Reflective Essay: OSCE Assessment

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18th May 2020 Personal Development Reference this

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Reflective Essay: OSCE assessment

The purpose of this reflective essay is to critically reflect on the Objective Structured Clinical Exam (OSCE) Assessment as part of my role as a Psychological Wellbeing Practitioner (PWP). PWP’s use assessments to gain an understanding of disorder-specific information to decide whether they are suitable for treatment within the Improving Access to Psychological Therapies initiative (IAPT) (Richards and Whyte, 2011). Throughout this piece of writing I will be establishing strengths of the assessment performance and areas in which could be improved.

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Carrying out this critical analysis and level of reflection helps to address my skills as a PWP using the Declarative-Procedural-Reflective (DPR) model of skill development. The DPR model consists of three entities to become a competent and reflective practitioner. These include gaining and acknowledging certain Cognitive Behavioural Therapy (CBT) themes. Using this knowledge in practice to follow the procedures and develop my skills and finally being able to critically reflect on this process in order to move forward and make progress as a practitioner (Bennett-Levy, 2006). This essay will employ the Gibbs (1998) model to use as a reflective tool of writing. This model allows for an in-depth analysis of what happened, my feelings around the event, what went well and areas for improvement, exploration of why these areas did or didn’t go well, learning points from this and how I can implement this in my future practice.

An important aspect of working with people in a therapeutic setting is the alliance that you build when delivering CBT (Ghaderi 2006, as cited in Langhoff et al, 2008). Common factor skills are particularly important in this alliance and some of these are “empathy, warmth, cooperation, transparency, and structure” (Langhoff, Bär, Zubrägel and Linden, 2008, p.69). Maintaining this therapeutic alliance with the patient is of great importance and one that I will be focusing on throughout this critical analysis. I will do this by identifying and evaluating the common and specific factor skills used in this assessment.

Active-Listening – Empathy

Empathy is perhaps one of the most essential common factor skills and this can be construed as the ability to sense and understand others emotions and have a willingness to imagine what an individual might be feeling (Thwaites and Bennett-Levy, 2007). Research suggests that in order for an effective therapeutic alliance in CBT and for a positive outcome in therapy, empathy must be present from the practitioner (Evans-Jones, Peters and Barker, 2009). Empathy can be communicated using verbal or non-verbal communication and Thwaites and Bennett-Levy (2007) suggest that an acknowledgement of what somebody is going through using verbatim helps to bind the relationship between practitioner and patient.

During my OSCE assessment, I can be seen to express verbal empathy a number of times [03:11, 04:27, 05:55, 11:36, 11:41]. One example of me showing empathy is saying “That must be quite difficult for you” [05:55] in which the patient responds “Yeah”. These responses from the patient show that they feel listened to and that I am able to acknowledge how difficult things are for them. My aim was to ensure the patient felt comfortable, understood and listened to, all of which are important aspects of empathy (Feller and Cottone, 2003). I feel as though these moments helped to bind the therapist-patient alliance and that these are moments that went well within the OSCE and helped to form a positive relationship, which is important within CBT (IAPT, 2010). In my future practice, I will ensure that I continue to show empathy to build and maintain an effective therapeutic alliance.

Although I demonstrated some good examples of empathy, there were times in which I missed opportunities to display appropriate empathy [04:42, 08:55]. A particular example of this is when the patient is explaining how she is worried she might get diabetes as it runs in her family [04:42] and I acknowledge this by saying “Okay” but miss offering the chance for her to open up further about this situation by using an empathy statement. This then caused the patient to hesitate answering the next question, which could indicate they didn’t feel listened to [04:55]. This caused these areas of the OSCE to not go as well as planned and this could have been because throughout the OSCE, it was performed in an artificial environment, I was feeling anxious and I was focused on gathering all the disorder-specific information. Not feeling listened to or non-genuine responses have been shown to negatively effect the therapeutic relationship (Hill and Knox, 2009) and could have led me to appear distant and therefore diminished the relationship, hence the following hesitation from the patient.

This could have been made a more positive experience for the patient by adapting these common factor skills. The use of reflective silences could have resolved this as these are shown to positively impact the therapeutic alliance (Huckabee, 2018). These silences allow for the patient to witness genuine reflection from the therapist. As well as this, instead of using phrases such as “Okay”, I could have used more “Mmm” statements, as research suggests these reduce interruption but continue the flow of speech and therefore maintain the therapeutic relationship (Wills and Sanders, 2012).

In order to action these learning points, I must be able to reflect on my own empathic practice and this will help to improve the reflection entity of the DPR skill development and allow for greater competency as a practitioner. I have outlined the ways in which I can expand on my active-listening skills in my Action Plan (Appendix 1), which will further my development as a PWP.

Reflecting: Mirroring and Paraphrasing

Having the ability to show genuine empathy is an important aspect of building a strong therapeutic alliance and is utilised effectively when used alongside other verbal skills such as reflection. Reflection is important in therapeutic communication as it allows for the patient to ‘hear’ their own thoughts and check that everything has been understood from both perspectives (Heller-Levitt, 2008). Bethea (2018) proposes that there are two main types of reflection – mirroring and paraphrasing. Mirroring is where the therapist repeats almost word for word what the patient has said and paraphrasing is where the words are slightly rephrased.

Throughout my OSCE assessment, I can be seen to use effective mirroring [01:46, 02:07, 04:10, 09:08, 18:38] which allowed for the assessment to flow. A particular example of this is when the patient says, “I’ve been getting shoulder pain and headaches” [02:00] in which I mirror her with the reflection “So you’ve been getting shoulder pain and headaches” [02:07]. As well as this, there were times when I adequately paraphrased the patient [03:45, 05:37, 06:18, 08:52, 19:14, 20:38]. An appropriate example of this is when the patient says; “When I am on my own the worries are less controllable” [06:14] and I rephrase this by saying “It is worse when you’re on your own” [06:18]. This helped to demonstrate that I was listening, able to clarify and positively impacted the therapeutic relationship. This confirms the argument that reflection is one of the most important aspects of the therapeutic alliance and the idea that it helps to get to the root of the problem by allowing the patient to hear their thoughts out loud (Carl Rogers, 1949).

There were also times I did not use reflection as well as I could have [05:10, 05:30, 19:09]. An example of this is when the patient is talking about medication and I end up asking the same questions due to not adequately listening and reflecting when the patient explains their medication and this is likely to have had a negative impact on the therapeutic relationship. As well as this, I missed an opportunity to paraphrase [05:10] where the client tells me how she is waking up in the night to talk over her worries but I did not hear this and this led to a pause in the flow of assessment which had a clear impact on the therapeutic alliance. The importance of showing you have listened is detrimental to the therapeutic relationship as it shows therapist competence in being able to reanalyse, re-evaluate and find new meanings in thoughts, behaviours and feelings (Bennett-Levy, 2003).

The less competent listening and reflective skills here are likely to be because I can be seen to glance at the timer [05:10]. I was very aware of the time throughout the assessment as during my formative OSCE, I ran out of time. This resulted in me having poorer reflection skills and having an impact on the alliance. These common factor skills could have been adapted to make it a smoother experience for the patient. This could have been done by not looking at the clock when the patient was speaking and doing this when there was a pause in the flow of speech, rather than when they were talking.

To consolidate my learning to practice, I will need to further develop these verbal methods of communication to help enhance the therapeutic alliance and I have detailed how I will do this in my action plan (Appendix 1).
 

Funnelling

Whilst empathy and reflection are important aspects of the assessment process, adequate questioning is also important as this helps to gain a clear understanding of the patient’s difficulties (Lehay, 2008). The type of questioning used in CBT is called ‘Funnelling’ and is a technique that consists of open, probing and closed questions (Richard and Whyte, 2011). An example of an open question is “How does that make you feel?” and then specific details of the feelings would be able to be gathered and then closed questions could be used to summarise, reflect and confirm what the patient has expressed (Burnard, 2005). This kind of effective questioning helps to strengthen the therapeutic alliance by showing you are listening and keen to gather all the specific information (Richard and Whyte, 2011).

Throughout the assessment, I exhibited good funnelling skills in which I gained more general information, leading to specifics. An example of this is when I ask, “Would you mind just beginning with what bought you to the service today?” [01:40]. This allows for me to gain an understanding that the patient has been feeling stressed and to begin with asking other open questions such as “Can you tell me a bit more about that?” [01:47] which leads her to tell me specific physical symptoms and allows for me to ask the patient the more specific details such as when she experiences these symptoms [02:09]. Having the ability as a practitioner to elicit this type of information helps collaboration within the assessment and this in turn benefits both the patient and the therapist, developing a sold therapeutic relationship (Dattilio and Hanna, 2002). This kind of common to specific funnelling skill could by why I was able to go on and make an adequate probable diagnosis of what the person was experiencing [28:20], which is an important aspect of therapy to ensure the patients narrative is heard and understood (Prilleltensky 1997). These are moments I felt went well in the OSCE and will continue to use in clinical practice.

There were times when the funnel did not flow and became disjointed, causing a disruption in the alliance [04:30, 06:25]. A particular example of this is when the patient expresses her concerns about her father being ill and that she is concerned she might get ill too [04:30]. At this point I could have asked for more information on how she is managing that particular worry, to rule out other specific disorders such as health anxiety. Instead I asked a closed question which led to an early closing off of the funnel and caused me to revisit this again later in the assessment. This kind of ineffective funnelling may have had an impact on how the patient felt about my competency during the assessment, which is important in building trust and effective communication within the therapeutic alliance (Gilburt, 2008).

I think this particular patient-contribution [04:30] caused me to have doubt about disorder specifics, which in turn made me less confident in the diagnosis. As a result, I lost the flow of the funnel and this impacted the alliance. These are aspects of the OSCE which I felt did not go so well. To rectify this, I could have used better Socratic questioning to help rule out other disorders and this would form a genuine collaborative relationship through guidance and discovery (Padesky, 1993). By advancing on this skill, I might feel more confident in offering a probable diagnosis, explaining correct treatment choices for the patient and therefore have productive supervision, which is important as a PWP (Westwood, 2017). I have detailed in my action plan how I will develop this skill (See Appendix 1).

This process of critical reflection has been useful in my development as a PWP. Metaphorically it has allowed me to hold a mirror up to my practice and see my strengths as a practitioner but also see the areas in which I need to develop to enhance my common and specific factor skills. These action points are discussed further in my action plan below. Overall I think reflecting on practice is essential in order to feel competent and develop as a PWP.

Appendix I      Action Plan

Action required

How will this be achieved

Impact if undertaken

How will I measure this and know it has been achieved

Will anyone be able to help me with this

Target Date

Develop my empathic active-listening skills so that I am able to demonstrate competency as a practitioner.

Record role-plays with peers and ask supervisor to observe and feedback.

Read literature on alternative empathy statements.

Record myself with real-patients and count the number of empathy statements provided.

Evans-Jones, Peters and Barker, (2009) Suggest that empathy at assessment is crucial for good outcomes in treatment. This is because the patient feels listened to and their feelings validated.

Asking for feedback from supervisor from recorded role-plays.
 

Ask University tutor’s to observe assessment practice and specifically give feedback on active-listening skills.

Colleagues, peers and supervisors. Through clinical skills and discussion with peers during these skill-enhancing sessions.

November 2019 towards the end of the diversity module.

Undertake practice of adequate funnelling skills – moving from open to closed questions.

Practice the specific funnelling aspect of the assessment. Watch the UEA videos, which demonstrate good competency of funnelling and practice these techniques on colleagues.

Burnard, (2005) shows that good funnelling is necessary in order to gather disorder-specific information, better understanding of the patient’s problem, an accurate diagnosis and therefore improved treatment outcomes for the patient. This will help me in these ways in my practice.

Discuss with qualified PWP’s the specific questions they ask to gather disorder-specific information. Practice role-plays with peers asking for feedback on funnelling technique.

Supervisor will be able to give feedback on my technique. Peers and colleagues will be able to role-play with me.

I would like to feel competent on qualification in January 2020.

To develop reflection skills – mirroring and paraphrasing.

Record myself with patients in order to assess how well I listen and then reflect back to them.

Discuss in clinical skills supervision how to have an adequate balance of listening and reflecting.

Practice with peers using role-plays.

Ask in patient review questionnaires how they found the assessment.

Heller-Levitt, (2008) suggest that reflection is necessary in order to show you have listened and so that the patient is able to hear their thoughts. If I am able to adequately listen and reflect then this will
have a positive effect on timings, the therapeutic alliance and treatment outcomes.

Review my performance during role-plays – use the structured marking guide to mark my own performance. I will know this has been achieved when I am able to capture the information in the given timeframe.

My peers, colleagues and supervisors will be able to help me with this as they can give constructive feedback about my reflection skills. .

Upon qualification – January 2020.

 

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