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CASE
STUDY 7: The Consultation
Competency 1 – Clinical and pharmaceutical
knowledge. Has up to date clinical and pharmaceutical knowledge relevant to
own area of practice
Competency 2 - Establishing options. Makes a diagnosis and generates
treatment options for the patient. Always follows up treatment.
Competency 3 – Communicating with patients. Establishes a relationship based
on trust and mutual respect. Sees patients as partners in the consultation.
Applies the principles of concordance.
Evidence
Janice, a young mother with a 12 week old
baby, aged 28, attended surgery complaining of a sore throat. She was
already well known to me as I had seen her with her baby, Samuel, when she
brought him for his immunisations. She felt generally unwell, and had done
so for 48 hours. She was able to eat and drink as usual and did not think
she had had a high temperature. However, she felt weary and was finding it
difficult to cope with Samuel, who still did not sleep through the night.
On examination, her throat looked a little red but the tonsils were not
enlarged and there was no exudate. Her temperature was 35.6 (aural) and she
had no lymphadenopathy. I suspected that she had a viral sore throat. I
explained that most sore throats are caused by viruses, not bacteria, and
that antibiotics have no effect against viruses. Janice looked disappointed.
“I was afraid you would say it was a virus. I was hoping that I could just
have some antibiotics to get me over it more quickly. I’m exhausted with
having to get up and see to Samuel”.
I explained that antibiotics would not affect the course of the condition,
which was likely to be short and self-limiting. I was careful to listen to,
and take seriously, Janice’s concerns about her baby and her own ability to
cope. I suggested that she take regular paracetamol 500mg tablets, 2 to be
taken four hourly until the symptoms had resolved, also suggested that she
ask the pharmacist to advise a suitable throat lozenge. We discussed ways in
which she could get some extra rest for herself until she was feeling
better.
However, despite his, Janice remained dissatisfied, and more openly
requested antibiotics. I again reinforced the viral nature of most sore
throats, but also took a throat swab and advised Janice that if her symptoms
had not improved in 48 hours, or if they worsened, she should contact
surgery for the results of her swab. I reassured her that if she did need to
re-consult, I would see her immediately and she would not have to wait for
an appointment. She seemed satisfied with this.
As predicted, the throat swab was negative, and these results were conveyed
to Janice later in the week, by which time she was fully recovered.
Hopefully, this will reinforce to her the self limiting nature of such a
condition, and increase her confidence in managing future episodes herself.
Reflection
On case study of consultation for sore
throat
Reflective model: (Gibbs, 1988.)
The Consultation:
Although various consultation models have been described (Byrne
and Long, 1976; Pendleton, 1984 ;
Stott and Davis, 1979), these are based upon
observation of doctor, not nurse consultations. Little would appear to have
been published on nurse consultations, (Paniagua,
1997a; 1997b) as distinct from nursing
models, which do not readily lend themselves to general practice. In this
discussion, as in my practice, I have chosen to use Roger Neighbour’s model
(Neighbour, 1987) of the consultation. This
incorporates various elements of the other consultation models, whilst being
sufficiently flexible to allow for those qualities of the nurse-patient
relationship which are valued by patients, eg, the ability to form friendly
relationships; the equality of social footing which nurses enjoy with
patients; the perception that nurses have more time; and that they are
better able to explain things in ways the patient can understand (Luker,
1998).
Neighbour (1987) describes the consultation as a
journey from one state of affairs to another, where one set of symptoms,
thoughts and feelings evolve into another. He refers to 5 “Checkpoints” in
this journey, namely:
-
Connecting
-
Summarizing
-
Handing over
-
Safety netting
-
Housekeeping
Connecting
“Connecting” refers to establishing and
maintaining a non- threatening relationship with the patient (Byrne
and Long, 1976) and to achieving some level of rapport. In the scenario
above, Janice was already well known to me as I had seen her for a variety
of things in the past, including routine smear tests and the immunisation of
her baby. I considered that I had a good relationship with her. However,
these previous consultations had been for more traditional nursing duties,
and it might be that as a nurse moving into a new role, one more
traditionally undertaken by a doctor, this relationship could be challenged.
Gibbs (1988) suggests that the practitioner examines
their own feelings with regards to the incident being reflected upon. In
this case, I was aware that I wanted to maintain a good relationship with
the patient. I was also aware that she was consulting me with a condition
more commonly dealt with by a GP, and would be judging me against the
standards she expected of a GP. This may involve the expectation of a
prescription, a possibility I was aware of from the outset, though she did
not initially make this request explicit.
Summarizing
“Summarising” refers to taking a
comprehensive history, not only of the presenting physical complaint, but
one which takes into account the patients ideas, concerns and expectations (Pendleton,
1984). The practitioner needs to elicit from the patient their real
reason for attendance, and ideally reflect this back to them to ensure they
have understood. Although it might seem obvious, failure to do this at this
stage will result in a failed consultation, or one in which the true reason
for attendance is revealed only later on.
It this example above, I elicited only part of Janice’s concerns initially.
It was later in the consultation that she explicitly revealed her desire for
antibiotics. Although this could be seen as confrontational, the outcome of
the consultation is more likely to be satisfactory if this request is openly
acknowledged.
Denig and Bradley (1998) have suggested that the
pressure experienced by GPs to prescribe, at times inappropriately, is
influenced by several factors. These include pressure from patients;
precedent set by other doctors or themselves in a previous consultation; and
pressure from the pharmaceutical industry. However, it has been suggested
that GPs may in fact overestimate patient demand for a prescription, and
then prescribe accordingly to protect the doctor / patient relationship. (Cockburn
and Pitt, 1997; McFarlane et al, 1997;
Stevenson et al, 1999). This perception of patient
expectation has been found to be the strongest indicator of the decision to
prescribe.
As a nurse moving into a new role, it is likely that I would experience the
same pressure. The ability to issue a prescription has previously been the
unique privilege of the doctor, and is linked with perceptions of status,
which could have been tempting in the circumstances (Hall,
1980). Although nurse prescribers cannot prescribe antibiotics for a
sore throat, I could have approached the GP for such a prescription.
However, there is much in the literature to suggest that antibiotic
prescribing in sore throats is unnecessary, given that the majority of
episodes are viral in origin and will resolve without intervention. (Scottish
Intercollegiate Guidelines, 1999). Even where the episode is bacterial
there is no evidence that these are any more serious or prolonged that viral
episode, and antibiotics would appear to shorten the duration of the illness
by only a few hours. Prescribing in this situation merely serves to
medicalise the condition and encourage re-attendance for future episodes.(Little,
et al, 1997). It also has implications for promoting antibiotic
resistance, an increasing problem (DoH, 1998) and one
which has led to the limitations placed on the nurse prescribing of
antibiotics in the new formulary.
Handing over
The practitioner and the patient may well have different objectives for the
consultation; the negotiation and handing over the consultation may involve
some degree of compromise on both sides. A successful hand over will involve
some acknowledgement of the patient’s agenda.
In the example above, Janice still requested antibiotics despite seeming to
accept that her condition was probably caused by a virus, possibly because
of a lack of understanding of the difference between viral and bacterial
infections. Whilst patients have complained about doctors’ lack of
explanation as to why antibiotics are not required, some doctors have
maintained that patients do not understand such explanations (Butler
et al, 1998). This is where the ability of the practitioner to discuss
the condition with the patient is important. Nurses have been found to be
particularly good at explaining things in non-medical language (Luker,
1998). Establishing the treatment options, in discussion with the
patient, is an important part of any consultation if a successful outcome
for both parties is to be achieved. The nurse patient relationship is seen
as being a relationship of equals, unlike the doctor/patient relationship
where many still see the doctor as being in a position of power,
particularly in the ability to grant or withhold a prescription (Denig
and Bradley, 1998). Interestingly, the limited prescribing rights so far
granted to District Nurses and Health Visitors do not seem to have altered
this relationship (Luker, 1998). It remains to be seen
whether or not expanded prescribing will.
As discussed above, nurses are unable to prescribe antibiotics for sore
throats. Other prescribing options might include simple analgesia (aspirin
or paracetamol); advice to consult with a pharmacist over proprietory throat
lozenges; or the prescription-only lozenge, fluriprofen, which is available
to nurse prescribers. Although this has been shown to be superior to placebo
(Watson et al, 2000) it has not been directly compared
with simple analgesia and, as a prescription only medicine, its use might
encourage re-attendance with future episodes. As paracetamol is recommended
as the drug of choice in acute sore throat (SIGN 1999),
it would be difficult to justify use of fluriprofen and it is perhaps rather
surprising that is has been included in the formulary.
In this case, however, Janice required further reassurance. Throat swabs
have not been found to be a good indicator of infection, being neither
sensitive nor specific for bacterial infection, and their use is not
routinely recommended. (SIGN 1999) However, I felt that
they might provide her with the necessary reassurance. In retrospect, other
methods of reassurance could have been used at this stage. Some commentators
advocate the use of patient information leaflets on common conditions such
as sore throats, and these have been found to be effective in reducing
re-consultation rates and increasing patient satisfaction (Mcfarlane
et al, 1997). The use of a delayed prescription, which the patient
collects if their symptoms have not improved in 48 hours has also been found
to be effective (Little et al, 1997). Also of value in
consultations for sore throats is the Dobbs scale (Dobbs,
1996), which assigns a value to symptoms, enabling the practitioner to
calculate the likelihood of the infection being bacterial.
Safety-netting
Safety netting refers to providing the
patient with information on what to expect and what to do if they do not
improve. General practice has been described as the art of managing the
uncertain (Neighbour 1987) and provision needs to
be made within the consultation for this. Patients will feel more secure if
they have a clear outline of what to expect from their treatment and under
what circumstances to re-consult.
In this situation, much of the safety netting had been carried out during
the negotiation phase described above, and Janice was happy to know that she
would be seen again if her symptoms had not resolved. It is good practice to
record such advice in the medical record (UKCC, 1993)
House-keeping
Neighbour acknowledges the need for the practitioner to take care of their
own feelings, particularly those brought about by a consultation. If not,
the emotions, possibly negative, engendered by one consultation, may spill
over into the next. Acknowledging these concerns may be all that is
required.
Another aspect of good housekeeping is reflecting on a consultation and
possibly considering how to handle things differently in the future. This
corresponds to Gibbs’ (1988) final phase of the
reflective cycle, the action plan.
For myself, this consultation and the reflection upon it which has come
about as a result of this paper, has resulted in several changes which I
plan to incorporate into future practice. These include discussing with the
GPs our practice management of sore throats, with the suggestion that we
incorporate the Dobbs scale into clinical practice and produce a patient
information leaflet on sore throat. This would hopefully reduce the number
of antibiotic prescriptions dispensed, as well as provide a more united
approach within the practice.
References
Byrne, P.S. and Long, B.E.L. (1976). Doctors talking to
patients. London, HMSO.
Butler, C. Rollnick, S. Pill, R et al. (1998).
Understanding the culture of prescribing; qualitative study of general
practitioners’ and patients’ perceptions of antibiotics for sore throats.
British Medical Journal. 317; 637-642.
Cockburn, J. and Pit, S. (1997). Prescribing
behaviour in clinical practice; patients’ expectations and doctors’
perceptions of patients’ expectations. British Medical Journal 315; 520-523.
DoH, (1998). The path of least resistance; A report by the
standing medical advisory sub-group on antimicrobial resistance. DoH,
London.
Denig, P. and Bradley, C. (1998). How doctors chose
drugs. In Hobbs, R and Bradley, C. (Eds). Prescribing in primary care.
Oxford University Press, Oxford.
Dobbs, F. (1996). A scoring system for predicting group
A streptococcal throat infection. British Journal of General Practice.
46(409): 461-4
Gibbs, G. (1988). Learning by doing. A guide to teaching
and learning methods. Further education unit, Oxford Poytechnic, Oxford.
Hall, D. (1980). Prescribing as a social exchange. In:
Mapes, R. (Ed). Prescribing practice and drug usage. Croom Helm, London.
Little, P. Gould, C. Williamson, I. et al. (1997).
Reattendance and complications in a randomised treial of prescribing
strategies for sore throat; the medicalising effect of prescribing
antibiotics. British Medical Journal 315; 350-352.
Luker, K. Austin, L Hogg, C et al. (1998). Nurse-patient
relationships: the context of nurse prescribing. Journal of Advanced
Nursing. 28(2), 235-242.
Mcfarlane, J.T. Holmes, W.F and McFarlane, R.M.
(1997). Reducing reconsultations for acute lower respiratory tract illness
with an information leaflet; a randomised controlled study of patients in
primary care. British Journal of General Practice 47, 719-722.
Neighbour, R. (1987). The Inner Consultation. MTP
press, Lancaster.
Paiguana, H. (1997a) Consultations: the process.
Practice nursing 8(7), 18-20
Paiguana, H. (1997b) Consultations: in practice.
Practice nursing 8(8), 20-22
Pendleton, D et al. (1984). The consultation: an
approach to learning and teaching. Oxford: Oxford University press.
SIGN – Scottish Intercollegiate Guidelines Network
(1999). Management of sore throat and indications for tonsillectomy. SIGN
publication no. 34 (give web address).
Stevenson, F. Greenfield, S.M., Jones, M. Nayak, A.
and Bradley, C. (1999). GPs perceptions of patient influence on prescribing.
Family Practice. 16(3), 255-261.
Stott, N.C.H. and Davis, R.H. (1979). The exceptional
potential in each primary care consultation. Journal of the Royal College of
General Practitioners. 29, 201-5.
Watson, N. Nimmo, WS. Christian, J et al. (2000).
Relief of sore throat with the anti-inflammatory lozenge flurbiprofen
8.75mg; a randomised, double-blind, placebo-controlled study of efficacy and
safety. International Journal of Clinical Practice 54(8); 490-6.
UKCC, (1983). Standards for Records and Record Keeping.
UKCC, London.
Appendix
Performance by Jo Cannon: "This is your stage."
Sit down, compose your face
Lines rehearsed in the waiting room
Family can’t hear you
“Leave mum, she has a headache”
Headache
Muscle ache
Spirit ache
Tired all the time
Tired much of the time
Too much time
Let me perform for you
Let me touch you
Measure your blood pressure
Measure your worth
You are worth my time
When you get home they’ll ask what I did
Rehearse the lines
This is your chance
This is your stage
(Cannon, J. In: Bolton, G. Reflective Practice. Writing and Professional
development. Paul Chapman Publishing, London. 2001.)
I have included as an appendix this poem by Jo Cannon, GP. I feel it
reflects wonderfully the nurturing and caring aspects of the consultation
which can be neglected if too analytical an approach is adopted. As young
mother, Janice required mothering herself when she was feeling unwell. As
nurses, we will do well not to forget these aspects of care, which may well
be more valuable than any medication we are, or are not, able to prescribe.
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