A counseling training session at work

Study targets skills, confidence levels

Lee, A.J., et al. Staff development in pharmacist-conducted patient education and counseling. Am J Health-Syst Pharm 1998; 55:1792-8.

A new study conducted at the Veterans Affairs Medical Center of San Francisco has found that counseling training programs are necessary for pharmacists to gain the competence and confidence they need to effectively counsel patients.

The study complements the findings of a recent survey of pharmacists in Ohio covered in the Sep tember 1998 issue of Drug Utilization Review (see p. 159 in that issue). In that study, surveyors found that while the vast majority of respondents want to counsel patients, most simply don’t.

Specifically, 67% of the Ohio pharmacists said they counsel no patients, 21% said they counsel one to two patients per day, just 5% counseling three to four patients daily, and 2% counseled more than six per day.

Most respondents said a lack of time/workload, lack of private setting or hospital support, and even patient attitudes were the main barriers to effective counseling. But while most Ohio pharmacists did not cite the lack of a counseling training program as a major barrier, the San Francisco study found that without such a program, the competence and confidence needed to effectively counsel patients was lacking. This was despite the assumption that "pharmacists are expected to provide individualized patient consultations in a variety of pharmacist-managed clinics, in decentralized outpatient pharmacy modules, and at the time of discharge."

The VA’s pharmacy staff development committee reacted by launching a counseling training program detailed by the authors.

The program began with the formation of a planning subcommittee within pharmacy, staffed by inpatient and outpatient pharmacy supervisors, the VA’s education and quality-improvement coordinator, a regional pharmacy coordinator from the University of the Pacific in Stockton, CA, an outside pharmacoeconomics specialist, and a pharmacy practice resident.

As part of the training sessions, the group established seven patient cases based on VA files for role-playing techniques. These consisted of the patient’s list of problems, a simulated medication profile, and a group of prescriptions to be filled. Included in the role-playing were cases that "involved patients with communication barriers such as visual or auditory demonstrating the use of an inhaler and spacer to a hypothetical patient with asthma."

Pharmacists were required to rotate as either a patient or pharmacist, followed by counseling two real patients while being observed by a facilitator.

Another major part of the program required pharmacists to pass with a score of 90% or higher an open-book, written exam of 50 multiple choice questions concerning use indications, adverse effects, interactions, administration, precautions, storage, and compliance.

To assist pharmacists when the real counseling began, manuals were compiled as references covering 70 individual drugs commonly used at the center, along with 32 common disease states. Pharmacists carried the manuals during the training programs, along with handouts describing proper techniques for oral and nasal inhalers, spacers, and ophthalmic agents.

As the training programs were conducted, pharmacy officials established standard counseling policies on identifying what types of patients would receive mandatory counseling. Policies also dictated that documentation of counseling sessions must be put into the center’s computer system.

And in another major step, the VA created the position of the discharge counseling pharmacist (DCP), who is "responsible for counseling patients who are not being monitored by one of the ward pharmacists," note the authors. The DCP position is filled by all inpatient pharmacists on a rotating basis, with the DCP available weekdays, 7:30 a.m. to 3:30 p.m. For ambulatory care, pharmacists were made available in decentralized private counseling rooms.

The authors also note that about 100 hours were needed to "plan the program, develop the cases and the examination, and reproduce the references." It took another five hours for pharmacists to complete the program (minus the time it took to complete the written exam).

Pharmacists were queried before and after the program about their experience and confidence levels concerning patient counseling. Predictably, the latter increased after completion.

For more details or reprints, contact Audrey Lee, PharmD, BCPS, Veterans Affairs Medical Center, 4150 Clement St., San Francisco, CA 94121.