Novel educational training program for community pharmacists

American Journal of Pharmaceutical Education, Fall 2000 by De Almeida Neto, Abillio C, Benrimoj, Shalom I, Kavanagh, David J, Boakes, Robert A

There is little evidence that workshops alone have a lasting impact on the day-to-day practice of participants. The current paper examined a strategy to increase generalization and maintenance of skills in the natural environment using pseudo-patients and immediate performance feedback to reinforce skills acquisition. A random half of pharmacies (N=30) took part in workshop training aimed at optimizing consumers' use of nonprescription analgesic products. Pharmacies in the training group also received performance feedback on their adherence to the recommended protocol. Feedback occurred immediately after a pseudo-patient visit in which confederates posed as purchasers of analgesics, and combined positive and corrective elements. Trained pharmacists were significantly more accurate at identifying people who misused the medication (P

INTRODUCTION

Pseudo-patients studies are those in which a patient enters the health setting, not to seek treatment, but to observe and/or test the health care process. In previous pseudo-patient studies, the focus has been primarily on assessment of the practitioners' skills. The current paper differs from these studies as pseudopatient methodology is used in a randomized trial as part of an educational program.

Direct observations have a number of strengths as assessments of practitioner behavior. They are conducted in the naturalistic environment, rather than in artificial testing settings (such as role-played assessments in a workshop context). They focus on the key behaviors to be tested, rather than on proxy measures such as file records of interventions that are made by the practitioner. When the practitioner is not aware that the person is not a real patient, the method also minimizes the risk of the assessment being reactive (as can occur when an observer is present or the interview is being taped)(1). However, the issue often induces some anxiety or resentment among practitioners. Such resentment is particularly prone to occur if the observation is very critical or was undertaken without prior consent. It is felt that pseudo-patient research often results in very critical reports of practitioners' behavior.

Pseudo-patient studies have also been conducted to evaluate training on pharmacy-based intervention(2) as self reported rates of intervention delivery would have been likely to be inflated in relation to pseudo-patient observations. However, if pseudo-patient assessments were more fully integrated in the training, we might be able not only to derive an accurate assessment of changes in clinical practice, but we might be able to use feedback from the assessments as a basis for further skills acquisition. Some pseudo-patient studies in pharmacies have provided pharmacists with feedback from the assessments, but these typically have been delayed(3). We know that performance feedback is most effective when it is provided immediately after the performance(4). The present study attempted to incorporate the assessment strengths of the pseudo-patient methodology, but used it in a collaborative manner to promote further skill development.

The Use of Pseudo-Patients as an Educational Tool Continuing education of health professionals tends to rely on workshop training as a primary means of skill development. However, there is substantial evidence that workshops often have little lasting impact on the day-to-day practice of participants. The data cover areas as diverse as training general practitioners to provide advice to stop smoking(5,6) and on rates of reminders about Pap smears(6), training mental health staff to deliver family intervention(7) and training health workers to develop and record behavioral patient goals(8).

There are several possible reasons for this failure to generalize skills. In some cases, participants may not be committed to skill acquisition when they attend the workshop; the procedure that is taught may not be suitable for implementation, or there may be insufficient incentives for implementation when participants attempt it in the field(7). Alternatively, the workshop may not include sufficient opportunity for skills practice with corrective feedback, or the skills practice may not be in a sufficiently similar context. Preliminary data collected by the authors reinforced the notion that a keen group of participants and a practical procedure were not enough to ensure continued application of the skills in the field(9). In the current paper, we examined a strategy to increase skills and incentives in the natural environment using pseudo-patients. A pilot study conducted by the authors involved developing and testing the viability of an intervention for inappropriate analgesic use that could be used in a retail context(10). In Australia, compound analgesics containing paracetamol, codeine and doxylamine are available to the public from a pharmacist without a medical prescription. However, pharmacists are legally required to deliver personally these analgesic products ("pharmacistonly") to the consumer. In the pilot study, the authors predicted that an approach that provided immediate feedback to pharmacists on the use of the intervention with their own consumers of analgesics would maximize generalization to the natural setting and maintenance of the skills(10). In this previous study three hundred and twenty-one pseudo-patient visits were used to assess, coach and motivate participants to deliver the pharmacy-based intervention. Baseline data collection and training were conducted over a period of 8 weeks. Results showed that compared with controls, the trained pharmacists were significantly more likely to identify inappropriate analgesic use (P