Int J Clin Pharm (2014) 36:976–985 DOI 10.1007/s11096-014-9984-z
RESEARCH ARTICLE
PACE: Pharmacists use the power of communication in paediatric asthma Amanda Elaro • Smita Shah • Luca N. Pomare • Carol L. Armour • Sinthia Z. Bosnic-Anticevich
Received: 26 February 2014 / Accepted: 21 July 2014 / Published online: 3 August 2014 Koninklijke Nederlandse Maatschappij ter bevordering der Pharmacie 2014
Abstract Background Paediatric asthma is a public health burden in Australia despite the availability of national asthma guidelines. Community pharmacy interventions focusing on paediatric asthma are scarce. Practitioner Asthma Communication and Education (PACE) is an evidence-based program, developed in the USA for general practice physicians, aimed at addressing the issues of poor clinician-patient communication in the management of paediatric asthma. This program has been shown to improve paediatric asthma management practices of general practitioners in the USA and Australia. The development of a PACE program for community pharmacists will fill a void in the current armamentarium for pharmacist-patient care. Objectives To adapt the educational program, PACE, to the community pharmacy setting. To test the feasibility of the new program for pharmacy and to explore its potential impact on pharmacists’ communication skills and asthma related practices. Setting Community pharmacies located within the Sydney metropolitan. Method The PACE framework was reviewed by the research team and amended in order to ensure its relevance within the pharmacy context, thereby developing PACE for Pharmacy. Forty-four pharmacists were recruited and trained in small groups in the PACE for Pharmacy workshops.
Pharmacists’ satisfaction and acceptability of the workshops, confidence in using communication strategies pre- and postworkshop and self-reported behaviour change post workshop were evaluated. Main Outcome Measure Pharmacist selfreported changes in communication and teaching behaviours during a paediatric asthma consultation. Results All 44 pharmacists attended both workshops, completed pre- and postworkshop questionnaires and provided feedback on the workshops (100 % retention). The participants reported a high level of satisfaction and valued the interactive nature of the workshops. Following the PACE for Pharmacy program, pharmacists reported significantly higher levels in using the communication strategies, confidence in their application and their helpfulness. Pharmacists checked for written asthma self-management plan possession and inhaler device technique more regularly, and provided verbal instructions more frequently to paediatric asthma patients/carers at the initiation of a new medication. Conclusion This study provides preliminary evidence that the PACE program can be translated into community pharmacy. PACE for Pharmacy positively affected self-reported communication and education behaviours of pharmacists. The high response rate shows that pharmacists are eager to expand on their clinical role in primary healthcare.
A. Elaro (&) L. N. Pomare C. L. Armour S. Z. Bosnic-Anticevich The Woolcock Institute of Medical Research, University of Sydney, Glebe, NSW 2051, Australia e-mail: [email protected]
Keywords Australia Childhood asthma Communication Community pharmacy PACE Paediatric asthma Pharmacist Primary care intervention
S. Shah Primary Health Care Education and Research Unit, Western Sydney Local Health District, Sydney, NSW 2145, Australia
Impacts on Practice
S. Shah Sydney Medical School, University of Sydney, Sydney, NSW 2006, Australia
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The interactive PACE program, guided by social cognitive theory and principles of self-regulation, has both transprofessional and transcontinental plausibility.
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Pharmacists are eager to form a collaborative working relationship with general practitioners in the devising of written asthma self-management plans. Pharmacists are ideally positioned within the primary health care spectrum to optimise patient disease selfmanagement.
Introduction Paediatric asthma is a chronic disease affecting 16 % of Australian children [1]. Despite the availability of national asthma guidelines, which focus not only on specific medical treatment, but also on the skills of health care professionals and their ability to facilitate patient self-management, paediatric asthma continues to be a major contributor to the burden of illness in children [2–4]. The resultant uncontrolled asthma has widespread impact resulting in time off school and work for the child and carer respectively, sleep deprivation and reduced quality of life, thus imposing an economic burden on the carer and the Australian health system [5]. Additionally, despite the proven benefit of written asthma self management plans, currently less than 50 % of Australian children with asthma own one [6]. This may be attributed to the gap that exists between evidence based recommended practice and the current practice of health care professionals in managing paediatric asthma in primary care [5, 7, 8]. This emphasises the need to facilitate the translation of national guidelines into primary care. In paediatric asthma, the knowledge, communication skills and commitment of health care professionals have been shown to be essential in allowing the paediatric patient and carer to adopt effective management practices and beliefs. A recent study by Grover and colleagues identified a key barrier to the management of paediatric asthma in primary care to be the inability of health care professionals to effectively communicate with the patient/ carer [5, 9]. In further support of this point, 38 % of Australian parents feel they do not have enough information about their child’s asthma [8]. Practitioner Asthma Communication and Education (PACE) is an evidence-based program, with an innovative focus on self-regulation theory, a principle of Bandura’s social cognitive theory which proposes that increased self-efficacy, intrinsic motivation and achievement can be gained when health care professionals are given the opportunity to selfobserve, develop strategies to reach goals and evaluate the success of these strategies [10, 11]. PACE was originally developed in the United States for general practice physicians, aiming to address the issues of poor clinician-patient communication and education in the management of paediatric asthma. PACE provides primary health care practitioners with clinical paediatric asthma knowledge and most importantly ten key evidence based communication strategies and
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protocols by which practitioners can assess their own behaviour regarding patient communications, to support the development of skills that will enable practitioners to communicate more effectively with paediatric patient’s and their carers, and support patients/carers management efforts [4, 12–14]. It has been modified and tested with Australian general practitioners (GPs) and named PACE Australia [4, 14]. The implementation of PACE in the USA and Australia resulted in improved participants’ confidence in communicating and educating paediatric asthma patients and their carers, more appropriate and tailored prescribing of medications and increased provision of written asthma self-management plans. Pharmacists are at the frontline of the primary health care team [15]. They are experts in medication use and have been shown to effectively deliver interventions in the pharmacy, which have resulted in improved asthma outcomes [16–24]. Although in Australia, pharmacists are not able to authorise the implementation of written self-management plans, studies have shown that when pharmacists have intervened with patients in regards to requesting asthma self-management plans, there has been an increase in asthma self-management plan ownership [16, 18]. Interventions focusing on pharmacist-patient communication behaviour, patient-teaching and asthma self-management in the management of paediatric asthma are scarce. Hitherto, Australian pharmacists are not trained in communication associated with paediatric asthma specifically, with the majority of pharmacy-based programs focusing on patient care and disease management [25, 26]. Thus, the translation of PACE Australia into pharmacy will add to the current armamentarium available for training pharmacists in communication and patient care.
Aim of the study The aims of the study were to adapt PACE Australia to the community pharmacy setting thereby developing PACE for Pharmacy, to test the feasibility of the new program for pharmacy and to explore the potential impact of PACE for Pharmacy on pharmacists’ communication skills and asthma related practices.
Ethical approval This study was approved by the University of Sydney Human Research Ethics Committee (Protocol 2012/969).
Method This study takes the form of a pre-post, mixed method design [14]. By taking an eclectic approach, and combining
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qualitative and quantitative methodologies, the research aims are better addressed. In order to achieve the aims of this study, the PACE Australia program needed to be modified to suit the pharmacy context, followed by the implementation and evaluation of the PACE for Pharmacy program. Development of PACE for Pharmacy PACE for Pharmacy was developed on the framework of PACE Australia, which is based around five central themes (Table 1). Each key resource from PACE Australia including the workshop outlines, slides, participant toolkit and the ‘PACE Australia: Training of Presenters’ manual [27] were reviewed by the research team and amended in order to ensure their relevance to the pharmacy context.
(‘‘Workshop Reflection’’) solicited feedback from pharmacists on what aspects of the workshop they found most useful and enjoyable and what could be improved on. Perceived impact of the PACE for Pharmacy program Pharmacist confidence and behaviour with regards to communicating with paediatric asthma patients and their carers were recorded at baseline through the completion of a structured, self-reported questionnaire (Baseline Questionnaire). The Baseline Questionnaire covered six Domains: 1. 2. 3. 4. 5.
Pharmacist recruitment Seventy-nine eligible pharmacies located throughout the Sydney metropolitan were directly contacted by a pharmacist peer (research member) and invited to participate in the PACE for Pharmacy program. Similar to PACE Australia, there was no limit to the number of Pharmacists recruited per pharmacy. Outcomes and evaluation PACE for Pharmacy workshop evaluation A qualitative analyses of pharmacists’ satisfaction and acceptability of the workshops was performed. Participating pharmacists completed an anonymous, self-reported, reflective, open-ended questionnaire at the end of the second PACE for Pharmacy workshop. The questionnaire
6.
Confidence in using communication strategies. Beliefs of the helpfulness of communication strategies. Frequency of use of communication strategies. Ability to self-reflect on the use/effectiveness of strategies. Frequency of use of strategies when counselling on new medication. Confidence around the use of inhaled corticosteroids.
Responses to items within Domains 1–3 were based on a 5-point Likert scale while the items within Domains 4–6 were based on a 6-point Likert scale. Pharmacist demographic data was also collected. One month following the completion of the PACE for Pharmacy workshops, the pharmacists were required to complete a Follow-Up Questionnaire that was identical to the Baseline Questionnaire. For this questionnaire, participating pharmacists were required to consider their behaviours during the month of practice, post workshops. This allowed the detection of changes in pharmacist selfreported communication and asthma related practices post workshops. All questionnaires described were those used previously to evaluate PACE both in the USA and Australia [13, 14].
Table 1 Comparison of themes from PACE Australia and PACE for Pharmacy PACE Australia
PACE for Pharmacy
Additional/modified components
Theme 1
Patient education
Patient education
Addition of an inhaler technique checklist [30]
Theme 2
Doctor-patient communication
Pharmacist-patient communication
N/A
Theme 3
Assessment of the pattern of asthma
Assessment of the pattern of asthma
Focus shifted from diagnosing to assessing a child’s clinical pattern of asthma
Theme 4
Appropriate use of medicines
Appropriate use of medicines
Focus shifted from prescribing asthma medication according to clinical pattern, to making informed referrals to the general practitioner regarding appropriate medication prescribing.
Theme 5
Provision of a Written asthma selfmanagement plan
Recommend and motivate the patient to request a written asthma self-management plan from their doctor
Addition of segment on the benefits of pharmacists recommending and motivating patients to request a written asthma self-management plan from their general practitioner.
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Data management
Table 2 Demographics of PACE for Pharmacy feasibility study pharmacist participants
Demographic data was analysed descriptively. A thematic analysis of the data obtained from the Workshop Reflection was performed in order to determine workshop satisfaction and acceptability. Shapiro Wilks test was used to determine the normal distribution of data. The mean pharmacist self-reported scores for each item in Domains 1–6 were calculated at Baseline and Follow-up and compared using a Paired Samples Student’s T-Test (significance 0.05, power 0.8). The proportion of pharmacists who reported a higher score between Baseline and Follow-up in each item within Domains 1–6 was also calculated. Analyses were performed using SPSS version 21.0 (SPSS Inc, Chicago, I11, USA).
Characteristic
PACE for Pharmacy (n = 44)
Male (%)
36
Results
Age range \26 years (%)
32
27–46 years (%)
48
47–56 years (%)
20
Mean years since graduation
12 (range 2–37)
Years practicing as a pharmacist (%) 0–10
52
11–19
16
20? Country of graduation (%)
32
Australia
89
Other
11
Sessionsa worked each week (%)
Of the 79 pharmacies that received an invitation, 37 pharmacies expressed interest (47 %) and 44 pharmacists from these pharmacies enrolled in the study within 2 weeks. All 44 pharmacists attended both PACE for Pharmacy workshops and completed both Baseline and Follow-up questionnaires and provided feedback on the workshops (100 % retention). Table 2 shows the demographic and professional characteristics of the pharmacists enrolled in this study.
\6 per week
66
6–10 per week
25
11? per week
9
Amount of pharmacists working in your community pharmacy (%) \3 pharmacists
23
3–6 pharmacists
61
7? pharmacists
16
Have a copy of the National Asthma Council (NAC) Asthma Management Guidelines (%)
20
a
Session comprised of a morning, afternoon or evening shift
Development and implementation of PACE for Pharmacy The PACE Australia framework (workshop outlines, slides and the ‘PACE Australia: Training of Presenters’ manual [27] was amended in order to ensure its relevance to the pharmacy context. The key workshop modifications are summarised in Table 1. The PACE for Pharmacy program involved educating pharmacists over two three-hour, interactive small group workshops held 1 week apart. Workshops had strict size restrictions (up to 15 pharmacists per workshop) and seating was set up in such a way that the presenters and pharmacist participants formed a circle; these facets ensured optimal interaction between participants and presenters. The program was delivered by a PACE Educator (Community Physician) and two pharmacists who developed the didactic skills required for PACE, by completing the training module outlined in the amended ‘PACE Australia: Training of Presenters’ manual [27]. A debriefing session was held at the end of each workshop to allow the presenters to discuss what worked well and to provide recommendations for future improvement.
Fig. 1 Pharmacists Paediatric Asthma Toolkit containing; placebo devices [TurbuhalerTM, AccuhalerTM and metered dose inhaler (pMDI), volumatic spacer and airway models]
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Table 3 Pharmacist reports of useful workshop aspects, most important points gained and potential improvements Theme
Useful workshop aspects/important points gained
Potential improvements
Patient education (theme 1)
‘‘The training was effective as it was hands-on and interactive’’
‘‘More time needed’’
‘‘Vital to physically demonstrate to patient’’ ‘‘Learnt from others’ device training experiences and perspectives’’ Pharmacist-patient communication (theme 2)
‘‘Importance of effective communication with parent and child’’
‘‘More time on approaching difficult or resistant customers’’
‘‘Gained key notes from video on communication strategies’’
‘‘More role plays’’ ‘‘Video of a pharmacy counselling case’’
‘‘Confidence in dealing with and counselling younger asthma patients’’ Assessment of the pattern of asthma (theme 3)
‘‘Learned about the classes of asthma’’
‘‘More case studies’’
‘‘Recognising patterns of asthma in children’’
‘‘Needed more time’’
Appropriate use of medicines (theme 4)
‘‘Gained knowledge on the use of asthma therapies with paediatrics’’
‘‘Needed more time on treatment choices and doses’’
Recommend and motivate the patient to request a written asthma self-management plan from their doctor (theme 5)
‘‘Important to collaborate with general practitioner to facilitate writing of a written asthma self-management plan’’
‘‘More time on written asthma selfmanagement plan development’’
‘‘Learnt how to write and interpret a written asthma self-management plan’’
‘‘Schemes on how to improve pharmacistGP relationships’’ ‘‘It is important to provide more discussion which would help in the pharmacists communication with GPs’’
Table 4 Pharmacist (n = 44) mean self-reported scores for Domains 1–6 at baseline and follow-up PACE for Pharmacy Domains
Baseline
Followup
Difference
P value*
Domain 1: Confidence in using communication strategies (1 = not at all confident to 5 = very confident)
3.5
5.0
1.5
0.040
Domain 2: Beliefs of the helpfulness of specific strategies (1 = not at all helpful to 5 = very helpful)
4.3
4.6
0.3
0.001
Domain 3: Frequency of use of strategies (1 = never to 5 = very often)
3.5
3.9
0.4
0.000
Domain 4: Ability to self-reflect on the use/effectiveness of strategies (1 = never to 6 = always)
3.2
4.0
0.8
0.000
Domain 5: Frequency of use of strategies when counselling on new medication (1 = never to 6 = always)
3.5
4.2
0.7
0.000
Domain 6: Confidence around use of inhaled corticosteroids (1 = not confident to 6 = very confident)
3.5
4.1
0.6
0.000
* Paired Samples Student’s T test. All items were on a 5/6-point Likert scale
Participating pharmacists received a workshop folder with a copy of the workshop slides and handout to reflect the workshop content and a paediatric asthma, pharmacist toolkit (Fig. 1) containing placebo devices (TurbuhalerTM, AccuhalerTM and metered doseinhaler (pMDI) with a spacer) and airway models to assist with patient education. Satisfaction and acceptability with the PACE for Pharmacy workshop Pharmacists reported a high level of satisfaction with the workshops. They particularly valued the interactive nature
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of the workshops, reporting it to be; ‘non-threatening environment, enabled everyone to express themselves’, ‘it was enjoyable, interactive’ and ‘very interactive and relaxed, helpful to a learning environment’. Themes 1, 2 and 5 (Patient Education, Pharmacist-Patient communication and Recommend and motivate the patient to request a written asthma self-management plan from their doctor respectively) were primarily referred to as most useful and enjoyable. Table 3 outlines the common positive statements and future recommendations that pharmacists made regarding the 5 workshop themes. The primary suggestions for improvement were to increase the duration of the segment on writing
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asthma self-management plans, and to incorporate a stronger focus on pharmacist-GP communication to help facilitate the development of written asthma self-management plans. Perceived impact on communication and asthma related practices Table 4 summarises the mean scores for Domains 1–6 at Baseline and Follow-up (based on responses to Baseline and Follow-up Questionnaires). There was a statistically significant increase in the mean self-reported scores from Baseline and Follow-up in all six Domains. The proportion of pharmacists who reported higher levels in the scores of individual items within Domains 1–6, when comparing from Baseline to Follow-up, are displayed in Figs. 2, 3. Figure 2a indicates the proportion of pharmacists who self-reported a higher level in confidence when using specific communication strategies (Domain 1) from Baseline to Follow-up. Over 70 % of pharmacists reported being more confident in helping the patient/carer to make asthma management decisions and in setting/reviewing both short and long term goals for managing asthma (Fig. 2a). On average, almost 40 % of the pharmacists reported higher levels in the frequency of using each of the communication strategies (Domain 3) when counselling a paediatric asthma patient 1 month following the PACE for Pharmacy workshops compared to Baseline (Fig. 2c). Specifically, the majority of pharmacists more frequently reviewed long-term goals and checked whether medications were tailored to the patients’ asthma patterns (Fig. 2c). Figure 3a indicates the proportion of pharmacists who demonstrated a self-reported improvement in their ability to self-reflect on the effectiveness of the different
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communication techniques and strategies (Domain 4) from Baseline to Follow-up. A large proportion of pharmacists (74 %) perceived an improvement in their ability to review if their patients applied recommendations given during previous consultations. Most pharmacists however, did not perceive an increase in their ability to observe patient behaviour as a cue for effectiveness, with only 36 % of pharmacists reporting an improvement in this item. Figure 3b indicates the proportion of pharmacists who reported higher levels, from Baseline to Follow-up, in their frequency of using specific communication strategies when dispensing new asthma medication (Domain 5). The greatest portion of pharmacists (64 %) reported an increase in checking that a written asthma self-management plan had been provided while counselling on new medication. A high proportion of pharmacists (62 %) provided verbal instructions more frequently to patients/carers at the initiation of a new medication. Over half of the pharmacists (57 %) provided an inhaler device demonstration when dispensing a new inhaler medication more often, 1 month after the PACE for Pharmacy workshops compared to Baseline. The proportion of pharmacists who reported higher levels of confidence around the use of inhaled corticosteroids (Domain 6) is summarised in Fig. 3c. The majority of pharmacists reported higher levels of confidence in monitoring side effects associated with inhaled corticosteroids (53 %) and in determining which paediatric asthma patients would benefit from inhaled corticosteroids (65 %).
Discussion This study evaluated the feasibility of the newly developed PACE for Pharmacy program with 44 pharmacists from the
Fig. 2 Proportion of pharmacist’s (n = 44) who demonstrated a self-reported improvement in a confidence in using specific communication techniques or strategies (Domain 1), b beliefs of the helpfulness of the specific communication techniques or strategies (Domain 2), c frequency of using the specific communication techniques or strategies (Domain 3) from baseline to 1 month following completion of the PACE for Pharmacy workshops
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(a)
(b)
(c)
Sydney metropolitan region. Our results provide preliminary evidence that the PACE for Pharmacy program can improve pharmacist reported paediatric asthma management practices and is feasible for application with community pharmacists. In reviewing the results of this study, several factors need to be taken into consideration. Although the questionnaires used were not validated, they have previously been used, published and have been shown to successfully detected perceived communication and behaviour change in PACE evaluation studies in Australia and the USA [13, 14]. This study entailed testing the feasibility of PACE for Pharmacy, therefore the time allocated to its implementation was limited. We had only waited 1 month after the workshops before collecting follow-up data. By having a
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longer time frame, pharmacists would have had the opportunity to see more paediatric asthma patients and implement the strategies and asthma related practices adopted in the workshops. This might have resulted in greater improvement in pharmacist reported confidence and frequency of application of the communication strategies and asthma related practices. On the other hand, a longer follow up period could have led to reduced pharmacist reported improvement due to the possibility that the effect of the behaviour change intervention could wear off with time. Other considerations in interpreting these results include the use of self-reported data and pharmacist recall. These methods may have led to social desirability bias through the over reporting of positive behaviours. However, efforts were made to reduce any over-reporting of behaviours by assuring the pharmacists that the
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questionnaires will remain anonymous. In future patientreported pharmacist ratings should be used to evaluate PACE for Pharmacy. Another factor that must be considered when interpreting the results is the self-selection of pharmacists. The pharmacists who chose to participate in this study may have had a particular interest in the content covered, therefore the results obtained may not be generalisable. PACE for Pharmacy was modelled on PACE Australia for general practitioners. However, due to the distinctive roles of pharmacists and general practitioners, there were some minor components of PACE Australia that needed to be modified for the community pharmacy setting. PACE for Pharmacy added assessment of inhaler technique [22, 24] within the theme of ‘Patient education’. Additionally, the theme of ‘Appropriate use of medicines’ was amended to focus on making appropriate referrals to GPs. A key aim of PACE Australia is to train doctors to provide a written asthma self-management plan’. In PACE for Pharmacy, this theme was amended, and was renamed to ‘Recommend and motivate the patient to request a written asthma self-management plan from their doctor’. Pharmacists learned to draft written asthma self-management plans and referrals to GPs. This was one of the most popular themes for the pharmacists and they recommended that more time and attention be directed towards advising on written asthma self-management plans. This highlights that the pharmacists are motivated and interested in extending their current knowledge regarding asthma selfmanagement plans. A potential future role for pharmacists could be to allow them to use their medication expertise and take on a stronger role in devising asthma self-management plans for their patients. In looking at the data in more detail, we notice some interesting findings. Although the pharmacists may not have been familiar with the ten key communication strategies prior to the PACE for Pharmacy training, the baseline questionnaire still enquired about their confidence, perceived helpfulness and frequency of use of these strategies. From the baseline data it can be seen that prior to the PACE for Pharmacy training, the pharmacists believed the communication strategies were helpful (Domain 2) however, they did not report using these strategies (Domain 3) while counselling paediatric asthma patients/carers. Whereas following the PACE for Pharmacy workshops, there was a significant increase in the self-reported frequency of use of these strategies (Domain 3). We suggest that this may be due to the pharmacists lacking confidence, not only related to communication, but also in relation to clinical knowledge in paediatric asthma. Since the clinical management of asthma in paediatrics differs to that of adults, so too do the issues for parents of children with asthma compared with adults with asthma. It
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is possible that the pharmacists did not feel well equipped to manage paediatric asthma patients and their carers specifically. This may explain why the pharmacists had an awareness of the helpfulness of the strategies yet still did not implement them prior to the PACE for Pharmacy workshops. However, in line with this argument, we cannot disregard the possibility that the pharmacists’ lack of knowledge of the ten communication strategies and protocols, prior to the workshops, could have also contributed to their underuse. A similar finding was identified with regards to inhaler technique. Although pharmacy-based interventions focusing on inhaler technique exist and have been widely disseminated in the profession [22–24, 28], as a result of PACE for Pharmacy, there was a significant increase in the proportion of pharmacists regularly reviewing inhaler technique (Domain 5). It may be that with regards to inhaler technique in paediatrics, pharmacists lack confidence and/or knowledge, or alternatively, it may be that despite knowing about the importance of reviewing inhaler technique, it was not a priority in practice prior to this study. A reminder in reprioritising inhaler technique review through continuing professional education may be valuable. The original PACE intervention addressed barriers to paediatric asthma management by improving GP reported practice in the areas of communication and teaching behaviours [14, 29]. This study shows that PACE for Pharmacy has the same impact on pharmacist practice. The success of PACE, between nations and primary care professions, can be attributed to its strong focus on communication strategies rooted in self-regulation theory. The program applies principles of self-regulation to specific communication behaviours that can equip practitioners with skills. Specifically, during the workshops practitioners learn how to create an interactive conversation with patients to derive information for making therapeutic decisions and recommendations, create a supportive environment to promote patient trust, reinforce positive efforts of patients/carers, provide a supportive climate for mutual problem-solving, strengthen patients’ skills in using medicines and build the patients’/carers’ confidence in reaching optimal asthma control. Therefore, PACE has both transprofessional and transcontinental plausibility due to the theoretic self-regulation framework on which it is modelled. Although pharmacists responded positively to the workshops, a recurrent recommendation for the future was to focus on pharmacist-GP communication. Although reasons were not given, it can be postulated that PACE for Pharmacy has alerted pharmacists of the significance of effective communication and the segment on written asthma selfmanagement plans highlighted the need/importance of
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interacting with the GP. The videos used in training showed GPs facing and addressing the challenges of communication with regards to the management of paediatric asthma. Pharmacists would have recognised these as common to their own challenges. A potential next step for PACE would be to focus on interdisciplinary communication and behavioural strategies for GPs and allied health providers in the management of paediatric asthma. A possible future strategy that may lead to the increased ownership of asthma self-management plans would be to incorporate a collaborative effort where pharmacists have the authority to draft these plans for GPs. A dual effort from pharmacists and GPs in the promotion of written asthma self-management plans could increase the low levels of patient ownership that currently stand. Therefore through working in close contact with a GP, the two professions can both support and promote chronic disease management. A collaborative PACE program has the potential to target community pharmacists and GPs working together on improving the management of paediatric asthma.
4.
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7. 8.
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Conclusion PACE has the potential to enhance pharmacists’ fundamental skills and may add an additional communication framework for more effective management of paediatric asthma in the pharmacy setting. This research has shown that pharmacists are keen to embrace the opportunity to do more and expand on their clinical role in chronic disease management through better communication strategies. The next step should be to evaluate the impact of PACE for Pharmacy on paediatric asthma outcomes and on the interaction between the pharmacist and paediatric patient/ carer.
14.
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18. Acknowledgments A. Elaro is the recipient of scholarships from the Australian Postgraduate Award (APA). Funding
None.
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Conflicts of interest The authors declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
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practitioner review for adults with asthma. Cochrane Database Syst Rev. 2003(1):CD001117. Shah S, Sawyer SM, Toelle BG, Mellis CM, Peat JK, Lagleva M, et al. Improving paediatric asthma outcomes in primary health care: a randomised controlled trial. Med J Aust. 2011;195(7):405–9. Grover C, Armour C, Asperen PPV, Moles R, Saini B. Medication use in children with asthma: not a child size problem. J Asthma. 2011;48(10):1085–103. Drakeford PA, Davis AM, Van Asperen PP. Evaluation of a paediatric asthma education package for health professionals. J Paediatr Child Health. 2007;43(5):342–52. Szefler SJ. Advances in pediatric asthma in 2010: addressing the major issues. J Allergy Clin Immunol. 2011;127(1):102–15. Haby MM, Powell CVE, Oberklaid F, Waters EB, Robertson CF. Asthma in children: gaps between current management and best practice. J Paediatr Child Health. 2002;38(3):284–9. Chong JJ, Davidsson A, Moles R, Saini B. What affects asthma medicine use in children? Australian asthma educator perspectives. J Asthma. 2009;46(5):437–44. Bandura A. Social foundations of thought and action: a social cognitive theory. Englewood Cliffs: Prentice-Hall Inc.; 1986, ISBN-10: 013815614X. Clark NM, Valerio MA. The role of behavioural theories in educational interventions for paediatric asthma. Paediatr Respir Rev. 2003;4(4):325–33. Clark NM, Gong M, Schork MA, Evans D, Roloff D, Hurwitz M, et al. Impact of education for physicians on patient outcomes. Pediatrics. 1998;101(5):831–6. Cabana MD, Slish KK, Evans D, Mellins RB, Brown RW, Lin X, et al. Impact of physician asthma care education on patient outcomes. Pediatrics. 2006;117(6):2149–57. Shah S, Toelle BG, Sawyer SM, Roydhouse JK, Edwards P, Usherwood T, et al. Feasibility study of a communication and education asthma intervention for general practitioners in Australia. Aust J Prim Health. 2010;16(1):75–80. Mehuys E, Van Bortel L, De Bolle L, Van Tongelen I, Annemans L, Remon JP, et al. Effectiveness of pharmacist intervention for asthma control improvement. Eur Respir J. 2008;31(4):790–9. Armour C, Bosnic-Anticevich S, Brillant M, Burton D, Emmerton L, Krass I, et al. Pharmacy Asthma Care Program (PACP) improves outcomes for patients in the community. Thorax. 2007;62(6):496–502. Saini B, Krass I, Armour C. Development, implementation, and evaluation of a community pharmacy-based asthma care model. Ann Pharmacother. 2004;38(11):1954–60. Dolovich L, Sabharwal M, Agro K, Foster G, Lee A, McCarthy L, et al. The effect of pharmacist education on asthma treatment plans for simulated patients. Pharm World Sci. 2007;29(3): 228–39. Smith L, Bosnic-Anticevich SZ, Mitchell B, Saini B, Krass I, Armour C. Treating asthma with a self-management model of illness behaviour in an Australian community pharmacy setting. Soc Sci Med. 2007;64(7):1501–11. Saini B, LeMay K, Emmerton L, Krass I, Smith L, Bosnic-Anticevich S, et al. Asthma disease management-Australian pharmacists’ interventions improve patients’ asthma knowledge and this is sustained. Patient Educ Couns. 2011;83(3):295–302. Barbanel D, Eldridge S, Griffiths C. Can a self-management programme delivered by a community pharmacist improve asthma control? A randomised trial. Thorax. 2003;58(10):851–4. Basheti IA, Reddel HK, Armour CL, Bosnic-Anticevich SZ. Improved asthma outcomes with a simple inhaler technique intervention by community pharmacists. J Allergy Clin Immunol. 2007;119(6):1537–8. Bosnic-Anticevich SZ, Sinha H, So S, Reddel HK. Metered-dose inhaler technique: the effect of two educational interventions
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24.
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delivered in community pharmacy over time. J Asthma. 2010;47(3):251–6. Giraud V, Allaert F-A, Roche N. Inhaler technique and asthma: feasability and acceptability of training by pharmacists. Respir Med. 2011;105(12):1815–22. Liu Y, Nevins JC, Carruthers KM, Doucette WR, McDonough RP, Pan X. Osteoporosis risk screening for women in a community pharmacy. J Am Pharm Assoc. 2007;47(4):521–6. Heilmann RM, Friesleben CR, Billups SJ. Impact of a pharmacist-directed intervention in postmenopausal women after fracture. AJHP. 2012;69(6):504–9. Shah S. PACE Australia manual. Sydney: University of Sydney; 2011, ISBN: 1-74080-128.
985 28. Basheti IA, Armour CL, Reddel HK, Bosnic-Anticevich SZ. Long-term maintenance of pharmacists’ inhaler technique demonstration skills. Am J Pharm Educ. 2009;73(2):32. 29. Bratton SL, Cabana MD, Brown RW, White DF, Wang Y, Lang SW, et al. Asthma educational seminar targeting Medicaid providers. Respir Care. 2006;51(1):49–55. 30. Bosnic-Anticevich SZ, Stuart M, Mackson J, Cvetkovski B, Sainsbury E, Armour C, et al. Development and evaluation of an innovative model of inter-professional education focused on asthma medication use. BMC Med Educ. 2014;14:72.
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RESEARCH ARTICLE
PACE: Pharmacists use the power of communication in paediatric asthma Amanda Elaro • Smita Shah • Luca N. Pomare • Carol L. Armour • Sinthia Z. Bosnic-Anticevich
Received: 26 February 2014 / Accepted: 21 July 2014 / Published online: 3 August 2014 Koninklijke Nederlandse Maatschappij ter bevordering der Pharmacie 2014
Abstract Background Paediatric asthma is a public health burden in Australia despite the availability of national asthma guidelines. Community pharmacy interventions focusing on paediatric asthma are scarce. Practitioner Asthma Communication and Education (PACE) is an evidence-based program, developed in the USA for general practice physicians, aimed at addressing the issues of poor clinician-patient communication in the management of paediatric asthma. This program has been shown to improve paediatric asthma management practices of general practitioners in the USA and Australia. The development of a PACE program for community pharmacists will fill a void in the current armamentarium for pharmacist-patient care. Objectives To adapt the educational program, PACE, to the community pharmacy setting. To test the feasibility of the new program for pharmacy and to explore its potential impact on pharmacists’ communication skills and asthma related practices. Setting Community pharmacies located within the Sydney metropolitan. Method The PACE framework was reviewed by the research team and amended in order to ensure its relevance within the pharmacy context, thereby developing PACE for Pharmacy. Forty-four pharmacists were recruited and trained in small groups in the PACE for Pharmacy workshops.
Pharmacists’ satisfaction and acceptability of the workshops, confidence in using communication strategies pre- and postworkshop and self-reported behaviour change post workshop were evaluated. Main Outcome Measure Pharmacist selfreported changes in communication and teaching behaviours during a paediatric asthma consultation. Results All 44 pharmacists attended both workshops, completed pre- and postworkshop questionnaires and provided feedback on the workshops (100 % retention). The participants reported a high level of satisfaction and valued the interactive nature of the workshops. Following the PACE for Pharmacy program, pharmacists reported significantly higher levels in using the communication strategies, confidence in their application and their helpfulness. Pharmacists checked for written asthma self-management plan possession and inhaler device technique more regularly, and provided verbal instructions more frequently to paediatric asthma patients/carers at the initiation of a new medication. Conclusion This study provides preliminary evidence that the PACE program can be translated into community pharmacy. PACE for Pharmacy positively affected self-reported communication and education behaviours of pharmacists. The high response rate shows that pharmacists are eager to expand on their clinical role in primary healthcare.
A. Elaro (&) L. N. Pomare C. L. Armour S. Z. Bosnic-Anticevich The Woolcock Institute of Medical Research, University of Sydney, Glebe, NSW 2051, Australia e-mail: [email protected]
Keywords Australia Childhood asthma Communication Community pharmacy PACE Paediatric asthma Pharmacist Primary care intervention
S. Shah Primary Health Care Education and Research Unit, Western Sydney Local Health District, Sydney, NSW 2145, Australia
Impacts on Practice
S. Shah Sydney Medical School, University of Sydney, Sydney, NSW 2006, Australia
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The interactive PACE program, guided by social cognitive theory and principles of self-regulation, has both transprofessional and transcontinental plausibility.
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Pharmacists are eager to form a collaborative working relationship with general practitioners in the devising of written asthma self-management plans. Pharmacists are ideally positioned within the primary health care spectrum to optimise patient disease selfmanagement.
Introduction Paediatric asthma is a chronic disease affecting 16 % of Australian children [1]. Despite the availability of national asthma guidelines, which focus not only on specific medical treatment, but also on the skills of health care professionals and their ability to facilitate patient self-management, paediatric asthma continues to be a major contributor to the burden of illness in children [2–4]. The resultant uncontrolled asthma has widespread impact resulting in time off school and work for the child and carer respectively, sleep deprivation and reduced quality of life, thus imposing an economic burden on the carer and the Australian health system [5]. Additionally, despite the proven benefit of written asthma self management plans, currently less than 50 % of Australian children with asthma own one [6]. This may be attributed to the gap that exists between evidence based recommended practice and the current practice of health care professionals in managing paediatric asthma in primary care [5, 7, 8]. This emphasises the need to facilitate the translation of national guidelines into primary care. In paediatric asthma, the knowledge, communication skills and commitment of health care professionals have been shown to be essential in allowing the paediatric patient and carer to adopt effective management practices and beliefs. A recent study by Grover and colleagues identified a key barrier to the management of paediatric asthma in primary care to be the inability of health care professionals to effectively communicate with the patient/ carer [5, 9]. In further support of this point, 38 % of Australian parents feel they do not have enough information about their child’s asthma [8]. Practitioner Asthma Communication and Education (PACE) is an evidence-based program, with an innovative focus on self-regulation theory, a principle of Bandura’s social cognitive theory which proposes that increased self-efficacy, intrinsic motivation and achievement can be gained when health care professionals are given the opportunity to selfobserve, develop strategies to reach goals and evaluate the success of these strategies [10, 11]. PACE was originally developed in the United States for general practice physicians, aiming to address the issues of poor clinician-patient communication and education in the management of paediatric asthma. PACE provides primary health care practitioners with clinical paediatric asthma knowledge and most importantly ten key evidence based communication strategies and
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protocols by which practitioners can assess their own behaviour regarding patient communications, to support the development of skills that will enable practitioners to communicate more effectively with paediatric patient’s and their carers, and support patients/carers management efforts [4, 12–14]. It has been modified and tested with Australian general practitioners (GPs) and named PACE Australia [4, 14]. The implementation of PACE in the USA and Australia resulted in improved participants’ confidence in communicating and educating paediatric asthma patients and their carers, more appropriate and tailored prescribing of medications and increased provision of written asthma self-management plans. Pharmacists are at the frontline of the primary health care team [15]. They are experts in medication use and have been shown to effectively deliver interventions in the pharmacy, which have resulted in improved asthma outcomes [16–24]. Although in Australia, pharmacists are not able to authorise the implementation of written self-management plans, studies have shown that when pharmacists have intervened with patients in regards to requesting asthma self-management plans, there has been an increase in asthma self-management plan ownership [16, 18]. Interventions focusing on pharmacist-patient communication behaviour, patient-teaching and asthma self-management in the management of paediatric asthma are scarce. Hitherto, Australian pharmacists are not trained in communication associated with paediatric asthma specifically, with the majority of pharmacy-based programs focusing on patient care and disease management [25, 26]. Thus, the translation of PACE Australia into pharmacy will add to the current armamentarium available for training pharmacists in communication and patient care.
Aim of the study The aims of the study were to adapt PACE Australia to the community pharmacy setting thereby developing PACE for Pharmacy, to test the feasibility of the new program for pharmacy and to explore the potential impact of PACE for Pharmacy on pharmacists’ communication skills and asthma related practices.
Ethical approval This study was approved by the University of Sydney Human Research Ethics Committee (Protocol 2012/969).
Method This study takes the form of a pre-post, mixed method design [14]. By taking an eclectic approach, and combining
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qualitative and quantitative methodologies, the research aims are better addressed. In order to achieve the aims of this study, the PACE Australia program needed to be modified to suit the pharmacy context, followed by the implementation and evaluation of the PACE for Pharmacy program. Development of PACE for Pharmacy PACE for Pharmacy was developed on the framework of PACE Australia, which is based around five central themes (Table 1). Each key resource from PACE Australia including the workshop outlines, slides, participant toolkit and the ‘PACE Australia: Training of Presenters’ manual [27] were reviewed by the research team and amended in order to ensure their relevance to the pharmacy context.
(‘‘Workshop Reflection’’) solicited feedback from pharmacists on what aspects of the workshop they found most useful and enjoyable and what could be improved on. Perceived impact of the PACE for Pharmacy program Pharmacist confidence and behaviour with regards to communicating with paediatric asthma patients and their carers were recorded at baseline through the completion of a structured, self-reported questionnaire (Baseline Questionnaire). The Baseline Questionnaire covered six Domains: 1. 2. 3. 4. 5.
Pharmacist recruitment Seventy-nine eligible pharmacies located throughout the Sydney metropolitan were directly contacted by a pharmacist peer (research member) and invited to participate in the PACE for Pharmacy program. Similar to PACE Australia, there was no limit to the number of Pharmacists recruited per pharmacy. Outcomes and evaluation PACE for Pharmacy workshop evaluation A qualitative analyses of pharmacists’ satisfaction and acceptability of the workshops was performed. Participating pharmacists completed an anonymous, self-reported, reflective, open-ended questionnaire at the end of the second PACE for Pharmacy workshop. The questionnaire
6.
Confidence in using communication strategies. Beliefs of the helpfulness of communication strategies. Frequency of use of communication strategies. Ability to self-reflect on the use/effectiveness of strategies. Frequency of use of strategies when counselling on new medication. Confidence around the use of inhaled corticosteroids.
Responses to items within Domains 1–3 were based on a 5-point Likert scale while the items within Domains 4–6 were based on a 6-point Likert scale. Pharmacist demographic data was also collected. One month following the completion of the PACE for Pharmacy workshops, the pharmacists were required to complete a Follow-Up Questionnaire that was identical to the Baseline Questionnaire. For this questionnaire, participating pharmacists were required to consider their behaviours during the month of practice, post workshops. This allowed the detection of changes in pharmacist selfreported communication and asthma related practices post workshops. All questionnaires described were those used previously to evaluate PACE both in the USA and Australia [13, 14].
Table 1 Comparison of themes from PACE Australia and PACE for Pharmacy PACE Australia
PACE for Pharmacy
Additional/modified components
Theme 1
Patient education
Patient education
Addition of an inhaler technique checklist [30]
Theme 2
Doctor-patient communication
Pharmacist-patient communication
N/A
Theme 3
Assessment of the pattern of asthma
Assessment of the pattern of asthma
Focus shifted from diagnosing to assessing a child’s clinical pattern of asthma
Theme 4
Appropriate use of medicines
Appropriate use of medicines
Focus shifted from prescribing asthma medication according to clinical pattern, to making informed referrals to the general practitioner regarding appropriate medication prescribing.
Theme 5
Provision of a Written asthma selfmanagement plan
Recommend and motivate the patient to request a written asthma self-management plan from their doctor
Addition of segment on the benefits of pharmacists recommending and motivating patients to request a written asthma self-management plan from their general practitioner.
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Data management
Table 2 Demographics of PACE for Pharmacy feasibility study pharmacist participants
Demographic data was analysed descriptively. A thematic analysis of the data obtained from the Workshop Reflection was performed in order to determine workshop satisfaction and acceptability. Shapiro Wilks test was used to determine the normal distribution of data. The mean pharmacist self-reported scores for each item in Domains 1–6 were calculated at Baseline and Follow-up and compared using a Paired Samples Student’s T-Test (significance 0.05, power 0.8). The proportion of pharmacists who reported a higher score between Baseline and Follow-up in each item within Domains 1–6 was also calculated. Analyses were performed using SPSS version 21.0 (SPSS Inc, Chicago, I11, USA).
Characteristic
PACE for Pharmacy (n = 44)
Male (%)
36
Results
Age range \26 years (%)
32
27–46 years (%)
48
47–56 years (%)
20
Mean years since graduation
12 (range 2–37)
Years practicing as a pharmacist (%) 0–10
52
11–19
16
20? Country of graduation (%)
32
Australia
89
Other
11
Sessionsa worked each week (%)
Of the 79 pharmacies that received an invitation, 37 pharmacies expressed interest (47 %) and 44 pharmacists from these pharmacies enrolled in the study within 2 weeks. All 44 pharmacists attended both PACE for Pharmacy workshops and completed both Baseline and Follow-up questionnaires and provided feedback on the workshops (100 % retention). Table 2 shows the demographic and professional characteristics of the pharmacists enrolled in this study.
\6 per week
66
6–10 per week
25
11? per week
9
Amount of pharmacists working in your community pharmacy (%) \3 pharmacists
23
3–6 pharmacists
61
7? pharmacists
16
Have a copy of the National Asthma Council (NAC) Asthma Management Guidelines (%)
20
a
Session comprised of a morning, afternoon or evening shift
Development and implementation of PACE for Pharmacy The PACE Australia framework (workshop outlines, slides and the ‘PACE Australia: Training of Presenters’ manual [27] was amended in order to ensure its relevance to the pharmacy context. The key workshop modifications are summarised in Table 1. The PACE for Pharmacy program involved educating pharmacists over two three-hour, interactive small group workshops held 1 week apart. Workshops had strict size restrictions (up to 15 pharmacists per workshop) and seating was set up in such a way that the presenters and pharmacist participants formed a circle; these facets ensured optimal interaction between participants and presenters. The program was delivered by a PACE Educator (Community Physician) and two pharmacists who developed the didactic skills required for PACE, by completing the training module outlined in the amended ‘PACE Australia: Training of Presenters’ manual [27]. A debriefing session was held at the end of each workshop to allow the presenters to discuss what worked well and to provide recommendations for future improvement.
Fig. 1 Pharmacists Paediatric Asthma Toolkit containing; placebo devices [TurbuhalerTM, AccuhalerTM and metered dose inhaler (pMDI), volumatic spacer and airway models]
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Table 3 Pharmacist reports of useful workshop aspects, most important points gained and potential improvements Theme
Useful workshop aspects/important points gained
Potential improvements
Patient education (theme 1)
‘‘The training was effective as it was hands-on and interactive’’
‘‘More time needed’’
‘‘Vital to physically demonstrate to patient’’ ‘‘Learnt from others’ device training experiences and perspectives’’ Pharmacist-patient communication (theme 2)
‘‘Importance of effective communication with parent and child’’
‘‘More time on approaching difficult or resistant customers’’
‘‘Gained key notes from video on communication strategies’’
‘‘More role plays’’ ‘‘Video of a pharmacy counselling case’’
‘‘Confidence in dealing with and counselling younger asthma patients’’ Assessment of the pattern of asthma (theme 3)
‘‘Learned about the classes of asthma’’
‘‘More case studies’’
‘‘Recognising patterns of asthma in children’’
‘‘Needed more time’’
Appropriate use of medicines (theme 4)
‘‘Gained knowledge on the use of asthma therapies with paediatrics’’
‘‘Needed more time on treatment choices and doses’’
Recommend and motivate the patient to request a written asthma self-management plan from their doctor (theme 5)
‘‘Important to collaborate with general practitioner to facilitate writing of a written asthma self-management plan’’
‘‘More time on written asthma selfmanagement plan development’’
‘‘Learnt how to write and interpret a written asthma self-management plan’’
‘‘Schemes on how to improve pharmacistGP relationships’’ ‘‘It is important to provide more discussion which would help in the pharmacists communication with GPs’’
Table 4 Pharmacist (n = 44) mean self-reported scores for Domains 1–6 at baseline and follow-up PACE for Pharmacy Domains
Baseline
Followup
Difference
P value*
Domain 1: Confidence in using communication strategies (1 = not at all confident to 5 = very confident)
3.5
5.0
1.5
0.040
Domain 2: Beliefs of the helpfulness of specific strategies (1 = not at all helpful to 5 = very helpful)
4.3
4.6
0.3
0.001
Domain 3: Frequency of use of strategies (1 = never to 5 = very often)
3.5
3.9
0.4
0.000
Domain 4: Ability to self-reflect on the use/effectiveness of strategies (1 = never to 6 = always)
3.2
4.0
0.8
0.000
Domain 5: Frequency of use of strategies when counselling on new medication (1 = never to 6 = always)
3.5
4.2
0.7
0.000
Domain 6: Confidence around use of inhaled corticosteroids (1 = not confident to 6 = very confident)
3.5
4.1
0.6
0.000
* Paired Samples Student’s T test. All items were on a 5/6-point Likert scale
Participating pharmacists received a workshop folder with a copy of the workshop slides and handout to reflect the workshop content and a paediatric asthma, pharmacist toolkit (Fig. 1) containing placebo devices (TurbuhalerTM, AccuhalerTM and metered doseinhaler (pMDI) with a spacer) and airway models to assist with patient education. Satisfaction and acceptability with the PACE for Pharmacy workshop Pharmacists reported a high level of satisfaction with the workshops. They particularly valued the interactive nature
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of the workshops, reporting it to be; ‘non-threatening environment, enabled everyone to express themselves’, ‘it was enjoyable, interactive’ and ‘very interactive and relaxed, helpful to a learning environment’. Themes 1, 2 and 5 (Patient Education, Pharmacist-Patient communication and Recommend and motivate the patient to request a written asthma self-management plan from their doctor respectively) were primarily referred to as most useful and enjoyable. Table 3 outlines the common positive statements and future recommendations that pharmacists made regarding the 5 workshop themes. The primary suggestions for improvement were to increase the duration of the segment on writing
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asthma self-management plans, and to incorporate a stronger focus on pharmacist-GP communication to help facilitate the development of written asthma self-management plans. Perceived impact on communication and asthma related practices Table 4 summarises the mean scores for Domains 1–6 at Baseline and Follow-up (based on responses to Baseline and Follow-up Questionnaires). There was a statistically significant increase in the mean self-reported scores from Baseline and Follow-up in all six Domains. The proportion of pharmacists who reported higher levels in the scores of individual items within Domains 1–6, when comparing from Baseline to Follow-up, are displayed in Figs. 2, 3. Figure 2a indicates the proportion of pharmacists who self-reported a higher level in confidence when using specific communication strategies (Domain 1) from Baseline to Follow-up. Over 70 % of pharmacists reported being more confident in helping the patient/carer to make asthma management decisions and in setting/reviewing both short and long term goals for managing asthma (Fig. 2a). On average, almost 40 % of the pharmacists reported higher levels in the frequency of using each of the communication strategies (Domain 3) when counselling a paediatric asthma patient 1 month following the PACE for Pharmacy workshops compared to Baseline (Fig. 2c). Specifically, the majority of pharmacists more frequently reviewed long-term goals and checked whether medications were tailored to the patients’ asthma patterns (Fig. 2c). Figure 3a indicates the proportion of pharmacists who demonstrated a self-reported improvement in their ability to self-reflect on the effectiveness of the different
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communication techniques and strategies (Domain 4) from Baseline to Follow-up. A large proportion of pharmacists (74 %) perceived an improvement in their ability to review if their patients applied recommendations given during previous consultations. Most pharmacists however, did not perceive an increase in their ability to observe patient behaviour as a cue for effectiveness, with only 36 % of pharmacists reporting an improvement in this item. Figure 3b indicates the proportion of pharmacists who reported higher levels, from Baseline to Follow-up, in their frequency of using specific communication strategies when dispensing new asthma medication (Domain 5). The greatest portion of pharmacists (64 %) reported an increase in checking that a written asthma self-management plan had been provided while counselling on new medication. A high proportion of pharmacists (62 %) provided verbal instructions more frequently to patients/carers at the initiation of a new medication. Over half of the pharmacists (57 %) provided an inhaler device demonstration when dispensing a new inhaler medication more often, 1 month after the PACE for Pharmacy workshops compared to Baseline. The proportion of pharmacists who reported higher levels of confidence around the use of inhaled corticosteroids (Domain 6) is summarised in Fig. 3c. The majority of pharmacists reported higher levels of confidence in monitoring side effects associated with inhaled corticosteroids (53 %) and in determining which paediatric asthma patients would benefit from inhaled corticosteroids (65 %).
Discussion This study evaluated the feasibility of the newly developed PACE for Pharmacy program with 44 pharmacists from the
Fig. 2 Proportion of pharmacist’s (n = 44) who demonstrated a self-reported improvement in a confidence in using specific communication techniques or strategies (Domain 1), b beliefs of the helpfulness of the specific communication techniques or strategies (Domain 2), c frequency of using the specific communication techniques or strategies (Domain 3) from baseline to 1 month following completion of the PACE for Pharmacy workshops
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(a)
(b)
(c)
Sydney metropolitan region. Our results provide preliminary evidence that the PACE for Pharmacy program can improve pharmacist reported paediatric asthma management practices and is feasible for application with community pharmacists. In reviewing the results of this study, several factors need to be taken into consideration. Although the questionnaires used were not validated, they have previously been used, published and have been shown to successfully detected perceived communication and behaviour change in PACE evaluation studies in Australia and the USA [13, 14]. This study entailed testing the feasibility of PACE for Pharmacy, therefore the time allocated to its implementation was limited. We had only waited 1 month after the workshops before collecting follow-up data. By having a
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longer time frame, pharmacists would have had the opportunity to see more paediatric asthma patients and implement the strategies and asthma related practices adopted in the workshops. This might have resulted in greater improvement in pharmacist reported confidence and frequency of application of the communication strategies and asthma related practices. On the other hand, a longer follow up period could have led to reduced pharmacist reported improvement due to the possibility that the effect of the behaviour change intervention could wear off with time. Other considerations in interpreting these results include the use of self-reported data and pharmacist recall. These methods may have led to social desirability bias through the over reporting of positive behaviours. However, efforts were made to reduce any over-reporting of behaviours by assuring the pharmacists that the
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questionnaires will remain anonymous. In future patientreported pharmacist ratings should be used to evaluate PACE for Pharmacy. Another factor that must be considered when interpreting the results is the self-selection of pharmacists. The pharmacists who chose to participate in this study may have had a particular interest in the content covered, therefore the results obtained may not be generalisable. PACE for Pharmacy was modelled on PACE Australia for general practitioners. However, due to the distinctive roles of pharmacists and general practitioners, there were some minor components of PACE Australia that needed to be modified for the community pharmacy setting. PACE for Pharmacy added assessment of inhaler technique [22, 24] within the theme of ‘Patient education’. Additionally, the theme of ‘Appropriate use of medicines’ was amended to focus on making appropriate referrals to GPs. A key aim of PACE Australia is to train doctors to provide a written asthma self-management plan’. In PACE for Pharmacy, this theme was amended, and was renamed to ‘Recommend and motivate the patient to request a written asthma self-management plan from their doctor’. Pharmacists learned to draft written asthma self-management plans and referrals to GPs. This was one of the most popular themes for the pharmacists and they recommended that more time and attention be directed towards advising on written asthma self-management plans. This highlights that the pharmacists are motivated and interested in extending their current knowledge regarding asthma selfmanagement plans. A potential future role for pharmacists could be to allow them to use their medication expertise and take on a stronger role in devising asthma self-management plans for their patients. In looking at the data in more detail, we notice some interesting findings. Although the pharmacists may not have been familiar with the ten key communication strategies prior to the PACE for Pharmacy training, the baseline questionnaire still enquired about their confidence, perceived helpfulness and frequency of use of these strategies. From the baseline data it can be seen that prior to the PACE for Pharmacy training, the pharmacists believed the communication strategies were helpful (Domain 2) however, they did not report using these strategies (Domain 3) while counselling paediatric asthma patients/carers. Whereas following the PACE for Pharmacy workshops, there was a significant increase in the self-reported frequency of use of these strategies (Domain 3). We suggest that this may be due to the pharmacists lacking confidence, not only related to communication, but also in relation to clinical knowledge in paediatric asthma. Since the clinical management of asthma in paediatrics differs to that of adults, so too do the issues for parents of children with asthma compared with adults with asthma. It
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is possible that the pharmacists did not feel well equipped to manage paediatric asthma patients and their carers specifically. This may explain why the pharmacists had an awareness of the helpfulness of the strategies yet still did not implement them prior to the PACE for Pharmacy workshops. However, in line with this argument, we cannot disregard the possibility that the pharmacists’ lack of knowledge of the ten communication strategies and protocols, prior to the workshops, could have also contributed to their underuse. A similar finding was identified with regards to inhaler technique. Although pharmacy-based interventions focusing on inhaler technique exist and have been widely disseminated in the profession [22–24, 28], as a result of PACE for Pharmacy, there was a significant increase in the proportion of pharmacists regularly reviewing inhaler technique (Domain 5). It may be that with regards to inhaler technique in paediatrics, pharmacists lack confidence and/or knowledge, or alternatively, it may be that despite knowing about the importance of reviewing inhaler technique, it was not a priority in practice prior to this study. A reminder in reprioritising inhaler technique review through continuing professional education may be valuable. The original PACE intervention addressed barriers to paediatric asthma management by improving GP reported practice in the areas of communication and teaching behaviours [14, 29]. This study shows that PACE for Pharmacy has the same impact on pharmacist practice. The success of PACE, between nations and primary care professions, can be attributed to its strong focus on communication strategies rooted in self-regulation theory. The program applies principles of self-regulation to specific communication behaviours that can equip practitioners with skills. Specifically, during the workshops practitioners learn how to create an interactive conversation with patients to derive information for making therapeutic decisions and recommendations, create a supportive environment to promote patient trust, reinforce positive efforts of patients/carers, provide a supportive climate for mutual problem-solving, strengthen patients’ skills in using medicines and build the patients’/carers’ confidence in reaching optimal asthma control. Therefore, PACE has both transprofessional and transcontinental plausibility due to the theoretic self-regulation framework on which it is modelled. Although pharmacists responded positively to the workshops, a recurrent recommendation for the future was to focus on pharmacist-GP communication. Although reasons were not given, it can be postulated that PACE for Pharmacy has alerted pharmacists of the significance of effective communication and the segment on written asthma selfmanagement plans highlighted the need/importance of
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interacting with the GP. The videos used in training showed GPs facing and addressing the challenges of communication with regards to the management of paediatric asthma. Pharmacists would have recognised these as common to their own challenges. A potential next step for PACE would be to focus on interdisciplinary communication and behavioural strategies for GPs and allied health providers in the management of paediatric asthma. A possible future strategy that may lead to the increased ownership of asthma self-management plans would be to incorporate a collaborative effort where pharmacists have the authority to draft these plans for GPs. A dual effort from pharmacists and GPs in the promotion of written asthma self-management plans could increase the low levels of patient ownership that currently stand. Therefore through working in close contact with a GP, the two professions can both support and promote chronic disease management. A collaborative PACE program has the potential to target community pharmacists and GPs working together on improving the management of paediatric asthma.
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Conclusion PACE has the potential to enhance pharmacists’ fundamental skills and may add an additional communication framework for more effective management of paediatric asthma in the pharmacy setting. This research has shown that pharmacists are keen to embrace the opportunity to do more and expand on their clinical role in chronic disease management through better communication strategies. The next step should be to evaluate the impact of PACE for Pharmacy on paediatric asthma outcomes and on the interaction between the pharmacist and paediatric patient/ carer.
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18. Acknowledgments A. Elaro is the recipient of scholarships from the Australian Postgraduate Award (APA). Funding
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Conflicts of interest The authors declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
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