Survey on satisfaction and needs of pharmacists in prescription-checking training: a cross-sectional study

Background Prescription-checking is becoming increasingly popular in medical institutions, but the prescription-checking ability of pharmacists needs improvement. This study aimed to explore the key aspects of the prescription-checking training and provide an empirical reference for standardizing the prescription-checking training for pharmacists in medical institutions. Methods Trainees who were willing to complete the Likert questionnaire were enrolled in this study. Percentage and composition ratio were used for statistical description. The chi-square test and exploratory factor analysis were used for statistical analysis. A difference with p<0.05 was considered statistically significant. Results The questionnaire had good internal consistency and validity. The overall satisfaction of the trainees was 90%. Three dimensions, training organization, teaching mode as well as consolidation and assessment of knowledge were extracted using exploratory factor analysis. The average examination score of the 20 courses was 89.21±2.62 points. From the perspective of needs, 94.66% of the trainees preferred face-to-face lectures, 89.33% of the trainees expected high professional skills of the lecturers, and 62.27% of the trainees believed that clinical expertise was highly desirable. Conclusion There was a great demand for prescription-checking training among pharmacists. Trainees enrolled in this training showed high satisfaction and good examination results. The key aspects of prescription-checking training were training organization, as well as consolidation and assessment of knowledge. It is recommended to conduct training in a stratified manner according to pharmacists’ educational background, in order to effectively improve their prescription-checking competence. The pharmacists preferred face-to-face lectures and interaction to supplement clinical disease-related knowledge.

showed that 14% of prescriptions had errors (50% were dose errors) in a pediatric intensive care unit [4], most of which were avoidable medication errors. Prospective prescription-checking by pharmacists can ensure the safety and rationality of medication [5][6][7], and reduce irrational drug treatment, drug waste [8,9], and the number of emergency department visits and hospital readmissions [10]. In the "new medical reform" environment, prescription-checking is also an important development direction for the transformation of pharmacists' function. Recently, three national departments jointly issued and implemented the Regulation for Prescription-checking for Medical Institutions (No. 14 [2018] of the Ministry of Health), which clarifies that pharmacists are the first responsible persons for prescription-checking. Hence, the role of advising and checking for medication becomes increasingly important [4,[11][12][13], which also places greater need of comprehensive quality on pharmacists. Prescription-checking requires optimal clinical knowledge, pharmacy knowledge, and work experience. However, pharmacists in medical institutions receive chemistry-based pharmacy-centered education [14], which is not closely related to their work [15].
Pharmacists in China must complete continuing education [16], but the traditional continuing education is not very helpful, which is similar to the situation in Lebanon [17]. In addition, practical experience is based on supplying medicine, which lacks knowledge and experience of medication, such as medicine review, pharmaceutical monitoring and rational drug use [18]. The prescriptions of doctors in medical institutions involve all departments of the hospitals, while the clinical knowledge of pharmacists is far below the requirements of checking prescriptions of different departments. Hence, prescription-checking is a big challenge for pharmacists in medical institutions. Pharmacists must continue to study and improve their skills and knowledge in order to adapt to development and changes of the pharmacy [12,19]. Therefore, medical institutions should urgently conduct prescription-checking training with high frequency and intensity, in order to supplement relevant knowledge, strengthen professional knowledge, increase clinical medication experience and improve the comprehensive skills and prescription-checking competence of pharmacists. In order to effectively improve the prescription-checking ability of pharmacists and the rational use of drugs in hospitals in our province, the Shanxi Pharmaceutical Specialist Alliance organized the phase 1 class for prescription-checking training of pharmacists in medical institutions, which ended in May 2019.
Given that the pre-requisite prescription-checking is still in an exploratory stage in medical institutions of our country [20], and the standardized training for pharmacists is in a nascent stage [21], the training can only refer to the training experience of individual hospitals that have already conducted training and past training experience of pharmacists. In response to the relevant issues of this training in our province, the training satisfaction and requirements were surveyed using Likert scale, in order to explore the needs of prescription-checking training for pharmacists from different classes of medical institutions, of different ages and positions, aimed at providing a reference for the follow-up standardized prescription-checking training, building a team of prescription-checking pharmacists, improving the prescription-checking ability, and promoting clinical rational drug use.

Methods
The training was divided into theoretical study, practice and assessment. The theoretical study involved 20 courses, which were completed within 33 hours on four rest days. The practice was completed on working days during the training. The trainees reviewed and commented on the prescriptions of their institutions based on what they had learned to consolidate the knowledge. The assessment was an online open test. The test had a total score of 100, and questions were singlechoice or multiple-choice. Each course was tested online on the same working day after the face-toface lectures. The test link was opened at 18:00 on the working day, and closed at 18:00 on the next day, and the answer query link was opened at the time when the test link was closed for one day to provide learning. In Shanxi Province, a total of 826 pharmacists from different medical institutions were registered for prescription-checking training, of which 150 (18.16%) participated in the phase 1 training. From June 9-20, 2019, the questionnaire link was issued to the trainees in the WeChat group through the Sojump platform. Trainees could fill the questionnaire on their mobile phones. A total of 150 questionnaires were returned, all of which were valid after excluding those with unanswered items and with the same answer throughout the whole questionnaire. The effective recovery rate was 100%.
The questionnaire consisted of three parts: The first part introduced the background and objective of the survey. The second part involved the demographic information of participants, including gender, age, work experience, educational background, title, level and position in the medical institutions. The third part was the survey on the satisfaction for the training, needs of pharmacists and teaching effect. The questionnaire included a total of 23 items. Among them, 19 items were scored on the Likert scale, in which forward problems were set, scored in the order of 1-5 points, where the higher the score, the stronger the positive tendency of the measured content and the higher the satisfaction or demand. The other four items were open-ended questions. The trainees filled in the course duration, content and requirement for improvement based on their own situation. In terms of teaching effect evaluation, the trainees evaluated their own competency of prescription-checking, where 100 points referred to fully qualified, and 60 points referred to qualified.
In addition to the above scales, we also collected the score of each course of trainees, which reflected the mastery of the corresponding course.
The survey data were exported from the Sojump platform, and analyzed using SPSS22.0 (SPSS Inc., Chicago, IL, USA). Quantitative data were expressed as ±, of which those in line with non-normal distribution were described using median (quartile) and analyzed using non-parametric test.
Qualitative data were described using percentage and composition ratio, and analyzed using chisquare test. Exploratory factor analysis was used to analyze latent variables in the satisfaction items.

Basic information of trainees
The trainees were aged 36.91±6.74 years. Their basic information such as gender, work experience, educational background and titles are listed in Table 1.

Reliability and validity test
Consistency reliability is considered reliable when Cronbach-α coefficient is >0. 7[22]. In the present study, the coefficient of the scale was >0.8, indicating good internal consistency reliability ( Table 2).
The Cronbach-α coefficient was not calculated for the teaching effect since it only contained one item.
Questionnaires were reviewed by several pharmacy experts such as pharmacy education experts and directors of pharmacy department of grade-3 hospitals in Shanxi Province. Of these, eight experts were asked to score each item and evaluate the relevance of the item to its dimension. There were four levels for each item, from weaker to stronger correlation. The ratio of items scored 3 or 4 points by all experts to the total number of items (S-CVI) reflected the content validity of the scale. In the present study, the S-CVI of the scale was 0.91, which could be considered good content validity. The structural validity of the questionnaire was measured using KMO and Bartlett sphere test values.
Statistical analyses showed that the KMO was 905, which was >0.8, and the chi-square value by Bartlett sphere test was 10169.46 (p<0.001), which indicated good validity, and prompted the feasibility of factor analysis.

Overall satisfaction
From the personal satisfaction data of the respondents, 135 trainees had a satisfaction score of ≥4 points, accounting for 90%, 13 trainees indicated dissatisfaction (<3 points), accounting for 8.7%, and two trainees shared basic satisfaction (3 points), accounting for 1.3 %. The mean score was 4.51, which was higher than the theoretical score of satisfaction (4 points), and indicated that trainees were satisfied with the training.

Item satisfaction
The composition ratio and average value of satisfaction of each item were analyzed. The results are shown in Table 3. The trainees showed different satisfaction levels for various aspects of the training. They were most satisfied with the services of the staffs and professional skills of the lecturers, and were least satisfied with the amount of training assignment and one-day course for each training.

Influence of educational background of pharmacist on satisfaction
Trainees were divided into subgroups according to their educational background. The analysis showed that the influence of educational background on D2, D10, D12 and D13 was statistically significant (p<0.05).
The trainees below undergraduate background showed low satisfaction with one-day per training, and were dissatisfied with the short course of 33 classes and 1.65 hours for each class. They recommended that each class should be longer than 3.13 hours. Meanwhile, the trainees with undergraduate background showed low satisfaction with the assignment and mode of submitting assignment. The higher the trainees' educational background, the higher was their satisfaction with the professional skills of the lecturers (Table 4).

Factor analysis for training satisfaction
In order to further explore the potential relationship among the 13 items except the overall satisfaction, the satisfaction evaluation data were subjected to factor analysis. After oblique rotation (Tables 5 and 6), the cumulative variance contribution of each factor was 73.78% (factors corresponding to eigenvalue >1 were included), and the commonality of the 13 variables over the three factors exceeded 0.5, which indicated that these three potential factors better summarized the meaning of the 13 items, that is, the 13 indicators actually measured the three dimensions reflecting the training satisfaction.
As shown in Table 5, each indicator shows a high factor load on the corresponding factor. Factor 1 is mainly demonstrated by D1, D2, D3, D4 and D5, which reflects the organization and effectiveness of the training. Factor 2 is mainly demonstrated by D6, D7, D9, D11 and D13, which reflects the teaching mode. Factor 3 includes D8, D10 and D12, which reflects the solidification and assessment of knowledge gained. These results indicated that the training can be mainly focused on the abovementioned three factors to improve the overall satisfaction, in order to improve the quality of training.

Assessment results
A total of 20 courses were included in the training, all of which had a total score of 100 points. The average score of all courses was 89.21±2.62, of which essential points of prescription-checking for cerebrovascular diseases scored highest (average 93.63 points)( Table 7), and essential points of prescription-checking for antibacterial drugs (average 77.63 points) scored lowest.

Self-evaluation of prescription-checking competency
At the time of enrollment, the trainees were asked whether they were qualified for prescription-checking, 90% of trainees believed they were not qualified, and self-evaluated a score below 60 points. Meanwhile, after the training, the trainees self-evaluated an average score of 70.21 points, and 73.33% of them believed they were qualified for prescription-checking ( Figure 1).
Multivariate regression was performed by considering the three potential factors in the satisfaction factor analysis as independent variables, and the self-evaluation of prescription-checking competency as dependent variables, which was statistically significant (F=2.715 p=0.047), with the equation y=70.267+3.736X 1 -1.055X 2 +2.105X 3 . This result indicated that the prescription-checking training should focus on organization and development of the training, as well as consolidation and assessment of knowledge.

Abilities that need improvement for prescription-checking
Notably, 48% of the trainees felt a need to improve their ability to be competent in prescription-checking, especially to improve clinical expertise and practical capability, as well as communication skills and ability to search English literature, etc.

Demand for training knowledge
Analysis of demand for training knowledge showed that trainees had highest demand for clinical expertise, and lowest demand for pharmacy basics (Table 8).
Relevant analysis of needs for each category with the score of corresponding item showed that the correlation of subject 1-4 (prescription-checking for drugs that require skin test, r=0.163 p=0.047) with subject 1-5 (prescription-checking for off-label drugs, r=-0.161 p=0.049) was statistically significant, which indicates that trainees with a higher need for training in these two categories should strengthen their knowledge in these two categories.

Evaluation of offered courses
Trainees were asked to score the 20 offered courses according to their perceived importance of the courses. The results are listed in Table 7. The correlation analysis of the importance of courses with the trainees' scores revealed that the course 1-6 (i.e. tools and application of literature search) was statistically significant (r=0.026 χ 2 =0.184), which suggested that underestimating the importance of the course led to a low score in this course.
Work experience affected evaluation of the importance of the courses. All 10 courses, including prescription-checking related regulations, basic elements, essential points of prescription-checking for high-alert drugs, drugs requiring skin test, off-label drugs, common pediatric drugs, anti-cancer drugs, antibacterial drugs, chronic senile drugs and drugs for arrhythmia were greatly affected by work experience, while the other courses did not show statistical significance (Table 9).

Demand of new courses
In addition to the above-mentioned courses, 38.67% of the trainees believed the following knowledge needs to be added in the training: perioperative administration, rheumatism and immunology, nephropathy, microorganism, respiratory disease, liver disease, narcotic drugs, psychoactive drugs, estrogen, oculopathy, dermatologic disease, enteral and parenteral nutrition, gynecological drugs, mental disease, analgesics, ancillary drugs and other drugs for specialized diseases.

Preferences for teaching organization
The trainees favored face-to-face training, which showed a very high average score. Notably, 94.66% of the trainees preferred this mode of teaching, and 63.33% of the trainees liked this teaching mode very much (Table 10).

Needs for trainers
Trainees felt the greatest need for the trainer's professional skills and believed it was the most important, followed by teaching attitudes, methods or means, organization, teaching style and appearance (Table 11).

Discussion
The prescription-checking training course in Shanxi Province could quickly and effectively improve the prescription-checking ability of pharmacists in a short period of time using a combination of centralized theory teaching, position practice and online assessment. The present study aimed to investigate the training-related situations of 150 trainees and explore the needs of trainees and key aspects of prescription-checking training, in order to provide a reference for prescription-checking training, improve the quality of continuing education of pharmacists [23], and train qualified pharmacists.
The questionnaire had good internal consistency and validity. The participants came from all districts and counties of the province, which could reflect the basic situation of pharmacists in the entire province. Therefore, the survey results can be used for reference. The training effects were evaluated using three dimensions: satisfaction, examination score and self-evaluation of the trainees in terms of prescription-checking competence. In addition, the needs of trainees for prescription-checking training were analyzed from four dimensions: needs for prescription-checking ability, needs for training contents, teaching mode and needs for trainers. Due to the limited duration and tight schedule, the training might lead to limited improvement in prescription-checking skill and knowledge of pharmacists, but is more likely to increase the confidence of pharmacists [28] who lack confidence [29] in their abilities of prescription-checking and medication suggestion. After the training, the average score for prescription-checking competence was 70.21 points, and 73.33% of the trainees believed they were qualified for prescription-checking.
The analysis showed that in order to improve the prescription-checking competence, the training should focus on training organization, consolidation and assessment of knowledge.
In addition to training pharmacists, prescription-checking in medical institutions also relies on the information platform, in which pharmacists can consult the medical record, test results, medical order and other information, as well as communication platform between pharmacists and doctors [29].
Some medical institutions can perform risk pre-judgment using an embedded rational drug use monitoring software, in order to help pharmacists complete prescription-checking during peak hours. Therefore, the support from leadership of medical institutions greatly impacts prescription-checking. it was important, but lacked related knowledge, which resulted in a low examination score. The pharmacists underestimated the importance of tools and application of literature search, and paid less attention to it, which led to a poor grasp of knowledge and a low examination score. In terms of drug-related laws and regulations as well as commonly used drugs for common clinical diseases, pharmacists with a longer work experience ranked higher importance. Hence, the trainees expected the training knowledge to be related to their work practice [30]. The survey in the present study revealed that the pharmacists had less exposure to clinical basic knowledge and frontier knowledge of disease treatment in their continuing education and daily work, which they generally considered lack of knowledge. Therefore, medication for common clinical diseases [16], frontier knowledge of pharmacy as well as key points in prescription-checking were typically demanded, followed by regulations, query tools and other aspects, while the demand for basic pharmacy knowledge was lowest. Furthermore, supplementary knowledge of tools, such as pharmacy consultation, communication skills [16], drug incompatibility, clinical test and popular science of pharmacy were

Conclusion
The pharmacists had a great demand for prescription-checking training. Trainees enrolled in this training showed high satisfaction and good examination results. The key points of prescriptionchecking training were training organization, as well as consolidation and assessment of knowledge. It is recommended to conduct training in a stratified manner according to pharmacists' educational background, in order to effectively improve the prescription-checking competence of the pharmacists.
The pharmacists favored face-to-face lecture and interaction. It is necessary to supplement clinical disease-related knowledge.

List Of Abbreviations
CPD: continuing professional development.

Availability of data and materials
All data generated or analysed during this study are included in this published article [and its supplementary information files].

Competing interests
The authors declare that they have no competing interests    Figure 1 Self-evaluation of trainees for prescription-checking competency. The histogram shows the self-evaluation of qualification for prescription-checking. The score ranges 0-100 points, the X axis represents five fractions, the Y axis represents the number of trainees, which is divided into four segments.