In this four-part series, the College focuses on each domain of the community pharmacist practice assessment while incorporating trends seen in practice by the College’s community practice advisors (CPAs). This final installment focuses on the Communication and Education domain. The previous domains examined in the past three issues can be viewed by visiting Practice Assessments Practice Tool on the website as well as in our archived Pharmacy Connection stories available on our website library or at pharmacyconnection.ca.
STANDARDS OF PRACTICE
Communication and Education are critical aspects to delivering optimal patient care and comprise one of the four domains evaluated during a pharmacist practice assessment. Good communication skills, both verbal and written, are essential for providing appropriate and comprehensive patient care.
Pharmacists must also be able to provide information and educate their patients to help them make informed decisions and receive the intended benefits of their medications or therapies. Engaging sound communication strategies enables pharmacists to gauge patient comprehension which is paramount to ensuring medication regimens are successfully implemented.
The use of open-ended questions during assessments with patients and/or their advocates is a useful technique shared by CPAs as it encourages dialogue and avoids the yes/no answers that hinder free-flowing conversation that can be crucial to the delivery of safe and quality patient care. Imparting information in a conversational tone, making eye contact and asking patients questions (such as what they know about the medication and what their doctor has told them about the medication) helps to foster effective care-focused dialogue between both the patient and the professional. Closing a consultation by inviting questions or asking the patient to repeat the information they found important are other communication tools commonly suggested by CPAs.
In the course of a consultation, it is the pharmacist’s role to instruct patients to take medication appropriately and also to confirm the medication is therapeutically appropriate. Taking time from a busy environment to communicate with patients is a mutually beneficial activity as engaging with patients at each encounter can create an opportunity for collaboration in the course of their care and ensure each medication is indicated and still effective such as in the case of refills.
Active listening by pharmacists is important as it ensures patient questions, needs and concerns are both understood and being addressed. A first step is being aware of a patient’s health conditions that require appropriate verbal and non-verbal adjustments such as situations in which a patient is hearing impaired. It is important that pharmacists recognize that patients may have various communication or comprehension barriers that may or may not be readily apparent and that these need to be accommodated.
CPAs encourage pharmacists to give their full attention to patients during counselling. Some suggestions include avoiding documenting as you speak in order to focus on non-verbal patient cues such as surprise and distress, taking the time to acknowledge and respond to the patient’s reaction with empathy. Professionals can also use relevant information to identify drug therapy problems and/or issues that have the potential to affect the optimization of health outcomes (patient issues, patient-specific needs) and to create, adjust or review the patient profile.
CPAs have emphasized the need for pharmacy staff to ensure patients receive counselling for prescriptions flagged specifically for patient follow-up. Counselling is not an option left to the discretion of the patient because pharmacists must acquire all required therapeutic information about the patient and the prescription in order to make a proper assessment. This is a part of the Standards of Practice.
Interaction within a pharmacy extends beyond the patient to encompass the pharmacy team and other healthcare professionals to ensure continuity of care. Communication can take the form of a phone call, written note, face-to-face conversation, sometimes through an agent or third party. Several options exist to ensure information is shared in an appropriate manner to each audience within scope. Each situation may necessitate a unique combination of communication tools to support effective and safe patient care.
The past three issues of the practice assessment series in Pharmacy Connection has featured the following patient scenario to reinforce learning:
The patient is a 59-year-old male who has filled his prescriptions at the pharmacy for about one year. His patient profile shows that his medical conditions are type 2 diabetes, dyslipidemia and osteoarthritis and he is also a smoker. He fills his medications mostly on time, doesn’t say much when picking up his medications and you haven’t noticed any changes on his prescriptions profile. He is currently on:
- Atorvastatin 10mg once daily
- Metformin 1000mg twice daily
- Gliclazide MR 30mg daily
- Venlafaxine 150mg once daily
The prescriptions were written six months ago, with a one year supply. There is nothing on file that indicates whether he is on any over-the-counter medications or natural health products. It is not likely that he will have any kind of follow-up until his refills run out.
In looking at this patient case, what decisions may be made during the course of the interaction?
Consider the following:
- What type of conversation would you engage in with this patient?
- What tools could you use to help guide this conversation?
- What special considerations would you be mindful of?
- What needs to be communicated to the patient and is any additional education needed?
Begin the conversation by asking him open-ended questions such as: How well are your medications working for you? Are you experiencing any side-effects? Have you recently had bloodwork? Did you get the results? Have you tried to quit smoking?
Use the IESU (Indicated, Effective, Safe, Use) tool to guide the conversation and engage in active listening. Watch for non-verbal cues to learn if the patient has misgivings about his course of treatment and if he has specific concerns. If the pharmacy is busy and you sense the patient is self-conscious about the conversation being overheard by others, continue the dialogue in a more private area.
Pharmacy professionals may also adopt a more interactive approach in this type of scenario. An example is to provide education to the patient but ensure it’s a conversation, not a monologue. Guide the dialogue to cover appropriate questions pertaining to reassessing, asking for changes, new information, etc. Ask about his use of over-the-counter medications and natural health products.
You may also consider providing a written communication to follow-up with the physician regarding a monitoring parameter for diabetes and perhaps the need for patient follow-up or communicating something new that was discovered in the course of conversation. When doing so, it’s important to ensure that the written communication is clear and concise, free of spelling/grammar issues and is generally relevant, professional and organized.
Wrap up the conversation to confirm the patient’s level of understanding through questioning that encourages further feedback to make sure the patient hasn’t misunderstood something previously or during this interaction. Before he leaves, ask the patient if he has any questions.
Finally, consider how you will document or communicate within the health-care team (including within the pharmacy team) to make sure that new information is noted to others to help ensure continuity within the pharmacy and the patient’s broader healthcare team.
How a pharmacist’s open-ended approach to patient counselling can help overcome assumptions related to the indication of a medication (in this case, metformin).
Using a one-sided monologue, the pharmacist:
- Begins counselling by telling a patient that he/she must have diabetes as metformin has been prescribed.
- Does not confirm this indication and continues with regular counselling for metformin without encouraging patient feedback.
- Does not make eye contact with the patient to confirm that he/she is listening or is confused/upset by the indication being discussed.
Using open-ended questions, the pharmacist:
- Begins by asking such questions as what did you see the doctor for today? and what has your doctor prescribed this medications for?
- Could have learned the medication is for an off-label use PCOS (polycystic ovarian syndrome) for young women on metformin.
- Could have learned the indication is for arthritic pain and the prescriber meant to give meloxicam. The electronic software used by the prescriber auto-populated the drug and directions on the prescription. The prescriber did not have an opportunity to check the prescription for accuracy before sending it to the pharmacy via fax.
RESOURCES RELATED TO PHARMACY COMMUNICATION AND EDUCATION
- Code of Ethics
- Code of Ethics Module: Principle of Respect for Persons/Justice
- Practice assessment criteria for pharmacists – Communication & Education
- Article – Close Up on Complaints: The Importance of Sensitivity and Communication (Fall 2015)
- Video – Optimizing Patient Care: Motivating Patients to Promote Adherence
- Chat, Check, Chart (Alberta College of Pharmacy)