USING ROLE PLAYING IN THE INTEGRATION OF KNOWLEDGE IN THE TEACHING-LEARNING PROCESS IN NURSING : ASSESSMENT OF STUDENTS

To assess role-playing as a methodology in the teaching-learning process for the Nursing Degree. To identify the attitude of nursing students towards role-playing. To analyze the response of students to their teaching-learning process after role-playing. Relationship is one of the main functions of nursing care in all fields, as it contributes to developing and coping with the various stimuli of life through therapeutic communication, which helps nurses know their role and how to behave according to the situation. Third-year students from the Nursing School of the “X”. Academic years 2006-2007 and 2007-2008. The reflexive nature of qualitative research is based on Symbolic Interactionism. The subject category chosen is role-playing and it is sorted into the subcategories and codes. Findings from the analysis of the summaries have allowed us to see what actually happens when using role-playing as a teaching-learning tool in nursing, why and what the consequences are. DESCRIPTORS: Role-playing. Teaching-learning process. nursing degree. Students from the Nursing. Integration theory and practice. UTILIZACIÓN DEL ROLE PLAYING EN LA INTEGRACIÓN DE CONOCIMIENTOS EN EL PROCESO DE ENSEÑANZA-APRENDIZAJE DE ENFERMERÍA: VALORACIÓN DE LOS ESTUDIANTES RESUMEN: Evaluar el role-playing como metodología en el proceso de enseñanza-aprendizaje en la enseñanza del Grado de Enfermería. Identificar la actitud de los estudiantes de enfermería ante el role-playing. Analizar la respuesta de los estudiantes después de realizar el role-playing en su proceso de enseñanza-aprendizaje. La relación de ayuda es una de las funciones principales de los cuidados de enfermería, en todos los ámbitos con el fin de que se pueda desarrollar y hacer frente a los diversos estímulos de la vida a través de la comunicación terapéutica, que permite a las enfermeras ver su rol con las personas como un marco para “saber estar” en la relación de ayuda. Estudiantes de tercer año de la Escuela de Enfermería de la “X”. Año académico 2006-2007 y 2007-2008. El carácter reflexivo de la investigación cualitativa está fundamentado en el Interaccionismo Simbólico. La categoría temática seleccionada, es la de role-playing que permite una clasificación de subcategorías y códigos. Los resultados del análisis de las síntesis nos han permitido identificar lo que sucede realmente con la utilización del role-playing como herramienta de enseñanza-aprendizaje en enfermería, por qué y cuáles son las consecuencias. DESCRIPTORES: Role-playing. Proceso enseñanza-aprendizaje. Grado de enfermería. Estudiantes de la enfermería. Integración teoría y práctica. USANDO ROLE PLAYING NA INTEGRAÇÃO DO CONHECIMENTO NO PROCESSO ENSINO-APRENDIZAGEM EM ENFERMAGEM: AVALIAÇÃO DOS ALUNOS RESUMO: Avaliar o role-playing como metodologia no proceso ensino-aprendizagem no ensino de graduação de enfermagem. Identificar as atitudes dos estudantes de enfermagem relacionadas ao role-playing. Analisar a resposta dos alunos no proceso ensinoaprendizagem após realizarem o role-playing. a relação de ajuda é uma das principaisfunções dos cuidados de enfermagem, em todas as dimensões e, através da comunicação terapêutica busca o desenvolvimento das pessoas para enfrentar os diversos estímulos da vida. A comunicação terapêutica permite às enfermeiras reconhecerem seu papel, como um marco para “saber estar” na relação de ajuda. Estudantes de terceiro ano da Escola de Enfermagem “X” nos períodos letivos de 2006-2007 e 2007-2008. A natureza reflexiva desta pesquisa qualitativa baseia-se no interacionismo simbólico. A categoria temática selecionada foi o role-playing, que permitiuuma classificação em subcategorias e códigos. Os resultados permitiram identificar o que realmente acontece com o uso do role-playing como uma ferramenta de ensino e aprendizagem em enfermagem, porquê e quais suas consequências. DESCRITORES: Role-playing. Processo ensino-aprendizagem. Grauduação em enfermagem. Estudantes de Enfermagem. Teoria e prática integração.


INTRODUCTION
If we take into account that, from a holistic point of view, nurses regard their patients as the centre of their professional attention, it is understandable that the training of new professionals is focused on this helping relationship.
] It is essential to help nursing students detect the responses that patients expect to hear.
That is why teaching and learning methods should be included within the learning curriculum, through which students are expected to obtain certain results.

Objectives
To assess role-playing as a methodology in • the teaching-learning process for the Nursing Degree.
To identify the attitude of nursing students • towards role-playing.
To analyze the response of students to • their teaching-learning process after roleplaying.

Educating new nurses
From this perspective, educating new nurses should not be merely based on being prepared to think. 3tudents need to be provided with abilities to face situations where human relationships are highly significant.Thus, affective elements play an important role in decision-making in various dynamic social environments.At the same time, the ability to assess other people's intentions plays an essential role and is related to the interpretation of real situations. 4iven the above and based on the results of the bibliography review undertaken, we can distinguish different contexts regarding dramatization.These results follow the theoretical framework of Hinds, Chaves and Cypress 4 and have been divided into four interactive layers: immediate context, specific context, general context and metacontext.These differ amongst themselves and range from the universal meaning where a researcher describes and analyzes conceptual aspects by interpreting the results found and integrated in subsystems, to the conceptual perspective of each context.

Role-playing in the education of new nurses
:53 Studies conclude that students go through an important experience through dramatization.15] These circumstances provide students with the opportunity of improving both individually and collectively, since the interaction established in this process leads to the student's transformation, helping them understand that they should not expect everything to happen systematically.][17] Through dramatization and the added influence from the teacher and learning conditions, students benefit more from the learning process.Therefore, the teacher's role in this process is clear.The teacher acts as a link between the school, the students and then the contents presented.Principles of interdisciplinarity and interdepartmentality in the learning process are also of high importance, as they allow students to gain abilities which will enable them to cope with several real situations by relying on the knowledge they obtain and not limiting themselves to simply learning it. 18ursing teachers need to redefine their vision of the teaching-learning process.][21][22] Role-playing, conceived as a learning method based on experience, enables us to be more specific about the issues raised above.

Advantages of role-playing
Learning with role-playing enables students to reduce their anxiety while they gain confidence.They have a better professional know-how when they understand the situations, roles and questions asked or to be asked, the answers they should give, and how to actively listen (by paying attention to words, gestures, actions and situations).These abilities are gained because role-playing allows repetition and the acquisition of reflexes and habits.
There is no better way of sympathizing with others than to put yourself in their own difficult situation, avoiding the limelights that prevent true identification of their problems, needs and demands.
Role-playing enables the participants to understand group dynamics and personal freedom.Role-playing sharpens perception and encourages creativity and self-fulfilment. 23

METHODOLOGY
The methodology used for this investigation should lead to understanding how to use a methodological tool in the teaching-learning process of nursing, such as role-playing.We chose qualitative methodology as a reference for the study, since it is the one that best illustrates the process of understanding to be achieved.
When looking for a wider understanding of phenomena, qualitative methodology applies the constructivist paradigm, which understands that realities are constructed specifically and locally. 24Thus, the researcher is concerned with exploring the world of the individual's experience to distinguish and classify their realities and perceptions.That is why we understand what is being studied from the "emic" perspective, i.e. from within the situation. 25his constructionist perspective highlights the interaction of the researcher with the data and the fact that they develop the analysis mainly based on the participants' social constructions.From the constructionist perspective, the researcher has an active role and a capacity for social interaction with informants, so data are gathered in a systematic and non-intrusive way. 26he reflexive nature of qualitative research is also based on symbolic interactionism.
Meaning linked to the situation is not permanent but rather it changes along with the situation.The stages of the process can be identified through the assumption of symbolic interactionism, which is the ideal setting to study the communication that takes place during role-playing.According to symbolic interaction, meanings are negotiated and change over time.

Participants and context
Third-year students from the Nursing School of the University of Alicante.Academic years 2006-2007 and 2007-2008.The study was conducted at the School of Nursing of the University of Alicante, where the interviews and the recording of the role-playing needed for this research were carried out.
This research is based on the analysis of the data of the summaries* that students do at the end of each year.Doing this helps us better understand the phenomenon studied, that is role-playing.Summaries explain the feelings, concerns and fears that students experience when they carry out the role-playing.
We selected data from summaries to achieve the saturation of data and the technical sample through periods of intense analysis (new cases were selected according to their potential to better explain the concepts and theories already developed).A total of 250 summaries were analyzed.
Given the large amount of data obtained about role-playing, a subsequent encoding of these data is needed to separate and segment them in order to obtain more general and simple categories and to be able to formulate new questions and levels of interpretation.
In order to encode the data, we organized, processed and retrieved the most significant segments.We condensed most of them into analyzable units, assigned them tags based on our concepts and created categories that would enable us to strictly review what the data said.We linked every segment of data to a particular idea or concept and later related these concepts to each other, which enabled us to create a connection between codes, categories and concepts in order to analyze those links manually.This way we managed to obtain fragments of data * Summaries are the written expression of students about their experiences, criticisms, contributions... about the subject of Integrated Nursing and the enactment of role-playing.These summaries are carried out at the end of the academic year.
sharing a common code.However, our goal was not just to reduce the data to a common denominator but to expand and reconceptualise them in order to obtain wider analytical possibilities that would allow creative thinking by asking questions based on the data obtained and generating conceptual frameworks.Later, segments of data linked to a particular code or category are presented together in order to be able to explore the composition of each encoded set and turn them into significant data.
With this analysis we did not only classify, codify or compare the obtained data.Our aim was not only to inform about what we found but also to explain role-playing and, by doing so, we create different versions of care situations.Therefore, the analysis inevitably entails an enactment.
In order to encode and analyze the data, they have been classified according to the information extracted from students' summaries.

COLLECTION OF DATA -SUMMARIES
The subject category chosen is role-playing and it is sorted into the subcategories and codes presented below (Picture 1).

Facing reality
Role-playing has helped us understand how to act in a real situation and how to assess it, even if it is a simulation, with a certain basis of knowledge.
Role-playing enactments are essential.Through them you can visualize and face different situations that we will probably experience.
Role-playing has been the most appropriate way to deal with a situation very similar to reality.
Role-playing was the most interesting project.With this activity you realize how prepared you are to deal with this kind of situations and I realized I had no idea how to do so.Now I can't say I'm an expert but at least I know more or less how to act.
Cures and techniques are something you learn automatically by practicing, but facing situations that you really do not know how to cope with is quite scary, so role-playing has turned out to be very helpful [...].

Initial assessment vs. final assessment
Contrary to what I thought at first, role-playing is very useful [...].
Learning from others [...] you learn a lot from classmates and criticism from the group and teachers.
[...] I appreciated being told where I went wrong.

Self-assessment. Assessment of what has been learnt.
Thanks to role-playing I have learnt to listen emphatically.With role-playing, it was as if I was looking at myself through a mirror.There were things I thought Using role playing in the integration of knowledge in the...

I was doing well and during the enactment I realized I wasn't, so I managed to correct them. I have learnt a lot with role-playing. I have acquired new knowledge to face new situations that I did not have previously. I think it will be useful for my profession.
The thing I was most interested in was the simulation of different situations.I have learnt much more than I would have if I had read about them in a book, and they have also taught me to develop new abilities and what my limitations are.
This was the most positive and useful activity of the entire degree...

Difficulties in the learning process
Although it has been controversial, we have learnt a lot with role-playing [...].
I think it is a very good way of learning, but we feel rather uncomfortable when we are recorded.We feel under pressure.

Importance of role-playing in the learning process I think the activity I have learnt the most from has been role-playing. I think it is an essential part of the learning process [...].
It is a very thorough activity for applying integrated knowledge.
Role-playing was the best activity.You succeeded in making us think about how difficult it can be to communicate, empathize, give feedback, etc. Theory was easy to understand but we thought it would be easier to put it into practice.

You do not realize how important role-playing can be and to what extent it can help you until you face a real situation...
It is the closest thing to a real situation...These are situations that can happen to us in any time of our lives and careers and where we would not know very well how to act.Now it seems we would be able to deal with difficult situations [...].

Application of theory
It was very useful to apply theory [...].
We can put the acquired knowledge into practice in order to make a better approach to certain situations [...].
It has provided us both with the knowledge needed to cope with difficult situations and the experience [...].something that other subjects have not offered us up to now [...].

Fear of participating
It helped us overcome the stage fright many of us had.We have learnt quite a lot from it, as our degree is mostly based in practice.
At first we thought it was something nobody would ever be able to achieve, but results show that we have been able to deal with the situations pretty well [...].

Insecurity/anxiety before real situations
Insecurity, overwhelming situations and inexperience are a clear obstacle to putting into practice the skills needed in the area of interpersonal relationships.That is why role-playing is so very important [...].

One of my biggest fears is not knowing what to do in a given situation once I become a professional and that my intervention may worsen the situation. Role-playing somehow teaches you communication and interaction
skills and how to face potential future situations.

Gaining self-confidence
It is true that the situation we will be in later will be different to the one we experienced in class, but it makes you feel more self-confident anyway.It's a foundation to know how to act later.
It helped me feel a little bit more self-confident It was the only way of making us not feel so afraid of talking to patients, as you taught us it must be.

Presenting qualitative evidence
The analysis of the summaries process is based on the contributions of Morse et al 27 and Paterson et al 28 They are direct evidence from the analytical process, a summary of the findings.They are short and explicit clauses that describe actual facts, ob-served phenomena related to the dimensions studied on the teaching-learning process of nursing.
Role-playing is an effective tool that enables us to interpret real situations that students will have to face soonand that they are afraid to face. 3,29 ] Initial resistance to the use of role-playing coincides with what Robbins pointed out.However 30 , the resistance is reduced and the idea of failure fades or disappears once we provide information about what role-playing is and how to use it; what students learn and how; the uses of role-playing in their personal and professional life; and assessment guidelines for the final mark.
Through interactive work, role-playing stimulates the learning process by helping the students identify the importance of team work and understand that working in group can help them analyze anxieties and motivate learning. 11,31By learning through role-playing students feel they are part of a group with a common goal: learning.
Through role-playing, students learn to assess, criticize and think about their individual teaching-learning process. 32Likewise and according to Calatayud, role-playing makes it easier to understand the teaching-learning process regarding the difficulties that arise, the objectives achieved, etc. Studies carried [6][7][9][10][11]15 coincide with our findings in the importance that students give to role-playing regarding the perception of theoretical aspects, the development of communication skills, ethical aspects of care situations, the helping relationship, interaction and empathy.
Andrés Pérez C. et al 34 reveal in their work that it is really difficult to convey to students a unified and complementary image on theory and practice, just as we have concluded in our study.
][17] Role-playing prepares students to face real situations by giving them the skills to identify the best way to deal with the situations of each individual, family or community depending on the context and culture. 11n other studies 21,[18][19] we highlight the importance of what is learnt through role-playing for putting it into practice, as it contextualizes a new reality in which the most appropriate response to each situation is given. 10,17hrough role-playing students are encouraged to discuss not only theoretical concepts and situations experienced, but also feelings, values, beliefs and other emotional aspects involved in the process of care. 35This method contributes to giving students the confidence and peace of mind necessary to get over this "stage fright" and thus be able to take advantage of role-playing and the subsequent discussion.
We have not found in the literature any data related to the feelings or experiences of roleplaying observers, what López and Población, 36 call the "fishbowl technique" and other authors simply call spectators or observers.However, it is important to highlight the key role of observers in the criticism, debate or discussion on the situations represented and the way they live this experience.
][8][9][10][11] However, our study highlights that these abilities should not only be linked to the acquisition of professional skills but also to the education of the students as individuals, coinciding with the work of: Ashmore RJ 7 ; Gaeta Chauhan AL 11 Moreover, coinciding with Goldenberg D et al 18 , we consider in our study the acquisition of skills based on the knowledge acquired, without being restricted to rote learning and without taking into account the integrity of both teaching and the person.
The difficulty of identifying and following nursing models to guide future nurses is an important finding of our study that is not reflected in any of the works consulted, even though the study of Germán and Muro 37 , mentions the difficulty students find in playing the role of a nurse in role-playing.
Although most of the studies consulted report a high degree of satisfaction with the use of role-playing and/or its results in general, none of them include a detailed analysis of the degree of satisfaction from the students, teachers and professionals, as we do in our study.We highlight the study of Padilla 38 which provides quantitative data on the effectiveness of role-playing as a teaching-learning strategy.This study shows that those who worked with role-playing obtained better results in the exams.Hernández Flores et al 6 and Germán and Muro 37 however, only mention the students' satisfaction with the use of roleplaying, but without providing data to support this affirmation.As for teachers, the studies of Goldenberg 18 ; Jeffries 39 show the degree of teacher satisfaction with the use of role-playing, but they do not go into detail.
None of the works consulted mention the use of video recording in the simulations and its subsequent assessment by the "actors" involved in carrying out the role-playing.Our study on the other hand gives high importance to the use of video recording, which is positively assessed by both the person who records and the one who is being recorded.

CONCLUSIONS
The findings of this study show a reality described in a narrative form.We have avoided judging the informants, their behaviour or their experiences, in order to focus on facts provided by data, classified and arranged in order to make the phenomenon coherent and understandable.This does not mean that the analysis is not objective.**Findings from the analysis of the summaries have allowed us to see what actually happens when using role-playing as a teaching-learning tool in nursing, why and what the consequences are.Our aim is therefore to integrate role-playing in the teaching-learning process in order to achieve better integration of theory and practice and a greater involvement of students in their learning process.
Therefore, attempting to sum up, we drew the following conclusions: Role-playing is an important and effective • methodological tool for the teaching-learning process in nursing.
** The method of analysis has been objective and systematic.The way of gathering data and their interpretation are determined by the subjectivity of the researcher.
Role-playing allows students to deal with • care situations from an individual and realistic perspective.Role-playing is an element that integrates the • theory and practice of nursing.
Nursing students consider that the use of • role-playing in the teaching-learning process is very positive, although it initially causes resistance and rejection.
Nursing students admit that role-playing • enables them to cope with anxiety, fear, doubts, etc. before facing future real-life care situations.
Nursing students highly value active par-• ticipation and interaction with teachers in the teaching-learning process through roleplaying.
Team work in role-playing is identified by • nursing students as a very positive aspect in their learning process.The use of video as a support tool in role-• playing is highly valued.The critics on the simulations represented • are positively valued.
Stage fright is the main problem identified • in the enactment of role-playing.
There is a need to maintain and increase • the use of role-playing and its integrative capacity.