Tutting Words into Action' project:using roie piay in sidiis training

Debbie Lewis, Marie O'Boyle-Duggan, Jim Chapman, Philip Dee,Katharina Seiiner and Stevie Gorman

AbstractResearch highlights the need to use experienced role-players withskilled facilitation to deliver effective communication skills training(CST) but this is challenging in a large faculty of health. In thispilot project, students from Birmingham City University*s Schoolof Acting and role-players from the Learning Disability nursingprogramme received role-player training (Phase I) before delivering26 CST sessions to 520 first year BSc nursing students (Phase 0),using role-plays based on clinical scenarios in adult, mental health,learning disability and children's nursing. A pre- and post-sessionsurvey assessed student confidence, with feedback gathered fromrole-players, and facilitators. Pre-session confidence levels in studentswho participated and observed the role-play were similar, and usingWilcoxon and Mann Whitney non-parametric tests, a statisticallysignificant increase in post-session confidence levels was demonstratedacross all four fields of nursing. This increase in confidence applied torole-play participating students and observers, although role-playingstudents gained the largest confidence increase. A Higher EducationAcademy Collaborative Grant extended the project in 2012/13.

Key words: Simulation • Communication • Education • Nursing• Roleplay

The Nursing and Midwifery Council (NMC)educational standards for pre-registracion nursing(Box 1) highlight communication and interpersonalskills, across all fields of nursing, as a key feature

of effective nursing practice (NMC, 2011). Such standardsare timely in a challenging healthcare environment, withshorter hospital stays, more seriously ill patients anddramatic increases in the elderly population leading to arenewed emphasis on patient education and self-care inchronic illness (Department of Health, 2001). Complaintsabout a lack of care and compassion in dealing withpatients' concerns are common place (Patients Association,2012) and there are specific concerns regarding clientswith developmental disability (M.ENCAP, 2012), whoincreasingly receive care in general rather than long-stayfacihties (Phillips, 2012).

Debbie Lewis, Marie O'Boylc-Diiggan.Jini Chapman and Philip Dee

are Senior Lecturers; Katharina Seilncr is Third Year Drama Student and

Stevie Gorman is Professional Role-player at Faculty of Health,

Birmingham City University',.

Accepted for ptibiicnlion: May 2013

Such care issues heighten the need to develop nursingstudents' communication skills to assess patient and carerneeds, establish trust, to demonstrate empathy and to addressthe often forgotten, but important, psychosocial concerns (DelPiccolo et al, 2011). On entering a healthcare environment,many student nurses are anxious about interacting withpatients and children who may be exhibiting physical aaidpsychiatric conditions of which they have no experience(Kanieg et ai, 2009). Redesigning a BSc (Hons) programmeat Birmingham Cit>' University's large Faculty of Healthto meet the new NMC educational standards provided anopportunity to improve communication skills training (CST),with firmer integration into the curriculum. To supplementa lecture style teaching session promoting SOLER (Eg?n,2010) {Box 2), active listening, effective questioning, reflectingback and paraphrasing, 520 first year students from fournursing fields participated in a two-hour simulation-basedCST session using drama students and existing role-playersalready used in the Learning Disabilities nursing programme.Phase 1 of the project,'Putting Words into Action', focused onrole-player training and Phase II on session implementation.

What do we know about communicationskills training?Early Audit Commission (AC, 1993) reports lijikcommunication skills to high patient satisfaction, greatercompliance and recovery, although evidence suggests limitedsuccess in obtaining this aim within the NHS (NursingTimes, 2012). Acquiring these skills and the confidenceto communicate effectively with patients, has been left topractitioners to gain from experience or by luck. Within pre-registration nurse education there is evidence of confusionin deciding what needs to be taught, varying degrees ofprovision and a lack of field-specific training (Chant et al,2002). Few nurses receive training on dealing with issuesrelated to end-of-life care, diíFicult emotional situationssuch as dealing with distress or anger, or communicatingon the telephone, although these are common activities.When training has been provided there is a tendency towardsmechanistic skills checklists or using counselling models,which may not be transferable to all practice areas (Boschmaet al, 2010) rather than relational communication, whichmay help nurses deal effectively with issues and demonstratecompassion and empathy. The need to progress from simpleto complex skills throughout the undergraduate programmeis recognised (Boschma et al, 2010), but rarely achieved, andeffective evaluation of CST has also been lacking (Kruijver etal 2000, Chant et al, 2002).

638 British Journal ofNurîing, 2013.Vol 22. No t l

EDUCATION AND TRAINING

In the UK and elsewhere, health practitioners' CSTeducation has been informed by research including randomisedcontrolled trials. Maguire et al (1996) demonstrated the valueof using simulated patients to promote open questioning toelicit psychological as well as physical concerns, and to reducegiving advice prematurely Fallowfield et al (2002, 2003) usedvideo-recorded simulations, highlighting the longevity ofrole-play-based CST. No skills attrition was seen 12-15 monthspost-training in participants who had previously shown skillsimprovement. Such experiential learning promotes thepersonal involvement of students stimulating feelings andthe cognitive aspects of communication following the cycleof learning. This was developed by Kolb (1984), wherebysimulation of a skill with debriefing is followed by reflectionin order to inform practice and aid performance (Aldridgeand Wanless, 2012). Although recent national initiatives havefocused on oncology and palliative care staff (Connected,2012) using role-play in CST is becoming more commonplace for staff working with chronic diseases such as heartfailure (Wilkinson et al, 2008) and with learning difficulties(O'Boyle-Duggan et al, 2012). In addition to practicingkey skills, such training promotes the value of therapeuticcommunication moving between the patients physical andpsychological needs, which may be neglected in practice(Kruijver et al, 2001). It may also raise awareness of blockingbehaviours when professionals ignore discussion of emotionalor challenging issues despite receiving cues from patients thatthey would welcome the opportunity to discuss fears. Theadditional time needed to make reasonable adjustments forclients with complex communication needs, such as thosewith learning difficulties, is required by the Equahty Act(2010), and is an area of deficiency highlighted by MENCAP(2012). Practitioners often cite a lack of time to communicateeffectively with such patients (Hemsley et al, 2011), thoughthe use of good skills is not necessarily more time consuming(Fallowfield et al, 2003).

Phase I—^Training role-playersSimulated patients and carers for role-play may be laypersons,staff or other students. Often in CST, such as the nationaUyaccredited Connected (2012) programme, professional actors,specifically trained for working with health practitioners, helpteach practitioners how to interact with clients during clinicalencounters. Tliis allows a teachable moment to be created,giving students constructive feedback on their performancein a supportive environment. Although used for some time inmedical education (Rees et al, 2003), using professional actors isprohibitively expensive for large cohorts of nursing students soin this project alternative options were sought.

Using inhouse pilot funding Phase I increased the poolof role-players within the faculty by training four third yearstudents from Birmingham City University's School of Actingand three existing role-players from the learning disabilitiesfield of nursing. The group participated in a two-day role-

3 player training programme {Box 3) to standardise practiceI and provide a common level of training for all role-players.Í Already well-versed in aspects of communication, such asg observing non-verbal behaviours, being attentive, hsteninge and responding to cues, finding a common language with the

Box I. Nursing and Midwifery Council (NMC) Standards for Pre-RegistrationNursing (NMC, 2010)

Nurses must be able to:-• Communicate safely and effectively• Build therapeutic relationships taldng into account differences, capabilities and needs• Be able to engage in, maintain, and disengage ffom therapeutic relationships• Use a range of communication kills and technologies• Use verbal, non-verbal and written communication• Recognise the need for an interpreter• Address communication in diversity• Promote well-being and personal safety• Identify ways to communicate and promote healthy behaviour• Maintain accurate, clear and complete written or electronic records• Respect and protect confidential information

Box 2. SOLER—A modei of non-verbal behaviours conveying attention (tgan, 2GI0)

Square-on position facing towards the patient

Open position

Leaning towards the interviewee

Eye contact

Relaxed position

Box 3. Role-player training programme

I What is the job of a professional role-player? How does it differ from stage andscreen acting?

I Naming the skills - What skills do we want to promote?I The value of care, compassion and empathy? How can students demonstrate it'I What do you need to do as a communication skills training (CST) role-player?D Preparing for role-playD Using pre-written scenario• Giving constructive feedbackD The value of a lay person's perspectiveD Establishing a suitable playing levelD Flexibility and improvisation

I Practising role-plays and giving feedbackI Role-playing sensitive issues and self-care strategies

drama students proved easier than anticipated. The trainingincluded identifying key communication skills, practicingrole-plays and giving feedback in role including viewingvideos of best and worst practice to generate discussion. Therole-player training was also useful in developing writtenscenarios based on commonly occurring issues (Box 4).Whenwritten initially these did not include suflîcient demographicinformation for reahstic re-enactment by actors—withmedical and nursing jargon also a barrier to understandingthe scenario. Redesigning them in collaboration with, therole-players included discussion of differing playing levelsrelated to difEculty and identifying a degree of challengesuitable for first-year nursing students, although in practicethe skill and confidence exhibited between nursing groupsvaried widely. CST often involves exploration of emotionalissues such as serious illness, disabilities and end-of-life care,so role-player training included the value of giving sensitivefeedback, adequate debriefing and self-supportive strategiessuch as withdrawing from topics close to personal difficulties.Feedback after the two days highlighted the benefits ofintegrating actors and clinicians with exisdng facultyrole-players, valuing the opportunity of seeing drama students'

Britishjournal of Nursing, 2013, Vol 22, No 11 639

Box 4. Role-play scenarios

Adult nursing

I After a ward round responding to patient's request 'What does palliative mean?'I Responding to a shocked and distressed patient after a consultation in anoutpatient ciinic

I Helping an irritable and aggressive older patient who is unlikely to be able toreturn home

I Approaching a relative of a large extended family who are staying on the wardbeyond normal visiting times

Mental health

I Approaching a patient having found a half-empty whisky bottle under their bedI Helping an aggressive, bed-bound patient who has been moved from anotherward and is suffering nicotine withdrawal

I Dealing with an approach from a patient to meet up with them for a drink aftertheir discharge from ihe ward

Children's nursing

I Discussing the care of a baby with a cold v̂ nth her anxious and socicOIy isolated motherI Gaining dialogue with a withdrawn adolescent patient with cystic fibrosis after thedeath of their close friend

Learning disabilities

I Assessing pain in a patient with moderate learning difficulties and limited speechwho wants to return to her home

I Managing a patient in casualty with autism and limited speech wlx) wants toremove a head dressing

Box 5. Pendleton s Rules for Feedback (Garala et al, 2007)

I The student participating in the roIe-pIay has the opportunity to talk first and isencouraged to discuss positive points

I The participating student has the opportunity to suggest alternative strategies toimprove their performance

I The observing group are invited to provide feedback but again positive points arerequired first

I The facilitator and group can provide constructive feedback on the areas identifiedwith care taken to ensure comments are not given in a negative manner

Box 6. Survey items—Pre- and post-assessment of confidence

Nominal data

I Branch of nursingI Participant and/or observer

Ordinal data—Quantification of confidence In:-

I Approaching patients to explain a nursing procedureI Ability to use key skills e.g. SOLER, open questioning, eliciting patient concernsI Exploring patient cuesI Identifying patient and relative concernsI Explaining professional boundaries to patients and relativesI Handling strong emotions such ¿is anger or distressI Communicating with specific patient groups e.g. learning disabilities, children,those with mental health issues or dementia

skills in action and drama students highlighting the benefitsof clinicians' experience in role-playing clients with mild,moderate and severe learning diíFiculties.

Phase II—Implementing the Xommunlcation 2Skills' sessionsIn Phase 11, 26 two-hour sessions were delivered before thefirst year students' first clinical placement, with volunteer

faculty lecturers as faciÜtators. A lesson plan and writtenfacilitator guidance was provided before the session, alongwith session ground rules and feedback strategy. Workshop-style training for facilitators was offered to promote competentfacilitation of each session, as recommended by Byland et al(2009). Due to time pressures and the experience of manylecturers, this was not taken up, but a facilitators' guidancesheet was well received. Informally, facilitators also contactedproject team members for advice and tips particularly withregard to obtaining role-play participant volunteers in lessconfident groups.

Ground rules and the feedback strategy were reinforcedat the start of each class with an emphasis on activenon-judgmental participation from facilitators, role-players,student volunteers and observers alike. Giving individualfeedback during role-plays was based on Pendleton's Rules{Garala et al, 2007) (ßo.\- 5), a strategy widely used in medicaleducation to give constructive feedback on performance.This helped focus on the students' positive achievementsbefore constructive suggestions for improvement, helpingto avoid humiliation, and generating a supportive learningenvironment to encourage student participation. Ea:hsession included two facilitators and one role-player, withfield-specific groups of between nine and 20 students. Explicitwithin the ground rules was a student's right to withdrawfrom the class if a role-play topic was too closely related toa personal difficulty, though this happened rarely. An initialice-breaking exercise, which deliberately incorporated anelement of surprise, was popular and useful in gaining activeparticipation in the quieter groups.

How successful were the sessions?Student evaluationsEvidence suggests CST is poorly evaluated (Chant et al, 2002),so a systematic approach to session evaluation was taken to assessthe effectiveness of this method in teaching students. Studentswere asked to voluntarily complete an anonymous pre- andpost-session survey quantifying their level of confidence incominunicating with patients in practical nursing activitiesand emotional issues. Of approximately 520 first-year studentswho participated in the CST, a representative sample of300 completed the evaluation exercise at the start and endof the teaching sessions. In total, 290 surveys were returriedat the close of the session with 82 students able to take partin the role-play (identified here as participants) and a further196 students observing and giving feedback to move therole-play to a satisfactory resolution (observers).Twelve studentsdid not give their identifying group in the questionnaire.Students were asked to add their field of nursing, namelyadult, mental health, learning disabilities or children's nursing.Ignoring'missing' data in the form of incomplete surveys, 271completed questionnaires were returned.

Survey data focused on the students' level of confidencebefore and after the teaching sessions using a Likert scale linkedto seven variables such as explaining a nursing task, respondingto patients verbal and non-verbal cues, explaining professionalboundaries, dealing with strong emotions and communicatingwith patients with specific issues such as dementia and learningdisability {Box 6). On the survey, students were also given

640 British Journal of Nursing, 2013,Vol 22, Nc 11

EDUCATION AND TRAINING

the opportunity to add additional comments which were alsocollated.Written feedback on the sessions from the role-playersand the facilitators was also requested.

Quantitative analysisStatistics were gathered using a 10-point Likert scale measuringconfidences across various themes within the questionnaire,both before and after the CST. Though there are nostandardised values of acceptable levels of confidence, suchstatistical techniques have been used to assess communicationcompetence in delivering clinical skills (SookYoo et al, 2010)and it is a technique commonly used by CST specialists(Wükinson et al 1998, 2008). A useful visualisation of thepre- and post-session confidence scores for the survey as awhole is shown in Figure Í. As the data is at an ordinal levelrather than interval or ratio (Polit and Hungler, 1999) themedian scores allow a quick comparison of pre- and post-confidence scores to determine if there are any areas ofimmediate interest. Table 1 illustrates that for the pre-sessionquestions, there was a lower general level of confidence amongthe students (median=6) compared to the same students post-session (median=8) suggesting both role-play participants andobservers benefited from the teaching session.

As the data was ordinal in nature, non-parametric inferentialtests were used to demonstrate if these differences were'real' and unlikely to be due to chance. The WOcoxon test(see Table 1) revealed a statistically significant increase inconfidence following the teaching session with Z=-13.091,p<0.0005, and with a large effect size (r=0.56).The effectsizes have been calculated and interpreted according toCohen (1988) using the recommended groupings (0.1=smalleffect; 0.3=medium effect; 0.5=large effect). Table 1 showsthe Wilcoxon test results when applied across the fields,illustrating that this global picture is essentially rephcated inaU fields. All differences have a p-value well below 0.05 (i.e.below 5%) and are therefore statistically significant.

Quantitative analysis was helpful in identifying that bothparticipants and observers benefit firom the CST sessionswhich, building on previous faculty research, added to existingknowledge (O' Boyle-Duggan et al, 2012) {Table 2). Alldifferences seen are statistically significant with the exceptionof the learning disability participant group, as only four surveyswere returned in this group. Applying the Wilcoxon test it canbe shown that, variable-by-variable, there is an improvementin confidence comparing pre-session and post-session. Splittingthe data into the two groups of participants and observers.Appendix 1 also demonstrates the amount of improvementin confidence (the 'effect size') is generally larger in theparticipant group compared to the observer group.This may beexplained as the act of participation possibly leading to a greatersense of'ownership' in the topic of communication, whereasobservers may feel less engaged in the session. To establish ifthis difference between participants and observers is 'real' andnot due to chance, the Mann Whitney statistical test was used

3 to give a 'between groups' comparison. This illustrated a small1 positive effect size between observers and participants (rangingJ fi-om r=0.132 to r=0.219) and as the statistical significance (p)2 is less than 0.05 in most cases the differences between theseo two groups is very unlikely to be due to chance.

30

25

10

Pre-sessionPost-session

Figure 1. Response frequencies totalled for all seven questions pre-session and all seven questionspost-session (no other splitting of data)

Table 1. Pre- and post-session Wiicoxon Test of ali measures of confidence

Branch

Mentalhealth

Learningdisabiiity

Child

Adult

N

31

11

57

171

Medianpre-session

6

6

6

6

Medianpost-session

7

7

7

8

Z

-3.798

-2.803

-6.263

-10.463

P

<0.0005

0.005

<0.0005

<0.0005

r

0.48(medium)

0.60 (large)

0.59 (large)

0.57 (large)

Tabie 2. Pre- and post-session of aii measures of confidence (median) acrossfieids for observers and participants

NursingBranch

Mentalhealth

Learningdisability

Child

Aduit

Observerpre-session

6

6

6

6

Observerpost-session

7

8

7

8

Participantpre-session

6

6

6

6

Participantpost-session

7

7

8

8

Qualitative analysisQualitative analysis in this project -ivas limited and this hasbeen highlighted as an area for future project developmentusing a Higher Education Academy Collaborative Grant.Students were encouraged to add free text comments to thesurvey and although the number of free text comments wassmall they were predominately positive, focusing on the valueof this style of learning. As one student notes:

'Talk to them and ask questions—will allow themto open up. This session taught me to concentratesolely on patient (sic.) and relatives and themexpressing their concerns'.

Other comments were similarly positive, with only onerespondent suggesting the session had not been helpful.Students also highlighted the need for repeated practice, withone student noting:

'Need practice to gain confidence and becomemore competent'.

British Journal of Nursing, 2013, Vol 22, No 11 641

Appendix 1. Pre- and post-session Wilcoxon Tests for observer andparticipant groups for ail fieids dispiaying effect size

Variables

NProcedures &vN Proced uresPost

KeySkillsAbility &vKeySkillsAbilityPost

ExplorPtCues ßvExplorPtCuesPost

PtRelConcerns &.PtRel Concerns Post

ProfessBoundaries &.ProfessBou ndari es Post

StrongEmotions &.StrongEmotionPost

ComsConfSpecGroups &.ComsConßpecGroupsPost

Observer Effect Size, r

0.460(medium)

0.464(medium)

O.5Í5(large)

0.46 i(medium)

0.448(medium)

0.362(medium)

0.399(medium)

Participant Effect Size, r

0.510(large)

0.478(medium)

0.552(large)

0.508(large)

0.441(medium)

0.398(medium)

0.398(medium)

Box 7. Facilitator competencies (Byiand et al, 2009)

Single occuiTence items

I Makes introductions

I Estabiishes rules of roie-piay

I Normalises anxiety

I Allows time for reading/discussing role-play

I Discusses the patient's potential needs

Maintaining a iearn er-centred environment

I Invites learner's feedback first

I Stays focused on the learner's need's and agendas

I Elicits learning goals

I Assesses if learning needs are met

Managing the role-play

I Gives the actor direction

I Ensures the learner understands the starting point

Faciiftating Feedback

I Facilitates a balance of positive and constructive feedback

I Invites positive feedback first

I Reinforces specific communication skills

I Uses video playback to reinforce learning

Involving the group

I Invites all group members to give feedback

I Involves all group members in addressing challenges or solving problems

timeI Allocates time equally among learners

Using a predominately quantitative survey to collectqualitative data was largely unfruitful and other qualitativeresearch techniques such as in-depth interviewing or focusgroups will be used in future to collect a more detailedanalysis of the students' CST experience. Specificallyidentifying what aspects of the CST were actively usedin clinical practice would be helpful along with a greaterunderstanding of the communication issues nursingstudents encounter both inter-professionally and withpatients, clients and carers. More information may also helpthe development of CST across all three years of the BScNursing programme.

Facilitator feedbackFeedback collated from facilitators and role-players suggestí;dthe ground rules and feedback strategy was helpful inprotecting all participants in the sessions from unnecessarystress and emotional burden. Guidance in the form of asession pack was well received and informal conversationswith project team members did take place to clarifyteaching issues. Gaining student cooperation was easier whenfacilitators stressed that students were not being required toact, only to 'be themselves', thereby fulfilling their role asa student nurse. Though the art of enlisting volunteers wasrecognised as a skill that facilitators can develop. Facilitatorsdid suggest the CST may have improved students intheir performance in other fields such as in an ObjectiveStructured Clinical Examination (OSCEs) held shortlyafter the sessions. This is perhaps unsurprising as verbal andnon-verbal communications skills are recognised as a criticalcomponent of patient consultations (Collins et al, 2011), andin nursing even practical procedures require communicationcompetence (SookYoo et al, 2010).

There was no formal assessment of the facilitators'competence though evidence suggests this can be a key factorin ensuring effective CST (Byiand et al, 2009). Facilitationcompetencies have been designed for CST {Box 7} withstandards being taught, reinforced, and reassessment advocatedto maintain the quality of training. It is acknowledged thatsome skills are more easily acquired than others, such asmaking introductions, giving the actor direction and invitinglearner feedback first. More difficult tasks include discussingthe patient's potential needs, summarising learning andinvolving group members in solving problems. Regular peerreview with individual feedback is also recommended (Byiandet al, 2009). In the light of this evidence, promoting facilitatorcompetencies and prompting feedback between facilitatorsmay be a useful development in future CST sessions.

Role-player feedbackThe role-players' feedback stressed the satisfaction they feltin using their acting expertise to help health professionalsdevelop key skills for clinical practice. A drama studentcommented:

*I guess all of us have been in a situation wherewe have been misunderstood by a nurse ordoctor and it is a great feeling to see all of thesetalented young people really try to get to thebottom of a problem...'

It was also helpful to their own development with onerole-player noting:

*Personally, I loved working as a role-player. Itgave me a chance to work a little more on myimprovisation skills and respond immediately towhatever the student nurse came up with in thescenario. They seem to have fully understood intheory how to approach a patient and were verykeen to try out everything they had learned*.

Although some role-players already working in learningdisabilities nursing had clinical experience, most role-players

642 British Journal of Nursing, 2013, Vo! 22, No 11

EDUCATION AND TRAINING

had not and were therefore able to give a lay person's viewof the participating student's performance. This can be veryuseful in highlighting to nursing students unhelpful aspectsof communication in clinical practice, such as the use ofjargon, as well as promoting discussion on issues such as theuse of touch, the individuality of emotional responses andwhat may be as a compassionate and empathie approach.Negative comments from role-players related to the problemsof drama students and clinical staff balancing role-playingsessions with the requirements of academic courses or chnicalpractice. Although seven role-players were initially trainedthis proved inadequate to meet the needs of a large faculty ofhealth. Since the initial 26 sessions, the majority of the dramastudents have undertaken additional CST sessions within thefaculty, expanding the repertoire of their work. This may bea useful bridge between university and their employment.

Practical issues and recommendationsfor the futureIn a large faculty of health, adding experiential sessions to thecurriculum has the capacity to increase lecturers' workloads,though this did not prove to be a barrier to implementingchanges. A coordinator—the role undertaken here by alecturer—is also needed to contact role-players, organisetheir attendance and ensure they arrive in the classroom ingood time. The long-term benefits of the session to studentsalso need to be assessed. Some debriefing is usually requiredbetween facihtator and role-player before and after thesession. If, as happened occasionally, an actor was unable toattend at short notice another lecturer or one of the twofacilitators undertook the acting role. Although this wasappreciated by facihtators, the actors were considered bythe .facilitators as more effective. There were costs incurredincluding the role-player training and an hourly rate paid tothe role-players. Initially funded as a pilot project, the projecthas been successful in attracting an HEA Grant CollaborativeGrant to develop the initiative. Working in collaborationwith a primary care trust and two hospices it is hoped todevelop first-year nursing CST sessions and pilot sessions,with increasing complexity in the second and final years—perhaps video-recording role-plays to promote reflection.Such a vision is supported by Waters and Whyte (2012) whoalso suggest communication skills should be taught withincreasing levels of complexity throughout the three yearsof nurse training.

ConclusionUsing role-players within CST is a productive way ofintroducing student nurses across all fields to communicationskills that may assist them in clinical practice. It appears, inaddition, to be a useful way of exposing students to issuesmore commonly encountered in other fields, enhancingtheir repertoire of skills. Notably, the scenarios highlightedthe commonality of mental health and emotional issues as

3 well as the need to assist patients with learning difficulties,1 and making reasonable adjustments to ensure care equality.^ The latter may be particularly pertinent in view of the2 rising concern of care of people with learning difficulties,o particularly at the end of hfe. Drama students acting as

KEY POINTSI Research indicates effective communication si<iils training (CST- recuüresexperiential iearning using roie-play and skiiied faciiitation, including constructivefeedback for students

I Large student numbers and financiai constraints can nnai<e the integration ofexperiential communication training in a iarge facuity of heaith challenging

lUsing drama students to undertake the roie of patients and cara-s iscost-effective and mutually beneficial

I Using pre-written scenarios focusing on commonly occurring issues inadult, mental health, learning disabilities and children's nursing can raisestudents' awareness of the range of communication issues they will encounterin clinical practice

I Statistical analysis of confidence levels suggests the differences bet»veenpre- and post-session scores have statistical and clinical significance across allfields x)f nursing

role-players are a cost effective means of providing suchteaching and it appears to be a useful addition to their ownportfolio. Providing a structure for such sessions is helpfulin providing a protective and supportive environment withsuccess perhaps improving performance in OSCE styleexaminations. Such teaching should be integrated into ailthree years of a nursing programme, although further researchis needed to assess the benefits of such teaching in chnicslpractice and on patients. D Q

Conflict of interest: none

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