Developing and evaluating training for community pharmacists to ...

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Derek Stewart. Received: 4 August 2008 / Accepted: 22 January 2009 / Published online: 7 February 2009 ... programme for pharmacists to deliver brief interventions to problem drinkers ... Prior to the development of pharmacist training, tele-.
Pharm World Sci (2009) 31:149–153 DOI 10.1007/s11096-009-9284-1

SHORT RESEARCH REPORT

Developing and evaluating training for community pharmacists to deliver interventions on alcohol issues Niamh Fitzgerald Æ Hazel Watson Æ Dorothy McCaig Æ Derek Stewart

Received: 4 August 2008 / Accepted: 22 January 2009 / Published online: 7 February 2009  Springer Science+Business Media B.V. 2009

Abstract Objective To evaluate community pharmacists’ readiness to provide brief interventions on alcohol and to use study findings to develop training to enable them to screen for hazardous or harmful drinking and intervene appropriately. Setting Community pharmacies in Scotland. Method Eight community pharmacies in Greater Glasgow, Scotland were purposively selected on the basis of pharmacy (independent, multiple), population deprivation index, location (rural, urban, suburban), and local level of hospital admissions for alcohol misuse. Baseline pharmacist telephone interviews covered: current practice; attitudes towards a proactive role; and perceived training needs. A two-day course was designed focusing on: consequences of problem alcohol use; attitudes; sensible drinking; familiarity with client screening using the Fast Alcohol Screening Tool; brief interventions and motivational interviewing. Main Outcome Measures Knowledge of problem alcohol use and brief interventions; attitudes; competence. Results Participants felt it was feasible for trained pharmacists to provide brief interventions. Core

N. Fitzgerald Director, Create Consultancy, Glasgow, G51 3BA, Scotland/ Senior Research Fellow, School of Pharmacy, The Robert Gordon University, Schoolhill, Aberdeen AB10 1FR, Scotland, UK H. Watson School of Nursing, Midwifery and Community Health, Glasgow Caledonian University, Glasgow G40BA, Scotland, UK D. McCaig  D. Stewart (&) School of Pharmacy, The Robert Gordon University, Schoolhill, Aberdeen AB10 1FR, Scotland, UK e-mail: [email protected]

training needs centred on communication and alcohol related knowledge. The training course was positively evaluated and led to increases in knowledge, attitudinal scores and self related competence. Conclusion A training programme for pharmacists to deliver brief interventions to problem drinkers was successfully delivered resulting in enhanced knowledge, attitudinal scores and self related competence. Keywords Alcohol  Competencies  Education  Evaluation  Pharmacy  Scotland

Impact of findings on practice •



Our findings can be used to inform the undergraduate, pre-registration and post-registration training of pharmacists to provide brief interventions in relation to hazardous or harmful drinking. Participants in the study felt that it is feasible for trained pharmacist to provide an intervention in the field of alcohol use.

Introduction There is increasing concern about levels of alcohol consumption. Alcohol-related attendances at Scottish hospitals have increased by almost 50% over the last decade and alcohol-related death rates have more than doubled [1]. Mortality rates in Scotland are now twice that of the rest of the UK. The Scottish Health Survey shows that of those respondents who drank in the previous week, 63% of men and 64% of women drank more than the sensible drinking

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guidelines on at least one occasion. In addition, 34% of men and 23% of women reported that they exceeded recommended weekly limits of 21 units of alcohol for men and 14 for women [1, 2]. There is strong evidence that short discussions or ‘‘brief interventions’’ delivered by professionals are effective in reducing drinking and are cost-effective [3]. SIGN (Scottish Intercollegiate Guidelines Network) recommends that ‘‘GPs and other primary care health professionals should opportunistically identify hazardous and harmful drinkers and deliver a brief (10 min) intervention’’. Similarly there is evidence that training healthcare providers in the use of structured interventions enhances the efficacy of brief interventions [4]. SIGN also recommends therefore that ‘‘training for GPs, practice nurses, community nurses and health visitors in the identification of hazardous drinkers and delivery of a brief intervention should be available’’. However these interventions have not been tested in community pharmacy settings.

‘‘Role adequacy’’ is the belief that the professional has sufficient knowledge. ‘‘Role legitimacy’’ involves the belief that alcohol issues are a legitimate area for the professional. ‘‘Role support’’ relates to having confidence that advice is available when needed. The AAPPQ was adapted to use language consistent with the type of intervention proposed i.e. work with ‘‘hazardous/harmful drinkers’’ rather than ‘‘problem drinkers’’. ‘‘Hazardous or harmful drinkers’’ were defined as ‘‘those whose drinking exceeds recommended sensible drinking limits, but who are not dependent on alcohol/alcoholic’’ [3]. Each item was scored on a 7-point scale from strongly agree to strongly disagree. The second questionnaire (‘‘The Competencies Questionnaire’’) rated knowledge and confidence in relation to established competencies in addressing alcohol issues. Competencies were adapted from a generic set on the management of alcohol and drug issues by health and social care practitioners [6]. Pharmacists were asked to rate themselves against each competency using the following scale:

Aim of the study

1.

The aim was to evaluate community pharmacists’ readiness to provide brief interventions on alcohol and to use study findings to develop a training programme to enable community pharmacists to screen for hazardous or harmful drinking and to intervene appropriately.

2.

Methods

The data from these questionnaires collected prior to the training were used to develop a two-day training course for the eight pharmacists to prepare them to be able to screen clients for hazardous or harmful drinking and to intervene appropriately where indicated using a brief intervention. Training aimed to address competencies with emphasis on sensible drinking limits, units of alcohol, screening, brief interventions and communicating with clients. Emphasis was placed on screening clients for hazardous or harmful drinking using the Fast Alcohol Screening Tool [7]. The course was interactive and encouraged discussion, particularly in relation to sharing good practice in terms of communicating with clients. Post-training, the two baseline questionnaires were repeated to assess impact on perceptions of role adequacy, legitimacy and support and on perceptions of competence. Prior to use, all tools were reviewed by a panel of health professionals and researchers for readability and ease of use. No formal pilot was conducted due to the small number of participating pharmacists. This research was approved by the Research Ethics Committee of the Primary Care Division of NHS Greater Glasgow & Clyde.

All pharmacies in the Greater Glasgow area of Scotland (n = 222) were informed of the study and invited to express interest in participation. Seventeen were interested and a final sample of eight purposively selected to include a variety of pharmacies in terms of type (independent, small or large chain), local deprivation, location (rural, urban, suburban), and local level of hospital admissions for alcohol misuse. Prior to the development of pharmacist training, telephone interviews were conducted, covering topics of: current practice in addressing alcohol issues; attitudes towards a more proactive role; and perceived training needs. Pharmacists were also asked to complete two questionnaires prior to the training and both were repeated after the course. The first was based on the Alcohol Attitudes and Problems Perceptions Questionnaire (‘‘The AAPPQ’’) which measures the readiness of health professionals for working with problem drinkers [5]. Items relating to role adequacy, role legitimacy and role support as well as motivation, workspecific self-esteem and work satisfaction were included.

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3. 4.

I would not be confident about managing this task and would not know what to do/say. I think I could manage this task but would be a little unsure of what to do/say. I think I would manage this task well and I would have a good idea of what to do/say. I am sure I would manage this task well; I know exactly what to do and/or say.

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Results All pharmacists reported that alcohol arose as an issue in community pharmacy either rarely or occasionally and primarily in the context of interactions between alcohol and prescribed medicines or specific prescriptions to treat alcohol dependence. Most reported that they would not raise it as an issue, but would only discuss it if clients brought it up. A few reported occasionally advising clients on safe drinking guidelines and how alcohol may affect health. None had ever given advice on how to reduce drinking. All agreed that it was feasible for community pharmacists to ‘‘opportunistically identify hazardous and harmful drinkers and to deliver a brief (10 minute) intervention’’ focusing on ‘‘benefits as perceived by the patient versus the disadvantages of the current drinking pattern’’ as recommended by SIGN Guideline 74. All acknowledged that

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they would have to be careful about how they raised and handled the issue to avoid causing offence. All felt that they would need additional training before taking on role of screening clients and providing brief intervention if appropriate. The two topics most requested were: communication—how to raise the issue and communicate with clients; and information about alcohol— limits and motivational interviewing. None were able to correctly outline the recognised daily limits for alcohol consumption and only one was able to correctly explain how much lager, wine and spirits make up one unit of alcohol. Immediately post-training there was an increase in participants’ self-ratings of confidence, knowledge and competence as illustrated in Tables 1 and 2. The most substantial improvements related to screening, awareness of services, describing alcohol metabolism and physical

Table 1 Participant AAPPQ scores before and after two days of training Adapted AAPPQ Statements (scale of 1 = Strongly agree, 7 = Strongly disagree)

Median rating at baseline

Median rating after training

1. I feel I have a working knowledge of alcohol and alcohol-related problems.

4

2

2. I feel I know enough about the factors which put people at risk of developing drinking problems to carry out my role when working with hazardous drinkers.

4

2

3. I feel I can appropriately advise my patients about hazardous drinking and its effects.

4

2

4. At times I feel I am no good at all with hazardous drinkers.

4

6

5. I feel I have a clear idea of my responsibilities in helping hazardous drinkers.

3

1

6. I feel I have the right to ask patients questions about their drinking.

4

3

7. I feel that my patients believe I have the right to ask them questions about drinking. 4

3

8. If I felt the need I could easily find someone who would be able to help me formulate the best approach to a hazardous drinker.

4

1

9. I am interested in the nature of alcohol related problems and the responses that can 2 be made to them.

1

10. I feel that the best I can personally offer hazardous drinkers is referral to somebody else.

6

5

11. I feel that there is little I can do to help hazardous drinkers.

7

7

12. Pessimism is the most realistic attitude to take toward hazardous drinkers.

7

7

13. I feel I am as able to work with hazardous drinkers as with other patients.

3

3

14. In general, one can get satisfaction from working with hazardous drinkers.

2

2

15. In general, it is rewarding to work with hazardous drinkers.

3

2

16. In general, I feel I can understand hazardous drinkers.

4

2

17. In general, I like hazardous drinkers.

4

3

Do you currently discuss alcohol consumption with patients who may be drinking hazardously? hYes h No The following questions should only be answered by those who currently work with hazardous drinkers. 18. On the whole, I am satisfied with the way I work with hazardous drinkers. This was completed by two pharmacists before the training, but only one completed it after the training. 19. I often feel uncomfortable when working with hazardous drinkers. 20. In general, I have less respect for hazardous drinkers than for most other patients I work with. Key to Statements:

Role Adequacy: Questions 1–3

Task-specific Self Esteem: Questions 4,13, 18

Role Legitimacy: Questions 5–7

Work Satisfaction: Questions 14–17, 19

Role Support: Question 8

Motivation: Questions 9–12

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Table 2 Competency scores before and after 2 days training Competency statements

Median rating At baseline

After training

1. Explain what alcohol is and how it affects the body

2

4

2. Explain units of alcohol and know the alcohol content of common drinks

3

4

3. Explain the metabolism of alcohol including myths and facts about sobering up 4. Explain gender differences relating to alcohol metabolism.

2 2

4 4

5. Describe the physical/medical harm associated with alcohol use to patients

2

4

6. Describe the psychological harm associated with alcohol use to patients

2

4

7. Describe the social harm associated with alcohol use to patients

3

4

8. Give sensible drinking advice including daily and weekly drinking limits and harm reduction strategies

3

4

9. Outline options and harm reduction strategies to help drinkers to cut down or modify their drinking

2

4

a. Hazardous drinking

2

4

b. Harmful drinking

2

4

c. Binge drinking

2

4

d. Alcohol dependence

2

4

11. Understand, administer and interpret validated screening tools relating to alcohol consumption

2

4

12. Be able to respond appropriately to the results of screening including giving advice, and linking individuals to appropriate interventions.

2

4

10. Understand, define and explain the following terms: (each term separately)

13. Understand and deliver brief interventions on alcohol

2

4

14. Understand and use basic motivational interviewing techniques in relation to alcohol consumption

2

4

15. Describe and provide information about and contact details for a range of organisations dealing with alcohol misuse 2 or providing relevant services

4

16. Understand the role and function of specialist alcohol services, when individuals should be referred to these services 1 and how to make such referrals.

3

17. Understand confidentiality issues of different services around sharing of information 18. Provide to and discuss with patients health promotion information and advice relating to alcohol including its contribution to other health issues.

3 2

4 4

19. Access and use appropriate health promotion materials/resources and provide these to individuals.

2

20. Respond, intervene and support appropriately to address situations in which alcohol issues may affect children and 1 families.

4 3.5

1. I would not be confident about managing this task and would not know what to do/say 2. I think I could manage this task but would be a little unsure of what to do/say 3. I think I would manage this task well and I would have a good idea of what to do/say 4. I am sure I would manage this task well; I know exactly what to do and/or say

harm, and delivery of brief interventions. Of note, all participants rated themselves highest for ‘‘giving sensible drinking advice including daily and weekly drinking limits’’, ‘‘outlining options and harm reduction strategies to help drinkers cut down or modify their drinking’’ and for ‘‘describing the physical harm associated with alcohol to patients’’. These are key elements of an effective brief intervention.

Discussion To our knowledge, this is the first study to report the evaluation of a community pharmacist training programme

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related to alcohol issues and brief interventions. Core training needs to be centred on communication and alcohol related knowledge. A two-day course designed to meet these needs was positively evaluated and led to increases in knowledge, attitudes and self related competence. There are, however, limitations which should be borne in mind. A small number of interested and possibly motivated pharmacists were purposively sampled for participation and hence the findings cannot be generalised to the population of community pharmacists. Changes in knowledge, attitude scores and self related competence were only measured in the short term and may not be maintained or translated into practice. However, recently published data of a pilot project has shown that it is feasible

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to screen clients for hazardous or harmful drinking and to intervene appropriately [7]. Our research aimed to evaluate pharmacists’ readiness to provide brief interventions on alcohol and use these results to develop a training programme. This small but unique body of data suggests that community pharmacists who are motivated enough to agree to take part in alcohol interventions research do not regularly enquire about alcohol with clients. They were concerned about client reaction to enquiries on alcohol consumption. After training the, pharmacists’ sense of role adequacy, legitimacy and support were clearly enhanced. There are a number of implications of these findings in terms of NHS policy, implementation and practice which are entirely in line with the recommendations of the Royal Pharmaceutical Society of Great Britain report, ‘Community Pharmacy and Alcohol Misuse Services—A Review of Policy and Practice’ [8]. If community pharmacists are to assume an evidence-based role in addressing hazardous/ harmful drinking, they will need comprehensive training. Training has been shown to be an essential component of other community based service developments including smoking cessation and asthma management [9, 10]. In addition, findings of this study suggest that training enhances their sense that this is a legitimate role for them, which will be essential to ongoing implementation. Acknowledgements Thanks to all study participants and the following for their contribution: each of the participating pharmacists; Scott Bryson (NHS Greater Glasgow & Clyde); Joyce Craig (AERC); Julie Dowds (Create Consultancy); Professor Nick Heather (Northumbria University); Professor Ray Hodgeson (AERC); Dr Eileen Kaner (University of Newcastle upon Tyne); Kathryn McGrory (Centre for Population Health); David Thomson (NHS Greater Glasgow & Clyde); Joanne Winterbottom (Glasgow Council on Alcohol); and NHS Greater Glasgow Audit Facilitators.

153 Conflicts of interest

None.

Funding We wish to thank the Alcohol Education and Research Council (AERC) for funding this research.

References 1. Alcohol Information Scotland http://www.alcoholinformation. isdscotland.org/alcohol_misuse/CCC_FirstPage.jsp (Accessed on 13/11/2008). 2. Scottish Executive Health Department. The Scottish Health Survey. Edinburgh:SEHD; 2002. 3. Scottish Intercollegiate Guidelines Network. The management of harmful drinking and alcohol dependence in primary care. A national clinical guideline. No. 74 Edinburgh:SIGN; 2003. 4. Kaner EFS, Beyer F, Dickinson HO, Pienaar E, Campbell F, Schlesinger C, Heather N, Saunders J, Burnand B. Effectiveness of brief alcohol interventions in primary care populations. Cochrane Database of Systematic Reviews 2007. 5. Shaw S, Cartwright A, Spratley T, Harwin J. Responding to drinking problems. London: Croom Helm; 1978. 6. Fitzgerald N, Fleming A. Proposed knowledge, skills and approaches to addressing alcohol & drug issues. Glasgow: Joint Addictions Training Board; 2004. 7. Fitzgerald N, McCaig D, Watson H, Thomson D, Stewart D. Development, implementation and evaluation of a pilot project to deliver interventions on alcohol issues in community pharmacies. Int J Pharm Pract. 2008;16:17–22. doi:10.1211/ijpp.16.1.0004. 8. Watson M, Blenkinsopp A, Harrison A, Neilson E. Community pharmacy and alcohol misuse services—a review of policy and practice. London: Royal Pharmaceutical Society of Great Britain 2008. 9. Sinclair HK, Bond CM, Stead LF. Community pharmacy personnel interventions for smoking cessation. Cochrane Database of Systematic Reviews; 2004. 10. 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. doi:10.1136/thx.2006.064709.

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