reflective essay on consultation skills

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• S Afr Fam Pract (2004)
• v.62(1); 2020

Learning person-centred consultation skills in clinical medicine: A randomised controlled case study

Jakobus m. louw.

1 Department of Family Medicine, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa

Johannes F.M. Hugo

Associated data.

The data that support the findings of this study are available from the corresponding author, J.M.L., upon reasonable request.

Training institutions need to ensure that healthcare students learn the skills to conduct person-centred consultations. We studied changes in person-centred practice over time following a quality improvement (QI) intervention among Bachelor of Clinical Medical Practice undergraduate students.

Students were randomised to intervention and control groups. The intervention group received training and did a QI cycle on their own consultation skills. Consultations with simulated patients were recorded during structured clinical examinations in June (baseline) and November (post-intervention) 2015.

Matched consultations for 64 students were analysed. The total SEGUE (Set the stage, Elicit information, Give information, Understand the patient’s perspective and End the encounter scores) were significantly higher in the final assessment compared to baseline for both the whole group and the intervention group ( p = 0.005 and 0.015, respectively). The improvement did not differ significantly between intervention and control groups ( p = 0.778). Third-year students improved significantly more than second years ( p = 0.007).

The person-centred practice (including collaboration) of clinical associate students did improve over the period studied. The results show that students’ learning of person-centred practice also happened in ways other than through the QI intervention. There is a need to develop students’ collaborative skills during the medical consultation.

Introduction

Person-centred practice can be described as practice where clinicians and patients collaborate on the basis of a holistic understanding of the patient and his or her health needs in the milieu of a therapeutic alliance between patient and clinician. 1 Ethically, it is driven by the obligations to apply the principles of beneficence and autonomy in healthcare. 2 Practically, it has benefits for patients, clinicians and the healthcare system. 3 , 4 , 5 , 6 , 7 Benefits include increased patient 6 , 8 , 9 and clinician 8 , 10 , 11 satisfaction, improved adherence to management plans 8 , 12 , 13 and more efficient care being delivered. 14

Collaboration, including shared decision-making, is regarded as quintessential person-centred practice. 15 As articulated in the Salzburg Global Seminar statement on shared decision-making, 16 this means recognising the ethical imperative to share important decisions with patients, stimulating a two-way flow of information and encouraging patients to ask questions, explain their circumstances and express their personal preferences.

Given the importance of and the need for clinicians to have person-centred practice skills, every institution training healthcare professionals needs to ensure that students learn person-centred practice, including the skills needed to involve the patient in understanding the problem, share decision-making and negotiate as part of collaboration in the medical consultation. 17 , 18 They need to be guided in their attitudes to show empathy, compassion and caring, and they need to become proficient in communication, reflection, negotiation, collaboration, mindfulness and other critical ‘soft skills’. Among the ways that these skills and attitudes can be learned are through role-plays of simulated consultations, 17 , 19 review of recorded consultations, 20 feedback on directly observed consultations, 10 , 21 , 22 patient feedback, 23 observing and working with positive role models, 24 , 25 reflective practices, 26 small group discussions with role models, student-centred community-based learning, 27 , 28 patient-centred learning (learning from real patients) 29 and mindfulness training. 26 , 30

Despite the numerous methods suggested for improving skills, a recent Cochrane’s review 31 could not find any good evidence for the effectiveness of any interventions to increase the use of shared decision-making by healthcare professionals. There is therefore a need to develop training methods so that patients can experience ‘nothing about me without me’. 15

The study reported here aimed to measure changes in person-centred practice over time following a quality improvement (QI) intervention for learning person-centred consultation skills among Bachelor of Clinical Medical Practice (BCMP) undergraduate students. As graduates, clinical associates qualify to practise as mid-level medical professionals who perform many of the tasks medical doctors usually perform, similar to the physician assistant or clinical officer professions in other countries such as Malawi, Tanzania and the United States. 32 , 33

In this case study, an intervention group of second- and third-year students was randomly selected through clustered sampling with the remaining students serving as controls.

Study population

All second- and third-year BCMP students at the University of Pretoria in 2015 were eligible. They were learning in 19 different clinical learning centres (CLCs) based at public hospitals in the Gauteng, Mpumalanga and KwaZulu-Natal provinces.

Five of the CLCs had both second- and third-year students, while seven had only second-year and seven only third-year students. From each of these three clusters of CLCs, three CLCs were randomly selected. After randomisation, the three students at one of the selected second-year CLCs were moved individually to three other CLCs (two intervention and one control CLC). The remaining eight selected CLCs received the learning intervention, while the students at the other 10 CLCs served as controls.

Information on the study was provided to all BCMP II and III students and they indicated their consent electronically on the computer-based testing system at the University of Pretoria.

To be included second- or third-year BCMP students had to complete both a baseline and final consultation assessment and consent to audio or video recording of the consultations.

Because of equipment malfunction on the first day of assessment recording, several third-year students were also excluded.

A total of 64 sets of recordings of baseline and final consultations were available for analysis ( Figure 1 ).

Sampling framework for recordings analysed.

Intervention

The researcher sent emails with reading material and detailed instructions for the intervention to the students in the intervention CLCs. During subsequent site visits to intervention CLCs, the intervention was explained. Role-play was used to demonstrate how to observe a consultation and give appropriate feedback. Any questions were clarified and students were encouraged to engage with the QI process.

The students in the intervention CLCs were expected to:

• form a team of two to four fellow students in the same year group to work together to improve their consultation skills
• read and reflect on two articles describing the medical consultation 34 , 35
• study four consultation assessment tools: Kalamazoo Essential Elements Communication Checklist (adapted) – KEECC(A), 36 Consultation Peer Assessment Tool (as adapted for students at the University of Pretoria), CARE Patient Feedback Measure 37 and Patient Enablement Instrument 38
• measure their current consultation practice by assessing each other’s consultations with the tools provided. Consultations could be video-recorded, audio-recorded and/or observed in person. Then they were required to give feedback to each other based on the tools and to reflect on patients’ perceptions of their consultations as recorded in the tools. The final measurement was a self-assessment using one or two of the tools
• plan and implement measures to improve their own consultations
• repeat the measurements of their consultation practice
• reflect on changes in their performance and submit a report on this QI process.

Fidelity of implementation was reviewed using the conceptual framework proposed by researchers at the University of Sheffield. 39

Measurements

During the objective structured clinical examinations (OSCEs) at the end of each semester (June and November 2015), consultation skills were evaluated. All students (intervention and control groups) conducted a 13-min consultation with a simulated patient based on one of five standard scenarios. The scenarios were allocated according to the particular clinical rotations the specific student group did in the preceding semester. Students had no access to the scenarios before the examination and no student had the same scenario in the baseline and final measurements. Only one of the five scenarios was used in both the baseline and final evaluations. The consultations were video- and/or audio-recorded in line with the consent provided by the student. For the purpose of this study, only audio recordings were coded for person centeredness. Where only a video recording was available, it was converted to audio before scoring. The SEGUE (Set the stage, Elicit information, Give information, Understand the patient’s perspective and end the Encounter) framework was selected as the preferred measurement tool based on a systematic review. 40 It consists of 32 tasks, each of which can receive a code of ‘Yes’, ‘No’ or ‘Not applicable’ ( Appendix 1 ).

Two qualified clinical associates received 4 hours of training in the use of the SEGUE measurement tool. Every audio recording was randomly assigned to one of them. They were blinded as to the pre- or post-intervention status of each recording and to the group (intervention or control). Each coder was assigned equal numbers of intervention and control group recordings. The baseline and final recordings of each student were coded by the same person.

Task 5 (Maintain patient’s privacy) and task 21 (Acknowledge waiting time) were not applicable in the context of the OSCE and therefore not coded.

Statistical analyses were conducted on the scores using the IBM Statistical Package for Social Sciences (SPSS) statistics version 25 software. Statisticians from both the Faculty of Health Sciences and the internal consultation service of the University of Pretoria’s Department of Statistics were involved in data analysis. Effect size was measured with Cohen’s d , and p < 0.05 was regarded as statistically significant. Bonferroni adjustment was applied for multiple comparisons.

Intra- and inter-rater reliabilities were measured by assigning 24 recordings to both coders and by re-allocating at least 22 previously coded recordings under a new random number to the same coder later in the process. The mean of kappa (measure of agreement) calculated for intra-rater reliability across the 30 tasks was 0.9 for coder A and 0.82 for coder B. The mean kappa for inter-rater reliability over 22 tasks was lower at 0.54. (For eight tasks, inter-rater agreement could not be calculated because of a lack of variability in at least one measurement).

Considering the nature of medical consultations, the SEGUE framework contains a mix of tasks measuring various communication abilities. Internal consistency is therefore not regarded as an appropriate criterion for the SEGUE framework. 41

To summarise the degree to which person-centred communication tasks were accomplished, total SEGUE scores were calculated by assigning a value of 1 to each ‘yes’ and 0 to each ‘no’ and summing the scores for each consultation as performed in previous research. 41

Results were first compared using paired samples t -tests. Multivariate regression was employed to model the final total SEGUE scores against group (intervention group vs. control group), year of study (second vs. third) and gender (male vs. female), taking into account the interactions between gender and year of study and between gender and group, adjusted for the baseline total SEGUE scores.

To evaluate the possible effect of variable implementation of the intervention by students in the intervention group, the intervention group results were divided into those who fully implemented the intervention (submitted written reports), those who implemented partially (did not submit written reports) and those who did not implement the intervention.

Totals for each of the five components of the SEGUE framework were calculated and analysed as subscales. The seven tasks under ‘New or modified treatment or prevention plan’ were analysed as part of the ‘End the encounter’ subscale.

Ethical consideration

The study was granted ethical clearance from the Research Ethics Committee of the Faculty of Health Sciences, University of Pretoria. The QI intervention was specifically approved as an amendment to the original protocol (128/2013). No patient identifying data were collected. For the statistical analysis, student data were arranged by numbers to ensure confidentiality.

The demographic characteristics of the study population and participants are presented in Table 1 .

Demographic data.

The 25 missing data points were because of poor quality of audio recordings. The SEGUE total scores and subscale scores were adjusted for missing values before analysis.

Fidelity of implementation

Only 5 of 62 intervention group students did not attend the training. Matched recordings of three of these five were included in the intervention group for analysis.

Of the 31 students analysed in the intervention group, eight did not implement the QI cycle. However, their results were analysed with the intervention group (intention-to-treat analysis). Only 12 students in the intervention group submitted reflective reports.

Results of total SEGUE scores

The total SEGUE scores of the 64 pairs of matched student consultations showed a significant improvement over the 5 months studied ( Table 2 ). Although the intervention group improved significantly from the baseline to the final assessment, this improvement was not significantly better than for the control group. The control group’s scores did not improve significantly.

Comparison of means of total SEGUE scores.

SD, standard deviation; SEGUE, Set the stage, Elicit information, Give information, Understand the patient’s perspective and End the encounter.

The multivariate regression model demonstrated that third-year students improved significantly more than second-year students, but the difference in improvement in scores between male and female students was not significant ( Table 2 ).

Figure 2 compares the means of the total SEGUE scores in the final assessment of the control group with the subgroups in the intervention group after adjustment for the baseline scores. The subgroup of the intervention group students who implemented the intervention partially had the highest adjusted means (signifying that they had the best improvement), whereas those who did implement the intervention completely had the least improvement. The difference between these groups was significant ( p = 0.035).

Comparison of adjusted means according to degree of implementation of the intervention with 95% confidence interval.

Excluding the non-implementing subgroup from the analysis (per-protocol analysis) did not affect the significance of the difference between the intervention and control groups.

Neither the relationship between student age and total SEGUE scores, nor between age and changes in the total SEGUE scores were statistically significant.

When students interviewed simulated patients of a different gender (discordant) than their own in the final assessment OSCE, they achieved a significantly higher total SEGUE score. The mean difference was 2.34 (95% CI, 0.9–3.7) and p = 0.002 (Cohen’s d = 0.82). However, gender discordance did not have any effect in the baseline scores. The simulated patients’ gender did not have any significant effects independently.

Results of analysis in subscales

The ‘Give Information’ and ‘End Encounter’ SEGUE subscales relate closely to collaboration in the consultation. These had lower scores than the other three subscales but improved significantly over the 5 months studied. Changes in the other three subscales were not significant ( Figure 3 ).

Changes in SEGUE subscale scores between baseline and final assessments.

Third-year students improved significantly more than second-year students in the ‘Elicit information’ subscale ( p = 0.020; Cohen’s d = 0.59, 95% CI, -5.85 to 6.70).

There was a significant, moderate degree of positive correlation between the improvement in the ‘Elicit information’ and the ‘End encounter’ subscales (Pearson’s correlation coefficient = 0.321, p = 0.01).

There were no statistically significant relationships between student age and any of the subscale scores nor with any changes in the subscale scores.

Results of analysis of specific tasks

In comparing the improvement in specific tasks between intervention versus control groups, third- versus second-year students and male versus female students, differences were not significant (two-sided Fischer’s exact test with Bonferroni adjustment).

This study evaluated the actual behaviour of students in the medical consultation and not merely self-reported attitudes regarding person centeredness. We tested whether a QI intervention implemented by students themselves would improve their person-centred practice. The study did not demonstrate a statistically significant effect of the intervention when comparing the intervention group to the control group. This may be because of the exposure of both the control and intervention groups to other avenues of learning person-centred practice such as the role models (healthcare practitioners) 24 , 25 they worked with, small group discussions and role-plays. 17 , 19 It is also possible that motivated, self-directed students in the control group used the information provided during the informed consent process to learn person-centred practice. 42 Students were not closely supervised during the intervention and as it would not directly affect their marks, some students probably lacked motivation to put effort into the QI. Even so, analysis of the results according to the assumed degree of implementation of the intervention did not reveal a dose–response effect. Why the 12 students who implemented the intervention completely had the lowest total adjusted SEGUE scores ( Figure 2 ) is not clear. This result could suggest that reporting on learning does not correlate with actual learning of person-centred practice. Equally, it may be the consequence of other, unaccounted for variations in implementation.

The effect size of the improvement measured in the group as a whole can be regarded as educationally significant though not necessarily practically or clinically relevant. 43 , 44 , 45

Previous research in the United States could not find a difference between the total SEGUE scores for first-year family medicine residents compared to third-year residents. 46 In our study, the baseline measurements of second- and third-year students did not differ significantly. However, third-year students improved significantly more than second years over the period studied resulting in significantly higher scores in the final assessment. The effect size of this difference in improvement was moderate to large (Cohen’s d = 0.76) and, therefore, both practically and educationally meaningful. 43 , 44 , 45 The difference can be attributed to third years improving significantly more in the ‘elicit information’ subscale and to some extend in the ‘end encounter’ subscale, perhaps suggesting a more mature approach to the consultation.

When trying to learn both clinical reasoning and person-centred consultation skills simultaneously, students can feel overwhelmed. 47 Consultations with real patients trigger empathy and a sense of responsibility in students. Even so, feeling primarily responsible for their patient’s medical decisions, students tend to prioritise clinical reasoning. 47 The greater improvement by third-year BCMP students, as compared to those in second year, can thus be understood in terms of cognitive load theory. Second-year students could not learn complex consultation skills as well because they have less information organised in cognitive frameworks or concepts (automated schemas) to help them organise and interpret new information, compared to third years who have already internalised more skills in schemas and thus can learn new skills more efficiently without overloading their working memory. 48 , 49 This demonstrates the important role of time that goes beyond spacing effects in acquiring person-centred consultation skills. Students need time to develop from clinical knowledge to critical thinking and decision-making skills. 50 In addition, third-year (final) students could be more focused and motivated to learn because they would soon have to pass final examinations and then enter practice as clinical associates.

Intra- and inter-rater reliabilities were lower than what has been reported in the literature, 41 but the means of total and subscale scores did not differ significantly between the coders. Poor inter-rater reliability is a common problem. A recent systematic review reported it to be poor in six of seven coding schemes for which they could find valid measurements. 51

It is difficult to understand the effect of gender discordance in the final assessment in light of the absence of such effect in the baseline assessment.

As shared decision-making – or collaboration with the patient – is crucial for person-centred practice, 15 we have to evaluate if and how clinical associate students learn to collaborate with patients.

For medical students, lower scores for ‘Ending the session by summarising and clarifying the plan’ than for other subscales have been reported. 21 Similarly, BCMP students had their lowest scores in the ‘End the encounter’ subscale. However, it is encouraging to find an increase in this subscale over the period studied – especially among third-year students. Its positive correlation with the ‘Elicit information’ subscale has logic: a clinician cannot collaborate with a patient without a good holistic understanding of the patient. The observation that third-year students improved significantly more than second years in the ‘elicit information’ subscale shows that learning of biomedical consultation skills accelerates towards the end of the course.

The data analysed in this study concur with the literature that students are more likely to implement ‘caring’ aspects of person-centred practice while struggling to consistently share power or collaborate with patients. As stated elsewhere: ‘Although talk about patient-centred care is ubiquitous in modern healthcare, one of the greatest challenges of turning the rhetoric into reality continues to be routinely engaging patients in decision making’. 15

The finding that male students had higher total SEGUE scores than female students was surprising and contrasts with most other reports of measures of person centeredness where female healthcare providers are usually more person-centred than their male counterparts. 21 , 52 , 53 In the intention-to-treat analysis, the effect of student gender did not reach statistical significance but it warrants further quantitative and qualitative research to confirm or refute it and to understand the possible reasons for it.

Limitations

There are a number of limitations to the study, including the fact that measurements in this study relied on simulated consultations, and thus, results may not be generalisable to clinical practice with real patients.

All aspects of the students’ implementation of the QI were not documented. We can therefore not be sure about the effect of variable implementation of the intervention on the results.

The analysis did not control for other possible methods of learning person-centred practice neither for the possibility of partial implementation of the intervention by the control group.

The smaller than intended sample size limited the statistical power to detect differences. With a larger sample, the difference between male and female students may have reached statistical significance in the intention-to-treat analysis.

Person-centred practice of second- and third-year clinical associate students did improve marginally over the 5-month period studied, although the study intervention did not contribute significantly to this improvement. The fact that person-centred practice improved significantly more among third-year students’ suggests that these skills are most effectively learned in the last part of the course.

This said, the measurement of person centeredness in the medical consultation remains difficult. 54 , 55 Further research should explore comparisons with locally developed measurement tools and/or the appropriate adaptation of existing international tools. Also, the quality and extent of the implementation of any intervention needs to be monitored and effectively documented to derive definitive conclusions on its effectiveness.

Recommendations

Clinical associate students learn person-centred practice through a range of activities. Further research is indicated to identify and measure sources of such learning.

Further studies are needed to understand the effect of gender concordance versus discordance between student and simulated patient in consultation OSCE stations.

Acknowledgements

The authors would like to thank Prof. T.S. Marcus and Prof. J.M. Pettifor for their valuable input on several versions of this article, Ms D. Nonyane and Mr S. Khambule for coding the recordings, Prof. P.J. Becker and Mr A. Masenge for statistical analysis and Mrs N. Smit for editing of the manuscript.

Competing interests

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article.

Authors’ contributions

J.M.L. conducted the research, reviewed the literature and wrote the article. J.F.M.H. contributed to concept development, review and editing of the article.

Funding information

This research received financial support from the Faculty of Health Sciences, University of Pretoria’s Scholarship of Teaching and Learning fund.

Data availability statement

The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors.

Appendix 1: The SEGUE framework.

SEGUE, Set the stage, Elicit information, Give information, Understand the patient’s perspective, and End the encounter.

How to cite this article: Louw JM, Hugo JFM. Learning person-centred consultation skills in clinical medicine: A randomised controlled case study. S Afr Fam Pract. 2020;62(1), a5109. https://doi.org/10.4102/safp.v62i1.5109

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Reflection on practice: consultation skills.

In January 2019, the Department of Health and Social Care (DHSC) published the highly anticipated NHS Long Term Plan ( NHS, 2019 ). While the publication of a White Paper is not typically celebrated, some of the key paradigms outlined in the Plan signal a move away from a traditional view of health being ‘what's the matter with someone’ to a more personalised approach that embraces a philosophy based on ‘what matters to someone’. Against the backdrop of the increasing number of children, young people and adults living with at least one long-term condition, the change from the pathogenic to the salutogenic model heralds a very different approach to care based on the comprehensive model of personalised care ( NHS England, 2018 ) which highlighted the significance of the ‘person’ and not just the ‘patient’. This article will outline this model and focus on social prescribing as integral to successful operationalisation of the personalised approach.

The NHS Long Term Plan

Personalised care promotes the health professional to consider the ‘person’ as opposed to the ‘patient’ ( NHS England, 2018 ). In doing so, the person's needs are placed central to decision-making, facilitating patient choice and control over their care.

The NHS Long Term Plan ( NHS, 2019 ) promoted a paradigm that actively encourages the shift from pathogenic to salutogenic approaches through its comprehensive personalised care model. Salutogenesis focuses on factors that promote and support health and wellbeing rather than factors that cause disease. It is estimated that up to 2.5 million people will benefit from the model by 2024 and that personalised care will become ‘business as usual’ ( NHS, 2019 ). Re-orienting healthcare with the underpinning theory of salutogenesis is not a new concept ( World Health Organization (WHO), 1986 ; Lindström and Eriksson, 2005 ); however, its resurgence provides opportunities to alleviate the challenges and demands of general practice nursing in the 21st Century ( The Queen's Nursing Institute, 2015 ).

Delivering universal personalised care using the comprehensive personalised care model will involve the implementation of trained ‘social prescribing’ link workers, personal health budgets, and the coproduction of personalised care and support plans to help individuals experiencing long-term conditions; 75 000 clinicians and professionals will be needed to provide support for personalised care in their practice ( NHS England, 2019 ). Underpinning this approach are six core principles:

• Shared decision-making
• Personalised care and support planning
• Enabling choice
• Social prescribing and community-based support
• Supported self-management
• Personal health budgets and integrated personal budgets across the NHS and the wider healthcare system ( NHS, 2019 ).

These are all necessary ingredients for a universal personalised care model. Key to the success is the social prescribing systems and processes that will help professionals and individuals navigate the many non-medical, community health assets available to support the personalised approach to wellbeing. All communities have local health assets which can include the skills, knowledge, motivation of individual community members, existing friendships and neighbourliness, formal or informal voluntary groups and associations, physical, environmental and economic resources available in the community, as well as assets brought by external agencies ( Public Health England (PHE), 2015a ).

Social prescribing

One of the key components to enabling personalised care is social prescribing. This is a form of community referral that enables frontline staff to refer a person for non-medical, non-clinical support. It involves using assets in the community to support a person through a wellbeing conversation, predicated on what matters to the person rather than what is the matter with them. Understanding a person's perspective of a ‘community’ (place, geography, interest or identity) is an integral part of valuing people as active participants in the planning and management of their own health and wellbeing ( PHE, 2015a ). This strengths-based approach focuses more on the individual's assets rather than their deficits, and embraces a personalised approach to care. Putting this into operation this has led to a Government pledge for 1000 trained social prescribing link workers to work with primary care networks (PCNs) and the voluntary community and social enterprise (VCSE) sector to create pathways for people into social prescribing interventions. Essentially, this approach considers the wider determinants of health by placing an emphasis on wellbeing rather than on health alone. Social prescribing uses non-medical, asset-based, salutogenic approaches to promote a personalised paradigm that places the person at the centre of decision-making.

Social prescribing models

Anchored in primary care, social prescribing is considered a pathway to participation in the family of community-centred approaches for health and wellbeing ( PHE, 2015a ). Although social prescribing is influenced by national agenda, the way in which it has been implemented across the UK can differ significantly. Kimberlee (2015) identified four different types of social prescribing models:

• Social prescribing signposting, a frontline practitioner can send someone to an organisation, such as a knitting group, for social conversation
• Social prescribing light, sending at-risk or vulnerable population groups to specific social prescribing programmes
• Social prescribing medium, there is a conversation between an individual and a dedicated social prescribing practitioner to understand what matters to the person and determine an appropriate referral, for example someone who may be overweight maybe referred to a walking group
• Holistic social prescribing, actively promotes personalised care using the ‘wellbeing’ conversation as integral to empowering personal choice.

There are a number of non-medical services available ranging from art workshops to nature-based interventions

The wellbeing conversation is led by a link worker, who may have up to eight meetings to determine what matters to the individual, after which, the person is referred to a non-medical service to support them. The holistic approach is predicated on multi-professional, cross-agency communication and collaboration; integration is therefore considered to be the fabric of the model, enabling the person to have a choice over their care.

The need for a different approach

There are a number of non-medical services and interventions available across the UK. These range from Arts on Prescription (a series of art workshops for people experiencing depression, anxiety and other mental health conditions), to nature-based interventions, such as allotment or gardening groups. Evidence suggests that nature-based activities such as gardening or walking outdoors can improve our wellbeing ( Annersted and Währborg, 2011 ). Interestingly, joining a gardening group can help reduce social isolation for older people ( Howarth et al, 2016 ) and those with mental health problems ( Wood et al, 2015 ). It is estimated that being socially isolated can have significant detrimental effect on health and social isolation is known to cause early death ( Holt-Lunstad et al, 2010 ). Equally, mental health is now a major global burden ( WHO, 2019 ) and is the main cause of ill-health ( GBD 2016 Disease and Injury Incidence and Prevalence Collaborators, 2017 ). Social prescribing can provide a non-medical solution to supporting people across a range of age groups with diverse needs to regain control of their wellbeing and help tackle future and existing long-term conditions.

Public health and wider agenda

To ensure that the comprehensive model of personalised care becomes ‘business as usual’, the ten-point action plan for general practice nursing ( NHS England, 2017 ) recognises that practice nurses need access to educational programmes to develop skills to support case-finding and promoting self-care for all people with long-term conditions.

To deliver the radical upgrade still needed in prevention ( NHS, 2019 ), a new online learning platform called All Our Health has been developed with GPNs in mind to help embed and extend prevention, health protection and promotion of wellbeing and resilience into everyday practice ( PHE, 2015b ; NHS England, 2017 ; Health Education England (HEE), 2019 ).

PHE (2013) re-emphasised its vision that public health practice becomes every nurse's responsibility at an individual, community and population level vision more than 5 years ago. The All Our Health framework for personalised care and population health ( PHE, 2015b ) identified seven evidence-based approaches that all health professionals, including nurses, could adopt to ensure that public health is embedded into practice:

• Improving the wider determinants of health
• Health improvement
• Health protection
• Supporting health, wellbeing and independence
• Life-course approaches to improving health and wellbeing
• Place-based services of care.

Social prescribing provides numerous aspects of this framework of evidence that aims to help all health professionals, including practice nurses, to use their skills and relationships to maximise their impact on avoidable illness, health protection and the promotion of wellbeing and resilience ( PHE, 2018 ).

An all-age, whole-population approach to social prescribing

The comprehensive personalised care model sets out how social prescribing is a universal population intervention that can be used in primary care to support people to stay well and build community resilience ( NHS England, 2018 ). This suggests that health improvement efforts such as Making Every Contact Count (MECC) could routinely include non-medical solutions such as social prescribing to address MECC's five core elements: stopping smoking, reducing alcohol use, maintaining a healthy weight and diet, and promoting mental health and wellbeing ( PHE and HEE, 2018 ).

The estimated 30% of a general practice population living with long-term physical and mental health conditions will benefit from targeted support to build knowledge, skills and confidence to live well with their health condition(s) and self-manage. A further 5% of the practice population living with complex needs will benefit most from specialist interventions that empower people, including the use of personal health budgets. NHS England (2018) is clear that people living with long-term physical and mental health conditions will benefit from targeted interventions plus universal interventions, and that those with complex needs will benefit from specialist interventions plus targeted and universal interventions, thus suggesting that social prescribing offers an effective intervention for the whole population.

The comprehensive personalised care agenda provides nurses with an opportunity to revisit the significance of salutogenesis and the call to action for every nurse to maximise their impact on the public's health – in practice, education and research. Keeping abreast of the social prescribing movement in communities and working in collaboration with link workers will help the practice nurse community to empower patients and not just regain control of their health – but also invigorate and promote their wellbeing.

• Salutogenesis is an asset-based approach to supporting an individual's wellbeing
• There is a need for practice nurses to be aware of and work with social prescribing link workers to enable them to form part of the social prescribing pathway and support them
• Practice nurses may already be familiar with the concept of community referral; the wider personalised care agenda has refreshed the language used and social prescribing offers an opportunity to rebalance practice through salutogenic principles
• All Our Health is a call to action for every nurse to maximise their impact on the public's health – in practice, education and research

Annersted M, Währborg P. Nature-assisted therapy: systematic review of controlled and observational studies. Scand J Public Health. 2011;39(4):371–88. https://doi. org/10.1177/1403494810396400 Dumbreck S, Flynn A, Nairn M et al. Drug-disease and drug-drug interactions: systematic examination of recommendations in 12 UK national clinical guidelines. BMJ. 2015;350:949. https://doi.org/10.1136/bmj.h949 Health Education England. All Our Health – e-Learning for healthcare. 2019. https://www.e-lfh.org.uk/programmes/allour-health/ (accessed 13 May 2019) Holt-Lunstad J, Smith TB, Layton JB. Social relationships and mortality risk: a meta-analytic review. PLoS Med. 2010;7(7):e1000316. https://doi.org/10.1371/journal. pmed.1000316 Howarth ML, McQuarrie C, Withnell N, Smith E. The influence of therapeutic horticulture on social integration. J Public Ment Health. 2016;15(3):136–40. https://doi. org/10.1108/JPMH-12-2015-0050 GBD 2016 Disease and Injury Incidence and Prevalence Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 328 diseases and injuries for 195 countries, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet. 2017;390(10100):1211–59. https://doi.org/10.1016/ S0140-6736(17)32154-2 Kimberlee R. What is Social Prescribing? Advances in Social Sciences Research Journal. 2015;2(1):102–10. https://doi. org/10.14738/assrj.21.808 Lindström B, Eriksson M. Salutogenesis. J Epidemiol Community Health. 2005;59(6):440–42. http://dx.doi. org/10.1136/jech.2005.034777 NHS. NHS Long Term Plan. 2019. https://www.longtermplan. nhs.uk/publication/nhs-long-term-plan/ (accessed 6 June 2019) 340 Practice Nursing 2019, Vol 30, No 7 © 2019 MA Healthcare Ltd Social prescribing.indd 340 28/06/2019 10:10 Downloaded from magonlinelibrary.com by 213.123.122.025 on February 14, 2020. PRESCRIBING PRESCRIBING PROFESSIONAL NHS England. General practice – developing confidence, capability and capacity. 2017. https://www.england.nhs.uk/ publication/general-practice-developing-confidence-capabilityand-capacity/ (accessed 6 June 2019) NHS England. Comprehensive model of personalised care. 2018. https://www.england.nhs.uk/ publication/ comprehensive-model-of-personalised-care/ (accessed 6 June 2019) NHS England. Universal personalised care: implementing the comprehensive model. 2019. https://www.england.nhs.uk/ publication/universal-personalised-care-implementing-thecomprehensive-model/ (accessed 6 June 2019) Public Health England. Nursing and midwifery contribution to public health: improving health and wellbeing. 2013. https://assets.publishing.service.gov. uk/government/uploads/" class="redactor-linkify-object"> https://assets.publishing.service.gov. uk/governmen... system/uploads/attachment_data/file/210100/NMR_final.pdf (accessed 6 June 2019) Public Health England. Health and wellbeing: a guide to community centred approaches to health and wellbeing: full report. 2015a. https://www.gov.uk/government/ publications/" class="redactor-linkify-object"> https://www.gov.uk/government/ publications/ health-and-wellbeing-a-guide-to-community-centredapproaches (accessed 6 June 2019) Public Health England. All Our Health: personalised care and population health. 2015b. https://www.gov.uk/government/ collections/all-our-health-personalised-care-and-populationhealth (accessed 6 June 2019) Public Health England. Health matters: community-centred approaches to health and wellbeing. 2018. https://www. gov.uk/government/publications/health-matters-health-andwellbeing-community-centred-approaches/health-matterscommunity-centred-approaches-for-health-and-wellbeing (accessed 6 June 2019) Public Health England, Health Education England. Making every contact count (MECC): quality marker checklist for training resources. 2018. https://assets.publishing.service.gov. uk/government/uploads/system/uploads/attachment_data/ file/769489/MECC_Training_quality_marker_checklist_ updates.pdf (accessed 6 June 2019) The Queen’s Nursing Institute. General practice nursing in the 21st century: a time for opportunity. 2015. https://www. qni.org.uk/wp-content/uploads/2016/09/gpn_c21_report.pdf (accessed 6 June 2019) Wood CJ, Pretty J, Griffin M. A case-control study of the health and well-being benefits of allotment gardening. J Public Health. 2015;38(3):e336–44. https://doi.org/10.1093/ pubmed/fdv146 World Health Organization. The Ottawa charter for health promotion. 1986. https://www.who.int/healthpromotion/ conferences/previous/ottawa/en/ (accessed 6 June 2019) World Health Organization. Mental health. 2019. https://www. who.int/mental_health/en/ (accessed 6 June 2019)

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McLeish, L., & Snowden, A. (2017). Reflection on practice: Consultation skills. Nurse Prescribing , 15(12) , 600-604. https://doi.org/10.12968/npre.2017.15.12.600

Prof Austyn Snowden 

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Consultation; reflection; guidelines; pain; pain ladder; antibiotics; melatonin

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How do I improve my communication skills?

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Clarity, feedback, and reflective practice are key, finds Abi Rimmer

“Communication failures can lead to complaints”

— Emily Shepherd, medical adviser, Medical and Dental Defence Union of Scotland (MDDUS)

“Effective communication is a key part of the doctor-patient relationship and has a direct impact on patient safety. At MDDUS we have dealt with many examples of patient complaints as a result of communication failures. Many of these could have been avoided by taking some simple steps.

“One common scenario we encounter is when a doctor issues unclear instructions. Doctors have a duty to discuss their patient’s condition and treatment options in a way that’s easily understandable—this lets the patient make informed decisions. Use clear, simple, and consistent language and avoid complex explanations or jargon.

“Many complaints can be prevented by listening to the patient’s worries and adopting an open and constructive approach. It is important to avoid acting defensively and instead show empathy and foster an atmosphere that encourages questions. The GMC’s Good Medical Practice guidance states that doctors must “give patients the information they want or need in a way they can understand.

“Ask for feedback to gauge how you’re doing”

— Sarah Coope, GP and communication skills trainer and coach

“Firstly, what feedback have you had about your communication skills? It could be formal or informal, from patients or colleagues. Reflect on the feedback and clarify the impression you would like to be making. For example, if you’ve been told you seem rushed and disinterested, then set your intention as being more empathetic and calm.

“Secondly, “observe” yourself during interactions with others to gain insight into what you are doing. Notice the other person’s verbal and non-verbal responses to what you’re saying and doing—do they appear to feel understood, reassured, and respected by you? If not, what, specifically, are you doing or not doing that is getting in the way?

“Thirdly, decide what you are going to do differently, one step at a time. For example, to be more empathetic and a better listener, start by allowing the other person to fully finish what they are saying without interrupting and show that you have heard by recapping what they’ve told you and reflecting back any emotion that you pick up on.

“Finally, ask for feedback to gauge how you’re doing and keep practising until the new skills become automatic.

“Reflective practice is required to improve communication skills”

— Angela Rowlands, senior lecturer in clinical communication, Queen Mary University of London

“Extensive reflective practice is required to develop clinical skills, 1 and improving communication skills is no different. Evidence shows that doctors who attend workshops to improve their skills and then have the opportunity to get feedback about how they communicate in real consultations will learn the most. 2

“Learning to communicate effectively means making the most of every interaction. Simulated patients are often used in communication skills training, giving students and clinicians the chance to immerse themselves within a protected and controlled environment. 3 Although their use has been criticised for the occasional lack of authenticity, simulated patients can give valuable practice opportunities and feedback. 4 5

“Annie Cushing, Vivien Cook, and I have written about a project aimed at supporting students in communicating with patients in clinical settings during their undergraduate years. 6 Students learnt about communication within the consultation process and got immediate, focused, one-to-one feedback. Moreover, they were able to maximise the feedback by immediately applying it to further consultations.

“Doctors can continue their learning over time by self and peer assessment, and attending further courses or workshops.”

• ↵ Ericsson KA, Krampe RT, Tesch-Romer C. The role of deliberate practice in the acquisition of expert performance. Psychol Rev 1993 ; 100 : 363 - 406 doi:10.1037/0033-295X.100.3.363 . OpenUrl CrossRef Web of Science
• ↵ Maguire P, Pitceathly C. Key communication skills and how to acquire them. BMJ 2002 ; 325 : 697 - 700 . doi:10.1136/bmj.325.7366.697   pmid:12351365 . OpenUrl FREE Full Text
• ↵ Nestel D, Morrison T, Pritchard S. Simulated patient methodology. In: Nestel D, Bearman M, eds. Simulated patient methodology: theory, evidence and practice. John Wiley & Sons, 2014 : 1 - 30 .
• ↵ Nestel D, Kneebone R. Perspective: authentic patient perspectives in simulations for procedural and surgical skills. Acad Med 2010 ; 85 : 889 - 93 . doi:10.1097/ACM.0b013e3181d749ac   pmid:20520046 . OpenUrl PubMed
• ↵ Nestel D, Tierney T. Role-play for medical students learning about communication: guidelines for maximising benefits. BMC Med Educ 2007 ; 7 : 3 . doi:10.1186/1472-6920-7-3   pmid:17335561 . OpenUrl CrossRef PubMed
• ↵ Rowlands A, Cushing A, Cook V. Meeting the students on their own territory. International Journal of Practice based . Learn Health Soc Care 2013 1 : 93 - 7 . OpenUrl

NHS priorities

Whether it’s to prepare for the next Pharmacy Quality Scheme deadline, or to increase your confidence in helping people with a learning disability, this section provides topic-specific pages that link to current NHS priorities. This section will support you in keeping your knowledge and skills up to date in order to provide high-quality pharmacy services and be service-ready.

Clinical pharmacy

Our clinical portfolio is expanding on a frequent basis, helping you to advance your knowledge and skills and deliver medicines optimisation in practice for all sectors of pharmacy. From two new focal points a year to our small group learning for hospital pharmacists – Optimise – this section focuses on clinical pharmacy, diseases and therapeutics.

Public health

The public health agenda is embedded in pharmacy, yet topics such as emergency contraception or stop smoking support are as prevalent as ever. As well as our public health workshops, use this section to access a wide range of resources to assure and maintain your competence, all underpinned by the Declaration of Competence system.

--> Module 5 assessments PCPEP -->

CPPE has designed an efficient way to record the key activities and assessments you undertake as you progress on your journey along the General practice pharmacist training pathway . This will help you to track your progression with learning and assessments throughout the 18 month pathway.

Register for Module 5 assessments

Sign up for this activity series to record and view your progress with module 5 assessments of the Primary care pharmacy education pathway .

Case-based Discussion two

The case-based discussion (CbD) is a retrospective structured discussion designed to assess your input into patient care. The CbD assesses your professional judgement, clinical decision making and the application of pharmaceutical knowledge to the case presented. You will present a case to your learning set and will answer questions from your peers and clinical mentor. Your clinical mentor will be responsible for assessing you and they will provide written and verbal feedback including strengths and areas for development for your PDP.

Record here the date that you have completed this assessment .

Multisource feedback two

You will use the CPPE Multi-Source Feedback (MSF) tool to collect colleagues’ opinions on your overall professionalism and clinical performance. You will receive a report of your collated feedback. You will reflect on the feedback from your MSF, complete a portfolio entry and discuss this with your education supervisor/or a peer at a group tutorial. You should identify actions to address your development areas and include these in your Personal Development Plan (PDP)..

Access the MSF tool

Record here the date of your MSF professional discussion with your education supervisor. .

Reflection on patient feedback – Patient satisfaction questionnaire (PSQ)

You will use the CPPE patient satisfaction questionnaire (PSQ) to gather and reflect on feedback from patients and/or care home residents. You will reflect on the feedback from your PSQ and write a short reflective essay (800 to 1000 words) which will be submitted for assessment via the CPPE website.

Use the following link to access the reflective essay Reflection on patient feedback

Direct observation of practice: consultation skills one

You will undertake two consultation skills assessments in your workplace. Your assessor will directly observe your practice and use the CPPE Medicines Related Consultation Assessment Tool (MR-CAT) form to assess your consultations.

Record here the date you passed this assessment. .

Direct observation of practice: consultation skills two

Patient safety toolkit e-assessment, learning pathways .

• Developing your career
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• Enhancing your skills
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• Supporting educators and trainers
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Quick links 

• Access Optimise
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Useful links 

• Go to theLearningpharmacy.com™
• Consultation skills for pharmacy practice
• General Pharmaceutical Council
• Royal Pharmaceutical Society
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Reflective account example: a community pharmacist reflects on his communication skills

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As the General Pharmaceutical Council’s (GPhC’s) revalidation deadline (31 October 2019) approaches, many pharmacists will be recording their learning and considering how to complete their reflective account.

The following example reflective account is intended to act as a guide to better enable you to complete your own learning record for submission to the myGPhC site. You should not replicate or copy and paste this material, rather create your own entry based on your experience. You should reflect on your own practice and consider how your patients or service users have benefited from your learning.

In your first year of completing a reflective account, you need to reflect on one or more of the following standards:

• Standard 3 – pharmacy professionals must communicate effectively;
• Standard 6 – pharmacy professionals must behave professionally;
• Standard 9 – pharmacy professionals must demonstrate leadership.

The following example is based on standard 3.

Improving my communication technique

What’s your area of work/ who are your service users?

Provide us with a reflective account of how you met one or more of the standards for pharmacy professionals. Give a real example(s) taken from your practice to illustrate how you meet the standards we have selected.

I am a community pharmacist manager working in a small pharmacy chain based in Scotland. I work alongside a pharmacy technician, two dispensers and several pharmacy counter assistants.

My service users vary, but are generally made up of patients, parents/carers, pharmacy staff members and other healthcare professionals (e.g. those from nearby general practices).

It is necessary as a community pharmacist to communicate effectively on a daily basis, whether this is with patients, staff or other healthcare professionals. However, after several years of practice, I realised I had not considered the effectiveness of my communication skills.

When considering the third standard ‘Pharmacy professionals must communicate effectively’, I thought about how I could improve my communication to ensure I am delivering person-centred care. I was conscious that communication encompasses not simply the words I use, but also body language and tone of voice. I wanted to ensure that I was being as effective as possible and where I could make improvements for my patients.

To better understand my current communication style, I asked a pharmacy colleague to observe me while I spoke to a patient about a minor ailment and make notes based on what she thought went well and what did not go well. Prior to the patient consultation I informed the patient that a colleague would be observing, but that the consultation would continue as normal and no details of the patient were going to be recorded. The patient was happy to continue with the consultation with an observer.

After the consultation my colleague collected her thoughts and made a list of points. We discussed these and I was able to find aspects of my professional practice that required improvement, such as consciously changing my body language and trying to ask fewer closed questions. In order to do this, I practiced body positioning in front of the mirror and created a list of open questions that would aid me in future consultations. I shared my learning with the team and encouraged them to let me know if they observed further communication issues.

The colleague who conducted the initial observation has since observed my general consultation and communication skills and provided me with feedback indicating that I have addressed the issues discussed. This has experience has helped me ensure patients are getting the best possible experience from me during consultations.

Before creating your own reflective account, see ‘ Revalidation: how to complete your reflective account ’, which provides a step-by-step guide for pharmacists and pharmacy technicians writing and submitting this vital part of revalidation.

You may also find the following articles on effective communication useful:

• ‘ Dispensing errors: where does responsibility lie? ’
• ‘ A day caring for vulnerable people with learning disabilities ’
• ‘ WhatsApp groups improve communication within pharmacy teams, finds study ’

How the Royal Pharmaceutical Society is supporting members with revalidation

A dedicated revalidation support hub, which also provides more information on the various support services offered is available on the Royal Pharmaceutical Society (RPS) website and includes:

• RPS MyCPD app – An app supported by The Pharmaceutical Journal. Available for iOS devices via the App Store and Android devices via Google Play . For information on how to use the app, see  ‘ How to use the new ‘RPS MyCPD’ app for pharmacy revalidation ’.
• Revalidation support service – Members can contact this service by phone (0333 733 2570 Monday to Friday 9:00 to 17:00) or email [email protected] .
• Revalidation events – Information on the latest events can be found on the website.
• MyCPD Portfolio – members can create a portfolio allowing you to make records of any CPD you have engaged with and retain these records throughout your career.

You may also be interested in

The importance of diverse clinical imagery within health education.

Government should consider ways to prevent ‘inappropriate overseas prescribing’ of hormone drugs, review recommends

Roz Gittins: ‘The longer fitness-to-practise processes take, the longer registrants are left in purgatory’

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Bickley LS. Bates' guide to physical examination and history taking, 13th edn. Netherlands: Wolters Kluwer Health; 2020

Brock D, Abu-Rish E, Chiu C-R Interprofessional education in team communication: working together to improve patient safety. Postgrad Med J. 2013; 89:(1057)642-651 https://doi.org/10.1136/postgradmedj-2012-000952rep

Burt J, Abel G, Elmore N Assessing communication quality of consultations in primary care: initial reliability of the Global Consultation Rating Scale, based on the Calgary-Cambridge Guide to the Medical Interview. BMJ Open. 2014; 4:(3) https://doi.org/10.1136/bmjopen-2013-004339

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Fairhurst K, Dover AR, Innes JA. Chapter 1. Managing clinical encounters with patients, 14th edn. In: Innes JA, Dover AR, Fairhurst K (eds). London: Elsevier;

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Health Education England, Skills for Health, Health Education England, Skill for Care. Person-centred approaches: empowering people in their lives and communities to enable an upgrade in prevention, wellbeing, health, care and support. 2017. https://tinyurl.com/yy7mv5dl (accessed 15 February 2021)

Hocking G, Kalyanaraman R, deMello WF. Better drug history taking: an assessment of the DRUGS mnemonic. J R Soc Med. 1998; 91:(6)305-306 https://doi.org/10.1177/014107689809100605

Innes JA, Fairhurst K, Dover AR. Chapter 2. General aspects of history taking, 14th edn. In: Innes JA, Dover AR, Fairhurst K (eds). London: Elsevier;

Jack E, Maskrey N, Byng R. SHERPA: a new model for clinical decision making in patients with multimorbidity. Lancet. 2018; 392:(10156)1397-1399 https://doi.org/10.1016/S0140-6736(18)31371-0

Krug SE. The art of communication: strategies to improve efficiency, quality of care and patient safety in the emergency department. Pediatr Radiol. 2008; 38:S655-S659 https://doi.org/10.1007/s00247-008-0893-y

Kurtz SM, Silverman JD. The Calgary-Cambridge Referenced Observation Guides: an aid to defining the curriculum and organizing the teaching in communication training programmes. Med Educ. 1996; 30:(2)83-89 https://doi.org/10.1111/j.1365-2923.1996.tb00724.x

Kurtz SM, Silverman J, Draper J. Teaching and learning communication skills in medicine, 2nd edn. Oxford: Radcliffe Publishing; 2005

Kurtz S, Silverman J, Benson J, Draper J. Marrying content and process in clinical method teaching. Enhancing the Calgary–Cambridge Guides. Acad Med. 2003; 78:(8)802-809 https://doi.org/10.1097/00001888-200308000-00011

Kuehlein T, Sghedoni D, Visentin G Quaternary prevention: a task for general practitioners (original in German). Primary and Hospital Care. 2010; 10:(18)350-354 https://doi.org/10.4414/pc-d.2010.08739

Martins C, Godcki-Cwirko M, Heleno B, Broderson J. Quaternary prevention: reviewing the concept. Eur J Gen Pract. 2018; 24:(1)106-111 https://doi.org/10.1080/13814788.2017.1422177

Revisiting models of the consultation (online-only content, https://tinyurl.com/yaxqupm3). 2012.

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Undertaking consultations and clinical assessments at advanced level

Sadie Diamond-Fox

Senior Lecturer in Advanced Critical Care Practice, Northumbria University, Advanced Critical Care Practitioner, Newcastle upon Tyne Hospitals NHS Foundation Trust, and Co-Lead, Advanced Critical/Clinical Care Practitioners Academic Network (ACCPAN)

View articles

Once deemed the reserve of doctors, ‘the medical interview’ has since transitioned across professional boundaries and is now a key part of the advanced clinical practitioner (ACP) role. Much of the literature surrounding this topic focuses on a purely medical model; however, the ACPs' use of consultation and clinical assessment of complex patient caseloads with undifferentiated and undiagnosed diseases is now a regular feature in healthcare practice. This article explores how knowledge of the fundamental principles surrounding ACP–patient communications, along with the use of appropriate consultation frameworks and examination skills, can provide a deeper insight and enhance the existing skills of the ACP. A comprehensive guide to undertaking patient consultations, physical examination and diagnostic reasoning on a body systems basis is explored in future issues of this Advanced Clinical Practice series.

The process of conducting a patient consultation and performing a subsequent clinical assessment has historically been termed ‘the most powerful and sensitive and most versatile instrument available to the physician’ ( Engel, 1973 ). Despite the rapid growth of healthcare technology, this remains the case today. A skilled advanced clinical practitioner (ACP) in this area has the potential to make a significant contribution to several fundamental outcomes: patient satisfaction, patient concordance with prescribed therapies/interventions, overall diagnostic accuracy and overall patient outcomes. Evidence suggests that, by conducting a high-quality medical history alone, 60-80% of the relevant information to form a diagnosis can be ascertained ( Peterson et al, 1992 ; Roshan, 2000 ). The overall aim is to identify symptoms and physical manifestations that represent a final common pathway of a wide range of pathologies, which may be highly suggestive or even pathognomonic of one such pathology, or multiple concurrent pathologies.

Communication

Communication with patients is key to all aspects of clinical practice. Seminal NHS frameworks and policy drivers place effective communication at the core of providing a person-centred approach in health and care ( Health Education England (HEE) 2017 ; HEE et al, 2017 ; NHS England 2019a ; 2019b ). Communication skills are consequently core strands of ACP training and ongoing professional development. Effective communication with patients can lead to improvement in both treatment quality and safety metrics ( Scalise, 2006 ; Krug, 2008 ; Brock et al, 2013 ); conversely, poor communication has been highlighted as one of the main concerns that lead to complaints to the Parliamentary and Health Service Ombudsman (2020a ; 2020b ).

In order to develop effective ACP-patient relationships we must consider some of the fundamental principles of effective/therapeutic communication within the healthcare setting, such as patient health literacy, cultural understanding and language barriers. However, there are other aspects that could potentially have an impact ( Table 1 ).

The traditional history-taking format meets many challenges in the time-critical situation, and the nature of these dynamic situations often means that a quick, focused history is required. The mnemonic ‘AMPLE’, originally developed for use in the context of trauma ( Zemaitis et al, 2020 ), may be applied to quickly obtain pertinent information:

• A = allergies
• M = medications
• P = past medical history
• L = last meal (timing)
• E = events related to presentation.

Clinical assessment: aspects of physical examination

Although a well-conducted, thorough physical examination requires a systematic approach, it does not always require a full examination for each body system. Salient points from the initial consultation stage may guide the clinician as to the focus of a general examination. Future issues of the ACP series will cover the body's systems, such as the cardiac and endocrine systems, in more depth, but the process of performing a full physical examination, along with a non-exhaustive list of potential examination findings, is presented below. Again, there may be time-critical situations in which this approach is not appropriate, and these situations lend themselves to an ABCDE (airway, breathing, circulation, disability and exposure) approach ( Resuscitation Council UK, 2015 ).

The following is a guide to performing a systematic examination, but this is not an exhaustive list:

General survey

• Observe environment for treatments or adjuncts
• Signs of distress: cardiac or respiratory
• Pain and anxiety
• Skin colour and obvious lesions
• Personal hygiene
• Facial expression
• Odours: alcohol, acetone/fruity
• Posture and gait
• Body habitus (body mass index).

Vital signs

• Respiratory rate and rhythm
• Blood pressure
• Level of consciousness
• Temperature.

Hands and nails

• Inspect: nail-bed deformities, clubbing, koilonychia, splinter haemorrhages; palms—erythema; joint deformities; peripheral oedema
• Palpate: radial pulse.
• Inspect: deformities or markings, needle-track marks, bruising, striae

Head and neck

• Inspect: hair, eyes, nose, mouth, voice, jugular venous pressure
• Palpate: carotid pulses, generalised swelling, lymph nodes, thyroid and parathyroid glands
• Integrate cranial nerve exam, if necessary.
• Inspect: deformities of tracheal positioning/chest wall appearance and/or movement, galactorrhoea or gynaecomastia, spider naevi, scars and devices, audible clicks, visible apex beat
• Palpate: tracheal position, cricosternal distance, parasternal heave, apex beat, thrills, costochondral joints, percussion, lung fields
• Auscultation: breath sounds—anterior and posterior thorax, whispered pectoriloquy, added sounds, heart sounds.
• Inspect: scars and devices, distension, caput medusae, striae, hernia, Cullen's sign, Grey-Turner's sign
• Palpate: light and deep palpation of all nine regions; liver, spleen, aorta and bladder. Ballot kidneys and assess for Murphy's sign
• Percussion: liver (span), spleen (span), bladder, shifting dullness
• Auscultation: bowel sounds, liver for venous hum, aorta and renal arteries–bruits.

Lower limbs

• Inspect: swelling and oedema (general or unilateral), calf pain, deformities, scars, striae, nail beds, hair loss, ulcers, colour changes
• Palpate: pulses (femoral, popliteal, dorsalis pedis)
• Temperature
• Auscultation: femoral pulse—bruits
• Integrate lower limb neuro exam, if necessary
• Consider ankle-brachial index and Buerger's test, if concerns for peripheral venous disease (PVD).

Consultation and clinical assessment are fundamental skills of the ACP role, the process of which is complex and requires an array of underpinning knowledge in physiology, pathophysiology and theories of effective communication within the healthcare setting. There are multiple frameworks to guide the process, not all of which will be suitable for many specialist areas in which ACPs practice. There are multiple opportunities throughout the clinical consultation process in which ACPs can engage with their patient population, in order to work in partnership to enhance primary, secondary and tertiary prevention of disease and the healthcare intervention burden. A number of newer consultation frameworks now address quaternary prevention; however their use in the secondary and tertiary care settings is yet to be evaluated.

• Consultation and clinical assessment (C&CA) was once seen as solely the domain of doctors; however, the ACP role crosses traditional boundaries
• Through the use of C&CA, there is potential to make a significant contribution to several fundamental outcomes: patient satisfaction, patient concordance with prescribed therapies/interventions, overall diagnostic accuracy and overall patient outcome
• To develop effective ACP-patient relationships we must consider some of the fundamental principles of effective/therapeutic communication
• There are multiple evidence-based frameworks that exist to aid the practitioner in their consultation and clinical assessment that focus on effective communication and promoting successful practitioner-patient relationships

• Pharmacist Independent Prescriber Course
• Minor Illnesses And Acute Conditions Course
• Setting Up A Private Clinic

Non-medical prescribing reflection examples

• Non-Medical Prescribing

Why do non-medical prescribers need to learn to become reflective practitioners?

During your non-medical prescribing course and clinical practice, nurse prescribers and pharmacist prescribers will be required to regularly reflect on their clinical practice to develop reflection and reflective practice skills.

Moreover, if you’re undertaking a non-medical prescribing course, you will be expected to submit as part of your coursework many reflective essays, i.e., a reflective account – so understanding what a reflection is and how to reflect is undoubtedly worth the investment.

Do medical prescribers need to reflect on their practice?

There is no one-size-fits-all answer to this question, as the need for reflection will vary depending on the individual and their clinical practice. However, medical prescribers should generally reflect on their practise to improve patient care and ensure they use evidence-based practices. Additionally, reflection can help medical prescribers identify areas where they need further education or training.

Do independent prescribers need to reflect on their practice?

Independent prescribers need to reflect on their practice to ensure that they prescribe safely and effectively. By reviewing their own practice, independent prescribers can identify areas where they may need to improve and make the necessary changes. This is important to protect patients’ safety and ensure that they are receiving the best possible care.

The above is relevant for all non-medical prescribing students, including; (1) future nurse prescribers, ; (2) allied healthcare professionals and (3) pharmacist prescribers wanting to undertake advanced practice training.

What is reflection?

Reflection is a mental process where people examine their experiences to better understand their whole profession. It allows individuals to enhance their work habits or the care they provide to patients regularly. It is an essential, continuous, and routine element of the job of healthcare and social service providers.

Teams comprised of professionals with different backgrounds, skill sets, and working experiences should be encouraged to reflect openly and honestly on what occurs when things go wrong. These practical reflective activities help develop resilience, enhance well-being, and increase professional devotion.

To be reflective during your prescribing practice, healthcare professionals must first be open to new ideas, explore them from various perspectives, be inquisitive – asking questions – and remain patient if the problem isn’t “simple.” (While this may suddenly leap out at you).

Your prescribing practice and reflective accounts need to make transparent to others and what you’re getting wrong or right. Therefore being honest with yourself is essential as a non-medical or independent prescriber.

Why do nurse prescribers, pharmacist prescribers and non-medical prescribing students need to reflect and write reflective accounts?

Reflection may help you learn a lot from your prescribing practice and prescribing decisions. There are several reasons to reflect. You can use it to:

• Learn from the experience of independent prescribing
• Improve your prescribing decision-making skills
• Help you make decisions in the future
• Identify continued professional development (CPD) needs

You can reflect on anything, but as a non-medical or independent prescriber, you should focus on your prescribing experiences. This will help you understand and develop your skills as a prescriber.

When thinking about your experiences, you should consider both the good and the bad. It’s important to reflect on what went well and what didn’t go so well. This will help you learn from your mistakes as well as your successes. Furthermore, it will ensure you identify gaps in your professional development needs.

There are many different ways to reflect. You can use written reflection, audio recordings, or even video. The important thing is that you’re taking the time to think about your experiences and what you can learn from them.

If you’re not sure how to get started, some helpful reflection templates and examples are below. You can also talk to us at MEDLRN for guidance on how to reflect on your independent prescribing experiences.

Remember, reflection is an integral part of being a successful non-medical prescriber. By reflecting on your experiences, you can improve your practice and make better decisions in the future.

Reflective practitioners and the benefits

The General Pharmaceutical Council, the General Chiropractic Council, the General Dental Council, the General Medical Council, the General Optical Council, the Health and Care Professions Council, the Nursing and Midwifery Council, and the Pharmaceutical Society of Northern Ireland’s top executives have signed a joint statement called Benefits of becoming a reflective practitioner.

https://www.pharmacyregulation.org/sites/default/files/document/benefits_of_becoming_a_reflective_practitioner_-_joint_statement_2019.pdf

This is what they say:

“We are committed to supporting our registrants in their professional development and we recognise the benefits of registrants engaging in reflective practice.

Reflective practitioners are more resilient, and adaptable and have a greater capacity to maintain their registration throughout their careers. They demonstrate professionalism by being able to reflect on their own values and behaviours, and how these might impact the people they care for.

Reflective practitioners are able to make well-informed decisions, using a range of strategies including critical thinking, problem-solving and lifelong learning. They can identify their own development needs and are committed to maintaining their registration by engaging in continuing professional development (CPD).

We would encourage all registrants to reflect on their practice and to use reflective tools and resources to support their professional development.

Reflective practice is a key part of being a healthcare professional. It helps us to learn from our experiences, both good and bad so that we can improve our practice and make better decisions in the future.

How to get started with reflective writing

Most people are unfamiliar with the concept of reflective writing. However, the following comments indicate a lack of clarity regarding reflective writing when it comes to courses and assessments: ‘I thought I wasn’t supposed to use “I” in my work.” ,,,,,,,,,, ‘I won’t say what I truly believe unless it is going to be evaluated.’

The following points will help you to understand what is meant by reflective writing and how it can be used to support your non-medical prescribing course:

• Reflective writing is a way of exploring and analyzing your own thoughts and experiences.
• It can help you learn from your own experiences and make better decisions in the future.
• Reflective writing is different from other types of academic writing as it allows you to share your own thoughts and feelings on a subject.
• When writing reflectively, you should use first-person pronouns (I, me, my) to share your own experiences.
• You should also be honest about your thoughts and feelings, as this will help you learn from your experiences.
• Reflective writing is usually informal in style and can be written in the first or third person.
• It is important to remember that reflective writing is about your own thoughts and experiences, so you should use “I” when sharing your reflections.
• When writing reflectively, it can be helpful to use a reflection template or guide. This will help you to structure your thoughts and ensure that you cover all the essential points.
• Reflective writing is an integral part of the non-medical prescribing course, as it helps you learn from your experiences. By reflecting on your prescribing experiences, you can improve your practice and make better decisions in the future.

What is a reflective essay?

A reflective essay is a type of writing in which you (the author) interact with an audience (readers, listeners, viewers) to describe an experience and how that experience has changed you.

Reflective essays are usually written after a milestone. For example, a student may write a reflective essay at the end of a course of study or after completing an internship or other practical work.

The purpose of a reflective essay is to describe the experience and examine the meaning of the experience and how it has affected you as an individual.

Reflective essays are personal pieces of writing, so they should use first-person pronouns (I, me, my, we, us) and express your own thoughts and feelings about the experience.

Reflective essays can take many different forms. Standard formats include journals, letters to the editor, blogs, and photographic essays.

When writing a reflective essay, it is essential to use descriptive language. This will help the reader to understand your experience and how it has affected you.

It is also important to use concrete details and examples in your writing. This will make your essay more attractive and easier to read.

Finally, remember to proofread your essay before you submit it. This will help ensure that there are no errors or typos in your writing.

Writing critically and reflectively during your non-medical prescribing course

Both critical and reflective may be used in a directive to ‘reflect critically’ on anything. The terms describe a writing trait in which the reader can discern that the text has been carefully considered.

To be critical, you must go beyond description and into the analysis. You evaluate ideas or methods (evaluate), apply them in your work (apply), and defend or refute them (defend). You also reflect on what you have read, thought, or experienced.

In both types of writing, the key features are similar: good, strong, and well-written essays. The major distinctions between critical and reflective writing are as follows:

1 You and your thoughts will be more apparent in your writings.

2 Your personal history – what you have done, thought about, read, and changed throughout your life – is a significant source of evidence in your writing.

3 You are more likely to use the present tense when writing reflectively.

The key features of critical and reflective writing:

Critical Writing 

• More formal
• Focuses on ideas and methods
• Uses evidence from other sources
• Tends to use the past tense

Reflective Writing 

• Less formal
• Focuses on you and your thoughts
• Uses your personal history as evidence
• Tends to use the present tense

Reflective writing for non-medical prescribing students and medical prescribers

Non-medical prescribing students and medical prescribers will be expected to:

• Participate in or observe an incident (such as the care of a patient)
• Discuss what went well and not so well about it
• Examine their thoughts about it by linking to relevant theory/policy/science/guidance and to the experience of others in similar circumstances
• Draw conclusions about what might be done differently next time and how this might improve patient care.

The use of frameworks to help non-medical prescribing students and medical prescribers write reflective essays or reflective accounts

A ‘framework’ is a method for structuring and analyzing an issue, scenario, or experience. It may help you extract the learning points from an event by taking a systematic approach:

• What happened?
• What was my role in it?
• What went well and not so well?
• What could I have done differently?
• What did I learn from it?
• How can I use what I learned in the future?

Reflective writing using the Gibbs Reflective Cycle

The Gibbs Reflective Cycle is a framework for reflection that helps you to think about your experiences and how they relate to your learning. The cycle is made up of six stages:

• Description
• Action Plan

These stages can be usefully applied to any reflective writing task.

An example of reflective writing using Gibbs reflective cycle

I recently observed an incident in which a patient was being discharged from the hospital. I was part of the team responsible for their care. I felt that the discharge process could have been better organized and that the patient could have been given more information about their condition and what to expect after leaving the hospital.

I evaluated the situation and identified some areas for improvement. I discussed my observations with the team, and we came up with a plan of action. I learned that it is important to be organized when discharge planning and to make sure that patients are given all the information they need to make a smooth transition from hospital to home. I will use this learning in future when discharge planning.

Example two of a reflective account using Gibbs reflective cycle

When I was first asked to do this reflective essay on weight loss, I was a little apprehensive. I wasn’t sure if I wanted to share my personal journey in this way or not. But after giving it some thought, I decided that it might be helpful for others who are either considering or currently trying to lose weight. So here goes…

I started my weight loss journey about 6 months ago. I had been feeling unhappy with my appearance for a while, and my health was also starting to suffer. I knew I needed to make a change, but I didn’t know where to start. Thankfully, a friend of mine recommended the Atkins Diet, and I decided to give it a try.

The first few weeks were tough. I had to make a lot of changes to my diet and lifestyle, and it was all very new to me. But I stuck with it, and after a few weeks, I started to see results. I felt better, both physically and mentally, and people were starting to notice the difference too.

Since then, I’ve lost a total of 30 pounds, and I’m still going strong. It hasn’t been easy, but it’s definitely been worth it. I’m now at a healthy weight, and I’m feeling the best I’ve ever felt.

The whole experience has taught me a lot about myself. I’ve learned that I’m capable of making big changes in my life, even when it’s hard. I’ve also learned that I’m stronger than I thought I was.

If you’re considering losing weight, or if you’re currently on a weight loss journey, then I encourage you to keep going. It’s not easy, but it’s so worth it. Trust me, I know from experience.

Gibbs’s Reflective Cycle (Gibbs, 1998) helps you to understand and practice your reflective skills. Use the template to reflect on a recent event in which you demonstrated a reflected ability to improve or demonstrate the need for further learning or development.

Description: what happened? 

I had undertaken a supervised consultation as part of the non-medical prescribing course in the presence of my designated medical practitioner(DMP) and university tutor. Mary (pseudonym) middle-aged woman with a previous diagnosis of hypertension, was invited to attend the OSCE, which involved taking a comprehensive medical history in order to undertake a clinical assessment of the patient. Mary was invited to attend the OSCE, and prior to the OSCE, she was informed of the particulars of the assessment, e.g. the presence of my university tutor and DMP etc.

 Mary was called to the consultation room, and verbal consent was gained. The consultation involved the following; undertaking a comprehensive history taking using the Cambridge and Calgary model, taking blood pressure, and an explanation of the pathology of hypertension and its management.

Upon completion of the consultation, I was informed by the DMP I had passed my assessment and feedback was given.

Feelings: what were you thinking and feeling?

As a pharmacist, this was the first time I had undertaken a structured consultation using the Cambridge and Calgary model. However, having been qualified for over 5 years, I was confident with my consultation skills, in particular, my communication skills and my knowledge of the pathophysiology and management of hypertension. In addition, I was comfortable and relaxed when taking Mary’s blood pressure as I have had considerable practice during my placement with taking blood pressure and felt confident when explaining the relevance of the readings as well as offering health advice. After the OSCE, I felt satisfied with the outcome and in agreement with the feedback of my DMP.

Evaluation: what was good and bad about the experience?

On evaluation, the event was good for a number of reasons. Firstly, Mary said she was satisfied with the advice and the explanation she was given regarding hypertension and the relevance of her blood pressure readings. In addition, feedback from my DMP included my good use of communication skills, especially eye contact and body language(NICE,2010). Furthermore, another positive of the consultation was that I was able to follow the Cambridge and Calgary model and address all the relevant assessment requirements. However, a negative of the consultation was that Mary had asked me to quantify how much of various fruits count towards your ‘5-a-day fruits requirements; however, I was a bit unsure and had to double-check the advice with my DMP even though it was correct. As such, I would have liked to have been more confident in providing that advice.

Analysis: what sense can you make of the situation?

Mary had asked me to explain to her what amount of different fruits count toward the ‘5-a-day’ requirement (NHS,2015), and I was unable to provide the answer confidently as mentioned above; this was the ‘part’ of the OSCE that did not go too well. A reason for this was that I had assumed certain health advice is ‘common knowledge and would not require much explanation. As such, It had never occurred that this was a gap in my knowledge. This negative aspect could have been avoided had I thought more deeply about the advice I offered and affirmed the understanding of patients. Conversely, a part of the consultation that did go well was that I was able to utilize the Cambridge and Calgary model to structure my consultations.

This was because I had undertaken considerable learning regarding structuring a consultation and practised the Cambridge and Calgary model on multiple occasions with my DMP and modified it slightly to address my needs. Furthermore, with regards to taking blood pressure, during my training with my DMP, I had reviewed best practice guidelines when undertaken taking blood pressure and asked for regular feedback, which ensured I was constantly improving my technique and skills.

Conclusion: what else could you have done?

As a result of the consultation, I have learned that I must confirm the understanding of the patient with regard to the health advice that is being given (Nursing Times, 2017) and ensure there is no confusion or misunderstandings. In addition, this experience (of undertaking a consultation) has highlighted the importance of ensuring there is structure to consultation and how I can use a model of consultation to suit the needs of the situation (Royal College Of General Practitioners Curriculum, 2010). Furthermore, I would have liked to have undertaken a level 3 clinical medication review (Brent CCG,2014) to determine adherence to the medication, as many hypertensives have poorly controlled blood pressure (heart Foundation,2016) with a lack of adherence to treatment cited as a major reason (Izzat,2009).

Action plan: if the situation arose again, what would you do?

In order to be better prepared to face a similar experience, I have decided I will continually practice using the Cambridge and Calgary model of consultation wherever possible and undertake self-appraisal (Royal College of General Practitioners,2013); in addition, in order to ensure I have adequate knowledge in health education, I will continue to undertake CPD and have decided to attend a training course within the next 4-8 weeks. Also, currently, I am trained to take blood pressure using an electronic machine but am not confident in measuring blood pressure manually, which would be useful if a patient had atrial fibrillation (NICE,2016). As such, I have decided to take further training under the supervision of my DMP to develop this clinical skill.

• Brent CCG ,2014. Medicines Optimisation:Clinical Medication Review [pdf]. Available at:<https://www.sps.nhs.uk/wp-content/uploads/2016/08/Brent-CCG-Medication-Review-Practice-Guide-2014.pdf> [Accessed 2nd April 2018].
• Heart Foundation,2016.  Guideline for the diagnosis and management of hypertension in adults [pdf]. Available at:<https://www.heartfoundation.org.au/images/uploads/publications/PRO-167_Hypertension-guideline-2016_WEB.pdf> [Accessed 2 April 2018].
• Izzat, L.,2009.  Antihypertensive concordance in elderly patients  [Online] Available at <https://www.gmjournal.co.uk/media/21571/gm2april2009p28.pdf> [Accessed on 28 February 2018]
• National Institution for Health and Clinical Excellence, 2010.  Principles of Good Communication [pdf].Available at:<file:///C:/Users/ProScript%20Link/Downloads/supportsheet2_1.pdf> [Accessed 1 April 2018].
• National health service, 2015.  Nhs Choices 5 A Day portion sizes . [Online] Available at:<https://www.nhs.uk/Livewell/5ADAY/Pages/Portionsizes.aspx> [Accessed 1st April 2018].
• National Institute for Health and Care Excellence (2016).  The clinical management of primary hypertension in adults (NICE Guideline 127). [Online] Available at: https://www.nice.org.uk/guidance/cg127 [Accessed 25 February 2018]
• Nursing Times, 2017.  Communication Skills 1: benefits of effective communication for patients [online]. Available at:<https://www.nursingtimes.net/clinical-archive/assessment-skills/communication-skills-1-benefits-of-effective-communication-for-patients/7022148.article> [Accessed 1 April 2018].
• Royal College Of General Practitioners Curriculum, 2010.  The GP Consultation in Practice [pdf]. Available at:<https://www.gmc-
• uk.org/2_01_The_GP_consultation_in_practice_May_2014.pdf_56884483.pdf> [Accessed 1st April 2018].
• Royal College Of General Practitioners, 2013.  What are consultation models for? [pdf]/ Available at:<http://journals.sagepub.com/doi/pdf/10.1177/1755738013475436> [Accessed 2nd April 2018].

Author:  Faheem Ahmed

Pharmacist Prescriber, 2x Award-Winning Pharmacist, Pharmacy and Clinic Owner, Founder of MEDLRN and loves sharing his experience with pharmacists.

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