Patient Centred Counselling

Question 1

What are the goals of patient-centred care?

Answer 1

• Understand the illness experience of the patient
• Build a therapeutic alliance with patients to meet mutually understood goals
• Understand each patient’s experience is unique
• Develop selfawareness of personal effect on patients
• Foster an egalitarian relationship with the patient i.e. patient is a member of the health care tea

Question 2

What are the benefits of patient centred care?

Answer 2

• Positive outcomes in chronic health problems (increased health literacy of patients)
• Increased patient satisfaction, QOL, engagement (more adherent)
• Reduced patient anxiety (more knowledge and info about their conidtion and how it is treated)
• Improved personal satisfaction
• Improved business outcome = increased market share

Question 3

What are the 8 dimensions of PCC?

Answer 3

• Patients’ Preferences
• Emotional Support
• Physical Comfort
• Information and Education
• Continuity and Transition
• Coordination of care
• Access to Care
• Family and Friends

Question 4

What are the FIVE key principles of PCC?

Answer 4

1. bio-psycho-social perspective: broadening the focus of the pharmacist-patient interaction to include psychological and social factors as well as physical symptoms
2. patient as a person: exploring the meaning of illness and health to each individual patient
3. sharing power and responsibility: including the patient in decision making and considering them to be an expert in their own health
4. therapeutic alliance: valuing the relationship between pharmacist and patient as a means of promoting health
5. pharmacist as a person: pharmacists are not interchangeable, the particular qualities, attitudes and values of the doctor are important and will suit one patient better than another

Question 5

What are some barriers to PCC in pharmacy?

Answer 5

• Staff or clients with poor communication & cognitive skills
• Workforce issues –> not enough staff/trained staff
• Time constraints (note: Shared decision-making takes on average only an additional 10% of the entire duration, i.e., 2 min for a 20 min consult) „
• Remuneration models „
• Lack of private consulting areas „
• Poor implementation and change management strategies –> lack of senior leadership
• Variable support from GPs and pharmacy owners „
• Constraining nature of institutions, including physically or spiritually impoverished environments of care

Question 6

What are some methods to overcoming barriers to PCC?

Answer 6

Shift in mind set

Practice and experience

Train staff & lead by example

Life-long learning

Rethink organisation

Environment

Question 7

What are the two aspects of patient centred communication?

Answer 7

The consultation process

• shared problem defining
• shared-decision making

Patient-pharmacist therapeutic relationship

• trust
• context and time
• therapeutic alliance
• empathy
• biopsychosocial perspective

–> has to be built

Question 8

What is an example of a patient centred interview?

Answer 8

• Pharmacist tries to enter the patient’s world and tries to get a holistic picture of the patient „
• should begin with a patient-led storytelling process in which the patient selects the headlines and details of the story told „
• includes information from all the levels of the biopsychosocial model: physical level, psychological-individual level, and familycommunity level „
• Begins with open-ended questions „
• pharmacist may have to interrupt to clarify what patient has said (not too early during the interview) „
• Pharmacist explicitly introduces the summary and invites the patient’s comment, not just medical but also social and emotional issues are included

Question 9

What THREE factors need to be considered for the patient in PCC?

Answer 9

Biopsychosocial perspective „

• Understanding the patient within his or her unique psychosocial context „

Health Promotion „

• Consider other problems, including continuing problems and risk factors „

Patient as a person „

• Understanding the whole person „
• Holism

Question 10

What THREE factors need to be considered for the pharmacist in PCC?

Answer 10

Required skills

• Picks up the patient’s cues „
• Uses communication skills effectively – verbal and non-verbal

Empathy „

• Facilitate patients’ expressions of feeling „
• Emotionally responsive communication
• Nonverbal behaviour

Pharmacist as a person „

• Taking care of yourself „
• Leave from consultation: time for reflection „
• Building a relationship - requires an awareness that pharmacist’s own ideas, feelings, and values influence the relationship

Question 11

What three factors need to be considered for building a therapeutic relationship for PCC?

Answer 11

Building a relationship

• Connecting; achieving a working rapport with the patient; getting on the same wavelength
• Requires an awareness that ideas, feelings, and values of both the patient and the pharmacist influence the relationship

Therapeutic alliance

• Fostering healing relationships

Trust

• Confidence „
• Managing uncertainty

Context and time

• ‘‘Being realistic’’ about personal limitations and issues such as the availability of time and resources

Question 12

For consultation, what happens in the

A) beginning

B) middle

C) ending

Answer 12

A)

patient centred skills

B)

pharmacist centred skills

C)

patient centred skills

Question 13

What is shared problem defining in consultation? What does the process include?

Answer 13

Process of exploring and understanding the patient’s view

Outcome = shared understanding and agreement of the pharmacist and patient on the problem(s)

process includes

• Involving patient
• Exploring patient’s perspective
• Pharmacist considers the patient’s situation and shares their expert opinion

Question 14

for shared problem defining, how to involve the patient?

Answer 14

At the start of the consultation –> the pharmacist

Greets patient and introduces themselves

Gathers information with actively listening using nonverbal and verbal techniques „

Allows patients to express their expectations of the visit, their problem(s) and concerns „

Watch for patient cues „

Lets the patient talk „

Partnership building - active enlistment of patient input „ Invest in the beginning (Habit 1 of the Four Habits model)

Question 15

patient’s story may be ambiguous, vague or include jargon. What comments can pharmacist use to calrify/interrupt?

Answer 15

‘‘I’m not clear about that – tell me again’’

or ‘‘Let me see if I have understood you correctly …’’

or ‘‘Let me check to see if I understand what you have told me so far.’’

or “sounds like ….have I got that right?

Question 16

For shared problem defining, how to explore and understand the patient’s perspective?

Answer 16

• Elicit patient’s perspective of their illness and beliefs
• Exploring both the disease and the illness experience and impact on life & functioning
• Prior to the consultation: what did patient expect? Not expect?
• Explore anxieties, major concerns
• Any goals for treatment/health status?
• Summarising; obtaining a sufficiently comprehensive idea of the patient’s perspective, needs, values
• Patient language
• Demonstrate empathy (Habit 3)

Question 17

What are some ideas for how to encourage sharing of ideas and feelings?

Answer 17

Check the environment – privacy, tissues, seating

• Begin with open-ended questions such as

> ‘‘What can I do for you today?’’ – may lead to a task orientated response

> How are you today? –> start with this

> ‘‘Can you tell me more – whatever you feel is important?’’

> ‘‘What do you think might be causing your problem or illness?’’

Try to reflect back what they said and paraphrase

> so you feel

> sounds like you are

look for cues esp non verbal

Question 18

What are some ideas for how to respond to feelings?

Answer 18

‘‘This must be very hard for you. Now I understand your situation better.’’

‘‘I want to help you in any way I can. Please, let me know what you expect me to do to help.’’

“Thanks for letting me know how you’ve been going. This information will help me know how I can support you/ or what treatment options we can look at together/ or what information I can give you.”

LIMITED self-disclosure is appropriate and supportive (but do not make it about you or someone else)

• ‘‘When (…close friend or family member) had symptoms like yours some years ago, she and I felt upset like you do now.’’
• ‘‘oh this must be a difficult time. I have seen similar kinds of issues in other patients. I hope you know we are here to help you.’’

Question 19

For shared problem defining, how to consider the patient’s situation? How to invest in the end?

Answer 19

Shared problem defining may enhance the role of pharmacists: their expert knowledge may add to the patient’s perspective

> Pharmacist may identify benefits of medication or possible drug related problems the patient is not aware of

Invest in the end

• give clear explanations „
• test for comprehension „
• encourage questions „
• use patient’s frame of reference „
• allow time for patient to absorb information „
• encourage the patient to respond to the information given –> what do you think about this new information

Question 20

for consultation, what does shared decision-making involve?

Answer 20

• pharmacist encourages the patient to actively participate and thus share the power and responsibility
• Interaction: negotiation on what to do
• Involving patients in choices to the degree that they wish (they may not want to be involved)

Question 21

How to inform the patient for shared decision-making?

Answer 21

• Patients need to be well informed to be able to make an informed decision about treatment of their illness
• Both pharmacist and patient share information with each other
• use language the patient can understand
• check for comprehension
• check patients’ information needs
• encourage questions

Question 22

How to consider options and preferences for shared decision-making?

Answer 22

Advises the patient about possible treatment options „

The patient may have specific requests „

Patient may experience (practical) barriers – explore „

Involve patients in developing a treatment plan „

Consideration of the patient’s ambivalence or self-efficacy

Question 23

How to choose management plan for shared decision-making? What three aspects does reaching an agreement include?

Answer 23

Patient and pharmacist should reach an agreement on a management plan, which is concordant with the values of the patient

• Action Planning: discuss the practicality of the plan, the follow up and plan for the unexpected
• Enable self-management: Pharmacist enables and encourages the patient to take responsibility for the self-management of the disease
• Agreement check: Pharmacist summarises the agreements and ask for feedback, in order to check agreement

Question 24

What should pharmacist do in patient-centred communication?

Answer 24

• Encouraged the conversation by reflecting what patient had said and then asking open-ended questions to elicit more information
• Reacted to patient cues – sighing, no eye contact, abrupt response – patient was unsure or ambivalent about taking meds, was surprised by diagnosis
• Let patient decide what information and knowledge to share
• Elicited patient’s own expectations, views of the symptoms, concerns, fears and other feelings
• Elicited other physical and biopsychosocial information – FIFO worker, conflict in marriage, has friend with depression, has sore neck and shoulders, initial complaint was insomnia
• Invested in the beginning, encouraged a therapeutic relationship
• Involved the patient in the treatment plan

Question 25

What is the traditional way a pharmacist does medication-centred communication?

Answer 25

• Pharmacist lead the conversation with closed-ended questions (basic training in WWHAMMA)
• Ignored patient cues – sighing, no eye contact, abrupt response
• Pharmacist makes decisions about what information and knowledge is necessary and important
• Patient’s own expectations, views of the symptoms, concerns, fears and other feelings are not elicited
• Pharmacist has accepted without checking that the patient’s only reason for coming to the pharmacy is to just pick up prescription
• Has not invested in the beginning, in creating a therapeutic relationship