Posters Practice Research - Wiley Online Library

Posters

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medication incident reporting frequency. A convenience sampling approach was employed. All interviewees gave their consent to participate. Interviews were digitally recorded and transcribed verbatim. Transcripts were analysed using content analysis to identify emerging themes. IJPP 2011, Supplement 2: 65–105 © 2011 The Authors IJPP © 2011 Royal Pharmaceutical Society

Posters Practice Research Abstract 61 Learning from medication errors: the ‘bulletin’ as a communication tool S. Haymana, S. Cookb, M. Jenkinsonb and S. Corletta a

Medway School of Pharmacy, Chatham Maritime, kent, UK and bEast Kent Hospitals University NHS Foundation Trust, Kent, UK

Focal points • Semi structured interviews were conducted with Nurses, Pharmacists and Doctors to evaluate the effectiveness of a bulletin as a method of disseminating information on medication errors. • Interviewees were generally positive about the content and appearance of the bulletin although problems with dissemination of the bulletin using e-mail were identified. • Improvements suggested to enhance learning from medication errors were to ensure regular updates of e-mailing lists, to consider in-house mailing of hard copies to all wards, the addition of face to face training sessions and greater Pharmacist involvement at ward level.

Introduction An organisation with a memory indicated that the NHS should adopt a much wider appreciation of the value of the systems approach in preventing, analysing and learning from patient safety incidents1. Mistakes and near misses should be reported and shared so that similar errors are prevented2. The East Kent Hospitals University NHS Foundation Trust produces a monthly bulletin, learning from medication incidents, which summarises the errors and near misses that have occurred and have been reported within the Trust, and advises staff how to avoid these in the future. This bulletin is e-mailed to all Pharmacists, Doctors and Nurse Managers. The aim of this study was to assess the effectiveness of the bulletin as a method of disseminating information on medication errors to staff. The objectives were to assess staff awareness of the bulletin, and to identify any improvements that could be made to its appearance, content or method of dissemination.

Method Trust approval to conduct this study was obtained. The five wards which were selected for the study, included medical and surgical specialties, and those with the highest and lowest

Results Twenty two healthcare professionals (fourteen Nurses, five Doctors and three Pharmacists) participated in the study. All of the Pharmacists interviewed were familiar with the bulletin, compared to only three of the five Nurse Managers and one of the Doctors. The Nurse Managers were not on the mailing list due to an administrative oversight. The Doctors were on the mailing list but commented that they did not use their Trust e-mail. All Pharmacists and most Nurses thought that the appearance and content of the bulletin was good. However, three of the Doctors suggested that it was ‘too busy’ and the number of points covered should be reduced. Staff commented that it was good to see that errors or near misses that they had reported had been acknowledged. Face to face training updates with the Pharmacists on medication incidents and greater availability of the Pharmacist on the wards were suggested as ways of enhancing learning from errors and reducing the likelihood of further errors occurring.

Discussion This study highlights the importance of maintaining accurate and up to date distribution lists to achieve effective dissemination. A preferred e-mail account should be considered to improve distribution to Doctors. Suggestions by staff to enhance dissemination included mailing hard copies to all wards. Interviewees were generally positive about the appearance and content of the bulletin. The Trust should consider the introduction of face to face training sessions with staff, and greater pharmacist involvement at ward level as part of their medication safety strategy.

References 1. Department of Health. (2000). An organisation with a memory. London: The Stationery Office. Available at http://www.dh.gov. uk/en/Publicationsandstatistics/Publications/Publications PolicyAndGuidance/DH _4065083. [Accessed 15 August 2010]. 2. World Health Organisation. (2005). Draft guidelines for Adverse Event Reporting and Learning systems. Available at http://www. who.int/patientsafety/events/05/Reporting_Guidelines.pdf. [Accessed 4 October 2010].

Abstract 62 Patient experiences of their Medicines Use Review (MUR) A. Latif, K. Pollock and H. Boardman University of Nottingham, Nottingham, UK

Focal points • Thirty-four patients were interviewed to explore their experiences of the MUR service. • Patients were unclear as to the purpose of the MUR; some framed the encounter as a ‘monitoring’ activity.

© 2011 The Authors. IJPP © 2011 Royal Pharmaceutical Society 2011 International Journal of Pharmacy Practice, 19 (Suppl. 2), pp. 65–105

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International Journal of Pharmacy Practice 2011; Supplement 2

• A review of the current format for the MUR is needed if a patient-centred and tailored service is to be achieved. • Pharmacists need to work collaboratively with GPs to deliver MURs effectively.

Introduction Few studies have qualitatively explored patient perceptions of the MUR service with most having used questionnaires.1,2 One focus group study reported that many patients took part in their MUR out of politeness, or felt they were being tested but talked favourably about the amount of time spent with the pharmacist.3 To our knowledge no previous studies have sought to observe patients’ MURs as they occur in practice and explored their experiences. This paper presents data from a wider qualitative study exploring patient and professional perceptions of MURs and reports on their experiences.

Methods Following NHS ethical approval, two pharmacies were recruited and five weeks of ethnographically-orientated observations carried out in each pharmacy over a 12-month period. Observations were made of all pharmacy activities, including MURs. Pharmacists were requested to invite patients as normal practice. Fifty-four MURs were observed and thirty-four patients interviewed either face-to-face or by telephone about their experience of the MUR. Five pharmacists and twelve support staff were also interviewed after the observational period about their experiences of MURs. All interviews were audio-recorded and transcribed verbatim. A thematic approach to analysing the data was used involving the principles of constant comparison to test and refine themes. This paper will report findings from the data collected from patient interviews.

Discussion Patients provided ambivalent accounts of their experiences of the MUR. This was framed as a monitoring activity rather than an opportunity for them to discuss their use, beliefs and concerns about their medicines. Their perception of the subordinate status of the pharmacist compared with the GP meant that some patients were aware of the potentially negative impact of MURs on inter-professional boundaries, relationships and responsibilities. Pharmacists should be encouraged to communicate the purpose of the MUR clearly to patients and work collaboratively with GPs to deliver the service effectively.

References 1. Hussain S, Upton D. Do patients perceive any benefit from medicines use reviews offered to them in community pharmacies? Pharm J 2010; 284: 165–166. 2. Krska J, Nesbitt J, Baylie K, O’Kane A. Patient views on the medicines use review service Int J Pharm Prac 2009: 17 (Suppl 1): A41–A42. 3. Blenkinsopp A, Bond C, Celino G, Inch J, Gray N. 2007. National evaluation of the new Community Pharmacy contract. London: The Pharmacy Practice Research Trust.

Abstract 63 A peer review of Medicine Use Reviews (MURs) conducted by community pharmacists in Guernsey during the thirteen months after their inception E. Brachea,b, G. O’Riordanc and J. Clemersona a Sunderland University, Sunderland, UK, bHealth and Social Services Department, Guernsey, UK and cPrescribing Support Unit, Guernsey, UK

Results Patient awareness of MURs was poor and most reported they were not expecting an MUR when they visited the pharmacy. Several patients assumed the MUR was a task the pharmacist was required to undertake rather than one being carried out for their benefit. In describing what happened in their MUR they reported that the pharmacist “went through” their medicines. Several accounts referred to how the pharmacist checked with the patient whether they understood why they were on the medicine. The MUR was framed as a monitoring activity. Most patients perceived their GP to be the main authority over their medicines and considered that “significant” medicine problems would best be resolved by talking to them rather than with the pharmacist during the MUR. Several patients reported there was potential for the MUR to cause tension between the GP and pharmacist. Patients described their MUR as “satisfying” or “interesting” rather than useful. Most were indifferent when asked whether they wanted another MUR in the future. A few patients suggested that the pharmacist should use a more interpersonal approach to allow patients to “open up”. Most patients reported their MUR did little to increase their knowledge or affect their use of medicines. Despite this, patients welcomed the attention they received in the MURs and all felt comfortable speaking with the pharmacist who was seen as an approachable and knowledgeable professional.

Focal points • To analyse the Medicine Use Review (MUR) forms submitted to the General Practitioners (GPs) and to the States of Guernsey Prescribing Support Unit (PSU). • To evaluate their quality in relation to the aims of MURs as stated in The New Contractual Framework for Community Pharmacy.1 • Information recorded on the forms and the advice given were frequently deficient. • Enhanced training and access to patient medical records would expand the service and improve the relationship between healthcare professionals.

Introduction An agreement between the PSU and the community pharmacies to introduce MURs, similar to those in Britain, for a one-year trial basis commencing November 2007 presented an opportunity to evaluate their quality and effectiveness. The Prescribing Advisor was to lead the trial which would be in accordance with the aims of the New Contractual Framework for Community Pharmacy (2005).1 Conducted with the patients’ agreement the aims were to improve their knowledge and use of drugs by (i) Establishing the patient’s actual use, understanding and experience of taking medicines. (ii) Identifying side effects that affect the patient’s compliance


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with treatment. (iii) Identifying, discussing and resolving poor and ineffective use of medicines, and (iv) Improving the clinical and cost effectiveness of drugs prescribed to patients, thus reducing wastage. An authorised research project would run concurrently with the proposed trial, for which ethical approval had been sought and obtained.

Method Criteria agreed for both the MUR trial and the research project were: (i) Patients aged seventy years and over and/or on five or more medicines per month, (ii) Nursing home residents, (iii) Individuals receiving topical preparations such as antifungal creams and emollients on regular repeat prescriptions, (iv) Patients who can tolerate Simvastatin, who have been taking Atorvastatin for more than one year, (v) Patients who can tolerate Aspirin, who have been taking Clopidogrel for more than one year, (vi) Patients who can tolerate ACE Inhibitors (ACEIs), taking Angiotensin 2 Receptor Antagonists (ARBs), (vii) Patients on inhalers, (viii) Type 2 Diabetics. These would be re-assessed should MURs become a permanent feature. All MUR forms submitted to the PSU between November 2007 and December 2008, indicating the willingness of patients to take part in the research element were peer reviewed. Patients were categorised according to the pre-determined criteria. Both the advice given by pharmacists and their recommendations to GPs for each criterion were clearly analysed, at which time only the researcher had access to patients’ blood indices.

Results

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2. BMA/RPS. British National Formulary 61. London: BMJ Group / Pharmaceutical Press; 2011. 3. Scottish Intercollegiate Guidelines Network SIGN Guideline 95: Management of chronic heart failure http://www.sign.ac.uk/ guidelines/fulltext/95/section3.html. Accessed: 13 January 2011. 4. Youssef, S. (2010) Medicines Use Reviews. London: Pharmaceutical Press. ISBN 9780853698876.

Abstract 64 Pharmacy prescribing in Northern Ireland – a patient perspective L. McCanna, F. Lloydb, C. Parsonsa, G. Crealeyc, G. Gormleyd and C. Hughesa a

School of Pharmacy, Queen’s University, Belfast, UK, bNorthern Ireland Centre for Pharmacy Learning and Development, Queen’s University, Belfast, UK, cClinical Research Support Centre, Belfast Health and Social Care Trust, Belfast, UK and dDepartment of General Practice and Primary Care, School of Medicine, Dentistry and Biomedical Sciences, Queen’s University, Belfast, UK

Focal points • This study sought to explore the views of patients on pharmacist prescribing in Northern Ireland. • Patient benefits such as increased follow-up, improved medical conditions and additional time were reported. • Patients acknowledged the doctor’s role as diagnostician or where they had complex illnesses. Participants perceived a multi-disciplinary approach to patient care as the ideal model.

36 of the 257 volunteer patients did not fit any of the criteria and 57 received medication that they did not take. As an example the analysis for Criterion 6 elicited the following: 30 patients were prescribed ARBs with a monthly value of £493.08. 4 Patients taking ACEIs were advised to change to ARBs because they were experiencing a dry cough. 3 Patients’ potassium levels were slightly elevated 5.1 to 5.2 mmol/litre (3.5–5.0 mmol/litre). Six patients were also taking Non-Steroidal Anti-Inflammatory Drugs (NSAIDs). The attention of their GPs was not drawn to the fact that these combinations can increase potassium levels and risk of renal failure.2 (p807) None of these patients were advised to limit their salt intake3 and to avoid potassium (low-sodium) salts.4 (p19) 14 Recommendations were made to GPs to switch to ACEIs.

The drive for non-medical prescribing has progressed quickly since the late 1990’s and currently involves a range of health care professionals including pharmacists1. A number of early findings on this form of practice have been reported, such as increased job satisfaction and time-saving by prescribers, but this was tempered by financial/organisational problems2. As part of a commissioned research project, this qualitative element of a larger case study methodology focused on patients of pharmacist prescribers. The aim was to explore the patients’ perspective of pharmacists as prescribers.

Conclusion

Method

Information recorded on forms, advice given to patients and recommendations made to GPs were generally unsatisfactory and indicative of a lack of information. The MUR service and the relationship between healthcare professionals would benefit if accredited pharmacists had access to (a) an enhanced training programme designed specifically for conducting MURs and (b) access to patients’ medical records, in particular their blood results.

Three pharmacists working as independent prescribers in the clinical areas of (i) hypertension, (ii) cardiovascular and diabetes management and (iii) anti-coagulation were recruited to 3 case studies of pharmacist prescribing in Northern Ireland. 105 patients were invited to take part in focus groups after they had been prescribed for by the pharmacist. The focus groups took place between November 2010 and March 2011 (ethical approval granted), were audio taped, transcribed verbatim, read independently by the authors and analysed using thematic analysis.

References 1. Department of Health. The New Contractual Framework for Community Pharmacy. 2005 Available at: http://www.dh.gov.uk/ en/Publicationsandstatistics/Publications/PublicationsPolicy AndGuidance/DH_4109256 Accessed: 3 April 2010.

Introduction

Results Thirty-four patients (P) agreed to participate across 7 focus groups. Twenty males and 14 females took part in focus group


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Table 1 groups

Illustrative quotes for the main themes from the patient focus

Themes

Illustrative quotes

Team approach

“Yes it takes them both I think – you have to have both (a doctor and a pharmacist)” (P33, SC) “That’s the sort of service I would like . . . that it’s a multidisciplinary team sitting round discussing one individual. I just like the bigger picture to be looked at” (P13, SC) “People are human and one doctor might miss something, whereas if there is more than one people looking after you then it’s more likely to be a better approach to it all” (P24, SC) “That’s what makes it for me (the follow-up) is that you know that whatever you’re taking is going to be checked in a month or 6 weeks or whatever we have arranged” (P1, PC) “My blood sugars are absolutely tickety-boo now where I had a terrible time before (pharmacist started prescribing)” (P19, SC) “If you go to your own GP you’re quite aware that you’ve got a short time and you’re trying to remember all the things you want to ask them” (P12, SC) “I don’t know whether it’s just tradition, but I think that the doctor would be better at the diagnostic element of it, whereas the pharmacist does know the medicines better” (P24, SC) “No I would be happy enough with the pharmacist (for warfarin) unless – well if other things broke down you might have to go to the doctor (laughs) you don’t want to abandon the doctor either” (P31, SC)

Patient benefits

Doctor’s role

PC: primary care; SC: secondary care

4. Hacking S. Taylor J. An evaluation of the scope and practice of Non Medical Prescribing in the North West. For NHS North West. 2010; http://www.prescribingforsuccess.co.uk/documents/pfs_ FinalNMP10.09.10.pdf (Accessed 31 March 2011).

Abstract 65 An exploration of the views of community pharmacists on the relationship between Medicines Use Reviews (MURs) and public health J. Waterfield and A. Dhir De Montfort University, Leicester, UK

Focal points • This study aims to determine the views of community pharmacists on the relationship between Medicines Use Reviews (MURs) and public health (PH). • The study found that 68% (n = 101) of pharmacists agreed that lifestyle advice and advice relating to general improvement of health should always be included in an MUR action plan. • Community pharmacists recognise the positive contribution of MURs to the PH agenda and 61% (n = 91) state that they have observed improved health outcomes following MUR consultations.

Introduction discussions. The shortest time that patients had attended the pharmacist prescriber was two months and the longest time was 8 years. Analysis of the data revealed the emergence of one over-arching theme: team approach to patient care. A number of sub themes related to patient benefits and the role of the doctor. Table 1 provides supporting quotes which illustrate these themes:

Conclusion Patients discussed the importance of a multi-disciplinary approach to their care especially for those with more complex conditions. Pharmacist prescribing was a positive experience and identified benefits included increased follow-up, improvement in their medical conditions and additional time, which have been proposed previously3. However, patients wanted to consult their doctor for the initial diagnosis or if a more “serious” or acute medical problem arose; as has been reported elsewhere4.

References 1. Offredy M. Development of non-medical prescribing – Historical background and competency framework for successful prescribing. In Sodha, M. and Dhillon, S. (2009) Non-medical prescribing. 2009; Pharmaceutical Press: London. 2. George J, McCaig D, Bond C et al. Supplementary prescribing: Early experiences of pharmacists in Great Britain. Ann Pharmacother. 2006; 40: 1843–1850. 3. Weiss MC, Sutton J, Adams C. Exploring innovation in pharmacy practice: a qualitative evaluation of supplementary prescribing by pharmacists. 2006; Royal Pharmaceutical Society of Great Britain.

The Medicines Use Review (MUR) is an advanced service that can be useful in the promotion of a healthy lifestyle.1 However, there are a number of problems associated with MURs such as an emphasis on procedural issues rather than consultation skills,2 and a commercial target driven approach.3 The areas of interest targeted in this study include: the opinion of pharmacists on the incorporation of healthy lifestyle advice during an MUR consultation, pharmacist perception of the value of MURs in improving patient health and finally the relationship between pharmacists and other healthcare professionals in relation to the MUR and PH outcomes.

Method Following a literature review a postal questionnaire survey using a Likert scale was developed by the authors and sent to 400 community pharmacies selected randomly using an online search engine across six counties: Bedfordshire, Cornwall, Devon, Oxfordshire, Somerset and Surrey. Different counties in the south of England were used to avoid bias of data from one specific county. A follow-up reminder letter and questionnaire was sent to the same pharmacies two weeks later. The data was analysed using Excel® 2010. The study was approved by the ethics committee of the Faculty of Health and Life Sciences at De Montfort University.

Results A total of 148 (37%) of the 400 pharmacists returned the completed, self-administered, anonymous questionnaire. The study found that 68% (n = 101) of pharmacists agreed that


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lifestyle advice and advice relating to general improvement of health should always be included in an MUR action plan. When questioned about their experience of personal observation of positive impact on patient health as a result of an MUR consultation, 61% (n = 91) of pharmacists agreed with this outcome. In response to the statement that ‘there is effective communication with other healthcare professionals about patients relating to MURs and public health issues’, 16% (n = 24) of pharmacists were in agreement. A total of 86% (n = 128) of respondents answered yes to the question: ‘Do you think that MURs can improve PH? All qualitative written responses were thematically analysed by assigning a code to the overall comment and quantifying each of these codes. The written comments were based on the value of health promotion issues (32%), resource and lack of remuneration issues (23%), lack of time to carry out MURs (18%), poor relationships with other healthcare professionals (13%) and other unrelated comments that could not be assigned a particular code (14%).

Discussion The results demonstrate that pharmacists are generally positive about the opportunity that the MUR provides to promote public health issues. A large proportion of respondents believe that they have seen a positive impact on individual health as a result of MUR consultations. However, this perceived potential impact on individual health cannot be interpreted as a wider impact on PH. The study reveals negative findings that relate to the lack of effective communication with other healthcare professionals about MURs in relation to public health issues. The study also highlights specific concerns of community pharmacists about a lack of remuneration and time resources to effectively engage in this PH role which implies a need for further investigation.

References 1. Youssef S. et al. Do patients perceive any benefit from medicines use reviews offered to them by community pharmacies? Pharm J 2010; 284: 165–166. 2. Wilcock M, Harding G. What do pharmacists think of MURs and do they change prescribed medication? Pharm J 2008; 281: 163–167. 3. Bradley F. et al. Determinants of the uptake of medicines use reviews (MURs) by community pharmacies in England: A multi method study. Health Policy 2008; 88: 258–268.

Abstract 66 Antimicrobial prescribing in residential homes: a point prevalence study P. McClean, C. Hughes, M. Tunney, C. Parsons and D. Gilpin Queen’s University, Belfast, UK

Focal points • The purpose of this study was to investigate systemic and topical antimicrobial prescribing in residential homes for older people in Northern Ireland.

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• The research consisted of a point prevalence study (PPS) in 30 residential homes in November 2010. • The mean rate of prescribing was 9% (range 0%–33%) for systemic antimicrobials and 5% (range 0%–22%) for topical antimicrobials. • The reasons for the variation in antimicrobial prescribing between residential homes are currently unknown and should be the focus of further research.

Introduction Several studies have investigated antimicrobial prescribing in nursing homes;1 however, in the literature only one study has been published investigating antimicrobial use in residential homes.2 Residential homes provide accommodation, personal care and meals; however, they differ from nursing homes in that there is no requirement to have nurses on-site 24 hours per day. A complex range of risk factors for infection exist in older people. The purpose of this study was to investigate antimicrobial use in residential homes for older people in Northern Ireland.

Method The research consisted of one point prevalence study (PPS) in 30 residential homes in November 2010, with a further PPS scheduled in April 2011. Following ethical approval, residential homes were recruited and all residents in these homes were invited to participate in the PPS either personally or via next-of-kin (if unable to give consent). Data were obtained from nursing notes, medication administration records and staff in relation to antimicrobial prescribing, facility and resident characteristics. Data (from November 2010 only) were analysed in SPSS and odds ratios (ORs) with 95% confidence intervals (CIs) and Chi square were used to determine significant associations. Rates were calculated at the home level and the mean of these proportions were then calculated to give combined prevalences for all homes.

Results Consent was obtained for 585 residents [70.5% ± 14.8 (SD-Standard Deviation)] who were eligible to participate and 60.0% ± 26.6 (n = 361) residents personally consented. The mean age was 84.6 ± 3.2 years, 75.1% ± 17.3 (n = 440) were female, 49% ± 23.3 (n = 234) were reported by staff to have some element of confusion, 41.4% ± 17.5 (n = 276) were incontinent of urine and/or faeces and 11.5% ± 12.8 (n = 68) required assistance from staff to mobilise or were wheelchair bound or bed bound. The rate of systemic antimicrobial prescribing was 9.4% ± 8.2 (n = 56). Trimethoprim was the most frequently prescribed antimicrobial 23.4% ± 37.2 (n = 14) and the main indication resulting in systemic antimicrobial prescribing was the prophylaxis of urinary tract infections (UTIs) 30.1% ± 36.4 (n = 14). When resident risk factors were investigated, only resident immobility was associated with a higher rate of systemic antimicrobial prescribing (OR 2.8, 95% CI 1.1–7.1, p = 0.04). The rate of topical antimicrobial prescribing was 6.3% ± 6.4 (n = 32) with chloramphenicol eye drops and ointment most frequently prescribed 21.8% ± 24.5 (n = 7), followed by Timodine® cream 18.8% ± 35.1 (n = 6) and Daktacort® cream and ointment 12.5% ± 16.9 (n = 4).


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Discussion The rate of systemic antimicrobial prescribing in residential homes in Northern Ireland was high (9%) compared to Italian residential homes (6%)2 but lower than in nursing homes in Northern Ireland (13% in April & 11% in November 2009 – unpublished data). Despite the prophylaxis of UTIs being the most common indication resulting in systemic antimicrobial prescribing, there is little guidance for doctors to follow with regards to the use of antimicrobials for this purpose.3 Chloramphenicol eye drops were frequently prescribed; however, it has been reported that doctors have difficulties in distinguishing between viral and bacterial conjunctivitis.4 Furthermore, conjunctivitis is usually self-limiting and will resolve without treatment. The reasons for the variations in antimicrobial prescribing between residential homes are currently unknown. Further quantitative and qualitative research is needed to understand the contributing factors (which may include culture, beliefs and attitudes of patients and prescribers) to the use of antimicrobials in residential homes in Northern Ireland.

References 1. Warren J, Palumbo F, Fitterman L, et al. Incidence and characteristics of antibiotic use in aged nursing home patients. J Am Geriatr Soc 1991; 39: 963–972. 2. Moro M, Mongardi M, Marchi M et al. Prevalence of long-term care acquired infections in nursing and residential homes in the Emilia-Romagna region. Infect 2007; 35: 250–255. 3. Nicolle L, Bentley D, Garibaldi R et al. Antimicrobial use in long-term care facilities. Infect Control Hosp Epidem 2000; 21: 537–545. 4. Everitt H & Little P. How do GPs diagnose and manage acute infective conjunctivitis? A GP survey. Family Pract 2002; 19: 658–660.

Abstract 67 Revalidation in pharmacy: role of appraisals and employer involvement E. Schafheutle, P. Noyce, R. Elvey, K. Hassell, S. Jacobs and S. Jee University of Manchester, Manchester, UK

Focal points • The study explored current appraisal systems in the main pharmacy sectors and their adaptability for revalidation. • Appraisals were common across managed sectors but lacking among independent owners and locums. • Emphasis was on organisational focus and generally did not include professional/clinical performance. • Adaptability for revalidation will require employer engagement.

Introduction To ensure that healthcare professionals maintain fitness-topractise, regulatory systems have been under review in Great Britain (GB). Medical practitioners have introduced a licence

to practise as a first step towards the introduction of revalidation. Their system will use a portfolio of evidence, with appraisals as core. Revalidation is being considered for other healthcare professions, including pharmacy. This paper aims to explore the use of existing appraisals in different pharmacy sectors and whether they lend themselves to adaptation for revalidation purposes.

Methods A multi-method programme of Department of Health funded work was commissioned by the pharmacy regulator; data collection occurred between November 2009 and April 2010. A questionnaire surveyed individuals with clinical governance responsibilities in 67 primary care trusts and 28 acute hospital trusts in England (response rates 44% and 33%). In community pharmacy, telephone interviews were conducted with a convenience sample of 14 senior staff from five national chain and four supermarket pharmacies, nine independent owners, three locum agency senior managers, and four pharmacy technician stakeholders. In non-patient-facing sectors, telephone interviews were conducted with five senior pharmacist academics in schools of pharmacy and nine pharmacy professionals in the pharmaceutical industry. All qualitative elements were undertaken in GB. Quantitative data were analysed using SPSS16; qualitative analysis was thematic. The Research Ethics Service deemed the study service development and evaluation.

Results The use of regular appraisals was widespread in all managed sectors involved in this study, yet they were lacking amongst independent pharmacy owners; locums did not appear to fall under any formal management or appraisal structure. Appraisals covered learning and development needs, objective setting, and reviewed performance; the emphasis of performance was guided by the sector’s organisational focus. In community pharmacy and the pharmaceutical industry, performance had a business focus, in academia performance focussed on teaching and research. Continuing professional development (CPD) records only featured in NHS organisations’ appraisals; professional/clinical performance was seen as the individual’s rather than the manager’s/ employing organisation’s responsibility. Across sectors, appraisals were conducted by line managers, who were not necessarily pharmacy professionals. They tended to be seen as supportive and formative, and concerns were voiced over compatibility with summative revalidation assessment. The general consensus across sectors was that current appraisals would not be appropriate to assess pharmacy professionals’ fitness-to-practise. Respondents considered that revalidation ‘assessors’ ought to be pharmacy professionals themselves, with good sector understanding, and that external guidance would be required. There was consensus that revalidation should comprise a portfolio of evidence, including CPD, and possibly patient/ peer feedback and/or evidence from monitoring/inspection visits. It was also noted that revalidation requirements in patient-facing versus non-patient-facing sectors were distinctly different. Pharmacists and technicians in all sectors lacked understanding of the purpose/process of revalidation,


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particularly because there was no clarity about standards that would apply to revalidation assessment.

Discussion The pharmacy profession comprises pharmacists and pharmacy technicians working in different sectors, and not all are patient-facing; therefore, revalidation requirements are likely to vary. Despite appraisals being common in all sectors, some pharmacy professionals are not included; focus of appraisals is commonly on organisational performance and an individual’s contribution to this, rather than on professional/clinical performance, which was commonly seen as the individual’s responsibility. A better understanding of revalidation and assessment standards, and engagement with employers should their appraisal systems play a role in pharmacy revalidation, will be imperative.

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Postgraduate Education (CPPE) to a random sample of 3,000 pharmacists who had undertaken CPPE learning on the RP regulations. Advice was sought and ethics committee approval was not required. Anonymous survey data were imported into SPSS16 for cleaning, coding and analysis; valid percentages are reported.

Results

• Investigate understanding and implementation of the Responsible Pharmacist (RP) regulations in community pharmacy. • Despite respondents’ confidence in understanding the RP regulations, there were clear areas of misconception. • The two-hour absence was used little for increased service delivery and most commonly as a lunch break. • Further developments regarding supervision are informed by these findings.

Following one e-mail reminder, 476 surveys were completed (response rate 15.9%). 378 (79.4%) respondents identified their main job as community pharmacy; the rest were hospital (71; 14.9%); primary care organisations (19; 4.0%) or “other” (6; 1.2%). Only responses from community pharmacy were analysed; 35.9% worked as locums, 30.4% were managers, 9.9% relief and 7.4% second pharmacists, and 5.3% were owners. Over two-thirds (67.6%) were female; the most common age bands were 51–60 (31.2%), 41–50 (22.8%), and 31–40 (21.7%). Three-quarters of respondents (74.8%) agreed with the statement “I completely understand the Responsible Pharmacist regulations.” When given a number of true/false statements to assess actual understanding of key features of the regulations, there was good understanding of some but not all aspects. 69.3% chose true for the statement “If there is more than one RP in a day, all pharmacists can collectively be absent for up to two hours.” A statement causing confusion was “When you are the RP, you are responsible for errors made by other pharmacists even when clinical governance procedures are in place,” which 50.5% thought was true. In response to statements exploring implications, 59.7% disagreed that there was a need for the introduction of the RP regulations in community pharmacy. 37.5% agreed (25.0% were unsure) that when they are the RP, they now have more responsibility than before. Only 5.8% agreed that the legislation had freed up pharmacist time, allowing them to improve delivery of services to patients. When asked specifically about the use of the two-hour absence, 109 (28.9%) said they used it at least occasionally. Of those, 74.1% said they used it as a lunch break, 17.6% for support staff to assemble medicines. Only 22.2% used the absence to meet other healthcare professionals; 10.2% to run services out of the pharmacy premises.

Introduction

Discussion

The Health Act 2006 amended the Medicines Act to remove the requirement of ‘personal control’ and replaced it with the concept of a Responsible Pharmacist (RP) being in charge with the legal duty of securing the safe and effective running of a pharmacy, with the aim of enabling pharmacists to pursue a greater clinical role within and away from the pharmacy. The regulations1 came into force on 1 October 2009. The aim of this survey was to investigate the understanding and implementation of the RP regulations in community pharmacy.

This study has a number of limitations, including that responses were only from pharmacists in England and female pharmacists appeared overrepresented.3 This study does offer important and novel insights into pharmacists’ understanding of the RP regulations, and some areas of misinterpretation have been identified. It would be important to address these before further policy changes around supervision can be developed and implemented.

Abstract 68 Early implementation of the responsible pharmacist regulations in community pharmacy E. Schafheutle, S. Patel, M. Javed, C. Cutts and P. Noyce University of Manchester, Manchester, UK

Focal points

Methods A questionnaire was developed using the RP regulations1 and guidance,2 and a thematic review of commentaries/letters in the Pharmaceutical Journal. It was piloted and minor changes were made. In December 2010, a cover letter and link to an online questionnaire were e-mailed by the Centre of Pharmacy

References 1. The Medicines (Pharmacies) (Responsible Pharmacist) Regulations 2008. 2008. 2. Department of Health. The Medicines (Pharmacies) (RP) Regulations 2008: Guidance. London: Crown Copyright, 2008. 3. Seston, L. and Hassell, K. Pharmacy Workforce Census 2008: Main findings. London & Manchester, RPSGB & CPWS, 2009.


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Abstract 69 The usability of the reverse of the FP10 prescription form and repeat counterfoil S.N. Hussain, B. Shooter and J. Davies Department of Practice and Policy, School of Pharmacy, University of London, London, UK

Focal points • The aim of this research was to investigate the ease of use of the reverse of a National Health Service standard prescription form (FP10) from a patient’s perspective, and also to assess patients’ perceived user-friendliness of the repeat prescription counterfoil. • There is scope for improving the typography and userfriendliness of the reverse of the FP10 and repeat counterfoil as a third of patients deemed the form uneasy to read. • Pharmacists have an important role in helping educate and support patients in the use of the FP10 prescription forms as nearly half of all patients thought the reverse of the FP10 form was exclusively for healthcare professionals use.

Introduction

16 of the respondents reported problems with their repeat slips. This was linked to loss of slips and forgetfulness in ordering, rather than problems associated directly with the counterfoil. 16 semi-structured interviews with patients were performed to validate the survey findings. Common themes concerning the reverse of the form were difficulty in reading the small text and reported eyesight trouble as well as the amount of information provided in such a small space. In terms of the counterfoil, patients expressed positive views about the ease of ordering repeats. Concerns were voiced about the loss of slips and lack of synchronisation between prescription items suggesting that reminders and dates could help this process.

Discussion There is scope for improving the typography and user-friendliness of the reverse of the FP10 and repeat counterfoil, especially for the elderly considering this age group represents the biggest users of prescription medicines. Two million people in the UK live with a sight problem, of which 90% are aged over 60. Pharmacists have an important role in helping educate and support patients in the use of the FP10 prescription forms.

Reference

Patients are expected to complete the reverse of a National Health Service standard prescription form (FP10) to indicate their exemption status when collecting one of the 813 million prescription items that were dispensed in England last year1. With such a widely used document it is important that patients are able to use these forms as well as the repeat counterfoils which represent a central part of the repeat medication supply process. The aim of this research was to investigate the usefulness of the information given on the back of an FP10 prescription form from a patient’s perspective, and also to assess patients’ perceived user-friendliness of the repeat prescription counterfoil.

Method A cross sectional descriptive study using pre-piloted self administered questionnaires and semi-structured interviews were administered by a researcher over a period of two weeks at an independent community pharmacy in London. A convenience sample of patients over 16 years, claiming a familiarity with FP10 prescription forms and competent enough to grant informed consent completed a self-administered questionnaire. Interviews were completed on an ad hoc basis until saturation. Institutional ethics approval was received from the School of Pharmacy, University of London.

Results 112 patients responded to the survey with 60% (n = 67) of respondents being female. 58% (n = 65) of respondents were aware that they were the expected users of the reverse of the prescription, with 42% (n = 47) attributing its use to healthcare professionals. 30% (n = 34) deemed the form uneasy to read. This was attributed to the text being “too small”. Improvements included 39% (n = 43) opting for the use of a larger print form and 37% (n = 41) wanting “less to read”.

1. The NHS Information Centre Prescribing Support Unit (2010). General Pharmaceutical Services in England 1999–2000 to 2009– 10. London, Department of Health.

Abstract 70 Exploring community pharmacists’ experiences with and attitudes towards people with dementia H. Barrya, C. Hughesa, C. Parsonsa and P. Passmoreb a School of Pharmacy, Queen’s University Belfast, UK and bDepartment of Geriatric Medicine, School of Medicine, Queen’s University Belfast, UK

Focal points • A questionnaire was mailed to community pharmacists to explore their knowledge of and attitudes towards dementia, and the management of pain in this condition. • While respondents demonstrated positive attitudes towards people with dementia, they were uncertain about how best to assess and manage pain in this patient population. • Opportunities exist for the provision of training to community pharmacists on the topics of dementia and pain.

Introduction As prevalence of dementia increases, greater opportunity will exist for community pharmacists to provide pharmaceutical care to people with dementia. The management of pain should be of particular concern to healthcare providers, as pain is under-recognised and under-treated in this population1. This


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study aimed to explore community pharmacists’ knowledge about dementia, their experiences of people with dementia, and the knowledge and attitudes they hold regarding the assessment and management of pain in this patient population.

particularly around the use of opioid analgesia. However, this is not surprising given the lack of training received in this area to date. Further training and education on dementia in general, and the management of pain in dementia is required, and would be welcomed by pharmacists.

Method

References

A pre-piloted self-administered postal questionnaire was distributed to all community pharmacies in Northern Ireland (n = 530) during March 2011. A second mailing took place 2 weeks later. The survey instrument comprised five sections: demographic data; respondents’ experiences of and provision of pharmaceutical care to people with dementia; approaches to dementia; views on assessment and management of pain in people with dementia; and information on training received on this topic area. While the approaches to dementia section was based upon a validated scale2, the remaining sections of the questionnaire were developed by the research team based upon the literature. Data were coded and entered into SPSS 18.0 for statistical analysis. Descriptive analyses were used where appropriate, and Chi-squared analysis was used to explore associations between responses and demographic information, with P < 0.05 considered significant. Ethical approval was obtained for this study.

1. Morrison S and Sui A. A comparison of pain and its treatment in advanced dementia and cognitively intact patients with hip fracture. J Pain Symptom Manage 2000; 19: 240–248. 2. Lintern T, Woods R and Phair L. Before and after training: a case study of intervention. J Dement Care 2000; 8: 15–17. 3. Zwakhalen S et al. Nursing staff knowledge and beliefs about pain in elderly nursing home residents with dementia. Pain Res Manage 2007; 12: 177–183. 4. Barry H et al. An exploration of nursing home managers’ knowledge of and attitudes to the management of pain in residents with dementia. Int J Pharm Pract 2010; 18(S2): 8–9.

Results One hundred and eighty one responses have been received, providing a response rate of 34%. The majority of respondents were female (60%), and had been working in community pharmacy for a mean of 14 years. Most respondents had not attended any recent training on either dementia (96%) or pain (93%). A greater proportion of respondents (91%) provided pharmaceutical care to dementia patients living in the community than those living in care homes (38%). Community pharmacists commonly dealt with queries about starting new medications (79%), patient compliance (81%) and the use of compliance aids (85%) in community-dwelling dementia patients. Queries about medication formulation type (67%) were more commonly encountered for those in care homes. Respondents had a mean total score of 73 (out of a possible 95; higher the score, more positive the attitude) for the approaches to dementia section. Pharmacists who had not attended any recent training on pain were unsure if people with dementia are more likely to experience pain than cognitively intact people (p = 0.003). Almost half of respondents (41%) were unsure if it was possible for people with dementia to provide a self-report of pain. Seventy per cent were uncertain about the availability of pain assessment tools for use in people with dementia; pharmacists who were providing pharmaceutical care to people with dementia were more likely to agree that such tools existed (p = 0.010). Just over half of respondents (51%) were uncertain about the safety of using opioid analgesics to treat pain in people with dementia.

Discussion Community pharmacists appeared to have positive attitudes towards people with dementia. They demonstrated similar knowledge deficits and attitudes about the assessment and management of pain as had been found with nursing staff 3,4,

Abstract 71 Adherence to bone protection treatments W. Baqira,b, R. Guya and R. Slanea a University of Sunderland, Sunderland, UK and bNorthumbria Healthcare NHS Foundation Trust, North Shields, UK

Focal points • Adherence to bone sparing medication was assessed. • Almost half of patients were under complying with treatment. • Highly effective agents are not being adhered to, putting patients at risk and potentially adding to health care costs.

Introduction Osteoporosis is a systemic, skeletal disease characterised by low bone mass and micro-architectural deterioration of bone tissue, with a consequent increase in bone fragility.1 Guidelines from the National Institute for Health and Clinical Excellence (NICE) and the National Osteoporosis Guideline Group (NOGG)2 have advocated treatment with bone sparing drugs for patients at risk of fracture. Adherence to bone sparing therapy, is generally poor. This project aims to quantify adherence to bone sparing medication in a primary care cohort.

Method This study was undertaken at a North East general medical practice. All patients prescribed bone sparing treatment, between November 2009 and November 2010, were retrospectively identified from the medical practice’s clinical system. Patients on treatment for less than two months were excluded. The primary outcome for this study was Mean Possession Ratio (MPR): the number of days patients had requested their medication as a proportion of the number of days they should have received. The study team set limits of


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85 to 100% as normal adherence. The effect of age, sex and concomitant medications on MPR was statistically analysed using t-tests and ANOVA. Ethical approval from Sunderland University Ethics Committee.

Results 168 patients (from 10,200 patients) were prescribed bone sparing drugs in the study time period. Fifteen had been receiving treatment for 100%. In the non-adherent cohort (MPR < 85%), MPR ranged from 7.7% to 84.6% (Average 61.7%; SD 23.2). There was no statistical difference between gender (123 women and 27 men) and MPR (p = 0.933). Age range was 21–95 years (Average: 74.6 years; SD: 12.4 years). There were 3, 12, 76 and 58 patients in the four age groups (20–40 years; 41–60 years; 61–80 years and >80 years), respectively. There was no significant difference between age group and MPR (p = 0.549). The number of concomitant medicines prescribed was 1–2 medicines (n = 6), 3–5 medicines (n = 27), 6–10 medicines (n = 68) and ≥11 medicines (n = 49). There was no statistical difference between any of these cohorts and MPR (p = 0.699).

Discussion Almost half of patients on bone sparing drugs poorly adhere to treatment as defined by MPR, placing them at increased risk of fracture. MPR is commonly used in bisphosphonate adherence studies3 but is only a surrogate marker for adherence and it is possible that subjects with normal MPR may be ordering medication but not taking it. In the low adherence cohort, patients were only ordering two thirds of their yearly bone sparing medication, on average. There were no statistical differences in adherence rates with gender, age and number of concomitant medicines, suggesting that adherence problems are specific to the medicines. It was not possible to compare different drugs due to low numbers. In conclusion, this study at a large general practice has demonstrated that patient adherence to bone sparing treatments remains poor. Further work is being planned in an attempt to understand the complex issues concerning low compliance with these medicines.

References 1. Consensus development conference: diagnosis, prophylaxis, and treatment of osteoporosis. American Journal of Medicine 1993; 94(6):646–650. 2. National Osteoporosis Guideline Group. Osteoporosis: clinical guideline for prevention and treatment. 2008. http://www.shef. ac.uk/NOGG (Accessed 25/01/2011). 3. Cramer JA, Silverman S. Persistence with bisphosphonate treatment for osteoporosis: finding the root of the problem. American Journal of Medicine 2006; 119:12–17.

Abstract 72 An exploration of the public acceptability of signposting by community pharmacies R. Rodgers, S. Collins and S. Ghir Medway School of Pharmacy, Universities of Kent and Greenwich, Chatham, Kent, UK

Focal points • To obtain the views of the general public on awareness, experience of and the acceptability of signposting services by pharmacies. • A majority of the adult population are aware of signposting services with nearly 40 per cent having experienced the service and reporting a high satisfaction rate. • Most signposting is to medical services however there is potential to expand and make better use of the service to direct the public to other social and support services.

Introduction Provision of advice and information from pharmacies is a key element of policy relating to public health as described in the best practice guidance, choosing health through pharmacy1. The pharmacy contract introduced in England in 2005 included for the first time an element of payment for the essential service ‘signposting’2. This requires the provision of information to people visiting the pharmacy who need further support, advice or treatment on health and social care providers or support organisations including referral if deemed necessary. Contractor pharmacies are provided with a directory of locally available services by the Primary Care Trust (PCT). Whilst it is known that pharmacists view signposting as an important service, research in Western Cheshire had indicated issues relating to the use of directories such as accessibility and content3. Although by 2007, 94% of pharmacies were participating in signposting4 little is known in relation to the public view of this service. The aim of the project was to evaluate public acceptability, awareness and experience of signposting.

Method English-speaking, adults (over 18 years of age) in the south east of England were approached in two town centre locations within a single Primary Care Trust (distant from registered pharmacies) and asked when they had last spoken to a pharmacist and whether they had ever been signposted to another service. If so, they were asked whether they were satisfied with the outcome and to indicate which type of service (medical services, social services or support services) they had been signposted to. The types of service had been generated utilising data from a previously conducted observational audit. The questionnaire and service type list had previously been validated with 16 non-pharmacist members of university staff. NHS ethics approval was not required.

Results A total of 384 participants were interviewed over a four day period. Sixty five percent of all participants (n = 252) indi-


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cated awareness of pharmacy as a local source of information. One hundred and fifty one (nearly 40%) reported that they had experience of pharmacy signposting services and nearly all of these (99%, n = 149) indicated that they had been satisfied with the information provided by the pharmacist. The vast majority of signposted individuals (92.7%, n = 140) had been directed to medical services which included dentists, opticians, nurses and walk-in centres. A small number of the remaining participants (4.6%, n = 7) had been referred or directed to social services and even fewer (2.6%, n = 4) to other support services including smoking cessation, Samaritans, and mobility services.

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supplying medicines moves towards more clinically orientated services1. Professional standards and codes set out the responsibilities and expectations of pharmacists dealing with such situations. There is limited research concerning the use of resources in ethical decision-making amongst pharmacists in England although research relating to pharmacists’ moral reasoning has been undertaken overseas2,3. The aims of this project were to identify the resources utilised by community pharmacists when resolving dilemma scenarios and compare the results obtained for two distinct groups of pharmacist: early career pharmacists (a maximum of 3 years post-registration practice) and more experienced pharmacists (registered for >5 years).

Discussion This survey has indicated a general acceptability and satisfaction by the public to pharmacies providing signposting to other healthcare and support services. The results indicate evidence of the value to patients of pharmacists undertaking the service, these are essential to support expansion and continuance of pharmacy in this public health role. Little or no research has yet been carried out to follow up the appropriateness and effectiveness of the signposting service provided by pharmacists.

References 1. Department of Health. Choosing health through pharmacy. 2005. 2. PSNC. NHS Community Pharmacy Contractual Framework. 2005. 3. Nkansah S., Cubbin I. and Vickers S. An investigation into the delivery of the signposting element of the Pharmacy Contract in Western Cheshire Primary Care Trust. IJPP 2009 17: Supplement 2, B51. [Accessed 18 April 2011] 4. Blenkinsopp A, Bond C, Celino G, Inch J and Gray N. National evaluation of the new pharmacy contract. PPRT 2007

Method A self-administered postal questionnaire was adapted with permission from that used by Chaar et al in Australia3 and validated with nine local practicing pharmacists. This was disseminated to 631 pharmacists, with early career and experienced individuals matched for number and gender, selected from a data base of pharmacists who had undertaken a short postgraduate qualification within the previous three years. The questionnaire included two practice scenarios: the first concerned promotion of short-dated overstocked over-the-counter medicine; the second, more complex scenario related to a request to dispense a nearly out-dated antibiotic prescription. Participants were asked how they would resolve each scenario and indicate what resources they would have consulted in reaching a decision. NHS ethics approval was not required.

Results

• To identify resources used as an aid to ethical decision making in pharmacy practice. • Most experienced community pharmacists did not refer to any specific resource whereas newly qualified pharmacists were far more likely to consult the Code of Ethics and professional standards or discuss the situation with others. • Dealing with ethical issues and problems are common in pharmacy practice however there is a need to highlight reference to resources used when justifying decision making.

A total of 117 pharmacists completed the two scenarios (37 early career pharmacists). The response rate of 18% (n = 117/631) had been affected by national postal strikes during the research period. In scenario one 86% (n = 100), the majority of all respondents would not make a sale in the circumstances described (84%, (n = 67) of experienced and 92%, (n = 34) of early career pharmacists). Early career pharmacists were at least twice as likely as more experienced pharmacists to have discussed the situation with another pharmacist or consulted the Code of Ethics and professional standards documents. Nearly three quarters (73%, n = 58) of experienced pharmacists claimed they had no need to check any resource compared to 41%, (n = 15) of the early career group. Scenario two was more finely balanced with 50%, (n = 58) of all respondents choosing not to dispense (45%, n = 36 experienced vs. 59%, n = 22 of early career). The situation varied from scenario one with early career pharmacists twice as likely to check with another pharmacist. Responses were more equally balanced in relation to using reference sources. A large minority, 38% (n = 44), claimed to not need any resources. In both scenarios the experienced pharmacists were more likely than the early career pharmacists to indicate they would seek additional information from or refer the patient.

Introduction

Discussion

Pharmacists face potentially greater exposure to ethical problems and dilemmas in practice as their traditional role of

This survey has indicated that early career pharmacists are more likely to seek assistance within the pharmacy or check

Abstract 73 Ethical decision making by community pharmacists in England: use of resources R. Rodgers, F. Eldin, E. Afetorgbor and A. Zyada Medway School of Pharmacy, Universities of Kent and Greenwich, Medway, Kent, UK

Focal points


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with resources when dealing with ethical issues in practice. The experienced pharmacists appear to be tending to relying on innate knowledge of pharmacy practice which might be out dated. Potentially this could pose problems were they to face any litigation or otherwise need to justify their actions at a time of major service change and increasingly clinical practice.

References 1 Cooper RJ, Bissell P and Wingfield J. 2007. Dilemmas in dispensing, problems in practice? Ethical issues and law in UK community pharmacy. Clinical Ethics 2:103–108. 2 Chaar BB, Brien JA and Krass I. 2009. Professional ethics in pharmacy practice: developing a psychometric measure of moral reasoning. PWS 31: 439–449. 3 Chaar BB, Brien JA and Krass I. 2005. Professional ethics in pharmacy: the Australian experience. IJPP 13:195–204.

Abstract 74 Impact of voluntary and legislative changes on over-the-counter sale of codeine and dihydrocodeine-containing analgesics in Wales H.C.T. Dua, D.N. Johna and R. Walkera,b a

Cardiff Univeresity, Cardiff, UK and bWelsh Assembly Government, Cardiff, UK

Focal points

Figure 1 Sales of selected C/DHC preparations in Wales for each 12-month period (Sept-Aug). Grey bars indicate the cumulative sale per 10,000 tablets/capsules ( effervescent non-effervescent). White bars indicate the cumulative sale per 1000 packs ( effervescent noneffervescent). The combined sales for effervescent/non-effervescent preparations are shown on the column heads.

legislative changes and the sale of OTC C/DHC analgesics in Wales.

Method The study had an ecological design and involved a retrospective analysis of OTC sales (IMS Health) from wholesalers to 622/707 (88%) community pharmacies in Wales. Monthly sales for 70 established, branded analgesic preparations containing C/DHC were monitored from September 2003 to August 2010. Sales were expressed for each 12-month period (September-August), as total tablets/capsules sold and packs of effervescent and non-effervescent oral dosage forms sold. Sales were compared with the previous 12 months and analysed using Wilcoxon’s signed rank test (SPSS v18).

• The impact of voluntary (2005) and legislative (2009) changes on the sale of selected OTC codeine/dihydrocodeine preparations in Wales was investigated from 2003/04 to 2009/10 (September-August). • The number of effervescent tablets/capsules sold in 2006/07 was significantly less than in 2005/06. Sales of non-effervescent preparations were significantly less in 2008/09 and 2009/10 compared to the previous 12-month periods. • The voluntary changes reduced the number of effervescent tablets/capsules sold, whereas the legislative changes reduced the tablets/capsules and packs of non-effervescent preparations sold in the following 12-months.

Year-on-year sales are summarised in Figure 1. For effervescent C/DHC the only significant reduction (P = 0.003) in tablets sold was from 2005/06 to 2006/07; there were no differences (P > 0.05) in packs sold between any other consecutive 12-month periods. Significant reductions in both tablets/ capsules sold and packs of non-effervescent preparations sold were observed in 2008/09 (P = 0.005 and 0.002) and 2009/10 (P = 0.005 and 0.002).

Introduction

Conclusion

The problem of misuse of over-the-counter (OTC) codeine and dihydrocodeine (C/DHC)-containing preparations is not new to medicine regulators1 and pharmacists2. In 2005, the Medicine and Healthcare product Regulatory Agency (MHRA) reached a voluntary agreement with the pharmaceutical industry to limit the pack size of OTC C/DHC products to 32 tablets and required larger packs of effervescent preparations to be overprinted ‘for dispensing only’ i.e. not for OTC sale.1 In September 2009, legislative changes classified all pack sizes of C/DHC preparations greater than 32 tablets as prescription-only medicines.3 Additionally, OTC packs were required to include a warning of addiction and to use for up to three days only. This study explored whether there was a temporal relationship between the voluntary and

The voluntary restrictions of 2005 reduced the number of effervescent tablets/capsules sold in the following 12-month period, presumably due to the supply of a similar number of packs but containing smaller quantities. The lack of effect on the sales of non-effervescent C/DHC preparations over the same period was expected because OTC products containing paracetamol were already restricted to pack sizes of 32. In contrast, there were reductions in both tablets/capsules and number of packs sold of non-effervescent C/DHC in the 12-month period before and after the legislative change in 2009. The pre-legislation sales reduction could have been due to the heightened awareness of concerns with C/DHC preparations.4 Data for own-brand and new C/DHC products launched during the study period were not included in the

Results


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analysis and consequently the findings should be interpreted with caution even though 14/19 leading proprietary brands were included. Whether patients were obtaining similar analgesics on prescription, switching to alternate products or were deterred from making purchases by the changes require further investigation.

References 1. MHRA. Updated patient information leaflets and labelling for painkillers. 2005. Available: http://tiny.cc/5upho [Accessed 01.12.10] 2. Peter, R et al. Misuse of over-the-counter medicines: A survey of community pharmacies in a South Wales health authority. Pharmaceutical Journal. 2002. 268(7184): 179–182. 3. MHRA. Updated advice on non-prescription medicine containing codeine or DHC. 2009. Available: http://tiny.cc/5w25a [Accessed 08.08.10] 4. APPDMG. All-Party Parliamentary Drug Misuse Group inquiry into physical dependence and addiction to prescription and overthe-counter medication. 2009. Available: http:// tinyurl.com/ yenrt8l [Accessed 02.09.10]

Abstract 75 Languages in the community pharmacy: the role of interpreters L. Hughes and N. Grew Cardiff University, Cardiff, UK

Focal points • Aim was to evaluate issues relating to the use of interpreters in the community pharmacy setting. • Use of informal interpreters such as family members is widely accepted, despite concerns about confidentiality. • Lack of use of formal interpreters could be explained by existing staff language skills and a view that it is the patient’s responsibility to provide an interpreter if needed, but may put patients at a disadvantage.

Introduction The UK census shows that the proportion of minority ethnic groups in England has risen1 and anecdotal evidence suggests the number of people for whom English is not their first language is also increasing. Previous research suggests that language is a major barrier to providing adequate health care to patients with limited English proficiency (LEP)2,3 and that translation is usually informal, using friends and family3,4. The aim of this study was to explore issues relating to the use of interpreters in the community pharmacy setting in an ethnically diverse area of the United Kingdom.

Methods Ethics approval was obtained from a University Ethics Committee. A questionnaire for community pharmacies was developed from key informant interviews and the literature. An ethnically diverse area was purposively chosen; following pilot, all 334 pharmacies were sent a copy of the confidential questionnaire together with a covering letter and freepost

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reply envelope. Non-responders were sent a second copy after the deadline. Data were entered into SPSS for analysis.

Results Seventy completed questionnaires were returned (21%). The majority (59%) were from Asian pharmacists, with most of the remainder classing themselves as white (31%). Over half (39, 56%) of the pharmacies dealt with LEP patients at least once a day; only one never dealt with such patients. A wide range of languages were spoken by the pharmacy staff, in particular Urdu (41 pharmacies) and Panjabi (50 pharmacies). Language interpreters were rarely used (only 5 pharmacies, 9%, used at least weekly) whereas use of family / friends as interpreters was common (30 pharmacies, 45%, used at least weekly). Only two pharmacists reported using a formal interpreter service. Pharmacists were asked to state their level of agreement with a range of statements; those relating to interpreters are shown in Table 1.

Discussion Results cannot be generalised due to the low response rate, possibly due to lack of interest from those with little contact with LEP patients. However, the study successfully targeted pharmacies regularly serving LEP patients, providing useful data. In common with other research3,4, use of informal interpreters is common and accepted but there are concerns regarding confidentiality. Lack of use of formal interpreting services may be explained by pharmacists’ views that provision of an interpreter is the patient’s responsibility or because the pharmacy staff already speak a range of languages, but could prove disadvantageous for the patient. Further research is needed to explore reasons for uncertainty over some issues; in addition a larger study could discover if these are common issues and explore the implications for patients.

References 1. Office for National Statistics. 2001. Census 2001 – Ethnicity and Religion in England and Wales. Available at: http://www.statistics.gov.uk/census2001/profiles/commentaries/ethnicity.asp [Accessed: 19 April 2011] Table 1

Respondents’ views regarding interpreters

Statement

Agreed or strongly agreed

Unsure

Disagreed or strongly disagreed

I would be concerned about confidentiality when using a patient’s family or friends as interpreters I would be happy to use a patient’s family and friends as interpreters It is a patient’s responsibility to bring someone to the pharmacy to translate for them if they cannot speak English Providing a translator for a patient is a pharmacist’s responsibility (1 missing value)

43 (61%)

11 (16%)

16 (23%)

54 (77%)

14 (20%)

2 (3%)

42 (60%)

16 (23%)

12 (17%)

3 (4%)

9 (13%)

57 (83%)


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2. Bradshaw, M., Tomany-Korman, S., Fores, G. Language barriers to prescriptions for patients with limited English proficiency: A survey of pharmacies. Pediatrics 2007; 120: e225–e235 3. Westberg, S.M., Sorensen, T.D. Pharmacy-related health disparities experienced by non-English-speaking patients: impact of pharmaceutical care. J Am Pharm Assoc 2005; 45: 48–54. 4. Schaafsma, E.S., Raynor, T.D.K., de Jong-van den Berg, L.T.W. Accessing medication information by ethnic minorities: barriers and possible solutions. Pharm World Sci 2003; 25: 185–190.

Abstract 76 General public’s views on community pharmacy public health services: a qualitative study K. Saramuneea,b, J. Krskaa, A. Mackridgea, P. Phillips-Howarda and J. Richardsa a

Liverpool John Moores University, Liverpool, UK and bMahasarakham Univerity, Maha Sarakham, Thailand

Focal points • To gather views from the general public on how to improve and encourage the use of community pharmacy public health services. • The public view community pharmacists positively in general but their expertise in delivering particularly public health services is unclear. • Public perception and a lack of advertising of pharmacy health services were identified as key barriers of service uptake.

Introduction UK community pharmacists currently provide a broad range of public health services, such as cardiovascular checks, weight management, and sexual health, although evidence is limited on their effectiveness.1,2 Health policy makers have encouraged these activities to extend accessibility to healthcare.1,3 However, members of the public have a limited awareness of extended health services from community pharmacies4 and public perspectives as a key barriers to uptake of health services in community pharmacies are of interest.

Method A random sample of 1,000 households in Sefton was sent postal invitations to participate in focus group (FG) discussions about community pharmacy public health services. Volunteering participants were stratified by occupation to high, middle or low socio-economic groups. One FG discussion was held independently for each socio-economic group. FG guides were developed from the literature to explore potential issues relating to public health services and community pharmacy to examine key barriers and facilitators for the use of these services. Discussions lasted approximately 45 minutes, were audio recorded and transcribed verbatim. Participants gave written informed consent prior to the discussion. Thematic analysis was conducted using NVivo software. This study was approved by Liverpool John Moores Research Ethics Committee.

Results Sixteen members of the public participated in 3 FGs (7 high socioeconomic group; 5 middle; and 4 low). FG discussions revealed strong concern about public health problems in particular smoking and drinking behaviour as well as health matters relating to cardiovascular disease. In general, they perceived community pharmacy as a source of prescribed medicines, and advice for minor health conditions. Most participants had used public health services such as blood pressure and diabetes screening in their GP surgery and considered that they could be delivered through community pharmacies. However, there was concern that pharmacists may not be able to perform such tasks. Participants reported a current lack of promotion or advertising of the available services and suggested that this could be a cause of pharmacy underutilisation.

Discussion An opportunity for delivering public health services through community pharmacy exists. However, further efforts are needed to enhance public understanding, service use and quality. The findings, in line with previous studies,4 show that the public are not confident of community pharmacists’ competence to deliver public health services. This, and other aspects of the public’s perception, appears to be crucial barriers to pharmacy service use. Better methods are required to advertise services, and to educate the general public on the community pharmacist’s roles in public health.

References 1. Department of health. Choosing health through pharmacy: A programme for pharmaceutical public health 2005–2015. In: Department of health, editor. London: Crown copyright; 2005. 2. Anderson C, Blenkinsopp A. Community pharmacy’s contribution to improving public health: learning from local initiatives. PJ. 1 November 2003;271:623–5. 3. Pharmacy Health Link. Public health: a practical guide for community pharmacists. In: Griffiths OBE S, editor. Royal Pharmaceutical Society of Great Britain. 4. Krska J, Morecroft C. Views of the general public on the role of pharmacy in public health. JPHSR. 2010;1:1–6.

Abstract 77 Screening for sexually transmitted infections: community pharmacists’ perceptions of their future roles M. Shaw, D. Ashcroft and P. Noyce University of Manchester, Manchester, UK

Focal points • To identify community pharmacists’ perceptions on their role in screening for sexually transmitted infections. • A questionnaire was sent out to 2000 practising community pharmacists in England. • Community pharmacists consider their role in testing for Chlamydia infection is appropriate.


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• There was agreement that invasive testing procedures for other sexually transmitted infections were not appropriate in community pharmacy.

Introduction In the UK, public health policy recognises the potential role of the community pharmacy and has continued to support increased access through this setting to a range of sexual health services for example provision of emergency hormonal contraception and Chlamydia testing and treatment1. Services have been developed to test for, and in some cases treat, Chlamydia infections through the community pharmacy2. Evaluation of the supply of Chlamydia testing through community pharmacy found that users appreciated the service3, but what do community pharmacists themselves think?

Aims and objectives To identify the perceptions of community pharmacists of their role in testing for sexually transmitted infections (STIs) using a survey.

Methods A survey tool was developed by the researcher and piloted with a group of practising community pharmacists in England. It was posted to a random sample of 2000 practising community pharmacists in England in April 2010, asking the extent to which they felt it was appropriate for the pharmacist to test for the six most commonly encountered STIs in the UK. Reminders were sent out after three and six weeks where no response was received. Responses were analysed using SPSS v16 and are presented as descriptive statistics in the table below. Ethical approval was granted.

Results A total of 789 valid responses were received and 67 participants indicated that they were no longer in the target group, giving an adjusted sample size of 1933 and a response rate of 41%. Responses showed agreement (see Table 1) that it was appropriate for community pharmacists to test for Chlamydia infection. There was overall agreement that it was not appropriate to test for other STIs in the community pharmacy setting using invasive testing methods.

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Conclusions Community pharmacists expressed strong support for testing for Chlamydia by urine testing. However it appears that pharmacists do not consider invasive testing procedures to be appropriate. Regardless of whether the testing method was blood testing, swabbing or physical examination, pharmacists did not agree it was appropriate for them to engage in these testing procedures.

References 1. Wanless J. Choosing Health: Making healthy choices easier. Department of Health, London, 2004. 2. Anon. Minister launches Boots Chlamydia service. The Pharmaceutical Journal. 12 November 2005; 275; 596. 3. TNS Healthcare. Pharmacy Chlamydia Screening pathfinder evaluation. Report for the Department of Health. London, 2007.

Abstract 78 Exploring medicines-related information and advice sharing in internet-based self-help groups: a qualitative study L. Hickmott and S. White Keele University, Staffordshire, UK

Focal points • This study aimed to explore UK Internet-based self-help groups (IBSHG) users’ perspectives on sharing medicines information and advice. • Medicines-related information that was shared on IBSHGs appeared to be based on users’ own experiences and was often incorporated in their own personal ‘research’ about their condition. • This personal ‘research’ was reported to often form the basis of consultations with health professionals. • Pharmacists and other health professionals can help patients proactively manage their condition by explicitly acknowledging and discussing issues, such as those about medicines, which arise from patients’ own ‘research’.

Table 1 Community pharmacists’ perceptions on screening for genital sexually transmitted infections It is appropriate to screen for

By this method

Chlamydia n = 778 Genital herpes n = 781 Genital warts n = 778 Gonorrhoea n = 781 HIV n = 780 Syphilis n = 781

Testing a urine sample Swabbing the ulcer Physical examination Vaginal or urethral swab Taking a blood sample and counselling Taking a blood sample

Strongly disagree % (n)

Disagree % (n)

Neither % (n)

Agree % (n)

Strongly agree % (n)

7.0% (55) 36.2% (286) 41.4% (327) 40.4% (319) 39.9% (315) 36.6% (288)

12.9% (102) 44.2% (349) 41.1% (324) 42.8% (338) 35.2% (278) 34.9% (275)

7.7% (61) 8.1% (64) 8.1% (64) 7.4% (58) 9.8% (77) 10.3% (81)

41.1% (324) 7.5% (59) 7.5% (51) 6.7% (53) 10.8% (85) 13.9% (110)

29.9% (236) 2.9% (23) 2.9% (12) 1.6% (13) 3.2% (25) 3.3% (26)


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Introduction Patient-run self-help groups offer support outside that offered by the healthcare system by providing an opportunity to discuss medical conditions with others, especially chronic conditions. IBSHGs are becoming increasingly popular due to factors such as their easy and constant accessibility, and their anonymous nature.1 Whilst a number of studies have demonstrated the psychosocial support offered by these groups,1 few have explored their role in medicines-related communication and these have been of an observational nature, analysing the content of existing messages, rather than engaging with the IBSHG users directly.2 Subsequently, it seems that little is known about the perspectives of IBSHG users themselves on medicines-related communication and the influence this may have on their use of medicines. As such, this study aimed to explore a group of UK IBSHG users’ perspectives on these topics.

Methods Following ethical approval from Staffordshire NHS Local Research Ethics Committee, qualitative interviews were conducted online with a purposive sample of 13 IBSHG users, who were recruited by posting messages on the discussion forums of a wide variety of UK-based IBSHGs.3 Interviews used open ended questions from an interview guide, which was developed from the study objectives and a review of the literature; subsequent questions followed from participants’ responses.3 Interview topics included participants’ experiences of using the discussion forums on IBSHGs and their perspectives on sharing medicine-related information and advice online. The data were analysed by framework analysis.4

experiences, as well as being a source of social and psychological support. Pharmacists and other health professionals can help patients to take a proactive role in the management of their condition by discussing issues about medicines and other aspects of their condition that arise from patients’ own research. Explicit acknowledgement of the legitimacy of such research may strengthen therapeutic relationships with patients.

References 1. Loader B, Muncer S, Burrows R, Pleace N, Nettleton S. Medicine on the line? Computer mediated social support and advice for people with diabetes. International Journal of Social Welfare 2002; 11: 53–65. 2. Burri M, Baujard V, Etter J. A qualitative analysis of an Internet discussion forum for recent ex-smokers. Nicotine and Tobacco Research 2006; 8 (Suppl 1): S13–S19. 3. Mann C, Stewart F. Internet communication and qualitative research. A handbook for researching online. London: Sage, 2000. 4. Pope C, Ziebland S, Mays N. Qualitative research in healthcare: Analysing qualitative data. British Medical Journal 2000; 320: 114–116.

Abstract 79 University students’ perspectives on community pharmacy public health services: a qualitative study T. Al-Kattan and S. White Keele University, Staffordshire, UK

Results

Focal points

All of the participants had a chronic condition such as diabetes, but factors such as age, duration of illness and IBSHG use varied between participants. The findings suggested that the online community and support network was the primary function of IBSHGs, strengthened by their constant accessibility. As part of this community, users appeared to take on responsibility for the wellbeing of others, in addition to taking a proactive approach to their own healthcare. Many of the respondents talked about doing their own ‘research’, which seemed to be an important aspect of the self-management of their condition. This involved searching for information from a variety of health-related sources, including the IBSHG. Medicines-related information and advice that was shared on the IBSHG appeared to be based on users’ own experiences and seemed to be an important part of their personal ‘research’. Participants reported often raising issues arising from their research with healthcare professionals, but sometimes did not reveal their sources to avoid disapproval. In particular all participants reported that they would discuss any changes to their treatment with their medical team first.

• This study aimed to explore university students’ perspectives on community pharmacy public health services. • Students appeared to have a good understanding of medicines supply services but seemed to be much less aware of public health-related services. • Most seemed unaware of private consultation rooms and reported that they would feel embarrassed asking about these services, particularly Chlamydia screening and supply of Emergency Hormonal Contraception (EHC). • Students’ awareness of these services and that they can discuss them in privacy may need to be raised.

Conclusion IBSHGs appear to play an important role in providing a place for patients with chronic conditions to share medicinesrelated information and advice based on their own

Introduction In recent years, an increased variety of public health services have been provided by community pharmacies in addition to the supply of medicines, for example smoking cessation services, alcohol reduction and weight management programmes, physiological measurement monitoring (e.g. blood pressure), Chlamydia screening, supply of EHC, and syringe and needle exchange services.1 However, previous studies have suggested that the general public may be largely unaware of these extended services.2 University students may be at particular risk of adverse health outcomes as a result of exposure to excess alcohol consumption, drugs and risky sexual behaviour,3 and subsequently may benefit from these services pro-


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vided by community pharmacies. However, little is known about students’ perspectives on community pharmacy public health services. As such, this study aimed to explore a group of University students’ perspectives on these services.

Method Following ethical approval from the School of Pharmacy Research Ethics Committee, qualitative interviews were conducted online with a purposive sample of 12 students using mobile-instant-messaging-applications. Participants were recruited by emailing all students at the University, personal contact with secretaries of University clubs and societies, and by posting messages on Student Union message boards. Those who responded were asked which course they were studying and whether or not they were from the UK to ensure sample heterogeneity and that pharmacy students were not targeted. Subsequently, most but not all were recruited. The interview guide was developed on the basis of the objectives of the study and a review of the literature. Interview topics included participants’ perspectives on community pharmacy services and their experiences of using community pharmacies. The data was analysed by framework analysis.4

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2. Krska J, Morecroft C. Views of the general public on the role of pharmacy in public health. Journal of pharmaceutical health services research 2010; 1: 33–38. 3. Rashad I, Kaestner R. Teenage sex, drugs and alcohol use: problems identifying the cause of risky behaviors. Journal of Health Economics 2004; 23: 493–503. 4. Pope C, Ziebland S, Mays N. Qualitative research in healthcare: Analysing qualitative data. British Medical Journal 2000; 320: 114–116.

Abstract 80 Potentially inappropriate prescribing and cost outcomes for older people: a population prevalence study M. Bradleya, T. Faheyb, D. O’Reillya, C. Cahirb, K. Bennettb and C. Hughesa a

Queen’s University Belfast, Belfast, Northern Ireland, UK and bRoyal College of Surgeons, Dublin, Ireland

Focal points Results In general, students appeared to have a good understanding of medicines supply services provided by community pharmacies but seemed to be much less aware of public healthrelated services, and were not aware of having seen any of these services advertised in pharmacies. The exceptions to this were that all of the participants were aware that smoking cessation services were provided by community pharmacies and female students appeared to have a greater awareness of Chlamydia screening services than male students. Students reported being concerned about the potential lack of privacy and confidentiality in community pharmacies in relation to issues that may be subject to stigma, such as sexual health services, especially Chlamydia screening and supply of EHC, as well as drug misuse services. In particular, most students seemed unaware of private consultation rooms in community pharmacies and reported that they would feel embarrassed asking about these services at the counter.

Conclusion These findings suggest that students’ awareness of the public health services provided by community pharmacies may need to be raised, if they are to benefit from these services. In doing so, pharmacists should place a particular emphasis on the existence of consultation rooms where sensitive issues can be discussed in private and how services can be accessed without students having to specifically ask about them at the counter. This may be achieved by University-based health promotion campaigns, but further research is needed to identify the most effective method of targeting this population.

References 1. Anderson, S. Community Pharmacy and public health in Great Britain, 1936 to 2006: how a phoenix rose from the ashes. J Epidemiol Community Health 2007; 61: 844–848.

• This study sought to estimate the prevalence and costs of potentially inappropriate prescribing (PIP) in an older population in Northern Ireland (NI), and to investigate the association between PIP, polypharmacy, gender and age. • Overall PIP prevalence among older people was 35%. The most common example of PIP was prescription of proton pump inhibitors, at maximum therapeutic dose, for >8 weeks, (17,494 patients [10.53%]). • The main determinant of PIP was polypharmacy.

Introduction Older people are particularly vulnerable to potentially inappropriate prescribing (PIP)1 because of multiple drug regimens, co-morbid conditions and age-associated pharmacokinetic and pharmacodynamic changes. The term “potentially” is used as often, there is little evidence to support the inclusion of certain agents in lists of so-called “bad drugs” and their use, in specific patients, may be appropriate in some cases. Optimisation of prescribing in older populations is a priority due to the significant clinical and economic costs of drug-related illness.2 This study aimed to estimate the prevalence and cost of PIP, in an older population, in NI using European based explicit prescribing criteria,3 and to investigate the association between PIP, polypharmacy, gender and age.

Methods A retrospective cross-sectional study, using primary care prescribing/dispensing data, from the NI Electronic Prescribing and Eligibility System (EPD), was carried out. EPD comprises a central database of all prescribed and dispensed drugs, for approximately 1.9 million patients, registered with general practitioners (GPs) in NI. The study population focussed only on those aged ≥70 years (n = 166,108), in the EPD database, from July 2009–June 2010. Data on all


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prescribed/dispensed medications for identified patients, in the given time period, were extracted from EPD. Thirty European based PIP indicators [Screening Tool of Older Persons Potentially Inappropriate Prescriptions (STOPP) criteria]3 were applied to the extracted EPD data. The overall prevalence of PIP and the prevalence per individual STOPP criteria, were calculated as a proportion of the total study population. The association between any (vs no) PIP and polypharmacy (categorised as 0–3 vs 4, 5, . . . , 10+ repeat drug groups), age and gender (previously seen as significant4) was assessed using logistic regression. The maximum gross ingredient cost and total expenditure analysis is ongoing and only the prescribing analysis has been presented below.

Abstract 81 Written medicines information in the UK and Australia: exploring patient opinions and preferences on tailoring medicine leaflets

Results

Focal points

The overall prevalence of PIP in the study population was 35% (58,023 recipients), [95% Confidence Intervals (CI), 34.77–35.23]. Just under 25% (24.2%; n = 40,081) of patients received at least one potentially inappropriate prescription, 12,357 (7.4%) received two and 5,585 (3.4%) received 3 or more. The main STOPP criteria contributing to the overall prevalence of PIP were prescribing of proton pump inhibitors (PPIs) at maximum therapeutic dose for >8 weeks (n = 17,494 recipients; 10.5%), prescribing of duplicate drugs (n = 14,893; 9.0%), prescribing of non-steroidal anti-inflammatory drugs (NSAIDs) for >3 months (n = 14,379; 8.7%), and prescribing of benzodiazepines for >1 month (n = 10,085; 6.1%). The main determinant of PIP was polypharmacy. Patients taking 10 or more different repeat medications were 14 times more likely to be in receipt of a PIP [Odds Ratio (OR) 14.99 95% CI 14.42–15.58] than those taking 0–3 repeat medications. A significant linear relationship was observed between likelihood of PIP and number of prescribed repeat drugs (P < 0.05). PIP was more likely in females vs males, after adjusting for age and polypharmacy, OR 1.32 (95% CI 1.29–1.35) and was not associated with age after adjusting for gender and polypharmacy OR 0.96 (95% CI 0.93–1.0).

• The tailoring of health communications to the individual has been shown to stimulate behaviour change and encourage patients to consider health information in more detail. • We investigated participants’ opinions and preferences on tailoring information in medicines leaflets through focus groups held both in the UK and Australia. • Participants were presented with an example of a cardiovascular medicine, tailored for a man aged 55 being treated for hypertension. • The results showed that, although acceptable, the generalised tailored information we provided was not as desirable as the concept of medicines information individualised to the participant’s particular circumstances.

Discussion This study has identified a high prevalence of PIP in NI, findings which are comparable to those in the Republic of Ireland.4 Improving prescribing in older people remains a major public health issue and requires close attention by health care professionals.

References 1. O’Mahony, D. & Gallagher, P.F. Inappropriate prescribing in the older population: need for new criteria. Age and Ageing 2008; 37: 138–141. 2. Hanlon, J.T., Maher, R.L., Lindblad, C.I. et al. Comparison of methods for detecting potential adverse drug events in frail elderly inpatients and outpatients. AJHP 2001; 58: 1622– 1626. 3. Gallagher, P. & O’Mahony, D. STOPP (Screening Tool of Older Persons’ potentially inappropriate prescriptions): application to acutely ill elderly patients and comparison with Beers’ criteria. Age and Ageing 2008; 37: 673–679. 4. Cahir, C., Fahey, T., Teeling, M. et al. Potentially inappropriate prescribing and cost outcomes for older people: a national population study. Br J Clin Pharmacol 2010; 69: 543–552.

R. Dickinsona, K. Hamrosib, P. Knappa, P. Aslanib, J. Sowtera, I. Krassb and D.K. Raynora a

University of Leeds, Leeds, UK and bUniversity of Sydney, Sydney, Australia

Introduction Research has shown then when prescribed a new medicine only 66% (Australia)1 and 70% (UK)2 of patients read the information provided. Complaints about current medicine leaflets include that they are ‘one size fits all’ and are too long.3 Tailoring health messages has been shown to have an impact on the ways patients use health information.4 We aimed to explore participants’ opinions and preferences on tailored written medicines information.

Methods 45 participants were recruited from community pharmacies and community groups (UK) and via a market research company (Australia) to 8 focus groups which were run concurrently in the UK and Australia. Participants were aged over 50 (Range: 53–97) and taking at least medicine. 29 females and 16 males were recruited. Participants were provided with exemplar leaflets for a cardiovascular medicine based on the ACE Inhibitor ramipril, which was tailored for a man aged 55 with hypertension. Hence reference to other indications of the medicine, children’s doses, pregnancy and breast-feeding information was removed. A topic guide directed the discussion and explored preferences and opinions on tailored leaflets. Focus groups were transcribed verbatim and analysed using content analysis. Data were synthesised using adapted cross-case study analysis. Ethics Approval was obtained from the School of Healthcare Research Ethics Committee, University of Leeds and the Human Research Ethics Committee, University of Sydney.


Posters

Results Participants welcomed the concept of tailored information, desiring shorter and more relevant information. Information tailored to their condition or disease was most sought-after, followed by tailoring by age or sex. However, some participants voiced concerns about the potential for the wrong information being given to vulnerable patients. Other concerns included how tailoring might impact upon the quality of information available and the feasibility of delivery. A key finding was the participants’ desire for a more individualised approach to tailoring medicines information, as opposed to the generalised tailored information provided in the study. Participants valued having spoken communication with a healthcare professional at the same time as they received tailored leaflets.

Discussion Most participants welcomed tailored leaflets but overall valued a more personalised approach than the generalised tailored information we provided. Despite concerns about quality and delivery, many felt tailoring written medicines information could improve the relevance of the information to the individual and potentially encourage them to value it. The provision of generalised tailored information leaflets could be a starting point to facilitate a dialogue about a patient’s information needs. Pharmacists need to be aware of a patient’s desire for personalised medicines information and seek to maximise communication about individual information needs during a consultation.

References 1. Aslani P et al (2010). The Investigating Consumer Medicine Report. CMI Effectiveness Tender. The Pharmacy Guild of Australia and the Department of Health and Aging http://www. guild.org.au/research/4cpa_project_display.asp?id=1853 2. Raynor D K et al. How do patients use medicine information leaflets in the UK? International Journal of Pharmacy Practice 2007; 15: 209–218. 3. Raynor et al. A systematic review of quantitative and qualitative research on the role and effectiveness of written information available to patients about individual medicines. Health Technology Assessment 2007; 11 No. 5. 4. Noar et al. Does tailoring matter? Mata-analytical review of tailored print health behaviour change interventions. Psychological Bulletin 2007; 133: 673–693.

Abstract 82 Including benefit information in medicines leaflets: patient perceptions and opinions in the UK and Australia R. Dickinsona, K. Hamrosib, P. Knappa, D.K. Raynora, I. Krassb, J. Sowtera and P. Aslania a

University of Leeds, Leeds, UK and bUniversity of Sydney, Sydney, Australia

Focal points • Despite evidence that patients want both benefit and harm information to enable them to make informed choices about

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medicines, in both the UK and Australia medicine leaflets are not required to include ‘benefit’ information. • Focus groups were held in Australia and the UK to explore participants’ opinions on benefit information about their medicines. • The results showed that participants do want benefit information in textual form, but presenting numerical information, in the style of ‘numbers needed to treat’, was widely disliked and misunderstood. • The presentation of benefit information needs further research, as numerical information might adversely impact on understanding, adherence and health outcomes.

Introduction When making decisions about medicines patients want clear and reliable information about the harms and benefits of their medicines.1 Current regulations surrounding written medicines information in both the UK and Australia require medicines leaflets to include all relevant information about the medicine’s side-effects. Currently there is no requirement for ‘benefit’ information to be included in written medicines information in either country. Benefit information has been associated with increased patient knowledge, intent to adhere and the safer use of medicines.2,3 This study aimed to explore preferences for benefit information in a medicine leaflet and examine patient understanding and reaction to treatment benefits.

Methods 45 participants recruited from community pharmacies, community groups (UK) and via a market research company (Australia) attended 8 focus groups; 4 in Australia and 4 in the UK. Participants were provided with 3 amended leaflets based on clopidogrel (renamed ‘CLOTMED’) containing: – General benefit information – Textual benefits information including the wording ‘if you take CLOTMED everyday it reduces your chance of having a heart attack or stroke caused by a blood clot’. – Numerical benefit information presented using numbersneeded-to-treat (NNT) including the wording ‘if 100 people took this medicine for 2 years • 3 of them would be saved from having a heart attack • 1 of them would be saved from having a stroke’ A topic guide which explored opinions on the leaflets directed discussion. Focus groups were analysed using content analysis. Data were synthesised using adapted cross-case study analysis. Ethics Approval was obtained from the School of Healthcare Research Ethics Committee, University of Leeds and and the Human Research Ethics Committee, University of Sydney.

Results There was consensus in the UK and Australia that benefit information was a positive addition. Many participants felt that textual benefit information offered an incentive to take a medicine. The presentation of numerical benefit information provoked strong feelings of disbelief and shock; participants in both countries were surprised that so few people would benefit. Many participants struggled to interpret the NNT and found it difficult to comprehend the magnitude of the benefit


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information. In both countries the provision of numerical benefit information appeared to undermine participants’ faith in drug treatments. Participants were concerned about how this might affect the less-informed patient. In the UK participants stated their adherence to treatment was also reinforced by their doctor’s advice.

schools of pharmacy (SoPs) and has given valuable data that came directly from students themselves.1 This study aimed to establish the views of a recent cohort of MPharm graduates at one SoP regarding how the degree could be amended to better prepare them for pre-registration training.

Method Discussion Participants wanted to receive information about the benefits of their medicines. A surprise finding was the expressed shock and disbelief at the small benefit to be gained from this treatment. This suggests that currently many patients overestimate the benefits of their medicines. Further research is required to ascertain the best method for presenting benefit information to ensure optimum understanding, adherence and health outcomes.

References 1. Raynor DK et al. A systematic review of quantitative and qualitative research on the role and effectiveness of written information available to patients about individual medicines. Health Technol Assess. 2007; 11: 5. 2. Amery WK. Coming full circle in pharmacovigilance: communicating safety information to patients through package inserts. Pharmacoepid Drug Saf. 1999; 8: 121–9. 3. Bersellini E, Berry D. The benefits of providing benefit information in a patient information leaflet. IJPP. 2007; 15: 193–7.

Abstract 83 Obtaining recent graduates’ feedback on their preparedness for the pharmacy pre-registration year: informing the MPharm curriculum D.N. Johna, N. Proctora,b, E.C. Hughesb and S.A. Coulmana a

Cardiff University (Welsh School of Pharmacy), Cardiff, UK and Cardiff & Vale University Health Board, Cardiff, UK

b

Focal points • To establish the views of recent graduates from one school of pharmacy on how the MPharm degree could be amended to better prepare them for pre-registration training. • Although 93% of respondents (51/55) stated the degree had prepared them extremely well/well for pre-registration training, several areas in which the majority of pre-registration pharmacists could be better prepared for training were identified, namely, assessing blood results, dealing with problems, counselling actual patients, clinical checking and reviewing patient notes. • This approach may be adopted/adapted by other SoPs to provide the GPhC with feedback from graduates as part of the re-accreditation process.

Introduction Previous research into the MPharm degree has provided a systematic review of teaching, learning and assessment in UK

University research ethics approval was obtained. A convenience sample of pre-registration pharmacists in the local health board area was invited to participate in a focus group. All six attended. Semi-structured one-to-one interviews were undertaken with four pre-registration tutors. Interviews were audio-recorded and transcribed ad verbatim. One further tutor provided responses to questions via email. Interview and focus group data were used to construct a questionnaire which asked for suggestions on what could be done to better prepare graduates for pre-registration training. Chi-Square (χ2) and Mann-Whitney (M-W) were used (SPSSv16) to compare responses between community and hospital respondents. Questionnaires (n = 94) were sent by post to each 2009 graduate working in the UK in Spring 2010, that is, approximately half way through their pre-registration year.

Results Fifty-five (of 93) questionnaires were returned (59% response). One was not delivered, the respondent having moved address. Thirty-four were based in community and 21 in hospital. Fifty-one (93%) said the MPharm prepared them extremely well/well for their pre-registration year. Of those subjects identified during interviews as needing more experience during the MPharm, the majority wanted more experience in: assessing blood results (n = 45), dealing with (rather than identifying) problems (n = 40), counselling actual patients (n = 39), clinical checking (n = 33) and reviewing patient notes (n = 30). Less than half indicated more experience was required in calculations (n = 12), dispensing (n = 12), reviewing PMRs (n = 16) or drug charts (n = 23), drug history-taking (n = 18), accuracy checking (n = 19) and counselling skills not using patients, e.g. actors (n = 19). Only three significant differences were found between hospital and community respondents namely; those in community wanted more experience in dispensing (χ2 p = 0.013) and accuracy checking (χ2 p = 0.044) and hospital pre-registration pharmacists indicated a lower level of agreement that communication assessments prepared them for communicating with patients in practice (M-W p = 0.005).

Discussion The preliminary interview stage was successful in informing the questionnaire design and a reasonable response rate was achieved. Limitations include small numbers in the interview stages which may not have identified other areas for inclusion in the questionnaire and that non-responders may have held different views. The findings have been useful to this SoP as part of its MPharm curriculum review. Following a recent consultation, the General Pharmaceutical Council (GPhC) has agreed changes to the education standards2 and accreditation methodology3 for MPharm degrees in Great Britain. One recommendation in the latter document is that SoPs should


Posters

gather views of their pre-registration graduates and submit findings as part of the re-accreditation process.3 We suggest the multi-method approach described here is one which the GPhC may find acceptable and SoPs may wish to adopt or adapt to obtain feedback from recent graduates.

References 1 Wilson, K. Jesson, J. Langley, C. Clarke, L. Hatfield, K. MPharm Programmes: Where are we now? Pharmacy Practice Research Trust. 2005. [http://www.pprt.org.uk/Publications/2005 Publications.aspx] Accessed 21 April 2011. 2. GPhC. New standards for the initial education and training of pharmacists. 2011. [http://www.pharmacyregulation.org/pdfs/ council/april2011newstandardsfortheinitialeducationandtrainin gofpharmacists.pdf] Accessed 21 April 2011. 3. GPhC. A new accreditation methodology of courses leading to registration or annotation as a pharmacist in Great Britain. 2011. [http://www.pharmacyregulation.org/pdfs/council/april2011ac creditationmethodology.pdf] Accessed 21 April 2011.

Abstract 84 The pharmacist as a member of healthcare team in Karachi, Pakistan: perception of patients S. Jamsheda, L.B. Yeana, M.J.A. Siddiquia and Z. Babarb a

International Medical University, Kuala Lumpur, Malaysia and bSchool of Pharmacy, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand

Focal points • To explore the perception of high-income group Pakistani patients about pharmacists. • A convenience sample of 400 exit patients outside the hospital out-patient department was recruited. • A very large majority expressed positive perception towards the presence of pharmacists in the hospital pharmacies. • More than half of the respondents advocated the need of a separate counselling counter and more counselling time from the pharmacists.

Introduction The trail of uninterrupted expansion of pharmacy profession apparently calls for development, re-emergence, transformation and rejuvenation of traditional principles of this profession. In Pakistan the profession of pharmacy is rapidly evolving with appreciable number of pharmacists shifting their paradigm from industry to community and hospital pharmacies. Additionally, health authorities in Pakistan urged to reinforce pharmaceutical care services to improve the quality of life of the patient and drug use. In context to this, this pilot study aimed to investigate the awareness and perception of high-income group patients about pharmacists and their role in the healthcare system.

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Method A validated questionnaire encompassing open and closed questions, Likert scale-based statements, and as well as a short demographic section was interview-administered to 400 conveniently selected exit patients outside the private tertiary healthcare setting in Karachi, Pakistan. The study was conducted from December 2009–March 2010. The inclusion criterion was to evaluate those patients who reported mean monthly income of ≥500 US Dollars. Awareness about the presence of pharmacists in the hospital and perception about their role were mainly ascertained by high-income group patients. Descriptive and inferential statistics were applied.

Results Of the total respondents, 300 (75%) were males, 150 (37.5%) were below 60 years of age, 375 (93.7%) had non-communicable diseases and 350 (87.5%) reported visiting both doctor and hospital pharmacist once a month. In comparison to doctors and nurses, a large majority of respondents (n = 350; 87.5%) stated the pharmacist as one of the most respected healthcare professional. The pharmacist was cited to be the most appropriate person to dispense medicines by more than three-quarters of the respondents (n = 375; 93.7%). Nearly all the respondents (n = 390; 97.5%) cited pharmacists as the most knowledgeable healthcare professional regarding medicines. More than three-quarters of the respondents (n = 330; 82.5%) stated pharmacists as the most appropriate person to provide drug-related information. Slightly less than half of the respondents (n = 180; 45%) cited counselling time as ‘inadequate and insufficient’ and rated the quality of verbal information as ‘average. More than three-quarters of the respondents (n = 350; 87.5%) expressed positive perception towards the presence of pharmacists in hospital pharmacies. A large majority (n = 250; 62.5%) advocated the need of a separate counselling counter and more counselling time from pharmacists. A statistically significant positive correlation (spearman r = 0.65; p = 0.01) was observed between perception and age.

Conclusion The current study is a mere reflection of a group of exit patients from only one tertiary healthcare setting of Karachi. The study reported awareness and positive perception of high-income group patients about pharmacists in hospitals. The study also highlighted that patients expressed unease towards inadequate and insufficient counselling time and also rated the feature of verbal information as ‘average’. Future directives for both pharmacists and patients to do collaborative discussions on the expectations and needs of patients might precipitate fruitful outcomes on patient compliance and concordance1,2 and better health state.

References 1. Raynor DK. Patient compliance: the pharmacist’s role. Int J Pharm Pract 1992; 1(3):126–135. 2. Stevenson FA. Concordance: what is the relevance for pharmacists? Int J Pharm Pract 2001; 9(2): 67–70.


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Abstract 85 What do community pharmacists really think of the electronic prescription service (EPS)? C. Carmichaela, M. Lalania, L.M. Poona, J. Scotta, R. Laaksonenb, P. Rogersa and J. Scotta a

Department of Pharmacy & Pharmacology, University of Bath, Bath, UK and bDivision of Social Pharmacy, Faculty of Pharmacy, University of Helsinki, Helsinki, Finland

Focal points • A questionnaire-based cross sectional study was undertaken to investigate the extent to which EPS is being used in community pharmacies; and to explore pharmacists’ perceptions and understanding. • Fewer pharmacies have migrated from EPS Release 1 to Release 2 than might be expected at this stage; pharmacists working in medium or large multiples have a less comprehensive understanding of EPS than those in independents or small multiples. • More work needs to be done to ensure that pharmacists can better engage with EPS Release 2, particularly once PCTs are abolished.

Introduction The Electronic Prescription Service (EPS) has been developed in response to the increasing amount of paper prescriptions written each year. NHS Connecting for Health has responsibility to maintain and develop the NHS national IT infrastructure, including EPS.1 As the commissioned evaluation of EPS Release 2 is not yet available2, there is no current measure of how community pharmacists view EPS in England, nor a detailed evaluation of how EPS is working in NHS practice. Progress with the implementation of electronic transmission of prescriptions has been faster in some countries; a study in Singapore showed general GP, pharmacist and pharmacy staff satisfaction with their system. The objectives of our study were to investigate the extent to which EPS, both Release 1 and Release 2, is being used in community pharmacies; and to explore pharmacists’ perceptions and understanding.

Method The project was a cross-sectional study with descriptive and analytical elements using a questionnaire. NHS research ethics approval was not required. The project protocol, participant information and questionnaire were reviewed under the University of Bath’s ethical approval process. Stratified sampling was used to split the 152 PCTs into three subgroups: EPS Release 1, Release 2a, and Release 2b. From each of these subgroups, four PCTs were randomly selected. A questionnaire and accompanying cover letter measuring the uptake of EPS in 500 pharmacies systematically sampled from 12 PCTs, and the pharmacist’s perceptions of its implementation and use. Two reminders were sent to non-responders at

fortnightly-intervals. Statistical tests used included MannWhitney U, chi-squared and Wilcoxon tests, using SPSS v18.

Results Responses were received from 250 pharmacists (50% response). Of 241 respondents, 223 (93%) had EPS Release 1 implemented and were receiving barcoded prescriptions; of these 18 (8%) had EPS Release 2 implemented. Problems with EPS were experienced by 151 of 229 respondents (66%). Training given by software providers appeared to be the most comprehensive and provided greater understanding than that provided by employers or PCTs. Pharmacists working in medium or large chains (>11 branches), who were mainly trained by their employers, were less likely to have a comprehensive understanding of EPS than those working in independents or small multiples (1–10 branches) (Mann-Whitney U = 5403, p = 0.015). Open comments included: downloading a prescription from the Spine was too slow (n = 63), software design was inappropriate (n = 16) and a lack of GP engagement and understanding of EPS (n = 15). Of 232 respondents, 40 (17%) strongly agreed or agreed that EPS had benefitted community pharmacy, whereas 102 (44%) disagreed or strongly disagreed.

Conclusion EPS Release 2 implementation appears much slower than might be expected and many pharmacies which might have implemented it are still only using Release 1. While limited to only 12 PCTs, we feel that results would be similar in other PCTs. Many problems were identified with the smartcards, implementation process, and the computer system which have hindered the smooth roll-out of EPS. Pharmacist engagement with EPS, particularly those working in medium and large multiples, needs to be improved; once PCTs are abolished it is unclear who will deliver the changes needed to ensure the success of EPS.

References 1. NHS Connecting for Health. http://www.connectingforhealth.nhs. uk [Accessed 21 April 2011]. 2. The Evaluation of the Electronic Prescription Service (EPS), the website for the independent evaluation of EPS Release 2 in England. http://www.epsevaluation.org.uk [Accessed 21 April 2011]. 3. Tan WS, Phang JSK, Tan LK. Evaluating user satisfaction with an electronic prescription system in a primary care group. Ann Acad Med Singapore 2009; 38: 494–500.

Abstract 86 Gestational diabetes mellitus management and its comparison on pregnancy outcome S. Velusamy, R. Ayyalu and V. Arumugam KMCH College of Pharmacy, Coimbatore, Tamilnadu, India

Focal points • To assess the maternal and neonatal outcome of Gestational diabetes mellitus (GDM) following to diabetic management by diet alone and along with Insulin.


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• There was no significant difference found in outcome of pregnancy between two groups. • All babies were normally in good health except for hyperbilirubinemia and hypoglycemia. • Result shows that the early screening and aggressive treatment for GDM will be advisable for the good outcome of GDM pregnancy.

Introduction There was worrisome rise in the prevalence of GDM1. Although perinatal mortality significantly reduced in GDM pregnancy2, still controversies exists regarding perinatal morbidity, clinical management and its impact on maternal and neonatal outcome3. Moreover there was less number of studies in Indian population. This study was aims to compare the maternal and neonatal outcome of gestational diabetes mellitus women treated by diet alone and along with Insulin.

Methods Women diagnosed and treated for GDM at Private corporate hospital, Coimbatore, India, between 2003 and 2010 were identified through Medical Record Department. Pre gestational diabetes mellitus, renal and autoimmune diseases women were excluded from the study. Diagnosis, management and outcome data for maternal and neonatal were collected and analyzed by using chi squire test.

Results Total of 10,333 women were given birth for the period of 8 years from January 2003 to December 2010. 222 women (2.1%) were diagnosed as GDM and included in the study. The prevalence ranged between 1.31 to 3.8% with an average rate of 2.1%. Of these, 36 (16.2%) were controlled with diet and 186 (83.78%) were required Insulin treatment. The overall average age was 27.62 ± 3.86 years and gestational age was 35.79 ± 2.12 weeks (respectively 27.80 ± 4.02 years, 36.69 ± 1.9 weeks and 27.63 ± 3.87 years, 35.93 ± 2.07 weeks for diet alone and Insulin treated women). For all the women glucose level was controlled within the normal range. There was no significant difference in term of delivery, birth weight and Apgar score. There was no history of macrosomia, Intra uterine growth retardation and still birth. All babies were normally in good health except for hyperbilirubinemia and hypoglycemia.58.3% neonates of diet alone mother and 56.9% neonates of Insulin required mother were exposed to hypoglycemic condition. 55.5% neonates of diet alone mother were found with hyperbilirubinemia where as 60.7% with neonates of Insulin treated mother. The development of Pregnancy induced hypertension (PIH) was 16.6% with diet alone group and 13.9% with Insulin treated group. There was significant difference in mode of delivery and size of the baby. Cesarean delivery was more with Insulin treated group (94.6%) the same was 83.3% with diet alone group. 83.33% neonates of diet alone mother were found with Average for gestational age (AGA) where as 75.8% neonates found AGA in Insulin treated mother.

Discussion There was no significant difference in the pregnancy outcome of GDM between two groups except for cesarean delivery and

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hypoglycemia. Achievement of normoglycemia without any complication is difficult by treatment alone but possible along with early screening, strict diet, aggressive treatment and patient education. This would give good outcome in GDM pregnancy.

References 1. Dabelea D, Snell-Bergeon JK, Hartsfield CL, Bischoff KJ, Hamman RF, MaDuffie RS. Increasing prevalence of gestational diabetes mellitus (GDM) over time and by birth cohort: Kaiser permanente of Colorado GDM Screening Program. Diabetes Care 2005; 28:579–84. 2. Langer O. Management of gestational diabetes. Clin Obstet Gynecol 2000; 43:106–15. 3. Garner P, Okun N, Keely E. A randomized controlled trial of strict glycemic control and tertiary level obstetric care versus routine obstetric care in the management of gestational diabetes: a pilot study. Am J Obstet Gynecol 1997; 177:190–5.

Abstract 87 Analysis of unprevented dispensing incidents involving insulin reported by hospital pharmacies N. Patela, R. Burfieldb, D. Robertsc and K.L. Jamesd a

King’s College London, London, UK, bHealth Solutions Wales, Cardiff, UK and cUniversity Hospital of Wales, Cardiff, UK, dUniversity of Bath, Bath, UK

Focal points • Incidence, types and causes of unprevented dispensing incidents involving insulin reported by 16 Welsh NHS hospitals (January 2000–September 2010) were investigated. • Unprevented dispensing incidents involving insulin occurred at a rate of 36 incidents per 100,000 items dispensed. • Incidents most commonly involved labelling and/or dispensing the wrong drug and supplying the wrong device. • Incidents could be minimised by using shelf-dividers to separate different insulin type and highlighting differences in drug names/devices using tallman lettering, font colour and text styles.

Introduction Insulin is a high risk medicine frequently involved in medication errors. The National Patient Safety Agency received 3,881 wrong dose incident reports involving insulin between August 2003–August 2009 resulting in the issue of a rapid response alert to promote the safer administration of insulin.1 However, a detailed analysis of dispensing incidents involving insulin has not been undertaken. This study aimed to investigate the incidence, type and causes of unprevented dispensing incidents, defined as dispensing errors detected and reported after medication had left pharmacy,2,3 involving insulin.


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Table 1 Types of unprevented dispensing incidents Unprevented dispensing Incidents Wrong Wrong Wrong Wrong Other Total

drug dispensed device dispensed drug on label & dispensed drug on label

n

%

34 28 16 9 20 107

32 26 15 8 19 100

Methods Retrospective, quantitative analysis was undertaken of unprevented dispensing incident data related to insulin (January 2000–September 2010), collected and reported by Welsh NHS hospitals (n = 16) using an established methodology.2,3 Data self-reported by pharmacy staff included the type of errors, drugs involved and perceived contributory factors.2,3 The overall incident rate was calculated for those hospitals with both incident and issue data. Ethics committee approval was not necessary as data was routinely collected by the hospitals.

Results 107 unprevented dispensing incidents were reported amongst 297,158 issues of insulin, giving an incident rate of 36 incidents per 100,000 items dispensed. Incidents were categorised as drug errors only (66.4%, n = 71), combined drug and label errors (22.4%, n = 24) or label errors only (11.2%, n = 12). The most common incident types are shown in Table 1. Drug combinations commonly involved in the supply of the wrong drug were Novorapid/Novomix (n = 17), Novomix 30/Mixtard 30 (n = 10). Supplying the wrong insulin device commonly involved confusion between disposable pens and cartridges (n = 14). Look-alike, sound-alike drugs (n = 42) was the most common contributory factor.

Discussion Insulin has previously been identified as a common drug involved in dispensing incidents.3 Similar to previous research, this study identified that dispensing incidents involving insulin frequently involved labelling and/or supply the wrong drug, and supplying the wrong insulin device.3,4 These incidents were attributed to look-alike, sound-alike drug names and packaging.4 Strategies suggested to aid correct product selection include use of shelf dividers to separate different insulin types, use of tallman lettering to highlight differences in names e.g. NovoRAPID and NovoMIX and use of different font colour or text styles to highlight drugs on computer screens.

References 1. Rapid Response Report NPSA/2010/RRR013: Safer Administration of Insulin. London: National Patient Safety Agency; 2010. 2. Spencer MG, Smith AP. A Multicentre Study of Dispensing Errors in British Hospitals. Int J Pharm Pract 1993;2:142–146. 3. James KL, Barlow D, Burfield R et al. A Study of Unprevented Dispensing Incidents in Welsh NHS Hospitals. Int J Pharm Pract 2008;16:175–188 4. James KL, Barlwo D, Hiom S et al. Development and Use of the Critical Incident Technique in Evaluating Causes of Dispensing Incidents. Int J Pharm Pract 2008;16:239–249.

Abstract 88 Pharmacovigilance and non-medical prescribers: exploring perceptions of training, contribution and potential for enhancement D. Stewarta, K. MacLurea, V. Paudyala, C. Hughesc, M. Courtenayd and J. McLayb a

Robert Gordon University, Aberdeen, UK, bUniversity of Aberdeen, Aberdeen, UK, cQueen’s University, Belfast, UK and dUniversity of Surrey, Guildford, UK

Focal points • Nurse and pharmacist prescribers’ perceptions of their training, contribution and potential for enhancement of their pharmacovigilance role were explored. • Non-medical prescribers reported they felt competent and aware of their pharmacovigilance role. • Increased publicity and education are key measures for enhancing Yellow Card reporting.

Introduction The UK based process for spontaneous reporting of suspected adverse drug reactions (ADRs), known as the ‘Yellow Card Scheme’ (YCS),1 encourages reports to be submitted by healthcare professionals, patients and the general public. However, poor reporting rates2 are a long-standing limitation affecting the YCS. The introduction of supplementary and independent prescribing rights3 for pharmacists, nurses and other healthcare professionals has the potential to enhance participation in the regulatory pharmacovigilance processes. The aim of this research was to determine nurse and pharmacist prescribers’ perceptions of their training, contribution and potential for enhancement of their pharmacovigilance role.

Methods A web based survey was developed, tested for face and content validity by an expert panel, and piloted in a sample of 148 non-medical prescribers. The final version comprised 5 sections on: prescriber demographics (13 questions); pharmacovigilance training (9 questions); experience of Yellow Card reporting (13 questions); attitudes toward ADR reporting (13 questions); comments and suggestions to encourage Yellow Card reporting (4 questions). Open and closed questions and Likert scale attitudinal statements were used. The survey was hosted on a dedicated website with a paper version available. The sample comprised nurse and pharmacist independent/supplementary prescribers. Nurse prescribers were sampled through and contacted via email by the Association of Nurse Prescribers (n = 912). Pharmacist prescribers (n = 2439) were targeted through various routes including: national continuing education organisations; national Pharmacy Boards; local practice forums and the National Prescribing Centre. Quantitative data were analysed using SPSS version 17.0 with a thematic approach used to analyse responses to open questions. The survey was live from


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January to May 2011. The North of Scotland Research Ethics Committee confirmed exemption from formal NHS review.

Results Responses were received from 293 nurse (32.2%) and 320 pharmacist (13.1%) prescribers. The majority of respondents were female (81.9%) and most had over 20 years experience (57.6%) in their healthcare profession. When asked whether pharmacovigilance featured in their prescribing training, a third ‘couldn’t remember’ (35.6%) with nurses indicating greater recall (p < 0.001). Of those who remembered (57.2%), the course level of difficulty/duration appeared appropriate. Almost half (46.7%) gave a neutral/inappropriate rating for the emphasis on legal implications while a third (34.8%) rated the relevance to their prescribing practice as neutral/irrelevant. While a third (34.2%) strongly agreed/agreed that they needed further training, fewer (29.6%) were unsure or did not agree that they were competent in all aspects of pharmacovigilance. Less than half (41.4%) had never submitted a Yellow Card. Pharmacist prescribers were more likely to have reported (p < 0.001). Those prescribing in a community setting were less likely to have reported (p < 0.001). Reported reactions included can’t remember (25.9%), skin related (9.5%), GI bleed (3.3%), death (0.8%). Few (14.7%) were concerned about YCS patient confidentiality but a third (35.1%) expressed concern about legal implications of ADRs from their prescribing. Respondents reported a positive attitude toward and awareness yet only a minority (22.8%) correctly answered seven questions about the YCS. The most commonly suggested measures to enhance Yellow Card reporting by non-medical prescribers, other healthcare professionals and patients were publicity and education.

Discussion Although the response rate was low, respondents provided detailed answers. Respondents felt competent and aware of their pharmacovigilance role with further training needs indicated. Findings may not be generalisable; no information is available on non-respondents. Increased publicity and education are identified as key measures for enhancing non-medical prescribers, other healthcare professionals and patients Yellow Card reporting.

Acknowledgements The research team wish to acknowledge and thank MHRA for their funding and also ANP, RPS, NICPLD, NES, CPPE and NPC for their assistance.

References 1. MHRA website. What is the Yellow Card Scheme? At http:// yellowcard.mhra.gov.uk/the-yellow-card-scheme/ [Accessed October 2010]. 2. BMA Board of Science (2006). Reporting adverse drug reactions: A guide for healthcare professionals. London: British Medical Association. 3. Tonna AP, Stewart D, West B, McCaig D. Pharmacist prescribing in the UK – a literature review of current practice and research. J Clin Pharm Ther 2007; 32: 545–56.

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Abstract 89 The impact of automation on workload and dispensing incidents in hospital pharmacy K.L. Jamesa, D. Barlowb, A. Bithellc, S. Lordc, P. Oakleyb, M. Pollardc, D. Robertsd and C. Whittleseab a

University of Bath, Bath, UK, bKing’s College London, London, UK, Wrexham Maelor Hospital, Wrexham, UK and dUniversity Hospital of Wales, Cardiff, UK

c

Focal points • The study investigated the effect of automation on workload and prevented dispensing incidents in hospital pharmacy. • Automation was associated with a higher workload and significantly lower rate of prevented dispensing incidents. • Automation improves dispensing efficiency and dispensing safety.

Introduction Recently the Royal Pharmaceutical Society of Great Britain has highlighted concerns with regards to the effect of workplace pressures on pharmacy staff well-being and patient safety.1 Original pack automated dispensing systems (ADS) have been advocated as a strategy for increasing workload yet minimising dispensing incidents.2 This study aimed to investigate the effect of installing an original pack automated dispensing system on workload and dispensing incidents in a hospital pharmacy.

Methods Data on dispensary workload and prevented dispensing incidents, defined as dispensing errors detected and reported before medication has left pharmacy,3 were collected over a six weeks at a 600 bed National Health Service Hospital in Wales before and after the installation of an ARX Rowa Speedcase ADS. The pharmacy department provided pharmaceutical services for inpatients, outpatients and discharged patients on medical, surgical, obstetric/gynaecology and paediatric wards. Workload was measured by a non-participant observer using two validated workload measurement techniques simultaneously: direct time and event recording.4 Prevented dispensing incidents were recorded by pharmacy staff on standardised forms using a validated methodology.3 Mean workload and prevented dispensing incident rate preand post-automation were compared using two sample t-test. Types of dispensing incidents were compared using Fisher’s exact. A p ≤ 0.05 was considered statistically significant. Ethical approval was obtained for this study.


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Table 1 Types of prevented dispensing incidents Prevented Dispensing Incidents

Drug error only Labelling error only Drug & label error Drug & issue error Label & issue error Drug, label & issue error Total

Preautomation

Postautomation

n

%

n

%

51 143 33 5 2 1 235

21.6 61 14 2 1 0.4 100

25 86 27 7 2 0 147

17 59 18 5 1 0 100

Results Dispensary workload determined using the event recording technique was significantly lower pre-automation (9.57 items/person/hour) compared to post-automation (12.67 items/person/hour, p < 0.001). There was no significant difference between workload measured pre- (7.27 items/ person/hour) and post-automation (7.01 items/person/hour) using the direct time technique (p = 0.77). Compared to preautomation (0.64%), the rate of prevented dispensing incidents was significantly lower post-automation (0.28%, p = 0.003). There was no statistical difference (p = 0.277) between the types of dispensing incidents reported pre- and post-automation (Table 1).

Abstract 90 Attitudes of Malaysian undergraduate pharmacy students towards complementary and alternative medicine M.A. Hadia, R. Rahmanb, S.S. Hassanc, M.A. Hassalid and T.M. Khane a School of Healthcare, Faculty of Medicine and Health, University of Leeds, Leeds, West Yorkshire, UK, bFaculty of Pharmacy, Universiti Teknologi MARA, Puncak Alam, Selangor, Malaysia, cInternational Medical University, Kuala Lumpur, Malaysia, dSchool of Pharmaceutical Sciences, Universiti Sains Malaysia, Penang, Malaysia and eCollege of Clinical Pharmacy, King Faisal University, Al-Ahsa, Saudi Arabia

Focal points • To evaluate extent of self use of CAM, information seeking behaviour about it and perception regarding its inclusion module in pharmacy curriculum among Malaysian undergraduate pharmacy students. • First year pharmacy students were more likely to use CAM products as compared to final year students (P < 0.05). • Lack of scientific evidence (84.0%) and lack of trained professionals (74.8%) were the most commonly cited barriers to CAM use. • Further research is required about the content, extent, time of integration and duration of CAM module in the pharmacy curriculum.

Discussion The study findings suggest that automation improved dispensing efficiency (measured using the event recording technique) and reduced the rate of prevented dispensing incidents. Automation appeared to have no impact on the dispensing workload when measured using the direct time technique. This is attributed to observer saturation and the sample of prescriptions selected for observation by the single observer may not have been sufficient enough to reflect dispensary workload. Post-automation there were fewer drug only errors and labelling only errors. Automation has the potential to eliminate all drug content errors as the drugs are no longer selected from shelves. However, as humans still have to enter drug data into the pharmacy computer system there is still the potential of the incorrect drug being labelled and supplied.

Introduction Complementary and Alternative medicine (CAM) is being widely used for health promotion and disease prevention across the globe. In US alone, it is estimated to be a 42 billion dollar industry with 30–50% of Americans consuming one of the CAM forms.1 Widespread use of Complementary and Alternative Medicine (CAM) necessitates integration of CAM knowledge into curricula of healthcare professionals. Pharmacists being drug experts are often asked by patients and healthcare professionals about the safety and efficacy of CAM. CAM knowledge is essential for pharmacists to make them well rounded professionals. The study was designed to evaluate: 1) self use of CAM and barriers to its use, 2) information seeking behaviour towards CAM and recommendation of CAM to others and, 3) perceptions regarding the inclusion of CAM module in pharmacy curriculum.

References 1. Professional Workload. London: Royal Pharmaceutical Society of Great Britain: 2009. 2. A Spoonful of Sugar. Medicines Management in the NHS. London: Audit Commission: 2000. 3. Spencer MG, Smith AP. A Multicentre Study of Dispensing Errors in British Hospitals. Int J Pharm Pract 1993;2:142–6. 4. James KL, Barlow D, Bithell A et al. Measuring dispensary workload: a comparison of the event recording and direct time techniques. Int J Pharm Pract 2011; 19: 264–75.

Methods Cross sectional survey was conducted from August to September 2009. Using non-probability sampling technique, undergraduate pharmacy students of all four academic years from three pharmacy schools across Malaysia filled in a selfadministrated and validated questionnaire. The face and content validity was done by two faculty members. The questionnaire was then pilot tested on 15 participants recruited


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from target population. The questionnaire was designed to gather information on demographic data, personal use of CAM, barriers to CAM use, sources of CAM information, and perception on the integration of CAM knowledge in pharmacy curriculum. No formal ethics approval was sought. However, permission was obtained from the heads of all the faculties before distribution of questionnaires.

Results Out of 360 questionnaires distributed, 330 were returned (Response rate = 91.6%). Majority of the respondents were female (64.8%), single (97.6%), Muslim (75.2%) and ethnically Malay (74.2%). Most frequently used CAM modality included Nutritional/dietary supplements (including vitamins and minerals) 262 (79.4%), herbal drugs 199 (60.3%) and massage 159 (48.2%). First year pharmacy students were more likely to use CAM products as compared to final year students (P < 0.05). Lack of scientific evidence (84.0%) followed by lack of trained professionals (74.8%), were the most commonly cited barriers to CAM use. Information about the CAM products was mainly obtained through media (TV, radio, newspaper) 227 (68.8%). Two hundred and thirty five (71.2%) agreed that CAM knowledge is necessary to become a well rounded professional and 50.9% of them believed that CAM is a part of pharmacy and it should be made compulsory in the primary degree.

Discussion The results showed that nutritional/dietary supplements are frequently used by pharmacy students in the prevention or treatment of ailments. The students believed that sound technical knowledge of CAM will enable them to advise their patients in future. These findings are in agreement with the findings of earlier studies among Australian and British pharmacy2,3. Further research is required about the content, extent, time of integration and duration of CAM module in the pharmacy curriculum.

Conclusion In conclusion, majority of Malaysian undergraduate pharmacy students consume at least one of the CAM modality and recognize the importance of CAM knowledge to become a good professional.

References 1. Kligler B, Maizes V, Schachter S, Park CM, Gaudet T, Benn R, et al. Education Working Group, Consortium of Academic Health Centers for Integrative Medicine. Core competencies in integrative medicine for medical school curricula: a proposal. Academic Medicine 2004;79:521–9. 2. Tiralongo E, Wallis M. Attitudes and perceptions of Australian pharmacy students towards Complementary and Alternative Medicine – a pilot study. BMC Complementary and Alternative Medicine 2008;8:2. doi:10.1186/1472-6882-8-2. 3. Freymann H, Rennie T, Bates I, Nebel S, Heinrich M. Knowledge and Use of Complementary and Alternative Medicine among British Undergraduate Pharmacy Students. Pharmacy World and Science, 2006;28:13–18.

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Abstract 91 Improving the management of cancer pain in the community: is there a place for MURs? A. Blenkinsoppa, I. Savageb, M. Bennettc and J. Clossd a

Keele University, Staffs, UK, bUniversity of London, London, UK and University of Lancaster, Lancs, UK, dUniversity of Leeds, Yorks, UK

c

Focal points • Patients with cancer report frequent contact with community pharmacists but little is known about support for optimal use of opioid analgesics. • In interviews with 25 community pharmacists four reported they had conducted MURs for people with cancer pain. • Barriers to provision included not knowing the diagnosis, lack of face to face contact with patients and assumptions about what patients already knew about opioid analgesics.

Background Research shows that cancer pain is not optimally controlled and that at least part of the reason is patients’ and families’ uncertainties about use of opioid medicines and how to deal with side effects from treatment1. Community pharmacists are the health professionals that patients with cancer and their families report having most frequent contact with2, offering the potential to support patients and their families in the use of opioid analgesics. Published literature on community pharmacists’ input is sparse and there are no previous studies of the use of medicines use review (MUR) in this area.

Aim To explore the use of medicines use reviews (MURs) for patients with cancer pain in the community.

Methods Semi-structured interviews were conducted with 25 community pharmacists in three Primary Care Trust areas. Sampling took into account geographical location and included some pharmacies providing a Local Enhanced Service for supply of palliative care medicines. Participants were asked about MURs as part of a wider study about community pharmacists’ experiences of dispensing and advising on opioid analgesics. Questions on MURs covered whether the pharmacist provided MURs; whether they had been asked to conduct, or had themselves initiated, MURs for patients with cancer pain; their approach to targeting MURs, and their experiences of providing them. Interviews were conducted by telephone and, with the participant’s permission, audio recorded. Recordings were fully transcribed and analysed using the Framework method.

Results 22 participants spoke about their provision of MURs. Most were initiated by the pharmacist or their staff and it was rare


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for either a patient or another health professional to ask for an MUR. Four pharmacists had conducted an MUR for a patient with cancer pain (two were Prescription Interventions). One had conducted an MUR for a patient whose husband had cancer pain, during which she discussed her stress arising from his illness. The accounts of the majority of pharmacists showed awareness of the problems and issues associated with cancer pain management. The main barriers to providing MURs for patients with cancer pain included not knowing the diagnosis and lack of face to face contact with the patient (prescriptions for opioids often being collected by someone else or delivered to the patient’s home). Some pharmacists were apprehensive that patients might raise emotional or social issues, both in relation to concerns about handling difficult conversations and also worries about lengthy MURs that might be difficult to conclude. Only one pharmacist had applied to their Primary Care Trust for permission to conduct domiciliary MURs. Some pharmacists were aware of the process for gaining authorisation for MURs in settings external to the pharmacy but considered this logistically unfeasible. Pharmacists made suggestions about how care could be improved, these mainly centred around access to information (clinically relevant information and also contact details for community based clinicians caring for patients with cancer) and higher awareness among other clinicians of the contribution pharmacists could make.

Discussion Pharmacists in the study were aware of the potential issues associated with the use of opioid analgesics. They rarely provided MURs for patients with cancer pain for a mixture of logistical and attitudinal reasons which limit the support pharmacists are able to offer.

References 1. Closs J, Bennett MI, Chatwin J. Cancer pain management at home (II): Does age influence attitudes towards pain and analgesia? Supportive Care in Cancer 2009;17:781–6. 2. Bennett MI, Closs SJ, Chatwin J. Supportive Care in Cancer 2009;17:787–92.

Abstract 92 Registration requirements among healthcare professions: how does pharmacy compare? R. Elvey, S. Jee, P. Lewis, E. Schafheutle, M. Tully, S. Willis and J. Hall The University of Manchester, Manchester, UK

Focal points • The objective of this paper is to compare and contrast registration requirements for pharmacy with those of optometry and medicine in Great Britain. • All three postgraduate professional training programmes reviewed are practice-based and focus on continuous

assessment where a trainee demonstrates competencies using a portfolio of evidence. • Key differences between the medical foundation training programme and those of pharmacy and optometry are the greater range of assessment methods employed and the multitude of assessors providing feedback.

Background Pharmacy pre-registration trainees undertake a period of inpractice training, and are also required to pass a universal registration examination before registering with the General Pharmaceutical Council (GPhC). The purpose of the work reported here is to compare and contrast registration requirements for pharmacy with those of optometry and medicine in Great Britain, and is part of a larger study commissioned by the GPhC to review registration requirements for pharmacy.

Methods A documentary review of the registration requirements for the three professions was undertaken. The review was informed by resources such as regulatory websites, guidance documents for potential entrants, training curricula and workbooks. These materials were reviewed and information on the overall nature of the training programme, the specific details of what is assessed, the methods used and the people involved in the process were extracted.

Results All three postgraduate professional training programmes reviewed are practice-based and focus on continuous assessment where the trainee demonstrates competencies using a portfolio of evidence. Trainee pharmacists undertake a fouryear MPharm degree, followed by a one year pre-registration programme, which takes place in practice. During this year, competencies are assessed via a portfolio of evidence which includes: three staged assessments, observation of the trainee at work or through role plays, and written project assignments. The pre-registration tutor, a pharmacist, assesses the trainee’s progress, and may work alongside the trainee on a day to day basis. Others, such as trainers or study day facilitators, can provide feedback or testimonials for the portfolio. Knowledge and understanding are assessed by a written examination with two multiple choice papers. Optometry also has a one year in-practice training programme, which follows a three-year Optometry BsC. Similarly to pharmacy, competencies are assessed via a portfolio of evidence. A supervisor works with the trainee in a practice setting and reviews their progress. However, unlike pharmacy, two different assessors visit the trainee on four occasions. Optometry has a universal registration examination, which is an objective structured clinical examination (OSCE) with 14 stations. Medical training consists of a five year MBChB followed by two years’ foundation training. Assessment methods used include: team assessment of behaviour, observation of doctor-patient encounters using direct observation of procedural skills or mini-clinical evaluation exercises and case-based discussion,


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which are carried out by medical and non-medical professionals. An educational supervisor manages the trainee’s overall progress, while clinical supervisors provide more specific feedback on clinical work.

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investigating a potential enhanced role for community pharmacy.

Methods Discussion Pharmacy and optometry both have universal registration examinations, although pharmacy is unique amongst the professions in using a written examination. Advantages of written examinations include the structured assessment of knowledge and understanding within a controlled environment, however, they do not allow for the assessment of behaviour. Key differences between the medical foundation training programme and those of pharmacy and optometry are the greater range of assessment methods employed and the multitude of assessors, resulting in trainees receiving multi-source feedback1. Pharmacy is also the only profession not to separate the ongoing educational role of the tutor from that of assessor, which is a feature of the optometry and foundation programmes.

Reference 1. Lockyer J. Multisource feedback in the assessment of physician competencies. J Contin Educ Health 2003; 23: 4–12.

Abstract 93 Medication use and access amongst adult patients with inflammatory bowel disease

A postal survey was sent to 393 adult members of the Tees branch of Crohn’s & Colitis UK in December 2010.2 The first section of the survey was designed to obtain data relating to medication use and access amongst respondents and responses to seven questions are reported. Ethical approval was obtained.

Results Before the cut-off date 196 surveys were returned giving an overall response rate of 50%. Current use of prescribed IBD medication was reported by 87% (n = 168) with the most frequently cited prescriber being a GP (n = 122; 62%) followed by a hospital doctor (n = 102; 52%) and hospital nurse (n = 28; 14%). Other prescribers accounted for ≤2% each including five responses of receiving a prescription from a pharmacist. Most patients obtained their IBD medication from a community pharmacy (n = 146; 89% of respondents) with fewer using a hospital pharmacy (n = 33; 20%) or a dispensing medical practice (n = 22; 13%). Of those using community pharmacies, 80% (n = 119) said they ‘always’ or ‘usually’ used the same pharmacy. Prescriptions were most commonly collected by the patient (n = 129; 78% of all respondents). Use of non-prescription medicines for IBD was reported by 24% of respondents (n = 45); 49% (n = 22) reported that they obtain these medicines from a health food or vitamin store, 33% (n = 15) from a supermarket including an in-store pharmacy, 20% (n = 9) from a community pharmacy, 16% (n = 7) from the internet or online, and 13% (n = 6) via mail order including magazine or television advertisements.

W. Horsleya, G. Rubina, J. Masona and W. Baqirb Discussion a

Durham University, Stockton, UK and bSunderland University, Sunderland, UK

Focal points • A postal survey was used to obtain data relating to medication use and access amongst adult patients with inflammatory bowel disease. • Responses demonstrated high rates of prescription and nonprescription medication use with management predominantly in primary care. • Community pharmacists are well placed to contribute to the care of adult patients with inflammatory bowel disease and are likely to have regular opportunities to engage with patients.

Introduction Inflammatory bowel disease (IBD) is, for many patients, a life-long condition managed principally through the use of a variety of medications.1 Baseline data describing the extent and nature of contact between patients with IBD and their community pharmacies was obtained to support new research

Medication use overall amongst adult patients with IBD is high, being largely managed in primary care and dispensed in the community. Community pharmacists may be in a position to contribute to the management of IBD patients given the stable use of the same pharmacy by patients for prescriptions thus providing complete, or near complete, medication records. Community pharmacists are likely to have regular opportunities to engage with IBD patients. Given the relatively high rate of non-prescription medication use, pharmacists could have a useful role in recording and guiding this use. However a high proportion of non-prescription medication users do not obtain these medicines from a community pharmacy.

References 1. The IBD Standards Group. Quality care: Service standards for the healthcare of people who have inflammatory bowel disease (IBD). 2009. http://www.ibdstandards.org.uk 2. Horsley W et al. Creation of a survey to assess interactions between patients with inflammatory bowel disease and community pharmacies. Pharmacoepidemiology and Drug Safety 2011;20:S3–4.


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Abstract 94 Impact of information communication technology on community pharmacies, pharmacists and patients in Europe: a preliminary analysis A. Manfrina, T.S. Gilla, C.M. Molinerob, L. Recaldec, A.S. Pozoc and L. Caparrottad a

Medway School of Pharmacy, University of Kent and Greenwich at Medway, Chatham, Kent, UK, bKent Business School, University of Kent, Canterbury, UK, cFaculty of Pharmacy, Campus Universitario Cartuja, University of Granada, Granada, Spain and dDepartment of Pharmacology and Anaesthesiology, Faculty of Pharmacy, University of Padua, Padua, Italy

Focal points • The aim was to determine how Information Communication Technology (ICT) influences community pharmacists’ practice in Europe. • Pharmacists used ICT to monitor patient adherence, avoid dispensing counterfeit medications and monitor adverse drug reactions. • ICT improved data sharing (patient medication records) among health care practitioners. • ICT helped pharmacists to control stock levels.

Introduction The aims of this project were to determine the way in which ICT is used by pharmacists in Europe and its impact on models of service delivery. The WHO estimated that 50% of patients typically do not take their medicines as prescribed and poor adherence is “a worldwide problem of a striking magnitude”1. Pharmacists are strategically best placed in the healthcare system to improve patients’ medication adherence2. ICT represents a huge contribution to pharmacists’ workload and is often used by pharmacists for different purposes. ICT is traditionally employed by pharmacists as a tool for stock control. However, it can also contribute to more patient focussed activities such as monitoring patient adherence. In Europe there are over 400,000 pharmacists, over 160,000 pharmacies. No two pharmacy systems are exactly the same3.

pharmacists to monitor patient adherence. 14% (n = 333) of pharmacists added dispensed OTC to the patient medication record (PMR) and 75% (n = 1784) checked adverse drug reactions (ADRs) in real time using ICT support. 20% (n = 475) of pharmacists kept electronic patient medication records (e-PMR). 15% (n = 356) confirmed that they were able to share e-PMR with other health care providers. Although 18% (n = 428) of pharmacists could receive electronic prescriptions only 16% (n = 380) could dispense them. 22% (n = 523) confirmed that ICT in pharmacies flagged when a counterfeit medication was dispensed. 98% (n = 2311) of pharmacies had in place a system to control stock level but only 41% (n = 975) of pharmacists correctly identified the appropriate stock level as a proportion to turnover. Relationships (p ≤ 0.001) were found between pharmacists who: a) used ICT to monitor patient adherence and their country of practice, b) kept e-PMR and used ICT to monitor patient adherence, c) added OTC sales to PMR and country of practice, d) had a system in place that flagged when dispensing counterfeit medication and checked drug interactions in real time, e) were owner, manager, locum, support pharmacists and the recognition of the appropriate level of stock required for their pharmacies.

Discussion Variation in the use of ICT to support Pharmacists’ practice has been demonstrated at a European level. ICT was used to monitor patient adherence, to improve patient medication sharing via e-PMR, to monitor ADRs from OTC and related medications and to enable the detection of counterfeit drugs enhancing patient safety. Almost all Pharmacists used ICT as a tool to monitor and control drug usage and expenditure. ICT allowed a more pro-active approach to the profession and contributed the pharmacist’s evolving role from dispensing to consulting. Further research will address the harmonization of ICT in European pharmacy to improve professional health services. This study will continue until November 2011 to allow the collection of more data which will enable more powerful statistical analysis using Multidimensional Scaling, Hierarchical Cluster Analysis and Property Fitting to be performed.

Method A 35 item online questionnaire in 7 different languages was launched in 30 different European countries in November 2010 for twelve months. Currently data from 2379 (75% response rate) pharmacists have been collected and analysed by means of descriptive, univariate, and inferential statistics. Relationships between variables were explored using Chisquared. School of Pharmacy Ethics approval to conduct this study was obtained.

Results Responses to the questionnaire were analysed and are summarised as follows. ICT was used by 25.5% (n = 606)

References 1. Sabate E. WHO Adherence Meeting Report. Geneva, World Health Organization, 2001. 2. PGEU/GPUE Pharmaceutical Group of the European Union, GPUE. Targeting Adherence: Improving Patient Outcomes in Europe through Community Pharmacists’ Intervention. Policy Statement. 2008 3. PGEU Statement. Why Pharmacies Need fully Qualified Pharmacists. Approved by the PGEU General Assembly on 10 March 2009 Available at: http://www.epha.org/IMG/pdf/09.01.08 EPGEU_Statement_Why_Pharmacies_need_fully_qualified_ Pharmacists-Approved_GA_10_March_2009.pdf [Accessed April 26, 2011]


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Abstract 95 Comparison of medical devices used for blood pressure and blood glucose measurement A. Serracino-Inglott, L.M. Azzopardi and S. Mallia Department of Pharmacy, University of Malta, Msida, Malta

Focal points • Medical devices used for point-of-care testing and patient self-monitoring of blood pressure and blood glucose levels were compared through a single-site, single-visit method. • There was a statistically significant difference in the diastolic blood pressure readings recorded with the digital wrist blood pressure monitor. • There is a statistically significant difference in the results obtained by the four different blood glucose meters evaluated. • The different characteristics of the devices and the reliability of the results generated are useful information when recommending medical devices to be used by patients or in point-of-care pharmacy settings.

Introduction Clinical usefulness of measurements of clinical parameters that are taken using medical devices used within a point-ofcare setting or by patient self-monitoring may be jeopardised due to the medical device used.1 The aim of the study was to compare medical devices used for point-of-care testing and patient self-monitoring of blood pressure and blood glucose levels.

Method A single-site, single-visit comparison of four blood pressure monitors (ICO medical Mercury Sphygmomanometer, S+K Manuell 50 KC Aneroid Sphygmomanometer, A&D Medical UA-767 Plus, Hartmann Digital HG140) and four blood glucose meters (Accu-chek Active, Glucometer Elite, OneTouch Horizon, Major II) was carried out. Approval to carry out the study was obtained from the University of Malta Research Ethics Committee. Hundred volunteers (>18 years) who were recruited from a community pharmacy and accepted to participate were divided into two groups of 50 patients; one group for the blood pressure devices comparison and the second group for the blood glucose devices comparison. Each device was assessed for ease of use, advantages and disadvantages. Data was analysed using the Paired Sample t-test and the Pearson Correlation Coefficient.

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cally significant difference between the diastolic blood pressure values recorded for the Hartmann Digital Wrist monitor and all the other three monitors (p < 0.05). The best correlation (0.994) was obtained between the mercury and the aneroid sphygmomanometer. The Hartmann Digital was the easiest to use but yielded the least reliable values whereas the digital upper-arm monitor A&D Medical UA-767 Plus is easy to use by patients and no maintenance is required. For the blood glucose meters, the demographic data for the volunteers was: mean age 48.7 years (range 18–87), 32 females, 18 were diabetics. The blood glucose results ranged from 3.2 mmol/L to 19.4 mmol/L. There was a statistically significant difference between the blood glucose levels obtained by the different meters with Major II giving high blood glucose readings (p < 0.05). Glucometer Elite and OneTouch Horizon showed the best correlation whilst Accu-chek Active and Major II showed the least correlation. OneTouch Horizon and Accuchek Active require a smaller blood sample size and display results much faster compared to the other two meters.

Discussion From the correlation analysis and user-friendly characteristics of the medical devices, the A&D Medical UA-767 Plus blood pressure monitor though showing a lower correlation compared to the mercury sphygmomanometer is the most patient friendly and cheaper option that should be recommended for patient use. The OneTouch Horizon glucose meter gave the best correlation and is easy to use for point-of-care settings or for patient self-monitoring. The study was funded through a University of Malta Research Grant and received no sponsorship from manufacturers of medical devices.

Reference 1. Rivers SM, Kane MP, Bakst G, Busch RS, Hamilton RA. Precision and accuracy of two blood glucose meters: FreeStyle Flash Versus One Touch Ultra. Am J Health-Syst Pharm 2006; 63: 1411–1416.

Abstract 96 A comparison of upper limb disorder risks between manual and automated cytotoxic compounding M. McLeoda,b, A. Zochowskac, D. Leonardb, M. Crowb, A. Jacklina,b and B. Franklina,b a

Centre for Medication Safety and Service Quality, London, UK, Pharmacy department, Imperial College Healthcare NHS Trust, London, UK and cPharmacy department, Medical University of Warsaw, Warsaw, Poland b

Results

Focal points

For the blood pressure devices, the demographic data for the volunteers was: mean age 47 years (range 18–87), 31 females, 13 had a history of hypertension. The systolic and diastolic blood pressure ranged from 81 mmHg to 179 mmHg and 51 mmHg and 105 mmHg respectively. There was a statisti-

• Our objectives were to compare the upper limb disorder (ULD) risk of manual and automated cytotoxic compounding, and comment on the suitability of the UK Health and Safety Executive Assessment of Repetitive Tasks (ART) tool1 for this purpose.


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• Manual compounding was associated with approximately four times greater ULD risk than automation. The ART tool was useful for assessing ULD risk of cytotoxic compounding. • Automation is an alternative to manual compounding that does not compromise operator safety from ULD risks.

Introduction In the UK, approximately one in five work-related injuries are attributed to ULDs2. Manual cytotoxic compounding is a highly skilled task that can cause ULDs such as stiffness and pain in the upper limbs, back or neck. The task requires multiple intricate manipulations within the confined space of a safety cabinet. Considerable force is required on occasions, whilst arm movements are restricted. In contrast, use of automation requires fewer manipulations and potentially a lower ULD risk. Our objectives were to compare the ULD risk of manual and automated compounding, and comment on the suitability of the ART tool1 for this purpose.

Methods We used the ART tool to assess the ULD risk of cytotoxic compounding in a UK hospital pharmacy aseptic unit. The tool evaluates the actions of the hands, wrists, arms, neck and back. There are 12 domains, each scored on an ordinal scale, which are used to calculate a ULD risk score. Ten domains were assessed using observation, one was based on self-report (operator) and one was based on a standard score (environmental conditions). One of two researchers observed 21 manual and four automated sessions (a smaller sample was used as automated sessions showed little variation in ULD risk). We compared the (i) ULD risk scores, (ii) ULD risk categories, where a ULD risk score between 0 to 11 represents low-risk, 12 to 21 medium-risk and over 22 high-risk1 and (iii) each domain-specific risk scores. The practicalities of the ART tool were documented. The local ethics committee confirmed that NHS ethics approval was not required; university ethics committee approval was granted.

Results Manual sessions were associated with a higher median ULD risk score (9.8, interquartile range IQR 8.8 to 12.0) than automation (1.0, IQR 0.9 to 1.3). Fourteen manual sessions were low-risk and seven were medium-risk. All four automated sessions were low-risk. The largest difference in median risk scores was for ‘force’ (manual: 4.0 IQR 2.0 to 8.0, automated: 0.0 IQR 0.0 to 0.0), ‘arm movement’ (manual: 4.0 IQR 3.5 to 4.5, automated: 0.3 IQR 0.0 to 0.8) and ‘arm posture’ (manual: 3.0 IQR 3.0 to 3.0, automated: 0.3 IQR 0.0 to 0.5). Practical considerations include: inclusion of ‘syringe-grip’ in the ART tool, and documentation of observations to support identification of manual- and automation-specific ULD risks.

Discussion This is the first study to use the ART tool to evaluate ULD risks of cytotoxic compounding, and the first to compare manual and automated processes. Automation was associated with a lower ULD risk than manual process, which was largely attributed to the ‘force’ required. This may be related to handling

large volumes, use of viscous drugs and inter-operator variation. Limitations include: unmatched numbers and types of drugs between sessions, a relatively small sample and each compounding session was observed by one of two researchers. The ART tool, with observation notes and inclusion of a ‘syringe-grip’, was useful for identifying specific ULD risks of cytotoxic compounding. Our findings provide a reference point for other pharmacy departments to identify and mitigate ULD risks associated with manual compounding, and confirm that introduction of automation can reduce these risks.

References 1. UK Health and Safety Executive. Assessment of repetitive tasks of the upper limbs (the ART tool). Sudbury: Health and Safety Executive; 2010. 2. Health and Safety Executive. The Health and Safety Executive Statistics 2009/10. Sudbury: Health and Safety Executive; 2010.

Abstract 97 Experiential placements: what competencies do preceptors expect fourth year pharmacy students to display? W. Goodall, B. Kirkbride, S. Mitchell, L. Lafuente-Laroudie, S. McMillan, N. Shapland and M. King Griffith University, Gold Coast, Australia

Focal points • Little is known about what competencies preceptors expect pharmacy students undertaking experiential placements to display or how these expectations align with curricula. • Preceptors expect students to display high levels of professional behaviour and counselling skills. • To ensure work readiness pharmacy education should focus on these skills both within universities and during experiential training.

Background Experiential placements allow students to acquire knowledge, skills and attributes in the work setting, apply theory to practice, clarify career directions, become “work literate” and develop a professional identity.1 At Griffith University, fourth year pharmacy students undertake ten weeks of placement, where each week they participate in one day of experiential training in a community pharmacy overseen by a preceptor. Preceptors are registered pharmacists who mentor and coach students, assisting them to develop skills and values.1 To make the best of this experience, students need to be well prepared, however, little is known of preceptor expectations or how they align with curricula.

Methods Course profiles were mapped and literature searched to identify competencies, i.e. areas of knowledge, skills and attri-


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butes that students should display while on placement. This information was prioritised and augmented through interviews with preceptors and used to develop a questionnaire. The questionnaire asked preceptors to rate competencies on a scale of 0 to 10 (0 no level of competence expected, 10 complete competence expected). There were also two open ended questions: one to identify competencies that may have been overlooked and one to identify the areas where students should show the most growth during placement. The questionnaire was piloted on two preceptors. All 143 pharmacies that had recently been involved with Griffith fourth year students on placement were telephoned and asked if the preceptor was willing to complete the questionnaire which was administered over the telephone, faxed or e-mailed based on the preceptor’s preference. Pharmacists who chose to complete the emailed or faxed questionnaire were supplied with an information sheet and given a date to respond by. Two reminder emails were sent. SPSS version 17.0 was used to analyse results. Ethical approval was obtained from Griffith University’s ethics committee.

Results The questionnaire was completed by 43 (30%) respondents, 16 (37%) of whom were female. The average age was 32 years (range 24–55) and 37 (86%) had been a preceptor for less than ten years. Ability to act ethically and professionally including maintaining confidentiality 9.3 ± 1.0 (mean ± SD) was the most important competency, followed by the skill of communication, including verbal and non-verbal, 8.1 ± 1.2, while knowledge and application of community pharmacy clinical services, e.g. National Diabetes Services Scheme, Webster packing and blood pressure monitoring, 5.2 ± 1.7 was the least important. Additional attributes identified by the open ended question were grooming, punctuality and willingness to learn. Counselling and communication skills, dispensing and product knowledge were the competencies that preceptors expected the most improvement in as a result of placement.

Discussion The expected competencies mapped well with the course profiles and the importance placed on them was consistent amongst preceptors. This consistency is reassuring as it is likely to be linked to a universal understanding of the role of a pharmacist. Professional behaviours and the ability to communicate with patients are central to this role; however, given the expected improvement in the latter during placement it would seem that experience adds greatly to communication theory, and the role playing and oral examinations undertaken by students during their programme. The lower importance given to clinical services may be due to the fact that these services are not offered by all pharmacies.

Reference 1. Owen S, Stupans I. Experiential Placements in Pharmacy: Quality Indicators for Best Practice Approaches to Experiential Placements in Pharmacy Programs. Carrick Institute, University of South Australia; 2008

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Abstract 98 Results from an observational study in community pharmacies detecting erectile dysfunction from risk factors or request for treatment or advice seeking J.R. Lladosa, A.M. Moralesb and V.P. Renedoc a Community pharmacist, National Health System SPAIN, Barcelona, Spain, bAndrologist, Carlos Haya University Hospital, Malaga, Spain and cPfizer International Operations, Madrid, Spain

Focal points • The study was designed to identify ED patients (by score of 21 or less in the validated Sexual Health Inventory for men (SHIM) questionnaire, an abridged version of the International Index of Erectile Function (IIEF) for screening and evaluation of ED severity) either by risk factors or advice/treament seeking without a valid prescription, within the pharmacy setting. • 85.7% of the patients included in the study (n = 196) had ED. • Pharmacists are able to detect ED so their active role in detecting, educating and referring to the doctor, which is of great benefit for patient care.

Introduction Erectile dysfunction (ED) is a male condition affecting 52% of men between 40–70 years, that significantly impacts quality of life and wellbeing1. Many men are reticent to seek medical help and some even look for treatment through illicit sources with the risk of acquiring counterfeit medicines2. ED has been linked to cardiovascular risk3. A Spanish epidemiological study within the community pharmacies showed that around 60% of new patients with ED come to the pharmacist first in order to seek advice and/or options for treatment4.

Methodology International, multi-centre, non-interventional, cross-sectional study to identify patients with potential erectile dysfunction (ED) within the community pharmacy. This data refers to the Spanish arm of the study. Study pharmacists completed a questionnaire to collect patient demographics and clinical/behavioural information including the SHIM. Mean values and 95%CI were calculated and ANOVA and Chi-square test were used for continuous and categorical data, respectively. The study was approved by the Ethics Committee of the Clinico San Carlos Hospital (Madrid) and was scientifically supported by the Spanish Association of Community Pharmacists (SEFAC).

Results Twenty-five pharmacists recruited 219 patients, of which 196 (90.3%) were included for analysis. Not included patients had not fully complied with inclusion criteria. 24% of them were identified by risk factors, 8.7% by the request of treatment or advice and 67.3% were included for both criteria. Mean age of study population was 56.82 (±12.26 years). At least one risk factor for ED was present in 179 patients: overweight, hyper-


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tension, diabetes mellitus, hypercholesterolemia, dyslipidaemia, benign prostate enlargement, hormonal disorders depression and stress. Median SHIM score was 15.23 (95%CI = ±5.40). The study showed that pharmacists could detect potential presence of ED measured by the SHIM score in 85.7% of the study population (n = 196) regardless of the inclusion criteria. Patients with ED were trained with an educational leaflet and referred to the doctor. The first person that patients approached to talk to about erection problems in 124 patients was a Healthcare Professional (HCP) and 56.7% of these had spoken with a pharmacist first. The mean time to come to a HCP since the first symptoms was 12 months. The OR to show presence of ED in patients who ask for advice/treatment and have risk factors is 6.03 IC95% = [1.388–26.193].

Discussion Pharmacists are often the first point of HCP contact for patients. The results of this study show pharmacists were able to detect ED in 86% of the cases by evaluating risk factors and consulting with patients who requested OTC advice or treatment for erectile problems. The risk for having ED is 6 times higher in patients asking for ED advice or OTC treatment and has risk factors for ED than in those that do not show ED. Patient education and referral to the doctor is crucial for patient care, in order to evaluate cardiovascular status and to avoid acquiring counterfeit medicines through illicit sources.

References 1 Feldman HA, Goldstein I, Hatzichristou DG, et al. Impotence and its medical and psychosocial correlates: results of the Massachusetts Male Aging Study. J Urol 1994;151:54–61. 2 Weiss AM. Buying prescription drugs in the Internet: promises and pitfalls. Cleve Clin J Med. 2006;73:282–288. 3 Hackett G, Kell P, Ralph D, et al. British Society for Sexual Medicine Guidelines on the Management of Erectile Dysfunction. J Sex Med. 2008; 5:1841–1865. 4 Ibañez, J, et al. Results of an Observational Study in 574 Community Pharmacies in Spain Characterizing Patient Profiles of Men Asking for Erectile Dysfunction Medication. J Sex Med. 2010;7:3153–3160.

around electronic health records, telemedicine and general ehealth supported shared care implementations. • Evidence of pharmacists’ perspectives on the impact of technology on their shared care role is very limited.

Introduction The World Health Organization (WHO)1 defines ehealth as ‘the combined use of information and communications technologies for health.’ eHealth strategies worldwide aim to promote quality, safety and efficiency by underpinning shared healthcare provision with technology1. The Scottish eHealth Strategy2 incorporates an ePharmacy programme to support pharmacists increasing role in shared care. It acknowledges organisational development and training for core and optional ehealth services as key elements in keeping patients and healthcare professionals ‘at the heart of this strategy’. The aim of this study was to explore and report methodologies, findings and gaps in research related to healthcare professionals’ perceptions of the adoption of ehealth technologies for shared care.

Methods A systematic review was conducted using a six phase metanarrative approach which applies ‘principles of pragmatism, pluralism, historicity, contestation and peer review.’3 A multidisciplinary team planned, searched, mapped and appraised the literature in preparation for synthesis and recommendation phases. The agreed search strategy was detailed in the protocol with iterative search refinement recorded. Articles published post-2004 in English were included; articles on Internet searches for health information or email were excluded. The storyline was mapped before critical appraisal tools and quality checklists were applied. Data were extracted, synthesised and summarised as a basis for recommendations. The review also tracked ehealth definitions. Ethical approval was not required.

Results

Abstract 99 A systematic review of the impact of technology on shared care: why not ask your pharmacist? K. MacLure, D. Stewart, L. McHattie and A. Strath Robert Gordon University, Aberdeen, UK

Focal points • Healthcare professionals’ perceptions of the adoption of ehealth technologies to promote shared care were explored. • Multiple stakeholders worldwide, including one pharmacist, identified organisational, social and technical themes

Screening reduced the initial 327 papers identified to 12 which included 3 reviews (one meta-narrative, one realist review); 4 qualitative (analysed using grounded theory, thematically, analytic induction with constant comparative); 2 mixed-methods (qualitative data analysed thematically, interpretively) and 3 quantitative studies. The studies collected data using combinations of questionnaires (3), case study (1), group (2) and individual (6) interviews, observation (3) and extraction of data from records (1). Practice settings were remote rural or urban featuring primary care, secondary care or both. Geographical settings were diverse. The focus was on electronic records (7), telemedicine (2) or general ehealth implementation (3) from the perspective of doctors, nurses, IT developers, policy makers and managers. One study included the views of a pharmacist. Acceptance of ehealth technologies is reported but with cost effectiveness, resourcing and training questioned. Emerging themes are organisa-


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tional, social and technical: need for realism, clarity and supportive change management; importance of context and compatibility with local work practices; similarity to nonhealthcare IT implementations and adoption of innovation theory.4 Where provided (5), ehealth definitions are similar to WHO’s; where omitted (7), the specific ehealth application functionality is defined.

Discussion Strategists worldwide believe technology has the potential to promote quality, safety and efficiency in shared care where organisational, social and technical issues are known and addressed. However, evidence of pharmacists’ views of these issues, their impact on shared care, organisational development and training needs have still to be identified.

References 1. World Health Organization, 2010. Atlas eHealth country profiles: based on the findings of the second global survey on eHealth. WHO: Geneva. 2. Scottish Government, 2008. eHealth Strategy 2008–2011. Available online at: http://www.scotland.gov.uk/Publications/ 2008/08/27103130/13 3. Greenhalgh, T. et al., 2005. Storylines of research in diffusion of innovation: a meta-narrative approach to systematic review. Social science & medicine, 61(2), pp. 417–430. 4. Rogers, E., 1962. Diffusion of Innovation. Free Press of Glencoe.

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Methods Data for over-the-counter (OTC) product transactions each month between wholesalers and community pharmacies were extracted from an IMS Health database and utilised to estimate the OTC sales of Clamelle®. Data from 2008 for Wales, Scotland, Northern Ireland and two regions in England were compared with an area of high deprivation (North East Strategic Health Authority (SHA)) and an area of low deprivation (South Central SHA) in England according to the Townsend Index. Data were formatted per 10,000 population (2009 statistics4) to facilitate comparison and analysis. Ethics approval was not required due to the use of anonymised sales data.

Results In all regions sales decreased from 2008 to 2010. Wales showed the largest fall in sales from 1.64 per 10,000 population in 2008 to 1.49 in 2009 to 0.44 in 2010. In Scotland sales fell from 1.32 in 2008 to 0.84 in 2009 and 0.48 by 2010. In England the equivalent figures were 1.41, 1.35 and 0.54 for South Central SHA and 1.14, 0.94 and 0.35 for North East SHA. Northern Ireland had the lowest sales: 0.35 in 2008, 0.31 in 2009 and 0.16 in 2010. An overall statistically significant difference was found by year (ANOVA, p < 0.05) but not by area. However, Northern Ireland figures were significantly lower than those for Wales and South Central SHA (independent t-test, p < 0.05).

Discussion

Abstract 100 Over the counter azithromycin (Clamelle®) – the early years R. Deslandes, L. Hughes and R. Walker Cardiff University, Cardiff, UK

Focal points • To investigate Clamelle® sales following reclassification in 2008 across different regions of the UK. • Sales figures have significantly decreased since the launch, although deprivation appears not to be a factor affecting sales. • It is unclear whether the apparent decrease in sales figures is due to a lack of engagement with this initiative, availability through alternate sources or the cost of the product and further research is therefore indicated.

Introduction Detection of chlamydia is increasing, particularly among the under-25s and rates are higher in more deprived areas1,2. To improve access to treatment2, in 2008 Azithromycin 500 mg tablets (Clamelle®) were reclassified to a pharmacy only medicine3. The aim of this study was to investigate Clamelle® sales from community pharmacy, to compare uptake across different regions of the United Kingdom and explore any relationship with deprivation.

High figures in 2008 could be accounted for by advanced stock purchase by pharmacies in anticipation of the new service. The reasons for the subsequent decline in sales are unclear and warrant further investigation, although the cost of the product (£19.57) and availability of NHS services (such as free availability through minor ailment schemes) in a given area may have impacted on uptake and also negated the deprivation-based analysis. Sales for Northern Ireland were significantly lower than other areas and the reasons for this also merit further investigation. Limitations of the study are that the data relate to wholesale transactions, rather than direct sales to the patient. In addition, data were not available for one multiple community pharmacy company. As this is a relatively new initiative, data will continue to be analysed to identify future trends in uptake.

References 1. Kufeji O, Slack R, Cassell JA, Pugh S, Heyward A. Who is being tested for genital chlamydia in primary care? Sex Transm Infect. 2003. 79: 234–236. 2. Department of Health. Pharmacy in England: Building on Strengths – Delivering the Future. 2008. London: Department of Health. 3. Medicines and Healthcare Products Regulatory Agency. Press Release. Medicines regulator gives go-ahead for first ever oral antibiotic to be made available without prescription to treat Chlamydia. 2008. [WWW], [Accessed 18/4/11]. 4. Office for National Statistics. Statistical Bulletin. Population estimates. June 2010. 2009. [WWW], [Accessed 15/4/11].


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Abstract 101 A qualitative exploration of the views of pre-registration pharmacists towards possible future roles as prescribers T. McIntosh and D. Stewart School of Pharmacy and Life Sciences, Robert Gordon University, Aberdeen, UK

Focal points • The views of a sample of Robert Gordon University 2009 pre-registration trainee pharmacists towards possible future roles as prescribers were explored via semi-structured telephone interviews. • Participants held largely positive views; most were keen to train as prescribers but thought it essential first to gain experience as pharmacists. • Barriers and concerns identified around taking on this role such as lack of organisational and logistical support should be addressed.

Introduction Pharmacists and certain other healthcare professionals may train and practise as supplementary1 and independent2 prescribers, aiming to make best use of their skills and improve patients’ access to medicines1,2. Research has largely focused on the views of healthcare professionals and patients; little is known about the views of pre-registration trainee pharmacists who may become prescribers in the future. Pharmacy students at the School of Pharmacy & Life Sciences, Robert Gordon University cover the university-based elements of the prescribing course in the final year of their degree. This study sought to investigate their views towards their possible future roles as prescribers.

Method All final year MPharm students at Robert Gordon University (n = 118) were invited via e-mail in May 2009 to participate in the study; two blanket reminders were sent. Those agreeing were asked in November 2009 for contact details. Semistructured telephone interviews were carried out during November and December 2009, some months into the preregistration period. The interview schedule covered participants’ prescribing-related education, experience and views. Interviews lasted between 13 and 31 minutes, were audio recorded and transcripts analysed thematically using N-Vivo® software. The study was reviewed by the School of Pharmacy & Life Sciences, Robert Gordon University Research Ethics Committee and the North of Scotland Research Ethics Committee, who advised that submission for full NHS ethics approval was not required.

Results Twenty three students initially agreed to take part; all were contacted in November and thirteen supplied contact details. One subsequently was unavailable and twelve interviews were carried out. Respondents’ demographics (age, sex etc) matched those of the cohort; data saturation was deemed to be reached

after the 10th interview. Notwithstanding varied experiences during their pre-registration periods in community and hospital pharmacy, all held largely positive views of the role of pharmacist prescriber; most were keen to train as prescribers after gaining experience as pharmacists. All, but particularly those in community pharmacy, thought prescribing would increase job satisfaction. Participants valued their prescribingrelated education during the MPharm course. Despite having covered the university-based element of the prescribing course, none thought it would be appropriate to be able to prescribe immediately on qualifying as a pharmacist, even after a period of learning in practice. Participants’ principal concerns regarding prescribing were around their lack of diagnostic and clinical skills; most would prefer to prescribe as supplementary prescribers for pre-diagnosed conditions. Some would prefer to prescribe for conditions with clear clinical guidelines; some were concerned about patients’ perceptions and expectations of pharmacist prescribers. Participants were aware that appreciable numbers of pharmacist prescribers in all sectors were not prescribing. The biggest barriers to prescribing identified were doctors’ influence and attitudes; organisational barriers such as lack of support and absence of a clear role were also identified, as was a perceived reluctance among some experienced pharmacists qualified as prescribers actually to prescribe.

Conclusions These pre-registration trainees were keen to train as prescribers after gaining experience as pharmacists, encouraged by a desire to improve their practice, but they would take a measured approach. The barriers and concerns they identified should be addressed in order to facilitate this. Participants were limited to one School of Pharmacy and hence findings cannot necessarily be generalised.

References 1. Department of Health. Groundbreaking new consultation aims to extend prescribing powers for pharmacists and nurses. London: HMSO; 2002. 2. Department of Health. Improving patients’ access to medicines: a guide to implementing nurse and pharmacist independent prescribing within the NHS in England. London: Department of Health; 2006.

Abstract 102 Perceived causes and effects of workplace stress in community pharmacy: findings from a postal survey of community pharmacists S. Jacobsa, K. Hassella, D. Ashcrofta, S. Johnsonb and E. O’Connorb a School of Pharmacy and Pharmaceutical Sciences, The University of Manchester, Manchester, UK and bManchester Business School, The University of Manchester, Manchester, UK

Focal points • To illuminate perceived causes and effects of workplace stress in community pharmacy.


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• In a postal survey of 2000 pharmacists, 379/903 respondents provided written comments which were thematically analysed. • Stress is predominantly perceived to be caused by pressure to achieve targets, paperwork and dispensing volumes in the context of insufficient staffing, profit-focussed organisations and unsupportive management and to adversely affect patient safety and pharmacists’ wellbeing. • These findings will inform future investigations of organisational interventions to combat workplace pressures.

environments (15). External stressors included demanding patients (40), healthcare commissioners (20) and the professional and regulatory bodies (16). Fifty-two comments suggested that patient safety had or was likely to be compromised by these pressures; there were 29 reported cases of staff quitting and some reported a negative impact upon mental (27) or physical (7) health and family relationships (9). A smaller number of comments offered solutions including leaving the profession (9), becoming a locum (7) or reducing hours (5); adequate staffing (8) or workload caps (8); and rest breaks (7).

Introduction

Conclusions

Workplace stress has been described as “a major cause of occupational ill health, poor productivity and human error”1 and is a growing concern in community pharmacy2. Increasing dispensing volumes and the rapid expansion of pharmacists’ roles following the 2005 general pharmaceutical services contract (GPSC) have left pharmacists struggling to cope and raised concerns that patient safety is being compromised3. To investigate the relationships between organisational factors, community pharmacists’ wellbeing and patient safety, a postal survey was conducted. This paper draws on an analysis of open comments invited in the questionnaire to illuminate the major factors perceived to contribute to work stress and its impact.

These findings provide evidence of the most commonly perceived sources of workplace stress in community pharmacy and the impact it has on the workforce and patient safety. Whilst their generalisation to the wider population of English community pharmacists is problematic, they are illustrative of a widespread and growing problem within the sector. Future research will focus in developing and evaluating organisational interventions to reduce the impact of workplace stress in community pharmacy.

Methods Approval for this study was granted by the University of Manchester Research Ethics Committee. An 8-page questionnaire was sent to a sample of 2000 practising community pharmacists in England randomly selected from the GPhC register. The questionnaire included items for measuring individual/organisational characteristics; workload/working patterns; stress; wellbeing; safety climate and dispensing errors. The eligible response rate after two written reminders was 47.8% (903/1890). Space was provided for “additional comments you might have about your job, pharmacists’ wellbeing and patient safety”. These comments were transcribed for thematic analysis using NVivo. Themes were developed under the headings, “positive comments”, “negative comments” (causes of stress; effects of stress; possible solutions), and “comments on questionnaire”.

Results Given the nature of the questionnaire it was unsurprising that the majority of the comments provided were negative. However, the strength of feeling conveyed by the pharmacists offering comments (n = 379; 42%) was compelling. Whilst a minority of respondents offered positive comments about their working conditions (e.g. the culture of their organisation (n = 23 comments); co-worker relationships (17)), many of these were tempered with negative comments. The aspects of work most commonly perceived as causes of stress were workload pressures (e.g. to achieve MUR and other targets (99); paperwork (36); dispensing volumes (28); enhanced services (15); management responsibilities (14)) in the context of insufficient staffing (98), organisational cultures putting profit over patient care (62), and unsupportive or bullying management (49). Stress was exacerbated by long working days (27) with few rest breaks (31) and sometimes poor physical working

References 1. Health and Safety Executive. Managing the causes of workrelated stress. 2007. Available at: http://www.hse.gov.uk/pubns/ priced/hsg218.pdf [Accessed April 22, 2011] 2. http://www.rpharms.com/current-campaigns/workplace-pressures.asp [Accessed April 22, 2011] 3. Willis, S. & Hassell, K. Pharmacists’ occupational well-being needs to be improved in order to avoid dispensing errors. Pharm. J. 2010. 285, 371.

Abstract 103 Developing a progressive and sustainable community pharmacy public health promotion service, which will meet the NHS’s QIPP (quality, innovation, productivity, prevention) agenda M. Stonea, V. Kernicka, J. Loaderb and M. Wilcockc,d a Devon Local Pharmaceutical Committee, Exeter, UK, bSouth West SHA, Taunton, UK, cCornwall and Isles of Scilly PCT, Truro, UK and d National Prescribing Centre, Liverpool, UK

Focal points • To identify how to evolve the current community pharmacy public health promotion/signposting role towards acting as a referral agent for patients to motivate healthier lifestyle decisions. • 73 interventions were recorded with 30 bookings made with service providers. Patient satisfaction was very high. • Pharmacy’s public health promotion role can be progressively enhanced toward a quality, innovative and productive, health prevention service.


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Introduction The evidence base for community pharmacy improving public health (PH) exists in the services of smoking cessation, emergency contraception, flu immunisation and drug misuse1, but there is only limited evidence of pharmacy’s public health promotion role. The recent Public Health White Paper 2 acknowledged pharmacy’s role in improving public health, and the vital part it can play in preventing ill health in the future NHS. This pilot study was designed to understand and identify possible evidence for this future public health role, and the development of community pharmacy to act as a referral booking agent to motivate patient healthier lifestyle decisions. The service design was focussed on whether the progressive evolution of the current pharmacy PH promotion role toward the Portsmouth Healthy Living Pharmacy (HLP) concept could be achieved, while still appreciating the NHS’s current economic drive towards quality outcomes and efficiency through QIPP.

3.4 to 4.4, and their confidence in their knowledge increased from 3.4 to 4.4.

Discussion Community pharmacy can provide a sustainable public health promotion service which provides quality interventions to motivate people into making healthier lifestyle decisions in PH priority areas, while fulfilling the current NHS QIPP agenda. Although this study is small and with self selected pharmacies, it shows that community pharmacy is effective as a referral agent, motivating patient engagement with PH providers. Patient feedback indicates a very high satisfaction with this service.

References 1. Anderson C, Blenkinsopp A, Armstrong M (2009) The contribution of community pharmacy to improving the public’s health. Pharmacy Health Link. 2. Healthy Lives, Healthy People – our strategy for public health in England. Department of Health (2010).

Method Ten pharmacies responded to an invitation for expressions of interest, and each identified a member of staff to become a Pharmacy Healthy Living Advisor (PHLA). A focus group was used to help design the structure of the pharmacy public health service, to identify pharmacy’s strengths and to consider how to overcome any barriers. A pre- and post-intervention period questionnaire was completed by the participants to measure their perceived confidence and skill levels. The quality of the activity and outcomes achieved by the 9 (1 dropped out) PHLAs were measured in this pilot study over a 6 week data collection period (March to April 2011). The number of interventions, topic of intervention, consultation outcome, patient/customer feedback, verification details, and the detail of actual service engagements arranged with PH service providers were recorded by the PHLAs. This is a service evaluation and ethics approval was considered unnecessary. In order to help meet the QIPP agenda aim this study relied on proactive utilisation of current pharmacy resources and customer contacts. It did not involve any promotional marketing as in the HLP and sought to identify quality and modifiable activity outcomes.

Results All of the PHLAs achieved a training award in Public Health, and during the six week data collection period 73 interventions and 30 bookings with local PH service providers were made by the 9 PHLAs. The topics of the interventions/bookings covered all of the major PH priorities: smoking cessation 49%/53%, weight management/lifestyle 14%/7%, sexual health 6%/3%, alcohol 6%/0% and depression 7%/7%. Feedback questionnaires were returned by 50 customers, 82% said ‘the information given was useful’, 80% said ‘they would follow the advice provided’ and 92% said ‘they would seek advice from a PHLA again’. The actions identified to address weaknesses and barriers from the focus groups increased the confidence of the PHLAs in their skills, the average rating (1–5 scale) increased from

Abstract 104 How pharmacy employers view their responsibility for testing the language proficiency of European-trained pharmacists Z. Ziaei, E.I. Schafheutle and K. Hassell University of Manchester, Manchester, UK

Focal points • Pharmacy employers have the responsibility to ensure that pharmacists have sufficient linguistic skills to communicate and perform their job safely. • This study explored how pharmacy employers viewed their responsibility for testing the language proficiency of European (EU) trained pharmacists. • All employers had a procedure in place to check the language proficiency, however, these procedures varied in type and rigorousness. • There is a need to establish a unified assessment system so all EU-trained pharmacists could be tested fairly and consistently.

Introduction Currently, based on a mutual recognition of qualifications, the General Pharmaceutical Council (GPhC) is powerless to test the language competency of EU-trained pharmacists when transferring registration to Great Britain (GB).1 Although under the GPhC standards of conduct, ethics and performance, pharmacists have a responsibility to ensure that they have sufficient linguistic skills to communicate and perform their job safely, the burden is on employers to ensure that this standard is met.1 However, the results of a survey carried out by the Royal Pharmaceutical Society in 2009 revealed that 63% of the employers did not undertake language testing of European


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job applicants.2 Furthermore, 40% of employers had encountered problems that were potentially related to the language proficiency of employees.2 A study was undertaken to explore how employers view their responsibility in terms of testing the language proficiency of EU-trained pharmacists.

Method Nine semi-structured, telephone interviews were conducted with a purposively selected sample of community (n = 7) and hospital (n = 2) employers who had employed or were employing EU-trained pharmacists. Employers were identified via personal networks and snowballing and were contacted by email. To obtain a diverse range of opinions, the director of human resources, the superintendent pharmacist or the area manager in a selection of small, medium and large community pharmacy chains were contacted. To recruit hospital employers, the chief pharmacist was contacted in a number of district and teaching hospitals. The interviews were recorded, transcribed verbatim, coded and analysed in NVivo using the framework approach. The study obtained National Research Ethics Service and university ethics approval.

Results All participants mentioned the importance of having processes in place to assure EU-trained pharmacists’ communication competency in the workplace. However, different strategies were used during recruitment to assure language competency. Some employers (n = 4) only conducted interviews to assess competency while others required candidates to achieve a certain level of proficiency in English language assessments. Participants were most familiar with the International English Language Testing System (IELTS) assessment option, although, a few (n = 3) shared several concerns related to it. There was an observation that some pharmacists pass the test, but still have communication problems. IELTS was described as being too general and not unique to pharmacy, and passing it was not seen as an indication of fluency in the workplace. To overcome these issues, English language assessment instruments that were related to pharmacy in GB, such as the University of Bath English Language Test and Linguarama English Assessment Test for Pharmacists, were used by some community employers (n = 3).3 Although employers preferred pharmacy-specific assessments, mostly still accepted EU-pharmacists with IELTS accreditations.

Discussion Pharmacy employers are responsible for ensuring that their EU-employees have sufficient linguistic skills to communicate.1 However, there is no one standard procedure in place to check the language competency of EU-trained pharmacists. The findings from this study suggest that there is need to establish a uniform assessment system so all the EU-trained pharmacists could be tested fairly and consistently.

References 1. General Pharmaceutical Council: EEA-qualified pharmacists – London 2011. [http://www.pharmacyregulation.org/regulating pharmacy/registration/registeringasapharmacist/eeaqualified pharmacists/index.aspx]

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2. Rivers F. Who should test the English language skills of European pharmacists? Pharmaceutical Journal 2009; 283:204–205. 3. Richardson J. Lost in translation: English language tests. Chemist + Druggist 2008. [http://www.chemistanddruggist.co.uk/ main-content/ /article_display_list/1390749/1390745]

Abstract 105 Content analysis of UK media coverage of pharmacogenetics B. Almomani and J. McElnay Queen’s University Belfast, Belfast, UK

Focal points • To quantitatively assess articles published in mainstream UK newspapers which addressed the area of pharmacogenetics. • The potential benefits of pharmacogenetics were emphasised while the potential risks were under-reported. • The lack of reporting of some important information (e.g. potential conflict of interest) highlighted an imbalance in newspaper reporting on this subject.

Introduction It has been suggested that the media should consider itself as a vehicle for questioning the role of new technology and new science and to provide unbiased reporting to the public1. As patients are becoming increasingly self-educated via the media, it is important to know how the print media portray information to the public. The main aim of this study, as part of a larger research project on current knowledge on pharmacogenetics, was to explore, through systematic content analysis, the trends in UK newspaper coverage of pharmacogenetics in general and in particular the potential benefits and risks of pharmacogenetic testing in support of personalised medicine.

Method A purposive sample of the 10 UK highest circulation national daily newspapers and their Sunday equivalents was investigated, covering the period Jan 2001–Dec 2010. The LexisNexis database was used to identify and retrieve full text articles from electronic archives. A standardised coding frame was developed to facilitate consistent data extraction and analysis. The main researcher manually coded the entire set of relevant newspaper articles while a second independent researcher reassessed a random sample (24%; n = 20) of the articles in order to provide a quantitative estimate of the overall reliability of the coding process. No ethical application was required for this type of research as it involves data from the public domain (newspapers).

Results Of the 233 articles captured by the search terms, 83 articles (with pharmacogenetics as a major component) met the study inclusion criteria and thus were included in the final detailed


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analysis. The mean inter- coder Kappa score was 0.84, indicating good agreement. Ten of the articles were directly linked to seven scientific journal papers. The vast majority (98.8%; n = 82) of the articles stated at least one benefit of the application of pharmacogenetics, while only 34.9% (n = 29) of the articles mentioned at least one risk. Overall beneficial effects were mentioned 5.5 more frequently than risks (P < 0.001). There was a marked unequal distribution of articles in broad sheet vs tabloid newspapers [85.5% (n = 71) vs 14.5% (n = 12); P < 0.001]. The most common illnesses for which pharmacogenetically based personalised medicine was discussed were cancer, cardiovascular disease, CNS disease, endocrine disorders and respiratory disease. Only one newspaper article of seven that cited a specific scientific study that was specifically linked with industry in the scientific paper, mentioned this link in the article. There was a positive correlation between the size of the article and both the number of benefits and risks stated (P < 0.01). The greatest number of risks reported related to adverse economic impact on the pharmaceutical industry, since blockbuster drugs would not result from a personalised medicine approach. Confidentiality and discrimination risks were the main patient risks reported.

• The TCM was found to be an interesting framework from which to examine commitment in community pharmacy.

Background Community pharmacy is in the grip of change encompassing the regulator, representation, the future role in healthcare, as well as socio-cultural changes1, such as the increasing feminisation of the workforce and greater use of alternative working practices. Such change can impact on community pharmacists, but the magnitude of this may be influenced by both professional and organisational commitment2. As there is little research in this area3,4, it is the aim of this study to explore how commitment maybe perceived by community pharmacists in Great Britain. To do this, the Three Component Model of Commitment (TCM) by Meyer & Co.2 is used as the theoretical underpinning of this study. It argues commitment is a force that binds an individual to persist in a chosen action, and is defined by one or a combination of the different mind-sets, affective (wish/desire), normative (sense of obligation) and continuance (need), which characterises an individual’s relationship with the profession/organisation.

Discussion

Method

The study demonstrated that pharmacogenetics is a topic of only marginal interest to UK newspaper editors, in particular the tabloid press. The majority of articles emphasised the benefits of pharmacogenetics testing while under-reporting the risks whereas a “balanced assessment” is required to allow readers to make informed decisions2. This trend of reporting is consistent with other studies that reported media analyses on health topics. Journalists have special responsibilities in conveying information to the public since readers may make important decisions based on what is presented3.

To maximise the richness of data yielded by the study a mixed methods approach consisting of two focus groups and twentyone semi-structured interviews was used. To gauge a wide range of experiences and opinions, a diverse yet representative sample of 32 community pharmacists was recruited from Northern England, to take part in this study. An a priori deductive approach shaped on the TCM was used to analyse the data. Ethical approval was obtained from the University Ethics Committee.

References

Affective commitment was perceived to be the most positive form of professional commitment; associated with the use of skills & knowledge, aligned with the role of a pharmacist. However continuance commitment was associated with feelings of being stuck, lack of support and regarded negatively; staying in the profession as there was no perceived alternative available that would sustain their accustomed lifestyle. Normative professional commitment was more complicated. It was viewed as less likely due to the increasing financial burden on pharmacy students, blurring of roles and the perceived decline of professionalism. However, pharmacists felt an obligation to their patients and community. Affective organisational commitment related to how well pharmacists perceived they were treated by the organisation through its agents. This was further boosted where the pharmacist perceived an alignment between professional and organisational goals. However, almost on par with affective commitment, continuance commitment was thought to have a strong influence on a pharmacist’s organisational commitment. This was primarily related to the potential cost of leaving the organisation including pensions, familiar working systems and processes, friendships, etc. Finally, normative organisational commitment was viewed as developing from reciprocity based on perceived organisational support, leading to feelings of indebtedness.

1. Prosser, H. (2010) Marvellous medicines and dangerous drugs: The representation of prescription medicine in the UK newsprint media. Public Understanding of Science, 19, 52–69. 2. Prosser, H. and Clayson, K. (2008) A content analysis of prescription drug information in the UK print news media. The International Journal of Pharmacy Practice, 16, 223–230. 3. BubelA, T., Boon, H. and Caulfiel, D. T. (2008) Herbal remedy clinical trials in the media: a comparison with the coverage of conventional pharmaceuticals. BMC Med, 6, 1–14.

Abstract 106 Commitment in community: a qualitative study of pharmacists A. Rashid, K. Hassell and S. Johnson The University of Manchester, Manchester, UK

Focal points • To explore the concepts of professional and organisation commitment in community pharmacy. • Affective commitment was found to be the most positive form of professional and organisational commitment.

Results


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Discussion/Conclusion The data suggests caution that not all forms of commitment maybe considered to be positive to the profession or the organisational context.

References 1. Hassell K. Destination, future intentions and views on practice of British-based pharmacists 5 and 10 years after qualifying. Pharm World Sci 2006;28:116–22.

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2. Meyer JP, Herscovitch L. Commitment in the workplace: Toward a general model. Hum Resour Manage Rev 2001;11(3): 299. 3. Gaither CA, Mason HL. A model of Pharmacists’ Career Commitment, Organizational Commitment and Career and Job Withdrawal Intentions. J Soc Adm Pharm 1992;9(2): 75–85. 4. Hussain S, Bates I. Determining the Influence of Formal Postgraduate Education on the Career Commitment of Hospital Pharmacists. Pharm Educ 2002 Jan 1;1(4):231–41.


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