After completing the chapter, the students should be able

to:

1. Differentiate between the terms patient counseling,

consulting, and patient education.

2. List the counseling and education goals of patient

counseling in pharmacy

3. Describe the differences between the various models of

patient-provider relationships.

4. Describe the adult educational approach of andragogy

as applied to patient counseling

5. Define patient counseling in pharmacy.

Counsel – giving advice, but it also implies mutual discussion and an exchange of opinions.

Consult – to seek advice, and suggests almost exclusively receiving advice rather than exchanging information.

Education – involves a slightly different sphere of interaction. It is defined as “instruction and development to impart skills and knowledge”

The theories underpinning the professional fields of counseling and education offer more comprehensive explanations of these terms.

Listening – psychotherapy

Questioning

Evaluating

Interpreting counseling

Supporting

Explaining

Informing

Advising

Ordering

In educational theory, education connotes much more than simply imparting knowledge.

It may defined as “progressive changes of a person affecting knowledge, attitudes, and behavior as a result of instruction and study.”

Education involves processes through which people develop their abilities, and enrich their knowledge, and which help bring about changes in their attitudes and behavior.

Form this semantic discussion, it may be

seen that the activity that pharmacists

refer to as “patient counseling” involves

counseling in the psychological sense, as

well as activities that aim to educate

patients.

It encompasses theories of counseling

and educating in varying degrees,

depending on the situation and the

needs of the patient.

BEHAVIORAL THEORY

B.F. Skinner – suggested that behavior that is reinforced is repeated and, conversely, behavior that is not reinforced or that is actually punished is not repeated.

A broader approach is cognitive behavior modification. It assumes that it is not the experience alone that is the cause of behavior, it is the individual’s underlying cognition of the experience (conceptions. Ideas, meanings, beliefs, thoughts, inferences, expectations, predictions, or attributions)

Vary from individual to individual and are acquired throughout the course of life through experiences.

When explaining to the patient the reasons behind medication instructions and the ways in which the medication will treat the condition, the pharmacist attempts to change the patient’s thoughts about the usefulness of the medication, and the importance of adherence.

This change in the patient’s thoughts is expected to result in a behavioral change with regard to taking medication.

Behavior therapy is the source of the patient education methods, such as self-monitoring, demonstration (modeling), and practice (behavior rehearsal)

THEORIES OF HEALTH BEHAVIOR

There have been attempts to analyze why patients

behave the way they do when they are ill and need to

take medication.

It suggests that patient’s perceptions about the severity

and possible outcomes of their conditions, the

effectiveness and benefits of medication use, and various

triggers to taking medication may be critical elements in

patient medication use.

These theories indicate that patient counseling involves

not only an exchange of information, but should also

involve an attempt to change the patient’s health beliefs.

HUMANIST APPROACHES TO COUNSELING

The humanist school of psychology considers people’s

thought and feelings in addition to behaviors.

When pharmacists counsel patients they should

acknowledge that patients are not only behaving due to

external controls of stimulus and reward, but also thinking

and feeling.

Pharmacists’ counseling should take the patient’s feelings

and thoughts into consideration.

The person-centered approach to counseling, by Carl

Rogers, is part of humanistic psychology and is one of the

greatest influences on the field of counseling.

This approach to counseling is based on the idea that people will naturally grow and develop their capacities (self-actualization)

From this perspective, the pharmacist helps patients get the most benefit from their therapy by helping them feel capable of controlling their own medication use – by helping them identify and solve their own problems in this area. This echoes the concepts in pharmaceutical care of patient-centered care.

A key element of Carl Roger’s patient-centered helping approach is the pharmacist’s genuine feelings of warmth and concern for patients and his or her trust in their abilities to solve their own problems.

This is exemplified in part by the pharmacist spending the necessary time with each patient and by the pharmacist’s helping attitude during the interaction

AN ECLECTIC COUNSELING THEORY

Gerard Egan – Process of helping. The aim of counseling is

to help people manage their problems more effectively.

The process of helping described by Egan involves three

stages:

1. Clarifying the problem (to explore the individual’s

viewpoint of the problem)

2. Setting goals (achieving an overview of the individual’s

problems and setting goals to overcome them)

3. Facilitating action (to help the person plan ways of

achieving the goals set, to carry out the goals, and to

evaluate the outcomes).

TREATMENT DECISION-MAKING MODELS

MODEL TYPE CHARACTERISTICS

PATERNALISTIC •Assumes doctor knows best

•Doctor selects treatment

•Patient involvement limited to giving consent

•No consideration of patients’ values or preferences

INFORMED DECISION

MAKING

•Patient alone will make decision when provided with all

necessary technical information

•Clinician’s role is to provide information to support patient

in decision

PROFESSIONAL-AS-

AGENT

•Assumes only doctor has sufficient technical knowledge

to make final decision

•Recognizes importance of incorporated patient’s

preferences

•Final decision made by clinician

SHARED DECISION

MAKING

•Patient and clinician engage in the decision-making

process

•Information and values are shared

•Uses physician’s technical knowledge and experience

and patient’s experience, culture, and prefrences.

In terms of pharmacist’s relationship with

patients, the pharmacist may be in a

decision-making position when discussing

self-medication.

But in the case of prescribed medication,

the pharmacist is more in a position of

mediating the relationship between

physician and patient.

Pharmacists are in an ideal position to assist

the patient and physician to share

information and common understanding.

Counseling is essentially a helping process.

The mission of pharmacy practice is to help people make the best use of medications.

Patient medication counseling – pharmacists talking with patient about the medications they are intended to take in order to educate them about medication-related issues and to help them get the most benefit from their medications.

Helping and education goals

Pharmacist must first establish a relationship with the patient and develop trust.

The pharmacist must also demonstrate concern and care for the patient in order for him to know that the information the pharmacist is providing and the questions the pharmacist is asking are in the patient’s interest.

The essence of all counseling is to help a person cope effectively with an important problem or concern.

Problem involves the individual’s health and the need to fit medication use into his or her daily life.

Patient counseling might also involve helping the patient cope with illness and with the changes it is likely to bring about in his or her lifestyle.

Counseling involves interventions to prevent the occurrence of later problems and to develop the individual’s capacity to deal with such problems if they should arise.

Problems can be emancipated and then prevented or at least minimized through discussion with the patient.

Future problems might involve the patient’s ability and intention to adhere to the medication directions.

Pharmacist could point out the risks of missing a dose of the medication and suggest alternatives to the patient.

Other future problems might involve the development of side effects or adverse effects.

The unknown is often more frightening than the known. Knowing what to expect and what action to take allow the patient to exert some control over unavoidable events.

Once present and future problems with medication use have been detected, the goal of counseling is to develop the patient’s capacity to deal with such problems.

The patient is an integral part of the problem solution.

The pharmacist must discover what the patient needs to know; what skills he or she needs to develop; and what problems need to be dealt with. Pharmacist must also determine which behavior and attitudes need to be modifies.

Finally, pharmacists can provide education and gather information from the patients about their needs and preferences in order to support the physician-patient relationship.

HELPING GOALS OF PATIENT COUNSELING

1. To establish a relationship with the patient and to develop trust

2. To demonstrate concern and care for the patient

3. To help the patient manage and adapt to his or her medication

4. To help the patient manage and adapt to his or her illness

5. To prevent or minimize problems associated with side effects, adverse

effects, or present and future nonadherance

6. To develop the patient’s capacity to deal with such problems

7. To help the patient and other health professionals to work together

toward shared decision making.

Educate the patient.

Education involves enhancing skills and knowledge in order to bring about changes in related attitudes and behaviors.

The pharmacist’s educational goal will be to provide information that meets the specific needs of each patient.

The educational goals of patient counseling also involve investing patients with the skills and techniques they need to optimize their prescribed therapy.

The pharmacist must provide information and instruction in a way that makes them effective for this particular patient in this particular situation.

Finally, pharmacists have opportunities to educate other health professionals about drug-related issues.

EDUCATIONAL GOALS OF PATIENT COUNSELING

1. To provide information appropriate to the particular individual and

the particular problem.

2. To provide skills and method that the patient can use to optimize the

usage and effects of the medication

3. To present information and instruction using educational method that

are appropriate to the particular individual and the particular situation

4. To educate other health professionals about drug-related issues.

THE HELPING APPROACH

Health professional-centered “medical-model” approach to the patient-centered “helping-model” approach.

The medical model and the helping model contrast with respect to the relationship between the health professional and the patient.

They differ in number of areas:

The role of each party in the relationship

The basis for trust

The approach to problem solving

The allowance for the solving of future problems.

MEDICAL MODEL HELPING MODEL

•The health professional is active and

the patient is passive

•Both patient and health professional

are active

•The basis for trust is the presumed

expertise and authority of the health

professional, to w/c the patient

automatically responds

•Trust is not automatic, but grows slowly,

based on the personal relationship –

trust develops mutually between the

professional and the patient.

•The health professional identifies the

problems, analyze information, arrives

at a diagnosis, and gives direction to

work on the solution.

•The patient is responsible only for

answering questions and following

directions.

•The professional assists the patient in

exploring the problem and possible

solutions.

•The patient is responsible for drawing

conclusions, making decisions, and

selecting a solution he or she can

follow.

•Patient becomes dependent on the

professional.

•The patient must return to the health

professional to deal with future

problems in the previously learned way

and to seek help if necessary

•The patient develops self-confidence

to manage his or her own problems.

•Parent-child relationship •Equal relationship

Pharmacists must decide for themselves where on

the continuum they feel most comfortable in their

relationship with the patient. and also where the

patient may feel most comfortable.

To attain the counseling goals most effectively, the

pharmacist must lean more heavily toward the

helping-model approach

THE EDUCATIONAL APPROACH

FOUR BASIC CONCEPTS that illuminate the conditions and

processes of adult learning:

a. Self –concept

In adult education, the teacher and learner develop a

helping relationship, characterized by reciprocity in the

teaching-learning transaction.

The pharmacist must join with the patient to help solve

problems relating to his or her illness and medication use.

b. Experience

Adults accumulate a vast range of experience over the course of their lifetime, which contributes to the way they view and interpret new experiences, and the way they approach the need for new information.

Patients may have certain beliefs arising out of previous experiences of their own or out of those of others that they have heard about.

When teaching adults, pharmacists can draw upon patient’s experiences as a resource – two-way communication techniques (group discussions, simulation, role-playing, and skill-practice sessions)

c. Readiness to Learn

Immediate concern and importance in their daily

lives.

Adults make themselves available for learning

because of their perception of a particular need

in a particular area. They will choose what they

need to know and when they want to learn about

it.

Pharmacist must act as a resource person to help

patients discover their own learning needs.

d. Time Perspective and Orientation to Learning

Adult education involves issues of concern in the

individual’s life at present and is problem-centered.

Through discussion with the patient, the pharmacist can

avid providing extraneous information – the kind that does

not apply to a particular patient or the particular situation.

It is up to the pharmacist to discover from the patient the

kind of information that will be useful for solving that

patient’s specific problems and then tailor the counseling

to the particular patient.

THE EDUCATIONAL APPROACH: CONDITIONS AND PROCESS OF ADULT

LEARNING

1. Helping relationship, with reciprocity

2. patient’s experience is drawn upon as a resource in learning

3. Educational methods involve two-way communication techniques

such as group techniques, discussions, simulation, role-playing, and skill-

practice sessions.

4. Educational tasks involve subjects of immediate concern and

importance in the individual’s daily life.

5. Adults choose what they want to learn, and when

6. Learning is problem-centered, and involves identifying and solving the

problem in the present.