Hospital Pharmacists’ Participation in Multidisciplinary Ward Rounds: Physicians’ Perceptions and Attitudes

Aims: To survey the physicians’ perceptions and attitudes towards pharmacists’ participation in multidisciplinary ward rounds (MDWRs) and to ascertain their acceptance of such practice in the University of Maiduguri Teaching Hospital (UMTH). Methods: This study was conducted at the UMTH, between September and October, 2011 using a validated questionnaire. The self-administered questionnaire was distributed to consented physicians out of the 246 physicians in the active service of UMTH as at the time of this study. The questionnaire was composed of three parts investigating the physicians’ perceptions and attitudes towards pharmacists’ participation in MDWRs. Data analyses were done using descriptive statistics and student’s t test with p < .05 significant difference. Results: A total of 151 questionnaires were completed and retrieved (response rate = 88.8%). Nearly one-half (49.6%) of the target physicians which translates to most participated physicians that perceived that drug related morbidity and mortality are often preventable and pharmaceutical Original Research Article Okoro and Auwal; BJPR, 5(5): 319-327, 2015; Article no.BJPR.2015.031 320 services can reduce the number of Adverse Drug Reactions (ADRs), and the length of hospital stay of a patient. A little above one-half (50.4%) of the population agreed that pharmacists’ participation in MDWRs enables pharmacists provide educational services on drug related issues to other members of health care team, while 49.2% agreed that it enables pharmacists function and serve as integral members of the health care team. Nearly one-half (49.2%) of the target physicians disagreed that pharmacists’ participation in MDWRs diminishes the responsibilities of physicians prescribing for patients. More than one-half (56.5%) of the target physicians reported that they consult pharmacists when confronted with drug related problems. The indices of physicians showing how they perceived pharmacists’ participation in MDWRs and their attitudes towards it were 42.1% and 48.7% respectively. The mean of physicians’ attitude index and that of year of experience in practice showed significant difference (p < .05) when paired, it was revealed that physicians with lower year of practice experience exhibited more positive attitudes than their older colleagues. Conclusion: Physicians at the study area had positive perceptions and attitudes towards pharmacists’ participation in MDWRs. Therefore, they were of the opinion that they would welcome such practice in the UMTH.


INTRODUCTION
Pharmacists are knowledgeable drug experts with traditional responsibilities of compounding and dispensing drugs. With the introduction of clinical pharmacy, the roles of pharmacists extended to direct patient care. A better interaction between physicians and pharmacists has led to safer, more effective, and less costly drug therapies [1,2]. Multidisciplinary ward rounds (MDWRs) is an avenue where such interaction can occur and become effective and beneficial to patients.
MDWRs is a structured round where key health care providers involved in the patient's care meet together to discuss the patient's care and the coordination of that care. In other words, it is an avenue where dialogue and feedback occurs in relation to the needs of the patient and provides the multidisciplinary team an opportunity to plan and evaluate the patient's treatment and transfer of care together. Moreover, it is patient centered and is based on the needs of the patient. However, in 2012, Royal College of Physicians and Royal College of Nursing jointly published a guidance which calls for multidisciplinary team of physicians, nurses, pharmacists, therapist and allied health professionals to be given dedicated time to participate, with clarity about individual roles and responsibilities during and after MDWRs [3].
These key health care professionals are required to work closely together, in order to develop and evaluate the patient's integrated plan of care. To provide seamless patient care, health care teams must move from a mindset of independence to one of interdependence [4]. An effective MDWRs present a valuable opportunity for both key health care professionals and the patient/career to share information, problem solve and plan treatment as an interdependent team [4]. When health care providers collaborate and work together, outcomes (clinical, humanistic, and economic) improve [5], and lack of representation for certain healthcare professional groups, including pharmacists may adversely affect the range of opinions and therapies for patient [6].
On MDWRs, the pharmacist assists and helps the physician in prescribing a drug to the patient. By doing so, pharmacists contribute to patient care through the provision of drug information and promotion of rational drug therapy. The goals of pharmacists' participation in MDWRs are to gain an improved understanding of the patient's clinical details, planned investigations and therapeutic goals; provide drug information; and optimize drug treatment by influencing therapy selection, implementation and monitoring [7]. They provide ample opportunities for pharmacist to assimilate additional information about the patient which may be relevant to their drug therapy, influence prescribing during decision making, detect adverse drug reactions and interactions, and participate in discharge planning. At the completion of the MDWRs, the pharmacists follow up outstanding drug related issues.
A study had shown that there is an increase in the incidence of hospitalization and death caused by the inappropriate use of prescription drugs [8]. For every heath care dollar spent on purchasing drugs, an additional dollar may be spent to deal with misuse of drugs [9]. These constitute a major public health problem. Therefore, fully utilization of pharmacists in both hospitals and communities would ensure that all the patients' drug therapy is appropriately indicated, effective, safe, convenient, and affordable [10]. The pharmacists' potential for saving and improvement of life of patients and reduction of health care cost is great.
A similar study that evaluated the attitude and perceptions of healthcare providers and medical students towards clinical pharmacy services in United Arab Emirates was conducted by Abu-Gharbieh et al. [11]. Another similar study investigated the physicians' perceptions and expectations of their experiences with the pharmacists in Qatar [12]. Currently, there are no published studies that surveyed the physicians' perceptions and attitudes towards pharmacists' participation in MDWRs in Nigeria. However, this study was embarked on, due to a lack of representation of pharmacists in the MDWRs in Nigerian hospitals. The aims of this study were to survey the perceptions and attitudes of physicians towards incorporating pharmacists in MDWRs and their perceived acceptance of such practice in the University of Maiduguri Teaching Hospital, Maiduguri in the north eastern Nigeria.

Study Area
The design is a uni-centre prospective survey conducted at the University of Maiduguri Teaching Hospital (UMTH). UMTH is about 530 bed tertiary health care facility spread over 17 wards, serving a population of over 20 million people in the north-east geopolitical region of Nigeria comprising six states (Borno, Yobe, Adamawa, Taraba, Bauchi and Gombe). As at the period of this study, UMTH has a total number of 246 active physicians including House officers.

Target Population
Two hundred and forty six (246) physicians in the active employment of UMTH.

Data Collection
Data were collected between September and October, 2011. The developed questionnaire was reviewed by a pharmacist in the hospital practice for face validity of questions. It was also assessed for content validity in terms of content, scope, depth and appropriateness of each item.
The questionnaire was pre-tested and appropriate corrections were made based on analysis of the pre-tested questionnaire. It was also assessed for reliability (cronbach alpha value = .675). The questionnaire had three sections-A and B were aimed at collecting demographics, and participants' perceptions respectively, while section C gathers information on participants' attitudes. The questionnaire was self-administered to the respondents by hand. Data from the questionnaires were extracted into the data collecting forms.

Data Analyses
Items on the questionnaire were self-reported on a three-point Likert scale (disagree, no response, and agree) and numerically coded as −1, 0, and 1 for perception items respectively whereas, items on attitude were coded vice versa for calculating the perception and attitude indices by adding all items for each individual respectively to show the overall impact of all the items on their perceptions and attitudes. Descriptive statistics were calculated for all the variables included in the study. Student's t-test was applied to obtain the significant difference in mean level of indices and year of working experience as a physician. A p value < .05 (twotailed) was considered as statistically significant.

RESULTS
Out of the 170 questionnaires that were administered, 151 were completed and retrieved thereby giving response rates of 88.8%.
The mean age of the study participants is 34.6±6.4 years with a range between 23 -52 years. Of the population, 37.0% and 22.8% were males and females respectively. The Summary of the respondents demographic data are shown in Table 1.
On evaluation of the respondents ranks in order to ascertain their reported year of experience in practice, it was found that majority of the respondents were 7(2.9%) Consultants with 11 -15 years experience, 17(6.9%) Senior registrars with 6 -10 years experience, 26(10.6%) Junior registrars with 1 -5 years experience, and 19(7.8%) Medical officers with 1 -5 years experience. The details are shown in Table 2. On evaluation of physicians' attitudes, this study revealed that an appreciable number (121, and 113) of physicians disagreed that pharmacist's presence during MDWRs diminishes the responsibilities of physicians prescribing for patients, and pharmacists making decisions about diagnosis respectively. Ninety physicians also disagreed that multidisciplinary ward rounds affords pharmacists the opportunity to learn the secret of medical practice. One hundred and thirteen (113) physicians disagreed that pharmacists are asking for too much to be part of MDWRs. Lastly, 139 physicians agreed that they consult pharmacists when confronted with drug related problems. These findings are illustrated in Table 4.
Out of 114 of the physicians that reported that they would welcome pharmacists' participation in MDWRs, 23 were with less than one year experience in practice, 41 were between 1 -5 years, 34 were between 6 -10 years, 7 were between 11 -15 years, 6 were between 16 -20 years, 1 between 21 -25 years and 26 -30 years respectively as shown in Table 5.
Out of the target physicians, 42.1%, and 48.7% physicians had perception and attitude indices greater than one respectively. Detailed results are shown in Table 6.
On comparing the mean of the indices and year of experience in practice, statistical difference was found between attitude index and year of experience in practice (p < .05) as shown in Table 7.

DISCUSSION
Practitioners from each key discipline of the MDWRs team can use their specialized training and skills to make significant contributions to patient care. In other words, treatment of patients is in most cases, a combined effort of several health care professionals and it is recognized that the outcome of a procedure is optimal when the professionals do indeed work together as a team. Obviously, pharmacists are part of treatment teams in healthcare establishments. With expertise of product and processes, they improve the therapeutic outcome and the quality of work flow. Although it seems obvious that pharmacists form part of a team, do we know the exact added value of their contributions [13]?
This study revealed that majority of the participated physicians was aware of the importance of incorporating pharmacists as members of the MDWRs team. This revelation is consistent with the philosophy of pharmaceutical care which is a patient centered collaborative care in which pharmacists partner with other key health care professionals and patient in designing, implementing, and monitoring a care plan aimed at preventing and resolving drug related problems [14]. Nearly one-half of the target physicians which translates to more than three quarter of the participated physicians agreed that drug related morbidity and mortality are often preventable and pharmaceutical care services can reduce the number of Adverse Drug Reactions (ADRs), and the length of hospital stay of a patient. Length of hospital stay is one of the measures used to study the impact of MDWRs on clinical outcomes. The finding of this study has been proved with that of a randomized, controlled trial conducted in a large, acute care tertiary hospital, where it was found that replacing traditional once-a-week rounds with daily MDWRs reduced length of patients' hospital stay [15].  Most of the respondents that constituted lower than the average of the target population perceived that pharmacists' participation in MDWRs enables prescribing to be influenced at the time of decision making. This finding lends credence to the fact that pharmacists are ideally placed to influence prescribing by physicians because they are knowledgeable in therapeutics. Therefore, pharmacists are often the ones who communicate with the treating physician, in order to offer the best possible treatment for hospitalized patients [16]. Other studies showed similar results [12,17]. This is reassuring that physicians understand that pharmacists as healthcare team members rendering suggestions on drug therapy ease their work on drug therapy. Collaborative care by the healthcare professionals improves patient care, enhances patient safety and reduces workload issues that cause burn out among a particular healthcare professional.

Consultant
A little below one-half of the target physicians that formed the majority of the participated physicians were of the opinion that pharmacists' participation in the MDWR ensures that patients receive the maximum benefit from drug therapy. Like other healthcare professionals, the main goal of pharmacists within the team is to benefit the patient. The United Arab Emirates study [11] revealed a similar finding, but in this case three quarter of the 3 key healthcare providers (physicians, pharmacists and Nurses) were in agreement. However, a German study provided evidence that the participation of a pharmacist during MDWRs contributed to the optimization of pharmacotherapy [18].
Majority of the participated physicians which translates to less than one-half of the population agreed that hospital pharmacists' participation in the MDWRs provides cost-containment initiatives in patient care. This perception is also in agreement with the finding of other studies [11,19]. This indicates that physicians knew that it is more costly to deal with the problems of inappropriate drug therapy. Studies undertaken in the United Kingdom and America provided proofs that the presence of pharmacists on the MDWRs reduced prescription costs [20,21].
In the present study, Nearly one-half of the target population that formed more than three quarter of the participated physicians agreed that pharmacists' participation in the MDWRs will make hospital pharmacists function and serve as integral members of the health care team. This is in agreement with the finding of another study [11]. This depicts that physicians are aware that pharmacist can only prove himself as a member of healthcare team by participating in MDWRs. Less than one-half of the target physicians that constituted more than one-half of the participated physicians perceived that pharmacists' participation in the MDWRs makes pharmacists play key roles in the development of disease specific drug treatment guidelines. This finding suggests that pharmacists can only make important contributions in the development or review of disease specific drug treatment guidelines if they were involved in the actual drugs use practice in patients which MDWRs is an indispensable avenue.
Majority of the participated physicians which translates to less than one-half of the target physicians opined that the presence of pharmacists on MDWRs improves the accuracy of drug history documentation, therefore perceived that drug history of admitted patients should be obtained by pharmacists. A German study provided evidence to this finding [18].
On evaluation of physicians' attitudes, this study revealed perceived positive attitude towards pharmacists participating in MDWRs. These attitudes were significantly dependent on the year of their experience in practice. These findings shows that physicians especially those with lower year of experience in practice exhibited positive attitudes that pharmacists in the MDWRs team do not in any way encroach on their roles, but collaborate with them to make life more meaningful for the patients.  Physicians knowing the importance of pharmacists in drug therapy, an overwhelming number of participated physicians reported that they consult pharmacists when confronted with drug related issues. In addition, a little more than two third of them were of the opinion that the practice of having pharmacists as members of the MDWRs team would be received and welcomed in the University of Maiduguri hospital. This is so, because they were aware that the absence of pharmacists in the MDWRs team creates a vacuum which no other healthcare practitioners can adequately fill.

Limitations of the Study
All physicians in the active service of UMTH did not participate in this study partly due to absence of some of them during the period of the study, whereas others outright declined to participate in the study owing to undisclosed reason(s).
Secondly, there was an unequal distribution of physicians according to year of working experience. Lastly, physicians might have different interpretations of the survey items and definition of pharmaceutical care.

CONCLUSION
Physicians opined that inclusion of pharmacists in the MDWRs team poses no threat to their clinical roles to patients, but enables pharmacists collaborate with them to optimize the quality of the patients' pharmacotherapy thereby increase drug-related patient safety. Therefore, physicians at the study area had positive perceptions and attitudes towards pharmacists' participation in MDWRs. Therefore, they were of the opinion that this indispensable practice which is the current hospital practice in most developed countries would be welcomed in the University of Maiduguri hospital.

CONSENT
Informed consent was obtained from the participants.

ETHICAL APPROVAL
Ethical approval was sought and obtained from the research and ethics committee of the University of Maiduguri Teaching Hospital.