Communications Training in Pharmacy Education, 1995-2010

INTRODUCTION

Effective communication plays an essential role in the provision of health services. As early as the 1970s, studies began emerging in the United States examining pharmacist-patient interaction and communication and its effect on patient compliance and overall health outcomes. In 1997, the World Health Organization (WHO) report entitled Preparing the Pharmacist of the Future: Curricular Development was released detailing the 7 essential roles of the pharmacist, one of which was “communicator.”¹ Studies examining specific interactions between pharmacy students, practicing pharmacists, and patients often find instances of communication breakdown attributable to poor communication skills.² Pharmacy communication skills can be improved by education and training.^3,4 In 1997 a report was issued by the International Pharmaceutical Federation and endorsed by the World Health Organization,⁵ containing international good pharmacy practice standards, and stating that “at all stages of pharmaceutical education the development and improvement of communication skills should be given due emphasis.”

The importance of good communication skills in pharmacy practice and the importance of effective training in these skills is also reflected in general guidelines for pharmacy. For example, in the United States the Accreditation Council for Pharmacy Education (ACPE)⁶ standards and guidelines state that, to be capable of fulfilling their responsibilities, pharmacy graduates must be able to communicate and collaborate with patients; care givers; physicians, nurses, and other health care providers; policymakers; members of the community; and administrative and support personnel to engender a team approach to patient care.⁶ In Europe the standards set by the European Union are low regarding communication skills. According to a 2005 European Council directive, pharmacy graduates should have “adequate knowledge to evaluate scientific data concerning medicines in order to be able to supply appropriate information on the basis of this knowledge” and must be able to give “provision of information and advice on medicinal products.”⁷ Australia incorporates even more training in social pharmacy fields than American,⁸ and communication skills are a mandatory competence for licensing.⁹

Different countries and educational systems contain different definitions of what “communication skills” entail, different communication skills development challenges, different professional careers for pharmacists, and hence, different guidelines about what should be integrated into pharmacy education. However, counseling patients seems to be a vital part in all pharmacy education programs. For example, in the United States, required elements for pharmacy communication courses are well defined and explicit in ACPE standards. ⁶ These elements include training in effective verbal and written interpersonal communication; health literacy; communicating with diverse patients, families, pharmacists, and other health professionals in a variety of settings, both individually and as a member of a team; interviewing techniques; active listening and empathy; assertiveness and problem-solving techniques; cultural influences on communication of health information; group presentation skills; strategies for handling difficult situations; documentation of pharmacist recommendations and consultations; and principles of behavior modification.⁶ Within the newly reformed Finnish bachelor of pharmacy degree program, specific components of the communications curriculum include patient education and counseling, interaction and communication, general communication skills, foreign language, and second national language.¹⁰ In Sweden, the education in communication skills for pharmacists is under discussion as a need for improvement has been identified at several universities.

There is a great deal of interest in further incorporating communication skills education into pharmacy curricula. Thus, it is important to explore published examples on how to devise, structure, and incorporate activities that will develop the desired communication skills in students. The purpose of this review was to identify published, peer-reviewed articles on communication training in pharmacy education and describe the structured learning activities within them and how these learning activities were assessed.

LITERATURE REVIEW

Searches were performed at the end of 2010 in the databases PubMed, EMBASE, ERIC, International Pharmaceutical Abstracts, and PsychINFO, for articles published after 1995 that contained the search words “pharmacy” and “communication” and “student” or “undergraduate.” Additionally a broad search on the Internet was done to identify relevant papers not indexed in the search engines. The papers in the International Journal of Pharmacy Education (2003-2010) and Currents in Pharmacy Teaching & Learning (2009-2010) were searched manually for relevant articles. The literature search found 433 articles.

The titles and abstracts of the articles were assessed to determine their relevance to the objectives for this review. This process reduced the number of studies to 95. A second round of assessment was performed in which the aim, methods, and results sections were examined. A final 61 studies were identified as matching inclusion criteria.^11-71 To be considered for inclusion, articles were required to describe either a method of assessment or intervention focusing on communication skills that was tested and implemented within an undergraduate pharmacy program. The studies chosen did not have to focus solely on communications. Studies were excluded if there was no mention of “communication” in the body of the article, if the article was not in English, or if the article was descriptive only, lacking active assessment or intervention to improve communication skills.

Articles were grouped and categorized based on which communication skill(s) the study was aimed at improving. Each of these categories was then further divided into common groupings. Once data were categorized and described in terms of communication skills, the studies were examined for commonalities of methodology, specifically the type of intervention used to teach individual skills. Assessment methods of communication were considered separately. Some studies were included in multiple categories.

FINDINGS FROM THE LITERATURE REVIEW

Of the 61 articles analyzed, 46 articles were published in pharmacy educational journals with 44 found in the American Journal of Pharmaceutical Education. Thirteen articles were published in other pharmacy or medicine-related papers and the remaining 2 were found in educational science-related journals. The literature search was intended to capture articles from around the world, but the results were dominated by American studies, which accounted for more than half of the articles (39 of 61). Five studies were from the United Kingdom, 1 from Ireland, 4 from Australia, 2 from Canada, and 1 from the West Indies. There were 2 studies from Thailand and 3 from Malaysia. Finally, 1 article originated from the United Arab Emirates, 2 from Finland, and 1 from Sweden. Areas of the world that are not represented by the data include South America and Africa.

DISCUSSION

This review is limited in that it only included published studies on activities for improving communication skills. Other activities for improving communication skills probably take place in pharmacy education but have not yet been studied and/or documented in the literature. Also, only those that were published in English were included. There is undoubtedly much done within the area of communication skills education that never gets published or is presented only in national forums. It is important to describe, assess, and publish course development. Sharing ideas and development helps move forward an area of common interest in pharmacy education.

The data collected from the studies identified in this review show a high degree of concurrence in both the specific communication skills targeted, as well as in the types of learning activities implemented. Although each learning activity category contains some amount of variation in the details resulting from innovative alterations to the “standard,” common frameworks are still readily apparent. Some learning activities and communication skills developed are more frequently used than others, but the same categories keep reappearing. Whether this reflects reality is difficult to say. On one hand, learning activities such as those involving simulated patients, seem to be widespread, at least in the United States, and hence frequently seen in the literature reviewed. On the other hand, teachers/researchers may tend to write about newly developed activities in research reports and hence articles. Pharmacy practice experience, for example, is an activity that is mandatory in most pharmacy education curricula and always contains communication skills training. Thus, if the number of published articles would reflect the communication skills training activities in pharmacy educations, it would probably include more articles dealing with this type of learning activity. Because of their complexity, pharmacy practice experiences are more difficult to assess; thus, fewer structured outcome measurements may take place and fewer papers are published.

The distribution of data shows that simulated and standardized patient interactions are the most common activity in the peer-reviewed literature used to reinforce pharmacy communication skills. This method is used both as a teaching tool and as a standalone assessment technique. A review of pharmacy education found that the majority of studies focused on the use of simulated and standardized patient encounters as an assessment technique rather than an educational tool.⁴ The activity was poorly defined in most studies and the specific competencies and skills being investigated often were poorly described. However, the simulated patient design seems to be flexible, can be adapted based on the amount and type of resources available, can be incorporated into the laboratory components of various courses, and reflects real practice scenarios. Despite the critique, the review of simulated and standardized patient encounters suggested this method of learning is underutilized in pharmacy communication education.

The second most common category for studies in this review was pharmacy practice experience courses, which targeted many different aspects of communication.^72,73 Completion of pharmacy practice experiences is a requirement for licensing in many countries, as it helps forge the link between theoretical knowledge and clinical practice through effective communication. The value of this intervention is decreased if the student is sent into the practice experience with no former communication skills training.^67,72 Although practice experiences in a pharmacy setting seem to be accepted as an effective way to improve interpersonal communication skills as well as some forms of written communication skills, in general they are difficult to arrange and draining to available resources such as educated preceptors, and there is a lack of appropriate assessment methods.^72,74 Portfolios are a method used to assess students’ skill and knowledge development in pharmacy practice experiences, often including communication skills assessments.^6,72,75

A common theme of the data described in this review is that most interventions are designed to target multiple communication skills. Interpersonal communications skills are often targeted alongside either clinical writing skills^12,16,30,71 or presentation skills.^13,23,35 Reflective writing exercises can be used as a follow-up component for most other interventions,^18,28 to promote student self-assessment⁵¹ and reinforce general writing skills. As an example, simulated or standardized patient interactions seem to be a common tool for teaching communication skills. Few simulated or standardized patient interactions are acted out in isolation; most are described as secondary components to communication courses or seminars, and are used as a practical way to reinforce concepts taught in a course. Also, the value of simulated or standardized patient interactions is not isolated to interpersonal communication skills. In the literature, it is a common theme in simulated or standardized patient interactions to include an interdisciplinary component to improve interprofessional communication skills,^13,14,71 or to strengthen clinical writing skills by recording patient medical histories or SOAP notes based on the simulated or standardized patient interaction.^12,16,24,71

Many of the articles describe interventions that are “fragments” (innovative or new additions to courses and curricula that already exist) and lack a description of the course in its entirety. Therefore, the communication exercise often seems to be assessed out of context. For example, one study talked about the use of “blogging” reflective exercises to reinforce pharmacy communication skills.⁴⁶ However, this activity is part of a larger communications course, and students are asked to reflect on course concepts in their blog, without any clear description of the scope of material taught in the course. It is therefore impossible to determine if the blogging exercise itself was responsible for students’ improved skills, or if instead communication skills improvement was the result of reflecting on communications concepts taught in the course. If such fragmented learning activities are integrated into a course, and especially without knowledge about the content and structure associated with them, the activity should be well delineated, and its impact should be assessed and validated without interference from concurrent, undefined course activities.

“Fragmented” activities may, however, be effectively used and integrated into the curriculum independent of associated (and ill-defined) courses through “scaffolding” techniques. Scaffolding is an instructional procedure used to aid a learner in working through problems or tasks to attain a higher level of skill.¹⁶ The idea behind this process is to ensure that activities are not acted out in isolation but are linked to later activities in such a way that student skills are advanced and that communications training can progressively increase in scope and difficulty. This is also in line with earlier studies of university educators’ views of successful communication skills development.⁷⁴ There is likewise a need for more knowledge about where in the students’ development (ie, the curriculum) different learning activities are best used, in what order, and in what combinations.

A further concern arising from the data relates to the form of assessment used to demonstrate the value of the educational intervention. Many studies used only subjective measures of assessment (student self-assessments, course evaluation questionnaires, and satisfaction measurements), lowering confidence in the validity of the results. It is difficult for subjective measurements to accurately prove that a skill was acquired or that student skills progressed. Communication skills are a difficult area to accurately judge and objective assessment of student abilities are largely dependent on fair and skilled evaluators. Hence, the question of to what extent objective assessment techniques can provide an accurate measure of a student’s communication skills must be raised. Using highly skilled evaluators is often difficult as the assessment process is time consuming and labor intensive, and qualified individuals are difficult to find. Hence, further research is needed to develop and evaluate new or more accurate assessment methods.

There is a lack of studies comparing different learning activities as to outcomes and/or effectiveness in relation to resources needed. Most of the learning activities identified are carried out by students individually and therefore require many work hours from teachers, supervisors, etc, to instruct, supervise, provide feedback on, evaluate, grade students’ activities, etc. Further research should aim at advancing knowledge in this area. This might call for larger studies than most of those identified here, preferably conducted in cooperation between different universities and different countries.

SUMMARY

Learning activities intended to improve communications skills are described in the literature. However, many of the activities described are fragments of larger communication courses and curriculum, and typically involve innovative interventions that have not previously been analyzed for educational value. Additionally, many studies are assessed by subjective methods. For these reasons, the effectiveness of the education interventions described in this review is uncertain.

Communication interventions should not be carried out in isolation, without progression of the complexity of the activity and the level of competency expected of the student. There is a need for further studies that include more than one, or a few, learning activities at a time, eg, comparing learning methods or studying communication skills development throughout the pharmacy curriculum.