TY - JOUR
AU - Dodds, Linda J
AB - Abstract Objectives To identify consultation tools cited in the published literature and undertake a narrative review which establishes their scope to support the delivery of person-centred medicine-focused consultations between community pharmacists and patients in the United Kingdom (UK). Key findings Nine consultation tools used in a pharmacy context were identified. Four tools (Calgary-Cambridge guide, MRCF, MUR and NMS advanced services and PaCT) were selected for further appraisal. None of the tools identified provided a suitable format or sufficient guidance to address all components required for the delivery of a person-centred patient consultation in practice. Summary Tools available to UK pharmacists are inadequate for fully supporting delivery of a person-centred consultation in practice. Revision of existing tools or creation of more pharmacy-specific tools will support UK pharmacists' delivery of person-centred consultations in practice. community pharmacy, counselling, decision aids, medicine review, professional training Introduction The need for health care to be person-centred has increasingly been recognised across the world. The World Health Organization has highlighted the importance of ‘people-centred’ approaches in order to optimise health and social outcomes across a broad range of social and economic contexts.[1,2] In the UK, person-centred care has been an aspiration for the National Health Service (NHS) and is endorsed within its constitution.[3–9] There remains no agreed single definition of what comprises person-centred care, and although a plethora of variations have emerged, in essence a person-centred approach encompasses maintaining respect for the individual, their rights and responsibilities.[5] It therefore describes an approach to care which is focused upon, and tailored to, the needs of the individual by taking into account their preferences, needs and values and viewing them as an equal partner in decision-making.[5] The principles of person-centred care most associated with influencing health outcomes include recognising the expertise and individuality of the patient, sharing decision-making and taking a holistic approach to care, including and involving families where appropriate, ensuring services are easy to access, navigate and are co-ordinated, providing a conducive environment and ensuring that staff are well trained in communication and have an enabling mindset. These principles are summarised in Table 1. Table 1 Principles of person-centred care (1) Getting to know the patient as a person and recognising their individuality and specificity (2) Taking a holistic approach to assessing needs and providing care (which may include families) and recognising social and environmental factors as part of a bio-social perspective (3) Seeing the patient as an expert about their health and care (4) Recognising autonomy and thus sharing power and responsibility, including enablement and activation in decisions about care (5) Ensuring that services are accessible, flexible to individual needs and easy to navigate (6) Co-ordination of services into an integrated pathway that views the whole experience of care from the patient's point of view and strives for continuity (7) Ensuring that the physical, cultural and psychosocial environment of health services is conducive to person-centred care (8) Having supportive staff who are well trained in communication and engagement and strive to put patients at the centre of care (1) Getting to know the patient as a person and recognising their individuality and specificity (2) Taking a holistic approach to assessing needs and providing care (which may include families) and recognising social and environmental factors as part of a bio-social perspective (3) Seeing the patient as an expert about their health and care (4) Recognising autonomy and thus sharing power and responsibility, including enablement and activation in decisions about care (5) Ensuring that services are accessible, flexible to individual needs and easy to navigate (6) Co-ordination of services into an integrated pathway that views the whole experience of care from the patient's point of view and strives for continuity (7) Ensuring that the physical, cultural and psychosocial environment of health services is conducive to person-centred care (8) Having supportive staff who are well trained in communication and engagement and strive to put patients at the centre of care Open in new tab Table 1 Principles of person-centred care (1) Getting to know the patient as a person and recognising their individuality and specificity (2) Taking a holistic approach to assessing needs and providing care (which may include families) and recognising social and environmental factors as part of a bio-social perspective (3) Seeing the patient as an expert about their health and care (4) Recognising autonomy and thus sharing power and responsibility, including enablement and activation in decisions about care (5) Ensuring that services are accessible, flexible to individual needs and easy to navigate (6) Co-ordination of services into an integrated pathway that views the whole experience of care from the patient's point of view and strives for continuity (7) Ensuring that the physical, cultural and psychosocial environment of health services is conducive to person-centred care (8) Having supportive staff who are well trained in communication and engagement and strive to put patients at the centre of care (1) Getting to know the patient as a person and recognising their individuality and specificity (2) Taking a holistic approach to assessing needs and providing care (which may include families) and recognising social and environmental factors as part of a bio-social perspective (3) Seeing the patient as an expert about their health and care (4) Recognising autonomy and thus sharing power and responsibility, including enablement and activation in decisions about care (5) Ensuring that services are accessible, flexible to individual needs and easy to navigate (6) Co-ordination of services into an integrated pathway that views the whole experience of care from the patient's point of view and strives for continuity (7) Ensuring that the physical, cultural and psychosocial environment of health services is conducive to person-centred care (8) Having supportive staff who are well trained in communication and engagement and strive to put patients at the centre of care Open in new tab Ethical and economic influences have driven the increasing focus towards adopting a person-centred approach in health care, and in turn pharmacists have been directed to provide more person-centred services.[3–52] A significant influence upon community pharmacists' need to deliver person-centred care in the UK has been the introduction of incentivised patient-facing services.[25] Revisions to the Community Pharmacy Contract for England and Wales in 2005 led to the commissioning of a Medicine Use Review (MUR) service and in 2011 to the introduction of a New Medicine Service (NMS). A similar service to these, the chronic medicine service, has been available in Scotland since 2009. These services have funded UK community pharmacists to provide bespoke medicine support through their consultations with targeted groups of patients.[34] The drive for pharmacists to deliver person-centred care has been supported strongly by UK professional pharmacy bodies. The General Pharmaceutical Council, which is the registration and governing body for pharmacists in the UK, has produced generic standards and guidance for pharmacy professionals.[24,39] These standards directly acknowledge the need for care to be person-centred and recognise specific elements associated with this concept, including effective verbal and non-verbal communication and the importance of collaborative interprofessional working. A set of standards for consultation skills in pharmacy practice, jointly endorsed by the Royal Pharmaceutical Society and the Association for Pharmacy Technicians, has been drawn up by the Centre for Pharmacy Postgraduate Education (CPPE) and NHS Health Education England.[37] Guidance for UK pharmacists is also available through the Pharmaceutical Services Negotiating Committee.[53] The latter guidance was prepared specifically in response to the commissioning of the MUR and NMS advanced service consultations.[34] These sets of guidance have been supported by training, which includes open learning programme and workshops, offered by the CPPE. [17,35–37] The CPPE has also promoted across pharmacies in England, ‘Consultation skills for pharmacy practice; Do you say…?’, which included a leaflet and online animations which offer key phrases which pharmacy professionals can apply to support their generic delivery of a person-centred consultation.[38] There is a paucity of evidence to support pharmacists' delivery of person-centred care in practice through consultations. Indeed, studies have instead highlighted concerns with respect to the delivery of consultations between pharmacists and patients both within the UK and overseas.[25,40–52] A preference towards drug or disease-focused as opposed to person-centred communication was a key finding of one review into pharmacist practice,[44] while MURs carried out in England and Wales were reported to have been primarily facilitated to meet the objectives of pharmacists rather than being patient-centred.[25,54] The reported difficulties encountered by pharmacists in terms of delivering person-centred care in practice, such as adopting a broader whole-person approach to consultations rather than focusing on a particular disease intervention, nonetheless reflect a picture seen more generally in health care.[3–5,7,9–,11,52,55–,62] While consultation tools and training are available to support person-centred consultations in pharmacy practice, their value and utility in facilitating consultations in practice have not been determined. The aim of this narrative review was to identify consultation tools used in pharmacy education or practice from searches of the literature and to compare them first against the principles of person-centred care identified by de Silva[5] and then for the feasibility of their use in practice, thus enabling their overall scope for supporting UK pharmacists to deliver truly person-centred consultations, within a community setting to be assessed. This novel review adds to the limited evidence base in this important area. Methods A structured process, guided by the principles of conducting a systematic review, was employed to search the literature[63] and appraise identified articles and consultation tools. Both qualitative and quantitative studies, and articles, including those detailing the development and validation of the tools and those describing the use of the tools in either education and training or any pharmacy practice context, were selected. Strategy for searches of the literature An initial background search of the literature was conducted to establish appropriate search terms. The final selected search terms were agreed via a series of discussions between the authors of this paper. Combinations of the following terms were selected to search the literature: pharmac*, consult*/ counsel*/ communicat*, and tool/ framework. Additional searches were undertaken using the titles of identified tools. EBSCOhost (MEDLINE, PsycINFO and CINAHL), PubMed and Cochrane Library databases were searched for original peer-reviewed articles. Searches were repeated between August 2014 and December 2018. Online searches and hard copies of policy and guidance documents available from organisations which provide professional support to UK pharmacists were also reviewed, along with the bibliographies of selected full articles. The full search strategy has been supplied as Appendix S1 to this paper. Eligibility criteria Articles were restricted to those published in the English language within the last 25 years (1993–2018) citing tools designed or used by pharmacists in their practice, education or the training of consultation skills. This broad time frame was utilised to identify tools developed alongside the concept of a person-centred approach to care. Articles were not restricted to the UK context so to identify consultation tools used globally that may have influenced UK practice. Review and selection of papers for inclusion All titles were first screened against the eligibility criteria, and duplicates were removed. The abstracts of remaining articles were then screened, and for those which were eligible, full papers were located and read. Bibliographies of selected articles were also screened for other potentially relevant titles. All full articles were reviewed using the Critical Appraisal Skills Programme tools[64] where appropriate to the study design. All screening activities were carried out by the lead author. Critical appraisal of identified tools A narrative review format was chosen for this study. This enables a theoretical and contextual review of a topic to be undertaken in an area where there is heterogeneity in the published studies. Consultation tools identified from the literature were appraised for their ability to support the delivery of a person-centred consultation, specifically within the context of UK pharmacy practice. As there is no universally accepted definition of person-centred care,[5,15,59,65–72] a pragmatic approach to identifying whether a person-centred approach was supported by the tool was adopted. This comprised reviewing whether the eight principles of person-centred care that emerged from the comprehensive and recently published evidence review by de Silva[5] had been incorporated into the tool (Table 1). Consultation tools identified through the search strategy were then reviewed and selected for detailed appraisal based on either evidence of their adoption into clinical practice (classified as being cited a minimum of six times within the literature) or their meeting a minimum of six of the principles identified by de Silva as fulfilling person-centred care. The methods used for detailed appraisal of the tools that achieved one or both of these criteria were guided by the recommendations of Aveyard[73] and included mapping content within the tool to each of the eight principles outlined by de Silva. Both stages in this process were carried out by the first author with the findings cross-checked and agreed with the secondary authors of this paper. Results A total of 778 titles were identified which were reduced to 622 following the removal of duplicates. After screening of their eligibility, 69 abstracts were retained. 45 full papers were selected for appraisal, of which 39 were retained and included in this review (Figure 1). Figure 1 Open in new tabDownload slide Results of literature search and selection process. From the review, a total of nine consultation tools were identified, and their characteristics are summarised in Table 2. The Calgary-Cambridge guide was the most frequently cited tool within the literature (n = 22). The Medicine-related Consultation Framework (MRCF) received six citations, with seven citations located collectively for the MUR and NMS advanced services. Fewer citations were identified within the UK and overseas literature in connection to other tools: Explore, Educate, Empower, Enable (4Es) (n = 3); Three Prime Questions (3PQs) (n = 1); Patient-Centred Communication Tools (PaCT) (n = 1); PharmaCat (n = 2); Roter Interactive Analysis System (n = 1); and SEGUE Framework (n = 5). A number of articles referenced multiple tools which accounts for why the collective number of citations to tools (n = 48) exceeds the total number of papers included within this review. Table 3 reviews all tools against the eight principles of person-centred care.[5] Four tools met the criteria for further review: Calgary-Cambridge guide; MRCF; MUR and NMS advanced services; and PaCT. Table 2 Summary of identified consultation tools Tool/Citations (n=) . Purpose/use . Development . Structure/design . Evaluation/validation . Calgary-Cambridge guide (C-Cg) n = 22[17,36,37,74,75,77–93] Educational tool for doctor–patient communication UK and Canadian development, based on earlier approaches – limited information re. synthesis in the development of the guide(s) Originally developed as two interconnected parts (Interviewing the Patient and Explanation and Planning with the Patient) – original/full version includes five sections and 71 prompts – iterations include simplified/diagrammatic/partial versions of the original guide Psychometric testing, but modified/partial versions of the Calgary Cambridge guide(s) using simulated patients in non-pharmacy context Medicine-related Consultation Framework (MRCF) n = 6[17,35,77,84,85,94] Teaching/assessment of pharmacists skills for medicine-related consultations UK development – multiple phases inc. lit review of models/tools teaching (inc. Calgary-Cambridge guide(s) and SEGUE) focus group/interviews with expert participants informed final version Five sections (A-D): Data collection and Problem Identification; Actions and solutions; and Closing Section E outlines commensurate behaviours, which inc. 46 consultation behaviours Validated as an educative tool for evaluation of medication-related consultation skills via psychometric testing and review of simulated consultations Medicine Use Review (MUR) and New Medicine Service (NMS) advanced services n = 7[25,34,95–99] Two tools to support UK pharmacists' delivery of consultations for Advanced Services (MUR and NMS) Developed for UK Advanced Services MUR: No information NMS: Input from pharmacy/psychology academics Two page formats: MUR: Seven questions with some additional prompts NMS: Two parts: Intervention Worksheet and Follow-up Worksheet – similar structure to MUR (above), with additional instruction No evidence 4Es n = 3[37,100,101] To support pharmacists' delivery of short (10-min) advanced service consultations UK tool based upon GROW model (validated health-coaching tool) – but limited information re. synthesis in the development of the tool Four sections/prompts: Explore; Educate; Empower; and Enable – not sufficient for entirety of a consultation Not specifically evaluated, but based upon a validated health-coaching tool (GROW model) Three Prime Questions (3PQs) n = 1[102] Patient-focused approach for assessing patient's knowledge/identifying information needs before educative intervention Developed in the United States in collaboration with Indian Health Services – limited information re. development Three sections: Purpose; Directions; and Monitoring – consisting of eight prompts Positive evaluation from feedback received from pharmacists Patient-Centred Communication Tools (PaCT) n = 1[85] Comprehensive instrument for education/assessment of student pharmacist–patient communication skills Developed in the United States via multi-step process inc. review of experience of using physician-centred model (Four Habits Model – FHM-1) and the literature, feedback from external experts/faculty assessors, piloting via student pharmacists' consultations with simulated patients Two parts: Communication Tools/Assessment Form: Communication Tools: Five sections inc. prompts: Establish a Consensus; Explore and Integrate Patient's Perspective; Demonstrate Interest and Empathy; Collaborate and Educate; and Communicate with Finesse Assessment Form: Pro-forma – sections A-E: Invest in the Patient; Integrate the Patient's Perspective; Demonstrate Interest and Empathy; Plan and Educate; and Communicate with Finesse Validated to assess student pharmacists' communication with patients as part of the development (see development section) PharmaCat n = 2[103,104] A pharmacy consultation skills assessment tool Development in the UK via revision of existing tool through addition of performance criteria specific to pharmacist prescribing – limited information re. this process 16 prompts inc. additional comment boxes for assessors (strengths, weakness and areas for improvement) Validated as a consultation skills assessment tool as part of the development process Roter Interactive Analysis System (RIAS) n = 1[105] Assessing dynamics of medical consultation Portugal/US development derived from social exchange theories related to interpersonal influence, problem-solving and empowerment, but inadequate information/transparency reported as to how these influences were synthesised in the development of the tool Four sections: Data-gathering skills; Patient education and counselling skills; Relationship skills; and Partnering skills Validated as an assessment tool in a variety of healthcare contexts, but not pharmacy SEGUE Framework n = 5[77,84,85,106,107] Developed for assessing medical consultations – widely used in North America medical education US developed research-based checklist – limited information to processes/influences on development Five sections: Set the stage; Elicit information; Give information; Check understanding; and End encounter – consisting of 25 prompts Validated for assessing the content of doctors consultations with patients Tool/Citations (n=) . Purpose/use . Development . Structure/design . Evaluation/validation . Calgary-Cambridge guide (C-Cg) n = 22[17,36,37,74,75,77–93] Educational tool for doctor–patient communication UK and Canadian development, based on earlier approaches – limited information re. synthesis in the development of the guide(s) Originally developed as two interconnected parts (Interviewing the Patient and Explanation and Planning with the Patient) – original/full version includes five sections and 71 prompts – iterations include simplified/diagrammatic/partial versions of the original guide Psychometric testing, but modified/partial versions of the Calgary Cambridge guide(s) using simulated patients in non-pharmacy context Medicine-related Consultation Framework (MRCF) n = 6[17,35,77,84,85,94] Teaching/assessment of pharmacists skills for medicine-related consultations UK development – multiple phases inc. lit review of models/tools teaching (inc. Calgary-Cambridge guide(s) and SEGUE) focus group/interviews with expert participants informed final version Five sections (A-D): Data collection and Problem Identification; Actions and solutions; and Closing Section E outlines commensurate behaviours, which inc. 46 consultation behaviours Validated as an educative tool for evaluation of medication-related consultation skills via psychometric testing and review of simulated consultations Medicine Use Review (MUR) and New Medicine Service (NMS) advanced services n = 7[25,34,95–99] Two tools to support UK pharmacists' delivery of consultations for Advanced Services (MUR and NMS) Developed for UK Advanced Services MUR: No information NMS: Input from pharmacy/psychology academics Two page formats: MUR: Seven questions with some additional prompts NMS: Two parts: Intervention Worksheet and Follow-up Worksheet – similar structure to MUR (above), with additional instruction No evidence 4Es n = 3[37,100,101] To support pharmacists' delivery of short (10-min) advanced service consultations UK tool based upon GROW model (validated health-coaching tool) – but limited information re. synthesis in the development of the tool Four sections/prompts: Explore; Educate; Empower; and Enable – not sufficient for entirety of a consultation Not specifically evaluated, but based upon a validated health-coaching tool (GROW model) Three Prime Questions (3PQs) n = 1[102] Patient-focused approach for assessing patient's knowledge/identifying information needs before educative intervention Developed in the United States in collaboration with Indian Health Services – limited information re. development Three sections: Purpose; Directions; and Monitoring – consisting of eight prompts Positive evaluation from feedback received from pharmacists Patient-Centred Communication Tools (PaCT) n = 1[85] Comprehensive instrument for education/assessment of student pharmacist–patient communication skills Developed in the United States via multi-step process inc. review of experience of using physician-centred model (Four Habits Model – FHM-1) and the literature, feedback from external experts/faculty assessors, piloting via student pharmacists' consultations with simulated patients Two parts: Communication Tools/Assessment Form: Communication Tools: Five sections inc. prompts: Establish a Consensus; Explore and Integrate Patient's Perspective; Demonstrate Interest and Empathy; Collaborate and Educate; and Communicate with Finesse Assessment Form: Pro-forma – sections A-E: Invest in the Patient; Integrate the Patient's Perspective; Demonstrate Interest and Empathy; Plan and Educate; and Communicate with Finesse Validated to assess student pharmacists' communication with patients as part of the development (see development section) PharmaCat n = 2[103,104] A pharmacy consultation skills assessment tool Development in the UK via revision of existing tool through addition of performance criteria specific to pharmacist prescribing – limited information re. this process 16 prompts inc. additional comment boxes for assessors (strengths, weakness and areas for improvement) Validated as a consultation skills assessment tool as part of the development process Roter Interactive Analysis System (RIAS) n = 1[105] Assessing dynamics of medical consultation Portugal/US development derived from social exchange theories related to interpersonal influence, problem-solving and empowerment, but inadequate information/transparency reported as to how these influences were synthesised in the development of the tool Four sections: Data-gathering skills; Patient education and counselling skills; Relationship skills; and Partnering skills Validated as an assessment tool in a variety of healthcare contexts, but not pharmacy SEGUE Framework n = 5[77,84,85,106,107] Developed for assessing medical consultations – widely used in North America medical education US developed research-based checklist – limited information to processes/influences on development Five sections: Set the stage; Elicit information; Give information; Check understanding; and End encounter – consisting of 25 prompts Validated for assessing the content of doctors consultations with patients Open in new tab Table 2 Summary of identified consultation tools Tool/Citations (n=) . Purpose/use . Development . Structure/design . Evaluation/validation . Calgary-Cambridge guide (C-Cg) n = 22[17,36,37,74,75,77–93] Educational tool for doctor–patient communication UK and Canadian development, based on earlier approaches – limited information re. synthesis in the development of the guide(s) Originally developed as two interconnected parts (Interviewing the Patient and Explanation and Planning with the Patient) – original/full version includes five sections and 71 prompts – iterations include simplified/diagrammatic/partial versions of the original guide Psychometric testing, but modified/partial versions of the Calgary Cambridge guide(s) using simulated patients in non-pharmacy context Medicine-related Consultation Framework (MRCF) n = 6[17,35,77,84,85,94] Teaching/assessment of pharmacists skills for medicine-related consultations UK development – multiple phases inc. lit review of models/tools teaching (inc. Calgary-Cambridge guide(s) and SEGUE) focus group/interviews with expert participants informed final version Five sections (A-D): Data collection and Problem Identification; Actions and solutions; and Closing Section E outlines commensurate behaviours, which inc. 46 consultation behaviours Validated as an educative tool for evaluation of medication-related consultation skills via psychometric testing and review of simulated consultations Medicine Use Review (MUR) and New Medicine Service (NMS) advanced services n = 7[25,34,95–99] Two tools to support UK pharmacists' delivery of consultations for Advanced Services (MUR and NMS) Developed for UK Advanced Services MUR: No information NMS: Input from pharmacy/psychology academics Two page formats: MUR: Seven questions with some additional prompts NMS: Two parts: Intervention Worksheet and Follow-up Worksheet – similar structure to MUR (above), with additional instruction No evidence 4Es n = 3[37,100,101] To support pharmacists' delivery of short (10-min) advanced service consultations UK tool based upon GROW model (validated health-coaching tool) – but limited information re. synthesis in the development of the tool Four sections/prompts: Explore; Educate; Empower; and Enable – not sufficient for entirety of a consultation Not specifically evaluated, but based upon a validated health-coaching tool (GROW model) Three Prime Questions (3PQs) n = 1[102] Patient-focused approach for assessing patient's knowledge/identifying information needs before educative intervention Developed in the United States in collaboration with Indian Health Services – limited information re. development Three sections: Purpose; Directions; and Monitoring – consisting of eight prompts Positive evaluation from feedback received from pharmacists Patient-Centred Communication Tools (PaCT) n = 1[85] Comprehensive instrument for education/assessment of student pharmacist–patient communication skills Developed in the United States via multi-step process inc. review of experience of using physician-centred model (Four Habits Model – FHM-1) and the literature, feedback from external experts/faculty assessors, piloting via student pharmacists' consultations with simulated patients Two parts: Communication Tools/Assessment Form: Communication Tools: Five sections inc. prompts: Establish a Consensus; Explore and Integrate Patient's Perspective; Demonstrate Interest and Empathy; Collaborate and Educate; and Communicate with Finesse Assessment Form: Pro-forma – sections A-E: Invest in the Patient; Integrate the Patient's Perspective; Demonstrate Interest and Empathy; Plan and Educate; and Communicate with Finesse Validated to assess student pharmacists' communication with patients as part of the development (see development section) PharmaCat n = 2[103,104] A pharmacy consultation skills assessment tool Development in the UK via revision of existing tool through addition of performance criteria specific to pharmacist prescribing – limited information re. this process 16 prompts inc. additional comment boxes for assessors (strengths, weakness and areas for improvement) Validated as a consultation skills assessment tool as part of the development process Roter Interactive Analysis System (RIAS) n = 1[105] Assessing dynamics of medical consultation Portugal/US development derived from social exchange theories related to interpersonal influence, problem-solving and empowerment, but inadequate information/transparency reported as to how these influences were synthesised in the development of the tool Four sections: Data-gathering skills; Patient education and counselling skills; Relationship skills; and Partnering skills Validated as an assessment tool in a variety of healthcare contexts, but not pharmacy SEGUE Framework n = 5[77,84,85,106,107] Developed for assessing medical consultations – widely used in North America medical education US developed research-based checklist – limited information to processes/influences on development Five sections: Set the stage; Elicit information; Give information; Check understanding; and End encounter – consisting of 25 prompts Validated for assessing the content of doctors consultations with patients Tool/Citations (n=) . Purpose/use . Development . Structure/design . Evaluation/validation . Calgary-Cambridge guide (C-Cg) n = 22[17,36,37,74,75,77–93] Educational tool for doctor–patient communication UK and Canadian development, based on earlier approaches – limited information re. synthesis in the development of the guide(s) Originally developed as two interconnected parts (Interviewing the Patient and Explanation and Planning with the Patient) – original/full version includes five sections and 71 prompts – iterations include simplified/diagrammatic/partial versions of the original guide Psychometric testing, but modified/partial versions of the Calgary Cambridge guide(s) using simulated patients in non-pharmacy context Medicine-related Consultation Framework (MRCF) n = 6[17,35,77,84,85,94] Teaching/assessment of pharmacists skills for medicine-related consultations UK development – multiple phases inc. lit review of models/tools teaching (inc. Calgary-Cambridge guide(s) and SEGUE) focus group/interviews with expert participants informed final version Five sections (A-D): Data collection and Problem Identification; Actions and solutions; and Closing Section E outlines commensurate behaviours, which inc. 46 consultation behaviours Validated as an educative tool for evaluation of medication-related consultation skills via psychometric testing and review of simulated consultations Medicine Use Review (MUR) and New Medicine Service (NMS) advanced services n = 7[25,34,95–99] Two tools to support UK pharmacists' delivery of consultations for Advanced Services (MUR and NMS) Developed for UK Advanced Services MUR: No information NMS: Input from pharmacy/psychology academics Two page formats: MUR: Seven questions with some additional prompts NMS: Two parts: Intervention Worksheet and Follow-up Worksheet – similar structure to MUR (above), with additional instruction No evidence 4Es n = 3[37,100,101] To support pharmacists' delivery of short (10-min) advanced service consultations UK tool based upon GROW model (validated health-coaching tool) – but limited information re. synthesis in the development of the tool Four sections/prompts: Explore; Educate; Empower; and Enable – not sufficient for entirety of a consultation Not specifically evaluated, but based upon a validated health-coaching tool (GROW model) Three Prime Questions (3PQs) n = 1[102] Patient-focused approach for assessing patient's knowledge/identifying information needs before educative intervention Developed in the United States in collaboration with Indian Health Services – limited information re. development Three sections: Purpose; Directions; and Monitoring – consisting of eight prompts Positive evaluation from feedback received from pharmacists Patient-Centred Communication Tools (PaCT) n = 1[85] Comprehensive instrument for education/assessment of student pharmacist–patient communication skills Developed in the United States via multi-step process inc. review of experience of using physician-centred model (Four Habits Model – FHM-1) and the literature, feedback from external experts/faculty assessors, piloting via student pharmacists' consultations with simulated patients Two parts: Communication Tools/Assessment Form: Communication Tools: Five sections inc. prompts: Establish a Consensus; Explore and Integrate Patient's Perspective; Demonstrate Interest and Empathy; Collaborate and Educate; and Communicate with Finesse Assessment Form: Pro-forma – sections A-E: Invest in the Patient; Integrate the Patient's Perspective; Demonstrate Interest and Empathy; Plan and Educate; and Communicate with Finesse Validated to assess student pharmacists' communication with patients as part of the development (see development section) PharmaCat n = 2[103,104] A pharmacy consultation skills assessment tool Development in the UK via revision of existing tool through addition of performance criteria specific to pharmacist prescribing – limited information re. this process 16 prompts inc. additional comment boxes for assessors (strengths, weakness and areas for improvement) Validated as a consultation skills assessment tool as part of the development process Roter Interactive Analysis System (RIAS) n = 1[105] Assessing dynamics of medical consultation Portugal/US development derived from social exchange theories related to interpersonal influence, problem-solving and empowerment, but inadequate information/transparency reported as to how these influences were synthesised in the development of the tool Four sections: Data-gathering skills; Patient education and counselling skills; Relationship skills; and Partnering skills Validated as an assessment tool in a variety of healthcare contexts, but not pharmacy SEGUE Framework n = 5[77,84,85,106,107] Developed for assessing medical consultations – widely used in North America medical education US developed research-based checklist – limited information to processes/influences on development Five sections: Set the stage; Elicit information; Give information; Check understanding; and End encounter – consisting of 25 prompts Validated for assessing the content of doctors consultations with patients Open in new tab Table 3 Appraisal of identified tools to support delivery of a person-centred consultation Tools . Summarised principles of person-centred care[5] . Scope to address six (75%) > pc principles . Know patient . Holistic inc. carers . Patient as expert . Autonomy . Accessible/flexible . Co-ordinated/integrated . Environment . Communication . C-Cg [17,36,37,74,75,77–93] – † † ‡ † † † ‡ Yes MRCF [17,35,77,84,85,94] – † † ‡ † † † ‡ Yes MUR/NMS [25,34,95–99] – † – – – – – † No 4Es [37,100,101] – † † ‡ – – – – No 3PQs [102] – – – – – – – † No PaCT [85] ‡ † † ‡ † – – ‡ Yes PharmaCat [103,104] – † † † – – – † No RIAS [105] † ‡ † † – – – † No SEGUE [77,84,85,106,107] – † – † – – – † No Tools . Summarised principles of person-centred care[5] . Scope to address six (75%) > pc principles . Know patient . Holistic inc. carers . Patient as expert . Autonomy . Accessible/flexible . Co-ordinated/integrated . Environment . Communication . C-Cg [17,36,37,74,75,77–93] – † † ‡ † † † ‡ Yes MRCF [17,35,77,84,85,94] – † † ‡ † † † ‡ Yes MUR/NMS [25,34,95–99] – † – – – – – † No 4Es [37,100,101] – † † ‡ – – – – No 3PQs [102] – – – – – – – † No PaCT [85] ‡ † † ‡ † – – ‡ Yes PharmaCat [103,104] – † † † – – – † No RIAS [105] † ‡ † † – – – † No SEGUE [77,84,85,106,107] – † – † – – – † No Extent tools address principles of person-centred consultations: fully (‡), partially (†) or not at all (–). Open in new tab Table 3 Appraisal of identified tools to support delivery of a person-centred consultation Tools . Summarised principles of person-centred care[5] . Scope to address six (75%) > pc principles . Know patient . Holistic inc. carers . Patient as expert . Autonomy . Accessible/flexible . Co-ordinated/integrated . Environment . Communication . C-Cg [17,36,37,74,75,77–93] – † † ‡ † † † ‡ Yes MRCF [17,35,77,84,85,94] – † † ‡ † † † ‡ Yes MUR/NMS [25,34,95–99] – † – – – – – † No 4Es [37,100,101] – † † ‡ – – – – No 3PQs [102] – – – – – – – † No PaCT [85] ‡ † † ‡ † – – ‡ Yes PharmaCat [103,104] – † † † – – – † No RIAS [105] † ‡ † † – – – † No SEGUE [77,84,85,106,107] – † – † – – – † No Tools . Summarised principles of person-centred care[5] . Scope to address six (75%) > pc principles . Know patient . Holistic inc. carers . Patient as expert . Autonomy . Accessible/flexible . Co-ordinated/integrated . Environment . Communication . C-Cg [17,36,37,74,75,77–93] – † † ‡ † † † ‡ Yes MRCF [17,35,77,84,85,94] – † † ‡ † † † ‡ Yes MUR/NMS [25,34,95–99] – † – – – – – † No 4Es [37,100,101] – † † ‡ – – – – No 3PQs [102] – – – – – – – † No PaCT [85] ‡ † † ‡ † – – ‡ Yes PharmaCat [103,104] – † † † – – – † No RIAS [105] † ‡ † † – – – † No SEGUE [77,84,85,106,107] – † – † – – – † No Extent tools address principles of person-centred consultations: fully (‡), partially (†) or not at all (–). Open in new tab Appraisal of selected consultation tools Calgary-Cambridge guide Person-centred appraisal of the Calgary-Cambridge guide is made more challenging due to the number of versions available. As the original two-part version of the guide represents the complete framework, this is the predominant focus of this appraisal. The Calgary-Cambridge guide addresses many aspects that are required for delivery of a person-centred consultation. Prompts are included which acknowledge holistic concerns and encourage collaborative working via elicitation and respect of the patient's perspective, promotion of autonomy and consideration of multi-disciplinary involvement. Specific guidance is also provided to optimise verbal and non-verbal communication. This includes a prompt to avoid the use of jargon and inclusion of examples of how to phrase specific questions which some users may find helpful, including for the opening of the consultation. Despite providing scope to address many aspects required for a person-centred consultation, the tool fails to address other key features. Development of a relationship in terms of ‘getting to know the patient as a person’ is not directly addressed. Furthermore, prompts related to patients' physical comfort and to identifying systems of support do not offer sufficient guidance on attending to the environment for a consultation or the potential involvement of family or carers which falls under the principle of holistic care. Use of the Calgary-Cambridge guide in pharmacy practice would likely be hindered by the length and structure of the tool (71 prompts contained within five sections), which reflects its original purpose as an educative aid. Latter iterations of the guide (basic, expanded and concluded)[74,75] offer truncated versions which may be more applicable for use in pharmacy practice. However, as these three modified versions merely address, with less detail, different sections within the original format, each fails to cover many of the principles required. Thus, overall they lack the comprehensiveness of the main guide, which is one of its strengths. Medicine-related Consultation Framework The MRCF provides a pharmacy-specific structure for a medicine-related discussion providing scope to at least partially address most of the principles required for a person-centred consultation. Overall, the tool provides an opportunity to develop a therapeutic alliance with the patient, and although attending to the need to develop a less formal relationship is not explicitly covered, prompts to explore social history do provide some scope for this as well as address holistic concerns. However, like other tools discussed, the potential inclusion of family/carers within a consultation is a notable omission. Promotion of patient autonomy is demonstrated throughout via encouraging a patient-led agenda and shared decision-making. The integration and co-ordination of healthcare services and accessibility of support are somewhat addressed through instruction to refer to other healthcare professionals as appropriate, plans for follow-up and the identification of a contact point. Emphasis is also placed on obtaining, respecting and incorporating the patients' perspective, although inclusion of the term ‘lay’ in connection to this may be interpreted as the antithesis of the patient being an expert about their condition and care. Ambiguous reference is also made within the introduction of the need to attend to matters of ‘comfort and privacy’ although explicit direction to consider the environment for a consultation is not included. The final section of the MRCF addresses the communication techniques required for the delivery of a successful consultation, such as the need to demonstrate active listening and use open questions. Unlike other tools included within this review, the MRCF does not provide any examples for possible phrasing of questions which some may find useful. Furthermore, information pertaining to styles of communication might be better and more appropriately placed at the start or included at different points within the tool in recognition that these are requirements for the entirety of the consultation. Overall, the MRCF offers a relatively succinct, chronologically ordered format which would likely make its use beyond the educative remit for which it was originally designed more attractive. Nonetheless, revision would be required in order for the tool to satisfy the multi-faceted requirements for a truly person-centred consultation. MUR and NMS advanced services In accord with their intention to support UK pharmacists' delivery of advanced services, the tools available for MUR and NMS contain instructional guidance which predominantly focuses on patients' management of their medicines. These tools, however, offer very limited scope to address the multiple dimensions required for a person-centred consultation. Prompts connected to healthy living partially address the holistic care principle, yet recognition of other matters related to this component of person-centred care, such as exercise or social history, is not included. As with other tools discussed, instruction is not included for the potential involvement of a third party within a consultation. The NMS tool does include additional guidance regarding appropriate communication and highlights that the success of a consultation is dependent upon the facilitators' skill and style of delivery. Nonetheless, guidance within these tools merely covers what to say, as opposed to providing support as to how to conduct a consultation. Considering that advanced services are designed to target groups of patients, who are likely to have specific communication needs due to their health condition, this is of particular concern and may contribute to patient or carer needs not being met through these consultations. The brevity of these tools may, however, make them more appealing for use within a real pharmacy setting given the constraints of practice which impact on the availability of time for a consultation. They also provide specific directions to address contractual requirements for advanced services which may further make them appealing for use in a live consultation. However, major revisions would be required to these tools to ensure that they were capable of supporting pharmacists to deliver a truly person-centred consultation in practice. Patient-Centred Communication Tools The more recently published PaCT provides a comprehensive structure to address most of the key components required for a person-centred consultation. This tool was developed specifically for pharmacist–patient consultations from a multi-stage process which included a review of the literature and the authors' experience of using a validated communication tool designed for physicians (Four Habits Model – FHM-1). It has been validated for face, content and construct validity and test–retest reliability using data from student pharmacist–patient communication skills training and assessment. This includes prompts which acknowledge the development of a longer-term relationship using a less formal approach consistent with the person-centred principle of getting to know the patient as a person. Throughout, the tool offers opportunities to ascertain and provide responses relative to individual views, knowledge and preference. This provides scope to satisfy person-centred principles related to acknowledging the patient as an expert about their care and the promotion of autonomy. The need to provide accessible, flexible and co-ordinated/integrated healthcare services is also possible to address via prompts at the end of the tool for follow-up. Despite recognition of the potential need to involve carers and family within a consultation, holistic requirements are also satisfied through, for example, prompts connected to diet. Matters relating to the physical environment for a consultation are not addressed at all; however, comprehensive instruction for verbal and non-verbal communication is provided together with examples of phrases to support optimal communication. Overall, PaCT provides information which is chronologically presented to reflect the natural progression of a typical encounter with a patient. With specific modification in order to fully address all principles of person-centred care including attendance to the environment for a consultation and reduction in the quantity of information within the tool, the PaCT would have value for supporting delivery of a person-centred consultation in a UK pharmacy practice setting. Discussion The literature search and selection criteria adopted led to four consultation tools being selected for detailed review (Calgary-Cambridge guide, MRCF, MUR and NMS advanced services and PaCT). Of these, three were designed for use in a pharmacy context. The exception was the Calgary-Cambridge guide which was originally designed for use in medical education but has latterly been extensively used in pharmacy education and training. Three were designed as educative tools, and only one (MUR and NMS advanced services) was designed for use in practice. The tools demonstrated their varying scope to address the principles identified by de Silva,[5] but none fully met all criteria to support UK pharmacists' delivery of a person-centred consultation. Each of the consultation tools submitted to a detailed appraisal against the de Silva criteria had some strengths but also a number of limitations, including a failure to acknowledge key features such as the involvement of family/carers and consideration of the environment during a consultation. Failure to address these areas may result in some patients not gaining maximum benefit from their consultations. The design and length of the educative tools would make them impractical for use in a UK pharmacy practice setting, while the tool designed to support MUR and NMS consultations in practice, while shorter, was least likely to fulfil the needs of a person-centred consultation. This novel paper presents a structured attempt to appraise current published consultation tools available to pharmacy educators and practitioners. Using a narrative format, it reviewed the tools in terms of their ability to support effective patient-centred consultations between pharmacists and patients. Delivering person-centred care is a high priority for all health services in the UK and is increasingly acknowledged as the way forward worldwide. In the UK, this is particularly relevant as pharmacists are currently rapidly expanding their clinical roles in both secondary and primary care, becoming independent prescribers with patient caseloads and engaging in ever more complex patient-facing services.31–34 The ability of pharmacists to engage in effective person-centred consultations with their patients thus becomes ever more important to the current and future direction of pharmacy services. However, evidence suggests that effective person-centred consultations are not yet being achieved by pharmacists either in the UK or elsewhere.[25,43–46,54] There are, however, limitations to this review. There are as yet no acknowledged guidelines for the narrative review format which has been used in this paper to describe and review published research, but a systematic approach was used to search for relevant literature and to select articles for detailed appraisal. Screening and data extraction undertaken independently in duplicate would have increased confidence in the reproducibility of the review findings; however, both activities were undertaken by one researcher. The lack of an agreed definition of what comprises person-centred care is an additional limitation. An alternative selection of search terms, locations and use of a different definition of person-centred care may have presented different results. It is also acknowledged that the appraisal of individual tools using the principles of person-centred care is a somewhat subjective process. Evaluation of necessity requires a degree of interpretation as to whether the guidance provided within the tools would be sufficient to partially or fully satisfy the specific principles as summarised by de Silva. However, these concerns were mediated via discussion and consensus on findings between the researcher and the secondary authors of this paper. Conclusion and implications for practice UK pharmacists are being increasingly directed to provide patient-facing, person-centred services.31–34 This review has identified that currently available consultation tools do not adequately incorporate the features outlined by de Silva that ensure the resulting interaction is person-centred.[5] In order to realise the goal for UK pharmacists to deliver person-centred consultations in practice, suitable tools are required which address the multi-faceted demands of person-centred care. This can be achieved via revision of existing tools or through the creation of pharmacy-specific consultation tools which provide scope to address the many dimensions of person-centred care. Educationalists and health services researchers within pharmacy, in collaboration with policymakers, professional organisations and practising pharmacists, should take the initiative to develop and validate such tools for the profession to ensure that the goal of delivering person-centred consultations within the constraints of community pharmacy practice can be realised. For example, a tool to support patient-centred consultations between community pharmacists and stroke survivors has recently been published.[76] Declarations Conflict of interest The Author(s) declare(s) that they have no conflicts of interest to disclose. Funding This research received no external funding. Acknowledgements The authors are grateful to Medway School of Pharmacy, Universities of Kent and Greenwich, for funding a PhD Scholarship for DLD. References World Health Organization . 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TI - A narrative review on the consultation tools available for pharmacists in the United Kingdom: do they facilitate person-centred care?
JO - International Journal of Pharmacy Practice
DO - 10.1111/ijpp.12587
DA - 2020-07-09
UR - https://www.deepdyve.com/lp/oxford-university-press/a-narrative-review-on-the-consultation-tools-available-for-pharmacists-ajuWpxEYSB
SP - 301
EP - 311
VL - 28
IS - 4
DP - DeepDyve
ER -