CHAPTER 12

Games are Multidimensional

in Educational Situations

Lynn Jaffe

Games are central to human experience and an

important way in which it is made meaningful.

—Dormann & Biddle (2006)

Today’s college students and adult learners seek more from academics and inservices than lecture formats (University of North Carolina, 2009). Current technology has fostered reduced attention spans and reinforced students’ reliance on instant gratification and immediate feedback, as well as innovation and novelty to sustain interest in learning situations (Greenfield, 2009; Oblinger, 2006a; Reiner

& Siegel, 2008; Sauve, Renaud, Kaufman, & Marquis, 2007). Games can address these needs because they are experiential and can provide frequent feedback.

Games used for educational purposes, or serious games, are a way to motivate, reinforce skills, and promote collaboration through their experiential format.

There is extensive literature on games theory and gaming in multiple disciplines.

This chapter is an introduction to the use of games as a teaching/learning tool within the classroom or clinical setting. Definitions, evidence regarding practice, and the types of learning that will fit most easily within the various game structures will be described, as will the limitations of game use within the educational or clinical environment.

DEFINITION AND PURPOSE

A game is an activity often classified as fun, governed by precise rules that involve varying degrees of strategy or chance, and one or more players who cooperate or compete (with self, the game, one another, or a computer) through the use of knowledge or skill in an attempt to reach a specified goal (Beylefeld & Struwig, 2007; Sauve et al., 2007). Educational or serious games expect learning benefits for all participants that last beyond the game itself. There are three major categories within the genre: games, simulations, and simulation games.

Game is the generic that includes board, card, and skilled activities. Many simple educational games have popular formats, such as Bingo, Jeopardy, Trivial 175

176 CHAPTER 12 • GAMES ARE MULTIDIMENSIONAL IN EDUCATIONAL SITUATIONS

Pursuit, Monopoly, and Who Wants to Be a Millionaire?, that provide frameworks for inserting content and creating learning activities. These games typically involve a set of rules for player moves and termination criteria so that winners may be determined. The frameworks are easily adaptable to a wide variety of content and instructional objectives usually in the lower cognitive domain areas.

These games have been described in the literature and examples are listed under Additional Resources. Also see Electronic Resources for templates of popular game shows for educational use.

Simulations, in this context, are role playing games and discussed in Chapters 14 and 16. Simulation games are contrived reality-based conflicts that must be resolved within the constraints of the game rules and have been shown to enhance competency development among health professionals (Allery, 2004; Graham

& Richardson, 2008; Sauve et al., 2007). They have the potential to attain new heights of efficacy in digital game formats where they can be used to enhance other aspects of the educational experience than mere review of content. Within authentic contexts, students have the opportunity to get immersed in the game and call on past knowledge and experience to problem solve and make decisions about clients (Oblinger, 2006b; Skiba, 2008).

Debriefing is an important aspect of the learning process that occurs after the game. It is a discussion about the concepts, generalizations, and applications of the topics covered within the game (Gee, 2008; Graham & Richardson, 2008).

This process assists learners in recognizing the learning that has occurred within the fun experience of the game and contributes to the learners’ ability to use self-reflection (Allery, 2004). Effective debriefing requires a good deal of skill and experience in the facilitator and should be allotted as much time as was spent actually playing the game.

ThEORETICAL FOUNDATIONS

The use of games for educational purposes is a very old idea. The earliest recorded use was for war games 3000 years ago in China, in the 18th century in Europe, and, within this century, by the US military. Game use was brought to the business community by ex-officers to provide training in problem solving and decision making. It was considered a bridge between academic instruction and on-the-job training. In the 1950s and 1960s, as the theoretical focus of learning shifted from the instructor to the student, experience-based learning became prominent and games were used to meet this goal. In health-related areas, psychologists and nurses made numerous contributions to the literature on game use in both academic and clinical education, although the research is still inconclusive when judging their effectiveness primarily due to small Conditions for Learning 177

sample sizes, poor operational definitions, and other design flaws (Akl et al.

2008; Beylefeld & Struwig, 2007; Blakely, Skirton, Cooper, Allum, & Nelmes, 2009; Bochennek, Wittekindt, Zimmermann, & Klingebiel, 2007; Royse & Newton, 2007).

Game use falls under the theoretical umbrellas of active learning strategies and cooperative learning described in Chapter 1 and under the concept of flow coined by Csikszentnikhlyi, which refers to a psychological state achieved when learning and enjoyment coincide (Beylefeld & Struwig, 2007). The focus is on actual engagement with both the educational material and classmates, engendering positive attitudes that promote deep processing of the learning experience. It can be intense, absorbing, and motivating (Dormann & Biddle, 2006).

TYPES OF LEARNERS

Games are being used throughout the educational continuum, from preschool through graduate education. They can be used for students who like to compete or for those who prefer to cooperate. For learners with achievement needs games motivate through competitiveness. Games may also be motivating for those with strong affiliation needs because games can require team play and cooperation for completion. The element of luck within an educational game gives all students, not just the studious ones, a chance at winning and thereby keeps engagement higher. Educators must appreciate the different maturational stages students pass through. Adult learners have a particular need to engage meaningfully with content and apply it in a variety of methods, which can be accomplished through the interactive, immediate, and diverse format of gaming.

Games can be structured to require a degree of flexibility on the part of the student to adapt to changing circumstances, especially when addressing the development of interdisciplinary awareness, problem solving, cultural sensitivity, and empathy with clients (Graham & Richardson, 2008; Jarrell, Alpers, Brown,

& Wotring, 2008). Finally, particularly with the use of digital simulation games, some degree of computer/technology comfort is required on the part of both the students and the faculty/trainer. Most millennial and postmillennial students arrive on campus equipped to use Web 2.0 technologies, some faculty need to increase their comfort level.

CONDITIONS FOR LEARNING

Games can be used to address all levels of cognitive objectives, from reinforcing the learning of basic facts, through developing application and analysis skills, and 178 Chapter 12 • Games are multidimensional in eduCational situations culminating in promoting synthesis and evaluation. They do this through the promotion of initiative, creative thought, and affective components within a safe forum for listening to others. Games are credited with supplementing rote memorization, providing useful organization of material, encouraging application of ideas, and providing comic relief from the otherwise anxiety-provoking task of preparing for exams.

Games are inherently student-centered and interactive, generating enthusiasm, excitement, and enjoyment. When new students are asked what their preferred learning style is the predominant answer is usually hands on/experiential. An experiential learning method, such as gaming, creates an environment that requires a participant to be involved in a personally meaningful activity. Fostering a match between teaching strategies and student needs is one of the key factors in effective education. In addition, learning has greater impact when it has an element of emotional arousal, takes place within a safe environment, and has a period of debriefing to provide a cognitive map for understanding the experience (Allery, 2004).

Board or card games tend to be most appropriate for skill-based knowledge and practice in the cognitive domain, such as memorizing or concept matching (Bochennek et al., 2007; Van Eck, 2006). Jeopardy and Trivial Pursuit are quite popular in many disciplines for reviewing course information in such subjects as abnormal psychology and research methods because of the quick mobilization of facts or labels required. In health care, both would lend themselves to reviews in human development, clinical conditions, or other primary knowledge topics.

These games are used to review facts, reinforce or test knowledge and understanding, and foster application (Patel, 2008). The games can be adapted in multiple ways—through the content and through the external attributes of the game itself, such as time limits and the degree of luck built into the format. Crossword puzzles, word searches, and bingo-style games have been used in nursing in-service training to review required materials as well as increase staff attendance and compliance.

Games can also be created for the psychomotor domain; speed of manipulation, safety in transfers, and knowledge of intervention techniques could all be addressed through a game format that would reward an individual or a team.

Simulation games, referred to as adventure games when in digital format, are more adapted to teaching problem solving, hypothesis testing, and the affective domain outcomes. Problem solving is best taught through practice and reflection. Within the format of the simulation game, especially in a computer or video game format, there is more opportunity for such repetition and practice than available during limited classroom or clinical time (Reiner & Siegel, 2008). Video games may also offer consistent assessment of clinical reasoning skills in case study situations of home or clinic visits (Duque, Fung, Mallet, Posel, & Fleiszer, 2008). The potential is there for multiple users in these virtual environments and professional exploration may be accomplished through digital simulation games.

Serious game design works best when communication is built in through blogs, Resources 179

Wikis, and other Web 2.0 technologies (Derryberry, 2007). The time/effort involved in creating such environments becomes more feasible when faced with overloaded clinical placements (Oblinger, 2006b; Skiba, 2008).

RESOURCES

Creating games for the classroom usually takes time, imagination, and desire.

The rewards can be great, although in our productivity-driven age the tradeoffs must be considered. As has been described, the quickest resources are based on those games that are currently available in toy stores or on television. Using the frames of these games requires loading in course material and then it is easy to introduce to the students because of their familiarity with the format.

Web sites that offer templates for such games include:

PowerPoint games at http://jc-schools.net/tutorials/PPT-games/

Game boards at http://jc-schools.net/tutorials/gameboard.htm Crossword puzzles or word games at http://www.crossword-puzzles.co.uk/ or GreenEclipse Crosswords at http://www.eclipsecrossword.com/

Digital games can be explored at ZaidLearn at http://zaidlearn.blogspot

.com/2008/05/75-free-edugames-to-spice-up-your.html

WebQuests has http://www.webquest.org/index.php as a good starting point A more challenging approach is developing the entire game from your imagination, although if you engage small groups from a class to create the game using some of the guiding principles in the next section, this may become more doable (Patel, 2008). Digital game developers have been creating structures that may be available as frameworks for cognitive and affective domain objectives. These frameworks range from addressing the lower/moderate end of knowledge/awareness, as in a WebQuest search for specific information, through to the high-end evaluating/internalizing found in The Pod Game (ZaidLearn) where one is making judgments and decisions under a time constraint. The challenge for the educator is in finding and then using such formats because of the technological knowledge required on top of the content application (Van Eck, 2006). Currently there are only a few such games that are directly applicable to health care. It has been recommended that it is better to make teaching practices more gamelike rather than trying to develop whole games that may actually detract from the educational intent because of the novelty or the development time involved (Begg, 2008).

Additional Resources has a variety of articles describing gaming used in classroom education and in-service training. Some articles specifically target a greater use of technology, such as computer or Web-based games. The references that 180 Chapter 12 • Games are multidimensional in eduCational situations describe active learning and cooperative learning are excellent background information for the new academician and are available online.

USING ThE METhOD: BASIC hOW-TO

Many authors have described the methodology behind using games in the classroom and their advice is summarized in Table 12-1. To begin, games rarely succeed as add-ons, they must be integrated into the overall educational strategy (Ridley, 2004). A game pulled out of nowhere, just to be novel, will have no effect on outcome measures. In essence, when developing a game, the educator must determine the content area, statement of the problem, and objectives of the game. After this, determine the game format, number of players, time frame, and rules. If using a frame game, the generic rules already exist and can be adapted for the topic within health care. The next decisions regard roles players assume and scenarios in which play occurs. These can be simple adaptations for frame games, or more complex if setting up a simulation game of a clinic. The scoring system and physical elements of a frame game tend to remain consistent with the original game; for simulation games they need to be created outright. The media used, whether common materials or specially constructed components, are chosen by the designer based on available time and resources. The game needs to be piloted, critiqued, and possibly revised. Finally, it is beneficial to the community of healthcare educators if the game is then disseminated (Blakely et al., 2008).

Overarching elements that must be considered when using instructional games include the layout and amount of space in the classroom or availability of technology, to ensure equal opportunity to play. Time to be spent during the game with enough time for the debriefing must be planned. Also essential in planning are the method by which the students will become aware of the rules of the game and rewards for results, including whether the rewards are intrinsic or extrinsic.

Remember that for best effect, the game must be integrated into the instructional strategy of the course and directly related to the subject. It must be challenging enough and not feel like work.

POTENTIAL PROBLEMS

Effective use of games in the classroom can be undermined in the ways most strategies fail: poor planning, lack of attention, and lack of follow-up. One example of inappropriate game use stemming from each of these obstacles was the use of a simulation game to evaluate treatment skills. There was a specific scoring sheet to test students on the use of a computer program for cognitive rehabilitation. The students were therapists with faculty clients. This experience Potential Problems 181

Table 12-1 Process for Game Development

Step

Element

Probes

1

Specific objectives for

Do they parallel and/or facilitate the course

game

objectives?

2

Fit within the

Are the concepts relevant? Is this for review or to

curriculum and the

move understanding forward? Is there adequate

environment

functional space for implementation? If digital, are

there enough computers and technical support?

3

Employs conflict

This could be a time limit, competition between

teams, or competition with manager, depending on

the objectives. Does it provide a just-right challenge?

Can the student alter the level of challenge?

4

Rules of play and

Are all the rules known up front, or are they

criterion for closure are learned over time? If there are deadends or elimi-easily communicated

nations, what happens next?

5

It is fun

If not, stop right here and rework or discard

6

Provides immedi-

Do students know how they are doing at all times?

ate feedback to the

Is uncertainty part of the game? Does the feedback

participants

assist the student in modifying beliefs or perfor-

mance in order to improve?

7

Meets the needs of the

Does the game help organize the course material?

students

Is it a reliable measure of their comprehension, or

will it mislead them? Does the game encourage

the players to “laugh with” as opposed to “laugh

at” one another? Is it inclusive in nature?

8

Field-test to eliminate

Did it go as planned, or are there needed

bugs

revisions?

9

Mechanism (such as

Other than student satisfaction, check to see if ac-

pretesting and posttest-

tual learning occurs.

ing) that allows mea-

surement of learning

10

Share it with

Publish or post—there are many educational game

colleagues

Web sites.

182 Chapter 12 • Games are multidimensional in eduCational situations was to provide feedback on the student’s knowledge of the computer program, as well as provide valuable lessons on therapist–client interaction and use of the environment (e.g., paying attention to the physical environment even though they were intervening for a cognitive task). The main drawbacks to this experience were neglecting to emphasize the game nature of the simulation to reduce trepidation and having faculty be the clients, which increased anxiety. More planning would have improved the introduction of the activity. More faculty attention during the experience may have provided the impetus to revise the format so that there could have been peer clients. More knowledge about the use of educational games could have made this a more relaxed and appreciated learning experience.

Other potential pitfalls of game use require the instructor to be aware of:

• Timing: monitoring play, termination, and transition to the next learning activities. Fun activities can take on a life of their own. Simulations (especially) and games reduce control of the timing of the class period, the instructor must be comfortable with that reduced control or it will not work. While spontaneity and flexibility are admirable, there is also a need for planned sequences of activities and firm timekeeping.

• Competition: motivation may be limited to those who win; losing may produce a failure experience that decreases self esteem. Be conscious of all class members and monitor the degree of competition and cooperation required to achieve educational goals.

• Costs of developing and running a game may be high initially: it is quite time-consuming to create or flesh-out even a frame game. In some instances it is no more than developing more test questions (as in Jeopardy or Trivial Pursuit games), but that is often easier said than done. In the case of simulation games, a lot of thought is necessary to create an adequate situation and produce a complete cast of characters with goals and belief systems.

• Needs of all participants may not be met within a simulation or game: Therefore, do not depend on these strategies as solo teaching approaches.

• Closure: Facilitate appropriate debriefing by allowing adequate time for this phase of the learning experience and being an active listener.

CONCLUSION

Games are a suitable supplement for a variety of academic and clinical situations. They are a method of helping students recognize how much they know, or how much they still need to study. Different types have been described, as has the appropriate usage within the wide variety of instructional objectives and References 183

APPLIED EXAMPLES: DESCRIPTIONS OF STRATEGY IN USE

The format of Jeopardy lends itself for review of lots of material. One example was for pre-exam reviews in an undergraduate mental health class for occupational therapy students with categories covering such areas as theories, Diagnostic and Statistical Manual of Mental Disorder (DSM-IV), defense mechanisms, leadership techniques, and pharmaceuticals. The class was divided into three teams.

The regular Jeopardy and Double Jeopardy were employed, although Final Jeopardy was not. Each team had a person designated as the “beeper” and they could col aborate within the team to come up with the question that matched the answer on the overhead projector. Most of the class engaged in the spirit of the game. During the process there was time for discussion and clarification of the topic areas. There were errors made on the exam itself, despite the review, so the game did not lead to the degree of achievement expected. However, it was not formally evaluated nor compared with other methods. The participation and apparent enjoyment of that review class was clear though.

An example of a simulation game used in a class on life span development employed the use of percentage dice rol s that each pair of students used to create families and newborns that would function across the semester to demonstrate typical human development from birth through adolescence. Each newborn had characteristics (motor skil , cognitive level, appearance, longevity, social environment, financial environment, etc.) that would be based on a limited number of dice rol s. The higher the dice rol , the better the performance or status of the attribute to which it was assigned. The students’ first objective was to determine which combination of attributes would lead to the best life outcomes for their children. Was it more important to be very smart, or very attractive? Could you be successful in life with poor motor skil s? After these decisions, there were journaling assignments regarding the development of the children and lots of negotiation between the partners regarding a series of developmental issues, culminating in special dice rol s in adolescence that determined whether the adolescent engaged in smoking and/

or sexual activity, was involved in violence, etc. Student feedback on this experiential assignment was mostly positive, although some did report that it was quite time consuming. The expected degree of learning regarding human development was demonstrated in the journals. However, the greater learning experience was attitudinal change based on the discussions between partners of differing backgrounds and how they managed to cope with some of the unexpected events of these simulated lives.

content in healthcare curriculums. The choice and time management required may seem daunting, but educators have found they enjoyed the respite from standard classroom practice while developing and implementing an educational game. It is well worth the effort.

REFERENCES

Akl, E. A., Sackett, K.M., Pretorius, R., Bhoopathi, P.S., Mustafa, R., Schünemann, H., et al. (2008).

Educational games for health professionals. Cochrane Database of Systematic Reviews, (1), CD006411.

184 Chapter 12 • Games are multidimensional in eduCational situations Allery, L. A. (2004). Educational games and structured experiences (Commentary). Medical Teacher, 26(6), 504–505.

Begg, M. (2008). Leveraging game-informed healthcare education. Medical Teacher, 30, 155–158.

Beylefeld, A. A., & Struwig, M. C. (2007). A gaming approach to learning medical microbiology: students’ experiences of flow. Medical Teacher, 29, 933–940.

Blakely, G., Skirton, H., Cooper, S., Allum, P., & Nelmes, P. (2009). Educational gaming in the health sciences: systematic review. Journal of Advanced Nursing, 65(2), 259–269.

Bochennek, K., Wittekindt, B., Zimmermann, S., & Klingebiel, T. (2007). More than mere games: A review of card and board games for medical education. Medical Teacher, 29, 941–948.

Derryberry, A. (2007). Serious games: online games for learning (White Paper). Retrieved June 20, 2009, from http://www.adobe.com/resources/elearning/pdfs/serious_games_wp.pdf Dormann, C., & Biddle, R. (2006). Humour in game-based learning. Learning, Media and Technology, 31(4), 411–424.

Duque, G., Fung, S., Mallet, L., Posel, N., & Fleiszer, D. (2008). Learning while having fun: The use of video gaming to teach geriatric house calls to medical students. Journal of American Geriatric Society, 56, 1328–1332.

Gee, J. P. (2008). Learning and games. In K. Salen (Ed.), The ecology of games: Connecting youth, hames, and learning (pp. 21–40). Cambridge, MA: MIT Press.

Graham, I., & Richardson, E. (2008) Experiential gaming to facilitate cultural awareness: its implication for developing emotional caring in nursing. Learning in Health and Social Care, 7, 37–45.

Greenfield, P. M. (2009). Technology and informal education: What is taught, what is learned. Science, 323, 69–71.

Jarrell, K., Alpers, R., Brown, G., & Wotring, R. (2008). Using BaFa’ BaFa’ in evaluating cultural competence of nursing students. Teaching and Learning in Nursing, 3, 141–142.

Oblinger, D. (2006a). Games and learning. EDUCAUSE Quarterly, 29(3), 5–7.

Oblinger, D. (2006b). Simulations, games, and learning. EDUCAUSE Learning Initiative. Retrieved June 24, 2009, from http://www.educause.edu/ELI/SimulationsGamesandLearning/156764

Patel, J. (2008). Using game format in small group classes for pharmacotherapeutics case studies.

American Journal of Pharmaceutical Education, 72(1), 1–5.

Reiner, B., & Siegel, E. (2008). The potential for gaming techniques in radiology education and practice. Journal of the American College of Radiology, 5, 110–114.

Ridley, R. T. (2004). Classroom games are COOL: Collaborative opportunities of learning. Nurse Educator, 29(2), 47–48.

Royse, M. A., & Newton, S. E. (2007). How gaming is used as an innovative strategy for nursing education. Nursing Education Perspectives, 28(5), 263–267.

Sauve, L., Renaud, L., Kaufman, D., & Marquis, J. (2007). Distinguishing between games and simulations: A systematic review. Educational Technology & Society, 10(3), 247–256.

Skiba, D. J. (2008). Nursing education 2.0: Games as pedagogical platforms. Nursing Education Perspectives, 29(3), 174–175.

University of North Carolina. (2009). Eshelman School of Pharmacy learning & teaching resources.

Retrieved June 20, 2009 from http://www.pharmacy.unc.edu/labs/teaching-resources/nuts-and-bolts-for-teaching-and-learning/students-and-learning-styles/millennial-students Van Eck, R. (2006). Digital game-based learning: It’s not just the digital natives who are restless.

EDUCAUSE Review, 41(2), 16–30.

Additional Resources 185

ADDITIONAL RESOURCES

Cowen, K. J., & Tesh, A. S. (2002). Effects of gaming on nursing students’ knowledge of pediatric cardiovascular dysfunction. Journal of Nursing Education, 41(11), 507–509.

Dologite, K. A., Willner, K. C., Klepeiss, D. J., York, S. A., & Cericola, L. M. (2003). Sharpen customer service skills with PCRAFT Pursuit©. Journal for Nurses in Staff Development, 19(1), 47–51.

Flanagan, N., & McCausland, L. (2007). Teaching around the cycle: Strategies for teaching theory to undergraduate nursing students. Nursing Education Perspectives, 28, 310–314.

Gifford, K. E. (2001). Using instructional games: A teaching strategy for increasing student participation and retention. Occupational Therapy in Health Care, 15, 13–21.

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Masters, K. (2005). Development and use of an educator-developed community assessment board game. Nurse Educator, 30(5), 189–190.

Morton, P. G., & Tarvin, L. (2001). The pain game: Pain assessment, management, and related JCAHO

standards. Journal of Continuing Education in Nursing, 32(5), 223–227.

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CHAPTER 13

Role Play

Arlene J. Lowenstein

DEFINITION AND PURPOSES

Role play is a dramatic technique that encourages participants to impro-vise behaviors that illustrate expected actions of persons involved in defined situations. A scenario is outlined and character roles are assigned. The drama is usually unscripted, relying on spontaneous interplay among characters to provide material about reactions and behaviors for students to analyze following the presentation. Those class members that are not assigned character roles participate as observers and contribute to the analysis.

Part of the category of simulation, role play allows participants to explore why people behave as they do. Participants can test behaviors and decisions in an environment that allows experimentation without risk. The scenario and behaviors of the actors are analyzed and discussed to provide opportunity to clarify feelings, increase observational skills, provide rationale for potential behaviors, and anticipate reactions to decisions. New behaviors can be suggested and tried in response to the analysis.

Role play is used to enable students to practice interacting with others in certain roles and to afford them an opportunity to experience other people’s reactions to actions they have taken. The scenario provides a background for the problem and outlines the constraints that may apply. Defining the important characteristics of the major players establishes role expectations and provides a framework for behaviors and actions to be elicited. The postplay discussion provides opportunity for analysis and new strategy formation.

Although it is a dramatic technique, the focus is on the actions of the characters and not on acting ability. An actor plays to the audience; the role player plays to the characters in the scenario. The audience also has a role, that of observing the interplay among characters and analyzing the dynamics occurring.

The instructor’s role is that of facilitator rather than director. The impetus for the 187

188 CHAPTER 13 • ROLE PLAY

analysis and discussion belongs with the learners. The instructor’s role is more passive, clarifying, and gently guiding.

Clinical simulations often incorporate role play. Although the simulation computer and mannequin provides the physiological issues in the scenario, students or faculty members may play the human roles, such as the doctor or family members. The computer operator may also provide a voice for the patient, to which the nurse needs to relate, and allows for better assessment of a patient’s response to issues such as anxiety or pain. The use of role play allows the nurse providing care to the simulated patient to work in a more realistic environment, and requires reactions to more complexity in the situation. Smith-Stoner used high-fidelity simulation together with role play to provide a scenario where a student nurse, who was caring for a simulated patient who died during the scenario, needed to interact with the family member, who was in the room. The exercise allowed the students in the class to explore their attitudes toward death and caring for dying patients (Smith-Stoner, 2009).

Role play can also be used in online courses. Although there may be no person-to-person drama, a scenario can be set up, parts assigned, and the conversation could be carried out in a chat room or on the discussion board. Riddle (2009) noted that online educational role plays engage students in the learning, and can be an improvement over didactic teaching strategies alone. Online role play systems afford students the opportunity of acting and doing instead of only reading and listening.

Role play is a particularly effective means for developing decision-making and problem-solving skills (Hess & Gilgannon, 1985). Imholz (2008) studied clinical research on psychodrama practice of role play, looking at the therapeutic activity that has both cognitive and emotional outcomes of the role play as change agent, but also as a process that contributes to personal growth. Through role play the learner can identify the systematic steps in the process of making judgments and decisions. The problem-solving process—identification of the problem, data collection and evaluation of possible outcomes, exploration of alternatives, and arrival at a decision to be implemented—can be analyzed in the context of the role play situation. The scenario can include reactions to the implementation of the decision as well as the evaluation and reformulation process (Alden, 1999; Domazzo & Hanson, 1977). Role play has also been used to increase student cultural awareness, aiding in the development of cultural competence in patient care (Shearer & Davidhizar, 2003).

Role play provides immediate feedback to learners regarding their success in using interpersonal skills as well as decision-making and problem-solving skills.

At the same time, role play offers learners an opportunity to become actively involved in the learning experience but in a nonthreatening environment. Role play is not limited to use in the classroom. Corless et al. (2004) successfully used role play as a student assignment that required the adoption of a persona of a person Conditions 189

with HIV who was required to take a number of medications over a specific period of time. Students carried out the role play in their homes, taking placebos in place of medication over a specific time frame. Their experiences in following the HIV regime was then discussed in class, leading to an awareness of the difficulties patients faced in following the regime. Role play is also being used as a teaching strategy in online courses (Mar, Chabal, Anderson, & Vore, 2003).

THEORETICAL RATIONALE

Role play developed in response to the need to affect attitudinal changes in psychotherapy and counseling (Shaffer & Galinsky, 1974). Psychodrama, a fore-runner of role play, was developed by Moreno as a psychotherapy technique.

Moreno brought psychodrama to the United States in 1925 and continued to develop it during the 1940s and 1950s (Moreno, 1946). In psychodrama, players may be required to recite specific lines or answer specific questions and may represent themselves, whereas in role play players are encouraged to express their thoughts and feelings spontaneously, as if they were the persons whose roles they are playing (Sharon & Sharon, 1976).

Psychodrama provided a foundation for further development of role play as an educational technique. Corsini (1957) and other psychotherapists and group dynamicists began using role play to assist patients to clarify people’s behavior toward each other. Further development led to the use of role play in sensitivity training, a technique that became popular in the 1970s. Human relations and sensitivity training events share a common educational strategy. The learners in the group are encouraged to become involved in examining their thought patterns, perceptions, feelings, and inadequacies. The training events are also designed to encourage each learner with the support of fellow learners to invent and experiment with different patterns of functioning (Gordon, 1970). Role play can be used to meet those educational objectives and is often used in human relations and sensitivity training but has many other uses as well. DeNeve and Hepner (1997), in a study comparing role play to traditional lectures, found that students believed that the use of role play was stimulating and valuable in comparison to the traditional lecture method, their learning increased, and they remembered what they had learned.

CONDITIONS

Role playing is a versatile technique that can be used in a wide variety of situations. One set of learning objectives might be role play dealing with the 190 Chapter 13 • role play

practice of skills and techniques, whereas another different group of objectives would use role play to deal with changes in understanding, feelings, and attitudes.

Van Ments (1983) points out that role play is conducted differently for these two sets of learning objectives. The role play used for the practice of skills may be planned with the emphasis on outcome and overcoming problems. The second type of objective may be best met with an emphasis on the problems and relationships. This method explores why certain behaviors are exhibited and requires expertise from the instructor in dealing with emotions and human behavior. The teacher is responsible for helping the students to avoid the negative effects that could come from the exploration of their feelings and behaviors.

PLANNING AND MODIFYING

Teachers who are new to the technique need to plan before class, but they should monitor the needs of the group as the experience progresses and be able to modify those plans if necessary. The situation developed should be familiar enough so that learners can understand the roles and their potential responses, but it should not have too direct a relationship to students’ own personal problems (McKeachie, 2002). It can also be effective to use two or more presentations of the same situation with different students in the roles if the objective is to point out different responses or solutions to a given problem. When that method is used, the instructor may choose to keep those students involved in the second presentation away from viewing the first presentation, to avoid biasing their reactions. The same role play scenario can be used throughout the semester to allow students to react to changing events within the same scenario (Rabinowitz, 1997).

Role play strategy qualifies as an adult-learning approach because it presents a real life situation and tries to stimulate the involvement of the student. It has special value because it uses peer evaluation and involves active participation.

However, it must be carefully guided to be sure participants have an understanding of the objectives and that feedback received from other players is congruent with outcomes that would exist in the real world (Mann & Corsun, 2002).

TYPES OF LEARNERS

Role play is appropriate for undergraduate and graduate students. It is especially effective in staff development programs because of its association with reality. It is used effectively to reach affective outcomes. Role play can be simple or complex, depending on the learning objectives. Regardless of the simplicity of the play itself, it is important to allow adequate time for planning, preparing the Using the Method 191

students for the experience, and postplay discussion and analysis. The actual role play may be as brief as 5 minutes, although 10 to 20 minutes is more common.

Van Ments (1983) suggests that the technique be broken into three sections: briefing, running, and debriefing. Equal amounts of time may be spent for each session for simple objectives, or a ratio of 1:2:3, with most time spent on the debriefing or analysis, for more complex learning objectives.

RESOURCES

Role play can be used in most settings, although tiered lecture rooms may inhibit the ability of the players to relate to each other and to the observing students. In that setting, the theatricality of the technique is likely to be emphasized over the needed behavioral focus (Van Ments, 1983). Special equipment or props may be simple or not used at all, again depending on the objectives. An instructor may choose to use video or audio taping. This can be especially helpful to review portions of the action during the debriefing and analysis section. Reviewing tapes may also be helpful for participating students who, because of their roles, were not in the room to hear and see some of the interaction that occurred in other role plays.

Outside resources are not usually needed for most role play situations, although additional instructors, trained observers, or specific experts may appropriately be used to meet certain objectives. The technique is best for small groups of students so that those not involved in the character parts can be actively involved in observing and discussing the action in the debriefing or analyzing portion. Van Ments (1983) found role play increasingly unsatisfactory as a technique in groups with more than 20 to 25 students, although there may be exceptions, depending on objectives and strategies for involving the audience.

USING THE METHOD

Planning is crucial to effective use of role play as a learning technique. It may be helpful to pilot the exercise before running it in the class situation to allow the instructor to anticipate potential problems and evaluate if the learning objectives can be met. Discussing critical elements of the role play with colleagues can be useful if full-scale piloting is not feasible. A small amount of time going through the plans with someone else may prevent a critical element from going wrong and disrupting the exercise (Van Ments, 1983).

Selecting a scenario and deciding on character roles is an important part of planning. McKeachie (2002) cautions that situations involving morals or subjects 192 Chapter 13 • role play

of high emotional significance, such as sexual taboos, are apt to be traumatic to some students. He found that the most interesting situations, and those revealing the greatest differences in responses, are those involving some choice or conflict of motives. Student input into planning can also be effective.

To implement the role play, the scenario and characters need to be described briefly but with enough information to elicit responses that will meet the learning objectives. This planning is extremely important for obtaining good results.

Spontaneity should be encouraged, so it is preferable to avoid a script, other than bare outlines of the action. Although spontaneity is valued in character dialogue, students need to have a clear understanding of their characters and their basic attitude and/or thought patterns. In some instances, spontaneity in the character description area could compromise the objectives and results, but if students understand the expected character, they can still be spontaneous within the character parameters. Allowing students in the character roles to have a few minutes to warm up and relate to the roles they will be playing is often helpful.

Observing students absolutely must be briefed on their role. Enough time must be allotted for discussion and analysis of the action. The debriefing following the role play also allows for evaluation of the success in meeting the learning objectives.

In addition to the development of learning objectives and planning, the instructor is responsible for setting the stage for the role play, monitoring the action, and leading the analysis. Students need a clear understanding of the objectives, the scenario, the characters they are to play, the importance of the role of the observers, and the analysis as a vital part of the process. On occasion, the instructor may take a character role, but usually character roles are given to students.

When planning a role play session, the instructor needs to be concerned with the amount of time students may be excluded from the room while waiting for their turn to participate. This issue is especially important when two or more presentations of the same situation are to be used, or the role play has characters that should not be exposed to the dialogue that occurs before they appear in their roles. It is important to avoid the need for the excluded students to roam the cor-ridors with nothing to do for long periods.

In some instances, it may be appropriate to have students switch roles during the role play. This technique can be useful if the group is large and more students need to be involved in the action. This approach also may provide students with an opportunity to see and feel different reactions to similar situations. Another example of when to use this technique might be when the objective is to learn how to conduct a group. Students may benefit by playing group member and switching to leader or vice versa during the exercise.

The instructor needs to encourage students to respond to interactions in the role play in a spontaneous, natural manner, avoiding melodrama and inappropriate Potential Problems 193

laughing or silliness. Effective use of role play focuses on student participation and interaction. The instructor, as facilitator, channels the discussion to meet the learning objectives but avoids monopolizing the play or discussion. The instructor must also be able to monitor and control the depth of emotional responses to the situation or interplay as needed; terminating the play when the objective has been met or the emotional climate calls for intervention.

Students need to understand the importance of playing the character roles in ways in which they believe those characters would act in a real life situation (Mann

& Corsun, 2002). Students in the observer role must be strongly encouraged to present their observations and contribute to the discussion and analysis. Students can also take part in the developing role play scenarios; identifying their learning objectives, issues, and problems they feel need to be explored; and identifying scenarios that may provide that exploration.

Role play can be used in the online environment using the same basic principles, but with some differences, since the characters will not be visible to each other or to the audience (Mar et al., 2003). A synchronous environment, where all parties are online at the same time, will allow for a written dialogue flow between parties, with more similarity to an actual conversation (Phillips, 2005). An asynchronous environment, where parties log on at different times, will take longer to carry out the scenario, and may not have as much spontaneity, but can be as effective (Lebaron & Miller, 2005). As in all cases of role play, designing an online role play will depend on the learning objectives.

POTENTIAL PROBLEMS

Van Ments (1983) refers to the “hidden agenda” and warns that stereotyping may occur as roles are presented, often reflecting the expectations and values of the students or the teacher. This stereotyping may lead to unanticipated learning that can reinforce prejudices and preconceptions. Instructors need to be aware of this possibility and avoid writing in stereotypes. They should describe only functions, powers, and constraints of the role described. Roles should be rotated to avoid over-identification of one student with a specific role. In the debriefing session, the students are invited to question and challenge assumptions.

Students may not always make a distinction between an actor and a role.

Criticism of the student playing the role must be avoided, while allowing for critique of the behavior of the role character. The instructor must be aware of the emotional tones involved in the role play and channel the emotions into activities that will lead to successful attainment of the learning objectives.

Planning and learning objectives should determine the course of the role play.

Students may take the role play in an unexpected direction, possibly because 194 Chapter 13 • role play

they have a need to explore another issue or problem. If it is not appropriate to revise the learning objectives to accommodate student needs, then the play can be terminated. In that case, the postplay discussion can be used to assist students in recognizing why the technique was not effective. Students should advise how to improve the role play or develop a different teaching strategy. Repeating a scenario with the same or different characters can sometimes afford a more in depth examination and add to the experience.

The instructor and students need to be aware that this is not a professional drama. Some students, because of stage fright, shyness, or other reasons, do not like participating (Middleton, 2005; Turner, 2005). Although at times it may be appropriate to change actors, if the role play does not seem to be going well, it is important not to blame the students. In most cases, the teaching strategy needs changing, rather than the actors. If that is understood and addressed, role play can be an effective and creative strategy to provide active student participation to meet specific learning objectives.

Example Role Play

Shawna Patrick

BACKGROUND

The use of mock trials in nursing education has been an effective teaching method used to make nurses aware of the legal implications of nursing practice. In a lawsuit, nurses are typically charged with negligence. Negligence is defined as, “failure to act as a reasonably prudent person would have acted in specific circumstances” (Chitty & Black, 2007). There are six major categories of negligence that may result in malpractice lawsuits including failure to follow standards of care, failure to use equipment in a responsible manner, failure to communicate, failure to document, failure to assess and monitor, and failure to act as a patient advocate (Chitty & Black, 2007).

In a lawsuit, there are four elements of negligence that the plaintiff must prove by a preponderance of the evidence to demonstrate that a nurse was liable for a patient’s injury. First, duty to treat, the nurse accepted the duty to care for and treat the patient. Second, breach of duty, the nurse breached that duty typically by failing to meet the standard of care. Third, causation, the breach of duty was the proximate cause of the patients harm. Fourth, damages, the injury and the nurse’s negligence caused damage or losses to the patient. Consider these elements in the following mock trial role play.

Instructions

1. Read the mock trial role play and the standards of care for dehydration and hypokalemia (Box 13-1). Assign staff to play the roles of bailiff, attorney, witness, and judge and provide them with the script in advance so they can practice before class.

2. The day of class, review the following with jury members: standards of care in question (Box 13-1), courtroom procedure (Box 13-2), and hospital summary. Next, explain the Potential Problems 195

role of the jury, including instructions concerning how to prove negligence by the four elements, based on a preponderance of the evidence presented in court.

3. Final y, conduct the mock trial role play as described here and conclude the mock trial with jury deliberation and determination of a verdict. (Fig. 13-1 provides the layout for the classroom/courtroom.) Provide follow-up discussion with the class to talk about why and how the jury reached its decision.

4. note: The education team is responsible for providing support to staff, educating staff as mentioned here, facilitating the mock trial, serving as a moderator for jury deliberation, and facilitating classroom discussion following the mock trial.

Role Key

J: Judge

B: Bailiff

da: defendant attorney

Pa: Plaintiff attorney

MS: Martha Smith, widow

kJ: kathy Jones, Rn

dW: amy Brown, defendant expert witness

PW: Mary Johnson, plaintiff expert witness

Mock TRIal RolE Play

Hospital Summary

John Smith, age 55, arrived in the Emergency department (Ed) on January 10, 2009, at 11 PM.

He complained of severe nausea and vomiting for the past 3 days and muscle weakness for the past 1 day. He presented with hypotension (blood pressure [BP] 90/60), tachycardia (heart rate [HR] 110), and decreased serum potassium (potassium [k] 1.8 mEq). after evaluation by the Ed physician, he was diagnosed with dehydration and hypokalemia. He was given 2 liters of normal saline intravenous (IV), 4-mg Zofran IV, and started on a continuous infusion of normal saline with 20-mEq potassium at 100 ml/hour. a Foley catheter was inserted with a 50 ml return of urine; and strict intake and output measurements were ordered every 2 hours. He was placed on continuous cardiac monitoring and admitted to the Medical-Surgical Telemetry unit at 1 AM. The admitting physician ordered 3 doses of 10-mEq potassium/100-ml normal saline IV over 1 hour per dose. The unit was extremely busy and understaffed. kathy Jones, the admitting nurse, was assigned eight patients instead of the hospital’s standard nurse to patient ratio of five patients per one nurse for the medical-surgical telemetry unit. no one was available to help kathy, so she took it upon herself to mix the potassium infusion and administer the first dose. However, instead of mixing 10 mEq of potassium in 100-ml normal saline, she mixed 100 mEq of potassium in 100-ml normal saline. Fifteen minutes after the start of the infusion, kathy returned to John’s room to assess his tolerance of the potassium infusion. When she entered the room, she noticed that John was unable to arouse and the cardiac monitor showed ventricular tachycardia. a code blue was cal ed and resuscitative measures were taken, but they were unsuccessful. John Smith was pronounced dead at 1:45 AM on January 11, 2009. The family is suing kathy Jones for negligence.

Calling of the Case

Bailiff (B): all rise, the court of Mountain Valley Hospital is now in session. Honorable Judge X

presiding. (The judge will be seated and will strike the gavel three times.) 196 Chapter 13 • role play

Judge (J): you may be seated. We are assembled to hear the case of John Smith v. Kathy Jones. are both attorneys ready to present opening statements? (Both answer, “yes.”) Plaintiff Opening Statement

John Smith was a loving husband and dedicated father of four children. He was a caring man and diligent provider. His death was tragic and the direct result of negligent nursing care by kathy Jones, who gave him 10 times the prescribed dose of potassium on the night of January 10. you wil hear from his widow, Martha, how his premature death caused total devastation for her family. The defendant will try to convince you that kathy Jones was not the cause of John’s death. That, considering the circumstances, she acted as a reasonably prudent nurse would. They wil encourage you to make a decision based on the poor management of her nursing unit and the number of patients she was assigned.

Members of the jury, I will show you solid evidence that kathy Jones was negligent and blatantly neglected to fol ow hospital policy. as a result, John Smith died from a total y preventable error.

Defendant Opening Statement

kathy Jones is a competent, dedicated nurse committed to the safety of all patients. She has been a registered nurse (Rn) for 20 years and has never been proven to have caused harm to any patient.

Today, the plaintiff will try to disprove the competence of kathy Jones and tell you that she was the direct cause of John Smith’s death. They will tell you that she neglected to treat him appropriately.

They will have his widow, Martha, testify to persuade you to make a decision based solely on emotions, not facts. I will prove that kathy behaved in a manner consistent with the normal care of a patient diagnosed with dehydration and hypokalemia. I wil prove that John’s death was a tragic and utter mistake related to the mismanagement of kathy’s nursing unit and the unsafe number of patients assigned to her. Members of the jury, I urge you to look at the facts of the case and the diligent care that was given John. I ask you to put yourself in kathy Jones’ shoes so you can see that her only goal was to help John.

Plaintiff’s Case

J: Is the plaintiff prepared to call its first witness?

Plaintiff attorney (Pa): yes, your honor. The plaintiff calls Martha Smith to the witness stand.

B: Please state your name.

Martha Smith (MS): Martha Smith

B: Please raise your right hand (she does). do you swear to tell the truth, the whole truth, and nothing but the truth? If so, answer “I do.”

MS: I do.

B: Thank you, you may be seated.

Pa: Hi, Mrs. Smith. can you tell me about your relation to the patient in question, John Smith?

MS: John was my husband for the last 30 years.

Pa: do you have any children?

MS: yes, we have four beautiful children; two boys, ages 10 and 12, and two girls, ages 14 and 16.

Pa: Tell me about John’s occupation, length of employment, and annual income.

MS: He was a stock broker for the last 25 years and made about $125,000/year.

Pa: Tell me about your relationship with John.

MS: amazing. He was the love of my life. We were high school sweethearts and kept the love growing for the past 30 years. I don’t know what I wil do without him.

Potential Problems 197

Pa: When you visited John briefly on the night of January 10, how did he appear to you?

MS: He had been sick for the previous 3 days but after he was given the medicine for nausea, he looked a little better.

Pa: What has been the impact of this tragic event on your family?

MS: We are completely devastated. He was the breadwinner of the family and we counted on him for everything. I have never worked because I stayed home to raise the children. I don’t know how we’ll manage financially; I just don’t know what we will do.

Pa: Thank you Mrs. Smith, the plaintiff has no further questions for this witness.

J: Would the defendant like to cross-examine this witness?

defendant attorney (da): yes, your honor. Mrs. Smith, you said you are a homemaker, is that correct?

MS: yes, that’s correct.

da: So you have no formal medical training, do you?

MS: no, I don’t.

da: So when you said that your husband, “looked a little better,” you really didn’t know that he was getting better, did you?

MS: no.

da: Were you at the hospital at the time of John’s death?

MS: no, I wasn’t.

da: So you don’t specifically know what happened to cause his death, do you?

MS: no, I don’t.

da: The defendant has no further questions for this witness.

J: The witness may step down. Would the plaintiff like to call another witness?

Pa: yes, your honor. The plaintiff calls Mary Johnson to the stand.

B: Please state your name.

Plaintiff Expert Witness (PW): Mary Johnson

B: Please raise your right hand (she does). do you swear to tell the truth, the whole truth, and nothing but the truth? If so, answer “I do.”

PW: I do.

B: Thank you, you may be seated.

Pa: Hi, Ms. Johnson, can you tell me about your professional experience?

PW: I have been an Rn for 25 years. I worked on a medical-surgical unit for the first 15 years of my career and have been working as a legal nurse consultant for the past 10 years.

Pa: What is your educational background?

PW: I have a Bachelor of Science degree in nursing and certifications in Medical-Surgical nursing and legal nurse consulting.

Pa: What is your background with caring for patients with dehydration and hypokalemia?

PW: I have cared for hundreds of patients with both of these conditions.

Pa: Based on your experience with patients diagnosed with dehydration and hypokalemia, you are deemed an expert on these subjects?

PW: yes, I am.

Pa: Have you reviewed the facts of the case including the medical record and hospital policy?

PW: yes, I have.

198 Chapter 13 • role play

Pa: do you believe that you have a good understanding of the case?

PW: yes, I do.

Pa: given the facts, did kathy Jones comply with the standard of care for dehydration and hypokalemia?

PW: no, she did not. She neglected to fol ow hospital policy. She mixed the potassium independently without having a second nurse double check her. She also mixed 10 times the dose of potassium that was ordered and administered this to John.

Pa: could giving 10 times the dose of potassium cause death?

PW: yes, giving that much can cause lethal cardiac dysrhythmias, which can lead to death.

Pa: The plaintiff has no further questions for this witness.

J: Would the defendant like to cross-examine this witness?

da: yes, your honor. Ms. Johnson, are you a practicing nurse?

PW: I was for the first 15 years of my nursing career, but have been working as a legal nurse consultant for the past 10 years.

da: So, you haven’t cared for a patient with dehydration and/or hypokalemia for at least 10 years, is that correct?

PW: yes, but . . .

da: So, you don’t know what the current standards of care are for dehydration and hypokalemia?

PW: I would imagine they haven’t changed too much.

da: Please answer either yes or no.

PW: no.

da: So you don’t know for a fact that kathy Jones actions directly caused John to die, do you?

PW: no, I don’t, but . . .

da: no further questions for this witness.

J: The witness may step down.

Defendant’s Case

J: Would the defendant like to call its first witness?

da: yes, your honor. The defendant calls kathy Jones to the witness stand.

B: Please state your name.

kathy Jones (kJ): kathy Jones

B: Please raise your right hand (she does). do you swear to tell the truth, the whole truth, and nothing but the truth? If so, answer “I do.”

kJ: I do.

B: Thank you, you may be seated.

da: Hi, Ms. Jones, how long have you been a practicing nurse?

kJ: For the past 20 years.

da: can you tell me about your professional experience, including where you currently work?

kJ: I have worked at Mountain Val ey Hospital in the medical-surgical telemetry unit for the past 20 years.

da: What was your initial assessment of John on the night of January 10? What was he being treated for?

kJ: When I assumed care of John, he was being treated for dehydration and hypokalemia. He was calm and he did not appear to be in any acute distress.

da: What type of education did you receive at Mountain Valley Hospital in regard to treating a patient with hypokalemia?

Potential Problems 199

kJ: We are required to read the policy for potassium administration and take a test every year to demonstrate competence.

da: and did you complete this annual education?

kJ: yes, I did.

da: What type of education did you receive in regard to dehydration?

kJ: We are not required to complete this education annual y because it is a basic condition that I am routinely exposed to and have learned about in nursing school.

da: Tel me about the medical-surgical telemetry unit and your patient assignments on the night of January 10.

kJ: The unit was completely filled with patients. We had two nurses call in sick so we were severely understaffed. We are usually assigned five patients each, but because of understaffing, I was assigned to eight patients.

da: did you feel like you could safely accept the assignment of eight patients?

kJ: Well, no, but I didn’t have a choice. I spoke with the house supervisor but there weren’t any other nurses to pull from. The patients needed a nurse and I had to do the best I could.

da: Is it a common practice at your hospital for nurses to mix potassium infusions for patients?

kJ: It is common on the night shift because there is not a pharmacist in the hospital at night.

Pharmacists are only in the hospital during the day shift.

da: So on the night of January 10, did you mix the potassium infusion yourself?

kJ: yes, I did. I was worried about John because his potassium level in the Ed was 1.8 mEq, which is considered critically low. The other nurses on the unit were also assigned eight patients and no one could help me at that time.

da: If you did not give the potassium upon his arrival to your unit, what could have happened to John?

kJ: He could have died from a lethal arrhythmia.

da: So you were acting in the best interest of John?

kJ: yes, I was.

da: The defendant has no further questions for this witness.

Pa: Ms. Jones, isn’t it true that your hospital policy dictates that a second nurse must double check any potassium infusion that is mixed by a nurse?

kJ: yes.

Pa: Isn’t it true that potassium is considered a high-alert medication and can quickly cause lethal arrhythmias if mixed and administered incorrectly?

kJ: yes.

Pa: But, you stated that your unit was understaffed, so did you mix the potassium and give it without double checking it with another nurse?

kJ: yes.

Pa: So you neglected to follow your hospitals policy?

kJ: yes, but . . .

Pa: and what was the ultimate outcome for John after you administered the potassium infusion?

kJ: We tried to resuscitate him but he died.

Pa: The plaintiff has no further questions for this witness.

J: The witness may step down.

200 Chapter 13 • role play

da: The defendant calls amy Brown to the stand.

B: Please state your name.

defense Expert Witness (dW): amy Brown

B: Please raise your right hand (she does). do you swear to tell the truth, the whole truth, and nothing but the truth? If so, answer “I do.”

dW: I do.

B: Thank you, you may be seated.

da: Ms. Brown, are you a practicing nurse?

dW: yes.

da: Tell me about your professional experience.

dW: I have been an Rn for the past 18 years and have worked on a medical-surgical telemetry unit my entire career. I have also worked as a legal nurse consultant for the past 5 years on a part-time basis.

da: What is your experience with the standards of care for dehydration and hypokalemia?

dW: I have cared for thousands of patients with these conditions as they are very common conditions seen on my nursing unit.

da: Based on your experience with dehydration and hypokalemia, you are deemed an expert on these conditions?

dW: yes, I am.

da: Have you had a chance to review the facts of the case such as evaluating the medical record and hospital policies related to these conditions?

dW: yes, I have.

da: In your expert opinion, did kathy Jones comply with the standards of care for dehydration and hypokalemia?

dW: yes, she did.

da: Were the actions of kathy Jones the direct cause of John’s death?

dW: no, they weren’t. He could have died without the potassium.

da: The defendant has no further questions for this witness.

J: Would the plaintiff like to cross-examine this witness?

Pa: yes, your honor. Ms. Brown, you stated that you reviewed the hospital policy for hypokalemia and potassium administration, is that correct?

dW: yes, I did.

Pa: did you read that all potassium infusions mixed by a nurse must be double checked with a second nurse before administration?

dW: yes.

Pa: Isn’t it true that kathy just testified that she did not have a second nurse double check the potassium infusion prior to administration and this is reflected in the medication record?

dW: yes.

Pa: So kathy Jones did not follow the hospital’s policy regarding hypokalemia and potassium administration, did she?

dW: no, she didn’t, but . . .

Pa: and isn’t it true that giving too much potassium quickly can cause lethal arrhythmias?

dW: yes.

Pa: and remind me again, what was the outcome for John?

Potential Problems 201

dW: He was pronounced dead after aggressive resuscitative measures were taken.

Pa: The plaintiff has no further questions.

J: The witness may step down. are the plaintiff and defendant prepared to give their closing arguments? (Both say “yes.”)

Plaintiff Closing Argument

Today we have proven that kathy Jones was negligent in the care of John Smith. We have demonstrated that Ms. Jones was knowledgeable of the policy regarding hypokalemia and potassium administration, but chose to breach hospital policy. She mixed potassium, a dangerous high-alert medication, and administered it to John without having a second nurse double check it. as a result, Ms. Jones gave 10 times the prescribed amount resulting in John’s untimely death. The family is devastated both emotionally and financially. John was the breadwinner of the family and now they wil have to struggle for food and shelter. Members of the jury, we urge you to make the right decision and find kathy Jones liable for the death of John Smith.

Defendant Closing Argument

on the night of January 10, kathy Jones’ nursing unit was severely understaffed and poorly managed. kathy was assigned to care for eight patients, three more than the hospitals standard nurse to patient staffing ratio, and no one was available to help her. We have told you how John could have died without the potassium infusion and how kathy was doing her best to give it to him quickly in order to save his life. In her 20 years as a professional nurse, kathy has never been proven to cause harm to any patient and this trend continues today. Members of the jury, we urge you to look at the facts of the case so you can see that John’s death was a tragic mistake, and not the result of negligent care by kathy Jones. We implore you to find kathy Jones not liable.

J: We wil now proceed with jury deliberation and determination of a verdict. If the jury determines that the defendant, kathy Jones, deviated from the standard of care for dehydration and hypokalemia, the jury must find in favor of the plaintiff. If the jury determines that the defendant did not deviate from the standards of care for dehydration and hypokalemia, then the jury must find in favor of the defendant. The jury will now deliberate and determine a verdict of liable or not liable. If the verdict is liable, the jury will award compensation for damages incurred by the plaintiff.

Box 13-1 Standard of care Summary for dehydration and Hypokalemia dEHydRaTIon

Signs and Symptoms

dry eyes and/or mouth, fever, vomiting, postural hypotension, change in mental status, pulse

 100 beats/minute and/or systolic blood pressure  100 mm Hg, dizziness, and/or lethargy and weakness.

Diagnosis

The following criteria must be present to make a clinical diagnosis of dehydration:

O Suspicion of increased urinary output and/or decreased oral intake

O a minimum of two signs or symptoms of dehydration

202 Chapter 13 • role play

O a blood urea nitrogen (Bun)/creatinine ratio of  25:1; orthostasis defined as a drop in systolic blood pressure  20 mm Hg with a change in position; heart rate of  100 beats/

minute; or a change of 10 to 20 beats/minute above baseline heart rate with a change in position (national guideline clearinghouse, n.d.).

Monitoring

Fluid intake and output, blood chemistry including sodium and potassium, and urinalysis including osmolality and specific gravity.

Treatment

O If the patient is able, offer oral fluids by mouth. If the patient is unable to tolerate oral replacement, IV rehydration is necessary.

O For mild to moderate volume depletion, a safe regimen is to administer isotonic saline at 50

to 100 ml per hour in excess of continued losses.

O For severe volume depletion, 1 to 2 liters of isotonic saline should be given rapidly and continued at a rapid rate until clinical signs stabilize (Rose, 2008a).

HyPokalEMIa

Diagnosis

O Mild to moderate hypokalemia is defined by serum potassium between 3.0 and 3.5 mEq/l and does not typically cause symptoms.

O Severe hypokalemia is defined by serum potassium less than 2.5 to 3.0 mEq/l or by symptoms including arrhythmias and marked muscle weakness (Rose, 2008).

Treatment

O If serum potassium is 3 to 3.5 mEq/l, administer 40 to100 mEq daily divided into 2 to 3 doses, with no more than 20 mEq given per dose.

O If serum potassium greater than 2.5 mEq/l, administer 10 to 15 mEq/hour IV, up to a maximum of 200 mEq/day.

O If serum potassium less than 2 mEq/l, administer 20 to 40 mEq/hour IV with continuous cardiac monitoring, up to a maximum of 400 mEq/day (“Potassium,”2009).

Box 13-2 courtroom Procedure

1. cal ing of the case: Typical y announced as, “al rise. The court of X is now in session.

Honorable Judge X presiding.” The judge wil then be seated and wil cal the court to order by striking the gavel three times, and stating, “you may be seated.”

2. opening Statements: used to present a story to the judge and jury about the facts surrounding the case and the evidence they wil present during the trial. The plaintiff presents first, followed by the defendant.

3. Plaintiff’s case: The plaintiff’s attorney presents testimony through examination of their witnesses with direct examination questions, fol owed by cross-examination questions Potential Problems 203

by the defendant’s attorney, and completed with redirect examination questions by the plaintiff’s attorney, if necessary. This process is repeated for each of the plaintiff’s witnesses.

4. defendant’s case: The process for examining witnesses is the same as for the plaintiff except the defendant’s attorney cal s their witnesses first, fol owed by the plaintiff’s cross-examination, and completed with redirect examination by the defendant’s attorney, if necessary.

5. closing arguments: used by each side to summarize the testimony and evidence they presented during trial in order to sway the jury in their favor. The plaintiff’s attorney presents first, followed by the defendant’s attorney.

6. Jury deliberations: The jury deliberates about the testimony and evidence among themselves and determines a verdict for the defendant. note: Before the trial, the judge wil provide the jury with instructions about how they should judge the case based on the claim.

7. Verdict announcement: The verdict is announced and damages are awarded if the defendant is found liable.

Source: Patrick, S. (2008). The mock trial method: An innovative approach to nursing education.

Aspen, Colorado: Nurses for Nursing.

Figure 13-1 Courtroom Layout: A, attorney; B, bailiff; D, defendant; J, judge; P, plaintiff; W, witness stand.

J

W

B

J

u

r

y

D/A

P/A

Expert Witness/Spectator Seating

(Source: Patrick, S. (2008). The mock trial method: An innovative approach to nursing education.

Aspen, Colorado: Nurses for Nursing.)

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