Understanding the Processes of Role Adoption in Pedagogical Role-Play Games (RPGs): A Narrative Dramaturgical Perspective on “Social RPGs” in Health Professions Education

Abstract

Background

Health professional training interventions based on role-playing games (RPGs) have been shown to be an increasingly popular way to advance health professional students’ skills in communication and empathetic engagement with patients and colleagues. However, role adoption itself is largely assumed, with little research focusing on how students come to engage, or fail to engage, in role play.

Objective

This study aimed to identify the processes by which healthcare professionals and trainees (HCP/Ts) adopt roles in role-based serious games designed for health professions education (HPE). The theory of narrative dramaturgy informed this qualitative study, to illuminate the relationship between the participant and the role.

Methods

Four focus groups were conducted at the conclusion of four iterations of an RPG, in which different groups of healthcare professionals participated, focused on joint deliberation over a case in pediatric oncology. The data were analyzed thematically.

Results & Conclusion

Four themes were developed that characterize the process of role adoption: role commitment; simultaneous evocation of front and back stages; reflexivity; and visceral lingering. Our findings contribute to delineating the processes of role adoption that suggest specific conditions under which role play may or may not be beneficial, and how it can be taught and enhanced in health professional education. In doing so, the study draws attention to an under-researched form of RPG – a “social RPG” – grounded in interaction.

Introduction

The use of serious games has garnered increasing attention in research and practice in health professions education (HPE) (Olszewski & Wolbrink, 2017). Serious games are games developed with a pedagogical purpose and they can be conducted either in-person or online (Ellaway, 2016; Gleason, 2015; Olszewski & Wolbrink, 2017; Sader et al., 2021; Wang et al., 2016). They have been shown to lead to higher satisfaction for learners by allowing them to learn new skills in a safe and interactive environment (Cook et al., 2011; Ellaway, 2016; Gleason, 2015; Olszewski & Wolbrink, 2017; Sader et al., 2021). Such an approach has been taken to teach communication skills in medical education, and other skills that focus on relating to others (Aboushawareb et al., 2025; Gelis et al., 2020; Nestel & Tierney, 2007). Serious games vary in design. One particular design that is gaining more attention is the role-playing game (RPG) (Gelis et al., 2020; Nestel & Tierney, 2007). An RPG is defined as a serious game that puts emphasis on the interactions between the participants and the different roles each participant represents in different game settings (Nestel & Tierney, 2007). RPGs are designed to foster a safe environment that allows the participating healthcare professionals and trainees (HCP/Ts) to learn an array of skills through first-person interactions (Baile & Blatner, 2014; Billings, 2012; Dickson et al., 1991; Lateef, 2010). The medical skills that are targeted by RPG-based training interventions in HPE vary from being specific, such as interviewing patients, to being more general, such as engaging emotions as well as communication skills with patients, families, and other HCP/Ts (Baile & Blatner, 2014; Billings, 2012; Dickson et al., 1991; Lateef, 2010). RPGs have been reported to be used most commonly in teaching communication skills to HCP/Ts (Nestel & Tierney, 2007). Although this approach to medical education has been gaining increasing interest, little is known about the processes by which HCP/Ts participating in RPG actually adopt roles or seek to adopt roles. Such knowledge is important to understand how learning occurs through role play games in order to provide specific educational guidance to optimize their use in HPE.

Researchers have increasingly recognized that simulated activities provide dynamic settings that require participants to assume roles, create their narratives, improvise, and interact around a main plot or multiple plots (Crea, 2017; Pearce et al., 2003; Vangsnes, 2009). This structure resembles the essence and elements of drama and theatre (Crea, 2017; Pearce et al., 2003). As such, some researchers have advocated for the use of a dramaturgical approach as the simulated activities in healthcare and healthcare education (Crea, 2017; Pearce et al., 2003). Dramaturgy comes from the Greek word dramatourgia, which means “to create action or a play” (Pearce et al., 2003). Dramaturgical theory comes primarily from the work by the sociologist Erving Goffman (1922-1982), who argued that when a person enters any social setting, they consciously or unconsciously put into effect information about their roles in that setting as well as information about the roles of others (Goffman, 1959, 1967).

Goffman suggests that a person consciously or unconsciously presents themselves in a social setting according to the social norms and expectations of the role they are taking in that setting and they adjust their behaviors accordingly (Goffman, 1959; Riggins, 1990). Goffman argues that individuals, when in public, act in the way that the society expects from their roles in that society and that they also have private lives that are not shared and which involve preparing for their expected roles (Goffman, 1959, 1967; Manning, 1992). This “presentation of self”, according to what is dictated by the expectations from that social role (front stage), can be different to how the person actually behaves in a more relaxed setting (back stage) (Goffman, 1959; Manning, 1992; Riggins, 1990). Although an interactionist perspective on frontstage and backstage holds that they are integrated, we define them both distinctly for heuristic purposes. This facilitates use of the terms themselves and recognizes that people have an individual dimension of their activity, however integrated their public behavior is or needs to be. A dramaturgical view of role-play games emphasizes the performative alignment with perceived expectations that are observable, more so than behaving as a reflection of one’s thoughts.

In this paper, we engage the idea of “narrative dramaturgy” as the overarching theory to emphasize the fact that the participants are seeking to develop, through their talk, a particular and believable role (Crea, 2017). In narrative dramaturgy, the focus is not only on the enacting of the roles, but also on the narrative created by the participants’ experience of an RPG, its structure and order, to better understand the scenario design and experience of a simulated activity (Crea, 2017). While dramaturgy is a theory that examines how individuals present themselves in social interactions, narrative dramaturgy emphasizes the way stories are constructed and presented (Goffman, 1959; Goffman, 1967; Cantillon et al., 2021; Ellingson, 2005; Crea, 2017; Melaver & MacLean, 1989). Any collective work is about public performance and hence, the influence of other people is indicated by people’s responses. Juxtaposing the concepts from dramaturgy and narrative dramaturgy to RPGs in medical education has shown that RPGs require narrative construction that is similar to dramaturgy (Goffman, 1959; Goffman, 1967; Cantillon et al., 2021; Ellingson, 2005; Crea, 2017; Melaver & MacLean, 1989). Social RPGs are distinguishable from other RPGs that might be played individually in a home setting, for example, in that the activity is centrally related to collective action. We argue that, in a social RPG, an overarching story is put forward, and plots are introduced which lead to building tension, triggering emotions, and further engaging the participants in the experience (Crea, 2017; Goffman, 1959, 1967; Manning, 1992).

Some studies of role adoption in serious games have focused on the “inner experience” of role adoption, or identity of the role adoptee (Gaydos & Devane, 2019; Stenros & Sihvonen, 2020). Other studies have focused on outcomes of role adoption (David et al., 2024). Such studies overlook the potential to more closely examine role adoption processes. It has been acknowledged in commentary pieces that theoretical insights about role adoption ought to illuminate understanding of RPGs (O’Brien, 2012). More empirical work is needed to elaborate such commentary.

Previous research drawing on dramaturgy in simulated activities in healthcare has placed most emphasis on the performative aspect of the drama – what Goffman is calling the “frontstage” (Crea, 2017). However, for Goffman, the “frontstage” – what other people witness – is intertwined with, and not fundamentally separated from, the “backstage” – what is individually conveyed. An important assumption in this view is that thought does not always precede action, as is often assumed; indeed, shared beliefs and experiences can influence thought, suggesting a dynamic interplay between thought and action, or between frontstage and backstage (Crea, 2017; Vangsnes, 2009). Because role-playing, for example, involves the mutual engagement of mind and body, it can be said to be an “embodied” activity (Alsmith & de Vignemont, 2012). Separating the two implies an artificial distinction between the cognitive aspects of one’s subjective, individual experience, and the publicly available aspects which others are able to see and hear.

In light of the mutual engagement as what has been distinguished as “mind” and “body”, overlooking the interplay of one’s engagement with a role, for example, and how it is presented publicly, has limited the insight which can be gained into the processes by which participants adopt their assigned roles in medical education settings. This is important knowledge to gain in order to advance the specific design and assessment of the use of RPGs as a pedagogical approach in HPE to enable future HCPs to “step into others’ shoes” and empathize with them, whether they be patients or colleagues. As such, this study presents the dynamics of what can be called “social role-play games”. Therefore, in this study, we aimed to identify the processes by which HCP/Ts who participate in pedagogical RPG adopt, or fail to adopt, their assigned roles.

Methods

The Role-Playing Game Setting

Following human research ethical approval, and written consent from individual participants, qualitative research was engaged to understand participants’ engagement with roles, the setting being a specific RPG. This RPG was adapted to simulate a pediatric oncology clinical encounter that involves clinicians, a sick child, and the child’s parents. Participants were randomly assigned one of those roles (clinician, parent, or child). To maximize the range of role interactions, four separate RPGs were staged drawing on the scenario of a sick child. The RPGs focused on pediatric oncology, in particular, the condition of neuroblastoma. This condition ideally served the study’s purpose because it allowed for a dramatic array of prognostic possibilities that followed from different interventions, and were reflective of potentially different priorities held by different roles, such as parents, children and health care professionals. The scenario was broadly the same for each RPG, but with slight differences of levels of adversity, role requirements and decision points, to engage diversity of possible points of agreement or disagreement.

The RPG itself was intended to use role-playing to advance the learning of communication skills, and promote understanding of different perspectives, in particular, patients, family members and clinicians. A particular focus was on education to value the decision-making capacity of the child and the importance of their involvement in making decisions that affect them. Trainees were included in light of the emphasis on learning. From a research point of view, we were using the participants to try to illuminate the mechanisms of role-play embeddedness, evident in the change in views. The focus was on the process of change rather than the participants’ specific views. The RPG provided an opportunity to see how people respond to different perspectives and what this means for the direction of the dialogue.

The participants were evenly distributed throughout the sessions. We ensured that there was at least one clinician role, at least one parent role, and one child role in each session. At the start of each RPG session, participants were instructed to undertake a 10-minute warm-up exercise to allow them to explore and understand their assigned roles. The parent and child roles, on the one hand, and the clinician roles, on the other hand, were given separate prompts to introduce them to their roles. The parent and child roles were asked to discuss their most recent family vacation. The clinicians were asked to discuss how the delivery of bad news to a patient.

The first round of the RPG commenced by presenting the participants with the child’s diagnosis of neuroblastoma as well as five different treatment options. The participants were then instructed to individually make decisions on the treatments to be administered and to come to a conclusion on the treatment to be administered to the child with the child having the final say about it. The second round of the RPG commenced by introducing pharmacogenetic information on the child’s risk of developing adverse drug reactions associated with each treatment. The participants were then asked again to come to a conclusion about treatment. Thus, the participants had two opportunities to discuss the child’s condition. The first is when presented with the case and the treatment options. The second is after pharmacogenomic testing results are provided, to what the impact of that new information might be. These stages served to trigger potential similarities and differences of opinion. This design was deliberate to help the participants engage in the RPG experience and especially the conversations for a longer period (the session lasting for 2 hours), and hence become more immersed in the experience.

Participants

Healthcare professionals and trainees were recruited (CIHI, 2020). This involved a combination of purposive sampling in the form of maximum variation, whereby HCP/Ts were recruited based on variation in their areas of specialty, and convenience sampling, in which participants within each professional group were approached from the professional network of the researchers (Etikan et al., 2015; Marshall, 1996). A total of 19 HCP/Ts participated. Participants included seven general practitioners, one family doctor, one pediatrician, four pharmacists, one pediatric nurse, one occupational therapist, one kinesiologist, two medical residents, and one undergraduate medical student. The majority of participants were female (n = 15). Although the overall logic of sampling was purposive, recruitment continued until data saturation was reached, saturation only being applied within each purposive sampling category. Themes generated in the analysis became repetitive and no new themes were generated (Etikan et al., 2015).

Data Collection and Analysis

The RPG sessions were all recorded including the post-game debrief sessions which took the form of open-ended focus groups. The focus group discussions, convened by SAEA, were held immediately following the RPGs and drew on participants’ perspectives and experiences of the RPG, asking, for example, “How did you feel taking part in this role-playing game?” (Morgan, 1996). The recordings were transcribed verbatim, and an inductive thematic analysis was systematically undertaken (Kim et al., 2017; Neergaard et al., 2009; Sandelowski, 2000, 2010). Initial codes were generated for each of the participants and then similar codes from participants with similar assigned roles were agglomerated. Segments of text were compared and contrasted on a line-by-line basis, within particular roles and then across roles. The process was applied systematically and any data that diverged from the identified pattern were reported in separate codes (Silverman, 2020). Researchers gathered multiple times to discuss the codes and conceptualize the emerging major themes.

Findings

Our findings show that embodied immersion into roles involves four particular dimensions: (i) role commitment; (ii) simultaneous evocation of front and back stages; (iii) reflexivity; and (iv) visceral lingering. These are elaborated and exemplified below.

Role Commitment

Role embodiment requires participants to develop a commitment to a role they have been assigned. The immersive nature of this RPG experience, over an extended two-phase period of time, facilitated the role adoption of the different participants. Participants reported that they perceived other participants in the RPG session to be convincingly “in-role”, which, in this interactive environment, in turn influenced them to engage deeply with their roles.

“I mean, for me, I think it is a great exercise because I liked how Wendy [the assigned role name of a clinician in the RPG] played her role, how they thought about the priority of the kid in general and how they [children] think. And like also David [the assigned role name of a male parent character in the RPG] – I think men are more … numbers people in general [in my opinion].” [Participant in parent role, post-RPG focus group]

The participant showed the importance of observing the role adoption of others, triggering appreciation for the role-playing context. Whether one agrees or not with the proclivity of men to engage with numbers, this participant was impressed with the role engagement of others, even referring to them by their role names. An implicit criterion of such engagement was to be able to convey entry into a shared world with other participants, showing them empathy.

One participant who was assigned the clinician role related their own work to how they felt uneasy observing the “parent” pressuring the “child” into agreeing to particular treatment decisions that the child character did not favor:

“Even in the context of the game, he [the child role in the RPG] even (seemed to feel) pressured by the characters playing his parents and he [the child role in the RPG] did not really make the decision. He (seemed to feel) that he was pressured even in the context of the game. And so, (the whole RPG) was an interesting experience.” [Participant in clinician role, post-RPG focus group]

Such immersion through role commitment contributed to participants’ minds and bodies mutually engaged in a shared understanding of the situation, because the role embodiment of others was believable and the participants shared the adoption of roles in which they could imagine themselves and others engaging.

Simultaneous Evocation of Front and Back Stages

Role engagement involved evidence that participants were engaged in believable public displays of role, while being able to reflect on role engagement – at the same time. The active construction of narrative is evident in role development being a consciously effortful process. The participants shared reflections on how they had to make a conscious effort in order to assume their roles. They were exposed to vastly different perspectives on the decision-making process than what they were used to through their own training and clinical practice. This led the participants at one point in time during the role play experience to have their front and back stages meet. This means that, at one point in time, engaging in the role play experience, the participants reflected on and changed their normal behavior (back stage) to that of the role they are portraying (front stage) as is shown by the following excerpt:

“I think one of the things that I was thinking about is how much I was reflecting on myself at the same time. It was very hard. I thought I will take (down) numbers. I thought I am a numbers person (in real life), but when I was thinking about my kid [in the role of a parent], it (was) weird. I thought … “no, I want her to live like a kid, I do not want these numbers. It does not make (a) huge (amount of) sense”. It’s not like 50% versus, like, 90% [risk level associated with the different treatment options presented to the participants during the RPG]. So, I was very surprised, because I thought I would go with the numbers [risk percentages], and I could not (while I was assuming the role).” [Participant in parent role, post-RPG focus group]

The significance of the dramaturgical character of the front and backstage interaction here is that they happened simultaneously, and not in a linear fashion by which thought / cognition necessarily precedes public action. A sense of role adoption is evident in the above participant seeing their decisions as “naturally” differing from their “real” function, such that their new decisions appeared to be the natural way of laying out the treatment options.

Reflexivity

Participants conveyed the indispensability of reflexivity in role engagement – that is, reflection on the influence of their own circumstances, roles backgrounds and beliefs, on the roles they adopted, which they recognized. Participants pointed out that adopting the roles, especially the more vulnerable ones, such as the sick child, was a challenging task. They shared reflections on how “heavy” the experience of adopting that role was. The participants’ experiences of the “heaviness” of their roles enabled them to recognize vulnerabilities in their own practice, and participation itself prompted reflections on participants’ real lives as HCP/Ts:

“It was heavy, but interesting, and it gives you, like, another perspective (from your role in real life) when you are dealing with people of all sorts of vulnerabilities. So, it was interesting. Also, at the beginning, [in the role of the child] I felt a bit like it was my fault, everything that was happening, you know, like everyone was here because of me. So, I felt, like, this kind of blame, but then, at the end, I felt like (the other participants taking other roles in the RPG session) were all helping me, you know – that we were all part of the same team, trying to figure out some things with my life [as the child role in the RPG]. So, it was interesting.” [Participant in child role, post-RPG focus group]

Given that this was the “real” clinician reflecting on them as a role person, that is, out of role in the focus group, the excerpt shows the bidirectional influence of frontstage and backstage engagement. The participant indicated that the RPG provided the opportunity to bring genuine emotion from their real world. The heavy emotional load that the participant carried enabled them to reflect deeply on the genuine empathy for the child character that they felt as a participant in the RPG.

Another participant recognized that their real-life role as an HCP/T can involve a lack of empathy for the patient, but the emotional commitment that participation in the RPG involved enabled them, in the role of the parent, to empathize with the child.

“This is actually definitely a very interesting exercise, because I am usually not on this side of the conversation. I am usually on the other side of the conversation. So, I had to think about it and then for me, you know – super busy consulting numbers – (being assigned the role of the) father – or at least that is the persona that I had tried to play [during the RPG] – it seems, like, in my head, well, obviously this should be the natural way of, like, you know, putting the options [for treatment] in this order. Like, this is just so obvious. Like, this is the most logical way of approaching the situation. Then you come into the discussion [about the clinical decision] and then you see drastically different opinions. And you are, like, ‘Oh, I did not realize that what was obvious to me in my mind and how I processed it actually wasn't as obvious and clear to Melanie [the role name of the sick child character in the RPG] or to Ann [the role name of the mother character in the RPG] in the same situation’. And then, the process of trying to figure out, okay, so how can we balance these very different priorities that each of us have, in a way that we can come to a consensus where we can all feel like we're all on the same team and that we're going to be on [the treatment journey of the sick child] together and that everybody, is at least at a certain level of feeling like we're giving [the treatment decision] the best shot, valuing each of our values of what this family holds dear, basically with each individual person.” [Participant in parent role, post-RPG focus group]

Upon reflecting on their RPG experience, the participants who took on roles of the parent or the child expressed surprise that they were able to resort to different strategies in their decision-making process than those they normally used in “real life” as clinicians in a professional setting. This goes to show that, although HCP/Ts are trained to think and make decisions according to apparently “factual” information, such as risk factors and survival rates, they were, at the same time, able to adopt a more empathic parental tone and take broader quality-of-life aspects into account more than they did in real life.

This shows that the context of this social RPG, in which all participants taking on the roles of the different stakeholders are asked to have discussions around treatment decisions, allowed the participants to make particular observations about the inter-stakeholder narratives and dynamics, in this case of the above excerpt parents pressuring the child to agree to their treatment decision. Such observations led the participants to be reflexive in terms of the relationship between the RPG and real life.

Visceral Lingering

The data showed that however foreign were the roles to the “real lives” of the participating HCP/Ts, either professional or personal, participants were still able to feel the emotional load to the extent that it left a lasting effect after the end of the game. We call this “visceral lingering”. The following quote shows an example of the visceral lingering experienced by a participant who took on the role of a parent:

“So, putting my feet in [the sick child’s] parents’ shoes was interesting – like, not a nice thing to feel. Actually, even though in my (actual) profession, I do not work with oncology at all because I feel it is overwhelming for everyone, for the parents, for the child, and even for the healthcare team. So, I think (that), overall, oncology, in general, is overwhelming, and being a parent [in the RPG] who loves her kid, (I) cannot even imagine that someone… from a medical background… can put a poison into his body. … As a cautious person, [in the role of the mother], I was very concerned about harming (my) child, (and I was not as much concerned as I would be in my real-life as an HCP about) … making the “best (clinical) decision” [inverted commas added]. So, .... it was interesting to know how people in this position would feel …. [Participant in parent role, post-RPG focus group]

Thus, the collaborative and dramatic setting triggered engagement in this participant’s role. Going through the experience of an RPG that is designed to be immersive for the participants helped the participants to connect to the experience on an emotional level that was to last beyond the time frame of the RPG. The experience for this HCP of playing the role of the parent evidently influenced the way they thought about the impact of parenthood on their current clinical role.

Discussion

This study contributed to understanding processes involved in role adoption, taking a narrative dramaturgical approach. The existing literature on the topic has paid relatively little attention to the processes by which role play participants can engage with their roles (Bosse et al., 2012; Nestel et al., 2002; Nestel & Tierney, 2007). Previous literature on role adoption has considered inner experiences and identity, and role adoption outcomes (David et al., 2024; Gaydos & Devane, 2019; Stenros & Sihvonen, 2020). We expand such studies by articulating role adoption as a social process. We contribute empirical work to such commentary pieces. The contribution of this study was to elaborate a narrative dramaturgical perspective as evoking roles by virtue of the influence that people have on each other in social RPGs. It was the influence of others in the RPG – that is, sociability itself – that facilitated engagement in collaborative role play.

Such a process must account for the simultaneous engagement of frontstage (publicly performed) and backstage (individual, private) dimensions of social life, characterized by dramaturgy (Crea, 2017). Through thematic analysis, and emerging simultaneously as themes, we identified four processes of role engagement: role commitment, simultaneous evocation of front and back stages, reflexivity, and visceral lingering. As such, our findings advance the literature beyond advocacy for role-play-based serious gaming, demonstrations of the efficacy of RPGs, and even recommendations to engage a dramaturgical perspective. This study engaged a dramaturgical perspective to show processes of role engagement and reflects a qualitative research approach that could be applied to other social, educational and clinical research settings. The performative theory of narrative dramaturgy conveys the display of the four dimensions themselves as evidence of processes, since, as the data show, the participants experienced influence on each other.

The adoption of roles in RPGs involves the display of the four thematic dimensions. The first dimension of the role adoption process that we identified was commitment to role. Taking a dramaturgical approach to our analysis, we treated the RPG as a drama piece of characters moving through a story plot (Crea, 2017). Our findings showed that assigning the participants to the roles of the different stakeholders of a pediatrics clinical encounter and allowing them to dialogue their way around medical decisions through the story plots (the diagnosis and pharmacogenetics results) allowed the participants to create their own narratives within their assigned roles. This process of narrative creation was shown to have allowed the participants to “step out” of their “real-life” roles as healthcare professionals and trainees and adopt their assigned roles of other stakeholders of the clinical encounter (including the sick child or the parents).

As a part of the process of role adoption, we found that, at one point in time, there was overlap and coherence in the participants’ presentation of themselves and behavior in their assigned roles (front stage), and with their own beliefs of their real-life roles as HCP/Ts and their clinical practices and training (back stage). This was invoked by the opportunity they had, through the RPG experience, to make observations on their roles as clinicians as well as the roles of other stakeholders of the clinical encounter (sick child and parent). Emotion was shown to be a feature of displays of reflexivity. The emotional engagement – turmoil, in some cases – experienced and reported in the RPG, accompanied observations around the weight of clinical encounters and medical decisions on the patients, especially if they were children, as well as their parents. Relatively strong emotion also accompanied compulsions of the child role to yield to treatment decisions with which they may not have been comfortable. This resonates with ethical questions in relation to allowing children to have a say in their treatment decisions (Boland et al., 2019).

Having an immersive, though transient, experience was found to be another factor that contributes to narrative creation and hence the process of role adoption. Although reflexivity is considered to involve the impact of one’s real life on research or practice, this study showed how research involvement can also prompt reflection on one’s real life. Furthermore, participants showed that there was an abiding influence, which we called “visceral lingering”, to their role engagement and the empathy it was intended to impart as an educational intervention. Building future interventions based on the understanding of the processes of role adoption will allow for improvement in the way roles are encouraged or taught in RPGs, and hence foster deeper role engagement to maximize the chance that the experience will have a prolonged effect, or “visceral lingering”, as we call it.

A limitation of the study is the possibility that role-playing perspectives reflect participants’ pre-conceived ideas, such as those reflecting the gender of the participants. Nevertheless, the study’s account for role-play embeddedness was evident through change in views, more so than what their particular views were. The RPG provided an opportunity to see how people respond to different perspectives and what this means for the direction of the dialogue. This study brings to the fore an under-recognized form of RPG – that of a “social RPG” – based on interaction. Social RPGs are intended to tap into “real-life” experiences that can conceivably by employed by others, given our shared status as human beings (Goffman, 1959; Goffman, 1967; Cantillon et al., 2021; Ellingson, 2005; Crea, 2017; Melaver & MacLean, 1989). To understand the processes by which HCP/Ts engaged in their roles during a pedagogical RPG for teaching SDM, the concepts from dramaturgy and narrative dramaturgy were engaged to provide a deeper understanding of the manifestation of roles. The focus on dynamics of embeddedness of roles in RPGs suggests that the four processes contributing to role engagement are transferable to other clinical, social and educational settings.

Conclusion

Beyond advocacy for, and descriptions of, uses of RPGs in HPE, this study elaborated four processes that contribute to role engagement in RPGs. Roles do not merely involve thinking about engaging in such a role, and then enacting the role, in such a strict causal and temporal order. Narrative dramaturgy gave effect to the bi-directionality and shared impact of frontstage and backstage in engaging with roles. This manifested in role commitment, simultaneous displays of frontstage and backstage, reflexivity, and visceral lingering. RPGs have been seen as an ideal way to enable health professional learners to step into the shoes of another and to empathize with them, whether they are patients or colleagues. The backstage-frontstage conjunction has enabled us to show how collaborative serious gaming activity is performative and subject to interdependence among participants.

Clinical and faculty development training initiatives ought to take greater advantage of RPGs, given the evident benefit of being able to engage clinical experience to benefit new understanding of others’ perspectives. Since the intention of RPGs has been to help develop communication skills, leadership, professionalism, and empathy in health professional learners, among others, the four processes elaborated in this study can be used as guides to teach, foster, and assess non-technical skills. The four processes can comprise criteria against which policies and educational interventions can be implemented and evaluated. Educational interventions, incentivized by education and health policy-makers, can apply these four processes to state, firstly, whether these factors are present, and, secondly, either how or how well they are implemented or engaged. For undergraduate interprofessional education, for example, this could be assessable against formal educational modules with content from the literature. For residency or continuing professional development (CPD), this could also include scenarios from the everyday worklife of participants. The “how” can be assessed qualitatively and the “how well” can be assessed quantitatively. As such, the four processes can comprise criteria against which policies and educational interventions can be implemented and evaluated. This would help ensure that future healthcare practitioners and systems are better equipped to handle the complex social and bio-social challenges of the future.