Int J Clin Pharm DOI 10.1007/s11096-015-0130-3

RESEARCH ARTICLE

Interprofessional communication training: benefits to practicing pharmacists Karen Luetsch1 • Debra Rowett2

Received: 2 December 2014 / Accepted: 27 April 2015  Koninklijke Nederlandse Maatschappij ter bevordering der Pharmacie 2015

Abstract Background Interprofessional communication skills are important for pharmacists to build collaborative relationships with other health professionals, integrate into healthcare teams, maximise their effectiveness in patient care in addressing complex care needs and meet the demands of health care reforms. Objective This qualitative study explores clinical pharmacists’ experiences and reflections after completing a learning and practice module which introduced them to a framework for successful interprofessional communication. Setting The postgraduate clinical pharmacy program at The University of Queensland and the clinical pharmacy practice environments of forty-eight hospital and seven community based pharmacists. Method A learning and practice module outlining a framework for successful interprofessional communication was designed and integrated into a postgraduate clinical pharmacy program. Enrolled pharmacists applied newly learnt communication skills in pro-actively initiated, clinical discussions with a health professional in their practice environment. They provided written reflections on their experiences which were analysed using thematic analysis. Main outcome Pharmacists’ perceptions of the impact of applying the communication framework during their interaction with a health professional in their practice setting. Results Themes which emerged

from reflections described pharmacists’ confidence and capabilities to successfully conduct a clinical discussion with a health professional after initial apprehension and nervousness about the scheduled interaction. The application of the communication framework enhanced their perception of their professional identity, credibility and ability to build a collaborative working relationship with other health professionals. Conclusions Pharmacists perceived that a learning and practice module for successful interprofessional practice integrated into a postgraduate clinical pharmacy program enhanced their interprofessional communication skills. The development of pro-active, interprofessional communication skills has the potential to increase interprofessional collaboration and pharmacists’ personal role satisfaction. Pharmacists also observed it added value to their professional contribution in health care teams when addressing the demands of increasingly complex health care needs and reforms. Keywords Australia  Clinical pharmacy  Health care  Health professional  Interprofessional communication  Postgraduate  Reflection

Impact of Findings on Practice •

& Karen Luetsch [email protected] 1

School of Pharmacy, The University of Queensland, 20 Cornwall St, Brisbane, QLD 4102, Australia

2

Drug and Therapeutics Information Service, Repatriation General Hospital, Daws Rd, Adelaide, SA 5041, Australia



Identifying and addressing a lack of confidence in initiating interprofessional communication by pharmacists reduces potential barriers to becoming an effective member of healthcare teams. Training for pharmacists in interprofessional communication skills can increase their perceived capability and confidence to proactively communicate with clinicians.

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Introduction Effective communication is essential for the provision of patient centred healthcare. Future practice will require pharmacists to be adaptive and resilient with high level interprofessional communication skills to lead the change in attitude and culture required of the health workforce to deliver integrated care. Competency standards for pharmacy practice include requirements for demonstration of effective communication skills in line with the WHO/FIP eight star pharmacist concept [1–8]. Programs of study which lead to a registrable pharmacy qualification include the teaching, practice and assessment of communication skills as they are recognised as a core competency for pharmacy practice. At the pharmacy student and intern levels the focus is often on professional communication with patients. Interprofessional communication (IPC) generally receives less attention and structure in pharmacy training compared to patient counselling [9, 10]. At the same time interprofessional education (IPE) is increasingly being included in pharmacy curricula and continues to evolve as understanding, teaching and learning research guides IPE curriculum development [11, 12]. Undergraduate and postgraduate pharmacy programs incorporating aspects of IPC often facilitate collaboration with other health professional students in case-based, simulated or supervised practice settings [13–16]. Some programs utilise simulation where pharmacists role-play health professionals, for example during objective structured clinical examinations (OSCE). In OSCE scenarios students are experiencing how pharmacists perceive a physician, nurse or other health professional would behave as a clinician, limiting a true insight into the motivations for practice, barriers to practice change and clinical reasoning of the ‘other’ practitioner [17–19]. Overall opportunities to practice communication with licensed health professionals are limited and the involvement of physicians in the training and assessment of effective communication skills is uncommon, with medical students or recent medical graduates taking on the role of the physician [20]. The degree of interaction and collaboration of registered pharmacists with other health professionals is mainly determined by their practice setting [21, 22]. For pharmacists performing medication reviews in residential settings in Australia, for example in the home of patients or aged care facilities, there are opportunities to interact with other health professionals, mainly nursing and other care staff or the referring general practitioner (GP) [23]. In most pharmacy practice settings communication with other health professions usually revolves around brief interventions related to an individual patient to improve medication use, making recommendations on the quality use of medicines,

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communicating pharmaceutical care plans and correcting prescription or administration errors as well as providing drug information on request [24–28]. Successful IPC increases the visibility of pharmacists’ capabilities and competencies to other health professions, moving them from behind the scenes into a collaborative, open exchange, sharing their skill and knowledge, which many pharmacists feel are unrecognised or underappreciated [29, 30]. It also allows pharmacists to pro-actively engage with other health professions and clinicians, moving from improving care for one patient or intervention at a time to influencing future decisions for future patients through facilitation of practice change. The postgraduate clinical pharmacy program (PCPP) at The University of Queensland (UQ) aims to extend pharmacists’ practice and understanding to fulfil the roles delineated in the WHO/FIP eight star pharmacist concept [1]. For this purpose it includes a unique learning and practice module introducing a ‘‘Framework for successful interprofessional communication’’ which is based on the Drug and Therapeutics Information Service (DATIS) training framework to support their development as skilled and intuitive communicators, teachers and team players. Design of learning and practice module The learning module introducing pharmacists to a framework for successful interprofessional communication (the IPC framework) employed within the PCPP at UQ has been designed through collaboration with DATIS and the School of Pharmacy. Its teaching is positioned within the context of social pharmacy. The module includes an overview of social marketing with online tutorials exploring the application of social marketing techniques with exercises to elicit features, benefits, barriers and enablers for selected key messages [31]. The framework ‘deconstructs’ an interprofessional educational visit which is structured around the principles of academic detailing and provides communication and interaction skills training in the techniques of academic detailing [32]. Session topics include: exploring values and beliefs; the concept of needs; identifying needs; barriers to behaviour change; communication theory; and influencing techniques. Building on existing skills and experiences the two main goals in the design and application of the IPC framework are teaching pharmacists effective communication skills to move from clinical interventions for individual patients to a more global role as change agents in the quality use of medicines and medication safety and facilitate interprofessional collaboration. The IPC framework emphasises engagement with a health professional which transforms an educational interaction beyond communicating information or facts to

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understanding existing behaviour and practice as well as barriers to behaviour change. This approach to interprofessional communication differs from how pharmacists usually impart knowledge through education to patients and health professionals, moving the interaction from a transactional to a relationship based approach [33]. The semester long course employs role-plays, role-modelling, practice-based learning and other interactive and reflective methods. Incorporating action learning, pharmacists scheduled a short visit to a health professional, preferably a medical doctor, after completion of the module and submitted a reflection on their experience and learning [34]. In preparation for their scheduled visit pharmacists familiarised themselves, using standardised resources, with a relevant clinical topic (safe and effective use of anticoagulation), which was contemporary and promoted quality use of medicines in their practice and healthcare setting. Concise, visual materials supported them during their interprofessional encounter and were given to the health professional at conclusion. After completing their educational encounter pharmacists submitted a written reflection on their experience via the university’s online platform. Structured reflection is an integral part of all PCPP courses and guidance on reflective writing was provided to participants, with most structuring their reflections along the Gibb’s reflective cycle [35, 36]. These reflections, submitted within a maximum of 5 weeks after their encounters but usually written shortly after, were then analysed. The impact of IPC training on overall pharmacy and individual practice has not been described comprehensively in the literature.

Aims To explore pharmacists’ experiences and reflections after completing a learning and practice module which introduced them to a framework for successful interprofessional communication.

Ethical approval Ethical approval was granted from the UQ Human Research Ethics Committee (approval number: 2013000966).

Methods Evaluation of interprofessional encounters All reflections written by pharmacists who consented to participate in the study were evaluated. An inductive approach to the analysis of participants’ reflections was developed, employing thematic analysis to identify patterns of meaning.

Open coding was used to identify commonly recurring themes and develop exclusive categories and sub-categories of these themes. Statements in the participants’ writing were then selectively coded and grouped into categories under central themes which emerged through the analysis of similarities and differences. Some subcategories were collapsed further to maintain their exclusiveness [37–39]. The process of analysis was iterative and immersive with the researchers reading reflections multiple times over a 12 month period, discussing the interpretation and deciding on codes, categorisation and themes which encapsulate participants’ perceptions of experiences, their attitudes and beliefs until saturation was reached when no more unique themes emerged. Central themes were condensed into two main categories of clinical pharmacy practice and interprofessional learning. Subcategories and themes relating to the central theme of professional and clinical pharmacy practice are discussed here.

Results Fifty-five of 85 pharmacists (65 %) studying the module as part of the PCPP over 2 years provided informed consent to participate in the study. Their reflections were independently anonymised and consecutively numbered (R1–R55) prior to analysis by the authors. At the time of submission the majority of participants (48) had been working clinically in hospitals for an average of 3 years. The majority of pharmacists worked in public and private hospitals across Australia, some in tertiary referral centres in capital cities others as sole pharmacists in small rural sites. A minority of participants (6) worked in community pharmacy at the time of the study. One participant worked as an ‘educational visitor’ with skills in the technique of academic detailing. Forty-eight pharmacists were able to arrange their visit with medical professionals, mainly junior doctors, most of the remaining seven arranged their visit with experienced nurses (clinical nurses, nurse educators) and most encounters lasted for 10–20 min. Three subcategories relating to the theme ‘professional and clinical pharmacy practice’ are described in detail. Confidence and capability Although most pharmacists were working clinically in proximity to and communicating with other health professionals some felt apprehension or nervousness at the thought of discussing clinical information in a pro-active, structured, appointment based, one-on-one interaction. Concerns before or at the start of their encounter revolved around adequate preparation, therapeutic knowledge and competence, lack of familiarity with the task and fear of rejection and losing one’s credibility. Participants doubted

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their capability in providing a service that hadn’t been asked for. They seemed uncertain about which information doctors may require and appreciate around the chosen topic and how to best prepare for the initiation of the educational interaction. I was feeling quite anxious about the educational visit, as this was my first experience delivering information to a doctor in this manner. (R40). I was a bit nervous before starting as the whole idea of academic detailing would be a change in context from our usual interaction and I really didn’t want to make a fool of myself, resulting in damaging our rapport. (R54). Despite much research and study prior to the AD session, my main concern was not knowing enough about the topic and losing credibility with the doctor. (R43). Others were concerned that the health professional, in most cases a doctor, wouldn’t engage and doubted the value of their contributions, lacking confidence in their own professional competence. I also initially felt nervous that I would not be able engage the doctor in the discussion. I usually find the introduction of clinical conversations quite intimidating, as I often doubt that people will value what I have to say. I can see that I sometimes come across as unsure when I really do have the knowledge. (R20). At the time I was thinking ‘I hope this won’t turn out to be a waste of the doctor’s time, I hope I impart some knowledge, or spark some interest from the doctor’, and ‘I hope I don’t stumble and look like a fool’. (R30). Some described their pleasant surprise and relief when their negative expectations were not fulfilled. I expected the session to feel very contrived and ingenuine, as this is how I felt during the training weekend workshop, however contrary to this the actual session felt very natural and flowed well with one topic leading into another. (R26). Professional identity Despite the initial nervousness and not having reconciled an interaction which resembled a structured, educational visit with their previous experiences as clinical pharmacists or teachers most participants described the encounter with the health professional in positive terms. Two distinctive

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subthemes about the value of using the IPC framework and applying a structure to their interprofessional interactions emerged. One was validation of their role as pharmacists and gaining personal and professional satisfaction, particularly when receiving positive feedback from the health professional. Pharmacists expressed how the use of the IPC framework allowed them to cement or extend their recognition and credibility as ‘‘medication expert’’, feeling personally and professionally rewarded and satisfied with their role in providing a service which makes use of their unique skills and knowledge. At the end of it all I came out a little more confident, with better communication skills and an increased sense of pride in the pharmacy profession. (R1). After the conclusion of the visit, she applauded the way I delivered the key messages, and stated that the visit felt collegiate in nature. I felt very pleased with the consultant’s complement. (R9). I felt empowered in my role as a ‘medication expert’. (R14). Some participants reflected on how professional recognition strengthened their relationship with the health professional, having a positive effect on their professional collaboration. Overall I was honestly ecstatic with how the session went. I was so sickly nervous about it all week and when it flowed so well and so naturally I was relieved! My relationship with the JHO (Junior House Officer) was strengthened by the exercise and he came to me with so many clinical questions (although about different topics) in the days following. (R54). In the second subtheme pharmacists extended from an individual and personal level by describing the value which communicating within the IPC framework and using basic principles of academic detailing adds to the pharmacy profession as a whole in contributing to the quality use of medicines and becoming visible and valued by other health professionals. I feel that activities such as academic detailing should be at the core of what we do as pharmacists. It can build and establish credibility with other health professionals, demonstrate to them what a valuable contribution we can make to improving and optimising patient health outcomes. This change in structure could also improve our profession by allowing pharmacists to promote themselves as medication specialists, whilst enhancing and expanding our roles so that pharmacy keeps moving forward as a profession. (R6).

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… I have never had the opportunity to have a formal discussion with a Doctor. The structure of the session encourages the opportunity for academic discussion. It demonstrates how we can improve use (safety and appropriate prescribing) of medication through active discussions. …..Looking outward to the influence of the Pharmacist, the Resident’s interest in the session demonstrated how the knowledge of a Pharmacist is valued and sought after in the healthcare setting. (R14). The use of academic detailing and better inter-professional communication in the clinical setting between doctors and pharmacists is important as poor communication is a major cause of medication errors and doctor-pharmacist collaboration can significantly improve patient care. (R43).

recommendations which they may/may not take on board. It felt good to engage in a proper conversation with a doctor and it allowed me to understand their perspective. I’ve learnt that if you allow the conversation to develop naturally and acknowledge the doctor’s experiences, the doctor is more likely to respond to the questions and the outcome is much more beneficial. (R53). Although the IPC framework specifically focuses on interprofessional communication it became obvious how learning and applying it changed pharmacists’ perceptions of their overall practice to date. They realised how their learning will influence communication strategies in all areas of practice, including communication with patients.

Discussion Value to future integrated practice roles Many reflected on how what they learnt will change their communication strategies and practice. They realised the value and potential their newly learnt and applied skills offer for their effectiveness in their roles as pharmacists. One particular skill which I learned at the workshop I value very highly. I implemented that skill during my interview and it is the skill of active listening. This skill provides the person presenting information with the ability to tailor the talk specifically to the interests of the recipient. It sounds very simple, but I find that it often gets underused, as we, as pharmacists, are trained to rattle-off information to patients/colleagues without reaching out and really listening and only then providing the help that is asked of us. …… I believe that I have acquired very useful skills which definitely make me a better health professional – despite the fact that I did not feel that I needed help in inter-professional communication before attending the workshop and conducting this educational visit. (R46). I actively try to elicit more information from the person I am speaking to (whether it be a patient, doctor, nurse or multidisciplinary team member) by using effective questioning and listening techniques or principles of motivational interviewing to resolve a clinical concern. In the past, my approach was more direct or task-driven rather than trying to identify potential motivations for or barriers to the person’s behaviour. (R13). Usually my doctor interaction involves telling them what they’ve done wrong and offering

Reflections provided by pharmacists applying the IPC framework in practice allowed the construction of a number of themes describing their feelings, beliefs, ideas and experience. Strengths of integrating written reflection lie in pharmacists retrospectively realising and verbalising the weaknesses, strengths and future potential of their practice. A qualitative analysis of reflections gave insights into how pharmacists made sense of the experience of an educational encounter, which differed from their usual interaction with health professionals, who in this study for the majority of participants was a junior doctor. Although the majority of pharmacists enrolled in the PCPP were practicing with clinical competence they lacked confidence meeting with a doctor one on one. They seemed to doubt their capability in leading a clinical discussion, expressed in their obvious nervousness or anxiety about whether the knowledge and information they can offer would be at a satisfactory level and detail. Concerns about losing credibility are understandable when entering the often unfamiliar territory of pro-actively offering a tailored service and advice. Participants either practiced or observed an exemplar of a structured, evidence based discussion, modelled on educational outreach visits, before their actual encounter and frequently referred to applying the proposed structure to their interaction. They expressed the realisation of how framing their clinical discussions in this way will potentially influence the overall quality use of medicines and therapeutic decisions for not just one patient at a time. They perceived an influence on decision making processes impacting on many future patients, adding an enhanced sense of responsibility to the interactions [32]. The lack of confidence in their own competence and their initially limited capabilities to engage pro-actively in in-depth

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discussions with health professionals pointed to a skill gap in the study participants’ clinical pharmacy practice, which potentially limits their positive impact on individual and global patient care. As encouraged in the application of the IPC framework, once pharmacists had empathetically elicited the health professional’s practice and particular information needs around the discussed topic most were able to satisfy these needs. They felt successful at delivering the content and discussing the therapeutic and clinical aspects of the topic in an interactive professional exchange. Their writing clearly reflected that reciprocally their own needs for professional recognition and role effectiveness were met in the encounter. Structuring and conducting discussions utilising the IPC framework has the potential to build the confidence and competence of pharmacists and accelerate the transition from performing brief, task-orientated, retrospective interventions to becoming pro-active communicators and drivers in patient care. This means engaging successfully with a variety of health professions, recognising information needs and the most appropriate strategies to address them. The study showed that participating pharmacists overcame their lack of confidence to engage doctors in a pro-active, detailed clinical discussion. They described how they built relationships and credibility, potentially taking a step to overcome internal and external barriers to team based health care [40–42]. Addressing any gaps in IPC skills needs to occur earlier in a pharmacist’s career than at the time of voluntary enrolment into a postgraduate program. It became obvious that learning how to build rapport and credibility with other health professionals provided opportunities for pharmacists to demonstrate and receive recognition for their clinical skills. The personal professional satisfaction with the interprofessional encounter expressed by participants seemed to translate into overall satisfaction with their professional role as pharmacists. Learning to practice within an IPC framework at the time of or before becoming registered as pharmacists could potentially mitigate later dissatisfaction with their role and exodus from the profession [43, 44]. The development of IPC skills allowed pharmacists to showcase their unique clinical competence and become visible to and valued by other health professionals, in this case mainly medical professionals. Utilisation of these skills will support pharmacists in meeting the standards for communication and collaboration in advanced practice roles and extending collaboration with other health professionals, meeting some of the aims of current health care reform agendas [45–47]. Integrating collaboratively into health care teams using IPC skills will improve the success in evolving professional roles in hospitals, primary and community based care, at transitions of care as well as

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educators for other health professions, maximising the profession’s impact on patient centred healthcare [48–52]. Preparing pharmacists for interprofessional collaboration through training in IPC and extending their practice to taking on more pro-active, leading roles as change agents, educators and advocates for the quality use of medicines will contribute to the organisational learning within their place of practice [53]. There are several limitations to this study, in that participants submitted their reflections as part of an overall course assessment which may have influenced their writing, although reflections were not assessed on specific content but the quality and depth of reflective writing only. As not all enrolled pharmacists provided consent for participation in the study there is the chance of bias towards more positive experiences, although this seemed to be insignificant when considering all submitted reflections. There is a lack of follow up to investigate whether the aspirations for practice change have been translated into current practice and the training module resulted in significant long-term effects. This study intended to interpret the perceptions and sense-making of pharmacists expressed through reflective writing about a novel experience in their practice. As qualitative research methods have been employed and no direct observation of the interactions occurred there are no objective measures to validate participants’ perceptions but the candidness and richness of their writing and the high numbers of participants and analysed reflections support the use of reflections as a valid source of data and theme development.

Conclusions This qualitative study provides new insights into how the integration of a learning and practice module introducing a ‘‘Framework for successful interprofessional communication’’ into the PCPP at UQ changed pharmacists’ perceived competence and overcame an initial lack of confidence in clinical discussions with other health professionals. Pharmacists described that their effectiveness and success of interprofessional communication increased after training, practice and application of a specifically designed communication framework, supporting them in meeting the standards for communication and collaboration required for advanced pharmacy practice. They felt it improved their professional standing and relationships with other health professionals, allowing them to use their unique skills and knowledge to increase impact and benefit in patient care. Developing pharmacists as skilled, pro-active communicators creates the potential to demonstrate their value as members of health care teams, increasing their personal role satisfaction but also the prospects of the

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profession in addressing the demands of increasingly complex health care needs and reforms. Acknowledgments We would like to thank all pharmacists who participated in this study, the skilled educational visitors who assisted in the facilitation of experiential learning and the overall course coordinator. Funding

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None.

Conflicts of interest The authors declare that they have no competing interests.

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Interprofessional communication training: benefits to practicing pharmacists.

Interprofessional communication skills are important for pharmacists to build collaborative relationships with other health professionals, integrate i...
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