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Int J Clin Pharm (2011) 33:101110

DOI 10.1007/s11096-010-9465-y


Constraints and perspectives of pharmacists counseling patients

with depression at hospital discharge
Franciska A. Desplenter Gert M. Laekeman

Steven R. Simoens

Received: 5 May 2010 / Accepted: 29 November 2010 / Published online: 13 January 2011
 Springer Science+Business Media B.V. 2010

Abstract Objective of the study This study aims to explore support. Future initiatives depend upon human and other
experiences, barriers and enabling factors during an antide- resources. There is a demand for more information by the
pressant counseling study as well as to explore future initia- patient. A more structured way of working is necessary. The
tives. Setting 11 Flemish psychiatric hospitals Method Focus provision of medication information can be performed at
group discussions were organized. Pharmacists who could not different points in time using different formats. Conclusion
be present at a focus group discussion answered the questions Participation in a clinical pharmacy study was well appreci-
of the interview guide on paper. The focus group discussions ated by the pharmacists. Future initiatives were welcomed if
were tape recorded, verbatim transcribed and analyzed using they remain feasible within actual job responsibilities.
NVivo7-software applying a framework approach. Main
outcome measure Evaluation of barriers, enabling factors, Keywords Barriers and facilitators  Belgium  Clinical
negative and positive experiences during the study. Sugges- pharmacy  Depression  Medication information 
tions for future initiatives. Results For experiences, barriers Psychiatric hospital  Qualitative research  Study
and enabling factors, five categories were identified: indi- evaluation
vidual patient contacts, interdisciplinary contacts, hospital
management, study performance and study support. There
Impact of findings on practice
existed differences in culture between hospitals on how they
appreciated the role of the clinical pharmacist. A major dif-
Differences exist between different psychiatric hospi-
ference between hospitals was the interdisciplinary relations.
tals with regard to the role for the clinical pharmacist.
Negative experiences and barriers were: the absence of
Timely interventions at discharge of psychiatric
openness for a role for the pharmacist in the team, difficult
patients require a smooth, constructive and pro-active
interdisciplinary communication, the uncertainty about the
interdisciplinary communication.
time of discharge, the need of patients to tell their story and the
Tailored interventions on medicine information are
timing of the intervention. Positive experiences and enabling
well appreciated by patients.
factors included the individual focus of the intervention, the
Human and material resource management are impor-
position of the pharmacist as a reliable health care profes-
tant when considering a potential role for the clinical
sional, the pharmacist as the key person in this study, the
integration of the pharmacist in the team, the gained knowl-
edge and skills of the pharmacist and the professional study

F. A. Desplenter (&)  G. M. Laekeman  S. R. Simoens
Research Centre for Pharmaceutical Care and Pharmaco- The GIPPOZ-study (Dutch acronym for Differentiated
economics, Faculty of Pharmaceutical Sciences, Katholieke Information for Psychiatric Patients at Hospital Discharge)
Universiteit Leuven, ON2Herestraat 49, P.O. Box 521,
3000 Leuven, Belgium explored the impact of providing information on antide-
e-mail: pressants to patients with major depression at hospital

102 Int J Clin Pharm (2011) 33:101110

discharge. The GIPPOZ-study is described elsewhere [1, of life and satisfaction. As it was the first time that the
2], but summarized in the next paragraph. The current participating pharmacists were involved in an intervention
qualitative study is a follow-up study to evaluate the study, they were trained at the start and follow-up meetings
GIPPOZ intervention by the clinical pharmacists in the were organized during the GIPPOZ-study. The training at
participating hospitals. the start consisted of explaining the different steps, pro-
cedures and forms used in this study. A three-hour inter-
The GIPPOZ-study active training on communication and counseling was
organized. It comprised a presentation on different aspects
Patients were eligible for inclusion in GIPPOZ if they were of communication and role plays. The pharmacists received
at least 18 years old, if they had a major depressive episode the instruction book Communication in the pharmacy [8]
as primary diagnosis according to the DSM-IV-TR criteria, as methodological support.
it they took at least one antidepressant, if they were Dutch-
speaking, if they could be reached by telephone for follow- Background
up and if the treating psychiatrist confirmed these inclusion
criteria. The GIPPOZ-study is a longitudinal study in 11 The discharge counseling was the topic of interest of
Flemish psychiatric hospitals. The pharmacist coordinated GIPPOZ as previous literature has reported on the unmet
the study in his/her hospital but asked for collaboration need regarding medication information. Satisfaction or
with staff members (nurses and psychiatrists) to check knowledge on medicines among inpatients and patients at
patient inclusion criteria and to communicate the patients discharge was low in several studies [911]. The lack of
discharge date to the pharmacist. When the inclusion cri- information and knowledge on medicines among patients
teria were satisfied, patients were asked to participate by taking antidepressants has also been observed during a
the pharmacist a few days prior to discharge. A quasi- qualitative study in all participating hospitals carried out
experimental design was applied. It comprised three study prior to the GIPPOZ-study [3]. Discharge counseling has
groups: one control group (usual carenone of the par- proven to be effective [12].
ticipating hospitals provided systematic discharge coun- Whereas the role of the clinical pharmacist in a psychi-
seling on antidepressants [3, 4]) and two experimental atric setting has yet to be defined in Belgium, psychophar-
groups (undifferentiated and differentiated information). macists are active in other countries for more than 20 years
Undifferentiated medication information is the provision of [1315]. The role of these psychopharmacists is multiple:
an information intervention on the prescribed antidepres- providing direct patient care (towards an optimal pharma-
sants independent of the patients information desire. Dif- cological treatment), compiling medication histories, pro-
ferentiated medication information is the provision of viding patient education, providing information and
information which takes into account patients information education for staff on psychopharmacology, and developing
desire: patients with a high desire for information received programs for evaluation and review of patients [13, 16].
information on their antidepressants, while patients with a Literature supports a clear role for pharmacists informing
low desire for information did not receive this information. patients and health care professionals on medicines [13, 16
Information desire was assessed by the six-item Extent of 19]. Clinical pharmacy is developing in general hospitals due
Information Desired questionnaire. A cut-off value of 19 or to financial support of pilot projects by the Belgian govern-
more was applied to identify patients with a high desire for ment since 2007. The majority of the projects is focusing on
information (range score is 630) [5, 6]. Each hospital was admission or discharge management and medication recon-
assigned to one of the three study groups. The counseling ciliation. Some focused on patient counseling. In 2010, the
followed a standardized procedure and was guided by the first pilot project in a psychiatric hospital was approved. As
study documents and the use of patient leaflets [7] on the the number of staff in Belgian psychiatric hospitals tends to
antidepressants prescribed. The counseling aimed at an be limited to one pharmacist, opportunities to start clinical
interactive discussion on the antidepressants in which the pharmacy are limited by the traditional pharmacy work
topics of the leaflets were systematically discussed. consisting mainly of medicine distribution. Counseling of
Patients were asked regularly if they had any questions. patients is not a standard task of the pharmacist in Belgian
During counseling, pharmacists took notes of the topics psychiatric hospitals. In some hospitals, patient counseling is
discussed and questions asked. This study wanted to sup- done on demand and occurs seldomly [3]. No other clinical
port patients in their antidepressant pharmacotherapy at the pharmacy activities were performed in the psychiatric hos-
transition from hospital to home. Outcomes assessed in the pitals before the start of the GIPPOZ-study.
GIPPOZ-study were compliance, depressive symptoms, A survey in US (Ohio) on counseling by hospital
somatic symptoms, side effects, costs of medicines and pharmacists showed that two-thirds of pharmacists did not
health care professionals, number of work days lost, quality perform any patient counseling. The most cited barriers

Int J Clin Pharm (2011) 33:101110 103

were lack of time and insufficient staff. Enabling factors hospitals from different psychiatric networks: Broeders
most often cited were decentralization and resource avail- van Liefde (n = 3), Broeders Hieronymieten (n = 3)
ability [20]. In a Nepalese study, language was found to be and university hospitals (n = 2). None of them were pri-
the major barrier to patient counseling [21]. To the best vate hospitals. The hospitals were located in different
knowledge of the authors, no information is available on geographical regions of Flanders. The number of beds per
the pharmacists attitudes towards medication counseling hospital ranged from 85 to 500 (mean standard devia-
in a psychiatric hospital setting and our study is the first tion: 214 106). In 10 of the 11 hospitals, only one
one in this field. pharmacist was employed at the hospital. All pharmacists
participating in the GIPPOZ-study were asked to partici-
pate in a FGD. In eight of the 11 hospitals, one pharmacist
Aim of the study was involved. In three hospitals, two pharmacists were
involved due to organizational reasons (n = 1) or due to
The aims of this study are to identify: (1) experiences maternity leave (n = 2). In total, 14 pharmacists collabo-
(positive and negative), barriers and enabling factors of rated. Two FGDs were organized in order to have a rea-
antidepressant counseling by the pharmacist at discharge; sonable group size of seven participants [23]. The FGDs
and (2) the feasibility of future initiatives involving medi- were organized at two different locations in Flanders
cation counseling by the pharmacist in a psychiatric setting. (Ghent and Leuven). As the experiences of all pharmacists
had to be heard, dates were chosen in consultation with
them. Pharmacists of the three study groups were mixed in
Methods the FGDs as they could have different reflections on their
Focus group discussions
Data collection
The current study applied a qualitative approach in order to
gather experiences and to identify barriers and enabling The FGDs were moderated by the main researcher (F.D.)
factors. Focus group discussions (FGDs) were used as and were assisted by a co-moderator. The co-moderators
group interaction among participants has the potential for were the supervisors of the GIPPOZ-study (G.L. and S.S.).
greater insights to be developed [22]. Field notes were taken by an independent pharmacist
(S.D.C. and K.P.). Each participant received an interview
Participants guide (see Table 1) at the start of the FGD. The interview
guide consisted of six open-ended questions given that
Eleven psychiatric hospitals voluntarily participated these types of questions demand for more description and
(through personal contact and mailing to all hospitals in explanation by the participants [23]. The questions asses-
Flanders) in the GIPPOZ-study. This sample represented sed the implementation of the study, experiences of patient
one-third of all psychiatric hospitals in Flanders. This contacts, experiences of interdisciplinary collaboration,
sample included individual hospitals (n = 3) as well as study support and future initiatives. Each participant was

Table 1 Interview guide for the

1. Considering your hospital before and after the GIPPOZ-study, did the GIPPOZ-study contribute to
patient care (more particularly, in the regard of your role as clinical pharmacist)? In what way did it (not)
2. How was the GIPPOZ-study implemented in your hospital?
3. How did you experience the study support in order to perform the GIPPOZ-study in your hospital?
(guidance/training/study documents/study protocol/feasibility)*
4. How did you experience the patient contacts? How did the patient contacts work out?
(informed consent/intervention)*
5. In what way did the GIPPOZ-study contribute to your role as a clinical pharmacist in your hospital? How
was the interdisciplinary collaboration?
* The items between brackets
were not shown to the (psychiatrists/nurses/management/others)*
participants. If the listed items 6. Keeping the experiences with the GIPPOZ-study in mind, what is worthwhile to take along for future
did not emerge during the initiatives?
FGDs, these were probed by the (feasible/useful/valuable/need assessment/future interventions/future approach)*
moderator or co-moderator

104 Int J Clin Pharm (2011) 33:101110

asked to write down his/her views for each question on a range from junior hospital pharmacists to pharmacists with
separate card. The cards were collected and grouped by a full professional career in a psychiatric hospital. Quotes
question. The questions were consecutively discussed are referenced to the pharmacist (16) and to the group:
among all participants starting with the presentation of the FGD Ghent (G), FGD Leuven (L) and written report (W).
answers noted on the cards. The FGDs ended with the The experiences (negative and positive), barriers and
question whether there was any experience regarding the enabling factors were studied. For each of them, five dif-
GIPPOZ-study that was not yet mentioned. The FGDs took ferent categories were identified: three on organization
about one and a half hour. The FGDs were tape recorded level (individual patient contacts, interdisciplinary contacts
and verbatim transcribed. If a pharmacist was in the end and hospital management); and two related to the study
not able to attend one of the FGDs, he/she was invited to (study performance and study support).
write down his/her views and experiences using the same There existed differences between hospitals on how they
interview guide. All names of participants were made appreciated the role of the clinical pharmacist. A major
anonymous. Approval by an ethical committee was not difference between hospitals was the interdisciplinary
needed. The study has been discussed with and approved relations. Due to these differences, a positive experience in
by the pharmacists, physicians and management of the one hospital may be a negative one in another hospital and
participating hospitals. Ethical approval was obtained for vice versa.
the GIPPOZ-study itself.
Providing medication information to patients, thats
Data analysis the domain of the physicians and it has always been
like that(G6)
The FGDs and written reports were inductively analyzed The idea that a pharmacist does not only distribute
according to the five stages of the framework analysis medicines in the hospital is growing.(W2)
described by Pope and Mays: (1) familiarization (reading of
the transcripts and notes, listening to the tapes), (2) identi- Negative experiences
fying a framework, (3) indexing (application of the frame-
work to the data), (4) charting and (5) mapping and The pharmacists had negative experiences with some
interpreting [24]. The software QSR NVivo 7 for Windows physicians, patients and management.
(QSR Intenational Pty Ltd; 2006) was used to facilitate the Although psychiatrists agreed with the conduct of the
analysis. GIPPOZ-study and were aware of the importance of the
A thematic framework was built by consensus between intervention, some were not committed to including
the main researcher (F.D.) and the co-moderators in the patients. The pharmacists had the feeling that they had to
FGDs (G.L. and S.S.) The interviews were indexed inde- manage the study on their own.
pendently by the main researcher and one co-moderator
But the psychiatrists euh were positive about it
(G.L.). Any discrepancies in the findings were discussed
but made little contributions for the inclusion of
until consensus was reached. If needed, a third reader
patients. They did not call me.(L2)
assisted to consent on the indexing. Quotes were selected by
consensus. Planning of the intervention was sometimes difficult. As
the pharmacists were not always timely informed that
patients would be discharged, eligible patients were lost for
inclusion. In some other cases, the pharmacist barely had
time to include the patient who was discharged shortly after
Eleven of the 14 pharmacists attended one of the two
the study intervention.
FGDs. The three other pharmacists submitted a written
report. Demographic characteristics of the pharmacists are Yes, I had euh 6 or 7 last minute calls. I mean, there
summarized in Table 2. Participants covered the whole was a patient eligible for inclusion in the GIPPOZ-

Table 2 Demographic
Number of Gender GIPPOZ study group
characteristics of the FGD
participants Male Female Control Undifferentiated Differentiated
group study group study group

FGD Ghent 6 3 3 3 1 2
FGD Leuven 5 3 2 0 3 2
Written report 3 1 2 2 0 1

Int J Clin Pharm (2011) 33:101110 105

study but he was going to be discharged within two many questions on their antidepressants. Counseling on
hours.(L2) antidepressants was not an easy task for the pharmacists as
they wanted to support the treatment plan of the psychia-
Some patients who received the antidepressant coun-
trist but they had no access to the medical file of the patient
seling wondered about the timing of the intervention. They
to obtain information on the diagnoses, personal charac-
preferred to have this information earlier, e.g. at time of
teristics (e.g. educational level), motivation of the psychi-
first prescription, rather than at hospital discharge.
atrist for the prescribed pharmacotherapy or issues related
The only question some patients had was why do to this pharmacotherapy (e.g. non-compliance during hos-
we get this information so late?.(G4) pital stay).
The pharmacists were disappointed to hear that despite There was a great demand for information but there
the financial reward received by the hospital for study is an equal demand to have some space to tell their
participation, no incentive for the pharmacy or the partic- story.(L4)
ipating wards was possible (e.g. to buy a new computer or a Patients had really a tendency to describe their sit-
software subscription). uation and to justify why they were admitted to hospi-
tal. Some of them reported that they could not tell their
Barriers story (to the health care professionals).(W3)
Yes, if you informed on how they obtained their
Several barriers were identified with respect to patient information, then you experienced that this was lim-
inclusion. Information flow from the wards to the phar- ited Is this due to lack of time of the treating
macy on discharge times of eligible patients was often physician or is it due to something else?(G5)
difficult. Time of discharge was regularly not scheduled in Pay attention you do not say anything that may be in
advance. Diagnosis of patients sometimes changed contradiction to the things said by the
whereby patient were or were not any longer eligible for psychiatrist.(L1)
inclusion. The availability of supervising health care pro-
One pharmacist reported that the interactive training on
fessionals on the ward was linked to patient inclusion: part-
communication and counseling prior to the start of the
time working schedules, shift work, maternity leave or
GIPPOZ-study had an inhibiting effect.
holidays were linked with lower inclusion rates. Attention
for including patients decreased during the course of the Actually, I became frightened. I always thought I
study. Time constraints and workload of health care pro- could do the patient talks and so And then, I came
fessionals were mentioned as a barrier in multidisciplinary here and it was a bit artificial. I did not feel
collaboration. comfortable.(G1)
On the other hand, there was also a difficult com-
Positive experiences
munication with and within the wards The phar-
macy did not have control of the whole process to
Although difficulties in interdisciplinary contacts were
include effectively all eligible patients.(W3)
encountered in some hospitals, other hospitals reported on
Yes, I also think the availability too because they
the positive support of the interdisciplinary team. Support
were not there at times I was busy with the study.
was provided by psychiatrists and nurses. The GIPPOZ-
They are usually gone in the afternoon.(G1)
study contributed to the integration of the pharmacist in the
The situation does not need much change: or the
discharge is cancelled or the discharge indeed can go
through(L1) I telephoned: I would like to have an appointment
with this patient, when is it possible? I went to the
Pharmacists reported that during patient contacts, a large
ward. They called the patient and no one had any
proportion of patients expressed the need to tell their story
problem with it the psychiatrist did not, the nurses
and to justify their admission. Patients wanted to talk about
did not, the therapists did not.(G4)
other topics besides their medicines: some of them shared
their worries of what would happen after discharge. Anti- Pharmacists reported that patient contacts generally
depressant counseling showed that patients were not went smoothly. They experienced that patients were will-
always well informed about their medicines during hospital ing to participate and were satisfied to talk with the phar-
stay. Some patients did not know the names, the types, the macist. One pharmacist reported that patients provided
indications, the correct instructions for use, the need for positive feedback on the intervention to their psychiatrist.
compliance or the possible side effects. Patients asked Pharmacists stressed the importance of the individual focus

106 Int J Clin Pharm (2011) 33:101110

of the intervention: patients got the opportunity to ask their professionals, sending reminders to health care profes-
own questions regarding their own medicines without a sionals, regular visits to the wards to check and insist on
time limitation. enrollment of eligible patients.
The psychiatrists also received feedback from the I made a list of names of patients I displayed the
patients. The psychiatrist was satisfied with what Ive list in large lettering so they knew. And then I regu-
done. I really took my time. They told the psychia- larly asked how is the patient evolving.(L3)
trist: yes he really explained us well. I was pleased
The pharmacist was seen as a person without ulterior
to hear the counseling turned out to be useful.(L2)
motive. Topics discussed during intervention were confi-
I think we really could say that because of this
dential as the discussion was not included in the patients
GIPPOZ-study. We could emphasize a lot more by
medical file. Additionally, the pharmacists had no access to
saying you really need to take this further because of
the patients medical file. This facilitated the conversation
this. But I think we could do so, especially because
as this was the first time they met the pharmacist.
we could approach them on an individual basis.(L1)
They knew it would not come in their file. Thats a
Pharmacists indicated that participation in this kind of
motivating factor.(L2)
study resulted in a personal improvement of knowledge
and skills. The more patients were included, the better the The study documents were clearly and logically struc-
study process worked out. tured, and supported the patient contacts. Feedback by the
main researcher was experienced as being constructive
As a hospital pharmacist, you are partially seen as a
rather than controlling.
stock manager. There is too much basic work to
perform additional scientific work. The study was I appreciated the study documents as supportive. So,
good for the personal development.(W3) when you went through the file, there was a certain
chronological order you had to respect.(L5)
By participating in the GIPPOZ-study, the hospitals
management became more aware of the need for more
Future initiatives for clinical pharmacy interventions
medication information for patients.
in the psychiatric hospital setting
Now there is more attention for correct information
on medicines.(W2) Talking about future initiatives, preconditions as well as
topics concerning format and content were discussed.
The study support was evaluated as positive and pro-
Pharmacists indicated that future initiatives have to be
fessional. The interactive training on communication and
taken in a broad view of human and other resources. Time
counseling seemed to be a good starting point. Regular
constraints and financial resources are at present a barrier
updates and personal contacts were much appreciated.
to take more initiatives. Future initiatives were welcomed
Support was good in the sense of communication, avail-
if they remain feasible within the actual job responsibili-
ability of the research team and logistical support.
ties. One of the pharmacists suggested implementing future
Right from the start it was good. The interim eval- initiatives via projects.
uation was performed well. Your regular emails, your
But you are tied to your core business which does
telephone contacts yes, that was good. It was a
not run away. You have to do them.(L2)
very good study support. Otherwise, it would not have
I think that in a psychiatric setting we temporarily
worked out I think.(L2)
have to turn on projects And that cannot be six
projects on the same time.(L2)
Enabling factors
To fulfill the demand for more information, a structured
The pharmacists were the key persons of the study in their way of working seemed necessary. This structure would be
hospital. They managed the study from start till end and needed on several levels: structured in time, structured
monitored all steps. This key person was essential for a collaboration, role of the pharmacist in the team and
successful course of the study. selection of patient population. Participants agreed that the
information intervention was feasible for patients with
Obviously, the pharmacy did perform the work
major depression but questioned the feasibility in other
(except of the diagnosis).(W1)
populations (e.g. elderly and psychosis). Several par-
Enabling factors for patient inclusion were: listing ticipants stressed that knowledge on the context and
names of eligible patients on a visible place for health care background of the patient would facilitate contacts.

Int J Clin Pharm (2011) 33:101110 107

Additionally, they were aware that providing such a service did not work in other hospitals and vice versa. Organiza-
demanded new competencies for which training would be tional culture has been defined as the values, beliefs, and
recommended. norms of an organization that shape its behavior [25]. It
can be studied by exploring the views of staff members
We have now done a group of patients with
mutual interaction and their interaction with patients [26].
depression where information is easy But
Effective implementation of change in patients care is
imagine you will have to talk to psychotic patients.
possible but generally requires comprehensive approaches
Thats another story.(G4)
at all levels of the organization tailored to the specific
When a pharmacist would discuss medicines with
setting and target groups [27]. This entails a hospital-spe-
patients, then you have to have an idea on the context
cific approach as well as a specific approach towards
of the patient: what can you say and what cant you
mental health care professionals as psychiatrists perceived
their discipline as more complex than other disciplines
The provision of drug information can be performed at [28]. Because the pharmacists were the only participants in
different points in time and in different ways. The inter- the FGDs, conclusions can only be drawn about the barriers
vention at discharge was estimated as valuable but can and enabling factors towards interdisciplinary contacts at
already take place earlier, e.g. when the acute symptoms the level of the pharmacist and not at the level of the
decreased. Medication information can be given in group hospital. The pharmacist was accepted to coordinate the
(psycho-education) but preferably on an individual basis: study in all hospitals. Ideally, other health care profes-
discharge letter, medication scheme, leaflets or pharmacy sionals of the multidisciplinary team involved in the GIP-
consultation hour. Although written materials were men- POZ-study should have been included to have a more
tioned, the participants recommended to add oral expla- comprehensive idea on barriers and enabling factors.
nation or to refer to the pharmacist in case of questions. Barriers and enabling factors to implement an inter-
The importance of useable and practical information for the vention can act at different levels: individual, team and
patient was a major point regarding the content of future organization. It is important to understand the barriers and
interventions. Patients need correct and understandable enabling factors at each level to tailor strategies for
information. implementation or change accordingly. Barriers to imple-
mentation can be classified according to the following
I think a leaflet can never never replace a
levels: organizational context (e.g. organizational con-
straints, patients expectations, financial disincentives),
Ideally, it seems to me you can provide psycho
social context (e.g. standards of practice, opinion leaders,
education once the acute phase passed by While
medical training) and professional context (e.g. clinical
when they are going to be discharged, you can say
uncertainty, sense of competence, information overload)
something more specific on these products. Yeah, that
[27, 29]. A good understanding of underlying processes
seems a good concept to me.(G4)
and systems is essential to succeed and to improve care
[25]. All three levels have been detected during the focus
group discussions: organizational context (e.g. availability
Discussion of health care professionals), the social context (e.g.
commitment of health care professionals to include
Eleven psychiatric hospitals participated in a clinical patients) and the professional context (e.g. experience of
pharmacy intervention study on antidepressant counseling the interactive training). In some hospitals each of these
prior to discharge. After finalizing the GIPPOZ-study, examples was experienced as positive or being an enabling
pharmacists were invited to share their experiences and factor while it was experienced as negative or as a barrier
ideas. This was of interest for the evaluation of the GIP- in other hospitals.
POZ-study in itself as well as to bear these topics in mind Another barrier mentioned by the participants was the
for future research projects in this setting. Differences difficult communication on discharge times resulting in
existed between hospitals. Difficult interdisciplinary missed inclusions of eligible patients. Lack of communi-
information flow to the pharmacist and limited availability cation between health care professionals has also been
of staff members negatively influenced patient inclusion. identified in previous mental health care research [30]. This
Positive and negative experiences, enabling factors and lack of communication complicates the integration of dif-
barriers were discussed. Future initiatives were welcomed ferent aspects of care [30]. Some of these identified barriers
but several preconditions should be considered. might be prevented: regular reminders can help to ascertain
Some differences in hospitals were reported. Approa- attention for patient inclusion; one contact person on each
ches used in one hospital (e.g. use of discharge reminders) ward could facilitate communication with the pharmacy; a

108 Int J Clin Pharm (2011) 33:101110

summary of relevant patient medical information could be involved in medication counseling and that patients might
provided to the pharmacist when the psychiatrist is con- be referred to them whenever needed. Health care profes-
firming inclusion criteria to overcome the lack of back- sionals can also contact pharmacists for questions related to
ground knowledge; and a certain amount of time can be medicines. Information need could be detected to ask
dedicated to have a small talk with the patient before patients if they request any information on their medicine.
starting the intervention to give the patient the opportunity Implementing this question in daily clinical practice could
to tell his/her story if he/she wants so. Other barriers must assist health care professionals in identifying patients
be prevented at a higher level: workload and availability of needing more information on their medicines. Future
health care professionals; and the planning of the discharge research on educational interventions during hospital stay
date. The role of the clinical pharmacist within their hos- and/or at discharge will have to be performed to identify an
pital was a point of discussion. Although the management effective approach with regard to content, format, repeated
in some hospitals was not yet in favor of this new role of or more complex interventions.
the pharmacist, participants did take the opportunity to Pharmacists experienced that patients had a need to tell
participate in the GIPPOZ-study to introduce the idea of their story and discuss how they would manage when
clinical pharmacy in their hospital. To broaden their role as returning home. This was mentioned in the results as a
pharmacist in the future, the demand for new competencies barrier. The question is if this is really a barrier or rather an
arose among participants. Training for these competencies opportunity for the pharmacist to build a valuable phar-
seemed necessary. The same finding was observed in a macist-patient relationship leading to discussions on med-
qualitative study performed among staff of UK community icines. Pharmacists were also appreciated by patients as an
agencies [31]. The aim of this study was to assess the independent health care professional.
extent to which staff was equipped to address mental health This qualitative approach allowed in-depth exploration
issues; to identify further development of their knowledge of the experiences, enabling factors and barriers from the
and skills; and to make recommendations about a new pharmacists perspective. The interaction between partici-
training initiative. Training was asked on dealing with pants revealed topics which could probably not have been
difficult behavior; increasing awareness of symptoms and detected through another approach. A number of limita-
available treatment; counseling and negotiating skills [31]. tions and strengths need to be addressed.
To further develop clinical pharmacy in a psychiatric set- A first limitation of conducting FGDs is the lack of
ting, external barriers such as the need for additional generalisability of the results. The results presented are
human and financial resources needs to be addressed at only valid for the GIPPOZ-study and are specific to the 11
policy level. Currently, Belgian legislation restricts the hospitals. A second weakness is the choice of moderator
number of pharmacists working in a hospital. In 2010, the and co-moderators. These were the main researcher and the
first governmental funding of a clinical pharmacy project supervisors of the study. They were responsible for all
focusing on the use of atypical antipsychotics in a psy- aspects of the study and were well known by the partici-
chiatric hospital is a first official step in supporting clinical pants. Therefore, independence of these persons may be
pharmacy in this specific setting. questioned. Social desirable answers might have been
Future initiatives focusing on medication information provided by participants, even though participants provided
are necessary to fulfill the demand for more information. detailed answers on each question and motivated their
This demand for more information might be an indication answers. The moderator and co-moderators were aware of
that medication information should be more systematically this weakness and moderated the discussion accordingly.
provided to patients. Medication information can be pro- Participants were encouraged to discuss both positive and
vided by the psychiatrist, the pharmacist and also by nur- negative aspects. Third, the experiences of the specific
ses. Nurses can for instance detect non-adherence which approach of differentiating medication information
might be indicative of a lack of knowledge on the use of according to the patients information need were not
medicine in that particular patient. Non-adherence or explored when discussing future initiatives. The pharma-
medication knowledge problems could be a fixed item on cists expressed the willingness to continue counseling
the agenda of interdisciplinary team meetings. Medication psychiatric patients if this task would be supported by the
information could also be introduced in the clinical path- hospital management. Fourth, the number of participants
ways on a systematic basis. The format and content of such and the number of FGDs was limited. Number of partici-
interventions should be designed according to the patients pants was adjacent to the ideal size of six to eight partic-
needs. A combination of oral and written information as ipants in each group [23]. Due to the low number of
well as easy understandable information has shown to be eligible participants (n = 14) no more than two FGDs
more effective [32]. We recommend hospitals to commu- could be organized. However to maximize our data col-
nicate to their staff members that pharmacists can be lection, participants who were unable to be present at a

Int J Clin Pharm (2011) 33:101110 109

FGD (n = 3) were afterwards invited to share their expe- 3. Desplenter F. Exploring the impact of medication information for
riences and ideas on paper. Finally, all fourteen pharma- psychiatric patients at hospital discharge [PhD Dissertation],
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