Introduction

Community pharmacists today are involved in a wide variety of professional activities. These activities can be classified as either product or patient-oriented (Faris and Schopflocher, 1999; Bradshaw and Doucette, 1998; Rosenthal et al., 2011). Although a large number of papers have been published on description of the pharmacists’ responsibilities and attitude towards patient counseling (Brook et al., 2003; Oliveira and Shoemaker, 2006; Kansanaho et al., 2004), little attempts have been carried out in Saudi Arabia to assess pharmacist’s attitude towards such an issue (Bawazir, 1992; Al-Arifi et al., 2007). Thus in this study an in depth approach is made to justify pharmacists’ attitude towards professional responsibilities and examine factors that encourage or inhibit pharmacists from counseling.

Methods

The survey was done in a total of 114 pharmacies (Riyadh, Saudi Arabia) by a questionnaire during 2009-2010. The self-questionnaire used was described in a previous article (Ortiz and Thomas, 1984). Respondents were given 36 items with a variety of issues on patient counseling. Items on the questionnaire were grouped in three categories by type of subject matter as follows:

• Attitude to professional responsibilities 6 items.

• Reasons for deciding to counsel 15 items.

• Reasons for deciding not to counsel 15 items.

All items were scored on five-point (Strongly Agree to Strongly Disagree), Likert scale. Scores were represented by numerical. 5 for strongly agree, 4 for agree, 3 for uncertain, 2 for disagree, and 1 for strongly disagree. Collected data were then analyzed and results are presented as means and standard deviations. An average score for each item was determined by multiplying the responses’ numbers times the relevant score. These findings were then divided by the total number of respondents. Average score of each item was obtained.

Results

A total of 114 out of 126 respondents completed the questionnaire. The results are shown in Tables 1, 2, 3 and 4. Table 1 show that scores on attitudes regarding professional responsibilities generally were high, usually over 4 on a 5-point scale. The results also show that the great majority of the respondents (>90%) agreed or strongly agreed that community pharmacists should counsel the patient about OTC and prescription medications. They also agreed that the pharmacists should have good relationships with other health care providers (92%) and keep up-to-date with current drug information (85%).

The exception was for the item “the need to attend a continuing education function”, which had an average score of 3.75, whereas the highest score is for the item “The community pharmacist should be committed to the rules and regulations governing the practice of pharmacy with an average score of 4.68. Comparison of level of agreement shown in Table 1 with the level of counseling, such as number of patients and time spent in counseling produced a correlation coefficient (r) of +0.513. Moreover, the results shown in Table 2 indicate a number of reasons in favor of counseling. Over 90% of the pharmacists agreed or strongly agreed that the public respects pharmacists as drug experts and drug information providers’ worth to be consulted. The good rapport between pharmacists and their regular customers is invaluable to the pharmacist to offer an effective counseling which will enhance patient compliance. Furthermore, about 88% of the respondents agreed or strongly agreed that medications must be taken correctly according to stated instructions and patient counseling will add more professional responsibilities to pharmacists as well. On the other hand, 87% of the pharmacists agreed or strongly agreed that counseling may prevent the patient from experiencing adverse drug effects. Similar proportion, agreed or strongly agreed that counseling improves the pharmacist’s knowledge (81%) and practicing ability (84%) and consequently increases job satisfaction.

In contrast, 7 of the 15 items regarding reasons for deciding to counsel had scores generally below 4 with agreement rating of 3 to 4. This illustrates that respondents were uncertain about these 7 items on reason given for counseling which include that counseling improves patient-pharmacist and pharmacist-physician relationships. This appreciates the extra care interest shown by them, reduces drug wastage, brings more people into the pharmacy, enables pharmacist to be an active member in the health care team and increases sales. Scores on attitudes dealing with reasons against counseling were shown in Table 3 which indicates a much wider distribution of low-score values than was true for items in Tables 1 & 2. None of the scores on the 15 items was above 3, showing that the overall trend in these items is towards disagreement with stated reasons against counseling. Despite this, the results show that there are many factors which inhibit the pharmacist from counseling. Lack of medical history, meager confidence in knowledge, perceiving of the benefits of counseling by customers and lack of feedback from patients were among these factors. Furthermore, less than 18% of the pharmacists may have been presumably inhibited from counseling because they were too busy and people attitude toward pharmacist’s consultation is of no significant value on their health. Other factors that may significantly influence counseling such as unnecessary and unacceptable extra responsibility by pharmacists and their belief that patient counseling is the physician’s responsibility or they do not know how to approach the people. Finally to obtain a professional role attitude, average scores of each item in Tables 1-3 have been combined to form a scale reflecting two attitude scores namely, professional responsibilities and orientation towards patient counseling attitude scores. The later attitude scores were computed by summing the responses to the reasons for deciding to counsel and subtracting the sum of the responses against counseling. Table 4 shows that pharmacists expressed a high level of agreement with items concerning professional responsibilities. On scale of 6 as a minimum value to 30 as a maximum value, the average level of agreement was 25.92±SD. Like wise, orientation towards scores based on data in Tables 1-2 shows an average score of 27.5±SD.

Figure 1

Table 1: Pharmacists’ attitudes to items about the professional responsibilities of the community pharmacist (n=114)

a. The average level of agreement which is obtained by averaging responses according to the following scale: Strong agree=5, Agree=4, Uncertain=3, Disagree=2, Strongly disagree=1. n. Total number of respondents

Figure 2

Table 2: Pharmacists’ attitudes towards items about reasons for deciding to counsel (n=114)

a. The average level of agreement which is obtained by averaging responses according to the following scale: Strong agree=5, Agree=4, Uncertain=3, Disagree=2, Strongly disagree=1. n = Total number of respondents

Figure 3

Table 3: Pharmacists’ attitudes towards items about reasons against deciding to counsel (n=114)

a. The average level of agreement which is obtained by averaging responses according to the following scale: Strong agree=5, Agree=4, Uncertain=3, Disagree=2, Strongly disagree=1. n = Total number of respondents

Figure 4

Table 4: Professional role attitude scores and orientation towards patient counseling score

Discussion

The study revealed that most of the respondents are in support of counseling, and believe that counseling is of benefit to the patient. Table 1 shows that over 90% of the responding pharmacists agreed or strongly agreed that community pharmacists should counsel about both prescription and non-prescription drugs. These results are in agreement with reported findings by other investigators (Sutters et al., 1993; Covington, 2006; Gull et al., 2007). ^{The responding pharmacists also agreed with the activities needed to support counseling behaviors and improve communication skills of the pharmacist such as maintaining a good working relationship with other health care professionals and the need to be up-to-date with drug information (Manias et al., 2007). Furthermore, an overwhelming support was given for the item “The community pharmacist should be committed to the rules and regulations governing the practice of pharmacy”. The results reflect the willingness of a majority of the pharmacists to adhere to these regulations and show higher level of loyalty to their profession. In addition, it may also indicate the awareness of the community pharmacist about the consequences of not complying with the law that may not only encourage self-medication but also exposes the population to hazards of medications (Gull et al., 2007; Trewin and Veitch, 2003). In contrast, analysis of individual items regarding pharmaceutical responsibilities shows much uncertainty about the need for a continuing education function. It is clear that unwillingly-ness among these pharmacists towards this statement could be attributed to long working hours and the complexities and competing demands of their schedules of duties in the community pharmacy which was observed in a previous study (Driesen et al., 2005). Moreover, Table 2 indicates a high level of recognition by most of pharmacists of the possible benefit of patient counseling, as well as a high level of agreement by responding pharmacists (>90%) that the community respects pharmacists and expects them to counsel and that knowledge about customer which will enable them to offer an effective counseling. They also agreed that counseling improves patient compliance and increases job satisfaction. However, some pharmacists were still uncertain about the remaining reasons given for patient counseling, namely whether counseling could improve pharmacist-patient and pharmacist-physician relationships or could lead to any economic advantages.}

Analysis of individual items’ responses (Table 3) shows a considerable difference in opinions and much disagreement about reasons against deciding to counsel. Although the trend in all attitudes is towards disagreement with the stated reasons not to counsel, one could recognize that the stated attitude is highly desirable, and could be considered as a major factor that inhibits some pharmacists from counseling. However, maintaining a patient medication record and asking information about medical history does not necessarily mean that the pharmacist adequately monitors drug information or uses the information to appropriately counsel the patient. So it is clear that there is a need to develop guidelines or regulations for professional-practice pertaining to medical records, and taking medical history as far as the needs of counseling by community pharmacist are concerned. In this context, the collaboration between the different health care professionals can be best achieved by electronic links between hospitals or clinics and pharmacies (Negishi et al., 2003). Likewise, the lack of feedback from patients was another reason that prevents some pharmacists from counseling. Clearly, the feedback from patient is valuable for proper counseling and greatly assists in the development of communication skills. Similarly, a slightly high level of support given for items “I lack confidence in my knowledge” and “I do not know enough about drugs and their effects” were not accepted as justifiable reasons to inhibit counseling among these pharmacists on the basis that pharmacists are considered as experts in ensuring the rational use of drugs and in communicating drug information to patients and other health professionals. Apart from these reasons, other factors that contribute adversely to counseling are presented in Table 3. In fact, these factors were generalized and can be considered as a basis for the development of counseling and communication skills. For testing the consistency of attitudes with counseling behaviors’ scores regarding professional responsibilities, they were correlated with the time spent in counseling. Even though these correlations were weak but positive (0.513), the attitude scale stated did not explain all of the variations between respondents. Therefore, coefficient of determination (r²) was calculated and a value of (+ 0.263) was obtained which indicates that 26.3% variability in the level of agreement can be accounted for by its linear relationship with time spent in counseling. This low level of correlation illustrates that time spent in counseling depends on other factors such as type of problems required to be counseled for and how busy is the pharmacist. Further, the presented orientation towards patient counseling scores revealed that the higher respondent score, the more advice received by the patient. In addition, those respondents with higher professional responsibilities scores were expected to counsel more patients.

Conclusions

The appreciation of counseling community pharmacists by patients in this study indicated ability of pharmacists to play a vital role in health education and recognition of professional responsibilities. The results obtained showed that (i) the communication skills are helpful to maintain good working relationship with other health care professionals to up-date the drug information, (ii) awareness of law may not encourage self-medication and avoid exposure to toxic medicines, (iii) uncertainty to continue education was due to long working hours and complexities of the schedule of duties, (iv) uncertainty also prevailed about the importance of counseling in pharmacist-patient and pharmacist-physician relationships and the possible economic advantages, (v) there is often a paucity of medical history which obstructs counseling, (vi) there is a need to develop guidelines or regulations for professional-practice pertaining to medical records (vii) the collaboration between the different health care professionals can be best achieved by electronic links between hospitals or clinics and pharmacies (viii) there is a need for an in-depth study on patient’s attitude towards community pharmacy counseling in other regions of Saudi Arabia.