Clinical Pharmacy	Pharmaceutical Care
Place	Clinical setting	Everywhere
Target	Healthcare providers	Patient
Goal	Clinical Outcomes, Pharmacoeconomic outcomes	Patient Related Outcomes
Time	Discontinuous	Continuous
Global Benefits	Specialization	Futuristic and holistic

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The skills, activities and services inherent in the provision of pharmaceutical care include, but are not limited to the following:

• Patient assessment: Clinical skills for physical assessment, eliciting barriers to adherence and identification of psychosocial issues.
• Patient education and counseling: Pharmacists must have patient interview skills, communication skills (e.g., empathy, listening, speaking or writing at the patient's level of understanding), ability to motivate or inspire patients to follow through a recommended therapy plan, ability to develop and implement patient education plan based on an initial education assessment and the ability to identify and resolve compliance barriers.
• Patient-Specific Pharmacist Care Plans: Recognition, prevention, and management of drug interactions, interpretation of laboratory tests, have knowledge of community resources, professional referrals, communication and rapport with community medical providers.
• Drug Treatment protocols: The pharmacist should be able to develop and maintain (update) protocols, follow protocols as a pharmacist clinician and monitor aggregate adherence to treatment protocols (e.g., drug utilization evaluations {DUE}) especially for managed care or health system facilities (e.g. hospitals).
• Dosage adjustment: The pharmacist should be able to identify patients at risk for exaggerated (pediatric or geriatric patients) or sub-therapeutic response, apply pharmacokinetic principles to determine patient-specific dosing especially for drugs that are considered high risk (e.g. warfarin, digoxin), order and interpret relevant tests at correct time intervals to assess dosage adjustment (e.g., plasma drug concentrations, blood glucose levels, blood pressure measurements).
• Selection of therapeutic alternatives: The pharmacist should be able to use drug information resources effectively; review and critique drug literature and construct comparative analyses to support therapeutic decisions.
• Prescriptive authority in designated practice sites or positions: This is not currently operational in Nigeria. It is envisioned that as roles of pharmacists expand and available reviews point to the cost effectiveness of pharmacist interventions, provider status may be accorded even in Nigeria.
• Preventive services: Immunizations, screenings, health and wellness education can be carried out successfully at a community practice.

The pharmacist should also be skilled to plan, direct and implement pharmaceutical care activities within various practice environments, such as community pharmacy, ambulatory care settings, managed or contractual care, home health services, long-term care facilities, inpatient hospital practice, and others. Allocating resources in the pharmacy is also a direct responsibility of the pharmacist.

Pharmaceutical Care as the Model for Pharmacy Practice

The concepts, activities and services in pharmaceutical care form the basis for provision of clinical services directly to, and for the benefit of patient in all pharmacy practice settings. These settings include home health, hospital, ambulatory care, primary care, consultation, long term care, and community pharmacy practice. Workflow, staffing patterns, processes, and pharmacy programs might differ, but the core approach to patient care remains pharmaceutical care in all settings.

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Documentation of Pharmaceutical Care

Documentation of pharmaceutical care is integral to the continuity of care, demonstration of clinician competence, communication among health care providers, evidence of contributions to patient care, and reimbursement of professional services.

1. Pharmaceutical care, including the pharmaceutical care plan process (CORE, PRIME & FARM/ SOAP), is a systematic method for recording the pharmacist's examination of a patient pharmacotherapy and subsequent identification of medication-related problems.
2. In most practice settings, computer software programs maintain patient data and drug profile records. Thus, after documentation of the initial pharmaceutical care plan, patient data or drug regimens are included in subsequent FARM notes only if a change occurs that is relevant to the therapeutic issue being addressed in the note.
3. Forms that summarize pharmacist's interventions using a unified coding system are useful for processing reimbursement of billing forms, but these forms are not adequate documentation of pharmaceutical care. These forms do not communicate to other health professionals the depth and quality of pharmacist interventions or the pharmacist's plan for ongoing pharmaceutical care.

Pharmaceutical Care: An ongoing Process

The patient profile is revised and re-assessed each time a new drug is added to or deleted from the medication regimen, a new disease or condition is diagnosed, or the patient undergoes other clinical intervention, such as surgery. When the patient returns to the pharmacy or is readmitted to the health system facility, the pharmacist uses the patient profile, PWDT, and FARM notes (maintained in the patient pharmacy chart or in the medical chart) as the basis for ongoing pharmacists-patient interactions.

Importance of Pharmaceutical Care in Today's Pharmacy Practice

The potential for medication errors is growing, and one professional group must assume a primary role in addressing this issue rather than fragmented efforts by various groups or individuals. The pharmacist is trained specifically to address these therapeutic issues. The use of prescription and nonprescription medications is growing and now constitutes the primary therapeutic modality available to health care practitioners and patients. The number, complexity, and efficacy of prescription and non-prescription drug products are also increasing. These challenges put the pharmacist in the best position to combat these drug therapy problems.

The need for pharmaceutical care secures an enduring role for the pharmacist in the Nigerian health care system. Every encounter with patients, regardless of practice setting provides an opportunity for pharmaceutical care. The Pharmaceutical care activities will also integrate pharmacists into the health care system of the future.

Pharmacist Work-up of Drug Therapy

1. Data collection
2. Develop or identify the CORE
   • Condition of the patient
   • Outcomes desired in the specific patient
   • Regimen selected
   • Evaluation parameters
3. Identify the PRIME pharmacotherapy need
   • Pharmaceutical based problems
   • Risks to the patient
   • Interactions
   • Mismatch between medication and condition or patient needs
   • Efficacy issues
4. Formulate a FARM/ SOAP note:
   • Findings- patient specific information
   • Assessment- evaluation of findings e.g. severity, duration
   • Resolution (including prevention) -- rationale for the intervention should be mentioned
   • Monitoring (and follow up)- assess efficacy, safety and outcome of the intervention

Also Read: Interpretation of Laboratory Results

COMMUNICATION SKILL AND PATIENT COUNSELING

1.0 Communication Skills

Communication (from Latin commūnicāre, meaning "to share" [1]) is the activity of conveying information through the exchange of ideas, feelings, intentions, attitudes, expectations, perceptions or commands, as by speech, gestures, writings, behaviour and possibly by other means such as electromagnetic, chemical or physical phenomena. It is the meaningful exchange of information between two or more participants (machines, organisms or their parts).

The communication process is not complete until the receiver understands the meaning of the message sent and gives a feedback.

Also Read: Communication in Pharmacy

Media for Communication

Communication is carried out using a broad spectrum of media, the means through which the message is encoded for transmission to the receiver.

The medium used in conveying a message must be appropriate for the purpose it is intended e.g. use of text message to inform client of the death of a loved one will be inappropriate. The medium used must also retain the integrity of the message from when it is sent, to when it is received. The medium used must also be matched to the audience size e.g. in small groups verbal communication with(out) the use of amplifiers will be appropriate, while for large groups, mass media will be deployed.

In the Pharmacy, it one-to-one interpersonal communication that is the most commonly used method and this does not require amplifiers but can be enhanced when tone, voice quality, and other media aids like pictograms etc are used.

Elements of the Communication Process

Every message must be appropriately matched. And requires certain properties to ensure it is not muddled or lost in translation.

The following acronym MSCREF describes the basic elements of the communication process

• M- Message should be clear, concise and straight to the point. It is important that there are no exaggerations if unintended or if it will distort the message or elicit an adverse reaction in the receiver. Tone is very important especially since messages are often interpreted messages based on the tonality.
• S- Sender of the message must be in the appropriate frame of mind to encode the message aright, and attempt to eliminate obstacles to the appropriate message being sent to the appropriate recipient.
• C- Channel is same as medium, i.e. the medium through which message reaches the receiver. Channel must be effective and culturally acceptable to the target. The sender must be able to use the medium appropriately i.e. encode the message appropriately for it to be relayed to and decoded by the receiver.
• R- Receiver is the final recipient. The receiver must be appropriately tooled to decode and interpret the message i.e. must be able to process the message, leading to understanding and appreciation of the intended message.
• E- Effect or reactions to the message received by the recipient. Effects may be appropriate, timely and effective. A good message will elicit the appropriate response without any bias leading to the expected action.
• F- Feedback originates from the recipient of the message. This may include seeking clarification or (if the message is clear enough) verbalizing receipt. Feedback is important in helping the sender know if the message was received as intended.

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Types of Communication

Intra-Personal Communication

• This is talking within oneself.
• It is the thought going on within a person.
• Takes place before any other form.
• Before you talk to any type of audience or take any action, you must think about it.
• It follows therefore, that conflict within oneself can negatively influence communication with others .

Interpersonal Communication

Interpersonal communication is the face-to-face verbal and nonverbal exchange of information, ideas or feelings between individuals or groups.

Types of Interpersonal Communication:

• Verbal Communication: This is the exchange of ideas through spoken or written expression (word).
• Non-verbal Communication: This involves the expression of ideas, thoughts or feelings without the spoken or written word. This is generally expressed in the form of body language that includes gestures and facial expressions.
• Both verbal and non-verbal form the basis of interpersonal communication

Also Read: Prescribing

Non-Verbal Communication (NVC)

NVC are forms of communication other than verbal messages. The body language and manner in which something is said (vocals) are important components.

Non-linguistic NVC comprise of four main elements:

• Body contact
• Interpersonal space
• Body movement (sometimes referred to as 'kinetics'), eyes, face, hands and arms, legs and feet, posture, appearance .
• Appearance

Linguistic NVC include vocal pitch, tone, etc

Essential Skills for Effective Communication

• Questioning skills
• Listening skills
• Participatory skills
• Explaining skills

What is a question?

It is a request for information. The purpose is to:

• Obtain specific information
• Diagnose specific difficulties
• Open interactions (e.g. 'Hello, how may I help you?')
• Assess knowledge and understanding
• Help create enlightenment
• Maintain control of interactions
• Encourage full participation
• Show interest and concern (e.g. 'How are you today, sir?')
• Ascertain attitudes, opinions and feelings (e.g. 'How do you feel about...').

Also Read: Barriers to Communication

Types of Questions

• Open and closed questions
• Direct and Indirect Questions
• Loaded and Leading Questions
• Multiple questions

Questioning Tips

• Use a tone that shows interest, concern and friendliness
• Use words that the client understands
• Ask one question at a time and wait with interest for the answer
• Ask questions that encourage clients to express their needs, e.g." May I ask you about your school and family?"
• Use words such as 'then' "oh". These words encourage clients to continue speaking
• Avoid starting a question with 'why'; this suggests that one is finding fault
• When asking a delicate question, explain why you are asking (e.g. when asking about the numbers of sexual partners to find out about STI/HIV risk)
• Ask the same question in other ways if the client has not understood

What is Listening?

It is a fundamental part of communication process. It is not just physiological process of hearing but listening is a mental process. It is important to listen carefully to respond appropriately.

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Indicators of Listening

• Can be verbal or nonverbal
• Reinforcers
• Probing
• Verbal following

Obstacles/Barriers to Listening

Listening is normally a difficult process and can be made more difficult with obstacles like

• Speech and Thought Rates
• Speaker Fluency and Clarity
• Message Emotion
• Individual Bias
• Inattentiveness
• Mental Set
• Dichotomous Listening
• Other Distractions

On deliberate choice to close interaction or decision to divert focus of conversation, useful tactics to achieve these include:

• Rejecting involvement
• Denial of feelings
• Selective responding
• Admitting insufficient knowledge
• Topic shift
• Referring, Deferring
• Pre-empting any communication

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Participatory Skill

It is a skill to actively engage or involve the patient in the discussion. It involves encouraging feedback from patient.

Explaining Skills

Good explanations are crucial to effective communication. Explanations can be by oral, visual aids, presentations or combinations of these.

• Oral explanations -no other form of aid is available.
• Visual aids to illustrate information difficult to convey.
• Illustrations are the most important elements of instructions.
• Presentation is the core of explanation
• Feedback: This is a method for assessing the effectiveness of explanations. It can be obtained prior to giving explanation.

Features of Explanation

Like good bikinis, should be brief, appealing, and cover essential features. Reflecting - a reference to past statements is an effective means of summarization.

Factors Affecting Communication

• Not paying enough attention to message
• Not clarifying message
• Partial listening
• Partial understanding
• Personal interpretation of message
• Message -- Too long
• Mood of sender/receiver
• Tone of language/speech
• Language barrier
• Senders/ receivers mannerism
• Differences in pronunciations and accents
• Culture, beliefs
• Age
• Incomplete/distorted information
• Noise
• Physical Barrier- An example of this is the natural barrier which exists if staff are located in different buildings or on different sites.
• System design- Examples might include an organizational structure which is unclear and inefficient or inappropriate information systems
• Attitudinal barriers -as a result of problems with staff in an organization
• Ambiguity of words/phrases- Words sounding the same but having different meaning
• Physiological barriers - may result from individual's personal discomfort, caused, for example, by ill health, poor eyesight or hearing difficulties.

Also Read: Assertiveness of Community Pharmacists

Communication Noise

In any communication model, noise is interference with the decoding of messages sent over a channel by an encoder.

• Environmental noise- standing next to loud speakers at a party or a rowdy time at the pharmacy.
• Physiological-impairment noise- deafness or blindness
• Semantic noise- Different interpretations e.g. weed
• Syntactical noise-mistake in grammar
• Organizational noise- unclear and badly stated direction
• Cultural noise e.g. wishing a non-Christian 'Merry Christmas'
• Psychological noise- great anger or sadness may cause someone to lose focus on the present moment

Counseling

Counseling is an interaction between two or more persons whereby information is received from the other on an issue and the information is provided with all possible solutions highlighted and the person is allowed to make an informed decision.

Counseling can also be said to be interpersonal communication in which a counselor (service provider) helps the client to:

• identify
• clarify
• resolve problems

Types of Counseling

• Individual Counseling
• Couple Counseling
• Group Counseling

Principles of Counseling

In Counseling the following must be noted:

• What does the individual already know? One should never assume that people do not know anything
• Age should be considered when counseling
• Always be patient, try to understand clearly what the person is saying/wants
• Use the language the person understands
• Never guide or advice to choice making
• Be honest and nonjudgmental
• Support expressed fears and feelings
• Maintain a culturally accepted distance between client and counselor
• Ensure confidentiality

Counseling Process

The Processes is best explained with the acronym GATHER which means Greet Ask Tell Help Return

Difficult Moments in Counseling

This can occur if client stops talking (usually due to a concern of confidentiality or judgment), client cries, or counselor cannot provide answer. Sometimes, the counselor has little time to attend to client and client talks continuously and inappropriately. If the client is well known to counselor, it may be more appropriate to refer them to another counselor. If the counselor is embarrassed by the subject matter, then refer.

Qualities of a Good Counselor

• Approachable
• Friendly and warm
• A good listener
• Tolerant and patient
• Welcoming and humorous
• Well focused
• Self-confident
• Confidential and willing to go extra mile

Patient Counseling

This is a patient-focused intervention. It can be non-drug counseling where the patient receives education for positive behavioral changes -- health promotion and disease prevention measures. Whereas with drug-focused intervention, the focus is on Medication education for appropriate adherence to pharmaceutical care plans by patients or rational prescribing or resolution of a drug therapy problem.

Drug Focused Counseling

After a session of medication/drug focused counseling, it is important that the patient should have been provided a minimum of;

• The name and purpose of medication
• How much of the medication that should be taken, when to take it and how long to take it.
• How to administer medicines.
• Prescription refill information.
• What to do when a dose is missed.
• Important side effects e.g. causes dizziness, stomach irritation, etc.
• Precautions e.g. causes sleep do not drive; avoid exposure to sunlight when on this medication.
• Interaction with foods, beverages and other medicines.
• How to store medicines at home.

Good communication skill and correct patient counseling are very important skills that every pharmacist irrespective of area of practice must develop and grow to achieve measurable pharmacological and non-pharmacological therapeutic output in patients and other clients.

References

1. Harper, Douglas. "communication". Online Etymology Dictionary.
2. Wiener, Norbert (1948). Cybernetics, or Control and Communication in the Animal and the Machine. Cambridge: MIT Press.
3. Jump up^ de Valenzuela, Julia Scherba. (1992). American Speech-Language-Hearing Association (ASHA): Guidelines for Meeting the Communication Needs of Persons With Severe Disabilities
4. West African Postgraduate College of Pharmacists (WAPCP) Communication lecture note.