FormalPara Key Points for Decision Makers

• Formation of trusting relationships between consumers and carers and community pharmacy staff appear contingent on consumers’ and carers’ experience of the service that they received.

• Community pharmacy service characterised by elements of patient-centred care was key to the establishment of initial rapport, which in turn encouraged open communication and facilitated the building and nurturing of trusting relationships. Consumers ascribed multiple benefits to established relationships, such as being empowered to take a proactive approach in the management of their health, and that the pharmacist would protect them from adverse drug events.

• Patient-centred care does not appear to be routinely delivered by community pharmacy staff, thus highlighting the need for education and training to support and enable staff to utilise a patient-centred approach in the provision of services for mental health consumers and their carers.

1 Introduction

Studies exploring health consumers’ perspectives highlight the importance of relationships with health care providers in health management [1–11]. This is particularly important for those with chronic conditions such as mental disorders [12], where relationships between consumer and health care providers are integral to effective management and supporting recovery [4, 7, 8, 10, 12–14]. As health care providers and primary suppliers of medications for the management of mental disorders, community pharmacy staff are well placed to form relationships with mental health consumers and their carers and to play a greater role in mental health care [15]. However, research to explore consumer–staff relationships and their impact on the management of mental health is limited.

The formation of trust is crucial in establishing and maintaining consumer–health care provider relationships [6, 16–19]. For example, the increasing importance of doctors’ ability to cultivate trust to address clinical uncertainty and reinforce consumers’ beliefs in chosen therapeutic options has been highlighted [17]. Specifically, consumers have emphasised the importance of health professionals listening to them, adopting a caring approach, and being compassionate in gaining their trust [16, 18]. Interactions that create a safe space for open dialogue have been described as fundamental to ‘trust building’ [18, 19]. However, trust may be difficult to establish in vulnerable populations that experience conditions associated with stigma or uncertainty over disease outcome, including mental illness, because the consequences of misplaced trust may be high [16].

Health care that is individualised, explores consumer experiences and promotes engagement, empowerment and partnership in care also reflects elements of the health-related concept of patient-centred care [20, 21]. Patient-centred care is defined as care that is holistic (understand the whole person, address needs beyond those related to medicine); individualised (personalised delivery of services to meet individual needs); respectful (supports individuals as competent and active decision makers); and empowering (encourages consumer autonomy and self-determination) [22]. Trust in the health care provider has been shown to be facilitated by providers adopting a patient-centred care approach to service delivery [6, 9, 11]. A relationship between consumer and health care provider that inspires trust, encourages open communication, and values the consumer as an equal partner in therapeutic decision making defines a therapeutic alliance [1, 12]. In mental health care, therapeutic alliance has been linked to better consumer engagement, improved treatment adherence and subsequent health outcomes [1, 5, 11, 23].

Australian community pharmacy staff deliver a range of pharmacy services directly to consumers, including people with mental disorders [15]. The effectiveness of pharmacy services is contingent on staff forming collaborative relationships with consumers and carers and with other health care providers [24–27]. Consumers have identified that pharmacist attributes of approachability, responsiveness, trustworthiness, caring and respect are important in forming trusting relationships and therapeutic alliance [24]. The quality of consumer–pharmacist relationships has also been positively associated with consumer satisfaction and perceptions of pharmacists’ medication expertise [28]. Although the importance of trusting relationships between mental health consumers and a range of health care providers have been acknowledged [12, 16, 18, 29], it is unclear whether such relationships exist between community pharmacy staff and mental health consumers and carers. Likewise, studies that have explored patient-centred care are not specific to the experiences of mental health consumers in community pharmacy [20, 21, 30]. These limited insights are further compounded by a lack of information as to how community pharmacy staff can, or already do, deliver patient-centred care in the context of mental health. A greater understanding of how relationships are formed, the delivery of patient-centred care in community pharmacy, and the related impact on the management of mental health is needed. The influence of non-pharmacist support staff should also be considered since they represent over 70 % of the community pharmacy workforce [31], are involved in most aspects of service provision, and yet are often neglected in community pharmacy practice research.

The aim of this study was to explore mental health consumers’ and carers’ perceptions of community pharmacy services, and to describe the nature of relationships between mental health consumers and carers and community pharmacy staff.

2 Methods

2.1 Study Design

The research was conducted between November 2011 and March 2012 in the Australian states of Queensland, New South Wales and Western Australia, and formed part of a larger project to improve outcomes for mental health consumers and their carers through the provision of community pharmacy services [32]. Researchers promoted the project in these target states by distributing flyers and emails to consumer and carer support organisations and participating community pharmacies. Convenience sampling was used to recruit adults residing in the three target areas, who lived independently, and used community pharmacy, and were either a consumer experiencing a mild to moderate mental illness such as depression or anxiety, and/or caring for someone with a mental illness. Participants who met these inclusion criteria self-selected into the study by responding to an invitation given to them by a participating community pharmacy, or volunteered through their local mental health consumer support groups and networks. Perspectives of consumers and carers living in metropolitan, rural, and remote and indigenous communities were sought [33, 34]. To ensure participants’ comfort and convenience, participants were offered the choice between attending a focus group or a one-to-one interview. Recruitment and interviews continued until saturation was reached. Ethics approval was granted by the Griffith University Human Research Ethics Committee.

2.2 Procedure

Interview guides (Table 1) were developed to collect narrative data through open dialogue between interviewer and participant, and to promote focus-group discussions [35]. The guides were designed to explore participants’ experiences, needs and expectations of community pharmacy services, perceptions of medicine taking, therapeutic alliance; and perceived outcomes of treatment. Two researchers were present at focus groups, one acting as the primary facilitator and the other taking field notes [36]. All focus-group interviews followed a similar format for consistency purposes, and took on average 1 hour to complete (range 40–100 min). Researchers debriefed immediately following each focus group to share personal reflections and theoretical insights [35, 36]. Six of the eight individual interviews were conducted via telephone, and two were face-to-face (range 27–45 min). All focus groups and semi-structured interviews were audio recorded, transcribed verbatim and prepared for analysis by (i) conducting quality checks of a sample of the transcribed interviews; (ii) removing identifiable information; and (iii) storing the recordings and transcripts in a secure location accessible only to research team members. NVivo software (QSR International Pty Ltd) was used to manage the data.

Table 1 Guide for interviews and focus groups
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2.3 Data Analysis

Thematic analysis was primarily informed by the general inductive approach [37].

Transcripts were read and re-read by the two researchers involved in conducting and transcribing the interviews to gain an understanding of the broad issues relative to the key evaluation questions. To ensure reliability, the two researchers agreed on a coding framework that captured the core messages reported by participants. Then, specific themes were developed which captured core messages reported by the participants. This process was undertaken to code ‘units’ of data, then categorise (‘cluster’) units until themes emerged. An additional consistency check was conducted on a sample of transcripts to verify that data was coded in a similar way by a third researcher who had not been involved in conducting or transcribing the interviews.

This study reports on participants’ perceptions of their interaction with community pharmacy staff, any relationships that may exist between them, alongside any perceived benefits for mental health care.

3 Results

Focus groups and semi-structured interviews were conducted with a convenience sample of 74 mental health consumers or carers who self-selected into the study. Of these, 66 people participated in nine focus groups, and eight selected to be interviewed on a one-to-one basis. Of participants who provided demographic information, the majority were female and over the age of 26 years (range 18–55 years and over). Participant characteristics are summarised in Table 2. Two interlinked themes emerged from the analysis of interview data: (i) the role of consumer and carer experiences; and (ii) the pharmacist protector role. Quotes have been identified and coded to indicate whether the participant was a consumer (C), carer (CA) or both (C/CA), interviews conducted via a focus group (FG) or semi-structured interviews (SSI), and numeric values are unique identifiers for the transcripts.

Table 2 Participant characteristics
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3.1 Consumer and Carer Experiences are Key in Establishing Relationships

Formation of relationships appeared to be strongly shaped by participants’ experiences in the pharmacy. Positive experiences were identified as the main facilitator to (a) forming initial rapport, and (b) nurturing a relationship over time through open engagement and the development of trust. Participants related positive experiences to knowledgeable staff and feeling welcomed in the pharmacy through a friendly greeting, a smile, recognition and acknowledgement. The shift from initial rapport to trust appeared to be contingent on participants being welcomed into a safe health care space by staff who knew them personally and cared about their wellbeing.

“Just going there regularly and they got to know me a bit. They’re friendly and warm and I feel that they actually care.” (C SSI120208)

This approach to service delivery aligns with elements of patient-centred care such as individualised and holistic care (Table 3).

Table 3 Elements of patient-centred care described by consumers or carers
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For example, when pharmacy staff adopted a holistic approach by showing interest in participants’ health and wellbeing, they reported feeling more comfortable to discuss personal information and believed that they were cared for.

“…it’s very genuine…they’ll say how’re you going and how’s the grandkids…It’s very, very personal…” (C FG120206)

Participants also appeared to value relationships with pharmacists more than support staff. While they showed great appreciation for pharmacists’ knowledge, those who had formed relationships identified attributes such as approachability, sensitivity and a willingness to go above and beyond their personal expectations as being important in building and maintaining relationships. Participants appeared to relate these attributes to a reduced sense of stigma or ‘feeling labeled,’ and perceived that this made it easier to speak openly.

“…sometimes [you can] have a chat with the pharmacist and that just makes you feel a part of the community and make it [a] more enjoyable and less depressing experience having to go get medication and remind you that you’ve got a medical condition.” (C SSI120208)

In contrast, while most participants perceived support staff to be front-line and approachable, they were less likely to develop or value relationships with them. Some participants expressed the view that support staff lacked professionalism, lacked communication skills, or both.

“I had a friend who asked for something right, from the pharmacist’s assistant and she’s 74 years old. The pharmacy assistant was saying to her you know, wash your hands now won’t you…that sort of thing. And they can be a little bit inappropriate” (C FG111207)

Others expressed their objections to being questioned by support staff, perceiving the questions as time wasting and did not value their advice. Others felt that support staff did not protect their confidentiality and lacked knowledge. These views appear to be attributed to the young age and presumed lack of experience of support staff.

“The pharmacy assistant wouldn’t give me the ones [medication] I wanted…she says no, you can’t have those…she gave me lesser strength ones…but I took double of them [medication] anyhow…” (C FG120206)

“The jobs are offered to kids that are too young to realistically understand what any of that medication is about.” (C FG120224)

For some participants, frustration with support staffs’ inability to assist with their enquiries was compounded by perceptions of support staff acting as barriers to accessing the pharmacist.

“Sometimes they do a bit of gate-keeping to the pharmacist. So you say “Oh look I’ve got a rash and I really want to know” and they’ll ask you a few questions, but I’ve always found that they’ve pretty much then “Oh I’ll get the pharmacist” (C FG120224)

Omission of patient-centred care appeared to contribute to negative experiences reported by participants. This included being inappropriately questioned, feeling judged, staff failing to protect confidentiality, or feeling taken advantage of when unnecessary products were suggested:

“…the staff made me feel like I was nothing. And because I stutter occasionally which makes it even worse, they would just stand there and look around as if you are a total dork. They started to be really rude and arrogant towards me and they said, “oh we can’t deal with you, just go away” and it just made me feel, well, why do I bother…” (C FG111216)

Although participants described negative experiences resulting from interactions with both pharmacists and support staff, the majority were associated with support staff. Some consumers reported that as a result of negative experiences, they simply chose not to return to the pharmacy, thereby removing the opportunity to build a relationship with staff. Others reported more detrimental consequences from these experiences, such as the erosion of self-confidence or a sense of disempowerment.

3.2 Trusting Relationships were Linked with Pharmacist in a Protector Role

Some participants viewed community pharmacy as having a limited role in mental health care, and considered it to be outside community pharmacists’ scope of practice. These views appeared to be shaped by the retail environment of community pharmacy, consumers’ doubts over the mental health care ‘competence’ of pharmacy staff, and experiences of seeing pharmacists heavily involved in the physical aspects of dispensing.

“…if you want to ask a pharmacist a question about contraindications, well, you’re standing out in the middle of a big shop and everyone’s looking…he [the pharmacist] …says ‘Is there any private or personal information that you’d like to talk to me about?’ Not here!” (C FG111207).

“I don’t think that very many pharmacists have a clue about the various types of mental illness there are…they don’t really have that understanding.” (C/CA FG120121)

“I don’t tend to see people asking pharmacists for advice. I see pharmacists tucked up in their little corner putting labels on boxes” (C FG120206)

Despite these views, the potential for a more involved role of pharmacists as ‘protector’ from possible drug interactions and adverse drug events emerged. Pharmacists who provided information alongside their knowledge of consumers’ medication history created a sense of security amongst participants, with perception that the pharmacist would protect them from drug interactions and inappropriate purchase of non-prescription medications.

“My pharmacist is fantastic…they keep a register of all your medication so if we’re ever given a different medication then they can check for interactions … and when I’m buying over the counter medication it’s all on file so they can check whether it’ll interact.” (C SSI111205)

This protector role was most evident when trusting relationships between pharmacists and participants had been established. Participants who patronised a regular pharmacy and reported this relationship to include therapeutic alliance with their pharmacist perceived questioning and being given detailed advice as the pharmacist caring for their health.

“I was diagnosed as having bipolar too and so I felt free to discuss it with [the pharmacist]. He explained very in-depth what each of the medications was… It took a few goes to find the right ones, because I’m allergic to quite a lot of drugs…so that’s in their records and so that meant that that’s another trust area…” (C/CA FG120121)

The theme of protector was further reinforced when participants felt that their pharmacist was more likely to pick up prescribing changes or refer them to other health care services when something seemed amiss because they knew them and their medication history. Noticeably, consumers and carers who spoke about having an established relationship with the pharmacist were more likely to perceive value in existing community pharmacy services and in pharmacists providing more in-depth health services, such as medication adherence support.

4 Discussion

Development of trusting relationships and therapeutic alliance are vital to the delivery of health care, particularly for chronic conditions, including mental disorders [12, 15, 29, 38]. In this study, the formation of a trusting relationship and therapeutic alliance between mental health consumers and carers and pharmacy staff was perceived to be fundamental to community pharmacy being considered a safe health care space for the provision of services. Trust and therapeutic alliance appeared to be established, and relationships nurtured, when participants received individualised service, perceived a sense of safety in the environment to engage in open communication, and observed the pharmacist as caring. While these findings concur with reports of consumer development of trust with medical practitioners [16, 18], of importance is the finding that in the community pharmacy context, discussions around mental health issues appeared to be reserved until trust was established and consumers and carers felt safe to do so.

A potential ‘protector’ role for pharmacists emerged, particularly when participants felt that they had established a therapeutic alliance with the pharmacist, and they reported trusting pharmacists to monitor their wellbeing and intervene if necessary. The formation and nurturing of relationships appeared to be based on pharmacy services that aligned with one or more of the four domains of patient-centred care described earlier. Of these, respectful care and concern for consumers’ overall wellbeing (holistic care) appeared important in facilitating development of trust, and subsequent delivery of health care that encouraged consumer self-confidence in managing their mental health (empowering care). These findings are consistent with earlier research which indicated that, for mental health consumers, aspects of positive experiences included empowerment, being treated with dignity and respect, and feeling safe and cared for [8, 10, 12, 39]. Conversely, when negative interactions were described (such as consumers feeling judged or stigmatised), in many cases one or more elements of patient-centred care (particularly respectful and empowering care) were missing.

The need for community pharmacy staff to adopt a patient-centred approach to service delivery has been recognised by pharmacists in a recent study [40]. In the Australian context, this need has been emphasised with the recent release of a guiding document for pharmacist professional practice [41]. Elements of patient-centred care, particularly holistic and respectful care, underlie the delivery of pharmacy services to mental health consumers and their carers and also align with pharmacists’ evolving role in medication management [15, 41]. The current findings evidence the potential benefits of pharmacists adopting a patient-centred approach, and suggest that this will facilitate their ability to fulfill their professional obligations and extend beyond. However, patient-centred care does not appear to be consistently delivered by community pharmacy staff. In previous research, pharmacists expressed positive views towards providing services for mental health consumers, yet reported that they felt uncomfortable discussing symptoms, and lacked the time, private counseling space, and communication skills to provide individualised care [42–44].

In this study, some participants did not recognise the role of support staff, or value forming relationships with them. Some perceived support staff as gatekeepers preventing direct access to the pharmacist, a finding that is consistent with an earlier study of general health consumers [45]. Despite the recent introduction of Mental Health First Aid™ training for pharmacy staffFootnote 1 [46], and the requirement for support staff to be trained to provide a range of pharmacy services [47, 48], there are no mental health-specific competency standards or qualification requirements for community pharmacy support staff in Australia [49–51]. In reality, support staff interact more regularly with consumers than pharmacists [45], so the significance of their impact on relationship building must be considered. Whilst consumers and carers ascribed multiple benefits to having a good relationship with their pharmacist, limiting access to the pharmacist would restrict the formation of these relationships.

5 Limitations

Convenience sampling might have introduced recruitment bias towards motivated participants. However, calling for self-selected volunteers through consumer and carer support organisations and networks was deemed to be appropriate in recruiting vulnerable populations, such as those with mental health disorders [52]. Furthermore, purposive sampling from within the targeted areas was undertaken to ensure the perspectives of consumers and carers living in the diverse range of communities, such as metropolitan, rural, and remote and indigenous communities, were included [33, 34]. Collecting self-reported data might have been influenced by social desirability responses and, in the case of focus groups, more dominant opinions may have overshadowed the views of other group members [52]. Interviewers took care to ensure all participants were given the opportunity to express their opinion through setting the ground rules prior to the start of the discussions and by addressing each participant to invite their specific views during the interview process. Interviewer bias was minimised with the use of a standardised interview framework.

6 Conclusion

This study has provided valuable insights into mental health consumers and carers’ perceptions of community pharmacy services and their relationships with staff. Many examples of good community pharmacy service were highlighted and valued by participants, and associated with positive attitudes towards a greater role for pharmacists in mental health. Trusting relationships between consumers and carers and pharmacy staff were perceived to be fundamental to community pharmacy being considered a safe health care space. A patient-centred approach appeared to foster relationships, particularly when consumers felt welcomed into a safe space and felt supported and valued as an equal contributor in the management of their mental health. However, a patient-centred approach was not consistently described by participants. These findings support calls for community pharmacy staff to adopt a patient-centred approach to service delivery [40, 41], and indicate a clear need for targeted mental health training for Australian community pharmacy staff. The training should support staff mental health practice needs, and reinforce key recommendations from a recent review of mental health educational needs of community pharmacy staff [51]. For example, training should contain specific strategies that assist staff to better engage with mental health consumers and carers, improve mental health knowledge and communication skills, and build confidence in delivering mental health care. For support staff, education and training that includes specific strategies to reduce stigma and promotes greater engagement with consumers and carers is needed. In addition, further research is required to identify relevant strategies for support staff to strengthen their role in mental health care and associated content of mental health education and training. As highlighted in this study, strengthening community pharmacy–consumer and carer relationships is key to improving the role of community pharmacy in mental health care.