My Health Career is pleased to present a second 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 more information about motivational interviewing, and how it can be applied by pharmacists……

In our introductory article on Motivational Interviewing (MI) we looked at its general principles as an effective communication tool with patients and the importance of empowering a patient to help contribute and take control in decisions about their health and treatment.

In this article we’ll look at the communication styles that health professionals use and how we employ these styles to put the principles of MI into action.

It is very difficult to summarise all forms of communication in healthcare, but many health professionals would identify with three common styles of communication (perhaps not directly by name, but by nature).

The communication styles that we will discuss in this article include;

– Following;
– Guiding; and
– Directing

Each style has its pros and cons, and in any given consultation, a health professional may successfully use a combination of different styles. Each communication style will require a mix and different emphasis on communication skills of; asking, listening and informing. However, the principles of MI favour a refined form of Guiding as the optimum method for uncovering patient motivations and encouraging compliance with prevention and treatment plans.

Following style of communication

In the Following style, the predominant skill used is listening.

Some people believe they are good at listening; however, good listening doesn’t involve persuading or advising, agreeing or disagreeing, instructing or directing. A truly good listener is able to suspend their own thoughts and prerogatives and instead give full attention to the other person to allow them to voice their thoughts and experiences.

For an example of the Following style, think of a good friend you know who is a good listener. This style is particularly useful to remember when dealing with patients who may be very emotional, particularly after receiving bad news.

Attributes of Following include going along with, being responsive to, having faith in, understanding and observing.

In a Following style of communication, you might use words like:

‘I’m not going to try to change or push you. I’ll let you work through this in your own time and when you’re ready, I’m here if you need me.’

A brief period of Following and good listening at the start of a consultation can improve a health professional’s understanding of the patient’s symptoms.

Guiding style of communication

The second communication style often used by health professionals and the one most directly used to facilitate MI is the Guiding style.

This style involves helping another person to effectively ‘find their way’. A Guiding style of communication assists a health professional to act as a guide in helping behavioural change.

An example of a Guiding style of communication is:

‘I can help you solve this, or alleviate this problem yourself.’

Attributes of the Guiding style include encouraging, motivating, supporting, accompanying and looking after.

We’ll consider some different skills for achieving a Guiding style of communication later in the article; for now, let’s learn about the final communication style – Directing.

Directing style of communication

The style of Directing involves taking charge, at least for a time. It can imply an uneven relationship with regard to knowledge, expertise, authority and power. However, this approach can be very important in health care because it can achieve significant health outcomes and potentially save lives.

A ‘director’, or one who employs a Directing style, essentially tells a person what to do without necessarily explaining all the rationale. A director as a health professional would see themselves as responsible for the performance of a patient with regards to adhering to a therapy or treatment.

In a Directing style of communication, you may use the following types of phrases:

‘I know you can improve your health; I know what you should do.’
‘You should take this medication because it’s what the doctor has prescribed for your high blood pressure.’

The bulk of medication counselling by a health professional will feel like Directing because it is a basis of needing to effectively tell another person how to correctly take a medication.

Many health professionals will feel as though a bulk of their role should be directing. It is appropriate when a patient is depending on you for expertise and advice, to make a decision or decide on a course of action for them. Often health professionals may be time-poor yet need to tell patients several points about a new medicine, so they try to tell them in a short time frame to ‘tick them off the list’.

Many patients may expect and want this style of communication because it does have a ‘take-charge’ approach; however, there is a danger of over-using it. When over-used, the Directing style can reduce the patient’s involvement in their own care to a very passive role and can compromise the effectiveness of advice given.

From the health professional’s perspective, time constraints and the need to deliver a lot of information can also lead to an over-use of Directing.

Attributes of the Directing style include leading, taking charge, managing and showing the way.

Remember: Listen to your patient and understand their motivations and expectations for a therapy. There will be a need for directing a patient in using the therapy effectively, but without actively listening, these directions may not be received as we intended.

A Directing style is appropriate in many consultations and interactions with patients, particularly when imparting information about a medication or treatment approach. However, it’s important not to rely on it as the sole way of communicating.

When used in the right way, a Directing style can be used by the health professional to deliver relevant, quality information to the patient. When not used well, Directing can appear tactless and authoritarian, and be demotivating for the patient.

Instead, the principles of MI suggest that we should rely most heavily on a Guiding approach, with judicious use of the other two styles (Following and Directing) as necessary.

So far in this article we have discussed communication styles. Now it’s time to apply this knowledge using communication skills.

Three basic communication skills that are critically important in effective communication, not only in healthcare but everyday life, are:

• • • • Asking
      • Listening
      • Informing

These three basic skills are used to varying degrees in each of the Following, Guiding and Directing communication styles. Below we’ll consider each skill in more detail.

Asking questions involves using open and/or closed questions to elicit information from the patient about their condition or current medication management.

You may recall in the last article on MI we looked at the concept of open and closed questions. Open questions are those that cannot be answered with a ‘yes’ or ‘no’ response and are useful for getting the patient to expand on information.

Examples of open questions include:

‘So tell me, how long have you been experiencing this discomfort?’

‘If you don’t mind me asking, what was the reason for seeing the doctor today?’

‘How long have you been taking this medication?’

A helpful way of thinking about useful open questions to ask patients follows the old edict of ‘who, what, when, where, why and how’. Not all of these questions need to be asked, but it’s helpful to keep them in mind when trying to elicit information.

Closed questions can be answered with a ‘yes’ or ‘no’ response and are useful for clarifying specific information. Some examples include:

Do you take any other medications?’

‘Have you tried anything for this before?’

‘Have you seen a doctor yet about this problem?’

It can be very tempting to predominantly use closed questions when asking the patient about their medical history or complaint. Although this is helpful in clarifying specific information, it doesn’t give the patient the opportunity to discuss their thoughts, views or perceptions about their health.

If a closed question receives a ‘yes’ response, it should be followed up with an open question to clarify this information. For example, if a patient states that they do take other medications or have tried a treatment before; open questions can be used to find out more information.

The second important communication skill is Listening. Throughout our previous article on communication styles, you discovered the importance of listening to the patient and allowing them to communicate their perceptions, understandings and motivations.

To get the most out of Asking, it is essential to listen to the patient’s responses.

As mentioned earlier, Listening is an active process that also relies on positive non-verbal communication. It is also important to note that throughout the Listening phase of a consultation, a patient needs to feel as though their privacy and confidentiality is maintained. If it isn’t, this can have a range of undesirable effects including:

• • • The patient not feeling comfortable enough to give expansive enough or completely truthful answers to questions.
    • The patient and the health professional becoming distracted from the conversation.
    • The patient feeling hurried and not wanting to fully participate in the conversation with the health professional.

Listening is a core skill within all three styles of communication but particularly the Guiding style, which is essential for MI.

Informing Style of Communication

The third communication skill we’ll consider is Informing.

Like the Directing style of communication, many healthcare professionals will feel comfortable with Informing because it forms the predominant part of professional practice. That is, patients often ask a question and Pharmacists respond with an answer based on their own clinical expertise, knowledge and experiences. Furthermore, when a health professional recommends a particular treatment, this also forms part of the Informing communication skill base.

However, it isn’t possible to undertake effective Informing unless a health professional has Asked questions and Listened to the responses to make a judgement on what information needs to be provided.

As an individual, you obviously have a preference for particular communication styles and skills – and that’s perfectly OK. What we have tried to cover in this article is introduce you to the different styles and skills available so you can add them to your ‘toolbox’ and improve your patient outcomes even further.

Most healthcare professionals tend to follow an ‘Ask and then Inform‘ line of consultation, but may forget to include a statement that verifies they have heard and understood the patient (to demonstrate they have been Listening). A verification statement might look like the following:

So if my understanding is correct, you haven’t tried anything for this complaint yet and it has been going on for about three days.’

‘It sounds as though you’ve been having a very difficult time with your husband’s health. No wonder you feel upset.’

As a general overview, a ‘following’ style of communication will predominantly use the ‘listening’ communication skill. The ‘guiding’ style of communication will have a similar level of ‘listening’, ‘asking’ and ‘informing’ communication skills used whilst the ‘directing’ style of communication will predominantly have a ‘informing’ skill used.

The point of understanding these different ‘styles’ and ‘skills’ is to not pre-empt or necessarily have a ‘one size fits all’ approach. It’s about ensuring awareness of how your verbal communication can impact (or not impact) the patient. It’s also about being aware how a mixture of different skills and style can help build trust and relationships with your patients to accept advice and participate in decision making to achieve quality healthcare outcomes. Ultimately, this is the aim for each and every practising health professional.