PASfP 2 Communication and consultation skills Study pack 2024-2025 pdf.pdf

Communication and consultation skills Facilitators Required References Jyoti Buxani This study pack [email protected] Pharmaceutical practice 5th edition. Rees, Smith,...

Communication and consultation skills Facilitators Required References Jyoti Buxani This study pack [email protected] Pharmaceutical practice 5th edition. Rees, Smith, Watson www.consultationskillsforpharmacy.com Any further directed materials/references specified within the study pack Learning Outcomes On completion of this pack you should: 1. Know about interpersonal models and barriers to communication 2. Be able to explain verbal and non-verbal communication 3. Understand the need for empathy and building rapport with a patient 4. Be able to explain what is meant by active listening, summarising and paraphrasing 5. Understand and be able to use the Calgary-Cambridge model for consultations 6. Understand how to take an accurate medication history and a full medical history from a service user 7. Understand how to perform medicines reconciliation 1 Table of Contents Last year............................................................................................................................................. 4 Interpersonal communication models............................................................................................... 5 Other models..................................................................................................................................... 6 Characteristics of face-to-face communication............................................................................. 9 Barriers to communication.................................................................................................................... 9 Non-verbal communication................................................................................................................. 12 Verbal communication......................................................................................................................... 13 Written communication....................................................................................................................... 17 Providing written information for patients..................................................................................... 18 Choose your register........................................................................................................................ 18 Make it readable.............................................................................................................................. 19 Spelling and grammar...................................................................................................................... 20 NHS guidance................................................................................................................................... 20 Readability:...................................................................................................................................... 21 Patient information leaflets............................................................................................................. 22 Consultations....................................................................................................................................... 23 Consultation Models............................................................................................................................ 25 The Calgary-Cambridge model............................................................................................................. 26 1. Initiation................................................................................................................................... 26 Building a relationship................................................................................................................. 29 Consent........................................................................................................................................ 29 2. Information.............................................................................................................................. 30 Questioning.................................................................................................................................. 31 First problemitis........................................................................................................................... 33 Listening........................................................................................................................................... 35 Active listening............................................................................................................................. 35 3. Explanation and planning........................................................................................................ 37 Decision aids................................................................................................................................ 38 4. Closing and forward planning.................................................................................................. 38 Safety netting................................................................................................................................... 39 The national practice standards for pharmacy consultations............................................................. 39 Taking accurate and complete medical histories from patients......................................................... 40 2  Medicines Reconciliation..................................................................................................................... 44 Reliable sources:.............................................................................................................................. 44 Less reliable sources:....................................................................................................................... 44 Steps involved in taking a medication history................................................................................. 47 Conclusion............................................................................................................................................ 51 PASfP2 Study Pack 2: Communication Skills – how does this apply Importance? Communication is key to every sector a pharmacist can work, particularly in patient-facing roles (community-based, primary and secondary care). In particular, you cover medicines reconciliation in this pack and pharmacists are responsible for this process, at any patient transfer of care. There are tasks and activities to complete in this study pack which will enhance and benefit your learning. Relevance? Placements – communication with patients in a clinical setting is invaluable experience for your future career. This PASfP pack aims to ensure you are well prepared to communicate with patients professionally and to gain maximum benefit from your placement. You will need to speak to patients and conduct histories and medicines reconciliation from patients on your hospital placements. In a community setting, you will be interacting with patients over the counter; handling queries and medicines. Assessment – communication is a skill which is evaluated as part of your OSCE in the summer examinations. All of your team applications (tAPPs) in class are extremely valuable in preparation for your end of year assessment. They are opportunities to refine your skill set. Preparation? This TBL cycle Experience in pharmacy (or any customer facing situation) – talking with patients Read clinical articles, guidelines and service specifications as well as patient information sources (notice how professional documentation translates to patient information leaflets/posters/advertisements). 3 Introduction “I know that you believe you understand what you think I said, but I am not sure you realize that what you heard is not what I meant” Allegedly, a quote from Robert McCloskey, then U.S. State Department spokesperson in 1984. Politicians can get away with talking nonsense but in order to be an effective healthcare professional (HCP) you will need to be able to communicate effectively with many different groups of people in a wide range of situations and reassure individuals that the material you are delivering is correct and factual. This study pack is primarily concerned with communication between HCPs and patients and carers. Last year Last year, your year group had workshops and dispensing classes where communications skills were considered in general and ways in which you can improve them. In this pack, we will take this further. In particular, you will look at applying communication skills to patient-centred consultations. Use your notes that you obtained from last year, or a reputable resource, to help you with the next task:- 4  Interpersonal communication models TASK 1 Complete the diagram of the model below before checking the correct answer. Shannon Weaver Model of (Two Way) Communication: Interference and distortion Takes in the Person initiating message that the communication source has sent out 5 TASK 1 ANSWER: The correct diagram of the Shannon-Weaver model is below Other models Of course, this is not the only model available. Consider the following models; do they apply to situations you have encountered? Can you make better use of them to manage your patient communications? Linear Example:- a lecture (didactic delivery of information). 6 Interaction (note the similarities to the Shannon Weaver model) Examples: - questions between lecturers-students, students-students. Transaction Example:- probably a more accurate representation of an ordinary conversation than any of the other models. 7  TASK 2 Complete the table below to summarise the models, their advantages and limitations. Use examples in everyday life that you might come across and that maybe related to pharmacy. Model Examples Advantages Limitations Linear Lecture TV Email Interaction Instant messaging Transaction Most realistic model of face to face conversation An example answer can be found at the end of this section of the pack Person-centred consultations need to be transactional. Why is this? Consultations are about creating a shared outcome and the HCP needs immediate, strong feedback from the patient. For this reason, consultations are generally face-to-face. There are now changes with some consultations carried out remotely online. They can be mediated through a technical channel such as instant messaging, email or phone but these have many limitations. Technically, mediated communications suffer from more noise/interference and the messages are easier to misinterpret because there is less feedback or feedback can be delayed. This places greater demands on the communications skills of the HCP and requires a higher level of expertise on their part. However, technical channels can sometimes be helpful in removing barriers, such as language or hearing difficulties. Methods such as software to help with language barriers You may have seen advertisements for online GP or pharmacy services. What do you think of these services? During the pandemic the ways in which many healthcare professionals worked changed to incorporate more remote consultations over the phone, via video link or online. In some cases, remote consultations are very useful such as when the patient’s clinical need is straightforward e.g. issuing a repeat prescription. You have access to the patient’s medical notes, no examination is necessary and the 8 patient has the capacity to understand all the information provided. However, in many cases a face- to-face consultation would be of greater benefit. Activity to complete Can you think of some incidences where face-to-face consultations and communication is preferable? Characteristics of face-to-face communication There is immediate, very strong, feedback. It is a dynamic process as you interact with another person and react to their messages. It is multi-channel. Meaning is transferred through verbal and non-verbal channels as well as by context. There is both deliberate and accidental transfer of meaning. Face-to-face communication is irreversible. Once you have said it you cannot take it back. It is inescapable. We cannot refuse to communicate. Any attempt not to communicate communicates something. Face-to-face communication is complicated. No form of communication is simple. Because of the number of variables involved, even simple requests are extremely complex. What counts is not what you said but what they understood. Barriers to communication There are many potential barriers to effective communication. As a HCP it is your responsibility to recognise and address these barriers to allow effective consultations to take place. Barriers can generally be placed into four main categories. o Environment o Patient factors o Pharmacist and team factors o Time 9 TASK 3 Consider each of the potential barriers below and put them into the appropriate category in the table over the page. For each, think about how they can obstruct communication and how you might alleviate them. A busy pharmacy A patient with hearing impairment Physical barriers (e.g. a high pharmacy counter) Illiteracy Lack of interest Lack of confidence Interruptions Comprehension difficulties Noise Lack of Privacy Confidentiality concerns Patients with sight impairment Poorly trained staff Stereotyping and pre-judgement Any other barriers you can think of… One example is shown already in the table Type of barrier How it can be managed Environment Lack of privacy Use consultation room or screen Patient factors Pharmacist and team factors 10  Time Answers for this task are not provided as you are expected to be able to categorise these appropriately and the suggestions for management are open. If you have any questions, please ask a member of staff. Self-directed reading: Now read the section on barriers to communication in Pharmaceutical Practice 5th edition (page 159 - 161). 11 Non-verbal communication Last year we discussed verbal (speaking and listening) and non-verbal communication. TASK 4 Which components of non-verbal communication can you recall? Make notes below on what you can remember. See the end of this section of the study pack to check your answers against some suggested answers. TASK 5 Watch the video below for a tutorial on non-verbal communication based on a Pixar film clip https://www.youtube.com/watch?v=nYTrIcn4rjg This video may be about birds but we can still learn some important lessons about non-verbal communication from it. You can clearly see how the birds are feeling just from the expressions on their faces and body language. How do you think a patient would feel if you got too close to them during a consultation, invading their personal space, like when the birds stay too close together in the video? It is commonly said that non-verbal communications account for up to 93% of the meaning that people take away from human communication. This figure is a distortion of the work of Albert Mehrabian, now a Professor at UCLA. TASK 6 Click here to learn more about Mehrabian’s work. Clearly, the figure of 93% cannot apply to all communications; if it did, as lecturers we could perform all of our lectures in mime or interpretative dance! For some types of communication all you need is the words. If I told you the building is on fire and we need to evacuate immediately I think you would understand me however I stood and whatever the tone of my voice. This brings us to the principle of congruence. Our communications are said to be congruent when our verbal communication is backed up by our non-verbal communication. 12  TASK 7 Watch the video to see an example of incongruence. (https://www.youtube.com/watch?v=_Zyax-iZBk8) Watching James Nesbitt tell someone that they are ‘very, very nice people’ whilst aggressively finger pointing is interesting and, in this case, the incongruence creates humour. However, there is no doubt that the non-verbal communication is at least as powerful as the words that are spoken. Consider how this may apply to your pharmacy practice if you tell a patient some bad news whilst smiling, or look very sombre whilst greeting someone in your pharmacy with a chirpy voice. Body language Some body language is the same in all people regardless of culture or ethnicity. For example smiling and frowning. TASK 8 Click here to find out about six universally recognisable facial expressions. Charles Darwin first proposed these. Some researchers suggest there are seven but some research has cast doubt on the concept. Even if we accept the six universal facial expressions, body language is specific to a particular cultural or ethnic group. Click here or here for some examples of cultural body language differences. Verbal communication We discussed verbal communication last year. TASK 9 Try to recall what is meant by register and make notes below: 13 Your register is the way you speak and the words you use in a particular situation. Do you speak the same way with your parents as you do with your friends? Two of the most obvious registers are formal and casual. Do you use different words in a formal situation with a group of older adults than when you are texting one of your friends? Context Degree of formality Key issues Between colleagues Often informal Must demonstrate respect for each other Between Usually informal Professionals must adapt their language professionals and (not use technical terms or jargon) in people using services order to be understood. With professionals People using services may Professionals must take responsibility for communicate informally. checking their understanding. Professionals may respond formally. Multi-professional Usually formal – may need Different professional people must be working within the formal planning to produce careful to check that they are MDT ‘agendas’ for business understood. Table 1: Differences in communication in different contexts. We all learn to adapt our register according to our situation but it can be difficult to do so in a situation that is unfamiliar. For this reason, you must consciously adopt an appropriate register when talking to patients. Choose an appropriate degree of formality: not too casual. Many older people do not respond well to informal greetings or use of first names. Use words that the patient is likely to understand. Remember that the patient may have had a different education from you and may not be familiar with some medical or scientific terminology. Do not use abbreviations or jargon words without confirming the patient has understood them. It is also important to avoid calling the person you are talking to “darling”, “sweetheart”, “love” or other words which are usually considered terms of endearment. You may use these terms with your family and friends, but service users, colleagues, and other professionals may find this a little overfamiliar and it may make them feel uncomfortable. Given the complexity of healthcare communication, the purpose of communication will vary depending on the setting e.g. hospital, primary care or community, as well as the context of care. To communicate safely there needs to be flexibility and considerations of what is required in each individual case. You may want to consider these questions to ensure your communication is tailored appropriately to the situation. 14  Questions to Reflective questions consider WHY What is the purpose? Is it to inform, gather information, discuss, check understanding, seek are you advice, and raise concerns or follow-up? communicating? Is there are specified person/or people that you need to communicate with? WHO Who else is part of the care team? Consider multidisciplinary team do you need to members and the patient, family or carer. communicate Is there one person responsible for the patient’s overall care? with? How do you know whom you need to communicate with? WHEN Are there procedures in place that specify when you need to communicate with other members of the clinical team? (E.g. transitions do you need to of care from hospital to GP, and high risk situations e.g. safeguarding information). communicate? What is the minimum information content that you need to communicate? Do you have all the relevant information? WHAT Do you need to check other sources, such as information from the patient information are themselves, family members or carer? you Are there any special considerations or risks that you need to consider for communicating? your specific patient? Does the patient and their family understand their diagnosis and management? Are they up to date on their progress. HOW What is the agreed method for communication? I.e. face-to-face, via the telephone, email, or a number of different methods? are you What communication skills do you need to exercise? communicating? 15  Questions to Reflective questions consider What are the processes, strategies or tools available to support your communication? I.e. a translator, different language leaflets or text reminders? How is the person you are communicating with receiving / responding to the information? Are you communicating in a way that is easily understood and meets the communication needs of the person you a communicating with (another clinician or patient)? WHERE Do you need to consider privacy and confidentiality issues? Does your environment support effective communication? E.g., can are you everyone hear? Are there many interruptions? communicating? 16 Written communication You will sometimes need to write information. Whether this is patient notes in a hospital, information about a complex drug regime for a nurse or instructions to a patient, your writing needs to be fit for purpose. That is, it needs to communicate effectively. Writing effectively is important for the following. Pharmacists could be expected to write any of these. Some examples have been provided which you should look at to see the style and standard of written communication that will be expected of you as a future pharmacist: Communicating with patients: information sheets, instructions (including on medication labels) and particularly when medication dosing is complex e.g. steroid reducing regimens, dosing warfarin (Warfarin Patient Information Leaflet, PIL and Warfarin counselling checklist) Communicating with other HCPs: referral letters and explanations of drug regimes. Maintaining patient records e.g. pharmacy Patient Medication Records (PMRs), records associated with pharmacy services (e.g. New Medicines Services (NMS) and Community Pharmacist Consultation Service (CPCS) require forms to be completed, hospital patient notes, controlled drug registers). Writing reports and assignments (like your laboratory report you have to write this year, or for CPD or further work-related courses you may need to undertake to progress in your career). Conducting research or audits (Investigational treatments for COVID-19) and Owings and out of stock items audit toolkit- click on links to see data collection forms pharmacy staff would be expected to complete clearly and accurately. You need RPS membership to access these which you should have already signed up for as a student) Applying for jobs (See the university careers section of the website for more details/advice Careers enterprise and the workplace). You should think carefully about this when updating your CV annually and if applying for placements and work experience Business plans (e.g. GPhC Vision 2030) Guidelines (The following guideline is now out of date, but it is still a good example of how to write a guideline and an example that one of our previous members of staff has done: Methotrexate asthma and sarcoidosis Standard Operating Procedures Unlike face-to-face communication, writing is not transactional; there is no feedback. This makes it easy to be misunderstood so you need to take extra care with choice of words (register), grammar, spelling and punctuation. All of these can affect your meaning. Health literacy is a key area for healthcare professions, one such special interest group is the Society for Academic Primary Care, who are dedicated to building the evidence base for health literacy, visit their website and explore their resources page for lots of useful links and tools: Health literacy 17 Providing written information for patients We will now focus on providing written information for patients. Most of the principles below apply to all written communication however, we must remember that patients do not always understand medical terms and complex language so if patients are to benefit from any written information we provide, it must be carefully written to make it readable and easy for the patient to understand. Written information needs to be clear, concise and carefully written. This creates an extra step for us to consider if the written information you are providing is intended for patients. A 2021 qualitative study on by Wongtaweepkij, Kamonphat et al. on patients’ experiences and perspectives of receiving written information about medicine conducted in Thailand where patient information leaflets (PILs) are not compulsory, identified that written information is perceived as useful by patients and influences their knowledge and behaviour of taking medicines. Written information can reassure and remind the patient of the verbal information provided by a healthcare professional. As future pharmacists, it is important that you can communicate effectively in a written format as well as verbally. You may have some resources available to you to provide written patient information including patient information leaflets (PILs), leaflets advising on the use of specific dose forms, and public health leaflets. NHS England produce numerous leaflet in alternative formats such as audio, braille, British Sign Language, easy read , large print and in alternative languages. Sometimes it may be necessary for pharmacists to provide individualised written information for a specific patient. If you are providing written advice yourself then you are responsible for ensuring that it is easy for the patient to understand. However, it is also important that you check any written information from other resources is fit for purpose and is easy for the patient to understand before handing it out. It is also important to note that any resources available to you are likely to have been written by a pharmacist (or a team involving a pharmacist) so one day you might be responsible for preparing written patient information as part of your job. It is important that you have excellent written communication skills as you cannot just rely on what has been written for you. Choose your register We mentioned register in relation to verbal communication. It is also important to consider in written communication. Although less than 1% of adults in England are completely illiterate (cannot read or write English at all); according to the most reliable research, around 16% are functionally illiterate. This means that 5,200,000 adults could not pass an English GCSE and have literacy levels below those expected of an average 11-year-old person. Most of these can read some things, but find it difficult to understand and cope with forms, official letters etc. This is particularly true if the information they are given is on an unfamiliar topic. Health literacy has been defined as the basic reading and numerical skills that allow a person to function in a health care environment. People with poor health literacy find it difficult to access healthcare, following instructions and taking medication effectively. They are more likely to be hospitalised and to have chronic diseases. You therefore need to consider firstly the general literacy 18 of your patient and their level of health literacy. As a rule, it is best to avoid any medical/pharmacy jargon. Consider which of the following is clearer: Helpful Beneficial Maintain Keep In the mean time Meanwhile I gave information to I informed For patient information, it may be appropriate to be informal in your writing. You can adopt a conversational tone. An active voice is used as it is more easily understood than a passive voice. Active voice Passive voice The boy threw the ball The ball was thrown by the boy The student made a dispensing error A dispensing error was made by the student I will send a report to your doctor A report will be sent to your doctor The active is shorter and clearer; using the passive voice is usually longer and potentially confusing. For PILs and other information for patients, try to write 90% in the active. Make it readable You may be familiar with the term “reading age”. We tend not to use this now because most adults with literacy problems have strengths in some areas and weaknesses in others so to average these out as a reading age is deceptive. Instead, we talk about readability of a document. A number of characteristics such as average word length and average sentence length influences readability. There are a number of standard tests for readability; the most widely used are: SMOG test Flesch Reading Ease Flesch-Kincaid Grade Level Drivel defence Microsoft Word™ can automatically calculate the readability of a document giving both Flesch and Flesch-Kincaid scores. Use the Word™ Help pages to find out how this is done, and what represents an acceptable score. Run the readability test on the following paragraph by copying and pasting the paragraph into Word: "This patient's confusion is from a multifactorial toxic-metabolic encephalopathy. This is primarily caused by, but not limited to, multifactorial causes from multifactorial medical issues, multifactorial medications, and other multiple multifactorial factors. Multifactorial treatments focused on 19 addressing these multiple multifactorial issues may or may not result in a polyfactorial and/or multifactorial improvement in his multifactorial toxic-metabolic encephalopathy." What do you think of the readability score and what do you think you would interpret from this if you were this patient described here and were given this information by your healthcare professional? Spelling and grammar Remember that first impressions count. If you give patients badly spelled and grammatically incorrect information, it reflects on you and makes the patients less likely to follow the advice or instruction you are giving them. Use the spellchecker and autocorrect in your software but remember you cannot rely on it. For example, a spellchecker cannot tell whether you meant there, their or they’re. It does not know the difference between principle and principal, or your and you’re. Spellcheckers are better than nothing, but there are many situations in which they cannot cope. Nothing can replace your own good English language skills and proof reading. You can find help with writing skills at Skills for learning. Pharmacists are expected to write well. If you know English language and writing skills are a weakness of yours, you need to improve. NHS guidance The NHS has produced general guidance about providing written information for patients. This will ensure that NHS England has a clear, consistent, transparent and fair approach to the provision of accessible, inclusive information and communication support to all and can be viewed at: NHS Accessible Information Standard. Patient information will vary depending on who it is for and what it is about. However, there are some general rules and guidelines that you should apply to all written patient information. When writing information for patients, remember the following points: 1. Try to write from the patient’s point of view Put yourself in the place of someone who may have little or no knowledge of what you are talking about. The exception here is the ‘expert patient’; someone who has a long-term medical condition and is very knowledgeable about it. 2. Use everyday language. Avoid jargon and acronyms. Use plain language but be aware that childish language can be patronising. 3. Use patient-friendly text Use personal pronouns such as ‘we’ and ‘you’, as this will help to create a sense of inclusion and trust. Avoid using language that may cause alarm. Phrases such as ‘electrodes will be 20  put on your chest’, for example, could frighten patients and deter them from pursuing further treatment. If you have to use medical terminology, explain clearly what these terms mean. 4. Be relevant to individual patients Make sure your information is relevant to and appropriate for the patient for whom it is aimed. 5. Make sure information is consistent. Your information should reflect and reinforce other information received by patients, such as letters, leaflets, appointment materials and all information delivered at local clinics. 6. Explain all instructions. When asking a patient to do something, such as ‘do not eat anything for six hours before an operation,’ always explain why you are making this request. This will help patients to understand treatment processes. 7. Be helpful. Help people to make decisions by giving them the facts: facts about the benefits, risks and side effects of treatment options or medical interventions. 8. Do not confuse people. Avoid discussing several different treatments and conditions in the same leaflet. Try to limit your leaflet to one or two subject areas and associated issues. 9. Signpost additional resources. Tell your patients about other sources of information and support. 10. Be up to date. Make sure that all the information you provide is evidence-based and up-to-date. You should also provide the most recent contact details for clinics, practices and hospitals. 11. Highlight alternative formats. Let patients know if the information you are providing is available in other formats, for example in Braille or on audiotape. Readability: 12. Use short sentences. In general, no more than 15 to 20 words long. Break longer sentences down in to shorter ones. Use one sentence per idea or concept. 13. Group sentences into paragraphs. All of the sentences in a paragraph should be on the same theme or topic and appear in a logical order. 14. Lowercase letters are easier to read, although uppercase is always required for the first letters of names and sentences. 15. Present and active tense will make your text more direct and engaging. For example, ‘your appointment is on…’, rather than ‘your appointment has been made for…’ 16. A question and answer format can help you to divide your text. 17. Bulleted or numbered points will help you to break down complicated information, and will help patients to digest it. 18. Small blocks of text. Long paragraphs can look daunting on the page; use headings and paragraph breaks to divide your information up. 19. White space. Makes information easier to read. 21  20. Numbers as words. From one to nine, numbers are easier to read if they are written as words. From 10 onwards, they should be represented as numbers. 21. Font size of at least 12 point. Any smaller than this, and text becomes difficult to read. 22. Diagrams and pictures can be very effective for illustrating and enhancing text. Make sure that all imagery you use supports our communications principles. You should clearly label all individual pictures and diagrams, but avoid printing over them. In addition, never use clip- art, as this can detract from our professional reputation. 23. Symbols and pictograms can be useful if their meaning is clear. They can however be misleading or confusing if their meaning is not generally understood. They must not replace text. Patient information leaflets Since 1999, it has been a legal requirement to supply a PIL with all medicines sold or supplied throughout Europe unless all relevant information appears on the packaging. Nowadays PILs are generally well written. There is extensive guidance on making PILs readable, available at: Best practice guidance on patient information leaflets (PILs) List the six main sections of the PIL and the information which must be included within each of these sections: 1. 2. 3. 4. 5. 6. There are no answers provided to this activity as it is expected that you can make appropriate notes from the resource. 22 Consultations A good working definition of a consultation is ‘a meeting to discuss something or get advice with the goal of discovering the best course of action to take’. This comes from Health Education England (HEE) and the definition is intended to include a number of services offered by pharmacists in both hospital and community settings. The definition includes various different consultations a pharmacist may hold, such as the New Medicines Service (NMS), Community Pharmacist Consultation Service (CPCS), providing Over the Counter (OTC) advice, responding to symptoms, smoking cessation, weight management, medicines reconciliation or optimisation, hospital bedside advice, discharge counselling, and advice when dispensing. Consultations need to be: Person-centred Respectful Responsive to o Patient preferences o Patient needs o Patient values Holistic …and should lead to shared decision-making. The GPhC Standards for Pharmacy Professionals are all about delivering effective person-centred care. Read standard 1 for an understanding of what person-centred care means. As this pack is all about communication, you should also read standard 3. For both standards 1 and 3 consider what skills you need to develop to meet these. Remember that these are the standards that you will be judged against throughout your professional career. HEE state ‘Being person-centred is about focusing care on the needs of individual. Ensuring that people's preferences, needs and values guide clinical decisions, and providing care that is respectful of and responsive to them’. You may hear the term patient-centred care too – in fact, we are likely to say this somewhere in this pack, or in a session. Person-centred is the preferred terminology as patient suggested a passive role - someone who simply complies with the orders of a healthcare professional. What we really want is the person receiving care to be involved in decisions about their treatment. The terms patient- centred and person-centred are often used interchangeably; however, they do have slightly different meanings. What you find in practice is that when terminology changes, it takes a long time for this to become habit, so healthcare professionals may use outdated terms. It is however, likely that despite this, they have good understanding of any updates and in this case, they will likely be practising person-centred care, even if they do not use these words. This fits well with the concordant process and with the principle of patient autonomy. The patient has the right to make decisions about their health care but can only do so if they have the appropriate information. You can only provide them with the correct, relevant information if you 23 understand their ideas, concerns and expectations. We will return to this when we consider concordance later this academic year. Look up a definition now if you are unsure what concordance means. Why person-centred? What benefits would you expect from a person-centred approach to consultation? Table 2 below gives some suggestions. BENEFITS FOR THE PATIENT BENEFITS FOR THE HCP BENEFITS FOR THE NHS Better understanding Better relationships with Reduced wastage patient Better relationship with HCP Better identification of patient Fewer consultations Increased satisfaction with concerns leading to fewer care consultations needed Increased adherence Increased job satisfaction Improved outcomes More responsibility Less work-related stress Improved health outcomes Table 2: Expected benefits from a patient-centred approach to consultation 24 Consultation Models You can use consultation models to take a structured approach to your consultations and to develop your consultation skills. Historically there have been a number of different models which reflect the ways in which health care professionals talk to their patients. Early models did not support a person- centred approach they tended to focus on the illness or the health care professional. Below are some examples of HCP consultation models: Bio-medical (since 1800s) - concentrates on disease and diagnosis and assumes that all disease has a physical or biological cause. Balint (1950s) - first model to recognise that psychological problems can manifest as physical problems and physical problems have a psychological effect. Transactional analysis (TA) – TA was first used as a tool in psychology in the 1960s. It explains how and why people behave in relating or communicating with each other. It involves three ego states, Parent, Adult and Child. Transactions or communications can be analysed to identify the ego states of each participant. Communication is effective if participants are in complementary states. Health belief (introduced in 1970s) – a psychological model developed to explain patients’ beliefs about their health. Six category intervention analysis (1970s) Byrne and Long ‘Doctors talking to patients’(1970s) Helman’s anthropological or folk model (1980s) Pendleton et al (1984) - 7 task patient-centred model. Roger Neighbour ‘The Inner Consultation’ – 5 checkpoints of connecting, summarising, handing over, safety netting and housekeeping. Calgary-Cambridge (1990s developed further 2002) BARD ‘Behaviour, Aims, Room, Dialogue’ (2002) 25 The Calgary-Cambridge model We are going to focus on the Calgary-Cambridge model. This was originally developed in 1996 by Kurtz and Silverman and further developed in 2002. The Calgary-Cambridge model was designed to integrate communication skills with medical content and is widely used in medical education. It is important to understand that the model is not intended to be followed rigidly but is simply a guiding framework used to help ensure that a counselling session is effective and complete. The model has four stages and two overarching themes. The stages are: 1. Initiation 2. Information 3. Explanation and planning 4. Closing The overarching themes are providing structure and building a relationship. 1. Initiation The purposes of the initiation stage are: To greet the patient Introduce yourself (there is a big campaign within the NHS to encourage HCPs to introduce themselves when talking to patients. Read more about this here Hello my name is Begin to establish rapport To identify and clarify the reasons for the consultation TASK 10 Watch the video at https://www.youtube.com/watch?v=dAWk4ujr-2A and decide whether this particular initiation is effective in meeting its purposes. Are there any other poor practices within this video? Once you have considered this, you may want to review this next video and compare the two consultations: https://www.youtube.com/watch?v=l4hZ69qbA2k Note this video may auto play following the video linked above. You can watch it either way as it is the same clip. There are no answers provided to this task but we will talk about some similar practices in your timetabled sessions and you are welcome to ask any questions about any of the practices in the videos you are unsure about then. 26 In stage 1 of the Calgary-Cambridge model, the first 90 seconds are vital to establish a good rapport. During this period, the patient decides if they like you and trust you (Cooper et al, 2006). Begin by introducing yourself and clarifying your role. Remember that first impressions count; Nair et al (2002) found that patients feel more comfortable when a practitioner dresses smartly, and this correlates with higher patient trust and confidence. Remember, when introducing yourself to ensure that the patient understands your role. For instance, you must not allow them to think that you are a medical practitioner, and as a current pharmacy student you must make it clear to any patients you interact with on placements and work experience that you are a student. As independent prescribing is incorporated into the MPharm degree you may begin to hear about the “golden minute” of consultations, after initiating the consultation, this is the first 60 seconds given to the patient to talk uninterrupted about their reasons for the consultation. During this minute, the patient will provide you with lots of the key information to explore further. If you are running late or the patient has had to wait to talk to you, apologise as part of your introduction. This usually defuses any pent up irritation the patient may have built up while waiting and opens up communication channels. During this phase of the model, it is critical to show respect and interest, if you fail to do so now it is very difficult to build a productive relationship later. Consider the environment you are consulting in; is it sufficiently private? Does it create a professional impression or does it look like a storage area for old stock? Does it meet the patient’s needs? Consider any special needs that the patient may have. Think about any barriers to communication that might exist and how they could be overcome. Key communication skills here are good eye contact, being polite and courteous, and allowing the patient to speak without being interrupted. Most people do not talk for longer than a minute, so even if you are in a rush you should allow the patient time to cover all the issues he/she wishes to express. A Canadian study looked at medical consultations and measured the average time patients need to complete their opening statement and what proportion of patients are allowed to complete their opening statement before interruption. 27  TASK 11 Choose what you think are the correct answers below: 1. Proportion of patients allowed to complete their opening statement without interruption: a. 10% b. 25% c. 50% d. 70% e. 80% f. 90% 2. Average time taken to complete their opening statement if uninterrupted: a. 12seconds b. 24 seconds c. 36 seconds d. 48 seconds e. 60seconds f. 90 seconds 3. Average time before interruption (resident physician, similar to a junior doctor in the UK): a. 6 seconds b. 12 seconds c. 23seconds d. 38 seconds 4. Average time before interruption (attending physician, more senior doctor): a. 12 -18 seconds b. 19 – 24 seconds c. 25 – 30 seconds d. 31 – 36seconds TASK 11 Answers… In fact, only 25% of patients were allowed to complete their initial statement before being interrupted. If they were allowed to speak without interruption, they spoke for an average of just 36 seconds although the actual times taken ranged from 6 to 150 seconds. In the 75% of cases where the patient was interrupted, junior doctors interrupted after an average of just 12 seconds, more senior doctors managed between 19 and 24 seconds before interrupting. I know everybody is busy but allowing the patient a few seconds to tell you what they hope to get out of the consultation really is not excessive. 28 Building a relationship Building a relationship with your patient is a key part of the Calgary-Cambridge model. As mentioned above, building rapport is very important in the initial stages of a consultation, however, it is an overarching concern which needs to be considered at all stages of the model. This can be achieved by: Open body language with plenty of eye contact Demonstrating empathy with the patient Showing holistic support for the patient rather than just their symptoms Encouraging the patient to ask questions and answering them Fully engaging with the patient without being pre-occupied with a computer screen TASK 12 Watch the following video clip on building rapport. (https://www.youtube.com/watch?v=FMt9EhGSLLs) Consent Before you examine a patient or perform any procedure, you must always obtain their consent. You should also be asking for a service user’s consent to hold a consultation with them/discuss their personal information. This is part of your duty of care and candour and you must give your patients autonomy (“the right of competent adults to make informed decisions about their own medical care”). Consent can be implied or explicit. An example of implied consent could be if you ask to see a rash on a patient’s arm and they pull up their sleeve and turn so that you can see it clearly. They have not said yes but their movements indicate their consent. Explicit consent is when a patient explicitly says yes to your request. Explicit consent can be verbal or written. In most situations in a pharmacy, verbal or implied consent is adequate. As you practice your consultation skills in classes, simulation and placements, consider the consultation and what type of consent is best. Nobody would take a patient to theatre for an elective operation without providing written information on the surgery to the patient and obtaining a signed consent form. On the other hand, if you did this for every patient interaction, you would not get any work done in your pharmacy! The difference here is that if you are obtaining consent e.g. for a patient to come to your consultation room for a brief chat about their new medication, this is not as high risk as sedating them and cutting them open in surgery. This is one of the factors that you would use to determine how best to obtain consent from a patient. The most important point is that consent should be informed, you must consider whether they have been given the information they want or need, and how well they understand the details and implications of what is proposed. This is more important than how their consent is expressed or recorded. Non-informed consent is not really consent at all. You need to determine what is a sufficient amount of information for the patient to have to make an informed decision – this can be difficult. You also need to communicate clearly to ensure that the patient understands what they are 29 consenting to. Something to consider here is that if you were questioned by someone (e.g. another healthcare professional, a manager, or a regulatory body), would you feel confident to defend that you obtained informed consent? In law, any deliberate contact with a person without their consent is battery. Pharmacist independent prescribers and those involved in the CPCS service often use the mnemonic I2C6 as a guide for their consultations, which also follows the first two sections of the Calgary- Cambridge model, described above. See below an example of a pharmacist carrying out an influenza vaccination for a patient. Example Questions Identity Hello my name is... I am the pharmacist on duty, What is your name and date of birth? How would you like me to address you? Inform You are eligible for this flu vaccine, this will involve me touching your arm, and you may feel a bit of sharp scratch. Consent Is that ok with you? Are you happy for me to proceed? Confidentiality Our discussion is confidential; if I need to tell someone else, I will let you know. Chaperone Would you like anyone else to be present during your vaccination? Comfort Are you comfortable? Could you lift your sleeve up for me please? Clean hands 2. Information As pharmacists, we know many things that we feel the patient should know. It is easy to leap straight in to giving advice without establishing first what the patient already knows or would like to know. If we do this, the patient may feel patronised and resist or reject our advice. We also risk giving inappropriate advice if we have not made decisions based on all of the information the patient has to offer. During this phase of the Calgary-Cambridge model, we start to find out what the patient knows and believes. We recognise that, although we may be an expert in medicines and healthcare, the patient is the expert in themselves, their social circumstances and other factors which affect their health behaviours. This section is all about gathering information. Remembering that our purpose is shared decision-making we need to understand the reasons why a patient might reach a particular decision. We need to explore: The patient’s beliefs about their condition and its treatment The patient’s ideas The patient’s concerns The patient’s expectations 30 All patients come with some knowledge. This is knowledge they have picked up from all sorts of sources such as online, newspapers, from TV, or from a neighbour or relative who had a similar condition. Some of this knowledge may be reliable and accurate, and some may be wildly wrong. You need to understand the patient’s beliefs about their condition or its treatment. Unless you know something of these beliefs, you cannot share appropriate knowledge to influence them. The patient will often have concerns about their condition or its treatment, these may be based on evidence or on misunderstandings but they need to be addressed. You cannot address them without exploring them first. Even if a concern is based on evidence, people in general are very poor at understanding risk and probability. You may be able to put their concerns into a context which helps them to understand the true implications. It is important to find out what the patient is expecting from a treatment and from their condition. If their expectations are unrealistic, they may make inappropriate decisions. Questioning You may have heard the phrase ‘garbage in – garbage out’. Usually it refers to computer systems. If you start with the wrong information, you will get the wrong answer. It also applies to gathering information from a patient. Ask the wrong questions and you will get the wrong answers. Last year we looked at questioning techniques and active listening. In this study pack, we will revisit these subjects. TASK 13 Complete the phrases: Closed questions are those which invite a _____ answer. Answers can often be either _______ or _____. They are usually ____ and quick to answer because the choice of answer is limited. They can be used early in a conversation to encourage participation and to establish facts or to test understanding. Give two examples of closed questions which you could use in a patient consultation: Open questions invite much longer responses and can be more difficult to answer but can gather more information. They ask your patient to think and reflect. They can be used to get opinions and feelings. Open questions include words such as what, why, how, describe, tell me or explain. Good questioning involves using a mix of open and closed questions moving appropriately from one to the other. 31 Funnelling We can use questioning to funnel our patient’s answers – that is ask a series of questions that become more restrictive at each step to allow us to close in on a problem. Funnelling can work the other way round too, starting with closed questions and working up to more open questions. Probing Use questions that include words like exactly or precisely to probe further and clarify. Examples of probing questions include: What, exactly, triggers the pain? Tell me more about… is a very open and general question which is good for gaining detail. Process questions. How does that work in practice? Vague questions. So, what do you think? Silence. A non-verbal probe such as raising your eyebrows and tilting your head shows your interest and asks for detail without any words. See the video at https://www.youtube.com/watch?v=2QVxg-QgmOU to explain more about funnelling and probing. Relevance Closed questions can be used as a way of maintaining control of a conversation. This means that when a patient starts to stray off topic (and they will) you can bring them back and refocus the consultation by asking a carefully chosen question. Narrative Encourage the patient to tell the story of their problem(s) from when it first started to the present in their own words. Establish timescales and the sequence of events. Time to respond Make sure that you give the patient enough time to answer your questions. They may need some thinking time before they answer; so do not just interpret a pause as ‘no comment’ and plough on. Avoid There are some types of question that you should avoid. Leading questions push the patient into giving a particular answer. E.g., you do not smoke do you? This prompts the patient to say no as you have already assumed they do not smoke in how you have asked the question. 32  Double questions are two questions in one and you rarely get answers to both parts. E.g. How long have you had it, have you tried anything already? Compound questions have even more parts than double questions. Patients find them confusing and rarely give you all of the information you need. It can also be difficult to tell which part of the question they have answered. E.g., have you had any nausea, vomiting or diarrhoea? Options. The patient will feel that they can only give you one of the options as their answer, even if none of them is absolutely correct. E.g., so, your brown inhaler, are you using it regularly twice a day now or still once a day? First problemitis Do not get first problemitis where you identify an issue and assume that is all there is and that, no more questions needed. There is often more than one problem and patients often do not tell you them all at once. 33  ASSESSMENT TIP: Your OSCE assessment may involve patient consultation and it is a common mistake amongst students to give out advice or answer the patient’s initial request too quickly before gathering all of the relevant information required. Make sure you have gathered all of the information you need using the questioning techniques above before giving an answer 34 Listening Skilful questioning needs to be matched by careful, active listening so that you understand what people mean by their answers Most of us are very poor at listening, we typically remember around 25% of what we hear. In conversations we spend time playing with our phones, thinking about lunch or that person we just met or what we are going to do tonight or how are we going to get home or … The distractions are endless. We can use active listening to improve our skills and to build a relationship with our patient. Active listening Active listening involves concentrating fully on what the patient is saying rather than just hearing the message passively. Active listening means using more than just your ears. Non-verbal behaviour can give you a lot of guidance about what the patient is feeling and thinking. You can learn as much by looking as by listening. Active listening also involves continuously confirming that you are listening. See the video at https://www.youtube.com/watch?v=U_I2IWLKfVc about active listening. Empathise and identify with your patient You will understand your patient’s points better, faster and more completely if you are able to empathise with them. This also allows you to put your own points in a way which is meaningful and avoids antagonising them. TASK 14 Write your definition of empathy in the space below: Winfield and Richards gave a good working definition of empathy in the 2003 edition of Pharmaceutical Practice. ‘The ability to enter in to the life of other people and accurately understand their meanings and feelings’. You can demonstrate empathy in a number of ways: Being reflective – acknowledging how the customer may be feeling. ‘You seem a little anxious about this appointment’ Legitimising – telling them that their feelings are legitimate. ‘I can understand…’ Being supportive – suggesting that you want to help in a constructive way. ‘You can comeback any time to ask questions’. 35  Encouraging partnership – suggesting that you will be working together to resolve a problem. ‘We will work out if this service is for you or not’. Being respectful – demonstrating admiration for the way in which someone is dealing with a situation. ‘You have done well to acknowledge your condition’. Pay attention Do not allow yourself to become distracted by whatever is going on around you. Do not spend time thinking about your response or your next question when you should be listening. ‘Listen’ to their body language. Pay attention to both verbal and non-verbal cues about how they feel. If you start to lose focus - ask a question, paraphrase or summarise, remembering to wait for a suitable point to do so. If you are finding it hard to concentrate, try repeating their words mentally (silently) as they say them. Ask them for as much relevant detail as they can provide. Show you are listening This can be as simple as: An occasional nod of your head. Eye contact, smiling and other facial expressions. Some encouraging verbal comments such as ‘yes’ or ‘uh huh’. Using an open and interested stance. Mirroring Provide feedback Remember communication is not about what is said it is about what is understood. Make sure that you understand what your patient said. Ask them to repeat themselves if necessary. Ask them to rephrase things if you are finding it difficult to understand. Paraphrase. Use paraphrasing to reflect what has been said back to your patient and get them to confirm your understanding. ‘It sounds like you are saying…’ or ‘What I’m hearing is…’ Ask questions to clarify. ‘What do you mean when you say…?’ Periodically summarise what they have said so far. All of this gives you a win/win situation. You are confirming that you are listening and confirming your understanding. 36 Do not judge or interrupt Interrupting is a waste of time and frustrates the patient. It also restricts your understanding. Allow the speaker to finish. Encourage with short utterances but do not interrupt. Listen openly and make sure you understand what they are saying before you form an opinion. Judge the content, not the person or their delivery. Active listening shows respect and enhances understanding. It needs concentration and determination. You will only get better at it by practising. 3. Explanation and planning In this stage, you will provide your patient with the information they need to reach a decision and help them to reach a shared decision. It is important to avoid giving advice or information before you have gathered all of the relevant information. Providing the correct amount and type of information. This will be different for every patient and you need to use the patient’s responses as a guide. Your information gathering in the previous stage of the model, should have given you a clear understanding of what they already know and what they need to know. Make sure that you use their existing knowledge as a starting point and ask them if there are specific things they would like to know. Be clear and concise in your language. Choose words that are appropriate for the patient’s level of understanding, their education, language and cultural background. All of your explanations in this stage must relate to the patient’s ideas, concerns and expectations. This is your opportunity to correct any misunderstandings or worries. Helping them to understand and recall the information. Remember that we only hear about 25% of what has been said in a normal situation and this drops significantly in a stressful situation. Patients may need a lot of information but may struggle to understand or recall it. You can use the following techniques to help them. ‘Chunks and checks’. This means giving information in chunks, in categories, and checking patient understanding before moving on to the next chunk. There is an old saying in education ‘Tell them what you’re going to tell them, tell them and tell them what you told them.’ Patients will listen more carefully if you tell them what you are going to tell them. For example, ‘Now we will talk about…’ Repetition. Summarise and repeat information to reinforce it. Tell them what you told them. Visual methods. Make use of visual forms of communication such as diagrams, written information, pictures, video clips etc. Many people find this easier to understand and they can often revisit it to clarify and reinforce later. Teachback. Get the patient to restate, in their own words, what you have told them and what they need to do. This is also known as closing the loop or ‘show me’. For example: 37  o To be sure I have explained this properly can you tell me what will happen next? o Please show me how you will use the inhaler so that I can be sure I have given you clear instructions. o We discussed a lot today. Can you tell me what you found most important? o So that I can be sure that what I have said was clear, can you tell me what you will tell your partner about our consultation when you get home? If they cannot restate the information, try explaining again using different words, a diagram or simplifying things. Then use teachback again. If after two or three attempts they still do not understand then you should ask a colleague for help or look for some explanation as to why you have not communicated well enough for them to understand. Reaching a shared decision The purpose of a consultation is to reach a shared decision about the way forward. See the video at https://www.youtube.com/watch?v=fhiwftNLtyc about shared decision making in healthcare. Remember that you are an expert on medicines, but the patient is an expert on themselves and their needs. You must negotiate a mutually acceptable plan. This will involve sharing your thinking and making suggestions as well as getting the patient to contribute their thoughts and preferences. You may also need to take into account the views of other healthcare professionals for multidisciplinary team working. Some patients may reach a decision that you do not agree with, for example deciding not to take their medication. You must respect their decision; they have the right to make a choice. Provided you have given them the information and guidance they needed to make a decision then you have done your job. You may make use of a decision aid (see below) to help the patient to reach an appropriate decision. Decision aids Decision aids are tools that can help a patient to reach a decision by presenting information in an easily understood way. They are often online and you can help a patient to input their own data. TASK 15 Take a look at the following decision aids: Statin choice A-Z list 4. Closing and forward planning The final step in the Calgary-Cambridge model is to close. To close a consultation, you need to summarise the discussion and clarify what has been agreed. That is, tell them what you have told them. 38 Ask them to recall the three key things they are going to take away from the consultation ‘We have covered quite a lot today so tell me the key things you are going to do now’. Take a final opportunity to make sure that the patient is happy with the agreed outcome of the consultation and ask if there are any other matters they want to discuss. Watch the video at https://www.youtube.com/watch?v=SnJMzXcYfBI. How well does the consultant close the session? Safety netting Safety netting advice can protect both the patient and the pharmacist. It can help to ensure that a patient with unresolved or worsening symptoms knows when and how they should seek help: What should they do if their condition gets worse? What should they do if it does not improve? What should they do if they get adverse effects? The national practice standards for pharmacy consultations These were developed to provide a framework of the key knowledge, skills and behaviours expected of a pharmacy professional when speaking with patients. They include core skills, such as active listening and applying appropriate questioning techniques in the consultation, as well as broader skills, such as considering a patient’s ideas, concerns and expectations of the consultation (ICE). As a pharmacy student and, later, as a pharmacist you are expected to work towards and demonstrate these standards. 39  TASK 16 Visit the website www.consultationskillsforpharmacy.com This website was created to help practising pharmacists improve their consultation skills and you will find a number of useful free resources there. Read some of these resources. You can also find the national practice standards which you should read through via this website: http://www.consultationskillsforpharmacy.com/docs/docc.pdf The Centre for Pharmacy Postgraduate Education (CPPE) also develop learning resources for pharmacists. You have access to a few of these as students via the British Pharmaceutical Students’ Association (BPSA) including one on consultation skills for pharmacy practice: https://www.bpsa.co.uk/cppe If you are not a BPSA member – why not? It is free and gets you access to resources like this to help you with your studies. We direct you to this CPPE resource on consultation skills later in your course, but you could start working on this now to support your learning in the CPS strand. Taking accurate and complete medical histories from patients You should already know the component sections of a medical history from the previous study pack. You may wish to refer back to the section of the previous study pack on interpreting medical notes to help you answer the following question: TASK 17 Briefly describe the component sections of a medical history in the space below: In hospital, the clerking healthcare practitioner will have undertaken a full history and examination of the patient on admission and documented this in the medical notes, however, to gain a better understanding of the patient and their history, and if there is missing data in the medical notes, pharmacists need to be able to take a history themselves. Pharmacist independent prescribers (in both 40 primary and secondary care) may undertake some of this role themselves to examine patients. More generally, pharmacists working in hospital, community or primary care may need to ask a patient questions about their medical history. It may not be necessary to complete a full history; however, we expect that you will practice taking a full history in the TBL sessions and on future placements so that you have this skill ready if you need it. You can also learn a lot about the medical conditions your placement patient has by asking about their medical history. To highlight the information collected as part of a medical history and how to approach questioning a patient, we will go through each of the sections found in a patient’s medical notes. Refer back to your study pack 1 resources if you cannot remember any of the acronyms used in the table below. Some of the below highlights information you would collect if completing a full medical history, other parts highlight what you might need to consider for future placements (or work as a pharmacist) to supplement what information you already have from a patient’s notes where another healthcare professional has already completed a clerking. DATA NOTES Personal You need to follow the advice given in later section in this pack about confirming the details patient’s identity. Remember to protect the patient’s confidentiality with anything that is documented. In terms of patient details, you only need to record what is asked for on your care plan for the purposes of your hospital placements. In practice, you may need to collect information on the patient’s name, age, gender, ethnicity, date of admission/first contact, but again, only if this is relevant to your job role in the patient’s care. PC Try to ask an open question here (even if you already know the PC from the medical notes). You could ask “what has brought you into hospital?” or “what has been troubling you recently?” You do not want to lead the patient into giving a particular answer and want the patient to give you a list of their main symptoms in their own words – try not to interrupt them or guide them too heavily. HPC Ask for further detail regarding the patient’s PC – remember this is the backstory of the PC. The patient may need further guidance with more directed questions for this. You want to find out things like:  Body location of PC  Severity  Aggravating/alleviating factors  Effects on normal activities  Chronology – when did it start, who noticed the symptom?  Has the patient tried any self-treatments?  Have they seen a healthcare professional about this problem previously?  Have they had any previous investigations?  Are there any other symptoms not mentioned in the PC? Often acronyms are used to help remember what information to gather e.g. SOCRATES for any pain the patient may mention. S = site O = onset (gradual/sudden) C = character 41  R = radiation A = associations (e.g. nausea/sweating) T = timing/duration E = exacerbating/alleviating factors S = severity (on a scale of 1 to 10, how painful is it?) Remember that not all of these questions are relevant for all PCs/diagnoses so make sure you only ask relevant questions. The acronym is only a suggestion. For example, if the patient presents with pain then asking about whether or not it radiates is relevant, if the PC is vomiting then it is not appropriate to ask about radiation. PMH Your patient may need some prompting in this section as they may have forgotten something from a long time ago, they may not think a condition is relevant or not current. Consider asking the following questions: “Have you been in hospital before?” “Have you had any operations?” You should start with some open questions so that you find out about all conditions, however, you may wish to ask closed questions about specific illnesses if they are relevant to the PC e.g. you may want to ask a patient admitted to the cardiac ward if they have/had any specific cardiovascular diseases. Remember to ask for approximate dates of diagnosis/surgery or the length of time the patient has had the condition. SH The SH can contain sensitive information or may seem to the patient like you are just prying so make sure you ask for this data tactfully. Concerning smoking, alcohol and recreational drugs, patients tend to underestimate their usage, it is also important to separate weekday, and weekend usage as this can differ. When asking about smoking status remember to find out how many cigarettes they smoke, how long they have smoked for, and if they are a previous smoker you still need to ask how many cigarettes they used to smoke, how long they smoked for and how long ago they stopped. When asking about alcohol intake remember that the patient may not know how many units they drink – you may need to ask them what type of alcohol they drink and the volume. You can also ask about the pattern of their drinking e.g. do they binge drink, drink little and often, only with meals etc. Be very cautious asking about illicit drug use. It is easy to offend a patient if you suggest that they use illicit drugs when they do not. If you discover that your patient does take illicit drugs then you need to ask them about which drug(s) they take, how many, how often, over how long and the pattern of usage. Consider how you will ask these questions sensitively. FH Again, you need to be sensitive asking about a patient’s family members as they may not understand the relevance and may think you are just prying. You could say something like: “In order for me to get a fuller picture I need to ask you some questions about your family’s health. Are you happy for me to do this?” Consider what is relevant to your patient, e.g. you might want to ask “Has anyone else had a similar problem?” [to the PC] 42 DH See the section on medicines reconciliation and taking a medication history from a patient for further details on what is required in this section. You tend to find that another healthcare professional will only collect basic drug information and will not record a complete history. It is therefore a role of a pharmacist (or the wider pharmacy team) to do additional work to ensure a complete and accurate drug history is obtained. ROS and In practice, pharmacists only perform a patient examination when they work in general specialist roles where patient examinations are relevant to their professional practice. physical Community pharmacists may perform certain examinations when a patient presents examination for advice e.g. they may examine a patient’s eye if they ask for advice for red/sore eyes. As more and more pharmacists become independent prescribers, the need for examination skills grows. It is therefore important that you understand the processes involved in this. What you might want to consider for your studies this year is if you need to ask the patient questions about the body systems to add details to the PC/HPC. You will not be expected to perform patient examinations until you have received further training on this. Results You would not expect the patient to be able to tell you all of the results from their latest blood tests; however, you might want to ask the patient if they have been for any tests/scans, or have been told they need any tests/scans, as they may know this information. Problem list, Again, you would not necessarily expect the patient to know exactly what the diagnosis diagnosis is or the treatment plan, however, you can ask the patient something like: and plan “Has anyone said what they think is wrong with you?” or “Do you know what treatment you have been/will be started on?” 43 Medicines Reconciliation Medicines reconciliation forms part of medicines optimisation (which is a topic you will cover in a later study pack). You should read the section of the medicines optimisation NICE guidelines that relates to medicines reconciliation: Medicines reconciliation Using the document in the link below, find out more about what sources of information can be used for medicines reconciliation. You will find plenty of other reputable resources to use for this (including individual trust guidelines which are published online) however, if you want to do any wider reading, or if you are struggling to understand some of the topics in this pack then this resource is very good and will have some answers for you: Medicines Reconciliation A Toolkit for Pharmacists Consider which of the possible sources of information you have found out about are likely to be most reliable, and which are likely to be less reliable? Make a list below of reliable and less reliable sources. Sources used for Medicines Reconciliation task: Reliable sources: Less reliable sources: 44 Part of the medical history involves drug history taking as seen in the medical notes table outlined above. Drug history forms a vital part of medicines reconciliation. However, medicines reconciliation is more involved than simply taking a medication history. Medicines reconciliation is the process of identifying an accurate list of the patient's current medicines and comparing them with the current list in use, recognising any discrepancies, and documenting any changes, thereby resulting in a complete list of medicines, accurately communicated. Medicines reconciliation should be performed at all transfers of care for a patient (e.g. from primary to secondary care and vice versa). The following information must be recorded for each medication a patient is taking prior to admission to hospital for an accurate drug history: Name Strength Form Dosage Frequency Route of administration Duration of administration (if known) Identifying the indication of the medication is also useful. This must also include non-prescription items such as herbal medicines, vitamins, over-the-counter medicines, nutritional supplements and recreational drugs (World Health Organisation. Assuring Medication Accuracy at Transitions in Care. Patient Safety Solutions 2007;1(solution 6)). This list of pre-admission medicines is used to ensure the patient is prescribed appropriate medications on the inpatient drug chart and influence any changes or additions to the patient’s medication regime. This information needs to be the most accurate and up to date information available. Do not forget that we also collate information on allergies and intolerances when asking about a drug history. Pharmacists may need to elicit information from a patient regarding their medical and drug histories for a variety of reasons including to perform a medication review or to influence what you are able to advise a patient to do safely or make a supply to a patient over the counter. You will learn more about these in later study packs in this strand and next academic year. Ensuring that medicines reconciliation is taken from each hospital inpatient is an important role for hospital pharmacists and pharmacy technicians. You may also need to gather information from patients on their medical history in order to assess whether or not the medications prescribed for the patient will be safe and effective and make decisions about the care of the patient. When you go on your year 3 hospital placements, you will need to take an accurate and complete medical and medication history from a patient and review other sources of information to complete medicines 45 reconciliation. We will also practice these skills in class and simulation this year as part of the CPS strand. Remember that the communication skills you learnt in the first year and have been developing within this study pack are crucial here. We will now focus on taking a medication history from a patient and how to go about this. Remember that this is just one part of medicines reconciliation. Consider how this relates to the Calgary-Cambridge model you have learnt about in the earlier part of this study pack. 46 Steps involved in taking a medication history We will now focus in on the steps involved in taking a medication history from a patient. You will notice how this links to the Calgary-Cambridge model. You need to be prepared to put this into practice in your CPS sessions, so read this information carefully to ensure you know what you need to do.  Confirm the identity of the patient. In any consultation, it is important to confirm you are speaking with the correct patient. It is not unusual for hospital inpatients to wander over to someone else’s bed space or for the wrong patient to come up to your community pharmacy counter when you call out their name. You should confirm the identity of the patient using their full name and one other piece of information e.g. their date of birth, address, hospital patient number or NHS number. It is important that you ask for details that you already have recorded so that you can check against your records. You also need to consider what a patient will or will not know off the top of their head e.g. a patient would be expected to know their own date of birth and address, however, most will not know their NHS or patient number unless they have it written down on a letter or something. These pieces of information are more routinely used when you are talking about a patient to another HCP and need to ensure you are discussing the correct patient. Remember that confirming the identity of the patient is not unique to this type of consultation. You practised doing this in dispensing classes last year when receiving in and giving out prescription medications. It is routine practice to confirm a patient’s identity when you have a prescription or some other form of record to check information against e.g. a PMR, their drug chart, notes.  Introduce yourself to the patient. Remember that the Pharmacy Order 2010 states that you must not pass yourself off as a pharmacist, so make it clear to patients you speak to on your placements or on work experience that you are a student whilst you are on your MPharm course. This is also important when you become a foundation year trainee. You are a student studying pharmacy. When you are qualified and working as a pharmacist you will need to introduce yourself as a pharmacist. In the hospital setting in particular, patients see many HCPs at different times during their stay and often find it confusing as to who they have spoken to so it is important that you make it clear who you are. When we are role-playing in class or in simulation where real patients / healthcare professionals are present, you can introduce yourself as a pharmacist if that is the role you have been asked to simulate. If in doubt, ask a member of staff what is appropriate. The key advice is that whilst on a placement you are very clear that you are a student. Remember the #hellomynameis campaign mentioned earlier in the study pack? Try to get into the habit of introducing yourself in this way. 47   Inform the patient of the purpose of the consultation. Informing the patient about the purpose of the consultation (and introducing yourself as in the point above) can help to put the patient at ease. As a qualified pharmacist, there are various reasons you may want to talk to a patient so it is important that you outline this from the start of the consultation.  Obtain consent. After explaining the purpose of the consultation you must ask if the patient gives consent to proceed. These two points go hand in hand – you cannot expect a patient to consent to a consultation if they have not been informed about what is involved. The patient must give informed consent and so you must inform them about what you want to talk to them about.  Begin to ask the patient about their drug history. It is important to ask questions in a logical order to gain a history; you do not forget to ask questions, you need to ensure you have all the information you require, and you need to ensure the patient is not confused by questions flipping between topics. As you are practising your skills, you may need to learn what works best for you. There is not necessarily a set order to ask things in; provided you are logical, it does not really matter. In sessions where we provide you with a sheet to complete (e.g. a care plan proforma as we gave you in some of the cycle 1 tAPPs, consider whether it is logical to follow the order of the template or if there is a better way of doing this. Some patients are very knowledgeable about their medications but many patients struggle to remember the names and doses of their medications. Consider starting with open questions to allow the patient to describe what they know about their medicines and then move to closed questions to clarify finer details using the funnelling and probing techniques outlined in the communication section of the study pack. As mentioned previously, to obtain an accurate drug history you need to find out the name, strength, dose, frequency, route, formulation, brand name (where appropriate) and the duration of treatment for each medication a patient is using. Remember to ask about prescribed medications, OTC drugs, herbal and alternative therapies, and recreational/illicit drug use. Also, do not forget that we said asking the patient if they know what the medication is taken for (the indication) can also be very useful. To prompt the patient you can ask them about the conditions in their PMH e.g. if a patient has told you they have hypertension but cannot remember any medicines they take, you could ask - “Do you take any medications for your high blood pressure?” This may help them to remember, or at least confirm that they take medication for this condition. Remember that this is leading them a little though and it is usually better to ask more open questions 48 initially and only use prompts like this if they patient is struggling, or you think they have missed something. Patients often forget about medications such as creams, inhalers, eye/ear/nose preparations, patches, once weekly or monthly medicines, yearly infusions, insulins, injections (possibly because they only think about oral dosage forms when asked about their medicines) therefore you may want to ask specific questions about whether or not the patient uses any of these types of medicines. Also, take the opportunity to ask about how the patient finds their medication regimen. Ask them if they have any problems with their medications, do they experience any side effects, do they manage to take them properly? This can highlight potential issues you need to tackle as the pharmacist if the patient has problems with their medications. It can also be great to help you learn about how medications affect patients, the main side effects of medications and how patients handle side effects. It is also important to ask how long the patient has been taking the medication and if they know what each medication is being used for. Ask the patient if they have any allergies and remember that if they do, you need to ask them about the nature of the allergy i.e. the reaction that occurred, the severity and when it occurred. All of these details can be important to determine if the reaction was a true allergy or an adverse drug reaction. You should record all information that patient provides; even if you think it is not a true allergy.  Close the consultation When you have finished obtaining the history from your patient, make sure you close the consultation well using the points identified in the first part of the study pack e.g. summarising the medications you have talked about. Consider where you are e.g. if you are at a patient’s hospital bedside, you will close and move away from them. If a patient has come to see you in a GP surgery or clinic, you may have to close and get up to show them out. The above is only a guide. Each patient and their history are different and there may be patient-specific communication barriers which mean that you cannot ask each patient the exact same questions. You need to be flexible and respond to the patient in front of you in order to obtain the information you require and keep the patient at ease. Every year we receive re