a percepÇÃo do farmacÊutico no processo de … · preces e a quem eu tanto agradeci por cada...
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UNIVERSIDADE FEDERAL DE SERGIPE
PRÓ-REITORIA DE PÓS-GRADUAÇÃO E PESQUISA
MESTRADO EM CIÊNCIAS FARMACÊUTICAS
A PERCEPÇÃO DO FARMACÊUTICO NO PROCESSO
DE IMPLANTAÇÃO DE SERVIÇOS CLÍNICOS
FARMACÊUTICOS
Aline Santana Dosea
SÃO CRISTÓVÃO
2015
UNIVERSIDADE FEDERAL DE SERGIPE
PRÓ-REITORIA DE PÓS-GRADUAÇÃO E PESQUISA
MESTRADO EM CIÊNCIAS FARMACÊUTICAS
A PERCEPÇÃO DO FARMACÊUTICO NO PROCESSO DE
IMPLANTAÇÃO DE SERVIÇOS CLÍNICOS
FARMACÊUTICOS
Aline Santana Dosea
Dissertação apresentada ao Núcleo de Pós-
Graduação em Ciências Farmacêuticas da
Universidade Federal de Sergipe como
requisito parcial à obtenção do grau de Mestre
em Ciências Farmacêuticas.
Orientador: Prof. Dr. Divaldo Pereira de Lyra Júnior
SÃO CRISTÓVÃO
2015
DOSEA, ALINE SANTANA A PERCEPÇÃO DO FARMACÊUTICO NO PROCESSO DE 2015
IMPLANTAÇÃO DE SERVIÇOS CLÍNICOS FARMACÊUTICOS
FICHA CATALOGRÁFICA ELABORADA PELA BIBLIOTECA CENTRAL
UNIVERSIDADE FEDERAL DE SERGIPE
D722p
Dosea, Aline Santana
A percepção do farmacêutico no processo de implantação de serviços
clínicos farmacêuticos / Aline Santana Dosea ; orientador Divaldo Pereira
de Lyra Júnior. – São Cristóvão, 2015.
82 f. : il.
Dissertação (mestrado em Ciências Farmacêuticas)–Universidade
Federal de Sergipe, 2015.
1. Serviços farmacêuticos. 2. Farmacêuticos e pacientes. 3. Farmácias,
drogarias, etc. I. Lyra Júnior, Divaldo Pereira de, orient. II. Título.
CDU 615.15
A PERCEPÇÃO DO FARMACÊUTICO NO PROCESSO DE
IMPLANTAÇÃO DE SERVIÇOS CLÍNICOS
FARMACÊUTICOS
Dissertação apresentada ao Núcleo de Pós-
Graduação em Ciências Farmacêuticas da
Universidade Federal de Sergipe como requisito
parcial à obtenção do grau de Mestre em Ciências
Farmacêuticas.
Aprovada em: 26/02/2015
________________________________________________
Orientador (a): Prof. Dr. Divaldo Pereira de Lyra Junior
________________________________________________
1º Examinador (a): Prof. Dr. Alfredo Dias de Oliveira Filho
__________________________________________
2º Examinador (a): Profa. Dra. Adriana Inocenti Miasso
PARECER
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AGRADECIMENTOS
É com grande emoção que chego à conclusão de uma inesquecível etapa da minha vida, mais forte e
madura para alcançar mais objetivos e realizar todos os meus sonhos.
Agradeço inicialmente a DEUS, meu pai amado, amigo de todas as horas, que ouviu todas as minhas
preces e a quem eu tanto agradeci por cada vitória alcançada. Sem a TUA presença ao meu lado,
nada seria possível.
Aos meus pais queridos Ana e Eugênio, por lutarem pelo meu sucesso desde sempre, agradeço pelo
apoio em todos os momentos de alegria e tristeza, e por serem meu maior exemplo de amor e união.
Amo muito vocês.
Ao meu irmão André, pelos momentos de alegria que aliviaram minhas madrugadas de trabalho.
Agradeço também pelo exemplo de estudante disciplinado e esforçado, meu orgulho de você é
enorme. E à minha irmã Giselle, que viveu junto comigo a paixão pela pesquisa qualitativa que
rendeu lindos frutos. Você também é meu exemplo de estudante e trabalhadora incansável que faz
de tudo para realizar seus sonhos. Amo vocês.
Agradeço a toda minha família, que esteve do meu lado sempre me apoiando e incentivando a lutar
pelos meus sonhos. Meus domingos seriam muito tristes sem a presença de vocês, obrigada por tudo!
Ao meu melhor amigo e companheiro Adelson, obrigada por não medir esforços para me apoiar
sempre, pelo estímulo e força nos momentos difíceis e acima de tudo, pelo amor incondicional em
todos os momentos. Te amo muito.
Agradeço imensamente ao meu orientador Divaldo, por sempre acreditar em meu potencial e por me
proporcionar momentos únicos de aprendizado e crescimento. Obrigada por me fazer ver tantos
sonhos se tornarem realidade, seu apoio foi imprescindível nesta jornada!
À minha mãe acadêmica e amiga Giselle Brito, a sua presença ao meu lado em todos os momentos
foi muito importante. Fazer parte do seu doutorado foi muito mais gratificante do que imaginava,
sonhamos e realizamos juntas de forma muito especial. Agradeço infinitamente a Deus por ter me
dado a oportunidade de trabalhar ao seu lado, tudo que aprendemos juntas foi inesquecível. Muito
obrigada!!
A todos os amigos e amigas da Fundação Estadual de Saúde (FUNESA) e Farmácia Popular do
Brasil, que deram sentido ao meu trabalho e viveram comigo momentos que jamais vou esquecer.
Agradeço a dedicação de todos em construir uma linda história de sucesso, me sinto lisonjeada em
ter feito parte desta família de guerreiros que luta pelo avanço da profissão e pelo bem dos seus
pacientes.
Às minhas amigas de turma, Gabi, Ju, Day, Carol, Geo, Lari e especialmente a minha companheira
Carla, por todos os momentos incríveis que passamos juntas e pela amizade que fortalecemos nestes
dois anos, tenho muito orgulho de ser sua amiga. Aos meus amigos do peito Dani, Giulli, Lelo,
Adjane, Massia e Rodrigo pelo apoio e torcida pelo meu sucesso. Às amigas do Talibah, em especial
a Liana que dividiu comigo as mesmas angústias e alegrias do mestrado, obrigada pela amizade em
todos os sentidos!
Aos amigos do LEPFS por todo aprendizado agregado juntos, foi muito bom poder compartilhar
tantos momentos bons com vocês! Ao professor Wellington pelos valiosos conselhos e ensinamentos.
Aos colegas da UFRGS, em especial aos professores Mauro Castro e Denise Bueno pelo aprendizado
durante o PROMOB, e a Paulinha pela recepção calorosa em Porto Alegre.
Às professoras Jésia e Deborah, por cativarem em mim o amor à pesquisa qualitativa, devo a vocês
todo meu conhecimento construído e a minha vontade de trilhar novos caminhos nesta linha de
pesquisa.
A todos os professores do Núcleo de Pós Graduação em Ciências Farmacêuticas e à Coordenação de
Aperfeiçoamento de Pessoal do Ensino Superior (CAPES) pela concessão da bolsa do meu mestrado.
RESUMO
Em farmácias comunitárias, no momento em que o farmacêutico incorpora a prática clínica
em sua rotina, várias barreiras e facilitadores influenciam a implantação de serviços de
cuidado aos pacientes. Objetivos: Conhecer e compreender a percepção de um grupo de
farmacêuticos sobre o processo de implementação dos Serviços Clínicos Farmacêuticos em
farmácias comunitárias; Conhecer e compreender por meio de uma Revisão de Escopo da
literatura, a percepção farmacêutico na provisão de Serviços Clínicos Farmacêuticos em
farmácia comunitária. Metodologia: O estudo foi estruturado em duas etapas. A primeira
etapa correspondeu a Revisão de Escopo realizada nas bases de dados Lilacs, PubMed,
Scopus, Scielo e Web of Knowledge. Os estudos deveriam ser e se declarar de percepção de
farmacêutico e os Serviços Farmacêuticos deveriam ser centrados no paciente. A segunda
etapa correspondeu a um estudo qualitativo, no qual foram realizados três Grupos Focais
com um grupo de 11 farmacêuticos. A análise dos dados foi feita por meio da técnica de
análise de conteúdo. Resultados: Etapa 1 - A pesquisa bibliográfica resultou em 29 artigos
que cumpriram os critérios de inclusão. Os estudos foram realizados em oito países
diferentes, possuíam metodologias qualitativas (grupos focais, entrevistas, diários e
questionários) e quantitativas (questionários), e foram encontradas 12 diferentes
classificações de serviços farmacêuticos. Na maioria dos estudos, os farmacêuticos
acreditavam que seu papel em farmácias comunitárias era positivo para os pacientes,
barreiras e facilitadores para os serviços foram relatados. Etapa 2 - A gravação dos áudios
dos grupos focais foi integralmente transcrita e analisada. A percepção dos farmacêuticos
trouxe temas como acesso ao medicamento, barreiras e facilitadores para o serviço,
expectativas, mudanças geradas ao longo da implementação dos serviços, resultados
atingidos e a consolidação dos serviços. Conclusão: A Revisão de escopo apresentou
recomendações para a implementação de serviços clínicos farmacêuticos em farmácias
comunitárias, tornando mais fácil a provisão de serviços e valorizando as práticas em
farmácias comunitárias. A divulgação de experiências positivas em implementações de
serviços por meio de estudos de percepção têm mostrado que é possível desenvolver um
modelo de serviços clínicos em farmácias comunitárias.
Descritores: Serviços Clínicos Farmacêuticos, Farmácia Comunitária, Percepção do
Farmacêutico, Implementação de Serviços de Saúde
ABSTRACT
In community pharmacies, at the time the pharmacist incorporates clinical practice into their
routine, several barriers and facilitators influencing the implementation of patient care
services. Objectives: To learn and understand the perception of a group of pharmacists on
the process of implementation of Clinical Pharmacy Services in community pharmacies;
Understand through a Scoping Review of literature, pharmacist perception about Clinical
Pharmacy Services in community pharmacy. Methods: The study was structured in two
stages. The first step corresponded to Scoping Review held in the Lilacs, PubMed, Scopus,
Scielo and Web of Knowledge database. Studies should be of the pharmacist perception, and
the pharmaceutical services should be patient-focused. The second stage corresponded to a
qualitative study in which three focus groups were conducted with a group of 11 pharmacists.
Data analysis was done using the technique of content analysis. Results: Step 1 - The
literature search resulted in 29 articles that met the inclusion criteria. The studies were
performed in eight different countries, had qualitative methods (focus groups, interviews,
diaries and questionnaires) and quantitative (questionnaires) and 12 different classifications
of pharmaceutical services were found. In most studies, pharmacists believed that their role
in community pharmacies was positive for patients, barriers and facilitators for service were
reported. Step 2 - The audio recording of the focus groups were fully transcribed and
analyzed. The perception of pharmacists brought issues such as access to medication,
barriers and facilitators to service, expectations, changes generated during the
implementation of services, results achieved and consolidation of services. Conclusion: The
Scoping Review made recommendations for implementation of Clinical Services
Pharmacists in community pharmacies, making it easier to service delivery and enhancing
practices in community pharmacies. The dissemination of positive experiences in
implementations of services through perception studies have shown that it is possible to
develop a model of clinical services in community pharmacies.
Keywords: Clinical Pharmacy Services, Community Pharmacy, Pharmacist Perception,
Implementation of healthcare services
SUMÁRIO
1. INTRODUÇÃO............................................................................................ 10
2. ANTECEDENTES DA PESQUISA............................................................ 13
3. REVISÃO DA LITERATURA...................................................................... 17
3.1 Serviços Farmacêuticos.............................................................................. 18
3.2 Implementação de Serviços de Saúde....................................................... 19
3.3 Perfil Profissional do Farmacêutico............................................................ 20
3.4 Estudos sobre a Percepção do Farmacêutico............................................ 21
4. OBJETIVOS............................................................................................... 35
4.1 Objetivo geral.............................................................................................. 36
4.2 Objetivos específicos.................................................................................. 36
5. RESULTADOS........................................................................................... 37
5.1 CAPÍTULO I – Pharmacists’ perceptions regarding the provision of clinical
services in community pharmacies: a scoping review..............................................
38
5.2 CAPÍTULO II - Implementation of clinical pharmacy services in community
pharmacies: perceptions of a group of pharmacists..................................................
62
6. CONCLUSÃO GERAL......................................................................................... 82
10
INTRODUÇÃO
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1. INTRODUÇÃO
Embora os medicamentos, enquanto inovação tecnológica, sejam a forma mais
comum de tratamento das doenças e aumentem a expectativa de vida da população, estudos
demonstram que seu uso inadequado tem gerado problemas relevantes de saúde pública
como intoxicações por medicamentos, reações adversas e resistência a antimicrobianos. 1,2,3
Diante desses fatores, os serviços clínicos farmacêuticos (tais como, dispensação,
monitoramento de parâmetros clínicos, revisão da farmacoterapia e seguimento da
farmacoterapia) têm se desenvolvido como prática de prevenção de morbimortalidade
relacionada aos medicamentos. 4,5,6
Ao longo dos anos os serviços clínicos farmacêuticos foram aprimorados e podem
contemplar desde a atenção primária à saúde até o manejo de doenças crônicas. 7 Nas últimas
décadas, em consequência, a farmácia comunitária tem funcionado como cenário de prática
fundamental para o desenvolvimento e consolidação desses serviços, como por exemplo, os
serviços de revisão da farmacoterapia e dispensação providos neste cenário têm gerado
impacto econômico significativo com a redução do número de internações hospitalares e
mortalidade de pacientes com doenças crônicas. 8,9
Desfechos como aumento da adesão a farmacoterapia, melhora na qualidade de vida,
diminuição de problemas relacionados aos medicamentos (PRMs) e diminuição de custos
diretos e indiretos na saúde estão entre os objetivos que podem ser alcançados pelos serviços
clínicos farmacêuticos. 10,11 Além disso, a literatura mostra que quando resultados como
estes são alcançados, os pacientes se sentem satisfeitos, outros profissionais de saúde
reconhecem e apoiam a prática e os farmacêuticos se sentem valorizados no ambiente de
trabalho. 12-14
Na prática, a implantação de serviços farmacêuticos focados no cuidado aos
pacientes não se restringe às políticas públicas para o acesso a medicamentos essenciais.
Neste processo, o farmacêutico deve ter perfil e habilidades específicas, assim como toda a
equipe de técnicos ou profissionais envolvidos na implantação dos serviços deve estar
sensibilizada e capacitada, para que os resultados esperados sejam alcançados. 15-17 Além
disso, é necessário organizar recursos humanos, estruturais e procedimentos que permitam
o funcionamento pleno dos serviços. 5,15,18-20
Apesar do desenvolvimento da profissão ao longo dos anos, no Brasil, o perfil do
farmacêutico ainda é tecnicista e há resistência dos próprios profissionais em iniciar práticas
12
clínicas e implantar serviços com este propósito. 21,22 Devido a este e outros fatores, o
processo de implementação de serviços clínicos farmacêuticos é considerado lento em
muitos outros países. 23-26
Além de conhecimentos e habilidades em Ciências Farmacêuticas, o profissional
com o novo perfil deve ser capaz de desenvolver habilidades de comunicação e estabelecer
relações interpessoais com seus pacientes e com outros profissionais de saúde. 27-29 Além
disso, a mudança de perfil do farmacêutico está envolvida com diretrizes para a prática
farmacêutica que preconiza ações de prevenção e resolução de problemas relacionados aos
medicamentos para otimizar os resultados terapêuticos dos pacientes em hospitais, farmácias
e outros ambientes. 30-32
Para fortalecer a implementação desses serviços, alguns estudos demonstram os
resultados clínicos, humanísticos e econômicos que promovem impacto para gestores em
saúde. 8,25,33 Assim, pesquisas sobre implementação de serviços com variáveis que
conceituam e avaliam os resultados, tem o poder de melhorar a prática, demostrar o
desempenho das ações e aumentar a responsabilidade de organizações de saúde. 34,35
No Brasil, a Política Nacional de Assistência Farmacêutica (2004) definiu conceitos
e práticas para guiar ações dos profissionais de saúde voltadas à promoção, proteção e
recuperação da saúde, visando o uso racional de medicamentos. 36 No mesmo ano foi criado
o programa da Farmácia Popular do Brasil (FPB), visando implantar ações que promovam a
universalização do acesso à farmacoterapia, assegurar medicamentos básicos e essenciais à
população, bem como proporcionar a diminuição do impacto causado pelos gastos com
medicamentos no orçamento familiar. 37 No entanto, até o momento há registros escassos da
implementação e de avaliação do cumprimento e do impacto desses serviços, bem como
ainda há poucos modelos de serviços clínicos farmacêuticos no país que possibilitem o
atendimento completo das políticas públicas e das diretrizes do programa FPB.38-42
No país, a sensibilização de gestores da saúde pública pode trazer investimentos e,
consequentemente, resultados significantes para a população usuária do Sistema Único de
Saúde (SUS). 5,19,20 Porém, apesar do programa FPB favorecer as pesquisas com serviços
clínicos farmacêuticos, no Brasil estas ainda não obtiveram sucesso na manutenção e
consolidação de modelos de prática para usuários do SUS. 103
Diante disso, atualmente um grupo de farmacêuticos está envolvido na implantação,
implementação e consolidação de serviços de cuidado ao paciente em unidades da FPB no
Estado de Sergipe, ademais, o apoio de gestores da saúde pública, os investimentos
13
continuamente feitos e as experiências vivenciadas, tornaram o ambiente em questão rico
para realização de pesquisas na área.
Com o intuito de aprofundar as discussões sobre a implantação de serviços clínicos
farmacêuticos em farmácias comunitárias, esta pesquisa visa conhecer os estudos que
abordam a percepção do farmacêutico sobre a provisão destes serviços e compreender na
prática as percepções de um grupo que vivencia este processo.
2. ANTECEDENTES DA PESQUISA
O Laboratório de Ensino e Pesquisa em Farmácia Social da Universidade Federal de
Sergipe – Brasil (LEPFS/UFS) é uma iniciativa acadêmica, estabelecida em 2007, com o
intuito de desenvolver atividades relacionadas ao ensino, pesquisa e extensão e formar
profissionais capacitados para a execução de estudos na área da Farmácia Social. O
LEPFS/UFS tem como missão inovar e formar para o cuidado ao paciente e para promoção
do uso racional de medicamentos.
Em 2008, a prática do serviço de Atenção Farmacêutica foi iniciada como atividade
de pesquisa e ensino do LEPFS/UFS. Naquele ano, sob a orientação do Profº Dr. Divaldo
Lyra Júnior, duas mestrandas, realizaram duas revisões sistemáticas, as quais tiveram como
objetivo analisar a qualidade das pesquisas sobre Atenção Farmacêutica no
acompanhamento de pacientes portadores de Diabetes Mellitus e Hipertensão Arterial
Sistêmica.
Os resultados dessas revisões demonstraram falhas na qualidade dos estudos
analisados, sobretudo no que concerne a carência de resultados farmacoeconômicos, de
satisfação dos pacientes e a dificuldade de documentação do serviço, evidenciada
principalmente, pela ausência de classificação dos PRMs. 100, 101
Com base nos estudos acima referidos, foi notada a necessidade de mais pesquisas
na área da atenção farmacêutica para atribuir maior valor aos resultados desta prática. Desse
modo, entre 2009 e 2011, o LEPFS/UFS em parceria com a Secretaria Municipal de Saúde
de Aracaju deu início a estudos envolvendo a prática da Atenção Farmacêutica em idosos
portadores de Diabetes Mellitus, Dislipidemia e Hipertensão Arterial Sistêmica não
controladas em uma unidade própria de Farmácia Popular do Brasil de Sergipe, a fim de
14
atender a necessidade de melhorar os resultados clínicos de tais enfermidades e a qualidade
de vida destes pacientes. 5,19,20
Nestes estudos, as intervenções farmacêuticas destinadas a resolver e prevenir PRM,
associadas às intervenções educativas contribuíram para a sensibilização dos idosos usuários
do programa FPB com condições crônicas de saúde (como Diabetes Mellitus, Dislipidemia,
Hipertensão Arterial Sistêmica e, suas complicações), com a melhora do uso da
farmacoterapia, bem como de resultados clínicos e humanísticos positivos.
Apesar da Política de Assistência Farmacêutica do SUS-Sergipe (2010) ressaltar a
necessidade de se desenvolver o cuidado farmacoterapêutico individualizado e privativo, até
então não havia registros sobre o impacto social das atividades desenvolvidas pelos
farmacêuticos da FPB no que concerne a promoção do uso racional de medicamentos. Ao
contrário, os registros de atividades eram limitados apenas à cobertura da distribuição de
medicamentos essenciais a população. 102
Os três estudos obtiveram grande destaque no cenário farmacêutico nacional em
2012,20,24,100 em contrapartida ao apoio firmado, houve a apresentação dos resultados obtidos
às Secretarias Municipal e Estadual de Saúde de Sergipe, sendo neste momento ressaltada a
necessidade de implantar os serviços clínicos farmacêuticos previamente preconizados nas
Diretrizes do Programa FPB para assegurar o maior entendimento do novo paradigma focado
no cuidado ao paciente.
Interessada em replicar o sucesso dos estudos no serviço público do estado, a
coordenação da Fundação Estadual de Saúde de Sergipe (Funesa-SE) convidou o
LEPFS/UFS para iniciar o atual projeto de implantação de um modelo de serviços clínicos
farmacêuticos no programa FPB nas três unidades próprias geridas por esta fundação que
atende grande parte o estado de Sergipe.
Apesar de estudos sobre implantação de serviços clínicos farmacêuticos em
farmácias comunitárias serem continuamente feitos no país, poucos estudos tem sucesso na
continuidade dos serviços após a finalização das pesquisas 68,75,95, por isso, o presente projeto
é pioneiro no país a sugerir um modelo aplicável e sustentável de serviços clínicos
farmacêuticos aplicados ao Programa FPB. Este poderá servir como piloto e referência para
otimização da qualidade de serviços farmacêuticos e promover o uso racional de
medicamentos, bem como para a reprodução do modelo em todo o programa.
Nesse cenário, o LEPFS/UFS junto a Funesa-SE têm desenvolvido um estudo
transversal para avaliar a infraestrutura (física e recursos humanos) necessária para assegurar
15
a prestação dos serviços clínicos farmacêuticos nas FPB, um estudo longitudinal que
promove o nivelamento do conhecimento dos farmacêuticos para capacitá-los à prestação
dos serviços, o estabelecimento de processos de trabalho para a prática, a monitorização da
implementação dos serviços e a elaboração dos documentos e instrumentos necessários para
aplicação dos mesmos, e dois estudos longitudinais qualitativos que permitiram conhecer as
percepções dos farmacêuticos sobre a implantação dos serviços.
Algumas produções científicas do grupo de pesquisa nos últimos dois anos do
referido trabalho são apresentadas a seguir:
- Dosea, A.S.; Brito, G.C.; Santos, L.M.C.; Lyra Junior, D.P. Expectations of pharmacists
as the deployment of pharmaceutical services in community pharmacies. In: 9o International
Congress of Pharmaceutical Sciences, 2013, Ribeirão Preto.
- Cruz, C. F.S., Dosea, A.S.; Brito, G.C.; Almeida, M. C. T.; Victor, E. L., Lyra Junior, D.P.
Influência da formação do farmacêutico na promoção do uso racional de medicamentos. In:
5º Congresso Brasileiro sobre o Uso Racional de Medicamentos, 2014, São Paulo.
- Brito, G.C.; Dosea, A.S.; Boaventura, T.C.; Almeida, M.C.T.; Victor, E.L., Lyra Junior,
D.P. Modelo de coaching na consolidação serviços farmacêuticos em farmácias
comunitárias. In: 5º Congresso Brasileiro sobre o Uso Racional de Medicamentos, 2014, São
Paulo.
- Santiago, J. S.; Borges, C.L.; Souza, D.M.; Santos, D.S.; Oliveira, V.A.; Cardoso, A.V.;
Almeida, M. C. T.; Victor, E. L.; Dosea, A.S.; Brito, G.C.; Lyra Junior, D. P. Perfil de
pacientes com hipertensão que ingressaram no serviço de revisão da famacoterapia em três
unidades de farmácia comunitária. In: XXII Congresso da Sociedade Brasileira de
Hipertensão, 2014, Salvador.
- Oliveira, V.A.; Cardoso, A.V.; Santiago, J. S.; Borges, C.L.; Souza, D.M.; Santos, D.S.;
Boaventura, T.C.; Almeida, M. C. T.; Victor, E. L.; Dosea, A.S.; Brito, G.C.; Lyra Junior,
D. P. Serviços farmacêuticos de monitoramento da pressão arterial em farmácias
comunitárias como promoção de saúde. In: XXII Congresso da Sociedade Brasileira de
Hipertensão, 2014, Salvador.
- Dosea, A.S.; Cruz, C. F.S., Brito, G.C.; Pimentel, D.M.M.; Lyra Junior, D.P. Barreiras
para a implantação dos serviços farmacêuticos em farmácias comunitárias. In: I Congresso
Brasileiro de Assistência Farmacêutica e Farmácia Clínica, 2014, Fortaleza.
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Intervenções realizadas na dispensação de medicamentos em três unidades de farmácias
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17
REVISÃO DA
LITERATURA
18
3. REVISÃO DA LITERATURA
3.1. SERVIÇOS FARMACÊUTICOS
Segundo a Organização Mundial de Saúde (OMS), o uso racional de medicamentos
é conceituado como “o processo que compreende a prescrição apropriada; a disponibilidade
oportuna e a preços acessíveis; a dispensação em condições adequadas; e o consumo nas
doses indicadas, nos intervalos definidos e no período de tempo indicado de medicamentos
eficazes, seguros e de qualidade”. 43 Apesar deste conceito, a literatura demonstra que mais
de 50% de todos os medicamentos são prescritos, dispensados ou utilizados de forma
inapropriada. 3
Esta situação tem desencadeado ações em nível mundial com atenção especial por
parte dos gestores e responsáveis pelo gerenciamento da assistência farmacêutica, visando
aumentar a segurança no uso dos medicamentos. 44 Tal afirmativa corroborada pela literatura
que demonstra que serviços clínicos farmacêuticos proporcionam a melhora de resultados
clínicos, humanísticos e econômicos dos pacientes. 45-48
Na metanálise de Morgado et al. (2011), por exemplo, 87,5% das intervenções
farmacêuticas feitas no serviço de monitoramento de parâmetros clínicos resultaram em
melhoras relevantes para o tratamento com anti-hipertensivos, e 43,8% das intervenções
promoveram aumentos na adesão ao tratamento. 49 No ensaio clínico de Margolis et al.
(2013), farmacêuticos conseguiram o controle da pressão arterial em 71,8% dos pacientes
do grupo intervenção após 18 meses de monitoramento. 50
O serviço de revisão da farmacoterapia, por sua vez, no estudo de Lenander et al.
(2014), o número médio de PRMs reduziu de 1,73 por paciente no início do tratamento para
1,31 ao final do serviço farmacêutico. 51 Outrossim, no estudo de Gheewala et al. (2014),
83,8% das intervenções do serviço de revisão da farmacoterapia foram aceitas pelo prescritor
para resolver PRMs diagnosticados em idosos de instituições de longa permanência. 52 Na
revisão sistemática sobre o impacto da revisão da famacoterapia de Hatah et al., em 2014,
57,9% dos estudos apresentaram como resultado a melhora na adesão ao tratamento. 53
De forma semelhante, no estudo de Arroyo et al. (2013), o serviço de seguimento da
farmacoterapia conseguiu melhorar a adesão de pacientes em uso de terapia antirretroviral,
no qual dos 107 pacientes não aderentes no início do estudo, 43 tiveram boa adesão após um
ano de serviço e este número aumentou para 75 no final do estudo. 54 Assim como para outras
19
doenças, o seguimento da farmacoterapia foi determinante para atingir melhores resultados
clínicos, aumentar a qualidade de vida e reduzir gastos com saúde em hospitais, ambulatórios
e farmácias comunitárias.11,55,56
Atualmente, ainda não há consenso no mundo sobre a definição e nomenclatura dos
serviços clínicos farmacêuticos, porém a descrição das atribuições clínicas desses diferentes
serviços promove maior compreensão sobre os objetivos e níveis de complexidade de cada
um destes. Por isso, no presente estudo foi seguida a definição atualizada dos serviços
clínicos farmacêuticos pelo Conselho Federal de Farmácia (2014): 57
- Dispensação de medicamentos: entrega de medicamentos, geralmente como
resposta à apresentação de uma receita elaborada por um profissional autorizado, com
orientação sobre o seu uso adequado e intervenções educativas.
- Monitoramento de parâmetros clínicos ou monitoring of clinical parameters:
monitoramento da pressão arterial, glicemia capilar, peso, circunferência abdominal e índice
de massa corporal, com intervenções educativas.
- Revisão da Farmacoterapia ou medication review: avaliação e ajuste da
farmacoterapia (ajuste da dose, horário, frequência) e triagem de pacientes elegíveis a
serviços de seguimento.
- Seguimento da farmacoterapia: também conhecido como medication therapy
management (MTM), seguimiento farmacoterapéutico ou gestão da farmacoterapia, este
serviço visa garantir que os objetivos terapêuticos sejam alcançados com identificação,
prevenção e resolução de PRMs. Esta definição segue o conceito proposto Hepler e Strand
(1990).
3.2. IMPLEMENTAÇÃO DE SERVIÇOS DE SAÚDE
A literatura mostra que apesar das pesquisas em serviços de saúde terem à sua
disposição diversos modelos para implementação de ações e serviços, a maioria das
iniciativas não tem sucesso na consolidação. 58,59 A sustentabilidade de muitas metodologias
não é confiável, pois a maioria aborda apenas a efetividade das intervenções, deixando de
lado as ações necessárias para a sustentabilidade do serviço após a pesquisa. Por isso, é
necessário estruturar e avaliar cada medida aplicada por meio de indicadores, além de
conhecer previamente as possíveis barreiras e facilitadores do serviço que se propõe
implementar. 41,60,61
20
Estudos mostram que divulgar as barreiras e facilitadores para a implementação de
serviços farmacêuticos em farmácias comunitárias além de ajudar novas pesquisas e serviços
ainda não consolidados, é importante para a criação de novas oportunidades de cuidado ao
paciente. 62,63 Os resultados das pesquisas sobre implementação de serviços clínicos
farmacêuticos também reforçam a necessidade de avaliar o sucesso limitado destas ações.
12,64,65 Nestas pesquisas, a falta de estrutura e processos adequados dos serviços, lacunas na
formação do farmacêutico, falta de tempo e remuneração são barreiras frequentemente
relatadas para consolidação de serviços em hospitais, ambulatórios e farmácias comunitárias.
66-68
Em contrapartida, estudos destacam alguns facilitadores fundamentais para o sucesso
da implementação dos serviços em farmácias comunitárias. Dentre os quais, a boa formação
e capacitação dos profissionais, resultados positivos para os pacientes, satisfação no
trabalho, tempo suficiente para serviço, ambiente privado e confortável para o paciente e
parceria com outros profissionais de saúde. 24,69,70 Todavia, aspectos associados a influência
do perfil do farmacêutico ainda são pouco conhecidos e merecem maior destaque em futuros
estudos.
3.3. PERFIL PROFISSIONAL DO FARMACÊUTICO
Ao assumir a responsabilidade pelos tratamentos dos pacientes o farmacêutico
fortalece sua credibilidade, pois os usuários de medicamentos têm a segurança de encontrar
nas farmácias o profissional mais preparado para prover informações sobre o uso racional
de medicamentos e para o manejo da farmacoterapia. 11,17 Segundo Franceschet e Farias
(2005), a facilidade de acesso aos serviços farmacêuticos valoriza sua prática e, por isso, o
profissional precisa conhecer, aceitar e viabilizar o cumprimento de seu papel social. 71
Diante desta mudança do foco da prática profissional do produto para o paciente,
Oliveira (2003) afirma que a além da competência técnica do farmacêutico, o perfil deste
profissional deve ser de cuidador e precisa estar voltado para “outro”, como centro da sua
prática, de modo que deve manter interesse pela subjetividade do paciente. 72 Segundo Lyra
Júnior (2005), na relação farmacêutico-paciente deve haver troca de emoções e
preocupações, pois dessa forma serão criadas maiores oportunidades para o farmacêutico
cuidar dos pacientes. 38
21
Em compensação, outros estudos mostram que a maioria dos farmacêuticos
brasileiros ainda não vivenciou esta experiência profunda de cuidado ao paciente, pois
historicamente se afastou do público que utiliza medicamentos, e a definição dos conceitos
e práticas clínicas farmacêuticas no Brasil ocorreu de forma lenta em relação a outros países.
21,73-75
Embora desde 1993, a OMS preconize práticas do farmacêutico ligadas às
orientações para promoção do uso racional de medicamentos e a serviços de prevenção e
controle de doenças crônicas, 76,77 o farmacêutico brasileiro ainda não é formado para a
prática clínica. 39,78,79 No entanto, diversos estudos no mundo fortalecem esta mudança de
paradigma da profissão, por meio de padronizações de práticas, elaboração de protocolos,
avaliação de serviços e divulgação de resultados positivos de serviços clínicos
farmacêuticos. 80-83
Ante ao exposto, a demanda por farmacêuticos com perfil clínico levou alguns
pesquisadores a investigar ao longo dos anos a percepção destes profissionais em relação ao
seu novo papel. 84-86
3.4. ESTUDOS SOBRE A PERCEPÇÃO DOS FARMACÊUTICOS
As pesquisas sobre percepção dos farmacêuticos são amplas e colaboram com o
aprimoramento das práticas clínicas, pois abordam temas como visões, experiências e
atitudes que são de grande valia para esclarecer as questões que permeiam a profissão
farmacêutica na atualidade. 87-89
Vale ressaltar que todas as pesquisas citadas anteriormente usaram metodologias
quantitativas para avaliar a percepção do farmacêutico. Segundo Oliveira e Varela (2008), o
uso de metodologias qualitativas neste contexto pode ser útil para responder perguntas que
a quantificação de dados não é capaz de responder. 90 Embora esta metodologia ainda seja
pouco utilizada na Farmácia, a mesma possibilita o conhecimento de realidades empíricas
que servem de base para o desenvolvimento de serviços de cuidado ao paciente. 90-93
No estudo qualitativo feito por Maitreemit et al. (2008), os farmacêuticos não
consideraram os conhecimentos e habilidades clínicas como as competências mais
importantes para a prática profissional. 30 Ademais, Sarriff, Gillani e Babiker (2010)
mostraram que apenas a minoria de farmacêuticos na Malásia entendia a importância dos
serviços clínicos e se sentiam competentes para executá-los. 94 Hamarneh et al. (2011)
22
afirmaram que diante da demanda pelo novo perfil profissional, é essencial compreender a
cultura, o comportamento e os sentimentos do farmacêutico em relação à sua atuação na
prática. 32
No Brasil, Pereira et al. (2009) discutiram sobre a experiência de farmacêuticos
(dificuldades, expectativas, aprendizado e satisfação) na implementação de um serviço. 95
No estudo de Bastos e Caetano (2010) os farmacêuticos relataram que apesar de sentirem
realização profissional na provisão de serviços de cuidado ao paciente, a baixa remuneração,
a falta de qualificação dos funcionários da farmácia comunitária, bem como a falta de tempo
para atividades clínicas são obstáculos que trazem insatisfação no trabalho. 75
Além dos estudos supracitados, as revisões de literatura podem ser úteis para fornecer
uma visão ampla das pesquisas sobre a percepção do farmacêutico. Em especial, a revisão
de escopo ou scoping reviews fornecem a compreensão da questão da pesquisa, evidenciando
lacunas e incertezas sobre o tema e particularmente se mostra como um recurso valioso para
basear futuras revisões sistemáticas. Esta última avalia a qualidade dos estudos e sintetiza os
resultados qualitativamente ou quantitativamente. 96
Diante disso, a revisão de escopo de Agomo (2012) sobre o papel do farmacêutico
comunitário na saúde pública revelou diversas áreas de atuação do profissional, como
prevenção e controle de doenças crônicas e programas de cessação tabágica, e lacunas que
geram oportunidades da criação de novos serviços clínicos para farmacêuticos neste âmbito.
97 A revisão de escopo realizada por Babinec et al. (2010) também mostrou hiatos entre as
pesquisas sobre comunicação farmacêutico-paciente, pois estas até então abordavam
basicamente o conteúdo de orientações do farmacêutico, deixando de lado a influência das
habilidades de comunicação neste processo. 98
Apesar de informar futuras revisões sistemáticas, a revisão de escopo pode ser útil
para a formulação de políticas, pesquisadores e profissionais, reduzindo a duplicação de
esforços e orientando futuras pesquisas. 99
23
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35
OBJETIVOS
36
4. OBJETIVOS
4.1. Objetivo geral
Conhecer diferentes aspectos da percepção do Farmacêutico sobre a provisão e
implantação de serviços clínicos farmacêuticos em farmácias comunitárias.
4.2. Objetivos específicos
Realizar uma revisão de escopo da literatura sobre a percepção do farmacêutico na
provisão de serviços clínicos farmacêuticos em farmácias comunitárias
Compreender a partir da percepção de um grupo de farmacêuticos, como ocorre o
processo de implantação de serviços clínicos farmacêuticos em farmácias comunitárias.
37
RESULTADOS
38
CAPÍTULO 1
39
5. RESULTADOS
5.1. CAPÍTULO 1: PHARMACISTS’ PERCEPTIONS REGARDING THE
PROVISION OF CLINICAL SERVICES IN COMMUNITY
PHARMACIES: A SCOPING REVIEW
Aline S. Dosea, BPharm, M.Sc. Student a, Carla F.S. Cruz, BPharm, M.Sc. Student a,
Giselle de C. Brito, BPharm, MSc, Ph.D. Student a,b, Divaldo P. Lyra Junior., BPharm,
MSc, Ph.D. a
aTeaching and Research Laboratory Social Pharmacy, Department of Pharmacy, Federal
University of Sergipe, LEPFS-UFS, s/n, Avenida Marechal Rondon, Jardim Rosa Elze, São
Cristóvão, Brazil
bDepartartment of Pharmacy, Federal University of Sergipe, Health Campus, Lagarto, Brazil
Corresponding author: Divaldo P. Lyra Junior.
E-mail address: [email protected]
Abstract
Background: Over the years, pharmaceutical practices and the results thereof have suggested
a need for several actions, to encourage the deployment and maintenance of clinical
pharmacy services in community pharmacies. Pharmacists’ perceptions illuminate
experiences that could aid the provision of the relevant services and help other pharmacists
or policymakers identify implementation strategies for services in community pharmacies.
Objectives: This study aims to understand, through a scoping review of the literature,
pharmacists’ perceptions regarding clinical pharmacy services in community pharmacy.
Methods: A scoping review of literature was conducted, using the Lilacs, PubMed, Scopus,
Scielo, and Web of Knowledge databases, with articles indexed until February 2014. The
search included combinations of the following descriptors: “community pharmacy services,”
“pharmacist,” “pharmacist perception,” “pharmacist view,” “pharmacist function,”
“pharmacist expectations,” and “role of pharmacist.” The inclusion criteria were that each
study be on pharmacists’ perceptions and declare itself as such, and that the pharmaceutical
service under study be patient-focused. We excluded theoretical articles, case reports, other
40
reviews, conference abstracts, letters to the editor, reports, awards results, studies that did
not have an abstract or full text, and studies with a non-English full text. Results: The
literature search identified 694 articles; among these, 29 met the inclusion criteria. The
studies were conducted in eight countries, with the United States and New Zealand yielding
the highest number of publications, at five each. Thirteen studies used qualitative
methodologies (focus groups, interviews, and diaries), 13 used quantitative methodologies
(questionnaire), and three used mixed methods; 12 distinct classifications of pharmaceutical
services were found. In most of the studies, the pharmacists believed that they played a
positive role for patients in community pharmacies. Barriers and facilitators of services were
also reported and pharmacists perceived lack of training in the provision of clinical services.
In most studies, pharmacists felt that their relationships with other healthcare professionals
could enhance patient outcomes. Conclusion: This study provided recommendations for the
implementation of clinical pharmacy services in community pharmacies, to improve the ease
of service provision and ensure that practices in community pharmacies are highly valued.
Keywords: Clinical pharmacy services, community pharmacy, pharmacist perception,
implementation of healthcare services
41
INTRODUCTION
Over the years, community pharmacy has been recognized as a propitious and
accessible environment for pharmaceutical practices that promote the quality of life of
members of a given population. 1,2,3,4,5 Community pharmacy is often the last link between
health services and drug users, where, in addition to the purchase of supplies, guidelines for
rational use of medicines and services for the prevention and control of chronic diseases can
be provided. 6,7
As a consequence of the results achieved through the provision of these services,
health organizations and researchers have suggested several actions to encourage the
deployment and maintenance of clinical pharmacy services in community pharmacies, such
as the development of models of practice. 3,8,9 Along with that, studies on pharmacists’
perceptions of the provision of these services show how this process of deployment occurs.
10,11,12
Perceptions illuminate issues relating to experiences, barriers to services, facilitators,
and expectations; these, in turn, can aid the provision of similar services. Dolovich et al.
(2008) proposed recommendations for the reduction of bureaucracy in the provision of
clinical pharmacy services, based on pharmacists’ perceptions. 13 According to Eades et al.’s
(2011) systematic review, among other issues, studies have shown that the majority of
pharmacists who work in public health services felt a need for training, so as to attain
confidence in service provision. 12
In Morton et al.’s (2014) study on pharmacists’ perceptions, the participants
questioned as to whether pharmacists should give lifestyle advice in community pharmacy,
since they are not remunerated for it. 14 Such issues help other pharmacists or policymakers
identify implementation strategies for services in community pharmacies, in relation to
future projects in the pharmaceutical field. 15 Therefore, through a scoping review of the
literature, this study aims to identify and understand studies on pharmacists’ perceptions of
clinical pharmacy services in community pharmacy.
METHODS
Data sources and searches
A scoping review of literature was conducted, using articles indexed until February
2014 on the Lilacs, PubMed, Scopus, Scielo and Web of Knowledge databases. The
keywords used in the article search were obtained through consultations of the National
42
Library of Medicine’s controlled vocabulary encyclopedia, using Medical Subject Headings
(MeSH), and from articles on the topic, which contained the most frequently used terms. The
search strategy included combinations of fixed descriptors (“community pharmacy services”
and “pharmacist”) and mobile descriptors (“pharmacist perception,” “pharmacist view,”
“pharmacist function,” “pharmacist expectations,” and “role of pharmacist”). These words
were changed according to each database’s search protocol, as necessary.
Queries:
1) “pharmacist perception” AND “community pharmacy services” AND
“pharmacist”
2) “pharmacist view” AND “community pharmacy services” AND “pharmacist”
3) “pharmacist function” AND “community pharmacy services” AND “pharmacist”
4) “pharmacist expectations” AND “community pharmacy services” AND
“pharmacist”
5) “role of pharmacist” AND “community pharmacy services” AND “pharmacist”
Study selection
In this study, the following inclusion criteria were applied: (i) the study should be on
pharmacists’ perceptions and be specified as such; (ii) the pharmaceutical services should
be patient-focused, featuring clinical pharmacy services. This scoping review excluded
theoretical articles, case reports, other reviews, conference abstracts, letters to the editor,
reports, and awards results, as well as those without an abstract or full text and those with a
non-english full text.
Data Extraction
Two reviewers (ASD and CFSC) independently conducted a preliminary evaluation
of the relevant titles, abstracts, and full text. Possible discrepancies were reviewed and
judged by a third reviewer (GCB). Articles that were replicated in two or more databases
were considered only once. Two reviewers (ASD and CFSC) extracted the relevant data, in
order to investigate those considered important for the review.
The scoping review was conducted according to the recommendations of the
Cochrane Public Health Group. This statement provides essential information on the
43
methodology and development of scoping reviews, including the following: identification
of the research question, identification of relevant studies, study selection, the charting of
the data, collation, the summarizing and reporting of the results, and optional consultation.
16
Synthesis and data analysis
Articles that met the inclusion criteria for data extraction were carefully described,
with reference to the following aspects: country, the number of pharmacists, study design,
methods, description of pharmaceutical service, perceptions analyzed, results, and
limitations declared.
RESULTS
The literature search yielded 694 articles; no article was found in the Web of
Knowledge and the Lilacs databases. Twenty-nine articles met the inclusion criteria, thus,
constituting the final sample. Figure 1 shows the steps followed to select the final sample.
Figure 1. Flowchart of steps taken to select the final sample of articles included in
the scoping review
694 potentially relevant articles found in
databases:
PUBMED (435)
SCIELO (13)
SCOPUS (246)
61 articles were excluded: indexed in
two or more databases
simultaneously
31 articles selected to be
read in full
633 articles selected by
analysis of titles
61 articles were selected
by analysis of abstracts 32 excluded because they did not
describe the methodological
approach towards pharmacists’
perceptions regarding the
provision of clinical services
572 excluded because they did
not mention pharmacists’
perceptions and provision of
clinical services
29 full papers selected to
final sample
2 excluded because the
pharmaceutical services were not
clinical
44
The studies’ characteristics (country, study design, number of pharmacists, methods,
and the clinical pharmacy services provided), results, perceptions under analysis, and
limitations were described in figures and tables.
Characteristics of the studies
The studies were conducted in eight countries, but mostly, in Oceania 10,12,17-24 and
North America; 25-33 seven had been conducted in the United States and five in New Zealand
and Australia, respectively; these countries had the highest number of publications (Table
1). Only one study was conducted in Africa 34 and none in South America. Most studies were
cross-sectional, with the exception of one, which was a longitudinal intervention study. 20
The number of pharmacists participating in the studies ranged from 5–870. This was due to
the variety of methodologies used; 12 studies used qualitative methodologies,
12,17,19,21,23,24,26,29-31,36 14 used quantitative methodologies, 11,18,27,22,25,28,32,33,37-41 and three
studies used mixed methods (Figure 2). 10,20,34
Table 1. Studies (n = 29) included in the scoping review, according to continent
Continent No. (%) of studies (n = 29) Studies
Oceania
(Australia, New Zealand)
10 (34,48%) 10,12, 17–24
North America
(United States of America, Canada)
9 (31,03%) 25–33
Europe (England, Switzerland,
Belgium)
4 (13,79%) 35,36,38,42
Eurasia (Turkey) 2 (6,89%) 37,11
Asian (Qatar, Malaysia, Singapore) 3 (10,34%) 39–41
Africa (Sudan) 1 (3,44%) 34
45
An analysis of the clinical pharmacy services provided revealed that, in nine of the
studies, there was no intervention 24,25,27,32,33,39-42 and participating pharmacists expressed
their opinions about what could be done about the service; all of the studies referred to the
pharmaceutical service being provided. In this study, clinical pharmacy services were
defined as any services comprising interventions by pharmacists, aimed at optimizing the
use of drugs, regardless of the service’s methodology or level of complexity.
The following twelve classifications of pharmaceutical services were found:
medication review, 17,19 medicines management, 18 dispensing, 21 pharmaceutical care, 31,34,38
medicine use review, 10,23 medication therapy management (MTM), 25,27 therapeutic drug
monitoring, 32 cognitive pharmaceutical services, 26 disease management, 20,22,37 advice,
29,33,36,40,42 follow-up, 11,12,20 and counseling. 24,28,30,33,35,39,41 For this reason, we categorized
the services according to intervention type, to clarify the activities performed. Table 2 shows
the interventions in clinical pharmacy services, as found in the studies.
12 3
Quantitative Qualitative
14
- 14 questionnaires with
measurement scales - 8 interviews
- 3 focus groups
- 1 pharmacists’ diaries
- 2 interviews and questionnaires
- 1 control intervention and a
questionnaire with qualitative data
Figure 2. Methods used in the studies (n = 29) included in the scoping review
46
Table 2. Interventions in clinical pharmacy services, as depicted in the studies (n = 29) included in the scoping
review
Type of pharmaceutical intervention No. (%) of studies
(n = 29) Studies
Advice or counseling about medication 29 (100%) 10–12,17–42
Education for patient or health teams 13 (44,82%) 10,11,18,19,24,25,27,31,34,37–39,41
Drug-related problem management 8 (27,58%) 19,20,25,26,27,31,34,38
Collaboration with other healthcare
professionals 8 (27,58%) 12,17,18,20,25,32,30,31,39,41
Improvement of adherence 7 (24,13%) 10,19,20,22,23,27,39
Counseling about lifestyle and environmental
factors 7 (24,13%) 33–37,39,41
Adjustment of pharmacotherapy 6 (20,68%) 12,17–19,21,30
Help regarding self-medication and self-care 5 (17,24%) 22,25,29,40,42
Monitoring of health outcomes (clinical,
humanistic, and economic) 5 (17,24%) 20,25,31,34,38
Care plan development 4 (13,79%) 12,22,26,31
Home care 2 (6,89%) 21,32
Results of the studies
The perceptions of pharmacists, as analyzed in the studies, varied according to the
pharmacists’ involvement in the service, as well as the methodology used. There were
studies on the potential role of the pharmacist, 11,17,18,20,22,24,29,30,31,34,37 comfort level in
relation to service provision, 25,29,41 intention to provide services, 29 barriers to service
provision, 10,18-,22,25,26,28,29,30,34,36,38,39,41 provision of services by facilitators, 10,17,21,25,28
pharmacists’ education and training needs, 12,20,27,26,34,28,29,38,39,41,42 and their relationships
with other healthcare professionals. 10,20,21,22,26,30,31,34,35,39
With regard to the perceptions described in most of the results, the pharmacists
believed that the role that they played in community pharmacies was particularly positive
for patients, as it is linked to patient management or counseling therapy, and aimed at
improving the use of medicines. 11,18,20,22,24,29,30,31,34,37,38 Most pharmacists felt that their role
was very important, viewing it as being beyond that of the traditional pharmacist, and feeling
that they should be involved in therapy management.
In studies addressing pharmacists’ comfort regarding the provision of clinical
services, professionals reported feeling comfortable to implement educational interventions
and provide information on medicines; they also associated their comfort levels with
47
enhanced service and practical knowledge. 25,26,29,41 In one study, 29 the pharmacist did not
feel comfortable because of lack of information regarding a patient’s medical history; in
other studies, 27 pharmacists did not feel assured that a service would be profitable for their
pharmacies, despite their strong intentions to promote their services.
In many studies, the pharmacists addressed the barriers to service provision; the main
barriers were lack of time, 10,20,21,22,25,28,36,38,41 training, 12,20,29,34,38,39 skills and knowledge,
19,20,24,26,27,38 reimbursement, 10,25,34 confidence, 19,20 and a private environment. 28,38 Besides
hindering the implementation of services, the barriers discouraged the maintenance of
services provided by the pharmacists. 19,24,34
Another important factor identified, based on the perceptions of pharmacists, was the
facilitators of practice, such as educational training, 25,26,42 positive outcomes for patients,
10,20,34 job satisfaction, 21,26,34 physical layout, 26,28 support of healthcare professionals
10,21,27,31 and adequate support staff. 10,26,28 These factors enabled patients to obtain
satisfactory results from professionals and assisted in the development and consolidation of
services. 21,23
Some studies considered education and training needs a very important issue for
service maintenance, as the majority of pharmacists felt that they lacked training in the
provision and management of clinical services; 12,20,29,34,38,39 in studies in which there was
training, the pharmacists recognized the advantages thereof in their service provision and
felt more self-confident in their approach towards patients. 25,26,42
With regard to their relationships with other healthcare professionals, in most studies,
pharmacists felt that this relationship is beneficial in improving patient outcomes
10,21,22,26,27,31,35,39 and that the lack of such a relationship is a barrier. 20,30,34 With regard to the
limitations, as assumed by the authors, five studies did not report limitations 11,26,33,35,39 and
others mainly reported limits regarding the generalization of results, 17,21,25,27,41,42 the bias
associated with self-reports, 17,23,25,29,34,38 the influence of pharmacists’ experiences on
service provision, 12,26 problems with the data collection instruments, 22,28,37 and the use of
convenience and small samples. 20,22,24,29,31,41,42
DISCUSSION
Characteristics of the studies
The distribution of studies according to country may have been limited by language
and may have probably been due to developments in clinical pharmacy studies in the
48
countries of Oceania (i.e., public policy on the expansion of access to medication and
initiatives to enhance the role of community pharmacists), which rendered these studies
12,17,19,21 different from those found in previous reviews of clinical pharmacy services, in
which the majority of studies were had been conducted in the United States and Europe.
43,44,45 With regard to the methods used, questionnaires and interviews are commonly used
to obtain perceptions of professionals regarding their practices. Other than their ability to
yield study results quickly, these methods do not require the use of too many resources and
researchers can often count on the help of professional associations and councils to apply a
wide range of research. 18,46,47
The wide variety of the types of clinical pharmacy services described in studies is
due to the different characteristics of health systems in the various countries, coupled with
their respective public policies. 48,49 In addition, the lack of standardization of types of
clinical pharmacy services and their descriptions hinders the consolidation of the practice,
as it complicates the reproducibility of these services for working professionals and in the
education field. 50 An example of such an instance is in the systematic review by Allemann
et al. (2014), in which eighth definitions of pharmaceutical care were found. 51 Therefore, it
is suggested that a broad definition of pharmaceutical services be formulated, to enable the
evaluation and measurement of services, and valuing of community pharmacies. 52
With regard to the types of pharmaceutical interventions in clinical pharmacy
services, most studies addressed the provision of counseling and advice regarding
medication, whereas a minority addressed the development of a care plan and monitoring of
health outcomes; few studies provided follow-up assistance to the patient. In some
systematic reviews of clinical services in community pharmacies, studies described
strategies for improving patient outcomes and affirmed the importance of provision of more
complex interventions relating to medication management, such as MTM and medication
review services, since either education or information regarding medication is not enough
for the majority of patients. 53-56
Results of the studies
In all the studies in this review, the role of the pharmacist was associated with the
provision of patient care and generation of positive results, regardless of the type of service
provided. This result is corroborated by the reorientation of the profession in recent years,
in which the focus of pharmaceutical practice is the patient. 57 Therefore, in literature studies
49
on the improvement of clinical pharmacy services, as well as in this review, the prevailing
theme is that of pharmacists beginning to see more service opportunities in community
pharmacies and other settings. 45,58
The association between comfort level, the intention to provide clinical pharmacy
services, and the appreciation of the service or of the pharmacist’s practical knowledge is
understandable, since comfort levels decrease as a function of barriers and lack of training.
25,29 In a study by Bruchet et al. (2011), which identified actions taken to improve the quality
of clinical pharmacy services, it was suggested that managers consider educational programs
or mentorship for the improvement of pharmacists’ confidence and comfort levels. 8
Barriers to service provision, as found in the study, are in accordance with literature
and represent the major causes of low consolidation of clinical pharmacy services in the
world and have been shown to demotivate pharmacist in practice. 59-61 However, studies
show that the identification of these barriers is useful for the implementation of counteracting
strategies and improvement of the quality of the service provided. 21,62,63
The valuing of service provision facilitators is important in ensuring the quality of
clinical pharmacy services. In the reviewed studies, facilitators proved very important in
encouraging the development and expansion of services. 25 Some authors suggest that
literature should communicate about and disclose more facilitators of clinical pharmacy
service provision in community pharmacies, as this enhances patient care opportunities and
yields economic benefits for the pharmacy. 64,65 In addition, the identification of facilitators
could be one of the steps followed prior to the initiation of the practice; this could prevent
predictable barriers. 66,67
Despite it increasingly becoming a prerequisite for the provision of more complex
services such as therapy management, literature shows that lack of education and training is
a major obstacle in the provision of clinical pharmacy services; a similar finding emerged in
this review. 3,4 Other than improving technique, training and capacity building increase
professional confidence, especially in relation to increased knowledge and communication
skills. 2,68,69
Collaborative approaches between pharmacists and other healthcare professionals
help patients achieve therapeutic goals and enhance medication management; however, this
does not happen often, due to professionals’ lack of information, confidence, and
communication skills. 70,71 This was also observed in the studies included in this review.
Therefore, it is suggested that the relationship between these professionals be evaluated, so
50
that strategies for the implementation of a collaborative, patient-centered practice can be
proposed. 72,73
Recommendations for future research
The gaps found in this review could inform reflections and recommendations for
future research. Studies have shown the importance of emphasis on actions aimed at
improving the training of pharmacists and their staff, since pharmacists often report that their
higher education training does not fully enable them to consolidate clinical services in
community pharmacies, but that further training in chronic disease management, therapy
management, and communication skills is necessary. 74,75
Few studies have shown a need for the training and encouragement of pharmacy staff,
in providing the necessary support in pharmaceutical services. Staff could assist in the
recruitment of patients and the dissemination of services to clients of pharmacies, 76-78 and
take responsibility for tasks within the pharmacy, to optimize the pharmacist’s time, enabling
him or her to perform care work.
For optimal service provision, research should emphasize the importance of a private
environment for consultations, because the lack of such a structure would affect the service
negatively. 14 The environment should be comfortable, offering privacy, and having the
necessary resources that enable the documentation of data and measuring of patient
parameters, depending on the type of service performed. Moreover, Aguiar et al. (2013)
suggests the use of roundtables to facilitate confidence and create a close pharmacist-patient
relationship. 79
Aspects related to the economic impact of the service and the fair remuneration of
pharmacists were rarely addressed in the studies in this review, and should have more
prominence in future research. This theme may help enhance the services that attract
51
investment by managers and public-policy makers, and increase pharmacists’ remuneration,
improving their satisfaction in relation to their practice.
With regard to the barriers found in pharmacists’ relationships with other healthcare
professionals, it is important that new studies address strategies primarily aimed at
improving communication between these professionals. Pharmacists could disclose the
results of their services and avail themselves for partnerships with other healthcare
professionals who wish to improve patient management. 80
An additional gap presented was the detailed description of facilitators of service
provision, which could help professionals initiate services, with these strategies already in
place. It also enables reflection on the possible barriers, efficacy of facilitators, and the
feasibility of the service. Finally, it is important that studies disclose the means of
standardizing practices and disseminate consolidated service models. In this manner, it is
believed that service provision would be easier and that practices in community pharmacies
would be highly valued.
Limitations
Since this is a scoping review, trial quality was not assessed, but this choice was due
to the main objective of the current work, which was to know and understand pharmacists’
perceptions of clinical pharmacy services within community pharmacy. This review will
serve as a basis for subsequent systematic reviews that detail the quality of the reviewed
studies.
CONCLUSION
This review showed various aspects of pharmacists’ perceptions regarding clinical
pharmacy services in community pharmacies; perceptions regarding the pharmacist’s role in
relation to the orientation of the patient and regarding the lack of time and training in service
provision were identified as the most prevalent barriers. In addition, the support of other
healthcare professionals and job satisfaction were identified as facilitators of the service,
whereas education and training needs were perceived as limiting factors for practice.
Perceptions also highlighted partnerships with other healthcare professionals as a support
structure; important issues such as academic training, requirements for the structuring of
pharmacies, economic aspects, and the influence of public healthcare policies on service
implementation were also highlighted.
52
Furthermore, strategies aimed at the improvement of clinical pharmacy services and
at the development of practical models that meet health needs could be identified. The
following measures were proposed, based on the presented gaps: changes in the structures
of pharmacies, to ensure better patient care; actions aimed at improving the training of
pharmacists and their staff; strategies aimed at facilitating communication between
healthcare professionals; and the development of means to standardize practices and
disseminate consolidated service models. Thus, clinical pharmacy services are expected to
optimize drug use accordingly.
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62
CAPÍTULO 2
63
5.2. CAPÍTULO 2: IMPLEMENTATION OF CLINICAL PHARMACY
SERVICES IN COMMUNITY PHARMACIES: PERCEPTIONS OF A GROUP
OF PHARMACISTS
Aline S. Dosea, BPharm, M.Sc. Student, a Giselle de C. Brito, BPharm, MSc, Ph.D.
Student, a,b Lincoln M. C. Santos, Pharmacy Studant, a Tatiane C. Marques, BPharm,
MSc, Ph.D. Student,a Blície Balisa-Rocha, BPharm, MSc, Ph.D.,c Deborah Pimentel
M.D., MSc, Ph.D.,d Denise Bueno BPharm, MSc, Ph.D., e Divaldo P. Lyra Jr., BPharm,
MSc, Ph.Da
aTeaching and Research Laboratory, Social Pharmacy, Department of Pharmacy,
Federal University of Sergipe, LEPFS-UFS, s/n, Avenida Marechal Rondon, Jardim
Rosa Elze, São Cristóvão, Brazil
b Department of Pharmacy, Federal University of Sergipe, Health Campus, Lagarto,
Brazil
c Pharmacy Course, Faculty of Guanambi, Guanambi, Brazil.
d Department of Medicine, Federal University of Sergipe, São Cristóvão, Brazil
e Pharmacy Faculty, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
Corresponding author: Divaldo P. Lyra, Jr.
E-mail address: [email protected]
64
Abstract
Background: In community pharmacies, when pharmacists incorporate clinical practice
into their routine there are several barriers and facilitators influencing the implementation
of patient care services. Knowing the perceptions of pharmacists who promotes the
clinical pharmacy services can help improve the quality of implementation of services as
well as valorize the role of the pharmacist in providing patient care. Objectives: To know
and understand the perception of a group of pharmacists who were working in three units
of the Farmácia Popular do Brasil program on the establishment, implementation, and
consolidation of clinical pharmacy services. Material and Methods: This was a
longitudinal and observational qualitative study using focus groups. Data were analyzed
using content analysis. Results: The recording of the focus groups generated more than
210 minutes of audio that was fully transcribed and analyzed. The perception of the
pharmacists about the Farmácia Popular do Brasil program was that it facilitates access
to healthcare and medication. In addition, the pharmacists characterized the Farmácia
Popular do Brasil program as establishing an environment with less pressure on
pharmacists to make sales. In general, the pharmacists thought that the Farmácia Popular
do Brasil program pharmacies were better than most pharmacies, and that this model
brought the pharmacists using it greater satisfaction than other approaches. However,
several barriers to using the service emerged. The distance between neighboring cities
made it difficult for patients to return for services. In addition, patients were not
accustomed to identifying pharmacies as healthcare establishments. Lack of training of
staff, which created a lack of communication skills and knowledge, presented another
issue. The pharmacists expressed their expectations to have increased technical support,
skills development opportunities, and monitoring of researchers who assess the progress
of the service. Pharmacists overcame many of their insecurities in 2014 and felt more
proactive and committed to quality service. They began to reach their goals for patients,
and they gained more visibility. Consequently, the pharmacists feel that they have gained
further experience and professional enhancement. Conclusion: The dissemination of
positive experiences in services implementations through perception studies have shown
that it is possible to develop a model of clinical services in community pharmacies.
Keywords: Clinical Pharmacy Services, Community Pharmacy, Pharmacist Perception,
Implementation of healthcare services
65
INTRODUCTION
In recent years, advances in health technologies and new social demands for
specialized services have resulted in changes in pharmacy services.1,2,3 Within this
context, pharmacists have been included into health teams that guide their actions for the
promotion of services focused on the patient. Pharmacists thus have been encouraged to
become co-responsible for health outcomes and improved quality of life for patients.4,5,6
At the time the pharmacists began incorporating their clinical practices into
community pharmacies, several barriers and facilitators were influencing the
implementation of patient care services.7 Studies showed that barriers to implementation
included low professional remuneration and lack of investment in the infrastructure for
pharmacies.8,9,10 On the other hand, it is possible to observe facilitators as patient
satisfaction with the service and the support of researchers for the improvement and
maintenance of practice.11,12,13
In this context, knowing perceptions of the pharmacists who promote the clinical
pharmacy services can help improve the quality and implementation of services and
valorize the role of the pharmacist in providing patient care. Therefore, it is possible to
reveal from interviews with those working in pharmacy practices what issues there are
about structuring services and the work processes and what professional skills are
necessary for their success.14,15,11
Most studies related to this theme are linked to the perceptions and experiences of
patients using medication and healthcare professionals involved in the services provided
by the pharmacists.16,17,18,19,20,21 However, this practice is still new in Brazil, and there are
few studies on understanding the implementation of clinical pharmacy services from the
perspective of the pharmacists themselves.22,23,24 This study aims to know and understand
the perception of a group of pharmacists immersed in experiences involving the
establishment, implementation, and consolidation of clinical pharmacy services in
community pharmacies.
METHODS
This study has a methodology of collecting data on the understanding and
interpretation of the phenomena under investigation without judgment. Since the
collected data would not be measurable nor could hypotheses or causal relationships
between facts be formulated, we chose a qualitative research study approach, which seeks
to explain relationships, values, attitudes, beliefs, and habits.25,26
66
The setting of this study was composed of three units of the Farmácia Popular do
Brasil program. This program is a pharmacy network created by the government to sell
medications at subsidized prices and to facilitate the population's access to them.27 These
units of the Farmácia Popular do Brasil program are located in three cities in the
northeast. They are managed by a health foundation that established a partnership with
researchers who are interested in initiating a project to develop a model of clinical
pharmacy services in community pharmacies. For three years, these researchers have
developed projects to set up and evaluate the establishment, implementation, and
consolidation of pharmacy services.
The pharmacists received advanced training in order to provide quality clinical
services to their new patient load. The study sample consisted of 11 pharmacists who
were working in three units of the Farmácia Popular do Brasil program. The data were
obtained over the course of three focus groups. For this study there are a convenience
sample because the interest is only for person who had a significant relationship with
establishment, implementation and consolidation of clinical pharmacy services.
Following the recommendations of the consolidated criteria for reporting
qualitative research (COREQ)28, focus groups were conducted in a distinct setting of the
workplace in order to minimize possible interference. All pharmacists signed a consent
form that included permission to use video recording and data from the focus groups. This
study was part of the PhD project of researcher Giselle de C. Brito and was approved by
the Ethics Committee of the Federal University of Sergipe, CAAE number:
12639613.0.0000.5546.
Development of scripts
The scripts for the discussion groups were prepared by the researchers involved
in the project. The pharmacists addressed the lived experiences in three stages of the
project: in March 2012, at the beginning of establishing the project; March 2013, during
implementation; and March 2014 during the consolidation of clinical pharmacy services.
Interview questions addressed the perceptions of the pharmacists on the Farmácia
Popular do Brasil program model; the effects on patients because of receiving services;
barriers and facilitators of establishing, implementation and consolidation of the program;
and other factors related to patients, practice, training and the changes generated during
the process.
67
The interview questions were open and driven by a moderator who had the role of
stimulating an exchange of opinions and maintaining the focus of the discussion. Groups
were conducted for a maximum duration of two hours, and the discussions were
videotaped and later transcribed for analysis.
Analysis
Data were analyzed using content analysis29 in which the reports are organized
and systematized into categories and registration units. Two researchers (A.S.D. and
G.C.B.) independently analyzed the focus groups. In cases of disagreement, a third
investigator (D.B.) was also used. This reviewer also suggested improvement in
categorizations that have been accepted by consensus of three reviewers (A.S.D. and
G.C.B. and D.B.). Subsequently, a careful review by a senior evaluator was performed
(D.P.). After the definition of categories was performed a critical analysis of the three
focus groups.
RESULTS AND DISCUSSION
In the present study there was no withdrawal or refusal of any pharmacist invited
to participate in focus groups. The recording of the focus groups generated more than 210
minutes of fully transcribed audio. Subsequently, the material was organized and
analyzed in order to make it functional. This material generated 102 text clippings that
contained references to the topics of discussion. These text clippings were grouped by
similarities, and categories were formed according to the registration units. Table 1
presents the results of the focus groups.
68
Table 1: Pharmacist perceptions during the beginning of establishment (2012), implementation (2013) and consolidation (2014) of clinical
pharmacy services.
CATEGORIES REGISTRATION UNITS
Beginning of establishment
in 2012
During implementation
in 2013
Consolidation
in 2014
Facilitating access Access to pharmacist
Access to medication
Lack of pressure for sales
Ideal physical structure of pharmacy
Access to pharmacist
Access to medication
Lack of pressure for sales
Access to clinical service
Not reported
69
Table 1 (continuation): Pharmacist perception during the phases at the beginning of establishment (2012), implementation (2013) and
consolidation (2014) of clinical pharmacy services.
CATEGORIES REGISTRATION UNITS
Beginning of establishment
in 2012
During implementation
in 2013
Consolidation
in 2014
Barriers Distance from neighboring cities
Lack of physicians in the city
Difficulty in recruiting patients/creating demand
Difficulties in the provision of pharmaceutical services, need of
capacitation of pharmacists
Negative influence of paternalistic relationship between
physician and patient
Lack of recognition of the pharmacist by the population
Failures in human resources
Dichotomy between theory and practice
Bureaucracy in services
Professional insecurity for lack
of skills
Consolidation Barriers:
Problems in the structure
Human resources issues
Increased serviced
Overdue barriers:
Practice of clinical
services
Communication skills
70
Table 1 (continuation): Pharmacist perception during the phases at the beginning of establishment (2012), during implementation (2013) and
consolidation (2014) of clinical pharmacy services.
CATEGORIES REGISTRATION UNITS
Beginning of establishing
in 2012
During implementation
in 2013
Consolidation
in 2014
Pharmacist
Expectations
Technical support
Partnering with physicians to increase the
number of patients
Ability to generate outcomes for patients
Professional self-confidence
Idealization of service
Enhancement and professional achievement
Doing excellence /reference service
Maintenance of training and technical
support
More professional accomplishments
Expansion of services
Maintenance of technical
support
Changes generated
in implementation
Not Reported Improvement of service
Technical support
Overcoming of insecurities
Professional enhancement
Positive results for patients
Technical support
Professional enhancement
Service excellence implemented
Positive results for patients
71
Facilitating access
It was the general opinion of the pharmacists that the Farmácia Popular do Brasil
program greatly facilitated the public’s access to professional help and medication. They felt
that the fact that the government provided drugs at low cost and that the environment allowed
pharmacists to be more available to provide guidance for patients. The results from this
survey emphasize the importance of performing actions to reduce barriers to medication
access to increase adherence to treatment.30,31
Besides promoting greater access to medication, the Farmácia Popular do Brasil
program facilitates the visibility of clinical pharmacy services and pharmaceutical care that
provides comfort and privacy for patients.27,32 This factor has been reported as an essential
factor in building a trust relationship between the pharmacist and patients. Lack of this type
of structure was cited as a recurring problem for community pharmacies.33-36
In addition, pharmacists saw the program as an environment in which there was less
pressure to make sales; therefore, it was considered a better model for work with better job
satisfaction. This perception corresponds with studies showing that pressures on the business
side of healthcare can cause a lack of patient confidence in the information provided by the
pharmacist and frustration and tension in the pharmacy professional due to lack of job
autonomy.37,38 As one pharmacist noted:
"The pharmacy has a room for pharmaceutical care that allows patient privacy (...)
When you arrive at the service you are seen as a human."
Barriers to implementation
Several barriers emerged during the years of implementation of services; however,
over time the majority of problems were overcome. For example, the distance between cities
and the lack of physicians to evaluate clinic conditions presented difficulties for the
development of clinical pharmacy services. Previous researchers have approached the same
problems, in which besides lack of support from physicians there were also discordances
with pharmacist interventions.39,40 This points to the importance of multidisciplinary
monitoring.
72
Another issue that arose during patient recruitment was that the patients were not
accustomed to identifying pharmacies as healthcare establishments. Faced with similar
problems, several researchers developed strategies for engaging patients, such as
communicating with potential patients about the service benefits.11,35,41 In addition, the
approach of some physicians was exerting a negative influence on patient recruitment to
pharmaceutical services, because patients emphasized that the physician was the only
healthcare provider that should have knowledge and power over clinical decisions.
According to one pharmacist:
"She (the patient) said, 'but the doctor knows more than the pharmacist.’"
Study participants reported service delivery problems due to failures in academic
training and lack of clinical skills. This issue reinforces the need for training and continuing
education for pharmacists.36,42,43 By 2014, many of the barriers to service were overcome,
the performance of clinical pharmacy services had significantly improved, and pharmacists
felt better about the consolidation of services.
In Brazil, there is still no law regulating the presence of a qualified pharmacy staff in
community pharmacies.44 Therefore, one factor that also caused problems in the past was
the lack of knowledge and technical training of staff. This failure demanded time of
pharmacists who organized staff training activities and continuing professional development
to avoid problems on the pharmacy.
In 2013, the bureaucracy found in the community health services was considered to
be a barrier that drove away patients and slowed down service delivery. This was due the
necessary documents for the purchase of medicines, however this is a measure of the
program that ensures the control of drug sales. In addition, pharmacists felt insecure about
the provision of clinical services and by the lack of sources of information to improve care.
This brought on feelings of shame, fear, and frustration. One pharmacist said:
"Sometimes I feel weak. There are some skills that I still could not develop,
especially communication."
Regarding, increased service demand being a barrier:
“If we increase the amount of care service, we have to see how a new routine (...) is
a difficulty, is a new requirement, by the amount of care service that lie ahead."
73
In 2014, barriers such as lack of clinical skills were overcome and the performance
of clinical pharmacy services improved significantly, what proves that the support of
researchers helped to decrease the dichotomy between theory and practice and professional
insecurity for lack of skills.
Expectations and changes generated on implementation
Pharmacist expectations were linked to their idealization of the community pharmacy
service and what would be required for a successful first year of practice. They expected to
have technical support to develop skills and acquire knowledge. They also wanted to have
monitoring by researchers who could assess the progress of the service. Likewise, in the
literature it shows that pharmacists expect more training about management issues, specific
diseases, and approaches to the implementation of services.
Professional pharmacy education at the undergraduate level does not offer that kind
of expertise.45,42,46 For this reason, several studies like ours have advocated investing in
technical support with training, because this strategy will bring about improvement to the
practice of the pharmacist. Furthermore, the pharmacist can become safer and more self-
confident about the provision of clinical services in community pharmacies and other
primary care environments.47-51
In 2012, a pharmacist commented:
"We need to know we have the support of you (researchers) to clarify and facilitate
information for us."
In 2013, another pharmacist said:
"The expectation is to have to be a reference and have professional development,
which is the true pursuit of excellence."
Others commented:
"I think in that year (2014) I need to improve myself, always doing better." and "The
coordination support is 100% for me, (it) is very good (...) When I joined, I did not know
how to dispense medications like I dispense today. I did not know how to take care of patients
like I take care of them today."
74
After the first year of establishing of services, in 2013 the three pharmacies were able
to maintain the same level of evolution of practice, but the pharmacists also hoped that by
partnering with physicians they would increase the number of patient referrals to clinical
pharmacy services. According to studies on the issue, this partnership sometimes does not
happen because of resistance from other healthcare professionals regarding pharmaceutical
interventions or because of fear of approaching physicians on the part of pharmacists.52,53
Consequently, patient management can become more difficult and the therapeutic outcomes
can become diminished. Therefore, strategies for fostering good communication, trust, and
respect between physicians and pharmacists are recommended to improve collaboration
between these professionals.54,55
During implementation of the program, the pharmacists also had ideas about
improving medication compliance and quality of life for patients who used their services.
These goals, generated increased visibility and recognition by the local population of the
community pharmacy services in the same manner as in Bradley et al. (2012).
The service received increased appreciation from physicians after the positive results
were achieved by pharmacist intervention regarding drug interactions.56 In this sense, the
improved pharmaceutical services also make patients feel grateful for the improvement in
the understanding they have of their medications.49 The results of the study showed that
clinical pharmacy services bring benefits not only for patients, but also for the motivation
and productivity of pharmacists. As one pharmacist noted:
"We're getting to be a reference of healthcare facilities (...) I have seen an evolution
in 2013, and in 2014. I think it worked because (of) patient outcomes." and "If (we) reduced
the quality of services, patients will gonna miss! Because today the pharmacy has this
characteristic, there are people who will go there only for services. "
In 2014, healthcare services were consolidated. Pharmacists had become self-critical
and more independent from technical support. They incorporated practice routines that gave
a sense of professionalism to clinical services. By this time, they had become different
professionals, capable of transforming the reality of their patient population to being
motivated, accomplished, and valued:
"(The service) worked, but lacks the magnification, we need (to) disclose more (...)
want to recruit more patients (...) (and) attain and exceed the target that was (achieved) last
year. "
"I'm performed, I feel that I am important and I can change reality."
75
"Privilege, transformation, enhancement, experience (...) everyone is beginning to
know our role."
"We feel that we are actually exerting our function to society."
LIMITATIONS
Because of employee turnover, all pharmacists do not have the same level of training.
Although these results may elucidate some of the issues at hand, they are based only on self-
reported data from the participants, so they may not be generalizable to other pharmacy
settings.
CONCLUSION
Knowing the perceptions of pharmacists was essential to understanding how it was
possible to consolidate the clinical pharmacy services in community pharmacies and
understanding the barriers and facilitators influencing the process. The perceptions of
pharmacists can point to strengths, such as access to pharmacies and the importance of
technical support received. It is possible to note a gradual change in the pharmacists’
perceptions over the years, as well as the recognition of overcoming obstacles.
Pharmacists were involved with the Farmácia Popular do Brasil program to improve
the application of clinical services. Based on knowledge of the pharmacists’ perceptions,
various interventions for improvement were applied, such as mandating further training and
using the guidance of researchers. Therefore, the study has shown that it is possible to
develop a model of clinical services in community pharmacies.
Acknowledgments
To the pharmacists, Maria Cristiane Trindade de Almeida and Eulália Lins Victor,
coordinators of the Farmácia Popular do Brasil program managed by the Sergipe State
Health Foundation (Funesa) and to the 11 pharmacists who participated in the focus groups.
The financial support for this study was obtained from the Coordination for the Improvement
of Higher Education Personnel (CAPES) and the Foundation for Research Support of the
State of Sergipe (FAPITEC).
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6. CONCLUSÃO GERAL
Diante do exposto, foi possível compreender a partir dos estudos da revisão de
literatura que os farmacêuticos associam o seu papel a orientação ao paciente e que barreiras
como a falta de tempo para o serviço e falhas na formação acadêmica do farmacêutico podem
influenciar no sucesso dos serviços clínicos farmacêuticos e na sua satisfação com o
trabalho. Tais resultados serviram de base para apoiar os achados dos grupos focais, pois as
percepções encontradas nos dois estudos serão coerentes se comparadas.
Os relatos dos grupos focais apontaram questões como a importância do acesso aos
medicamentos essenciais e do suporte de pesquisadores na implantação de serviços clínicos
farmacêuticos. Apesar da maioria dos achados nos dois estudos não permitirem
generalização, foi possível compreender que a necessidade do desenvolvimento da formação
do farmacêutico durante a implantação dos serviços clínicos farmacêuticos pode ser
essencial para a consolidação dos mesmos e para o desenvolvimento da segurança do
profissional.
Neste sentido, sugere-se o aprimoramento dos serviços clínicos farmacêuticos a
partir do investimento no treinamento de conhecimentos e habilidades do profissional, de
adequações na estrutura de farmácias comunitárias, bem como do estreitamento das relações
entre outros profissionais de saúde para facilitar a ampliação destes serviços em ambientes
ainda não explorados.