1. COMMUNICATION SKILLSFOR DISPENSERS AT RDVs March 2, 2012 Milano Hotel, Mekele
2. Case I• A 1 year old baby is admitted to a clinic with a severe infection. The mother came to a nearby rural drug vendor and while the dispenser was speaking to her, he leant that about 1 wk ago, her son had developed a minor bacterial infection and received an antibiotic, which she gave him for 4 days until the infection appeared to be cleared up.
3. Case 1, contd.• When asked why she stopped the antibiotic, the mother stated that she was just following the directions on the label of the container which reads: • “Take one-half of teaspoonful three times a day for infection until all gone”.2. What went wrong with this communication?3. Was it possible to avoid the misunderstanding and how?
4. Say true or false to the following statementsbased on Case 1A The dispenser didn’t have a good communication skill T FB Communication barrier is a hindrance to therapeutic T F successC “Until all gone” is the wrong term in this T F communication that made the mother stop giving the antibiotic prematurelyD When advising clients, simple to remember terms have T F to be used (avoid medical jargons)E Such terms as “take a tablet; apply an eye drop; insert a T F suppository; apply a cream” have to be used in communication
5. Objectives Describe the basic principles and/or processes of communication Explain the various means of communication Identify the different barriers to communication Review the basic skills to effective communication Describe the best approaches to communicating with health care providers Demonstrate effective communication with patients and between providers
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7. Patient-oriented pharmaceutical services• Clinical pharmacy services are patient-oriented services developed to promote the rational use of medicines, and more specifically, • to maximize therapeutic benefits (optimize treatment outcomes), • minimize risk, reduce cost, and • support patient choice and decisions • there by ensuring safe, effective and economic use of drug treatment in individual patients.• Effective communication is the key to successful patient-oriented pharmaceutical services
8. Pharmaceutical Care• is the responsible provision of medicine therapy for the purpose of a definite outcome that improves a patient’s quality of life.• is based on a relationship between the patient and the healthcare providers who accept responsibility for the patient.• it implies the active participation of the patient in medicine therapy decisions, the cooperation of healthcare providers across disciplines, and gives priority to the direct benefit of the patient.
9. THE COMMUNICATION PROCESS Three parts of communication process Sender Message Receiver The goal of all communication is understanding Effective communication occurs only when the meaning of a message is held in common by the participants.
10. THE COMMUNICATION PROCESS (2)• Flow of communication
11. VERBAL AND NONVERBAL COMMUNICATION Verbal Communication Involves the words which are spoken Actual words convey about 10% of the message Non verbal communication Involves the use of body languages: Gestures, facial expression, eye contact physical contact, body posture body space and proximity
12. Challenges of Communication for Patients Inferiority Low-literacy Anxiety Conflicting information Forgetfulness Prefer not to disclose their concerns Impaired faculties of communication Blind, deaf, etc.
13. BARRIERS TO COMMUNICATION IN DISPENSARIES1. The Environment Physical barriers Lack of privacy Noise A busy rural drug vendor
14. Inside View of a Dispensing Unit - small dispensing window
15. Outside View of a Dispensing Unit - no privacy when counseling
16. Counseling: before renovation(privacy???)
17. Counseling: After renovation
18. Dispensing/Counseling Unit – Before Renovation
19. Dispensing/Counseling Unit – After Renovation
20. BARRIERS TO COMMUNICATION IN DISPENSING SETTINGS (2)1. The Patient Factors • Physical disabilities • Illiteracy2. The Dispenser Lack of adequate knowledge Lack of confidence Lack of interest Laziness Delegating responsibilities to untrained staff• Time: suitable timing of information
21. Case II• A young woman suffering from vaginal candidiasis was given the usual 15 nystatin vaginal tablets and was told by the dispenser to “use one tablet daily for two weeks.”• She returned to the pharmacy after two weeks in severe discomfort with a complaint that “those nystatin tablets taste terrible!” • What was the problem with this communication?
22. LISTENING AND QUESTIONING SKILLSListeningListening is extremely important to effective communication Good Listening Poor Listening Helps to get better information Creates misunderstandings Saves time Wastes time Solves problems Creates problems Reduces errors Allows for mistakes
23. LISTENING AND QUESTIONING SKILLS (2)Keys to Effective Listening: Take personal responsibility for understanding what you hear Concentrate and make a good effort to focus on the person speaking Listen without interrupting, disagreeing, or offering explanations Use body language (nonverbal gestures) to show that you are involved in the conversation. Example: nod your head, keep eye contact, keep hands at side Ask questions to be certain you are interpreting the message correctly. Example: summarize and paraphrase what you heard Take notes as necessary. This will help you remember or document what was said
24. Sharing experiences• Share your experience to the participants where mistakes were made because of poor listening.
25. LISTENING AND QUESTIONING SKILLS (3)Questioning ‘Questioning’ is one of the most widely used social skills In a health setting, questions are normally asked to encourage the listener to provide information The type of question asked and the way in which it is asked will dictate the level of response given Health care providers can use two types of questions • Close ended questions: Did you take your doses correctly? • Open ended questions: How did you take your doses last month?
26. STRATEGIES TO IMPROVE COMMUNICATION Explain things clearly in plain language Focus on key messages and repeat Use a “teach back” or “show me” technique to check understanding Effectively solicit questions Use patient-friendly educational materials to enhance interaction Together, these strategies and others will help ensure the environment is patient-friendly and shame-free for ALL patients.
27. 1. Explain Things Clearly in Plain Language Slow down the pace of your speech Use plain, non-medical language • “Blood pressure pill” instead of “antihypertensive” • Pay attention to patient’s own terms and use them back Avoid vague terms “Take 1 hour before you eat breakfast” instead of “Take on an empty stomach”
28. Using Plain Language: What could we say instead of… Adverse reaction Side effect Hypoglycemia Low sugar PRN When you need it Topical On skin Angina Chest pain Your H.I.V. test was negative You don’t have H.I.V
29. 2. Focus on Key Messages and Repeat Limit information Focus on 1-3 key points Develop short explanations for common medical conditions and side effects Discuss specific behaviors rather than general concepts What the patient needs to do Review each point at the end
30. 3. Use a “Teach Back” to Check UnderstandingTeach Back Scripts: I want to make sure I explained everything clearly. If you were trying to explain to your husband how to take this medicine, what would you say? Let’s review the main side effects of this new medicine. What are the 2 things that I asked you to watch out for? Show me how you would use this inhaler.
31. 4. Effectively Solicit Questions Don’t say: Do you have any questions? Did you take your doses correctly? Instead say: What questions do you have? How did you take your doses last month?”
32. COMMUNICATION B/N DISPENSERS AND PRESCRIBERS The provision of pharmaceutical care requires a collaborative relationship with the physician (Prescriber) With rare exceptions, the primary reason dispensers call physicians is that something is wrong or a problem needs to be resolved. Because these calls so often begin with a problem, they can start off in a negative or adversarial way and trigger defensiveness in the physician. But skillful and sensitive dispensers can turn these negatives into pluses.
33. Reasons for Communication Untreated condition(s) Improper drug selection Dosage too high Subtherapeutic dosage Adverse drug reactions and side effects that cannot be tolerated or won’t go away Drug interactions Unnecessary drug therapy Compliance problems Request for additional information about the patient
34. Preparation Before Communication Have the necessary facts ready, including your recommendation and rationale Have a literature citation ready, if possible Get sufficient information from the patient Be prepared to the SOAP approach Always have an alternative recommendation ready in case your initial recommendation is not accepted
35. Communication Considerations The entire focus should be on attacking problems or issues, not people or personalities There is a big difference between the following: • Dr. Solomon, Ato Samson can’t use those tablets you prescribed. I would like to recommend ….) and • Dr. Solomon, Ato Samson has trouble of swallowing. I would like to recommend ….) Make sure professional boundaries are respected Make sure that you listen completely to the physician’s rationale for the decisions made Use 4F communication: “I know how you feel. I felt the same way, too. But found in the literature….,” and stay focused on the problem
36. Handling the Communication Begin by identifying yourself Identify the patient whom you are to discuss Present the issue or concern that you have identified Do not be judgmental Use professional rapport to gain respect Be prepared to discuss the issue on a professional level Propose a solution Await feedback
37. Handling the Communication (2) You may not always have all of the answers to the questions that follow Be comfortable saying that you do not know the answer at the moment, that you will look into it and get back to the provider as soon as you can The provider will respect that you provide only information about which you are confident Over time, you will build a working relationship with the physicians and nurses that you work with
38. Outcome of the Communication Preparation, focus, and interpersonal skills can make a great deal of difference in the outcome of the dispenser-physician interaction Scenarios of pharmacist-physician interaction: same problem but different communication style affecting the final outcome
39. Dialogue 1 Dispenser: Hi Doctor, the amoxicillin you prescribed for Ms. Kidist’s kid is not working. We need to get her something else. Physician: Who is this? Dispenser: Zewdu at Lions rural drug vendor – the dispenser Physician: What do you mean it’s not working? Did she give it to the child correctly? He’s only been taking it for 5 or 6 days. She has a 10 days supply. Is the child still running fever? Dispenser : I guess she’s giving it to him right. She says he is not feeling good and she wants to give him something else. I didn’t ask about a fever. Physician: Tell her to call me. I will take care of it. Dispenser : You got it, Doctor! Discussion
40. Dialogue 2 Dispenser: Hi Doctor Kamil. This is Zewdu Kassa at Lions rural drug vender. I just got off the phone with Kidist Bikila, Tedy’s mother. She called because she was concerned about Tedy. His fever is 38 0C and he has been taking the amoxicillin for 6 days now, three times a day as you prescribed. She said he is still in a miserable condition. I assumed Tedy has otitis because she talked about his ear infection and I saw from his medication records that he was treated for otitis once before, about 3 months ago. I think it might be time to go to trimethoprim- sulfamethoxazole twice a day.
41. Dialogue 2 Contd… Physician: So he is still running a fever. From what you said it sounds like he is not responding to the amoxicillin. Ok, give him the trimethoprim-sulfamethoxazole twice a day. Do you have his weight? Dispenser: Sure Doctor. Physician: Good. Let’s keep him on it for 10 days. Dispenser: Ok, I’ll let Mss. Kidist know. Physician: Thanks for calling. Dispenser: You’re welcome. Thanks for getting back to me so quickly. Discussion
42. Lessons Learnt from this Dialogue Well-prepared and skilled dispensers who focus on patient problems rather than on prescribing problems can turn these interactions into opportunities for professional collaboration and cooperation, rather than conflict there by saving the patient from unnecessary drug related problems which is the ultimate goal of the communication.
43. Role Play Demis came to your rural drug vendor and tells you that he has been suffering from itching. He pulls up his shirt and shows you a rash on his skin. When you look at his medicine envelope, you realized that he was taking cotrimoxazole. Trying to gather more information from the patient to determine if he is having a mild or severe rash, you established that the patient has severe rash. Contact the prescribing nurse or physician to change the medication.
44. Role play• Negus, a 24 year old daily laborer, comes to your RDV with a prescription for Amoxicillin for community acquired mild pneumonia: Amoxicillin 500 mg capsule P.O. TID for 7 days• Provide him with the necessary information to enable him take the drug correctly
45. Role Play• A patient comes to your RDV with a prescription for Fansidar stat and Chloroquine for 3 days.• Contact the physician and propose a change of his/her medication.
46. KEY POINTS Successful communication of information, ideas, and concepts is an integral skill that must be learned, developed, and used by all dispensers. Relationship between patients and dispensers provide the basis for effective and valued communications. Understanding feelings properly and empathic responding strengthens the therapeutic alliance between the patient and the dispenser. Good communication with providers and patients is essential for successful care and treatment. The provision of pharmaceutical care requires a collaborative relationship and team work with providers