|Year : 2015 | Volume
| Issue : 2 | Page : 97-102
Assessment of the structural and process aspects of pharmaceutical care at a university hospital in Ethiopia
Abdrrahman Shemsu Surur1, Fitsum Sebsibe Teni2, Genet Girmay1, Elsabet Moges1, Meseret Tesfa1, Messele Abraha1
1 Department of Pharmaceutical Chemistry, School of Pharmacy, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
2 Department of Pharmaceutics and Social Pharmacy, College of Medicine and Health sciences, University of Gondar, Gondar, Ethiopia
|Date of Submission||11-Oct-2014|
|Date of Decision||27-Oct-2014|
|Date of Acceptance||21-Dec-2014|
|Date of Web Publication||1-Apr-2015|
MSc in Medicinal Chemistry Abdrrahman Shemsu Surur
Department of Pharmaceutical Chemistry, School of Pharmacy, College of Medicine and Health Sciences, University of Gondar, Gondar
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Objective: To assess the structural and process components of the pharmaceutical care at Gondar University Referral Hospital (GURH). Materials and Methods: An institution-based cross-sectional study was conducted on all the four pharmacies at GURH from October 1 to December 31, 2013. By adopting data collection instruments from a previously done study, the structural aspects of the pharmacies were assessed using an observation checklist and the process of pharmaceutical care delivery using a self-administered questionnaire. The data collected was entered to and analyzed using Statistical Packages for Social Sciences (SPSS) version 16.0. Results: none of the pharmacies had a private counseling room, fire extinguisher and meeting area. None of the pharmacy stores were equipped with fan and air ventilation system and had no cross aisles. The mean values for documentation, patient assessment and implementation of therapeutic objective were 12.14, 14.03 and 5.64 respectively. Many pharmacists (64.29%) did not participate in ward rotation with physicians. The overall pharmacy professionals' level of job satisfaction was found to be 2.77. Conclusion: There were gaps in the structure and the process of the provision of pharmaceutical care in GURH.
Keywords: Clients, donabedian model, pharmaceutical care, process, structure
|How to cite this article:|
Surur AS, Teni FS, Girmay G, Moges E, Tesfa M, Abraha M. Assessment of the structural and process aspects of pharmaceutical care at a university hospital in Ethiopia. J Pharm Bioall Sci 2015;7:97-102
|How to cite this URL:|
Surur AS, Teni FS, Girmay G, Moges E, Tesfa M, Abraha M. Assessment of the structural and process aspects of pharmaceutical care at a university hospital in Ethiopia. J Pharm Bioall Sci [serial online] 2015 [cited 2021 Feb 27];7:97-102. Available from: https://www.jpbsonline.org/text.asp?2015/7/2/97/154427
The traditional role of pharmacy professionals that involve the preparation, dispensing and selling medications has to be changed to deliver pharmaceutical care to the patients. The philosophy of pharmaceutical care has been accepted worldwide as the primary mission of pharmacy.  Pharmaceutical care is an outcome-oriented concept that has been proposed as a model of pharmacy practice in resolving the issue of preventing unwanted drug effects. The provision of pharmaceutical care requires monitoring of the regimen's effects, revising the regimen as the patient's condition changes, documenting the results, and assuming the responsibility for the pharmacotherapeutic effects. 
The quality of healthcare has been defined in these terms: What a system of care should deliver, what a healthcare professional or service unit should provide, what patients expect from providers of care, and what patient outcomes should be expected.  The structure-process-outcome paradigm of Donabedian is perhaps the best known and most often applied measure of quality. This model is a leading paradigm to assess the quality of health care services. 
The component structure refers to relatively static characteristics of the personnel who provides care and of the settings where the care is delivered. The characteristics included for personnel are education, experience and certification and for the settings where the care is provided are the adequacy of the facility's staffing, equipment, safety devices and overall organization. 
The component process denotes all the activities taking place during the delivery of care to the patients and is concerned with technical and interpersonal aspects. The technical aspect refers to the application of current pharmaceutical science and technology in an attempt to maximize the balance between benefits and risks. The interpersonal aspect is related to the pharmacist-patient relationship. 
A study conducted across Europe reported that pharmacy professionals are routinely engaged in general activities such as dispensing but was infrequently involved in patient centered professional activities.  In Ethiopia, the quality of pharmaceutical care was assessed separately by studying the structure of pharmacy units,  patterns of prescriptions and involvement of pharmacists in drug related problems. An inclusive assessment of the structure and process of the pharmaceutical care  is very scarce.
The objective of this study was to assess the structure and process aspects of pharmaceutical care in GURH. The objectives regarding the structural aspects were the assessment of the condition of dispensing room, the availability of dispensing aids and the condition of the pharmacy stores. The objectives regarding the process aspects included the assessment of the pharmacy professionals' level of involvement in pharmaceutical care, pharmacy professionals' level of job satisfaction and pharmacy professionals' perceived quality of care.
| Materials and Methods|| |
An institution-based cross-sectional study was conducted from October 1 to December 31, 2013 at GURH, which is located in Gondar town in the Amhara National Region state in north-western part of Ethiopia. All the four pharmacies in the hospital and all active pharmacy professionals working the pharmacies were included in the study. These were the outpatient, inpatient, anti-retroviral therapy (ART), and "Liyu" (special) pharmacies.
Data on the structural and process aspects the pharmaceutical services provided at GURH were collected using instruments adopted from a previous study by Eshetu and Gedif, 2011.  Accordingly, the structural aspects of the pharmacies were assessed using an observation checklist and the process of pharmaceutical care delivery aspects of the services were on the other hand surveyed through self-administered questionnaires.
Structured component was assessed using observation check lists, prepared and employed by Eshetu and Gedif, 2011,  based on the recommended standards by American Society of Health-System Pharmacists minimum standards for pharmacies in hospitals and the then Drug Administration and Control Authority of Ethiopia currently known as Food, Medicine and Health Care Administration and Control Authority of Ethiopia. ,
The self-administered questionnaire employed to assess the process of pharmaceutical care delivery included questions on the general sociodemographic characteristics of respondents as well as specific questions on the areas of level of involvement in pharmaceutical care, job satisfaction and perceived quality of care.
The data on both the structural and process aspects of the pharmaceutical care was collected by the principal investigators using the checklist and self-administered questionnaires.
The data collected in this study was analyzed using Statistical Packages for Social Sciences (SPSS) for Windows version 16.0, SPSS Inc  . The statistical package was used to calculate the mean, the percentage and the relationship between variables through Mann-Whitney U-test and Kruskal-Wallis test.
Ethical approval was obtained from the ethical review committee of the school of pharmacy and permission was secured from the pharmacy department of GURH. Moreover, the participants of the study were asked for their consent before the data collection process and their decision was respected. In addition, the data collected was kept confidential and used for the purposes of the study only.
| Results|| |
Structural aspects of the pharmaceutical care.
Physical and material aspects of the pharmacies
All of the four pharmacies at GURH were included in the study. The areas of the main pharmacy and inpatient pharmacy were 26.01 m 2 and 12.6 m 2 respectively. The maximum and the minimum dispensary areas were 6.88 m 2 and 26.625 m 2 respectively and the average number of pharmacy professionals working at a time was only two.
As regards to the availability of important equipment in the pharmacies, all had dispensing counter (table) with appropriate lighting and ceiling. But, none of the pharmacies involved in the study had a private counseling room, fire extinguisher and meeting area. Only two of the pharmacy units had a refrigerator with thermometer while only one of the pharmacies had a toilet. However, water supply for washing hands or equipment was available in three of the pharmacies [Table 1].
|Table 1: The condition of dispensing room and the availability of simple dispensing aids|
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The areas of the inpatient and main outpatient pharmacy store were 29.25 m 2 and 48.75 m 2 respectively. Electric power supply was available in both of the pharmacy stores. Water supply, however, was absent in one of the store. None of the pharmacy stores were equipped with fan and air ventilation system and had no cross aisles, floor layout and drain to catch run offs. Fire extinguisher and generators were absent in all pharmacy stores. None of the stores had a well-ventilated storage for inflammable substances, which is insulated and built with fireproof materials. A lockable cabinet for the storage of narcotic and psychotropic substances (NPS) and a separate area/room for drugs, medical supplies, diagnostic and medical equipments were found in only one pharmacy store.
Three of the pharmacy units had documentation system as the filled prescriptions were registered, separated and documented by days, months and years and were kept for 2 years (for ordinary prescription) and 5 years (for NPS). Two of the pharmacies, however, did not have adequate space for maintaining and storing records. On the other hand none of the pharmacies had documentation system for pharmacy professional's intervention, as there was no document on adverse effects and drug interactions identified by pharmacy professionals.
Staffing and administration of the pharmacies
The total number of pharmacists and pharmacy technicians working during the study period was 17 and 18 respectively. The average number of pharmacist and pharmacy technicians per pharmacy units, which is calculated by dividing the number of the pharmacy professionals by the number of pharmacy units, was 4.25 and 4.5 respectively. Only one of the pharmacy units had a secretary staff and the ART pharmacy had one data clerk. A staff involved in provision of pharmaceutical care but without relevant training in pharmacy was not found.
The head of the pharmacy department of GURH was a pharmacist and has 13 years of experience in the field of pharmacy. The director had no any long or short-term management training of any kind and a procedure for routine evaluation of the performance of the pharmacy personnel was not found. Written position description for pharmacy personnel was found in all except one pharmacy unit.
All pharmacy units except the ART pharmacy unit were providing 24-h service to patients. There was no on call basis for the pharmacists working in the ART pharmacy. Although Internet connection was available in all pharmacy units, only three of the pharmacy units had online access to drug information center resources. The national essential drug list and the GURH essential drug list were available in all pharmacy units.
Extemporaneous preparation service was found in one pharmacy unit. But adequate quality assurance procedure for the extemporaneous preparation had not been done.
Although pharmacists have immediate access to comprehensive medication histories for each patient's medical record, only pharmacists in ART pharmacy conducted medication history analysis for each patient.
A functional Drug and Therapeutic Committee (DTC) with a regular meeting of its members was available at Gondar University hospital. In addition to being a member of DTC committee, the pharmacists were also a member of infection control committee and other committee that make decisions concerning medication use.
| The process aspects of the pharmaceutical care|| |
Out of the total of 42 pharmacy professionals working at Gondar University hospital, 35 were on duty during the study period. The questionnaires were provided to all pharmacy professionals and 28 of them returned a filled questionnaire. Fifteen of the pharmacy professionals were female. The mean age of the respondents was 28.04 years. The majority of pharmacy professionals were single (59.1%) and were pharmacy technicians (60.7%). The average number of years since graduation and the average number of years at current job were 4.29 and 2.93 years. The average number of working hours per day and the average number of working days per week were found to be 8.14 h and 5.19 days respectively. Dispensing (69.23%) accounts for the highest percent of the primary job responsibility.
Pharmacy professionals' level of involvement in the provision of pharmaceutical care
Pharmacy professionals' level of involvement in the provision of pharmaceutical care was measured using behavioral pharmaceutical care scale (BPCS), which is a multi-item scale developed by Odedina and Segal (1996). The items were organized into different domains; documentation, patient assessment, implementation of therapeutic objective and monitoring plan, patient record screening, patient advising and counseling and verification of patient understandings, referral and consultation with colleagues, evaluation of patient satisfaction and provision of health information to patients. The first five domains were analyzed using items which were scaled 0-5 that reflect the number of patient to whom the activity were performed [Table 2].
|Table 2: Pharmacy professional's level of involvement in the provision of pharmaceutical care|
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The significance of difference in the level of involvement in pharmaceutical care between pharmacist and pharmacy technicians was assessed using Mann-Whitney test [Table 3]. The analysis showed a significance relation of highest academic achievement with documentation and implementation of therapeutic objective.
|Table 3: Significance of the relationship between various domains of level of involvement and highest academic achievement|
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The results for referral and consultation with colleagues, evaluation of patient satisfaction and provision of health information to patients is given using the scale running between not at all (0); Almost never (1); sometimes (2); often (3) and "very often" (4). Many pharmacy professionals (60.72%) did not provide physicians (upon referral) with written summary of patient medication history and any drug related problems. The majority of pharmacy professionals (74.90%) provided general medical information to the patients. More than half (53.58%) of the pharmacy professionals did not ask patients about their satisfaction with the service delivered.
Many pharmacists (64.29%) did not participate in ward rotation with physicians as 46.43% of pharmacy professionals responded not at all and 17.86% responded almost never. Twenty pharmacy professionals gave reasons for their absence and the major reasons given were lack of training (33.33%) and absence of system in the hospital to involve pharmacists in ward rotation (36.67%). Lack of communication skill (3.33%) and lack of resources (3.33%) were among the least frequent reasons. Two pharmacy professionals selected nonsmooth interaction between pharmacist and physicians and lack of space to give information.
Supply of medicines through nurses (15.69%) was the major activity provided by pharmacy professionals to inpatients admitted to GURH. Education and training of other health professionals and discharge planning for patients were the activities performed almost never.
Pharmacy professionals' level of job satisfaction
The items for analyzing pharmacy professionals' level of job satisfaction were categorized into three domains; work environment, professional interaction and personal outlook. The least satisfaction on the scale of 0-5 was the appropriateness of salary (2.11) while the highest satisfaction was for the decision to still choose pharmacy if they had to decide all over again (3.46). The mean values of satisfaction for working environment, professional interactions and personal outlook domains were 2.52, 2.84 and 2.93 respectively. The overall pharmacy professional's level of satisfaction working at GURH was found to be 2.77.
The significance between sex, marital status and highest academic achievement with job satisfaction was analyzed using Mann-Whitney U-test [Table 4]. The significance between primary job responsibility and job satisfaction, on the other hand, was analyzed using Kruskal-Wallis test. The Chi-square value of the Kruskal-Wallis test was 1.64 with P value of 0.65.
|Table 4: Analysis of significance between sex, marital status and highest academic achievement with pharmacy professional's level of job satisfaction|
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Pharmacy professionals' perceived quality of care
The pharmacy professionals' perception on the quality of service provided to the clients was assessed based on the scale of 0-5. More than 64% of the professionals rated that their pharmacy as poor or fair with respect to the internal organization of the pharmacy and the way they work with the physician. More than 74% of the professionals rated the quality of medicines that are purchased by the hospital pharmacy as good or very good. Only one professional rated the availability of medicines in the hospital pharmacy at all time as very good or excellent. almost none of the pharmacists rated their services as excellent.
Mann-Whitney test and Kruskal-Wallis test were used to assess the significance associated with perceived quality of care. Analysis of significance between the highest academic achievement and perceived quality of care gave a Mann-Whitney value of 83 with a P value of 0.62. A Chi-square value of 1.387 with P value of 0.709 was found in Kruskal analysis between primary job responsibility and perceived quality of care.
| Discussion|| |
The study assessed the quality of pharmaceutical care in GURH from the structural aspects of the pharmacy units and the process in the provision of pharmaceutical care.
There are no standard area set for pharmacy units in government hospitals in Ethiopia. But the standard for pharmacy units in private hospitals requires that the inpatient pharmacy dispensary should have at least 16 m 2 area and that of outpatient pharmacy to have at least 25 m 2 area.  Accordingly, the area of the main pharmacy (26.01 m 2 ) was in the recommended range unlike the area of inpatient pharmacy (12.60 m 2 ).
The availability of private counseling room was null even though the absence of consultation area and privacy were reported to affect pharmacist-client interaction. This is important as pharmaceutical care involve not only the transition from dispenser of pharmaceutical products to dispenser of information, but also a commitment on the well-being of the patient and the formation of therapeutic alliance, which implies the importance of communication.  This problem seems to be shared by government hospitals in Addis Ababa. 
One of the two pharmacy stores had water and electric supply, was equipped with fan and air ventilation system. Moreover both pharmacy stores had a refrigerator. This is very important for cold chain management system. One of the stores had no lockable cabinet for NPS, which was not in line with general recommendation for the facilities of medical store. 
The results of documentation, patient assessment and implementation of therapeutic objective and monitoring plan showed that those activities were underperformed. The results were comparable to government hospitals of Addis Ababa.  Patient advising and counseling (2.5) and verification of patient understanding (2.61) were slightly lower than those reported for government hospitals of Addis Ababa.  The association made between highest academic achievement and documentation showed statistical significance with documentation reported to be performed more by pharmacists. On the contrary, pharmacy technicians were a higher achiever in the implementation of therapeutic objective than pharmacists.
A majority of pharmacy professionals (64.49%) not at all or almost never participated in ward rounds with the physicians. The two major reasons given were absence of system in the hospital to involve pharmacists in ward rotation (36.67%) and lack of time (33.33%). The percentage of professionals who participated in ward rotation was lower than a similar study in government hospitals of Addis Ababa (84.3%).  The major reasons given by pharmacy professionals working at government hospitals were absence of system in the hospital to involve pharmacists in ward rotation and undergraduate education was not enabling and lack of communication skill. Improving policies to allow effective involvement of pharmacists in ward rounds is necessary.
Supply of medicine through nurses (53.57%), and medication error and adverse drug reaction monitoring (46.43%) were the major activities reported to be performed to inpatients. The study in government hospitals in Addis Ababa showed that the major service to inpatients was limited to supply of drugs through nurses (82.4%) and review of prescriptions or patient chart (43.1%).  Prescription monitoring in ward (94%) was the major activity done by pharmacy professional in United Kingdom.  Comparing the previous result to our current situation dictates that more effort is needed to boost the level of pharmaceutical care to inpatients.
The overall pharmacy professionals' level of satisfaction working at GURH was found to be 2.77. The overall satisfaction was calculated based on their satisfaction of the working environment (2.52), professional interaction (2.84) and personal outlook (2.93) on the scale of 0-5. The study showed that the overall satisfaction of pharmacy professionals' was slightly lower than pharmacy professionals working at government hospitals of Addis Ababa.  Pharmacist job satisfaction, or dissatisfaction, plays a major role in many aspects of community pharmacy practice. These performance problems can include incorrectly filling prescriptions, not detecting drug interactions and poor patient counselling. 
Based on the Mann-Whitney test, there was no statistically significant job satisfaction difference between male and female and between single, and married pharmacy professionals. No statistically significant relationship was found with regard to primary job responsibility (dispensing, inventory and drug supply, drug information service and administrative activities) and job satisfaction too. A similar finding of no statistically significant relation between gender, marital status and primary job responsibility with job satisfaction was reported in governmental hospitals of Addis Ababa. 
There was no significant difference in perceived quality of care between pharmacists and pharmacy technicians. The same was true for the difference between primary job responsibility and perceived quality of care.
| Conclusion and Recommendations|| |
This research has identified gaps in the structure and the process of the provision of pharmaceutical care in GURH. Pharmacy professionals should provide better advice and counseling to the clients and they need to work with other health care providers to promote pharmaceutical care at this hospital. Pharmacy professionals should also improve their patient assessment and documentation system. GURH should review their policies to create conducive conditions for pharmacist to participate in ward rotation. The managerial staff should also give a considerable attention to meet the minimum structural requirement set by the regulatory authority. Decreasing involvement of pharmacists in technical dispensing functions and delegating these functions to pharmacy technicians should improve the use of the pharmacist's time for optimal patient care.
| Acknowledgements|| |
The authors would like to acknowledge Mr. Eskinder Eshetu and Dr. Teferi Gedif for the checklist used for the evaluation of the structural components and for the structured checklist used for evaluating the process aspect of pharmaceutical care.
The authors would also like to acknowledge all the pharmacy professionals who participated in the study for their cooperation.
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[Table 1], [Table 2], [Table 3], [Table 4]