gms | German Medical Science

Patient-centredness (PCN) is an increasingly demanded aim in health care [1], [2]. Moreover, in recent years the topic has gained importance for the health care situation, for research, and for the education of healthcare professions. However, the literature shows that conceptually the term patient-centredness is not uniformly defined [3], [4], because models and definitions include different dimensions [5]. On the one hand, PCN points to a socially demanded new image of the patient, placing empowered and informed patients alongside medical experts who advocate strengthening patient autonomy [6]. On the other hand, the term PCN includes the orientation of structures, processes, and outcomes of the health care system, as well as the respect of interests, needs and wishes of individual patients. Patients experience empathy, receive beneficial and desirable services, and are granted their rights and responsibilities [7]. Central aspects, such as the dimensions physical and psychological support, patient information, empowerment, a biopsychosocial perspective, the practitioner-patient communication, as well as the practitioner-patient relationship and others are bundled in the integrated model for PCN by Scholl and colleagues (2014) [5] (see figure 1 [Fig. 1]).

The model of Scholl and colleagues (2014) [5], used as a theoretical-conceptual framework of PCN, is more and more integrated in the acquisition of competences. Thus, PCN is an examination subject for students of healthcare professions. Competences are a key reference value in vocational training for healthcare professions, to which examinations and their formats should be aligned. The term “competence” describes “the ability to apply knowledge and skills acquired through experience and learning independently, responsibly and appropriately in always new situations” ([8], p.148). At the latest with the Lancet report by Frenk et al [9] published in 2010, competence orientation moved in into universities for health professionals, nursing and medicine and has since been strived for to be implemented by means of various didactic approaches. To meet the demand of competence orientation, the examination format “Objective Structured Clinical Examination (OSCE)” is focused on, a format that has found a high degree of acceptance in the teaching of healthcare professions [10].

The focus is on the objective, structured assessment of clinical competence, as well as decision-making competence with reference to aspects of action. For a high standardization of action processes, within the framework of OSCE simulated persons (SP) are engaged, who form an integral part of today’s teaching of health professionals [9]. SP refers to actors and actresses trained to perform patient roles within teaching contexts to facilitate credible practice, examination, and feedback scenarios at a high level of standardization. In the context of competence acquisition, SPs are thus required to include conceptual bases of PCN also in OSCE examinations and, to this purpose, to relate to frameworks such as the dimensions of the integrated model of Scholl and colleagues (2014) [5]. This could mean, for instance, to design the role descriptions for the following aspects:

1.

to convincingly simulate realistic situations regarding good or bad practitioner-patient communication;

2.

to integrate a biopsychosocial perspective of functioning for practicing patient-oriented goal formulations; or

3.

to include aspects reflecting the practitioner-patient relationship, and also for further aspects.

To fulfil their role, SPs should be able to take the perspective of the persons affected in health-related situations and to know multiple symptoms with their life-changing consequences for these persons [5]. Gaining insight into subjective experiences from the patients’ point of view and into related stories of their life and disease can support the SP in this process. Individual, real experiences from the perspective of the person affected are gaining increasing importance [11]. In addition, listening to and including the experiences of individuals directly affected and their families is recognized as an important factor for continuous improvement of health care. Experiences are mostly described in the form of narratives and are accessible, for example, via the Internet, as described in the following project “DIPEx”.

The project “DIPEx” stands for “Database of Individual Patients' Experiences”, originated in England in 2000, in which real patient experiences are collected, are processed by the Health Experiences Research Group (HERG) of the University of Oxford, and are made available on the Internet at [https://healthtalk.org/]. The DIPEx project is embedded into an international research network [https://dipexinternational.org/], which now includes 14 countries, among them Switzerland, Germany, the USA, Japan, the Netherlands, and others. The DIPEx websites cover more than 100 different diseases or health topics. The special feature of the project is the systematic collection, evaluation, and presentation of subjective experiences of health and disease based on established scientific methods that are defined, manualized and reviewed within the research network [https://www.krankheitserfahrungen.de/], [12]. Thus, the project differs from the currently diverse forms of using patient narratives in social media such as forums, blogs, or commercial sites on the Internet [13]. The overall aim of the project (see figure 2 [Fig. 2]) is to meet the diverse information needs of patients and their caregivers, but also to familiarize all stakeholders, including students in health and social care professions, with the perspective of patients and to stimulate PCN in its various dimensions [14], [15].

This paper outlines excerpts from a workshop held at a conference on Interprofessional Education (IPE) at the Bern University of Applied Sciences (BUAS), in cooperation with the Zurich University of Applied Sciences (ZUAS) Winterthur in February 2020. The aim of this workshop was to show

1.

how PCN can support the writing of case vignettes¹, as well as

2.

the preparation of simulation subjects for "OSCE" exams in the healthcare professions, based on real patient experiences from systematically collected narratives from the DIPEx project.

The 90-minute IPE workshop entitled: “Learning situations with case vignettes: instruction to work with cases that is conducive to interprofessional engagement”, consisted of the following six steps and was led by two co-facilitators (AG&PZ):

1.

Welcome, explanations on how to proceed, recall of participants’ experiences on case development.

2.

Input 1: Theoretical introduction to case development for SPs and conceptual framing of PCN.

3.

Input 2: Presentation of DIPEx project including the theoretical concept of PCN.

4.

Work in small groups on statements of IPE as basis for case development.

5.

Presentation of results and synthesis.

6.

Outlook and conclusion.

The 15-minute input presentation introduced the systematic case development for OSCE with SPs based on four steps. In Miller’s learning pyramid [16] OSCE tests students at the level of “shows how”, using different stations in a structured way. Students should demonstrate their competencies to be tested involving PCN [17]. Therefore, the starting point was the development of an interprofessional case vignette with reference to selective dimensions of PCN from the integrative model of Scholl et al 2014 [5]. In order to design the roles of SPs short examples were developed,, first orally in the plenary and then in writing in the small groups, e.g. the inclusion of a biopsychosocial perspective for the formulation of treatment goals, or aspects that are conducive to or might hinder practitioner-patient communication (see chapters 1 and 2) .

As introduced in chapter 3, the 15-minute input presentation first outlined core contents of the project including video examples from DIPEx Germany, as well as the interactive exchange on two studies from teaching with DIPEx [18], [19]. Obtaining subjective experiences from the patient's perspective [20], [21], via text, video or audio contribution served to contextualize the case events for the participants. Real patient narratives thereby show the connection to the dimensions of PCN from the model of Scholl et al. (2014) [5] and help to prepare for the role of SP for OSCE. The short examples from input 1 mentioned above were related to the video examples shown. This was followed by the introduction to the group work assignment.

Two small groups of five people each were formed including the two co-facilitators. The task was to discuss the content from input 1 and 2 and to reflect on guiding questions for an interprofessional case vignette. From the reflection, statements for the case development were recorded on flip charts. The moderated presentation of the results was followed by a joint synthesis of the results of the two groups. From this, the steps for the next IP workshop on case development in the fall of 2020 were derived.

The results of the IP workshop show that the eight participants (five female) from four health professions (physiotherapy, occupational therapy, midwifery, and nursing) had diverse experience with interprofessional case development. However, they were breaking new ground in terms of a structured approach for case development for OSCE examinations and in working with SPs, except for one participant.

The synthesis of the workshop includes outcomes at the following two levels:

Level 1 in terms of outcomes that did not explicitly address the aims of the workshop.

Level 2 in terms of outcomes that explicitly addressed the two aims of the workshop:

• Aim 1: To support PCN using real patient experiences from systematically collected narratives.
• Aim 2: To support the preparation of simulation subjects for "OSCE" examinations in the healthcare professions.

Level 1: Outcomes that did not explicitly address the aims of the workshop: this related to setting specific prerequisites for the workshop and about participants who had no prior experience in working collaboratively on case vignettes for OSCE.

1.

Interprofessional teaching is full of presuppositions and requires clarification in advance of perspectives that will be included in case development. The following four perspectives were discussed: the student perspective, the faculty perspective, the patient perspective, and the simulation subject perspective.

2.

Before the development of a new case vignette can be actively started, terms and action steps for case development need to be clarified together, such as a common interprofessional understanding of PCN, examination content, aims and competencies. The theoretical-conceptual framework on PCN was useful to address these issues and served as a starting point.

Level 2: Outcomes that explicitly addressed the aims of the workshop:

1.

Listening to and including real experiences and narratives of patients and their relatives was seen as an important learning aspect for PCN in relation to the practitioner-patient relationship. Furthermore, this is recognized as a significant factor for the continuous improvement of health care.

2.

It was important to be informed about systematic and non-systematic narratives and to receive knowledge of where systematically collected narratives are available.

3.

Video contributions to real narratives provide a first impression of the person and the situation in a simple way. Even in short film sequences, non-verbal signs such as the gaze, gestures or body posture are help simulated patients to shape their role more specifically at a later stage.

4.

Five central statements emerged from the group work on explicit aims for case development involving PCN. These are summarized in table 1 [Tab. 1].

On the one hand, the IP workshop served as a basis for writing interprofessional oriented case vignettes for the healthcare professions incorporating theoretical concepts on PCN. On the other hand, it was intended to support SPs in preparing competency-based examination formats, such as for OSCE examinations. Real patient experiences from systematically collected narratives were proposed for writing the case vignettes. Patient narratives serve as so-called “role models” so that SPs can convey practical relevance, convincingly assume the facets of their roles, and present the patient perspective. The intention is to integrate real patient experiences into the role of the case vignette in a lifelike manner. The true-to-life portrayal gives the SP a higher degree of credibility, persuasiveness, and identification with the role. Video and audio contributions from the DIPEx websites [https://healthtalk.org/], [https://www.krankheitserfahrungen.de/] and in the future [https://dipex.ch/] provide a variety of real-life templates for this purpose in order to embed them directly into the script of the vignette to the minute (see table 1 [Tab. 1]). “As a writer (...) of a role, writing a role becomes easier if you are inspired by a person from your working or living environment (...).” ([10], p.37).

Initial results from an RCT study were able to show that medical students benefit from real patient narratives and performed more competently in terms of their communication skills than students in the comparison group who were taught content by subject matter experts [18]. Results from interprofessional learning settings (physical therapy and social work) support this initial evidence [19]. Narrative interviews represent a possible access to experiences in this context. They open the perspective on PCN regarding the inner experience of illness, experiences with the health care system, treatment successes or failures, and coping with illness [22]. With regard to strengthening PCN, Charon 2007 and Shao-Yin et al. 2020 could show that the ability of active listening is to be considered as a central influencing variable for the practitioner-patient relationship, which is associated with appreciation, respect, and empathy, among others [23], [24]. Video, audio or text contributions of systematically collected online patient narratives can support teachers and SPs in strengthening this skill in students in order to develop it as a sub-component for narrative competence and to test it accordingly, for example with OSCE formats [24], [25].

Among the limitations of the workshop, it should be noted that this was a first introduction to the topic. Thus, the different theoretical concepts on PCN, or also on the methodological procedure within the writing process for a case vignette, were not introduced in depth. The composition of the interprofessional group of participants was random. A limited time window was available to discuss content and questions for the workshop assignment and to write up the results in the form of statements. If running the workshop again, it was suggested that the time window for the group work be extended by at least 45 minutes. Follow-up tasks and wishes for a follow-up workshop were noted.

This IP workshop laid the foundation for developing an initial common understanding for the development of future case vignettes for OSCE examinations. The theoretical concept on PCN served as a common starting point. A continuation of this workshop is already in preparation and will follow in the form of an “online atelier” as a writing workshop for case development. For patient-centredness the competence-oriented interprofessional education in the healthcare professions (including physicians) can benefit from the embedding of real patient narratives on health and illness as simulated patients in OSCE formats can portray patient roles convincingly and more realistically.

¹ The instructions for writing up the case vignettes are described in a separate article.

We would like to thank the highly motivated participants of the workshop, who discussed the guiding questions on case development in a lively and constructive way and openly shared and presented their reflections on them. Furthermore, we would like to thank Brigitta Spiegel- Steinmann (Interprofessional Education and Collaborative Practice Unit at ZUAS) and Dr. Francesco Spöring (Competence Centre for Interprofessional Education, Department of Health Bern, University of Applied Sciences (UAS) Bern. for their support in planning and conducting this meeting at BUAS on February 27, 2020. We would like to thank Dr. David Stamm for his support in translating this manuscript from German into English. Thanks, are also due to the anonymous reviewers whose critical comments helped to improve this manuscript.

The authors declare that they have no competing interests.