THE PATIENTS' PERCEPTION OF THE QUALITY OF COMMUNITY PHARMACY SERVICES USING THE CRITICAL INCIDENT TECHNIQUE (CIT)

Introduction / Aim. The Critical Incident Technique (CIT) is a qualitative research method for measuring consumer satisfaction by collecting and analysing information on participants and their activities. This method allows participants to present their detailed experiences related to a particular service in the way they perceive them. The study aimed to examine patients' perceptions of an incident occurred in community pharmacies using CIT and determine recommendations for improving the quality of pharmacy services. Methods. A qualitative study using an interview based on CIT was conducted in three pharmacies in Serbia, on the territory of Krusevac city. The entire course of the interviews was recorded, which provided detailed research. Results. A total of 68 critical incidents were collected and divided into two groups: positive (37) and negative (31), depending on the (dis)satisfaction of patients with the services of pharmacists in community pharmacies. The following thematic clusters of pharmacy services were covered: accessibility of community-based pharmaceutical services, pharmacist behaviour, patient counselling, dispensing of drugs and / or medical devices, compounding, and pharmacy sales / commercial practice. Conclusion. The results show that CIT is a useful tool for evaluating and improving pharmaceutical services. Based on the data collected, various aspects of community pharmacy services can be improved and further research should be carried out.


Introduction
An integral part of pharmacist contribution to healthcare is the improvement of rational and economical prescribing and proper use of drugs. The goal of each part of pharmaceutical care service is relevant to each patient, clearly defined, and comprehensively and clearly presented to each healthcare provider (HCP) involved in the treatment and care of patient 1 .
Most of the researches conducted in the field of quality of pharmacy services are based on practice; they are focused on the identified problem and seek its clarification, evaluating and improving services 2 .
The Critical Incident Technique (CIT) is a well-established qualitative research tool used in many areas of health science, education, as well as management and marketing. John C.
Flanagan was the first to describe the Critical Incident Technique (CIT) and the original purpose of this method was applied in organisational psychology 3 . The Critical Incident 5 Technique (CIT) is used to find the cause of system problems to minimize loss of person, property, money or data. The technique takes into the account the collection, analysis and interpretation of reports on actions taken by experts in response to their experience. This includes the development of constructs that report critical incidents into defined categories; subsequent analysis allows the researcher to draw conclusions on improving results for future scenarios.
CIT is a method for measuring consumer satisfaction with services by collecting and analyzing information about participants and their activities. This method allows participants to present their details about experiences regarding a particular service, in the way they perceive them, instead of asking them questions defined by others.
This approach also allows participants to express their satisfaction or dissatisfaction with a particular part of the service. In this paper, CIT was used to determine (dis)satisfaction of patients with pharmaceutical care services in the community pharmacy.
Studies using CIT in health care have involved nursing staff, physicians, student-patient relations and healthcare workers (HCW), as well as their behaviour in daily work, the standpoint of HCWs in dealing with patients and their complicated chronic conditions and specific patient needs 4 .
In nursing practice, the CIT as a research tool is used to investigate the experiences of patients suffering from age-related wet macular degeneration; how these patients perceive nursing care and to what extent they are satisfied 5 . Also, the CIT tool has been used in patients struggling with advanced COPD and lung cancer 6 , as well as in cancer survivors to investigate and collect information on complementary and alternative medicine (CAM) 7 .
Other studies have examined how HCWs make decisions regarding patient health; reveal why medication errors occur and how to avoid them 8 . The patients suffering from chronic conditions were investigated concerning their perceptions in interactions with HCWs and their time spent in the hospital setting 9,10 .
When searching for publications from pharmaceutical practice, not enough researches regarding the quality of pharmaceutical services exist as well as any specific tools that could help in measuring / assessing patient satisfaction.

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In Elvey et al. 11 study, conducted by CIT tool, the patient-centred professionalism and behaviour of early-career pharmacists working in community and hospital pharmacies were examined; other researches were focused on revealing which factors have an impact on pharmacy students when making decisions about OTC drug recommendation to a patient 12 .
A few studies have also dealt with pharmacist-related issues, e.g. how they perceive specific situations in their work, the root of patient aggression, the consequence of this aggression on the pharmacist's work and behaviour 13,14 or why community pharmacists might violate the rules of standardised procedures that should be applied when such a violation could pose a potential threat to patient safety 15 .
The study aimed to examine patients' perception regarding the incident occurring in community pharmacies by using CIT and to determine recommendations for improving the quality of pharmacy services.

Methods
A qualitative CIT-based study 3 using the interview method was conducted following the approval of the Ethics Commission in three community pharmacies located in central Serbia.

Sample
The sample of patients was selected based on two criteria: (i) patients who visited the pharmacy to collect chronic therapy for themselves (for hypertension, asthma, osteoporosis or diabetes mellitus) and (ii) patients who had any of the acute symptoms such as headache, high fever or rash.
The participant had to meet all two criteria, after which the time and place of the interview were subsequently agreed. The participants were informed of the purpose and protocol of the study and ensured the confidentiality of the data collected and signed an informed consent.
Sampling was continued until saturation occurred, e.g. until the addition of new incidents contributed to further information for the analysis. The number of participants ended after new critical incidents did not appear in the respondents' answers.

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The research was conducted in three community pharmacies ("Benu", "Andjela" and "Lazarica") on the territory of Krusevac city. One pharmacy is located in the city centre and two other pharmacies are located on the outskirts of the city (not on the same side). The pharmacies were selected so that one pharmacy is in public ownership ("Lazarica" Pharmacy), and the other two pharmacies are in private ownership, in the pharmacy chain.
One of the pharmacies operates only in the local municipality ("Andjela" Pharmacy), while the other operates throughout Serbia ("Benu" Pharmacy).
Ethical approval and consent for participation was applied and waived by the Ethics Committee of the Faculty of Pharmacy, University of Belgrade, No. 430/2. Twenty patients were examined; half of them were in the age group of 30 to 50 and were predominantly female (90%).

Procedure, analysis and rigor of data collection
An open-ended interview was designed (Appendix 1); the interviewer (TC) was trained on the way of approaching participants during the interview. Each interview was audiorecorded and conducted at a time and place convenient to each patient. The interviews lasted 5 to 20 minutes (average 10 minutes). All interviews were transcribed verbatim in written format. Each episode was analysed to gain an in-depth understanding of the significance of the previous participant in a given context 16 .
An inductive analysis 16 was performed by identifying the mechanism on which each episode is based and comparing all mechanisms to identify differences and similarities between the studied events. A descriptive list of elements was made and subsequently revised to remove redundancies. Then a list of descriptive elements is organized into a cluster of topics. The expert group (VM, LJT, IK) reached a consensus on the final list of the thematic cluster of pharmacy services and the relationship between the topics. For each example, citations were identified and included anonymously (patient statement only in relation to a particular incident).

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A total of 20 respondents (90% women and 10% men) were included in this study. Table 1 shows data on the socio-demographic characteristics of 20 interviewed respondents including their age, gender, employment, and the pharmacies they visit. Table 1 Demographic characteristics of the respondents included in the survey.

Characteristics
Number All critical incidents were sorted according to patients' satisfaction and their experience with particular pharmacy service and pharmacist behaviour. After classifying the critical incidents, all elements were classified into six thematic clusters (three categories of the structure and three of the procedures), as shown in Table 2.
A total of 68 critical incidents were collected and divided into two groups: positive (37) and negative (31)  descriptions of situations, whether positive or negative, are listed in Table 2 and Table 3.  13

Discussion
Patient-centred care describes the partnership between the patient and HCW, where patients' expectations and experiences with their disease as well as experiences with drugs determine their willingness to adhere to prescribed drugs 17 .
In recent years, pharmaceutical practice has expanded significantly, with the increase mainly related to person centered care and patient needs 18 .
The context in which health care services are provided by different HCW, such as physician, nurse or pharmacist, is different, but the expectations of patients in these systems are somewhat similar 6 .
The behavioural research involving patients exists, but research in pharmaceutical practice from the patients' point of view is rare, so the research instrument used in this study is interesting because it has been used in other disciplines before (e.g. nursing, doctor).
In this study, the number of actual critical incidents (37) exceeded the number of negative critical incidents (31), indicating that participants were generally satisfied with pharmacy services in community pharmacies. Positive experiences with patients mean that in cooperation with a pharmacist, patients could achieve positive clinical outcomes, while negative critical incidents indicate that pharmacy services require improvement to reduce errors in the provision of pharmacy services in community pharmacies. A significant cluster of pharmacy services is the process of counselling at the time of dispensing drugs that should be processed with sufficient privacy.
Our results are consistent with research by Emsfors et al. 5 , in which when patients were perceived to have been treated with respect and when they were involved in the process; this created confidence and trust among them and a willingness to cooperate. The most common reasons why participants said they were discouraged to ask for advice and help from a pharmacist were: lack of time, lack of privacy, insufficient number of qualified pharmacists in the pharmacy, pharmacist dealing with administrative matters and inadequate pharmaceutical education. Lack of perceived privacy is an obstacle to patients as well as in the study conducted among cancer survivors, where privacy concerns were a restrictive factor for participants, the same as for patients in our study. 7  altruism, sharing emotions, and it has been noticed that it has a positive effect on the patient's well-being and his perception of the therapy that is received 20 .

Implications
The results of this study show that CIT could be a useful tool for improving the quality of pharmacy services in the community by increasing patient satisfaction. Based on the results obtained, various aspects of community pharmacy services can be improved. Further research is needed using CIT in more community pharmacies and more countries to allow comparison of results.

Limitations
This study describes the experiences of patients from three different pharmacies in a smaller city in Serbia (Krusevac, about 60,000 citizens). Therefore, the small size of the sample does not allow a conclusion to be drawn about the wider population of patients.

Conclusion
The CIT recognises six descriptors / thematic clusters of incidents in community pharmacy practice, as foundation for a quality improvement recommendation. The patient's perception of pharmacists' behaviour is considered a very important descriptor. It is identified especially in three basic pharmacy services (such as dispensing, cancelling and compounding of drugs) to meet the patients' needs and achieve positive therapeutic results A good communication between a patient and a pharmacist has increased patient 16 satisfaction. Also, it had an impact on the quality use of non-prescribed drugs (selfmedication). Based on the data collected, various aspects of public pharmacy services can be improved and further research should be carried out.