Quality supply of nonprescription medicines in Portuguese community pharmacy: An exploratory case study

Research in Social and Administrative Pharmacy j (2015) j–j

Original Research

Quality supply of nonprescription medicines in Portuguese community pharmacy: An exploratory case study Paulo Veiga, M.Pharm.a,*, Luı´ s V. Lapa˜o, Ph.D.b, Afonso M. Cavaco, Ph.D.a,c, Mara P. Guerreiro, Ph.D.d,e a

Instituto de Investigac¸a˜o do Medicamento (iMed.ULisboa), Faculdade de Farma´cia, Universidade de Lisboa, Av. Prof. Gama Pinto, 1649-003 Lisboa, Portugal b WHO Collaborating Center for Health Workforce Policy and Planning, Global Health and Tropical Medicine, Instituto de Higiene e Medicina Tropical, Universidade Nova de Lisboa, Portugal c Faculdade Farma´cia Universidade de Lisboa (FFUL), Lisbon, Portugal d Centro de investigac¸a˜o interdisciplinar Egas Moniz (CiiEM), Instituto Superior de Cieˆncias da Sau´de Egas Moniz (ISCSEM), Monte da Caparica, Portugal e Escola Superior de Enfermagem de Lisboa (ESEL), Lisboa, Portugal

Abstract Background: Inappropriate use of non-prescription medicines (NPM) can increase morbidity, mortality and health care associated costs. Pharmacists have a well-established role in self-medication; however, the literature shows that pharmacies performance in the supply of NPM is often suboptimal. Objective: To explore the interaction and dependability of pharmacy staff use of oral language, as well as staff’s own assessment of reasons underlying their behavior during consultation regarding NPM. Methods: In a case-study design, a high street urban community pharmacy was purposively selected as the setting. Covert patient simulation, using trained simulated patients (SPs), was used to ascertain staff’s performance in dispensing NPM, via 4 symptom-based scenarios (SbS) and 3 product-based scenarios (PbS). Performance data were converted into 2 composite indexes: the Interpersonal Performance Index (IPI) and Technical Performance Index (TPI). Audiotaped interactions were transcribed verbatim and participants’ utterances were identified, time stamped and coded employing the eight higher level categories of a framework inspired by the Roter interaction analysis system (RIAS). The transcripts of the in-depth interviews were analyzed using the Framework Approach. The tripartite model of attitudes was employed to develop the thematic framework. Results: Ten SP visits were considered for analysis. Overall, the mean TPI score was 50% and the mean IPI score was 78%. TPI was higher for SbS (63%) than PbS (31%), whilst there was little difference IPI between SbS (79%) and PbS (76%). The mean number of questions in the evaluation section of technical performance was 4 for SbS and 1 for PbS. There was a clear predominance of closed questions (32%), when compared with open questions (5.5%). Providing advice was more frequent (23.5%) than giving information (12.5%). In line with the SPs data, comparison of information-gathering in SbS and PbS shows that more questions were asked in the former (44% versus 31%), which resulted in more information given by SPs (56% and 49%, respectively). Staff’s reaction to their performance showed all the * Corresponding author. Tel.: þ351 917 153 592. E-mail address: paulojcveiga@ff.ul.pt (P. Veiga). 1551-7411/$ - see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.sapharm.2014.12.009

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3 dimensions of attitude: affective, cognitive and behavioral. Divergence between staff’s views on what should be done in NPM consultations and performance data surfaced in the interviewees’ accounts on direct product requests. While performance data shows that information gathering was scarce, its importance was overtly acknowledged. Conclusions: The supply of NPM appears to be influenced by both cognitive and emotional issues. This suggests that multimodal improvement interventions are needed, targeting not only technical and interpersonal communication skills but also the organizational context. Managerial tools such as the balanced scorecard, may prove valuable in addressing improvement in the quality supply of NPM. Ó 2015 Elsevier Inc. All rights reserved. Keywords: Pharmacies; Non-prescription medicines; Patient simulation; Case-study; Patient-oriented communication

Introduction Self-medication is a phenomenon of growing importance. In Europe, non-prescription medicines (NPM) recorded a net growth greater than prescription only medicines (POM) for the first time in 2008; the current value for the total NPM market stands at around V73 thousand million.1 In Portugal the use of NPM for the relief of minor illnesses has been encouraged by Government policy for more than a decade, resulting in a list with approved indications for self-medication.2,3 Table 1 depicts information to enable an understanding of the context within which NPM are supplied. It has long been recognized that selfmedication can be beneficial for multiple stakeholders – consumers, health care professionals, pharmaceutical industry and the health system – but it is not without risks.4 Inappropriate use of NPM can increase morbidity, mortality and health care associated costs.5,6 Pharmacists have a well-established role in self-medication, by screening signs and symptoms, aiding product selection and advising on the safe

and effective use of NPM.7 Pharmacies are often the first port of call for consumers with minor illness. However, the literature shows that pharmacies performance in the supply of NPM is often suboptimal.8 Notably, most published studies measured professionals’ adherence to commonly accepted technical standards, but only a minority assessed both technical and interpersonal communication aspects of NPM provision.8,9 Acknowledging the potential to learn from pharmacies whose performance stands out according to accepted quality criteria for dispensing NPM, this study aims to address pharmacy technical and interpersonal performance in this respect and aspects that might influence it. It is a study objective to explore the interaction and dependability of the pharmacy staff use of oral language, as well as staff’s own assessment of reasons underlying their behavior.

Methods A case-study design was chosen. This approach enables the investigation of complex issues in a

Table 1 Key notes on NPM supply in Portugal  Medicines are classified into prescription-only (POM), pharmacy-only (P) and non-prescription (NPM). The former two categories are available only in pharmacies; the latter is available in pharmacies and independent/chain retail stores. In any case medicines are only available behind the counter.  P and NPM prices are set under free market rules, as opposed to POM, which have fixed prices by the government.  Pharmacies are privately owned and managed; ownership is open to non-pharmacists (with exceptions, such as medical practitioners, wholesalers and pharmaceutical companies) and restricted to a maximum of 4 pharmacies per approved person.  Each pharmacy must be staffed with at least 2 pharmacists, the pharmacy manager and a pharmacist who replaces the manager’s duties in his absence (pharmacies which have less than 60% value of the average annual turnover nationally can legally dispense the second pharmacist).  Retail outlets selling NPM must operate with a responsible person (pharmacist or pharmacy technician) for every 4 sites.

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naturalistic setting, by employing multi-methods in purposive samples.10 A high street urban community pharmacy was purposively selected, due to standing out performance in a previous smallscale patient simulation study and ease of access.11 Ethical approval was granted for the study. Pharmacy staff signed informed consents and

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confidentiality agreements were obtained from simulated patients (SPs). The pharmacy was subjected to SP visits, using 4 symptom-based (SbS) scenarios – dry cough, diarrhea, dyspepsia, productive cough (Table 2) – and 3 product-based scenarios (PbS) – topical nasal decongestant, oral diclofenac and oral

Table 2 Symptom-based scenarios for patient simulation SbS

Complaint

Diarrhea

Information to be provided only if asked Expected outcome

I would like something Went 3 or 4 times to the bathroom with for my diarrhea. liquid diarrhea since yesterday. No fever, cramps or bloating. Hasn’t taken anything for the diarrhea yet. Doesn’t take any medication. No recent traveling, change in daily routine, medical conditions or allergies. Doesn’t think she’s pregnant. Prompting after a product has been recommended: “I’m on the pill, does this medicine interact with the pill?” Had diarrhea in the 4 h following taking the pill. Dyspepsia I need something for a The medicine is for the SP. If location is stomach ache. asked – points to the pain (epigastric region), relates the pain with stress (exams or work related, pending on SP age). Has symptoms for a month and has already taken 2 packets of non-prescription omeprazole in accordance with the correct posology. Doesn’t take other medication. No dark feces or weight loss. Notes that symptoms are worse after drinking coffee. No health problems or allergies. Dry cough I need a syrup for my Dry cough, which worsens at night, SP’s mother’s cough. mother hasn’t been sleeping well the last month. Has taken 2 bottles of syrup; doesn’t remember the names. Takes a medicine to lower blood pressure. If asked, describes a packet of an ACE inhibitor and pronounces the name incorrectly, confirms that it’s lisinopril if checked by pharmacy staff. No other health problems or allergies. Productive I want something to It is for the SP’s father. He has a cough relieve a cough. productive cough for the last 2–3 days. Hasn’t taken anything yet. He is on diabetes medication. No other symptoms, health problems or allergies. Patient doesn’t smoke. a

Selection and dispensing of an appropriate NPM, based on adequate evaluation, followed by appropriate counseling.

Medical referral, based on treatment failure.a

Medical referral, based on symptom duration and possible iatrogenic effect (ACE inhibitor-induced cough).

Selection and dispensing of an appropriate NPM, based on correct evaluation followed by appropriate counseling.

Two weeks is the maximum approved treatment duration, according to the summary of product characteristics.

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Table 3 Product-based scenarios for patient simulation PbS

Product request//prompting (if no questions asked)

Information to be provided only Expected outcome if asked

Medical referral, based on Topical Nasal Can I have a packet of NasexÒ, The medicine is for the SP’s possible iatrogenic effect please?//Is there anything mother, who has nasal Decongestant (rebound congestion) better? My mother is using congestion and uses this for a few weeks but isn’t decongestant several times a getting better. day. She has been with symptoms for a few weeks. Has only used this medication and says “it was better at the beginning, now she uses it more frequently”. No other medication. Patient has asthma and allergies. Dispensing Voltaren 25Ò or Oral Diclofenac Can I have a packet of Voltaren It is for the SP’s girlfriend/ 25Ò, please?//Is this bad for another analgesic, based on boyfriend. S/he takes a capsule correct evaluation and the stomach? My boyfriend/ in the morning and another at appropriate counseling night. Works a lot with a girlfriend has stomach problems. computer, occasionally complains of wrist pain when working for longer hours (which is the case now). Has only used this medication and doesn’t take any other meds. Had stomach ulcers in the past. OEC dispensing, based on OEC I want a morning-after pill, NPM is for SP. Sexual correct evaluation and please.//No prompting intercourse occurred in the appropriate counseling. previous night; no contraceptive method was adopted. Has never taken OEC and doesn’t take any other medication. No health problems or allergies. Last menstrual cycle 2 weeks ago. Has no reason to believe she’s pregnant.

emergency contraception (OEC) (Table 3). The use of diverse scenarios is justifiable considering that the literature shows variations in pharmacies performance according to scenario type, especially in SbS versus PbS.12–16 SPs were trained in a 2-h session, which included scenario role-play and filling in data collection forms. These consisted of previously tested checklists with interpersonal and technical criteria (Table 4). SPs were instructed to show no signs of hurry or impatience and to accept the recommended product(s), with exception of the NasexÒ scenario, in which only this medicine should be purchased. Some of technical criteria used to score evaluation in the OEC scenario were different:

establishes when did sexual intercourse occur, confirms that sexual intercourse was unprotected, asks whether OEC had already been used in the current menstrual cycle, inquires about current medication, and collects other pertinent information (possible pregnancy, medical conditions). In any case compliance with criteria described in Table 4 would indicate the quality supply of NPM. SPs completed the checklists immediately after each visit. Additionally, visits were audiotaped, which allowed verification of data integrity and analysis of verbal communication. Performance data were converted into 2 composite indexes, the Interpersonal Performance Index (IPI) and

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Table 4 Criteria to assess the quality supply of NPMa  Technical performance: B Evaluation: asks who is the medicine for (if applicable); obtains a description of symptoms; establishes symptoms duration; asks about actions already taken to alleviate the symptoms; inquiries about current medication; gathers further pertinent information (e.g. chronic conditions); refers the consumer to a physician, if applicable. B Product selection: appropriate product; the selected medicine is non-prescription. B Advice-giving: explains what is the medicine for; counsels verbally about dosage; counsels verbally about treatment duration; provides written posology information; provides verbal or written supplementary information (e.g. nonpharmacological measures, information leaflet); advises on what to do if symptoms persist. B Follow-up: encourages reporting on treatment outcomes.  Interpersonal performance: B Consultation opening: greets the client; establishes the reason for the consultation; maintains eye contact. B Body of the consultation: checks for understanding of the advice provided. B Consultation closure: indicates the consultation closure; maintains eye contact; says goodbye and thank you. a This metrics has been developed based on a literature and pilot-tested by 4Choice Health Consultancy to measure the quality supply of NPM. There is on-going validation work.

Technical Performance Index (TPI), expressed in percentage:

Perspectives of staff members on the quality supply of NPM and their performance were

IPI ¼ ðnumber of interpersonal criteria met=total number of applicable interpersonal criteriaÞ  100 TPI ¼ ðnumber of technical criteria met=total number of applicable technical criteriaÞ  100

Performance data were analyzed with the aid of SPSSÒ v.18. Audiotaped interactions were transcribed verbatim and participants’ utterances – i.e. the smallest distinguishable speech segments – were identified, time stamped and coded employing the eight higher level categories of a framework inspired by RIAS.17 Coding categories included open questions about medical, therapeutic and lifestyle (LS)/psychosocial (PS) aspects, closed questions about medical (e.g. “do you have high blood pressure?”), therapeutic and lifestyle (LS)/ psychosocial (PS) (e.g. have you been on vacation recently?) aspects, the provision of information on medical, therapeutic (e.g. this medicine should not be used for more than five consecutive days) and lifestyle/psychosocial aspects and the provision of advice in the same topics. Provision of information is identified in utterances related to all information stated in a non-interrogative form and provision of advice is identified in utterances that suggest or imply some resolution to be taken by the SP.

collected using qualitative semi-structured interviews. The topic guide (Table 5) was informed by the results of the previous SP visits as well as the study objectives, and deployed by general feedback on NPM dispensing performance. The interviews took place in the pharmacy, in a private area, with minimum interruptions; these were audiotaped and transcribed in full, using participants’ own words. Interviews data were analyzed using the Framework Approach,18 with the aid of NVivoÒ v10. The tripartite model of attitudes was employed to develop the thematic framework. This theory, put forward by Rosenberg and Hovland, categorizes responses to attitude objects into cognitive, affective and behavioral types.19 Cognitive responses are grounded in thoughts and conceptions about an attitude object and they can be discerned as verbal expressions of beliefs. Affective responses refer to emotional evaluations and feelings either verbally expressed or detected as physiological reactions. Behavioral responses can be either expressions of behavioral intentions or overt, observed acts.19

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Table 5 Semi-structured interview guide Main topics 1. What’s the role of the pharmacy in self-medication? 2. Consider when consumers present a complaint of a minor ailment: can you think of an example of a good consultation from your own practice? 3. Consider when consumers present a complaint of a minor ailment: can you tell us an example of a consultation where you had difficulties? (after the initial response prompt with performance data) 4. What could be done to surpass these difficulties in NPM consultations? 5. Consider when consumers ask directly for an NPM: can you think of an example of a good consultation from your own practice? 6. Consider when consumers ask directly for an NPM: tell us one example of a consultation where you had difficulties. (after the initial response prompt with performance data) 7. Relating strategies to overcome difficulties – do you wish to add something to what you have said before? 8. For you, what’s the importance of performing quality dispensing interactions? 9. Do you feel that quality supply of NPM is a priority in the pharmacy where you work? 10. In your opinion, which measure(s) could be taken by the various stakeholders to improve self-medication assisted by the pharmacy?

Results Simulated patients’ data A total of 14 visits were conducted. Ten visits were considered, covering the 4 SbS and 3 PbS presented (the diarrhea, productive cough and VoltarenÒ scenarios were repeated twice). Checklists underestimated staff’s performance in 5 visits and overestimated their performance in 2 visits; in the remainder 3 scores were unchanged. Three visits were excluded from analysis because audio records indicated that the SP had provided information without being asked; a fourth visit was excluded since it involved a pharmacy student in his community rotation. Visits included in the analysis involved 1 pharmacist (P), 1 pharmacy technician (PT) and 3 counter assistants (CA1, CA2, CA3), who were later interviewed. The pharmacist was involved in 5 interactions (diarrhea, dyspepsia, 2 time’s productive cough and OEC) and the other staff members were subjected to the remaining 5 interactions (dry cough, diarrhea, NasexÒ and 2 VoltarenÒ consultations). Overall, the mean TPI score was 50% and the mean IPI score was 78%. TPI was higher for SbS (63%) than PbS (31%), whilst there was little difference IPI between SbS (79%) and PbS (76%). As depicted in Fig. 1, in SbS the evaluation criterion more frequently met was information gathering about other pertinent aspects (n ¼ 6) and symptom duration (n ¼ 5). In contrast, questions about “other medication” were only asked in 1 visit. The mean number of questions per visit was 4. The question “Who is the medicine for?”

was posed in 2 of the 3 applicable interactions. Referral was recommended in 1 of the 2 applicable interactions (which was not subsequently analyzed for advice-giving). In what concerns advice giving in SbS (Fig. 2), the criteria that pharmacy staff better complied with was verbal counseling about dosage (n ¼ 5), verbal counseling about treatment duration (n ¼ 4) and providing verbal or written supplementary information (n ¼ 4). In contrast, the least met criteria were providing written dosage (n ¼ 1) and advising on what to do if symptoms persist (n ¼ 1). Pertaining to PbS, evaluation was poorer (mean number of questions per visit was 1), and occurred only after prompting by SPs. Criteria regarding who was the medicine for and actions already taken were never met. Notably, no question was posed in the OEC scenario. Referral was suggested as one of the options in the rebound congestion scenario, the others were

Fig. 1. Performance in symptom-based scenarios (evaluation criteria).

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Fig. 2. Performance (advice giving).

in

symptom-based

scenarios

nasal irrigations with saline or seawater spray. Referral to a physician was recommended in one of the VoltarenÒ consultations. Advice-giving was also poorer in PbS, when compared to SbS. When VoltarenÒ was dispensed, providing oral supplementary information was the only criteria met. Supplying of OEC was coupled to verbal counseling about dosage and providing oral supplementary information. Transcripts from visits resulted in 129 utterances from staff (92 in SbS and 37 in PbS; 45 from the pharmacist and 84 from other professionals) and 124 from simulated patients (79 in SbS and 35 in PbS). Overall, the mean duration of an

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interaction was 4 min and 20 s, ranging from 1 m:08 s to 8 m:22 s. The analysis of verbal content is presented in Table 6. The absolute frequencies were divided by number of interactions in order to obtain comparable results. There was a clear predominance of closed questions (32%), when compared with open questions (5.5%). Providing advice was more frequent (23.5%) than giving information (12.5%). Longer interactions were not necessarily associated with more extensive evaluation or patient counseling. In line with the SPs data, comparison of information-gathering in SbS and PbS shows that more questions were asked in the former (44% versus 31%), which resulted in more information given by SPs (56% and 49%, respectively). Qualitative interviews The quality supply of NPM in pharmacy was unanimously regarded as important by interviewees. Both altruistic and business reasons seem integral to understanding this stance. Some accounts illustrate a concern for consumers’ convenience. For example, the pharmacist said: “It’s very important . dispensing non-prescription medicines, because it prevents people from going to hospitals and health

Table 6 Verbal communication – relative frequencies of coded categories in percentage: % ¼ (X utterances/SbS utterances or PbS utterances)  100

Closed questions 1. Medical 2. Therapeutic 3. Lifestyle (LS)/psychosocial (PS) Open questions 4. Medical 5. Therapeutic 6. LS/PS Give information 7. Medical 8. Therapeutic 9. LS/PS Advice 10. Medical and therapeutic 11. LS/PS Other utterances 12. Orientation 13. Personal dialog 14. Concern 15. Optimism

SbS: pharmacy staff

SbS: simulated patient

PbS: pharmacy staff

21% 7% 8%

0% 10% 1%

14% 14% 0%

0% 6% 0%

5% 3% 0%

0% 0% 0%

0% 3% 0%

3% 3% 0%

0% 10% 1%

33% 15% 8%

3% 11% 0%

20% 26% 3%

13% 10%

0% 0%

24% 0%

0% 0%

8% 13% 1% 1%

0% 30% 0% 3%

3% 27% 3% 0%

0% 37% 0% 3%

Number of interactions: SbS ¼ 6; PbS ¼ 4; Pharmacist ¼ 5; Other professional ¼ 5.

PbS: simulated patient

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centers when there is no need, we can easily solve their problems in the pharmacy” (P). Other accounts emphasized a concern with the business: “We have to pay more attention, there will be more competition and if we get more customers with non-prescription medicines it’s a plus for the pharmacy, so we have to concentrate and focus on that” (PT). Interviewees attempted to demonstrate that a quality supply of NPM, which differentiates the pharmacy from competitors, was beneficial for capturing and retaining customers. As one counter assistant put: “. because of all the competition out there [ . ], if you also have quality in serving customers they’ll obviously seek that pharmacy . where they feel well, where they feel informed” (CA1). However, there was a general perception that questions or advice were not always well received by consumers, either because of their “fixed ideas” on products, which could differ from what pharmacy staff regarded as the most suitable option, or their perceptions of medicines as an ordinary good: “. people have become so accustomed to medicines that it seems it’s just a simple thing [ . ] they even say, but this is sold without prescription .” (PT). Interviewees showed awareness of the importance of good interpersonal communication to overcome these difficulties. Data analysis of staff’s reaction to their performance showed all 3 dimensions of attitude: affective, cognitive and behavioral. The affective dimension was expressed either as disappointment, caused a mismatch between staff’s perception of performance and evidence provided in this respect, or satisfaction, for what was considered acceptable performance. Additionally, it emerged when conveying feelings about dispensing interactions, such as stress and lack of self-confidence: “There are situations where I have more doubts, where there is more pressure and one gets a little intimidated” (CA1). Cognitive and behavioral dimensions arose when staff attempted to justify their actions. Interviewees provided several reasons to explain incomplete evaluation in their consultation performance. For example, one counter assistant invoked the case of acetaminophen when attempting to demonstrate that not all questions are necessarily relevant: “There are certain types of questions you don’t need to cover, basically Ben-uronf does not have any kind of interaction with other medicines or illnesses, as far as I can recollect, and therefore it makes no sense to ask about other medicines or health problems” (CA3). f

Brand of acetaminophen tablets.

Divergence between staff’s views on what should be done in NPM consultations and performance data surfaced occasionally. This is illustrated by interviewees’ accounts on direct product requests. While performance data shows that information gathering was scarce, its importance was overtly acknowledged: “I think we have to bear in mind that we can’t overlook evaluation, we can’t jump into counseling. Often we check if the person knows how to take the medicine but we don’t check whether it’s really needed or if it is the right medicine” (P).

There was unanimous agreement on how forgetfulness could negatively impact on evaluation and advice giving; several issues emerged as contributors to this problem, such as tiredness, distractions and pressure from awaiting or difficult clients: “. those cases of forgetfulness also . one is tired, the colleague is under pressure or thinking about something else and it’s possible to forget to do every step, we all know the steps, right?” (CA2).

When talking about incomplete counseling, a common stance was assuming that a consumer requesting a medicine by its name would be already informed about it: “I guess many times we assume that if the person asks (for the medicine) it’s because she already knows how to use it, knows what is it for, has used it previously” (P).

Two interviewees discussed how they would used information leaflets to replace counseling in topics that were perceived as embarrassing for consumers, such as OEC: “you bag in the information leaflet, the person takes it home and reads it ( . ) sometimes you try to explain it at the counter but they look a bit uncomfortable” (CA2). In regards to providing written dosage information, a commonly held belief was of not being welcomed by consumers: “many times the person doesn’t want us to write in the package, they say that they already know . and don’t want (us to write)” (P). It was recognized that often this would rest on staff’s perceptions, and not necessarily confirmed by asking the client. Other reasons invoked for not providing written dosage information were inconvenience to the pharmacy in case the transaction fell short and believing it was unnecessary, as the consumer would be informed.

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When discussing facilitators to improve consultation performance, there was general concordance about the importance of proper training. Protocols, mnemonics and using medicines information in the pharmacy computer system were also mentioned: “we can see the interactions, contraindications, almost without the customer noticing, and I think that helps a lot” (PT). Praising and encouragement from the pharmacy manager was unanimously regarded as a contributor: “of course that helps, encouraging and recognition of one’s work,” (CA3). Discussion This study set out to explore the quality of NPM consultation, from both a technical and interpersonal perspective, using a case study that involved in-depth interviews with staff informed by previous covert observation of dispensing interactions. This approach has seldom been employed and it is one of the strengths of the study. Case studies traditionally use multi-methods in small samples. Only one pharmacy has been recruited for this exploratory study. While this should be acknowledged as a limitation, it yielded interesting insights and informed the design of a later study within the program of work. Data suggest that pharmacy staff accepted the criteria employed to measure the quality supply of NPM, although each staff member emphasized different aspects. Ideally, quality criteria to measure performance should be endorsed by stakeholders; a popular approach for this purpose is using a consensus technique.20 At the time of data collection the metrics used in this study had not been validated; other published studies suffer from the same problem.12,14 Overall and based on the quality criteria used, technical performance was satisfactory (50%) and interpersonal performance was excellent (78%). In accordance with the literature12–16 technical performance was higher in SbS (63%) than PbS (31%). In the latter, evaluation was limited or absent. The finer analysis of interpersonal communication shows that staff tends to control the exchange of information and its contents through closed questioning (32%), when compared with open questions (5.5%). Analysis of qualitative data showed that both cognitive issues, such as staff’s preconceptions, and emotional issues, such as stress and motivation, influenced NMP consultation performance. Staff’s motivation toward the quality supply of NPM was grounded

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on both personal traits, such as altruism, a business concern and leadership’s incentive. A study comparing data collected via checklists by SPs with the respective audio recording demonstrated 10% of data variation.21 In this study audio recording was used to check data integrity. Additionally, it led to the exclusion of non-conforming visits, thus enhancing data validity. The fact that SPs did not always behaved in accordance with instructions stresses the importance of selecting trustworthy persons, train them appropriately and maintain quality control procedures during data collection. An overuse of closed questions in consultations is corroborated by literature.9,17 All except one counter assistant provided examples of commonly used therapeutic closed questions, which were among the most frequently asked questions. Although most interviewees provided examples of medical and therapeutic open questions, analysis of oral communication in consultations shows these were rarely asked. This may jeopardize effective information gathering, especially if closed question are used in the initial stages of patient consultation. The prevalence of advice giving (23.5%) versus the provision of information (12.5%) is hardly surprising, considering the framework in which pharmacists and other staff members are trained and the practice context. Nonetheless, in the absence of effective information gathering, tailoring advice to patients’ needs and desires may prove challenging. Other studies also identified the need for pharmacy consultations to become more patient-oriented.9,17,22,23 Given the sensitive nature of OEC requests these consultations should be carried in a private area.24,25 In the present study the SP was not offered this option, although the pharmacy was equipped with a separated seated consultation area. No insights were obtained as to why this infrastructure was not used when interviewing the staff member involved in the consultation. A recent validation study of the metrics employed to measure the quality supply of NPM suggests that the use of private consultations areas may be impaired by a perception of longer consultation times, judged unfeasible in light of the current remuneration system.26 Additionally, some staff members were of the opinion that some consumers felt confortable with consultations taking place at the counter. An Australian survey on women’s experiences obtaining OEC in community pharmacy showed that 38% felt there was

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not enough privacy, generally because they unable to talk in private or could be observed by other people getting the medicine.27 While the occasional lack of customers in the pharmacy may ensure privacy even when consultations take place at the counter more research is needed on consumers preferences in this respect. Facilitators identified by participants to improve performance are not unexpected. For example, training was unanimously cited in this respect but some found this approach to be insufficient to improve performance.28 It is unlikely that change is dependent on a single factor.29 On the contrary, the influence of leadership reminds us that staff’s performance cannot be isolated from the organizational and management context, including aspects such as organizational culture,30 organizational flexibility31 and entrepreneurial vision.32

Conclusion The supply of NPM appears to be influenced by both cognitive and emotional issues. This suggests that multimodal improvement interventions are needed, targeting not only technical and interpersonal communication skills but also the organizational context. Managerial tools such as the balanced scorecard, which take into account clients’ perspectives, internal processes, innovation and learning and a financial perspective, seem unexplored but may prove valuable in addressing improvement in the quality supply of NPM. More research is warranted on clients’ perspectives, as this study suggests that discrepancies exist in the perceptions of “quality” between consumers and community pharmacy staff. Also, larger studies, involving in-depth interviews with staff informed by previous covert observation of NPM consultations, would enable a better understanding of the reasons underlying discrepancies between staff’s perceptions and their behaviors and possible facilitators for improvement. Acknowledgments This research project was only possible due to the kind participation of pharmacy staff and the enthusiasm of the pharmacy manager in welcoming the study. Appreciation is also due to simulated patients. Finally, a thank you goes to Sara Martins, who helped with data collection and participated in the earlier study design.

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