CLEAR 2008 Annual Conference Anchorage, Alaska “Improving Communication Assessment” John Pugsley...

CLEAR 2008 Annual Conference

Anchorage, Alaska

“Improving Communication

Assessment”

John Pugsley

Carol O’Byrne

The Pharmacy Examining Board of Canada (PEBC)

CLEAR 2008 Annual ConferenceAnchorage, Alaska

Session Objectives• Discuss the importance of assessing oral Communication

• Explain how PEBC assesses Communication– to infer, from ratings of candidates’ communication, that

candidates have (or do not have) the communication ability needed to positively influence client outcomes

• Discuss problems encountered

• Involve you in assessing Communication

• Review Communication assessment research

• Discuss future plans and options to improve Communication assessment


Why is Oral Communication Important?

• In general, client outcomes are directly related to the effectiveness of communication

• In pharmacy, most of the communication with patients and other health professionals is oral

• The pharmacist communicates with patients (and other health professionals) in order to:– ensure that medications to be used by a patient are

appropriate for that patient – enable patients to use their medications safely and

effectively, to achieve optimal health outcomes


Communication in Pharmacy Practice

To impact positively on a patient’s optimal health and well-being, a pharmacist has a responsibility to:

• Establish an effective rapport with the patient• Develop mutual trust and confidence - with the patient, caregivers

and other professionals• Consult with the patient to determine the patient’s needs, limitations

and values• Collaborate with the patient and other health professionals to

determine the optimal treatment plan• Educate and support the patient

– to use medications and other therapies safely and effectively– to adopt healthy lifestyles– to self-monitor the effectiveness of therapy and adverse effects– to obtain further help if needed


How does Poor Communication Impact Patients/Clients?

• Failed communication between pharmacists and patients may lead to unsafe medication use

• Unclear messaging between pharmacists and other health care providers may lead to errors in medication therapy management


Why Examine Oral Communication?

• To observe and evaluate candidates’ Communication skills – in a standardized manner (interactions, scoring)

– in selected contexts (settings, clients, challenges)

• To make valid inferences …• If certification/licensure exams test competencies that are

critical, including Communication, and

• if scores are reliable and generalizable and pass/fail decisions are dependable

then we can infer that successful candidates have what is needed to achieve safe and effective practice outcomes


WHAT IS AN OSCE?

Objective, Structured, Clinical Exam• Simulations of common, critical professional tasks• Series of stations through which all examinees

rotate– examinees perform professional tasks – behaviours are observed & evaluated

• Stations / tasks involve interactions with standardized clients/patients/health professionals– individuals trained to portray an important interpersonal

situation consistently and repeatedly


The PEBC OSCE

Based on national competencies (NAPRA)

• Pharmaceutical care (29%)• Ethical, legal, professional

issues (9%)• Drug information (5%)• Communication (43%)• Drug distribution (9%)• Practice management (5%)

Fifteen, 7-minute “stations”• common/critical situations

– 10 patient encounters– 2 health professional

interactions– 3 non-client interactions

• 1 pharmacist assessor per station

Administered twice yearly

650 + Canadian grads

900 + foreign-trained pharmacists


6. Recommends immediate medical attention:

Candidate:___________________

Be sure to attach candidate id barcode label. Also, ensure that your assessor id barcode or client (spid) barcode are correct. If not correct, please mark an X through the barcode box and enter the correctnumber in the spaces (blank lines) provided above the box.

2. Cautions: Do NOT take Pepto Bismol.

3. Explains Pepto Bismol:

1. Asks about / confirms / mentions:

OutcomeProblem SolvedSolved/ MarginalUncertainUnsolved

PerformanceAcceptableAcceptable/ MarginalUnacceptable/ MarginalUnacceptable

Misinfo

Risk

CommunicationsAcceptableAcceptable/ MarginalUnacceptable/ MarginalUnacceptable

4. Recommends appropriate therapy for travellers' diarrhea:

Unique Response (if any)

5. Recommends appropriate dosing:

If another response is givenwhich you are unsure isappropriate - or whichinfluences your grading below -please shade in the bubble andnote details

Client_____Assessor:_____Start Stn:__Shift :__

8 0 0 0 6 0 0 0

7. Discusses prevention of diarrhea:

8. Discusses supportive measures for diarrhea:

9. Suggests wearing a MedicAlert Bracelet/tag with ASA allergy information.

COMMENT (if rating less than Acceptable/Marginal or Solved/Marginal) : use back of sheet if needed

Gathers patient information and assess patient's needs:

Fill in one bubble for each rating scale below - to score the candidate's performance.

Recommends appropriate therapeutic (NPM) and preventive (lifestyle)measures:

Location:0 1 2 3 4 5 6 7 8 9

0 1 2 3 4 5 6 7 8 9

0 1 2 3 4 5 6 7 8 9

Track:A B C D E F G H I J1 2 3 4 5 6 7 8 9 0

TRAVELLERS' DIARRHEA - TRAINING STATION #2

ATTACH CANDIDATEBAR CODE HERE

Imodium (loperamide) and/or Kaopectate

Imodium: two tablets to start, then one tablet after each loose bowel movement, to a maximum of 8 tablets dailyKaopectate - 2 Extra Strength tablets or 2 tablespoonfuls of Kaopectate Suspension after each loose bowelmovement; maximum 7 doses per day

for (persistent) diarrhea

use only bottled water for drinking, making ice, brushing teethwash fresh fruit and vegetables using bottled water OR peel them before eatingavoid salads (unless in a hotel which follows these same precautions)

if diarrhea lasts several days use Gastro-lyte or Pedialyte to maintain electrolyte balanceincrease fluid intake and avoid dairy products

*

*

*

*

*

*

10. Agrees that Pepto Bismol can be taken (even if not recommended). (incorrect response)

Shade circles & rectangles completely.

Like this:

NOT like this:

PHARMACY EXAMINING BOARD OF CANADA QUALIFYING EXAMINATION - Part II (OSCE) - PS07 revised 27-Apr-07

STATION #2

*

ASA allergynature of ASA allergy (reaction)

contains salicylate (aspirin like substance)may cause an allergic reaction

if accompanied by fever, blood in stool and/or persistent vomiting (any one of)


Candidates’ Scores

• Scored with 3 holistic scales, 4 anchors each:Unacceptable Marginally Unacceptable Marginally Acceptable Acceptable

– Communication – same scale for all interactive stations– Outcome – global scale guided by case-specific critical

checklist items (required to solve the station problem)– Performance – global scale reflecting

• Communication• Outcome • Thoroughness (non-critical items)• Accuracy of information (misinformation)• Risk to patient (if not performed adequately)


Rating Communication - 4 Anchored Subscales

Process(organized, flexible &

focussed)

ClientCentredness

VerbalSkills

Non-verbalSkills

Client centredness, e.g.• sets client at ease, establishes rapport and trust• shows genuine interest in client’s concern• listens and makes responses specific to client• involves client in discussion/decision making

Process, e.g.• stays on track, coherent, makes smooth transitions• flexible, adjusts to client’s input, etc.

Non-verbal skills, e.g.• no distractions• appropriate body posture (faces SP/MD)

Verbal skills, e.g.• uses suitable vocabulary, grammar, pronunciation,

volume, pace, and tone• expresses ideas clearly, in terms


Supportive Written Comments

Rating: Unacceptable

Comments: relevant to three or four factors • Client-centredness: not client-centered - should

respond more specifically to client• Process: very disorganized • Non-verbal: looked at books while speaking• Verbal: didn’t use lay terms - said “prophylaxis”,

other medical words; read out of brochure; choppy, stopped speaking mid-sentence


PEBC Prior Research - Scoring

On a 15-station OSCE – across all scales• Negligible error due to pharmacist- assessors,

using either holistic or analytical (checklist) scoring schemes

• Holistic ratings are more consistent than checklist ratings

• One pharmacist-assessor per station yielded consistent, generalizable, dependable holistic scores

(alpha, G and D ~ 0.9)


PEBC Prior Research - Scoring

• Rating consistency was higher between two pharmacist assessors than between a pharmacist-assessor and the SP simulator when rating Communication

• SP simulators should not replace pharmacist-assessors for rating candidates’ performance (including Communication)

• Consistency of rating scales– Communication - lowest consistency


Ratings & Comments – Candidate A

Assessor 1 Rating: ‘Unacceptable Marginal’ (2/4)• Comment: “Candidate did not understand the sequence of

events, suggesting solving the problem by calling the doctor; minimized the seriousness of drug allergy.”

Assessor 2 Rating: ‘Unacceptable Marginal’ (2/4)• Comment: “Quote: Did the doctor prescribe this for the

rash? This kind of drugs can make XXX allergy. You have sensitivity/allergic rashes...”

SP (simulator) Rating: ‘Unacceptable Marginal’ (2/4)• Comment: “Did not listen very well and told me XXX was

prescribed for YYY. Smiled a lot when talking about symptoms (inappropriate)”.


Ratings & Comments – Candidate B

SP Rating: ‘Unacceptable Marginal’ (2/4)• Comment: “I was not sure what I was supposed to

do, when to see the doctor, whether or not to continue the medication or when I should be concerned”.

Assessor Rating: ‘Unacceptable Marginal’ (2/4)

• Comment: “…was chewing gum when talking to patient and rocking the chair”.


Ratings & Comments – Candidate C

SPR Rating: ‘Unacceptable Marginal’ (2/4)

• Comment: “Asked many questions, rambled, cut patient off, shifted in seat throughout interaction.”

PA Rating: ‘Acceptable Marginal’ (3/4)

• Comment: “Rushed, hard to follow his recommendations.”


PEBC’s Communication Assessment Challenges

Communication assessment tools• May lack clarity – communication behaviours not

easy to describe • Descriptors are ‘indicators’ – they do not capture

the whole construct• Training tool differs from the exam tool• Multi-factorial – difficult to recognize and

assimilate into one rating (‘connoisseurship’)


PEBC’s Communication Assessment Challenges

• Assessors and raters differ in their ability to– Interpret and apply the assessment criteria

e.g. Acceptable rating – with comment: “Spoke very quickly; SP could not get a word in”

– Ignore non-relevant behaviors e.g. ‘Seemed nervous’

– Evaluate a multi-dimensional construct (processes & impact)

– Separate Communication (process and impact) from Outcome (station-specific content and outcome)


How Does PEBC Assess Communication?

• Tools– Communication scoring sheet – factor scales with

descriptors, summative scale

– Station scoring sheet – checklist, rating scales, comments

• Orientation and Training– Assessor web site: videos, station scoring sheet, scoring

key

– Pre-exam Orientation & Exam Day: PPT, DVD for practice, Communication and Station scoring sheets, feedback

• Exam Administration– Station scoring sheet only


Let’s try it!

• Brief orientation and training

• Review Communication rating criteria

• Score DVD Performances

• Compare & deliberate results (each table)– Communication factor ratings– Communication overall rating– Similarities and differences (report)

• PEBC scoring key and rationale


Assessor Orientation & Training

1. Review Communication rating guidelines (handout)

2. Review case (handout)

3. Watch performance #1 (DVD)– Complete station checklist (station scoring sheet)

– Complete Communication rating form

4. Assign an overall Communication rating (rating form)– Consider all four factors to be equivalent, unless the station

requires a particular Communication skill or poses a particular challenge

5. If rating is Unacceptable/Marginal or Unacceptable, write the reason/s in the Comments box


Rating Communication - 4 Anchored Subscales

Process(organized, flexible &

focussed)

ClientCentredness

VerbalSkills

Non-verbalSkills

Client centredness, e.g.• sets client at ease, establishes rapport and trust• shows genuine interest in client’s concern• listens and makes responses specific to client• involves client in discussion/decision making

Process, e.g.• stays on track, coherent, makes smooth transitions• flexible, adjusts to client’s input, etc.

Non-verbal skills, e.g.• no distractions• appropriate body posture (faces SP/MD)

Verbal skills, e.g.• uses suitable vocabulary, grammar, pronunciation,

volume, pace, and tone• expresses ideas clearly, in terms


Attends/responds to client’s needs/feelings/concerns, with a

professional manner that treats clients respectfully

acknowledges/greets client in a timely/professional manner

focuses on client’s specific concerns

encourages questions, checks client’s understanding

makes responses specific to client

invites client’s responses in discussion / decision making

acknowledges/validates client’s feelings & needs (empathy)

is non-judgemental, unbiased / sensitive to cultural differences

does not greet client in a timely/professional manner

does not focus on client’s specific concerns

does not invite questions generalizes, monopolizes,

lectures does not involve patient in

discussion/decision making ignores / does not validate

client’s feelings and needs; is glib

is judgemental, biased / insensitive to cultural differences


Candidate #1

• Score independently• Fill in the Station checklist

as you watch the DVD• Rate each factor on the

Communication scoring sheet afterward

• Based on these ratings assign an overall Communication rating


Candidate #2

• Score independently• Complete the station checklist • Rate Communication – lower

left box (without completing the Communication rating form)

• If rating is low (UM or U) write comments– what you observed – possible impact on the patient


Deliberate…

• Communication ratings for Candidate #1– Factor ratings– Overall Communication rating– Comments

• Communication ratings for Candidate #2– Overall Communication rating– Comments

• Value of Communication rating form?


What is your experience?

• What thoughts do you have about communication assessment and using these tools a result of doing these exercises?

• How important is it to assess communication in your profession? If you are assessing communication, how are you doing it?


Our Ongoing Challenges

Defining Communication

• Break factor 2 out into pharmacists’ communication tasks?

e.g. interview patients, counsel on medication use, promote healthy lifestyle, etc.

• Add ‘setting the stage’ – ‘concordance’?

– developing a shared understanding of the patient’s goals, value of the medication and how to implement therapy (including monitoring and lifestyle changes if appropriate)


2007-2008 Research Questions

Can we improve Communication rating consistency by

• clarifying the criteria?

• separating communication and content assessment? – using separate tools?

– using other raters? SPs? SP raters?

• enhancing training? – communication and what it looks like

– more practice with feedback

– other?


2007-2008 ResearchType of Assessor/ Rater

Data Collected

Checklist and/or Holistic Ratings -

Communication (C), Outcome (O), Performance(P)

1 Pharmacist Assessor (PA 1) Checklist and COP ratings

Whole exam - same station

2 Roving Pharmacist Assessor

(PA 2)

Checklist and COP ratings

1/2 exam – alternating between two stations

3 Standardized Patient Rater (SPR)

Checklist and Communication rating only

1/2 exam – alternating between two stations

4 Standardized Patient Simulator (SP)

Communication rating only

Whole exam - same station


Fall 07 ResultsRaters (observers)

• Mean ratings: PA (3.05); RPA (3.42); SPR (3.31)– PA1 ratings were generally the lowest– PA2 and SPR ratings were generally higher than PA1 ratings

• When rounded to the nearest scale point, they were the same (in 10 of 12 comparisons and overall)

Inter-rater Consistency (Communication Rating) between• PAs & SPRs: low in 3 of 4 stations (0.04 to 0.82)• SPs & SPRs: generally higher (0.41 to 0.80)• PAs & PAs: highest (0.54 to 0.77)

More than one pharmacist-assessor would be required to achieve consistency in Communication ratings on par with that of Outcome and Performance.


Rater Considerations

Rater training and experience• Assessors and RAs had previous experience rating

Communication - SPs and SPRs did not • Some SPs and SPRs involved in teaching

Communication – different perspectives?• Pharmacists not formally trained in Communication

Focus and complexity of exam tasks• SPs are active participants; others are observers• Assessors completing station checklist and all ratings

– may confound Communication and content– may miss some visual cues


Spring 2008 Study - Refinements• Rating criteria

– Clarified, describing observable behaviors

– Factors more clearly distinguishable

• Assessor and rater selection – All had prior experience, except for one SPR and a few SPs

(simulators)

– Most SPRs were the same as in Fall 07

– Training tools – criterion wording

• Assessor and rater training– Participants oriented to study purpose and method

– New DVDs, more discussion / reflection

– Examples of comments reflecting performance in each factor

– Increased emphasis on comments - observations and impact


Preliminary Spring 08 Findings

• Assessor/Rater/Coordinator Feedback– Much smoother than Fall 07 (training and exam day)

– Prior rating experience gave SPs and SPRs confidence

– Training enhancements & new resources were useful to experienced assessors and raters

– Rating criteria were clearer

• Comments– More comments were documented– Comments were more specifically related to factors in the

scale and impact on the patient


Research Comments

• This study was based on small sample sizes (from 34 to 74 candidates).

• Further studies need to be done regarding non-pharmacists’ ability to rate candidates’ Communication before assessors can take the place of pharmacist assessors in rating Communication.


Recommendations

• The consistency and reliability of Communication ratings should be improved further

• Improve instrument design & rater training

– clarify rating criteria; relate to Canadian pharmacy practice

– more practice and feedback

• Consider having raters complete a Communication checklist (to inform the rating) and a Communication rating,

• Consider combining SP and Assessor ratings (SPs’ ratings may be more independent)


RecommendationsTraining strategies might include:

• Continue to focus on standardizing the trainers (who train raters)– Involve communication experts

– More benchmarking exemplars and exercises

• Refined training materials for assessor/rater training• Additional rater training

– more practice – training sessions, online

– reflection - documentation of rationale for all ratings

– feedback – compare with rating key and rationale

• Online Communication training (assessors, raters and candidates?)


References• Quero-Munoz, L, O'Byrne, C, Pugsley, J, and Austin, Z. (PEBC). Reliability,

validity and generalizability of an objective structured clinical examination (OSCE) for assessment of entry-to-practice in pharmacy. Pharmacy Education. 5(1):33-43, March 2005.

• Hodges, B et al. Analytic global OSCE ratings are sensitive to level of training. Medical Education 2003; 37:1012-1016.

• Humphrey-Murto, S, Smee, S, Touchie, C, Wood, TJ, and Blackmore, DE. A comparison of physician examiners and trained assessors in a high-stakes OSCE setting. Academic Medicine. 80(10) Supplement:S59-S62, October 2005.

• Makoul, G, Curry, R. The value of assessing and addressing Communication skills. JAMA. 2007; 298(9):1057-1059.

• Schneider, B. Clarity in Context: rethinking misunderstanding. Technical Communication. 59(2), May 2002.

• Tamblyn, R et al. Physician Scores on a National Clinical Skills Examination as Predictors of Complaints to Medical Regulatory Authorities. JAMA. 2007;298:993-1001.


Speaker Contact Information

Dr. John Pugsley, Registrar-Treasurer

Carol O’Byrne, Manager, PEBC QE-II (OSCE)

Pharmacy Examining Board of Canada

717 Church Street

Toronto ON M4W 2M4

Email: [email protected]

Tel: 416-979-2431, ext 226

Web site: www.pebc.ca

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