Emergency contraception in Australian community pharmacies: a simulated patient study

Knowledge, attitudes, and practices of community pharmacists providing over-the-counter emergency hormonal contraception: a scoping review

OBJECTIVES

Reducing the rate and impact of unintended pregnancy through effective contraception is a public health goal. Since deregulation, globally, ease of access to community pharmacists has enabled them to play a key role in the provision of emergency hormonal contraceptive pills (ECP). The aim of this scoping review is to explore pharmacists' overall knowledge of and attitudes and practices towards the provision of emergency contraception.

METHODS

A systematic literature search for the period from 1999 to 2023 was conducted using Scopus, Medline (Ovid), CINAHL, Emcare, Web of Science, and Google Scholar. Keywords such as emergency contraception, emergency contraceptive, morning after pill, plan B, pharmacist, community pharmacist, and pharmacy were applied. Articles published only in English that described the knowledge, attitudes, and practices of community pharmacists providing emergency contraception were included in this review.

KEY FINDINGS

Twenty studies met the inclusion criteria. Despite positive attitudes towards the provision of ECP, there is a clear deficit in both the knowledge and counselling practices of pharmacists, with some pharmacists lacking an open attitude towards the supply of ECP to adolescents and third parties. Usage of a private counselling area ranged from 0% to 90% highlighting privacy for patients seeking ECPs is lacking during consultations. In countries where practice guidelines are available, these are often not being optimally utilized.

CONCLUSIONS

This review has highlighted gaps in pharmacists' knowledge and counselling practices, demonstrating shortcomings in pharmacists' education, training, and application of professional practice guidelines. Future research on ECP guidelines is recommended to improve implementation and usability in practice.

Knowledge, Attitudes, and Practices of Community Pharmacists in Qatar Towards Contraceptives: A Cross-Sectional Study

In Qatar, hormonal contraceptives are available over the counter in community pharmacies. However, improper use, particularly by women with specific health conditions, can result in adverse events. Community pharmacists (CPs) play a role in counseling women and assessing eligibility for contraceptives. This study evaluated the knowledge, attitudes, and practices of CPs in Qatar regarding hormonal contraceptives through a survey conducted from August to December 2021. Of 377 respondents, 136 completed the questionnaire (response rate: 35.3 percent). The mean knowledge score was 3.01, reflecting poor to moderate knowledge. The score fell between 3 and 4, with a maximum score of 6. CPs mostly counseled patients about contraceptives' names, instructions on administration, and when to start (82.2 percent, 90.2 percent, and 90 percent respectively). About 40 percent of CPs agreed that their religious beliefs do not affect recommendations about contraceptives. Lack of private rooms (57 percent), and limited counseling time (55.1 percent) were identified as counseling barriers. The study concluded that CPs had poor to moderate knowledge but positive attitudes and fair to good counseling practices, suggesting a need for educational programs and interventions to overcome barriers.

Pharmacists' Perspectives on Nicotine Vaping Products (NVPs) for Smoking Cessation in Australia: A Qualitative Analysis

Vaping, particularly the use of nicotine vaping products (NVPs), has emerged as a public health concern. The regulatory environment surrounding NVPs in Australia has rapidly evolved, shifting from a prescription-only model to availability through community pharmacies. Pharmacists play a critical role in addressing vaping-related health concerns. This study explores Australian pharmacists' perspectives on their professional roles and the support needed to manage vaping-related enquiries. Qualitative semi-structured interviews were conducted with 25 practicing pharmacists using a topic guide developed from the current literature and team expertise. The interviews were transcribed verbatim and analysed thematically using an inductive approach to identify key themes. Key themes included risk perception, professional vaping health-related services, professional practice and other support-related needs. Pharmacists expressed significant uncertainty about the risks and harms associated with vaping. There was apprehension around the regulatory complexity of supplying NVPs, and participants called for greater education and support, particularly around NVP's place in smoking cessation and potential vaping cessation services. Effective public health messaging and risk communication about vaping are crucial. At the centre of recent legislative changes, pharmacists require training and professional support to address vaping-related scenarios and provide counselling that aligns with individual risk perceptions, ensuring NVP use is clinically appropriate.

Pharmacist recommendations for emergency contraception in Belgium: a simulated user study

BACKGROUND

Emergency contraception reduces the risk of unintended pregnancy, after unprotected sexual intercourse or contraceptive failure. In Belgium, emergency contraception is available without a prescription and pharmacists play therefore a crucial role in dispensing emergency contraception.

AIM

This study assesses the dispensing practices of emergency contraception by pharmacists in two regions of Belgium.

METHOD AND DESIGN

Simulated patient study, using a predefined scenario, evaluating a request for emergency contraception. The scenario involves a 25-year-old woman not using contraception, who had unprotected sexual intercourse 84 h (3.5 days) ago. Her last menstrual period was 10 days ago.

POPULATION

260 pharmacies were randomly selected. Principal outcome: proportion of pharmacists who deliver the adequate emergency contraception. We considered the following responses as adequate: Prescribing ulipristal acetate or redirecting to another pharmacy, in case of unavailability, or referring for a copper IUD.

RESULTS

We analysed the data obtained in 216 pharmacies (216/260 = 83.1%). In 64% of cases, adequate dispensing of emergency contraception (dispensing of ulipristal acetate or referral for intrauterine device insertion) occurred. There was an association between correct dispensing and asking appropriate questions, such as the date of the last menstrual period and the date of the risky sexual intercourse.

CONCLUSION

More than one-third of visited pharmacies did not distribute appropriate emergency contraception, underlining the need for improvement. We hypothesise that this may be achieved with appropriate training, use a dispensing checklist.

A cross-sectional survey exploring the knowledge, experiences and attitudes of Australian pharmacists toward medicinal cannabis

BACKGROUND

Australian pharmacists currently dispense a wide range of prescription-only cannabis-based medicines. Recent regulatory changes will expand the role of pharmacists, allowing certain low-dose cannabidiol products to be supplied without a prescription in pharmacies. This harmonises Australia with many other countries where cannabidiol products are readily available to consumers.

AIM

To examine Australian pharmacists' experience, knowledge and attitudes towards medicinal cannabis and their preparedness to supply over-the-counter low-dose cannabidiol products.

METHOD

We conducted a cross-sectional study using a 51-item on-line questionnaire that was informed by previous surveys of health professionals and assessed for face validity. Australian pharmacists were recruited to complete the survey between May and December 2021, primarily through professional pharmacy organisations. Pharmacists were included in the final dataset if they completed the demographic characteristics section and at least one additional section of the questionnaire. Data were analysed using descriptive and relational statistical tests.

RESULTS

There were 272 attempts to complete this survey and 217 responses included in the final dataset. Over half of the respondents (60.0%, 130/217) had dispensed at least one medicinal cannabis prescription during their career and 58.5% (127/217) had received at least one medicinal cannabis enquiry in the last fortnight. Only around half (53.9%, 117/217) felt comfortable supplying medicinal cannabis products and fewer (39.3%, 79/201) were confident discussing cannabis-related enquiries. More than half of the respondents (58.7%, 118/201) supported the provision of low-dose cannabidiol products through pharmacies. Two-thirds (67.8%, 80/118) of respondents achieved relatively low scores (< 60%) in the knowledge component of the survey. Most respondents (94.2%, 178/189) endorsed a need for further training in this area.

CONCLUSION

Australian pharmacists tended to support medicinal cannabis availability and improved access to low-dose cannabidiol products via pharmacies. However, results highlight a need for improved training and education of pharmacists around cannabis-based medicines.

Development and Pilot Testing of a Dispensing Protocol on Emergency Contraceptive Pills for Community Pharmacists in Belgium

Community pharmacists in Belgium frequently dispense emergency contraceptive pills (ECPs). However, variable and insufficient counseling practices exist across pharmacies, highlighting the need for standardization and quality improvement strategies. The aim of this project was to develop and test an ECP dispensing protocol for pharmacists. An ‘experience-based’ co-design approach involving academic and practicing pharmacists was applied, followed by a 4-month test period and interviews to assess users’ experiences. In total, eight geographically dispersed pharmacies participated. Pharmacists (n = 15) reached a consensus on most items to be included in the protocol, which was subsequently tested in seven pharmacies, with overall 97 registered ECP conversations. Pharmacists considered the protocol complete but felt that not all items should be mentioned/questioned during all conversations. They suggested only subtle modifications to be made prior to delivering a final protocol ready for nationwide distribution. Despite attributing positive effects to having a protocol, no single pharmacist ‘actively’ used it at-the-counter but used it instead as a ‘checklist’ after the encounter. Pharmacists found that the paper-based format of the protocol hindered protocol-based dispensing. Future research is needed to provide evidence on the actual benefits of protocol application, as well as to identify factors influencing the implementation of ECP dispensing using a software-integrated protocol.

The simulated patient method: Design and application in health services research

The simulated patient method is becoming increasingly popular in health services research to observe the behaviour of healthcare practitioners in a naturalistic setting. This method involves sending a trained individual (simulated patient among other names), who is indistinguishable from a regular consumer, into a healthcare setting with a standardised scripted request. This paper provides an overview of the method, a brief history of its use in health services research, comparisons with other methods, ethical considerations, and considerations for the development of studies using the simulated patient method in health services research, with examples from pharmacy and other fields. Methods of analysis, mixed-methods, and the use of simulated patients with feedback are also discussed.

Accessing emergency contraception pills from pharmacies: the experience of young women in London

INTRODUCTION

Over-the-counter provision of emergency contraception pills (ECP) has increased since deregulation of progestogen-only formulations and is now the most common public health service provided by UK pharmacists. Important questions relate to women's perceptions of their experience of receiving ECPs from pharmacists.

METHODS

Qualitative study: in-depth interviews with young women reporting ECP use, recruited from clinic (10); pharmacy (6) and community settings (5) in London.

RESULTS

Key advantages of pharmacy provision were ease and speed of access and convenience. Disadvantages included a less personal service, inadequate attention to information needs and to prevention of recurrence of ECP need, and unsupportive attitudes of pharmacy staff. Suggested service improvements included increasing privacy, providing more contraceptive advice, adopting a more empathetic approach and signposting follow-up services.

CONCLUSION

Pharmacies are important in the choice of settings from which ECPs can be obtained and many aspects of pharmacy provision are appreciated by young women. There is scope to further enhance pharmacists' role.

The Quality of Counselling for Oral Emergency Contraceptive Pills-A Simulated Patient Study in German Community Pharmacies

Background: In Germany, there are two different active substances, levonorgestrel (LNG) and ulipristal acetate (UPA), available as emergency contraception (the “morning after pill”) with UPA still effective even 72 to 120 h after unprotected sexual intercourse, unlike LNG. Emergency contraceptive pills have been available without a medical prescription since March 2015 but are still only dispensed by community pharmacies. The aim of this study was to determine the counselling and dispensing behaviour of pharmacy staff and the factors that may influence this behaviour in a scenario that intends that only the emergency contraceptive pill containing the active substance UPA is dispensed (appropriate outcome). Methods: A cross-sectional study was carried out in the form of a covert simulated patient study in a random sample of community pharmacies stratified by location in the German state of Mecklenburg-Vorpommern and reported in accordance with the STROBE statement. Each pharmacy was visited once at random by one of four trained test buyers. They simulated a product-based request for an emergency contraceptive pill, stating contraceptive failure 3.5 days prior as the reason. The test scenario and the evaluation forms are based on the recommended actions, including the checklist from the Federal Chamber of Pharmacies. Results: All 199 planned pharmacy visits were carried out. The appropriate outcome (dispensing of UPA) was achieved in 78.9% of the test purchases (157/199). A significant correlation was identified between the use of the counselling room and the use of a checklist (p < 0.001). The use of a checklist led to a significantly higher questioning score (p < 0.001). In a multivariate binary logistic regression analysis, a higher questioning score (adjusted odds ratio [AOR] = 1.41; 95% CI = 1.22–1.63; p < 0.001) and a time between 12:01 and 4:00 p.m. (AOR = 2.54; 95% CI = 1.13–5.73; p = 0.024) compared to 8:00 to 12:00 a.m. were significantly associated with achieving the appropriate outcome. Conclusions: In a little over one-fifth of all test purchases, the required dispensing of UPA did not occur. The use of a counselling room and a checklist, the use of a checklist and the questioning score as well as the questioning score and achieving the appropriate outcome are all significantly correlated. A target regulation for the use of a counselling room, an explicit guideline recommendation about the use of a checklist, an obligation for keeping UPA in stock and appropriate mandatory continuing education programmes should be considered.

The provision of care provided by the pharmacy workforce in relation to complementary medicines in Australia

BACKGROUND

The use of complementary medicines (CMs) is prevalent across the world. Some CMs, such as St John's Wort, when taken with specific pharmaceutical medicines, may cause drug-herb interactions. In this context, pharmacists have the opportunity to play an important role in preventing harm to patients.

OBJECTIVE

The aim of this study was to explore real-life pharmacy practice in relation to CMs in New South Wales, Australia.

METHODS

The study design involved 'pseudo-patient' pharmacy visits while posing as a patient's relative requesting St John's Wort and using a standardized set of questions to document details of the interaction with a range of pharmacy staff.

RESULTS

Of the 110 metropolitan pharmacy visits made, the pharmacy workforce who were involved in assisting the pseudo-patient's request included 51 pharmacists (46.4%), 57 pharmacy assistants (51.8%) and 1 naturopath (0.9%). Advice that may have resulted in harm to the patient, was offered by pharmacists in 11.8% (n = 13) of the encounters, and 20.9% (n = 23) by pharmacy assistants. Conversely, advice that prevented harm was provided by only 17.3% (n = 19) pharmacists and 10.9% (n = 12) pharmacy assistants. History-taking was not attempted by 84 pharmacy staff.

CONCLUSION

The majority of pharmacy staff involved in this study did not manage a request for a CM with known drug-herb interactions in a way that would prevent harm. These findings highlight the need for the pharmacy workforce to engage in education and training in CMs, with a focus on how to consult evidence-based resources regarding interactions in the interest of patient safety.

Status of Pharmacy Ethics Education in Australia and New Zealand

Objective. To explore models of teaching in, resources available to, and delivery of a standardized course in pharmacy ethics. Methods. An email invitation was sent to the educator responsible for teaching pharmacy ethics at each of 19 institutions in Australia and New Zealand. Over a six- to eight-week period, semi-structured interviews were conducted in person, by email, or by phone, and were audio-recorded where possible, transcribed verbatim, and entered into data analysis software. Using an inductive analysis approach, themes related to the topics and issues discussed in the interview process were identified. Results. Of the educators invited to participate, 17 completed an interview and were included in this study. Participants reported a paucity of resources available for teaching pharmacy ethics at schools in Australia and New Zealand. Compounding this issue was the lack of expertise and ad-hoc process educators used to create their courses. Assessment methods varied between institutions. Participants felt schools needed to move toward a more standardized pharmacy ethics course with clear and defined guidelines. Conclusion. This study identified many areas in pharmacy ethics that need improvement and revealed the need to develop resources and course structure that adhere to the highest level of Miller's pyramid, while using known frameworks to evaluate ethical competency.

Development and content validation of an instrument to support pharmaceutical counselling for dispensing of prescribed medicines

RATIONALE, AIMS, AND OBJECTIVES

Counselling is essential in drug dispensing, since it enables patients to receive and understand the information to correctly use their medicines. Although counselling is a quality indicator on drug dispensing, models that guide pharmacists in this practice are scarce. Thus, this study aimed to develop and validate the content of an instrument to support pharmaceutical counselling for dispensing of prescribed medicines.

METHOD

A two-stage validation study was conducted out from February to October 2017. The first stage involved the development of the instrument, and the second involved content validation. Instrument development included the following three steps: (1) drafting of the prototype; (2) an academic brainstorming meeting, and (3) a pre-Delphi process. Content validation was then conducted using the Delphi technique. At this stage, 40 pharmacists who were experts in drug dispensing, were invited to assess the instrument. Consensus among experts was calculated according to the content validity index (CVI).

RESULTS

The development stage generated three versions of the instrument: the prototype, Version 1 (modified after brainstorming meeting), and Version 2 (modified after the pre-Delphi process). Version 2 underwent the content validation process, in which 29 pharmacists participated during the first round (rate of return: 72.5%) and 23 of these during the second round (rate of return: 79.31%). All items obtained CVI > 0.82 and were thus considered to be validated. The final instrument comprised three components: suggestions for questions, dispensing process reasoning, and suggestions for counselling, and other conduct in 11 stages, each representing a step in the clinical reasoning process.

CONCLUSIONS

An instrument was developed to support pharmaceutical counselling for dispensing of prescribed medicines, suggesting main questions, counselling, and conduct to be taken by pharmacists, and its content validity was verified.

Do Swiss community pharmacists address the risk of sexually transmitted infections during a consultation on emergency contraception? A simulated patient study

Objectives: Since 2002, Swiss community pharmacists have dispensed emergency contraception (EC) as pharmacist-only medicine ideally using the official Swiss protocol. Our study aimed to determine pharmacists' resolution of an imaginary EC case, compliance with the protocol, and provision of information on the risk of sexually transmitted infections (STIs). Methods: We conducted a simulated patient study with 69 students who each visited a community pharmacy. The scenario started with the student requesting the 'morning after pill'. Current practice was assessed using an online evaluation form adapted from the Medication-Related Consultation Framework. Descriptive and statistical analyses were carried out. Results: All pharmacists correctly identified that the person needed EC. All pharmacists used an EC protocol and asked on average 10.9 (standard deviation 0.68) of 11 compulsory EC assessment questions. In total, 93% of pharmacists addressed EC counselling items and 56% addressed the risk of STIs, mainly by mentioning that condoms offered the best protection (76%). Conclusions: Community pharmacists correctly issued the EC, complied with the dispensing protocol and used their professional judgement to ensure optimal EC use. There is nevertheless room for improvement regarding pharmacists' STI counselling. Finally, the protocol's STI section could be enriched with specific information to guide counselling.

A systematic review of the use of simulated patient methodology in pharmacy practice research from 2006 to 2016

OBJECTIVES

Simulated patient (SP) methodology (mystery shopping) is used increasingly to assess quality of pharmacy services, and evaluate impact of interventions. Our objective was to review papers reporting on the use of SP methodology in pharmacy practice research 2006-2016 in community pharmacies worldwide.

METHODS

We searched EMBASE and MEDLINE for papers reporting on the use of mystery shopping in pharmacy settings, using a wide range of terms for SPs, based on previous review. We removed irrelevant papers, duplicates, papers not written in English, and review papers and reviewed remaining papers. Two reviewers carried out data abstraction, using the same tool as the previous review and inserting data into Excel, focusing on how the SP methodology is used.

KEY FINDINGS

A total of 148 papers from 52 countries from all regions of the world were included in the review. A wide range of terms described the method, and simulated patient was the most common (49 papers). Most studies were cross-sectional (124), and most investigated only community pharmacies (115). The most common aim was to evaluate some aspect of pharmacists' or other staff's advice and counselling (94). Number of visits is 2-7785. Many papers did not cover details, such as number of visits planned, and carried out, scenario used, training and background of SPs, and ethical approval for the study.

CONCLUSIONS

The use of SP methodology has increased substantially in the field of pharmacy over the past decade. This is a useful method in a wide range of countries and settings. Greater detail is required in reporting.

Development of a Theory-Based Intervention to Enhance Information Exchange during Over-The-Counter Consultations in Community Pharmacy

(1) Background: Community pharmacy personnel help mitigate risks of self-care by consumers who seek over-the-counter (OTC) medicines or treatment of symptoms and/or conditions. Exchange of information facilitates the OTC consultation, but pharmacy personnel often report difficulties in engaging consumers in a dialogue. The aim of this study was to describe the development of a behaviour change intervention to enhance information exchange between pharmacy personnel and consumers during OTC consultations in community pharmacies. (2) Methods: The Behaviour Change Wheel methodological framework was used to link factors that influence consumer engagement with information exchange during OTC consultations with intervention functions to change behaviour. Options generated were rationalized and the final intervention strategy was derived. (3) Results: Education, persuasion, environmental restructuring, and modelling were determined to be potential intervention functions. The intervention incorporated placing situational cues in the form of posters in the community pharmacy modelling information exchange behaviour, persuading through highlighting the benefits of exchanging information and educating about its importance. (4) Conclusions: A systematic, theoretically underpinned approach was applied to develop candidate interventions to promote information exchange in OTC consultations. The feasibility and efficacy of the intervention strategy has since been tested and will be reported elsewhere.

A systematic review of community pharmacies' staff diagnostic assessment and performance in patient consultations

BACKGROUND

Increases in patients seeking advice at pharmacies has led to pharmacy staff engaging in diagnostic behaviours. Approaches to diagnosis include using mnemonics and clinical reasoning.

OBJECTIVES

The primary aim of this review was to assess the degree to which the criteria researchers use to evaluate diagnostic performance in pharmacy consultations, in studies that have simulated patients or vignettes, conform with a clinical reasoning and a mnemonic framework. A secondary aim of the review was to characterize staff performance in the studies, based on the authors' comments of their results.

METHODS

MEDLINE, EMBASE and Web of Science were searched between October 2016 and April 2017. Only peer-reviewed studies assessing pharmacy staff's diagnostic performance using simulated patients or vignettes were eligible for inclusion. Data were extracted about how each study's criteria conformed with clinical reasoning and mnemonic frameworks. A scoring system between 0 and 4 was devised to determine the degree to which studies aligned to these two approaches. Risk of bias was assessed using the NHI Study Quality Assessment Tools. The review was registered in PROSPERO with identification number CRD42017054827.

RESULTS

Sixty-eight studies (55 cross-sectional, 11 educational interventions and 2 RCTs) with sample sizes between 10 and 2700 were included in the review. Most studies were of poor or fair quality. Performance of pharmacy staff was overwhelmingly reported as poor by study authors. This was the case regardless of geography, scenario used, or assessment framework adopted. Scrutiny on how authors arrived at these conclusions revealed that mnemonic criteria were employed to assess pharmacy staff's diagnostic performance rather than a clinical reasoning approach.

CONCLUSIONS

Potentially important aspects of the decision-making process, such as clinical reasoning, were left unexplored. The number and geographic distribution of the included studies is a strength of this review; however, a validated tool was not employed.

Barriers and Facilitators of Partner Treatment of Chlamydia: A Qualitative Investigation with Prescribers and Community Pharmacists

Chlamydia trachomatis is the most frequently-notified sexually transmitted infection in Australia. Effective and timely partner treatment of chlamydia is essential to reduce overall prevalence and the burden of infection. Currently in most of Australia, the only avenue for partner treatment of chlamydia (“standard partner therapy”) is a tedious, and often inconvenient, process. The barriers and facilitators of standard partner therapy, and newer models of accelerated partner therapy (APT), need to be identified in the Australian setting. Additionally, the potential role of community pharmacists need to be explored. Semi-structured interview guides for two key stakeholder groups (prescribers and pharmacists) were developed and piloted. Eleven prescribers (general practitioners, sexual health clinicians and nurse practitioners) and twelve pharmacists practicing in the Perth metropolitan region were interviewed. Key reported barriers to standard partner therapy were lack of or delayed chlamydia testing. Key facilitators included ability to test and educate sexual partner. Key barriers for APT included prescribers’ legal responsibility and potential for medication-related adverse effects. Healthcare provider consultation and chlamydia testing were seen as potential facilitators of APT. Pharmacists were receptive to the idea of expanding their role in chlamydia treatment, however, barriers to privacy must be overcome in order to be acceptable to prescribers and pharmacists.

Barriers and Facilitators for Information Exchange during Over-The-Counter Consultations in Community Pharmacy: A Focus Group Study

Consumers are confident managing minor ailments through self-care, often self-medicating from a range of over-the-counter (OTC) medicines available from community pharmacies. To minimise risks, pharmacy personnel endeavour to engage in a consultation when consumers present with OTC enquiries however they find consumers resistant. The aim was to determine stakeholder perspectives regarding barriers and facilitators for information exchange during OTC consultations in community pharmacies and to understand the elicited themes in behavioural terms. Focus groups were undertaken with community pharmacist, pharmacy assistant and consumer participants. Independent duplicate analysis of transcription data was conducted using inductive and framework methods. Eight focus groups involving 60 participants were conducted. Themes that emerged indicated consumers did not understand pharmacists' professional role, they were less likely to exchange information if asking for a specific product than if asking about symptom treatment, and they wanted privacy. Consumers were confident to self-diagnose and did not understand OTC medicine risks. Pharmacy personnel felt a duty of care to ensure consumer safety, and that with experience communication skills developed to better engage consumers in consultations. They also identified the need for privacy. Consumers need education about community pharmacists' role and responsibilities to motivate them to engage in OTC consultations. They also require privacy when doing so.

Application of process mapping to understand integration of high risk medicine care bundles within community pharmacy practice

OBJECTIVE

The Scottish Patient Safety Programme - Pharmacy in Primary Care collaborative is a quality improvement initiative adopting the Institute of Healthcare Improvement Breakthrough Series collaborative approach. The programme developed and piloted High Risk Medicine (HRM) Care Bundles (CB), focused on warfarin and non-steroidal anti-inflammatories (NSAIDs), within 27 community pharmacies over 4 NHS Regions. Each CB involves clinical assessment and patient education, although the CB content varies between regions. To support national implementation, this study aims to understand how the pilot pharmacies integrated the HRM CBs into routine practice to inform the development of a generic HRM CB process map.

METHODS

Regional process maps were developed in 4 pharmacies through simulation of the CB process, staff interviews and documentation of resources. Commonalities were collated to develop a process map for each HRM, which were used to explore variation at a national event. A single, generic process map was developed which underwent validation by case study testing.

RESULTS

The findings allowed development of a generic process map applicable to warfarin and NSAID CB implementation. Five steps were identified as required for successful CB delivery: patient identification; clinical assessment; pharmacy CB prompt; CB delivery; and documentation. The generic HRM CB process map encompasses the staff and patients' journey and the CB's integration into routine community pharmacy practice. Pharmacist involvement was required only for clinical assessment, indicating suitability for whole-team involvement.

CONCLUSIONS

Understanding CB integration into routine practice has positive implications for successful implementation. The generic process map can be used to develop targeted resources, and/or be disseminated to facilitate CB delivery and foster whole team involvement. Similar methods could be utilised within other settings, to allow those developing novel services to distil the key processes and consider their integration within routine workflows to effect maximal, efficient implementation and benefit to patient care.

Knowledge and opinion of pharmacists on emergency contraceptive pills in Hungary

Background Emergency contraceptive pills (ECPs) are used to prevent unintended pregnancy. There is a worldwide intention to improve access to ECPs; therefore, identifying potential barriers to introducing over-the counter (OTC) access is of utmost importance. As pharmacists are the key personnel to convey accurate drug information, their knowledge and attitude on ECPs is important. Objective We aimed to conduct a nationwide study to assess pharmacists' knowledge on ECPs and to survey their opinion on sales category change of ECPs (i.e. to introduce OTC access in pharmacies). Setting Registered pharmacists in Hungary. Method A prospective cross-sectional study was conducted with an anonymous, web-based questionnaire. Univariate analysis (Mann-Whitney U test and Fischer's exact test) was used to identify factors associated with supportive opinion toward OTC provision. Main outcome measure Knowledge level of pharmacists, proportion of pharmacists with supportive opinion on OTC access. Results 357 out of 2019 pharmacists completed the questionnaire, yielding a 17.7% response rate. Almost 30% of pharmacists (N = 99) agreed that ECPs should have an OTC availability in Hungary. More than 40% of pharmacists (N = 145) considered ECPs as contraceptives. On average, 55.18% (standard deviation: ±12.40%) of the answers were correct, showing moderate knowledge of the pharmacists. Age and rating ECPs as contraceptives were significantly associated with supportive opinion toward OTC provision (p < 0.001). The effect of knowledge on the pharmacist's opinion was significant in young pharmacists (p = 0.02). Conclusion Pharmacists' knowledge and opinion on ECPs should be improved, especially that of the young ones. Currently the attitude of pharmacists does not favor sales category changes of ECPs in Hungary.

Role of the community pharmacist in emergency contraception counseling and delivery in the United States: current trends and future prospects

Women and couples continue to experience unintended pregnancies at high rates. In the US, 45% of all pregnancies are either mistimed or unwanted. Mishaps with contraceptives, such as condom breakage, missed pills, incorrect timing of patch or vaginal ring application, contraceptive nonuse, forced intercourse, and other circumstances, place women at risk of unintended pregnancy. There is a critical role for emergency contraception (EC) in preventing those pregnancies. There are currently three methods of EC available in the US. Levonorgestrel EC pills have been available with a prescription for over 15 years and over-the-counter since 2013. In 2010, ulipristal acetate EC pills became available with a prescription. Finally, the copper intrauterine device remains the most effective form of EC. Use of EC is increasing over time, due to wider availability and accessibility of EC methods. One strategy to expand access for both prescription and nonprescription EC products is to include pharmacies as a point of access and allow pharmacist prescribing. In eight states, pharmacists are able to prescribe and provide EC directly to women: levonorgestrel EC in eight states and ulipristal acetate in seven states. In addition to access with a prescription written by a pharmacist or other health care provider, levonorgestrel EC is available over-the-counter in pharmacies and grocery stores. Pharmacists play a critical role in access to EC in community pharmacies by ensuring product availability in the inventory, up-to-date knowledge, and comprehensive patient counseling. Looking to the future, there are opportunities to expand access to EC in pharmacies further by implementing legislation expanding the pharmacist scope of practice, ensuring third-party reimbursement for clinical services delivered by pharmacists, and including EC in pharmacy education and training.

Evaluating the practice of Iranian community pharmacists regarding oral contraceptive pills using simulated patients

BACKGROUND

As oral contraceptive pills are available over the counter in pharmacies, pharmacists are professionally responsible for checking and informing patients about every aspect of taking these drugs. Simulated patient method is a new and robust way to evaluate professional performance of pharmacists.

OBJECTIVE

The aim of the present study was to evaluate the pharmacy practice of Iranian pharmacists regarding over-the-counter use of oral contraceptive pills using simulated patient method.

METHODS

Simulated patients visited pharmacy with a prescription containing ciprofloxacin and asked for oral contraceptive pills. The pharmacist was expected to ask important questions for using these drugs and to inform the patient about them properly. Moreover, the Pharmacists should advise patients in regard to the possible interaction.

RESULTS

Ninety four pharmacists participated in this study. In 24 (25.3%) visits, the liable pharmacist was not present at the time of purchase. Furthermore, In 13 (18.57 %) visits by the simulated patients, the liable pharmacists did not pay any attention to the simulated patients even when they asked for consultation. Twenty nine (41.43%) pharmacists did not ask any question during dispensing. Nausea was the most frequent described side effect by pharmacists (27 (38.57%)). Yet important adverse effects of oral contraceptive pills were not mentioned by the pharmacists except for few ones. Only twelve (17.14%) pharmacists mentioned the possible interaction. There was a significant relation between the pharmacists' gender and detection of possible interaction (p value= 0.048).

CONCLUSION

The quality of the pharmacists' consultations regarding the over the counter use of oral contraceptive pills was not satisfactory and required improvement.

Utilization of community pharmacy space to enhance privacy: a qualitative study

Background

Community pharmacists require access to consumers’ information about their medicines and health‐related conditions to make informed decisions regarding treatment options. Open communication between consumers and pharmacists is ideal although consumers are only likely to disclose relevant information if they feel that their privacy requirements are being acknowledged and adhered to.

Objective

This study sets out to explore community pharmacy privacy practices, experiences and expectations and the utilization of available space to achieve privacy.

Methods

Qualitative methods were used, comprising a series of face‐to‐face interviews with 25 pharmacists and 55 pharmacy customers in Perth, Western Australia, between June and August 2013.

Results

The use of private consultation areas for certain services and sensitive discussions was supported by pharmacists and consumers although there was recognition that workflow processes in some pharmacies may need to change to maximize the use of private areas. Pharmacy staff adopted various strategies to overcome privacy obstacles such as taking consumers to a quieter part of the pharmacy, avoiding exposure of sensitive items through packaging, lowering of voices, interacting during pharmacy quiet times and telephoning consumers. Pharmacy staff and consumers regularly had to apply judgement to achieve the required level of privacy.

Discussion

Management of privacy can be challenging in the community pharmacy environment, and on‐going work in this area is important. As community pharmacy practice is increasingly becoming more involved in advanced medication and disease state management services with unique privacy requirements, pharmacies’ layouts and systems to address privacy challenges require a proactive approach.

Non-prescription treatment of NSAID induced GORD by Australian pharmacies: a national simulated patient study

BACKGROUND

Patients regularly present to community pharmacies for advice about and treatment for reflux symptoms and NSAIDs are a common cause of these symptoms. There is no published literature detailing the approach that pharmacies take to these enquiries, the pharmacotherapy they recommend or whether they contribute to the safe and effective use of reflux medicines.

OBJECTIVES

To assess in an observational study design the clinical history gathering, recommendations for GORD management and counselling provided by community pharmacies in a simulated patient scenario involving suspected NSAID induced reflux symptoms. Setting Australian community pharmacies.

METHOD

Simulated patients visited 223 community pharmacies to request treatment for reflux symptoms. The interaction was audiotaped and assessed against guidelines for the treatment of reflux symptoms.

MAIN OUTCOME MEASURES

Alignment of community pharmacies with international expert gastroenterologist guidance and national professional practice guidelines for the treatment of reflux symptoms by pharmacists including: consultation with a pharmacist; confirmation of reflux diagnosis based on symptoms; recommendation of short courses proton pump inhibitor (PPI) therapy; advice on the safe and effective use of reflux medicines and referral to a doctor for further assessment.

RESULTS

Pharmacists consulted with the simulated patient in 77% of cases. Symptoms were enquired about in 95% of cases and a medicines history taken in 69% of cases. Recommendations for treatment included: PPIs (18%), histamine H2 antagonists (57%) and antacids (19%). Advice on product use was given in 83% of cases. Referral to a doctor to discuss reflux symptoms was made in 63% of cases.

CONCLUSION

When assessing patients for the symptoms of GORD, Australian pharmacists and non-pharmacist support staff take a comprehensive history including symptomatology, duration of symptoms, concomitant medicines and medical conditions and any GORD treatments previously trialled. They provide comprehensive counselling on the use of antisecretory and antacid medicines. Counselling could involve more comprehensive information on lifestyle approaches for GORD management and side effects of antisecretory and antacid medicines. Further alignment with guidelines for the management of GORD would result in greater referral to a doctor for assessment of recurrent GORD and greater recommendation of PPIs for symptoms. However alignment with guidelines by all pharmacists is unrealistic if the guidelines are not universally available to them.

Quality supply of nonprescription medicines in Portuguese community pharmacy: An exploratory case study

BACKGROUND

Inappropriate use of non-prescription medicines (NPM) can increase morbidity, mortality and health care associated costs. Pharmacists have a well-established role in self-medication; however, the literature shows that pharmacies performance in the supply of NPM is often suboptimal.

OBJECTIVE

To explore the interaction and dependability of pharmacy staff use of oral language, as well as staff's own assessment of reasons underlying their behavior during consultation regarding NPM.

METHODS

In a case-study design, a high street urban community pharmacy was purposively selected as the setting. Covert patient simulation, using trained simulated patients (SPs), was used to ascertain staff's performance in dispensing NPM, via 4 symptom-based scenarios (SbS) and 3 product-based scenarios (PbS). Performance data were converted into 2 composite indexes: the Interpersonal Performance Index (IPI) and Technical Performance Index (TPI). Audiotaped interactions were transcribed verbatim and participants' utterances were identified, time stamped and coded employing the eight higher level categories of a framework inspired by the Roter interaction analysis system (RIAS). The transcripts of the in-depth interviews were analyzed using the Framework Approach. The tripartite model of attitudes was employed to develop the thematic framework.

RESULTS

Ten SP visits were considered for analysis. Overall, the mean TPI score was 50% and the mean IPI score was 78%. TPI was higher for SbS (63%) than PbS (31%), whilst there was little difference IPI between SbS (79%) and PbS (76%). The mean number of questions in the evaluation section of technical performance was 4 for SbS and 1 for PbS. There was a clear predominance of closed questions (32%), when compared with open questions (5.5%). Providing advice was more frequent (23.5%) than giving information (12.5%). In line with the SPs data, comparison of information-gathering in SbS and PbS shows that more questions were asked in the former (44% versus 31%), which resulted in more information given by SPs (56% and 49%, respectively). Staff's reaction to their performance showed all the 3 dimensions of attitude: affective, cognitive and behavioral. Divergence between staff's views on what should be done in NPM consultations and performance data surfaced in the interviewees' accounts on direct product requests. While performance data shows that information gathering was scarce, its importance was overtly acknowledged.

CONCLUSIONS

The supply of NPM appears to be influenced by both cognitive and emotional issues. This suggests that multimodal improvement interventions are needed, targeting not only technical and interpersonal communication skills but also the organizational context. Managerial tools such as the balanced scorecard, may prove valuable in addressing improvement in the quality supply of NPM.

Provision of smoking cessation services in Australian community pharmacies: a simulated patient study

BACKGROUND

With the rising interest in expanding pharmacists' role in smoking cessation, it is pertinent that community pharmacists be equipped with up-to-date knowledge and competence to provide optimal therapeutic services that meet the demands of various presenting subsets of smokers.

OBJECTIVE

To investigate and evaluate responses to requests of quitting smoking from 'high risk' smokers seeking assistance and treatment within the pharmacy venue.

SETTING

Community pharmacies located within Sydney greater metropolitan area, New South Wales, Australia.

METHOD

A simulated patient methodology was utilised. Two scenarios were developed and enacted by two trained simulated patients in 100 randomly selected pharmacies. Scenario 1 involved a 28-year-old pregnant female who presents with a request for help in quitting smoking. Scenario 2 involved a 22-year-old female requesting a quit smoking product for her 55-year-old father who has cardiovascular problems. A standardised scoring key was designed to assess the performance of pharmacists during each encounter.

MAIN OUTCOME MEASURE

The primary outcome measure was the supply/non-supply of nicotine replacement products and the corresponding provision of counselling and advice to facilitate smoking cessation.

RESULTS

A product(s) was supplied in 42 % of the 100 encounters, while a product was adequately suggested pending doctor's referral in 45 %. In 13 % of the cases, a product was not supplied based on inappropriate notions of nicotine replacement therapy not being safe in the presented scenario. Pharmacists performed better in dispensing scores (counselling about product use) as compared to pre-dispensing scores (eliciting patient history). ANOVA followed by regression analysis indicated that the estimated age and gender of the pharmacist/staff were significant predictors affecting total scores.

CONCLUSION

Whilst pharmacists' counselling about smoking cessation aids seems satisfactory, further education is required to improve practice standards in terms of matching a patient's history and smoking status to an appropriate product.

The use of a written assessment checklist for the provision of emergency contraception via community pharmacies: a simulated patient study

Background

The Pharmaceutical Society of Australia recommends use of a written assessment checklist prior to supply of emergency contraception by pharmacists.

Objective

The aim of this research was to determine the prevalence of use of a written assessment checklist by community pharmacists and secondly, to ascertain the effect of the checklist on appropriate assessment and supply.

Methods

Three female simulated patients visited 100 randomly selected pharmacies requesting supply of ‘the morning after pill’. Information provided when assessed by the pharmacist was that she had missed one inactive pill of her regular hormonal contraception. The amount of assessment provided and the appropriateness of supply were used as comparative outcome measures.

Results

Eighty-three pharmacies used a written assessment checklist. Twenty-four of the pharmacies visited provided the appropriate outcome of non-supply. Pharmacies that used a written assessment checklist provided a greater quantity and consistency of assessment (11.3 ±2.5 v. 6.5 ±3.8 questions, p<0.0001) but this did not result in an improved frequency of an appropriate outcome (20%, n=16 v. 23%, n=3).

Conclusions

While a written patient assessment checklist improved the quantity and consistency of patient assessment, it did not improve the advice provided by community pharmacies when handling requests for emergency contraception.

Management of over-the-counter insomnia complaints in Australian community pharmacies: a standardized patient study

Objective

To evaluate the current management of over-the-counter (OTC) insomnia complaints in Australian community pharmacies using standardized patient methodology.

Methods

Trained standardized patients visited a sample of 100 randomly selected South East Queensland community pharmacies in June 2011. The standardized patients enacted two OTC insomnia scenarios: a direct product request (DPR) (n = 50) and a symptom-based request (SBR) (n = 50). Results of the interactions were documented immediately after each visit and evaluated using the Pharmaceutical Society of Australia's WHAT STOP GO protocol as a standard comparison.

Key findings

Of all DPRs, 30% were handled entirely by the pharmacist, 70% of staff enquired about specific symptoms and 28% investigated the cause of insomnia. No staff investigated the frequency of product use. The DPR scenario resulted in a 92% supply of the requested doxylamine product (Restavit). In the SBR scenario, 18% of requests were handled entirely by the pharmacist, 58% of staff enquired about specific symptoms and 44% investigated the cause of insomnia. Staff recommended medicated products (38%), or herbal (78%) or non-drug techniques (18%). Investigation into smoking and alcohol intake was not undertaken in DPR or SBR interactions, while questioning on caffeine intake was undertaken in 2 and 14% of cases respectively. There were no significant differences found in the handling of sleep requests by pharmacists compared to pharmacy assistants.

Conclusion

The standardized patient methodology was a successful way to assess the community pharmacy counselling provided with OTC sleep requests and suboptimal staff responses were found when compared with recommended practice standards.

Nova Scotia pharmacists' knowledge of, experiences with and perception of factors interfering with their ability to provide emergency contraceptive pill consultations

Objective

The objective of this research was to explore pharmacists' knowledge of, experiences with and perception of factors interfering with their ability to provide non-prescription emergency contraceptive pill consultations in the Canadian province of Nova Scotia.

Methods

A self-administered paper questionnaire was mailed, using Dillman's tailored design method, to all pharmacists (n = 1123) registered with the Nova Scotia College of Pharmacists.

Key findings

The response rate was 53.0% (595/1123), with 451 respondents working in community practice. Most respondents reported that they had provided consultations for the emergency contraceptive product Plan B since it became available without a prescription (93.6%), and that Plan B is kept behind the pharmacy counter (83.6%). Pharmacists most frequently (47.8%) reported spending 6–10 min providing Plan B consultations. Respondents were generally knowledgeable about Plan B; however, only 39.2% knew that it can be effective for up to 5 days and 69.3% knew that the incidence of vomiting is less than 50%. The factors interfering the most with providing Plan B consultations were lack of privacy (46.1%) and lack of staff to cover during the consultation (50.9%).

Conclusions

In general, Nova Scotia pharmacists are knowledgeable about emergency contraceptive pills; however, education regarding effective timing for use of such pills would be helpful. Private areas for counselling and consideration of pharmacy staffing schedules in community pharmacies may help address pharmacist concerns regarding their ability to provide Plan B consultations.

A review of the information-gathering process for the provision of medicines for self-medication via community pharmacies in developing countries

BACKGROUND

Currently, no review has been completed regarding the information-gathering process for the provision of medicines for self-medication in community pharmacies in developing countries.

OBJECTIVE

To review the rate of information gathering and the types of information gathered when patients present for self-medication requests.

METHODS

Six databases were searched for studies that described the rate of information gathering and/or the types of information gathered in the provision of medicines for self-medication in community pharmacies in developing countries. The types of information reported were classified as: signs and symptoms, patient identity, action taken, medications, medical history, and others.

RESULTS

Twenty-two studies met the inclusion criteria. Variations in the study populations, types of scenarios, research methods, and data reporting were observed. The reported rate of information gathering varied from 18% to 97%, depending on the research methods used. Information on signs and symptoms and patient identity was more frequently reported to be gathered compared with information on action taken, medications, and medical history.

CONCLUSION

Evidence showed that the information-gathering process for the provision of medicines for self-medication via community pharmacies in developing countries is inconsistent. There is a need to determine the barriers to appropriate information-gathering practice as well as to develop strategies to implement effective information-gathering processes. It is also recommended that international and national pharmacy organizations, including pharmacy academics and pharmacy researchers, develop a consensus on the types of information that should be reported in the original studies. This will facilitate comparison across studies so that areas that need improvement can be identified.

Requests for emergency contraception in community pharmacy: an evaluation of services provided to mystery patients

BACKGROUND

Requests for supply of the emergency contraceptive pill (ECP) through community pharmacies require consideration of a range of factors and the application of professional judgment. Pharmacists should therefore be able to follow a structured reasoning process.

OBJECTIVES

The research involved an assessment of history taking and counseling by pharmacy staff through mystery patient emergency contraception product requests.

METHODS

Two challenging ECP request case scenarios were developed with assessment tools. Mystery patients were trained to present the scenarios to pharmacies. A project information package and expression of interest form was posted to 135 pharmacies in the Gold Coast, Australia; 23 (17%) pharmacies agreed to participate.

RESULTS

Pharmacy staff was exposed to 1 of 2 scenarios during December 2010. Staff interactions were recorded, analyzed, and rated to evaluate the management of ECP requests. The results identified practice gaps among pharmacy staff with respect to information gathering and the provision of advice.

CONCLUSION

Ongoing training is required to enhance the skills, competence, and confidence of pharmacy staff in managing complicated requests for nonprescription medicines, such as the ECP. The impact of time pressures and financial burdens on the provision of pharmaceutical services needs to be acknowledged.