Ellen Westh Sørensen

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: Borums theory of organisational change, which categorises 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 interview guide was produced, combining the factors 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.

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

Objective of the studyThe 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 methodDuring 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.ResultsA 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.ConclusionThe 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.

Implementation of cognitive pharmaceutical services (CPS) in professionally active pharmacies

Objective To investigate the implementation process of cognitive pharmaceutical services (CPS) in ‘professionally active’ pharmacies in Denmark; to describe the factors that influence the implementation process in the context of organisational theory.

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.

Implementation of cognitive pharmaceutical services in Danish community pharmacies — perceptions of strategists and practitioners

Objective To understand how projects for the implementation of cognitive pharmaceutical services (CPS) are perceived as facilitators of change from the perspectives of practitioners and strategists. Setting Sixteen community pharmacies in Denmark and three organisations working on implementing CPS in pharmacy practice.

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.

Social constructivist analysis of a patient medication record experiment — why a good idea and good intentions are not enough

Objective — To explain the limited success of a local patient medication record (PMR) experiment in pharmacy practice in Denmark from a social constructivist perspective and to promote a discussion among pharmacy practice researchers of how on‐going social constructivist analysis can be used to manage experiments in pharmacy practice.

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 professionaltechnical perspective with the life-world perspective of patients. However, patients were not encouraged to become more involved in the disease management process.

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.

Action Research in Pharmacy Practice

Action research (AR) is based on a collaborative problem-solving relationship between researcher and client, and the aims of this research are to solve the problem and to generate new knowledge. The chapter describes and shows how several different methods might be used for data collection in an AR-based study. Concepts related to AR are described; in addition, the multifaceted role of the action researcher is described, along with a set of data quality criteria for evaluating the quality of an AR-based study. Then follows a thorough description of a Danish AR-based pharmacy practice study. The chapter concludes with a list of experience-based recommendations for others who are interested in running an AR-based study. This is followed by an Appendix describing four different AR-based studies.