A Structured Approach for Teaching Students to Counsel Self-care Patients

American Journal of Pharmaceutical Education, 2007 by Buring, Shauna M, Kirby, James, Conrad, Wayne F

Objectives. To determine whether the use of a structured interviewing framework improved students' ability to treat self-care patients.

Design. First-professional year pharmacy students (P1) in their first quarter of Pharmacy Practice Skills Development were taught self-care through a series of 4 modules. In each module students' content knowledge and application were assessed using quizzes and role-play scenarios, respectively. During the second module, a structured interview model (QuEST process) was presented by the instructor and students were tested on the same content and role-play used in module 1.

Assessment. Sixty-four students completed the 4 self-care modules. Quiz scores improved from the first to the second module (75.8% vs. 88.4%, p

Conclusion. The QuEST process is an effective tool to teach students how to counsel patients with self-care issues.

Keywords: nonprescription medications, QuEST, self-care, active learning

INTRODUCTION

Assisting patients with self-care is an important component of pharmaceutical care and is an element of the practice standards of several professional pharmacy organizations.1-3 Pharmacists are the most readily accessible health care providers to assist patients in nonprescription product selection and counseling. The use of nonprescription drug products by consumers is and will continue to be an essential component of the US health care system. More than 100,000 nonprescription drug products, containing approximately 1,000 active ingredients, are currently marketed in the United States.4 Almost 80% of Americans use a nonprescription product each year, which is twice the number of people who went to see their physician or who received a prescription medication4 underscoring the value and importance of the pharmacists' role in advising patients about their self-care choices.

Several US and European studies investigating the counseling effectiveness of pharmacists with self-care patients indicate that many pharmacists are not providing adequate self-care counseling for patients.5-11 One approach to address deficiencies in pharmacists' ability to effectively assist self-care patients is to ensure that pharmacy students receive adequate instruction on selfcare during their pharmacy curriculum. Medication selfmanagement counseling has been identified in the CAPE Outcomes that focus on pharmaceutical care and pharmacy practice.12 Ninety-five percent of faculty members who responded to a survey about nonprescription curricula in US colleges of pharmacy indicated that nonprescription product therapeutics was included in their curriculum.13 In the same survey, over 80% of respondents indicated they teach students how to conduct a differential diagnosis by observation and an interviewing process.13 Students should be afforded the opportunity to practice self-care counseling and receive feedback on their performance. Therefore, faculty members may need to examine how they are teaching self-care counseling and evaluate the pedagogy that is being utilized.

At the University of Cincinnati College of Pharmacy (UCCOP), nonprescription product therapeutics is taught primarily in the Pharmacy Practice Skill Development (PPSD) course series. PPSD is a series of 4 performancebased courses for 4 quarters during the first-, second-, and third-professional years. In the Skills Development courses, the class is divided into small groups of 6-8 students who rotate through a different learning module each week. Self-care is one of the fundamental knowledge and skill areas taught in this course series.

As initially constructed, students learned about nonprescription therapeutics in the first part of a nonprescription teaching module. However, faculty members teaching the module discovered that students had difficulty when asked to apply this knowledge in a counseling session with a faculty member posing as a self-care patient. Although they had been taught an informal nonprescription counseling approach, students' difficulty focused on remembering the questions to ask a patient to gain background information and analysis of the self-care issue. Students reported that they found interviewing methods previously taught based on the nonprescription textbooks cumbersome and overwhelming.

In order to seek an improved methodology for teaching self-care, a search of the literature was performed. Several self-care counseling methods or strategies were identified in the literature or from professional meetings. The WWHAM method is highly popular in England and programs have been developed by the National Pharmacy Association to train pharmacists and pharmacy staff in this questioning method.9 WWHAM is a mnemonic for remembering the assessment questions of Who is the patient? What are his/her symptoms? How long have the symptoms been present? Action already taken by the patient? and Medication already taken by the patient.9 The AS METTHOD has also been suggested in the European pharmacy literature as an assessment process that can assist pharmacists in questioning patients and improve pharmacists' ability to give the appropriate advice about self-care.11 AS METTHOD is a mnemonic for Age, Self or someone else, Medicines taking, Exact symptom, Time or duration of symptoms, Taken anything, History of diseases, Other symptoms, and Doing anything to alleviate or worsen condition. McCallian purports that before recommending a nonprescription product, the patient's chief complaint and concomitant conditions should be analyzed by the pharmacist.14 Two methods to assist with this analysis are CHAPS-FRAPS and the more common Basic 7.14 CHAPS-FRAPS helps one to remember Chief complaint, History of present illness, Allergies, Past medical history, Social history, Familial history, Review of other symptoms, Assessments, Plan, and SOAP. The Basic 7 are location (where? What?), quality (what's it like?), severity, timing, context (how/cause?), modifying factors (better/worse?), and associated symptoms.14 Boyce recommends using a similar iteration of the Basic 7 within the context of the SOAP system (ie, subjective, objective, assessment, and plan) to help the patient with self-care.15 Finally, PQRST is a popular mnemonic used to communicate information about a patient's condition.16 Each letter in PQRST represents a step in the assessment of a patient's condition (eg, Pallation and provocation, Quality and quantity, Region and radiation, Signs and symptoms,Temporal relationship).16 However, each of these methods is incomplete in some area. Many do not include an evaluation of the patient's current health conditions and medications which could include valuable information affecting nonprescription medication selection or physician referral. Nor do they outline a process for recommending a drug product, discussing general care measures and counseling patients on important points for the nonprescription product.