Pharmacoethics: A Problem-Based Approach (Pharmacy Education Series)

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To utilize a team-based learning approach in teaching ethics in pharmacy practice to undergraduate pharmacy students. The ethics section of a pharmacy practice course consisting of 11 contact hours was modified in to a team-based module consisting of initial individual and group readiness assurance tests followed by group application exercises. Faculty-student contact time was about the same for both the traditional method and the team-based method. Students rated the TBL sessions positively. Faculty time preparing for the course increased since it is the first time to introduce the course using this approach.

The approach has shown to benefit student performance in their assessments and to help in attaining skills of higher problem solving and application of knowledge.

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Students possibly acquired team-working and self-learning skills needed in the future. The effect of team-based learning in medical ethics education. Med Teach, 31, Conway, S. Integration of team-based learning strategies in to a cardiovascular module. Am J Pharm Educ, 74 2 , Article Gettman, D. Pharmacoethics: A problem-based approach. Haidet, P. A controlled trial of active versus passive learing strategies in a large groups setting. Adv Health Sci Ed, 9 1 , Hunt, D. The effect of using team based learning in an evidence-based medicine course for medical students.

Teach Learn Med, 15 2 , Latif, D. Teach, 7, The relationship between ethical dilemma discussion and moral development. Am J Pharm Educ, 64, Letassy, N. Using team-based learning in an endocrine module taught across two campuses. Am J Pharm Educ, 72 5 , Article Michaelson, L.

Team-based learning in large classes. In Michaelson, L. K, Knight, A. Team-based learning: a transformative use of small groups pp. Westport, CT: Praeger. Nieder, G. Team-based learning in a medical gross anatomy and embryology course. Clin Anat, 18, Self, D. If so, it should be listed in the space provided for learning issues. After the student facilitator does this nudging, it becomes almost automatic for your PBL group to recognize learning issues and to put them on the chalkboard. This conditions you to recognize when you need to learn in your future real pharmacy practice.

An important task for your student facilitator is to make sure that your PBL group reveals the extent of the knowledge and understanding you already have during your problem-solving activities and discussions and, most important, recognizes the knowledge needed. All terminology and concepts mentioned in discussions should be defined. You soon take up these student facilitator challenges to each member of your PBL group in their discussions.

As mentioned, the student facilitator can usually begin to be less noticeable in this process, only interjecting a question now and then as appropriate. This process continues until your PBL group has carried the analysis of the case as far as it can with its own knowledge and skills. Consistent with pharmacy practice, the results of inquiries are usually not discovered right away, but will be reviewed when your group returns to the problem after student-centered self- directed study.

Here, your student facilitator will ask each member of your PBL group to commit, on the chalkboard, to what is probably going on with your patient. Although you will feel that you certainly do not have enough knowledge to make such a decision and would like to look up some things, the student facilitator must insist, in spite of everything, that you must now make your best guess.

This commitment provides a strong motivation for student-centered problem-based learning as you will want to find out if your best guesses were correct. It prepares you for the real world of practice, in which decisions often have to be made when data are lacking. Reviewing learning issues When you have reasoned your way through the problem as far as possible with the knowledge and skills possessed by your group and have each made a commitment as to what you feel is the explanation for the problem, your group needs to review the learning issues that have accumulated on the chalkboard and decide how they are to be tackled.

The learning issues can be reviewed in the light of the objectives agreed on in the beginning of the session. At this point, you should see how each issue should be expressed to best define the area and depth of study required. Some may seem trivial or unrelated to their objectives at this point and can be eliminated. Also, in retrospect, your group may now realize that there are other issues that need to be listed for study relative to the problem at hand. Your group has to make a decision about breadth and depth of learning and how far beyond immediate relevance to the problem the learning should be.


Those learning issues that are directly related to analyzing and understanding the problem are the most important. However, the problem may make you realize that there are larger topics or important subject areas raised by the problem that you do not understand or understand fully. These could profitably be reviewed at this time. Next, your group should decide on how to divide the learning issues. Although there is a tendency for you to want to research and study all the learning issues on your own, there are a number of good reasons not to do this.

Usually, there are a large number of learning issues, and if each member of your group takes them all, learning is bound to be superficial. The resources you are accustomed to using are textbooks; it will be hard to get you to use more primary sources of information when each of you feels there is so much to learn. Textbooks, at best, can only give an overview. It would be far more valuable for you to go after resource faculty, other faculty experts, review articles, original articles, computerized information resources, and the like as necessary in your self- directed study.

With these resources, you can pursue one or two learning issues in depth using careful searches. Second, members of your PBL group have a few assigned learning issues, then have the task of transferring this information effectively to the other members in your group in ways in which you will understand it and apply it to the problem at hand. This is a challenge to your communication and educational skills.

Of course, the last thing you would want your group to do is to lecture each other, violating the whole point behind problem-based learning. You need to present the information you have acquired in the context of the problem. The appropriate level of detail is important because it makes available to members of your group the proper copies of notes or outlines, diagrams, references, or pictures that you put in your own files for later review.

Sometimes, it is valuable for you to arrange for a resource faculty member or other expert in the area of study to visit your group, comment on the way you have put the problem together, and answer questions from your group. There are usually some learning issues that may be of such central interest to your group that your group members may all want to research them and then compare what they have learned. It is very important that you do not take on learning issues in areas in which you have considerable prior knowledge and experience.

For example, if you have worked previously in a large nursing home with a pharmacist, you may repeatedly take on clinical and behavioral problems related to geriatric patient care. It is far more important for you to take on learning issues in your areas of ignorance to achieve a balanced background in your knowledge for pharmacy practice. This allows problem-based learning to be tailor-made for you. Once the learning issues have been identified and assigned, you should describe the resources you intend to use in your study. This is another important commitment that has to be made. You should eventually be able to decide on the most appropriate and efficient resource for every learning need.

This commitment sets the stage for the beginning of the second session, when you return to continue with the problem and are asked to critique the resources you set out to use. As a last step in this first session, your PBL group members then look at their calendars and decide how long you should give yourselves, considering the extent and complexity of the learning issues decided on and the kinds of resources that you plan to use, and when you will meet to continue with the problem, armed with your new knowledge.

Student-centered learning The period of student-centered learning that follows the first session is at the heart of problem-based learning. You are learning what you have determined is important for you to learn and what you want to learn. You seek out the information on your own. You go to a variety of resource books in your personal collection, to the faculty, and to the library with unresolved questions about a problem with which you are working and have tried to analyze on your own. You realize the information you are seeking is something you definitely did not know and should know because it relates to being a successful pharmacist.

In contrast to assigned readings in more conventional instructor-directed learning, for which maintaining the attention and interest needed to assimilate information is often a difficult labor for you, this information that you seek on your own initiative to answer your questions literally seems to jump out of the pages. What the resource faculty you consult might tell you, in answer to your questions, makes sense and is eagerly received because you want the information and your own study has not resolved your questions.

The resource faculty will often be quite pleasantly surprised to find you act more like a graduate student in the quality, depth, and detail of your questions. Conversations with you can be very stimulating. Your health science librarians may describe to you their complete surprise at your remarkable increase in library use, at all hours.

The members of your PBL group collaborate in their study. You work in pairs and larger groups as you pool resources and your understanding of the information to be learned relative to the problems. In these collaborative discussions, you teach and learn from each other. The second session with the problem resource critique When you return following your self-directed study to continue your work with the problem, you are asked to describe the learning resources you ultimately used to satisfy your learning needs.

You are also asked to critique the resources you intended to use, why you went to other resources, and the problems you had with all the resources used. You are asked to comment on whether you would use them again for future learning needs and in what way your approach would change. Early in your attempts at student-centered self-directed learning, you may run into many difficulties. Sometimes, references are difficult to find, some references are superficial and have too little information, and others are too detailed and have too much information.

Some resource faculty are hard to contact; you cannot find a satisfactory reference to answer your question. Each member of your PBL group who had problems with resources should describe how he or she would attack a similar learning issue differently in the future. This is less of a problem if there has been a lot of collaborative learning carried out during student-centered self-directed learning.

Nevertheless, there has often been considerable individual learning or work in groups of two or three, and these subgroups may be eager to discuss what they have learned with the whole group. This would, in essence, now put lecturing into the hands of your PBL group, and a number of minilectures by each member of the PBL group would not only be boring, but also would be counterproductive in problem-based learning. Members of your group may not be as interested in displaying the information learned, and there is a need to want to apply it to the problem to enhance understanding and later recall it in real pharmacy practice.

At these opportunities, you can briefly elaborate on what you learned and hand out summary materials, xerographic copies, notes, and the like that you may have prepared for the members of your PBL group. There may often be a fine line when a brief presentation actually becomes a lecture, and it is something that all in the group need to monitor and discuss. Any learning issue that was researched by a member of your PBL group but not brought up in the patient-oriented discussion needs to be discussed before the group decides what you have learned from the problem and what your next step will be.

Summarizing what has been learned The great advantage to problem-based learning is that the information you acquired in the problem-solving process will be recalled, by association, and applied to similar problems in the future. To capitalize on this advantage, several activities need to be carried out in your PBL group. Without this important step in the problem-based learning process, the recall of information may not be a verbal recollection of the facts learned as much as a recall of which hypotheses should be considered with a new problem and the actions that should be taken.

This is seen in experienced practicing pharmacists, who can come up with the right questions and tests that ought to be undertaken and the medication regimen needed. Yet, if you ask yourself why you performed these things, you may not be able to give yourself any kind of a self-discussion of the clinical or ethical principles and concepts involved and, if pushed, may just indicate that the actions just seemed right. Sometimes, you might recall a similar patient problem for which these actions were used.

The former can be applied to problems but cannot be verbalized, abstracted, and intellectually manipulated for adaptation to new problems; the latter cannot be recalled in work with problems, but can be verbalized in response to questions. This is one reason for this important stage in the problem-based teaching sequence. When you are encouraged to verbalize what you have learned, you have the best of both methods.

You can be challenged to produce definitions, draw diagrams, and make lists. A second reason for this stage in problem-based learning is to enhance transfer of the information learned and the experience gained from one problem to new problems for which the information and experience are relevant. You need to discuss how your new learning and experience with the present problem relate to the previous problems you have encountered and how it may help you when you encounter similar patient problems in the future.

A third phase of this important stage is for you to develop abstractions as you see how similar facts, structures, principles, or processes from clinical and behavioral pharmacoethics apply in different settings and with different problems and how common features among different problems suggest overarching principles. These concepts have to be developed, as for the expert, through experience with many different instances and problems; with reflection, these produce a personally constructed, and therefore owned, big picture.

You will be asked to make an evaluation of your reasoning for the problem. As your PBL group worked on the problem together, the challenge is for you to separate your thinking and its adequacy. You should attempt to recall and comment on the adequacy of the ideas you generated about the problem hypotheses , the questions and actions you suggested with the patient inquiry , the way you put it together in your own mind synthesis , and the decisions you made about the underlying processes involved and how these might have been managed.

Furthermore, you should address the appropriateness of learning issues undertaken and whether appropriate references were used. Finally, you should evaluate your support of your PBL group in its task with the problem at hand. After you present your self-assessment, the other members in your group are then asked to comment on their self-assessments and to add their comments, good or bad, about your performance.

The ability to provide honest, accurate, and constructive feedback to a peer may be even more difficult for you. In the beginning, you may all be very civil to each other. If, for example, during a self-assessment one member of your group should express concern that you did not get enough information to your group about the learning issue you were assigned, the other members will invariably reassure that member that it was a difficult topic or that there were no good resources available to you. The student facilitator must then interject. If, indeed, a poor job was done, the student facilitator needs to openly comment on this.

More important, if there was a poor performance by you or a member of your PBL group that was not mentioned during self-assessment, the student facilitator must comment on this poor performance. Once any group has been together for a week or so, they will get beyond the usual initial civilities and become open in their criticism or support of other members of the PBL group. Self-assessment requires you to monitor your performance and to judge its adequacy. The development and practice of this ability is central to lifelong, self- learning skills.

The practicing pharmacist must be aware of inadequacies in daily work to be able to recognize the need for more learning and to update knowledge and skills to keep contemporary and meet the new challenges faced in practice. The ability to provide constructive feedback to others is an essential skill for working effectively in health care or research teams. Moving toward individual learning In the above sequences, you work in a PBL group to take advantage of the peer support and accumulated knowledge that occurs in collaborative learning.

You learn to work effectively in team settings and to increase the personal and individual contact between members of your PBL group and faculty. However, once you have become proficient in this learning process and have developed experience with a sufficient number of patient problems in the 18 cases in this textbook, you can and should begin to work individually with patient problems. You will use the same sequence of activities; afterward, as part of a group, you will confer and compare your individual approach and learning just before the step at which you summarize what has been learned.

Barrows, H. Mennin, S. Norman, G. Vernon, D. A meta-analysis of evaluative research, Acad. If the patient is not ready to change, it is more effective for the pharmacist to assist with the decision-making process rather than to provide advice on how to change. If pharmacists used the concept of readiness-to-change to match patients to different forms of intervention, their commitment to pharmacy Prochaska and DiClemente, may provide the conceptual framework through which patient-based interventions would be enhanced because they would experience a greater sense of self-efficacy in dealing with all types of patients.

The stages-of-change model The stages-of-change model proposes that those who need to change could be optimally allocated to different types of interventions depending on their level of readiness to change. Prochaska and DiClemente proposed the existence of five stages that reflect a process of change.

The model conceptualizes change as a process, not an event, a linear continuum with individuals going through a state of being unaware or unwilling to act on the problem precontemplation stage , to a state of considering the possibility of change contemplation stage , then to becoming determined and prepared to make the change preparation stage , and finally to taking action action stage and maintaining the change over time maintenance stage. Precontemplation describes the stage at which a person is not considering change.

Usually, precontemplators do not consider that there may be adverse effects associated with their behavior or that change is possible. Contemplation is the stage at which a person is considering change. Contemplators are usually of two minds about changing; they will often convey that part of them wants to change and part does not. Preparation describes the stage at which the individual has made the decision to change and is now choosing strategies.

The impetus to move into this stage occurs when the negative aspects of the behavior outweigh the positive. A person in this stage really wants to change. Action is the period when the person engages in efforts aimed at modifying the inappropriate behavior. The person usually implements the plan made in the preparation stage. This stage is said to be a stressful one because individuals are not accustomed to the new lifestyle.

Maintenance is the period when the person is working toward maintaining the changes made earlier. As time passes, the person becomes adjusted to the new lifestyle, and the behavior in question is no longer a problem. Is the model applicable to pharmacoethics? It is true that the greatest body of research supporting the stages-of-change model comes from the area of substance addiction, such as smoking and alcohol dependence. Whether the behavior in question is drinking, lack of exercise, smoking, low self-esteem, risky sexual behavior, or other behavior, the structure of change appears to be the same.

Individuals go from being unaware or unwilling to do something about the behavior to contemplating change, then to preparing for self-change, taking action, and finally maintaining behavior change. Insofar as the model is concerned with differentiating patients according to their preparedness to change rather than the idiosyncrasy of the behavior, it is reasonable to assume that the model applies to a broad range of high-risk behaviors, including unethical professional practices.

Evidence of the robustness of the model across different types of behavior is provided by the fact that researchers have been able to replicate basic findings from the smoking and alcohol area across a diversity of behaviors, such as weight control, exercise, psychological distress, radon exposure, sun exposure and sunscreen use, mammography screening, high blood pressure risk reduction, and adolescent delinquent behavior Prochaska et al.

Motivational interviewing If a patient does something that may violate a legal or ethical code and walks into a pharmacy, the individual can be at any point in the process of change. Motivational interviewing recognizes that not all patients who have problems enter a pharmacy in a state of readiness to change their way of doing something. Providing strong advice to a patient who is not ready to change will most likely make the patient argue to defend his or her behavior. According to motivational interviewing principles, eliciting opposing arguments from the patient is the worst thing the interventionist can do because it will make behavior change less likely to occur.

This means that having the patient verbalize the reasons why he or she should continue certain inappropriate behavior will make the patient more committed to maintaining the inappropriate behavior Miller, Intervention methods This section describes a brief intervention based on the stages-of-change model and motivational interviewing principles.

It is based on the assumption that not everybody who performs an inappropriate behavior is ready to change. It also allows understanding the context in which the behavior is being used, and it helps the pharmacist assess whether the patient is acting inappropriately. Intervention strategies for precontemplators Those who use inappropriate behaviors and are not even thinking about change precontemplators will most likely resist any attempt from the pharmacist to discuss the problem behavior. Precontemplators will need to be provided in a nonthreatening manner with more information about their practices and their consequences.

The pharmacist should ask for permission to provide the information because this will minimize resistance. When providing information, the pharmacist should talk in the third person, that is, talk about what happens to people rather than to the individual. The pharmacist should encourage the patient to think about the information and make it clear that the pharmacist will be there to help if the patient decides to talk about it at a later stage. The pharmacist should be mindful that it is not the role of the pharmacist to make patients face up to the inappropriateness of their behavior or to convince them to change.

The pharmacist should simply provide patients with insight into the behavior. Remember that strong arguments for change will cause the patient to take up the other side, becoming more committed to the inappropriate behavior Miller, Intervention for contemplators When individuals enter the contemplation stage of change, the negative aspects start to outweigh the positive aspects of the behavior, although both are still very important for the individual Prochaska and DiClemente, On the one hand is recognition of a problem; on the other is avoidance of change due to what the patient perceives as the benefits of the inappropriate behavior.

Contemplators will need to be helped with the decision-making process so they can work through ambivalence about behavior change. The use of motivational interviewing techniques can accomplish this best. A good strategy is to do a decisional-balance exercise with the patient. Talking about the positive aspect of the inappropriate behavior also helps the pharmacist demonstrate empathy by recognizing that there is also a good side to the inappropriate behavior. This can be done by succinctly summarizing the good things and the less-good things. A good way of starting is to set a date for behavior change to occur.

If the misbehavior is being caused by misinformation, the patient may commit to change on being provided with information on how to behave appropriately. However, in the case of chronic misbehaviors, the individual will most likely need a few days to prepare for changing behavior. Patients will need to learn a new set of skills that will enable them to cope with the change.

The cognitive-behavioral approach advocates the replacement of the inappropriate behavior with more adaptive ways of satisfying the needs that it fulfilled.

Pharmacoethics: A Problem-Based Approach (Pharmacy Education Series) - PDF Free Download

Patients should be encouraged to think about alternative behaviors. If appropriate, the pharmacist should also provide the patient with self-help materials. Intervention for patients in the action stage In the action stage, patients put into practice the skills acquired in the preparation stage. Support from the pharmacist is crucial in this stage; it is important for patients to have someone with whom to discuss the progress and difficulties encountered in making the change. Rollnick, Mason, and Butler, in their groundbreaking book, Health Behavior Change: A Guide for Practitioners , outlined a seven-step process to elicit change in patients.

Patient problems can be characterized as follows:. When the patient is first encountered, there is always insufficient information available for the pharmacist to decide immediately what may be going on with the patient and to determine an appropriate plan of care. Most patients present with only a prescription, and it is quite obvious that more information will have to be obtained by the pharmacist through a pharmaceutical care history form and maybe one or more laboratory tests to derive a care plan.

In fact, no matter how much information may be present when the pharmacist first encounters the patient pharmaceutical care history form, laboratory results , the pharmacist will always want more to decide on a care plan. Pharmacists have to obtain the necessary additional information needed for patient care through a deductive inquiry process. A second important point is that the real challenge to the practicing pharmacist is the patient problem that does not fit into any common pattern. Experience with real patient problems, as students learn from the very beginning of pharmacy school, provides them with the best opportunity to develop the flexible thinking necessary to accommodate these challenges of practice.

There is no one right way for the pharmacist to obtain the additional information needed. If different pharmacists are given the same patient problem, each will go about getting more information for that same patient problem in different ways. Although there may be some common questions shared by all, each will ask different questions in a different order, order different laboratory tests, and counsel a patient in a different way.

Despite these differences, they will often come up with similar pharmaceutical care plans. Each pharmacist has different patient and educational experiences in long-term memory. These produce unique configurations of data and different experiences of what works to make and care for a particular patient. As a consequence, each requires different information to support or deny the ideas considered. The way the patient presents information to the pharmacist is not unlike the tip of the iceberg.

Important data that a pharmacist might like to have to make a pharmaceutical care plan decision may not be available from the patient for a variety of reasons. Even in straightforward cases, there can be an unsuspected complication to care management.

What do pharmacists do

Despite all of this, the pharmacist has to make decisions and take actions. Unlike problem solving in other professions or in scientific investigations, the pharmacist has to provide care for the patient then and there, taking action despite the fact that there is a chance of being wrong. The patient is a necessary and important partner in the treatment process. The patient expects to receive professional service from the pharmacist and expects care and understanding. A frightened, hostile, unhappy, or confused patient will not communicate, cooperate, or comply with the care plan as well as a reassured patient who understands the care being offered and is satisfied with it.

It is not sufficient for the pharmacist to have good technical and problem-solving skills to care for patients. Interpersonal, communication, and patient education skills are equally essential. With these characteristics of patient problems in mind, we now need to look at how the effective, efficient, and ethical pharmacist can effectively deal with the challenges patient problems offer.

It is also important to have faculty from different disciplines and content areas periodically review the specific problems in each PBL case to see if the seven-step method discussed below produces the necessary behavior change. Step 1: Establish rapport Sometimes, it is difficult to get started on a discussion about behavior change with a simulated patient. Rapport is sometimes quickly established, and the agenda is often obvious. It is not difficult to get things off to a good start. Three items, discussed below, are essential for establishing rapport: physical setting, thoughts and feelings about the counseling session, and a typical day.

Physical setting The physical setting for the counseling session may either promote or obstruct the development of rapport. An equal power relationship is essential for successful negotiation. The patient will expect to be handled by the pharmacist in a certain way. Check these expectations and clarify any misunderstandings. The patient may also have immediate concerns that will need to be addressed before the patient will be comfortable about addressing other matters like behavior change.

It is important to identify these and respond appropriately. It is also worth acknowledging the context of the consultation for the patient. If the patient feels respected and cared for from the beginning, any subsequent discussion will be easier. Here, the patient describes a typical day and usually says where the behavior under discussion fits into this context. It is useful to employ this strategy near the beginning of a counseling session, even if the subject of behavior change has not been raised. If one has time to spare, it can be a most worthwhile experience for both parties.

One can follow the account of a typical day in general without reference to any behavior.

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If this is carried out skillfully, rapport will be considerably strengthened. Of all the judgments made in a behavior change counseling session, the poorest often arise from a premature leap into specific discussion of a change when the patient is more concerned about something else. Sometimes, it can be a relatively routine matter that prevents a focus on behavior change: a patient who arrives at a counseling session upset about a minor accident might not be able to concentrate on anything the pharmacist says.

Sometimes, it is a personal matter that concerns the patient and that he or she might want to talk about; someone who has recently had a heart attack might be preoccupied with matters of life and death. It would be poor timing, even insensitive, to talk about getting more exercise or changing diet under these circumstances. A critical early task, therefore, is to agree on the agenda. Even when behavior change is a possible topic for discussion, one is often faced with multiple interrelated health behaviors.

For example, many excessive drinkers also smoke. Thus, health behaviors deemed risky often coexist in individual patients. Those who suffer from diabetes, heart disease, and other chronic conditions frequently face the challenge of changing more than one behavior. Deciding what to talk about is thus a crucial first step. Pharmacists will need to make a clear and conscious choice between using either a strategy for multiple behaviors or a strategy for a single behavior.

This is because so many health care practitioners, when faced with a range of possible behaviors, prematurely compel a patient to discuss one particular behavior at the expense of others. At this stage of the counseling session, the patient should be given control of its direction. Multiple behaviors Negotiating behavior change is a specific process. It is applicable to a range of behaviors, but can only be used with regard to one specific behavior at a time.

Account Options

Everyone is at a different stage of readiness to change due to different issues. Even within one topic, such as diet, a patient may be ready to make one change e. Sometimes, changing one behavior will also begin change of another, but it is important to keep the process to one behavior at a time. When there is a range of behaviors that could be discussed, it is essential to prioritize and focus on one clear objective. This makes the whole process more manageable.

The aim here is to be open and honest about the agenda the pharmacist may have, to understand the agenda the patient may have, and to help the patient select a behavior, if appropriate. The patient, however, might prefer to talk about a pressing personal matter. This agenda setting can be done informally by asking a series of open questions.

Consider talking about the importance of change and the building of confidence. If time is running out, you might consider asking the patient to keep a diary of the behavior or simply to think about it. Many behavior change discussions have stress as an underlying theme. Rather than leave this topic to one side, it can be helpful to bring it out into the open and consider which behavior changes, if any, might help. The aim here is to help the person take an initially very broad view of stress, its causes, and its consequences. Having done this, if you sit back and are prepared to tolerate a period of uncertainty with the patient, the patient will often lead you to talk about a change.

A genuinely curious tone needs to be adopted; the practitioner sits back and tries to understand how the patient sees things. Everyone has different causes or reasons why stress builds up. Some causes can be changed; others cannot. Some come in a downpour, others in a slow stream.

Symptoms are the things that happen to the patient as the level rises. They affect the body e. Solutions are the things that lower the level of stress in the patient e. This kind of discussion often leads to talk about change. If this happens, be careful not to close the discussion prematurely. Patients can sometimes seem confused, and silences can follow as they talk about the possibilities.

The only guideline is to stay with them and retain a genuinely curious tone that reflects the underlying spirit of the exercise. It is not essential to make decisions now. The aim is just to have a look at the situation. Single behavior In some circumstances, the pharmacist may clearly identify one particular behavior to discuss. In the pharmacy, a patient may present with a particular symptom, and the pharmacist may identify a probable or certain link with a particular behavior.

Pharmacists may believe that it is their professional duty to raise a concern about risky health behavior, and not raising the issue would be to shirk this responsibility. Therefore, the pharmacist should consider this the first priority. Be honest about your agenda and invite the patient to express personal views on the subject. There are some occasions when raising the subject can be difficult. There is no better formula than taking time to establish good rapport.

Raising the subject of heavy smoking is a good example. A proud person who feels concerned about being stigmatized as a smoker can make things difficult for the pharmacist concerned about his or her health. Under these circumstances, it seems easier to say what one should not do. If one encounters immediate resistance, this is a signal to change strategy. A productive way of building this kind of rapport is to use the typical day strategy. If the pharmacist raises the subject and gets the impression that the patient is feeling threatened, it can be useful to give the patient time to think.

This is fairly easy in a pharmacy, where continuity of care is a possibility. The patient can come back and see the pharmacist again. Back off in a nonthreatening way, and come back to it later. Step 3: Assess importance and confidence and readiness It seems that some patients cannot change, and others do not want to change.

Having agreed to talk about a particular behavior, the assessment of importance and confidence is a useful next step. Put simply, it will help the pharmacist understand exactly what the patient feels about change. This task need not be carried out in every counseling session.

A pharmacist might, for example, know how a patient feels about change or at least have a strong intuition. A patient might be convinced of the personal value of change importance , but not feel confident about mastering the skills necessary to achieve it confidence.

This applies to many smokers. Heavy drinkers, on the other hand, can be quite different: they often have mixed feelings about the value of change importance , but say that they could achieve this fairly easily confidence if they really wanted. When it comes to changes in eating patterns, people often have relatively low levels in both dimensions. A pharmacist can assess readiness in addition to importance and confidence.

The assessment can be done informally by simply asking the patient to clarify how he or she feels about importance and confidence. It can also be done more formally using a standard set of questions. In either case, the assessment can take as little as 2 to 3 minutes, but the patient must be actively involved.

There is no single way of doing this. In keeping with the meaning of the term self-efficacy, here confidence is about mastering the various situations in which behavior change will be challenged. The patient has little concern about one dimension, and the obvious difficulty lies with the other one. It is then a matter of deciding which strategy will help this person to either explore importance or build confidence. Sometimes, the outcome of this assessment is not clear, or both dimensions appear salient.

Under circumstances like this, a pharmacist will need to lower his or her sights if the contact time is brief. Being too ambitious is probably the biggest mistake to make, often taking the form of a premature recommendation. Resistance is a likely outcome. One possibility is that the discussion returns to agenda setting and moves on to another issue. If behavior change is to be talked about, a period of uncertainty is likely to prevail in which the pharmacist should ultimately use the patient as the guide for deciding whether to focus on importance or confidence.

There can be situations for which it is useful to assess readiness, either instead of or in addition to importance and confidence. It can be a useful platform for taking a counseling session a step further. This more global dimension is often viewed as something to be aware of throughout the session, not necessarily something to be assessed. The assessment of readiness is a process, not an event, involving conversation and reflection.

A pharmacist can use a numerical scaling method here, too. Why are you at x and not [a lower number]? What would have to happen for you to move up to [a higher number]? The pharmacist needs to decide the next step and which of these two dimensions receives focus. Here, the pharmacist has a selection of strategies for working within either dimension.

In moving both within and between these dimensions, the pharmacist will require considerable skill to lead a partner through a sequence of movements, simultaneously leading and being led, keenly alert to subtle threats to the synchrony of the partnership. Resistance from the partner is not met by force, but by transforming the movement in a constructive direction if at all possible.

No amount of dedicated adherence to the strategies described below will be effective if this state of mind is absent. A certain degree of relaxation is required to maintain this spirit in the counseling session. It is useful to develop a committed but curious state of mind when talking about behavior change. The pharmacist cannot be expected to have all the answers. Indeed, the pharmacist must believe that these lie mostly within the patient.

Step 4: Exploring importance Some of the strategies for working on importance are best used at fairly high levels of this dimension i. Use of words to describe different degrees of concern about a behavior can be critical. If the pharmacist gives people a chance to talk, they will use a variety of words about change.

The pharmacist should watch for these and match them as much as possible. Many of the strategies below start with a leading question that implies knowledge of how concerned the patient is about a behavior. Sometimes, however, one does not get a lead from the patient, and one has to take a deep breath and see what happens. If one imagines a continuum of importance, from 0 to 10, different words are suitable at different points along this continuum. In ascending order, the following terms are appropriate as the level of importance increases: dislikes or less-good things 2 or 3 of 10 , concerns 6 of 10 , difficulty or problem 7 or 8 of The range of strategies for exploring importance is best viewed as a menu.

Care should be taken not to view these strategies as techniques applied to patients. The strategies are simply ways of structuring a purposeful conversation. Creative adaptation, not mindless adoption, should be the goal. How this is done is important. The pharmacist could leave the patient feeling downhearted or even reluctant to come back.

Acknowledge the uncertainty; do not just leave the patient hanging. If the pharmacist is unsure what to do, then ask the patient. For example, the patient might want to talk about it again in another encounter. Many health care practitioners faced with this situation are tempted to take a deep breath and simply provide information, seeing it as their professional responsibility at least to inform the patient of existing or potential risks.

If this does not damage rapport, the approach seems understandable and justified. Scaling questions Scaling questions involves using a set of questions designed to understand the patient and to encourage the patient to explore personal value or the importance of change in more detail. Typically, having elicited a numerical judgment of importance, the six recommendations listed below can open a very productive discussion in which the patient does most of the talking and thinks hard about change. Ensure that the pace of the discussion is slow and develop a genuine curiosity to know how this person really feels.

You should listen to the answers to your questions, using techniques like reflection and other simple open questions to help patients express themselves as fully as possible. Your attention should not be on your thought processes e.

Pharmacoethics: A Problem-Based Approach

Trust the process and the patient. Watch carefully for resistance because this is a signal that you are going too far. A first method for scaling questions moves down from the number given by the person. You can then follow these questions with other open questions or reflective listening statements. Ask why he or she scored a given number and not a lower number. Your task is now to elicit the range of reasons why the person wants to change. The pace should be slow, and simple open questions can be very useful here.

If the answers are obvious, then elicit them and move on. If the answers are more complex, then take your time trying to understand all the ramifications. A second method for scaling questions moves in the opposite direction, up the scale from the number given by the person. Note that one can ask about either the score or just the person. The second method often feels like the better one. Start with the positive, which will help with rapport building and place the behavior in a normal context.

This can be a shock in some situations, particularly when the patient believes that the behavior is a problem. Try to deal with this in a straightforward way by explaining that there must be benefits from the activity or behavior, otherwise the person would not be doing it. Explore concerns about the behavior Exploration of concerns about the behavior focuses solely on the costs of the current behavior.

One can only use it if the patient appears concerned. Misjudgment of this will result in resistance. Otherwise, it is ideal for helping the patient take time to express exactly what the issues are. Two principles guide the use of this strategy. First, the patient expresses the concerns; second, once the patient has reached the end, the pharmacist asks some key questions about the possibility of change. Take your time. Go through any other concerns the patient might have. Exchange information if appropriate, but try not to wander off task.

Then, summarize these concerns for the patient. Ask the patient about the next step. Do this in a gentle and nonconfrontational way. This kind of question is deliberately phrased in neutral terms. The patient can either move toward or away from a decision to change. A question that explicitly asks about change can be useful, but carries the risk of the patient feeling pushed too far. I understand why. I know what to do, and why I should do it. It is important to them to do so. However, they feel pessimistic about the success of such a venture.

This section describes strategies for building confidence to succeed. These strategies provide a framework for something that is pervasive in counseling sessions: helping people find practical solutions to their difficulties. The strategies described below are not meant to be counseling strategies for dealing directly with low self-esteem and helplessness. Rather, they deal with more specific changes in self-efficacy about behavior change. Sometimes, however, the pharmacist will find that if someone can be encouraged to look at small changes and succeeds with these changes, they often have a bearing on gradually improving self-esteem.

If not, simply acknowledging the way a person feels can start a process of reversal of low self-esteem, particularly if you can offer further support. Goals, strategies, and targets are among the most widely used. It can be useful to note the way in which the use of terms like these varies from the general to the specific. They can be likened to signposts on a journey.

The start might be with talk about a general goal. Usually, this refers to behavior change, although the goal of losing weight provides an interesting exception: losing weight is an outcome of behavior change rather than a behavior. The journey often continues with talk about strategies and, becoming more specific, about targets. Thus, numerous strategies might be considered in pursuit of a single goal; in turn, numerous targets might be considered in pursuit of a single strategy.

A menu of strategies was constructed for exploring importance. Choose a strategy that fits the way the patient describes his or her lack of confidence. These strategies are not completely separate from each other. They are overlapping, different ways to approach the subject of confidence building.

Do little more Most decisions to change do not take place during a single discussion. The patient does not necessarily need to set specific targets in conversation with you. It might be enough simply to raise the issue, mention the possibility of taking action, and leave it at that. If you plan to see the patient again, this is often a very good starting point, much better, for example, than pushing too hard for change.

Scaling questions The scaling questions strategy is linked to the numerical assessment of confidence. It is simply a way of opening the door to talk about strategies and targets. The patient does most of the thinking and talking, while your role is to ask questions and help clarify the stumbling blocks to change. Having conducted an assessment of how confident the person feels to make a particular change, you have been given a rating on a point continuum. You now have a platform for understanding exactly how the patient feels and what might lead to successful change.

Keep the pace of the discussion slow and adopt a curious attitude. Your hope is that the answers lie within the patient. Brainstorm solutions Some patients, in some situations, apparently want to be told what to do. Certainly, if someone has an acute life-threatening condition, the person will probably take your advice.