Action research methodology in clinical pharmacy: how to involve and change.

Introduction The focus in clinical pharmacy practice is and has for the last 30-35 years been on changing the role of pharmacy staff into service orientation and patient counselling. One way of doing this is by involving staff in change process and as a researcher to take part in the change process by establishing partnerships with staff. On the background of the authors' widespread action research (AR)-based experiences, recommendations and comments for how to conduct an AR-study is described, and one of their AR-based studies illustrate the methodology and the research methods used. Methodology AR is defined as an approach to research which is based on a problem-solving relationship between researchers and clients, which aims at both solving a problem and at collaboratively generating new knowledge. Research questions relevant in AR-studies are: what was the working process in this change oriented study? What learning and/or changes took place? What challenges/pitfalls had to be overcome? What were the influence/consequences for the involved parts? When to use If you want to implement new services and want to involve staff and others in the process, an AR methodology is very suitable. The basic advantages of doing AR-based studies are grounded in their participatory and democratic basis and their starting point in problems experienced in practice. Limitations Some of the limitations in AR-studies are that neither of the participants in a project steering group are the only ones to decide. Furthermore, the collective process makes the decision-making procedures relatively complex.

Evaluation of a Danish pharmacist student-physician medication review collaboration model.

BACKGROUND: Interprofessional collaboration between pharmacists and physicians to conduct joint home medication reviews (HMR) is important for optimizing the medical treatment of patients suffering from chronic illnesses. However, collaboration has proved difficult to achieve. The HMR programme "Medisam" was launched in 2009 at the University of Copenhagen with the aim of "developing, implementing and evaluating a collaboration model for HMRs and medicine reconciliations in Denmark". The Medisam programme involves patients, pharmacy internship students, the (pharmacist) supervisor of the pharmacy students and physicians. OBJECTIVE: To explore if it was possible through the Medisam programme to obtain a fruitful HMR collaboration between pharmacy internship students and physicians as a means to develop HMR collaboration between trained pharmacists and physicians further. SETTING: Ten matching pairs of student-physician collaboration were studied across Denmark. METHOD: Semi-structured interviews about existing collaboration were conducted with pharmacy internship students in the HMR programme, their supervisors and physicians partners. The theoretical framework forming the analyses was derived especially from works of Bradley et al. (Res Soc Adm Pharm 8:36-46, 2012), and Snyder et al. (Res Soc Adm Pharm 6:307-23, 2010) on pharmacists/physician collaboration. MAIN OUTCOME MEASURE: The development of inter-professional collaboration between students and physicians according to the three collaboration drivers: trustworthiness, role specification and professional interaction. RESULTS: Full collaboration was not achieved. Physicians found collaboration satisfactory, students however expressed the need of more interaction with physicians. The written collaboration contracts did not ensure a possible need of students to re-negotiate roles and tasks, and did therefore not entirely ensure role specification. Developing mutual professional interdependence through students being recognized by physicians to contribute to improved patient outcomes was also limited. CONCLUSION: Some challenges to fruitful collaboration were identified. Solutions to these challenges include students and their pharmacist supervisors to find ways to present their collaborative needs to physicians and for students to illustrate more explicitly the benefits patient achieve if physicians implement the recommendations of students.

[Successful collaboration between community pharmacies and general practitioners on reviews and comparisons of home medication]. / Samarbejde mellem apotek og praktiserende læge om gennemgang og afstemning af medicin.

The study developed and tested collaboration models for home medication reviews (HMR) between community pharmacies and general practitioner (GP)s. Three pairs (each comprising one pharmacist and one GP) developed a collaboration agreement on the patient group, content and place for HMR, responsibilities, continuation etc. The collaboration models were evaluated by the pairs and by a project group. The models were very different - adjusted to the GP's and the pharmacist's individual wishes. The entering of collaboration agreements is a good platform for effective cooperation between the pharmacist and the GP and leads to successful HMRs. We recommend that others develop collaboration models too.

Exploring communications around medication review in community pharmacy.

OBJECTIVES: Investigation into aspects that influence outcomes of medication reviews have been called for. The aim of this study was to assess how pharmacy internship students in a Danish medication review and reconciliation model communicated with both diabetes patients and the patients' General Practitioners (GPs) when conveying the results of the review by writing letters to the different parties. Special attention was drawn to how differences in health care provider and patient perspectives of the disease as well as inclusion of the patient in the decision making process is influenced by the identified practices of communication. SETTING: 18 Danish community pharmacies with The Department of Pharmacology and Pharmacotherapy at the Faculty of Pharmaceutical Sciences, University of Copenhagen. METHOD: Number of identified drug related problems, life-world problems and solutions to these described in the letters sent to patients and their GPs were registered. Further a qualitative documentary analysis was conducted by analyzing the letters using the theory of transactional analysis, developed by Berne. MAIN OUTCOME MEASURES: Identified and conveyed drug related and life-world related problems when comparing patients' letters with GPs' letters. Whether students assumed a superior, inferior or equal role in relation to the recipient of the letter and compared whether students assumed the same role in relation to patients and GPs. RESULTS: 18 pairs of patient and GP letters were analyzed. The analysis showed that students conveyed more drug-related problems to GPs than to patients. Furthermore, students assumed an equal relationship to GPs, whereas they frequently took superior positions when writing to patients. Students reported lifestyle problems both to GPs and to patients. CONCLUSION: Pharmacy students in a Danish medication review and reconciliation model managed to detect and address lifestyle problems of patients to their GPs, thereby facilitating the merger of their professional-technical perspective with the life-world perspective of patients. However, patients were not encouraged to become more involved in the disease management process.

Using an action research process in pharmacy practice research--a cooperative project between university and internship pharmacies.

BACKGROUND: Action research (AR) is a common research-based methodology useful for development and organizational changes in health care when participant involvement is key. However, AR is not widely used for research in the development of pharmaceutical care services in pharmacy practice. OBJECTIVES: To disseminate the experience from using AR methodology to develop cognitive services in pharmacies by describing how the AR process was conducted in a specific study, and to describe the outcome for participants. METHODS: The study was conducted over a 3-year period and run by a steering group of researchers, pharmacy students, and preceptors. The study design was based on AR methodology. The following data production methods were used to describe and evaluate the AR model: documentary analysis, qualitative interviews, and questionnaires. RESULTS: Experiences from using AR methodology and the outcome for participants are described. A set of principles was followed while the study, called the Pharmacy-University study, was being conducted. These principles are considered useful for designing future AR studies. Outcome for participating pharmacies was registered for staff-oriented and patient-oriented activities. Outcome for students was practice as project leaders and enhancement of clinical pharmacy-based skills. Outcome for researchers and the steering group conducting the study was in-depth knowledge of the status of pharmacies in giving advice to patient groups, and effective learning methods for students. CONCLUSION: Developing and implementing cognitive pharmaceutical services (CPS) involves wide-reaching changes that require the willingness of pharmacy and staff as well as external partners. The use of AR methodology creates a platform that supports raising the awareness and the possible inclusion of these partners. During this study, a set of tools was developed for use in implementing CPS as part of AR.

Pharmaceutical care in community pharmacies: practice and research in Denmark.

OBJECTIVE: To review the current status of Danish community pharmacy in both practice and research and discuss future trends. FINDINGS: Denmark has a social welfare system that provides health care, social services, and pensions to its population. Medical care and surgery are free. Prescription medicines are reimbursed by an average of 56%. Community pharmacies are privately owned, but the health authorities regulate drug prices and the number of pharmacies. At present, Denmark has 322 pharmacies, corresponding to 1 pharmacy per 16,700 inhabitants. All pharmacies provide prescription and over-the-counter products, advice about medicine use, dose dispensing, generic substitutions, and administration of individual reimbursement registers. Except for very simple processes, compounding is centralized at 3 pharmacies. Many pharmacies offer measurement of blood glucose, blood pressure, and cholesterol, and 60% offer inhalation counseling, a reimbursed service. Research in pharmacy practice is well established and conducted primarily at universities and at Pharmakon A/S, which is owned by the Danish Pharmaceutical Association. DISCUSSION: Extended services in clinical pharmacy are priorities for all Danish pharmacy organizations. Reimbursement is sought at the national level, as well as from payers in the new local authority structures in Denmark. The trend in research focuses on collaborative health care, on developing and documenting the value of community pharmacy services, and on optimizing services and strengthening implementation. CONCLUSIONS: Denmark has few, but large, community pharmacies and a long tradition of research and development resulting in several well-documented cognitive and clinical services. However, few services are reimbursed and implementation is still a challenge.

Drug-related problems in patients with angina pectoris, type 2 diabetes and asthma--interviewing patients at home.

OBJECTIVE OF THE STUDY: The objective of the overall study was to create a foundation for improving the quality of counselling practice in pharmacies. The research question addressed in this sub-study was to describe drug-related problems (DRPs) in terms of frequency as well as type in people with angina pectoris, type 2 diabetes and asthma, as the problems were identified through medication reviews and home interviews. SETTING AND METHOD: During their pharmacy internships, fourth-year pharmacy students collected data for the study in 1999, 2000 and 2001 by carrying out medication reviews, conducting home interviews and registering DRPs for 414 patients. Data were collected from the following patient groups in the years indicated: in 1999, 123 angina pectoris patients; in 2000, 192 type 2 diabetes patients, and in 2001, 99 asthma patients. The interviews dealt with the patient's drug-related experiences, knowledge, perceptions, problems and actions. The DRPs were registered according to the so-called PI-Doc system. RESULTS: A medication review was supplemented by qualitative interviews with the three patient groups, which revealed a relatively high number of DRPs compared to other studies. An average of 2.8 DRPs were identified per angina pectoris patient; 4.1 DRPs per type 2 diabetes patient and 4.0 DRPs per asthma patient. "Inappropriate use of medicines by the patient" and "Other problems" (such as limited knowledge of the illness, inappropriate lifestyle, fear of medication, lack of information, etc.) were the two most common DRP sub-categories identified in all three patient groups. CONCLUSION: The study provided a profile of a pharmacy-based population of 414 patients visiting the pharmacy, all of whom are at high risk of experiencing drug-related problems. Pharmacy staff needs to take this high rate of DRPs in people with angina pectoris, asthma and type 2 diabetes into account when dispensing medicines to and advising patients from the three groups, especially when explaining how to use medicines appropriately.

Understanding practice change in community pharmacy: a qualitative research instrument based on organisational theory.

INTRODUCTION: The past decade has seen a notable shift in the practice of pharmacy, with a strong focus on the provision of cognitive pharmaceutical services (CPS) by community pharmacists. The benefits of these services have been well documented, yet their uptake appears to be slow. Various strategies have been developed to overcome barriers to the implementation of CPS, with varying degrees of success, and little is known about the sustainability of the practice changes they produce. Furthermore, the strategies developed are often specific to individual programs or services, and their applicability to other CPS has not been explored. There seems to be a need for a flexible change management model for the implementation and dissemination of a range of CPS, but before it can be developed, a better understanding of the change process is required. OBJECTIVES: This paper describes the development of a qualitative research instrument that may be utilised to investigate practice change in community pharmacy. Specific objectives included gaining knowledge about the circumstances surrounding attempts to implement CPS, and understanding relationships that are important to the change process. METHODS: Organisational theory provided the conceptual framework for development of the qualitative research instrument, within which two theories were used to give insight into the change process: Borum's theory of organisational change, which categorizes change strategies as rational, natural, political or open; and Social Network Theory, which helps identify and explain the relationships between key people involved in the change process. RESULTS: A semi-structured affecting practice change found in the literature that warranted further investigation with the theoretical perspectives of organisational change and social networks. To address the research objectives, the instrument covered four broad themes: roles, experiences, strategies and networks. CONCLUSION: The qualitative research instrument developed in this study provides a starting point for future research to lead to a description and understanding of practice change in community pharmacy, and subsequent development of models for the sustainable implementation of CPS.

Medication- and illness-related factual knowledge, perceptions and behaviour in angina pectoris patients.

As part of a study in Danish internship pharmacies, 70 fourth-year pharmacy interns interviewed 123 angina pectoris patients. Information was collected about the patients' medication- and illness-related factual knowledge and perceptions as well as their medication use. The results obtained showed that patients' perceptions and factual knowledge about medications and illness varied greatly, and that they administered their medication in a variety of ways. Patients' factual knowledge on illness, illness prevention and the function of medication was generally low. The patients were grouped in different categories according to their perceptions of illness and medication. A quarter had actively and reflectively self-regulated their medication and the rest of the patients did not do any deliberate self-regulation in terms of their medication. Half of the patients occasionally forgot to take their medication. Health care personnel should incorporate the results of this study in their efforts to improve patient counselling on illness, medication and other health-related matters.

Basing pharmacy counselling on the perspective of the angina pectoris patient.

AIM OF THE STUDY: A participatory action research study design was developed and tested in 40 Danish internship pharmacies as part of a 3-year study supported by the Research Centre for Quality in Medicine Use. The aim of the study was to create a foundation for improving the quality of counselling practice in pharmacies by comparing the pharmacy staff's views on, knowledge of and behaviour towards a specific patient group with the knowledge, perceptions and medication use of the same patients. METHOD: Pharmacy students in their fourth year collected data for the study. In 1999, the students carried out 123 qualitative interviews with angina pectoris patients and collected 569 questionnaires from pharmacy staff in 40 internship pharmacies. RESULTS: The results indicate that discrepancies exist between the patients' and pharmacy staff's perspectives on important issues such as knowledge about medicines (patients)/provision of information about medicines (pharmacy staff), experienced side effects (patients)/information about side effects (pharmacy staff), knowledge on prevention and lifestyle (patients)/information on lifestyle and prevention (pharmacy staff) and expectations of pharmacies (patients)/initiatives started in pharmacies (pharmacy staff). CONCLUSION: The study gives reason to believe that angina pectoris patients might benefit if pharmacies provided more information on the relationship between lifestyle factors and angina pectoris, the possible side effects of medicines and the function of medicines.