Ethics OSCE Station Blueprint

Station Name: Battered Woman

Issue:

Women's Health

Presenting Situation:

Jennifer Davis is requesting tranquillizers because she has been on edge, under a lot of stress and has had trouble sleeping.

Activities:

Patient encounter.

Time Required:

10 minutes

This station was developed by Dr. Peter A. Singer (Centre for Bioethics and Department of Medicine, University of Toronto), and Anja Robb (Department of Family and Community Medicine, University of Toronto. It is part of the Ethics OSCE Project which is funded by Educating Future Physicians for Ontario (EFPO). There is an accompanying videotape. This material can be used for teaching or evaluation. It is not copyrighted and may be freely reproduced for educational purposes.

Instructions to Candidate:

You are about to see Jennifer Davis, a new patient. The nurse tells you she wants a prescription for tranquillizers because she has been "on edge", "under a lot of stress", and has had "trouble sleeping".

You have a very busy office today and only have 10 minutes to see her.

CHECKLIST ITEMS:
^^^^^^^^^^^^^^^^

YES     NO     The Candidate:
        
               1.      asks about history of abuse/experience
                       of violence.
----|-----------------------------------------------------------
               2.      asks about use of weapons and/or weapons
                       in house.

----|-----------------------------------------------------------
               3.      asks about hospitalizations or hospital
                       visits for abuse.
----|-----------------------------------------------------------
               4.      states that wife assault is a criminal
                       offence (illegal).
----|-----------------------------------------------------------
               5.      informs patient that police involvement
                       tends to stop or decrease violence.
----|-----------------------------------------------------------
               6.      asks if children have been abused.
----|-----------------------------------------------------------
               7.      informs patient that exposure to these
                       violent interactions between parents can
                       adversely affect a child's behaviour and
                       future mental health. 
----|-----------------------------------------------------------
               8.      expresses concern for patient's safety.
                       (i.e. her life may be at risk)
----|-----------------------------------------------------------
               9.      acknowledges difficulty of leaving the
                       situation.
----|-----------------------------------------------------------
               10.     asks about support systems (e.g. family,
                       friends).
----|-----------------------------------------------------------
               11.     informs patient of community resources
                       (e.g. emergency housing, legal aid).
----|-----------------------------------------------------------
               12.     offers support, follow-up appointment,
                       and follow-up services (e.g.
                       counselling, referral to social worker).
----|------------------------------------------------------------ 
=================================================================

                              
RATE FROM 1-5:
 +------------------------------------------------------------+
 |        |          |          |    VERY    |                |
 | POOR   |   FAIR   |   GOOD   |    GOOD    |    EXCELLENT   |
 |  1     |    2     |    3     |     4      |       5        |
 +------------------------------------------------------------+

1.      How would you rate the candidate's communication skills?                                 
        1      2       3      4      5

2.      How would you rate the candidate's ability to address the
        ethical issue in this case?                 
        1      2       3      4      5

Instructions to Standardized Patients:

Your name is Jennifer Davis. You are between 35 and 45 years old. You have been married to the same man for several years. You have 2 children, aged 13 (son) and 9 (daughter).

You have a high school education. You do not work outside the home. You are socially isolated. Your parents do not live nearby. You really don't have a support system.

You are a sensitive person with low self-esteem. You are pleasant and shy. You are well dressed and well spoken.

When Asked Why You've Come:

"I was hoping you could prescribe some tranquillizers or something to help me sleep.
"I've been on edge lately and can't seem to relax... and I'm making mistakes. If I could just get some rest I'd manage better."

The Situation at Home:

It is very tense. Your husband is going through a hard time. He is worried about money but he will not let you work even though you have offered. People in your husband's firm (real estate) have been laid off and it has made him very nervous. He is drinking more. He is actually an alcoholic. You want to be supportive. You're trying your hardest to please him. You're trying to keep the kids out of the way and meals on the table the way he likes, but you're so nervous you keep triggering his temper.

It is necessary to hint strongly about "problems" with your husband and that he's "out of control" lately. You quickly add that "things have always gotten better before". You admit to the abuse if the candidate asks you how he's "out of control".

History of Abuse:

Your husband has always had a temper. (He's immature and controlling.) He started pushing you around when you were pregnant. In times of stress or after drinking he would go on "rampages"- sometimes just yelling and screaming, but sometimes physical. Lately, his demeanour has become increasingly frightening (related to alcohol). Now he is squeezing your throat and not letting go. Before, it had always been lashing out. He has never used a weapon and you would like to believe he wouldn't now. (There are no weapons in house.)

A few times you've had to get emergency treatment - for a dislocated wrist, broken collarbone, and cuts. The latest episode of violence occurred last Friday, after an evening out with his colleagues. You are afraid of next Friday.

Concerns About Children:

You don't believe he would hurt them and he hasn't in the past. You're afraid they overhear his tirades. You've noticed a distinct change in your oldest son's attitude toward his father (insolent, cold), and you (protective, sad). This is subconsious, realized when asked questions that lead this way.

Attitude Toward Husband:

You are protective of your husband. ("It's not his fault.") You want to be loyal to him but his new behaviour really has you frightened, forcing you to come in today. You still minimize what has happened to you in the past.

General Health:

You've always been a little nervous, but more so lately. You feel tired most of the time and really don't feel like doing anything. You're not getting any exercise and don't go out much.

You've had problems in the past with headaches, stomach pains, back pain, chest pain. Tests have been done, but results are always normal. Your family doctor couldn't figure out what was wrong with you.

You do not smoke. You have been drinking a little more lately. (You think it calms your nerves and helps you fall asleep.) You don't have much of an appetite.

Re: Your Upbringing

Your father was "very strict" in dealings with family (mother and kids). He believed in "spare the rod, spoil the child". You are aware that your father struck your mother once or twice. Your husband comes from a similar situation.

Prompts are used to standardize the scenario and give all candidates an opportunity to address relevant issues.

PROMPT 1 (by 2-3 minutes):
"Things are tense at home. I'm not getting along with my husband."

PROMPT 2 (by 3-4 minutes):
"But he's my husband. There's nothing I can do."

PROMPT 3 (by 5-6 minutes):
"What can I do?"

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