Using unfolding case scenarios to promote clinical reasoning for nurse practitioner students

Introduction

Case studies are one of students' most preferred methods of learning and are engaging, effective teaching methodologies (Hampton et al., 2017; O'Rourke & Zerwic, 2016). Case scenarios somewhat mirror reality and require students to apply their knowledge by working through a fictitious patient situation (Bowman, 2017; O'Rourke & Zerwic, 2016). Traditional case studies are static and generally present a point-in-time situation with related data, where students are asked to consider the information and recommend a course of action. Alternatively, an unfolding or evolving case study mirrors the experience of an illness situation over time and provides sequential information about a patient's illness as they live through this experience (Bennett et al., 2011; Moench, 2019). The National League for Nursing (2020) describes an unfolding case as one that changes over time, with new information being learned at each encounter. Unfolding cases have been found to be useful as a pedagogical methodology that allows for the continual evolvement and expansion of new information (Padgett et al., 2020).

Unfolding case studies are innovative, inexpensive, low-fidelity teaching methods that require less resources than high-fidelity simulations. The patient's situation continues to change, requiring the student to rethink their initial plan. Students are asked thought-provoking questions along the unfolding case illness continuum and are expected to suggest measures the nurse should be taking at each stage. Unfolding cases are generally considered ideal teaching strategies for novice learners (Moench, 2019), which include new nurse practitioners (NPs) who are preparing for a new role and acquiring new competencies. Unfolding cases are a method of formative assessment in simulated experimental situations (Riley et al., 2020). Thus, to best capture students' formative assessment, this case scenario was designed to prompt students to respond to patient clinical examination findings and vital sign changes. Providing opportunities for growth in diagnostic skills and clinical prioritization through case scenarios allows for dynamic patient changes that need to be recognized by the student.

Unfolding case scenarios are more like true reality (Englund, 2020) and thus seem to be more effective than traditional cases in developing critical thinking skills (Hong & Yu, 2017). The patient may progress from being slightly ill to critically ill or the administrative challenge may go from being a minor situation to a major event that involves multiple providers or the entire organization. Instead of learning only the required skills to deal with one situation, students are continually challenged to determine the next steps and figure out what to do as new situations happen (Porter-Wenzlaffs, 2013). Additionally, unfolding cases may be incomplete, requiring the student to seek additional information and try to reason through the situation, leading to increased learning. Unfolding cases also allow the instructor to follow the student's decision-making processes over time (Bowman, 2017). This article will highlight how an unfolding case study can be used to promote the development of clinical reasoning competencies, although at the same time facilitating collaboration among providers from various specialties.

Literature review

The American Association of Colleges of Nursing (AACN) is leading the charge in advocating for competency-based education. AACN promotes learning approaches for students to be creative, interactive, and link knowledge and plans of action together (AACN, 2021). Unfolding cases have been shown to promote active learning, clinical reasoning, and competency development (Altmiller, 2020). Active learning involves engaging students in the learning process through meaningful activities as they think about the things they are doing (Austin & Mescia, 2004; Phillips, 2005; Prince, 2004). Active teaching strategies foster higher level cognitive processes such as critical thinking (Tedesco-Schneck, 2013), a cognitive process used for analyzing knowledge and elements of a situation (Victor-Chmil, 2013) to cumulate with a clinical decision (Sommers, 2018). Clinical reasoning involves cognitive and metacognitive processes used for analyzing information relative to a clinical situation or specific patient (Simmons, 2010; Victor-Chmil, 2013). Simmons (2010) defined clinical reasoning as “a complex cognitive process” using both formal and informal thinking strategies to obtain information, evaluate the significance of data, and consider alternative options. Good clinical reasoning is essential for sound clinical judgment, which involves making decisions about a patient's diagnosis and needs, and then deciding whether to take a specific action (Fugate et al., 2021); clinical judgment involves cognitive, psychomotor, and affective skills (Victor-Chmil, 2013). Traditional teaching methods may not stimulate critical thinking that is required for making good patient care decisions (van Wyngaarden et al., 2019).

Nurse practitioners who have good clinical reasoning skills are better clinical decision makers who more readily identify deterioration in the patient's condition, with resultant better patient outcomes. Tyo and McCurry (2019) noted that poor clinical reasoning skills are associated with the top three reasons for adverse patient outcomes, including failure to recognize, failure to intervene, and inappropriate follow-up to manage complications. In addition to helping facilitate the development of clinical reasoning (Tyo & McCurry, 2019), which is a critically important competency, unfolding cases provide the opportunity for students to work together collaboratively in groups to reach decisions together, which is an important skill for NPs to perfect (Prince, 2004).

Although the literature includes considerable information about the value of unfolding case scenarios to facilitate critical thinking and learning for undergraduate students, minimal information could be located about the value of using unfolding cases in NP education. O'Rourke & Zerwic (2016) published an article in 2016 focused on how unfolding cases can be used to measure clinical decision-making abilities of NPs. Through consultation with experts, they developed rubrics from expert consultants and tested NP students' ability to collect, interpret, and evaluate patient data from two different case studies (bib_orourke_and_zerwic_2016O'Rourke & Zerwic, 2016). The conclusion from the authors O'Rourke & Zerwic (2016) was that case-based learning is learner-specific but can serve as a measure for clinical decision making. Student feedback about unfolding cases has been positive (Bowman, 2017). When evolving cases are incorporated as part of teaching methodologies, student confidence increases, and care outcomes improve over time (Joy, 2016) facilitated by more sound critical thinking (Tedesco-Schneck, 2013)—which are important outcomes to see as NPs become more expert in their new role.

Managing patients in real time is always “unfolding.” Rarely in clinical practice do we encounter a patient with one symptom or one problem. Patients often have dynamic clinical examination findings in the setting of complex medical conditions, thus requiring the clinician to have strong clinical reasoning skills. As educators we need to teach/train students to apply high level clinical reasoning so they can apply critical reasoning when managing patients.

Methods Development of unfolding case study

The college of nursing (CON) setting for this project included several NP specialty tracks including pediatric primary care, pediatric acute care, family, adult gerontologic acute care, and psychiatric mental health. The development of the evolving case began with collaborative dialogue among all track coordinators (TCs) from each of the NP specialty tracks reporting on current utilization of evolving case studies in their individual tracks. This led to a discussion regarding ways all NP specialty tracks could use one evolving case study to simulate real-life patient care scenarios requiring NPs to collaborate with interdisciplinary and intradisciplinary team members.

Track coordinators scheduled a series of meetings to create a patient care evolving case scenario that would be applicable for all NP tracks and created learning objectives. TCs focused objectives on students learning to practice in multidisciplinary medical teams, developing concepts of critical thinking, and clinical reasoning. The case was developed with the leading diagnosis focusing on a common mental health condition that would progress in severity, resulting in complex medical complications and require increasing levels of care. The case included a 17-year-old patient diagnosed with major depressive disorder who attempted suicide by overdosing on an antidepressant medication. The patient presented to the emergency department and within 24 hours developed serotonin syndrome.

The TCs wanted to develop a case that was realistic and representative of what students would encounter during real-world practice. This patient scenario was applicable to students of all NP tracks because of the patient's age, diagnosis, and clinical presentation. Caring for a 17-year-old patient falls within the scope of all the NP track specialties, and depression is a common diagnosis that is treated by NPs in primary and mental health care settings. Serotonin syndrome is also a diagnosis that requires higher specialty care that is applicable to acute care NPs.

After the leading diagnosis and patient presentation were established, TCs from all NP specialty tracks worked to incorporate information that was pertinent to each respective specialty. The pediatric primary care TC developed the adolescent history. The psychiatric mental health TC developed the psychiatric and social history. The adult gerontology acute care TC developed the presenting status of the patient. The family TC developed discussions regarding transitions of care and follow-up care that the patient encountered. The pediatric acute care TC coordinated the development of the case and compiled all information received from the various TCs into one evolving case. Before implementing the evolving case with students, all TCs met to review the case, make final revisions, and delegate who would cover various aspects of the case study with the students. Refer to Figure 1 for specific details included in the patient encounter.

F1Figure 1.:

Brief description of the evolving educational case presented to the nurse practitioner students.

Use of unfolding case as a teaching methodology

The CON has scheduled immersion dates each academic year when students meet with college faculty and student colleagues to engage in various learning opportunities. During immersion, senior-level NP students across all NP track specialties were required to join via Zoom to engage in the evolving case study. Students were either enrolled in their final NP specialty didactic course or in a subsequent final clinical practicum course. Thirty-four students attended the evolving case study, including 3 pediatric primary care, 2 pediatric acute care, 11 adult gerontologic acute care, 6 psychiatric mental health, and 12 family NP students.

Before starting the case, students were provided with information regarding how evolving case studies work and learning objectives for the learning experience were discussed. The three learning objectives were as follows: (1) After completion of the evolving case, students will demonstrate knowledge and understanding on how to best approach the care of a medically complex patient within a multidisciplinary medical care team. (2) After completion of the evolving case, students will demonstrate critical thinking skills through patient evaluation and intervention. (3) After completion of the evolving case, students would have more knowledge on how to use clinical reasoning skills when developing solutions for patients with combined medical and mental health problems. The evolving case study was presented to the students via a PowerPoint presentation, and each TC participated in leading the group of students through respective sections of the evolving case study. The students were presented with the chief complaint, history of present illness, medical history, current medications, and social history. Students were then asked several questions to discuss in small groups, regarding the patient's psychiatric history and appropriate screening measures for patients with mental health disorders. The evolving case study progressed with the patient experiencing a significant medical decline. The students were required to work as a team to come up with a diagnosis, differential diagnoses, determine needed diagnostic tests, and provide information regarding key interventions for the medical emergency. Once the students were successful at stabilizing the patient, they collaborated with each other regarding discharge planning and follow-up care.

At the conclusion of the evolving case study, each TC met with their individual NP specialty students in breakout rooms to debrief. Track coordinators created a safe environment for learning by allowing students to discuss their initial reactions to the evolving case. Every student was expected and asked to participate in the debrief. Students provided a short summary of the case and the working diagnoses. The TCs and their students discussed several performance domains, including assessment, diagnosing, decision making, communication, and teamwork. Debriefing then concluded with identifying key takeaways of the case that were pertinent to their respective specialties.

Evaluation of effectiveness of unfolding case for student learning

Before the discussion of the unfolding case with students, an exempt Institutional Review Board (IRB) application was submitted to obtain approval to survey the students to obtain opinions about the value of the unfolding case study review and discussion. The IRB determined that this project did not meet the definition of research and noted that IRB approval was not required.

A survey was developed using REDCap (Vanderbilt University, Nashville, Tennessee) that included Likert scale and open-ended descriptive items. The goal of the survey was to obtain student perceptions about the value of the evolving case in promoting clinical reasoning, critical thinking, and learning. Students were provided with the definition of critical thinking and asked if the experience of reviewing and talking about the unfolding case facilitated critical thinking. Students were provided with the definition of clinical reasoning and asked if this experience facilitated clinical reasoning ability. Students were also asked to complete three Likert scale items focused around how effective the unfolding case format was in helping them problem solve, determine a differential diagnosis, critically think, and develop a plan of care and treatment options. Additionally, students were asked to rate their overall learning experience from the faculty presentation and guided discussion about the case and to answer an open-ended question about what would have improved their learning experience (see Table 1 for variable detail).

Table 1. - Descriptive summary of survey variables (N = 23) Variable n (%) NP specialty  AGACNP 5 (21.7%)  Family 8 (34.8%)  Psychiatric/Mental Health 3 (13.0%)  Pediatrics, primary or acute 7 (30.4%) Previous participation in an unfolding case  Yes 3 (13.0%)  No 20 (87.0%) Overall learning experience from faculty presentation and guided discussion  Not beneficial or minimal benefit for my learning 1 (4.3%)  Neutral 1 (4.3%)  Some benefit for my learning 9 (39.1%)  Significant benefit for learning 12 (52.2%) Effectiveness of unfolding case in facilitating learning  Not at all or somewhat effective 4 (17.4%)  Moderately effective 2 (8.7%)  Very or extremely effective 17 (73.9%) Experience of reviewing and discussing case facilitated critical thinking  Not at all or somewhat effective 3 (13.0%)  Moderately effective 2 (8.7%)  Very or extremely effective 18 (78.3%) Experience of reviewing and discussing case facilitated clinical reasoning  Not at all or somewhat effective 2 (13.0%)  Moderately effective 2 (8.7%)  Very or extremely effective 18 (78.3%) Unfolding case review offered value  Provided opportunity to problem solve and determine differential diagnosis   Not at all or somewhat 1 (4.3%)   Moderately 3 (13.0%)   Very or extremely 19 (82.6%)  Provided opportunity to critically think   Not at all or somewhat 2 (8.7%)   Moderately 1 (4.3%)   Very or extremely 20 (87.0%)  Allowed time to discuss treatment options and discuss plan of care   Not at all or somewhat 1 (4.5%)   Moderately 4 (18.2%)   Very or extremely 17 (77.3%)  Relevance of educational exercise to my NP specialty   Not or minimally relevant 5 (21.7%)   Somewhat relevant 6 (26.1%)   Very relevant 12 (52.2%)

Note: AGACNP = adult gerontology acute care nurse practitioner; NP = nurse practitioner.

Each TC sent an email to students in their group after the unfolding case discussion, inviting them to click on a survey link to complete a confidential survey about the experience. No identifying information was obtained, but students were asked to indicate the NP track that they were from. Frequency distributions were used to summarize study variables. All data analyses were conducted using SPSS version 28.

Results

Twenty-three students completed the survey. Of the 23 students, over one-third were family practice (35%), less than one-third pediatric family or acute care (30%), approximately one-fifth were adult gerontology acute care (22%), and the remaining 13% were psychiatric/mental (see Table). The survey began with asking students to answer a question regarding prior exposure to an evolving case. Only three students (13%) had ever participated in an evolving case discussion. Nearly three fourths of students rated the effectiveness of the unfolding case as “very or extremely effective” in facilitating learning (74%). When asked to rate the overall learning experience related to faculty presentation and guided discussion, more than half of students (52%) stated the review of the evolving case offered “significant learning value” and 39% felt the review offered “some value.” The students were asked if the evolving case format provided an opportunity to apply critical thinking and clinical reasoning, in which 78% of students rated the evolving case as being “very to extremely” helpful in creating opportunities for both critical thinking and engagement in clinical reasoning. The majority of students felt the review of the case was “very valuable to extremely valuable” in problem solving and developing diagnoses for the patient (83%) and provided them the opportunity to critically think (87%). Seventy-seven percent felt the case allowed them an opportunity to develop a plan of care and discuss potential treatment options. Over half of the students agreed that the educational exercise was “very relevant” to their NP specialty (52%).

In addition, to answering specific questions students were given the opportunity to provide written suggestions related to what would have made the learning experience better in relation to the presentation and discussion of the evolving cases. Positive comments included, “I really enjoyed the whole experience; it was extremely helpful” and “I thought this was a fantastic exercise, and I really enjoyed getting to work with my peers in other specialty areas.” Suggestions for improvement included: “It was a large group, making the discussion sometimes difficult; maybe breaking into smaller groups would help with this” and “It seemed like there were too many people, so it was hard to give input without being repetitive.” Other student feedback comments included: “[We should do] these more frequently. I liked when specific tracks were called on to hear their thoughts/area of expertise,” and “I think it was very beneficial and more of these throughout the semester would be helpful.”

Lessons learned and implications for faculty

The unfolding case exercise discussed in this article provided a positive learning experience for the senior-level advanced practice nursing Doctor of Nursing Practice students who participated. Students agreed that the unfolding case provided an opportunity for critical thinking and facilitation of clinical reasoning. Students also indicated that this was a valuable exercise for problem solving, developing a diagnosis and a plan of care, and discussing potential treatment options. These findings are consistent with other studies that have demonstrated that students value and learn from clinical simulation learning activities, and particularly unfolding cases (Altmiller, 2020; Hampton et al., 2017; O'Rourke & Zerwic, 2016).

Students also enjoyed the collaborative experience and opportunity to interact with peers in other specialty tracks. Use of unfolding cases is ideal for advanced health professions learners such as NP students, residents, medical students, and pharmacy students and can be used across a variety of disciplines to provide an interprofessional educational opportunity (IPE) that helps learners gain insight to other specialties and professions' roles and perspectives. It is difficult to ensure substantial and quality interprofessional interaction in the clinical setting and especially to do this in a standardized way, so all students get the same type and degree of opportunity and interaction. Applying the same or a similar case to an IPE activity within several disciplines including graduate nursing, pharmacy, medicine, and social work could easily be applicable to students from each discipline and would provide a valuable and unique opportunity for learning.

Much of the research on the use of unfolding cases in nursing education has been focused on undergraduate nursing education (Englund, 2020). The evidence that does exist for graduate nursing education supports the effectiveness of the unfolding case for developing critical thinking and clinical reasoning skills and the increased student confidence and improved care outcomes that result (O'Rourke and Zerwic, 2015). Evidence also supports the increased effectiveness of using an unfolding or evolving case to promote student learning, compared with a traditional case, where the case does not evolve (Hong & Yu, 2017). Considering the critical need for NPs to have sound clinical decision making and clinical judgment skills, we recommend that graduate nursing programs incorporate evolving cases into their clinical-related courses. Adding live role-play as part of the evolving case may be a way to further strengthen the learning value from the experience, as discussed by Younger (2019). Evaluation of faculty and student perceptions and student outcomes is important to add to the body of research for the use of unfolding cases in graduate nursing education.

Unfolding cases provide the opportunity to assess all students using a standardized approach. Unfolding cases may be useful as a method of teaching and then assessing competencies and subcompetencies for many of the new AACN essentials (AACN, 2021). Evolving cases could be used at key points during the program as formative assessments or progression indicators (AACN, 2021) and finally as a summative assessment, such as during the student's last semester in the program, to assess readiness for practice. Clinical performance and readiness to practice is often evaluated by a preceptor through a subjective process. The same subjective process was done for this evolving case evaluation. To better determine student competency and readiness to practice from knowledge ascertained from evolving case studies, faculty should consider a validated instrument as a standardized grading tool.

Although student response was overwhelmingly positive, we also received valuable feedback from students about ways to improve use of evolving cases in the future. Although we had breakout rooms for the specialty tracks at the end of exercise, breaking into smaller groups composed of students from different specialty tracks along with a faculty facilitator may have enhanced the experience. Smaller groups could provide more opportunity for the student to practice clinical reasoning skills and for the faculty to assess them and possibly allow for a more substantial interaction with students from other specialties.

Another recommendation for improvement identified by the faculty as well as the students was to start the unfolding case in the primary care setting rather than at the point of the ER visit. Thus, faculty plan to revise the case to start with the mother bringing the patient to see her primary care provider for complaints of fatigue and depressive symptoms. We were concerned about the complexity of the case being overwhelming for the students but learned that having the case cover the care trajectory was best—to include from primary care to the ER, to admission into the hospital followed by a transfer to critical care, with eventual discharge home with applicable follow-up referrals.

Conclusion

An unfolding case study can be used to promote the development of NP student knowledge and clinical reasoning. Implementing unfolding case studies in NP student curriculum promotes critical thinking and clinical reasoning and allows opportunities to engage in interprofessional collaboration (Johnson and Flagler, 2013.) As demonstrated by this study, students also found that reviewing and discussing an unfolding case was effective to help them learn. The unique format of unfolding case studies provides rich layers of knowledge and learning for NP students. Providing a synchronous and virtual setting promotes an interactive learning experience. The learning environment allows students to critically think and make clinical decisions but also compels students to engage with their peers. This dialogue is an invaluable learning experience, building communication skills, promoting collaborative management strategies, and overall stimulating teamwork. Educators strive to teach critical thinking and clinical reasoning while using inspiring and innovative teaching formats. Advanced nursing education can be strengthened by including effective teaching methodologies such as evolving cases in graduate level curriculum.

References Altmiller G. (2020). “Perioperative unfolding case study”—A lesson in quality and safety. AORN Journal, 112(2), 104–111. doi: 10.1002/aorn.13101 American Association of Colleges of Nursing. (2021). The Essentials: Core competencies for professional nursing education. https://www.aacnnursing.org/Portals/42/AcademicNursing/pdf/Essentials-2021.pdf Bennett C., Kennedy S., Donato A. S. (2011). Preparing NPs for primary care: Unraveling complexity with unfolding cases. Journal of Nursing Education, 50(6), 328–331. https://doi.org/10.3928/01484834-20110228-05 Bowman K. (2017). Use of online unfolding case studies to foster critical thinking. Journal of Nursing Education, 56(11), 701–702. https://doi.org/10.3928/01484834-20171020-13 Brown Tyo M., McCurry M. K. (2019). An integrative review of clinical reasoning teaching strategies and outcome evaluation in nursing education. Nursing Education Perspectives, 40(1), 11–17. https://doi.org/10.1097/01.NEP.0000000000000375 Englund H. (2020). Using unfolding case studies to develop critical thinking skills in baccalaureate nursing students: A pilot study. Nurse Education Today, 93, 104542. https://doi.org/10.1016/j.nedt.2020.10454 Fugate S., Hampton D., Ashford K., Welsh D., Marfell J. (2021). Effect of clinical reasoning seminars on medical-surgical specialty HESI examination scores. Nurse Educator, 46(5), E132–E136. https://doi.org/10.1097/NNE.0000000000000963 Hampton D., Pearce P. F., Moser D. K. (2017). Preferred methods of learning for nursing students in an on-line degree program. Journal of Professional Nursing, 33(1), 27–37. https://doi.org/10.1016/j.profnurs.2016.08.004 Hong S., Yu P. (2017). Comparison of the effectiveness of two styles of case-based learning implemented in lectures for developing nursing students' critical thinking ability: A randomized controlled trial. International Journal of Nursing Studies, 68, 16–24. https://doi.org/10.1016/j.ijnurstu.2016.12.008 Johnson G., Flagler S. (2013). Web-based unfolding cases: A strategy to enhance and evaluate clinical reasoning skills evaluate clinical reasoning skills. Journal of Nursing Education, 52(10), 589–592. https://doi.org/10.3928/01484834-20130919-02 Moench B. (2019). Using unfolding case studies to develop clinical forethought in novice nursing students. Quality and Safety Education for Nurses. https://qsen.org/using- unfolding-case-studies-to-develop-clinical-forethought-in-novice-nursing-students/ O'Rourke J., Zerwic J. (2016). Measure of clinical decision-making abilities of nurse practitioner students. Journal of Nursing Education, 55(1), 18–23. https://doi.org/10.3928/01484834-20151214-0 Padgett T. M., DeRose B. S., Woolf S. K., Tielker S. L. (2020). Implementing an unfolding case study throughout the nursing curriculum to increase opioid addiction education. Journal of Nursing Education, 59(4), 235–238. https://doi.org/10.3928/01484834- 20200323-12 Phillips J. M. (2005). Strategies for active learning in online continuing education. The Journal of Continuing Education in Nursing, 36(2), 77–83. https://doi.org/10.3928/0022-0124-20050301-08 Porter-Wenzlaffs L. J. (2013). Unfolding multicourse case study: Developing students' administrative competencies. Nurse Educator, 38(6), 241–245. https://doi.org/10.1097/01.NNE.0000435263.15495.9f Prince M. (2004). Does active learning work? A review of the research. Journal of Engineering Education, 93(3), 223–231. https://www.engr.ncsu.edu/wp- content/uploads/drive/1smSpn4AiHSh8z7a0MHDBwhb_JhcoLQmI/2004-Prince_AL.pdf Riley E., Ward N., McCormack L., Capps N. (2020). Unfolding case study to teach assessment and care of the high-risk newborn. https://qsen.org/unfolding-case-study-to- teach-assessment-and-care-of-the-high-risk-newborn/ Simmons B. (2010). Clinical reasoning: Concept analysis. Journal of Advanced Nursing, 66(5), 1151–1158. doi: 10.1111/j.1365-2648.2010.05262 Sommers C. L. (2018). Measurement of critical thinking, clinical reasoning, and clinical judgment in culturally diverse nursing students: A literature review. Nurse Education in Practice, 30, 91–100. https://doi.org/10.1016/j.nepr.2018.04.002 Tedesco-Schneck M. (2013). Active learning as a path to critical thinking: Are competencies a roadblock?. Nurse Education in Practice, 13(1), 58–60. https://doi.org/10.1016/j.nepr.2012.07.007 van Wyngaarden A., Leech R., Coetzee I. (2019). Challenges nurse educators experience with development of student nurses' clinical reasoning skills. Nurse education in practice, 40, 102623. https://doi.org/10.1016/j.nepr.2019.102623 Victor-Chmil J. (2013). Critical thinking versus clinical reasoning versus clinical judgment: Differential diagnosis. Nurse Educator, 38(1), 34–36. https://doi.org/10.1097/NNE.0b013e318276dfbe Younger A. (2019). Unfolding case study with live role play. https://qsen.org/unfolding-case-study-with-live-role-play/

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