RESEARCH ARTICLES Pharmacy Students Perceptions of Pharmaceutical Care in Retail and Clinic Settings

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1 RESEARCH ARTICLES Pharmacy Students Perceptins f Pharmaceutical Care in Retail and Clinic Settings Lesa Lawrence, PhD, Justin Sherman, PharmD, Edwin Adams, PharmD, and Shravanthi Gandra, MPharm Schl f Pharmacy, Cllege f Health Sciences, The University f Luisiana at Mnre Submitted Octber 7, 2002; accepted July 28, 2003; published March 5, Objectives. T determine whether cmpletin f a patient cunseling curse imprved pharmacy students perceptins f the imprtance f pharmaceutical care and whether there was a difference in students perceptins f pharmaceutical care prvided in retail settings cmpared t that prvided in clinic settings. Methds. A pre-curse and pst-curse survey instrument was designed t measure students perceptins f the imprtance f pharmacists perfrming 20 items describing pharmaceutical care. Als, each student wrte a technical reprt describing a cunseling encunter bserved between a pharmacist and a patient. This reprt was subject t cntent analysis. Results. After taking a patient cunseling curse, students perceived five ut f 20 pharmaceutical care tasks perfrmed by pharmacists t be mst imprtant. Als, student analyses f pharmacist/patient interactins indicated that barriers t cmmunicatin were fewer, students experiences were mre educatinal, and privacy, mnitring and assessment were better in clinic settings. Accrding t students perceptins, the applicatin f pharmaceutical care was different between clinic and retail settings. Cnclusins. Therefre, teaching the cncept f pharmaceutical care and incrprating it int a patient cunseling curse is mre educatinal when a clinic setting is used. Keywrds: pharmaceutical care, patient cunseling, clinic, cmmunity pharmacy INTRODUCTION Pharmaceutical care has been described as a multifaceted prcess that results in psitive utcmes fr patients thrugh identificatin, reslutin, and preventin f drugrelated prblems. 1 Fr many years, pharmacists have been in transitinal rles, mving tward a target f prviding pharmaceutical care. Thrugh strategic planning, pharmacy schls anticipated this transitin and have begun preparing students fr evlving prfessinal rles with mre patient-centered care and cunseling, expanded drug use mnitring, apprpriate drug selectin, and respnsibility fr patient utcmes. Pharmacy schls have a duty t prvide pharmaceutical care educatin fr students regardless f future practice settings since the fundamental elements exist in a variety f settings. 1 Teaching methds shuld be designed t instruct students hw t prvide pharmaceutical care with a prcess t evaluate students ability t prvide this care. 2 Prjects implemented t evaluate the prvisin f pharma- Crrespnding Authr: Lesa Lawrence, PhD. Address: Schl f Pharmacy, Cllege f Health Sciences, The University f Luisiana at Mnre, Mnre, LA Tel: Fax: lawrence@ulm.edu 1 ceutical care in simulated settings have been described in the literature. 3 Althugh pharmacy students are taught in the classrm, students shuld als be expsed t practice envirnments at an early stage in their curriculum. This will help empwer them t practice in cvenant relatinships with patients. A natinal survey distributed t pharmacy schl faculty wh teach cmmunicatin revealed that the mst innvative prgrams teach cmmunicatin skills early, with additinal curses t integrate and reinfrcement cmmunicatin thrughut the curriculum. 4 Furthermre, the respndents in the survey valued the use f real patients and practitiners t assist in teaching cmmunicatin skills. This allwed students t view their learning experience within the cntext f actual pharmacy practice. While pharmacy schl educatrs are preparing graduates fr greater rles in patient care, students may develp frustratin because f a pssible mismatch between what is taught and hw pharmacists practice. 5 Sme students may nt perceive the value f educatin centered n pharmaceutical care in different practice envirnments. The attitudes and skills f pharmacists themselves may serve as barriers t prviding pharmaceutical care. 6 Phar-

2 macy schl educatrs are cuntering this perceptin f pharmaceutical care as an ideal and nt a reality by expsing students t experienced practitiners wh practice in a variety f settings and by using actual patients in the classrm. 4,7 It is imprtant t cnsider whether students perceptins and bservatins validate teaching f pharmaceutical care when students are intrduced t different practice envirnments early in the pharmacy schl curriculum. Expsure f students t innvative practice mdels may fster develpment f thse mdels. 5 This is a cncept that is practiced in ther health care prfessins, such as medicine and dentistry Learning patient care cncepts by mdeling preceptrs prepares students t care fr patients in a realistic practice envirnment. Students perfrm better and with increased prductivity cmpared with their perfrmance in a labratry setting. 10 This research was designed t examine hw pharmacy students perceive the imprtance f pharmaceutical care and t cmpare these perceptins between retail and clinic practice settings. Als, students perceptins cncerning the imprtance f 20 aspects f pharmaceutical care were measured befre and after a patient cunseling curse. 2 METHODS This study was designed t determine whether cmpletin f a patient cunseling curse imprved pharmacy students perceptins f the imprtance f pharmaceutical care and t determine whether there was a difference in students perceptins f pharmaceutical care prvided in retail settings cmpared t that prvided in clinic settings. The first bjective was addressed using a singlegrup, befre-after study design. A pretest was administered t 81 secnd-year Dctr f Pharmacy students wh were enrlled in the Patient Cunseling and Cmmunicatin curse (PHAR 385). An utline f the tpics cvered in this curse is included as Appendix 1. The bjective f this curse was fr students t understand the principles and techniques f cmmunicatin applicable t pharmacy practice. All pharmacy students enrlled at The University f Luisiana at Mnre are required t cmplete this curse in their secnd year f prfessinal schl. A survey instrument was designed t measure students perceptins f the imprtance f pharmacists perfrming 20 items describing pharmaceutical care. A pretest was administered during the first week f classes during the Fall 2001 semester. A Likert scale measuring the level f imprtance was used, with 1 equaling unimprtant and 4 equaling very imprtant. A psttest using the same items was administered t students during the last week f classes in December Fr the secnd bjective, each student was assigned t write a technical reprt fllwing a prescribed utline describing a cunseling encunter bserved between a pharmacist and a patient. A cunseling encunter was defined as ne-t-ne interpersnal cmmunicatin between a pharmacist and a patient cncerning the patients medical cnditin and/r prescriptin fr medicatin. Students were required t schedule an appintment with a pharmacist befre bserving the encunter. Fr the bservatin, each student selected either a retail r clinic pharmacy practice setting. Frty-seven students bserved a pharmacist in a retail setting and 34 bserved a pharmacist in a clinic setting. A retail setting was peratinally defined as a chain r independent pharmacy where prescriptins fr pharmaceuticals were filled and dispensed. Pharmacy students wh already served as interns fr a retail pharmacy were allwed t bserve at the practice site where they wrked. The alternate setting was an ambulatry care clinic. Students wh self-selected a clinic pharmacy practice setting had a chice f bserving a pharmacist in either the anticagulatin clinic r the diabetes-care clinic. The pharmacists wh cnducted bth clinics were independently respnsible fr prviding primary care. They maintained care f patients between regularly scheduled physician appintments. This care included btaining patient histry infrmatin, cnducting a physical assessment, rdering r perfrming labratry tests, manipulating drug therapy, and scheduling fllw-up visits. Nne f the pharmacy students wh chse t bserve either f the ambulatry care clinics had ever been expsed t this type f practice setting. Students technical reprts were graded based n cmpleteness f the assignment. The reprts were later analyzed using cntent analysis methdlgy. Students were nt aware f the methdlgy used in this study. Althugh cntent analysis has been used in the scial sciences t identify trends within the discipline, it has als been used t assess literature that relates t cntrversial medical issues Specifically within the field f medicine, cntent analysis has been used t identify whether cntrversial scientific papers use language that is factual r emtinal. 11 This methdlgy has als been used t analyze written messages t physicians frm third year pharmacy students regarding alternative drug therapy recmmendatins. 15 Pharmaceutical Care Variables Each pharmaceutical care variable was peratinally defined as part f cntent analysis methdlgy. The fllwing variables were cnsidered cmpnents f cunseling sessins between pharmacists and patients that wuld mst likely ccur in bth types f practice settings. The variables were extracted frm research literature n the cre elements f pharmaceutical care, including the prvisin f drug infrmatin, educatin, and mnitring f drug therapy utcmes. 1-4,16 Students were required t describe the fllwing as-

3 pects f the cunseling sessins between pharmacists and patients using a preset utline that related t these variables: Barriers t cmmunicatin: physical and emtinal barriers t cmmunicatin, such as the check-ut register, nise, hearing impairment, etc; Dsing and directins: pharmacist cunseling n dsing and directins fr medicatins, taking medicatins with r withut fd, and specific drug/fd interactins, drug/drug interactins, and/r drug/disease state interactins; Educatinal experience: the educatinal value f bserving the cunseling sessin frm a pharmacy student perspective and whether they learned anything frm their bservatin; Mnitring and assessment: The pharmacists mnitring f the disease cnditin f the patient and their assessment f any tests that had been cnducted; Use f pen-ended questins: The pharmacist s use f pen-ended questins (thse starting with wrds such as What, Hw, r Why ) t assess the patients knwledge f their drug therapy. Privacy during the cunseling sessin: the privacy f the cunseling sessins (excluding any student bservers) and whether designated cunseling areas. Cntent Analysis Students technical reprts f the cunseling sessins they bserved between pharmacists and patients were evaluated by a graduate student using cntent analysis f the technical reprts accrding t a prescribed cntent analysis methdlgy. A sample f 10 reprts was analyzed again 30 days after the initial cding. Intra-rater reliability was 100%. The data were entered in Access 2000 and were analyzed using Statistix, Versin 7.0 Wilcxn Rank Sum Test with an alpha level f Using the peratinal definitin each variable, cding was as fllws: Barriers t Cmmu- r nicatin: Cded (yes r n) fr the presence absence f barriers t cmmunicatin, physical r emtinal. Dsing and Directins: Cded (yes r n) whether r nt there was cunseling n dsing and directins fr medicatins, n taking medicatins with r withut fd, and n specifics regarding drug/fd interactins, drug/drug interactins, r drug/disease state interactins. Educatinal Experience: Each reprt was cded as cntaining ne f the fllwing patterns: The student stated that they were disappinted with the cunseling sessin that 3 they bserved. The student was satisfied with the cunseling sessin but stated that it needed imprvement r listed sme ways that the cunseling sessin culd be imprved. The student liked what they saw and did nt mentin any ways t imprve the sessin. Mnitring and Assessment: Mnitring f the disease cnditin f the patient and assessment f any tests cnducted (yes r n). Use f Open Ended Questins that started with What, Hw, r Why r if the student stated that pen-ended questins were used (cded yes r n). Privacy During the Cunseling Sessin: Each reprt was cded as cntaining ne f the fllwing patterns: The student did nt mentin privacy. The sessin was nt private at all. The student either mentined this as a fact r stated that the cunseling sessin tk place thrugh a drive-thrugh-windw r near a cash register. The sessin was semi-private but still had the pssibility f ther persns bserving r listening t the sessin. The cunseling sessin tk place in a private rm. RESULTS Objective 1 Of the 20 pharmaceutical care activities listed, 5 were cnsidered by students t be significantly mre imprtant at the end f a curse n patient cunseling. Table 1 shws the beginning and ending ranking f each f the items included in the study. Of these 20 items, 9 had a pretest mean scre f 3.5 r greater n the 4-pint Likert scale. Thse items n which students placed significantly greater imprtance at the end f the semester were the fllwing: prviding fllw-up services fr drug therapy, perfrming limited physical examinatins including btaining vital signs in rder t initiate, mnitr, and adjust drug therapy, btaining labratry tests r ther medical recrds in rder t adequately cunsel the patient regarding changes in drug therapy, accessing patient medical recrds t adequately dcument all patient care activities prvided by the pharmacist, and detecting nnverbal cues in thers. Nt all scres were higher at the end f the semester. The students ranked five f the items as having less

4 Table 1. Results f pretests (N=80) and psttests (N=71) measuring the imprtance f pharmaceutical care activities perfrmed by pharmacists The pharmacists ability t: Pretest Mean Psttest Mean P Identify expected utcmes f drug therapy Select parameters f patient care t mnitr Prvide fllw-up services fr drug therapy * Perfrm limited physical exams * Obtain lab recrds * Discuss patient with physician Interview patients Access t patient recrds * Make dse adjustments Prvide cmplete drug therapy infrmatin Have accurate inf n all meds currently taken by patient Have inf n tcs Receive cmpensatin fr all activities related t patient care Cmmunicate with ther members f health care team Recgnize patient persnality traits Detect nnverbal cues * Listen t patients Manage cnflict Use assertiveness effectively Cmmunicate with special patients =unimprtant; 2 = smewhat imprtant; 3 = imprtant; 4 = very imprtant * significant at alpha imprtance than at the beginning f the semester althugh this change was nt statistically significant. Thse items were: identifying expected utcmes f drug therapy, selecting parameters f patient care t mnitr, cmmunicating t the patient s physician changes in drug therapy, having an accurate and cmplete list f all medicatins taken by the patient, including ver-the-cunter and prescriptin medicatins, and cmmunicating with special patients. Objective 2 The results f cntent analysis f the students technical reprts shwed that 4 f the 6 pharmaceutical variables included in this part f the study were practiced in clinic settings mre than in retail settings. Specifically, thse items were: fewer barriers t cmmunicatin, better educatinal experience, mre privacy during the cunseling sessin, and mre mnitring and assessment f patients cnditin. The results f Wilcxn Rank Sum Test using Statistix, Versin 7.0 are included in Table 2. 4 Table 2. Cmparisn f retail and clinic pharmaceutical variables. Mean Rank Variable Retail Clinic P Barriers t cmmunicatin * Dsing and directins Educatinal experience * Mnitring and assessment * Use f pen-ended questins Privacy during cunseling * *significant at alpha Nte: Mean rank values indicate the presence f the variable in the bserved setting. DISCUSSION The finding that nly 5 f 20 pharmaceutical care variables were cnsidered by students t be mre imprtant at the end f the semester may be explained by the fact that many f these activities already were rated as highly imprtant by the students at the beginning f the semester; thus further raising the level f imprtance as perceived by the students was difficult t accmplish. In additin t the items included in the curse utline, students learned the imprtance f fllw up, perfrming physical assessments, using labratry tests results, having access t patient recrds, and detecting nnverbal cues as an imprtant part f pharmaceutical care.

5 Cntent analysis f technical reprts was used t cmpare pharmaceutical care emplyed in different practice settings as perceived by pharmacy students. Hwever, several limitatins t the study may have resulted frm using tw different ambulatry care clinics fr student bservatin. Differences in the clinic settings included patient ppulatin served, diseases mnitred (ie, diabetes versus anticagulatin care), age f the patient ppulatin, and pharmacists interactins with patients physicians (ie, independent versus nsite physicians). Als, ambulatry care clinics reflect a cntinuum f care, while patients in retail settings interact with pharmacists in a limited (ie, ne-time) cunseling and dispensing prcess. This inherent difference in practice sites may have als skewed the results f the study. Fr example, care fr patients in the clinic setting may nt require an extensive cunseling sessin with penended questins if that particular patient had been seen by the pharmacist several times already. Furthermre, clinic settings require that pharmacists fcus n each patient s unique prblem instead f fllwing the standard cunseling and dispensing prcess that ccurs in retail settings. Further limitatins may als be inherent in the study since a cmparisn amng the different retail settings culd nt be made. Since the students were allwed t chse the retail setting in which t cmplete the prject, variatins in prescriptin vlume, whether the pharmacy was adequately staffed, and custmer demgraphics culd have influenced the utcmes reprted in the technical reprts. All f these factrs have the ptential t increase barriers t cmmunicatin. Furthermre, previus expsure t a particular retail setting culd have intrduced either a psitive r negative bias. Specifically, mre students wh bserved the retail pharmacy envirnment identified a lack f privacy in this setting. Inadequate privacy has been identified in the literature as an impediment in the delivery f pharmaceutical care in the retail setting. 17 Indeed, several f the technical reprts f retail settings explicitly stated that the cmmn practice f cnducting the patient interview thrugh the drive-thrugh windw r t the side f the check-ut cunter was a barrier t patient care. Students recgnized the imprtance f decreasing barriers in rder t achieve gd cmmunicatin. Althugh cmmunicatin is just ne cmpnent in the prvisin f pharmaceutical care, it has been assciated mre frequently with patient satisfactin. 18 The students perceptins that clinics ffered a better educatinal experience culd be explained because these settings may allw fr the creatin f a learning climate where the teaching encunter is planned in advance. 19 Preceptrs can create a learning envirnment within a 5 clinic setting by selecting patients that match the abilities f the student and by briefing the student n the patient s relevant histry prir t the encunter. Preceptrs can als mdel caring attitudes and behavirs, values, and patterns f thinking in additin t clinical practices. 20,21 Furthermre, students expsed t such a learning envirnment may begin t understand the relevance f the breadth f material taught in the curriculum. Fr example, ne student stated in the technical reprt that the fast pace and structure f the clinic experience made her aware f the preparatin that wuld be needed t take care f patients in the future. CONCLUSIONS At the end f a semester curse n patient cunseling and cmmunicatin, students rated nly 5 f 20 pharmaceutical care activities perfrmed by pharmacists as having higher imprtance than at the beginning f the semester. When cmparing retail and clinic settings fr bservatin f pharmaceutical care activities, students perceived the applicatin f 4 f 6 pharmaceutical care variables as mre significant in clinic practice settings. Specifically, the students nted fewer barriers t cmmunicatin, mre privacy during cunseling, and greater mnitring and assessment in the clinic practice setting. Thse students als reprted having a better educatinal experience than students wh cnducted their bservatin in a retail pharmacy setting. The pharmaceutical care variables that did nt appear t differ significantly between retail and clinic settings were pharmacist s explanatin f dsing and prvisin f directins t the patient, and the pharmacist s use f pen-ended questins. Althugh the specific cmpnents f pharmaceutical care and pharmacy care standards and hw they are applied may vary frm setting t setting, the results f this study d nt imply that pharmacists serving in retail envirnments lack the ability t prvide quality pharmaceutical care. Pharmaceutical care can be practiced in a variety f settings including utpatient care, clinic and retail settings, and inpatient care. 1 In rder t enhance clinical skills amng pharmacists practicing in retail envirnments, a number f training prgrams and wrkshps have been develped The clinical skills targeted fr imprvement, such as analyzing drug and disease infrmatin, identifying drug-related prblems, and cllecting pertinent patient infrmatin, are the nes mst ften used in actual pharmaceutical practice. 22 REFERENCES 1. Hepler CD, Strand LM. Opprtunities and respnsibilities in pharmaceutical care. Am J Hsp Pharm. 1990;47: Ciplle RJ, Strand LM, Mrley PC. Pharmaceutical Care Practice. New Yrk, NY: McGraw-Hill Cmpanies; 1998.

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