Implementation in practice

Knowing what to do in practice is just part of the challenge of improving care. Actually implementing what you have learnt into real practice - and then sustaining this advanced practice - can often be trickier.

There's no magic formula to ensure your practice standards improve because each clinical situation is unique. However, there are well-established strategies that will increase your chances of successfully improving your disease state management counselling. These strategies help you to critically  analyse the challenge of applying your counselling skills in a busy practice, and are applicable at any stage of your career.

See if the following strategies help you - you'll find that rather than being mutually exclusive steps, they will each help in different ways.

Identify and address all relevant stakeholder perspectives

You need to think about the attitudes and needs of others before implementing a formal counselling process in practice. Key personnel include your supervisor, other staff, and patients. For example, other staff may have concerns about the amount of time you will spend counselling and could react negatively.  Consequently, you may negotiate initially only doing this when the pharmacy is fully staffed, or with a limited number of patients.

Your supervisor may have concerns about your competency, in which case you might negotiate a very narrow scope of service initially. For example, focus on a particular group of patients, or limiting your intervention to a brief message and written materials. If you are undertaking interventions as a  trainee or intern, establishing agreed counselling protocols with your supervisor to ensure patient safety and efficient workflow will be very important.

Identify and address barriers and enablers

In most clinical situations there is an ‘ideal' standard of practice we would like to achieve. Often this seems impossible to deliver but some simple reflection on practical barriers and enablers before racing ahead can at the very least help to improve the situation. For example, it's very easy  to forget about being pro-active with patients about smoking because we forget, or are too busy (barriers).

An enabler that might help us remember more often might be to install computer alerts for whenever medicines are dispensed for clinical groups with high smoking prevalence (e.g. mental health patients - antispychotics) or patients who would benefit most (e.g. asthmatics - any inhalers dispensed).  Putting up a poster about smoking cessation counselling might encourage patients to approach you instead.

Start small, monitor progress and step up incrementally: think SMART

It's better to implement something modest and succeed than to be overambitious and fail spectacularly! This may mean undertaking your interventions with a smaller number of patients, or offering them less-dazzling interventions for a trial period (e.g. basic counselling plus screening for adherence).  Document your progress, focusing on meaningful outcomes that are easily identified (e.g. number of patients screened each day).

When you are confident you have ‘mastered' this, you can start to consider increasingly more complex issues with a small number of patients (e.g. undertaking blood pressure monitoring, recommending treatment changes), until you have achieved your ultimate goal.  Consider the SMART principles  when defining your achievement goals (SMART = Specific, Measurable, Attainable, Relevant, Time-specific).

Ensure a smooth, collaborative approach for better and sustained practice

It's important to include your supervisor and colleagues from the outset in your efforts to improve practice. It rightfully gives them equal ownership of the ‘project' and an interest in helping you to achieve your goals. It will also allow you to gain potentially valuable insights into practice  that will help in your efforts (e.g. maybe they have successfully run patient awareness programs previously and have ideas about what to do, or what not to do).

Pathman et al. (1996)  describes a simple four-step process for improving practices so that they are more acceptable to your colleagues and successful. These steps are:

• AwarenessBefore commencing, there should be a clear explanation about the problems with current management of hypertension or smoking cessation with all relevant personnel.
• AgreementYour colleagues should first agree that pharmacists can be an effective part of the solution. Only at this point you can start to discuss how your intervention might take place. Part of this step means genuinely working with your colleagues to ensure a mutually acceptable intervention;    this should not be ‘imposed' upon them.
• AdoptionOnce everybody agrees on the intervention, you can them implement your changes in practice. It's an important part of professional development to document interventions and outcomes, and to reflect and refresh your approach as you continue to learn.
• Adherence ‘Adherence' to good practice means identifying ways to embed it into your practice, and that of your colleagues where relevant. At a personal level, this may involve integration into your professional development portfolio plan. Steps at an organisational level are also    essential to maintain god practice (e.g. guarantee you some time every week to develop your skills, link clinical performance to job promotions, make sure the success of the program is made an ongoing feature of staff meeting agendas).

Module summary

Hopefully this module has provided you with a number of practical strategies you can use to improve patient care and develop your counselling and organisational skills.

Having the clinical knowledge to underpin disease state management is essential, and identifying evidence-based clinical guidelines is a great way to familiarise yourself with key management issues. Applying this clinical knowledge in a busy workplace can also be a considerable challenge.

Remember to start by doing what is easily achievable, then become more ambitious in your management of chronic conditions. Achieving your potential as a health practitioner is pursuit which needs continual refinement over your professional career.
Final step