Models of Consultation and Assessment Tools for Prescribing

Consultations are a vital part of assessment and diagnosis during the patients journey, it is imperative for the practitioner to carry this out in a holistic and systematic manner in order to promote wellbeing and therefore creating a safe and evidence based management plan tailored to each patient (Nutall and Rutt-Howard 2015). Neighbour (2005) identifies the effectiveness of consultations, irrespective of which professional registration is held, as a key element each individual should aspire to improve and maintain to a high professional standard. Thomson et al. (2005) concluded that effective consultations give positive outcomes. To the benefit of Advanced Nurse Practitioners (ANP), research has show that consultations completed by such professionals give excellent satisfaction percentages, more time spent consulting/information given, especially regarding self care and management (Horrocks et al. 2002; Kinnersley et al. 2000 and Shum et al. 2000). In the case of primary care and Out of Hours (OOH) appointment times are strict and therefore spending more time consulting has an effect on waiting times.

The ongoing development of Advanced Practice (AP) not only in nursing but also in the role of paramedics, pharmacists and other allied health professionals has allowed for consultations to move away from a skill predominately carried out by and regarded as a medical practitioners role (Stenner 2010; Franklin 2017). The Non Medical Prescriber (NMP) is still developing as a role, which is now fundamental in AP due to increased demands and reduced resources, especially in the role of autonomous practice in primary care and OOH services. Despite this, research had previously been aimed towards General Practitioner (GP) consultation models, something which is formally assessed throughout their training (Evans et al. 2001; Courtenay and Griffiths 2010). The Consultation, Assessment and Improvement Structure for Nurses (CAIIN) is considered a useful tool which can be used for ongoing assessment and development of consultation skills in nursing practice (Hastings and Redsell, 2006). Due to the rapid development of AP and autonomous working, the ANP in primary care would be expected to have a level of consultation equal to a GP. Hastings et al. (2003) have shown that although the CAIIN framework is useful, there are problems faced in it’s use such as the lack of assessors and protected learning time required.

Consultation models are used in healthcare as a framework and guide for the practitioner when in contact with a patient, this can be at any point of contact through the patients journey (Harper and Ajao 2010; Nutall and Rutt-Howard 2015). Models have developed and now have a broader focus on patient-centred care rather than symptoms and physical health. Furthermore, models now involve more patient participation rather than the use of biomedical models aimed at patients with physical symptoms which the medical practitioner would identify and treat, requiring minimal input from the patient and the assumption that the diagnosis can be made by variances of normal (Perry 2011). A study by Little et al. (2001) has shown that compared to a biomedical consultation, patient satisfaction is greater when using a patient-centred approach and their is the preferred method when attending a primary care practitioner.

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Generally, consultation models are divided into two types: normative and descriptive (Nutall and Ruth-Howard 2015). Meaning what does happen and what should happen during a consultation. Byrne and Long (1976) model is an example of a descriptive model. Split into six phases in a logical manner, the aim is to complete each phase. However, if one part of the phase is not completed or fails then the consultation in unlikely to be complete and could lead to the wrong diagnosis or treatment (Courtenay and Griffiths 2010). Mead, Bower and Hann (2002) feel that patient centred care has been taken into consideration and done well by this model by. The creators themselves did point out that a practitioner (in this study, medical) was shown to interrupt a patient within 18 seconds of the beginning of the consultation. Therefore, this model does not appears as patient-centred as the aim and more doctor-centred. For use in OOH this would not be appropriate, having a very short period with the patient and most likely to have been the first time to consult with the patient, there needs to be a well established relationship during this short time and allowing the patient to speak and trust the practitioners diagnosis and plan. Cooper, Forrest and Cramp (2006) show that a patient decides in the first 90 seconds if he/she likes or trust you, therefore it is vital to establish a connection within this time period.

Pendleton et al. (1984) model is mostly known for it’s consultation base on patient’s ideas, concerns and expectations. This certainly is patient-centred rather than doctor-centred. The idea being the practitioner is able to acknowledge the concerns the patient has, allowing for the practitioner and patient to create a solution which both parties accept (Courtenay and Griffiths 2010). However, not all patients wish to be involved in the decision making. Therefore, the practitioner requires to discover the patient’s perspective and level of involvement they would like in the decision making process (Illingworth 2010). Pendleton et al. (1984) model would be appropriate for use in OOH as it is a useful way of building a relationship with the patient, involving them in care and decisions during the short time the practitioner will meet them.

Another comprehensive and widely used model is Calgary-Cambridge Guide which is based on previous older models which Kurtz and Silverman (1996) have used as a body to create a model which values patients ideas and compliments traditional holistic approach used by nurses (Munson and Wilcox 2007). Calgary-Cambridge describes the behaviour and skills required to complete each step. This model uses six steps for structure, which unlike most, includes closing the consultation. Similarly to Pendleton et al. (1984), patient-centred care and joint decision making is incorporated into consultation. Kurtz, Silverman and Draper (2005) highlights communication to show skill and certainty, as without these it is likely to put doubt into the patients confidence in the practitioner.

Consultation models are clearly useful tools for practitioners to use during the patients journey. Not all are useful for OOH, often the situation needs to be judged by the practitioner and use which consultation method they feel fits best. After all, these models are guides for practitioners (Perry 2011). It has been shown however that although they are guides, a practitioners consultation must continue to be patient-centred, confident and with shared decision-making which will lead to overall patient satisfaction and compliance (Nutall and Rutt-Howard 2015).

References

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