Tobacco Cessation CounselingObjective Structured Clinical Exam

(OSCE) Tutorial

To b u i l d y o u r l e a r n e r s ’ c o n f i d e n c e

a n d s k i l l s f o r p r o v i d i n g t o b a c c o

c e s s a t i o n c o u n s e l i n g i n c l i n i c a l

p r a c t i c e .

Tobacco Cessation Education

∗ Resource development ∗ Active SP program: review training nuances and begin SP training ∗ No formal SP program: review guide as a “how-to” tool ∗ Somewhere in between: pick and choose applicable modules

Utilizing this Guide

∗ Rx for Change: Clinician-Assisted Tobacco Cessation is a comprehensive tobacco cessation training program that equips health professional students and practicing clinicians, of all disciplines, with evidence-based knowledge and skills for assisting patients with quitting.

∗ http://rxforchange.ucsf.edu

Program Rationale

∗ What is an OSCE?

∗ Series of stations designed to assess performance

∗ The SP cases for the tobacco cessation OSCE were built to deliberately mirror and enhance the training the students have previously completed

Objective Structured Clinical Examination

http://www.aspeducators.org/

Healthcare Simulation Dictionary (citation: Lopreiato J O. Healthcare Simulation Dictionary. Rockville, MD: Agency for Healthcare Research and Quality; October 2016. AHRQ Publication No. 16 (17)-0043.

∗ Designed for students who have previously completed the Rx for Change and Virtual Patient training program

∗ The 6 cases include 2 patients in each of the following categories: ready to quit, not ready to quit, and relapse

∗ Institutions will ideally select 1 or 2 cases from each category for a series of either 3 or 6 encounters

∗ Institutions that are able to implement fewer encounters should select the ones that are most representative of the skills sets they want their students to develop

Objective Structured Clinical Examination

∗ Continued development of communication and counseling skills ∗ Assessment of knowledge and skills ∗ Evaluation of effectiveness and competency ∗ Opportunity for formative feedback

Purpose of the OSCE

Where to begin?

Existing SP Program∗ The resources to implement the

tobacco cessation OSCE are likely already in place

∗ Access the case materials found as part of this tutorial

∗ Familiarize yourselves with the cases and training nuances specific to this OSCE

No Existing SP program∗ The OSCE cases can be utilized

by health professional programs without an SP program

∗ Contact active SP programs ∗ Train members of the

educational community ∗ Outside resources

Ann M. King, Linda C. Perkowski-Rogers & Henry S. Pohl (2009) Planning standardized patient programs: Case development, patient training, and costs, Teaching and Learning in Medicine, 6:1, 6-14, DOI: 10.1080/10401339409539636

Standardized Patients

∗ In addition to participating in the standardized simulated patient encounter, SPs also complete checklists following the encounter

∗ Checklists allow the SPs to give meaningful feedback

∗ Document actions performed by the examinee

∗ Assess the examinee on behavior related to interpersonal and communication skills

Checklist Completion

∗ Students complete a self-reflection following each encounter

∗ Allows students the opportunity to self-identify key counseling points that they omitted

∗ Leads to continuous improvement throughout the OSCE stations

Student Self-Reflection

∗ The training video was developed to provide an overview of Standardized Patient training

∗ Topics include ∗ SP training handouts ∗ SP case materials ∗ SP checklists ∗ Feedback training overview ∗ Video review

∗ These topics are also covered in the following Power Point slides

SP TRAINING VIDEO

Training of Standardized Patients

∗Review the Rx for Change and Virtual Patient modules prior to training SPs

∗Focus on accurate standardized case portrayal and case-specific feedback

∗Train to the case materials

∗ Provide the SPs with the training handouts included with the OSCE materials

∗ SPs should have an understanding of the training learners have completed prior to the OSCE

∗ SPs should be familiar with the 5A’s and 5R’s elements to tobacco cessation counseling

Training Handouts

∗ The SP cases for the tobacco cessation counseling OSCE contain all relevant information needed to train SPs on the specifics of the case

∗ Each case also includes additional information for the SP

∗ Scripted, standardized responses are provided for anticipated learner questions

∗ Responses to questions not addressed in the materials should be provided in a “neutral” fashion that does not contradict other information provided in the case materials

Training to the Case Materials

∗ Standardized Patient checklist

∗ Communication checklist

∗ Completed immediately following the encounter

Reliable Checklist Completion

∗ Checklists vary based on patient’s stage of quitting

∗ SP guide to the checklist ∗ Training and standardization tool ∗ Provides examples of questions learners might ask ∗ Fundamental to accuracy and consistency

Scoring the SP Checklist

Item numbers vary based on whether the

patient is ready to quit, not ready to quit or has relapsed

Standardized Patient Guide to the Checklist: Ready to Quit  

1) The examinee assessed the patient’s readiness/willingness to quit. You mentioned you wanted some help quitting so it sounds like you are ready. Are you ready to quit? What are your thoughts about quitting? Will you consider quitting in the next month?

2) The examinee asked about current tobacco usage (amount, duration, pattern, recent changes, etc.).

How much do you currently smoke? How long have you been smoking? Do you smoke at certain times of day? Is there a pattern to your smoking routine? Have you made any recent changes in the amount you smoke?

  3) The examinee asked about past quit attempts.

Have you ever tried to quit in the past?

4) The examinee asked what methods the patient has used in the past to help quit. What methods have you used to help you quit?

Scoring rubric ∗ Yes ∗ Needs improvement ∗ No

The tobacco cessation communication checklist can be adjusted to better reflect existing checklists

Scoring the Communication Checklist

9 total items comprise the

communication checklist

The design of the Rx for Change tobacco cessation OSCE allows for

both written and verbal feedback

Feedback

∗ Constructive feedback

∗ Feedback should be given in a supportive manner

∗ Comment first on areas in which the learner performed well

∗ Then comment on areas for improvement

Feedback Training

∗ Comment specifically on the 5 A’s and 5 R’s ∗ Refer to the Rx for Change Tobacco Cessation Counseling Guidesheet

during feedback ∗ The SP checklist and student self-reflection mirror one another and

provide opportunities for feedback ∗ The items included on the checklists provide an excellent starting point

for both written and verbal feedback ∗ Ask the learner what they were working on and provide feedback on

those elements of the encounter ∗ Identify counseling elements the learner can work on in the next case

Tobacco Cessation Feedback Specifics

Feedback Language Useful words and phrases for verbal and written feedback

I felt _______ when you _______

∗ Reassured

∗ Confident

∗ Optimistic

∗ Understood

∗ Encouraged

∗ Cared for

∗ Guided

∗ Connected

∗ Comfortable

∗ Comfortable ∗ Supported ∗ Empathized with ∗ Listened to ∗ You showed interest ∗ Unsure ∗ Overwhelmed ∗ Opportunities were missed

∗ In the future it would be helpful to… ∗ You could benefit from… ∗ These are good things to maintain and why… ∗ I was confident that… ∗ In your next encounter consider… ∗ An area for improvement is… ∗ A suggestion may be… ∗ Communication could be improved by… ∗ I appreciated that you…

Feedback Language Continued Useful words and phrases for verbal and written feedback

∗ Use professional language in your written feedback ∗ Assume you are always writing directly to the learner ∗ If you do not give full credit for an item on the communication

checklist, provide the reasoning for the deduction ∗ Reread your comments after writing them to make sure they are

constructive and supportive ∗ Keep your comments succinct

Written Feedback Instructions for SPs

∗ Seek the learner’s perspective and involve them as much as possible in the feedback process

∗ Ask the learner to identify what they found challenging during the encounter

∗ Ask them to identify areas in which they did well during the encounter

∗ During verbal feedback provide concrete, specific examples of observed behavior: acknowledging what was done well and instructing on performance gaps

Verbal Feedback Instructions for SPs

∗ What did you find most challenging during this encounter? ∗ What did you think went well during this encounter? ∗ What were you working on in this encounter? ∗ What would you like to work on in your next encounter? ∗ Do you have any questions? ∗ Is there any portion of the encounter you would like to try again?

Useful Questions for Verbal Feedback:

∗ SPs and trainers complete the scoring checklists while observing video footage

∗ Each individual watching the video independently completes the checklists

∗ Scoring should be compared and discussed as a group

∗ Guidance from the trainer on scoring standardization

∗ View the video a second time, and the trainer can pause the video to point out specific moments within the encounter that are relevant to checklist scoring reliability 

Guided Practice in Checklist Completion Utilizing Training Videos

∗ SPs can role-play the case with one another, with one acting as the SP and the other as the learner

∗ Role-play feedback between a learner and SP

∗ Trainer observation and guidance

Role-Playing as a Method of Training SPs

∗ Assess the available resources at the institution

∗ Potential locations to complete the OSCE

∗ Availability of financing

∗ Identification of faculty and staff to assist with logistics

Implementation: Where to Begin?

∗ Simulated clinical or pharmacy settings ∗ Recording equipment ∗ Checklist completion ∗ Learner scheduling ∗ SP scheduling

Implementation Planning

∗ Rotation schedule ∗ Student orientation ∗ Student instructions ∗ Checklists (SP and student) ∗ Timing ∗ Session organization

Implementation of the OSCE

∗ Whether the purpose of the OSCE is formative or summative determines how the data are analyzed

∗ Formative assessment is meant to identify learner strengths and weaknesses

∗ A summative assessment is usually at the completion of learning

Evaluation of OSCE Data

∗ A multiple-case OSCE is always formative, to some degree, because students will improve as they move from case to case

∗ If the OSCE is formative, SP feedback is the most crucial component

∗ If the OSCE is summative, you will want to compare students’ scores to each other for grading purposes

Evaluation of OSCE Data cont.

∗ The SP case-specific checklist, SP communication checklist, and the student self-reflection each are scored as a ratio of achieved items over the total number of items on the list

∗ To create a percentage score for an individual case, the points from the three checklists can be added together for each case and divided by the total number of points possible

∗ To create a single overall score for the OSCE, the average percentage score of the three cases can be calculated

Utilization of OSCE Data

∗ For some education programs, there might be interest in calculating a communication score utilizing the SP communication checklist from all three cases

∗ Specific benchmarks utilizing standard deviation or Z scores can be used if normed grades for each case are desired

Utilization of OSCE Data, continued

∗ OSCE cases should be used in combination with Rx for Change and virtual patients

∗ The OSCE provides the students with the opportunity to practice their counseling skills

∗ Broad spectrum approach to learning

Conclusion