BY MELANIE RANTUCCI
More and more I am seeing patients in my community pharmacy who are critically ill or even dying, who previously would have been in hospital. As I am not used to dealing with critically ill patients, I find it very hard to talk to them. Their prescriptions are usually delivered or picked up by their caregivers, so I only contact them by telephone. I try to avoid this by just passing on information through the caregivers or including written information with the delivery. If they do call me for information, I act as if they were just any patient, and try to be casual. This is not very comfortable–it’s as if there was a barrier there. I can’t help but think I should be saying something to clear the air, but I don’t know what to say. How can I deal with this?
When pharmacists deal with patients we are aware that they have feelings about their illness and medication use, but we often would prefer to ignore them. However, if we wish to provide pharmaceutical care, we need to develop a relationship with the patient. Part of that is verbally communicating with the patient, and at best, reaching out to them on an emotional level.
Dealing with critically ill patients is rarely comfortable for anyone, even the nurses and doctors who deal with this issue every day. In order to feel more comfortable and address your patient’s emotions, you need to first confront your own feelings. When you face someone who is critically ill or dying, you also face your own mortality. A range of emotions, including pity and fear as well as anxiety, is not unusual. Once you recognize and accept this, you can then go on to address those feelings, hopefully coming to a more balanced way of reacting to dying patients. You will then be more able to consider the patient’s feelings, which may range from denial, anger, bargaining and depression, through to ultimate acceptance. Rather than pity, you need to offer acceptance of these feelings, and let patients know you understand how they are feeling, even if you have not experienced it yourself.
Be prepared for days when the patient’s anger is directed at you, or when the patient is too depressed to show interest in the information you provide. Above all, you can ask and listen to what the patient has to say about how he or she is feeling about the medication. You may feel out of your depth with the dosing and choice of medications used (such as the many drugs and drug regimens for cancer and HIV); however, you have an important role to play. Because you may be the person who is most often in touch with the patient, and the most knowledgeable about the drugs used (compared to hospice workers and nurses), you can recognize side effects, suggest ways to prevent and minimize these effects, and assess when the efficacy of pain medication may be improved by adjusting dosage, therapeutic category or route of administration.
It will also help to establish a helping and caring relationship if you arrange a home visit with these patients as soon as they are able, and at intervals as needed.
I recently hired a pharmacy technician, which I hoped would free me up to implement pharmaceutical care into my pharmacy. She is the first technician that I have hired who is college-trained, and she seems very competent and good with patients. At the moment I have just given her tasks similar to the other technicians–prescription data input and counting pills. This hasn’t freed me up much, but I’m not sure how else she can help.
College-trained technicians are taught to take on a wide range of tasks in the dispensary. Although these tasks should focus on technical, product-oriented duties–leaving patient-oriented tasks to the pharmacist–this can still relieve a great burden from the pharmacist. Inventory control tasks such as ordering, stock-taking, checking for expiry dates, handling returns and receiving and marking orders, can all be handled by a trained technician. They can also handle medication preparation tasks such as compounding (supervised by pharmacists), bulk solution preparation, and unit dose packaging. In addition, technicians can take on responsibility for managing the dispensing staff, including scheduling and daily supervision. They can even take on bookkeeping tasks such as handling store accounts and supervising the delivery receipts.
Although direct patient care should remain the pharmacist’s focus, technicians can handle non-medication-related customer service tasks. They can also be involved in planning and running clinic days or other in-pharmacy wellness promotions, freeing up the pharmacist to interact with consumers who are attending these functions.
Depending on the energy and organizational abilities of the technician, the tasks they can take on can allow the pharmacist to reclaim a professional role and relinquish the “shop-keeper” role.
I am having a people management problem! I employ three other dispensary assistants, two of whom are store-trained with more than 10 years experience, who have both been employed in my pharmacy for more than five years. The third technician was recently hired, and is college-trained. I also employ four front store clerks with various amounts of experience and seniority, but who have only high school education.
Although the new technician is very pleasant, and more than willing to do any and all tasks presented, she is finding it hard to “fit in.” The other technicians have made a few comments suggesting that her extra training doesn’t make any difference to the job she is doing. I am worried that she will get frustrated with this attitude, and leave. Also, the atmosphere in the dispensary is tense. How can I bring harmony back into my dispensary?
As noted above, there are many tasks that properly trained technicians can take on, but the key is that the tasks must be clearly stated and agreed upon by all parties. Also, all staff must be clear on what the lines of authority and responsibility are. In this case, where a new staff member will result in a change in the previous order, the pharmacist should make a job description for each employee, and a management tree. Then a meeting should be held with each staff member individually to discuss their roles and, if necessary, negotiate this role and revise as required. It may be necessary to encourage staff members to take on new responsibilities, particularly if they are unsure of their abilities, or if they see it as giving them increased, unwanted responsibility. You may need to suggest a trial period for the new order, with a review after a set period, at which time both you and the employee will have the opportunity to make adjustments.
Regular staff meetings are important to maintain a team atmosphere, air any problems, and allow input by all staff.
While you’re at it, don’t forget to make a new job description for yourself, to avoid falling into old habits of handling technical tasks. You may find that you have to force yourself to take a “hands off” approach for a while. Also, remember that things won’t necessarily be done the way you would have done them, but as long as the outcome is what you have requested, that is all that’s important.
MELANIE RANTUCCI, M.Sc.Phm., Ph.D., is president of MJR Pharmacy Communications, Mississauga, ON
email: mjrpharm@ home.com