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Abstract
A person-centred approach to care is central to NHS England’s health policy agenda and a standard for pharmacy practice from the General Pharmaceutical Council. Health coaching is a method of delivering person-centred care. A pilot of a health coaching support package, including a 2-day course and practice-based follow-up, was delivered to 70 London North West Healthcare NHS Trust pharmacy staff between December 2015 and July 2017.
Objectives To evaluate the support package, identifying key themes from course feedback, evaluating staff perception and evidence of application in practice. To identify key benefits of the support package.
Methods Qualitative analysis of written course feedback was undertaken to identify staff learning themes about person-centred care. The themes were used to design a survey, administered to support package recipients (staff), exploring staff perception of the package. Qualitative review of written examples highlighted use of person-centred themes in practice.
Results Twelve person-centred themes emerged from 49 course evaluations forms, describing what participants learnt about patient-centred care. Of 24 surveys completed, respondents reported increased awareness of themes; however, use in practice varied between themes. Overall, respondents valued the support package and rated practice-support more highly than the course for ongoing development. Patient examples described the use of themes in practice.
Conclusions The support package increased awareness of person-centred themes, portrayed within the practice examples submitted. While the course provided a foundation for use of a person-centred approach, continuing practice-based support is desired by staff to embed learning into day-to-day practice.
- person-centred care
- health coaching
- hospital pharmacy education
- hospital pharmacy competencies
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What this paper adds?
What is already known on this subject?
Person-centred care is a core component of health service delivery.
A person-centred approach is a global imperative for health practitioners.
Pharmacy practice has yet to incorporate this approach into everyday practice.
What this study adds?
Skill development to improve person-centredness within pharmacy consultations can be undertaken using a coaching approach to behaviour change.
A combination of taught and practice-based support may be valuable in embedding these skills within pharmacy practice.
Introduction
A person-centred approach to healthcare encompasses coordinated, personalised and compassionate care alongside supporting the individual to recognise their strengths and promote their independence.1 This approach is now considered an essential component of healthcare1 2 and a focus of NHS England’s health policy agenda.3
Coaching is a cognitive-based behaviour change method, defined as an intervention focussing on changing thoughts and feelings about medicines-taking and improving patient confidence and motivation to adhere.4 This approach supports person-centred care by considering the patient as an individual with values and preferences, understanding the patient’s experience and encouraging clinicians to tailor patient care to meet individual needs in the context of their lives.1 A review of evidence for health coaching indicates that it is an effective method for all health professionals to increase patient motivation towards self-management and improve health.5 The World Health Organization (WHO) 6 states that this approach may be the best way to ‘enhance people’s health and ensure the future sustainability of health systems’. Additionally, actively involving patients in their care, shared-decision making and empowering patients lead to better health outcomes.
Communication skills training in pharmacy endorses the application of health coaching to medicines-related consultations.7 This approach aligns with all four principles of the Royal Pharmaceutical Society medicines optimisation agenda,8 particularly supporting principle one, the patient experience. The Medicines Optimisation agenda was introduced in 2013 to promote understanding of the patient experience and promote safe, effective use of medicines as part of everyday pharmacy practice. Health coaching techniques in pharmacy support medicines optimisation in short consultations.9 This fosters building rapport and encourages shared-decision making, which have also been demonstrated in pharmacy consultations.10
Despite recognition of the merits of person-centred approaches to healthcare, it does not appear to be ‘common-place’ among medical consultations.11 The General Pharmaceutical Council recently published professional standards for pharmacy, which are applicable to pharmacists and pharmacy technicians in Great Britain; the first standard is a requirement for person-centred care.12 The Royal Pharmaceutical Society professional standards highlight the need for pharmacists to understand the patient experience as part of patient care.13 While continuing professional development to deliver person-centred consultations is available to pharmacy staff,7 it does not yet appear to be part of routine clinical practice.2
At London North West Healthcare (LNWH) NHS Trust, a large hospital in Greater London, UK, the author (NLB) observed consultations in the pharmacy dispensary and on the wards to be mostly information-based. While education about safe and effective use of medicines is required, optimal use of medicines requires additional understanding of patient beliefs, values and attitudes.14 To address this, a coaching approach was implemented at LNWH Trust in dispensary settings.9
This pilot will evaluate perceptions of pharmacy staff on the impact of a support package within the trust. This package consisted of a 2-day health coaching course and options for individual accompanied ward visits, email support, telephone support and small group workshops. This package aimed to equip staff with the necessary approach, knowledge, skills, tools and techniques to embed a person-centred approach to pharmacy consultations. This paper uses ‘person-centred care’ as this is now preferred terminology.6 However, ‘patient-centred care’ was used for evaluation forms and survey questions as it was more familiar to participants.
Background to the study
The pharmacy department at LWNHT includes more than 200 staff across three sites. Over half the staff, including pharmacists and pharmacy technicians, have patient-facing roles.
Following a successful health coaching course in 2014 for 18 pharmacy staff, a proposal for a further course was submitted to the Education and Training Department at LWNHT. Funding was received and the course delivered in spring 2016. A further three courses were funded by LWNHT charitable fund in autumn 2016.
Between May and November 2016, four 2-day health coaching courses were delivered and attended by 57 LWNH staff (38 pharmacists, 16 pharmacy technicians, 3 doctors). The courses were facilitated by one of the authors (NLB), an LWNH consultant pharmacist and experienced health coaching trainer and practitioner, alongside either a health psychologist or neurosurgeon coach from The Performance Coach (now TPC Leadership). Based on the TPC health coaching manual,15 the courses were adapted to include medicines adherence and support for medicine-related consultations. The courses aimed to provide staff with theory and knowledge of a person-centred approach to healthcare consultations using a coaching approach. This formed the first part of the support package and was followed by practice-based support described in box 1.
Description of support package
Follow-up group workshops to support the application of new skills to pharmacy-specific contexts in the dispensary, clinic and during consultations on the ward.
Group meetings also allowed space for case discussion and peer support as a group as well as providing an opportunity to share experiences, both positive and negative, of using the approach in practice. Ongoing group meetings were delivered every 2–3 weeks following that, lasting 1 hour each meeting. Topics covered included medicines reconciliation, high-risk medicines consultation, discharge medicines consultation and dispensary consultation. Telephone and email support was continually provided over this time.
Accompanied ward visits aimed to provide real-time support and feedback on participant’s ability and confidence to use this training in practice. There were 16 accompanied ward visits lasting about 45 min each. These supported visits were continually offered over the 6-month period.
Email and telephone discussions enabled participants to discuss individual cases.
The practice-based support package was led by one of the authors (NLB) and offered to all staff attending the courses. Staff were encouraged to submit (to NLB) anonymised case examples of situations where they had applied this approach in their consultations.
Aims
To deliver a person-centred consultation support package to pharmacy staff.
Objectives
To evaluate this support package in three ways:
Identify key learning themes from written feedback of a 2-day skill development course.
Administer a survey to pharmacy staff who had received any part of the support package.
Reflect on written ‘real life’ examples, provided by pharmacy staff, who had received any part of the support package.
To identify the elements of the support package which provide benefit to pharmacy staff in developing and maintaining health coaching-based person-centred consultations.
Method
Data collection
This pilot study was undertaken between December 2015 and July 2017.
The evaluation of the aforementioned person-centred support package for pharmacy staff (pharmacists and technicians) working at LWNHT was undertaken in three stages:
Participant evaluation of 2-day health coaching course
Participants were asked to complete an evaluation form at the end of the 2-day course in order to provide qualitative data of their experience of the course. Completion of the section relating to name and job role was optional to allow for anonymity. The form (see online supplementary file 1) was developed by TPC, a training provider who has supported evaluation of health coaching training for a number of NHS organisations. The areas of enquiry explored in this form are listed below.
What the participant hoped to achieve from the course.
Whether the course met the participants expectations.
What the participant considered to be the most important aspect of the course.
What the participant intended to do differently as a result of attending the course.
Whether the participant would recommend the course to others (and if so whom).
Supplementary file 1
Participants were also provided with opportunity to offer any additional comments. Forms were analysed by NLB and IL and anonymised so that individual participants could not be identified. Summary data were collated for points (1), (2) and (5) listed above. Points (3) and (4) were the main focus of evaluation; participant’s views on the most important aspect of the course and what they intended to do differently. These data were subjected to a thematic analysis. Initial coding to identify key themes was undertaken by IL; NLB cross-checked this analysis independently.
Questionnaire of staff perceptions of the support package
A 10-item questionnaire, created from the feedback themes identified in stage one of the analysis, was delivered to all 52 pharmacy staff receiving the support package currently employed within LWNH Trust. The questionnaire was administered using an online tool (Survey Monkey) and was open for responses for 5 weeks, with weekly reminders sent. Questionnaire face validity was established using three participants, who had left the Trust, prior to wider dissemination.
Box 2 indicates main areas of enquiry in the questionnaire including confirmation of respondent job role and perceived level of experience.
Main aspects of enquiry from the participant survey
Which elements of the health coaching support package the respondent had received.
Which aspects of the patient-centred approach (identified as key themes from stage one of our analysis) respondents were now more aware of.
Which aspects of the patient-centred approach (identified as key themes from stage one of our analysis) respondents were now using in their patient consultations.
Which aspects of the support package respondents perceived to be most useful (each aspect was rated on a 5-point Likert scale).
The respondents overall perceived confidence in delivering health coaching-based patient-centred care (rated on a 10-point scale).
The respondents perceived importance of the support package received for delivering patient-centred consultations.
The respondents preferred support package elements for supporting their future patient-centred consultations.
Evaluation of participants’ patient examples to illustrate the use of the health coaching approach in practice
One of the authors (NLB) requested that pharmacy staff, who had received any part of the support package, to email anecdotes of patient examples which demonstrated their use of a coaching approach to deliver person-centred care. These anecdotes were anonymised and analysed by NLB, then cross-checked by IL to identify themes from the anecdotes linking with themes from the course evaluation forms (table 2). Participant comments, reflecting these themes, were extracted to illustrate the participant’s view of the key skills they were using in practice. Anecdotes were submitted by participants who had received a range of support package elements. Quotations are written verbatim.
Results
The following results relate to the 2-day training course and subsequent elements of the support package.
Interpretation of evaluation forms completed after 2-day courses
Overview
Of the 57 LWNH staff completing the 2-day health coaching course, 49 evaluation forms were returned (86%). Comments indicated that participants felt they had learnt new skills and behaviours to support a more person-centred approach which they intended to put into practice. For example:
What was the most important aspect of the course for you? ‘How not to have a set mind when speaking to patients and the importance of listening to patients and showing empathy’. (course 1, participant 1)
What do you intend to do differently in your work as a result of learning from the course? ‘Start practicing skills that I learnt from this course for example, spend time to ask questions and listen to the patient’. (course 3, participant 2)
Participant’s responses around expectations, intended use and recommendation of the course were summarised. Most participants hoped to achieve a better understanding of health coaching and how to use it in practice. The course met the expectations of the participants and attendees stated that they would recommend the course to others.
Thematic analysis of participant responses
Thematic analysis of the participant responses to the question relating to aspects of the course they considered most important generated a coding frame of key person-centred themes as summarised (with participant examples) in table 1. Twelve themes were identified relating to the health coaching models, patient perspective and person-centred communication and consultation skills.
Key person-centred themes identified from thematic analysis of 2-day course feedback forms with participant examples
Questionnaire-based evaluation of staff perceptions towards support package
Participant demographics and level of experience
Twenty-four questionnaires were completed, by 19 pharmacists and 5 pharmacy technicians, giving a response rate of 46%. When asked to rate their level of experience in consulting with patients, 58% rated themselves as ‘experienced’, with five respondents (21%) rating themselves as ‘very experienced’ or ‘somewhat experienced’.
Elements of health coaching support programme received
The majority of participants (88%) had received the 2-day health coaching training course. Seven respondents (30%) reported receiving group meetings and the same number had received email support. Slightly fewer respondents (25%) reported receipt of accompanied ward visits with experienced health coaching staff and just one respondent (4%) had received telephone support.
Awareness and use of person-centred themes (identified from phase one of analysis)
Figure 1 summarises the percentage of respondents who, following receipt of the health coaching support package, reported awareness and use of the person-centred themes. While awareness of all 12 themes increased, this was greatest for ‘understanding the patient’s context’ (understanding the patient’s life and what matters to them); 21 respondents (91%) reported an increased awareness of this theme. Nineteen respondents (83%) reported greater awareness of ‘engaging for meaningful conversations’, ‘building rapport and empathy’, ‘active listening’ and ‘encouraging patients to develop their own solutions’. The reported increase in awareness was lowest for the ‘goal setting’ and ‘shared agenda’ themes; nevertheless, 15 respondents (65%) reported an increased awareness of each of these themes.
Percentage of participants reporting an increase in their awareness and use of health coaching themes
Twenty-one respondents (91%) reported using ‘active listening’ more often in their patient consultations after their health coaching training. However, overall, use of the themes in practice was reported to be lower than awareness. Despite stating that awareness of health coaching models had increased, this was the least used person-centred theme with only three respondents (14%) using models within consultations.
Perceived confidence in using person-centred approach and reported usefulness of support package elements
The average participant rating for confidence in a person-centred approach, using a 0–10 scale, was 6.7 (23 respondents). Usefulness of each element of the support package was rated on a scale of 0–5. Eighteen of the 21 respondents (86%) who had received the 2-day health coaching course rated as 4/5 or 5/5. Nine out of the 10 (90%) respondents who had received accompanied ward visits rated its usefulness as 4/5 or 5/5. There was a wider variation of usefulness for group meetings and email support. Ten of the 12 respondents for group meetings and 11/13 respondents for email support rated at least 3/5. Four of the five respondents who indicated receiving telephone support rated it as 4/5–5/5.
Future support requirements
The final survey question addressed the issue of what respondents would like to receive moving forward to best support them in delivering person-centred consultations (figure 2). Sixty-eight per cent (15/22 respondents) would like accompanied ward visits, followed by group meetings (64%, 14/22), then email support (55% 12/22) and telephone support (32%, 7/22 respondents). Less than a quarter of respondents chose the 2-day health coaching course as ongoing support (22%, 5/22 respondents). One respondent felt strongly that the approach was of no value, stating: ‘It’s really a waste of time. Most of the things are not feasible in real life situations. It’s good for people who don’t have much to do in their job role’.
Results indicating which types of supports respondents would like to continue receiving
Anecdotes illustrating use of themes in practice
Forty anecdotes were received by email, from 19 pharmacists and pharmacy technicians, between December 2015 and July 2017. All the anecdotes described the application of 12 patient-centred themes, in a range of clinical situations, integrated within their everyday consultations. One or more of themes could be identified in each of the forty anecdotes. Table 2 provides examples of this; quotations from six emails sent by five participants illustrate the application of the themes.
Key quotations from anecdotes received from participants of the support programme, highlighting the use and combination of key themes in practice
Discussion
Person-centred care is an essential component of the General Pharmaceutical Council’s professional standards for pharmacy12 and pharmacy has an imperative to deliver this approach in all consultations. While this approach is not yet part of routine clinical practice,2 progress is being made to implement person-centred care in pharmacy.9 Health coaching training has been delivered to a variety of clinical professionals within the NHS;5 however, the authors are not aware of published evidence describing the impact of health coaching training to support person-centred consultations in hospital pharmacy practice. This pilot provides an insight into potential benefits of a coaching approach, as part of a person-centred support package, delivered in a hospital pharmacy setting.
Qualitative analysis of the course evaluation forms indicates that staff found the training useful and intended to put their new skills into practice. Our findings concur with other reports of the usefulness of these techniques in practice.5 Health coaching training has been shown to be beneficial across hospital, community and general practice settings where more than two thirds of clinicians who had undertaken a 2-day training course were using the skills with patients a year later.16 A review of health coaching training in the UK also reported benefits to NHS efficiency including increased patient compliance and reduces medication waste.17 However, while the course increased awareness, the quantitative work in this pilot study suggested that some participants were not applying the knowledge and skills gained. Further work is required to identify reasons for this.
Twelve person-centred themes emerged from the qualitative analysis of course evaluation forms. These included empathy, shared decision making and building rapport which are supported by literature on person-centred care.2 18 These themes reflect good practice guidance for consultations within pharmacy and in wider clinical practice.1 2 6 7
The results of the survey indicated that while respondents valued the course, they felt that practice-based support was more useful than the course for ongoing development to embed person-centred care into consultations. Most of the respondents were aware of the themes and valued the support package.
One respondent, who attended 2-day course but received no further support, felt that the approach was inapplicable in practice and stated that it was too time consuming for busy practitioners. However, this conflicted with an anecdote where the pharmacy staff member described saving time. Using a person-centred approach, this staff member identified that the patient had already read what they needed to know about the medication, obviating the need for explanation. The authors hypothesise another benefit of this approach is for staff to identify more quickly when the patient does not wish to have a detailed consultation and signpost the patient to relevant alternative resources, optimising the patient-focus and reducing consultation time. The use of goal-setting focuses consultations on a shared agenda which reduces the time taken to identify issues and prevents unnecessary diversion in the conversation. The authors suggest that while the course provides knowledge and skill development, the ward visits, email and telephone support as well as group workshops may enhance methods for application in practice.
The anecdotes submitted by participants illustrate the use of the fundamental principles of person-centred care1 are also described in the themes from the course. These include understanding the patient’s perspective, building rapport and encouraging patients to develop their own solutions. These anecdotes indicate that delivery of person-centred care supports participants’ understanding the patient’s needs and their ability respond to these needs. This benefit is particularly important for staff in the challenging environment of today’s NHS.
Limitations
While the study has provided some useful insights into the practical application of a support package for person-centred care in pharmacy, there are limitations to the work. The evaluation forms from the initial 2-day course were completed on the last day of the course. The forms did not require names of respondents; however, they were completed with the facilitators present. This may have created social desirability bias, where respondents have a desire to be viewed favourably, therefore submitting more positive feedback. The authors recognise that the sample sizes were small and response rate for the survey was low, with 24/80 trained staff responding to the survey. This can be explained in part by the fact that a few participants were not pharmacy staff (less than 10%) and some staff had left the trust at the time of the survey. Another limitation is the use of self-reported data for the majority of data collected, rather than objective measures. While the ward visits were observed by one of the authors (NLB), adding some objectivity to behaviour change, these were not undertaken for all participants. Therefore, it was not possible to verify either knowledge gained from most of the support package or change in practice behaviour of the pharmacy staff . This work was not controlled for primacy and recency of training and support offered and therefore participants may have remembered the initial training and the most recent support. The course delivered, while it contained an element of pharmacy focus, was mostly generic to healthcare which may have left some participants who only attended the course unsure how to apply the principles into pharmacy practice. It is noted that one participant who responded with a rating of 1/5 for usefulness of all types of support also responded that they had only received the 2-day training course. Of the practice-based support offered, only 25% of the survey respondents had received the ward visits. While this may reflect the respondents who completed the survey, the challenge of only one trained staff member offering the support visits needs to be addressed in future work. Although the survey was tested for face validity, more rigorous validation may have improved the usefulness of the responses. The anecdotes were submitted voluntarily and therefore may not represent participants either not using the approach or who had negative experiences.
Local recommendations and next steps
The 2 day training course was valued for providing a foundation for the use of a person-centred approach. Given the financial constraints of the service, an in-house, shorter provision of this type of structured training would be beneficial to introduce the concepts into practice for all local pharmacy staff. Continuing funding of an externally provided course is unlikely to be cost effective. Practice-based support is needed to support staff in embedding a person-centred approach into the day-to-day practice of pharmacy. Access to an expert and advice on individual patient cases should be made available to pharmacy staff to support development of their use of this approach. An approach to using person-centred principles in pharmacy practice may be useful where pharmacy staff activities are interpreted in a person-centred way.
A local programme for preregistration pharmacy graduates, employed for 1 year before registration, is being prepared using the learning from this work. These graduates will accompany a pharmacy staff member to visit a patient within their first 6 weeks of employment to observe the use of a person-centred approach in practice. They will receive a short training course within 3 months of starting their role. This will include: experiential learning of person-centred care using a coaching model, application to medicines history, medication review and discharge consultations as well as short conversations in the dispensary. Preregistration pharmacy graduates will attend a group workshop to explore their use of the techniques in practice 1 month later. They will then be asked to submit an anecdote describing their use of this approach in practice. Each graduate will be assigned a staff member who is using person-centred approaches as a mentor. Graduates will be accompanied to the ward by the mentor during their ward-based rotations and given formative feedback on their progress. In order to assess the benefits of this programme, an evaluation form will be designed for use at the start and end of the graduate’s 1-year training programme
Wider recommendations and next steps
Person-centred care is a core component of global health service delivery, as highlighted in both national and international publications. This pilot study included a number of arms within the support package and it is not clear which elements are most valuable. In order to understand the potential benefits of this work, more rigorous investigation of the intervention and its specific components are essential next steps. Identification of the most effective intervention to deliver a person-centred approach is very important given the resource-limited capacity of the NHS. Future work should focus on identifying the most useful elements in embedding a person-centred approach to pharmacy consultations. This could be explored both in a hospital, general practice and community setting in the future. This work can serve as a foundation to explore the benefits of the specific elements of the support package in other hospital pharmacy settings. Future work may have far reaching and strategic implications, influencing policy makers and educators to provide appropriate guidance and support for delivering person-centred care in pharmacy practice.
Conclusion
This was a pilot study, designed to lay the foundation for further work investigating methods of applying a person-centred approach to pharmacy practice. A support package delivered to pharmacy staff at LWNH Trust increased awareness of person-centred themes which emerged from evaluation of a 2-day training course. The use of themes in practice was described within the anecdotes submitted by recipients of the support package. While the 2-day course provided a foundation for use of a person-centred approach, continuing practice-based support is desired by staff to embed learning into day-to-day practice. Future work should focus on the use of objective measures to determine the most effective specific intervention, to deliver support to pharmacy staff, which leads to embedding of a person-centred approach within pharmacy consultations.
Footnotes
EAHP Statement 4: Clinical Pharmacy Services
Contributors NLB: concept for study, execution of study and write-up. IL: execution of study, interpretation of the work and write-up. CE: study design, interpretation of results and write-up.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.