Table Of Content"PHARMACY COUNSELLING": A STUDY OF THE
PHARMACIST/PATIENT ENCOUNTER
USING CONVERSATION ANALYSIS'
by Alison Pilnick, BPharm, MA, MRPharmS.
Thesis submitted to the University of Nottingham
for the degree of Doctor of Philosophy, May, 1997
CONTENTS
page
Acknowledgements 3
Abstract 4
Introduction 6
1. Literature Review 23
2. Methodology 64
3. Methods 93
4. The Organisation of the Pharmacist/Patient/Carer
Encounter: A Putative Stmcture 109
5. "I'm not going to say anything to you because you've had it all before...":-
A Provisional Typology of Methods of Arrival at Advice Giving 136
6. "Patient Counselling" by Pharmacists:
Advice, Information or Instmction? 174
7. "When are you due to come back then?":-
Exits from Advice Giving and Closings 230
8. " Why didn' t you just say that?": -
Dealing with Issues of Knowledge, Competence and Asymmetry 255
Conclusions 295
Appendix: Glossary of Medical Terms 325
Patient Information Leaflet 328
Key to transcripts 329
Basic Transcripts 330
Bibliography 395
ACKNOWLEDGEMENTS
The author wishes to acknowledge a sincere debt of gratitude to the following people:
The staff and clients of the Pharmacy and Paediatric Oncology Departments in the
study site, for giving their permission for the smdy to take place. Special gratitude
is due to all those patients, carers and pharmacists who allowed themselves to be tape
recorded, especially Catherine.
Professor Robert Dingwall and Dr David Greatbatch for their support and
encouragement in supervising this thesis.
Professor Anssi Perakyla for his invaluable comments on and insights into the study
data.
My fellow PhD and Enterprise Scheme smdents, especially Sarah-Jo Lee and Davina
Allen, for their moral support.
Sharon Moran for her objective and honest comments which have enabled me to
retain a sense of perspective throughout the preparation of this thesis.
This study was funded by the Department of Health under the Pharmacy Practice
Research Enterprise Scheme, and the author wishes to acknowledge their generous
support both in practical and financial terms.
ABSTRACT
Pharmacy as a profession is changing rapidly in the UK. Over recent years, the
increased utilization of ready-prepared dmgs has led to a decline in the need for the
traditional skills of formulation, while computerization has resulted in a situation
where much of the routine dispensing work can be undertaken by less qualified
personnel. The decline in the traditional aspects of pharmacy has been matched by the
emergence of a much greater advisory role. Pharmacy practice researchers have been
drawn to support these developments by investigating related areas, but the common
factor linking this research is its focus on clinical as opposed to communication
issues. Rather than investigating the nature of face-to-face interaction between
pharmacists and clients as a topic in itself, researchers instead have been largely
concerned with patient/health care system mteractions as a function of dmg therapy.
Those few studies that have focused exclusively on communication have done so from
a quantitative, social psychology framework, thus ignormg the two way, reactive
nature of the interaction process.
This study, using data collected from patients' and carers' consultations with
pharmacists in a hospital paediatric oncology outpatient clinic, uses the sociological
methodology of Conversation Analysis (CA) in order to analyze the encounters which
take place. In so doing, it aims to shed some light upon what is actually involved in
the process of "patient counselling" in this setting. The body of CA literature which
considers advice-giving in health care settings provides the starting point for a
consideration of the ways in which pharmacists give advice in this setting, and how
this is responded to. The auns are thus twofold: to enlarge the methodological
resources of PPR, and also to begin an examination of the communicative
competencies required of pharmacists in this setting.
INTRODUCTION
Pharmacy as a profession is changing rapidly in the UK. Over recent years, the
traditional role of the pharmacist as simply a formulator and dispenser of medicines
has evolved to encompass a far greater range of tasks and activities. A key part of
this development has been the concept of the 'extended role', which emphasises the
contribution that pharmacists can make in four key areas: the management of
prescribed medicines; the management of chronic conditions; the management of
common ailments; and the promotion and support of healthy lifestyles (RPSGB,
1996a). Since pharmacists are highly trained health care professionals, easily
accessible on every high street and in hospitals, the evolution of this 'extended role'
has arisen primarily as a response by the profession, and by the Government, to a
perceived undemse of the skills and the potential of pharmacists. In particular, the
White Paper 'Promoting Better Health' (Secretaries of State, 1987) encouraged the
preventative and health promoting activities of community pharmacists. It also, for
the first tune, provided set fees for such services as the development and maintenance
of patient medication records, and other services such as the provision of
pharmaceutical advice to residential homes. Such developments make clear that the
evolution of the 'extended role' also has a commercial and financial dimension, as a
response to changing market conditions (Mays, 1994). In this sense the changes may
be alternatively described as a 'survival strategy' for pharmacists, who with the
advent of computerization and the increased numbers of ready prepared dmgs, had
seen the erosion of a large part of their traditional skill base.
This message of survival is conveyed by the Royal Pharmaceutical Society of Great
Britain in hs consultative document, 'Pharmacy in a New Age' (RPSGB, 1996a)
which describes how pharmacists need to find new and effective ways of brmgmg
their skills to bear where they are needed. A number of forces for change are
identified, including government concern to get the best value for money from
investment in healthcare, a trend towards a greater power for consumers, and a
change in the hospital sector which has resulted in shifts in the location of care. Since
today's health service increasingly focuses on outcomes, taking responsibility for
these outcomes is described as the "acid test" in evaluating whether individual
healthcare professions have somethmg to offer. Thus, a future is envisaged in which
pharmacists are better integrated into healthcare teams, collaborate more closely with
each other, and make their patient services more accessible.
At the heart of all these developments, and of the extended role itself, is the provision
of advice to patients or clients, specifically concerning sensible and effective ways
of using medicines, and more generally m terms of health promotion and lifestyle.
It is now well recognised that pharmacists act as health advisers to the general public;
this extension of the primary health care role was explicitly recommended by the
Nuffield Committee of Enquhy into pharmacy (1986) and is continuously being
pursued by the profession. Both the Royal Pharmaceutical Society and the Department
of Health have sought to encourage community pharmacists to acknowledge the
breadth of their contribution and to seek new ways of providing advice and support
to people about their health and about the safe and effective use of medicines. The
Code of Ethics for pharmacists, published by the Royal Pharmaceutical Society and
containing the legal and ethical requirements for professional practice, discusses this
specifically under the heading of "Counselling/Information and Advice". It states that
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"A pharmacist must seek to ensure that the patient or his agent understands sufficient
information and advice to enable safe and effective use of medicines. This must
include seeking to ensure that the directions on the labels of dispensed products are
understood." (RPSGB, 1996b, plOO). Further, under a section headed "Standards for
Relationships with Patients and the Public", it is stated that "The pharmacist should
be prepared and available at all times to give advice on general health matters"
(RPSGB, 1996b, pl02).
The description of these activities as patient "counselling" is a common one in the
professional literature, and is frequently used by pharmacists themselves to describe
their advising and informmg activities. However, since the British Association for
Counselling defines counselling as "Giving clients an opportunity to explore, discover
and clarify ways of living more resourcefully and towards greater well being", whilst
the Code of Ethics defmes it as "The discussion of medicmes and treatment, and the
giving of advice in a professional context", it is unclear what relationship the
activities which pharmacists carry out bear to the general perceptions of counselling
held by the public. As Rees (1996) contends, it is perhaps more accurate to say that
"pharmacists act as facilitators rather than counsellors, facilitating an individual's
ability to take and use medicines correctiy and knowledgeably" (Rees, 1996, p200).
Whatever the terminology which is used, these activities of "pharmacy counselling",
and the increased importance which is attached to them, have had a far reaching
impact on both research and training. Mays (1994) suggests that "the existence of and
promotion of the 'extended role' have further compelled a recognition within a
profession trained in the natural sciences that pharmacy is an applied science which
takes place in a social context through specific organisational tasks which are part of
an ever changing health care delivery system (Harding, Nettieton and Taylor, 1990).
This in turn has prompted the realisation that pharmacists would benefit from some
training in social, behavioural and managerial sciences, all of which are relevant to
pharmacy practice research" (Mays, 1994, plO). The Nuffield Report (1986) also
drew attention to health services research in pharmacy, noting that "It is in the area
of HSR that the greatest weaknesses are to be found. There is too little information
available, relatively weak stmctures and very little funding" (Nuffield, 1986,
Appendix 1).
This is not to say, however, that there has been a complete lack of research mto the
professional activities of the pharmacist, or as the profession terms it, 'Pharmacy
Practice Research' (PPR). Just as the role of the pharmacist has developed, so
pharmacy practice researchers have been drawn to support these developments by
investigating related areas, encompassing the factors which influence people's
decisions to seek advice from health care professionals in the first place, and more
particularly the extent to which this guidance or advice is complied with. Much of
this research, however, which will be considered in detail in the following chapter,
has concentrated on the search for simple correlations between 'inputs' and 'outputs',
with evaluation of the pharmacist's advice giving resting on the patient's correct or
otherwise completion of a medication 'sequence' at a later date. There is also a
tendency in such studies for non-compliant behaviour on the part of the patient to be
10
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