Guide to undertaking person-centred inpatient (ward) outpatient (clinic) and dispensary-based pharmacy consultations

Abstract

WHO uses the internationally accepted term ‘person-centred care’, also usedby the Royal Pharmaceutical Society in the UK, to highlight the importance of considering that patients are people first; they have families, communities and are living with conditions for which they receive healthcare. The challenge that faces pharmacy professionals is embedding a person-centred approach to pharmacy practice. In a hospital setting, there are specific processes that must be completed to optimise safe, efficient and effective practice, however thesetend to be professionally focused. The coaching model, GROW, supports more person-centred conversations and has been used successfully in health in the National Health Service (NHS) in the UK . Inin pharmacy, practitioners were challenged with the task of integratingperson-centred consultation techniques as part of the pharmacy processes they were required to complete within their everyday activities. Therefore, a set of person-centred questions were developed, using concepts from GROW and the Four E’s, to create guides for practitioners to use within each of the pharmacy processes they commonly undertook. The guides were piloted with three pre-registration pharmacists and, following modification, were included in the skill development sessions described in a related publication in this issue ’A pilot study to evaluate knowledge of person-centred care (PCC), before and after a skill development programme, in a cohort of pre-registration pharmacists (PRPs) within a large London Hospital’. These guides are used by pharmacy staff in the author’s organisation to support a person-centred approach to pharmacy practice.

What this paper adds.

What is already known on this subject

• Person-centred care is not routinely practised in clinical consultations.

• Pharmacists have an opportunity to engage patients in optimising medicines-related care through person-centred consultations.

• Pharmacy professionals use structures and processes to undertake everyday activities.

What this study adds

• A coaching approach can be used to develop structures for person-centred pharmacy consultations.

• This can be incorporated into delivery of an in-house programme in two half-day sessions.

Introduction

WHO¹ uses the internationally accepted term ‘person-centred care’ to highlight the importance of considering that patients are people first; they have families, communities and are living with conditions, for which they receive healthcare. In the UK, person-centred care is the first standard of the General Pharmaceutical Council² standards for pharmacy professionals and the Royal Pharmaceutical Society³ have produced guidance on the delivery of person-centred care in pharmacy practice.

There is a challenge that faces pharmacy professionals in addressing methods of embedding a person-centred approach to pharmacy practice. In a hospital setting, there are specific processes that must be completed to optimise safe, efficient and effective practice. These include inpatient activity such as medicines reconciliation on admission, following the National Institute for Health and Care Excellence guidance,⁴ medication consultations aboutnew/high-risk medicines, consultations with patients prior to hospital discharge and outpatient activity such as dispensary and clinic consultations. While these processes are technically effective and robust, they are focused on the pharmacy professional asking patients questions in order to complete the specific activity. Therefore, there is an opportunity to develop a person-centred approach to these processes which encourage the patient to become a more active participant in their care.

The coaching model, GROW,⁵ supports person-centred conversations and has been used successfully in health in the National Health Service (NHS) in the UK.⁶ The Centre for Postgraduate Pharmacy Education (CPPE) promotes this approach and uses the Four E’s model to support person-centred consultations in pharmacy practice⁷ Pharmacy staff have been trained using this model through participation in generic health coaching courses and bespoke pharmacy courses.⁸ Local evaluation and personal reflections led the author (NB) to conclude that while the coaching modelare useful in changing the mindset of pharmacy professionals to a more person-centred view practitioners were challenged with the task of using coaching techniques and processes as part of their pharmacy everyday activities. This was particularly evident for less experienced staff who had a greater reliance on instruction in undertaking their daily activities.

Method

A set of person-centred questions were created, using concepts from GROW and the Four E’s, to create guides for practitioners to use within each of the common pharmacy processes that were undertaken daily. The guides used concepts from goal setting to help the practitioner focus the patient on what they wanted to know about their medicines.

This reduced the chance of patients diverting the conversation onto other topics, as they chose to speak about what was important to them about in the first instance.

The guides were piloted with three pre-registration pharmacists and, following modification, were included in the skill development sessions described in a related publication in this issue ’A pilot study to evaluate knowledge of person-centered care (PCC), before and after a skill development programme, in a cohort of pre-registration pharmacists (PRPs) within a large London Hospital’.⁹

Results

Four guides were produced , shown in the boxes below. Additional explanations for the reader are given in italics.

General instruction: For all ward-based consultations (boxes 1–3).

• Introduce yourself to the patient and explain the reason for visit (talking about medicines).

• Ask if it is convenient to speak to the patient:

  • If convenient, place a chair next to the patient and sit down. If the patient is not in a single room, offer to draw curtain for privacy.
  • If not convenient to speak, arrange an alternative time to see the patient

Box 1. Medicines reconciliation (clinic or ward).

1. Explain to the patient that you are visiting them in order to confirm their medication history (the medicines they were taking before they were admitted to hospital) and add a question, in your own words, such as

   • ‘Before I ask you about your medicines, what would you like to ask me about your medicines?’

   • If the patient has something they want to discuss, answer their question.

   • If not, continue to question 2.

2. Explain to the patient that you need to ensure the medication on the list you have aligns with the medication they were taking before admission to hospital (excluding any new medicines prescribed in hospital). Then add a question, in your own words, such as

   • ‘How would it be easiest for you to go through the medicines you took before you came into hospital?’

   • If they don’t know or don’t give an answer, you can suggest some options (preferably three options) such as

     • ‘Would it be helpful to review the current list from the medication chart?’

     • “Would you prefer to tell me what medicines you were taking before you came into hospital/is there someone else who will know?’

     • ‘Shall we look at the containers of the medicines together so you can explain how you use or take the medicines?’

   • This maintains choice and control of the conversation with the patient.

3. If you identify a difference between what the patient was taking before admission and the current list, show the patient that you are curious about the difference (not judgemental because they ‘aren’t taking something as it is prescribed’). In your own words, you might wish to say

   • ‘I notice that there is a difference between the list I have and what you were taking before you came into hospital. Please tell me more about that (medicine).’

   • It is important to avoid asking a question that begins with ‘why’ as this can appear judgemental or critical of their medicines taking, when you are trying to build rapport with your patient and reduce the barriers between health professional (in control of the medicines) and patient.

4. Once you have confirmed the medication list, offer the patient an opportunity to ask you questions again, for example,

   • ‘Is there anything else you would like to ask me about your medicines?’

   • Remember the first question about what they want to know is open (‘what would you like to ask …') and the last one is closed (‘is there anything else …')

5. Let the patient know how you or a colleague can be contacted for further questions.

Box 2. High-risk* medicines consultation (clinic or ward).

1. Explain to the patient that you would like to discuss using and taking their (new) medicine(s) safely and effectively. For example, you might wish to say

   • ‘The medicines I want to talk about is (name of medicine)but before I tell you about this medicine, what would you like to ask me about this/your medicines?’

   • If the patient has something they want to discuss, answer their question.

   • If not, continue to question 2.

2. Explain that you have some important information you want to share with them about the specific medicine (especially if this is a ‘high-risk medicine’ consultation). Then add a question, in your own words, such as

   • ‘In order to make sure I give you the information that you need to know, please tell me what you already know/have been told about this medicine.’

     • If the patient tells you that they have already read the leaflet/know about the medicine, acknowledge this, then ask the patient if they would prefer to tell you the main points that they have understood from the leaflet/information or whether they would like you to summarise key points for them. This maintains choice and control of the conversation with the patient.

     • If the patient tells you that they don’t know/haven’t been told anything, add a question, in your own words, such as

   • ’I have some important information about this medicine which I would like to share with you, are you happy for me to discuss this with you now?’

     • If not, suggest options (three) such as

       • ‘Would you prefer to go through a short summary of key points with me?’
       • ‘Would you like a leaflet/information about a website on this medicine to take home?’
       • ‘Perhaps we can look at the leaflet together?’

   • The reason for this is that if the patient chooses a method of receiving the information they are more likely to take notice of it and retain it.

3. Once you have completed the discussion, offer the patient an opportunity to ask you questions again, for example,

   • ‘Is there anything else you would like to ask me about your medicine (s)?'

   • Remember the first question about what they want to know is open (what would you like to ask) and the last one is closed (is there anything …)

4. Complete the consultation as follows:

   1. Advise the patient about the information leaflets inside the medicine containers and any additional leaflets.

   2. Remind them of instructions on the labels.

   3. If available, show them the patient information helpline number on the leaflet and encourage them to call if they have any questions.

   4. If applicable, tell the patient how to contact you or colleagues for further information.

Box 3. Discharge consultation (ward).

1. Explain to the patient that you would like to talk to them about the medicines they are being given to take home, including any medicine stopped, changed or added. For example, you might wish to say:

   • ’I would like to talk to you about the medicines you are being given to take home. Would you like me to go through this with you now?’

2. If yes, continue to question 3.

   • If the patient does not want you to talk them about their medicines, you can offer them an alternative time to return (if possible) and/or complete the consultation as follows:

     • Advise the patient about the information leaflets inside the medicine containers and any additional leaflets.

     • Remind them of instructions on the labels.

     • If available, show them the patient information helpline number on the leaflet and encourage them to call if they have any questions.

     • If applicable, tell the patient how to contact you or colleagues for further information then end the consultation.

3. Before explaining the medication prescribed, add a question, in your own words, such as

   • ‘Before I tell you about your medicines, what would you like to ask me about your medicines?’

   • If the patient has something they want to discuss, answer their question.

   • If not, continue to question 4.

4. Find out what the patient already knows about their existing and new medicines:

   • ’I’d like to go through your medicines with you now, but first, please tell me what you already know about the medicines you have been prescribed?'

   • This shows that you appreciate they may have knowledge of the medicines and prevents you repeating information they already know, making your consultation more tailored to their needs.

   • Then add, for the remaining medicines, a question such as

   • ’I’d like to go through your new and stopped medicines and any changes now, which medicine would you like to discuss first?’

5. When you have completed discussing all relevant medicines, offer the patient an opportunity to ask you questions again, for example,

   • ‘Is there anything else you would like to ask me about your medicines?’

   • Remember the first question about what they want to know is open (what would you like to ask) and the last one is closed (is there anything …)

6. Complete the consultation as follows:

   1. Advise the patient about the information leaflets inside the medicine containers and any addition leaflets.

   2. Remind them of instructions on the box.

   3. If available, show them the patient information helpline number on the leaflet and encourage them to call if they have any questions.

   4. If applicable, tell the patient how to contact you or colleagues for further information.

Dispensary consultation.

1. Go through your local dispensing safety checklist, which may include patient name, address, whether the medicine is for the patient and if they have had it before.

2. Before explaining the medication prescribed, add a question, in your own words, such as

   • ‘Before I tell you about your medicines, what would you like to ask me about your medicines?’

   • if nothing, go to 3. If something raised, address it using Four E’s.¹⁰

     1. Explore what the patient already knows, what worries them about their medicines, how they think medicines help them.

     2. Educate according to what the patient already knows, including relevant safety information.

     3. Empower by asking what the patients wants to do now they have more information about the medicines.

     4. Enable by asking the patient specific questions, such as when and how they will take the medicine, how they will remember it and how they will monitor effect/their adherence. Then

3. Offer to go through the medicines with the patient, for example ,’Would you like me to go through this with you now?’

   • If yes, then ask question such as

     1. ’What, if anything, would you specifically like to know about your medicines?’ Then address this

     2. When you have completed this part of the conversation, ask,  ‘Is there anything else you’d like to know?’ and respond appropriately

   • If not,

     1. Give the patient the information you wish to tell them, highlighting warnings, safe method of use, storage, additional supplies, etc.

4. Complete the consultation as follows:

   1. Advise the patient about the information leaflets inside the medicine containers and any additional leaflets.

   2. Remind them of instructions on the labels.

   3. If available, show them the patient information helpline number on the leaflet and encourage them to call if they have any questions.

   4. d. If applicable, tell the patient how to contact you or colleagues for further information.

Discussion

These guides are now used by pharmacy staff in the author’s organisation to support a person-centred approach to pharmacy practice. The author seeks to learn how others could use these guides in their practice and welcomes feedback from readers.