key: cord-0878115-kmnqjnd5
authors: Okuyan, Betul; Bektay, Muhammed Yunus; Kingir, Zehra Betul; Save, Dilsad; Sancar, Mesut
title: Community pharmacy cognitive services during the COVID‐19 pandemic: A descriptive study of practices, precautions taken, perceived enablers and barriers and burnout
date: 2021-09-23
journal: Int J Clin Pract
DOI: 10.1111/ijcp.14834
sha: 0bc45ccd73d04f63aba1ed5bde49f8707e93e835
doc_id: 878115
cord_uid: kmnqjnd5

OBJECTIVE: The objectives of this study were to identify community pharmacist (CP)‐led cognitive services and CPs’ precautions taken related to COVID‐19, perceived enablers and barriers related to pharmaceutical services and burnout levels during the COVID‐19 pandemic. METHOD: In this descriptive study, the survey was administered online to CPs in all regions of Turkey. The frequency of their provision of patient counselling, provision of medication information and practices towards precautions during the pandemic were evaluated based on CP self‐reports. The Turkish version of the Burnout Measure Short Form was used, and a 30‐item questionnaire based on the 12‐domain Theoretical Domains Framework was developed to determine CPs’ perceived enablers of and barriers to pharmaceutical service delivery during the COVID‐19 pandemic. Data were collected using convenience sampling methods. Besides internal consistency reliability, principal component analysis, and correlation analysis, Mann‐Whitney U‐test was conducted in group comparisons. RESULTS: A total of 1098 complete responses were received, for a response rate of 4.11% among 26 747 CPs. The CPs’ median burnout score was 3.3 (2.5‐4.2). More than half of the CPs (54.5%) referred probable patients with COVID‐19 to the hospital. Commonly delivered cognitive CP‐led services included preventive health services (89.5%) and medication information services (86.3%). Perceived barriers to delivering pharmaceutical services were a lack of environmental resources and support and a lack of innovation in pharmaceutical services. Perceived enablers were CPs’ knowledge, skills, self‐confidence, actions, impacts, emotions and perceived behavioural control. CONCLUSION: To increase the preparedness of pharmacists for future pandemics or disasters, this study highlighted CP‐led cognitive services, precautions taken related to COVID‐19, perceived enablers and barriers and burnout during the COVID‐19 pandemic. Pharmaceutical services guidelines that could be followed during a pandemic or other disaster should be designed by addressing these findings.

The World Health Organization (WHO) announced the outbreak of a novel coronavirus disease 

Emergency of International Concern on 30 January 2020, after the disease first emerged in Wuhan, China, in December 2019. 1 More than 122 million people have been infected with COVID-19, and more than 2.7 million deaths have occurred because of COVID- 19. 2 Community pharmacists (CPs) play a vital role in dispensing medicine and other medical devices and delivering cognitive services (non-dispensing services such as pharmaceutical care, patient counselling, and the provision of medication information) during disasters. 3 Cognitive pharmaceutical services were defined as "the use of specialized knowledge by the pharmacist for the patient or health professionals for the purpose of promoting effective and safe drug therapy". 4 Pharmacist-led cognitive services promote the rational use of medication. In delivering these services (such as health promotion, medication therapy management and preventive healthcare services), pharmacists have a potential impact on the quality of medication therapy and the healthcare delivery system by using their specialist knowledge of medications. [4] [5] [6] [7] [8] [9] These services delivered by CPs during disasters are within the scope of pharmacy practice and are usually an extension of the pharmacist's daily routine, which includes ensuring the supply of medicines and the provision of pharmaceutical care services. 3 During the COVID-19 pandemic, community healthcare systems have been overwhelmed and interrupted due to the higher demands of patients. This pandemic has psychologically affected all healthcare workers, including CPs. 10 In these circumstances, CPs have had little knowledge of how to deliver pharmaceutical services to patients who may have COVID-19

and those with chronic diseases. Pharmacists may contribute to the early detection and appropriate referral of COVID-19 patients as well as the provision of patient-oriented services, education about infection and prevention methods, psychological support and chronic disease management services during a disaster or pandemic. [11] [12] [13] [14] According to guidance from the International Pharmaceutical

Turkey have taken precautions, such as the regulation of opening hours; social distancing and identification of warning signs; the use of individual protective equipment, such as masks and goggles; the disinfection of pharmacies and the improvement of medical waste management. 15, 16 However, delivering all these services may overload CPs and cause burnout. There are many definitions of burnout. [17] [18] [19] Pines and Aronson 19 defined burnout as a loss of energy, enthusiasm, perspective, idealism and purpose and suggested that it is a state of physical, emotional and mental exhaustion. 18, 19 Burnout is more common in professionals who communicate directly with people, such as healthcare professionals. 17 Healthcare workers (physicians, nurses and pharmacists) have a high risk of stress, anxiety, depression, burnout, addiction and posttraumatic stress disorder due to the increase in stress and workload during the COVID-19 pandemic. [20] [21] [22] [23] During the COVID-19 pandemic, pharmacy employees have been found to have high burnout scores related to many difficulties, such as job stress, a lack of staff and resources, general anxiety, a fear of infection and communication difficulties. [23] [24] [25] [26] [27] AlAteeq et al 28 showed that during the COVID-19

pandemic, anxiety and depression were prevalent among healthcare workers in Saudi Arabia. Algunmeeyn et al 24 identified important COVID-19 pandemic-related factors, such as job stress, a lack of staff and resources, a fear of COVID-19 infection and interprofessional relationships in healthcare practice. In a study in France, 35% of CPs reported psychological disturbances. 23 The majority of healthcare workers exposed to COVID-19 have reported symptoms of depression, anxiety, insomnia and distress. 29 Although the continuity of pharmaceutical services provided by pharmacists is important, CPs' role in disasters/pandemics has not been defined in detail. 3 The COVID-19 pandemic is not the first disaster that humanity has faced, and it will not be the last. Thus, CPs' perceived enablers of and barriers to the delivery of pharmaceutical services under such conditions should be investigated to develop and implement pharmaceutical services guidelines for use in future disasters.

The objectives of this study were to identify CP-led cognitive services and CPs' precautions taken related to COVID-19, perceived enablers and barriers related to pharmaceutical services and burnout level during the COVID-19 pandemic. The research questions were listed as follows: (1) 

• Community pharmacist-led cognitive services during the COVID-19 pandemic were mainly medication information services, preventive healthcare services, and patient counselling for those with chronic disease.

• Community pharmacists reported insufficient environmental resources and support and a lack of innovation in pharmaceutical services as barriers during the COVID-19 pandemic.

In this descriptive study, a national online survey was conducted with CPs in all regions of Turkey between 21 and 29 May 2020. All Turkish CPs were included this study. A sample size of 379 was required within a 5% margin of error, confidence intervals (CI) of 95%, and expected rate of CPs' high burnout level of 50% based on the study of Tiete et al. 30 Data were collected using convenience sampling methods. This study is reported according to the recommendations of the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) standards. 31

The survey was uploaded onto the Marmara University web platform provided Lime Survey ® . The invitation letter and survey were distributed online by the Turkish pharmacist chambers nationally.

Turkish CPs were sent an e-mail or WhatsApp message containing a link and information regarding the present study. To maximize the response rate, the survey link was posted on websites and social media accounts frequently visited by CPs during their daily professional work. CPs' consent was obtained electronically. After giving their consent, the participants were directed to the questionnaire.

The online survey consisted of the following five sections: characteristics of CPs (six questions), the Turkish version of the Burnout Measure Short Form, 18 Age, gender, duration since graduation (year), professional experience as a CP (year), the region where they lived and position at community pharmacy were collected.

The Burnout Scale Short Form developed by Pines and Aronson 19, 32 was used to measure occupational burnout, including physical, mental and emotional exhaustion. The Turkish adaptation and validation of this scale was conducted by Capri. 18 Ten items rated on a scale ranging from 1 (never) to 7 (always). Higher scores indicated greater burnout. The threshold was 4, which indicated a critical level of burnout. 18, 19 Questions related to CP-led cognitive services during the COVID-19 pandemic were developed based on a previous classification of cognitive pharmaceutical services. 33 The frequency of the provision of patient counselling (including the frequency compared with that before the pandemic) was evaluated both in general and in relation to the COVID-19 pandemic based on CP self-reports. 

Descriptive statistics (such as those used for demographic data and the frequency of cognitive services) are presented as frequencies and percentages. Data normality was assessed by a Kolmogorov-Smirnov test. All continues variables were non-normally distributed and represented as median (interquartile range [IQR]).

Mann-Whitney U-test was used for testing unpaired sample of two groups (male vs. female, CPs with 20 years or less of professional experience vs. CPs with more than 20 years of professional experience, CPs with high level of burnout vs. CPs with low level of burnout) with non-normally distributed variables. Spearman's rank correlation was used to determine the possible correlations between the continuous variables (such as those used in the test-retest reliability assessment). The internal consistency of the questionnaire was assessed using Cronbach's alpha coefficient. A principal component analysis (PCA) with varimax rotation was conducted to evaluate the 30-item questionnaire based on the 12-domain TDF. The number of components was determined using the total variance explained, a scree plot, assumptions tests, factor loadings and component loadings according to a previous study. 38 The Kaiser-Meyer-Olkin (KMO) measure of sampling adequacy and Bartlett's test of sphericity were also used. The data were suitable for principal component analysis, as they met the following conditions: matrix coefficient ≥0.30, KMO sampling adequacy ≥0.60, and Bartlett's test of sphericity ≤0.05. The median and interquartile range of each item and each component of the behavioural determinant questionnaire were calculated. 39 Each item and component were scored from 1 to 5 as described previously. 40, 41 Negatively phrased items were reverse scored. Based on a previous study, items with low median scores (<3) were considered barriers, and those with high median scores (≥3) were considered enablers. 40, 42 A P value of less than .05 was considered statistically significant. SPSS version 11.0 was used for data analysis.

The study received ethical approval by the Uskudar University Non-Interventional Research Ethics Board (approval number of 61351342-2020/224 04.05.2020). Study permission was obtained from the Turkish Republic, Ministry of Health. Online informed consent was obtained from all individual participants included in the study.

A total of 1098 CPs were completed the online survey, for a response rate was 4.11% among 26 747 CPs ( Figure 1 ). The characteristics of the participants are given in Table 1 . The median age of the CPs was 41.0 (32.0-50.0) years, and the majority of the participants (64.8%) were female.

The median burnout score was 3.3 (2.5-4.2) ( Table 1 ). There were negative correlations between CPs' burnout level and professional experience (r = −.245, P < .001), and age (r = −.255, P < .001). Female 

The CPs reported an increase in the frequency of patient counselling for products related to enhanced immunity (90.8%), dermatological problems (50.2%) and immunization (43.0%). The CPs stated that they frequently provided counselling to patients with chronic disease (71.7%) during the COVID-19 pandemic. Regarding CP-led cognitive services, the CPs reported that they responded to questions F I G U R E 1 STROBE flow chart related to COVID-19 (86.3%) and provided preventive health services (89.5%) during the COVID-19 pandemic (Table 2) . Overall, more than half of the CPs (54.5%) referred their patients to the hospital if they were suspected to have COVID-19 (Table 3 ). The CPs received many questions on different subjects (Table 3) . Almost all CPs (95.4%) were asked about the use of herbal and dietary supplements during the COVID-19 pandemic. The CPs stated that patient resources related to these questions were television (84.8%), friends/neighbours (65.1%), WhatsApp groups (52.1%) and Facebook (50.6%).

The most common personal protection measures used by the CPs were avoiding direct contact (93.7%), more frequently washing their hands (93.2%) and using masks (92.8%). Of all CPs studied, 19.1% took hydroxychloroquine tablets as an unproven preventive agent against COVID-19 (Table 4 ).

The CPs reported more enablers of than barriers to the delivery of pharmaceutical services during the COVID-19 pandemic. Of the 30 TDF items, the CPs rated nine items as barriers (items with a median score <3) to the delivery of pharmaceutical services during the COVID-19 pandemic; however, they rated 21 items as enablers (items with a median score ≥3; Tables 5-9).

According to PCA, the KMO measure of sampling adequacy was 0.890, and Bartlett's test was significant (P < .001). The extracted five-factor model accounted for 53.0% of the total variance. The Allowing their staff with chronic illness or advanced age to stay home. 

This study highlighted CP-led cognitive services, precautions taken In the present study, higher levels of burnout were associated with the female gender, younger age and less professional experi- 23 This study showed that in Turkey, 2 months after the first COVID-19 case was confirmed, almost one-third of CPs experienced burnout. Female health care providers were previously found to be more likely to experience burnout during the COVID-19

pandemic. 43, 44 This finding was in line with the results of the present study. Burnout in health care professionals has been associated with job stress, time pressure, workload and a lack of organizational support. 45 According to the job demands-resources model, 46 Gaither et al 47 The CPs in this study reported an increase in the frequency of patient counselling for products related to enhanced immunity, dermatological problems and immunization during the COVID-19 pandemic.

Regarding CP-led cognitive services, the CPs responded to patients' pandemic. These findings were line with those of a previous study. 49 Hoti et al 50 Barriers related to environmental resources and support might be addressed through social support (practical), prompts/cues and the addition of tools and resources to the environment. 58, 59 Changes at the organizational and health system levels could be required to cope with barriers related to environmental resources and support during a pandemic. The development and implementation of interventions targeting these domains could be more effective for such situations. 61

This study was a national survey with an adequate sample size.

However, there could be sampling bias (selection and response bias)

because CPs who frequently used the Internet and/or more interest in cognitive pharmaceutical services may have been more likely to participate in the survey. This could impact the generalizability of the results to all CPs in Turkey. Another strength was the theorybased approach using the TDF taken in this study to determine enablers of and barriers to the delivery of pharmaceutical services 

The COVID-19 pandemic has impacted every aspect of life. In pandemic.

We would like to thank all CPs who completed the survey, all healthcare workers who have been working on the frontline and those who lost their lives during the COVID-19 pandemic.

The authors declare that there is no conflict of interest.

World Health Organisation WHO. WHO Director-General's statement on IHR Emergency Committee on Novel Coronavirus

Coronavirus disease (COVID-19) pandemic Weekly operational update on COVID-19 -22

Defining pharmacists' roles in disasters: a Delphi study

Pharmaceutical Care Practice. The Patient-Centered Approach to Medication Management. McGraw-Hill Companies

Evidence of the clinical effectiveness of cognitive pharmaceutical services for aged patients

Effect of outpatient pharmacists' non-dispensing roles on patient outcomes and prescribing patterns

Expanding the roles of outpatient pharmacists: effects on health services utilisation, costs, and patient outcomes

Impact of pharmaceutical care interventions on health-related quality-of-life outcomes: a systematic review and meta-analysis

Community pharmacist-led interventions and their impact on patients' medication adherence and other health outcomes: a systematic review

The psychological and mental impact of coronavirus disease 2019 (COVID-19) on medical staff and general public -a systematic review and meta-analysis

On the frontline against COVID-19: community pharmacists' contribution during a public health crisis

Recommendations and guidance for providing pharmaceutical care services during COVID-19 pandemic: a China perspective

Community pharmacist in public health emergencies: quick to action against the coronavirus 2019-nCoV outbreak

Provision of clinical pharmacy services during the COVID-19 pandemic: Experiences of pharmacists from 16 European countries

COVID -19-Guide lines -for-pharm acist s-and-the-pharm acy-workf orce

Pande miTed birle ri_28c0b 97b-827d-44fe-ad4b-48438 060a3 4c

Burnout: The Cost of Caring

The Turkish Adaptation of the Burnout Measure-Short Version (BMS) and Couple Burnout Measure-Short Version (CBMS) and the Relationship between Career and Couple Burnout Based on Psychoanalytic-Existential Perspective

Career Burnout: Causes and Cures

COVID-19 burnout, COVID-19 stress and resilience: initial psychometric properties of COVID-19 Burnout Scale

How essential is to focus on physician's health and burnout in coronavirus (COVID-19) pandemic?

A comparison of burnout frequency among oncology physicians and nurses working on the frontline and usual wards during the COVID-19 epidemic in Wuhan

Impact on mental health of the COVID-19 outbreak among community pharmacists during the sanitary lockdown period

Understanding the factors influencing healthcare providers' burnout during the outbreak of COVID-19 in Jordanian hospitals

Needs assessment and impact of COVID-19 on pharmacy professionals in 31 commonwealth countries

The burden of COVID-19 on pharmacists

Prevalence and risk factors of burnout in community pharmacists

Mental health among healthcare providers during coronavirus disease (COVID-19) outbreak in Saudi Arabia

Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019

Mental health outcomes in healthcare workers in COVID-19 and non-COVID-19 care units: a cross-sectional survey in Belgium

The strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies

The burnout measure, short version

How community pharmacists prioritize cognitive pharmaceutical services

World Health Organisation W. Coronavirus disease (COVID-19) advice for the public: Mythbusters

Measuring determinants of implementation behavior: psychometric properties of a questionnaire based on the theoretical domains framework

Measuring implementation behaviour of menu guidelines in the childcare setting: confirmatory factor analysis of a theoretical domains framework questionnaire (TDFQ)

World Health Organisation W. Process of translation and adaptation of instruments

Quantifying behavioural determinants relating to health professional reporting of medication errors: a cross-sectional survey using the Theoretical Domains Framework

Likert scales: how to (ab)use them

Current practice and barriers and facilitators to outcome measurement in aphasia rehabilitation: a cross-sectional study using the theoretical domains framework

Barriers and enablers to implementation of dietary guidelines in early childhood education centers in Australia: application of the theoretical domains framework

Turkish community pharmacists' behavioral determinants in provision of pharmaceutical care to elderly patients

Burnout and somatic symptoms among frontline healthcare professionals at the peak of the Italian COVID-19 pandemic

Mental health among otolaryngology resident and attending physicians during the COVID-19 pandemic: national study

Prevalence and factors associated with burnout among frontline primary health care providers in low-and middle-income countries: a systematic review

The job demands-resources model of burnout

Interpersonal interactions, job demands and work-related outcomes in pharmacy

Community pharmacists' burnout levels and related factors: an example from Turkey

Evidence of community pharmacists' response preparedness during COVID-19 public health crisis: a cross-sectional study

Provision of community pharmacy services during COVID-19 pandemic: a cross sectional study of community pharmacists' experiences with preventative measures and sources of information

Defining Roles for pharmacy personnel in disaster response and emergency preparedness

SARS-CoV-2 outbreak: how can pharmacists help?

Pandemic preparedness of community pharmacies for COVID-19: a cross-sectional survey

Social distancing and the use of PPE by community pharmacy personnel: Does evidence support these measures?

Community pharmacy response to infection control during COVID-19. A cross-sectional survey

Perceived barriers and facilitators to uptake of non-traditional roles by pharmacists in Saudi Arabia and implications for COVID-19 pandemic and beyond: a qualitative study using Theoretical Domain Framework

Making psychological theory useful for implementing evidence based practice: a consensus approach

From lists of behaviour change techniques (BCTs) to structured hierarchies: comparison of two methods of developing a hierarchy of BCT s

The behavior change technique taxonomy (v1) of 93 hierarchically clustered techniques: building an international consensus for the reporting of behavior change interventions

Extending the scope of community pharmacists' practice to patients requiring urgent care-an evaluation of a training programme using the Theoretical Domains Framework

The use of theory in research

Community pharmacy cognitive services during the COVID-19 pandemic: A descriptive study of practices, precautions taken, perceived enablers and barriers and burnout

Author elects to not share data.

https://orcid.org/0000-0002-7445-3235