Ethics in patient counseling and pharmaceutical practice by emotions management

According World Health Organization (WHO) there are many factors that influence the state of a person’s health that are known as determinants of health. These factors can be grouped into five major categories: (i) clinical health care; (ii) genetic vulnerability; (iii) socio-economical characteristics; (iv) environmental and physical influences; and (v) individual health behaviors (such as tobacco use, diet and exercise, and Ethics in patient counseling and pharmaceutical practice by emotions management

only 10-20% of a person's health, whereas the largest contribution comes from the social determinants of health as well as individual health behavior.
Modern medicine follows a bio-psycho-social model of care that is a holistic framework to describe and explain how illness is the result of the interplay of biological, psychological and social factors plus individual health-related behaviors. The aim of this model is to develop a realistic patient-centered care plan in order to achieve the best possible health outcomes [3]. This means that all health care providers need to be able to work as a team to improve the health of a patient while reducing costs.
While the pharmacy practice uses drugs as the main means of health care intervention, the professional and ethical responsibility of pharmacists create a holistic framework of care. Pharmacists, in their Code of Ethics, promise to place the well-being of the patient at the center and take into account their stated needs as well as those defined by science [4,5].

EtHicS in tHE PHArMAciSt-PAtiEnt rELAtionSHiP
Effective communication between pharmacist and patient is a crucial factor for achieving desired patient satisfaction as well as for improving appropriate medication use and treatment outcome [6,7]. In 2000, WHO introduced the "Seven Star Pharmacist" concept, which declares that pharmacists play an important role as "communicators". In other words, pharmacists are positioned between physicians and patients and are expected to play a vital role in providing patients with appropriate health and medical information [8,9].
Modern pharmaceutical assistance is held in a patient centered way involving patients in the treatment decision [3,10,11]. Pharmacy is the place where you use all your knowledge to respond to the objective and psychological needs of the patients, because the patients don't buy products, they buy solutions for their problems. This is making communication with patients a vital component of daily practice of the pharmacist [9]. Good communication skills are needed for complex activities such as conducting medicine reviews, motivating people to adhere to treatment and health promotion. Pharmacists must, therefore, adapt their communication to the wide variety of patient needs and achieve patient-centered communication [12].
In order to regulate pharmacist-patient communication legally, professional associations from different countries have developed the codes of ethics for pharmacists. These include both regulations on the daily work of the pharmacist and regulation on the relationship between pharmacist and patient, the relationship with other team members or with the administrative authorities [13].
In the following, we will examine those aspects related to pharmacist-patient communication found in the codes of pharmaceutical ethics of different countries.
In UK, the Code of Ethics for Pharmacist and Pharmacist Technicians [14] regulate 3 principles of communication between pharmacist and patient: the pharmacists must show respect for others, encouraging patients to participate in decisions on their health and the pharmacist must be honest and trustworthy. The code states that caring for the patient should be the pharmacist's first concern. Therefore, finding out the most important information for the assessment of the individual needs of the patient is the starting point for providing the appropriate treatment. By providing data on how to use medicines, the pharmacist can influence the patient's satisfaction with their use. Also, it is specified the need to maintain the accuracy of the most important information obtained from the patient and to keep it in a clear and legal form.
Pharmacists must show respect for those around them, be they patients, colleagues or other persons, manifested by treatment them with politeness and consideration. Also, they must protect the dignity and privacy of patients, taking all security measures to ensure that confidential information is not disclosed without the patient's consent. Maintaining the professional limits of relations with patients or other categories of people with whom the pharmacist comes into contact, protects the pharmacist if he has to deal with vulnerable people.
Another principle contained in the UK Code of Pharmacists refers to encouraging the patient to participate in decisions on their own health. The patient has the right to be involved in decisionmaking regarding his treatment and should be encouraged to work as a team with pharmacists and doctors. The success of this partnership requires effective communication based on the pharmacist's ability to identify the patient's particular needs. In the partnership, the pharmacist listens to the patient, explains him the available options and helps him to make an informed decision on pharmaceutical services or treatment options.
The pharmacist must respect the patient's right to refuse treatment or other services offered. Acting with honesty and integrity, the pharmacist, through his attitude, must maintain the reputation of his profession. In communicating with the patient the pharmacist must not exploit his vulnerability or lack of knowledge, must be precise and impartial in providing or publishing information.
Ethical code of the profession of pharmacist developed by Pharmacy Council -Malta [15] stated that the pharmacist must respect and protect the individual dignity, physical and mental integrity and rights of the patient. Also he must respect personal and cultural differences, beliefs and values of the patient. The pharmacist must not judge or impose his beliefs on patients, offering his services with consideration and professionalism.
Members of the pharmacist profession should establish and maintain professional relationships with their patients, to cultivate and to maintain the trust of patients and society, to protect the interests of patients through the confidentiality of the information obtained in the course of their work. In professional relations, the pharmacist must show honesty and integrity. The information provided to both patients and society or colleagues must be real, objective, up-to-date and easy to understand. The pharmacist must respect the patient's autonomy, encourage his involvement in making decisions vis-à-vis his own health and keep an opened dialogue with him. By promoting pharmaceutical products or services, the pharmacist should not limit the patient's decision on the choice of pharmacist or service provider. In the context of the pharmacist-patient communication, members of the pharmaceutical profession must not use the titles or position held to discredit other colleagues or to promote or support any medicinal or other product through advertising.
According to the WHO and the International Pharmaceutical Federation (FIP), the pharmacists should "provide advice to ensure that the patient receives and understands sufficient written and oral information to derive maximum benefit from the treatment" [16].
In Sweden the pharmacists are obligated to give the patient personalized information and must ensure that he knows how to use the medicinal products. Pharmacists must also make sure that the patient is obtaining the desired effects from the drugs prescribed [6].
The Romanian legislation, through the Code of Ethics of the Pharmacist and the Law 81/1997 [5,17], shows similarities with those encountered in the codes of ethics of other countries and emphasizes respect for the rights and dignity of the patient in the pharmacist-patient relationship. Compared to the other ethical codes studied, the Code of Ethics of Pharmacists in Romania emphasizes the importance of the pharmacist's involvement in public health information and education in combating drug addiction, doping and self-mediation. However, we do not see any reference to one of the issues encountered in the UK and Malta codes, namely encouraging patients to participate in establishing their own treatment strategy.

dEMonStrAtinG EMPAtHY And coMPASSion in PrActicE
Despite advancements from medical technology, the therapeutic relationship between healthcare professionals and patients remains essential to quality care. More importantly, patients should be considered not only as clinical cases but also as human beings who are facing difficulties and uncertainties [10,12]. Treating patients with compassion, dignity and empathy is fundamental to the concept of patientcentered care practice [18]. Thus, the pharmacists need to be emotionally intelligent in their time-constrained consultations (interactions with patients).
Pharmacists need to have the skills to dynamically interact with their patients to build a trustworthy relationship with patients and to discuss the use of medication for ensuring that the patients have comprehensive understanding their treatment goal and the strict adherence with an improvement of their quality of life [10]. According Allinson and Chaar [19,20] the pharmacists are required to be aware of non-verbal as well as verbal communication, actively listen to patients and demonstrate empathy, competence, and confidence to encourage full disclosure from patients and to respect cultural diversity.
Next we will identify the types of emotions that occur in each of the 4 steps of the patient's visit to the pharmacy: (i) the approach, (ii) the need identification, (iii) the recommendation and (iv) the phase of closure with loyalty. During the pharmacist-patient interview we will discover what are the elements that help us to manage the relationship with him and that would influence patients' predisposition to return to the pharmacy for receiving pharmaceutical services and continuity of care.
Establish initial rapport. Building a lasting relationship starts from the first contact with the patient, as we never have the opportunity to make a second good first impression. In this moment we show him our openness by making oneself available, not only with time but also by the manner in which the patient and their perspectives are acknowledged. The greeting should never be absent and especially on the initiative of the pharmacist. This is a sign of respect and so will begin the fidelity that will continue throughout the dialogue. A short-spoken greeting and appearing rushed or inconvenienced communicates to patients shows that their time and concerns are not important.
More properly, identifying a patient by name in a warm greeting, offering a smile, being attentive and maintaining friendly eye contact creates a very pleasant impression, but more importantly, will listen carefully the message that we send.
Establish the reason for the consultation with needs identification. Once the conversation begins, the next step is to correctly identify the patient's needs. Attentive body language (e.g. open posture, eye contact, and social distance of 2 extended arm), paralanguage (slightly nasalized low voice, volume and tone of voice), paraphrasing to confirm understanding and keeping questions to a minimum demonstrates to the patient a genuine interest for him on the part of the pharmacist.
To promote medical adherence and to facilitate shared decision making there are very important to use skills like (i) open questions and show you are interested in what your patient has to say, (ii) take time to listen to the patient (practice active listening and reflection, reiterating what the patient has said in your own words), (iii) respect patient views, opinions, beliefs and feelings (avoid being judgmental); (iv) avoid interrupting the patient.
Recommendation. Once we found out what are the patient's needs, we should present as convincingly as possible the advantages and benefits of the product that we offer. This requires a very good knowledge of the product concerned: (i) the characteristics of the product (e.g. chemical composition), (ii) the advantages conferred by the characteristics (the superiority of the product over others) and (iii) the benefits (how the patient can use the advantages of the product).
When our recommendation contains a real benefit to the patient, the emotions generated are of confidence, optimism and surprise. When our recommendation does not contain a real benefit to the patient the emotions generated are of distrust, fear, aggression and disappointment Closure with loyalty. Patient's loyalty is not achieved only at the end of the discussion. It starts from the first moment of the relationship. Loyalty is based on the positive opinion that he has formed about the pharmacy and pharmacist. Patients who have overcome their expectations through the service that we have offered and who is going to return with pleasure will thank us for making their day more beautiful and will look for us when they need health or beauty. When at the end of the discussion there are greeting, eye contact, attention and invitation on return, the emotions generated are of confidence, optimism and joy. When there are not greeting, eye contact, attention and invitation to return to the end of the discussion, the emotions generated are of distrust, anger, aggression and disappointment.

concLuSionS
Treating patients with compassion, dignity and empathy is fundamental to the concept of patientcentered care. This involves communication with patients to understand their overall health and perspective on their disease. Deve-o-ping that relationship can involve knowing patients' emotional responses to therapy, as well as acknowledging their concerns or frustrations. The pharmacists need to have the knowledge and abilities not only to be competent pharmacists. Pharmacists also need to be able to communicate, to interact, to collaborate, to counsel and to lead their patients, co-workers, and other healthcare professionals. The abilities like being self-aware of their emotions and feelings, understanding other's emotions and feelings and emotional intelligence allow pharmacists to be more adaptive for solving problems, and to be more creative and flexible with others.