Enjoyable spin on an interesting assignment, I think it worked quitewell overall and we had no real issues at any point of theassignment.

Discussion

Fostering the development of communication skills for anyhealth professional student is important, but can be difficult ascurrently there is no systematic approach to teaching such skills.For example, Aspergen conducted an extensive literature review ofteaching and learning communication skills in medical educationwhen 180 papers on the subject were reviewed and found thatthere are 10 commonly used measures of evaluating the effec-tiveness of communication skills learned (summarised in Table 2).This author concluded that instructional methods for teachingthese skills should not be used, as communication is best taughtexperientially (Aspegren,1999). This review has not been replicatedhowever, experience from this roleplay suggests that theseconclusions remain true today. Certainly the midwifery studentsundertaking this project welcomed the opportunity to practice anddevelop their communication skills in an online experientialenvironment.

Face-to face roleplay has long been recognised as a means topractice communication skills (Lane and Rollick, 2007). Asynchro-nous online roleplay is less well used however, other reports havealso indicated that it shows promise as being an effective means tofoster student engagement in collaboration and communication(Bell, 2002; Wills et al., 2010; Maier, 2007). The students in thisproject also indicated that the roleplay provided them with anopportunity to engage in and learn communication skills in anactivity which was both engaging and enjoyable.

Barton et al. (2007) point out that a sense of professionalauthenticity is required in order for students to learn effectively anddeeply. Psychological fidelity, which refers to how authentic thelearner believes the simulated setting to be, is also important forlearning to occur (Jeffries and Rizzolo, 2006). Students all stated

Table 3Summary of frequency of responses to midwifery student Likert scale survey.

Strongly agree/Agree n (%)

Neutral n (%) Strongly Disagree/Disagree n (%)

Skill development1. The online roleplay assisted me to understand the role of the Registered Midwife in

immunization uptake10 (83%) 2 (17%) 0 (0%)

2. The online roleplay assisted me to understand primary health care principles in thecontext of the mandatory immunization debate

11 (92%) 1 (8%) 0 (0%)

3. The online roleplay gave me the opportunity to practice problem solving in a real-worldcontext

9 (75%) 3 (25%) 0 (0%)

4. The online roleplay assisted me to learn how to apply theoretical principles (such asepidemiology, primary health care) to midwifery practice

8 (67%) 4 (33%) 0 (0%)

Active and collaborative learningThe online roleplay required that I utilise effective communication techniques when

communicating with other group members11 (92%) 1 (8%) 0 (0%)

The online roleplay assisted me to further understand my communication style 11(92%) 0 (0%) 1 (8%)My ability to work in collaboration and cooperation with others has increased through

participating in the online roleplay10 (83%) 1 (8%) 1 (8%)

Communication with other students playing my character was easy 8 (67%) 3 (25%) 1 (8%)Other students sharing my role contributed equally 8 (67%) 0 (0%) 4 (33%)I successfully adopted the persona (got into the role) of my character 11 (92%) 1 (8%) 0 (0%)The online roleplay provided me with the time to think about and research my role’s

responsea8 (73%) 0 (0%) 3 (27%)

Enriching educational experienceOverall the experience of participating in the online roleplay was beneficiala 10 (91%) 1 (9%) 0 (0%)

All percentages have been rounded to the nearest whole number.a One student did not provide a response to this question therefore n ¼ 11.

J. Warland, M. Smith / Nurse Education in Practice 12 (2012) 279e283282

that they effectively adopted the role of their character whichsuggests that they considered their assigned roles to be realistic andpsychological fidelity high.

Clinical simulation does not necessarily improve student’sconfidence with respect to communication skills (Pike andO’Donell, 2010). However, Ammentorp et al. (2007) attest to thefact that learning to communicate through debate and advocacypromotes the students’ ability to trust their communication skillsand probably also promotes self reflection. This activity wasestablished as a means to debate this important topic online andassist students to develop their advocacy skills, even if the views oftheir persona were different from their own. Hence this activityprovided an important opportunity to develop skills required formidwifery practice.

Knowledge development in the area of infant immunizationwasalso a part of this online roleplay. Whilst engaged in the roleplaystudents learnt about the standard immunization schedule, as wellas risk and benefits of early childhood immunization. They werealso required to research different perspectives, including alterna-tive (‘natural’) immunization as well as explore common popularlyheld beliefs. At the same time they needed to understand primaryhealth perspectives, as well as the impact of choosing to immunizeor not on the individual family. All this meant that they needed topresent their point of view to the ‘Summit’ in a dispassionate,logical and succinct manner. Such knowledge and skills are all vitalfor the qualified midwife to acquire during their education (e.g.ANMC, 2006; NMC, 2004).

Whilst the number of students involved in this roleplay wassmall, online roleplay has been successfully conducted with largenumbers of students with equal degrees of success (McLaughlanet al., 2001; Warland et al., 2012) demonstrating that this isa versatile method for teaching a variety of skills.

Conclusions

Even though the number of students who responded to thissurvey was small their response was emphatic. They agreed thatthe online roleplay provided them with the opportunity to utiliseeffective communication and fostered development of negotiation

and collaboration skills. It may therefore be concluded thatstudents believe online roleplay provides a means to allowcommunication skills to be developed and practised.

Knowledge acquisition tied into the issues around infantimmunization is also an important skill for a qualified midwife topossess. This online roleplay provided an avenue to learn thisinformation in an engaging and enjoyable manner.

Online roleplay has been in use for some years, however, it hasnever been formally evaluated to test its effectiveness against otherlearning activities. Nevertheless, it has been used in a variety ofsettings in a number of disciplines to foster a cluster of differentgraduate skills with all reports coming to similar positive conclu-sions regarding student response to the use of this innovativepedagogy.

Conflict of interest

None declared.

Acknowledgements

We would like to thank Dr Colleen Smith for her ongoinginterest and support of the use of online roleplay in the School ofNursing and Midwifery UniSA. This midwifery roleplay arose out ofa larger project which was funded by an UniSA Division of HealthSciences Teaching and Learning grant. We would also like to thankAnn Davenport (private consultant) and Dale Wache (UniSA) fortheir willingness to pass on their extensive knowledge of onlineroleplay design. Alison Hall and Caroline Jasper (EdNA) providedwonderful assistance in setting up and hosting the roleplays. Wewould also like to thank all students who took the time to evaluatethe roleplay.

References

Ammentorp, J., Sabroe, S., Kofoed, P., Mainz, J., 2007. The effect of training incommunication skills on medical doctors’ and nurses’ self-efficacy. A random-ized controlled trial. Patient Education and Counselling 66, 270e277.

Aspegren, K., 1999. Teaching and learning communication skills in medicine e Areview with quality grading of articles. Medical Teacher 21, 563e570.

J. Warland, M. Smith / Nurse Education in Practice 12 (2012) 279e283 283

Australian Nursing and Midwifery Council, 2006. National Competency Standardsfor the Midwife ANMC. retrieved november 14th 2011. Website. http://www.anmc.org.au/.

Australian Council for Educational Research, 2009. Australasian Survey of StudentEngagement. retrieved November 14th 2011. Website: http://ausse.acer.edu.au/.

Barton, K., McKellar, P., Maharg, P., 2007. Authentic fictions: simulation, profes-sionalism and legal learning. Clinical Law Review 14 (1), 143e193.

Beard, L., Wilson, K., Morra, D., Keelan, J., 2009. A survey of health-related activitieson second life. Journal of Medical Internet Research 11 (2), e17.

Bell, M., 2002. Why Use Role-play?. retrieved december 16 th 2010. From Learningdesigns Web Site: http://www.learningdesigns.uow.edu.au/guides/info/G1/more/C3Cliplist.htm#stm.

Bergh, A.M., Van Staden, C.W., Joubert, P.M., Krüger, C., Pickworth, G.E., Roos, J.L.,Schurink, W.J., Du Preez, R.R., Grey, S.V., Lindeque, B.G., 2006. Medical students’perceptions of their development of ‘soft skills’ part II: the development of ‘softskills’ through ‘guiding and growing’. South African Family Practice 48 (8), e15.

Bos, N., Shami, N., 2006. Adapting a face-to-face role-play simulation for onlineplay. Educational Technology Research and Development 54 (5), 493e521.

De Wever, B., Van Winckel, M., Valcke, M., 2008. Discussing patient managementonline: the impact of roles on knowledge construction for students interning atthe paediatric ward. Advances in Health Sciences Education 16 (1), 25e42.

Fanning, R., Gabba, D., 2007. The role of debriefing in simulationebased learning.Simulation in Healthcare 2 (2), 115e125.

Jeffries, P.R., Rizzolo, M.A., 2006. Summary Report: Designing and ImplementingModels for the Innovative Use of Simulation to Teach Nursing Care of Ill Adultsand Children: A National, Multi-Site, Multi-Method Study. National League for

Nursing, New York. Available from: <http://www.nln.org/research/laerdalreport.pdf> (accessed 14.11.11.).

Kamel Boulos, M.K., Hetherington, L., Wheeler, S., 2007. Second life: an overview ofthe potential of 3D virtual worlds in medical and health education. HealthInformation and Libraries Journal 24, 233e245.

Lane, C., Rollick, S., 2007. The use of simulated patients and role-play in commu-nication skills training: a review of the literature to august 2005. PatientEducation and Counseling 67, 13e20.

McLaughlan, R., Kirkpatrick, D., Hirsch, P., Maier, H., 2001. Using Online Roleplay/simulations for Creating Learning Experiences CAL-laborate, vol. 7, pp.23e24.

Maier, H., 2007. Meeting the challenges of engineering education via online roleplaysimulations. Australasian Journal of Engineering Education 13 (1), 31e39.

Nursing and Midwifery Council, 2004. Nursing and Midwifery Council, Standards ofProficiency for Pre-registration Nursing Education. Nursing and MidwiferyCouncil, London.

Pike, T., O’Donnell, V., 2010. The impact of clinical simulation on learner self-efficacyin pre-registration nursing education. Nurse Education Today 30 (5), 405e410.

Schellens, T., Valcke, V., 2005. Collaborative learning in asynchronous discussiongroups: what about the impact on cognitive processing? Computers in HumanBehavior 21 (6), 957e975.

Warland, J., Smith, M., Smith, C., 2012. Much ado about the flu. Design andimplementation of an e-role play for a large class of undergraduate students.Nurse Education in Practice 12, 65e71.

Wills, S., Leigh, E., Ip, A., 2010. The Power of Role-based e-learning: Designing andModerating Online Role Play. Routledge, London.