Background
Medication use is one of the most common types of interventions in healthcare and it is ubiquitous. Many years ago, most Western and European countries identified the positive impact of a clinical pharmacy service in improving quality use of medicines (QUM) which in turn improves overall patient care [
1].
However, collaboration between medical staff and clinical pharmacists in providing patient care is a novel concept in Sri Lanka. At present pharmacists are not a part of the multidisciplinary healthcare team and their role is limited to drug dispensing, providing limited medicine information and compounding within the hospital.
Non-communicable chronic diseases (NCCDs) comprise a major group of diseases that necessitate the long term use of medications. NCCDs are a significant global health challenge affecting both the developed and developing world [
2,
3]. Sri Lanka is a developing country with a high burden of NCCDs that in 2012 accounted for almost one-third of hospital admissions [
4].
In many countries hospital treatment of NCCDs utilizes multidisciplinary teams that include clinical pharmacy services [
5‐
7]. McAlister, et al. in their systematic review of randomized controlled trials had revealed that multidisciplinary approaches that included clinical pharmacy services in managing patients with heart failure had reduced mortality and morbidity [
6]. Another systematic review analyzing 126 studies in United States showed a cost benefit on health outcomes in pharmacist directed pharmaceutical care services [
8].
In order to inform policy makers in Sri Lanka regarding future developments in health care delivery we conducted a study to evaluate the implementation, impact, and acceptability of the introduction of a ward-based clinical pharmacy service as a novel intervention in a tertiary care hospital in Sri Lanka [
9,
10].
This paper describes the level of acceptance of the clinical pharmacy service; in the aforementioned primary study, by the other members of the healthcare team. This sub-study utilizes the observational data gathered from the intervention arm of the clinical trial and data gathered from a separate staff survey. The aims of this sub-study were to determine the level of acceptance of the clinical pharmacist’s recommendations to resolve Drug Related Problems (DRPs) by the healthcare staff, to determine the quantity and quality of drug information queries directed to the clinical pharmacist from other staff and to assess the views and attitudes of the other members of healthcare staff towards the clinical pharmacy service.
Methods
Study design, setting and procedure
We established a controlled clinical trial to assess the effectiveness of a clinical pharmacy service in improving QUM in patients with NCCDs. This paper described a descriptive cross-sectional sub-study of abovementioned controlled trial under the area of the acceptance and attitudes of healthcare staff on the introduction of a clinical pharmacy service to a tertiary care hospital in Sri Lanka. Within the intervention arm acceptance of the clinical pharmacy service was measured by quantitatively examining the rate of acceptance of the clinical pharmacist’s recommendations regarding DRPs by the healthcare staff and by quantitatively and qualitatively examining the drug information queries directed to the clinical pharmacist by the healthcare staff. Staff attitudes towards the acceptance of the clinical pharmacy service was determined by repeated surveys which conducted before and after the trial intervention period.
Clinical trial
The clinical trial was conducted over a thirteen months period (recruitment from March 2013 to September 2013; follow-up from October 2013 to March 2014), in the University Medical Unit of Colombo North Teaching Hospital, Sri Lanka; a large tertiary care teaching hospital having 1421 beds with more than 500,000 admissions annually. There was no established ward-based pharmacy service in the hospital and the existing hospital pharmacy service was limited to dispensing and it did not have a formal process for pharmacists’ provision of medication education to patients. The University Medical Unit consists a female and a male ward accommodating approximately 55 and 65 patients, respectively.
Study population
Eligible patients were those with non-communicable chronic diseases (NCCDs) who needed long-term follow-up at the medical clinic. Each day the first five eligible patients in each ward as recorded chronologically in the admission register were approached by an independent medical officer to be consented and recruited to the study.
In the first 3 months of the study, patients from the male ward received the intervention and patients from the female ward were recruited to the control arm. In the second 3 months of the study, patients from the female ward received the intervention and patients from the male ward were recruited to the control arm. The control group received usual care which did not include clinical pharmacist’s input whereas the intervention group received a clinical pharmacy service in addition to usual management.
Staff survey
The views and general perspectives of healthcare staff was assessed through a self-administered questionnaire at baseline (before introducing the clinical pharmacy service) and at the end of the trial (post-intervention) to determine any change in the views and attitudes of doctors and nurses towards the clinical pharmacy service.
This questionnaire was developed and pre-tested in a pilot study and reviewed by a team of clinical pharmacists and consultant physicians prior to the study. The questionnaire was developed in such a way that it sought the general perspectives of health staff on how this integrated medicine management related to both patients and to the healthcare staff. In the questionnaire there were 17 questions in total. The answers to the first 9 close-ended questions were designed using a five-grade Likert scale, ranging from “strongly agree”, “agree”, “no opinion”, “disagree” and “strongly disagree” (Additional file
1: Table S1 and Additional file
2: Table S3). The other questions were customized for medical or nursing staff and addressed specific tasks of the clinical pharmacy service provided (Additional file
3: Table S2 and Additional file
4: Table S4). These questions were answered with a dichotomized response alternative, “Yes” or “No”. An independent research assistant distributed the questionnaires among all the healthcare members (consultant physicians, senior-registrars, registrars, grade medical officers, intern house officers and nursing staff) who worked in the University Medical Unit during the relevant study period were included and the completed questionnaires were collected in a sealed box kept in the staff room. Participants were given a participant information sheet and in addition they were informed about the purpose of the survey verbally by the investigator. An individual consent form was attached with the questionnaire and it clearly explained the purpose of the survey and the capability of participants to voluntarily withhold their consent.
Study outcomes
The study outcomes included level of acceptance of the pharmacist’s recommendations regarding DRPs, quantity and nature of drug information queries directed to the clinical pharmacist by the healthcare staff and the views and attitudes of the healthcare staff towards clinical pharmacy service.
The clinical pharmacist identified and classified DRPs according to the adapted Pharmaceutical Care Network Europe (PCNE) classification system V5.01 [
11]. A subset of 52% of DRPs were externally validated by Australian clinical pharmacy team and two consultant physicians involved in the study. The pharmacist’s recommendations were identified as “Accepted” (the healthcare staff accepted the pharmacist’s recommendations) and “Not accepted” (the staff did not agree with the recommendations) interventions. Accepted interventions were further classified into two categories depending on the implementation of the accepted recommendation (“Implemented” or “Not implemented”). Implementation of the recommendation was considered as resolution of the DRPs.
Details of medication-related queries directed to the clinical pharmacist from healthcare staff were recorded on a pre-prepared data collection form.
The attitudes and views of the healthcare staff were obtained from the self-administered questionnaire as described under staff survey above.
Data analysis
The data were inputted into SPSS, V.21. Sample proportion tests in Minitab 14 were used to calculate the proportions. P values less than 0.05 (P < 0.05) were considered to be statistically significant.
Discussion
Clinical pharmacy is a health science discipline which delivers patient-oriented pharmaceutical care, with an aim of improving safe and rational use of medicines [
12]. Studies conducted in different parts of the world have shown the benefits of a clinical pharmacy service in terms of reducing negative outcomes of DRPs and improving patient safety [
13,
14], improving appropriateness of prescriptions [
15,
16] and reducing the impact of healthcare expenditure [
17].
In Sri Lankan hospitals clinical pharmacy service does not exist and this is a completely new concept to the existing healthcare environment. This is the first interventional study carried out in Sri Lanka evaluating the acceptance of the recommendations made by a clinical pharmacist by other members of the healthcare team. This study showed that the addition of a clinical pharmacist to the study setting was positively received by the attending doctors. An acceptance rate of 83.0% of pharmacists’ recommendations regarding DRPs by doctors was comparable to developed world settings where acceptance rates range between 63 and 90% [
18‐
20]. The implementation of the pharmacist’s recommendations of 73.5% was comparable to a study done in Sweden by Gillespie, et al. where 75% of the pharmacists’ suggestions were implemented [
21]. The acceptance of pharmacist’s recommendations regarding DRPs shows that the physician-pharmacist inter-professional relationship was successfully established in the busy tertiary care hospital where the study was carried out.
The attitudes and views of doctors ranging from specialist physicians, senior registrars and registrars to intern medical officers about the incorporation of clinical pharmacy service and its benefits were positive. A great majority (91.7%) of doctors agreed that adding a pharmacist to the team would be cost effective and is vital to the current healthcare system. Physicians’ perspectives on collaborative work with a clinical pharmacist had been studied widely in many other countries [
22‐
25]. Gillespie, et al. reported that 95% of physicians were satisfied with the incorporation of a clinical pharmacy service to the university hospital in Uppsala in Sweden, which was a new introduction to that setting at that time [
22].
However the pharmacist-nurse interaction on team-based patient management had not been explored extensively [
22,
26]. In this study, even though a wide proportion of doctors acknowledged the importance of clinical pharmacy service, the response received from the nursing staff was negative as assessed at the baseline. Lack of awareness and knowledge about the importance of clinical pharmacy service in improving QUM and potential benefits to patient care could be the likely reason for this negative response. The survey results showed that none of participated nurses had been worked with a clinical pharmacist in overseas or any private sector hospital. Another survey conducted in Sri Lanka to evaluate the perception of healthcare staff towards the addition of clinical pharmacy service had showed similar findings. According to the results of that survey, 60% of medical staff believed that the incorporation of clinical pharmacists would improve the rational prescribing of medications [
27]. However similar to the results of our study the responses of nurses were mostly negative; only 10% appreciated the usefulness of clinical pharmacy service [
27]. A study from Pakistan published in 2012, showed a negative perception from nurses towards the role of pharmacist in Pakistan’s healthcare setting [
28].
Data from our study emphasizes that there is a need to improve awareness and build trust and relationships with nursing staff in order to demonstrate the potential benefits and promote a clinical pharmacy service in Sri Lankan hospitals.
The foundation for building an efficient team is to encourage learning as a team. Training students on team care at undergraduate and postgraduate levels is likely to improve the awareness of skills and strengths of each category of professionals and help to overcome the barriers for implementation of the clinical pharmacy service [
29,
30].
Results of this study demonstrated that the clinical pharmacy service is well accepted and utilized by the medical staff in the tertiary care hospital indicating that there is a significant opportunity for the Sri Lankan clinical pharmacist to make a valuable contribution to enhance the QUM. It also demonstrated that a significant number of DRPs could be identified and acted upon in a manner consistent with best practice multidisciplinary healthcare teams. As in other countries it is reasonable to expect that this will result in improved health outcomes for patients and reduced costs for health system. Thus, our study provides evidence to support health policy change in order to introduce clinical pharmacy service to the healthcare system in Sri Lanka and the other low and middle-income countries (LMICs).
Strengths and limitations
The study was undertaken in a tertiary level teaching hospital with strong support from lead clinicians. This level of support may not be available in smaller hospitals in the country. Therefore, the results on the acceptance of the pharmacist recommendations by the doctors to resolve DRPs are likely to be generalizable primarily to tertiary hospitals. Tertiary hospitals are a logical place to start as they provide higher exposure of health professionals-in-training to pharmacists being included in multidisciplinary care, which will eventually facilitate expansion to smaller hospitals.
In a study of this duration it is inevitable that there will be turnover of medical staff within the two hospital wards where the study was carried out. The average number of doctors working in both wards was around 12. Thus we were able to offer the survey to a significant proportion of doctors in the clinical team. The numbers of doctors who participated at baseline and after intervention changed mainly because of a change in intern medical officers as they completed their intern period during the study. While this is a limitation in comparison of results it is unlikely that the prior beliefs of the doctors had changed. In addition the continued acceptance of pharmacist recommendations supports the survey observations.
Even though the nurses withdrew from the post-intervention survey, they actually did not withdraw from the clinical trial. As we mentioned the nurses refused to give the consent for participation in the post-intervention staff survey due to a trade union issue. This trade union issue was about the nurses being surveyed and being asked to express their views and not about the pharmacy intervention. Although desirable, within that context it was not possible to perform any kind of in-depth interviews, focus groups or similar qualitative methods with the nursing staff to explore the reasons for their reluctance to collaborate in this component of our study. While the second survey of nursing staff could not be undertaken the 25% of the medication related questions generated by nurses was evidence of nurses acceptance of the trial.
Eventhough all the doctors and nurses participated in the staff survey the number was small. This limits the generalizability of the results generated from the staff survey.
Acknowledgements
We would like to thank Staff of Professorial Medical Unit, Colombo North Teaching Hospital in Sri Lanka for their assistance.