HEALTH SERVICES RESEARCH METHODS IN PHARMACY: Focus groups and observation studies

Drug change: 'a hassle like no other'. An in-depth investigation using the Danish patient safety database and focus group interviews with Danish hospital personnel

Background:

Drug change (DC) is a common challenge in Danish hospitals. It affects the work of hospital personnel and has potentially serious patient safety consequences. Focus on medication safety is becoming increasingly important in the prevention of adverse events. The aim of this study is to identify and describe patient safety challenges related to DCs, and to explore potential facilitators to improve patient safety in the medication process in Danish hospital setting.

Method:

Two qualitative methods were combined. Data were obtained from the Danish Patient Safety Database (DPSD) containing incidents reports of adverse events related to DCs. Additionally, five semi-structured focus group interviews with hospital personnel (doctors, nurses, pharmacists and pharmacy technicians) from the five regions of Denmark were held.

Results:

The DPSD search identified 88 incidents related to DCs due to tender or drug shortage. The incidents were linked to prescribing errors, incorrect dose being dispensed/administered, and delayed/omitted treatment. Four themes from the interviews emerged: (1) challenges related to the drug itself; (2) situational challenges; (3) challenges related to the organization/IT systems/personnel; (4) facilitators/measures to ensure patient safety.

Conclusion:

DC is as a complex challenge, especially related to drug shortage. The results allow for a deeper understanding of the challenges and possible facilitators of DCs on the individual and organizational level. Pharmacy personnel were identified to play a key role in ensuring patient safety of DCs in hospitals. Indeed, this emphasizes that pharmacy personnel should be engaged in developing patient safety strategies and support hospital personnel around drug changes.

Evaluating the implementation and impact of a pharmacy technician-supported medicines administration service designed to reduce omitted doses in hospitals: a qualitative study

BACKGROUND

Of the various types of medication administration error that occur in hospitals, dose omissions are consistently reported as among the most common. It has been suggested that greater involvement from pharmacy teams could help address this problem. A pilot service, called pharmacy TECHnician supported MEDicines administration (TECHMED), was introduced in an English NHS hospital for a four-week period in order to reduce preventable medication dose omissions. The objective of this study was to evaluate the implementation, delivery and impact of the pilot TECHMED service using qualitative methods.

METHODS

Semi-structured interviews with pharmacy technicians, nursing staff and senior management involved with the pilot service were undertaken to evaluate TECHMED. Interviews were transcribed verbatim and analysed using the framework approach, guided by Weiss's Theory Based Evaluation model.

RESULTS

Twenty-two stakeholder interviews were conducted with 10 ward-based pharmacy technicians, nine nurses and three members of senior management. Most technicians performed a range of activities in line with the service specification, including locating drugs from a variety of sources, and identified situations where they had prevented missing doses. Nurses reported positive impacts of TECHMED on workload. However, not all technicians fully adhered to the service specification in regard to directly following nursing staff during each medication round, citing reasons related to productivity or perceived intrusiveness towards nursing staff. Some participants also reported a perceived lack of impact of TECHMED on medicine omissions. Seventeen of the 22 interviewees supported an extension of the service. There were however, concerns about the impact on technician workload and some participants advocated support for targeted service extension to wards/rounds with high schedule dose volumes and omitted dose rates.

CONCLUSIONS

The findings of this study suggest that the implementation of a pharmacy technician-supported medicines administration scheme to reduce omitted doses may be acceptable to staff in an NHS hospital, and that issues with service fidelity, staff resource/capacity and perceived interventions to avoid dose omissions have important implications for the feasibility of extending the service. The study has identified targets for future development in relation to individual and system factors to improve operationalisation of technician-led initiatives to reduce medicines omissions.

A qualitative evaluation of the implementation of guidelines and a support tool for asthma management in primary care

Background

Asthma management in Australia is suboptimal. The “Guidelines for provision of a Pharmacist Only medicine: short acting beta agonists” (SABA guidelines) and a novel West Australian “Asthma Action Plan card” (AAP card) were concurrently developed to improve asthma management. The aim of this qualitative research was to evaluate the collaborative, multidisciplinary and multifaceted implementation of these asthma resources and identify the lessons learnt to inform future initiatives.

Methods

Feedback was sought about the implementation of the SABA guidelines and the AAP card using focus groups with key stakeholders including pharmacists (×2), pharmacy assistants, asthma educators, general practitioners, practice nurses and people with asthma (patients). Audio recordings were transcribed verbatim. Data were analysed thematically using constant comparison. The common themes identified from the focus groups were categorised according to a taxonomy of barriers including barriers related to knowledge, attitudes and behaviour.

Results

Seven focus group sessions were held with 57 participants. Knowledge barriers were identified included a lack of awareness and lack of familiarity of the resources. There was a significant lack of awareness of the AAP card where passive implementation methods had been utilised. Pharmacists had good awareness of the SABA guidelines but pharmacy assistants were unaware of the guidelines despite significant involvement in the sale of SABAs. Environmental barriers included time and workflow issues and the role of the pharmacy assistant in the organisation workflows of the pharmacy. The attitudes and behaviours of health professionals and patients with asthma were discordant and this undermined optimal asthma management. Suggestions to improve asthma management included the use of legislation, the use of electronic resources integrated into workflows and training pharmacists or practice nurses to provide patients with written asthma action plans.

Conclusions

Greater consideration needs to be given to implementation of resources to improve awareness and overcome barriers to utilisation. Attitudes and behaviours of both health professionals and patients with asthma need to be addressed. Interventions directed toward health professionals should focus on skills needs related to achieving improved communication and patient behaviour change.

Electronic supplementary material

The online version of this article (doi:10.1186/s40733-016-0023-9) contains supplementary material, which is available to authorized users.

Consumers' experiences and values in conventional and alternative medicine paradigms: a problem detection study (PDS)

Background

This study explored consumer perceptions of complementary and alternative medicine (CAM) and relationships with CAM and conventional medicine practitioners.

A problem detection study (PDS) was used. The qualitative component to develop the questionnaire used a CAM consumer focus group to explore conventional and CAM paradigms in healthcare. 32 key issues, seven main themes, informed the questionnaire (the quantitative PDS component - 36 statements explored using five-point Likert scales.)

Results

Of 300 questionnaires distributed (Brisbane, Australia), 83 consumers responded. Results indicated that consumers felt empowered by using CAM and they reported positive relationships with CAM practitioners. The perception was that CAM were used most effectively as long-term therapy (63% agreement), but that conventional medicines would be the best choice for emergency treatment (81% agreement). A majority (65%) reported that doctors appeared uncomfortable about consumers' visits to CAM practitioners. Most consumers (72%) believed that relationships with and between health practitioners could be enhanced by improved communication. It was agreed that information sharing between consumers and healthcare practitioners is important, and reported that "enough" information is shared between CAM practitioners and consumers. Consumers felt comfortable discussing their medicines with pharmacists, general practitioners and CAM practitioners, but felt most comfortable with their CAM practitioners.

Conclusions

This PDS has emphasized the perceived importance of open communication between consumers, CAM and conventional providers, and has exposed areas where CAM consumers perceive that issues exist across the CAM and conventional medicine paradigms. There is a lot of information which is perceived as not being shared at present and there are issues of discomfort and distrust which require resolution to develop concordant relationships in healthcare. Further research should be based on optimisation of information sharing, spanning both conventional and CAM fields of healthcare, due to both the relevance of concordance principles within CAM modalities and the widespread use of CAM by consumers.

Community pharmacists' attitudes towards research

Objectives

To investigate community pharmacists' perception of Pharmacy Practice research and to identify perceived barriers preventing their participation in research.

Method

A self-completed postal questionnaire, including 29 attitudinal statements was analysed using factor analysis.

Setting

The study group comprised pharmacists working in all 651 community pharmacies in East London and Essex.

Key findings

The response rate was 60 per cent. Factor analysis revealed five factors comprising correlated statements. The majority of respondents perceived community based practice research to be important and relevant to them and to the future development of community pharmacy. Fifty-four per cent agreed that they were prepared to participate in practice research, although 66 per cent of respondents felt their daily activities precluded this. Payment for a research related activity was a major issue impacting on their likely participation, with 72 per cent of pharmacists agreeing that they would only participate if paid to do so. Pharmacists' employment status, ie, whether employee or proprietor, was also associated with willingness and ability to undertake research.

Conclusion

Community pharmacists have a positive attitude towards practice research, and under the appropriate circumstances many would be prepared to participate in research.

Reassessing the MAI: elderly people's opinions about medication appropriateness

Objectives

To identify the criteria that the elderly use to assess the appropriateness of their medications, rank the identified criteria in terms of importance, and compare elderly people's and clinicians' ratings of the importance of medication appropriateness index (MAI) criteria

Methods

A qualitative method was used to understand why elders' rankings of appropriateness criteria may or may not differ from clinicians'. Five focus groups with 38 elderly people were completed and content analysed. The participants also completed a written ranking of 10 criteria, indicating them as being of high importance, moderate importance or low importance

Key findings

Overall, the group discussion cited indication, effectiveness and drug-drug interactions as most important. The written ranking of the MAI criteria suggested drug-drug interactions and correct directions as being most important. Elderly people appeared to have difficulty ranking the criteria of indication and effectiveness, as there was some evidence that they took these criteria for granted. Differences among focus group participants appeared to be due to their varied medication use experience

Conclusion

These findings suggest that drug-drug interactions may be ranked highly important and practicality ranked moderately important when elderly patients' opinions are sought about medication appropriateness. Further research should be conducted to assess whether the MAI is accountable to patient viewpoints

The clinical autonomy of community pharmacists in England. 1. Designing and testing a survey instrument

Objective

To design and test an instrument for measuring variations in the extent to which community pharmacists perceive they can exercise autonomy in clinical settings.

Method

To assist with the design of the instrument a focus group comprising practising community pharmacists from a variety of backgrounds was used. The group contributed ideas for 12 scenarios, based on critical incidents in community pharmacy, which comprise the core of the instrument, and a range of responses that reflect varying degrees of autonomy. Testing involved two pilot surveys in different areas of the UK and rigorous appraisal by the research team and focus group. Various refinements were subsequently made including simplification of the scale of responses and the addition of ‘reality checks’.

Key findings

Data from the two pilots provided evidence of variations in perceived autonomy between contractors, employees and locums.

Conclusions

The instrument was deemed to meet the criteria of credibility; reliability, in terms of consistency; and criterion and construct validity and therefore was suitable for a full-scale survey which is reported in a second paper.

Evaluating the views of paramedics, cardiologists, emergency department physicians and nurses on advanced prehospital management of acute ST elevation myocardial infarction

BACKGROUND

Although advanced prehospital management (PHM) in ST elevation myocardial infarction (STEMI) reduces reperfusion delay and improves patient outcomes, its use in North America remains uncommon. Understanding perceived barriers to and facilitators of PHM implementation may support the expansion of programs, with associated patient benefit.

OBJECTIVE

To explore the attitudes and beliefs of paramedics, cardiologists, emergency physicians and nurses regarding these issues.

METHODS

To maximize the potential to identify unpredictable issues within each of the four groups, focus group sessions were recorded, transcribed and analyzed for themes using the constant comparative method.

RESULTS

All 18 participants believed that PHM of STEMI decreased time to treatment and improved health outcomes. Despite agreeing that most paramedics were capable of providing PHM, regular maintenance of competence and medical overview were emphasized. Significant variations in perceptions were revealed regarding practical aspects of the PHM process and protocol, as well as ownership and responsibility of the patient. Success and failures of technology were also expressed. Varying arguments against a signed 'informed consent' were presented by the majority.

CONCLUSIONS

Focus group discussions provided key insights into potential barriers to and facilitators of PHM in STEMI. Although all groups were supportive of the concept and its benefits, concerns were expressed and potential barriers identified. This novel body of knowledge will help elucidate future educational programs and protocol development, and identify future challenges to ensure successful PHM of STEMI, thereby reducing reperfusion delay and improving patient outcomes.

Concordance-based adherence support service delivery: consumer perspectives

OBJECTIVES

To explore consumers' attitudes towards, and expectations of, adherence support services in primary health care, specifically in community pharmacy; and to explore consumers' attitudes towards the concept of concordance.

SETTING

An exploratory qualitative study conducted in Metropolitan Sydney, Australia.

METHOD

Three focus group discussions with consumers on chronic therapy (n = 22) and two focus groups with consumer representatives (n = 15) were conducted in 2002. Consumer representatives were peer educators volunteering in an association which promotes quality use of medicines among elderly patients. All discussions were audio-taped, transcribed verbatim and thematically content analysed.

MAIN OUTCOME MEASURES

Consumers' experiences with adherence support services delivered by general practitioners and pharmacists, their expectations towards general practitioners' and pharmacists' role in adherence support; and attitudes towards concordance in consultations.

RESULTS

Participants expected an increased provision of medicine information and a reduction in the number of medications taken as the main strategies to promote adherence. They believed that once understandable information had been delivered, it was their responsibility to take their medications as prescribed. Yet participants frequently complained about the information received, especially from doctors. Only a subgroup of participants expected pharmacists to be involved in adherence support services. These participants generally relied on pharmacists for medicine information and were satisfied with the communication process when interacting with the pharmacists. All participants were positive about concordance, because they valued two-way communication and increased consideration of their needs and beliefs by healthcare professionals. However, they were hesitant about being involved in a shared treatment decision-making process. Many participants focused on concordance with doctors and identified barriers to the establishment of concordance: time pressures, financial constraints, the gap of competence and power between patients and doctors.

CONCLUSIONS

Pharmacists should consider consumers' needs for information and establishing concordance, as well as their expectations of the pharmacy profession, in delivering concordance based adherence support services. Given participants' high demand for medicine information, an opportunity might exist for pharmacists to influence consumers' expectations by offering information which is tailored towards their needs.

Perceptions around concordance--focus groups and semi-structured interviews conducted with consumers, pharmacists and general practitioners

BACKGROUND

Achieving concordance by identifying beliefs about illness, treatment and medicine-taking should impact positively on behaviour and consumer satisfaction with respect to treatment, and health outcomes may be improved.

OBJECTIVE

To explore, in the Australian context, beliefs and expectations of general practitioners (GPs), consumers and pharmacists in relation to concordance to allow further exploration of the implementation of principles of concordance in Australia.

DESIGN

Qualitative analysis of focus group and semi-structured interview data.

SETTING AND PARTICIPANTS

Focus groups were held with seven consumers and nine pharmacists and, in-depth, semi-structured interviews were held with 10 GPs between February and May 2003, in Brisbane (Australia).

RESULTS

This explorative study identified a variety of issues. Consumers expressed the need for more input from health professionals - being given more information on their treatments and conditions, more time spent in discussion, and establishing a system where harmonious relationships between health professionals could take place, which would result in a more consumer-friendly health care system. The main issues voiced by the pharmacists were about the idea of organizing the health care system in a way that would accommodate more quality information sharing between all partners. GPs' issues included better and unlimited information-sharing, having more time to promote quality in health care and receiving remuneration for increased verbal contact with other health care professionals. Suggestions were made about ways to achieve concordance by improved information-sharing and shared decision-making.

CONCLUSION

The data from this study will lead to the development of models to explore and attempt to incorporate principles of concordance in Australian pharmacy and medical practice.

The Scope of pharmacy ethics-an evaluation of the international research literature, 1990-2002

This paper attempts to provide a critical overview of international published discourse relating to ethical issues in pharmacy practice from 1990 to 2002. We found that there is little research literature specifically addressing ethics in pharmacy practice and almost none addressing fundamental philosophical issues or values for pharmacy ethics. There is no dedicated journal for pharmacy ethics. Most material relating to pharmacy ethics is articulated as codes or pronouncements from professional bodies, as opinion or reflection in textbooks and in debate such as letters and articles. However, this should not be taken to mean that pharmacy and ethics are strangers; simply that such matters are not frequently analysed in published pharmacy literature. The presumption is usually that most matters of pharmacy ethics are very familiar and require no exploration or explanation. Where the research literature does target ethical issues, the most common method is to employ "the scenario approach". This term describes the technique of using a vignette or scenario from actual pharmacy practice and then exploring a variety of possible options to identify one or more defensible solutions. The vast majority of scenarios related to the delivery of healthcare per se; rather fewer derived from delivery of healthcare in a commercial environment. One notable exception to this approach is the body of work by Latif and colleagues on moral reasoning and community pharmacy practice. Our review suggests there is a need for the knowledge base in pharmacy ethics to be systematised and integrated into the wider scheme of general healthcare ethics. The principal areas in which research is needed include, how best to teach and assess "ethical competence" before practice; how to develop and update this competence in practising pharmacists; and how the business environment, particularly where there are corporate values and reward systems in operation, affects ethical competence. In addition, general research in pharmacy practice may benefit from a greater awareness and enquiry as to the ethical issues raised by the projects being undertaken.

Using focus groups to identify barriers to drug use in patients with congestive heart failure

STUDY OBJECTIVE

To explore barriers to adherence to drug therapy identified by patients with congestive heart failure (CHF).

SETTING

University-associated heart failure clinic and a family practice clinic.

PATIENTS

Twenty-six patients with CHF.

INTERVENTION

Four focus group sessions.

MEASUREMENTS AND MAIN RESULTS

Participants were asked to describe how their lives changed as a result of developing CHF and the challenges they face when taking drugs for the condition. In the second half of each session, participants were asked for their opinions regarding various teaching and memory aids for improving adherence with therapy. They recognized the value of these aids and often created their own when health care professionals did not supply them. Transcripts were reviewed and comments grouped to identify patient-perceived barriers to adherence. The disease placed significant limitations on lifestyle. Furosemide had dramatic effects on daily activities, and some patients altered the dosing schedule to accommodate their plans. Influences on adherence were generalized into five themes: confidence in health care providers; their own knowledge regarding the disease and drugs used to treat it; previous experience with drugs; support from family and friends; and ease of communication with health care professionals.

CONCLUSION

Focus groups are an effective and efficient method to explore patients opinions of barriers to drug therapy adherence. Such information can have a direct impact on management of patients with CHF. Information gathered in this study will be used to construct a survey to measure barriers to drug adherence and design interventions to improve adherence.