Utilizing Standardized Patients to Teach Motivational Interviewing to Gerontology Health Care Providers

Health care institutions across the United States are facing challenges to train their gerontology health care providers to offer the best care possible to older patients in order to achieve optimal patient health outcomes. Innovative training strategies for gerontology health care providers to improve patient care may include the utilization of standardized patients. This paper discusses the use of simulation training using standardized patients to teach motivational interviewing (MI) techniques to VA health care professionals who care for older Veterans. MI is a client centered approach for eliciting behavior change by assisting clients in exploring and resolving ambivalence about their treatment regimen [1].


Case Report
Health care institutions across the United States are facing challenges to train their gerontology health care providers to offer the best care possible to older patients in order to achieve optimal patient health outcomes. Innovative training strategies for gerontology health care providers to improve patient care may include the utilization of standardized patients. This paper discusses the use of simulation training using standardized patients to teach motivational interviewing (MI) techniques to VA health care professionals who care for older Veterans. MI is a client centered approach for eliciting behavior change by assisting clients in exploring and resolving ambivalence about their treatment regimen [1].
MI is a topic of interest nationally throughout the Veterans Health Administration (VHA) system. MI is a component featured in the National Center for health promotion and disease prevention (NCP) program at the VHA [2]. To implement MI, NCP has trained health behavior coordinators (HBC's) in MI skills and provided them with resources to provide MI training within their VA facilities. The HBC's have targeted predominantly nurses and physicians within the patient aligned care team (PACT). The PACT is a national initiative on delivering primary care and is similar to the medical home model used in the private sector. A PACT is part of the VA healthcare system's program with the mission of delivering health care that is patient oriented, data-driven, continuously improving, and team based [3].

Motivational Interviewing Training
Current VA MI training occurs over two sessions in two hour increments and is given in a lecture format in a traditional classroom setting. In order to enhance MI training, the providers (i.e. nurses, physicians, social workers, dieticians, pharmacists, physical therapists, and psychologists) participated in the traditional training in addition to a simulation training component utilizing standardized patients. After each of the two-hour MI lectures, the participants practiced MI interaction skills at a simulation center for approximately 30 minutes. The training at the simulation center focused on the four major motivational interviewing strategies known as O.A.R.S. (open-ended questions, affirmations, reflective listening, and summarizing) which were learned in the lecture and then applied to a case study simulation that is presented in this paper. Open ended question strategies gather broad descriptive information from the patient, facilitate dialogue, and require a more detailed response. Affirmation strategies must be done sincerely and promotes self-efficacy, acknowledges the difficulties the patient has experienced, and validates the clients' feelings [1]. Reflective listening strategies include an interest in what the person has to say and having the desire to understand how the person views things [1]. Summarizing strategies reinforce what has been said and illustrates that the health care provider has been listening carefully [1].

Case Study Simulation
The standardized patients were given the case study simulation prior to the training day, along with a script that prompted them to stay on target with their conversations with the health care providers. The health care providers were given the case study simulation on the day of training, along with a cue card of the four MI strategies that they needed to practice with the standardized patient. The target conversation for the simulation training centered on the issue of smoking and how it related to an older patient who is at risk for heart disease. The case study read as follows: Patient X who is 65 years old has several risk factors for heart disease and sees a health care provider when symptoms such as heart palpitations or gout attacks occur. The patient has been prescribed two blood pressure medications, one medication for gout, and one medication for high cholesterol. Unfortunately, the patient does not take these medications on a regular basis. For the past 6 years, the patient has smoked four packs of cigarettes a day and chews tobacco at least three times a week. The patient is overweight with a diet that consists of fatty foods, high cholesterol foods, and high sugary foods. The patient does not exercise and lives a sedentary lifestyle. After working a full day in a telemarketing call center, the patient goes home to a stressful home environment. The patient is the primary caregiver for three grandchildren ages ranging from 4 to 10. There is a family history of heart disease, heart attack, and lung cancer.

Evaluation
In the simulation center, 12 actors served as standardized patients while the 25 health care providers practiced the four MI strategies learned in the two-hour lecture. Each standardized patient and health care provider was given a simulated patient room for privacy. As illustrated in Table 1, a checklist of all of the MI strategies (i.e. openended questions, affirmation, reflective listening, and summarizing) were given to the standardized patients so that they could check off whether or not the health care provider implemented the MI strategy successfully. The interaction between the health care providers lasted for 30 minutes in total. Fifteen minutes were allotted for the actual interaction where the four skills were practiced by the health care provider. An additional 15 minutes for debriefing were allotted for the standardized patients to review the checklist with the health care provider. For research purposes, the data from the checklists can be used to provide information on the perception of health care providers' performance on each of the MI skills.
How well does the provider do the following?

Done
Needs Improvement/Not Done

Greets patient and establishes rapport
Establishes with the patient that smoking will be the topic of conversation Did the provider summarize most points in the interaction accurately?
Did the provider begin to prepare the client to move and consider change?
Did the provider suggest some type of follow up appointment?
Was the body language/tone of voice appropriate?
Was the provider enthusiastic about the follow-up visit with the patient?

Summary
Research on MI training illustrates that continuous training and follow-up coaching is necessary to achieve proficiency in MI skill [4]. Future MI training should incorporate a simulation education framework to guide the design, implementation, and evaluation of simulation activities for gerontology practitioners [5]. Further research is needed to evaluate the effectiveness of simulation in improving patient outcomes as well as evaluating provider satisfaction with regards to the simulation experience. The utilization of standardized patients to teach MI is an innovative teaching strategy for health care providers that may improve their communication with older patients in order to ultimately produce positive patient outcomes.