A Novel Simulation Program for Interprofessional Health Literacy Training
Abstract
Effective communication with patients and between members of the health care team are important strategies to enhance health care outcomes. Despite the prevalence of low health literacy and associated risks in the population, health professionals are often not trained adequately in health literacy communication practices. The purpose of this pilot program is to determine if offering learners an opportunity to practice health literacy communication techniques in a simulated patient care team can increase skills, attitudes, and confidence in this important area of patient care. We implemented a novel, team-based interprofessional Objective Structured Clinical Examination (iOSCE) focused on health literacy. Evaluation took place on three levels: student self-assessment of health literacy communication skills and beliefs about interprofessional teamwork, standardized patient assessment of skills during the clinical encounter, and observer assessment of interprofessional teamwork. Statistically significant gains were seen in students' health literacy communication confidence, as well as beliefs, attitudes and understanding of interprofessional teamwork. The aim of this article is to describe our pilot health literacy iOSCE findings. This pilot shows that an OSCE is an effective assessment tool for a mix of health professional learners at different levels to demonstrate health literacy practices in an interprofessional teamwork environment. [HLRP: Health Literacy Research and Practice. 2023;7(3):e139–e143.]
Introduction
Effective communication with patients and between health care team members are important strategies to enhance health care outcomes. Approximately 36% of adults in the United States are functionally illiterate, which translates to millions of individuals in the U.S. with low health literacy have high risk factors for poor health outcomes (Kutner et al., 2006). Low health literacy is associated with decreased ability to follow medical instructions, less use of preventive services, higher costs, and higher mortality (Berkman et al., 2011). Despite the prevalence of low health literacy and associated risks, health professionals are often not trained adequately in health literacy practices (Coleman, 2011). Previous research has identified that real-world or simulated learning opportunities are lacking in training (Saunders et al., 2019).
Prior research on health literacy training reflects a range of outcomes, from no change in students' ability to define health literacy or literacy issues (Milford et al., 2016; Ross et al., 2013) to improved self-reported confidence and understanding (Bloom-Feshbach et al., 2016; Milford et al., 2016; Mnatzaganian et al., 2017). Based on a conceptual framework for health literacy training in health professions education (Saunders et al., 2019), we sought to determine if offering learners simulated team practice in health literacy communication techniques can increase attitudes and confidence in this important patient care area. An Objective Structured Clinical Examination (OSCE) is an adaptable assessment tool providing a simulated environment for direct observation and evaluation of health care professionals' clinical competency. Students demonstrate a defined skill assessed against pre-determined criteria framing the competency outcomes allowing consistent testing through an objective assessment checklist. Standardized patients (SPs) are community members trained to demonstrate a scenario scripted for clinician-patient communication or team communication mimicking actual care delivery. Simulated patient training for health literacy skills demonstration through interprofessional teamwork was an ideal format to address the intersection of health literacy skill-building in the context of real-world health care team interactions, and one we did not find in the literature. Our novel program is an interprofessional OSCE (iOSCE) focused on health literacy—health literacy iOSCE. It assesses the development of the top three health literacy practices deemed most important for health professionals: Teach Back, avoiding medical jargon, and using a patient-centered interview approach (Coleman et al., 2017).
This pilot program had three objectives: (1) create a health literacy iOSCE based on best practices identified in the literature, (2) prepare students for small interprofessional teams participation, and (3) assess impact on students' skills, attitudes, and confidence in health literacy communication and beliefs, skills, and attitudes in interprofessional teamwork.
Methods
Interprofessional teams were created by assigning one medical student, one dental hygiene (DH) student, and one occupational therapy (OT) student together. Students were not equally distributed, so some teams had two DH students and one OT student. All received the same preparation: a leveling 2-hour introductory health literacy class including Teach Back skill practice. This session occurred at differing time points for student types, ranging from 2 weeks to 3 years prior to the iOSCE. The iOSCE is designed for any health professional student who completed the introductory health literacy session and addresses two interprofessional education competencies identified by Interprofessional Education Collaborative: interprofessional communication (competency 3) and teams/teamwork (competency 4) (Interprofessional Education Collaborative, 2016).
A SP case highlighting health literacy challenges and social determinants of health was developed, depicting an adult with type 2 diabetes and barriers to medical adherence, a familiar clinical scenario for our professionals that leveled learner engagement. The patient is experiencing social determinant stressors affecting medical management, including limited access to care, low health literacy, and financial difficulties. To elicit these factors, learners must demonstrate effective communication skills to gather details affecting shared medical decision-making between patient and clinician. Learners must demonstrate Teach Back, plain language, and effective questioning to ensure patient understanding. Communication skills and interprofessional teamwork basics (TeamSTEPPS) (Agency for Healthcare Research and Quality, n.d.) were reviewed in a pre-iOSCE session. To facilitate a teamwork approach, health literacy practices were organized into three roles for each team: Role 1 – take patient-centered medical history using effective questioning technique; Role 2 – use Teach Back to ensure understanding; and Role 3 – provide summary of plan and correct medical jargon. Students were expected to prepare for all roles. Role assignments were revealed just before the iOSCE and each student performed one role.
Data Collection and Analysis
Evaluation of the iOSCE was done at three levels with different perspectives: students completed self-assessment of health literacy communication skills and interprofessional teamwork beliefs, the SP assessed students' skills, and an observer (usually a faculty member) assessed interprofessional teamwork.
Student Self-Assessment
Students completed two pre-post assessments online. One assessed whether attitudes and confidence with health literacy communication techniques changed after iOSCE participation. This pre-post instrument has six Likert-scale questions on conviction and confidence of the three health literacy practices, adapted from the Always Use Teach Back Conviction and Confidence Scale (Institute for Healthcare Advancement, 2021). The other tool, the Performance Assessment Communication and Teamwork Tools Set (PACT), assessed change in students' beliefs and attitudes about interprofessional teamwork (National Center for Interprofessional Practice and Education, n.d.), a validated tool to assess interprofessional team simulation training.
Standardized Patient Assessment of Health Literacy Skills
SPs completed a Health Literacy Checklist (Table 1) after observing students' demonstration of communication techniques and provided verbal feedback to the team. We created this 19-item checklist, consisting of yes/no responses and descriptive comments, adapted from a health literacy OSCE checklist (Bloom-Feshbach et al., 2016). Checklist item examples include whether learners used medical jargon or open-ended questions to clarify understanding and employed Teach Back. To maintain consistency in student evaluation, all SPs were trained together in checklist use.
| Student #1: Patient-centered communication | ||
| Yes | No | Introduces self to patient |
| Yes | No | Elicits patient's agenda by asking “How may I help you today?” or “What can I do for you today?” |
| Yes | No | Starts with open-ended questions to elicit the patient's concerns:
|
| Yes | No | Asks direct questions to elicit details about the patient's concerns |
| Yes | No | Asks patient about their understanding of a diagnosis of diabetes |
| Yes | No | Speaks clearly |
| Yes | No | Demonstrates active listening |
| Yes | No | Asks about context of situation (e.g., reason for missing appointments, difficulty paying for medication, transportation issues, financial problems) |
| Student #2: Health literacy/Teach Back | ||
| Yes | No | Explains main problem: Lack of transportation and money constraints affect ability to take care of self (taking medication and keeping appointments) |
| Yes | No | Explains what patient needs to do: keeping up with clinic appointments and taking medications |
| Yes | No | Uses a tool/model to help explain what you want the patient to know |
| Yes | No | Uses Teach Back to explain what patient needs to do (example: “If you were to tell a friend how to take this medicine, what would you say?” or “Tell me what foods you need to avoid.”) |
| Yes | No | Normalizes Teach Back or puts burden on themselves (e.g., “I do this with all of my patients.” or “I want to make sure I explained things clearly.”) |
| Yes | No | Asks at least one open-ended question to clarify understanding (e.g., What questions do you have for me?” |
| Yes | No | Clarifies misunderstanding in nonjudgmental manner (e.g., “I must not have explained that well. Let me try again.”) |
| Student #3: Summary of care plan/medical jargon | ||
| Yes | No | Overall, do you feel the care plan was comprehensible (i.e., can the patient understand what is expected)? |
| Yes | No | Did the learner plan follow up/future appointments in the clinic considering the patient's transportation issues? |
| Yes | No | Uses plain language and avoids medical jargon. Or may use jargon that is immediately defined/clarified (e.g., the tingling in your feet might be peripheral neuropathy, a complication of your diabetes; must clarify this as inflammation of the nerves in your feet because of the high sugar levels.) |
| Yes | No | Corrects use of jargon used by other team members and clarifies statements |
Observer Assessment of Interprofessional Teamwork
To rate interprofessional team performance, the Team Observed Structural Clinical Encounter (TOSCE) instrument was used, an adaptation of the McMaster-Ottawa Scale (Lie et al., 2015), and completed by two observers for each student team. The scale measures six teamwork competencies and provides a global team rating.
Results
The health literacy iOSCE was piloted with three types of students: 4th year medical students, 2nd year DH students, and 2nd year OT students. Student characteristics are summarized in Table 2. The Software program used for analysis is R version 3.6.3.
| Variable | n (%) |
|---|---|
| Gender | |
| Female | 47 (81) |
| Male | 10 (17.2) |
| Race and ethnicity | |
| Asian | 8 (14.5) |
| Black/African American | 3 (5.5) |
| Hispanic or Latino/a/e | 24 (43.6) |
| White | 19 (34.5) |
| Race and ethnicity not reported | 1 (1.8) |
| Health profession | |
| 2nd year dental hygiene student | 22 (38.6) |
| 2nd year occupational therapy student | 19 (33.3) |
| 4th year medical student | 16 (28.1) |
| Previous exposure to the term “health literacy” | Yes 52 (89.7) |
| No 5 (8.6) | |
| Previous health literacy education | Yes 47 (82.5) |
| No 10 (17.2) | |
Health Literacy Confidence and Skills
For the Health Literacy Conviction and Confidence Survey, the Wilcoxon rank sum test showed a statistically significant improvement for all questions concerning confidence (p < .05) (Table 3). The SP Health Literacy Checklist found no statistically significant differences among the three professions across mean scores. The most missed item was that the student did not normalize Teach Back.
| Question | Time | Strongly agree | Agree | Somewhat agree | Neither agree nor disagree | Somewhat disagree | Disagree | Strongly disagree | p |
|---|---|---|---|---|---|---|---|---|---|
| n (%) | |||||||||
| I am confident in my ability to use Teach Back (ask patients to explain key information back in their own words) | Pre | 16 (28.6) | 20 (35.7) | 16 (28.6) | 2 (3.6) | 1 (1.8) | - | - | .025 |
| Post | 20 (35.7) | 29 (51.8) | 7 (12.5) | 0 (0) | 0 (0) | - | - | ||
| I am confident in my ability to avoid medical jargon in a patient encounter | Pre | 15 (26.8) | 25 (44.6) | 11 (19.6) | 3 (5.4) | 1 (1.8) | - | - | .008 |
| Post | 29 (51.8) | 17 (30.4) | 9 (16.1) | 1 (1.8) | 0 (0) | - | - | ||
| I am confident in my ability to use effective questioning techniques | Pre | 9 (16.1) | 20 (35.7) | 16 (28.6) | 6 (10.7) | 4 (7.1) | - | - | < .001 |
| Post | 25 (44.6) | 20 (35.7) | 8 (14.3) | 3 (5.4) | 0 (0) | - | - | ||
Interprofessional Teamwork Confidence and Skills
For the PACT student self-assessment, the Wilcoxon rank sum test found that sections with consistently significant improvements were “familiarity working and training with teams,” “learning and performance,” and “learning environments.” All items in the PACT section of understanding of interprofessional teamwork were highly significant for improvement (p < .001). The TOSCE showed a Global Rating Score of 2.3 (standard deviation [SD] 0.45; range, 1–3) as an average of two observer ratings. The lowest average subscore was “Collaborative Patient Family Approach” competency at 2.1 (SD 0.56), indicating improvement opportunity for this team-based skill.
Discussion
This was a pilot study of an interprofessional OSCE focused on health literacy practices. Our study revealed the feasibility of an iOSCE that accomplishes two goals: (1) assess improvement of health literacy communication skills and (2) engage students in interprofessional teamwork. Students have a forum to practice and receive feedback on their communication skills in a simulated learning environment with immediate reflective discussion. Our findings align with what is reported for student health literacy outcomes in related literature, which is described at the beginning of the article.
All learners had significant patient experience at the time of the iOSCE. They received the foundational health literacy instruction at varying time points ranging from 3 years to 2 weeks prior. However, this disparate exposure did not appear to have an effect, as no significant differences in health literacy skills were seen between professions, supporting our hypothesis that all levels of health professional students who have some health literacy curriculum can successfully develop their skills.
Limitations
There are limitations in our pilot. First, iOSCE observers did not undergo formal training on the TOSCE instrument, resulting in some team rating inconsistency. We advise standardized training similar to recommendations supported by the instrument's authors (Lie et al., 2015). Second, because students received prior education on health literacy and teach-back method, the iOSCE may have reinforced prior knowledge reducing the ability to see change in the pre-post assessment measures.
Conclusion
The Health Literacy iOSCE demonstrates that a mix of health professional students can gain confidence in health literacy skills and improve beliefs and confidence with inter-professional teamwork. Student participants recommended flexibility in scripted roles to engage more in their profession's particular skill set. The iOSCE will be refined to further balance health literacy and interprofessional teamwork objectives with individualized professional background. We encourage replication of this iOSCE at other institutions to improve reliability and validity of the training with health professional students.
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