Pharmacy Practice- Consultation Skills

Consultation

meeting to discuss or get advice, goal of discovering course of action

Person-centred approach

committing to putting the people at the centre of healthcare

- increases choice and decision making processes, all parties benefit

- underpins care principles

advising -> supporting -> coaching

Holistic view

taking into account social, physical, psychological and behavioural aspects during a consultation

Golden minute

letting the patient speak for the fist minute of the consultation without interruption

- for history taking

Clinical reasoning

evidence based, dynamic process combining scientific knowledge, clinical experience and critical thinking

Factors affecting clinical reasoning

- epidemiology- some conditions are more common than others

- age and sex- elderly more likely to have polypharmacy, gender-specific conditions

- general appearance of a patient

Medicines optimisation and adherence

meds are used sub-optimally and are not taken as intended, HCP duty to help increase med adherence

Compliance

extent to which a person's behaviour matches prescriber's recommendations

Concordance

nature of prescribing, relationship and med taking behaviour

- actively discussed with patient

Persistence

length of time person continues to take meds

Adherence

extent to which a person's behaviour matches agreed recommendations from the prescriber

Non-adherence

failure to comply fully with treatment recommendations for modification of a health habit or an illness state

- impairs health outcomes, increases risks, treatment failure/disease progression

- can be (un)intentional (demographics, age, gender, no support or care, beliefs)

Unintentional non-adherence

forgetfulness, unable to open or operate meds/apparatus/devices, swallowing issues, doesn't match lifestyle, child in school

Intentional non-adherence

active decision not to take meds

- due to concern about risks, health benefits, felt not listened to, unconvinced by meds, personal beliefs (e.g. vegetarian)

Informed adherence

accept that the patient has the right to decide not to take meds (as long as they have the capacity to decide)

Improving non-adherence

1- unintentional or intentional

2- consider support options

3- address beliefs and concerns

4- tackle practical problems (monitor, simplify treatment plan)

5- side effects, refer back to prescriber

Interventions on non-adherence

no 'one size fits all' strategy

- first explore the person's perspectives and attitudes towards change, dis/advantages, negotiate, shared decision making

- alter formulation, compliance aids, monitored dosage systems, change regime, reading aids

Age, ability and mental health on adherence

- encourage people of all ages to participate in therapy discussions

- be aware of different abilities

- people with mental health conditions may struggle to adhere with meds, so be patient, awareness

Communication skills

incorporating verbal and non-verbal methods of language to vocalise emotions and listen effectively

- building and maintaining rapport

Effective listening

receiver involved in listening experience by paying attention to visual cues, watching body language, asking relevant questions

Transactional analysis model

refers to states of mind, 'ego states'

- adult- 'here and now', appropriate response to stimuli

- child- echo the past, natural child (playful) or adaptive child (adapted by conforming)

- parent- reflected the behaviours of paternal figures (authoritative, paternalistic or caring)

consultations should aim to be A to A

Sharing expertise

each person is their own expert in their care, diagnosis and treatment

Barriers during consultations

lack of communication skills, time, personal/language/organisational barriers, inadequate knowledge, telephone restricted to verbal, blocking behaviours

Blocking behaviours

HCP- advice too soon, distress as 'normal' (dismissing), physical aspects only, changing topic, 'jollying' along

person- refusal, belief that nothing can be done, burden, pathetic or ungrateful, uncomfortable, fear

Taking a history in a consultation

considered the best way to obtain relevant info and accurate diagnosis (promotes empathy, understanding, learning)

- identify patient, encourage description one problem at a time, how effective is treatment, recent life changes, past illness, meds taken, family disease, social history, interpret

RESPECT all info

History of consultation theory

1800- bio-medical- concentrates solely on disease and physical issues

1950- Balint- psychological problems related to physical

1960- transactional analysis- states of mind

1970- health beliefs- factors influencing and predicting behavioural outcomes from person's viewpoint

1980- anthropological 'folk'- people ask themselves questions

Calgary-Cambridge model

1- initiating the session (prep, intro, rapport, agendas)

2- gathering information (LICEF)

3- physical examination (where and when appropriate)

4- explanation and planning (info, aids, discuss action plan)

5- closing the session (summarising, teach back, safety net)

Pendleton's framework

more person-centred approach:

- discuss reason for attendance, consider other problems, choose appropriate action, achieve shared understanding, involve person in management, appropriate time and resources, establish and maintain relationship

Neighbour's inner consultation

cultivating HCP ability to act on info-rich moments

- connect, summarise, handing over, safety-net, housekeeping (am I in good enough state for next person)

BARD

considers whole relationship and personality, will influence consultation

- behaviour, aims, room, dialogue

Medicines related consultation assessment tool (MR-CAT)

global assessment tool for identifying strengths and weaknesses to improve technique (based on Calgary-Cambridge)

LICEF

lifestyle, ideas, concerns, expectations, feelings

Shared decision making

patient and HCP work together to decide on a treatment plan

- "no decision about me, without me"

- awareness of balance of power

- active listening, working together, discussing opinions, making inferred decisions

Active listening

paraphrasing- restating info

summarising- concisely reiterating main points

clarifying- clearing up any misunderstanding in both parties

reflection- mirror and relay info

Types of questions

open- broad in nature (how, where, when, what)

closed- yes or no

leading- used when the patient is unsure ("does it get worse when XYZ?")

probing- "tell me more" (TED- tell, explain, describe)

Health coaching

HCP encourage to empower patients into their own decision making to take control of their healthcare (own insight, self-aware health goals)

- improves med optimisation, responsibility

- mutual partnership, balanced discussion, believing in potential, appropriate level of challenge, support behavioural changes

Pillars of healthcare coaching

patient activation, motivational interviewing, positive psychology

Grow model

goal, reality, options, way forward

Four E's model

explore, educate, empower, enable

OARS

open-ended questions, affirmations, reflective listening, summaries (leads to more exploratory questions)

Scaling questions

solution-focused

- subjective statement -> objective measure