PATIENT

COUNSELLING
SKILLS
KHENT P. ALCANTARA, RPh MSc
Faculty - College of Pharmacy
PURPOSE OF COUNSELLING
•  Ensure that pa:ents are adequately informed
about their medica:on
•  Pre-empt any problems which might cause loss
of efficacy of the drug or be detrimental to the
health of the pa:ent
•  Iden:fy any problems, which might cause loss of
efficacy of the drug or be detrimental to the
health of the pa:ent.
COMMUNITY PHARMACY

•  They all have to be done with limited :me available.

Unfortunately this oKen includes counseling pa:ents
on medica:on

COMMUNITY PHARMACY
•  Counseling on medica:on is not an op'onal extra,
but is an integral part of the dispensing of
a prescrip'on.

•  Pharmacists must ensure that they are

visible and accessible in community
pharmacies to provide it.
DISADVANTAGES OF COMMUNITY
SETTING
• No formal screening takes place
• The process is random.
CONSELLING IN HOSPITALS
There are many opportuni:es for pa:ent
counseling in hospital:

•  Upon admission
•  Needs assessment
•  On discharge
•  At outpa:ent clinics
•  Rehabilita:on groups
ADVANTAGE OF HOSPITAL
SETTING
•  In hospital, pharmacists have the advantage of
access to a considerable amount of informa:on
about the pa:ent.
•  This can include: details of disease states,
current therapy, home circumstances
•  Counseling in hospital can be approached in a
more formalized way
DISADVANTAGE OF HOSPITALS
SETTING
•  Subject to pressure and considerable :me
constraints.
•  Financial pressure in hospitals affects manpower
levels and, because the benefits of counseling
pa:ents on drug therapy is difficult to quan:fy,
staffing level may be reduced.
•  Not all wards have access to a pharmacist and,
therefore essen:al counseling may not occur.
 •  Pa:ents in hospital oKen have their medica:on
changed and they should be made fully aware of
any altera:ons. Unfortunately pa:ents may be
discharged from hospital without the knowledge
of the pharmacist. This can result in the pa:ent
going home with a variety of medicines but liTle
guidance on their use.

• In some case, because of limited
resources, pa:ents are screened to
priori:ze who is counseled. While this
means that the most needy cases are
dealt with, some other cases, where
counseling would be beneficial, are
missed.
THE PRESCRIPTION
•  Is it for a medicine, which the pa3ent has not had
before? CHECK ON THE (PATIENT MEDICATION
RECORD)PMR
•  Are there several items on the prescrip3on? PROBLEM
WITH COMPLIANCE
•  Are the instruc3ons clear? TRANSLATATION
•  Is the prescrip3on for drugs, which have a complicated
or unusual regimen? In some instances, with a liTle
thought the pharmacist can simplify maTers.

PRESCRIBED MEDICINES
•  Drugs with narrow therapeu:c index – need for
strict adherence to dosing should be
emphasized.
•  Poten:al drug interac:on
•  Drugs that requires addi:onal or precau:onary
labels.
•  Drugs with complex dosage forms
•  Side effects
•  ADR
PATIENT
•  Elderly – should be offered counselling and
advice
Factors in having problems with drug therapy:
1.  Physical disability causing problems in opening
containers.
2.  Confusion or forge^ulness
3.  Anxiety
4.  Known poor compliance
Patient
• Pa:ent asking to purchase drugs which are
incompa:ble with the prescribed
medica:on.
Case scenario
•  A pa:ent who is being prescribed Atenolol to
treat hypertension is heard asking for a packet of
Sinutabs for his nasal conges:on. Sinutabs
contain a sympathomime:c,
Phenylpropanolamine. Sympathomime:cs are
contraindicated in cardiovascular disease. The
pharmacist should inves:gate further, finding
out how severe the conges:on is. If medica:on
is considered necessary a more suitable product
can be recommended.
A MODEL PATIENT COUNSELING
SESSION FOR A NEW
PRESCRIPTION
•  A correct diagnosis and appropriately prescribed drug
therapy will be ineffec:ve unless the pa:ent
understands the reasons for the therapy, how it is to be
used, and the outcomes of the therapy.

•  The pharmacist should view the pa:ent counseling

interac:on as a two way sharing of knowledge. The
pharmacist is the expert in drug therapy. The pa'ent is
the expert with regard to the personal medical history,
past medica:on use, life-style is- sues, and pa:ent
aatudes toward medica:on use.
A MODEL PATIENT COUNSELING
SESSION FOR A NEW
PRESCRIPTION
•  Each pharmacist should develop a personal
pa3ent counseling rou3ne to ensure that all
important issues are discussed with each
pa:ent.

•  work from a checklist, at least un:l the process

becomes second nature to the pharmacist.
• 
Preparing for the session
•  Pharmacists should spend a few moments
mentally preparing for the interchange about to
occur.

•  Prepara:on greatly enhances the experience for

both par:es and, ul:mately, the quality of the
interac:on. The pharmacist should know as
much as possible about the pa3ent before
approaching the pa:ent or caregiver.
Preparing for the session
•  Another important issue to consider before a
session actually begins is the physical state of
the pa:ent.

•  Observa:on of the pa:ent prior to the

counseling session can reveal many clues about
the pa:ent’s physical and mental state.
Steps to a successful patient
counseling session
1.  Introduce yourself and iden:fy the pa:ent
2.  Ask pa:ent to talk with you about the medica:on.
Explain the purpose and the importance of the
counseling session.
3.  Update the pa:ent medica:on profile
4.  Assess what the pa:ent already knows about the newly
prescribed drug and the reason it was prescribed.
5.  Assess whether the pa:ent knows how to take the
medica:on.
6.  Assess the pa:ent’s understanding of what to expect
from the medica:on including the expected outcomes of
the therapy as well as its poten:al adverse effects.

Steps to a successful patient
counseling session
7.  Discuss any addi:onal informa:on that the pa:ent requires
for a par:cular medica:on.
8.  Ask the pa:ent if he/she has may concerns or ques:ons that
have not been addressed in previous discussion.
9.  Check pa:ent understanding of the informa:on discussed in
the counseling session.
10.  Closing the session
COUNSELING PATIENTS ON THE
USE OF REFILL PRESCRIPTIONS
•  The basic principles of a pa3ent counseling
session do not change whether the
pa:ent is star:ng a new medica:on or refilling
an ongoing prescrip:on.

•  However, the focus of the discussion is

somewhat different during a counseling session
for a refill.
A reEill counseling session should concentrate on the
following three areas:
•  Confirm that the pa:ent has been taking the correct medica:on
and knows the indica:on for its use.

•  Ask how the pa:ent has been taking the medica:on. This tells the
pharmacist whether the pa:ent has adhered to the regimen.

•  Ask how the medica:on is working for the pa:ent. What benefits
has the pa:ent gained from taking the medica:on? What
problems have arisen while taking the medica:on? How has the
pa:ent handled these problems?
APPROPRIATE TECHNIQUES TO
USE DURING A COUNSELING
SESSION
•  Throughout the pa:ent counseling session, the following
techniques for good communica:on should be u:lized:
1.  Nonverbal cues
2.  Listening
3.  Open-ended ques:on
4.  Use paraphrasing to clarify what the pa:ent says
5.  Avoid technical jargons
6.  Organize the session in a logical manner
7.  Maintain control of the session
8.  Use wriTen informa:on to supplement verbal counseling.
Counseling techniques in different
patient groups and situations:
•  Children and adolescents
•  Elderly
•  Pa:ent with emo:onal barriers
•  When pa:ents refuse pa:ent counseling
Children and adolescents
•  The USP Pediatrics Advisory Panel and its Ad Hoc
Advisory Panel on Children and Medicines have
developed a posi:on paper en:tled Ten Guiding
Principles for Teaching Children and Adolescents About
Medicines.

•  These principles encourage ac:vi:es that help children

and adolescents to become ac:ve par:cipants in their
own health behavior, par:cularly with regard to
medica:on use.
Ten Guiding Principles for Teaching Children
and Adolescents About Medicines
1.  Children, as users of medicines, have a right to appropriate
informa:on about their medicines that reflects the child’s health
status, capabili:es, and culture.
2.  Children want to know. Health care providers and health
educators should communicate directly with children about their
medicines.
3.  Children’s interest in medicines should be encouraged, and they
should be taught how to ask ques:ons of health care providers,
parents, and other caregivers about medicines and other
therapies.
4.  Children learn by example. The ac:ons of parents and other
caregivers should show children appropriate use of medicines.
5.  Children, their parents, and their health care providers should
nego:ate the gradual transfer of responsibility for medicine use in
ways that respect parental responsibili:es and the health status
and capabili:es of the child.
Ten Guiding Principles for Teaching Children
and Adolescents About Medicines
6.  Children’s medicine educa:on should take into account what
children want to know about medicines, as well as what health
professionals think children should know.
7.  Children should receive basic informa:on about medicines and their
proper use as a part of school health educa:on.
8.  Children’s medicine educa:on should include informa:on about the
general use and misuse of medicines, as well as about the specific
medicines the child is using.
9.  Children have a right to informa:on that will enable them to avoid
poisoning through the misuse of medicines.
10.  Children asked to par:cipate in clinical trials (aKer parents’ consent)
have a right to receive appropriate informa:on to promote their
understanding before assent and par:cipa:on.
What Children Want to Know about
Medicines at Different Ages
What Children Want to Know about
Medicines at Different Ages
What Children Want to Know about
Medicines at Different Ages
Counseling the Elderly Patient
•  The most rapidly growing segment of the
popula:on, the elderly, present a great number
of challenges to the communica:on skills of a
pharmacist.

•  The elderly pa:ent may have several func:onal

barriers (vision and hearing)
In addition, pharmacists should
consider the following:
1.  Addi:onal :me may be required to address the needs
of the pa:ent.

2.  WriTen informa:on and compliance reminder aids are

par:cularly helpful with large numbers of prescrip:on
products.

** Studies indicate that an effecAve way to provide

counseling to elderly paAents is to provide small pieces of
specific informaAon coupled with a reminder aid and verbal
reinforcement of the informaAon.

Pharmacists towards elderly
•  It is important for pharmacists to consider their
own feelings about aging.

•  Increase empathy for elderly pa:ents is to

consider what the pa:ent and the world were
like when he/she was younger and to remember
that the pa:ent was not always old.
Emotional barriers
•  Regardless of the type of emo:on the pa:ent
exhibits, dealing with a highly emo:onal pa:ent
is challenging for the pharmacist.

•  OKen the pharmacist is uncomfortable with the

emo:ons expressed by the pa:ent and responds
inappropriately by ignoring the issue at hand or
by focusing on trying to solve the pa:ent’s
problem.
Empathic response
•  The most effec:ve way to address pa:ents’ emo:onal
concerns is to use empathic responses, also called
reflec:ve responding.

1.  Pharmacists must truly listen to what the pa:ent says

(in words or nonverbal gestures)

2.  The pharmacist must have a desire to understand and

help the pa:ent.
How to Formulate empathic
response
•  Mentally paraphrase what the pa:ent has expressed and
to state that for the pa:ent.
•  Sample phrases:
• “It sounds like...“
• “I gather that...“
• “What I hear you saying is...“
• “It seems that...“
• “In other words...“
• “If I understand you correctly . . . “ • It appears that
you are saying . . . “
Empathic response
•  Use of this type of response tells the pa:ent that
the pharmacist is listening and is trying to
understand the pa:ent’s concerns.

•  It also tells the pa:ent what the pharmacist

thinks he or she is feeling.
What ReJlective Responses Are
Not ?
•  It is oKen easier to understand a good reflec:ve response by
looking at statements that are not truly empathic. The most
common errors in aTemp:ng to express empathy are to
offer advice or judge the pa:ent. Some examples will
illustrate the most common errors pharmacists make in
aTemp:ng empathic responding.
•  Mr. Roberts, a regular pa:ent in the pharmacy (looking
worried and upset): “My doctor says I might need to have
surgery if this drug doesn’t work.”

•  Pharmacist 1: “Oh, there is no need to worry. I’m sure this

medicaAon will work and everything will be fine.”
LISTENING AND EMPATHIC
RESPONSE
• Listening to pa:ents

•  – trying to understand their thoughts and

feelings (crucial to effec:ve
communica:on)

LISTENING WELL (Active
listening)
• Trying to do things at once makes it evident
that the pa:ent does not have your full
aTen:on.
• Jumping to conclusions before a pa:ent has
completed her message can lead to only
hearing parts of message – oKen pieces
that fit into preconceived ideas you have
• Focusing only on content, judging the
person or the message as it being
conveyed, faking interest communica:ng
in stereotyped ways – all cause us to miss
much of the meaning in messages people
send us.
SUMMARIZING
• Summarize the cri:cal pieces of
informa:on

• It allows the pharmacist to be sure you

understood accurately all that the pa:ent
conveyed and serves as well to allow the
pa:ent to add new informa:on that may
have been forgoTen.
PARAPHRASING
• When using this technique, you aTempt to
convey back to the pa:ent the essence of
what she has just said.

• It condenses aspects of content as well as

some superficial recogni:on of the
pa:ent’s aatudes or feelings.
EXAMPLE:
• Pa'ent No. : I don’t know about my
doctor. One :me I go to him and he’s nice
as he can be. The next :me he’s so rude I
swear I won’t go back again.

• Pharmacist 1: He seems to be very
inconsistent.
EMPATHY
• Communica:ng that you understand
another person’s feeling or point of
view is a powerful way of establishing
rapport and is necessary ingredient in
any helping rela:onship.
EXAMPLE
•  Pa'ent No. 1: I don’t know about my doctor. One :me I
go to him and he’s nice as he can be. The next :me he’s
so rude I swear I won’t go back again.

•  Pharmacist 1: it must be difficult for you to feel
comfortable with him if you never know what kind of
mood to expect.
EMPATHY V.S. PARAPHRASE
• Empathy serves primarily as a
reflec:on of the pa:ent’s feelings
rather than the content of the
communica'on.
Non-Prescription
Drug Counselling
Colds
•  Normally present as a complex or sequence of
symptoms.
•  Products marketed for their treatment are
usually compound formula:ons of several
ingredients, each intended to alleviate a
different symptom.
 •  Causes: Viral cause
•  Treatment: Most systemic products for colds
contain combina:ons of two or more of the
following:

1.  Seda:ng ant – histamines
2.  Sympathomime:c decongestants
3.  Vitamin C
4.  Cough suppressants
5.  Analgesics/ An: – pyre:cs
Anti-histamines
•  Muscarinic effect: drying up of nasal secre:ons,
urinary reten:on, blurred vision

•  Can cause seda:on

An'histamines are formulated with
Sympathomime'c decongestants in two products:
•  Ac:fed tablets and syrup (Triprolidine/
pseudoephedrine)
•  Pfizer Consumer Healthcare
•  Eskornade capsules (Diphenylpyraline/
Phenylpropanolamine)
•  Goldshield Pharmaceu:cals
Systemic Decongestants
•  Used to constrict the swollen mucosa and dilated blood
vessels of the nasal passages to improve air circula:on
and mucus drainage.
•  The same compounds are used as cough prepara:ons,
plus Phenylephrine, although this drug is not considered
to be effec:ve and it is also subject to first – pass
metabolism in the liver.
•  Phenylephrine is the only systemic decongestants
licensed for use in GSL products.
Local Decongestant
•  For local use compounds are employed which exert a
rapid and potent vasoconstric:ng effect when applied
directly to the affected
Compounds available
•  Ephedrine
•  Oxymetazoline
•  Phenylephrine
•  Xylometazoline