Role play methodology for OR nurses Diane Reid, RN Marjorie L Garrity, RN
Diane Reid, R N , MS, is an assistant professor at Arizona State University, Tempe. A diploma graduate of Michael Reese Medical Center, Chicago, she received a BSN from University of Illinois, Chicago, and an MS in psychiatric nursing from St Xavier College, Chicago. Marjorie L Garrity, R N , MS, received a BS
from the University of Bridgeport (Conn) and an MS in psychiatric nursing from Case Western Reserve University, Cleveland. She is an assistant professor at Arizona State University.
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ole play is a unique methodology, and its philosophy, techniques, and processes are adaptable for multiple situations and settings. Role play h a s i t s origins i n psychodrama, a method of psychiatric treatment developed by Moreno in the early 1900s.' Until World War 11, psychodrama was used predominantly as a treatment for psychiatric problems. Since then, however, psychodrama has been adapted for other uses, particularly in the fields of business, industry, and education.2 In nursing, role play is frequently incorporated into formal, in-service, and continuing education program^.^ The technique is used (1)t o identify values, attitudes, and feelings in relation to clinical situations; (2) to help nursing personnel learn to deal with sensitive subjects so they can discuss them comfortably with patients or clients; and (3) to facilitate learning, interview, and other process skills. This paper defines and explains role play methodology, describes different role play methods, and illustrates their potential uses to nurses in the operating room. Underlying the philosophy of role play is the belief that man is dynamically involved in a continuous process of personal growth. This growth process has two aspects-personal and interpersonal-and implies that the fully functioning person has multiple facets or roles. Through role play, these roles or their characteristics are explored, discovered, and expanded. An individual is able to gain awareness of himself or herself and to increase his o r her repertoire of behaviors inherent in these roles. Self-awareness is fundamental to personal growth. In spite of one's desire to function a t fullest potential, the process of self-discovery is difficult. One of t h e most common obstacles to selfawareness is a tendency to attribute all
AORN Journal, June 1978, Vol27, N o 7
experience and behavior to one or two roles that have been particularly successful or encouraged. For example, a young schoolboy encouraged and praised for his intellectual performance may have trouble identifying and using his feeling capacities and ability to love as he grows older. The young girl praised for her “cuteness” may have difficulty claiming and using her organizational and intellectual abilities. If, by adulthood, these children have not discovered, claimed, and begun t o use the roles that were not acknowledged when they were young, they may become unidimensional or suffer severe personal and interpersonal difficulties. Awareness, however, is not enough. Awareness of dormant roles and aspects of oneself produces frustration unless they can be comfortably expressed by new behaviors. New behavior feels awkward, self-conscious, o r even threatening when first tried. Therefore, when incorporating a new role, it is important that one is allowed to “practice” the behavior that goes with the new role. Role play affords an opportunity to do just that. The role player is able t o see himself or herself “in action” as old behaviors are revealed and new behaviors are tried in a safe risk-taking atmosphere, which is reinforced by clarifying and supportive feedback. There are two types of role play methods-structured and spontaneous. According to Weiner, “The goal of structured role play is to teach a skill or some systematic approach in dealing with a particular p r ~ b l e r n . ”The ~ focus is on cognitive learning experiences, and objectives include (1)developing specific skills, such as interviewing, leadership, and communication and interpersonal skills, and (2) learning procedures or tasks related to the work situation. In structured role play, the content is determined and “structured” in advance by the leader according to an identified
purpose for each role play session. The leader does not necessarily prepare a skit or specific dialogue; rather, the problem or situation is identified and a framework for the role play is provided. The spontaneous role play method focuses on affective learning. Its goals are to develop insight and t o gain a better understanding of the dynamics of interpersonal r e l a t i o n ~Objectives .~ may include (1) promoting self-discovery, (2) understanding the behavior of others, (3) facilitating attitudinal changes, and (4) increasing one’s ability to cope with change. The content of spontaneous role play is not determined ahead of time. The problem is identified and the scene set up by the members present at the time of the role play session. The leader does not prepare any material in advance but responds to whatever problems or needs emerge spontaneously through group discussion. Integrating components of both structured and spontaneous role play to meet the needs of the individuals concerned is usually advantageous. By understanding the differences and unique contributions of each, the leader can combine them in a creative manner to facilitate an optimal learning experience. The leader should create an atmosphere of spontaneity and safe risktaking at the beginning of a role play experience. Although the end results of role play are enlightening and gratifying, the anticipation of self-exposure and possible criticism from observers creates initial anxiety and discomfort for the role players. Therefore, the leader’s primary task is to be supportive throughout the role play session. This is done in part by helping the group members feel comfortable with one another. Members should be at least acquainted with one another. They should know each others’ names and something about each other. For example, the
AORN Journal, June 1978, V o l 2 7 , No 7
1311
he leader must know when to set limits during role play.
T
leader may ask members of the group to share why they are participating in the role play session, what their expectations are, and what they are feeling in anticipation of the role play experience. Differences and commonalities among individuals are recognized, and a sense of camaraderie begins. To facilitate spontaneity and a willingness to share among participants, the leader cannot be passive. He or she creates a sense of readiness for action by being active, by moving among the group easily and comfortably, and by initiating contact between himself or herself and others and between members of the group. How this occurs will depend on the style and personality of the leader. In addition to creating an atmosphere conducive to an active learning process, the leader is responsible for structuring the role play session so the objectives and ground rules of role play are clear to the group. This includes how and when to participate as role players or observers, how to share observations, and how to suggest alternate behaviors. It is also the leader’s responsibility to know when to set limits during the process to prevent unnecessary self-exposure that might prove to be embarrassing to the individual and impede learning. Also, the leader should define and perhaps model what constructive criticism is in contrast to destructive or blaming remarks, which cause a negative experience for participants. In essence, the functions of the leader demand that he
1312
or she be a resource, catalyst, and source of support for participants in a role play session. Although the goals, objectives, focus, and content of structured and spontaneous role play differ, the method or process of role play is essentially the same. The following stages occur in each situation: (1)warm-up, (2) enactment, (3) feedback and discussion, (4) reenactment, and (5) summary and closure. The warm-up, or the activity preceding the role play, is crucial for its success. The development of a safe atmosphere for this phase is facilitated through structured exercises, informal discussion among members, or a “mini” role play situation presented by the leader for practice. The group is ready to move into the enactment phase when the problem is presented, the interaction relating to the problem specified, and the primary role player or protagonist identified. In this phase, the leader sets the stage and identifies the players. Once the players are familiarized with their roles, action begins. When needed, the leader interrupts the action t o provide clarification, feedback, and to facilitate exploration and understanding of the role players’ behaviors. When the protagonist has acquired a new level of awareness of the situation the role play is stopped. The third phase, feedback and discussion, enables observers to identify their feelings about the enactment and relate these feelings to similar problems of
AORN Journal, June 1978, Vol27, No 7
their own. Through this integration of cognitive and affective aspects, growth occurs in the observers. In addition, the discussion by observers provides the protagonist with additional understanding of his or her own situation. During the reenactment phase the role players experiment with the alternate behaviors or approaches identified by the participants during feedback and discussion. Experimenting with alternate roles or behaviors is necessary for behavior change. After the role play session, the leader reviews the major components of the situation and those aspects of the role play in which change occurred. Before ending the session, time is allowed for the participants t o unwind from the intensity of the role play process. Operating room nurses use role play methods primarily to teach technical skills such as resuscitation or scrub techniques. Role play, however, may be overlooked as a means for developing new awarenesses, bringing about attitudinal change, and acquiring new interpersonal skills, often required in situations such as preoperative patient interviews, orientation of new staff nurses, coping with crises in the operating room, o r evaluation of nursing staff. Both structured and spontaneous role play techniques enable the OR nurse to try new behaviors or responses to these situations in a safe environment with the benefit of feedback from his or her peers. Structured role play methods, for example, can be effective in defined situations such as preparing the operatingroom nurse for conducting preoperative interviews. During an in-service or orientation program, the group leader may assign two nurses to play the roles of a patient and OR nurse during a preoperative visit. The technique of role reversal is used so each nurse can experience being in both positions. First,
one nurse experiences the interview as if he or she were the patient; the other nurse conducts the interview. Once the nurse playing the part of the patient understands the ramifications of being in the patient's role, he or she switches roles with the interviewer. After this second enactment, the group, the role players, acd leader provide feedback and discussion. Based on this input, the role players reenact the scene once more, experimenting with new approaches and behaviors. The total experience is then reviewed and summarized. Spontaneous role play method can be used for problems that emerge during daily situations. For example, the nurse who usually assists t h e chief of neurosurgery with his difficult cases is on sick leave, and this surgeon has just scheduled a difficult case for the following morning. During a staff meeting, the nursing supervisor assigns another nurse to assist the surgeon. This nurse immediately conveys that she does not feel confident in assisting the surgeon with this case. The supervisor sees this as an opportunity to assist the nurse in coping with this challenge using the role play technique future projection.' By asking the nurse to project herself into the future and visualize herself in the operating room the next day preparing for the operation, the supervisor helps her understand the basis for her reluctance. She is able to gain a more realistic assessment of her abilities t o handle the situation. The process used with this technique is similar to other role play situations because input and feedback are provided by the leader and observers at the end of the enactment. Role play methodology is used by nurses to identify values, attitudes, and feelings about clinical situations; help nursing personnel deal with sensitive subjects in a way that will enable them to discuss them effectively with pa-
AORN Journal, June 1978, Vol27, No 7
1313
tients; and facilitate t h e development of technical and interpersonal skills. Once familiar and comfortable with role play techniques, the nurse in t h e operating room can modify t h e m t o meet the special needs of h i s or h e r w o r k setting, physical plant, and personnel. As suggested in this paper, practical applicat i o n o f both structured and spontaneous role play may enhance preoperative i n t e r v i e w s , a i d in o r i e n t a t i o n and evaluation of nursing staff, and help in coping with changes and crises in t h e operating room. Role play is another means of helping t h e nurse improve or expand h i s or h e r skills. Notes 1. J LMoreno,Psychodrama, vol Ill (Beacon, NY:
Committee for quality health care formed A group of leading hospital administrators and other nonprofit health care officials have joined with a group of architects, building contractors, financing executives, and other suppliers to the health care industry in an effort “to make certain the American public continues to receive the highest possible level of medical service.” The National Committee for Quality Health Care was formed “in the belief that the cost of health care in the United States is rising too rapidly and must be restrained; that a high level of quality must be maintained in the delivery of health care service; and that these two goals are compatible,” according to committee trustee Thomas W Reed, president of Blyth Eastman Dillon Health Care Funding, Inc. The new committee has formulated a ten-point program that, if enacted, would introduce restraints on the rising cost of health care in the United States but, the committee believes, would not sacrifice the quality of service being delivered to patients today. According to the committee, the program would be a better alternative to simply placing an arbitrary limit on annual hospital
1314
Beacon Press, 1969). 2. Howard A Blatner, Acting-/n: Practical Applications of Psychodramatic Methods (New York: Springer Publishing Co, Inc, 1973). 3. Dolores Malo-Juerva, “Seeing is believing,” American Journal of Nursing 21 (September 1973); L Kalisch, “Experiments in empathy with nursing students,” Nursing Research 20 (1971); Daniel L Logan, “Action-oriented group therapy as a training method for psychiatric student nurses,” Journal of Psychiatric Nursing 7 (1969); David J Withersty, “Sex attitudes of hospital personnel: A model for continuing education,” American Journal o f Psychiatry (May 1976). 4. Hannah Weiner, “Psychodrama in law enforcement,” in Psychodrama: Theory and Therapy, I Greenberg, ed. (New York: Behavioral Publication, 1974) 352. 5. Ibid. 6. Adaline Starr, Rehearsal for Living: Psychodrama (Chicago: Nelson Hall, 1977). 7. Blatner, Acting-ln.
capital spending, as suggested by the US Department of Health, Education, and Welfare. The ten-point plan of the committee would 0 limit construction of new hospital beds except in medically underserved areas provide incentives for closing unneeded or seriously underutilized facilities maintain the quality of the physical plant of hospitals strengthen the local planning process by equalizing provider and planner access to professional consultants review proposals for capital expenditures in light of life-cycle costs and potential impact on the local health systems plan encourage cost-effective sharing of hospital services promote reasonable access for all patients to current medical technology adopt incentive-orientedpayment processes in lieu of retrospective reimbursement develop a national data base for capital expenditure policy through survey of local needs demand full use of current cost-containmentauthority during consideration of new strategies.
AORN Journal, June 1978, Vol27, No 7
Diane Reid, R N , MS, is an assistant professor at Arizona State University, Tempe. A diploma graduate of Michael Reese Medical Center, Chicago, she received a BSN from University of Illinois, Chicago, and an MS in psychiatric nursing from St Xavier College, Chicago. Marjorie L Garrity, R N , MS, received a BS
from the University of Bridgeport (Conn) and an MS in psychiatric nursing from Case Western Reserve University, Cleveland. She is an assistant professor at Arizona State University.
1310
ole play is a unique methodology, and its philosophy, techniques, and processes are adaptable for multiple situations and settings. Role play h a s i t s origins i n psychodrama, a method of psychiatric treatment developed by Moreno in the early 1900s.' Until World War 11, psychodrama was used predominantly as a treatment for psychiatric problems. Since then, however, psychodrama has been adapted for other uses, particularly in the fields of business, industry, and education.2 In nursing, role play is frequently incorporated into formal, in-service, and continuing education program^.^ The technique is used (1)t o identify values, attitudes, and feelings in relation to clinical situations; (2) to help nursing personnel learn to deal with sensitive subjects so they can discuss them comfortably with patients or clients; and (3) to facilitate learning, interview, and other process skills. This paper defines and explains role play methodology, describes different role play methods, and illustrates their potential uses to nurses in the operating room. Underlying the philosophy of role play is the belief that man is dynamically involved in a continuous process of personal growth. This growth process has two aspects-personal and interpersonal-and implies that the fully functioning person has multiple facets or roles. Through role play, these roles or their characteristics are explored, discovered, and expanded. An individual is able to gain awareness of himself or herself and to increase his o r her repertoire of behaviors inherent in these roles. Self-awareness is fundamental to personal growth. In spite of one's desire to function a t fullest potential, the process of self-discovery is difficult. One of t h e most common obstacles to selfawareness is a tendency to attribute all
AORN Journal, June 1978, Vol27, N o 7
experience and behavior to one or two roles that have been particularly successful or encouraged. For example, a young schoolboy encouraged and praised for his intellectual performance may have trouble identifying and using his feeling capacities and ability to love as he grows older. The young girl praised for her “cuteness” may have difficulty claiming and using her organizational and intellectual abilities. If, by adulthood, these children have not discovered, claimed, and begun t o use the roles that were not acknowledged when they were young, they may become unidimensional or suffer severe personal and interpersonal difficulties. Awareness, however, is not enough. Awareness of dormant roles and aspects of oneself produces frustration unless they can be comfortably expressed by new behaviors. New behavior feels awkward, self-conscious, o r even threatening when first tried. Therefore, when incorporating a new role, it is important that one is allowed to “practice” the behavior that goes with the new role. Role play affords an opportunity to do just that. The role player is able t o see himself or herself “in action” as old behaviors are revealed and new behaviors are tried in a safe risk-taking atmosphere, which is reinforced by clarifying and supportive feedback. There are two types of role play methods-structured and spontaneous. According to Weiner, “The goal of structured role play is to teach a skill or some systematic approach in dealing with a particular p r ~ b l e r n . ”The ~ focus is on cognitive learning experiences, and objectives include (1)developing specific skills, such as interviewing, leadership, and communication and interpersonal skills, and (2) learning procedures or tasks related to the work situation. In structured role play, the content is determined and “structured” in advance by the leader according to an identified
purpose for each role play session. The leader does not necessarily prepare a skit or specific dialogue; rather, the problem or situation is identified and a framework for the role play is provided. The spontaneous role play method focuses on affective learning. Its goals are to develop insight and t o gain a better understanding of the dynamics of interpersonal r e l a t i o n ~Objectives .~ may include (1) promoting self-discovery, (2) understanding the behavior of others, (3) facilitating attitudinal changes, and (4) increasing one’s ability to cope with change. The content of spontaneous role play is not determined ahead of time. The problem is identified and the scene set up by the members present at the time of the role play session. The leader does not prepare any material in advance but responds to whatever problems or needs emerge spontaneously through group discussion. Integrating components of both structured and spontaneous role play to meet the needs of the individuals concerned is usually advantageous. By understanding the differences and unique contributions of each, the leader can combine them in a creative manner to facilitate an optimal learning experience. The leader should create an atmosphere of spontaneity and safe risktaking at the beginning of a role play experience. Although the end results of role play are enlightening and gratifying, the anticipation of self-exposure and possible criticism from observers creates initial anxiety and discomfort for the role players. Therefore, the leader’s primary task is to be supportive throughout the role play session. This is done in part by helping the group members feel comfortable with one another. Members should be at least acquainted with one another. They should know each others’ names and something about each other. For example, the
AORN Journal, June 1978, V o l 2 7 , No 7
1311
he leader must know when to set limits during role play.
T
leader may ask members of the group to share why they are participating in the role play session, what their expectations are, and what they are feeling in anticipation of the role play experience. Differences and commonalities among individuals are recognized, and a sense of camaraderie begins. To facilitate spontaneity and a willingness to share among participants, the leader cannot be passive. He or she creates a sense of readiness for action by being active, by moving among the group easily and comfortably, and by initiating contact between himself or herself and others and between members of the group. How this occurs will depend on the style and personality of the leader. In addition to creating an atmosphere conducive to an active learning process, the leader is responsible for structuring the role play session so the objectives and ground rules of role play are clear to the group. This includes how and when to participate as role players or observers, how to share observations, and how to suggest alternate behaviors. It is also the leader’s responsibility to know when to set limits during the process to prevent unnecessary self-exposure that might prove to be embarrassing to the individual and impede learning. Also, the leader should define and perhaps model what constructive criticism is in contrast to destructive or blaming remarks, which cause a negative experience for participants. In essence, the functions of the leader demand that he
1312
or she be a resource, catalyst, and source of support for participants in a role play session. Although the goals, objectives, focus, and content of structured and spontaneous role play differ, the method or process of role play is essentially the same. The following stages occur in each situation: (1)warm-up, (2) enactment, (3) feedback and discussion, (4) reenactment, and (5) summary and closure. The warm-up, or the activity preceding the role play, is crucial for its success. The development of a safe atmosphere for this phase is facilitated through structured exercises, informal discussion among members, or a “mini” role play situation presented by the leader for practice. The group is ready to move into the enactment phase when the problem is presented, the interaction relating to the problem specified, and the primary role player or protagonist identified. In this phase, the leader sets the stage and identifies the players. Once the players are familiarized with their roles, action begins. When needed, the leader interrupts the action t o provide clarification, feedback, and to facilitate exploration and understanding of the role players’ behaviors. When the protagonist has acquired a new level of awareness of the situation the role play is stopped. The third phase, feedback and discussion, enables observers to identify their feelings about the enactment and relate these feelings to similar problems of
AORN Journal, June 1978, Vol27, No 7
their own. Through this integration of cognitive and affective aspects, growth occurs in the observers. In addition, the discussion by observers provides the protagonist with additional understanding of his or her own situation. During the reenactment phase the role players experiment with the alternate behaviors or approaches identified by the participants during feedback and discussion. Experimenting with alternate roles or behaviors is necessary for behavior change. After the role play session, the leader reviews the major components of the situation and those aspects of the role play in which change occurred. Before ending the session, time is allowed for the participants t o unwind from the intensity of the role play process. Operating room nurses use role play methods primarily to teach technical skills such as resuscitation or scrub techniques. Role play, however, may be overlooked as a means for developing new awarenesses, bringing about attitudinal change, and acquiring new interpersonal skills, often required in situations such as preoperative patient interviews, orientation of new staff nurses, coping with crises in the operating room, o r evaluation of nursing staff. Both structured and spontaneous role play techniques enable the OR nurse to try new behaviors or responses to these situations in a safe environment with the benefit of feedback from his or her peers. Structured role play methods, for example, can be effective in defined situations such as preparing the operatingroom nurse for conducting preoperative interviews. During an in-service or orientation program, the group leader may assign two nurses to play the roles of a patient and OR nurse during a preoperative visit. The technique of role reversal is used so each nurse can experience being in both positions. First,
one nurse experiences the interview as if he or she were the patient; the other nurse conducts the interview. Once the nurse playing the part of the patient understands the ramifications of being in the patient's role, he or she switches roles with the interviewer. After this second enactment, the group, the role players, acd leader provide feedback and discussion. Based on this input, the role players reenact the scene once more, experimenting with new approaches and behaviors. The total experience is then reviewed and summarized. Spontaneous role play method can be used for problems that emerge during daily situations. For example, the nurse who usually assists t h e chief of neurosurgery with his difficult cases is on sick leave, and this surgeon has just scheduled a difficult case for the following morning. During a staff meeting, the nursing supervisor assigns another nurse to assist the surgeon. This nurse immediately conveys that she does not feel confident in assisting the surgeon with this case. The supervisor sees this as an opportunity to assist the nurse in coping with this challenge using the role play technique future projection.' By asking the nurse to project herself into the future and visualize herself in the operating room the next day preparing for the operation, the supervisor helps her understand the basis for her reluctance. She is able to gain a more realistic assessment of her abilities t o handle the situation. The process used with this technique is similar to other role play situations because input and feedback are provided by the leader and observers at the end of the enactment. Role play methodology is used by nurses to identify values, attitudes, and feelings about clinical situations; help nursing personnel deal with sensitive subjects in a way that will enable them to discuss them effectively with pa-
AORN Journal, June 1978, Vol27, No 7
1313
tients; and facilitate t h e development of technical and interpersonal skills. Once familiar and comfortable with role play techniques, the nurse in t h e operating room can modify t h e m t o meet the special needs of h i s or h e r w o r k setting, physical plant, and personnel. As suggested in this paper, practical applicat i o n o f both structured and spontaneous role play may enhance preoperative i n t e r v i e w s , a i d in o r i e n t a t i o n and evaluation of nursing staff, and help in coping with changes and crises in t h e operating room. Role play is another means of helping t h e nurse improve or expand h i s or h e r skills. Notes 1. J LMoreno,Psychodrama, vol Ill (Beacon, NY:
Committee for quality health care formed A group of leading hospital administrators and other nonprofit health care officials have joined with a group of architects, building contractors, financing executives, and other suppliers to the health care industry in an effort “to make certain the American public continues to receive the highest possible level of medical service.” The National Committee for Quality Health Care was formed “in the belief that the cost of health care in the United States is rising too rapidly and must be restrained; that a high level of quality must be maintained in the delivery of health care service; and that these two goals are compatible,” according to committee trustee Thomas W Reed, president of Blyth Eastman Dillon Health Care Funding, Inc. The new committee has formulated a ten-point program that, if enacted, would introduce restraints on the rising cost of health care in the United States but, the committee believes, would not sacrifice the quality of service being delivered to patients today. According to the committee, the program would be a better alternative to simply placing an arbitrary limit on annual hospital
1314
Beacon Press, 1969). 2. Howard A Blatner, Acting-/n: Practical Applications of Psychodramatic Methods (New York: Springer Publishing Co, Inc, 1973). 3. Dolores Malo-Juerva, “Seeing is believing,” American Journal of Nursing 21 (September 1973); L Kalisch, “Experiments in empathy with nursing students,” Nursing Research 20 (1971); Daniel L Logan, “Action-oriented group therapy as a training method for psychiatric student nurses,” Journal of Psychiatric Nursing 7 (1969); David J Withersty, “Sex attitudes of hospital personnel: A model for continuing education,” American Journal o f Psychiatry (May 1976). 4. Hannah Weiner, “Psychodrama in law enforcement,” in Psychodrama: Theory and Therapy, I Greenberg, ed. (New York: Behavioral Publication, 1974) 352. 5. Ibid. 6. Adaline Starr, Rehearsal for Living: Psychodrama (Chicago: Nelson Hall, 1977). 7. Blatner, Acting-ln.
capital spending, as suggested by the US Department of Health, Education, and Welfare. The ten-point plan of the committee would 0 limit construction of new hospital beds except in medically underserved areas provide incentives for closing unneeded or seriously underutilized facilities maintain the quality of the physical plant of hospitals strengthen the local planning process by equalizing provider and planner access to professional consultants review proposals for capital expenditures in light of life-cycle costs and potential impact on the local health systems plan encourage cost-effective sharing of hospital services promote reasonable access for all patients to current medical technology adopt incentive-orientedpayment processes in lieu of retrospective reimbursement develop a national data base for capital expenditure policy through survey of local needs demand full use of current cost-containmentauthority during consideration of new strategies.
AORN Journal, June 1978, Vol27, No 7
