December 7, 2013

Patients Counseling: Applying Gagne’s Nine Events of Instruction

by Chris Dobroth, Doctor of Pharmacy Candidate, University of Maryland School of Pharmacy

“Excuse me. Where are the paper towels? Oh, and I have a prescription to pick up.” Or "Really? We have to talk to another person before we can be discharged?” Not an auspicious start to a conversation, much less one regarding someone’s health. This indifference by many patients combined with the many demands for the pharmacist’s time calls for counseling sessions that are quick and efficient. What makes these sessions both quick and efficient as opposed to just quick?

The American Society of Health System Pharmacists (ASHP) in Guidelines on Pharmacist-Conducted Patient Education and Counseling states that patient counseling and education should be approached by pharmacists as “interrelated activities.”1  According to the American psychologist Robert Gagne, there are nine events that should be included in every instructional activity to maximize its effectiveness.2  These events are the “why” behind the “how” of ASHP’s four steps to patient interaction.  Examining them more closely will help us develop a more complete understanding of what needs to happen during a patient counseling session. After all, at its core, effective patient counseling is a form of instruction.

Here are AHSP’s four step of patient counseling and how Gagne’s nine events of instruction related to each:1,2

Step 1. Establish caring relationship, explain pharmacist role, and ask for permission to counsel. Gagne’s first and second event of instruction are to gain the learner’s attention and inform them of the objectives.

Step 2. Assess the patient’s knowledge and capabilities. Gagne’s third event is to stimulate recall of prior learning.

Step 3. Provide information to fill in the gaps in the patient’s knowledge. Gagne’s fourth and fifth events are to present content and provide learning guidance.

Step 4. Verify patient’s knowledge and understanding. Here Gagne’s sixth through ninth events are to elicit performance, provide feedback, assess performance, and enhance retention and transfer.

Notice how efficiently ASHP’s four steps contain all of Gagne’s nine events of instruction?

Let’s consider the Indian Health Services Three-Prime Questions:3 
  1. What did the doctor tell you this medication was for?
  2. How did the doctor tell you to take this medication?
  3. What did the doctor tell you to expect?

Gagne’s nine events show that these questions are an integral part of the learning process.2 Here the use of opened questions serve to grab learners’ attention and engage them in conversation.  Now that you’ve got their brain running and you’re stimulating prior learning through the three questions, it’s your turn to assess their “knowledge and capabilities” as Gagne suggests and then to present the content and provide guidance.  You have already elicited the patient’s understanding, so now the holes can be filled in based on their level of health literacy. While the Indian Health Service’s Three-Prime questions lay the groundwork for an effective counseling session, they do not offer guidance from start to finish the way ASHP’s Four-Steps do.  Understanding Gagne’s nine events of instruction allows for an effective closer to the counseling session by utilizing the sixth through ninth steps: eliciting performance, providing feedback, assess performance, and enhance retention, and finally transfer to future situations.  Without these final steps, the patient will have endured a deluge of information but you won’t know if they really understood. While your intentions were good and the information thorough, the “teach back” technique is the only way to ensure the patient is truly ready to use their medication in an appropriate manner.

As the demands on our time increase, we must seek ways to be more efficient. By reminding ourselves that patient counseling sessions are a form of instruction, we can use Gagne’s nine events of instruction to master these techniques. Effective patient counseling leads to better outcomes and may decrease the amount of time spent re-answering the same questions at a later encounter.  So before your next patient encounter, take a few minutes to reflect on how you would approach it and remember Gagne’s nine events of instruction.

1.  American Society of Health Systems Pharmacists. ASHP Guidelines on pharmacist-conducted patient education and counseling. Am J Health-Sys Pharm. 1997; 54:431-434. [accessed 2013 Sept 22].
2.  Buscombe, C. Using Gagne’s theory to teach procedural skills. The Clinical Teacher. 2013; 10: 302-307. [Accessed 2013 Nov 16th].
3.  Indian Health Services: The Federal Program for American Indians and Alaska Natives [Internet]. Patient-Provider Communication Toolkit. Tool 9.  Pharmacist Consultation.  Rockville: Indian Health Services. [accessed 2013 Nov 16th].

No comments: