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GUIDELINES TO THE

MEDICATION-RELATED CONSULTATION FRAMEWORK

Abdel Tawab,R.; James, D.; Davies, J.G.; Horne, R.

School of Pharmacy & Biomolecular Sciences

Cockcroft Building

Lewes Road

Brighton

BN2 4GJ

United Kingdom

r.abdel-tawab@brighton.ac.uk

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Table of Contents

Table of Contents .......................................................................................................................... 2

Introduction.................................................................................................................................... 3

General purpose of the medication-related consultation framework ............................................ 3

What is a Medication-Related Consultation? ................................................................................ 4

Context or setting of medication-related consultations ................................................................. 4

Who is the framework for? ............................................................................................................ 4

General features of the framework ............................................................................................... 4

Basic framework structure ............................................................................................................. 7

Rating Scales for Evaluation ......................................................................................................... 8

Detailed description of competencies ......................................................................................... 10

A. Introduction ........................................................................................................................ 10

B. Data Collection And Problem Identification........................................................................ 14

C. Actions & Solutions ............................................................................................................ 20

D. Closing The Consultation ................................................................................................... 23

E. Consultation Behaviours .................................................................................................... 24

Appendix 1 Medication-Related Consultation Framework .......................................................... 29

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Introduction

The purpose of this document is to provide guidance on the use of the medication-related

consultation framework. The framework is designed to teach and evaluate the consultation skills

and behaviours of practitioners involved in medication-related consultations.

The framework is based on the concept of competency, meaning that a combination of

knowledge, skills and attitudes when applied to a particular consultation will lead to a given

pharmaceutical care outcome.

General purpose of the medication-related consultation framework

The framework provides a basic set of consultation competencies applicable to a range of

medication-related consultations. The competencies are evidence based and are considered to

be fundamental for an effective medication-related consultation between a patient and a health-

care practitioner. It is not designed to address all possible consultation and communication

problems that a practitioner might encounter in everyday practice (e.g. anger management,

bereavement counselling) as it is specifically aimed at addressing pharmaceutical issues.

The frameworks objectives are:

To provide a clear structure to the process of consulting with patients;

To provide the learner with a sense of purpose for learning consultation skills;

To allow the systematic observation and evaluation of practitioners consultation skills;

To allow the observer to provide systematic feedback to the practitioner;

To provide a basic structure for teaching programmes in focusing attention on specific

consultation strategies and skills.

These competencies are defined as observable, identifiable consultation skills and

behaviours. The tasks are set out in a logical sequence, providing a structure to the

consultation, but this is not necessarily the order in which they will be tackled in each

consultation. The framework should therefore be seen as flexible and not as a script.

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What is a Medication-Related Consultation?

A medication-related consultation is understood to be a face-to-face interaction between a

health-care practitioner and a patient undertaking a therapeutic review. The purpose of such a

consultation is to review a patients medication related issues in order to identify potential or

actual drug related problems, and to develop, with the patient, a plan for their resolution. The

emphasis lies on patient-centeredness, meaning that the practitioner works with the patient as a

co-worker.

Context or setting of medication-related consultations

The competencies included in the framework can be flexibly used in different contexts where

practitioners are conducting therapeutic reviews. This applies to settings ranging from

community pharmacy, specific disease clinics in primary care, hospital settings.

Who is the framework for?

The framework is designed to support the practice of both students and practitioners alike,

involved in medication-related consultations and who wish to improve their consultation skills. It

servers as a tool to identify the Continuing Professional Development (CPD) needs of

practitioners in relation to the consultation process.

General features of the framework

The framework is divided into five distinct sections, with the first four (A to D) focusing on the

content of the consultation (i.e. what should be covered). The final section (E) focuses on the

consultation behaviours which underpin the consultation process (i.e. how the practitioner

progresses through the consultation). A summary of the main framework sections and the

overall aims are illustrated in the Table 1 below.

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Table 1 Summary of framework sections

Section Aim
(A) Introduction Building a therapeutic relationship
(B) Data collection & Problem Identification Identifying the pharmaceutical needs
(C) Actions & Solutions Establishing an acceptable management plan
(D) Closing Negotiating safety netting strategies

(E) Consultation behaviours Note: section E is different to the other sections in that it
includes consultation behaviours that should be applied by
the practitioner throughout the entire consultation, as
opposed to consultation activities that are specific to a
particular section.

The consultation process consists of the following:

(1) An introduction phase, whereby the practitioner engages with the patient; (2) a data

gathering phase, whereby relevant information is obtained from the patient followed by an

identification of a patients pharmaceutical care needs; (3) a discussion on how to prevent or

resolve the problems identified and to negotiate shared management strategies; and finally (4) a

closing phase whereby the practitioner (i) determines whether the patient needs additional

information, (ii) discusses contingency plans in case something goes wrong and (iii) negotiates

follow-up plans. A summary of the competencies included in the framework is provided in Table

2.

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Table 2 A Summary of the Medication-Related Consultation Framework Sections & Corresponding Competencies

B. DATA COLLECTION & D. CLOSING THE E. CONSULTATION


A. INTRODUCTION C. ACTIONS & SOLUTIONS
PROBLEM IDENTIFICATION CONSULTATION BEHAVIOURS
A1. Introduces self to patient B1. Documents full medication history C1. Relates information to patients illness & D1. Explains what to do if patient has E1. Listens actively & allows patient to
A2. Confirms patients identity B2. Assesses patients understanding of the treatment beliefs difficulties to follow plan and whom complete statements without
rationale for prescribed treatment C2. Involves patient in designing a to contact interruption
A3. Discusses purpose and structure
of the consultation B3. Elicits patients (lay) understanding of management plan for identified D2. Provides further appointment or E2. Asks relevant questions
his/her illness problem(s) contact point E3. Uses open & closed questions
A4. Invites patient to discuss
medication and/or health related B4. Elicits concerns about treatment C3. Gives advice on how & when to take D3. Offers opportunity to ask further appropriately
issues medication, length of treatment & questions with regard to issues E4. Avoids or explains jargon
B5. Explores social history negotiates follow up (if necessary) discussed in the consultation
A5. Negotiates shared agenda Illness management E5. Accepts patient
C4. Checks patients ability to follow plan
A6. Pays attention to comfort and B6. Explores patients experience/ control of E6. Demonstrates empathy with and
privacy C5. Checks patients understanding supports patient
symptoms
C6. Discusses lifestyle issues/ prevention E7. Deals sensitively with
B7. Asks how patient monitors the illness strategies embarrassing & disturbing topics
B8. Undertakes appropriate physical C7. Determines whether patient wants
assessment (when indicated) E8. Shares thinking with the patient
additional information/ explanation (when appropriate) to encourage
Adherence assessment C8. Refers appropriately to other healthcare patients involvement (if wanted)
B9. Asks how often patient misses dose(s) of professional(s) E9. Uses information from test results
treatment to inform decision making and to
B10. Identifies reasons for missed dose(s) explain treatment option(s)
B11. Explores patients attitudes towards taking E10. Uses evidence based medicine-
medication type information to inform decision
Exploring patients wish for involvement making and to explain treatment
option(s)
B12. Asks how much/ what information patient
wants before discussing solutions to E11. Adopts a structured & logical
patients needs approach to the consultation
B13. Asks how involved patient wants to be in E12. Keeps interview on track or
decision making regains control when necessary
Problem identification E13. Manages time effectively (works
well within the time available)
B14. Identifies and prioritises patients
pharmaceutical problems E14. Provides logical and correct
documentation
B15. Re-negotiates agenda (if necessary)

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Basic framework structure

An example of the basic structure of the framework is provided in Figure 1. This describes the

heading of the framework section, the competencies included under the heading and the

different rating scales that are available for evaluation and assessment purposes.

Figure 1 Basic structure of the medication-related consultation framework

Framework Specific Individual Qualitative


section competencies Ratings comments

Did the practitioner undertake the following activities? 1 = not at all, 2 = touched upon; 3 = adequate; 4 = very good; N/a = not applicable
A. INTRODUCTION 1 2 3 4 N/a STRENGTHS
A1. Introduces self to patient

A2. Confirms patients identity (e.g. name plus address or


date of birth)

A3. Discusses purpose and structure of the consultation


(i.e. shares pharmacists agenda with the patient)

A4. Invites patient to discuss medication and/or health


related issues (explores patients agenda) WEAKNESSES

A5. Negotiates shared agenda (prioritising issues to be


discussed considering pharmacists objectives &
patients needs)

A6. Pays attention to comfort and privacy

0 1 2 3 4
GLOBAL RATING: The practitioner was not able The practitioner was partially The practitioner was fully able
to build a therapeutic able to build a therapeutic to build a therapeutic
relationship with the patient relationship with the patient relationship with the patient

Global rating for individual


framework sections

Final rating of entire consultation

Overall the practitioners ability to Poor Borderline Satisfactory Good Very good
consult was:

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Rating Scales for Evaluation

Three different rating scales are included in the framework.

(1) Individual rating scales

The assessment of individual competencies is on a 4 point scale ranging from not at all,

touched upon, adequate, and very good (Table 3). Some competencies may not be

relevant in every type of consultation and can therefore be marked as not applicable (n/a).

Table 3 Assessment ratings for individual competencies

1= Not at all No signs of competency

2= Touched upon Shows signs of meeting competency

3= Adequate Demonstrates good & acceptable performance of


competency

4= Very good Demonstrates exceptionally good performance of this


competency

(2) Global ratings for each framework section

Global rating scales are included at the end of the individual framework sections A to D.

These ratings are intended to assess whether the overall aim of each individual framework

section was achieved. This is measured on a 5 point scale with the middle and extreme points

anchored by explicit descriptors; and ranges from fully, partially, not achieved.

(3) Final overall rating scale

This allows for a final reflective assessment of the entire consultation and the assessment is

on a 5 point scale ranging from poor, borderline, satisfactory, good and very good

Space for comments

In addition to above rating scales a comment box is provided that gives the evaluator the

option to provide the learner with more specific feedback about his/her strengths and

weaknesses and/or to clarify ratings given.

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The following is a guide of how to assess an individuals consultation skills against the three

rating scales provided (Figure1; filled in example of section (A) Introduction).

The individual rating scale gives the evaluator the opportunity to assess each individual

competency (A1 A6) on a 4-point scale. In the example provided the practitioner showed an

adequate competence of introducing him/ herself (A1) and confirming the patients identity

(A2), was very good in discussing the purpose and structure of the consultation (A3), but had

only shown signs (i.e. 2 = touched upon) to invite the patient to discuss his/ her health

related issues (A4) and to negotiate a shared agenda (A5). Since this specific consultation did

not require the practitioner to pay attention to comfort and privacy (A6) this competency was

rated as not applicable (n.a.). The evaluator may find it helpful to make notes in the

additional comment boxes in terms of specific strengths and weaknesses.

The global rating scale for each individual framework section gives the evaluator the

opportunity to provide a score for the entire framework section, reflecting on the individual

ratings of each competency in the particular section. In the example (Figure 1), the evaluator

concluded by reflecting on the performance shown on each individual competency of the

introduction that the practitioner was partially able to build a therapeutic relationship with the

patient.

Finally, to provide a final rating score for the entire consultation the evaluator needs to

consider and reflect upon the global rating score for each section. When selecting a

category, he/she should attempt to consider the overall performance in the context of

achieving the desired patient outcome. In doing so, the consultation skills of the practitioner

assessed in the example were considered to be satisfactory as indicated by the final rating

of his/her entire consultation.

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Detailed description of competencies

A description of each competency included in the framework is provided in the following

section. In addition, quotes are provided to clarify the meaning behind some of the

competencies. These quotes are not to be understood as instruction; rather they are intended

to be illustrative samples, which should help to clarify a specific competency.

A. INTRODUCTION

The aim of this section is to establish a therapeutic relationship with the patient.

This is understood as a relationship between a practitioner and a patient, where the patient is

encouraged to actively involved in his/ her own care if they so wish. This involves the

development of a trusting and collaborative relationship between practitioner and patient.

This is an important step in the pharmaceutical care process as it may strongly influence the

ability of the practitioner to gather information and to make appropriate decisions regarding

the nature of the patients real problem and methods to resolve these problems.

A1. Introduces self to patient

The opening statement between the practitioner and the patient sets the stage for the

interaction. Welcoming the patient and establishing friendly eye contact conveys confidence

and a caring attitude.

For example:
Hello my name is and I am a pharmacy student form the University of Brighton. Hello my
name is I am the pharmacist running the clinic here today or I am your ward pharmacist.

A2. Confirms patients identity (e.g. name plus address or date of birth)

This is to ensure that the correct patient is receiving the correct medication and/ or advice.

The way how this is achieved depends on the situation, e.g., if a patient fills a prescription

then it is necessary to ask for a patients name and it is recommended to ask for one other

detail to make sure it is the right patient. If the patient is already known to the practitioner or if

the client is asking for general advice in a community pharmacy, then this task will be rated as

not applicable.

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The concept of agenda setting (i.e. planning the consultation)

The competencies A3, A4 and A5, below, are all concerned with the concept of shared

agenda setting, which means that the patient and the practitioner agree on a plan for the

consultation, i.e. what issues are to be discussed in the time available, in what order etc. As

proposed in this framework, shared agenda setting involves three tasks:

A3. Discusses purpose and structure of the consultation (i.e. shares pharmacists

agenda with the patient)

The practitioners agenda. The practitioner explains what issues/ objectives s/he would need

to cover in the consultation in order to fully assess a patients therapeutic needs. The

practitioner is expected to explain to the patient what s/he is planning to do and why s/he

would need to discuss certain issues, and approximately how long the consultation would

take.

This may involve for example, To make sure that you get the most benefit from your
medication I need to ask you a few questions about what medicines you are currently taking
and how you usually get on with your medicines. I can assure you that everything we discuss
will remain confidential and will only be used to help us both make decisions about your
health care. Would that be all right with you?

A4. Invites patient to discuss medication and/or health related issues (explores

patients agenda)

The patients agenda. The practitioner is expected to actively seek to involve the patient in the

consultation by inviting the patient to discuss any immediate medication-related and/or health-

related issues. Simply telling the patient what the practitioner is planning to do is not setting a

shared agenda.

For example:
Before we start is there anything that you would like to discuss with me? Or: Is there anything
about your treatment that you are particularly concerned about that you would like to discuss
with me?

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A5. Negotiates shared agenda (prioritising issues to be discussed considering

pharmacists objectives & patients needs)

Negotiating a shared agenda means that a balance is found between the patients needs

and the practitioners objectives for the therapeutic review. Patients who feel that their

priorities are not addressed tend to be passive and not engaged in the consultation, hence

rendering the consultation less effective and practitioner-centred. Whereas the negotiation of

a shared agenda gives a clear structure to the consultation, and both parties know what is to

be discussed, in what order and both have the chance to amend the agenda if necessary.

This could involve something like:


Practitioner: So, just to get this right and to use the next 15 minutes as effectively as
possible, you said that you are feeling dizzy after taking the hay-fever tablets, but if you dont
take the tablets you have itchy eyes and difficulties breathing. How about if I first of all find out
a bit more about yourself and what other medications you may be taking and then we will see
what we can do about your hay-fever tablets, would that be acceptable for you?

If the patient does not, at this moment in time, raise any issues, a preliminary agenda can be

set. The practitioner doesnt need to repeat the structure if it was already discussed in A3

above; however the patient should be invited to interrupt the practitioner and to raise any

issues they would like to address during the consultation. The practitioner could use a

transition statement and say something like:

Fine so if there is nothing you would like to ask me right now, how about we start with
Please feel free to interrupt me if there is anything that comes to your mind that you would like
to ask me or if anything is unclear.

A6. Pays attention to comfort and privacy

There are different situations in which a medication-related consultation can take place, but

whatever the situation the practitioner needs to pay attention to (1) the patients comfort and

(2) the patients privacy.

Comfort entails issues such as making sure the patient is comfortable sitting or standing (as

appropriate); that the patient understands what the practitioner is saying in terms of clarity,

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tone of voice, pitch, or language; or whether the patient has eye-sight problems. Distance and

posture between patient and practitioner can influence whether a patient is feeling relaxed

and interested in the interaction. For example, if the practitioner is talking to a child,

somebody sitting in a wheelchair, or lying in a hospital bed, they should be at an appropriate

eye level for interaction.

Privacy is an important condition for effective consultations. This includes giving the patient

a space where s/he feels that s/he has the full attention of the practitioner, without other

patients or staff listening. It may not always be possible to move into a consultation room, but

moving to a less crowded area or pulling the curtains around a hospital bed shows the patient

that s/he has the practitioners full attention and that same attempt has been made to respect

the patients privacy.

Asking a simple question by the practitioner such as:

Before I ask you about your medication, I want to check whether youre comfortable to
continue?

This also shows that, the practitioner is interested in ensuring that important pre-requirements

for the consultation are met (such as the patients ability to see or hear) and shows that the

practitioner is trying to engage with the patient.

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B. DATA COLLECTION AND PROBLEM IDENTIFICATION

The aim of this section is to identify the patients pharmaceutical care needs.

In this phase of a medication-related consultation, the practitioner aims to gather all

information from the patient which is necessary for a thorough therapeutic assessment with

the view to gaining an understanding of the patients perspective, identifying actual or

potential medication related-problems, and identifying the patients information needs.

B1. Documents full medication history

The information obtained from the medication history provides the foundation for planning

optimal medication regimens for the patient. This involves the practitioner enquiring about the

following issues:

Prescribed medication, frequency, dose, duration of course, route of administration

(includes prompts for inhaled, oral, tropical medications, vaccinations, etc.)

Medication recently discontinued by the doctor

Allergies type/ nature if known

Drug sensitivities or intolerances, adverse drug reactions

Self-medication (OTC, supermarket, dietary supplements, etc.)

Complementary & alternative therapies (e.g. homeopathy, herbal medicines, etc.)

Recreational drug use

B2. Assesses patients understanding of the rationale for prescribed treatment (i.e.

does patient know why treatment is prescribed and the likely benefits of

treatment)

This competency serves several purposes. It allows the practitioner to perform a baseline

assessment of what the patient already knows about his/her medicines, in what detail the

patient is informed about the medicines, and whether the patient thinks that the medicine is of

benefit to him/her. It also helps to determine whether the patient holds any misconceptions

about his/her treatment. In short the practitioner explores whether the patient has a clear

common sense rationale for the necessity of the prescribed treatment.

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The practitioner could ask questions like:


Before I go into detail about what your medicines are for and how you should take them,
maybe you could tell me what you know about them OR what your doctor has told you about
them, so that I am not repeating what you already know.
How did your doctor tell you to use this medication?
What did your doctor tell you to expect from this medication?

B3. Elicits patients (lay) understanding of his/her illness (this is particularly

relevant if patient is NOT clear about rationale for treatment)

This again allows the practitioner to establish what the patient already knows about his/her

illness and whether the patients understanding of his/her illness is consistent with their

understanding of their medication. This is of particular relevance if the patient expresses

doubts about the necessity or benefits of prescribed treatment or if the patient showes lack of

understanding about the reason for the prescribed treatment.

For example:
Perhaps could you tell me what (e.g. angina) means to you?

B4. Elicits concerns about treatment (e.g. beliefs about potential risks or side

effects)

This competency allows the practitioner to identify what concerns a patient may hold about

their medicines. It could be that the patient has already stated what the concerns are, when

s/he was asked about his/her understanding about the medicines and the illness. However, it

is necessary that the practitioner acknowledges those concerns, simply listening to the patient

volunteering that information does not demonstrate a practitioners competence to fulfil this

task.

For example:
You mentioned that you were worried that taking antibiotics may affect your bodys response
to them in the future. Are there any other worries that you have about the medicines youve
been prescribed?

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B5. Explores social history (alcohol, smoking, lifestyle, social support marital

status, living conditions, occupation, diet, impact of medication on patients

lifestyle)

These are all issues that can interfere with a patients success to follow prescribed treatment.

The practitioner should consider those factors for both diagnostic decision-making and

therapeutic planning. However, it is important that these questions are asked in such a way

that does not compromise the patient-practitioner relationship and that they are introduced in

a manner that appears relevant to the consultation.

For example:
As you know, some medicines interfere with alcohol for example. Do you mind if I ask how
much alcohol you normally have?

Illness management

B6. Explores patients experience/ control of symptoms

Taking a detailed account of the patients symptoms and establishing whether the experience

of these symptoms either remains the same, or improves or worsens when following

treatment advice, gives the practitioner an additional indication of (i) whether the patient is

responding to prescribed treatment; and (ii) what the patient may think about the necessity for

prescribed treatment.

For example:
Are you finding it helps the symptom or condition being treated?
Have you noticed anything unusual or out of the ordinary while taking this?

B7. Asks how patient monitors the illness (e.g. peak flow, BP measurement etc.)

This competency may not be relevant for every clinical situation, but for example asking a

diabetic patient how s/he checks his/her glucose levels and what the findings are provides

important information about (i) a patients understanding of his/her illness and (ii) how well the

illness is controlled.

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B8. Undertakes appropriate physical assessment (when indicated)

To undertake physical assessments is a fairly new skill for pharmacy practitioners. In order to

evaluate a patients response to prescribed treatment it may be indicated to undertake an

appropriate physical assessment. This may include for example to measure the blood

pressure of a patient who is prescribed antihypertensive medication or taking a pulse rate of a

patient prescribed digoxin.

Adherence assessment

The following three competencies B9, B10 and B11 are concerned with the concept of

adherence. Non-adherence with prescribed medication may lead to worsening of patients

symptoms, unnecessary diagnostic testing, hospitalisation, and use of additional medication,

especially if non-adherence is not identified and the practitioner believes that the patient is

taking the medication as prescribed.

B9. Asks how often patient misses dose(s) of treatment

Questioning regarding non-adherence can be difficult, because most patients feel guilty or

ashamed of admitting not to follow treatment recommendations to a health care professional.

The use of statements which acknowledge that many people find it difficult to follow

medication regimes or forget to take medication may encourage the patient to respond

truthfully.

For example:
Many people have difficulty remembering to take every dose of a medication thats been
prescribed several times a day. Whats your experience?

B10. Identifies reasons for missed dose(s) (unintentional or intentional)

If non-adherence is identified the practitioner should determine the reason for non-adherence

so that it can be corrected, if possible. The reasons could range from forgetting to take

medication, experiencing side effects, having difficulties reading labels or opening containers,

having difficulties paying for prescription fees, poor comprehension of the need for treatment

or strong concerns about the perceived risks associated taking specific medication.

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B11. Explores patients attitudes towards taking medication (e.g., asks whether

patient wishes to be prescribed treatment?)

It is well established that some patients have difficulties telling their doctor that they do not

want to take medication for their diagnosed problems. Therefore, to determine whether the

patient wishes to take medication for their illness is an important issue. This could (i) help

identify misconceptions the patient may hold about their illness, or (ii) highlight the need to

consider other management options that may help alleviate the patients condition.

For example:
Tell me more about why you dont like taking medications?
It sounds like you dont think that your problem is serious enough to need medication.
It sounds like you dont think the medicine will help you.

Exploring patients wish for involvement

B12. Asks how much/ what information patient wants before discussing solutions

to patients needs

This is a competency that clearly shows whether the practitioner tailors the consultation to the

individual patient. This involves actively finding out what the patient wants to know (relating to

what they already know, which should ideally have been identified earlier, by previous

competencies); followed by what more they want to know. This reduces the risk of providing

a one size fits all approach to information provision, and from missing issues that are

important to the patient.

For example:
It would be helpful for me to understand a little of what you already know so that I can try to
fill in any gaps for you
Theres a lot more information that Id be happy to share with you about your medicines.
Some patients like to know a lot about these things and some prefer to keep it to a minimum
how much information would you yourself like?

B13. Asks how involved patient wants to be in decision making

Patients vary in the extent to which they wish to be involved in decisions about treatment and

in planning future management. A patient who does not wish further specific information

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(B12), does not necessarily want to be left out of decisions about treatment management and

vice versa.

For example:
When we discuss how best to manage all your medications, would you like me to go through
some options that we have, or would you like me to decide what I think is the best choice for
you?

Problem identification

B14. Identifies and prioritises patients pharmaceutical problems (by summarising

the identified pharmaceutical problems)

This competency describes that stage of a consultation where the practitioner analyses the

information gathered and determines whether the patient is experiencing any medication-

related problems and whether the patients health outcomes are being met. The

pharmaceutical care problems identified need to be prioritised and communicated to the

patient. This is best achieved by summarising what the identified problems are. This serves

two purposes, (i) it actively involves the patient in the consultation by overtly clarifying what

the practitioner is thinking; (ii) it is advantageous to both parties because this process gives a

clear structure to the remainder of the consultation and avoids important issues from being

missed.

B15. Re-negotiates agenda (if necessary) (prioritising issues to be discussed

considering pharmacists objectives & patients needs)

This competency serves the same purpose as the competency negotiating a shared agenda

(A5) in the introduction sequence of the consultation. After having completed the data

collection phase, new issues or problems that need to be discussed may have emerged and

therefore priorities for discussion of pharmaceutical problems may have changed. In order to

continue the consultation as a two-way process and to keep the patient actively involved, the

agenda for the next sequence in the consultation needs to be overtly negotiated with the

patient.

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C. ACTIONS & SOLUTIONS

The overall aim of this section is to establish an acceptable management plan with the

patient.

In cases where actual or potential pharmaceutical problems were identified, the practitioner

and patient are expected to work jointly on a plan for their resolution.

C1. Relates information to patients illness & treatment beliefs (addresses

information gaps, selling benefits & addressing concerns/ risks of treatment)

This is a key patient-centred skill, which is also referred to as reactive explanation. A pre-

requirement to this task is that the practitioner has actively explored the patients

understanding about his/her illness and medication, about lifestyle issues or any other issues

that may influence the patients medication taking behaviour. Reactive explanation means

that the practitioner combines the patients own beliefs and theories with the practitioners

understanding of the patients problems and if applicable, gives reasons why the practitioners

theory is different to the patients. This task also means that the practitioner tailors his/her

information specifically to the patients life-style and social situation as opposed to a one size

fits all approach to explanation and planning.

C2. Involves patient in designing a management plan for identified problem(s) (e.g.

discusses options/ rationale)

As it is ultimately the patient who needs to take responsibility for his/her illness the practitioner

needs to clearly state all possible options that could be undertaken to solve the

pharmaceutical care problems identified. The execution of this competency allows the patient

to be actively involved in decision-making to the extent that the patient wishes to be involved.

The practitioner needs to review all available options with the patient. The patient should then

be allowed to decide what s/he prefers and is willing to do. This process is contrary to a

practitioner-centred practice where the patient is confronted with a plan that s/he might find

inconvenient, but is passively expected to follow.

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C3. Gives advice on how & when to take medication, length of treatment &

negotiates follow up (if necessary)

This competency is self-explanatory; the practitioner is expected to give clear and detailed

instructions to the patient. The negotiation of a follow up is necessary to ensure that the

patient is gaining the anticipated benefits from the medication and if not to discuss alternative

options.

For example:
When youre in pain, take them every 3 to 4 hours. Its best to take them with food or milk so
that the aspirin wont upset your stomach.

C4. Checks patients ability to follow plan (i.e. does patient anticipate any problem

following the plan e.g. in terms of motivation, resources, time or physical

ability)

Once a management plan has been established with the patient, it is important to ask the

patient whether s/he would anticipate any problems that would make it difficult to follow the

management plan and then to ask the patient whether s/he can think of possible solutions.

For example, these problems can range from motivation issues (e.g. the patient does not

want to take medication); resource issues (e.g. the patient cannot afford to pay for the

medication); or time issues (e.g. the patient may have unfavourable working conditions which

make it difficult to follow a strict time schedule).

C5. Checks patients understanding (e.g. invites patient to recap)

This competency is one of the most important competencies to achieve in a consultation. This

severs to determine whether the patient will be able to follow treatment advice and therefore

receive anticipated benefits of treatment. It is neither sufficient simply to assume that a patient

has understood and remembers all important information nor to say is that ok? without any

further checking.

For example:
I would like to make sure that I have covered everything and explained things well enough,
so may I ask you to tell me in your own words, how you will use this medication.

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Checking understanding has to be sensitively undertaken to avoid causing the patient to feel

uncomfortable or to feel tested, which could damage the practitioner-patient relationship.

However, not checking the patients understanding at all may mean that patients could leave

the consultation with gaps in their understanding or misunderstandings.

C6. Discusses lifestyle issues/ prevention strategies (health promotion issues)

This competency includes the discussion of health promotion issues, such as e.g. smoking

cessation, dietary advices, and exercise.

C7. Determines whether patient wants additional information/ explanation

After allowing the patient to consider the information that s/he has received, it is important that

the practitioner finds out whether the patient needs additional information or explanations

about their treatment.

For example:
Is there anything else you want to know about your medicines and how to monitor whether
they work?

C8. REFERS appropriately to other healthcare professional(s) (i.e., recognises own

professional boundaries & limitations)

This involves the practitioner to recognise personal limitations and professional boundaries

(work within the professional code of ethics) and to refer to appropriate other health care

professional if necessary.

For example:
If this continues on for X number of days, or seems to get worse then see your doctor.

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D. CLOSING THE CONSULTATION

The aim of this section is to negotiate safety netting strategies with the patient.

This allows the practitioner to plan for possible unwanted deviations from the negotiated

management plan and to discuss with the patient what steps to undertake if things go wrong.

D1. Explains what to do if patient has difficulties to follow plan and whom to

contact

The practitioner needs to discuss with the patient what if the patient is having difficulty

following the management plan; or if the patient is experiencing unwanted effects and what

action the patient could take in the event that things do not go as planned.

For example:
If you have any questions or problems, dont hesitate to call us.
Would you give me a call tomorrow to let me know how you are doing with the medication.

D2. Provides further appointment or contact point

The practitioner should encourage further appointments to check whether the medication is

effective and is being used appropriately. Or in cases where it was decided to opt for no

medication, the patient should be invited to discuss other possible interventions in case the

condition is unstable or not improving.

D3. Offers opportunity to ask further questions with regard to issues discussed in

the consultation

This gives the patient a final opportunity to raise any issues that s/he would need clarified.

For example:
Do you have any more questions about anything we have discussed here today?

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E. CONSULTATION BEHAVIOURS

E1. Listens actively & allows patient to complete statements without interruption

(i.e. keeps eye contact, verbal acknowledgement, non verbal feedback)

Active listening demands concentrated efforts to fully listen to a patients viewpoint. In active

listening there are clear indicators that show whether the message is coming across; these

include verbal facilitating statement such as Mmm, go on.., repetition of the last words the

patient was saying; as well as non verbal signs, such as keeping eye-contact, nodding, facial

expressions and gestures. By listening actively the practitioner encourages the patient to

disclose their real concerns.

The opposite is passive listening, whereby the listener shows no sign of actually hearing

what the other person is saying. At worst they may look bored or distracted and there is no

sign that what one participant was saying was actually heard.

E2. Asks relevant questions

The practitioner asks questions that are significant for the identification of a patients

pharmaceutical care needs as opposed to questions that are confusing to the patient,

jeopardise the therapeutic relationship or do not fit logically to the therapeutic assessment.

E3. Uses open & closed questions appropriately

Open-ended questioning techniques invite the patient to respond with a narrative and do not

restrict the answer in any way, while still directing the patient to a specific area of enquiry.

For example:

How have you been feeling since you started the new medication?
What medication are you currently taking?
How do you take your medication?

Closed-ended questioning techniques, or direct questions, ask for specific information and

details. The patient usually responds with short one- to two- word answers, such as yes or

no.

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For example:

Has this medication made you feel nauseous?


Do you experience any unwanted effects, such as light-headedness after taking this
medication?

Both techniques are essential for effective communication. However, a combination of open-

ended questions, gathering less structured information first, and moving to closed-ended

questions, eliciting specific details about a patients problems, are considered to be most

useful. This is also described as the open-to-close cone. Overusing closed-ended questions

may give the patient the impression of being interrogated; the patient may become passive

and the consultation may turn out to be impersonal and practitioner-centred.

E4. Avoids or explains jargon

Practitioners should avoid using jargon or medical terminology or in cases where jargon is

used the practitioner needs to explain what the terminology means. It is important that

practitioners communicate with the patient at the appropriate education level and adapt their

language level to that of the patient. Talking over the patients head does not encourage a

therapeutic, caring relationship.

E5. Accepts patient (i.e. respects patient, is non judgemental or patronising)

This again is key when building a trusting relationship with a patient. Accepting the patient

means that the practitioner acknowledges a patients problem or life-story without expressing

any personal disapproval or judgement of the patients thoughts, feelings, experiences, or

behaviours. This does not mean that a practitioner necessarily agrees with the patient, but it

enables the practitioner to understand the patient and avoids putting the patient in a defensive

position. Examples of unhelpful criticism are judging a patient who smokes; judging older

people as unable to follow treatment advice, judging people on their appearance or

background.

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E6. Demonstrates empathy with and supports patient (e.g. expresses concern,

understanding, willingness to help, acknowledges coping efforts)

Empathic responses tell the patient that the practitioner is trying to understand the patients

situation and concerns and is another fundamental behaviour when building a therapeutic

relationship with a patient. The expression trying to put oneself into another persons shoes

is frequently used to explain the concept of empathy. To demonstrate empathy the

practitioner needs to show that s/he is trying to understand how the patient is feeling and to

communicate this understanding to the patient.

This may include statements such as:


I can see how difficult it must be for you to take all these different medications
You seem worried about taking these medicines
You dont sound convinced about this treatment
You seem to have been through a lot lately

E7. Deals sensitively with embarrassing & disturbing topics

This may involve a number of different situations that patients may find difficult to talk about.

For example, questions regarding sexually transmitted disease, contraception, haemorrhoids

or impotence.

Other disturbing topics may involve issues regarding medications for life threatening diseases

or terminal illnesses.

E8. Shares thinking with the patient (when appropriate) to encourage patients

involvement (if wanted)

This again personalises the consultation and may encourage the patient to participate. The

practitioner lets the patient know what his/her thought processes are and how they relate to a

patients problem, as opposed to providing the patient with facts that might not make common

sense to the patient. For example statements such as:

What I am thinking now is


I think you might be right that taking these tablets make you feel tired

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E9. Uses information from test results to inform decision making and to explain

treatment option(s)

This refers to clinical situations where for example a diabetic patients blood sugar control is

being discussed, or where a patient who is taking anticoagulation medication needs to

understand what INR (International normalised ratio) means, or how well the blood pressure

of a patient taking antihypertensive medication is controlled. This competency refers to the

practitioners appropriate use of such information.

For example:
Looking at your blood results confirms what you have told me about the missed doses of
medicines

E10. Uses evidence based medicine-type information to inform decision making

and to explain treatment option(s)

This applies to the principles of evidence-based medicine. The competency shows whether

the practitioner demonstrates an appreciation of key literature applicable to the therapeutic

problem that is being discussed and whether the practitioner uses this information

appropriately to improve the patient understanding of his/ her illness and treatment. This may

not be relevant to every patient or to every clinical situation, because in many practice

situations clear evidence may not be available, or it may not be appropriate to overload the

patient with scientific facts.

E11. Adopts a structured & logical approach to the consultation

The use of skills like agenda setting, summarising and signposting allow the practitioner to

follow a clear logical process and to tailor the consultation to the individual patient.

E12. Keeps interview on track or regains control when necessary

Avoids the patient from wandering off unnecessarily, the practitioner leads the consultation

effectively and ensures that important issues are not missed.

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For example:
I am really sorry to hear about the difficulties your friend has had but I wonder if we
might go back to the point when you said your breathing had started to get
worseparticularly when you had forgotten to take your water tablets?

E13. Manages time effectively (works well within the time available)

This competency focuses on the practitioners ability to make effective use of the time

available. This included a judgement on whether or not the practitioner conducted a thorough

consultation and identified the pharmaceutical care needs of the patient within the time limits

of the consultation. Furthermore, this includes a judgement on whether or not the overall

consultation needs were met, and whether the consultation was rushed, prolonged

unnecessarily without real progress or conducted at the right pace.

E14. Provides logical and correct documentation

Documentation is necessary to provide the best possible pharmaceutical care, because it is a

valuable communication tool for future encounters with a patient and also provides helpful

information for the patients other health care professionals. In the assessment process a

pharmaceutical care plan allows to assess a practitioners problem solving skills and

therapeutic reasoning skills.

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APPENDIX 1 MEDICATION-RELATED CONSULTATION FRAMEWORK Formatted: Font: 9 pt, Not All caps

MEDICATION-RELATED CONSULTATION FRAMEWORK Formatted: Font: 10 pt


Formatted: Line spacing: Double
Please tick the relevant box to indicate how much you agree with the following statements. You may find it easier to tick the boxes, as they are addressed, rather than
waiting until the end of the consultation. If you are unsure which box to tick, please watch the consultation or sequences of the consultation for a second time and note this
on the framework.

Did the practitioner undertake the following activities? 1 = not at all, 2 = touched upon; 3 = adequate; 4 = very good; N/a = not applicable
A. INTRODUCTION 1 2 3 4 N/a STRENGTHS
Formatted: Font: (Default) Arial Narrow, 9 pt, Bold
A1. Introduces self to patient Formatted: Normal, Space Before: 3 pt, After: 0 pt
Formatted: Font: Arial Narrow, 9 pt
A2. Confirms patients identity (e.g. name plus address or date of birth)
Formatted: Bullets and Numbering

A3. Discusses purpose and structure of the consultation (i.e. shares pharmacists agenda Formatted: Bullets and Numbering
with the patient)
Formatted: Bullets and Numbering
WEAKNESSES
A4. Invites patient to discuss medication and/or health related issues (explores patients Formatted: Bullets and Numbering
agenda)

A5. Negotiates shared agenda (prioritising issues to be discussed considering Formatted: Bullets and Numbering
pharmacists objectives & patients needs)

A6. Pays attention to comfort and privacy Formatted: Bullets and Numbering

0 1 2 3 4
GLOBAL RATING: The practitioner was not able to The practitioner was partially The practitioner was fully able to
build a therapeutic relationship able to build a therapeutic build a therapeutic relationship
with the patient relationship with the patient with the patient

2003 Abdel Tawab, R.; James, D.; Davies, G.; Horne, R. School of Pharmacy & Biomolecular Sciences, University of Brighton. Please do not reproduce without
permission. r.abdel-tawab@brighton.ac.uk

February 2005 29
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Did the practitioner undertake the following activities? 1 = not at all, 2 = touched upon; 3 = adequate; 4 = very good; N/a = not applicable
B. DATA COLLECTION & PROBLEM IDENTIFICATION 1 2 3 4 N/a STRENGTHS
B1. Documents full medication history
Prescribed medication, frequency, dose, duration of course, route of
administration
Allergies type/ nature
Drug sensitivities or intolerances, Adverse drug reactions
Self-medication (OTC, supermarket, etc.)
Complementary & alternative therapies (e.g. homeopathy, herbal medicines,
etc.)
Recreational drug use
B2. Assesses patients understanding of the rationale for prescribed treatment (i.e.
does patient know why treatment is prescribed and the likely benefits of treatment)
B3. Elicits patients (lay) understanding of his/her illness (this is particularly relevant if
patient is NOT clear about rationale for treatment)
B4. Elicits concerns about treatment (e.g. beliefs about potential risks or side effects)
B5. Explores social history (alcohol, smoking, lifestyle, social support, occupation, diet,
impact of medication on patients lifestyle)
Illness management

B6. Explores patients experience/ control of symptoms

WEAKNESSES
B7. Asks how patient monitors the illness (e.g. peak flow, BP measurement etc.)
B8. UUndertakes appropriate physical assessment (when indicated)
Adherence assessment
B9. Asks how often patient misses dose(s) of treatment
B10. Identifies reasons for missed dose(s) (unintentional or intentional)
B11. Explores patients attitudes towards taking medication (e.g., Aasks whether patient
wishes to be prescribed treatment?)
Exploring patients wish for involvement
B12. Asks how much/ what information patient wants before discussing solutions to
patients needs
B13. Asks how involved patient wants to be in decision making
Problem identification
B14. Identifies and prioritises patients pharmaceutical problems (by summarising the
identified pharmaceutical problems)
B15. Re-negotiates agenda (if necessary) (prioritising issues to be discussed considering
pharmacists objectives & patients needs)
0 1 2 3 4
The practitioner was not able to The practitioner was partially The practitioner was fully able to
GLOBAL RATING:
identify the patients able to identify the patients identify the patients pharmaceutical
pharmaceutical care needs pharmaceutical care needs care needs

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Did the practitioner undertake the following activities? 1 = not at all, 2 = touched upon; 3 = adequate; 4 = very good; N/a = not applicable
C. ACTION/ SOLUTIONS 1 2 3 4 N/a STRENGTHS
C1. Relates information to patients illness & treatment beliefs (addresses information
gaps, communicates anticipated benefits & addresses concerns/ risks of
treatment)
C2. Involves patient in designing a management plan for identified problem(s) (e.g.
discusses options/ rationale)
C3. Gives advice on how & when to take medication, length of treatment & negotiates
follow up (if necessary)
C4. Checks patients ability to follow plan (i.e. does patient anticipate any problem WEAKNESSES
following the plan e.g. in terms of motivation, resources, time or physical ability)

C5. Checks patients understanding (e.g. invites patient to recap)
C6. Discusses lifestyle issues/ prevention strategies (health promotion issues)

C7. Determines whether patient wants additional information/ explanation

C8. Refers appropriately to other healthcare professional(s) (i.e., recognises own


professional boundaries & limitations)

0 1 2 3 4
GLOBAL RATING: The practitioner was not able to The practitioner was partially able The practitioner was fully able to
establish an acceptable to establish an acceptable establish an acceptable
management plan with the patient management plan with the patient management plan with the patient

Did the practitioner undertake the following activities? 1 = not at all, 2 = touched upon; 3 = adequate; 4 = very good; N/a = not applicable
D. CLOSING THE CONSULTATION 1 2 3 4 N/a STRENGTHS
D1. Explains what to do if patient has difficulties to follow plan and whom to contact

D2. Provides further appointment or contact point


WEAKNESSES
D3. Offers opportunity to ask further questions with regard to issues discussed in the
consultation

0 1 2 3 4
GLOBAL RATING: The practitioner was not able to The practitioner was partially The practitioner was fully able to
negotiate safety netting able to negotiate safety netting negotiate safety netting strategies
strategies with the patient strategies with the patient with the patient

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Did the practitioner demonstrate the following behaviours? 1 = not at all, 2 = poor; 3 = adequate; 4 = very good; N/a = not applicable
E. CONSULTATION BEHAVIOURS 1 2 3 4 N/a STRENGTHS

E1. Listens actively & allows patient to complete statements without interruption (i.e.
keeps eye contact, verbal acknowledgement, non verbal feedback)

E2. Asks relevant questions
E3. Uses open & closed questions appropriately
E4. Avoids or explains jargon
E5. Accepts patient (i.e. respects patient, Is not judgemental or patronising)
E6. Demonstrates empathy with and supports patient (e.g. expresses concern,

understanding, willingness to help, acknowledges coping efforts)

E7. Deals sensitively with embarrassing & disturbing topics
E8. Shares thinking with the patient (when appropriate) to encourage patients WEAKNESSES
involvement (if wanted)
E9. Uses information from test results to inform decision making and to explain treatment
option(s)
E10. Uses evidence based medicine-type information to inform decision making and to
explain treatment option(s)

E11. Adopts a structured & logical approach to the consultation

E12. Keeps interview on track or regains control when necessary

E13. Manages time effectively (works well within the time available)
E14. Provides logical and correct documentation

FINAL OVERALL IMPRESSION:

Overall the practitioners ability to consult was: Poor Borderline Satisfactory Good Very good

February 2005 32