Investigating the effectiveness of communication taking place between hospital pharmacists and patients during medication counselling

Abstract

Effective communication skills are necessary for the provision of high quality patient care by healthcare professionals. Poor communication exchanges have been associated with lower patient satisfaction, treatment nonadherence and negative clinical outcomes. Medication counselling opportunities are key times for pharmacists to speak with patients about their medications. Little has been published about the communication taking place between hospital pharmacists and patients with few details about what makes this exchange effective. Most papers’ methods are atheoretical. Effective pharmacist-patient communication may lead to improved clinical outcomes as described in physician-patient communication literature. However, before these relationships could be explored, it was essential to first investigate what was taking place in these pharmacist-patient interactions.The overall aim of this thesis was to investigate the effectiveness of communication between hospital pharmacists and patients during medication counselling.This theory-driven research employed qualitative, quantitative and mixed methods. Communication accommodation theory (CAT) was the theoretical framework invoked to study, analyse and interpret the pharmacist-patient communication exchanges. There are five CAT strategies which measure whether effective communication has occurred: approximation (speech tone, volume, rate, accent), interpretability (using easy-to-understand language, avoiding jargon), discourse management (asking open-ended questions or repairing conversations), emotional expression (appropriate reassurance to patients’ concerns) and interpersonal control (strategies to promote equality between speakers and encourage patients to take active roles in managing their healthcare). In this thesis, effective pharmacist-patient communication refers to the extent pharmacists accommodate, or not, to patients’ conversational needs based on accommodative behaviour described within CAT strategies.There were two phases to this thesis. The first involved six focus groups (24 pharmacists) from two large metropolitan hospitals. Pharmacists shared their perceptions of their roles and goals in patient medication counselling, and barriers and facilitators in meeting their goals. Audio recorded transcripts were thematically analysed and goals identified by pharmacists were successfully mapped onto the five CAT strategies. Results of phase one helped inform the contents of the semi-structured interview guides utilised in phase two.Phase two represented the major portion of this PhD, and took place at a large hospital with multiple specialities. Twelve pharmacists engaged four patients for a total of 48 medication counselling sessions. Each individual session took place first, followed by separate semistructured interviews with pharmacists and patients. Counselling sessions and interviews were audio recorded and observational field notes were taken. Transcribed recordings were selectively coded for the five CAT strategies in pattern-based discourse analysis. Discursis software, as an adjunct to qualitative analysis, was used to visualise pharmacist-patient speech patterns, episodes of engagement and to detect CAT strategies employed by pharmacists. Patients completed two medication taking behaviour measures, Beliefs about Medicines Questionnaire (BMQ) and Morisky 8-Item Medication Adherence Scale (MMAS-8) prior to their conversation with the pharmacist and then again by telephone four weeks after leaving hospital.Analysis of the pharmacist-patient counselling sessions revealed that most pharmacists effectively used all five CAT communication strategies during medication counselling sessions as they adapted to patients’ conversational needs. Non-accommodation occurred when pharmacists spoke too quickly, used terms not understood by patients, and did not include patients in the initial, agenda-setting phase. Discursis software identified pharmacist-patient engagement episodes, often revealing effectively applied CAT strategies.Semi-structured interviews with pharmacists and patients about their medication counselling experience indicated many shared CAT related themes. However, when pharmacists’ and patients’ assessments of their interaction were compared with an Observer’s ratings, differences in assessment were noted, particularly between the Observer and pharmacists. Pharmacists assessed themselves higher for emotional expression and discourse management and lower for interpretability and interpersonal control behaviours.Pharmacists and patients provided insights about what made pharmacist-patient conversations effective. An overarching shared goal was that patients need to be confident in managing their medications at home. To facilitate this, patients focussed on pharmacists’ delivery of medication information and interpersonal behaviours while pharmacists emphasised patient’s understanding and level of engagement.Exploratory research was conducted to elucidate potential relationships between effective pharmacist-patient communication and patients’ medication taking behaviour measures. Almost all patient assessed pharmacist communication behaviours and levels of patient satisfaction were strongly correlated, but few correlations were detected with the BMQ or MMAS-8. This exploratory research is a valuable foundation for future work as it provides some preliminary process mapping of the pharmacist-patient communication to outcomes.This thesis invoked theory (CAT) to investigate the effectiveness of hospital pharmacist-patient communication. The research demonstrated the dynamics that commonly occur in these types of interactions. Specifically, it showed how pharmacists successfully met patients’ conversational needs and how they did not. Many areas of strength were identified as well as communication skills that require improvement. The far-reaching training implications for both pharmacy practitioners and students are discussed and ways that they can learn and further develop effective communication skills through theory-based research informed training are proposed.