1. The contribution of OSCEs and simulation to achieve consistency in practice
Presented by Pat Day and Gale Hazleby
With thanks to Sue Peckover for her help in developing the research proposal and Hayley Chauhdry, Lucy Kirkham, and Janet McAleavy for conducting the focus groups

2. What are OSCEs?
Objective Structured Clinical Examinations (OSCEs) are a form of performance based testing used to measure the clinical competence of students.
They were developed by Harden in 1975 to assess the clinical skills and competence of final year medical students. OSCEs are defined as ‘‘an approach to the assessment of clinical competence in which the components of competence are assessed in a planned or structured way with the attention being paid to the objectivity of the examination’’ (Harden,1988).
OSCEs have been shown to be both valid and reliable in assessing complex communication and clinical skills in a variety of health professions (Rushforth, 2007).Research suggests that the OSCE is appropriate where the outcome of the assessment is critical for professional qualification (Rushforth, 2007).
The advantages of OSCEs include greater objectivity compared to traditional methods of assessment of practice. In addition, a broader range of skills can be tested (Rushforth, 2007). They enhance motivation for learning and are generally positively viewed by students and lecturers.

3. OSCEs in Specialist Community Public Health Nursing
OSCEs have been used as the method of assessment on the Specialist Community Public Health Nursing programme in order to observe the communication skills of students during simulated scenarios.
This has been integrated with a simulated record keeping exercise.
To achieve consistency in practice the module is very structured within an experiential teaching framework. Role plays, case studies and client stories are generated from practice to convey real life experience.

4. An example of a simulated therapeutic conversation
Example of an OSCE

5. Research into the impact of the teaching methods in the module on practice
Research has been conducted into the impact of the module’s teaching methods on practice through 2 focus groups held 6 months after the completion of the module.
The focus groups were semi-structured
Consisted of a number of standard questions
Allowed the respondent to bring up any other relevant details about the impact of the module and the teaching methods
There were 2 focus groups with 5 or 6 participants in each

6. Focus Group Questions/Prompts
1): How useful has it been to learn about behaviour change skills during the SCPHN course?
2): What opportunities have you had in practice to use behaviour change skills with clients?
3): Thinking about your experiences of using behaviour change skills with clients, how effective do you think this has been?
4): Thinking about your experiences of using behaviour change skills with clients, has it altered the nature of these consultations?
5): What do you think are the benefits of using behaviour change skills in your SCPHN work with clients?
6): What do you think are the challenges of using behaviour change skills in your SCPHN work with clients?
7): Has learning about behaviour change skills changed your approach to consultations with clients?

7. Preliminary Findings
The value of the simulation of real-life consultations is reflected in the responses to question 1 (How useful has it been to learn about behaviour change skills during the SCPHN course? )
Example response:

8. Responses to Question 1 How useful has it been to learn about behaviour change skills during the SCPHN course?
“I think like because they’re skills you should be using anyway that you like to think that all nurses and midwives, that that’s how they actually will speak to clients, but I think, because I know some of the practice teachers said, well, why are you learning that, you knew it all anyway, you’re doing it every day, but I think it’s got to be more of a conscious thing and yeah, I know you use a lot of those techniques naturally like good communication, but I think it’s different to actually, you spend a module learning it, practicing it and applying it.”
“It’s only by doing that that I learnt how to apply it properly, because we went into the theory and appropriate application a lot, didn’t we, with examples and we did a lot of worked examples and that really helped.”
“It was quite petrifying doing it in front of the whole class though at times! But I think that’s what helps in the sense of making you confident in doing it. If you can do it in front of a classroom of people then you can do it out in practice.”
“I was actually dreading that assessment. I think it’s totally nerve wracking, but it made me read a lot about it, because I thought, I need to be good at it!”

9. Responses to Question 2 What opportunities have you had in practice to use behaviour change skills with clients?
“I had one the other week which is really similar to the OSCE scenario that we did. It was a mum, it was at a two year review and she was feeling really isolated and low mood and not really wanting to go out and do anything and I felt it was just like the OSCE all over again and I feel like I approached that differently to how I would have a few years ago, so that’s my specific example.”
“I think I use it at every contact, I think that’s the basis of my practice is using that. You can use it from antenatal contact, talking about, I don’t know, diet, breastfeeding. I think it is a very useful tool to have.”
“I think the breastfeeding, especially antenatally, just the way you introduce yourself and the way you ask the client to start the consultation, that initial open question I think is the thing that I have learnt from and it guides where your conversation goes and I do find that really useful and it’s the, I think not the advice given so much, because as my previous experience I was adult nursing and I think it is advice giving and you do feel that as a nurse you’ve got to come up with the goods sort of thing and I think it’s like working back from that, so for me that’s been a big learning curve for me, but I find it really useful.”
“I’ve used it quite a bit and we, as part of our role as a school nurse we do health sessions, so we have consultations with teenagers so independent of their parents or carers and sometimes we invite them because an issue has been brought to our attention, so we’re …[unclear] that invites them down to talk to us and I’ve found it really useful in that scenario. Not so much in the sort of safeguarding meeting type things, the other aspect of our role, because I think that’s just the dynamics there and there’s lots of people, it’s not really an appropriate use I would have thought, but definitely in one to one consultations it’s proved it’s beneficial.”
“I think we, like the same as you really, have found that being a nurse beforehand you’re kind of solution focused and it’s that expectation”

10. Responses to Question 3 Thinking about your experiences of using behaviour change skills with clients, how effective do you think this has been?
“I think just even like the questions that I ask now, even if you’re only going to be with them five minutes I’m just thinking a little bit more, you know more open ended questions and things, I think you can still use them. You might not change their life”
“but I think you can still use the skills even if it’s just a one-off 10 minute appointment.”
“Yeah and I think it gives you the thing where you then, even if you’re just doing a one-off session you’re then sort of thinking like, shut up, let them talk, it’s about them. We are conscious that you want them to talk to you even if it’s just that one session.”
“Sometimes it’s just about reframing, isn’t it, and, say, they’ve got a particular issue and seeing how they can look at it a bit differently and then that allows you to signpost on to other services.”

11. Responses to Question 4 Thinking about your experiences of using behaviour change skills with clients, has it altered the nature of these consultations?
‘Yeah, I think it’s the balance of, in the past maybe I did more talking than I should have done in comparison to behaviour change, so it’s definitely altered. I tend to not - I wait for the point, well, I ask less direct questions and I’m more patient about trying to get to the core than before where it might have been a bit more like a sort of barrage of questions’. 
‘You’ve got to try and get their perspective and not try and put what you feel is needed on them and again, like I say, as a nurse, that’s your core thing, isn’t it, health advice and health promotion, but it’s moving back from that and just trying to let it be more client led I think is what I try to do, but again, it’s practice I think. I think you need a lot of practice. It’s not something that comes easily all the time’.
‘I think it’s changed the way I ask a question, because I’m used to asking closed questions that give me direct answers and it’s now changed the way I’ll ask a question, so a more open, like I say’ - 
‘- so it leads them where they want to go rather than where you want it to go’.
‘Yeah and leads to you having to ask less’. 
‘And the information comes in conversation rather than in question and answers’.
‘ I think you reflect more as well on the visit. I think you sort of, well, it does with me anyway, I think I go away and I do reflect a lot more on what’s been said and think about it after the visit as well’.

12. Responses to Question 5 What do you think are the benefits of using behaviour change skills in your SCPHN work with clients?
‘So that they recognise their change rather than us telling them they need to change. Clients identify their own need and methods, strategies to change, with some guidance’.
‘It’s not always about us giving them a solution. It’s about them coming up with the solution themselves or else thinking they’ve made that decision!’
‘We’ve guided them rather than told them basically, yeah’.
‘They’re more inclined to change, aren’t they?’
‘If you’re told to do something…’
‘ You’re going to do exactly the opposite!’
‘ It’s more nurturing’.
‘ And it’s not putting your standards on somebody else, is it, so what you think would be correct they might not have even thought about that or that could not even be anything that they’d ever achieve and I think you’ve got to accept that as well, that what you want might not be what they want, so you’re never going to get to that point. Unless it’s anything to do with like safeguarding or anything like that with children, then maybe sometimes you’ve just got to allow that to be, haven’t you and just, and in a sense that’s still an achievement for that person. You might not, at one point you might not think you’ve achieved anything because it’s not what you want and where you want to get, but actually it’s where they want to get, so that is the achievement, isn’t it, so it’s just realising that’.
‘And I think recognising a small change, like small steps rather than going for the big thing’  

13. Responses to Question 6 What do you think are the challenges of using behaviour change skills in your SCPHN work with clients?
‘I think we’ve mentioned the time constraints’.
’The time constraints and continuity’.
‘I think there’s an actual thing where it doesn’t always get, they don’t always engage straightaway and it’s like that coping with the fact that you’ve not, you might come away with not actually still progress very much further. I can’t really explain it, but yeah, it’s sort of like it’s a slow burner sometimes and that’s a bit frustrating, because as a nurse then you’re very, like we’ve said before, most of us have come from a solution focused model. Originally it was a very medical, this is what’s wrong, this is what we’re going to do, this is going to make it better, then we’ve gone a little bit more patient/client centred and then this is almost another step forward, but it doesn’t, it sometimes can be the slower process, which is potentially frustrating because of the time pressures that we work under
think sometimes clients think that as well. They expect you to come in and have an answer for a problem’

14. Responses to Question 7 Has learning about behaviour change skills changed your approach to consultations with clients?
‘I’m just trying to think of an example. It’s definitely made you realise how important that relationship is and how delicate it is, so if something does come up in that consultation, like you really should just be open and honest about it. I can’t think of an example, but if something came up where you might have to report it or get an outside service in, I think to protect your relationship it’s better to be open and honest and to keep you, so they’ve always got something to focus on within that, but yeah, it highlighted to me how important that therapeutic relationship was and how to maintain it really’.
‘Yeah, I think I probably plan it more now and look at where they’re at in regards to the theory, bringing that in, like where they’re at and where they could be before going into a - I mean if you don’t know that information before then you can’t really do it, but if you know then you can sort of plan ahead’.
‘ The module gave me the confidence to use it and be very aware of it and how to use it really actually I think, because I think it was XXXX was saying that you knew about it, but you’d never practiced reflecting back on people and what words to use and things like that and I think that really did help’.