Action Research in Pharmacy Practice

Abstract

Action research (AR) is based on a collaborative problem-solving relationship between researcher and client, and the aims of this research are to solve the problem and to generate new knowledge. The chapter describes and shows how several different methods might be used for data collection in an AR-based study. Concepts related to AR are described; in addition, the multifaceted role of the action researcher is described, along with a set of data quality criteria for evaluating the quality of an AR-based study. Then follows a thorough description of a Danish AR-based pharmacy practice study. The chapter concludes with a list of experience-based recommendations for others who are interested in running an AR-based study. This is followed by an Appendix describing four different AR-based studies.

Appendix: Four Examples of AR-Based Pharmacy Practice Research Studies

5.1.1 Study 1: Pharmacists’ Role in Improving Awareness About Folic Acid: A Pilot Study on the Process of Introducing an Intervention in Pharmacy Practice (Meijer et al. 2004)

Objective

To determine whether a multiple intervention program aimed at improving women’s awareness of folic acid was feasible in community pharmacy practice, to identify adjustments in organization and materials that could improve feasibility, and to assess how the target group experience the intervention. Setting: a core team in each of four community pharmacies in the eastern region of the Netherlands.

Methods

An AR study was undertaken in which four community pharmacies participated. In each pharmacy, a core team (one pharmacist and one to two technicians) was responsible for the organization and implementation of the intervention. The intervention had several possible levels. As a minimum, pharmacy staff added a label about folic acid to the box of dispensed oral contraceptives (OCs) and handed out a leaflet about folic acid. The intervention was discussed during core team meetings every 6 weeks. Modifications were made based on the experience of the pharmacy team, on responses from pharmacy customers, and on the results of a questionnaire sent to women 1 week after they visited the pharmacy with an OC prescription. This cycle of planning, action, observation, and reflection was repeated twice.

Results

The minimum intervention was carried out by all four pharmacies. Other activities differed: two pharmacies introduced a maximum client age limit for handing out the leaflet, two installed an electronic information display, three worked with posters and window displays, and in two pharmacies the pharmacy technicians wore project badges, and an information portfolio was placed in the pharmacy public area. From the target group, 44 % were positive about the label, 49 % were neutral, and 4 % were negative. Over half (56 %) of the target group stated that they appreciated the public health information given through the pharmacy.

Conclusion

Working with core teams seemed to be a successful strategy to implement practice change. By discussing and modifying the intervention during each research cycle in the core team meetings, an optimal intervention was reached that fitted in with the existing organization within the pharmacy and possible barriers were overcome. Feedback from the target group was mainly positive, and motivated the core teams to continue.

5.1.2 Study 2: Collaborative Medication Management Services: Improving Patient Care (Gilbert et al. 2002)

Objective

To implement and evaluate a collaborative medication management service model. Setting: the study was conducted from March 1999 to March 2000, with the participation of 1,000 patients, 63 pharmacists, and 129 general practitioners from six Divisions of General Practice in South Australia.

Methods

The design of the study was PAR, in which researchers worked with participants to design, implement, and evaluate the service, allowing researchers and participants to solve problems that arose as the research progressed. The PAR process involved GPs, pharmacists, and consumers in a series of workshops, focus groups, and feedback sessions. A collaborative service delivery model, involving a preliminary case conference, a home visit, and a second case conference, was agreed through discussions with medical and pharmacy organizations, and then implemented. Outcome measures were medication-related problems, actions recommended, actions implemented, and outcomes after actions taken.

Results

Overall, 2,764 problems were identified. The most common medication-related problem (17.5 % of all problems) was the need for additional tests. Thirty-seven percent of problems related to medicine selection, 20 % to patient knowledge, and 17 % to the medication regimen. Of 2,764 actions recommended to resolve medication-related problems, 42 % were implemented. Of the 978 problems for which action was taken and follow-up data were available, 81 % were reported to be “resolved,” “well managed,” or “improving.”

Conclusion

A collaborative service delivery model was agreed upon through discussions between pharmacists and doctors and accordingly implemented. The implementation model was successful in engaging GPs and pharmacists and in assisting in the resolution of medication-related problems.

5.1.3 Study 3: Roles and Competencies of District Pharmacists: A Case Study From Cape Town (Bradley 2013)

Objective

The aim of this study (a PhD thesis) was to explore the contribution of substructure and sub-district pharmacists to health system development and how to support them in their roles, by considering their roles and related competencies in the South African health system and by piloting an intervention to enhance their competencies. Setting: The managers in Cape Town City Health and Metro District Health Services, together with the district and sub-district pharmacists in the period from 2008 to 2011.

Methods

Participatory action research (PAR) was used as the approach to partner with pharmacists and managers in both organizations between 2008 and 2011. The partnership benefitted from the contextual and practice experiences of the health services stakeholders and the researcher’s evolving research expertise. Including a broad stakeholder group was considered important for developing the shared learning and understanding that would translate into action and change in the organizations. The flexible and emergent approach of PAR was considered to be suited to a complex health system in the midst of change. After an initiation stage, the research evolved into a series of five iterative cycles of action and reflection, each providing increasing understanding of the roles and related competencies of substructure and sub-district pharmacists and their experiences as they transitioned into these new management positions in the two organizations. The research centered around two series of three interactive workshops facilitated by researchers and attended by both pharmacists and managers. Semi-structured interviews and focus groups were conducted at various stages during the research, to inform conceptualization and supplement workshops and, later on, to reflect on the experiences of substructure and sub-district pharmacists.

Results and Conclusion

The research identified five main roles each for substructure and sub-district pharmacists. Four of these roles are the same for each: (1) substructure (sub-district) management; (2) planning, coordination, and monitoring of pharmaceuticals, HR, budget, and infrastructure; (3) information and advice; and (4) quality assurance and clinical governance. Their fifth role is different though: research for substructure pharmacists and dispensing at clinics for sub-district pharmacists. But although they look similar, there were substantial differences between substructure and sub-district pharmacist roles in the two organizations. Five competency clusters were identified for both cadres, each with several competencies: professional pharmacy practice, health system/public health, management, leadership, personal, interpersonal, and cognitive. Although the competencies appear similar, there were differences between the roles, so that the different cadres required different competencies within these competency clusters. Transitioning into these new management positions was an emergent process, which entailed pharmacists changing from performing technical and clinical functions associated with professional pharmacy practice to coordinating pharmaceutical services across the substructure or sub-district. They moved from working in a pharmacy to being a member of a multi-professional team in a substructure or sub-district. Adjusting to these new management positions took time and was facilitated by several personal and organizational factors which varied in the two organizations. Managers and pharmacists mentioned the positive contribution of the PAR in assisting with this transition through the development of shared understanding of the DHS and the roles and functions of pharmacists working in these management positions.

5.1.4 Study 4: “Medisam—A Model of Cooperation Between Patients, General Practitioners and Pharmacists for Medicines Review and Reconciliation” (see www.farma.ku.dk/index.php?id=7913, Kaae et al. (2011, 2014) and Sørensen et al. (2009, 2011)

Objective

The aim of the study was to develop, implement, and evaluate a model of cooperation for medicines review and reconciliation involving patients, pharmacists, and general practitioners in a multi-professional dialogue aimed at solving drug-related problems by involving the patients in decision-making around their medication.

Setting

The education pharmacies at the University of Copenhagen (app. 90), the pharmacy students (app. 170), and their pharmacist tutors, the physicians, and patients being involved in the home medication review. The project was run in the period 2008–2011, starting with a pilot study in 2007.

Methods

The project was carried out in cooperation between internship pharmacies, their pharmacy students, and the Faculty of Pharmaceutical Sciences. The working method of the project was based on AR principles, where research is focused on solving problems together with those who experience the problems, i.e., in this case the patients, pharmacists, and general practitioners. The project was carried out in a 3-year period, using the main steps of the AR cycle, starting in 2007 where the detailed project plans were elaborated, tested, and evaluated and continued the following 3 years. All internship pharmacies and their pharmacy students were each year invited to join the project. The pharmacist and general practitioner agreed on those patients who should be offered a medicines review and reconciliation. Methods used for data collection were: registration forms for drug-related problems, medication reconciliation forms, patient interviews, case summaries, minutes of various meetings, etc. Data about the AR process were collected each year using written material from meetings in the project group, yearly meetings with tutors, and questionnaires to the pharmacy students, supplemented with qualitative interviews with representatives for the students.

Data about the pharmacist–GP collaboration were collected in 2011 by conducting semi-structured interviews with pharmacy students along with their supervisors and with the connected physicians, in two separate interviews.

Results

A collaboration model for home medication review was developed. The model has been practiced as a compulsory part of pharmacy education at the education pharmacies at the University of Copenhagen since 2010. A database (www.medisam.dk) was developed during the project. The database was used by the students for registering the prescribed and used medicines, the drug-related findings, and recommended interventions at the patient level and used by the researchers for quantitative analysis of the data. New knowledge was gained in the following areas: cooperation between GPs, pharmacists, pharmacy education, and patients, implementation of medication review by using AR, the collaborative working relation between pharmacist and physician (theoretical perspectives), and communications around medication review in community pharmacy.

Conclusion

The study has taken a direction in accordance with the expressed needs of all participants. Conclusively, medication review has become a sustainable daily practice at the education pharmacies since 2010.