Abstract
Background
During conversations about medication switches, pharmacy staff often deliver a message to patients that may lead to negative emotions. In these situations, clear and patient-centered communication is important.
Aim
To gain insight into pharmacy technician-patient experiences regarding the communication during medication switching encounters, and in specific to map the needs and preferences of patients and whether pharmacy technicians (PTs) meet these.
Method
PTs were invited to fill in a questionnaire via the Dutch Panel on practical research for Pharmacy Employees. Online questionnaires were distributed to adult chronic mediation users in two patient panels. Questionnaires contained questions on how PTs and patients experience the medication switch conversations at the moment (i.e. type of information patients need/receive, timing of information, channel, communication style), and whether the needs and preferences of patients are met.
Results
In total, 138 PTs and 4679 patients responded. PTs indicated that they regularly struggle with these conversations due to emotional or negative responses of patients. Most patients expressed the need for information about why the medication switch took place (68%) and about the (same) effect of the medication (61%), while fewer patients currently receive this information (21% and 39%, respectively). Patients also indicated they need verbal information during pick-up/delivery (45%), written information beforehand (29%) and during pick-up/delivery (25%), while patients more often receive verbal information during pick-up (58%), and less frequently receive written information beforehand (6%) and during pick-up/delivery (18%).
Conclusion
Communication during medication switch conversations generally goes well. However, there is a difference between what PTs claim they do and what patients experience, e.g. space for questions and patients' satisfaction about this aspect. Dealing with patient emotions is also difficult for PTs. Patients emphasize they need more information than they currently receive, preferably before switching. Matching these needs and preferences can improve patient-centered communication.
Keywords: Patient-centered communication, Pharmacy technicians, Patients, Medication switching encounters, Information provision, Emotions, Pharmacy practice
1. Introduction
The role of the pharmacy team in delivering pharmaceutical care has changed over the past decades from a primarily therapy-based to a more patient-centered approach.1,2 For example, there is more focus on guidance of proper medication use and attention to patient education and counselling, including patients' needs and preferences. In challenging situations, where negative news has to be brought, clear communication tailored to the patient's needs is even more important.3 In particular, there should be a focus on the information content (i.e., message being communicated), medium (e.g., verbal or written information), and how the message is conveyed (i.e., communication style).4 In European countries such as the Netherlands and Denmark, pharmacy technicians (PTs) are often the first point of contact for patients at the pharmacy counter, and mostly take part in conversations with patients on a daily basis. PTs work in community and out-patient pharmacy settings. Their primary role is to prepare and supply medicines and healthcare products and to give advice and guidance to patients.5 Previous studies show that communication during pharmacy encounters can be improved.6, 7, 8, 9, 10, 11, 12 For example, pharmacy staff should more often ask about the needs and preferences of patients and actively seek the patient's perspective.6, 7, 8, 9 These aspects are crucial as they can help the PT address specific problems or concerns that patients may have.13,14
Situations that increase stress or negative emotions can intervene and act as a distractor in the two-way communication process between the patient and provider.15 It regularly happens in pharmacy practice that there are challenging situations, such as encounters about non-medical medication switches. Non-medical medication switches refer to changes in medications for reasons other than effectiveness, side effects or adherence. These switches are often related to changes in formularies to reduce costs.16,17 A potential stressful encounter, such as a medication switch conversation, can be difficult for both the PT or the patient. These conversations can be difficult because it can become more challenging to respond in a controlled and effective verbal manner.18 Conversations about these types of switches regularly result in the PT delivering a message to patients that lead to negative emotions. These types of emotions include being confused, upset, angry, frustrated, surprised, and even aggressive at the pharmacy counter.17,19 Some patients may also be worried or concerned about aspects of the new medication, such as effectiveness of the medicine or side effects.19 These types of conversations can have negative consequences, both on proper medication use by the patient1,20 and the PTs' job satisfaction. It is therefore important to investigate what is needed to support communication during these encounters.
During these difficult medication switch conversations it is essential for PTs to take patient needs and preferences into account. These needs and preferences include which information is given, in what way, and also how the message is conveyed.4 However, we are currently unaware whether the provided information suits the needs and preferences of patients. By investigating the experiences during these conversations from both parties involved, insights can be drawn into how the conversations are conducted, and whether the expectations of both parties involved match. The aim of this study was therefore to gain insight into experiences of both pharmacy technicians and patients regarding the communication during medication switching encounters, and in specific to map the needs and preferences of patients and whether pharmacy technicians meet these.
2. Methods
2.1. Study design
A quantitative study with online questionnaires was conducted to explore experiences of PTs and patients regarding communication and information provision during conversations about medication switches.
2.2. Participants
Pharmacy technicians included in the Panel on practical research for Pharmacy Employees (PAM) were invited to complete the questionnaire. This panel consists of circa 1000 pharmacy employees. About 90% of the PAM panel consists of PTs, the remaining 10% are other pharmacy staff members such as pharmacy managers and pharmacy consultants (specialized PTs). Previous panel consultations19,21,22 indicate that the response rate for online questionnaires in the PAM panel is around 15%.
Patients were invited to participate via two panels:
(i) Patients of the AMP, Pharmacy Monitoring Program panel. AMP is a representative panel of patients who visit community pharmacies regularly. The AMP patient panel consists of about 40,000 members, of which about half (47.5%) is male and the majority (78%) uses medication for chronic conditions.23 The AMP panel provided a response from a heterogeneous population.
(ii) Patients of the Dutch patient organization for cardiovascular diseases panel. This patient organization has medication switches as an important topic on their agenda, and these patients regularly complete questionnaires on different health-related topics. This panel includes approximately 2600 people with cardiovascular diseases. Compared to the AMP-panel, this panel provided a more in-depth insight into experiences of a specific group of patients who are often presented with medication switches. Previous research has shown that a 30% response rate is common.
2.2.1. Questionnaire design and data collection
The questionnaires were aimed at collecting experiences with the communication and information provision during conversations about medication switches. The questions asked to PTs and patients were not identical. Hence, we cannot compare the data.
2.2.1.1. Pharmacy technicians questionnaire
Pharmacy technicians were asked what their experiences were with conducting conversations about medication switches, specifically the way they communicate and provide information to patients about the switch. The questionnaire was drawn up based on previous questionnaires used for research on conversations at the pharmacy counter.1,2,24 Also, input from researchers was used, as well as pharmacy staff who tested the questionnaires and provided feedback.
Three pharmacy employees tested the survey for clarity and feasibility. Only one minor adaptation was made based on their feedback.
Questions included background characteristics of the PTs (i.e., age, education level, years of work experience, and how big the pharmacy is where they work), characteristics of the conversation (i.e., how the message is conveyed, what information is provided), their experience with the conversation (negative/positive experience) and their experience with delivering the message about the medication switch. PTs were also asked to indicate how they perceived that patients experienced the conversation. Answers of PTs were collected on a 5-point Likert scale (frequently, often, sometimes, rarely, never). Appendix 1 includes the questionnaire translated from Dutch to English. A link to the online survey was distributed to panel members via email. The PAM questionnaire was open from the 15th to the 25th of March 2021. No reminders were sent.
2.2.1.2. Patients
We sent out two versions of patient questionnaires. Firstly, we sent out an extensive questionnaire to the members of the cardiovascular diseases panel of the patient organization. Additionally, we included a smaller set of questions, as part of a larger survey scheduled to be sent out to the AMP panel.
Patients in both questionnaires were asked about the current information provision and experience with the communication with the PT during a conversation about a medication switch. Questions included their preferences in the ways of communicating and information provision (i.e., information type and content), and their background characteristics. We used pre-existing validated tools and questionnaires as a basis/inspiration for the questionnaires developed specifically for this study.24, 25, 26, 27 A questionnaire used was the Consumer Quality Index (CQ-index) Pharmacy. This questionnaire was developed with all relevant field parties, thoroughly validated and was used to evaluate patient experiences in all Dutch pharmacies.26 Another questionnaire used was the validated MEDICODE, a coding tool created for medication discussions within medical encounters.27 Additionally, we used the guideline “Consultation in the pharmacy” developed by the Royal Dutch Pharmacists Association,1 to ensure our questions aligned with important aspects of communication and information according to this guideline.
In Appendix 2., Table 1., is shown which questions were asked in which patient questionnaire and which scales/types of responses were used. The main topics were identical for both questionnaires, though more in-depth experiences (with additional questions) were asked in the patient organization questionnaire. The questionnaire was tested by two representatives of the patient organization, one of whom had much experience with drafting questionnaires for patients. The minor textual changes they posed were incorporated in the questionnaire.
Table 1.
Background characteristics of pharmacy technicians from the PAM panel and patients from the AMP panel and the patient organization panel for cardiovascular diseases.
| Pharmacy technicians | |
|---|---|
| PAM panel members, Total N = 138 | |
| Mean age (SD): range | 51.0 (9.2): 27–68 |
| Years of work experience, N (%) | |
| < 10 years | 4 (2.9) |
| 10–20 years | 21 (15.2) |
| 20 > years | 113 (81.9) |
| Size of pharmacy, N (%) | |
| Village (<20,000 inhabitants) | 46 (33.3) |
| Middle-sized city (20,000–150,000 inhabitants) | 67 (48.6) |
| Big city (>150,000 inhabitants) | 25 (18.1) |
|
Patients | ||||
|---|---|---|---|---|
|
AMP panel (Total N = 3962) |
N (responses) |
Cardiovascular diseases panel (Total N = 717) |
N (responses) | |
| Mean age (SD): range | 68.5 (10.0): 24–98 | 3747 | 67.2 (10.1): 24–93 | 683 |
| Male, N (%) | 2242 (59.1) | 3742 | 439 (62.2) | 706 |
| Education level, N (%) | 3742 | 704 | ||
| Low | 417 (11.1) | 68 (9.7) | ||
| Middle | 1586 (42.4) | 293 (41.6) | ||
| High | 1739 (46.5) | 322 (45.7) | ||
| Other | – | 21 (3.0) | ||
In both questionnaires, patients were asked whether they had experienced a non-medical medication switch in the previous year. Patients could respond either yes, once; yes, more than once; or no (see Table 1, Appendix 2). If the respondents did not experience a medication switch, they were asked what type of information they would prefer if they would experience a medication switch.
The identical questions in both questionnaires, were background characteristics (i.e., birth year, gender, highest obtained education level, previously experienced medication switch), currently received and needed information type and content by patients. The categorization of the education level (low, middle, high) is in accordance with the Dutch central office for statistics.28 Questions only posed in the extensive questionnaire included: satisfaction regarding different communication and information aspects of the pharmacy staff member. Respondents could answer these questions on a 5-point Likert scale (very) satisfied to (very) unsatisfied, and with the option not applicable and/or did not occur in conversation. Additionally, respondents were asked whether they received and need information about medication switching.
The questionnaire for AMP was programmed by the Utrecht Institute of Pharmaceutical Sciences (UPPER) and a link to the online survey was distributed to panel members via a personal email. The AMP panel questionnaire was distributed on the 19th of March 2021 and closed on the 30th of March 2021. The extensive questionnaire for the patient organizations was programmed online by Nivel, Netherlands Institute for Health Services Research, and the general link to the questionnaire was sent around in the newsletter of the patient organization. For the patient organization panel, the questionnaire was sent by email to the panelists on the 25th of February and closed on the 18th of March 2021. No reminders were sent.
Completed patient questionnaires, originally in Dutch, can be requested from the corresponding author.
2.2.2. Data analysis
All pseudonymized data were stored on a protected server and processed. Specialized PTs and managers were also included in the pharmacy technician sample, as all of them indicated that they conducted conversations about medication switches at least a few times per week. The frequency scale used for the responses was merged into three categories: ‘frequently-often’, ‘sometimes’, and ‘rarely-never’. All fully completed questionnaires were used for the data analysis.
Regarding the patient panel questionnaires, when questions from both panel questionnaires were identical, the two sample populations were merged into one for data analysis. The additional questions from the panel with cardiovascular disease patients were analyzed separately.
Data analysis for the PT and patient samples first included descriptive statistics to describe the sample populations. For patients, the different background characteristics, gender, and level of education were investigated separately for both panels in relation to which information content and type patients received and need during medication switch encounters (see Appendix 2 for questions). The differences between patient groups were analyzed with chi-square tests. The reason being that there were two categorical variables, two or more categories (groups) for each variable, and independence of observations.
A significance level of p < 0.05 was used. The statistical software STATA version 16 was used for the data analysis.
3. Results
In total 138 PTs and 4679 patients (3962 AMP panelists and 717 panel members with cardiovascular disease) filled out the questionnaires. Of the 1167 (2021) pharmacy employees in the PAM panel, 138 completed the questionnaire fully (response rate (138/1167 = 12%). The AMP questionnaire was sent to the entire panel (n = 34,986). In total, 4502 started the questionnaire, of whom 3962 respondents met our inclusion criteria (response rate 11%). Lastly, of the circa 2600 panel members in the patient organization for cardiovascular diseases panel, 782 members gave consent and completed the questionnaire. Of these 782 panel members, 65 were excluded based on the screening questions (28% response rate).
3.1. Background characteristics of three samples
The majority of PTs were female (97.1%), had >20 years of work experience (81.9%) and worked in a middle-sized city pharmacy (48.6%). In total, from both panels, most patients were aged older than 65 years. Specifically, for the patients from the cardiovascular disease panel, 75% experienced a medication switch once or multiple times before, while 25% had not. In the general pharmacy patient panel sample, 42% of the patients had experienced a medication switch once or multiple times before, while 58% had not. Table 1 shows the characteristics of the study samples.
3.2. Pharmacy technician experiences conducting conversations about medication switching
Pharmacy technicians frequently have conversations about medication switching: 54% on a daily and 30% hourly basis. About 40% of all PTs indicated that they regularly experience these conversations as difficult. For example, about three-fourths (72%) of all the PTs indicated that they experience anger by a patient, usually multiple times per week/month. As a result, 41% indicated that these difficult conversations often negatively influence job satisfaction.
Pharmacy technicians also indicated that patients experience such conversations as difficult. Specifically, patients who have experienced a previous medication switch (89%), patients who use multiple medications (79%), older patients (59%), and patients who use medication for a longer time (41%) appear to have more difficulties with a medication switch. PTs less frequently mentioned that the following patient groups experience medication switches as a problem: patients who are confused (33%), patients with lower health literacy skills (26%), limited language proficiency (23%), or use a specific type of medication (17%).
3.3. Pharmacy technician-patient communication about medication switching
The majority (81%) of the PTs indicated that they told the patient that the medication appearance or medication box has changed. Moreover, a majority (71%) of the PTs stated that they have to give a different medication brand as a result of the policy of health insurance companies.
Most pharmacy technicians (86%) indicated that there is a difference in how they bring the news regarding the medication switch per patient or situation. According to PTs, a previous experience with a medication switch (87%), strong emotions (79%), hurried patients (52%), and a low language proficiency (48%) are factors that play a role in how the pharmacy technician delivers the message about a medication switch.
Almost all (99%) PTs indicated they listen actively to what the patient has to say on a frequent basis, and almost always give the patient room to ask questions (97%) (Fig. 1).
Fig. 1.
Frequency (% of respondents that indicated this option) in which pharmacy technicians (PTs) (N = 138) indicated that they apply different communication aspects in a conversation about a medication switch*.
* values under 5% are not reported as percentages in the figure.
Patients from the cardiovascular disease panel, who were informed about the switch by the pharmacy, most often indicated that they are (very) satisfied about how much time the pharmacy staff had for them (56%) and how seriously the pharmacy staff took them (51%) (Fig. 2). About three-fourths (73%) of the PTs indicated that they have enough time for the patient during a conversation regarding a medication switch (Fig. 1). Patients also perceived this since this was the aspect where more than half of the patients (56%) were most satisfied about (Fig. 2).
Fig. 2.
Extent to which patients from the cardiovascular disease panel, who were informed by the pharmacy about the switch, were satisfied (% of respondents indicated this option) with communication aspects regarding a medication switch*.
* excluding patients who indicated non-applicable as a response to this question.
Patients from the pharmacy panel AMP were positive about pharmacy staff members‘communication about the switch: 70% of these respondents were (very) positive, 27% had a neutral opinion and 3% was (very) negative. Moreover, one-third (33%) of the patients from the cardiovascular disease panel was (very) positive, 43% had a neutral opinion, and about one-fourth (24%) was (very) negative.
3.4. Received and preferred information content and type about medication switching
In total, half of the patients (51%) from both panels indicated that they were informed by the pharmacy (as opposed to another healthcare professional) during their previous medication switch. More than half (58%) of these patients indicated that they were informed verbally during pick-up or delivery by the pharmacy staff about the medication switch (Fig. 3). More than three-fourths (77%) of the pharmacy technicians indicated that patients are not informed about the medication switch prior to picking up or receiving the new medication via delivery. While verbal information during pickup/delivery (45%) and written (i.e., information letter or email) or oral (i.e., via the telephone) before pickup/delivery (29% and 18%, respectively) are preferred by patients (Fig. 3). Of the patients who have and who have not experienced a medication switch in the cardiovascular disease panel, 90% indicated that they do desire information about a medication switch from the pharmacy team.
Fig. 3.
Type of information patients from both panels combined received (N = 1016) and preferred (N = 2106, those who filled in the questionnaire and that did not experience a medication switch), (% of respondents indicated this option) about a medication switch*.
* Respondents could give more than one response to this question, and excluding patient who indicated ‘non-applicable’ on this question) - values under 5% are not reported as percentages in the figure.
Specifically, in the group of patients from the AMP pharmacy panel, highly educated people more frequently indicated (27%) that they want to receive written information during pick-up/delivery than people with a low educational level (19%) (P < 0.05) (Appendix 3, Table 2). Women (22%) and people with a middle level of education (20%) more regularly indicated that they want to receive verbal information in advance of pick-up/delivery than men (14%) (P < 0.001) and highly educated people (14%) (P < 0.05) (Appendix 3, Table 2). These comparisons with background characteristics are similar to with those of the patients from the cardiovascular disease panel (Appendix 3, Table 2).
Overall, approximately half of the patients from the cardiovascular disease panel (54%) indicated that they received enough information during their previous medication switch. As shown in Fig. 4, on all inquired topics, patients want more information than they receive. Patients prefer information about why the medication switch took place (68%) and about the (same) effect of the medication (61%), while fewer patients indicated they currently receive this information (21% and 39%, respectively) (Fig. 4).
Fig. 4.
Type of information content patients from both panels combined received (N = 1016) and preferred (N = 2106, those who filled in the questionnaire and that did not experience a medication switch) (% of respondents indicated this option) during an encounter about a medication switch*.
* values under 5% are not reported as percentages in the figure.
Specifically, in the group of patients from the AMP pharmacy panel, women (67%) and younger people (<40 years old and 40–64 years, combined) more regularly indicated (70%) that they want information about why the switch occurs than men (61%) (P < 0.05) and people aged 65 and older (61%) (P = 0.001) (Appendix 3, Table 2). In the patient group from the cardiovascular disease panel people with a middle-level education indicated more often (78%) that they prefer information about the (same) effect than people with a higher (70%) and lower (65%) level of education (P < 0.05) (Appendix 3, Table 2). Also, next to women who need information about why the switch took place in comparison to men (resp. 85% vs 78%; P < 0.05), also people with a higher education level (84%) and younger patients (<40 and 40–64 years old) (86%) more often indicated they prefer this information compared to people with a lower educational level (69%) (P < 0.05) and older patients (≥65 years old) (78%) (P < 0.05) (Appendix 3, Table 2).
4. Discussion
The aim of this study was to gain insight in experiences of pharmacy technicians and patients regarding the communication during medication switching encounters, and in specific to map the needs and preferences of patients and whether pharmacy technicians meet these. Generally, the communication during conversations about medication switches goes well. However, dealing with the emotions of patients for PTs is difficult. Patient satisfaction with the technicians' communication about the switch is divided. The patient group from the AMP panel were more positive than the patient organization panelists who were more critical. Moreover, patients highlight that they wish for more information than they currently receive during medication switch encounters. In about half of the cases, patients received information about the medication switch. This included information given by the pharmacy about why the switch took place and the (same) effect of the new medicine. When asking patients, both who have and who have not experienced a medication switch, almost all patients indicated that they desire information about the switch. Specifically, they desired to receive information before the switch. Most PTs confirm that they do not give information beforehand. This is a gap in meeting patients' information needs about medication switches.
There may be a difference in technician perceptions and patient perceptions of medication switch conversations. For example, PTs perceive themselves as giving the patient space to ask questions and respond, whereas only about half of patient respondents were satisfied with the space they were given to express concerns. Similarly, the majority of PTs claimed to frequently or often check if the patient has questions. Also in this situation, only about half of the patients indicated they were satisfied that the pharmacy technicians had asked if they had questions. These observations seem to suggest that there is a difference in perceptions between what PTs claim they do during conversations about medication switches and what the patient perceives happens in these conversations. However, it is possible that there is a bias in the included respondents, particularly that those who are satisfied with switches may be more inclined to complete the questionnaire. Nevertheless, aligning these insights on how well the communication is perceived by both parties involved and by sharing these with pharmacy staff is important. By doing so, for example in the form of training on communication and consultation, this can only improve communication during encounters at the pharmacy counter.
Dealing with patients' emotions in conversations about medication switches is often experienced as difficult by PTs. A conversation about a medication switch is different than for example a standard pharmacy counter conversation (e.g., about a first dispense or refill), as it is about bringing a negative message that cannot be changed. For instance, the medication is simply not available, or the pharmacy technician cannot avoid the fact that the patient has to pay themselves if they want their preferred medication. For these reasons, conversations about medication switches can be seen as bringing negative news. This is because of the frequent emotion in these conversations and the need for finding solutions after addressing the patient's emotion. Due to the powerless position of the patient and the pharmacy technician, the impact of delivering negative news is high. Expression of negative emotions can be a way patients show underlying mechanisms such as fear of side effects or doubts about the effectiveness of the medication.19 Patients who become desperate, for example, those who often experience medication switches, in return may more frequently show these negative emotions. These negative emotions often include being upset, angry, frustrated, surprised, and even aggressive.17,19 These emotions have an impact on the job satisfaction of pharmacy technicians. PTs may not experience such difficult conversations daily, though these difficult conversations are usually the ones with the most impact. Hence, it is important that the pharmacy technician understands the reason behind the emotional response. By pinpointing the reason, the PT and patient can more effectively address solutions for the root of the patient-experienced problem.
Moreover, patient's satisfaction about the communication during these conversations was divided between the two patient populations. Specifically, there was a difference in satisfaction with communication in the conversation between the generic patient group and the patient organization group with cardiovascular disease. Reasons for this difference may be that patients from a patient organization are active members and are often also interested in completing a questionnaire and therefore willing to share their experiences. Perhaps these patients are more active patients who are more concerned with health and therefore have more expectations/needs with regard to healthcare providers. Also, these patients have more often experienced medication switches as opposed to the people in the other panel. Further, these patients may experience medication switches more sensitively. As a result, they may be more critical about their experiences regarding medication switch conversations.
Looking at the information needs of patients, most patients receive information verbally while picking up/delivery of the medication. There is also a group of patients that would like information on the medication switch before pick-up/delivery. Repetition of information to better uptake and remember information is a facilitating factor related to information provision and decision-making. These are crucial in patient care.29 This is particularly important in difficult conversations, as emotions also block how the patient receives the information. Hence, patient concerns must first be taken away, otherwise the patient will not take in the information. The reason being that patient's recall of provided information is hampered as their information processing does not work optimally in such situations. Previous research indicated that affective communication of the healthcare provider, i.e., expression of feelings about things, others, and themselves, is important to decrease patients' uncertainties, and thereby improving information recall.30
Also, according to previous research on breaking bad news, preparatory information is key in decreasing the experienced distress by patients.31 In this study, conversations about medication switches are on a different scale than, for example, a cancer diagnosis. However, the principles used in the conversations may be the same.32 As shown in previous research,20 providing information prior to the switch may already decrease potential negative emotions experienced by the patients. This idea is also echoed in literature as heightened emotion in bad news conversations highlights the need for patient preparation, mentally and emotionally, before the patient-provider interaction.18 Therefore, one of the best ways to prepare patients for such conversations is by providing them with medication information that matches their needs. This supports patients, so they can make informed decisions13,31,33, 34, 35, 36 where possible during these situations. In return, patients are better supported in understanding the information provided.1 This is crucial as patients who are better informed about their medications, feel less uncertain about their medication use, which increases treatment benefits and adherence.37,38 Henceforth, receiving written information beforehand, or even after the news has been brought is important so the patient can either prepare for the conversation or review the written information after the heightened emotion has returned to its normal state. The patient's need for written information prior to pick-up/delivery is also endorsed by the fact that the majority of the pharmacy technicians indicated that they indeed did not inform patients prior to pick-up. This gap in needs between the patient and what occurs in practice is important to fill.
4.1. Strengths and limitations
A strength of this study is that the experiences from both the patient and provider perspectives were investigated. Also, the use of anonymous questionnaires is a strength, as this creates a space where the respondents can be open and honest. Using questionnaires also allowed us to collate the experiences and opinions of many respondents in a short time frame, which was sufficient for the explorative nature of this study. Another strength is the use of two patient panels, which allowed for more variety of patients, and more generalizable results. The AMP panel is representative of pharmacy visitors. Additionally, using the population of chronic users from the cardiovascular disease panel allowed us to gain more in-depth views on their experiences regarding medication switches.
A limitation is that this study included self-reported experiences. However, due to the variation in type of participants included in this study, these new insights provided a complete picture of the how the communication and information provision is during a conversation regarding medication switching. Another limitation is the representativeness of the samples, where the pharmacy technicians were relatively old, and the patients were relatively highly educated. The mean age of pharmacy staff in the Netherlands is 41.6 years,39 while the mean age was about ten years older in this sample. The high number of female respondents reflects staff working in Dutch pharmacy practice, as about 90% of the staff working in Dutch communities is female.40 The AMP panel sample is representative for pharmacy visitors and chronic medication users in general. These patients are older compared to the general population. However, these differences are less relevant because we aimed at patients who have experienced a medication switch. The same goes for the sample from the patient organization. Moreover, a significant limitation is that we did not immediately send out the questionnaire after the medication switch. Hence, the potential recall bias on how well people remember what information was provided and recall between those with a positive and negative medication switch experience.
4.2. Implications for practice and research
It is important for pharmacy staff to continue to incorporate the (communication) aspects that are perceived as (very) satisfactory by the patients, as this increases tailored patient-centered communication in the pharmacy practice. Concrete examples are how seriously the pharmacy staff member treats the patient and how much time the pharmacy staff member has for the patient, which are aspects that are more focused on how well a patient is treated. Also, specific communication aspects, such as the room the pharmacy staff gives the patient to ask questions or the pharmacy staff member asking the patient if they understood the explanation, are important to incorporate in these types of conversations. These aspects can also be included in communication training and education programs for pharmacy staff. Making sure that the patient has understood what has been told is key to proper medication use, as these aspects can confirm the patient's understanding or reveal unanswered questions or uncertainties. Hence, by incorporating these aspects in pharmacy practice, this can lead to proper medication use and increased job satisfaction for pharmacy staff members.
Moreover, pharmacy staff can continue to give information during pick-up, but also call or provide written information before the switch, specifically about why the medication switch took place and if the effect of the (new) medication is the same. Time and occupancy remain a bottleneck, as well as the number of medicine switches and shortages, which do not seem to be decreasing yet. Informing the patient in advance, via the telephone or an information letter, can save time at a later point during a medication switch. Also, an upset or even angry patient at the counter takes extra time. At first, this extra effort may take additional time. However, as this is an investment in the relationship with the patient. In return, this will later give more trust and ease during conversations at the pharmacy counter. It is important to spread this knowledge to pharmacy staff via training/education, e.g., in the form of best practices as learning from practice examples is valuable.
Adapting the desired information content and type to specific types of patients is also a way to tailor the conversations to patients' needs and preferences. Previous literature shows that people have different preferences regarding patient-provider communication. Particularly, women often prefer a more active role during consultation than men,38 and so do younger people compared to older.41 Our study shows that particularly women and middle-level education patients wish to receive verbal information before the medication switch. In the pharmacy, the patient's education level is usually unknown. Hence, to focus on this patient trait is difficult. However, if the pharmacy staff member finds that the patient has trouble understanding or comprehending the information given, verbal information instead of written information may be preferred.
This study also serves as valuable input for a follow-up study, in which we give pharmacy team tools via a communication skill-based training on delivering the news during conversations about medication switches. In this way we ensure that the communication tools are in line with the experiences and needs from practice. It is important to address the needs and preferences in the training, as well as (further) develop tailored information to foster an understanding of switching in patients. Also, this study is a good starting point to further investigate how the emotions of both the pharmacy technicians and patients influence pharmacy-counter conversations in pharmacy practice.
5. Conclusion
Generally, pharmacy technicians believe that non-medical medication switch conversations are going well. However, there is a perspective difference between what pharmacy technicians claim they do during these conversations and what the patient experience. For example, this includes providing space for questions and how satisfied patients are with this communication aspect. This observed difference can partly be a sample selection matter. Additionally, dealing with the patients' emotions remains difficult. Regarding patients' needs and preferences, patients emphasize that they desire more information than they currently receive about a medication switch, preferably before the medication pick-up or delivery takes place. Most pharmacy technicians confirm that they do not provide information in advance. Matching these needs and preferences can improve patient-centered communication.
Declaration of Competing Interest
LS received funding from TEVA and EIT Health for studies not related to this study.
LvD received funding from Biogen, the Dutch Ministry of Health, Zilveren Kruis, ZonMw, EIT Health, and TEVA for studies not related to this study.
MV received funding from AstraZeneca, Biogen, ZonMw, EIT Health, and Teva for studies not related to this study.
MH has no competing interests to declare.
EK has no competing interests to declare.
Acknowledgements
The authors would like to thank all the pharmacists, pharmacy technicians, and patients who participated in the study. This work was supported by the Royal Dutch Pharmacists Association (Koninklijke Nederlandse Maatschappij ter bevordering der Pharmacie, KNMP).
Footnotes
Supplementary data to this article can be found online at https://doi.org/10.1016/j.rcsop.2023.100259.
Appendix A. Supplementary data
Supplementary material 1
Supplementary material 2
Supplementary material 3
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