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Learning objectives
- Understand the essential principles behind effective and meaningful consultations;
- Understand why implementing a consistent consultation approach in your pharmacy is needed and the benefits this has for patients;
- Appreciate how these principles and approach could be used in practice;
- Explain the differences between general sales list medicines, pharmacy — or ‘P’ — medicines and prescription-only medicines to patients.
Communication takes many forms, but typically involves the exchange of information. This information can be one way (e.g. a lecturer at university) but this is most often a two-way exchange in the pharmacy setting. These types of exchange involve more than words; listening, body language, tone of voice and even location are important factors.
Effective communication and consultation skills are essential in the delivery of care[1]
. Through structured but reactive consultations, pharmacists and their teams can involve patients in decisions about health and wellbeing.
Naturally, there is wide variation in practice across the sector and the subsequent inconsistencies in patient experience and expectations of community pharmacy varies[2]
.
This article outlines the principles behind effective and meaningful consultations, alongside a consistent approach that is achievable across community pharmacy. The latter ensures patients have clear expectations around what pharmacy can offer and aims to encourage patients to consider pharmacy as their first point of call for professional and reliable advice for the management of minor conditions, such as cold and flu.
Consistent consultation approach
First, it is important to consider where a consultation should occur. Pharmacists and their teams may need to use their professional judgement to decide when to offer a patient a private consultation, but the simplest method is to check the patient’s preference.
Once this has been decided, it is important to understand how to approach the consultation. In the UK, more than half of medical schools use the six-stage Calgary-Cambridge model in their communication skills programmes[3],[4],[5] but there are several other consultation approaches and models available, such as Neighbour[6] and Pendleton[7].
These approaches are based on consultations from a medical practitioner’s perspective. Although useful frameworks, these approaches need modification to fit the needs of community pharmacy teams. A five-stage consultation approach based on these models, suitable for use across the community pharmacy sector is outlined in this article, as well as more detail on what each stage involves and the principles behind good consultations. The next article in this supplement will outline how this approach can be applied to cold and flu consultations.
Stage 1: Initiate the consultation
How the member of the pharmacy team comes across when initially greeting a patient will create an immediate impression. A positive and professional image is essential — this does not mean a white lab coat, but ensuring that members of staff are neat and presentable.
It is important to note that the person in the consultation may not be the patient — they may be representing the patient (e.g. a parent, carer or partner). The approach outlined below is an example of speaking directly to the patient; therefore, the consultation will need to be appropriately adapted to suit whoever is attending the consultation.
The five steps in this first stage aim to establish rapport and identify the reason(s) for the patient presenting to the pharmacy.
Establishing rapport
1. Greet the patient, introduce yourself and clarify your role. For example: “Hello, my name is John, I’m the preregistration pharmacist, how can I help you today?”. This introduction may vary depending on the role (e.g. a busy counter assistant may not introduce themselves to each patient, whereas a pharmacist should typically identify themselves as a pharmacist).
2. Demonstrate interest and respect while understanding the patient’s physical comfort. For example: “I’m sorry to hear that. Would it be alright if I asked you a few quick questions to help me get an idea of how we can help?”. At this point it may be appropriate to direct them to a consultation room if there is a need for privacy.
Identify the reason(s) for presentation
3. Use appropriate questioning to identify the patient’s problems and issues that they would like advice or help with. For example: “Please tell me who this product is for?”; “Have you tried anything else so far?”; or “Are you on or have you recently started any medicines?”
4. Actively listen to what the patient is telling you and allow the patient to complete statements without interruption. Non-verbal cues can be used to show understanding (e.g. nodding, eye contact, and leaning forward) and brief verbal affirmations such as “I see”, “I know”, “Sure”, “Thank you”, or “I understand” can be used to help demonstrate concern and understanding[8].
5. Confirm what you have heard by repeating statements back to the patient. This may help clarify any ambiguities and you can ask or answer further questions if it helps clarify any misunderstandings.
Stage 2: Gather information
By asking the right questions you can further explore the patient’s problem or symptoms, understand their ideas, concerns and expectations, and acknowledge how the problem is affecting their quality of life.
Many pharmacy teams use the WWHAM (Who? What? How? Action? Medicines?) questioning approach to gather information[9], but patients may think the scripted nature of these questions feels more like an interview and potentially intrusive, especially if it takes place at the pharmacy counter. The TED and ICE principles are alternative methods that can be used to invite the patient to share information[10]
(see Box 1).
Box 1: TED and ICE principles
Pharmacy professionals should be able to use different questioning techniques during consultations to obtain the necessary information about the patient’s history to inform management decisions:
T — Can you TELL me why you have come to the pharmacy today?
E — Can you EXPLAIN who the medicine is for and what the problem is?
D — Can you DESCRIBE your symptoms to me and how long you have had these?
I — Do you have any IDEAS about what may have caused it?
C — Is there anything that is of particular CONCERN to you?
E — What were your EXPECTATIONS from your visit to the pharmacy?
Source: Centre for Pharmacy Postgraduate Education[10]
Exploration of problems
- Encourage the patient to describe their history, for example “When did the symptoms start?” and “Why did you come to the pharmacy today?”. Open and closed questioning techniques should be used throughout.
- Clarify any information the patient gives, check if anything seems unclear or if further information is needed (e.g. “Could you explain what you mean by…” or “you mentioned …, can you tell me a bit more about that?”).
- Regularly summarise to verify understanding of the problem and what the patient has said. Give the patient the opportunity to provide further information (e.g. “So what you are telling me is… Is that correct?” or “From what I understand you have been experiencing a blocked nose and dry cough for the past day which keeps you up at night. Is that correct?” or “Have I understood the problem?”).
Through questioning and the exploration of information, pharmacy staff should be able to establish the date and sequence of events and determine the patient’s beliefs, concerns, expectations and effects on their quality of life.
Stage 3: Shared decision making
Pharmacy teams should work together with patients to put them at the centre of decisions about their own treatment and care[11]
. This requires full exploration of the available pharmacological and non-pharmacological treatment options, along with their risks and benefits and a discussion of the choices available to the patient (see Box 2)[12]
. Once the patient is informed, they should be empowered to make decisions about their care, for example: “Now you have an idea of the treatment options available, what do you think would suit you best?”
It is important that members of the pharmacy team have appropriate training and feel empowered to share their own thinking (e.g. ideas, thought processes or dilemmas). This will help involve the patient when the pharmacist is not available and may help improve the consultation skills of other pharmacy staff.
Box 2: Explaining the differences between general sales list, pharmacy medicines and prescription-only medicines
Patients may not understand the differences between general sales list (GSL), pharmacy (P) medicines and prescription-only medicines (POMs) as potential options for the pharmacological management of their symptoms.
For example, a patient may have received a treatment on prescription that they cannot purchase or wonder why they need to come to the pharmacy to buy a certain product. Pharmacy teams should be able to provide a simple and clear explanation of the main differences, for example:
- GSL medicines are available from retail outlets and pharmacies;
- P medicines are medicines that can only be sold under supervision of a pharmacist and are available specifically from the pharmacy counter. These tend to be stronger medicines, contain unique ingredients or come in larger pack sizes;
- POMs are medicines that are subject to the restriction of a prescription written by an appropriate prescriber or made available in certain circumstances (e.g. patient group directions).
Source: Adapted from Royal Pharmaceutical Society[12]
Patients should be encouraged to contribute their own views and thoughts when determining a management plan. Once an agreement is reached about the next steps, address any additional concerns the patient may haveOnce an agreement is reached about the next steps, address any additional concerns the patient may have[13]
.
Stage 4: Patient education
Throughout this stage, pharmacy teams should provide patients with details regarding next steps for management, including public health and self-care information and using the pharmacy as the first point of call for minor conditions. There are specific messages that must be provided to patients during cold and flu consultations and conversations (see ‘Engaging patients with cold and flu: putting theory into practice’).
Pharmacy teams may move between stages 3 and 4 several times while outlining the options available in order to facilitate an informed and shared decision with the patient. Having explained the options available, the patient should feel empowered to decide what will work for them. Once product specific information is explained (e.g. dosage and how to administer) the patient should be able to take responsibility for the management of their symptoms.
Patient information leaflets are good tools to provide relevant management advice, including explaining the possible unexpected outcomes, what to do if the agreed plan is not working and when to seek help. It is important to check the patient is happy with their treatment plan; it may be advisable to ask them if there is anything they would like explained again or in more detail.
Manage the patient’s expectations around normal symptom duration and provide information about when they should return, seek advice from a GP or go to A&E. For example: “Come back to see us or another pharmacy if you do not feel better after three days of taking this product as directed” or “If your symptoms don’t clear after using the product for five days you should speak to your GP.”
Signposting to health information or patient leaflets may also be useful, but it should be remembered that not all patients are health literate – you may want to direct them to relevant charity websites that contain informative videos or podcasts.
Stage 5: Close consultation
It is important to confirm that the patient is happy with the agreed management and treatment plan. A positive way to summarise is by asking them how they are going to take the medicine. This should be followed by an explanation of when they should return to the pharmacy or set a time for follow-up. Useful tips and advice to support good consultations are included in Box 3.
Documenting and recording data on the numbers of consultations and the outcomes of interesting or particularly difficult or complex consultations (e.g. where additional intervention or referral may have been required) will allow community pharmacies to demonstrate the positive impact on patient care. This information can be used to support reflective practice and also annual performance reviews (see ‘Implementing a cold and flu training programme in the community pharmacy’).
Box 3: Tips for good consultations
- Smile and greet the patient, for example “Hi, how can I help you today” or “Hello, my name is … and I am [job role]. How may I help you?”
- Speak clearly and think about your tone of voice. For example, an upbeat cheery voice may not be appropriate if the patient is unhappy, whereas an impatient tone may put the patient off having a conversation;
- Ask questions. Use a mix of open and closed questions, consider the TED and ICE principles (see Box 1);
- Use concise language that is easy to understand and do not use jargon;
- Facilitate responses verbally and non verbally (e.g. provide encouragement, repeat, paraphrase and interpret the information being given);
- Look out for verbal and non-verbal cues (e.g. body language, speech, facial expression) and check and acknowledge these as appropriate (e.g. patient’s need to contribute information or ask questions, information overload or distress);
- Provide opportunities and encourage the patient to contribute (e.g. ask questions, seek clarification or express doubts and respond to these appropriately);
- Reflect the main points back to the patient so that they know that you are listening and have understood what they are telling you;
- Try and put yourself in the patient’s shoes to empathise with their situation and feelings (e.g. “I can imagine it, that must be difficult.”);
- Acknowledge and deal with sensitive subjects by saying “I can see this is difficult for you”; however, avoid saying “I know how you feel” because this may provoke a negative response from the patient. For more advice on demonstrating empathy and compassion, see learning article ‘How to demonstrate empathy and compassion in a pharmacy setting’ (Allison M & Chaar B. Pharm J 2019;302(7924):237–240);
- Do not rush the patient, but do encourage them to talk about relevant points;
- Do not judge the patient — even if you disagree with them, your personal views and opinions are not important.
Next steps
The next article in this learning campaign (see ‘Engaging patients with cold and flu: putting theory into practice’) will focus on how this approach and the principles described can be applied specifically to cold and flu consultations, including when patients present seeking advice about managing their symptoms or after self-selecting a product. It also highlights important public health messages to communicate to patients regarding infection control, the self-limiting nature of cold and flu, as well as self-care.
Citation:
The Pharmaceutical Journal, September 2019, online. doi: 10.1211/PJ.2019.20206990
References
[1] General Pharmaceutical Council. Standards for Pharmacy Professionals. 2017. Available at: https://www.pharmacyregulation.org/sites/default/files/standards_for_pharmacy_professionals_may_2017.pdf (accessed September 2019)
[2] Robinson J. Community pharmacy ‘must provide consistent care’ for cold and flu. Pharm J 2019;303(7929):S2–S4. doi: 10.1211/PJ.2019.20206798
[3] Kurtz SM, Silverman JD & Draper J. Teaching and Learning Communication Skills in Medicine. Oxford: Radcliffe Medical Press; 1998
[4] Silverman JD, Kurtz SM & Draper J. Skills for Communicating with Patients. Oxford: Radcliffe Medical Press; 1998
[5] Gillard S, Benson J & Silverman J. Teaching and assessment of explanation and planning in medical schools in the United Kingdom: cross sectional questionnaire survey. Med Teach 2009;31:328–331. doi: 10.1080/01421590801953018
[6] Neighbour R. The Inner Consultation. New York: Springer; 1987
[7] Pendleton D, Schofield T, Tate P & Havelock P. The Consultation: an approach to learning and teaching. Oxford: Oxford University Press; 1984
[8] Schilling D. 10 steps to effective listening. 2012. Available at: https://www.forbes.com/sites/womensmedia/2012/11/09/10-steps-to-effective-listening/#55f5fa9e3891 (accessed September 2019)
[9] Paul R. Community Pharmacy: symptoms, diagnosis and treatment. 4th edn. London: Churchill Livingstone; 2017
[10] Centre for Pharmacy Postgraduate Education. Consultation skills for pharmacy support staff. 2016. Available at: http://www.consultationskillsforpharmacy.com/docs/CounterCardsforweb.pdf (accessed September 2019)
[11] National Institute for Health and Care Excellence. Shared decision making. Available at: https://www.nice.org.uk/about/what-we-do/our-programmes/nice-guidance/nice-guidelines/shared-decision-making (accessed September 2019)
[12] Royal Pharmaceutical Society. 3.1 Classification of Medicines. In Medicines, Ethics and Practice. 43rd edn. London: Pharmaceutical Press; 2019
[13] GP-training.net. Calgary Cambridge guide to the medical interview — communication process. 2003. Available at: https://www.gp-training.net/training/communication_skills/calgary/guide.htm (accessed September 2019)
