It Was Like a Mirror: A Reflection on Filmed Role Play Simulation Deb Bennett, PhD, Department of General Education Faculty of Teaching and Learning, Mount Royal University Karen Dodge, MA, Former Project Coordinator Languages Institute, Mount Royal University Authors’ contact information Deb Bennett, PhD Department of General Education Mount Royal University 4825 Mount Royal Gate SW Calgary, Alberta T3E 6K6 Phone: 403-440-8892 Email: dbennett@mtroyal.ca Karen Dodge, MA Email: kmdodge13@gmail.com Abstract: “What brings you here today?” is a familiar question in a health clinic in Canada, but it may not be one that comes immediately to the mind of an internationally educated health professional. The way health professionals communicate with patients in their cultures can sound overly direct in Canadian clinics. “Why are you here?” would be typically asked to patients in settings such as the Ukraine and Egypt. A stepping stone that supports the understanding of linguistic appropriacy and the Canadian health care context is offered at the Languages Institute of Mount Royal University, Calgary. The Communication Skills for Health Professionals (CSHP) project teaches language and communication skills through a performance based approach. Our scholarship of teaching and learning inquiry explored how students in this project value filmed role play simulations as a learning tool for developing communication skills and knowledge. This article describes the instructional context of our study, its methodology, four key findings and implications for the role of the English language instructor, for student learning and for program implementation. The impact of filmed role play simulation on learning, acculturation into the Canadian health care context, professional identity formation, and the integration of communication skills within various contexts are discussed. Acknowledgements Thank you to the 2010 Fall semester PCIEHP course participants, the Program funder Alberta Employment and Immigration, and Mount Royal University Office of International Education, Languages Institute for its support and Mount Royal University Institute for Scholarship of Teaching and Learning. It Was Like a Mirror: A Reflection on Filmed Role Play Simulation Introduction Role play simulation is a common instructional tool in classrooms across many disciplines. Students typically learn by practicing rehearsed or improvised scenarios and by relying on their memories to reflect on their experiences. However, filming these scenarios using actors as simulation patients is an innovative approach in English language teaching and represents a departure from the way this common tool is typically applied. In this inquiry, benefits of recording student performance using video technology have been identified. Students have enhanced their learning by reviewing their own filmed performances more than once and those of their classmates without relying on recollection. During the Fall of 2010, we conducted a scholarship of teaching and learning research inquiry exploring how internationally educated health professionals (IEHPs) value role play simulations in enriching their communication skills and knowledge. Formalized role play simulations are a central component of the curriculum and support IEHPs to develop the skills required to interact with a patient. The simulations focus on typical aspects of the health professional - patient interview, such as gathering information, building rapport, giving explanations and discharge planning. This is achieved through a performance based instructional model (Watt, Violato & Lake, 2009) which incorporates the communication process skills of the interview based on the Calgary-Cambridge Guides (Silverman, Kurtz & Draper, 2005). Performance based Instruction The Professional Communication for Internationally Educated Health Professionals (PCIEHP) curriculum was originally developed in British Columbia (B.C.) with funding from the Ministry of Employment and Immigration and piloted at Kwantlen Polytechnic University. It was derived from the Medical Communication Assessment Project (M-CAP) at the University of Calgary. That project’s philosophy and design was motivated by “a particular view of the intersection of language, culture, instruction and assessment aimed at distinguishing the development of professional language proficiency in ELT programs from other approaches to language instruction” (Watt et al., 2009, p. 17). A performance based model of instruction was used to develop professional language skills in international medical graduates as it focuses on role play simulation with a variety of medical cases or scenarios structured on the medical interview. The model “advances participants through a weekly cycle of stages, towards a demonstrated internalization of the context specific to professional language proficiency” (Watt et al., 2009, p. 21). Key aspects of the instructional model are awareness raising, analysis of language and behavior, coaching, role rehearsal, filming, feedback and self-reflection. According to Watt and colleagues (2009), this method encourages the internalization of language as behavior. Students receive individual, structured feedback on their performance and advice for how to improve their communication 2 ©Bennett & Dodge, 2014 It Was Like a Mirror: A Reflection on Filmed Role Play Simulation interaction with their patient. Watt et al. (2009) maintain that feedback from instructors, simulation patients and peers combined with self-reflection is required to “accelerate change” (p. 20) and to increase familiarization with the appropriate Canadian healthcare culture and language. Standardized, or simulation patients that are used in PCIEHP have a significant impact on student performance. The actors’ reactions may be unpredictable and they are able to give immediate feedback to the students. In the final evaluation report on the Kwantlen Polytechnic University and Mount Royal University PCIEHP programs (British Columbia, 2011), it was noted that a key factor contributing to the success of both courses was the use of simulation patients. “Instructors noted that participants act very differently (i.e. they do not ‘buy into it’ to the same degree) when an instructor acts as a patient” (British Columbia, 2011, p. 36). Within the original PCIEHP curriculum, actors were used on alternate weeks. When the instructor played the role of patient, participants became more conscious of their linguistic errors. For a number of students like Maricel, “…talking to the patient was more comfortable, like I don’t get conscious of the sentence construction or of the grammar.”, while others, like Lian felt a greater sense of realism performing with a stranger, “When we talk to our teachers it is different because you know the teachers better, but if you talk with a stranger you actually really are like you are talking with a patient, and it is more like a reality situation.” Review of the Literature Role plays have been used worldwide as a teaching tool for many years within a variety of academic and training programs. This interactive approach has been used in disciplines such as, nursing (Chauhan & Long, 2000), medicine (Nestel & Tierney, 2007), social work, (Moss, 2000), and business (Mercado, 2000). Role plays have been used to teach communication skills (Mcmanus, Vincent, Thom, & Kidd, 1993), counseling skills (Moss, 2000), acquisition of language skills and cross-cultural training (Netsel & Tierney, 2007) leadership training (Sogunro, 2004), and the responsible conduct of research (Brummel, Gunsalus, Anderson, & Loui, 2010). Simpson (2008) suggests that role playing is a valuable tool for learning and encouraging students to examine how they usually communicate. Loui (2008) identifies that role play simulations facilitate student understanding and appreciation of perspectives, values and feelings of others as well as helping them develop skills such as empathy. The patient-centered communication skills and knowledge as well as the cultural context (Lane, Slavin, & Ziv, 2001) explored within the PCIEHP program is well suited for the use of role play simulations. Role plays have been identified as a teaching tool that is well suited for video recording and filming (Klapper, 1991; Koc, 2011; Orban & McLean, 1990). When using filmed role plays students are able to see, hear, review, and reflect on their learning. They are not tasked with having to rely solely on memory which can be selective (Robinson & Kelley, 2007) and at times unreliable. Filming and viewing role plays has been identified as increasing student motivation and understanding, while facilitating 3 ©Bennett & Dodge, 2014 It Was Like a Mirror: A Reflection on Filmed Role Play Simulation empathy development and personal identity formation (Koc, 2011). Like the use of role plays as a teaching tool, the use of video recording has also been used in a variety of contexts and settings (Robinson & Kelley, 2007). Klapper (1991) and Orban and McLean (1990) describe filmed role plays as a valuable and effective tool for communicative language teaching. The PCIEHP program is also well suited for the use of filmed role play simulations. Having the opportunity to view the filmed role play at different points in time as well as receiving feedback from a variety of sources facilitates the reflective practice needed for learning communication skills and knowledge. This reflective component of the learning process also occurs through filmed role plays as they support the connection of theory to practice (Burnard, 1991; Dixon, 2012; Koc, 2011). Robinson and Kelley (2007) describe video used as a tool to both develop and increase reflective thought. Dixon (2012) identifies the process of a “reflection in action approach” where students can reflect through the use of film. This reflection can result in increased motivation (Klapper, 1991) and gratification (Orban & McLean, 1990) as filmed role plays allow students “to monitor their progress not only aurally but also with visual impact” (Orban & McLean, 1990, p. 652). Role plays promote active learning and engage students with real-world situations (Joyner & Young, 2006), helping students to react as they would in a real-life scenario. Simulation is commonly used in healthcare education since it “enables learners to practice necessary skills in an environment that allows for errors and professional growth without risking patient safety.” (Galloway, 2009). Chant, Jenkinson, Randle, & Russell (2002) state being “able to communicate effectively with others is at the heart of all patient care” (p. 12). Communication and language skills can be gained, practiced and enhanced within role play simulations. Role plays incorporate the social context of learning (Netsel & Tierney, 2007) while offering an opportunity for self-discovery and self-understanding (Lane et al., 2001). They offer an authentic learning experience where students can “discover their own feelings about a particular situation and gain insight into the patient’s presenting problems or life situation” (Steinert, 1993). Garcia-Carbonell, Rising, Montero, & Watts (2001) note “It is clear to us that current thinking in the field of language acquisition ties in very well with simulation” (p.488). Garcia-Carbonell et al. (2001) describe that “research in the field of second or foreign language acquisition is relatively new” (p. 481). There is little written on how internationally educated health professionals value role play simulations in enriching their communication skills and knowledge. Like Shapiro & Leopold (2012), by sharing our experience with role play simulation, we hope to add to the “larger dialogue about incorporating creative, challenging activities” (p.128) into the classroom. Within our scholarship of teaching and learning inquiry we wanted to explore what students gained and how they learned from their experiences with role plays. We were particularly interested in hearing what the students had to say about this learning and 4 ©Bennett & Dodge, 2014 It Was Like a Mirror: A Reflection on Filmed Role Play Simulation teaching tool. We hoped to gain insight into how role play simulations improved students’ language and communication skills, and how students described their progression over the course. We also hoped to gain an understanding of how their learning in the class was transferred into contexts outside the classroom and what they did with their knowledge. Finally, we wanted to learn how simulations helped them with their understanding of the Canadian healthcare system, culture and context. Would their role play simulation learning facilitate feelings of confidence about communicating and integrating? Inquiry Method An interpretive qualitative approach was utilized for this study as it offered the opportunity to gain insight into student learning and experiences with role play simulations. Within this approach, experiences are explored with an attempt "to make sense of and interpret phenomenon in terms of the meanings people bring to them" (Denzin & Lincoln, 1994, p. 2). It presents the possibility for discovery as new perspectives and interpretations emerge through conversations, questioning, and dialogue. Interpretive inquiry offers a unique approach to the study of human experiences as those involved in the research share their experiences, stories and meanings. It presents the possibility of discovery. Cohen and Omrey (1994) described how interpretive research reveals common understandings and taken-for-granted meanings. It is a process of uncovering and revealing the meaning of an experience through exploration. The study’s research topic on students’ experiences with filmed role play simulations called for a dialogue with students, ensuring their voice is heard and facilitating an increased understanding of this teaching and learning tool. Study Sample Seventeen students from the Fall 2010 cohort were invited to participate in the study and all but one chose to be involved. All students who expressed interest were included in the study. These inquiry participants, who had been residents in Canada for an average of 1.9 years, included 7 qualified registered nurses, 8 physicians including surgeons and 1 pharmacist. Of these 16 participants, 11 were female and 5 were male, and they came from Bolivia, China (2), Colombia (4), Egypt, Iran, Japan, Syria, Philippines (2), Taiwan, Ukraine and Venezuela. The English language prerequisite for attending the course was a minimum Canadian Language Benchmark (CLB) levels of Speaking and Listening 7 and Reading and Writing 6. The study was approved by Mount Royal University’s Human Research Ethics Board and all data was anonymized. Data Collection The study’s data consisted of pre and post-course free write data sets, weekly one minute papers, and post-course semi-structured interviews. The pre and postcourse free writes identified changes in students perceptions of role plays during the 13week course by asking “What do you think about role play simulations?”. Weekly one5 ©Bennett & Dodge, 2014 It Was Like a Mirror: A Reflection on Filmed Role Play Simulation minute papers that posed questions, such as “What did you learn by receiving or giving feedback?” or “What did you learn by observing yourself and others?” offered students the opportunity to reflect on what and how they learned through filmed role play simulations. In a performance based curriculum, students practice unscripted scenarios in class with their peers according to the theme of the week, such as pain, chronic illness, smoking cessation, and difficult conversations. Each week, students are filmed with a simulation patient who has been trained to play the role of a patient with a specific condition related to the theme. The interview, which takes place in a nursing laboratory to enhance authenticity, is timed and assessed by the language instructor and health professional consultant. Immediately following the interview, the patient gives feedback, which is captured on film, and the instructor and consultant give written feedback based on criteria checklists. The following day in the computer lab, the students watch the video clips of their performances and share them with a small group of their peers in order to receive further feedback. Post-course interviews triangulated the data and offered new insights into student learning and growth as well as how communication skills became integrated into other contexts and settings. Data Analysis The data was analyzed through a line-by-line, word-by-word manual coding and categorizing procedure (Berg, 1989), where we looked for common language, ideas, thoughts or reflections. Key ideas, phrases or sentences were noted and discussed. The constant comparison method (Field & Morse, 1985) was used where the review and rereview of the data in order to ensure trustworthiness of the coding procedure. A recoding procedure resulted in the identification of themes that emerged from the students’ reflections and interviews. Our coding and interpretive processes resulted in the identification of themes that emerged from the students’ reflections and interviews. We began the coding portion of the data analysis individually, a process that contributed to the study’s trustworthiness. We then met together several times after the initial coding. Through these meetings themes were identified through our coding and interpretation processes. Key Findings Within our inquiry, students described how filmed role play simulations enriched the development of their communication skills and knowledge, facilitated their acculturation into the Canadian health care context, contributed to the reconnection with their professional identity, and integrated the skills they learned in role play simulation to other contexts and settings. 6 ©Bennett & Dodge, 2014 It Was Like a Mirror: A Reflection on Filmed Role Play Simulation 1. Filmed role play simulations enrich learning of communication skills and knowledge through observation and modeling. The weekly process of filming, reviewing, getting feedback from the assessors, letting other students watch their video recorded performance, and then receiving additional feedback, was described in the words of one of the participants, Hisham, as “a complete circle of learning.” Filmed performances were a key component of awareness raising and the development of an individual’s language and communication skills. According to Claudia, filming had a reflective quality, “And the camera, it was like a mirror. By seeing myself I could see that I learned during the class that I applied during the role play.” Likewise, Irina described the advantage of review,“ I had a chance to see my own performance as an audience from the other side. It helped me to notice my own mistake, my body language and face expression. I haven’t had such a chance before, so I learned a lot of things about myself.” The visual recording assisted students remember what actually happened and what was said. For Khalid it was helpful “because I have a bad memory so I can’t memorize what I did actually, so it is a good chance to watch my video again and I can see, ‘Oh, I shouldn’t have said that, it was better to say this in this way.’ ” On the other hand, for Analyn seeing was believing, “because if it is not filmed, then after that you might not believe the feedback. But if it is filmed so it is out there and “I really did say that’.” Students spoke of an increased awareness of their non-verbal behavior and its effect on the patient. For some like Cheng, “eye contact is not [something which comes] naturally for Chinese [people] but actually keep eye contact is a good way and facial expressions...sometimes nodding head is not enough.” Students also described a new awareness of their grammatical errors, pronunciation and intonation through filming. Hisham noted that he had problems with pronouncing a few words and that filming was “the ideal way to catch them”. A significant learning component of the filmed role play simulations included the students’ ability to both give and receive informative feedback about their developing skills. As identified by Lane et al. (2001) “feedback on performance is an essential component of the learning experience” (p. 300). Observation and feedback that lead to self-reflection are critical components of the curriculum as they foster an environment of mindful learning. Observing self and others in different scenarios each week opened up discussion of norms of behavior in Canada and other countries and the exploration of variations in health care systems and cultures around the world. By observing their colleagues’ film clips, a few students such as Khalid, claimed they learned communication skills and techniques from each other, “When I watch a video for someone who knows how to use what we learn from the course, I like that because I learn from him, so that is very good for me. And at the same time when I watch someone who is in a lower level than I am, it is good for me just to say, ‘Yah, I am improving,’ or, ‘I am good and I can continue to be better’.” 7 ©Bennett & Dodge, 2014 It Was Like a Mirror: A Reflection on Filmed Role Play Simulation Filming simulations ensured that each student had the opportunity to give and receive feedback as well as to further analyse their own performance. Students were required to submit reflective journals each week in which they wrote about their learning experiences and created goals for the following week. The feedback process was further enhanced by focusing on individual strengths and how to gradually build on these from week to week. Students identified what they did well in their performances and as a result, were motivated to modify their behavior and experiment with language forms in order to continuously develop their competency. As Analyn shared, “The role plays have been very effective especially with reflective practice. They are more effective with the feedback from the course instructors, simulation patients and my colleagues. I feel more ready to receive feedback from my colleagues now unlike before without feeling bad and above all, I am able to perform better when faced with similar situation.” Learning to give and receive feedback made some students like Analyn feel uncomfortable in the beginning, and filming performances every week was also met with some nervousness at the start. However, the post-course free write data provided evidence of how students increased their overall confidence as a result of filming as expressed by Lian, “In the beginning of filming, I didn’t feel comfortable to talk in front of camera. After a period of time, I see myself improved week by week. I think part of the reason is because I become more confidence to talk. I am glad that I see myself improve.” Pablo also admitted feeling more relaxed by the end of the course, “ I can see clearly my improving in the role play simulations comparing the first one with the last one. In the last one I feel more comfortable asking questions, using signposting, soft skills, even with the language.” Rather than focusing on errors, which can compound a sense of failure and undermine feelings of self-worth, the instructor focused on learning strengths reflected in the film clips. In this way, the proficiency of the students’ speaking was facilitated and listening skills increased, meeting one of the course’s key learning outcomes. 2. Filmed role play simulations facilitate acculturation into the Canadian health care context. Another learning outcome of the program was to increase students’ knowledge of professional and cultural contexts. A major component of the PCIEHP curriculum is an orientation to the Canadian health care system, culture and context. During the Alberta pilot, the instructional team focused on the development of intercultural competence. Memorizing norms of behavior and appropriate linguistic formula was insufficient for students to assimilate the knowledge they needed to learn. As Bennett & Bennett (2004) explain, “Although the primary emphasis of intercultural communication is behavior, no behavior exists separately from thought and emotion” (p. 149). Students wanted to understand why and by how much they needed to modify their behavior to fit into a Canadian patient-centred health care context, and they also needed to see 8 ©Bennett & Dodge, 2014 It Was Like a Mirror: A Reflection on Filmed Role Play Simulation the behavior that needed modification. For Maricel, role play simulations were “very helpful tools to learn how to communicate as well as assimilate into the Canadian health care system. It also helped me know the do’s and don’t’s in terms of communicating with patients. It also gave me an opportunity to practice and feel how it would be like to talk to colleagues and patients that are acceptable to Canadian culture.” After watching their role plays, students would discuss the diverse health care systems and cultures of their countries of birth and of Canada. For example, a patientcentered care approach was new for them. Claudia discovered that, “Canadians like to be participants of the decisions and this is something different from my country because they [sic: patients] come to us and they expect us to tell them what to do – it is like parenting health care – but here it is different.” Teresa, also from Colombia, thought “what was helpful for me and most important was the patient care approach so how asking patient questions, how to empathize with the patient. The culture is different. For example in my country usually we say the things more directly and try to avoid some phrases.” Hisham revealed that tailoring his information to the patient perspective increased the acceptance of the patient, “ I learned that involving the patient in his or her treatment plan makes it easier and more likely to achieve…I learned to include the patient in my consideration, try to put myself in his shoes to understand his perspective”. Filmed performances gave students a window through which they could analyse not only their language and non-verbal expression, but also understand and practice the behavioral norms of Canadian health care. Communicating information about a life threatening diagnosis to a patient’s relative or directly to the patient proved the most challenging scenarios for all the physicians. For some like Ana, who had no experience of this, the simulation gave her an unique opportunity, “when I was working in my country, Bolivia, I never gave bad news of death so for me it was my first experience doing it.” Teresa said she found it hard just finding the words, “Even in my language – Spanish – it is not easy, and in English it is difficult too because you have to think about the other person, you have to use the proper words so it is difficult.” For Maricel, delivering bad news to the patient challenged her own cultural norms of practice, “One of the things that really I had a really hard time was telling the patient that he is dying… because back home we never say it to the patient, we give the family the choice – always the family first. So here I recognize that it is important to tell the patient and I think it is a skill that I have to develop, especially as a physician.” The advantage of filming these challenging scenarios was pointed out by Irina. She was grateful for having the opportunity to view the approaches her colleagues took, “watching other people, for example delivering bad news – we don’t deliver bad news very often – so watching other people in the same situation I can see different way[s] how I can perform and I can get some experience from other people even if 9 ©Bennett & Dodge, 2014 It Was Like a Mirror: A Reflection on Filmed Role Play Simulation they are unsuccessful I can still learn [from] their mistake and understand what I can do.” Other essential skills which students practiced were summarizing and paraphrasing to clarify meaning and ensure understanding. Elena learned the importance of this, “ because I was trying to understand the patient and I needed to paraphrase to understand him because he told me something and immediately I believed another thing and he said, ‘I think you don’t understand what I tried to tell you,’ and I paraphrased and said, ‘You mean do you want to tell this?’ and he said, ‘Okay.’” Students also practised simplifying the way they spoke to patients to avoid medicalese. When talking about this in this in the interview, Khalid confirmed “…introducing yourself and asking the patient how he feels, it is very important, also I really liked the part when I have to explain to the patient the decision process. Yah, I really feel comfortable doing that and simplify[ing] that in terms of the way he would be able to understand it.” The recognition of Canada’s multiculturalism was an important learning for students. They were already in a strong position to use their own knowledge of culture “to analyse, predict and adapt” (Bennett & Bennett 2004, p. 149) within the familiar context of healthcare which was at the same time unfamiliar. As Khalid’s comment suggests, filmed role play simulations provided an opportunity to reflect, and seemed to contribute to a developing awareness of effective communication skills within a multicultural context, “I think the role play is the best way to teach health professionals especially here in Canada. Because Canada is multi-cultural. We are newcomers, we don’t know too much about the cultures – not only the Canadian culture but how to deal with other cultures.” Once more, the benefit of being able to review colleagues’ filmed performances was expressed by Pablo, “I tried to ask the questions like usually I did, but watching another colleague I found his questions more polite, more smooth and more used to the Canadian types, so I notice the difference and I think it is better so I adapt to that.” 3. Role play simulations contribute to professional identity formation within new contexts. The process of immigrating appears to have a profound effect on the confidence of newcomers to Canada who are health professionals. Although the majority of them are aware of the hurdles that face them on arrival, it may take years to regain their sense of professional self. For these professionals, the process of integration can be long and challenging. PCIEHP gave its learners a unique opportunity to observe, reflect, and “practice” their profession through filmed role play simulation and to redevelop their sense of professional identity. Claudia thought the best part of the course was role play simulation, “because it was acting but at the same time was doing a little bit of nursing again...it is more being in contact with my career.” 10 ©Bennett & Dodge, 2014 It Was Like a Mirror: A Reflection on Filmed Role Play Simulation The health professional-patient structured interview in the curriculum allowed students to use their clinical knowledge alongside their knowledge of English within the context of a specific scenario. The typical interview structure includes elements, such as gathering patient information, giving explanations, and negotiating a mutually acceptable plan. The scenarios gradually build in communicative complexity. In the early ones, the students are expected to introduce themselves to their patients and to ask questions to identify the problem, for example, to find out what kind of pain the patient is in and to use the pain scale. In subsequent interviews, students have to give patients simple explanations of a disease or condition using visual aids. By week 8 of the course, students negotiate a discharge plan with a patient who is unwilling to follow the health professional’s advice. Delivering bad news to a patient’s family and directly to the patient occur in the final weeks of the course. At the same time as increasing in communicative challenge, the scenarios increase in length from five minutes the early weeks of the course to eight minutes midway through and to ten minutes in the last four weeks. Gradually increasing the complexity and length of the scenarios as well as filming them was seen as a helpful learning tool by Cheng who said, “The role play is the clinical setting practice. From the beginning I learn basic communication skill[s] and different technical skills, so I learned step by step and I learned some complicated interview skill[s] later on. It is very good under the camera. I think it is a really good way to be under pressure even though under pressure the practise may not go well, it is a good way for improving my communication skills.” According to Aki, the scenarios themselves are “really close to the real situation…and it makes me feel like I am a nurse and I have to act like a nurse.” The feeling of authenticity created by filming in a nursing lab was noticed by Ana, “in the role where there were the bed and toys, I told my husband, ‘Oh, I feel like was working already.’ ” Through intensive practice of role play simulation, acting could feel like the real situation as Hisham explained, “the more you do it the more you are into it, and the more you get into the acting of it, and then you can get to another level, so “I am not talking with Michael now, I am talking with a patient and what would I say if a patient says the exact [same] thing to me? How would I react?”. Insights from the post-course interviews describe the personal impact of the filmed role play simulation experience. By seeing herself acting her profession, Claudia came to the realization that she could potentially reach her professional goal, “ I discovered about myself that despite of my language difficulties I am a nurse, so it is something like I didn’t leave at home, something that is in me, in myself this is something that I want to do because I want to get my career back.” Elena also realized role play was very useful “because if I want to work here as a family physician I need to learn to handle this kind of interview”. For some students, who were already participating in the workplace, role play simulation using the structured interview was an enormous benefit. According to Pablo, 11 ©Bennett & Dodge, 2014 It Was Like a Mirror: A Reflection on Filmed Role Play Simulation it reinforced his self-confidence, professional identity and goal of practicing in the Canadian healthcare system, “I am doing an observership with a Canadian doctor in his office… and this kind of thoughts and practices it make[s] me more secure, more self-confident interacting with Canadian patients because, for example, I have my guide, I have the questions and I memorize many questions in some situations that are already with me in the practice in the office so I feel more natural, more spontaneous in my communication with the patients and the doctor and he noticed it…sometimes the doctor say, ‘Okay, start the interview with the patient and I will be there with you in twenty minutes.’ ” We found that filmed role play simulation contributes to the development of confidence or conviction in individuals that they are able to practice their professions, and that it enhances professional identity development. For adult ESL learners for whom establishing identity is an issue, this type of simulation potentially offers a number of benefits. 4. Communication skills learned within filmed role play simulations are integrated to other contexts and settings. Student narratives suggest that their learning was not restricted to the class or that it was an isolated process. The practice of effective communication skills and concepts through role play simulations supported the integration of their newly developed skills and approaches into various settings including the workplace. The transfer of learning from the classroom to personal life was a common experience. Students spoke about the way the skills they learned helped to improve their family relationships and to resolve conflict. Meili talked about the effect of her learning at home,” I try to speak more with my sons because before we didn’t communicate a lot, we just ask one or two sentences, that is it, and now I am willing to talk more…we share a lot more...that is why I found this really helpful because we are encouraging each other to talk more and that why we have more harmony in the family. Before you know, there is some distance between me and my sons and now it seems more close.” When asked what skills the role play simulations helped to develop, Khalid, Amal and Ana stated that it was showing and using empathy. The filming allowed them to see empathy being expressed, to reflect on it, and to practice again what they had learned. Aki also learned about conflict resolution, “So we learned how to say ‘No’, or when we have a conflict not only say ‘you did’ or ‘you something’ and I should use ‘I’. It is not only the workplace, it is just regular relationship with my family or my friends and it is helpful to show empathy because I didn’t know. Every time when I talk with my patient he said something and I had no idea what should I say to him in English and now I have some ideas.” Teresa and Ana both said that learning through simulation had helped them avoid being judgmental of other people which would be useful for them not only in their professional life but also in their daily lives. 12 ©Bennett & Dodge, 2014 It Was Like a Mirror: A Reflection on Filmed Role Play Simulation According to Hisham, he gradually increased his confidence in his communication in the community, “I know that there has been an impact on my daily life because communication is not something we do only with patients; when I improve my communication I am doing it with my family, with my friends and even my neighbors and people I meet on the street.” Lian spoke of newly developing confidence to speak to her colleagues in her hospital workplace, “…after this course I start to not talk with them a lot but I start at least to say hello to someone. I start to know how to approach people and don’t feel like I bother anyone.” Filming played a large part in her development of confidence. She admitted that, ‘Now, I am not only more confident to perform in front of camera but also in my daily life conversation. I think it is a very useful tool in order to improve and assimilate how to approach a patient in the context of Canadian health field.” In Lian’s case, her transfer learning to her workplace had beneficial results. By facilitating the transfer of learning from the classroom, Meili discovered that role play, “enabled me to think in different direction and put myself in the shoe of others. I feel it really help in making improvement and widen our thinking. So, I think role play does a positive and effective job in adult learning process.” Irina felt that role play simulation had helped her “understand the steps of effective communication. The opportunity to practice communication improved my communication in real life”. These unique integration experiences have implications for teaching and curriculum delivery in any communications course. There is little written on how communication skills and knowledge learned through role plays are linked to other contexts and settings. Further research in this area would be helpful in identifying the wider and far reaching implications for professional practice, community involvement and interpersonal relationships. Implications for the Role of Instructor The role of the English language instructor is impacted and enhanced by the performance based approach to instruction. According to Watt et al. (2009), the pedagogy requires the instructor to be like a film director who observes through the camera lens and directs performance, while Brethower & Smalley (1992) describe the teacher as a coach who uses guided practice with feedback, a crucial role when using role play simulations as a teaching tool. At the end of term, the PCIHP coordinator asked the MRU language instructor to evaluate the program. In his evaluation, the instructor spoke of experiencing a shift in his traditional language teaching role to that of facilitator engaged in the development of adult learners, who came to the course with broad life and professional experience and knowledge of a health care related discipline, and who were fully motivated to participate in the learning, “What has impressed me the most from my involvement in this program is the adjustment I’ve had to make from language instructor to that of facilitator or trainer. The participants arrive with a very clear focus on where they want to go, and with 13 ©Bennett & Dodge, 2014 It Was Like a Mirror: A Reflection on Filmed Role Play Simulation generally higher language abilities than most English as a Second Language learners. They don’t need to be taught study skills. This context, in conjunction with the aims of our innovative program, demand that I demonstrate, guide, nudge, advise – and then step out of the way.” The transformation of the instructor to facilitator resulted not only in an expansion of his knowledge of content areas, such as health care, soft skills, role play, and performance-based methodology, but also became a means by which he “gained enormous confidence in what I can or might do.” In the classroom, the MRU instructor as facilitator encouraged his students to become aware of their strengths, to explore the variations of appropriate language use, and to build their confidence through practicing patient and colleague interaction. He initially elicited linguistic knowledge and content experience from his learners, guided them through correct grammatical structures, and then allowed them enough uninterrupted time to explore and practice with language through role play scenarios. He encouraged students to remain present and open to what they saw as a viewer of self and others. An essential skill for him to develop was listening. According to Kramsch (1993), teachers are “seldom trained to listen to silences and to their students’ implicit assumptions and beliefs. They also have little training in listening to themselves and reflecting on their own assumptions and beliefs.” (p. 245). Our second finding describes international health professionals who were discovering the meaning of multiculturalism in Canada and who were keen to understand how to modify their behavior to fit the Canadian health care context. The instructor needed to listen to their diverse viewpoints and experiences of health practice without judgment, to direct discussion in a way that broadened their understanding, and to support them through scenarios that challenged their cultural norms. Kramsch (1993) goes on to say that “Introspection and critical self-assessment are essential for the further development of any language teacher” (p. 245). The MRU instructor’s end of term evaluation was, therefore, an opportunity to reflect on his teaching experience and to encourage mindfulness around his role as facilitator in a classroom of diverse cultures, life experiences and health professions. Implications for Student Learning Aspects of performance based teaching provide valuable learning experiences when incorporated into the classroom. Our first finding supports the significance of teaching how to give and to receive informative feedback. For example, students learn to avoid making judgmental remarks, such as “That was great!”, or to give advice “You shouldn’t sit so close to the patient”. Instead, it helps them to focus on listening to what is actually said, hearing and watching how it was said, and to note concrete examples of inappropriate or unclear speech. By expressing what they actually observed avoids the potential for conflict. “When you pulled your chair closer to me, I felt uncomfortable and that I needed more space.” is more productive than “You moved way too close to me. You made me feel bad.” Students also learn respect by first asking their colleagues 14 ©Bennett & Dodge, 2014 It Was Like a Mirror: A Reflection on Filmed Role Play Simulation if they are ready to receive feedback. Through giving and receiving feedback students practice active listening skills in order to respond to their role play partner appropriately. In addition, asking questions to clarify understanding, rephrasing, and giving appropriate non-verbal response create greater awareness of their role play partner’s needs. As described in our first finding, filmed performances became a valuable reflective tool that heightened learner awareness of language and behavior by acting like a mirror. The effect of learning through a performance based curriculum with filmed role play simulation had an impact on the professional language proficiency of the learners. The Institutional Canadian English Language Benchmark Assessment for Nurses (ICELBAN) was used as a pre and post-assessment tool. The test is an appropriate match for the curriculum as it employs role play in the speaking assessment and authentic health care related tasks for listening, writing and reading. The differences in pre and post-assessment averages of benchmarks for the whole class showed an accelerated rate of acquisition over the twelve week course. There were increases of 0.72 benchmark in Listening, 0.81 benchmark in Speaking, 0.64 benchmark in Reading and 0.70 benchmark in Writing. Of the 16 inquiry participants, 9 increased their benchmark in one skill, four increased their benchmarks in two skills and one increased her benchmark in three skills. Implementing a Performance Based Methodology Certainly there are challenges to implementing role play simulation in class. As Shapiro & Leopold (2012) describe in their article on critical role-play in the English for Academic Purposes context “Like any task-based activity, critical role-play takes time to implement in class” (p. 128). Adding video technology to role play simulation increases the challenge of planning and finding the time to use it in class. Further considerations are that student confidentiality needs to be addressed before filming, and the instructor has to establish the logistics of filming and become comfortable with using the camera and tripod. The MRU instructor met the challenge by doing “some pre-term practice with the video camera”. He also became technically proficient at “learning how to upload student videos to their own assignment boxes on Blackboard.” Students also had to acquire computer skills that were new for some. The challenge of learning online was worthwhile according to their instructor, “Having students use Blackboard for their independent tasks on film day, submit feedback, read announcements and confirm homework assignments was surprisingly easy. Occasionally a student would submit his/her feedback in paper form because of some technical difficulty on their end, but in general the use of Blackboard was a very effective tool.” From the view of the program coordinator, critical aspects of preparing to implement this methodology were to secure a suitable health professional consultant to teach alongside the language instructor, and to recruit actors as simulation patients. 15 ©Bennett & Dodge, 2014 It Was Like a Mirror: A Reflection on Filmed Role Play Simulation The coordinator is not dealing with a single instructor, but a team of ten individuals all of whom require briefing and attention to individual needs. Another challenge is ensuring the success of the program as measured by its outcomes. This requires keeping track of students up to a year after they have completed the course in order to gather data concerning their employment status, further training experiences, and success in taking professional examinations. The impact of PCIEHP on the lives of the students is, therefore, every part as important as the course delivery itself. The nature of an innovative program such as PCIEHP with its performance based methodology demands the meeting and overcoming of challenges. They are the essence of a program that breaks the mold of English language teaching. For the team working with PCIEHP, the transformative experience has been in all aspects of its delivery, in what we have learned from it and from our students, and in what it has made us mindful of as educators. The transformation has occurred in the ways we have changed our usual way of doing things. Thanks to filmed role play simulation, “the cornerstone” of the students’ learning according to instructor feedback, we have found other ways of seeing and doing. Despite the challenges of implementation, as our findings and language assessment results suggest, the benefits of filmed role play simulation outweigh any disadvantages. The continued delivery of PCIEHP at MRU and at MacEwan University is evidence of its value. It is a program that has been shared between provinces, tailored to different settings, and that has changed the way a language program is commonly produced. Conclusion Filmed role play simulation, with thoughtful instruction and the opportunity to be part of an informative feedback loop and to reflect, can help students achieve important learning goals in many disciplines, but it is especially relevant to English for professional or specific purposes teaching. Performance based instruction with filmed role play simulation has been fundamental to our students’ understanding of the appropriate use of language and communication skills within the Canadian healthcare context. It increased their awareness of Canadian multiculturalism, helped them to regain confidence in their professional self, and encouraged them to apply their learning outside of the classroom. They were better prepared to enter their healthcare professions because they had effectively practiced interacting with patients and colleagues and reflected on their performances. As a result of our inquiry, we increased the number of simulation patients we use on PCIEHP, now rebranded Communication Skills for Health Professionals, to ensure that filmed role play simulation, a core component of the course, provides students with as authentic an experience as possible. 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