Consultation and Its Models Online Tutoring

Abstract

Consultation is the process of communication/interaction between the clinician and the patient in clinical setting. The right consultation process could directly impact the final primary care given to patients as the pivotal contribution of the patient’s history obtained through consultation stands at 82%. All the models (including Weiners, Maslow’s, Balint’s, Helman’s, Pendleton’s etc.) look at the consultation in different manner. In order to find the best suiting consultation style, it is important to understand each consultation process at an individual level. All the consultation processes aim at either diagnosing the patient’s medical issues or discovering the actual needs of the patients. With different aims in mind, several consultation models have already been devised with a mutual aim of obtaining a medical history from the patients. The assignment reviewed the present consultation models including Byrne-Long, Neighbour, Pendleton, Calgary-Cambridge, Stott-Davis and Bernes. Upon evaluation, the most suitable consultation model that was found to be easily applied to nurse’s practitioners was of Calgary-Cambridge developed by Kurtz, Silverman and Draper in 1996. This is because it is easy-to-use and provides nurses with traditional holistic assessment approach in which nurses can gather information, assess verbal & non-verbal patient cues and involve patient while developing the management plan. However, in devising the new model, the role of communication skills of nurses was kept in mind. This report outlined the model of consultation based on eight steps that was constructed as purely patient-centered. In the end, recommendations for improving the consultation process were also outlined.

Introduction

Consultation is the process of communication/interaction between the clinician and the patient in clinical setting (Pawlikowska, et al., 2007). The right consultation process could directly impact the final primary care given to patients as the pivotal contribution of the patient’s history obtained through consultation stands at 82% (Mcwhinney, 1972). Consulting with patients is considered to be the domain of medical practitioners and an appropriate consultation model helps in providing structure and right guidance to the overall process of interaction between clinician and the patient (Baird, 2006). In order to provide the best care to the patients, the nurses need to understand the common models of the consultation that has been proposed by various practitioners over time as well as they should devise their future consultation behavior by using and reflecting on these models.

 All the models (including Weiners, Maslow’s, Balint’s, Helman’s, Pendleton’s etc.) look at the consultation in different manner. In order to find the best suiting consultation style, it is important to understand each consultation process at an individual level (Lusignan et al., 2003). Many of the authors have devised consultation models differently ranging from those being doctor-centered to the ones where patient and doctor share equal responsibility throughout the consultation process (Lusignan et al., 2003). In order to devise a consultation model that best suits’ one’s consultation style, this assignment has been structured. This report will discuss various models of consultation considering both approaches of biomedical and psychosocial and reflect on their evolution over time. Ultimately, the role of communication skills of clinicians/nurses will also be discussed along. Finally, a best-suited nursing consultation model will be developed using the already constructed consultation models.

Defining Consultation

Consultation is an intimate and private communication process between the patients and the clinicians (Kaufman, 2008). It aids the clinicians in assessing the health problems and patients’ medical history in the clinical settings. As nurses expand the practice boundaries, the consultation and history taking skills of them are emerging out to be extremely important. Consultation process builds a therapeutic relationship between the practitioners and the patients in which the symptoms, problems and feelings of the patients are diagnosed (Walsh et al., 2006). All the consultation processes aim at either diagnosing the patient’s medical issues or discovering the actual needs of the patients. With different aims in mind, several consultation models have already been devised with a mutual aim of obtaining a medical history from the patients (Baird, 2004). Some of the concepts of nurses undertaking the consultation are relatively new; however, various consultation models and communication skills are famous in the medical literature. Some of the consultation models are discussed as below.

Consultation Models

Byrne-Long’s Model of Consultation

Historically, the consultation process is discussed from the general practitioner’s perspective. One of the best earliest models is of Byrne and Long that was formulated by listening to recordings of 2000 different consultations between the doctors and the patients (Lakasing, 2007). The model outlined six-stages of consultation i.e. doctor establishes a relationship with patient, then discovers/re-discovers the patients’ attendance reasons, conducts verbal/physical or both examination, doctor (in isolation or with patient) consider the medical condition, doctor details out the further treatment and finally the doctor terminates the consultation process. However, rarely enough, the consultation unfolds in this manner (Pawlikowska, et al., 2007).

Neighbor’s Model of Consultation

Later models like Roger Neighbor’s (introduced in 1987) tend to focus on checkpoints during interaction with the patients. According to Neighbour, the consultation process is patient-centered. Neighbor provided a consultation model based on five steps i.e. connecting, summarizing, handover, safety-netting and house-keeping. This consultation model was developed to enable the practitioners in carrying with patients more skillfully, intuitively and efficiently (Beaumont, 2012). Through this consultation model, the doctors tend to establish a rapport with patients in order to devise a summary of patient’s medical needs so that a medical management plan could be constructed. Contingency plan is also formulated in this model where the doctor plans for the things that could go wrong (Pawlikowska, et al., 2007). Using the house-keeping concept, the doctors applying this consultation model acknowledge and deal with emotions arising from previous consultation.

Pendleton’s Model of Consultation

Another consultation model is evident in medical research that was devised by Pendleton, Schofield, Havelock and Tate in 1984. Under this model, the consultation process takes place in seven steps where the patient and doctor together achieve the goal of medical needs’ assessment (Harper & Ajao, 2010). The Pendleton Model allows the medical practitioners to first establish the patient’s reason for attending the medical facility then move on to assessing relevant health issues and risk factors associated with the patient. At the later stages, the clinician tends to choose the appropriate management plan suitable for the patient after understanding the problems of the client. It is important to include the patient in the management plan so that responsibility of each problem identified can be shared mutually (Pawlikowska, et al., 2007). This model points out that the doctor must use time and resources efficiently so that a lasting relationship with patient could be based on trust and mutual investment in the “pot of experience” (Denness, 2013). As compared to Byrne-Long model, the Pendleton’s model seems to be more patient centered as it encourages the involvement of patient while designing a medical plan (Pawlikowska, et al., 2007).

In models like Pendleton, enough time and resources are required to explore multiple problems in detail that too in standard 10-minute consultation that we have today. Keeping in view the requirement of time, it becomes a little difficult and overwhelming to apply this model with accuracy as patient’s too have limited time to spend for “talking” with patient in order to discuss health promotion issues that they believe to be irrelevant (Beaumont, 2012). In this regards, another prevalent consultation model in the medical literature is that developed by Silverman, Kurtz and Draper in 1998 named as Calgary-Cambridge model.

Calgary-Cambridge Model of Consultation

According to Silverman et al. (1998), the Calgary-Cambridge model incorporates physical, social and psychosocial factors in the consultation process. This model is also very patient-centered as well as practical. It is based on five stages of consultation that runs through the initiation of session, gathering of information, physical examination of medical needs, explanation and planning of medical needs and closing of session. Throughout the consultation process that is based on Calgary-Cambridge model, the patient and doctor build the relationship together where the doctor can explore the medical problems of the patient by using open and closed questions (Denness, 2013). The doctor also uses patients’ ideas and concerns while devising a medical plan on which both the parties must agree upon. Despite of its practicality, the model is sometimes hard to be incorporated into every consultation style today (Denness, 2013). Due to being overly patient-centered, some of the patients might prefer a paternalistic approach where doctors could take all the decisions instead of relying on the patients’ ideas.

Communication Role and Shannon Model of Consultation

Communication plays an important role in the overall consultation process. In this regards, the Shannon Model (1948) that was further improved by Wiener, holds a specific important place in the medical consultation (Brady, et al., 2017). It is still considered to be one of the basic models of communication that can be easily applied in the clinical settings for improving the skills of nurses in consultation process. The Shannon-Weaver model shows the way in which information is transmitted from sender as a signal through a channel to the receiver (Brady, et al., 2017). The sender in this case would be the patient while the receiver could be the nurse. The use of this model in the clinical setting would demonstrate the clear pathway of communication from the nurse to a patient or from a physician to the nurse and vice versa. Despite of being one of the fundamental models, the interaction component seems to be missing the entire process.

Stott-Davis Model of Consultation

Another consultation model by Stott and Davis (1979) focused on building a theoretical framework that could be used and explored in routine surgery consultations based on four steps i.e. management of presenting problems, modification of help-seeking behavior, management of continuing problems and opportunistic health promotion. According to Stott and Davis, most of the doctors/nurses tend to miss on the second and third stage that should be considered at most for providing a comprehensive care to the patients (Baird, 2006).

Berne’s Model of Consultation

The consultation model by Berne looked at the application of psychoanalytical principles during consultation (Witko et al., 2005). Berne as an attempt to understand the interaction between practitioners and patients, developed a theory of social interchange called transactional analysis. According to this model, the consultation could take place in form of games where the participants tend to obtain as much satisfaction and advantage by carrying out the transactions with others. The transaction in this model can be considered to be consultation through which the patient tends to achieve benefits (Moulton, 2017). According to Berne (1964), the patients and nurses could be one of the three ego states i.e. child ego, adult ego or parent ego at any given point in the consultation (Moulton, 2017). Being familiar with the transactional analysis and behavioral patterns of the patient can be very useful for nurses during the consultation process. It can aid the practitioners in identifying why some patients keep coming back without being recovered and why some patients show unhelpful behavior. Based on the analysis and increased awareness, the nurses can create a more powerful yet flexible consultation framework while empowering the patients (Lakasing, 2007).

Newly Devised Consultation Model

Based on the literature above, the most suitable consultation model that can be applied to nurse’s practitioners is of Calgary-Cambridge developed by Kurtz, Silverman and Draper in 1996 (Burt, et al., 2014). This is because it is easy-to-use and provides nurses with traditional holistic assessment approach in which nurses can gather information, assess verbal & non-verbal patient cues and involve patient while developing the management plan. As communication plays a vital role in the overall consultation process, the proposed model will utilize the nurses’ skills in identifying the patient needs and observing verbal and non-verbal cues effectively. According to Maguire and Pitceathly (2002), the nurses with good consultation and communication skills tend to identify patient’s problems more precisely. When the nurses exhibit good communication skills, the patients are more satisfied and leave the consultation with a better analysis and judgment of their medical condition (Wilson, 2008). That means, they are more likely to carry on with the treatment due to which the anxiety is lessoned as well.

According to Baird (2004), the consultation skills are important for the nurses as it can aid the nurses in applying various strategies to support the patient in telling their medical history. Baird (2004) also pointed out that the nurses can use various communication skills during consultation with patients including open and closed questioning, observing body language, making eye contacts and actively listening to patients’ concerns. Research has shown that many patients find it difficult for voicing out their medical concerns, hence failure to communicate effectively might contribute to ineffective medical diagnosis and inappropriate prescriptions given by nurses (Baird, 2006).

Based on the analysis above, the new consultation model will be constructed as purely patient-centered. The reason for constructing a patient centered model is because it would help the patients in accepting appropriate level of responsibility for each problem during consultation. Moreover, Moulton (2007) highlighted that patients’ actually prefer consultations that are more patient-centered. In order to carry on a patient-centered approach, the nurses must ensure that the reasons for patient’s attendance are identified clearly and all aspects of the patient’s problems are scanned efficiently. The following consultation model is proposed for creating a more patient-centered experience where the patients would feel empowered and included (Shol et al., 2012). The proposed consultation model will be based on eight stages (see figure 1 below) during which the nurses will examine the body language, anxiety levels, eye contact and major concerns of patients through open ended and closed ended questions.

Conclusion

Each consultation is unique as it provides a privilege glimpse into the life of patients. Through creating a mutual consultation process, the nurses can get an opportunity to promote healthy living by providing the treatment for conditions that exists. With effective communication, the patients and doctors can achieve effective outcomes mutually. Keeping in view the importance of patient involvement and communication skills, this report proposed a consultation model that can be utilized by the nurses. The model proposed in this report has been developed for the nurses to deliver a patient-centered approach while practicing in primary care clinics. The model is developed by keeping in view several models that were previously developed for providing a patient-centered consultation. By analyzing the models like Calgary-Cambridge and Byrne-Long, it was analyzed that the patient-centered approach must be adopted by the nurses. Hence, these models were used as basis for the creation of proposed consultation model in previous section. The role of communication was also kept in mind while creating the model as it plays a vital role in the clinical practice. Nonetheless, it was also evident that the during the consultation process, the practitioners’ usually fail to pick-up the patient cues hence the consultation model that pays close attention to cues was important to be developed. In short, a compressed patient-centered consultation model with focus on patient cues and patient involvement will help nurses in providing better healthcare services to the patients.

Recommendation

Consultation models can provide a structure for the nurses for making most of the limited time available in everyday practice (Baird, 2006). An unstructured consultation model that runs out of time can become a major reason for failing to give patients the care they need. Hence, based on the above analysis and proposed patient-centered consultation model, following recommendations are made:

• The nurses must provide the patients and their families with understandable information on disease/illness prognosis, treatment benefits and harms, psychosocial support, palliative care and the total costs of the needed care(Maguire & Pitceathly, 2002).
• The nurses must communicate and personalize the patients’ history for making key decisions regarding medical prescriptions and/or recommending to concerned healthcare practitioners for further assistance(Maguire & Pitceathly, 2002).
• The nurses should also personalize the patients’ history by keeping in account the health literacy, emotional needs, informational concerns and patients’ language(McWhinney, 1972).
• The nurses must create an agreed-upon care plan that can outline the goals of needed care. The plan should reflect the patients’ needs, values and preferences clearly (Witko et al., 2005).
• Nurses should also engage the patients by asking them about their medication regimen and to know what the medications were taken for.
• The nurses should also offer recommendations, check and clarify the patients’ understanding and move/defer the decision and arrange the follow-up if needed.
• The nurses should also be competent and trained enough for understanding and responding to patient cues (both verbal and non-verbal)(Denness, 2013). For example, a verbal cue might be “patient’s father was diabetic” and a non-verbal cues can be facial expressions, tone of speech, changes in volume and body language. Patient cues are considered to be widely ignored and these must be taken into consideration during overall consultation process as it can play a vital role in making a diagnosis (especially for identifying psychological diseases) (Lusignan et al., 2003).

References

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