The simulated patient method: Design and application in health services research.

The simulated patient method is becoming increasingly popular in health services research to observe the behaviour of healthcare practitioners in a naturalistic setting. This method involves sending a trained individual (simulated patient among other names), who is indistinguishable from a regular consumer, into a healthcare setting with a standardised scripted request. This paper provides an overview of the method, a brief history of its use in health services research, comparisons with other methods, ethical considerations, and considerations for the development of studies using the simulated patient method in health services research, with examples from pharmacy and other fields. Methods of analysis, mixed-methods, and the use of simulated patients with feedback are also discussed.

Relationships Between Treatment Delivery, Program Attrition, and Reoffending Outcomes in an Intensive Custodial Sex Offender Program.

Retention of sex offenders to the completion of treatment is critical to program adherence to risk need responsivity (RNR) principles; however, it is also important to consider the potential interaction between attrition and treatment outcomes such as reoffending. The first aim of this study was to evaluate the influence of changes to treatment delivery in a residential sex offender treatment program (SOTP), including introduction of rolling groups and systematic emphasis on positive therapist characteristics, on likelihood of program noncompletion ( n = 652). Pooled regression modeling indicated that these operational interventions were associated with a significantly increased likelihood of program completion. We also examined whether variance in rates of participant attrition was related to reoffending outcomes for program completers ( n = 494). Incidence of attrition within completing participants' treatment cohorts had a significant negative association with hazard of sexual reoffending that was not accounted for by pretreatment risk. Results are discussed in terms of their implications for treatment delivery processes that aim to optimize both participant retention and treatment effectiveness.

Community pharmacy modifications to non-prescription medication requests: A simulated patient study.

BACKGROUND: Self-care, and hence self-medication, is becoming an increasingly popular practice worldwide. Community pharmacies are an important destination for those seeking non-prescription medicines, and pharmacists and their staff are in a prime position to facilitate appropriate and safe self-medication. PURPOSE: To determine what modifications (for example, a change in brand, change in drug, or non-supply) pharmacy staff make when presented with a request for a non-prescription medicine, and to determine what factors influence whether a modification is made. METHODS: Sixty-one third year Bachelor of Pharmacy students from The University of Sydney were trained as mystery shoppers to make 9 visits once a week to 36 community pharmacies in the metropolitan region of Sydney, Australia from March-October 2015. Students presented to a different, pre-allocated pharmacy once a week with a direct product request for a non-prescription medicine relating to a common ailment (e.g. asthma, insomnia, allergic rhinitis) for 9 weeks. Student mystery shoppers audio-recorded each visit and collected the details of the interaction and product sold. Descriptive statistics, chi-squared analyses, and binary logistic regression were performed to find factors influencing modifications made by pharmacy staff to the simulated patient initial request. RESULTS: Of 540 completed visits, 497 were eligible for analysis. Modification (change in brand, intra/interclass change, companion sale, or no product supplied) occurred in 49% (n = 245) of visits. Whether the product requested was deemed "not appropriate" given the scenario outline was the only significant predictor of whether a modification to the request occurred (42% modification, "appropriate" scenarios vs. 57% modification, "not appropriate" scenarios; χ2 = 8.90; p < 0.01). CONCLUSIONS: Modification from the original non-prescription medicine request occurred in approximately half the reported requests. A request for a product that was considered "not appropriate" was more likely to elicit a modification than a request for an "appropriate" non-prescription medicine.

A systematic review of simulated-patient methods used in community pharmacy to assess the provision of non-prescription medicines.

OBJECTIVE: To explore the use of simulated-patient methods in community pharmacy for non-prescription medicines. METHODS: The databases IPA (International Pharmaceutical Abstracts), EMBASE and MEDLINE were searched for articles published between 1990 and 2010 outlining studies using simulated-patient methods. KEY FINDINGS: Thirty studies from 31 articles were reviewed. The majority used simulated-patient methods to purely assess counselling behaviour of pharmacy staff, rather than as an opportunity to provide educational feedback to improve counselling behaviour. CONCLUSIONS: Few simulated-patient studies have incorporated performance feedback to encourage behavioural change and improve counselling skills. Studies that incorporated feedback did not provide sufficient detail, and few studies have explored participant perceptions. Additionally, very few studies have employed scenarios involving children's medicines. Future studies should test the feasibility of using the simulated-patient method, with appropriate performance feedback and describe participant perceptions of the value and acceptability of this training method.

Simulated caregivers: their feasibility in educating pharmacy staff to manage children's ailments.

BACKGROUND: Community pharmacy staff play a crucial role in the management of common childhood ailments. Simulated patient studies have not yet explored the management of children's cough/cold and fever, nor have many previous studies used simulated patient methods with focus on self-assessment as a training tool to shape future counselling behaviour. OBJECTIVES: To assess and shape the counselling behavior of pharmacy staff when dealing with children's cough/cold and fever; investigate influential factors of counselling behavior; and explore participant perceptions of simulated patient methods as a training tool, with particular emphasis on self-assessment. SETTING: Community pharmacies in the inner city region of metropolitan Sydney. METHOD: Six simulated caregivers visited eight community pharmacies. After applying their scenario, the interaction was scored and immediate performance feedback was delivered in the form of self-assessment. Semi-structured interviews followed, focusing on participant perceptions of self-assessment. MAIN OUTCOME MEASURES: Scores for each simulated patient interaction, and qualitative interviews responses from participants. RESULTS: The highest mean percentage score achieved was for the symptom based request for a cough/cold remedy in a five year old (48 ± 14.3 %), while the lowest was the direct product request equivalent (22 ± 8.5 %). Qualitative results showed that simulated patient visits were viewed positively and self-assessment was highly regarded. CONCLUSION: Using simulated caregivers in pharmacy to assess and improve children's cough/cold and fever management is feasible and acceptable. The opportunity to self-assess is particularly beneficial, allowing participants to demonstrate key psychology principles associated with behaviour change.

Developing communication skills in pharmacy: a systematic review of the use of simulated patient methods.

OBJECTIVE: To review the literature relating to the use of simulated patient methods to enhance communication skills of pharmacists. METHODOLOGY: We searched Embase, Lilacs, Medline, Scielo, and Scopus databases between 1980 and 2008, using "communication skills", "patient counseling" and "pharmacist" as keywords. This search was then further refined by using "simulated patients", "pseudo-customer", "standardized patients", and "mystery shoppers" as additional keywords. RESULTS: The initial search identified 241 published studies. Once further refined, 15 studies met inclusion criteria. CONCLUSION: The majority of studies had an assessment focus aimed at documenting counseling behavior of practicing pharmacists, rather than an educational focus aimed at equipping pharmacists with effective communication skills. In instances where simulated patient methods were used for educational purposes, little regard was given to the role of performance and corrective feedback in shaping communication behavior of pharmacists. The majority of studies failed to describe the competencies and skills being investigated in relation to communication in the practice of pharmacy. PRACTICE IMPLICATIONS: Simulated patient methods provide pharmacy educators with a tool for implementing communication skills in the practice of pharmacy and will serve as a basis for implementing communication skills development programs at the College of Pharmacy of the Federal University of Sergipe in Brazil.

National implementation of standards of practice for non-prescription medicines in Australia.

UNLABELLED: In Australia, there are two categories of non-prescription medicines: pharmacy medicines and pharmacist only medicines. Standards were developed to define and describe the professional activities required for the provision of these medicines at a consistent and measurable level of practice. OBJECTIVE: Our objective was to implement nationally a quality improvement package in relation to the Standards of Practice for the Provision of Non-Prescription Medicines. METHODS: Approximately 50% of Australian pharmacies (n = 2,706) were randomly selected by local registering authorities. Trained pharmacy educators audited each community pharmacy in the study three times, 7 weeks apart on Standards of Practice for the Provision of Non-Prescription Medicines, Visit 1 involved the educator explaining the project and conducting an assessment of the pharmacy's level of compliance. Behaviour of community pharmacists and their staff in relation to these standards was measured by conducting pseudo-patron visits. Pseudopatron visits were conducted at Visit 2, with the educator providing immediate feedback and coaching and a compliance assessment. Visit 3 involved a compliance assessment, and a second pseudo-patron visit for those pharmacies that had performed poorly at the first visit. RESULTS: At Visit 1, the lowest levels of compliance were to the standards relating to the documentation process (44%) and customer care and advice (46%). By Visit 2, more than 80% of pharmacies had met most criteria. At Visit 3, compliance had significantly improved compared to Visits 1 and 2 (P < 0.001). The lowest levels of compliance were to criteria which required written operating procedures for specific tasks, but these also improved significantly over time (P < 0.001). CONCLUSIONS: Professional practice in relation to the handling of pharmacist only and pharmacy medicines improved considerably as measured by the auditing process, and the results indicate that Australian pharmacies are well-equipped to provide high quality service to consumers of these medicines. The acceptability of national implementation of these standards of practice in Australia indicates that such an approach could be taken internationally.

When pharmacotherapeutic recommendations may lead to the reverse effect on physician decision-making.

For long the medical literature has shown that patients do not always receive appropriate care, including pharmacotherapeutic treatment. To achieve improved patient care, a number of physician-oriented interventions are being delivered internationally in an attempt to implement evidence based medicine in routine daily practice of medical practitioners. The pharmacy profession has taken an active role in the delivery of intervention strategies aimed at promoting evidence based prescribing and improved quality and safety of medicine use. However, the medical literature also supports the notion that valid clinical care recommendations do not always have the desired impact on physician behaviour. We argue that the well-established theory of psychological reactance might at least partially explain instances when physicians do not act upon such recommendations. Reactance theory suggests that when recommended to take a certain action, a motivational state compels us to react in a way that affirms our freedom to choose. Often we choose to do the opposite of what the recommendation is proposing that we do or we just become entrenched in our initial position. The basic concepts of psychological reactance are universal and likely to be applicable to the provision of recommendations to physicians. Making recommendations regarding clinical care, including pharmacotherapy, may carry with it implied threats, as it can be perceived as an attempt to restrict one's freedom of choice potentially generating reactance and efforts to avoid them. By identifying and taking into account factors likely to promote reactance, physician-oriented interventions could become more effective.

Exploring elements of interprofessional collaboration between pharmacists and physicians in medication review.

In medication review involving community pharmacists and physicians, there is an underlying assumption that if community pharmacists provide evidence based pharmacotherapeutic recommendations, physicians, in turn, will implement these recommendations. However, although in general medication review has been shown to improve the quality of medicine use, medication management plans arising from the medication review process are not always implemented. There is a need for better understanding of the factors that influence outcomes in medication review. The current paper will address some cultural and procedural factors that may assist in understanding outcomes in medication review using research into collaboration from areas outside the healthcare as a framework.