Victorian Guild President Anthony Tassone – essential communication skills for pharmacists
My Health Career is pleased to present a guest article from the Pharmacy Guild of Australia’s Victorian President Anthony Tassone on the topic of communications skills for pharmacists. Anthony is currently an Advisory Board member of Pfizer and Reckitt Benkiser, and is a Professional performance Panel Member at the Australian Health Practitioner Regulation Agency. He is a practising pharmacist and works on a weekly basis in a pharmacy that he co-owns.Here Anthony provides an introduction to motivational interviewing, and how it can be applied by health professionals including pharmacists……
An introduction to Motivational Interviewing and effective communication
As human beings, we often take communication for granted; it comes naturally, we communicate without thinking, and we build relationships with colleagues and patients based on our communications. Communication is not something we often take a step back from and look to apply methodology in our interactions, or analyse our effectiveness.
As an aspiring healthcare professional, you will build an appreciation of the importance of effective communication with your patients, and as someone drawn to a ‘helping’ profession, you will likely already find yourself building sustained professional relationships with patients.
However, even in daily life with which we frequently communicate, how often do you pause to assess if you’re communicating in a way that is sending the intended message? The topic of communication is a deep and complex one, with many factors to consider. Through tertiary and other studies, an immense amount of knowledge is collected, but without the ability to effectively communicate and impart this information – the use of this ‘asset’ is in danger of being wasted or not fully utilised.
One form of effective communication that is an emerging trend amongst health professionals is ‘Motivational Interviewing’ (or MI).
Despite ongoing medical advances, young adults of today may be the first generation in modern history to have a lower life expectancy than their parents. Historically, a patient’s approach to illness has been to visit a health practitioner, explain the complaint, be diagnosed, receive a recommendation for treatment (possibly a prescription) and then (hopefully) take the treatment and be cured.
However, in the 21st century, health care is more about prevention and long-term condition management than acute care. Long-term condition management generally requires behavioural change on the part of the patient, with some patients more successful in adopting or continuing with their treatment than others. A patient’s motivation to adopt or stick to their course of treatment can be affected by many things.
In understanding a patient’s motivation to adopt or continue treatment, health professionals can better address concerns or issues that may stop patients from adopting or adhering to their treatment. If issues affecting patient motivation can be identified and addressed by the health professional ‘on the spot’, patients should be better able to manage their condition.
MI is a form of counselling that aims to uncover the motivations patients have for their own health and help them make behavioural changes to meet those goals. At its core, MI involves:
- Guiding rather than directing
- Listening rather than telling
MI works by activating the patient’s own motivation for change to adhere to treatment. It is not meant to trick or deceive patients into doing something they don’t want to do. As 17th-century French writer Blaise Pascal explained, ‘People are generally better persuaded by the reasons which they have themselves discovered, than those which have come into the mind of others.’
So how long has MI been around and who uses it?
Clinical forms of MI were first described in 1983 to assist in the treatment of alcohol abuse and problem drinking. From the 1990s, it was used with other conditions and diseases and has shown positive clinical trial results in the treatment of cardiovascular diseases, diabetes, dietary issues, hypertension and psychosis. Clinical trials have shown that patients exposed to MI are more likely to maintain and complete treatment and comply with monitoring requirements and follow-up visits.
There are four guiding principles of MI, represented by the acronym R – U – L – E.
R = Resist the righting reflex
U = Understand your patient’s motivations
L = Listen to the patient
E = Empower your patient
Often, people become health professionals because of their own motivation to help people and promote well-being. So it’s very tempting to feel the need to confront patients who are not doing the right thing and say ‘Stop! You’re not doing this correctly!’ For example, a pharmacist or doctor may feel the need to say this to a patient who is non-compliant with medication or not effectively monitoring their blood glucose levels for diabetes management.
This urge to ‘right’ a patient’s ‘wrong’ is known as the ‘righting reflex’.
It may seem strange, but it’s important to resist ‘righting’ what is perceived to be a ‘wrong’ when first dealing with a patient. Jumping in and telling a patient they are not doing something right can have a demotivating effect on the patient – which is exactly the opposite of what is intended.
Non-compliant patients usually know they are non-compliant but they often have their own internal rationalisations for the behaviour. For example, have you ever tried to tell a friend or family member to quit smoking or reduce alcohol intake? Just telling the person to do so is unlikely to be successful, unless they can uncover their own motivation for taking the correct action instead.
As humans, we tend to believe what we hear ourselves say. This is known as the ‘internal voice dilemma’. The more a patient verbalises the disadvantages of a treatment, conditional management approach or behavioural change, the more they will believe these downsides and the more committed they are to sustaining the ‘status quo’.
So MI isn’t about ‘arguing’ with the patient to promote change; instead, it is about trying to encourage the patient to verbalise for themselves the reasons they need to change.
Research has found that most patients want to be healthier and intend on taking the appropriate action, but don’t actually achieve what they want to. This is known as the ‘intention gap’ – the gap between what we intend to do and what actually occurs.
As an aspiring health professional, you will hopefully one day be in a very powerful position to turn the ‘but’ into a positive motivation for your patients to improve their own health.
The second guiding principle of MI is to understand your patient’s motivations.
The most important reasons for patients to change their behaviour are those of the patient, not yours as a healthcare professional. To understand a patient’s motivations, it is important to be interested in their concerns, perceptions and the value they place on their condition and treatment.
Questions that help give the patient an opportunity to verbalise what they know or perceive about their condition or treatment are an important part of MI. The use of open questions (ones which cannot be answered with a simple ‘yes’ or ‘no’ response) helps obtain this information from patients because open questions can’t be answered with a yes or no answer; they allow the patient to expand on their thoughts. Examples include:
- ‘What have you been told about …?’
- ‘Tell me what you know about …’
The information and counselling a health professional would normally provide shouldn’t be reduced or compromised by MI. Before telling the patient what you want them to know, it may be of benefit to understand their motivations for seeing the prescribing health professional in the first place. For example, you might ask:
- ‘What made you see the doctor today?’
Many health professionals are time poor. Discovering extensive information from patients can be challenging in a short time frame. To help work effectively within these constraints, a health professional may ask the patient a question to find out if they know why they would benefit from making the change. To find out this information, they could ask:
- ‘What do you know about the medicine that will help improve your condition?’
After this type of conversation has occurred, then a health professional can commence with the counselling of the treatment. It’s a health professional’s general instinct to start telling the patient about the treatment that has been prescribed or recommended before understanding what they may already know about it or want to know about it.
The third principle of MI is to listen to your patient. Health professionals are amongst the most trusted people in the community because of the care and advice they give patients. However, when it comes to behavioural change and improving chronic disease management, the answers often lie with the patient and not the healthcare professional. Finding these answers requires good active listening. Good active listening is a clinical skill. It requires:
- Asking a question… and keeping quiet long enough to hear the reply!
- Interpreting non-verbal cues from the patient while you are explaining things to them.
When interpreting non-verbal cues, negative responses could include a furrowed brow, shaking, tilting or scratching of head or grimacing. Positive responses could include nodding of the head, smiling or engaged eye contact. These are general non-verbal cues that occur in everyday life. Has your parent ever said ‘it’s not what you say but how you say it’? Well another way of looking at it is also, ‘it’s not what you say that says the most’. Awareness of these non-verbal cues are just as important from a health professional’s point of view as they will be interpreted and processed as a message by the patient.
The final principle of MI is to empower your patient.
Empowerment involves helping the patient explore why they can make a difference in their own health. Health outcomes will be better when patients take an active interest and role in their own health care.
An example of how a patient might become empowered to improve their health is through increasing their physical activity. Most people know that exercising is good for their health but rather than telling a patient that they should exercise more, a better outcome could be achieved by exploring what they enjoy doing. Discussing how that activity could fit into their lifestyle and suggesting it as an ongoing activity that they have effectively chosen themselves is a great way to empower the patient to take action.
A health professional can therefore help the patient to think about the how’s and why’s of the behavioural change to bring the patient’s own thoughts and resources into consideration.
An important role for health professionals is to encourage the patient to understand that behavioural change is possible and that with support they can make the difference. This will not only bring about the most satisfaction for the health professional in the job – but the best health outcomes for the patient. It’s a win-win for all.