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Effective TB Interviewing for Contact Investigation: Facilitator Led Training Guide

2006

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10. Course Activities

Facilitator

Activity 9:  Simulated Patients

Objectives
  • To demonstrate effective communication and interviewing skills
  • To recognize strengths and areas requiring improvement in interviewing skills via self-assessment and observer feedback
Time
allotted

60 minutes total per interview

  • 35 minutes for the interview
  • 5 minutes for interviewer self-assessment
  • 5 minutes for patient feedback
  • 10 minutes for observer or group leader feedback
  • 5 minutes for break between interviews
Materials

Copies of

  • “Observer Instructions” on page 89
  • “Observer Assessment Form” on page 90
  • “Index Patient Instructions” on pages 92-93
  • Index Patient Roles for the actor patients (marked for “patients”) on pages 94-107
  • “Index Patient’s Evaluation Form” for the actor patients (marked for “patients) on page 108
  • “Interviewer Instructions” on page 110
  • Index Patient Roles for the course participants (marked for “interviewer”) on pages 111-117
  • and video camera with tripod (optional)
Pre-Course Procedure This activity involves conducting a full interview in a simulated environment with observation and critical feedback from other course participants and a group leader.  You will need some extensive preparation for this activity, including patient or actor recruitment, distribution of the relevant materials, and preparation of materials for the participants and actors.

The activity requires the use of outside individuals to portray index patients.  We suggest that you recruit actors or other health department employees who are not known by the course participants.  However, if this is not possible, this activity may be done with known persons or as role-play exercises amongst course participants.

Pre-Course Procedure (continued)

1.This manual contains seven patient roles (from previous exercises in this guide).  Choose which roles you will use ahead of time.  You may base the decisions on the types of patients the participants see frequently or with whom they have challenges.  Choose as many patients as you have groups.  The groups should have no more than three persons.

2. Recruit actors to play the roles of the patients for the day of the course.  You should create a separate confirmation letter for actors indicating

  • The date and time of the course activity
  • Where to meet you or a support person the day of the course
  • How payment for service will be made (optional)
  • Directions and parking arrangements
  • Description of the audience with which they will be working
  • The documents* you are enclosing with the letter, including

– Role description
– Instructions
– Interviewer evaluation form

*These attached documents are labeled as “Index Patient”

3. Prior to sending the letters, you will need to collect some basic information from each actor to put on their patient role sheets.  Some people may not want to use their own personal information for the course.  Therefore, ask each actor what personal information, real or made up, they would like to use for the purpose of the course.  This should be information that is easy for them to remember.  You will need a first and last name, age, address, and phone number.  Write this information on the patient role sheets so that the actors can remember what personal data they have chosen to use.  Keep a copy of this information to share with the participants later. 

4. After filling in the patient’s personal information, make copies of the index patient roles for the interviewer (these are labeled “Interviewer”).  Also, make copies of the Interviewer Instructions.

5. Make copies of the “Observer Instructions” on page 89 and the “Observer Assessment Form” on page 90 for the observers and facilitators.
 

Pre-Course Procedure (continued)

6. You should arrange to have one leader for each group.  Each group should consist of no more than three participants.  In this way, for each interview, you will have a maximum of three participants, who interchange the interviewer and observer roles, and one group leader, who observes and provides expertise.  You should create these groups ahead of time.  One suggestion is to do this based on level of participant experience.  Mixed experience-level groups allow less-experienced members to observe some stronger interviewing skills. Make copies of the Facilitator’s Instructions for the group leaders.

7. It is suggested that you provide the Index Patient Roles on pages 94-107 to the participants ahead of time so that they can prepare an interview strategy.  Give all of the patient scenarios to the entire participant group whether the individual members are doing a particular interview or not.  This way they can become familiar with all of the cases.  However, you must specify for each participant for which case each will be conducting the interview and for which they will each observe.

Also, provide the “Observer Assessment Form” on page 90 with the definitions.  You will need to give one form for each interview that will be observed.  Again, this will give the participants and group facilitators an opportunity to become familiar with the evaluation criteria for observation prior to the interview.  As a description, briefly state in a written cover memo the following:

“This course will include various skills-building exercises, including the completion of an entire TB interview with a simulated patient.  You will be in a group of (#) other course participants.  In this group, you will conduct an interview with Patient #___ and observe (#) other interviews done by your colleagues.  Also included in this packet, you will find instructions for conducting your interview as well as for observing the other interview(s).  The latter set of instructions mentions an Observer Assessment Form.  You will use this form to guide your feedback to the other interviewers.  Therefore, please become familiar with this form and its accompanying definitions prior to coming to the course.  Please also bring all of this paperwork with you on the day of the course.”

8. Ask participants to bring copies of their health department interview data collection form(s) so they can practice using these instruments.  If the course participants are all from the same health department, you may be able to obtain these forms yourself and duplicate them.
 

Pre-Course Procedure (continued)

9. Keep extra copies of all interviewer, observer, and patient information with you for the course date in case participants forget any documents.

10. Another way to enable self-assessment is to the interviews.  The interviewers can view their own interviewing techniques and have a clearer understanding of their individual strengths and weaknesses.  This does involve extensive arrangements.  While there may not be time during the course to review the tapes with the participants, the participants can view tapes on their own to supplement feedback given by the observers.

11. Arrange for rooms in which the interviews can be conducted.  If possible, a small room for each patient is best for a disturbance- and distraction-free environment.  Also, create signs that designate patient numbers to hang on each interview room door.  It is easiest if each patient stays in his or her room while the participant groups rotate from room to room.  If the rooms are close together, a coordinator for the entire activity may not be needed.  However, if possible, it will be helpful to designate a support person to make sure the activity is running smoothly.

12. Create a master plan for interviews to occur and make copies of this for the participants on the day of the course.  It can look something like the table (Figure 6) below:

 

Figure 6. Sample Simulated Patient Interviews Grid for 15 Course Participants

(5 groups of 3 people)

Group/Facilitator Name 1:00 pm – 2:00 pm
Patient #
2:00 pm – 3:00 pm
Patient #
3:00 pm-4:00 pm
Patient #
A – Facilitator Name 1 2 3
B – Facilitator Name 2 3 4
C – Facilitator Name 3 4 5
D – Facilitator Name 4 5 1
E – Facilitator Name 5 1 2

This manual contains seven patient roles.  You should choose the number that you require, noting that not all groups may be able see all patients.  This will vary based on the size of your groups. 

Course Procedure 1. Make sure all participants and facilitators have the information they require.  You will be providing the extra copies you made ahead of time.  On the day of the course, place groups with designated facilitators.

2. Instruct the facilitator to keep time for the groups.  The interviews should take 35 minutes; patient feedback, 5 minutes; and observer/facilitator feedback, about 10 minutes.  Prior to anyone giving feedback, however, the interviewer should be asked how he or she felt about his or her interview performance.

3. During the interviews, the facilitator should also encourage the observers to make observations and take notes.  This will enable them to give better feedback with specific examples.  Ask the facilitators to tell their groups that they will collect the completed forms at the end of the activity.  This may ensure that observers take notes.

4. After each group completes an interview, they should move on to the next room.  Some groups may finish more quickly than others and may have to wait to enter their next room.

5. After the entire activity is complete, all of the course participants should come back into the classroom together along with the facilitators.  This is good time for the course participants to discuss their experiences.  You may ask observers to comment on their colleagues’ skills, mentioning strategies they used to address challenging situations.  The facilitators should be asked at the end to summarize the work of their group, emphasizing what was learned by all.  Overall, the atmosphere for discussion should be kept positive. 

Group Leader’s Handouts

Facilitator: Hand to each Group Leader

  • 1 copy of the “Group Leader’s Instructions” on page 85
  • 1 copy of the “Observer’s/Group Leader as Observer Instructions” on page 86
  • Copies of the “TB Interview Assessment Form” on page 87 for as many interviews as will be observed
     
Leader

Activity 9:  Simulated Patients

Group Leader’s Materials, p. 1

Group Leader’s Instructions

In addition to being an observer in this interview activity, you will facilitate the group’s activities.  Please keep the following in mind:

  1. You will keep time for the group
    • 35 minutes – Interview
    • 5 minutes – Interviewer’s self-assessment.  Ask the interviewer for his or her brief thoughts on how he or she felt during the interview and what his or her strengths and areas for improvement might be
    • 5 minutes – Index Patient’s feedback based on the “Index Patient’s Evaluation Form”
    • 10 minutes – Observer’s feedback based on the “Observer’s Assessment Form”

  2. Encourage observers to take notes during the interviews so as to have feedback to provide to the interviewer.  Tell the observer that you will collect the assessment forms at the end of the interview activity.  You may also provide feedback as well, but allow the observer(s) to contribute as much as possible.

  3. At the end of the activity, collect all forms from the index patients and observers.

Group Leader as Observer Instructions

  • While observing the interview, remain at a distance from the interviewer and index patient, so that you do not intrude on their space.  However, position yourself so that you can hear the dialogue clearly and observe all body language
  • During each interview, complete the “Observer’s Assessment Form.”  The form lists processes and skills to be completed by the interviewer.  The processes are tasks that the interviewer must complete during the interview and the skills are techniques that are ongoing throughout the interview.  Use the form as a checklist and for taking notes about the interaction

Feedback

  • There will be a feedback session after the completion of the interview.  Take a few minutes to complete the “Observer’s Assessment Form,” and instruct the index patient and interviewer to complete the “Index Patient’s Evaluation Form.”
  1. The interviewer will talk about the process and his or her own skills and comfort with the interview based on the self-assessment form
  2. When the interviewer’s self-assessment is complete, the index patient should give feedback to the interviewer based on the completed Index Patient’s Evaluation Form
  3. Finally, you should review your completed the “Observer’s Assessment Form” with the interviewer and include both the interviewer’s strengths and areas in need of improvement
  4. When providing feedback, start with strengths and positive characteristics and then move into the areas in need of improvement
  5. Address each element of the interview and provide specific examples of strengths and areas in need of improvement as noted during the interview
  6. If any areas need improvement, offer techniques for improving certain skills.  Remember, the goal is to assist the interviewer in becoming more proficient while maintaining his or her confidence
leader

Activity 9:  Simulated Patients
TB Interview Assessment Form

Group Leader’s Materials, p. 3

Process & Skill

Group Leader: Check the appropriate rating for each process or skill.  Add any comments or examples from the interview to the back of this form so you can give more concrete feedback.
Excellent Satisfactory Needs Improvement
Introduction      
1.  Introduces self      
2.  Explains purpose of interview      
3.  Emphasizes confidentiality      
Information & Education Exchange      
4.  Collects/confirms index patient’s personal information      
5.  Determines index patient’s level of disease comprehension      
6.  Provides appropriate TB education      
7.  Reviews symptom history      
8.  Discusses basis of diagnosis      
9.  Discusses appropriate disease intervention behaviors      
Contact Identification      
10. Defines close and casual exposure      
11. Pursues detailed contact information      
12. Explains contact referral process      
Conclusion      
13. Invites index patient’s questions      
14. Reviews/reinforces adherence to treatment plan      
15. Closes interview      
Ongoing Skills      
16. Demonstrates professionalism      
17. Establishes trust and rapport      
18. Listens actively      
19. Uses open- and closed-ended questions appropriately      
20. Communicates at the index patient’s level of comprehension      
21. Provides factually correct information      
22. Provides encouragement      
23. Uses appropriate nonverbal communication      
24. Motivates and encourages active participation of index patient      
25. Displays nonjudgmental behaviors      
26. Displays flexibility in the interview process      
27. Identifies and addresses index patient’s concerns      
28. Recognizes and addresses verbal problem indicators      
29. Maintains control of interview      
30. Identifies and discusses barriers to adherence      

Observer’s Handouts

Facilitator: Hand to each participant

  • 1 copy of the Observer’s/Group Leader as Observer Instructions on page 89
  • Copies of the “TB Interview Assessment Form” on page 90 for as many interviews as will be observed

 

Observer

Activity 9:  Simulated Patients

Observer’s Materials
p. 1

Observer’s Instructions

  • While observing the interview, remain at a distance from the interviewer and index patient so that you do not intrude on their space.  However, position yourself so that you can hear the dialogue clearly and observe all body language.
  • During each interview, complete the “Observer’s Assessment Form.”  The form lists processes and skills to be completed by the interviewer.  The processes are tasks that the interviewer must complete during the interview and the skills are techniques that are ongoing throughout the interview.  Use the form as a checklist and for taking notes about the interaction.

 

Feedback

  • There will be a feedback session after the completion of the interview. Take a few minutes to complete the “Observer’s Assessment Form,” and instruct the index patient and interviewer to complete the “Index Patient’s Evaluation Form.”
  1. The interviewer will talk about the process and his or her own skills and comfort with the interview based on the self-assessment form
  2. When the interviewer’s self-assessment is complete, the index patient should give feedback to the interviewer based on the completed “Index Patient’s Evaluation Form”
  3. Finally, you should review your completed “Observer’s Assessment Form” with the interviewer and include both the interviewer’s strengths and areas in need of improvement
  4. When providing feedback, start with strengths and/or positive characteristics and then move into the areas in need of improvement
  5. Address each element of the interview and provide specific examples of strengths and areas in need of improvement as noted during the interview
  6. If any areas need improvement, offer techniques to improve certain skills.  Remember, the goal is to assist the interviewer in becoming more proficient while maintaining his or her confidence

 

Observer

Activity 9:  TB Interview Assessment Form

Observer’s Materials,
p. 2

Process & Skill

Observer: Check the appropriate rating for each process or skill.  Add any comments or examples from the interview to the back of this form so you can give more concrete feedback.

Excellent Satisfactory Needs Improvement
Introduction      
1.  Introduces self      
2.  Explains purpose of interview      
3.  Emphasizes confidentiality      
Information & Education Exchange      
4.  Collects/confirms index patient’s personal information      
5.  Determines index patient’s level of disease comprehension      
6.  Provides appropriate TB education      
7.  Reviews symptom history      
8.  Discusses basis of diagnosis      
9.  Discusses appropriate disease intervention behaviors      
Contact Identification      
10. Defines close and casual exposure      
11. Pursues detailed contact information      
12. Explains contact referral process      
Conclusion      
13. Invites index patient’s questions      
14. Reviews/reinforces adherence to treatment plan      
15. Closes interview      
Ongoing Skills      
16. Demonstrates professionalism      
17. Establishes trust and rapport      
18. Listens actively      
19. Uses open- and closed-ended questions appropriately      
20. Communicates at the index patient’s level of comprehension      
21. Provides factually correct information      
22. Provides encouragement      
23. Uses appropriate nonverbal communication      
24. Motivates and encourages active participation of index patient      
25. Displays nonjudgmental behaviors      
26. Displays flexibility in the interview process      
27. Identifies and addresses index patient’s concerns      
28. Recognizes and addresses verbal problem indicators      
29. Maintains control of interview      
30. Identifies and discusses barriers to adherence      

 

Index Patient’s Handouts

Facilitator: Mail to each Index Patient/Actor in advance of the course:

  • 1 copy of the Index Patient’s Instructions on pages 92-93
  • 1 copy of the “Role Information for Index Patient” on pages 94-107 for that actor to portray.  Fill in the appropriate personal information at the top of the first page of each role
  • Copies of the “Index Patient’s Evaluation Form” on page 108 for as many interviews as will be conducted with the actor

Also, have additional copies of all of these handouts available at the course if misplaced by the actor.

Activity 9:  Index Patient’s Instructions

Patient’s/Actor’s
Materials, p. 1

The activity that you are participating in is for training purposes.  Your role is to help develop healthcare interviewing skills.  The index patient background information that you have been given contains information about the person you will portray.  You are a TB patient.  Even though you are feeling ill, you will be interviewed by a healthcare worker.  The purpose of the interview is to build rapport, provide TB education, and find out about whom you may have infected.  Keep this in mind along with the patient’s background information to make your role as effective as possible.  The interviewer has your medical background, but limited information in other areas.

Before the Interview

  • Become familiar with the patient you will portray. Feel free to elaborate on this general background information without losing the essence of the role.  The interviewer will ask you the names, ages, and addresses of people you associate with closely.  Read the scenario carefully so that you can come up with relevant information that is easy for you to remember.  Other information may be asked about the people you associate with as well as how much time you spend with them, e.g., when you last saw them and their physical descriptions.
     
  • The scenario description suggests that either you or the interviewer is wearing a mask to reduce the spread of TB.  This is to simulate how a real interaction would take place, relevant to the barriers to communication while wearing a mask.  However, for the purpose of this exercise, neither you nor the interviewer will wear a mask.
     
  • Become familiar with the “Index Patient’s Evaluation Form” to assess the skills the interviewer uses while interacting with you.  You will use this form at the end of the interview to provide feedback to the interviewer.

     

During the Interview

  • During the interview, remain focused on the role you are playing.  The purpose of this exercise is to help the interviewer simulate the process of a TB interview for contact investigation.  If possible, do not keep the written role in front of you during the interview.
     
  • You may challenge the interviewer, but if he or she is having difficulty, try to assist by revealing some information as appropriate, particularly if this is an inexperienced interviewer.  If the interviewer seems more experienced, you may challenge him or her further.

– Act naturally and react as though you are the actual patient you are portraying.  For example, your role may specify that you are a person who does not reveal much information.  If the interviewer appears trustworthy and explains to you the importance of sharing certain information, you may then be more forthcoming.

– React to the interviewer’s interactive style.  For example, if the interviewer is empathetic, you may be more willing to open up to him or her.

After the Interview

At the end of the interview, take a few minutes to complete the “Index Patient’s Evaluation Form” to provide the interviewer with constructive feedback.  Review the list with the interviewer and include both the interviewer’s strengths and areas requiring improvement.  When providing feedback, start with positive characteristics and then move into the areas needing improvement.  Remember, you are assisting the interviewer to become more proficient while maintaining his or her confidence.

Activity 9: Role Information for Index Patient #1

Patient’s
Materials, p. 3

Name:
Phone Number:
Address:

Age: ____ years old Occupation: Lounge singer
Interview Scenario
Interview takes place at the health department clinic. You are
  • Wearing a mask during this interview.
  • Distracted during the interview, frequently talking about yourself but not your medical condition.
  • Not very educated about TB, but eager to learn.
  • Coughing frequently during the interview.
Medical History
Symptoms:

Cough

  • Persistent for about 2 months, producing phlegm
  • Didn’t see a doctor until a week ago since you thought the cough was due to second-hand smoke from night clubs

Weight

  • Lost about 10 pounds during the past month
  • Did not think much about weight loss because you wanted to lose weight

Fever

  • Never checked your temperature, but have occasionally felt feverish
  • Took aspirin to feel better, which worked temporarily

Medical Evaluation

General medical care limited due to lack of health insurance

  • Visited a medical clinic at the health department a week ago
  • At the health department a TB skin test (positive) and chest X-ray (abnormal) were done and your sputum (phlegm) was collected for testing
  • Returned to the clinic to talk about your test results.  You were told that your test results were suspicious for TB and you were placed on 4 different TB medications but aren’t sure of the names or the numbers of pills
  • An HIV test was done (awaiting results)
  • Will be on directly observed therapy (DOT), which means a healthcare worker will come to your house to watch you take medications every day
  • Let the interviewer know that when you go back on tour you don’t see how DOT can be arranged
  • Doctor instructed you to stay home until you are no longer contagious, but you have to make a living and are thinking about going back to work regardless of what the doctor says

Household – None

Work

  • Four-member band – travels with you on a private bus
  • Audiences – small and intimate; new location each week within a 250-mile radius

Social

  • Significant other – not much revealed about this person unless prompted; travels with you about 25% of the time
  • Grandmother – lives in a nursing home; you visit her frequently
  • No children or other relatives with whom you keep in close touch
  • Many friends – seen about once in two months depending on when you are in town
     

Activity 9:  Role Information for
Index Patient #2

Patient’s
Materials, p. 5

Name:

Phone Number:

Address:

Age: ____ years old

Occupation: Very busy accountant who works for a prestigious firm

Interview Scenario

Interview takes place in the hospital.  You are

  • Unhappy with the fact that the interviewer is wearing a mask while talking to you, and you mention this during the interview.
  • Impatient during the interview and frequently look at your watch and explain that you are expecting visitors and want the interview to end soon.
  • Uneducated about many aspects of TB; you try to hide your lack of knowledge at first, but eventually are willing to listen to what the interviewer shares.
  • Reluctant to share information about your contacts, but eventually do so if the interviewer is persuasive.
  • Angry with any references made to HIV infection or testing and “directly observed therapy” or “DOT.”
  • Concerned with having to follow up treatment in a health department setting and prefer treatment by your private doctor, whom you think is more qualified to handle your case and knows you better.
Medical History

Symptoms

  • Went to the hospital emergency room a week ago for severe “flu-like” symptoms (dry cough, night sweats, chills, high fever, loss of appetite, vomiting, dizziness, and chest pain); you’ve been coughing for about 1 month, but the other symptoms came on about 2 weeks ago
  • Sent home with prescription for antibiotics
  • When the symptoms did not resolve, went back to the emergency room where a chest X-ray was taken

Medical Evaluation

  • As a result of the abnormal chest X-ray, you were admitted to the hospital
  • In the hospital a TB skin test and other tests were performed
  • An HIV test was offered to you in the hospital but you refused, fearing the result
  • You were told that all of the initial test results indicated that you may have TB but final test results were pending

Medications

  • You were prescribed four different TB medications, which a nurse watches you take daily
  • Physician told you that you may be hospitalized as long as you are contagious (about 2 weeks).  For infection-control precautions, you were told to cover your mouth and nose when you cough
     
Contacts
Household – Spouse and two young children

Work

  • Three high-profile clients - seen regularly in the last 3 months in your office
  • 10 coworkers - in large, spacious, modern building; you work in your own office

Social

  • Large circle of friends - seen once a month at parties; you are very anxious about possibly having given TB to them and would be embarrassed if anyone found out about your condition
  • Co-worker - having an extramarital affair with this co-worker whom you allude to, but remain evasive about unless the interviewer is persistent
     
Activity 9:  Role Information for
Index Patient #3
Patient’s
Materials, p. 7

Name:
Phone Number
:
Address:
Age:
____ years old
Occupation:
Unemployed

Interview Scenario
 
Interview takes place in the hospital and the interviewer is wearing a mask.  You are
 
  • A resident of homeless shelter for the past 6 months
  • Very concerned about having shelter, food, and money. Your health is a secondary priority. You frequently deviate from the topics of the interview and talk about other aspects of your life.
  • Anxious to get back to the streets
  • Not very educated about TB. In the hospital, not much has been told to you, except that you have TB and may be contagious.  You feel that the hospital staff have treated you rudely by not sharing much information.
  • Currently unemployed with no income; considering applying for welfare assistance.
     
Medical History
Symptoms:

Cough

  • Persistent for 2 months
  • During the interview, you cough frequently without covering your mouth, unless asked to do so
  • Brought up blood one time, before entering the hospital

Night sweats – Have gotten soaking wet at night during the past 1 month

Fever – For several weeks have had chills and body aches but never checked temperature

  • Diagnosed with HIV infection 3 years ago, but have not followed up with HIV clinic appointments and have not been on HIV medications
  • Visited the hospital emergency room 3 days ago after one episode of coughing up blood
  • Admitted to the hospital that day after a chest X-ray was read as abnormal
  • After admission, a TB skin test and sputum (phlegm) collection were done
     
Medications
  • You were prescribed many TB pills (each morning for the past 3 days)
  • Nurse watches you taking the medications (you think you are reliable and do not need anyone to watch you take medications)
  • Now taking HIV medications regularly after being hospitalized, since the doctor explained that these medications will also help fight off the TB
  • All of the medications make you feel nauseous after taking them.  You tell the interviewer how you feel about the pills when talking about your TB treatment and that it could be tough to take both the HIV and TB medications once you leave the hospital
     

Contacts

Household – Live in the Salvation Army shelter.  The shelter houses about 50 people who sleep on cots close together in one large room; you sleep in the same corner each night.

Social – You are not allowed to spend the entire day at the shelter.  During the day, you spend time at soup kitchens and the bus station with 2 other people from the shelter.  You are afraid that talking about your friends would get them in trouble.  You only know their first names.
 

Activity 9:  Role Information for Index Patient #4

Patient’s
Materials, p. 9

Name:
Phone Number:
Address:
Age:
____ years old
Occupation: Unemployed; stay-at-home parent

Interview Scenario

Interview takes place in your home.  You are

  • Wearing a mask so that you will not infect others.
  • Cooperative with giving information about yourself and your family since you are very concerned about having given them TB.
  • Not very knowledgeable about TB and want to learn more.
  • Concerned about the confidentiality of this interview, asking about it several times.
  • Worried about your social contacts (see below) finding out about your TB.
     
Medical History
Symptoms

Cough

  • On and off for about 6 weeks; took cough syrup, which seemed to help until recently
  • No pain with the cough but a little bit of phlegm comes up; shortness of breath hindered your early morning walks starting about 2 weeks ago

Weight

  • Appetite has been lighter than usual
  • 10-pound weight loss in 1 month

Chills – For the past few nights

Fever – For 1 week which would not decrease with aspirin

Medical Evaluation

  • Visited private doctor 2 weeks ago who gave you a 10-day course of antibiotics for the cough
  • Cough got worse so a chest X-ray was done.  The doctor thought the X-ray was abnormal and referred you to a pulmonologist (lung doctor)
  • The pulmonologist immediately admitted you to the hospital (6 days ago)
  • In the hospital a TB skin test (positive), sputum (phlegm) collection, and HIV test (awaiting results) were done.  You were told you most likely have TB based on your test results and were started on medications. 
  • Left hospital against the doctor’s wishes since you had made no child care arrangements
     

Medications

  • Four different medications (a 3-month supply with monthly refills prescribed by your pulmonologist with instructions to visit your primary medical doctor each month for monitoring)
  • You are taking your medications on your own (once a day) but wouldn’t object, if asked, to someone watching you take these medications at home (directly observed therapy or DOT)
     
Contacts

Household

  • Infant – 10 months old; sleeping upstairs during the interview
  • Teenage child – At school during the interview
  • Spouse – At work during the interview; works long hours

Social

  • 2 friends – Seen during early morning walks
  • Son’s soccer team – At outdoor games twice per week; you cheer from the sidelines
  • Creative writing class (20 students) – One evening a week you attend a night class at the local community college
     

Activity 9:  Role Information for Index Patient #5

Patient’s
Materials, p. 11

Name:
Phone Number:
Address:
Age:
____ years old
Occupation: Bus driver for a junior high school

Interview Scenario
Interview takes place in the hospital and interviewer is wearing a mask.  You are
 
  • Vague when giving information about your job, since you are afraid you may get fired, but willingly reveal details about your friends. However, you eventually divulge information about your job if the interviewer is persuasive regarding the importance of contact identification.
  • Anxious to get back to work.
  • Not very knowledgeable about TB and listen patiently if the interviewer tries to educate you .
  • Frequently coughing during the interview and sometimes cover your mouth if reminded by the interviewer.
     
Medical History

Symptoms

Cough
 
  • Persistent for about 1 month
  • 2 weeks ago, the cough got worse, accompanied by phlegm

Fever – Low grade for 1 week
Weight – Lost an unknown amount of weight over a 1-month period
Other – Asthma and frequent colds; you use an inhaler for the asthma, as needed, for symptom relief

  • Positive skin test 2 years ago as part of a pre-employment physical
  • At that time, you were referred to a doctor for a chest X-ray, which was read as normal
  • You were told that since you were over the age of 35 you did not need to be on preventive TB medications; you are angry that you now have TB and that you were not offered medications in the past.

 Medical Evaluation

  • Could not get appointment with your doctor for several weeks for the cough
  • Four days ago, you had a very bad asthma attack and went to the hospital emergency room.  You were admitted that day after a chest X-ray and an exam.
  • In the hospital an HIV test was done (had a previous test which was negative; awaiting current test result) and sputum (phlegm) was collected; you were told by a doctor that you have TB.
     

Medications

  • You take many TB pills, but don’t know what they are.

  • The nurse in the hospital leaves pills in a cup by your bed for you to take each morning.  By the time you get to the fourth pill you feel sick, so you wait until late afternoon to take the rest.

  • You have been resting and feel much better.  You were told some things about your medical condition, but the doctor used so much medical terminology that you remain confused about many things.

 

Contacts
 

Household – live alone; no visitors in your apartment

Work – Students

  • On bus (6:30 a.m.-7:30 a.m., 2:30 p.m.-3:30 p.m., and 5:00-5:30 on weekdays).  During the first two routes, the bus is full (about 30 students; same students each day).  The last route is for students in after-school activities and is about half full (students vary day to day).
  • All bus windows are always shut since the children were caught throwing objects at cars; you never open your window since you have a fan on your dashboard, which keeps you cool.

Social – You associate with 2 friends at a small pool hall about 3 nights a week

 

Activity 9:  Role Information for Index Patient #6

Patient’s
Materials, p. 13

Name:
Phone Number:
Address:
Age:
____ years old
Occupation: Unemployed

 

Interview Scenario

Interview takes place in the hospital and interviewer is wearing a mask.  You are

  • A drug dealer and have used heroin (by injection) and cocaine steadily for several years; have been jailed many times in the past 5 years for a variety of offenses.
  • Withdrawn and tired; you feel the need to get high.  You are a 2-pack-a-day smoker but aren’t allowed to smoke in the hospital.
  • Not trusting of others and don’t say much unless you come across someone who may help you with money, food, or shelter; once you find someone like this, you eventually open up.
  • Very reluctant to share information about your illness and whom you associate with.
  • Coughing occasionally during the interview without covering your mouth, unless reminded.
     

Medical History

Symptoms

Cough

  • Very slight on and off for about 1 year
  • Worsened 1 month ago; has been a dry cough

Fever– On and off for the past 1 week
Night sweats – Began about 4 days ago

Medical Evaluation

  • You were arrested 2 weeks ago and put in the county jail
  • A TB skin test was done when you entered jail; it was read as negative
  • While you were in jail, symptoms got worse; you were transferred to a hospital 1 week ago
  • In the hospital a chest X-ray was taken and sputum (phlegm) collection was done
  • Your doctor also asked about taking an HIV test but you refused, since you were scared to find out the results
  • It was explained to you that you have TB in your lungs
  • You were prescribed four different TB medications
  • When you take the TB medications, you swallow all of them because a nurse watches you take them; once you leave the hospital, you don’t want to take all of these pills at once
     

Contacts

Household – Significant other; you live in significant other’s apartment (your official mailing address is your mother’s home)

Social

  • Mother and aunt – even though you care greatly for them, you see them only occasionally because they disapprove of your lifestyle
  • Two drug users – known by first name only.  You don’t know their addresses but can point out where they live; they come to your significant other’s apartment to use drugs every 2 or 3 days

Other

  • While in jail, you were in a cell with 6 people
  • Drug buyers – you meet them on the street and the meetings are very quick
     

 

Activity 9:  Role Information for Index Patient #7

Patient’s
Materials, p. 15

Name:
Phone Number
:
Address:
Age:
____ years old
Occupation:
Assembly-line work in a shoe factory (night shift)

Interview Scenario

Interview takes place in the hospital and interviewer is wearing a mask.  You are
  • An immigrant from Zlawamba;* you arrived 3 years ago with your spouse and child.

  • Learning the English language.  You can understand English if it is spoken slowly, and you speak broken English, with a non-American accent; you ask the interviewer to slow down if speaking too quickly.

  • A nice person, open to discussing your medical condition but not about your family and work. You ask with whom this interview information will be shared because you fear being fired from your job.  Also, you don’t want your aunt and uncle, whom you live with, to find out about your TB and you fear being asked to leave their home.  You reveal this to the interviewer.

  • Very anxious to get home since you have no medical insurance to cover the cost of hospitalization.

  • Giving a history of BCG vaccination at birth and you were told that this would prevent TB.  You believe that perhaps you have something other than TB and need to be convinced by the interviewer about your TB diagnosis.

  • Covering your mouth while coughing during the interview.

*Fictitious country

Medical History

Symptoms:

Cough

  • On and off for about 3 months, but has worsened recently
  • A lot of phlegm with the cough

Fever– On and off for the past week
Other– Painful lump at base of the neck for about 1 month

Medical Evaluation

  • Brought to the hospital emergency room 3 days ago after you collapsed at work
  • After chest X-ray, you were admitted to the hospital
  • During the hospital admission, a skin test and sputum (phlegm) collection were done and blood drawn.  A needle was also stuck into the bump on your neck and fluid was taken out.  You were told you had TB and some other things about your tests, which you didn’t really understand; you ask the interviewer what the tests mean and why they were done.
     

Medications:

  • You were prescribed many pills, including an injection everyday; a nurse watches you take your medications
  • The medications are hard to swallow all at once, but you manage to do so; the injection site hurts, however, and you wish to discontinue the shot
     
Contacts

Household

  • Elderly uncle and aunt – they own the small house in which you live
  • Spouse and child

Work

  • 2 co-workers – stand on either side of you on an assembly line in a large open room; there are about 25 people in the room, but you rarely talk to or associate with the others
  • Commute to work by car (round trip approximately 4 miles) with a co-worker

Social

  • Cousin visits once in a while and stays for the weekend
  • Not much time to socialize, as you sleep much of the day and spend the rest of your free time with your family
     

 

Activity 9:  Index Patient’s Evaluation Form

Patient’s
Materials, p. 17

Index Patient: After the interview, check off the appropriate column and write additional comments.  Please share your ratings and comments with the interviewer and observer group.

Process & Skill

Excellent

Satisfactory

Needs Improvement

Used simple language and gave clear explanations
Comments:
 

 

 

 

Established trust
Comments:
 

 

 

 

Appeared professional and nonjudgmental
Comments:
 

 

 

 

Appeared comfortable and confident
Comments:
 

 

 

 

Made conversation flow easily
Comments:
 

 

 

 

Identified and addressed your concerns
Comments:
 

 

 

 

Invited your questions and checked to see if you understood information given to you
Comments:
 

 

 

 

Made you feel comfortable about sharing personal information
Comments:
 

 

 

 

Interviewer’s Handouts

Facilitator:  Hand to each participant for interviewing:

  • 1 copy of the “Interviewer’s Instructions” on page 111
  • 1 copy of the “Patient Information for Interviewer” on pages 112-118, corresponding to the # interview he/she will be conducting.  Fill in the appropriate personal information which matches what was used for the corresponding Index Patient Role.
     
Particpant

Activity 9:  Interviewer’s Instructions

Interviewer’s
Materials, p. 1

In this exercise, you will simulate the interview of a suspected or verified TB patient for contact investigation.  You will be participating in a role-playing experience.  Role-playing is a means of practicing interviewing skills and tasks in a simulated atmosphere.  This role-play involves one person playing the role of an index patient requiring a TB interview and another person playing the role of the interviewer.  You have received the Index Patient Role which provides information regarding the index patient you will be interviewing.

Before the Interview

  • Become familiar with the index patient’s background.  This is information similar to what you may obtain from a medical record review prior to an interview.  The scenario description suggests that either you or the index patient is wearing a mask.  This is to simulate how a real interaction would take place, relevant to the barriers to communication while wearing a mask.  However, for the purpose of this exercise, neither you nor the index patient will wear a mask.
  • Ask your course facilitator any questions you have about the information that you have received about the index patient

During the Interview

  • Use all of the skills that you would normally use in interviewing a TB patient, and complete the appropriate health department interviewing forms.
  • Although the index patient has received very detailed information about his or her role, he or she may have to rely on creativity for developing certain circumstances.  Keep this in mind if the patient needs a minute to remember or devise some information.

After the Interview

  • Let the group know how you felt during the interview.
  • You will receive feedback from your group observer(s), group leader, and the index patient, providing an opportunity to learn new interviewing skills or refresh those that you have.
     

participant

Activity 9:  Patient Information for the Interviewer:

Index Patient #1

Interviewer’s
materials, p. 2

Name:
Phone Number: 
Address:

TB interview for contact investigation takes place at clinic; patient is wearing a respirator

Patient Profile
  • ____ years old
  • Visit to health department doctor 1 week ago
  • Productive cough x2 months, 10-pound weight loss over 1 month, fever
  • TST induration = 16 mm
  • Health department CXR abnormal with noncavitary disease
  • AFB 1+ on sputum smear; culture identification pending
  • HIV-test results pending
  • Diagnosed with suspected pulmonary TB
  • Four-drug regimen (INH, RIF, PZA, EMB) initiated today
  • On home isolation as ordered by clinic physician
  • Home-based, daily DOT
  • Self-employed, traveling singer
     

 

participant

Activity 9:  Patient Information for the Interviewer:

Index Patient #2

Interviewer’s
Materials, p. 3

Name:
Phone Number
:
Address:

TB interview for contact investigation takes place in hospital; interviewer is wearing a respirator

Patient Profile

  • ____ years old
  • Went to hospital emergency room 1 week ago complaining of dry cough, night sweats, chills, high fever, loss of appetite, vomiting, dizziness, and chest pain
  • Sent home with prescriptions for antibiotics
  • Returned to emergency room without symptom resolution 4 days later, and was admitted to hospital
  • TST induration = 22 mm
  • CXR abnormal with cavitary disease
  • AFB 2+ on bronchial wash; culture identification pending
  • HIV status unknown
  • Diagnosed with suspected pulmonary TB
  • Four-drug regimen (INH, RIF, PZA, EMB) started in hospital
  • Employed as an accountant
     

 

Activity 9:  Patient Information for the Interviewer:

Index Patient #3

Interviewer’s
Materials, p. 4

Name:
Phone Number
:
Address:

TB interview for contact investigation takes place in hospital; interviewer is wearing a respirator

Patient Profile

  • ____ years old
  • Admitted to hospital through emergency room 3 days ago with complaints of cough for 2 months and acute hemoptysis; history of weight loss and night sweats
  • TST induration = 0 mm
  • CXR abnormal with cavitary disease
  • Sputum smear negative; culture identification pending
  • HIV (+); treatment started during hospital admission
  • Diagnosed with suspected pulmonary TB
  • Four-drug regimen (INH, RBT, PZA, EMB) started in hospital
  • Lives in homeless shelter
  • Unemployed
     

 

Participant

Activity 9:  Patient Information for the Interviewer:

Index Patient #4

Interviewer’s
Materials, p. 5

Name:
Phone Number
:
Address:

TB interview for contact investigation takes place at home; patient is wearing a respirator during interview

Patient Profile

  • ___ years old
  • Productive cough x6 weeks, fever, 10-pound weight loss, chills
  • Visited primary medical doctor 2 weeks ago
  • CXR abnormal with right upper lobe infiltrate
  • Admitted to hospital 4 days ago; left against medical advice 2 days ago
  • TST induration = 20 mm
  • AFB 3+ on sputum smear; culture identification pending
  • HIV-test result pending
  • Diagnosed with suspected pulmonary TB
  • Four-drug regimen (INH, RIF, PZA, EMB) started in hospital
  • Treatment self-administered daily at home
  • Stay-at-home parent

 

Participant

Activity 9:  Patient Information for the Interviewer:

Index Patient #5

Interviewer’s
Materials, p. 6

Name:
Phone Number
:
Address: 

TB interview for contact investigation takes place in hospital; interviewer is wearing a respirator during interview

Patient Profile
  • ___ years old
  • History of documented positive TST 2 years ago (no mm reading), with no history of treatment for latent TB infection
  • Admitted to hospital through emergency room with asthma attack 4 days ago; complained of cough x1 month, fever, and unspecified weight loss
  • CXR abnormal with cavitary disease
  • AFB 4+ on sputum smear; culture identification pending
  • Diagnosed with suspected pulmonary TB
  • HIV-test result pending; previously negative
  • Four-drug regimen (INH, RIF, PZA, EMB) started in hospital
  • Employed as school-bus driver

* Note: Patient's age must be over 36 years to be consistent with medical history.

 

particpant

Activity 9:  Patient Information for the Interviewer:

Index Patient #6

Interviewer’s
Materials, p. 7

Name:
hone Number
:
Address:

TB interview for contact investigation takes place in hospital; interviewer is wearing a respirator during interview

Patient Profile

  • ___ years old
  • Admitted from county correctional facility 1 week ago with fever, night sweats, and cough
  • CXR abnormal with left upper lobe infiltrate
  • AFB <1 on sputum smear
  • HIV testing refused
  • Diagnosed with suspected pulmonary TB
  • Four-drug regimen (INH, RIF, PZA, EMB) started in hospital
  • Active substance abuser (cocaine, heroin)
  • Unemployed

 

Activity 9:  Patient Information for the Interviewer:

Index Patient #7

Interviewer’s
Materials, p. 8

Name:
Phone Number:
Address:

TB interview for contact investigation takes place in hospital; interviewer is wearing a respirator during interview

Patient Profile
  • ___ years old
  • Had productive cough x3 months with intermittent fever for 1 week; admitted through emergency room 3 days ago after collapsing at work
  • CXR abnormal; miliary TB
  • AFB 3+ on sputum smear; culture identification pending

  • Lymph node 2+ on smear; biopsy and final culture identification pending
  • TST induration = 33 mm
  • HIV-test results pending
  • Diagnosed with suspected pulmonary and nonpulmonary TB
  • Six-drug regimen (INH, RIF, PZA, EMB, SM, Levaquin) started in hospital
  • Employed as assembly-line worker in shoe factory
  • Foreign born, from Zlawamba*
  • English speaking, but comprehension is limited; Zlawamban interpreter is unavailable

* Fictitious country


 
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