Research in Social and Administrative Pharmacy 11 (2015) 63–73
Original Research
Pharmacists’ influences on prescribing: Validating a clinical pharmacy services survey in the Western Pacific Region Jonathan Penm, B.Pharm. (Hons.)a,*, Betty Chaar, B.Pharm., M.H.Law, Ph.D.a, Grenville Rose, B.A., Ph.D.b, Rebekah Moles, B.Pharm., Dip.Hosp.Pharm., Ph.D., Grad. Cert. Ed. Stud. (Higher Ed.), F.S.H.P.a a
Faculty of Pharmacy, World Hospital Pharmacy Research Consortium, The University of Sydney, Camperdown, NSW 2006, Australia b Aftercare, Rozelle Hospital, Church Street, Lilyfield, NSW, Australia
Abstract Background: Hospital pharmacists around the world are becoming increasingly involved in promoting the responsible use of medicines through clinical pharmacy services. This is reflected in the Basel Statements developed by the International Pharmaceutical Federation Hospital Pharmacy Section, particularly the theme ‘Influences on Prescribing.’ Some countries, particularly in Asia, are currently establishing clinical pharmacy services and would benefit from identification of facilitators. Objectives: To validate a survey exploring clinical pharmacy services focusing on pharmacists’ influences on prescribing, based on Basel Statements 28–31, and the factors that affect their implementation in the Western Pacific Region (WPR). Methods: Content and face validity of the survey (BS28-31) was established. This resulted in the BS28-31 consisting of 20 questions, which included a Clinical Pharmacy Services Facilitators (CPSF) scale (25 items) to measure respondents’ perceptions of facilitators of clinical pharmacy services. The BS28-31 was emailed to hospital pharmacy directors in the WPR. The survey was made available in English, Japanese, Chinese, Vietnamese, Lao, Khmer, French and Mongolian. Principal components and internal consistency analyses were conducted to assess the reliability and construct validity of the CPSF scale. Results: The final survey was sent to a total of 2525 hospital pharmacy directors in the WPR of which 726 were returned from 31 nations yielding a response rate of 29%. Two items in the scale were removed due to low communalities (0.22 and 0.16). The resulting 23 item scale produced a parsimonious two-factor solution, divided into internal (e.g. individual pharmacist traits and pharmacy departmental structure/resources) and environmental facilitators (e.g. government support, patient and physician expectations). This two factor solution explained 51.5% of the variance. In addition, the Cronbach’s a for the internal and environmental subscales were 0.94 and 0.78 respectively. The authors have declared no conflict of interest. * Corresponding author. Tel.: þ61 2 9036 5035; fax: þ61 2 9351 4391. E-mail address: [email protected] (J. Penm). 1551-7411/$ - see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.sapharm.2014.04.001
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Conclusion: The BS28-31 survey was found to be a reliable and valid instrument for assessing hospital pharmacy directors’ perceptions of clinical pharmacy services regarding pharmacists’ influences on prescribing and their facilitators in the WPR. Ó 2015 Elsevier Inc. All rights reserved. Keywords: Western Pacific Region; Hospital pharmacy; Clinical pharmacy services; Validation; Basel Statements
Introduction It is estimated that more than half of all medications prescribed, dispensed or sold worldwide are inappropriate.1 Inappropriate prescribing can lead to avoidable adverse drug events in patients and potential harm.2 To promote responsible use of medicines, pharmacists have endeavored to expand their role to promote patient safety and influence prescribing.3 Hospital pharmacists are well placed to pursue this role due to their close proximity to prescribers and have been shown to improve prescribing practices, prevent adverse drug events, reduce medication errors, costs and patients’ length of stay, and lower mortality.4–10 The movement toward pharmacists’ focus on patient safety is further reflected in the Basel Statements, which represent the unified vision of preferred hospital pharmacy practice services and functions around the world.11 The Basel Statements were agreed upon by 98 nations at the inaugural Global Conference on the Future of Hospital Pharmacy, hosted by the International Pharmaceutical Federation (FIP) in 2008 in Basel, Switzerland. The Basel Statements included 75 statements that were subdivided into ‘Overarching Statements’ and six themes, with medication safety being a core consideration for all the statements.11 Basel Statements 26–32 in particular, constitute the theme ‘Influences on Prescribing,’ a topic that is the main focus of this study. Hospital pharmacists’ influences on prescribing incorporates a large range of activities affecting prescribing at both institutional and individual prescriber levels. At the institutional level, hospital pharmacists are usually the key members of Pharmacy and Therapeutics Committees responsible for managing the hospital’s medicine formulary system and the responsible use of medicines within the hospital, as stated in Basel Statements 26 and 27.12–14 Basel Statements 28–31 outline the additional responsibilities of hospital pharmacists to extend their role to educate prescribers on the appropriate use of medications (Table 1).3 In response to this, hospital pharmacy services in some countries have incorporated pharmacists
into regular patient rounds and allocated to them the responsibility of reconciling patients’ medications on admission.3 These expanded clinical pharmacy services have further developed pharmacists’ influences on prescribing and increased their responsibility over patient outcomes.15 Bond and colleagues have published a number of studies showing the beneficial effect of such expanded clinical pharmacy services on major health care outcomes, such as mortality.7–9,16 In particular, clinical pharmacy services that influence prescribing like ward round participation, reconciling patients’ medications on admission and providing drug information or in-service education have been associated with decreased total costs of care,16 mortality rates,8 medication errors9 and adverse drug reactions.7 A number of facilitators have been recognized that could assist pharmacy departments develop
Table 1 Basel Statements 28–31 in the theme ‘Influences on Prescribing.’a Number Basel statement 28
29
30
31
Hospital pharmacists should have a key role in educating prescribers at all levels of training on the access to and evidence for optimal and appropriate use of medicines, including the required monitoring parameters and subsequent prescribing adjustments. Hospital pharmacists should be involved in all patient care areas to prospectively influence collaborative therapeutic decision-making. Hospital pharmacists should be an integral part of all patient rounds to assist with therapeutic decision-making and advise on clinical pharmacy and patient safety issues. Hospital pharmacists should provide continuity of care by transferring patient medicines information as patients move between sectors of care.
a Reproduced from: The Basel Statements on the future of hospital pharmacy. Am J Health Syst Pharm 2009;66:S61-66.
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clinical pharmacy services in hospitals where these services have not been established. Research from the United States (US) and Canada has identified factors such as: the number of staff, adoption of new technology, whether the pharmacy is based within the hospital, leadership, expectations of the physicians, and accreditation standards to facilitate the implementation of these clinical pharmacy services.8,9,17 Campagana and Newlin (1997) proposed eight factors as being the most influential in facilitating enhanced services.18 These factors were further classified as either environmental or individual. The environmental factors include: public expectations, law and regulations, economic structure and the practice setting itself.18 The individual factors included the pharmacist’s personality, attitude, expertise and motivation.18 Additional facilitators have also been identified in qualitative work conducted in Australia. Moles et al (2004) conducted over 50 interviews with hospital pharmacists in Australia and identified hospital size, type, location, model of service provision, hospital contracts, requirements for accreditation, resources and training of the pharmacists as affecting discharge counseling services provided by clinical pharmacists.19,20 Further qualitative work focusing on Basel Statements 28–31 has also been conducted in China with 130 participants, including hospital administrators, pharmacy directors, clinical pharmacists and dispensing pharmacists.21 The main issues identified affecting hospital pharmacists’ influence on prescribing included: external factors outside the control of the pharmacy department, resources available to implement the pharmacy services and the attitudes of the clinical pharmacists and the expectations of themselves and by others.21 As multiple factors have been identified, Campagana and Newlin proposed theoretically that the individual factors; attitude, expertise and motivation, are the most important as they can be changed and controlled by the pharmacists.18 The pharmacists’ personality was the only individual factor that they argued cannot be changed.18 In some countries, hospitals have accordingly developed a formalized competency assessment program and increased formal documentation in their medical records to positively address these individual factors.22–25 Within the community pharmacy sector, researchers have endeavored to validate scales to quantify which factors most strongly affect the implementation of expanded pharmacy services.
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Blake et al (2010) validated a scale in the US identifying three factors: perceived ability to respond to patient interest, pharmacy related factors and enabling factors.26 Enabling factors included adequate support staff and physician attitudes.26 The authors highlighted that the pharmacists’ perceived ability to respond to patient interest was the greatest facilitator for offering expanded services.26 Roberts et al (2008) also validated a scale in Australia and identified seven factors that affected pharmacy services.27 Of these, relationship with the physician had the highest median factor score and was believed to be the most important factor.27 Similar factors would be expected within the hospital setting. However, as these scales were validated within the community setting, all of them incorporated the importance of the pharmacy layout to allow additional services to be provided. This may not be required in the hospital setting as many clinical services are delivered on the ward and not within the pharmacy. With the expansion of pharmacists’ influences on prescribing and clinical pharmacy services in hospitals around the world, the development of a validated survey that could be used internationally could aid in prioritizing resources for hospitals developing their clinical pharmacy services. The Western Pacific Region (WPR) has been an area of great interest as it constitutes nearly onequarter of the world’s population, with countries that are socially and economically diverse.28 As such, it has been proposed that validating a survey in such a diverse area would render the instrument globally applicable.29 The WPR includes countries from Asia, Australia, New Zealand and numerous Pacific Islands (Fig. 1).28 Previous research in the WPR has explored hospital pharmacists’ influences on prescribing at an institutional level, focusing on medicine formularies, and Pharmacy and Therapeutics (P&T) committees as described in Basel Statements 26 and 27.13,29 This research highlighted that hospitals that have over half of their medication management policies overseen by the P&T committee and having a hospital pharmacy director that strongly believed in the benefits of medicine formularies were more likely to have more formulary medicines linked to standard treatment guidelines, based on the best available evidence, and have a policy for the use of off-label medicines.13 As a result, it appeared having strong hospital pharmacy leadership aligned with the goals of the hospital, facilitated hospital
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Fig. 1. Countries and nations within the Western Pacific Region are highlighted in yellow. The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the authors concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. SAR: Special Administrative Region. (For interpretation of the references to color in this figure legend, the reader is referred to the web version of this article.) Reproduced and modified from the World Health Organization. http://hiip.wpro.who.int/portal/Countryprofiles.aspx; Accessed 02.04.14.
pharmacists’ influences on prescribing at an institutional level. To further advance this global initiative, the aim of this paper was to validate a survey in the WPR to explore clinical pharmacy services regarding pharmacists’ influence on prescribing, and the factors that affect their implementation, based on Basel Statements 28–31.
Methods This study was approved by the University of Sydney Human Research Ethics Committee. Survey development and distribution An initial survey was developed by the research team based on Basel Statements 28–31 and previous research, along with review of the literature.13,21,29–33 Although Basel Statement 32 regarding collaborative prescribing by hospital
pharmacists was also included under the theme ‘Influences on Prescribing,’ it was excluded in this study. This statement was excluded as many countries in the WPR have only recently started implementing clinical pharmacy services and are not able to pursue collaborative prescribing without drastic legislative changes. Previous international surveys in hospital pharmacy were also reviewed in developing this survey.29,34 These surveys generally used ordinal responses for classifying pharmacy services such as !3% (very few), 3–50% (some), 51–97% (most) and 97% (nearly all).29,34 However, ordinal responses limit the interpretation of statistical analyses, as small changes cannot be measured.13 Accordingly, a continuous scale was adopted to measure the percentage of patients that received clinical pharmacy services and the percentage of time a pharmacist spent on providing these services, so more meaningful statistical analyses can be undertaken.
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The survey included questions designed to investigate the extent Basel Statements 28–31 (BS28-31) were implemented, such as the percentage of time spent on providing clinical pharmacy services and education to prescribers, as well as the types of services offered. Additional questions that may explain some of the variations in practice were also included such as the hospital’s funding status, number of beds and number of pharmacists. Additional factors affecting the implementation of clinical pharmacy services were included as
items in the Clinical Pharmacy Services Facilitators (CPSF) scale (Table 2). This scale measured respondents’ perception of the importance of each item using a 5-point Likert response from “Does not facilitate” to “Strongly facilitates.” All questions were sent to a WPR Advisory Committee that included prominent leaders of hospital pharmacy from Australia, China, Taiwan, Philippines and Singapore, to aid in the development and evaluation of the BS28-31 survey. These leaders were identified and recruited
Table 2 Factor loadings for the two-factor varimax rotated solution and communalities of the refined 23-item Clinical Pharmacy Services Facilitators (CPSF) scale Itema
Factor loadingsb
R. Having clinical pharmacists that are motivated to constantly improve their own practices and knowledge S. Having clinical pharmacists that take professional responsibility for the medicines prescribed to their patients Q. Having clinical pharmacists that are confident in their abilities T. Having clinical pharmacists with strong communication skills P. Having access to relevant treatment guidelines O. Having pharmacists specifically trained to deliver clinical pharmacy services U. Having role models for the clinical pharmacists to follow W. Having strong relationships between the pharmacy department and other health professionals in the hospital M. Access to competency standards or performance evaluation tools for clinical pharmacy services V. Ensuring clinical pharmacists document their recommendations in patients’ medical records L. Access to guidelines on how to implement clinical pharmacy services N. Having adequate staff to provide clinical pharmacy services X. Adoption of new technology by the pharmacy department Y. Increasing the role and responsibilities of pharmacy technicians/ assistants K. Pharmacy director support for clinical pharmacy services B. Hospital administrator support for clinical pharmacy services A. Government support for clinical pharmacy services F. Monetary remuneration for clinical pharmacy services C. Prescribers’ expectations of clinical pharmacy services D. Patients’ expectations of clinical pharmacy services E. The hospital is accredited by an external organization (e.g. Joint Commission International, JCI) G. The hospital is liable for medication errors J. Doctors are NOT remunerated by drug companies to prescribe H. Being part of a large hospitalc I. Being located in an urban areac
0.843
0.146
0.731
0.833
0.145
0.715
0.830 0.814 0.771 0.728
0.081 0.140 0.212 0.301
0.696 0.682 0.639 0.620
0.710 0.684
0.136 0.173
0.523 0.498
0.676
0.339
0.572
0.663
0.273
0.513
0.653
0.298
0.515
0.644 0.625 0.564
0.305 0.265 0.171
0.508 0.461 0.347
0.557 0.077 0.094 0.079 0.278 0.170 0.308
0.362 0.789 0.767 0.675 0.593 0.583 0.498
0.441 0.628 0.598 0.462 0.429 0.368 0.343
0.261 0.209 – –
0.494 0.438 – –
0.313 0.236 – –
Communalities
Component 1 Component 2
a
Items are displayed in descending order of factor scores. Factor loadings above 0.4 for each item are bolded. c Items H and I were removed from the analysis due to low communalities of 0.22 and 0.16 obtained respectively when analyzed with all 25-items in the CPSF Scale. b
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through FIP’s Western Pacific Pharmaceutical Forum (WPPF). All members have worked in hospital pharmacy for at least a decade and have held a leadership role at their respective institutions. Furthermore, each member had extensive knowledge of hospital pharmacy practices in the WPR. Based on our previous research in the WPR,13 the survey was also translated by certified translators from English to Japanese, Chinese, Vietnamese, Lao, Khmer, French and Mongolian, to allow participation from all countries within the WPR. The standard forward-backwards approach was used to ensure accuracy of these translations.35 This required the survey to be translated to the desired language and then translated back into English by a blinded certified translator to identify any discrepancies in translation.35 Furthermore, high-quality forward translations were ensured by employing certified translators experienced in health care translations as suggested by Leple`ge and Verdier (1995).36 The number of responses required to validate a scale used in a survey is contentious. Guadagnoli and Velicer (1988) suggest that the absolute magnitude of the loadings required is determined by the absolute sample size.37 However, as the absolute loadings are unknown prior to the study, this criterion is difficult to predict. Other recommendations have ranged from having 2–20 respondents per item38 and absolute sample sizes of 300 being a ‘good’ and 1000 being an ‘excellent’ sample size.39 To ensure that a high level of accuracy was obtained and the large variation of practices in the WPR was accounted for, the strict upper limited of 20 respondents per item was sought. With 25 items in the CPSF scale, a minimum of 500 responses was thus required.38 A 25% response rate was also assumed to account for decreased response rates observed in similar studies,13,40,41 thereby requiring at least 2000 surveys to be administered. To ensure timely distribution and collection of data, the survey was developed as an Internetbased survey on SurveyMonkey (SurveyMonkey, Portugal, Luxembourg, US). Hospital pharmacy associations in each nation were invited to send an email to pharmacy directors in their database, with a hyperlink to the survey. An email reminder was sent to nonrespondents at one week and three weeks after the initial email. The Pitcairn Islands were excluded as they do not have a hospital.28 Data collection occurred between July and December 2013.
Data analysis The BS28-31 survey data were analyzed for both validity and reliability. Validity ensures the survey is measuring what it is intended to measure, while reliability ensures it obtains consistent results on repeated trials.42,43 Data analyses were performed using IBM SPSS Statistics version 22 (IBM Corp, Armonk, NY) and a web-based parallel analysis engine called Parallel Analysis Engine to Aid Determining Number of Factors to Retain.44 Both face and content validity of the survey were assessed by the WPR Advisory Committee. Face validity ensures that the questions appear relevant, reasonable, unambiguous and measure what they intended to measure.45 Content validity ensures that the complete content range of the chosen construct under study is being tested.42,43 CPSF scale The CPSF scale within the BS28-31 survey was also subjected to both construct validity and reliability testing. Construct validity refers to the degree to which the survey measures the theoretical construct it is intended to measure.38,42,43 Principal components analysis (PCA) was used to investigate construct validity as it analyses the relationships among large numbers of variables.38 PCA allows related items to be grouped into a part of a construct or factor.38 Factors are identified when screened for eigenvalues greater than 1.046 and compared to the results obtained from the scree test47 and parallel analysis.48 These factors can then be interpreted by theoretically derived hypotheses concerned with the concept being measured. The factor loadings required to retain an item is also debatable, with authors traditionally retaining items with factor scores O0.3.49 However, absolute sample sizes have also been shown to affect the required factor score needed to produce reliable factor solutions. It is recommended that each loading is tested for significance at a ¼ 0.01 (two-tailed test).38 Thus, for a sample size of 300, a factor score O0.3 is required, while a sample size of 600 requires a factor score O0.21 to fulfill this requirement.38 Additionally, it is recommended that items share at least 15% of their variance with the factor when identifying new factors.38 This requires items to have a factor loading of R0.4. As a result, items that produced factor loadings !0.40 or cross-loaded on two or more factors were removed from the final CPSF scale.38
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The reliability of the CPSF scale was further measured using internal consistency analysis. This method produces a Cronbach’s a that examines the inter-item correlations, with a value of R0.70 being considered acceptable.50
Table 3 Number of survey responses collected by country or nation Country or nation
Number of Number of responses complete received responses to the CPSF scale received
Australia Cambodia China Cook Islands Fiji French Polynesia Hong Kong Japan Kiribati Korea, Republic of Lao People’s Democratic Republic Macao Malaysia Micronesia, Federated States of Mongolia Nauru New Caledonia New Zealand Northern Mariana Islands, Commonwealth of the Palau Papua New Guinea Philippines Samoa Singapore Solomon Islands Taiwan Tokelau Tonga Tuvalu Vanuatu Vietnam Total
117 5 161 3 4 1 10 213 1 38 19
97 5 138 2 3 1 9 189 1 17 19
3 26 2
3 19 2
2 1 2 19 1
2 1 2 18 1
1 10 14 1 2 2 37 2 1 1 2 25 726
1 8 9 0 2 1 23 2 0 1 1 20 597
Results To ensure an adequate response rate was achieved, all contactable hospital pharmacy directors in the WPR were emailed the link to the survey. A total of 2525 surveys were distributed to 37 different nations in the WPR (Table 3). A total of 726 responses were received from 31 nations giving a response rate of 29%. Of these, 298 respondents completed the survey in English, 213 in Japanese, 161 in Chinese, 25 in Vietnamese, 19 in Lao, five in Khmer, three in French and two in Mongolian. No responses were received from American Samoa, Brunei Darussalam, Guam, Marshall Island, Niue and Wallis & Futuna. Of those who responded, 75.8% (n ¼ 550/726) were from public hospitals and 24.2% were from private hospitals. The median bed size of the hospitals was 505 (range, 1–6000) with a median number of 20 pharmacists (range, 0–289). Validity Face and content validity of the BS28-31 survey Eleven experts in hospital pharmacy assessed the BS28-31 survey for both face and content validity. The initial draft survey contained 20 questions including the CPSF scale which consisted of 24 items. All questions were considered relevant and alterations in the wording and ordering of the questions were deemed necessary for 11 of the questions to enhance the usability of the survey. Questions regarding pharmacy services on weekends were modified to adjust for the diverse cultures in the Western Pacific Region, some of which do not follow a Saturday and Sunday weekend. As numerous questions required the respondent to calculate the percentage of time a pharmacist spent on varying tasks, specified time frames were given to aid interpretability, such as “within an average week.” The final survey retained all 20 questions and included an additional item to the CPSF scale, giving it a total of 25 items. Construct validity and reliability of the CPSF scale Due to missing data, the CPSF scale was only analyzed in 597 respondents (Table 3).
Results of this scale were initially assessed regarding its suitability for PCA. Inspection of the correlation matrix revealed the presence of many coefficients of 0.3 and above. The Kaiser-MeyerOlkin value was 0.93, exceeding the recommended value of 0.651,52 and the Bartlett’s Test of Sphericity reached significance with P ! 0.00153 supporting the factorability of the correlation matrix. PCA revealed the presence of five components with eigenvalues exceeding 1.0. The scree test revealed a break after the third component on
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the scree plot. In addition, the parallel analysis confirmed three components with eigenvalues exceeding the corresponding criterion values for a randomly generated data matrix of the same size (25 variables 597 respondents, Table 4). As a result, analyses with two, three and four components were undertaken for further investigation. The two component solution appeared the simplest to interpret. However, two items in the scale, items H and I, appeared to have relatively low communalities, 0.22 and 0.16 respectively, and factor loadings, 0.40 and 0.36 respectively. Item H related to ‘being part of a large hospital’ and item I related to ‘being located in an urban area.’ As items with communalities of less than 0.3 may indicate that they do not fit well with the other items in the component, they were removed and the data were re-analyzed.50 The refined 23-item CPSF scale produced a parsimonious two component solution and explained a total of 51.5% of the variance, with the first and second component contributing to 41.9% and 9.6% respectively. To aid in the interpretation of these two components, varimax rotation was performed. The rotated solution revealed the presence of simple structure with both components showing a number of strong factor loadings (R0.4) and all variables loading substantially on only one component (Table 2). The first component contained fifteen items describing internal factors of the pharmacy department. The second component contained eight items representing environmental factors. These results supported the bi-dimensionality of the CPSF scale in the BS28-31 survey. Reliability The Cronbach’s a value for the refined 23-item CPSF scale was found to be 0.93. In addition, the Cronbach’s a value for the first and second subscales were 0.94 and 0.78 respectively. These Table 4 Actual and random eigenvalues for the full 25-item Clinical Pharmacy Services Facilitators (CPSF) scale used for the parallel analysis Component
Average eigenvalue
Actual eigenvalue
1 2 3 4 5
1.39 1.33 1.28 1.25 1.21
9.88 2.22 2.06 1.23 1.04
values exceeded the recommended value of 0.7 indicating adequate internal consistency.50
Discussion The BS28-31 survey is the first survey to be validated in the hospital pharmacy setting exploring the implementation of clinical pharmacy services regarding pharmacists’ influences on prescribing. After establishing construct validity, the finalized CPSF sub-scale constituted 23 items. This is considerably less than the 43-item scale developed by Roberts et al (2008)27 but more than the 11-item scale developed by Blake et al (2010).26 Our review of the literature and previous research in China21 highlighted that additional factors appeared to affect the implementation of clinical pharmacy services in hospitals not included in either of these previously validated scales. These included additional standards and guidelines relevant to the hospital setting, accreditation of the hospital, government and hospital administrator support and individual factors such as the pharmacists training, professionalism and motivation.21 Furthermore, the 43-item scale produced by Roberts et al was considered too extensive as survey length has been associated with a decreased response rate,54 particularly for such a diverse region. Thus, our 23-item CPSF scale was the first scale tailored for the hospital environment. Both items H and I were removed from the initial 25-item CPSF scale during the construct validity analysis. Item H and I asked if large hospitals or hospitals that are located in an urban area facilitate the implementation of clinical pharmacy services. These factors have often been cited as affecting clinical pharmacy services in hospitals in countries within the WPR.19,21 However, their inclusion in the CPSF scale appeared problematic in producing a reliable factor solution. These items may have been difficult to answer, as many respondents may not have been exposed to a variety of hospitals which differed in size or location. Furthermore, the wordings of these items did not clearly specify what was meant by a large hospital or urban area and may have led respondents to subjectively interpret these items and decrease their validity. As a result, we recommend that using the hospitals’ number of beds and location via zip codes may be more accurate in future studies to identify the impact of size and location on the implementation of clinical pharmacy services.
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Doctors remuneration to prescribe, item J, was also considered for removal as it produced a low communality of 0.24, which fell below the 0.3 criteria.50 This item was included as financial incentives for physicians to prescribe certain medicines promoted by the pharmaceutical industry have been problematic, particularly in Asian countries, accounting for a large share of doctors’ and hospitals’ income.21,55 For instance, hospitals in China have been reported to generate more than half of their revenue from medications alone.56 Due to this item’s large importance in the WPR and the fact that it achieved a factor score above the cut-off of 0.4, item J was retained in the CPSF scale. The CPSF scale was shown to hold strong construct validity with the two-factor solution explaining over half the variance. These results were more favourable than the previously validated Medicines Formulary Scale aimed at hospital pharmacy directors in the WPR, which only explained 34% of the variance.29 While medicine formularies have been implemented in nearly all the of hospitals in the WPR (87%, n ¼ 691/ 797),13 the implementation of clinical pharmacy services has been suggested to be highly variable.3 The factor solution of the CPSF scale was very encouraging considering the large diversity in hospital pharmacy practices expected to appear in such a large region. The two factor solution identified in the CPSF scale of environmental and internal factors was consistent with other organizational change theories. Organizational change models applied to pharmacy have included Scott’s adapted version of Leavitt’s Diamond21,57,58 and the ‘three factor change’ model.59 In Scott’s adapted version of Leavitt’s Diamond two main factors exist, the environment and the organization. In this model, the organization would be the pharmacy department within a hospital structure. The organization is further subdivided to include the social structure, technology, participants and goals, all of which have been defined in previous studies in the pharmacy environment.57,58 The environmental and organizational factors in this model would correlate with the environmental and internal factors identified in the CPSF scale respectively. The three factor change model includes external and internal factors but also highlights the individual as another important component.59 Individual factors include their knowledge, experience and competence.59 This further reflects Campagana and Newlin’s (1997) proposal of the
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importance of the individual factors.18 In light of this, five items in the CPSF scale, item O, Q, R, S and T, were developed to highlight the pharmacist’s individual traits. However, these items did not load on a separate factor but loaded with other items relating to internal factors within the pharmacy department. This suggested that although the individual traits of the pharmacist could be theoretically perceived as unique and separate from the constructs within the pharmacy, they may actually be closely linked and highly correlated. This may occur as individual pharmacist traits cause certain internal factors to be developed within the pharmacy department. Conversely, internal factors within the pharmacy department may result in the recruitment of pharmacists with particular traits. Nevertheless, combining the individual and internal factors to create a two factor solution for the CPSF scale appeared to be a more accurate change model for hospital pharmacies. The survey received over 700 responses with a response rate of nearly 30%, similar to other studies in this field.13,41 However, selection bias of respondents may have occurred as respective hospital pharmacy associations were used to distribute the survey. This may have resulted in only highly motivated or engaged hospital pharmacy directors to receive the survey as they are more likely to be members of these associations. Non-response bias could also not be analyzed as demographic data for non-responders were not available to the research team and could not be assessed. Nonetheless, this validation process received responses from 31 different nations with an extensive representation of hospital pharmacy directors for a validation study. The Basel Statements appeared to provide a useful basis for exploring international hospital pharmacy practices, with the validated BS28-31 survey to explore the implementation of clinical pharmacy services pertinent to pharmacists’ influences on prescribing in the WPR. Conclusion The BS28-31 survey has been proven to be reliable and valid instrument, with the inclusion of the final 23-item CPSF sub-scale for measuring hospital pharmacy directors’ perceptions of clinical pharmacy service facilitators. With the development of this validated survey, quantifying the impact of these facilitators internationally is made possible.
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Acknowledgments and Contributions The authors thank Chinese Pharmaceutical Association, Food and Drug Department, Ministry of Health, Lao People’s Democratic Republic, Hong Kong Hospital Authority, Japanese Society of Hospital Pharmacists, Korean Society of Health-System Pharmacists, New Zealand Hospital Pharmacists’ Association, Pharmaceutical Services Division, Ministry of Health Malaysia, Pharmaceutical Society of Papua New Guinea, Philippine Society of Hospital Pharmacists, Society of Hospital Pharmacists of Australia, Taiwan Society of Health-System Pharmacists, Normita Leyesa, Camilla Wong, Wen Liou, Dechun Jiang, Shao Chiang, Faridah Aryani binti Md. Yusof, John Ware, Andy Gray, Terry Maunsell, Peter Barclay, John Jackson, and all those who participated in the study. Supported by an unconditional grant from the International Pharmaceutical Federation Hospital Pharmacy Section. References 1. World Health Organization. Continuity and Change: Implementing the Third WHO Medicines Strategy 2008-2013. Geneva, Switzerland: WHO Press; 2010. 2. O’Connor MN, Gallagher P, O’Mahony D. Inappropriate prescribing: criteria, detection and prevention. Drugs Aging 2012;29:437–452. 3. Nissen L. Current status of pharmacist influences on prescribing of medicines. Am J Health Syst Pharm 2009;66:S29–S34. 4. Anderson SV, Schumock GT. Evaluation and justification of clinical pharmacy services. Expert Rev Pharmacoecon Outcomes Res 2009;9:539–545. 5. De Rijdt T, Willems L, Simoens S. Economic effects of clinical pharmacy interventions: a literature review. Am J Health Syst Pharm 2008;65: 1161–1172. 6. Kaboli PJ, Hoth AB, McClimon BJ, Schnipper JL. Clinical pharmacists and inpatient medical care: a systematic review. Arch Intern Med 2006;166: 955–964. 7. Bond CA, Raehl CL. Clinical pharmacy services, pharmacy staffing, and adverse drug reactions in United States hospitals. Pharmacotherapy 2006;26: 735–747. 8. Bond CA, Raehl CL. Clinical pharmacy services, pharmacy staffing, and hospital mortality rates. Pharmacotherapy 2007;27:481–493. 9. Bond CA, Raehl CL, Franke T. Clinical pharmacy services, hospital pharmacy staffing, and medication errors in United States hospitals. Pharmacotherapy 2002;22:134–147.
10. Dooley MJ, Allen KM, Doecke CJ, et al. A prospective multicentre study of pharmacist initiated changes to drug therapy and patient management in acute care government funded hospitals. Br J Clin Pharmacol 2004;57:513–521. 11. The Basel Statements on the future of hospital pharmacy. Am J Health Syst Pharm 2009;66:S61–S66. 12. Dura´n-Garcı´ a E, Santos-Ramos B, PuigventosLatorre F, Ortega A. Literature review on the structure and operation of Pharmacy and Therapeutics Committees. Int J Clin Pharm 2011;33:475–483. 13. Penm J, Chaar B, Dechun J, Moles R. Formulary systems and pharmacy and therapeutics committees in the Western Pacific Region: exploring two Basel Statements. Am J Health Syst Pharm 2013; 70:967–979. 14. World Health Organization. Drug and Therapeutics Committees – A Practical Guide. Geneva, Switzerland: WHO Press; 2003. 15. Holland RW, Nimmo CM. Transitions, part 1: beyond pharmaceutical care. Am J Health Syst Pharm 1999;56:1758–1764. 16. Bond CA, Raehl CL, Franke T. Clinical pharmacy services, pharmacy staffing, and the total cost of care in United States hospitals. Pharmacotherapy 2000;20:609–621. 17. Hall K, Wilgosh C. Hospital Pharmacy in Canada 2009/2010 Report. Toronto: Eli Lily Canada; 2010. 18. Campagna KD, Newlin MH. Key factors influencing pharmacists’ drug therapy decisions. Am J Health Syst Pharm 1997;54:1307–1313. 19. Moles R, Brien J, Benrimoj SI. Factors influencing pharmaceutical service provision within NSW private hospitals. Aust Pharm 2004;23:238–243. 20. Moles R, Brien J, Benrimoj SI. New South Wales private hospitals and their pharmacy services. J Pharm Pract Res 2007;37:119–123. 21. Penm J, Moles R, Wang H, Li Y, Chaar B. Factors affecting the implementation of clinical pharmacy services in China. Qual Health Res 2014;24(3): 345–356. 22. Mutnick AH, Bergquist SC, Nelson SP, Bebout KL. The implementation of a pharmaceutical care practice system. Pharm Pract Manag Q 1997;16:45–52. 23. Rutter V, Wong C, Coombes I, et al. Use of a general level framework to facilitate performance improvement in hospital pharmacists in Singapore. Am J Pharm Educ 2012;76:107. 24. Coombes I, Avent M, Cardiff L, et al. Improvement in pharmacist’s performance facilitated by an adapted competency-based general level framework. J Pharm Pract Res 2010;40:111–118. 25. Goldsmith GM, Bates IP, Davies JG, et al. A pilot study to evaluate clinical competence in junior grade pharmacy practitioners. Pharm Educ 2003;3: 127–134. 26. Blake KB, Madhavan SS. Perceived barriers to provision of medication therapy management services (MTMS) and the likelihood of a pharmacist to
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Original Research
Pharmacists’ influences on prescribing: Validating a clinical pharmacy services survey in the Western Pacific Region Jonathan Penm, B.Pharm. (Hons.)a,*, Betty Chaar, B.Pharm., M.H.Law, Ph.D.a, Grenville Rose, B.A., Ph.D.b, Rebekah Moles, B.Pharm., Dip.Hosp.Pharm., Ph.D., Grad. Cert. Ed. Stud. (Higher Ed.), F.S.H.P.a a
Faculty of Pharmacy, World Hospital Pharmacy Research Consortium, The University of Sydney, Camperdown, NSW 2006, Australia b Aftercare, Rozelle Hospital, Church Street, Lilyfield, NSW, Australia
Abstract Background: Hospital pharmacists around the world are becoming increasingly involved in promoting the responsible use of medicines through clinical pharmacy services. This is reflected in the Basel Statements developed by the International Pharmaceutical Federation Hospital Pharmacy Section, particularly the theme ‘Influences on Prescribing.’ Some countries, particularly in Asia, are currently establishing clinical pharmacy services and would benefit from identification of facilitators. Objectives: To validate a survey exploring clinical pharmacy services focusing on pharmacists’ influences on prescribing, based on Basel Statements 28–31, and the factors that affect their implementation in the Western Pacific Region (WPR). Methods: Content and face validity of the survey (BS28-31) was established. This resulted in the BS28-31 consisting of 20 questions, which included a Clinical Pharmacy Services Facilitators (CPSF) scale (25 items) to measure respondents’ perceptions of facilitators of clinical pharmacy services. The BS28-31 was emailed to hospital pharmacy directors in the WPR. The survey was made available in English, Japanese, Chinese, Vietnamese, Lao, Khmer, French and Mongolian. Principal components and internal consistency analyses were conducted to assess the reliability and construct validity of the CPSF scale. Results: The final survey was sent to a total of 2525 hospital pharmacy directors in the WPR of which 726 were returned from 31 nations yielding a response rate of 29%. Two items in the scale were removed due to low communalities (0.22 and 0.16). The resulting 23 item scale produced a parsimonious two-factor solution, divided into internal (e.g. individual pharmacist traits and pharmacy departmental structure/resources) and environmental facilitators (e.g. government support, patient and physician expectations). This two factor solution explained 51.5% of the variance. In addition, the Cronbach’s a for the internal and environmental subscales were 0.94 and 0.78 respectively. The authors have declared no conflict of interest. * Corresponding author. Tel.: þ61 2 9036 5035; fax: þ61 2 9351 4391. E-mail address: [email protected] (J. Penm). 1551-7411/$ - see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.sapharm.2014.04.001
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Conclusion: The BS28-31 survey was found to be a reliable and valid instrument for assessing hospital pharmacy directors’ perceptions of clinical pharmacy services regarding pharmacists’ influences on prescribing and their facilitators in the WPR. Ó 2015 Elsevier Inc. All rights reserved. Keywords: Western Pacific Region; Hospital pharmacy; Clinical pharmacy services; Validation; Basel Statements
Introduction It is estimated that more than half of all medications prescribed, dispensed or sold worldwide are inappropriate.1 Inappropriate prescribing can lead to avoidable adverse drug events in patients and potential harm.2 To promote responsible use of medicines, pharmacists have endeavored to expand their role to promote patient safety and influence prescribing.3 Hospital pharmacists are well placed to pursue this role due to their close proximity to prescribers and have been shown to improve prescribing practices, prevent adverse drug events, reduce medication errors, costs and patients’ length of stay, and lower mortality.4–10 The movement toward pharmacists’ focus on patient safety is further reflected in the Basel Statements, which represent the unified vision of preferred hospital pharmacy practice services and functions around the world.11 The Basel Statements were agreed upon by 98 nations at the inaugural Global Conference on the Future of Hospital Pharmacy, hosted by the International Pharmaceutical Federation (FIP) in 2008 in Basel, Switzerland. The Basel Statements included 75 statements that were subdivided into ‘Overarching Statements’ and six themes, with medication safety being a core consideration for all the statements.11 Basel Statements 26–32 in particular, constitute the theme ‘Influences on Prescribing,’ a topic that is the main focus of this study. Hospital pharmacists’ influences on prescribing incorporates a large range of activities affecting prescribing at both institutional and individual prescriber levels. At the institutional level, hospital pharmacists are usually the key members of Pharmacy and Therapeutics Committees responsible for managing the hospital’s medicine formulary system and the responsible use of medicines within the hospital, as stated in Basel Statements 26 and 27.12–14 Basel Statements 28–31 outline the additional responsibilities of hospital pharmacists to extend their role to educate prescribers on the appropriate use of medications (Table 1).3 In response to this, hospital pharmacy services in some countries have incorporated pharmacists
into regular patient rounds and allocated to them the responsibility of reconciling patients’ medications on admission.3 These expanded clinical pharmacy services have further developed pharmacists’ influences on prescribing and increased their responsibility over patient outcomes.15 Bond and colleagues have published a number of studies showing the beneficial effect of such expanded clinical pharmacy services on major health care outcomes, such as mortality.7–9,16 In particular, clinical pharmacy services that influence prescribing like ward round participation, reconciling patients’ medications on admission and providing drug information or in-service education have been associated with decreased total costs of care,16 mortality rates,8 medication errors9 and adverse drug reactions.7 A number of facilitators have been recognized that could assist pharmacy departments develop
Table 1 Basel Statements 28–31 in the theme ‘Influences on Prescribing.’a Number Basel statement 28
29
30
31
Hospital pharmacists should have a key role in educating prescribers at all levels of training on the access to and evidence for optimal and appropriate use of medicines, including the required monitoring parameters and subsequent prescribing adjustments. Hospital pharmacists should be involved in all patient care areas to prospectively influence collaborative therapeutic decision-making. Hospital pharmacists should be an integral part of all patient rounds to assist with therapeutic decision-making and advise on clinical pharmacy and patient safety issues. Hospital pharmacists should provide continuity of care by transferring patient medicines information as patients move between sectors of care.
a Reproduced from: The Basel Statements on the future of hospital pharmacy. Am J Health Syst Pharm 2009;66:S61-66.
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clinical pharmacy services in hospitals where these services have not been established. Research from the United States (US) and Canada has identified factors such as: the number of staff, adoption of new technology, whether the pharmacy is based within the hospital, leadership, expectations of the physicians, and accreditation standards to facilitate the implementation of these clinical pharmacy services.8,9,17 Campagana and Newlin (1997) proposed eight factors as being the most influential in facilitating enhanced services.18 These factors were further classified as either environmental or individual. The environmental factors include: public expectations, law and regulations, economic structure and the practice setting itself.18 The individual factors included the pharmacist’s personality, attitude, expertise and motivation.18 Additional facilitators have also been identified in qualitative work conducted in Australia. Moles et al (2004) conducted over 50 interviews with hospital pharmacists in Australia and identified hospital size, type, location, model of service provision, hospital contracts, requirements for accreditation, resources and training of the pharmacists as affecting discharge counseling services provided by clinical pharmacists.19,20 Further qualitative work focusing on Basel Statements 28–31 has also been conducted in China with 130 participants, including hospital administrators, pharmacy directors, clinical pharmacists and dispensing pharmacists.21 The main issues identified affecting hospital pharmacists’ influence on prescribing included: external factors outside the control of the pharmacy department, resources available to implement the pharmacy services and the attitudes of the clinical pharmacists and the expectations of themselves and by others.21 As multiple factors have been identified, Campagana and Newlin proposed theoretically that the individual factors; attitude, expertise and motivation, are the most important as they can be changed and controlled by the pharmacists.18 The pharmacists’ personality was the only individual factor that they argued cannot be changed.18 In some countries, hospitals have accordingly developed a formalized competency assessment program and increased formal documentation in their medical records to positively address these individual factors.22–25 Within the community pharmacy sector, researchers have endeavored to validate scales to quantify which factors most strongly affect the implementation of expanded pharmacy services.
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Blake et al (2010) validated a scale in the US identifying three factors: perceived ability to respond to patient interest, pharmacy related factors and enabling factors.26 Enabling factors included adequate support staff and physician attitudes.26 The authors highlighted that the pharmacists’ perceived ability to respond to patient interest was the greatest facilitator for offering expanded services.26 Roberts et al (2008) also validated a scale in Australia and identified seven factors that affected pharmacy services.27 Of these, relationship with the physician had the highest median factor score and was believed to be the most important factor.27 Similar factors would be expected within the hospital setting. However, as these scales were validated within the community setting, all of them incorporated the importance of the pharmacy layout to allow additional services to be provided. This may not be required in the hospital setting as many clinical services are delivered on the ward and not within the pharmacy. With the expansion of pharmacists’ influences on prescribing and clinical pharmacy services in hospitals around the world, the development of a validated survey that could be used internationally could aid in prioritizing resources for hospitals developing their clinical pharmacy services. The Western Pacific Region (WPR) has been an area of great interest as it constitutes nearly onequarter of the world’s population, with countries that are socially and economically diverse.28 As such, it has been proposed that validating a survey in such a diverse area would render the instrument globally applicable.29 The WPR includes countries from Asia, Australia, New Zealand and numerous Pacific Islands (Fig. 1).28 Previous research in the WPR has explored hospital pharmacists’ influences on prescribing at an institutional level, focusing on medicine formularies, and Pharmacy and Therapeutics (P&T) committees as described in Basel Statements 26 and 27.13,29 This research highlighted that hospitals that have over half of their medication management policies overseen by the P&T committee and having a hospital pharmacy director that strongly believed in the benefits of medicine formularies were more likely to have more formulary medicines linked to standard treatment guidelines, based on the best available evidence, and have a policy for the use of off-label medicines.13 As a result, it appeared having strong hospital pharmacy leadership aligned with the goals of the hospital, facilitated hospital
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Fig. 1. Countries and nations within the Western Pacific Region are highlighted in yellow. The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the authors concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. SAR: Special Administrative Region. (For interpretation of the references to color in this figure legend, the reader is referred to the web version of this article.) Reproduced and modified from the World Health Organization. http://hiip.wpro.who.int/portal/Countryprofiles.aspx; Accessed 02.04.14.
pharmacists’ influences on prescribing at an institutional level. To further advance this global initiative, the aim of this paper was to validate a survey in the WPR to explore clinical pharmacy services regarding pharmacists’ influence on prescribing, and the factors that affect their implementation, based on Basel Statements 28–31.
Methods This study was approved by the University of Sydney Human Research Ethics Committee. Survey development and distribution An initial survey was developed by the research team based on Basel Statements 28–31 and previous research, along with review of the literature.13,21,29–33 Although Basel Statement 32 regarding collaborative prescribing by hospital
pharmacists was also included under the theme ‘Influences on Prescribing,’ it was excluded in this study. This statement was excluded as many countries in the WPR have only recently started implementing clinical pharmacy services and are not able to pursue collaborative prescribing without drastic legislative changes. Previous international surveys in hospital pharmacy were also reviewed in developing this survey.29,34 These surveys generally used ordinal responses for classifying pharmacy services such as !3% (very few), 3–50% (some), 51–97% (most) and 97% (nearly all).29,34 However, ordinal responses limit the interpretation of statistical analyses, as small changes cannot be measured.13 Accordingly, a continuous scale was adopted to measure the percentage of patients that received clinical pharmacy services and the percentage of time a pharmacist spent on providing these services, so more meaningful statistical analyses can be undertaken.
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The survey included questions designed to investigate the extent Basel Statements 28–31 (BS28-31) were implemented, such as the percentage of time spent on providing clinical pharmacy services and education to prescribers, as well as the types of services offered. Additional questions that may explain some of the variations in practice were also included such as the hospital’s funding status, number of beds and number of pharmacists. Additional factors affecting the implementation of clinical pharmacy services were included as
items in the Clinical Pharmacy Services Facilitators (CPSF) scale (Table 2). This scale measured respondents’ perception of the importance of each item using a 5-point Likert response from “Does not facilitate” to “Strongly facilitates.” All questions were sent to a WPR Advisory Committee that included prominent leaders of hospital pharmacy from Australia, China, Taiwan, Philippines and Singapore, to aid in the development and evaluation of the BS28-31 survey. These leaders were identified and recruited
Table 2 Factor loadings for the two-factor varimax rotated solution and communalities of the refined 23-item Clinical Pharmacy Services Facilitators (CPSF) scale Itema
Factor loadingsb
R. Having clinical pharmacists that are motivated to constantly improve their own practices and knowledge S. Having clinical pharmacists that take professional responsibility for the medicines prescribed to their patients Q. Having clinical pharmacists that are confident in their abilities T. Having clinical pharmacists with strong communication skills P. Having access to relevant treatment guidelines O. Having pharmacists specifically trained to deliver clinical pharmacy services U. Having role models for the clinical pharmacists to follow W. Having strong relationships between the pharmacy department and other health professionals in the hospital M. Access to competency standards or performance evaluation tools for clinical pharmacy services V. Ensuring clinical pharmacists document their recommendations in patients’ medical records L. Access to guidelines on how to implement clinical pharmacy services N. Having adequate staff to provide clinical pharmacy services X. Adoption of new technology by the pharmacy department Y. Increasing the role and responsibilities of pharmacy technicians/ assistants K. Pharmacy director support for clinical pharmacy services B. Hospital administrator support for clinical pharmacy services A. Government support for clinical pharmacy services F. Monetary remuneration for clinical pharmacy services C. Prescribers’ expectations of clinical pharmacy services D. Patients’ expectations of clinical pharmacy services E. The hospital is accredited by an external organization (e.g. Joint Commission International, JCI) G. The hospital is liable for medication errors J. Doctors are NOT remunerated by drug companies to prescribe H. Being part of a large hospitalc I. Being located in an urban areac
0.843
0.146
0.731
0.833
0.145
0.715
0.830 0.814 0.771 0.728
0.081 0.140 0.212 0.301
0.696 0.682 0.639 0.620
0.710 0.684
0.136 0.173
0.523 0.498
0.676
0.339
0.572
0.663
0.273
0.513
0.653
0.298
0.515
0.644 0.625 0.564
0.305 0.265 0.171
0.508 0.461 0.347
0.557 0.077 0.094 0.079 0.278 0.170 0.308
0.362 0.789 0.767 0.675 0.593 0.583 0.498
0.441 0.628 0.598 0.462 0.429 0.368 0.343
0.261 0.209 – –
0.494 0.438 – –
0.313 0.236 – –
Communalities
Component 1 Component 2
a
Items are displayed in descending order of factor scores. Factor loadings above 0.4 for each item are bolded. c Items H and I were removed from the analysis due to low communalities of 0.22 and 0.16 obtained respectively when analyzed with all 25-items in the CPSF Scale. b
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through FIP’s Western Pacific Pharmaceutical Forum (WPPF). All members have worked in hospital pharmacy for at least a decade and have held a leadership role at their respective institutions. Furthermore, each member had extensive knowledge of hospital pharmacy practices in the WPR. Based on our previous research in the WPR,13 the survey was also translated by certified translators from English to Japanese, Chinese, Vietnamese, Lao, Khmer, French and Mongolian, to allow participation from all countries within the WPR. The standard forward-backwards approach was used to ensure accuracy of these translations.35 This required the survey to be translated to the desired language and then translated back into English by a blinded certified translator to identify any discrepancies in translation.35 Furthermore, high-quality forward translations were ensured by employing certified translators experienced in health care translations as suggested by Leple`ge and Verdier (1995).36 The number of responses required to validate a scale used in a survey is contentious. Guadagnoli and Velicer (1988) suggest that the absolute magnitude of the loadings required is determined by the absolute sample size.37 However, as the absolute loadings are unknown prior to the study, this criterion is difficult to predict. Other recommendations have ranged from having 2–20 respondents per item38 and absolute sample sizes of 300 being a ‘good’ and 1000 being an ‘excellent’ sample size.39 To ensure that a high level of accuracy was obtained and the large variation of practices in the WPR was accounted for, the strict upper limited of 20 respondents per item was sought. With 25 items in the CPSF scale, a minimum of 500 responses was thus required.38 A 25% response rate was also assumed to account for decreased response rates observed in similar studies,13,40,41 thereby requiring at least 2000 surveys to be administered. To ensure timely distribution and collection of data, the survey was developed as an Internetbased survey on SurveyMonkey (SurveyMonkey, Portugal, Luxembourg, US). Hospital pharmacy associations in each nation were invited to send an email to pharmacy directors in their database, with a hyperlink to the survey. An email reminder was sent to nonrespondents at one week and three weeks after the initial email. The Pitcairn Islands were excluded as they do not have a hospital.28 Data collection occurred between July and December 2013.
Data analysis The BS28-31 survey data were analyzed for both validity and reliability. Validity ensures the survey is measuring what it is intended to measure, while reliability ensures it obtains consistent results on repeated trials.42,43 Data analyses were performed using IBM SPSS Statistics version 22 (IBM Corp, Armonk, NY) and a web-based parallel analysis engine called Parallel Analysis Engine to Aid Determining Number of Factors to Retain.44 Both face and content validity of the survey were assessed by the WPR Advisory Committee. Face validity ensures that the questions appear relevant, reasonable, unambiguous and measure what they intended to measure.45 Content validity ensures that the complete content range of the chosen construct under study is being tested.42,43 CPSF scale The CPSF scale within the BS28-31 survey was also subjected to both construct validity and reliability testing. Construct validity refers to the degree to which the survey measures the theoretical construct it is intended to measure.38,42,43 Principal components analysis (PCA) was used to investigate construct validity as it analyses the relationships among large numbers of variables.38 PCA allows related items to be grouped into a part of a construct or factor.38 Factors are identified when screened for eigenvalues greater than 1.046 and compared to the results obtained from the scree test47 and parallel analysis.48 These factors can then be interpreted by theoretically derived hypotheses concerned with the concept being measured. The factor loadings required to retain an item is also debatable, with authors traditionally retaining items with factor scores O0.3.49 However, absolute sample sizes have also been shown to affect the required factor score needed to produce reliable factor solutions. It is recommended that each loading is tested for significance at a ¼ 0.01 (two-tailed test).38 Thus, for a sample size of 300, a factor score O0.3 is required, while a sample size of 600 requires a factor score O0.21 to fulfill this requirement.38 Additionally, it is recommended that items share at least 15% of their variance with the factor when identifying new factors.38 This requires items to have a factor loading of R0.4. As a result, items that produced factor loadings !0.40 or cross-loaded on two or more factors were removed from the final CPSF scale.38
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The reliability of the CPSF scale was further measured using internal consistency analysis. This method produces a Cronbach’s a that examines the inter-item correlations, with a value of R0.70 being considered acceptable.50
Table 3 Number of survey responses collected by country or nation Country or nation
Number of Number of responses complete received responses to the CPSF scale received
Australia Cambodia China Cook Islands Fiji French Polynesia Hong Kong Japan Kiribati Korea, Republic of Lao People’s Democratic Republic Macao Malaysia Micronesia, Federated States of Mongolia Nauru New Caledonia New Zealand Northern Mariana Islands, Commonwealth of the Palau Papua New Guinea Philippines Samoa Singapore Solomon Islands Taiwan Tokelau Tonga Tuvalu Vanuatu Vietnam Total
117 5 161 3 4 1 10 213 1 38 19
97 5 138 2 3 1 9 189 1 17 19
3 26 2
3 19 2
2 1 2 19 1
2 1 2 18 1
1 10 14 1 2 2 37 2 1 1 2 25 726
1 8 9 0 2 1 23 2 0 1 1 20 597
Results To ensure an adequate response rate was achieved, all contactable hospital pharmacy directors in the WPR were emailed the link to the survey. A total of 2525 surveys were distributed to 37 different nations in the WPR (Table 3). A total of 726 responses were received from 31 nations giving a response rate of 29%. Of these, 298 respondents completed the survey in English, 213 in Japanese, 161 in Chinese, 25 in Vietnamese, 19 in Lao, five in Khmer, three in French and two in Mongolian. No responses were received from American Samoa, Brunei Darussalam, Guam, Marshall Island, Niue and Wallis & Futuna. Of those who responded, 75.8% (n ¼ 550/726) were from public hospitals and 24.2% were from private hospitals. The median bed size of the hospitals was 505 (range, 1–6000) with a median number of 20 pharmacists (range, 0–289). Validity Face and content validity of the BS28-31 survey Eleven experts in hospital pharmacy assessed the BS28-31 survey for both face and content validity. The initial draft survey contained 20 questions including the CPSF scale which consisted of 24 items. All questions were considered relevant and alterations in the wording and ordering of the questions were deemed necessary for 11 of the questions to enhance the usability of the survey. Questions regarding pharmacy services on weekends were modified to adjust for the diverse cultures in the Western Pacific Region, some of which do not follow a Saturday and Sunday weekend. As numerous questions required the respondent to calculate the percentage of time a pharmacist spent on varying tasks, specified time frames were given to aid interpretability, such as “within an average week.” The final survey retained all 20 questions and included an additional item to the CPSF scale, giving it a total of 25 items. Construct validity and reliability of the CPSF scale Due to missing data, the CPSF scale was only analyzed in 597 respondents (Table 3).
Results of this scale were initially assessed regarding its suitability for PCA. Inspection of the correlation matrix revealed the presence of many coefficients of 0.3 and above. The Kaiser-MeyerOlkin value was 0.93, exceeding the recommended value of 0.651,52 and the Bartlett’s Test of Sphericity reached significance with P ! 0.00153 supporting the factorability of the correlation matrix. PCA revealed the presence of five components with eigenvalues exceeding 1.0. The scree test revealed a break after the third component on
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the scree plot. In addition, the parallel analysis confirmed three components with eigenvalues exceeding the corresponding criterion values for a randomly generated data matrix of the same size (25 variables 597 respondents, Table 4). As a result, analyses with two, three and four components were undertaken for further investigation. The two component solution appeared the simplest to interpret. However, two items in the scale, items H and I, appeared to have relatively low communalities, 0.22 and 0.16 respectively, and factor loadings, 0.40 and 0.36 respectively. Item H related to ‘being part of a large hospital’ and item I related to ‘being located in an urban area.’ As items with communalities of less than 0.3 may indicate that they do not fit well with the other items in the component, they were removed and the data were re-analyzed.50 The refined 23-item CPSF scale produced a parsimonious two component solution and explained a total of 51.5% of the variance, with the first and second component contributing to 41.9% and 9.6% respectively. To aid in the interpretation of these two components, varimax rotation was performed. The rotated solution revealed the presence of simple structure with both components showing a number of strong factor loadings (R0.4) and all variables loading substantially on only one component (Table 2). The first component contained fifteen items describing internal factors of the pharmacy department. The second component contained eight items representing environmental factors. These results supported the bi-dimensionality of the CPSF scale in the BS28-31 survey. Reliability The Cronbach’s a value for the refined 23-item CPSF scale was found to be 0.93. In addition, the Cronbach’s a value for the first and second subscales were 0.94 and 0.78 respectively. These Table 4 Actual and random eigenvalues for the full 25-item Clinical Pharmacy Services Facilitators (CPSF) scale used for the parallel analysis Component
Average eigenvalue
Actual eigenvalue
1 2 3 4 5
1.39 1.33 1.28 1.25 1.21
9.88 2.22 2.06 1.23 1.04
values exceeded the recommended value of 0.7 indicating adequate internal consistency.50
Discussion The BS28-31 survey is the first survey to be validated in the hospital pharmacy setting exploring the implementation of clinical pharmacy services regarding pharmacists’ influences on prescribing. After establishing construct validity, the finalized CPSF sub-scale constituted 23 items. This is considerably less than the 43-item scale developed by Roberts et al (2008)27 but more than the 11-item scale developed by Blake et al (2010).26 Our review of the literature and previous research in China21 highlighted that additional factors appeared to affect the implementation of clinical pharmacy services in hospitals not included in either of these previously validated scales. These included additional standards and guidelines relevant to the hospital setting, accreditation of the hospital, government and hospital administrator support and individual factors such as the pharmacists training, professionalism and motivation.21 Furthermore, the 43-item scale produced by Roberts et al was considered too extensive as survey length has been associated with a decreased response rate,54 particularly for such a diverse region. Thus, our 23-item CPSF scale was the first scale tailored for the hospital environment. Both items H and I were removed from the initial 25-item CPSF scale during the construct validity analysis. Item H and I asked if large hospitals or hospitals that are located in an urban area facilitate the implementation of clinical pharmacy services. These factors have often been cited as affecting clinical pharmacy services in hospitals in countries within the WPR.19,21 However, their inclusion in the CPSF scale appeared problematic in producing a reliable factor solution. These items may have been difficult to answer, as many respondents may not have been exposed to a variety of hospitals which differed in size or location. Furthermore, the wordings of these items did not clearly specify what was meant by a large hospital or urban area and may have led respondents to subjectively interpret these items and decrease their validity. As a result, we recommend that using the hospitals’ number of beds and location via zip codes may be more accurate in future studies to identify the impact of size and location on the implementation of clinical pharmacy services.
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Doctors remuneration to prescribe, item J, was also considered for removal as it produced a low communality of 0.24, which fell below the 0.3 criteria.50 This item was included as financial incentives for physicians to prescribe certain medicines promoted by the pharmaceutical industry have been problematic, particularly in Asian countries, accounting for a large share of doctors’ and hospitals’ income.21,55 For instance, hospitals in China have been reported to generate more than half of their revenue from medications alone.56 Due to this item’s large importance in the WPR and the fact that it achieved a factor score above the cut-off of 0.4, item J was retained in the CPSF scale. The CPSF scale was shown to hold strong construct validity with the two-factor solution explaining over half the variance. These results were more favourable than the previously validated Medicines Formulary Scale aimed at hospital pharmacy directors in the WPR, which only explained 34% of the variance.29 While medicine formularies have been implemented in nearly all the of hospitals in the WPR (87%, n ¼ 691/ 797),13 the implementation of clinical pharmacy services has been suggested to be highly variable.3 The factor solution of the CPSF scale was very encouraging considering the large diversity in hospital pharmacy practices expected to appear in such a large region. The two factor solution identified in the CPSF scale of environmental and internal factors was consistent with other organizational change theories. Organizational change models applied to pharmacy have included Scott’s adapted version of Leavitt’s Diamond21,57,58 and the ‘three factor change’ model.59 In Scott’s adapted version of Leavitt’s Diamond two main factors exist, the environment and the organization. In this model, the organization would be the pharmacy department within a hospital structure. The organization is further subdivided to include the social structure, technology, participants and goals, all of which have been defined in previous studies in the pharmacy environment.57,58 The environmental and organizational factors in this model would correlate with the environmental and internal factors identified in the CPSF scale respectively. The three factor change model includes external and internal factors but also highlights the individual as another important component.59 Individual factors include their knowledge, experience and competence.59 This further reflects Campagana and Newlin’s (1997) proposal of the
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importance of the individual factors.18 In light of this, five items in the CPSF scale, item O, Q, R, S and T, were developed to highlight the pharmacist’s individual traits. However, these items did not load on a separate factor but loaded with other items relating to internal factors within the pharmacy department. This suggested that although the individual traits of the pharmacist could be theoretically perceived as unique and separate from the constructs within the pharmacy, they may actually be closely linked and highly correlated. This may occur as individual pharmacist traits cause certain internal factors to be developed within the pharmacy department. Conversely, internal factors within the pharmacy department may result in the recruitment of pharmacists with particular traits. Nevertheless, combining the individual and internal factors to create a two factor solution for the CPSF scale appeared to be a more accurate change model for hospital pharmacies. The survey received over 700 responses with a response rate of nearly 30%, similar to other studies in this field.13,41 However, selection bias of respondents may have occurred as respective hospital pharmacy associations were used to distribute the survey. This may have resulted in only highly motivated or engaged hospital pharmacy directors to receive the survey as they are more likely to be members of these associations. Non-response bias could also not be analyzed as demographic data for non-responders were not available to the research team and could not be assessed. Nonetheless, this validation process received responses from 31 different nations with an extensive representation of hospital pharmacy directors for a validation study. The Basel Statements appeared to provide a useful basis for exploring international hospital pharmacy practices, with the validated BS28-31 survey to explore the implementation of clinical pharmacy services pertinent to pharmacists’ influences on prescribing in the WPR. Conclusion The BS28-31 survey has been proven to be reliable and valid instrument, with the inclusion of the final 23-item CPSF sub-scale for measuring hospital pharmacy directors’ perceptions of clinical pharmacy service facilitators. With the development of this validated survey, quantifying the impact of these facilitators internationally is made possible.
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Acknowledgments and Contributions The authors thank Chinese Pharmaceutical Association, Food and Drug Department, Ministry of Health, Lao People’s Democratic Republic, Hong Kong Hospital Authority, Japanese Society of Hospital Pharmacists, Korean Society of Health-System Pharmacists, New Zealand Hospital Pharmacists’ Association, Pharmaceutical Services Division, Ministry of Health Malaysia, Pharmaceutical Society of Papua New Guinea, Philippine Society of Hospital Pharmacists, Society of Hospital Pharmacists of Australia, Taiwan Society of Health-System Pharmacists, Normita Leyesa, Camilla Wong, Wen Liou, Dechun Jiang, Shao Chiang, Faridah Aryani binti Md. Yusof, John Ware, Andy Gray, Terry Maunsell, Peter Barclay, John Jackson, and all those who participated in the study. Supported by an unconditional grant from the International Pharmaceutical Federation Hospital Pharmacy Section. References 1. World Health Organization. Continuity and Change: Implementing the Third WHO Medicines Strategy 2008-2013. Geneva, Switzerland: WHO Press; 2010. 2. O’Connor MN, Gallagher P, O’Mahony D. Inappropriate prescribing: criteria, detection and prevention. Drugs Aging 2012;29:437–452. 3. Nissen L. Current status of pharmacist influences on prescribing of medicines. Am J Health Syst Pharm 2009;66:S29–S34. 4. Anderson SV, Schumock GT. Evaluation and justification of clinical pharmacy services. Expert Rev Pharmacoecon Outcomes Res 2009;9:539–545. 5. De Rijdt T, Willems L, Simoens S. Economic effects of clinical pharmacy interventions: a literature review. Am J Health Syst Pharm 2008;65: 1161–1172. 6. Kaboli PJ, Hoth AB, McClimon BJ, Schnipper JL. Clinical pharmacists and inpatient medical care: a systematic review. Arch Intern Med 2006;166: 955–964. 7. Bond CA, Raehl CL. Clinical pharmacy services, pharmacy staffing, and adverse drug reactions in United States hospitals. Pharmacotherapy 2006;26: 735–747. 8. Bond CA, Raehl CL. Clinical pharmacy services, pharmacy staffing, and hospital mortality rates. Pharmacotherapy 2007;27:481–493. 9. Bond CA, Raehl CL, Franke T. Clinical pharmacy services, hospital pharmacy staffing, and medication errors in United States hospitals. Pharmacotherapy 2002;22:134–147.
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