PATIENT
COUNSELLING
Communication is
the transfer of information meaningful to those involved. It is the process in which
messages are generated and sent by one person and received and translated by another
person. However, the meaning generated by the receiver can be different from
the sender’s intended message.
The
communication process between health professionals and patients serves two
primary functions.
1. It
establishes an ongoing relationship between the professional and the patient.
2. It provides
the exchange of information necessary to assess a patient’s health condition,
implement
treatment of medical problems, and evaluate the effects of treatment on a
patient’s
quality of life.
The healthcare
professional must be able to
- understand the
illness experience of the patient
- perceive each
patient’s experience as unique
- foster a more
egalitarian relationship with patients
- build a
therapeutic alliance with patients to meet mutually understood goals of therapy
- develop
self-awareness of personal effects on patients
The healthcare
professional should encourage patients to share experiences with therapy because
- they have
unanswered questions
- they have
misunderstandings
- they
experience problems to therapy
- they can
“monitor” their own responses to treatment
- they make
their own decisions regarding therapy
- they may not
reveal information to you unless you initiate a dialogue
Communication
during drug therapy
- Purpose of
medication
- How medication
works
- Dose and
duration of therapy
- Goals of
therapy
- How
effectiveness will be monitored
- Adverse
effects and how to deal with them
- Drug specific
issues
The physician
must keep in mind that it is his or her responsibility to help patients achieve
desired health outcomes. Communication skills of pharmacists can
facilitate formation of trusting relationships with patients. An
effective communication process can optimize the chance that patients will make
informed decisions, use medications properly, and meet therapeutic goals.
Interpersonal
communication is the transmission and reception of verbal and
non-verbal
messages between
people.
Listening is an
ability which effectively enhances the communication process.
Listening
techniques for the patient interview process
- Stop talking.
You can’t listen while you are talking.
- Get rid of
distractions.
- Use eye
contact to show you are listening.
- React to ideas
rather than the person.
- Read nonverbal
messages.
- Provide
feedback to clarify the message. This shows that you listen and are trying to
understand.
Non-verbal
communication consists of meaning conveyed through body language
and facial
expressions.
As a physician,
you must recognize that interpersonal communication is a lot more than
just speaking to
others or giving a prescription. You must make sure that the
messages you transmit to others are received accurately. There is no guarantee
that the meaning of your
message will be
translated as intended. You need to make sure you enhance your listening skills
Interactive
communication involves dialogue with patients involving health
condition or
treatment.
Patients are engaged in conversation so practical matters are covered by the
doctor.
Empathy is
the ability to see the world through another person’s eyes and perceive his or
her
emotions.
The meaning of
the message is influenced by the receiver’s perception of the message.
Therefore, it is
important to remember the following points when communicating with
others.
1. Always anticipate
different perceptions in the communication process.
2. Try to be
aware of stereotypes you hold that may influence your perception of others and
also be aware of
stereotypes others have on you.
3. Ask for
feedback from the receiver about how well your intended message was received.
4. Provide
feedback to the sender to check your perception of the message and make sure
you
understood
correctly.Barriers to effective communication include physical,
psychological, administrative or time conflict. Such conflicts prevent
effective communication from being established.
Environmental
barriers such
as a lack of privacy or furniture that creates physical barriers
between patients
and doctors/pharmacists can prevent effective communication. Environmental barriers
are examples of physical barriers.
Semantics relate
to meanings of words and symbols used in interpersonal communication.
Words only
contain meaning in terms of people’s reactions to them. Words can also have
multiple
meanings. Therefore, effective patient communication requires the use of words
that are carefully chosen. Jargon should be clearly defined or avoided.
Semantics is an example of a psychological barrier.
Perception is
how a message is perceived by a patient. The patient may view the doctor as only
being interested in diseases, drugs and money, not people. If the patient views
the doctor as being incompetent or uncaring, he/she is less likely to trust the
doctor’s advice. Perception is an example of a psychological barrier.
Negative
attitude from
doctors or pharmacists are usually caused by a lack of confidence and low
self-esteem. Communication is far from ideal all the time, and doctors or
pharmacists should strive to improve their skills through practice. Many
doctors believe that it is not their job to counsel their patients, but it is.
Negative attitude is an example of a psychological barrier.
Personal
barriers include
low self-confidence, shyness, dysfunctional internal monologue, lack of objectivity, cultural differences,
discomfort in sensitive situations, and conflicting values to healthcare
practice.
Administrative
barriers such
as management may view the lack of money compensated for
communication as
a reason not to communicate. More money is made by prescribing medication, not
caring for patients.
Time barriers are
interlinked with administrative barriers because management is responsible for
staffing levels as well as allocation of work duties. Time limits are very
common when it comes to pharmacists and patients. Time restraints are often
excuses not to counsel, though it often does not take very long.
Interpersonal
communication, because of its complexity and human involvement, is a
fragile process.
Messages
become helpful to the patient only when they are accurately received and understood.
If messages are distorted or incorrect, they could be harmful to the patient
and prevent a positive patient outcome. It is important to understand these
potential communication barriers so a strategy could be developed to minimize
or remove them.
To conduct a
more efficient patient interview
- Avoid making
recommendations during the information-gathering phases of the
interview. Such
recommendations prevent the patient from giving you all the needed
information and
can interfere with your ability to grasp the big picture of patient need.
- Similarly, do
not jump to conclusions or rapid solutions without hearing all of the facts.
- Do not shift
from one subject to another until each subject has been followed through.
- Guide the
interview using a combination of open ended and closed ended questions.
- Similarly,
keep your goals clearly in mind, but do not let them dominate how you go
about the
interview.
- Determine the
patient’s ability to learn specific information in order to guide you in your
presentation of
the material. Reading ability, language proficiency, and vision or hearing
impairment all
would influence the techniques you use in interviewing and counseling a
patient.
- Maintain
objectivity by not allowing the patient’s attitudes, beliefs, or prejudices to
influence your
thinking.
- Be aware of
the patient’s nonverbal messages.
- Depending on
your relationship with patient, move on from less personal to more
personal topics.
This may remove some of the patient’s initial defensiveness.
- Note taking
should be as brief as possible.
False
assumptions about patient understanding and medication adherence
- Do not assume
that previous physicians have already discussed with patients the
medications they
prescribe. In fact, one study found that physicians frequently omit
critical
information.
- Do not assume
patients understand all information given.
- Do not assume
that if patients understand what is required, they are able to take
medication
correctly. Medication regimens take time to get adjusted to.
- Do not assume
that patients don’t take medication because they don’t care or aren’t
motivated. These
assumptions prevent you from focusing on their real problems.
- Do not assume
that once patients have problems they will contact you. Doctors need to
constantly
initiate interaction by asking open-ended questions.
- Patients must
not only know key points of information about their medication but also
perform specific
behaviors (taking medication at certain time, using an inhaler properly,
etc) to optimize
therapeutic outcomes. Doctors must assess patient knowledge about
medication and
educate them regarding essential information.
Communication
with special patients
- The Elderly
account for 30% of all prescription medication taken in the United States
and 40$ of all
OTC medication. As a group, sometimes the aging process affects certain
elements of the
communication process in some older adults. In certain individuals, the
aging process
affects the learning process, but not the ability to learn. Some older adults
learn at a
slower rate than younger persons. They have the ability to learn but they
process
information at a different rate. The elderly might also have problems such as
poor
vision, speech
or hearing. Therefore, it is very important to set reasonable short-term
goals, and break
down learning tasks into smaller components. It is also important to
encourage
feedback as to whether they understand the intended message.
- Terminally
Ill patients are usually intimidating to work with because people do not
want to say the
“wrong” things that would upset them. Before interacting with them, be
aware of your
own feelings about death and about interacting with terminally ill patients.
Simply being
honest with them can improve their interaction with them. It will also open
them up to voice
out their concerns as well. Many terminally ill patients know that they
can make others
feel uncomfortable. You should not avoid talking to them unless you
sense that they
do not want to talk. Not interacting with them only contributes further to
their isolation
and may reaffirm that talking about death is uncomfortable.
- Patients
with AIDS are not only dealing with life threatening diseases, but also the
social stigmas
that often accompany their conditions. The key is not to treat them as
different from
others. Due to the advent of highly effective antiretroviral therapy, health
professionals
should adjust their thinking to perceive HIV infections as a chronic
condition rather
than a terminal disease.
- Patients
who are mentally ill can be difficult to communicate with. Open-ended
questions would
be more effective as they can be used to determine the patient’s
cognitive
abilities. Ethical considerations include whether they require consent from the
patient for
treatment. Mentally Ill Patients might not always understand their treatments
or medication
purposes.
Communication
with Children
- Attempt to
communicate at the child’s developmental level
- Ask open-ended
questions rather than questions requiring only a yes or no response
- Use simple
declarative sentences for all children
- Ask the child
whether he or she has questions for you
- Augment verbal
communication with written communication
- Nonverbal
communication is very important with children therefore be aware of your
facial
expressions, tone of voice, gestures, and so on.
Children want to
know. Healthcare professionals should communicate directly with children
about medicines
and treatment.
Ethical principles
Beneficence is
the principle that health professionals should act in the best interest of the
patient.
Autonomy is
the principle that establishes patient rights to self-determination- to choose
what will be
done to them.
Honesty principle
states that patients have the right to the truth about their medical condition,
the course of
disease, the treatments recommended and the alternative treatments available.
Informed Consent
has
occurred and treatment can be implemented if all relevant
information is
provided, if the patients understand the information, and if consent is given
freely without
coercion.
Confidentiality serves
to assure patients that information about their medical conditions and
treatments will
not be given to individuals without their permission.
Fidelity is
the right of patients to have health professional provide services that promote
patients’
interests rather than their own. Ethically, the responsibilities of physicians
should be
directed towards
the patients rather than directed at the financial well-being of the clinic.
Steps in ethical
decision making
- Recognize and
state the ethical dilemmas involved in each situation or case
- Collect
all relevant facts including both medical as well as social or psychological
aspects
of the case.
These facts may clarify whether the problem really does involve ethical issues
or
not.
- If the problem
involves ethical issues, generate all possible alternatives to resolving the
dilemma
- Evaluate
alternatives in terms of principles that apply as well as possible consequences
of
the difference
choices.
- Choose the
best alternative and justify your choice in terms of the prioritization of
ethical
principles
involved. Often one principle must be suspended in favor of a more compelling
principle in
resolving a dilemma.
Physicians must
understand the principles that serve as foundations for ethical decisions in
health care. The obligation to respect patient autonomy, to
protect confidentiality of patient information, to serve patient
welfare, and to treat patients with respect and compassion are fundamental
duties for any health care professional. Use of a systematic decision-making
process when ethical dilemmas arise and principles seem to compete can assist
you in reaching decisions that are ethically valid..
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