This study was a scholarship study with ethical cod IR.MARAGHEHPHC.REC.1399.014 from Maragheh University of medical sciences. In the first stage, after implementing the teaching method of role model, students' satisfaction was evaluated using a self-made tool, and a semester later, they were re-examined to check the durability of the material. For this purpose, students who had passed the health examination in the previous semesters with the usual course method were also re-examined. Using interviews with faculty and clinical nurses, possible changes in students in higher semesters in terms of content retention, ability and self-confidence of students in physical examination and taking patient history were examined and their opinions were summarized and analyzed by thematic analysis.
Role model method
According to the role-playing method of Cherif, Verma and Somervill (1998), role-playing activities are divided into four stages [15]. In the first stage includes the preparation and description of the course activities by the instructor. In this stage, in order to prepare the group, by a clear description of the problem or using examples and asking questions, students were stimulated to think, and educational videos were used or what happened in the hospital was expressed on a case-by-case basis to denote the importance of the issue and motivate students.
In the second stage, which is to prepare students for the activity, the instructor introduced the students to the characteristics of the examiner and who it is? How does it feel? What will he do? Who helps him and.... Then he asked the students to volunteer to play a role in which the instructor played the role of examiner. With the help of the intern and the student, the private environment was prepared for the examination and the equipment and facilities needed for the examination were made available to the instructor and the students. Observers were then actively engaged to observe the examination performed by the instructor as a nurse on one of the students playing the role of patient so that they could analyze it. The instructor assigned tasks to the observers; e.g., Determining certain introductions to evaluate the implemented roles, their closeness to the existing realities, interpreting the effectiveness, the consequences of the behavior of the role players, etc. Of course, it should be noted that the instructor conducted the examination in the middle of the practice room in a way that is visible to all students and asks them to express their ambiguities and criticisms.
In the third stage, the actors (students) play the role of the nurse and the next person (classmate) plays the role of the patient and the instructor guides them. However, it was not expected that every actor would perform a smooth, problem-free performance. The performance continues until the goal is achieved and the students perform the desired examination or interview.
In the fourth stage, summary and discussion took place after the role-playing activities.
At this important stage, students were asked to present their assessment according to the designed criteria and measures, while also asking the questions that arose in their minds. The instructor also asks for critical comments and suggestions by raising questions such as the following:
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What do you think about the behavioral pattern of the role players?
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What suggestions do you have for optimizing behaviors?
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What are the characteristics of optimal performance from your point of view? And...
In this plan, criticisms and questions are expressed in two stages. The first time after the examination by the instructor and the second time after the students practice on each other. At this stage, cases that were ambiguous or their examination was difficult for most students were re-explained, and cases that were difficult or required more skills from students were repeated. Like using an ophthalmoscope to see the bottom of the eye.
The instructor then discusses and evaluates the role play again and questions such as the following questions were asked by the instructor:
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What percentage of criticisms and suggestions were applied?
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Can new reality-based solutions be achieved by new achievements and abilities?
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Identify repeated mistakes? And...
So that learners are able to relate the roles played in problematic situations and real problems, and to get closer to the principles of theory that they can apply in real life.
Generalization requires a lot of experience and will not happen immediately. In any case, the instructor should try to direct the discussions in such a way that the role players, after gaining long experience, can generalize the different approaches to the problematic situation and its consequences. Feedback received in the following semesters from clinical educators, instructors of adult and senior courses, as well as ward nurses are used to assess student learning and generalize the use of these abilities and skills acquired in the real clinical environment over the years by these students (Fig. 1).
In the conventional method, the topics are presented theoretically, then the film or in some cases, the examination on a replica is used, and the students also watch this examination. In this method, students usually do not enter the examination and are only observers.
Setting and method of implementation and sampling
This study was performed in the practice unit of Maragheh School of Medical Sciences. Maragheh School of Medical Sciences is located in northwestern Iran and accepts about 25 nursing students each semester. We conducted this study for four semesters and compared the results with previous years that were taught routinely (2018–2021). Out of about 100 students, 86 students participated in this study at the time of the research and in the re-examination stages, they filled out a questionnaire and attended 85% of the classes (inclusion criteria). Of these, 6 questionnaires were omitted due to incompleteness. Each part of the course was done in the practice hall with the method of role model and examination or taking practical biography of the student as a hypothetical client, and meanwhile, those cases that needed further or supplementary explanation for students were provided. Students usually filmed this stage of teaching or recorded the teacher's voice for practicing after class. During the presentation of the course, constantly feedback was taken from students and the existing shortcomings were corrected by using the provided solutions or by creative methods. Using the practical operating room and tripling some groups to make up for the lack of space, using male students to examine the chest in the girls' group, and dividing the students into two separate classes until there was enough partition to practice were examples of these corrections.
To evaluate the effectiveness of the teaching method and the persistence of the topics, through the interview method, the experiences of the faculty who taught adult and senior courses in the higher semesters were used. The experiences of clinical nurses and nurses who worked as student instructors in three teaching hospitals where students did their internships were also used. In this way, we evaluated these instructors and nurses about students' cognition and practical skills in performing physical examinations and the level of self-confidence of students who passed the health status assessment course using role model method. Some of the nurses unfortunately did not pay attention to the students' behavior and actions due to their busy schedule in the clinic, but the nurses that the students worked with and the nurses who worked as student instructors had valuable experiences in this regard. Initially, interviews were conducted with 2 faculty members and 2 nursing instructors. It was then continued by purposive sampling until saturation and until new data were not obtained in three consecutive interviews [16]. The characteristics of the participants in the quality section are given in Table 1. I have to say that informed consent was obtained from all subjects and all participants (students, faculty members, nursing instructors, and nurses) entered the study with satisfaction.
Table 1
Demographic characteristics of the participants in the qualitative part of the study
participants
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Gender
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Age
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Work experience
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8 faculties
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3 females
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3.2 ± 34
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1 ± 4
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7 nursing instructors
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6 females
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2.9 ± 31
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2.3 ± 6.8
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11 nurses
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8 females
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3.2 ± 33
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3.4 ± 7.2
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Tools used
Using the prepared tools, the level of satisfaction with this teaching method is measured so that they do not have any problems in terms of confidentiality and expression of their feelings. Also, in addition to the questionnaire, feedback on correction suggestions and students' comments and criticisms were received. A self-made questionnaire with 18 items was used to assess students' satisfaction with the teaching method, which was completed by students in either the conventional method or the role-playing method based on how the students passed this unit. The validity of the questionnaire was examined by ten nursing professors and their opinions were applied. The reliability of the instrument was evaluated by 20 students by retest method and was confirmed with a correlation coefficient of 85%. In this study, the self-confidence was evaluated using Eysenck Self-esteem Inventory (ESI) 1997, which includes 30 questions with validity and reliability in Iran [17]and in the present study, its Cronbach's alpha was 0.92. Regarding the retention of material in the minds of students, the level of knowledge and practical skills of students were examined, which was done using ten questions and performing practical skills of students who were randomly selected. In most cases, these questions were selected from the questions used in the students' final exam.
Data analysis
In the quantitative section, the data obtained from the questionnaire were analyzed using SPSS. Descriptive statistics and student t-test were used to assess the significance of the mean satisfaction in the two groups of students who were trained in the conventional method and role model method. In the qualitative part of the study, the experiences of faculty instructors and clinical instructors of nurses and clinical nurses were used to assess the durability of the topics and the ability to respond to relevant topics, students' ability and confidence in entering and performing physical examinations. Their experiences were collected and extracted for improving training. Data were analyzed line by line with Braun and Clarke thematic analysis method with the following steps: familiarity with the data, creating basic codes and searching themes, reviewing themes, defining and naming themes, and creating and reporting results [18].